Pacific Palms Healthcare

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide one of four sampled residents (Resident 1) medication as ordered by his physician when Resident 1 did not receive Refresh Liquigel Ophthalmic Gel 1 % (a thick, gel-like eye drop solution, often called artificial tears) in both eyes at bedtime for dry eyes.This deficient practice resulted in Resident 1 not receiving Refresh Liquigel Ophthalmic Gel 1 % as ordered and had the potential for Resident 1 to experience dry eyes.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 paraplegia (loss of movement and/or sensation, to some degree, of the legs).During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/4/2025, the MDS indicated Resident 1's cognition (ability to think and reason) was intact required substantial/ maximal assistance (helper does less than half the effort) from staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Order Summary Report (Physician Order's) dated 12/18/2025, Resident 1 was to receive Refresh Liquigel Ophthalmic Gel 1 % one application in both eyes at bedtime for dry eyes, ordered on 12/18/2025. During an interview on 12/30/2025 at 10:56 a.m., Resident 1 stated he has not been receiving the eye drops at night that were ordered by his physician.During a concurrent observation and interview on 12/30/2025 at 11:57 a.m. with Licensed Vocational Nurse (LVN) 1, of the East 2 Station medication cart, LVN 1 stated there were no Refresh eye drops in the medication cart for Resident 1 and would need to follow up with the supervisor.During a concurrent observation and interview on 12/30/2025 at 12:21 p.m. and subsequent interview on 12/30/2025 at 2:36 p.m., with Registered Nurse (RN) 1, of the facility's House Supply closet (a locked storage area where a collection of over-the-counter medications [any non-prescription medicine] are kept in the facility) RN 1 stated there was no Refresh drops in the House Supply closet. RN 1 stated she could not find any pharmacy delivery receipts of the Refresh drops for Resident 1 indicating the Refresh drops were delivered to the facility. RN 1 stated there should have been a follow up regarding Resident 1's Refresh eye drops to see why it was not delivered to facility. RN 1 stated if Resident 1 does not receive the prescribed eye drops then Resident 1's eye dryness will remain untreated.During an interview on 12/30/2025 at 1:07 p.m., the Pharmacist confirmed Resident 1's order for the Refresh eye drops was processed today (12/30/2025). The Pharmacist stated if the medication is an over-the-counter medication, the Pharmacy will not provide it, unless it was specifically requested by the facility. The Pharmacist stated there was no documentation that the facility called regarding the Refresh eye drops.During a review of the facility's policy and procedure (P&P) titled Pharmacy Services, dated 4/2019, the P&P indicated residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. The P&P indicated nursing staff should communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 2) who was under hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) was visited by hospice licensed nurses weekly per hospice care agreement.This failure had the potential to result in Resident 2 did not receiving hospice care as they agreed upon.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including respiratory failure (a condition in which the blood does not have enough oxygen or has too much carbon dioxide), dysphagia (difficulty swallowing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and cerebral infarction (loss of blood flow to a part of the brain) affecting right side of body. During a review of Resident 2's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 2 did not have the capacity (ability) to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 2 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, hygiene, shower, dressing, and bed mobility.During a concurrent interview and record review on [DATE], at 10:58 a.m., with Licensed Vocational Nurse (LVN) 7, Resident 2's Hospice Staff Visitation Flow Sheet, dated from [DATE] to [DATE] was reviewed. The Hospice Staff Visitation Flow Sheet indicated, Hospice Licensed Nurses visited on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and[DATE]. LVN 7 stated, Licensed Nurses should have visited Resident 2 once weekly per hospice agreement. LVN 7 stated, Hospice Nurses did not visit weekly during 9/2025, as well as early 10/2025, and the facility staff did not follow up to find out regarding missing visits on 9/2025 and early 10/2025. LVN 7 stated, Hospice nurses visits should be done weekly according to the hospice agreement, and Resident 2 would not receive specialty care and assessment if the hospice nurses' visits were not ensured as agreed. During a concurrent interview and record review on [DATE], at 3:55 p.m., with the Director of Nursing (DON), Resident 2's Physician's Certification for Hospice Benefit, dated [DATE] was reviewed. The Physician's Certification for Hospice Benefit indicated, family agreed to skilled nursing visit once weekly and Certified Home Health Aids (CHHA) visit twice weekly. The DON stated, the staff should have followed up with weekly hospice licensed nurses' visit to ensure Resident 2 received the care as agreed. The DON stated, the facility staff had responsibility for ensuring Resident 2 who was under hospice care received the best care, especially specialty care such as hospice assessment and palliative care (a medicine or form of medical care that relieves symptoms without dealing with the cause of the condition) as agreed.During a review of Resident 2's Order Summary Report (OSR), dated [DATE], the OSR indicated, admitted Resident 2 into Hospice care under routine level of care, and call hospice for any changes in condition was ordered on [DATE]. The OSR indicated, skilled nursing visit once a week and CHHA visit for twice a week was ordered on [DATE].During a review of Resident 2's Care Plan Report (CPR), initiated [DATE], the CPR Focus indicated, Resident 2 was on hospice care with expected deterioration. The CPR Interventions indicated, Hospice staff render care during their visits.During a review of the facility's Policy and Procedure (P&P) titled, Hospice Program, revised 7/2017, the P&P indicated, Policy Interpretation and Implementation: 9. (in general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: a. Determining the appropriate hospice plan of care; b. Changing the level of services provided when it is deemed appropriate; c. Providing medical direction, nursing and clinical management of the terminal illness; d. Providing spiritual, bereavement and/or psychosocial counseling and social services as needed; and e. Providing medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms. 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to: a. Perform hand hygiene when entering and exiting Resident 5's room.b. Replace Resident 96's tube feeding line when it was found on the floor without a cap. c. Implement and document control measures per water management policy and procedure.d. Monitor, document, and implement contact isolation precautions (infection control measures used to prevent the spread of germs by direct contact) for Resident 131. These deficient practices had the potential to transmit infectious microorganisms (living organisms that are too small to be seen with the naked eye) and increase the risk of infection for the residents. Findings:
a. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] with diagnoses including hemiplegia weakness to one side of the body) and hemiparesis (inability to move one side of the body) affecting right dominant side, gastrostomy (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and stiffness of right shoulder, elbow, and hand.
During a review of Resident 5's History and Physical (H&P), dated 3/18/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.
During a review of Resident 5's Minimum Data Set ([MDS] a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 5's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. The MDS indicated Resident 5 was dependent on chair/bed-to-chair transfer, bathing, upper (above waist) and lower (below waist) body dressing, and required maximal assistance (provide more than half the effort) for oral and personal hygiene. The MDS indicated Resident 5 had impairments on one side of the upper (arms/shoulders) and lower (hips/legs) extremities and utilized a wheelchair.
During a review of Resident 5's Order Summary (physicians order) dated 11/20/2025, the Order Summary indicated there was an order dated 8/31/2025: on Enhance Barrier Precaution (EBP: infection control measure requiring staff to wear a gown and gloves during high-contact activities with residents who have a g-tube and to prevent transmission of multidrug resistant organisms (MDROs infectious microorganisms that are resistant to multiple anti-infection medications): G-tube.
During a concurrent observation and interview on 11/20/2025 at 10:23 a.m., Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed not performing hand hygiene prior to entering (before wearing personal protective equipment (PPE: equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) and exiting (post PPE removal) Resident 5's room. The LVN 1 stated hand hygiene is performed before and after exiting the resident room, prior to interacting with the resident, or prior to providing treatment. The LVN 1 stated he did not do hand hygiene prior to and exiting Resident 5's room and indicated he had contact with Resident 5 when observing her abdominal binder (belt used to support the abdomen after surgery, improve physical function). The LVN 1 stated hand hygiene prevents the spread of infection and cross contamination.
b. During a review of Resident 96's admission Record, the admission Record indicated Resident 96 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis affecting left non-dominant side, gastrostomy (g-tube), and Type 2 Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing)
During a review of Resident 96's H&P, dated 8/22/2025, the H&P indicated Resident 96 could make needs known but could not make medical decisions.
During a review of Resident 96's MDS, dated [DATE], the MDS indicated Resident 96's cognitive skills were moderately impaired. The MDS indicated Resident 96 is dependent on all aspects of activities of daily living (ADLs: routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 96 did not have any impairments on both sides of the upper and lower extremities and utilized a wheelchair and walker.
During an observation on 11/19/2025 at 11:16 a.m., in Resident 96's room, the feeding tube that connected to the resident was on the floor with no cap covering the end that is connected to the resident. The tube feeding was dated 11/18/2025 at 9:20 p.m. and the fluids (water) bag was dated 11/18/2025 at 9:30 p.m.
During a concurrent observation and interview on 11/19/2025 at 2:42 p.m. with the Licensed Vocational Nurse 3 (LVN 3), LVN 3 was shown what was observed on 11/19/2025 at 11:16 a.m. (feeding tube on the floor) and confirmed the current feeding observed running into Resident 96 and the feeding tube that was observed at 11:16 a.m. were the same. LVN 3 stated when she arrived at the room if she observed the tubing was on the floor, she would have to replace it to keep the resident safe as the tubing was on the floor exposed to dirt, which increases the risk of infections due to contamination.
During an observation on 11/20/2025 at 9:51 a.m., Resident 96's feeding bag was dated 11/20/2025 at 12:30 a.m.(indicating the feeding was started 9 hours and 21 minutes ago).
During an interview on 11/21/2025 at 12:42 p.m. with the Director of Nursing (DON), the DON stated hand hygiene should be done every time care is provided to the resident, and prior to entering and exiting the resident room to prevent infection. The DON stated if the tube feeding line is on the floor, they will replace the whole thing right away due to infection control.
During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised 8/2019, the P&P indicated this facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; before and after entering isolation precaution settings. Hand hygiene is the final step after removing and disposing of personal protective equipment.
c. During a concurrent interview and record review on 11/20/2025, at 9:56 a.m., with the Maintenance Supervisor (MS), the facility's Water Management Program Binder, dated 2025 was reviewed. The Water Management Program (comprehensive plan aimed to prevent waterborne illnesses by controlling germs in the water) Binder indicated, Residents' room water temperature was documented daily, and Boiler and water heater maintenance log was documented on 1/3/2025, 2/14/2025, 3 /20/2025,3/24/2025, 4/22/2025, 5/1/2025, 6/10/2025, 7/22/2025, 8/12/2025, 9/19/2025, 10/14/2025, and 11/12/25. The MS stated, the facility was monitoring and documenting water temperature for randomly selected residents' room daily and maintenance log for Boiler and water. The MS stated, there were no other monitoring logs for control measures (actions taken to eliminate or reduce the likelihood or severity of exposure to a hazard) and limit (a specific, measurable, and quantitative range for a particular parameter that indicates when a water system is operating acceptably). The MS stated, he should have monitored and documented all control measures and limits as the policy indicated to prevent Legionella (a type of bacteria that is naturally found in [NAME] environments) outbreak (two or more linked cases of the same illness or the situation where the observed number of cases exceeds the expected number).
During a concurrent interview and record review on 11/20/2025, at 10 a.m., with the Infection Preventionist Nurse (IPN), the facility's Policy and Procedure (P&P) titled, Legionella Policy: Water Management Program, undated was reviewed. The P&P indicated, Record Keeping: The following records shall be kept on file for a period of five years in a log book .Completed report sheets for: weekly flushing of infrequently used outlets, Monthly hot and cold water temperature checks including flow and return temperature, quarterly shower head cleaning, Annual domestic water tank visual inspection and cleaning, and annual calorifier visual sampling of drain valve water. The IPN stated, the water management program committee should have follow through monitoring and documenting control measures and limit to reduce and prevent the risk of getting Legionella infection.
During an interview on 11/20/2025, at 3:52 p.m., with the Director of Nursing (DON), the DON stated, all control measures and limits should be monitored and documented per policy to prevent Legionella outbreak and to protect vulnerable residents.
During a review of the facility's Policy and Procedure (P&P) titled, Legionella Water Management Program, revised 7/2017, the P&P indicated, Policy Statement: Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation: 3. The purpose of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease .5. The water management program includes the following elements .e. specific measures used to control the introduction and /or spread of legionella. f. the control limits or parameters that are acceptable and that are monitored .h. A system to monitor control limits and the effectiveness of control measures.
d. During a review of Resident 131's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract ), pseudomonas infection (a group of bacteria commonly found in the environment, like in soil and water that can cause a range of infections, including lung infections) and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 131's History and Physical (H&P), dated 11/11/2025, the H&P indicated, Resident 131 had the capacity (ability) to understand and make decisions.
During a review of Resident 131's Minimum Data Set (MDS – a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 131 required maximal assistance (Helper does more than half the effort) from one staff for bed mobility, bathing/shower, toilet hygiene, toilet transfer, moderated assistance (Helper does less than half the effort) from one staff for bed mobility, dressing and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident competes activity) from one staff for eating.
During a concurrent observation and interview on 11/18/2025, at 10:04 a.m. with Resident 131 in Resident 131's room, there was a signage indicated Enhanced Barrier Precaution [EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes] near the entrance of Resident 131's room. Resident 131 stated, she was recently diagnosed with clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) and still having active diarrhea even this morning. Resident 131 stated, she had few episodes of diarrhea on 11/16/2025 and 11/17/2025 as well. Resident 131 stated, her nurse gave her the medication to stop diarrhea, but she still having diarrhea due to antibiotics (medicines that fight bacterial infections in people and animals) use for her UTI.
During a concurrent observation and interview on 11/19/2025, at 9:20 a.m., with House Keeping Staff (HKS) 1, in a hallway near Resident 131's room, HKS 1 came out of Resident 131's room and did not perform hand hygiene. HKS 1 stated, she did not wash her hand because she just went in to check for trash can. HKS 1 stated, she should have washed her hands regardless she touched objects or not to prevent spreading infection.
During an interview on 11/19/2025, at 9:27 a.m., with Certified Nurse Assistant (CNA) 5, CNA 5 stated, Resident 131 was on EBP that required to wear personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and hand hygiene with hand sanitizer. CNA 5 stated, hand washing with soap and water was not required for after caring Resident 131. CNA 5 stated, Resident 131 had diarrhea this morning and did not know if Resident 131 was having active C-diff infection.
During a concurrent interview and record review on 11/19/2025, at 3:35 p.m., with the Infection Preventionist Nurse (IPN), Resident 131's Order Summary Report (CSR), dated 11/19/2025 was reviewed. The CSR indicated, contact isolation precaution (intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the person or the person's environment) due to stool C-diff was ordered 11/14/2025. The IPN stated, Resident 131 was admitted to the facility on [DATE] and was not on contact isolation until 11/14/2025. The IPN stated, Resident 131 was having diarrhea upon admission and stool sample for C-diff was collected on 11/11/2025. The IPN stated, Resident 131 should have placed the contact isolation precaution while waiting for stool C-diff testing result to reduce the risk of spreading infection.
During a concurrent interview and record review on 11/19/2025, at 3:45 p.m., with the IPN, Resident 131's Nurse Practitioner (NP-an advanced practice registered nurse who serve as primary and specialty care providers, delivering advanced nursing services to residents) Skilled Nursing Home Progress Note, dated 11/18/2025 was reviewed. The NP Skilled Nursing Home Progress Note indicated, Resident 131 had mild abdominal pain and diarrhea on 11/17/2025. The NP Skilled Nursing Home Progress Note indicated, continue with Vancomycin (antibiotics) and contact isolation. The IPN stated, she did not follow through with NP's progress note. The IPN stated, she was not aware of the episodes of diarrhea. The IPN stated, the staff should have confirmed with physician or NP before discontinuing contact isolation precaution on 11/18/2025 to ensure Resident 131 was free of C-diff infection. The IPN stated, the staff should have washed hands with soap and water after caring for the residents with C-diff because the friction from rubbing removes the C-diff spores (an inactive form of the germ and have a protective coating allowing them to live for months or years on surfaces). The IPN stated, there was no documentation regarding the reason why the contact isolation precaution was discontinued.
During a review of Resident 131's General Acute Care Hospital (GACH) Laboratory Report, dated 11/12/2025, the GACH Laboratory Report indicated, Resident 131 tested positive (confirmation for infection) C-diff stool test on 11/12/2025.
During a review of Resident 131's Bowel and Bladder (B&B) Elimination Task, dated from 11/11/2025 to 11/20/2025, the B&B Elimination Task indicated, Resident 131 had loose stool on 11/16/2025 and 11/17/2025.
During a review of Resident 131's Medication Administration Record (MAR), dated 11/2025, the MAR indicated, Resident 131 received Imodium 2 milligram (mg) by mouth for control of diarrhea on 11/11/2025.
During a review of Resident 131's McGeer's Criteria for Infection Control Surveillance (standardized surveillance definitions used to identify and monitor infections in long-term care facilities), dated on 11/10/2025 and 11/13/2025, the McGeer's Criteria for Infection Control Surveillance indicated, Resident 131 had C-diff infection on contact isolation and had three or more liquid or watery stools above what is normal for the resident within a 24 hours period.
During a review of the facility's Policy and Procedure(P&P) titled, Infection Prevention and Control Manual Guidelines for Clostridium Difficile Infection (CDI), revised 2020, the P&P indicated, Isolation Precautions . A. Contact precautions should be used for CDI residents with diarrhea. B. Hands should frequently be washed with soap and water. An alcohol-based waterless hand cleanser is not effective against CDI spores . F. Precautions should continue until diarrhea ceases. (If no episodes of diarrhea are noted x 48 hours, DC Contact Isolation).
During a review of the facility's Policy and Procedure(P&P) titled, Infection Control Guidelines for All Nursing Procedures, revised 8/2012, the P&P indicated, General Guidelines: 3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non­antimicrobial soap and water under the following conditions . When there is likely exposure to spores (i.e., C. difficile or Bacillus anthracis) (Note: Alcohol-based hand rubs are inactive against spores. For effective mechanical removal of spores, wash hands for 30- 60 seconds with soap and water.
During a review of the facility's Policy and Procedure(P&P) titled, Isolation - Notices of Transmission-Based Precautions, revised 8/2019, the P&P indicated, Policy Statement: Notices will be used to alert personnel and visitors of transmission-based precautions, while protecting the privacy of the resident. Policy Interpretation and Implementation . b. Contact Precautions: (1) A notice at the doorway instructing visitors to report to the nurses' station before entering the room. (2) A sign indicating contact precautions on the door to the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:a. 1.Administer the coronavirus vaccination for one of five sampled residents (Resident 5). b. 2. Offer and educate coronavirus vaccinations for staff per facility's policy for three of five sampled employees. These failures had the potential to place all residents at risk for exposure to infection of coronavirus.Findings: 1. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] with a diagnosis of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (stroke - loss of blood flow to a part of the brain). During a review of Resident 5's History and Physical (H&P), dated 3/18/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 5 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required maximal assistance (helper does more than half the effort) when for oral hygiene and dependent (helper does all the effort) for toileting hygiene, upper and lower body dressing, and bathing. During a concurrent interview and record review on 11/20/2025 at 3:10 p.m., with the Infection Preventionist Nurse (IPN), Resident 5's medical record was reviewed. The IPN stated Resident 5's responsible party (RP) gave consent for Resident 5 to receive the coronavirus vaccine on 9/17/2025. The IPN stated there is no documentation that Resident 5 received the coronavirus vaccine. During an interview on 11/20/2025 at 3:52 p.m., with the Director of Nursing (DON), the DON stated if it is not documented, it was not done. During a review of the facility's policy and procedure (P/P), titled Coronavirus Disease (Covid-19) - Vaccination of Residents, revised December 2021, the P/P indicated Covid-19 vaccine education, documentation and reporting are overseen by the infection preventionist and coordinated by his or her designee. The individual who coordinates these responsibilities in the facility is: Infection preventionist. 2. During a concurrent interview and record review on 11/20/2025 at 3:16 p.m., with the IPN the Employee Tracking Record for Vaccination for 2025 was reviewed. The IPN stated the coronavirus vaccine booster and vaccines are encouraged to all employees. The IPN stated all employees should have the vaccine consent form. The IPN stated the vaccine consent form is proof that the facility educated the employee about the vaccination risks and benefits. The IPN stated Registered Nurse Supervisor (RNS) 3, Licensed Vocational Nurse (LVN) 8, and Certified Nurse Assistant (CNA) 4 do not have a vaccine consent form for the 2025 coronavirus vaccine. The IPN stated it is important that all employees are educated about the risks and benefits of the coronavirus vaccines so the employees do not acquire coronavirus which could be transferred to the residents. During an interview on 11/21/2025 at 2:56 p.m. with the DON, the DON stated it was important to educate and document staff coronavirus vaccinations in order to protect residents and staff from a coronavirus outbreak. The DON stated respiratory season is from November 1st to March 31st. The DON stated 100% of employees should have been educated and offered the coronavirus vaccine before during the respiratory season. The DON stated a declined vaccine consent form is proof that the employee was educated. During a review of the facility's policy and procedure (P/P), titled Coronavirus Disease (Covid-19) - Vaccination of Staff, revised January 2022, the P/P indicated all staff are required to be fully vaccinated for COVID-19 in accordance with 483.80(i).The facility maintains documentation related to staff COVID-19 vaccination that includes, at a minimum, the following (as applicable): a. That staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; b. That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; c. A copy of the informed consent; and d. Verification of vaccination or documentation of exemption/delay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the use of mirtazapine (a medication used to treat mental illness) was used to treat a medical condition diagnosed and documented in the medical record between 7/7/25 and 11/9/25 for one of five residents sampled for unnecessary medications (Resident 9.)The deficient practice of using psychotropic medications (medications that affect brain activities associated with mental processes and behavior) to treat medical conditions without sufficient documentation of their diagnosis increased the risk that Resident 9 may have experienced adverse effects (unwanted or dangerous medication-related side effects) related to the use of mirtazapine.A review of Resident 9's admission Record, dated 11/20/25, indicated she was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including anxiety disorder (a mental illness characterized by excessive worry, fear, or panic strong enough to interfere in everyday activities) and seizure disorder (a medical condition caused by uncontrolled electrical activity in the brain.) Further review of the admission Record indicated there was no diagnosis of major depressive disorder (depression - a mental illness characterized by depressed mood, difficulty sleeping, social withdrawal, or lack of interest in usually enjoyable activities) listed.A review of Resident 9's History and Physical (a record of a physician's comprehensive medical examination), dated 6/9/25, did not indicate depression of major depressive disorder as a current diagnosis or part of her past medical history.A review of Resident 9's Order Summary Report (a summary of all active physician's orders), dated 11/20/25, indicated on 7/7/25 she was prescribed mirtazapine 7.5 milligrams (mg - a unit of measure for mass) by mouth at bedtime for depression manifested by poor appetite.A review of Resident 9's clinical record and psychiatric progress notes (a record of a comprehensive psychiatric examination from a psychiatric care provider), dated 8/18/25 and 9/14/25, did not indicate depression or major depressive disorder listed as active diagnoses.A review of Resident 9's MDS (minimum data set - a comprehensive resident assessment) assessment Section I (active diagnoses), dated 9/17/25, indicated Resident 9 did not have depression as an active diagnosis.During an interview on 11/20/25 at 10:46 AM with the Director of Nursing (DON), the DON stated the facility failed to ensure Resident 9's mirtazapine was used for a diagnosis that was clearly documented in her medical record between 7/7/25 and 11/9/25. The DON stated Resident 9's admission record, MDS section I, and most recent psychiatric notes (prior to 11/9/25) do not contain any evidence that Resident 9 has depression or major depressive disorder. The DON stated the psychiatric note on 11/9/25, which was not included in her clinical record, is the first documentation available regarding the diagnosis of depression though the medication has been in continuous use since 7/7/25. The DON stated using psychotropic medications for a diagnosis that is not clearly documented in the resident's medical record increases the risk that the resident may experience adverse effects related to the use of those medications possibly leading to a decline in quality of life. A review of the facility's policy Behavioral Assessment, Intervention and Monitoring, revised December 2016, indicated Residents who do not display symptoms, or have not been diagnosed with, a mental, psychiatric, psychosocial adjustment or post-traumatic stress disorder will not develop a pattern of decreased social interaction or increased withdrawn, angry, or depressive behaviors that cannot be explained or attributed to a specific clinical condition that makes the pattern unavoidable. When medications are prescribed for behavioral symptoms, documentation will include: rationale for use. potential underlying causes of the behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one out of one sampled Certified Nursing Assistant (CNA) 3 was competent and knowledgeable with a pureed (foods that are blended, mashed, or whipped to a smooth, lump-free, pudding-like consistency, which is easier to swallow and does not require chewing) texture diet when passing the meal tray to Resident 13. This deficient practice had the potential for Resident 13 to aspirate (when something other than air gets into your airways) or for Resident 13 to lose weight because she was provided with a diet not consistent with her physician's orders. Findings: During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of hemiplegia (unable to move one side of the body) and a contracture (a permanent tightening of muscles, tendons, or skin that causes joints to become stiff and short, restricting movement) of the left hand. During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 13 had severe cognitive impairment (a significant loss of mental ability, such as memory, thinking, and reasoning, that prevents a person from living independently and often requires substantial supervision) and had an impairment on one upper extremity (left). The MDS indicated Resident 13 was receiving a mechanically altered (change in texture of food) and therapeutic diet (a meal plan designed to treat a medical condition by controlling specific nutrients, textures, or calories). During a review of the facility's Diet Type Report dated 11/20/2025, Resident 13 had a current physician's order for a fortified (adding extra vitamins, minerals, protein, or calories to foods to increase their nutritional content) pureed (foods that are blended, mashed, or whipped to a smooth, lump-free, pudding-like consistency, which is easier to swallow and does not require chewing) diet. During an observation on 11/20/2025 at 8:01 a.m., Resident 13 was sat up in bed, the meal tray was set up and placed in front of her by Certified Nursing Assistant (CNA) 3. Resident 13's meal tray contained eggs that were scrambled but not pureed. During an interview on 11/20/2025 at 12:23 p.m., CNA 3 stated she set up the meal tray this morning for Resident 13 and described Resident 13's eggs on the meal tray as soft, looked like normal scrambled eggs but they were not pureed. CNA 3 stated Resident 13 was on a puree diet. CNA 3 stated the process for serving meal trays was for nursing staff (licensed nursing staff) to check the trays compared to the orders then when the trays are ready, the CNAs pass the trays verifying the tray against the meal ticket, set up the tray and open everything for the residents. During an interview on 11/20/2025 at 12:55 p.m., [NAME] (CK) 1 stated a puree diet had to be completely smooth and no chunks so the residents would not choke. CK 1 stated that morning they served scrambled eggs with cheese sprinkled on top and if it was a puree plate it would have been very smooshed and not look the same as regular scrambled eggs. CK 1 stated it was important to follow the physician's diet order for patient safety. CK 1 stated after the meal was plated and placed on the meal carts, the meal cart is sent to the nursing unit where nursing staff was supposed to verify the diet provided matched the physician's order for a second check because everyone makes mistakes. That second check was supposed to keep the improper diet from reaching the resident. During a concurrent interview and record review on 11/21/2025 at 8:37 a.m., Registered Nurse Supervisor (RNS) 4 stated he reviewed Resident 13's Nurses Progress Notes for 10/31/2025, the day the Dentist recommended Resident 13's previous diet be discontinued (minced and moist diet (a texture-modified diet where all foods are chopped or mashed into soft, moist, small pieces, typically no larger than 4mm wide for adults, and must be easy to swallow with little to no chewing)) and changed to the puree diet due to Resident 13's dental status. RNS 4 stated it was very risky to serve the improper diet to the residents because there was a risk for aspiration. During an interview on 11/21/2025 at 3:37 p.m., the Director of Nursing (DON) stated if a resident was provided with the incorrect diet consistency, the resident may not be able to swallow the food correctly. The DON stated the CNA role while passing meal trays was to ensure the resident was getting the proper diet. The DON stated the CNA was supposed to make sure the meal ticket matched the diet the patient received. During a review of the facility's Certified Nursing Aide Job Description undated, the job description indicated it was part of the CNAs job duty to serve food and nourishments.

**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 resident's (Resident 20) Bilevel positive airway pressure ([BIPAP] type of noninvasive ventilation that helps you breathe) machine was maintained as indicated in facility policy and indicated in the BIPAP User Guide. The deficient practices had the potential to result in serious health risks such as bacterial growth and infection and potential damage to the device.Findings:During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD]a chronic lung disease causing difficulty in breathing) and chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body).During a review of Resident 20's Minimum data Set ([MDS] a resident assessment tool), dated 9/26/2025, the MDS indicated Resident 20 had intact cognition (ability to make decisions of daily living). The MDS indicated Resident 20 needed set up assistance when eating, supervision with oral hygiene, partial assistance (helper does less than half the effort) with personal hygiene, and substantial assist (helper does more than half the effort) with toileting hygiene. During a review of Resident 20's Order Summary Report, the report indicated, starting on 4/18/2025, BIPAP machine use starting at 8 p.m. and off at 7 a.m. every evening and night shift. During a concurrent observation and interview on 11/18/2025 at 12:37 p.m., at Resident 20's bedside, Resident 20's BIPAP machine was observed with water still in the humidifier canister. Licensed Vocational Nurse (LVN) 4 stated the water the staff used for the machine was purified water (water which may contain trace amounts of minerals or dissolved gases, unlike distilled water which removes nearly all impurities through evaporation and condensation).During a concurrent interview and record review on 11/20/2025 at 10:10 a.m., with Registered Nurse Supervisor (RNS) 2 Resident 20's physician orders and Medication and Treatment Administration records, dated 4/2025 to 11/2025, were reviewed. RNS 2 stated BIPAP machine, masks, tubing care and maintenance were not completed. During an interview on 11/20/2025 at 3:53 p.m. with the Director of Nursing (DON), the DON stated if BIPAP machine, masks, tubing care and maintenance was not documented it was not done. During a review of the facility's policy and procedure (P&P) titled, CPAP/BIPAP Support, revised 3/2015, the P&P indicated the policy was to promote resident safety. The P&P indicated specific cleaning instructions are obtained from the manufacturer/supplier of the device. The P&P general guidelines for cleaning, include:1. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed.2. Humidifier (if used):a. Use clean, distilled water only in the humidifier chamber.b. Clean humidifier weekly and air dry.c. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly.3. Replace disposable filters monthly.4. Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between use.5. Headgear (strap): Wash with warm water and mild detergent as needed. Allow to airdry. During a review of Resident 20's BIPAP User manual, undated, the User guide indicated the following:1. Regularly clean and check for damages the tubing assembly, humidifier and mask to receive optimal therapy and to prevent the growth of germs that can adversely affect your health.2. Clean the humidifier and tubing device weekly.3. Empty the humidifier daily and wipe it thoroughly with clean, disposable cloth and air dry. 4. Replace the air filter at least every 6 months or as needed.During a review of the guide titled, Looking after your CPAP gear, A guide to cleaning, maintenance and ongoing care, 2023, the guide indicated keeping the CPAP mask clean was key to ensuring that it fits and seals well. The guide indicated cleaning the mask cushion and tubing daily and the mask frame and headgear weekly. The guide indicated replacing the foam mask cushions a monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to discontinue an intravenous (IV, in the vein) catheter (flexible tube inserted into a vein to deliver fluids and medications into the blood stream) for two of two sampled residents (Resident 15 and Resident 121) per the facility's policy and procedure (P&P) titled Removal of a Peripheral IV (Over the needle, Peripheral Short) Catheter.As a result of this deficient practice, Resident 15 and Resident 121 were placed at risk for discomfort and infection at the IV site. Findings:
A. During a review of Resident 15's admission Record, the admission record indicated Resident 15 was admitted to the facility 9/22/2025 with diagnoses including history of malignant neoplasm (cancerous tumor) of the large intestine and type 2 diabetes (your body does not use insulin properly, leading to high blood sugar).
During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool) dated 9/25/2025, the MDS indicated Resident 15 had moderate cognitive impairment (a stage of decline in cognitive abilities like memory and thinking).
During a concurrent observation and interview on 11/18/2025 at 3:05 p.m., with Resident 15, Resident 15 was observed with an IV on the right wrist wrapped with a dry dressing. Resident 15 stated she had pain at the IV site and was unsure why she had the IV because it was no longer in use.
During a concurrent observation and interview on 11/19/2025 at 3:04 p.m., with Registered Nurse Supervisor (RNS)1, RNS 1 stated Resident 15 had a physician's order placed 11/11/2025 for two days of IV hydration (the process of replenishing water in the body) and the IV hydration was completed on 11/13/2025. RNS 1 stated Resident 15 did not have a current order for IV hydration. RNS 1 checked Resident 15's right wrist and confirmed there was an IV catheter still in place that was dated with an insertion date of 11/11/2025 (8 days prior). RNS 1 stated it was facility policy to remove an IV catheter after 3-4 days or once IV therapy was completed.
B. During a review of Resident 121's admission Record, the admission Record indicated Resident 121 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including chronic kidney disease (involves a gradual loss of kidney function [kidneys filter wastes and excess]), benign prostatic hyperplasia (a condition in which the prostate gland becomes very enlarged and may cause problems associated with urination), and presence of urogenital implants (injections of material into the wall of the urethra to help control urine leakage [urinary incontinence] caused by a weak urinary sphincter).
During a review of Resident 121's MDS, dated [DATE], the MDS indicated Resident 121 had severe cognitive impairment. The MDS indicated Resident 121 was dependent on staff for all Activities of Daily Living (activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 121's Admit/RE-Admit Nursing Evaluation, 11/12/2025 at 10:30 p.m., the evaluation indicated Resident 121 had an IV on the right-hand side.
During a concurrent observation and interview on 11/20/2025 at 3:45 p.m., with RNS 1, Resident 121 was observed with an IV line on the right forearm. RNS 1 stated Resident 121 had an IV line in place.
During a concurrent interview and record review on 11/20/2025 at 3:55 p.m., with RNS 1, Resident 121's medical records were reviewed and there was no physician order for an IV line, and no IV hydration or medications ordered. RNS 1 stated Resident 121 did not have any indication of having an IV line so it should be discontinued.
During an interview on 11/21/2025 at 3:37 p.m. with the Director of Nursing (DON), the DON stated IVs can stay in place for up to 4 days and if the IV treatment was completed the IV should be discontinued as soon as possible because it can cause discomfort for the patient and it was a potential risk for infection.
During a review of the facility's policy and procedure (P&P) titled, Intravenous Administration of Fluids and Electrolytes, revised 4/2016, the P&P indicated a physician order was needed to give IV fluids and electrolytes.
During a review of the facility's P&P titled, Removal of a Peripheral IV (Over the needle, Peripheral Short) Catheter, revised 9/2011, the P&P indicated the peripheral IV catheter was to be removed when therapy was discontinued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (GT - an opening to the stomach from the abdominal wall made surgically for the introduction of food) feeding formula was provided and documented as physician ordered for two of three sampled residents (Resident 28 and Resident 2).This failure had the potential to result in Resident 28 and Resident 2 receiving inaccurate amounts of GT feeding formula that could lead to unintended weight loss. Findings:a. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and cerebral infarction (loss of blood flow to a part of the brain) affecting left side of body. During a review of Resident 28's History and Physical (H&P), dated 9/6/2025, the H&P indicated, Resident 28 was alert and cooperative.During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool), dated 10/30/2025, the MDS indicated Resident 28 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, hygiene, shower, maximal assistance (Helper does more than half the effort) from one staff for dressing, and moderate assistance (Helper does less than half the effort) from one staff for bed mobility.During an observation on 11/18/2025, at 11:37 a.m., in Resident 28's room, Resident 28's GT formula was dated as 11/18/2025, at 1:30 a.m. and the feeding pump was turned off.During an observation on 11/19/2025, at 2:52 p.m., in Resident 28's room, Resident 28's GT formula was dated as 11/19/2025, at 6:45 a.m. and the feeding pump was turned on.During a concurrent interview and record review on 11/19/2025, at 3:02 p.m., with Licensed Vocational Nurse (LVN) 7, Resident 28's Order Summary Report (OSR), dated 11/19/2025 was reviewed. The OSR indicated, give GT feeding with Jevity (GT feeding formula with high protein and high fibers) 1.5 at 60 cubic centimeter (cc) per hour for 20 hours to provide 1200 cc or 1800 kilocalorie (Kcal) per day. The OSR indicated, start the GT feeding at 2 p.m. till dose is completed via enteral (feeding) pump was ordered on 9/29/2025. LVN 7 stated, the label Resident 28's feeding that indicated the starting date and time of feeding formula should reflect 2 p.m. as the physician ordered. LVN 7 stated, it was important to start the feeding at 2 p.m., as ordered to ensure Resident 28 received the 1200 cc of formula per day. LVN 7 stated, the staff should have changed all tubing of the GT feeding and started a new container of GT feeding formula at 2 p.m. LVN 7 stated facility staff should document the amount of GT feeding delivered every shift to ensure 1200 cc was delivered as ordered without delays due to interruptions in administering the GT feeding due to providing hygiene care and re positioning Resident 28.During a concurrent interview and record review on 11/20/2025, at 3:52 p.m., with the Director of Nursing (DON), Resident 28's Medication Administration Record (MAR), dated 11/2025 was reviewed. The MAR indicated, there was no documentation of the amount of nutrition delivered per shift or per day. The DON stated, the nursing staff should have provided, and documented prescribed amount of GT feeding formula. The DON stated, there was no documentation regarding the amount of the GT feeding delivered. The DON stated, there could be delays due to hygiene care and therapy sessions, but this should have been communicated between the staff to ensure delivery of 1200 cc as prescribed.b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and cerebral infarction (loss of blood flow to a part of the brain). During a review of Resident 2's History and Physical (H&P), dated 7/11/2025, the H&P indicated, Resident 2 did not have the capacity (ability) to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 required dependent assistance (Helper does all of the effort) from two or more staff for transfer, hygiene, shower, dressing, and bed mobility.During an observation on 11/18/2025, at 2:20 p.m., in Resident 2's room, Resident 2's GT formula was dated as 11/17/2025, and started at 7:30 a.m., the feeding pump was turned on.During an observation on 11/19/2025, at 2:57 p.m., in Resident 2's room, Resident 2's GT formula was dated as 11/19/2025, and started at 6 p.m., and the feeding pump was turned on.During a concurrent interview and record review on 11/19/2025, at 3:08 p.m., with LVN 7, Resident 2's OSR, dated 11/19/2025 was reviewed. The OSR indicated, give GT feeding with Diabetisource (GT feeding formula for controlling blood sugar) 1.2 at 60 cc per hour for 20 hours to provide 1200 cc or 1440 kilocalorie (Kcal) per day. The OSR indicated, starting the GT feeding at 2 p.m. to 10 a.m. or until dose is completed via enteral pump (feeding pump) was ordered on 9/27/2025. LVN 7 stated, new GT feeding formula should be hung at 2 p.m. and the label should be reflected at 2 p.m. as ordered. LVN 7 stated, all tubing should be changed when the formula was newly hung at 2 p.m.During an interview on 11/20/2025, at 3:14 p.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated, Resident 28 and Resident 2's GT feeding should be changed and dated 2 p.m. daily per physician's order. The MDSC stated, the nursing staff should have followed the physician's order to start new formula at 2 p.m. daily to ensure accurate amount of GT feeding formula being delivered as ordered. The MDSC stated, the amount delivered should be documented to ensure delivery of the prescribed amount of the feeding formula to prevent weight loss.During a concurrent interview and record review on 11/20/2025, at 3:55 p.m., with the Director of Nursing (DON), Resident 2's MAR, dated 11/2025 was reviewed. The MAR indicated, there was no documentation of the amount delivered per shift or per day. The DON stated, if the nursing staff did not provide GT feeding as ordered, the residents might not get the amount as prescribed and might be at risk for weight loss. During a review of the facility's Policy and Procedure (P&P) titled, Enteral Tube Feeding via Continuous Pump, revised 3/2015, the P&P indicated, Initiate Feeding .5. On the formula label document initials, date and time the formula was hung/ administered, and initial that the label was checked against the order . Documentation: The person performing this procedure should record the following information in the resident's medical record.1. The date and time the procedure was performed .4. Amount and type of enteral feeding .7. All assessment data obtained during the procedure.During a review of the facility's Policy and Procedure (P&P) titled, Enteral Nutrition, revised 1/2014, the P&P indicated, Policy Statement: Adequate nutritional support through enteral feeding will be provided to residents as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor the urine (liquid waste product made by the kidneys, stored in the bladder, and expelled from the body through the urethra) output for two out of two sampled Residents (Resident 15 and Resident 121) who had indwelling urinary catheters (a thin tube inserted into the bladder to drain urine continuously into a collection bag).This deficient practice had the potential to cause a delay in addressing Resident 15 and Resident 121's overall hydration status (the process of replenishing water in the body), kidney function (how well the kidneys are working), and fluid balance (the body's regulation of fluid intake versus output to maintain stable hydration and electrolyte levels for essential bodily functions) issues.Findings:
A. During a review of Resident 15's admission Record, the admission record indicated Resident 15 was admitted to the facility 9/22/2025 with diagnoses of history of malignant neoplasm (cancerous tumor) of the large intestine, type 2 diabetes (your body does not use insulin properly, leading to high blood sugar) and presence of urogenital implants (injections of material into the wall of the urethra to help control urine leakage [urinary incontinence] caused by a weak urinary sphincter).
During a review of Resident 15's Order Summary Report, the Order Summary Report indicated a physician's order was placed 9/23/2025 for an indwelling catheter to gravity drainage (a method that uses natural gravity to move fluids (urine)).
During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool) dated 9/25/2025, the MDS indicated Resident 15 had moderate cognitive impairment (a stage of decline in cognitive abilities like memory and thinking that is more significant than normal aging).
During an observation on 11/20/2025 at 8:16 a.m., Resident 15 was noted to have an indwelling urinary catheter draining pale yellow liquid.
B. During a review of Resident 121's admission Record, the admission Record indicated Resident 121 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including chronic kidney disease (involves a gradual loss of kidney function [kidneys filter wastes and excess]), benign prostatic hyperplasia (a condition in which the prostate gland becomes very enlarged and may cause problems associated with urination), and presence of urogenital implants (injections of material into the wall of the urethra to help control urine leakage [urinary incontinence] caused by a weak urinary sphincter).
During a review of Resident 121's MDS, dated [DATE], the MDS indicated Resident 121 had severe cognitive impairment. The MDS indicated Resident 121 was dependent on staff for all Activities of Daily Living (activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 121's Admit/RE-Admit Nursing Evaluation, dated 11/12/2025 at 10:30 p.m., the evaluation indicated Resident 121 had a foley catheter (medical device that helps drain urine from your bladder) in place.
During a concurrent interview and record review on 11/20/2025 at 3:45 p.m., with Registered Nurse Supervisor (RNS) 2, Resident 15 and 121's medical records were reviewed and there was no record of foley output being recorded. RNS 2 stated the facility does not measure or record foley catheter urinary output but it was a good idea to record the output to make sure the residents did not have any complications.
During an interview on 11/21/2025 at 3:37 p.m. with the Director of Nursing (DON), the DON stated foley catheter output was not measured unless there was a physician order. The DON stated measuring the output was important to prevent dehydration.
During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary revised 9/2014, the P&P indicated:
1) The purpose of this procedure was to prevent catheter-associated urinary tract infections.
2) Maintain an accurate record of the residents' daily output, per facility policy and procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of 10 sampled residents (Residents 101, 55, and 113) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to:1a. Provide Resident 101 with a Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) evaluation and assessment prior to increasing the wear time for both knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) from 30 minutes to two to four hours during Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment.1b. Objectively measure Resident 101's ROM in both legs during the PT Evaluation dated 7/13/2025.2a. Objectively measure Resident 55's ROM in the right leg during the PT Evaluation dated 9/26/2025.2b. Objectively measure Resident 55's ROM in the left hand during the Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation dated 9/26/2025.3. Ensure Resident 113 received appropriate interventions to prevent mobility decline.These deficient practices had the potential to cause injury and pain due to ill-fitting splints for Resident 101, prevent accurate monitoring of declines in range of motion for Residents 101 and 55, and cause decline in mobility in Resident 113.Findings:1.During a review of Resident 101's admission Record (AR), the AR indicated Resident 101 was admitted to the facility on [DATE] with diagnoses including but not limited to primary osteoarthritis (OA, a progressive disorder of the knee joint, caused by a gradual loss of cartilage) of right hip and left shoulder, polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and morbid obesity due to excess calories (disorder involving excessive body fat that increases risk for health problems). During a review of Resident 101's Minimum Data Set (MDS, resident assessment tool) dated 8/20/2025, the MDS indicated Resident 101 had no cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 101 required setup assistance with eating, supervision for oral hygiene, and substantial assistance for toileting hygiene, showering, lower body dressing and sit to lying. The MDS indicated Resident 101 required dependent assistance for bed to chair transfers and walking was not attempted. The MDS indicated Resident 101 did not have any functional limitations in range of motion (ROM, full movement potential of a joint) in the upper extremities (UE, shoulder, elbow, wrist/hand) and had functional limitations in ROM on both sides of the lower extremities ([NAME], hip, knee, ankle/foot). During a review of Resident 101's Care Plan Report (CP), the CP initiated 1/3/2023 and target date of 2/17/2026 indicated Resident 101 was at risk for decline in Activities of Daily Living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) functions, mobility and joint mobility related to OA, severe obesity, right knee contracture (loss of motion of a joint. The CP goal indicated Resident 101 will minimize potential declines in joint mobility. The CP interventions indicated to observe for pain or joint stiffness while providing RNA/ROM, RNA to provide both knee extension splints (splints to help keep the knee in a straight position) two to four hours three times a week or as tolerated, RNA to provide both UE active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) three times a week or as tolerated, RNA to provide both [NAME] passive range of motion (PROM, movement at a given joint with full assistance from another person) three times a week or as tolerated. 1a. During a review of Resident 101's Order Listing Report (OLR) dated 11/20/2025, the OLR indicated an order dated 7/30/2025 and discontinued on 9/23/20225 for RNA to provide both knee extension splints for 30 minutes three times a week or as tolerated. During a review of Resident 101's Restorative Assessment/Referral (RAR) dated 9/23/2025, the RAR indicated to discontinue the RNA order to provide both knee extension splints for 30 minutes three times a week or as tolerated.During a review of Resident 101's Order Summary Report (OSR) dated 11/20/2025, the OSR indicated an order dated 9/23/2025 for RNA to provide both knee extension splints for two to four hours three times a week or as tolerated. During a review of Resident 101's RAR dated 9/23/2025, the RAR indicated for RNA to provide both knee extension splints for two to four hours three times a week or as tolerated. During an observation and interview on 11/18/2025 at 10:35 a.m. in Resident 101's room, Resident 101 was lying in bed to the left side. Resident 101's knees were bent and rotated to the left side. Resident 101 stated she was supposed to have splints on her legs and staff put on the splints about 40 minutes at a time. During an observation and interview on 11/20/2025 at 9:47 a.m., RNA 1 performed Resident 101's RNA treatment in Resident 101's room. Resident 101 was lying in bed and was able to move both arms up and down. Resident 101 knees were bent all the way and rotated to the left side. RNA 1 attempted to lift Resident 101's right leg up but Resident 101 refused and stated it was painful. Resident 101 was able to move the left knee from the bent position and straighten the knee a little. RNA 1 put on both knee splints that were black and had dials on the side of the knee brace. The right knee brace dial was not next to the right knee and was lower next to the calf for the right leg. RNA 1 stated it was tricky to put on both knee splints. RNA 1 stated Resident 101 wore the knee brace for usually about an hour. During an interview and record review on 11/20/2025 at 10:56 a.m., the Occupational Therapist (OT 1) stated therapy staff was the profession that had the training and education to evaluate and assess whether a splint or brace was appropriate, including establishing a safe and tolerable splint wear time for each resident. OT 1 stated during therapy treatment sessions, the therapist will trial a splint and slowly increase the wear time to assess how long a resident was able to tolerate the splint. OT 1 stated it was important for a therapist to assess and slowly increase splint wear time, because the splint can be painful or cause changes in skin integrity if the splint was not fitted correctly. During the same interview and record review, OT 1 reviewed Resident 101's medical records and stated Resident 101 had an order dated 9/23/2025 for RNA to put on both knee extension splints for two to four hours three times a week. OT 1 reviewed Resident 101's PT records and indicated Resident 101's PT evaluation dated 7/13/2025 did not indicate any goals related to knee splints. OT 1 reviewed PT treatment records from 7/13/2025 to 7/23/2025 and PT Discharge summary dated [DATE] and indicated there were no PT treatment notes indicating PT addressed the knee splint or worked on increasing wear time for both knee splints. OT 1 reviewed Resident 101's PT records and stated Resident 101 did not receive any further PT treatment after Resident 101 was discharged from PT on 7/23/2025. During an interview and record review on 11/20/2025 at 2:34 p.m., OT 1 reviewed Resident 101's Restorative Assessment/Referral (RAR) forms dated 7/23/2025 and 9/23/2025 signed by OT 1 and PT 2 (who was no longer working at the facility). OT 1 stated Resident 101's RAR dated 9/23/2025 indicated to change Resident 101's RNA order for wearing both knee splints from 30 minutes to two to four hours three times a week. OT 1 stated there was no PT intervention or assessment on or around 9/23/2025 to safely assess Resident 101's tolerance from 30 minutes to two to four hours. OT 1 stated to increase wear time for any splint from 30 minutes to two to four hours was a lot of time and PT would need to assess and wear the knee splint first for two to four hours before an RNA order for splint wear time should be changed. OT 1 stated a therapy assessment was required first, because if a resident wore a splint for longer than a resident could safely tolerate, it could put pressure on bony prominences (where a bone is close to the surface of the skin), cause pain and a decline in skin integrity. During a phone interview on 11/20/2025 at 4:12 p.m., Physical Therapist (PT 1) stated a splint helped to prevent worsening of contractures and a lot of decision making from a therapist went into whether a splint was appropriate for each individual resident or not. PT 1 stated a therapist assessed and established a program for a splint or brace. PT 1 stated a therapist had to first establish a protocol in which the therapist assessed the type of splint was appropriate for a resident and how long to wear the splint for. PT 1 stated a therapist set up the parameters for splint wear time, because the tolerance for the splint needed to be assessed such as if a resident had pain, then the splint wear time needed to be decreased. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Resident Mobility and Range of Motion - Splinting, the P&P indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. 1b. During a review of Resident 101's PT Evaluation and Plan of Treatment dated 7/13/2025, the PT Evaluation indicated Resident 101's right hip, ankle, and foot were within normal limits (WNL) and the left hip, ankle, and foot were WNL. The PT Evaluation indicated Resident 101's right knee and left knee were impaired. The PT Evaluation did not include measurements of Resident 101's knees. During a concurrent interview and record review on 11/20/2025 at 10:56 a.m. with OT 1, PT Evaluation dated 7/13/2025 was reviewed. OT 1 stated the PT Evaluation dated 7/13/2025 indicated Resident 101's both knees were impaired, but the PT Evaluation did not indicate any specific ROM measurements. OT 1 stated based on the PT Evaluation, OT 1 could not tell how impaired Resident 101's knees were. OT 1 stated it was standard of practice for therapy evaluations to include ROM assessments. OT 1 stated therapy staff needed to include objective measurements for ROM to monitor changes in the joints. During a phone interview on 11/20/2025 at 4:12 p.m., Physical Therapist (PT 1) stated a PT would assess ROM during a PT evaluation. PT 1 stated if a joint had impaired ROM, the expectation would be to document the measurements and degrees of ROM the joint had. PT 1 stated PT and OT were the only disciplines that had the education and training to provide ROM measurements at a certain joint. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Charting and Documentation, the P&P indicated documentation in the medical record will be objective, complete, and accurate. The P&P indicated documentation of procedures and treatments will include care-specific details including assessment data. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Resident Mobility and Range of Motion - Splinting, the P&P indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. 2. During a review of Resident 55's admission Record (AR), the AR indicated Resident 55 was admitted to the facility on [DATE] with diagnoses including but not limited to parkinsonism (a group of conditions that cause movement problems), anxiety disorder, muscle wasting and atrophy (gradual decline). During a review of Resident 55's Physician Progress Notes dated 6/27/2025, the Physician Progress Notes indicated Resident 55 had the capacity to understand and make decisions. During a review of Resident 55's Minimum Data Set (MDS, resident assessment tool) dated 8/12/2025, the MDS indicated Resident 55 had moderate cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 55 required substantial assistance for eating, oral hygiene, toileting hygiene, showering, upper body dressing. The MDS indicated Resident 55 required dependent assistance for bed to chair transfers and walking was not attempted. The MDS indicated Resident 55 had functional limitations in range of motion (ROM, full movement potential of a joint) on one side of the upper extremities (UE, shoulder, elbow, wrist/hand) and had functional limitations in ROM on both sides of the lower extremities ([NAME], hip, knee, ankle/foot). During a review of Resident 55's Care Plan Report (CP), the CP initiated 9/25/2025 and target date of 2/9/2026 indicated Resident 55 was noted with decrease in ROM to both UE and both [NAME]. The CP goal indicated Resident 55 will not have further decrease in ROM to BUE and BLE by next review date, will show improvement. The CP interventions indicated for PT/OT as ordered. During a review of Resident 55's Occupational Therapy Evaluation and Plan of Treatment dated 9/26/2025, the OT Evaluation indicated Resident 55 had impaired ROM in the left index finger, middle finger, ring finger, and little finger. The OT Evaluation did not include measurements of Resident 55's left finger joints. During a review of Resident 55's Physical Therapy Evaluation and Plan of Treatment dated 9/26/2025, the PT Evaluation indicated Resident 55 had impaired ROM in the right ankle. The PT Evaluation did not include measurements of Resident 55's right ankle. During an observation and interview on 11/18/2025 at 9:26 a.m., Resident 55 was lying in bed with head of bed up about halfway. Resident 55 stated he received exercises for his arms and legs five days a week. Resident 55 was able to lift both arms to about shoulder level and open both fingers a little. Resident 55's left and right ring and little fingers were slightly bent at two joints closer to fingertips and could not fully straighten his fingers. Resident 55 was able to move both legs a little and both ankles were pointed away from the body. Resident 55 was able to move both ankles a little. During a concurrent interview and record review on 11/20/2025 at 10:56 a.m. with Occupational Therapist (OT 1), Resident 55's OT Evaluation dated 9/26/2025 and PT Evaluation dated 9/26/2025 were reviewed. OT 1 stated Resident 55's OT Evaluation dated 9/26/2025 indicated Resident 55's left fingers were impaired, but the OT Evaluation did not indicate any specific ROM measurements. OT 1 stated based on the OT Evaluation, OT 1 could not tell how impaired Resident 55's left fingers were. OT 1 stated Resident 55's PT Evaluation dated 9/26/2025 indicated Resident 55's right ankle was impaired, but the PT Evaluation did not indicate any specific ROM measurements. OT 1 stated based on the PT Evaluation, OT 1 could not tell how impaired Resident 55's right ankle was. OT 1 stated it was standard of practice for therapy evaluations to include ROM assessments. OT 1 stated therapy staff needed include objective measurements for ROM to monitor changes in the joints. During a phone interview on 11/20/2025 at 4:12 p.m. Physical Therapist (PT 1) stated a PT would assess ROM during a PT evaluation. PT 1 stated if a joint had impaired ROM, the expectation would be to document the measurements and degrees of ROM the joint had. PT 1 stated PT and OT were the only disciplines that had the education and training to provide ROM measurements at a certain joint. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Charting and Documentation, the P&P indicated documentation in the medical record will be objective, complete, and accurate. The P&P indicated documentation of procedures and treatments will include care-specific details including assessment data. 3. During a review of Resident 113's admission Record, the admission Record indicated Resident 113 was initially admitted to the facility 6/16/2025 with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty in walking, and pressure induced deep tissue damage (discolored skin over a bony prominence caused by prolonged pressure)of sacral (base of the spine) region. During a review of Resident 113's History and Physical (H&P), dated 6/19/2025, the H&P indicated Resident 113 had the capacity to understand and make decisions. During a review of Resident 113's MDS, dated [DATE], the MDS indicated Resident 113's cognitive (ability to learn, reason, remember, understand, and make decisions) ability was intact, required setup assistance when eating and oral hygiene, required for upper body dressing, moderate assistance (helper does less than half the effort) for toileting and lower body dressing, and required maximal assistance (helper does more than half the effort) for bathing. During an interview on 11/18/2025 at 10:01 a.m. with Resident 113, Resident 113 stated they used to walk with a walker with the staff, and but has gotten weaker and does not walk with the staff anymore. During a review of Resident 113's physician orders, the orders indicated: 6/26/2025 - 11/4/2025 Restorative Nursing Aide (RNA) to provide ambulation program with front wheel walker (FWW) 3x/week or as tolerated and document walking distance 11/4/2025 RNA to provide bilateral (both) upper extremity (BUE)/Bilateral lower extremity (BLE) active range of motion (AROM- resident can move independently with instruction) 3x/week or as tolerated. During a concurrent interview and record review on 11/19/2025 at 2:21p.m. with Restorative Nursing Aide (RNA a specialized Certified Nursing Assistant who supports residents in regaining or maintaining physical function) RNA 1 , Resident 113's daily and weekly RNA documentation from June 2025 to November 2025 was reviewed. RNA 1 stated the daily documentation indicated: In July 2025, Resident 113 ambulated 150 feet (ft- a unit of measurement of distance) with the RNA every week The week of 8/3/2025 - 8/9/2025, Resident 113 ambulated 80 ft with the RNA The week of 8/10/2025 - 8/16/2025, Resident 113 ambulated 40 ft with the RNARNA 1 stated if a resident refuses or there are changes such as a decline, the RNA reports the change to the Licensed Vocational Nurse (LVN) or the Director of Nursing (DON) who would report it to the physician. RNA 1 stated During a concurrent interview and record review on 11/21/2025 at 10:07 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 113's medical record was reviewed. The MDSC stated the physician was notified on 10/202/2025 that Resident 113 had lower back pain and right leg weakness and was notified on 10/24/2025 that Resident 113 refused to ambulate. The MDSC stated The MDSC stated if a resident's ambulation declines from 150 ft to less than 100 ft, it should be communicated to the physician. During a concurrent interview and record review on 11/21/2025 at 11:27 a.m. with LVN 1, Resident 113's medical record was reviewed. LVN 1 stated if there is a decrease in distance ambulated, they would expect the RNA to report the change to the LVN who would initiate a Change of Condition (COC) and notify the physician. LVN 1 stated they would have expected the physician to be notified by 8/11/2025 when the distance ambulated was trending down. During an interview on 11/21/2025 at 1:44 p.m. with the Director of Rehabilitation (DOR), the DOR stated any concerns or decline in resident ambulation should be discussed in the weekly RNA meetings which include the RNA's, the DON, and the DOR. During an interview on 11/21/2025 at 3:00 p.m. with the Director of Nursing (DON), the DON stated it is important to notify the physician when there is a change of condition such as a decline in ambulation so the provider is aware of the resident's condition, and so that the resident gets proper evaluation and treatment. During an interview on 11/21/2025 at 4:17 p.m. with the Medical Director (MD), the MD stated, in general, if there is a decline in ambulation the facility should notify the provider, and the provider would usually recommend a physical therapy evaluation. During a review of the facility's policy and procedure (P&P), titled Change in a Resident's Condition or Status, revised December 2016, the P&P indicated The nurse will notify the residents attending physician or physician on call when there has been a: .d. significant change in the residence physical/emotional/mental condition.f. Refusal of treatment or medication two or more consecutive times. During a review of the facility's policies and procedures (P&P) revised 7/2017 titled, Resident Mobility and Range of Motion - Splinting, the P&P indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one out of two sampled Residents (Resident 13) on the restorative nursing assistant (RNA) feeding program (staff provide feeding assistance) was supervised during two meals.This deficient practice had the potential for Resident 13 to aspirate (when something other than air gets into your airways) or for Resident 13 to lose weight if she was not encouraged to consume the meal. Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of hemiplegia (unable to move one side of the body) and a contracture (a permanent tightening of muscles, tendons, or skin that causes joints to become stiff and short, restricting movement) of the left hand.During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 13 had severe cognitive impairment (a significant loss of mental ability, such as memory, thinking, and reasoning, that prevents a person from living independently and often requires substantial supervision) and had an impairment on one upper extremity (left). The MDS indicated Resident 13 required supervision or touching assistance (helper provides verbal cues and/or touching/ steadying assistance during the task).During a review of Resident 13's Order Summary Report dated 11/21/2025, the Order Summary Report indicated Resident 13 had an order placed 9/30/2024 for RNA feeding program with breakfast and lunch.During an observation on 11/20/2025 at 8:01 a.m., Resident 13 was sat up in bed, the meal tray was set up and placed in front of her, but staff (unknown) did not stay with her during the meal. Resident 13 fed herself.During an interview on 11/20/2025 at 9:42 a.m., certified nursing assistant (CNA) 3 stated Resident 13 just needed her meal tray set up for her, but the staff do not stay in the room with her while she eats.During an observation on 11/20/2025 at 12:22 p.m., Resident 13 was feeding herself lunch. Resident 13 ate the vegetables on the plate and did not consume the meat or potatoes. RNA 1 came into the room and picked up Resident 13's meal tray.During an interview on 11/20/2025 at 2:33 p.m., the Quality Assurance Nurse (QAN) stated Resident 13 had an order for the RNA feeding program and the RNA staff were supposed to assist the resident with feeding and sit with her while she ate. The QAN stated RNA staff were not supposed to leave Resident 13 unattended until she finished her meals. The RNA staff is supposed to supervise that she was eating safely and encourage her to eat.During an interview on 11/21/2025 at 10:56 a.m., RNA 1 stated he was assigned to Resident 13 the day prior (11/20/2025) for the RNA feeding program (breakfast and lunch). RNA 1 stated to be honest he only set up the meal tray for Resident 13 but then left the room because he had other residents to attend to. RNA 1 stated Resident 13 could feed herself, the staff must monitor her while she was eating.During an interview on 11/21/2025 at 3:37 p.m., the Director of Nursing (DON) stated if a resident was on the RNA feeding program the RNA should be in the room with the resident throughout the meal. The DON stated that even though the residents were on the RNA feeding program for encouragement and queuing, the staff should still be in the room throughout the meal. The staff need to motivate the resident to eat and be there if resident needed anything. The DON stated there was a possibility for weight loss if the resident was not encouraged to eat. During a review of the RNA Job Description dated 2/2001, the RNA job Description indicated the RNA was to perform the restorative feeding program and notify the occupational therapist of any feeding problems, referrals, and reassessment needs.During a review of the RNA Task List undated, the RNA Task List indicated the RNAs were to help feed residents that needed to be fed and monitor residents on self-help feeding programs, if any.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for two of two sampled residents (Resident 11 and Resident 125) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and impaired blood sugar control. Findings:a. During a review of Resident 11's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/6/2023 and was readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and cataract (clouding of the eye's natural lens)During a review of Resident 11's History and Physical (H&P), dated 9/15/2025, the H&P indicated the resident had the capacity to understand and make decisions.During a review of Resident 11 Minimum Data Set (MDS - a resident assessment tool), dated 9/18/2025, the MDS indicated Resident 11 had intact cognition (ability to think and understand). The MDS indicated Resident 11 needed set up or clean up assistance from staff for eating and oral hygiene. The MDS indicated Resident 11 needed moderate assistance from staff for toileting hygiene and bathing.During a review of Resident 11's Physician Order dated 9/14/2025, the Physician Order indicated an order of insulin lispro (fast-acting insulin that works fast to lower blood sugar) injection solution 100 unit per milliliters (unit/ml, units of insulin contained within each milliliter of liquid), inject 3 unit subcutaneously three times a day for DM, hold if blood sugar is less than 100. During a review of Resident 11's Physician Order dated 9/15/2025, the Physician Order indicated an order of insulin glargine (long-acting insulin that works slowly and steadily to keep blood sugar stable) subcutaneous solution 100 unit/ml, inject 10 unit subcutaneously at bedtime for DM.During a review of Resident 11's Location of Administration Report from 11/1/2025 to 11/30/2025, indicated insulin glargine subcutaneous solution 100 units/ml was administered on:11/5/2025 at 8:53 p.m. on the arm-right11/6/2025 at 10:11 p.m. on the arm-right11/13/2025 at 10:26 p.m. on the arm-right11/14/2025 at 8:24 p.m. on the arm-right11/15/2025 at 10:12 p.m. on the arm-right11/17/2025 at 9:05 p.m. on the arm-right11/18/2025 at 8:47 p.m. on the arm-rightDuring a review of Resident 11's Location of Administration Report from 11/1/2025 to 11/30/2025, indicated insulin lispro injection solution 100 unit/ml was administered on:11/2/2025 at 5:26 p.m. on the arm-right11/3/2025 at 5:54 a.m. on the arm-right11/3/2025 at 5:48 p.m. on the arm-right11/4/2025 at 6:32 a.m. on the arm-right11/4/2025 at 5:30 p.m. on the arm-right11/5/2025 at 6:03 a.m. on the arm-right11/8/2025 at 11:51 a.m. on the arm-right11/9/2025 at 5:33 a.m. on the arm-right11/10/2025 at 6:53 a.m. on the arm-right11/13/2025 at 7:35 a.m. on the arm-right11/13/2025 at 10:26 p.m. on the arm-right11/14/2025 at 6:08 a.m. on the arm-right11/14/2025 at 8:24 p.m. on the arm-right11/15/2025 at 5:50 a.m. on the arm-right11/16/2025 at 5:40 a.m. on the arm-right11/17/2025 at 6:14 a.m. on the arm-right11/17/2025 at 6:24 p.m. on the arm-rightDuring an interview on 11/20/2025 at 9:31 a.m., with Resident 11, Resident 11 stated she preferred to receive insulin injections in her right arm, did not like injections in her abdomen and her left arm had a dialysis access site. Resident 11 stated she was not aware of the risks associated with repeated use of same site for insulin injections.During a concurrent interview and record review on 11/21/2025 at 9:53 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 11's Physician Order, Medication Administration Report (MAR), and Location of Administration Report for 11/1/2025 to 11/20/2025 were reviewed. LVN 3 stated Resident 11 received injections to same site on multiple occasions. LVN 3 stated insulin injections should be injected to different sites because repeated injections at the same site can lead to altered subcutaneous tissue integrity, resulting in inconsistent medication absorption. b. During a review of Resident 125's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 1/2/2024 and was readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).During a review of Resident 125 Minimum Data Set (MDS - a resident assessment tool), dated 11/16/2025, the MDS indicated Resident 125 had moderate impaired cognition (ability to think and understand). The MDS indicated Resident 125 needed set up or clean up assistance from staff for eating and dependent on staff for toileting hygiene and bathing.During a review of Resident 125's Physician Order dated 11/11/2025, the Physician Order indicated an order of insulin lispro injection solution 100 unit/ml, inject as per sliding scale: If 151-200=2 units; 201-250=4units; 251-300=6 units; 301-350=8 units; 351-400=10 units; If blood sugar less than 400 give 12 units and call MD, subcutaneously before meals and at bedtime for DM.During a review of Resident 125's Location of Administration Report from 11/1/2025 to 11/30/2025, indicated insulin glargine subcutaneous solution 100 units/ml was administered on:11/13/2025 at 12:36 p.m. on the abdomen-Left Upper Quadrant (LUQ)11/13/2025 at 5:31 p.m. on the abdomen-LUQ11/13/2025 at 8:08 p.m. on the abdomen-Right Lower Quadrant (RLQ)11/15/2025 at 5:33 p.m. on the abdomen-RLQ11/16/2025 at 5:42 p.m. on the abdomen-LUQ11/16/2025 at 11:02 p.m. on the abdomen-LUQDuring a concurrent interview and record review on 11/20/2025 at 11:40 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 125's Physician Order, Medication Administration Report (MAR), and Location of Administration Report for 11/1/2025 to 11/20/2025 were reviewed. LVN 1 stated Resident 125 received injections to same site on multiple occasions. LVN 1 stated failure to rotate injection sites can affect the subcutaneous tissue, resulting in decreased insulin absorption and reduced effectiveness of the medication and repeated use of same site may cause tissue damage.During an interview on 11/21/2025 at 12:43 p.m., with Director of Nursing (DON), the DON stated insulin injections should follow professional standards of practice by rotating injection sites. The DON stated failure to rotate injection sites can cause bruising to the skin.During a review of facility's Policy and Procedure (P&P) titled, Insulin Administration revised 9/2014, the P&P indicated Insulin may be injected into the subcutaneous tissue of the upper arm, the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. Injection sites should be rotated, preferably within same general area (abdomen, thigh, upper arm).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise a comprehensive care plan for one of two sampled residents (Resident 11), who preferred not to have subcutaneous (beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection sites rotated, to include individualized goals and interventions addressing resident preference and associated risks.This deficient practice placed Resident 11 at risk for skin tissue damage and inconsistent insulin absorption due to unmet care needs related to the absence of a revised, individualized care plan.Findings:During a review of Resident 11's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/6/2023 and was readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and cataract (clouding of the eye's natural lens.During a review of Resident 11's History and Physical (H&P), dated 9/15/2025, the H&P indicated the resident had the capacity to understand and make decisions.During a review of Resident 11 Minimum Data Set (MDS - a resident assessment tool), dated 9/18/2025, the MDS indicated Resident 11 had intact cognition (ability to think and understand). The MDS indicated Resident 11 needed set up or clean up assistance by staff for eating and oral hygiene. The MDS indicated Resident 11 needed moderate assistance from staff for toileting hygiene and bathing.During a review of Resident 11's Physician Order dated 9/14/2025, the Physician Order indicated an order of insulin lispro (fast-acting insulin that helps control blood sugar levels) injection solution 100 unit per milliliters (unit/ml, units of insulin contained within each milliliter of liquid), inject 3 unit subcutaneously three times a day for DM, hold if blood sugar is less than 100. During a review of Resident 11's Physician Order dated 9/15/2025, the Physician Order indicated an order of insulin glargine (long-acting insulin that works slowly and steadily to keep blood sugar stable) subcutaneous solution 100 unit/ml, inject 10 unit subcutaneously at bedtime for DM.During an interview on 11/20/2025 at 9:31 a.m., with Resident 11, Resident 11 stated she preferred to receive insulin injections in her right arm, did not like injections in her abdomen and her left arm where she had a dialysis access site. Resident 11 stated she was not informed of the risks associated with repeated use of same site for insulin injections.During a concurrent interview and record review on 11/21/2025 at 9:53 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 11's Physician Order for 11/2025, Medication Administration Report (MAR) for 11/2025, Location of Administration Report for 11/1/2025 to 11/20/2025 and Care Plan Report were reviewed. LVN 3 stated Resident 11 received injections to same site on multiple occasions. LVN 3 stated care plan should be updated by either a Registered Nurse (RN) or LVN when residents insist on getting their insulin injection on same site. LVN 3 stated there was no documentation of an updated care plan addressing resident preference and associated risks.During an interview on 11/21/2025 at 12:43 p.m., with Director of Nursing (DON), the DON stated residents had rights to refuse care and treatment, but nursing staff must educate residents that repeated injections in the same site can cause bruising or harm. The DON stated care plan must be updated by an RN or LVN for any changes to resident care or condition.During a review of facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered revised 12/2016, the P&P indicated Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive resident specific care plan for two out of seven sampled residents (Resident 9 and Resident 13). This deficient practice had the potential for Resident 9 and Resident 13 to not receive person-centered care.
Findings:
a. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of hemiplegia (unable to move one side of the body) and a contracture (a permanent tightening of muscles, tendons, or skin that causes joints to become stiff and short, restricting movement) of the left hand.
During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 13 had severe cognitive impairment (a significant loss of mental ability, such as memory, thinking, and reasoning, that prevents a person from living independently and often requires substantial supervision) and had an impairment on one upper extremity (left).
During a review of Resident 13's Occupational Therapy Treatment Encounter Note(s) dated 11/16/2025, the Occupational Therapy Treatment Encounter Note indicated Resident 13 was non-compliant in regard to wearing the left Wrist-Hand-Finger Orthosis (WHFO, a type of brace or support that extends from the forearm to the tips of the fingers and thumb, providing support and positioning for the entire hand and wrist structure).
During an observation on 11/19/2025 at 9:34 a.m., Resident 13 was noted to have a left hand and wrist contracture.
During an interview on 11/21/2025 at 1:02 p.m., Occupational Therapist (OT) 1 stated she reviewed Resident 13's Occupational Therapy Treatment Notes for the month of November 2025 and stated Resident 13 was being seen by occupational therapy twice a week and they were working on Resident 13's tolerance to the left WHFO splint to the left wrist. OT 1 stated Resident 13 had limitations to left upper arm, and she had a contracture on the shoulder, elbow, and hand of left upper arm.
OT 1 stated Resident 13 was supposed to wear the splint for one hour total for the week but based on the Occupational Therapy Treatment notes, Resident 13 often refused to wear the left WHFO.
During an interview on 11/21/2025 at 3:37 p.m., the Director of Nursing (DON) stated she reviewed Resident 13's care plans and there was no care plan created regarding refusing the left WHFO splint. The DON stated care plans for refusals were important to communicate between the different departments and for continuity of care. The DON stated care plans were important to ensure the resident was receiving proper care.
A review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised December 2016, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
b. A review of Resident 9's admission Record, dated 11/20/25, indicated she was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including anxiety disorder (a mental illness characterized by excessive worry, fear, or panic strong enough to interfere in everyday activities) and seizure disorder (a medical condition caused by uncontrolled electrical activity in the brain.)
A review of Resident 9's History and Physical (a record of a physician's comprehensive medical examination), dated 6/9/25, indicated she had fluctuating capacity to understand and make decisions.
A review of Resident 9's Order Summary Report (a summary of all active physician's orders), dated 11/20/25, indicated she was prescribed the following medications:
1. Buspar 10 milligrams (mg – a unit of measure for mass) by mouth twice daily for anxiety manifested by uncontrollable screaming/yelling.
2. Depakote DR 500 mg by mouth twice daily for seizure disorder.
A review of Resident 9's care plan for anxiety, initiated 11/12/23, did not indicate the use of Buspar as a targeted intervention related to Resident 9's anxiety disorder. A review of all available care plans indicated there were no other care plans to address Resident 9's use of Buspar for behavioral management.
A review of Resident 9's care plan for seizure disorder, initiated 11/1/23, did not indicate the use of Depakote as a targeted intervention related to Resident 9's seizure disorder. A review of all available care plans indicated there were no other care plans to address Resident 9's use of Depakote for the management of seizure disorder.
During an interview on 11/20/25 at 10:46 AM with the Director of Nursing (DON), the DON stated the facility failed to create a comprehensive care plan related to the use of Resident 9's Buspar and Depakote. The DON stated the seizure care plan does not list Depakote as a targeted intervention and the anxiety care plan does not list Buspar as a targeted intervention. The DON stated the care plans for psychotropic medications or medications with FDA black box warnings are necessary so that the nursing staff are educated in their specific risks and required monitoring for a resident's medication therapy. The DON stated if care plans are not made to address the use of high-risk medications, it is possible that the resident may experience adverse effects of those medications possibly leading to a decline in their quality of life.
A review of the facility's policy Care Plans, Comprehensive Person-Centered, revised December 2016, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
A review of the facility's policy Behavioral Assessment, Intervention and Monitoring, revised December 2016, indicated The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. The care plans will incorporate findings from the comprehensive assessment and be consistent with current standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) assessment accurately reflected one of three sampled Residents (Resident 74). This failure had the potential to negatively affect Resident 74's plan of care and delivery of necessary care and services. Findings: During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was initially admitted to the facility on [DATE] with diagnoses including major depressive disorder. During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating, required moderate assistance (helper does more than half the effort) for oral hygiene and upper body dressing, and was dependent for toileting hygiene, bathing, and lower body dressing. During a concurrent interview and record review 11/21/2025 at 9:55 a.m., with the MDS Coordinator (MDSC), Resident 74's medical record was reviewed. Resident 74's physician order summary indicated Ativan oral tablet 0.5 milligrams (MG- a unit of measurement) - give 1 tablet by mouth every 6 hours as needed for anxiety manifested by (m/b) physical restlessness for 14 days. Resident 74's care plans indicated on 8/5/2025 Resident 74 experienced new episodes of anxiety m/b physical restlessness and combativeness. The MDSC stated the psychiatry note dated 10/27/2025 indicated Resident 74 was diagnosed with anxiety. The MDSC stated the MDS dated [DATE] did not indicate that resident 74 had an anxiety disorder. The MDSC stated the anxiety disorder should have been reflected in the MDS. During an interview on 11/21/2025 at 2:56 p.m. with the Director of Nursing (DON), the DON stated the MDS assessment should accurately reflect the resident to ensure that the resident is receiving proper care and treatment. During a review of the facility's policy and procedure (P/P), titled Charting and Documentation, revised July 2017, the P/P indicated documentation in the medical record we'll be objective (not opinionated or speculative), complete, and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the binding arbitration agreement (a contract in which a person agrees to settle future disputes with the facility outside of court, through a private, neutral decision-maker instead of a judge or jury) was explained in a language that a resident could understand for two of three sampled residents (Resident 78 and Resident 82).This deficient practice had the potential to limit Resident 78 and Resident 82's understanding of the binding arbitration agreement and their legal rights.Findings:a. During a review of Resident 78's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 10/11/2023, with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).During a review of Resident 78's History and Physical (H&P), dated 7/7/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.During a review of Resident 78 Minimum Data Set (MDS, a resident assessment tool), dated 9/18/2025, the MDS indicated Resident 78's preferred language was Spanish. The MDS indicated Resident 78 had intact cognition (ability to think and understand). The MDS indicated Resident 78 needed set up or clean up assistance from staff for eating and oral hygiene. The MDS indicated Resident 78 needed supervision assistance from staff for personal and toileting hygiene.During a review of Resident 78's Arbitration Agreement, dated 10/12/2023, the Arbitration Agreement indicated Resident 78 signed the arbitration agreement provided in English.During an interview on 11/20/2025 at 10:09 a.m., with Resident 78, Resident 78 stated he was unable to recall signing an arbitration agreement. Upon presentation of the signed arbitration agreement, Resident 78 stated would have remembered and understood the content of the agreement if the document was written in Spanish.b. During a review of Resident 82's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 5/31/2023, and was readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure) and muscle weakness.During a review of Resident 82's History and Physical (H&P), dated 1/30/2025, the H&P indicated the resident had memory impairment and forgetful.During a review of Resident 82 Minimum Data Set (MDS, a resident assessment tool), dated 9/18/2025, the MDS indicated Resident 82 had moderately impaired cognition (ability to think and understand). The MDS indicated Resident 82 needed set up or clean up assistance from staff for eating. The MDS indicated Resident 82 needed maximal assistance (helper does more than half the effort) from staff for toileting hygiene and bathing.During a review of Resident 82's Arbitration Agreement dated 6/6/2023, the Arbitration Agreement indicated Resident 82 signature.During an interview on 11/20/2025 at 10:30 a.m. with Resident 82, Resident 82 stated she was unable to recall what she had signed or the purpose of the arbitration agreement. During an interview on 11/20/2025 at 2:40 p.m., with the admission Assistant (AA), the AA stated the arbitration agreement should have been explained in a manner residents could understand, including through an interpreter and using simple terms. The AA stated the resident's responsible party (RP) should have been contacted if a resident was confused or forgetful. The AA stated when residents do not understand arbitration agreement, residents would be unaware of available options for addressing issues with the facility and unable to exercise their legal rights. During an interview on 11/21/2025 at 3:23 p.m., with Director of Nursing (DON), the DON stated if residents' preferred language was a language other than English, the facility had to use an interpreter to ensure understanding of arbitration agreement before signing. The DON stated the RP had to be contacted for resident who were confused or forgetful, otherwise, residents had no way of knowing what was being signed. During a review of facility's policy and procedure (P&P) titled Arbitration Agreement, undated, the P&P indicated By signing this arbitration agreement below, the parties agree to be bound by the provisions of this Arbitration Agreement. Further the Resident (or Resident's Legal Representative and/or Agent on behalf of Resident) acknowledges that: (A) The agreement has been explained to the Resident (or Resident's Legal Representative and/or Agent on behalf of the Resident) by a representative of the Facility in a form and manner that the Resident understands, including in a language that the Resident understands; and (B) The Resident (or Resident Legal Representative or Agent on behalf of Resident) understands this agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform one of two sampled residents (Resident 11) of the risks associated with repeated subcutaneous (beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injections administered in the same anatomical site.This deficient practice had the potential to limit Resident 11's ability to make informed decisions regarding treatment.Findings:During a review of Resident 11's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/6/2023 and was readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and cataract (clouding of the eye's natural lens).During a review of Resident 11's History and Physical (H&P), dated 9/15/2025, the H&P indicated the resident had the capacity to understand and make decisions.During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 9/18/2025, the MDS indicated Resident 11 had intact cognition (ability to think and understand). The MDS indicated Resident 11 needed set up or clean up assistance from staff for eating and oral hygiene. The MDS indicated Resident 11 needed moderate assistance from staff for toileting hygiene and bathing.During a review of Resident 11's Physician Order dated 9/14/2025, the Physician Order indicated an order of insulin lispro (fast-acting insulin that works fast to lower blood sugar level) injection solution 100 unit per milliliters (unit/ml, units of insulin are contained within each milliliter of liquid), inject 3 unit subcutaneously three times a day for DM, hold if blood sugar is less than 100. During a review of Resident 11's Physician Order dated 9/15/2025, the Physician Order indicated an order of insulin glargine (long-acting insulin that works slowly and steadily to keep blood sugar stable) subcutaneous solution 100 unit/ml, inject 10 unit subcutaneously at bedtime for DM.During an interview on 11/20/2025 at 9:31 a.m., with Resident 11, Resident 11 stated she preferred to receive insulin injections in her right arm, did not like injections in her abdomen and her left arm had a dialysis access site. Resident 11 stated she was not aware of the risks associated with repeated use of same site for insulin injections.During a concurrent interview and record review on 11/21/2025 at 9:53 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 11's Physician Order for 11/2025, Medication Administration Report (MAR) for 11/2025, Location of Administration Report for 11/1/2025 to 11/20/2025 and Progress Notes for 11/13/2025 to 11/17/2025 were reviewed. LVN 3 stated Resident 11 received injections to same site on multiple occasions. LVN 3 stated when a resident preferred a specific insulin injection site, nursing staff should educate the residents on the risks of repeated injections and benefits of rotating sites to make residents aware and able to make informed decisions regarding care. LVN 3 stated there was no documentation in Resident 11 Progress Notes and MAR indicating that Resident 11 had been educated regarding insulin site rotation. During an interview on 11/21/2025 at 12:43 p.m., with Director of Nursing (DON), the DON stated residents had rights to refuse care and treatment, but nursing staff must educate residents that repeated injections in the same site can cause bruising or harm.During a review of facility's policy and procedures (P&P) titled, Resident Rights revised 12/2016, the P&P indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to.be informed of, and participate in, his or her care planning and treatment.participate in decision making regarding his or her care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call light devices were within reach for three of 26 sampled residents (Residents 7, 100, and 121).This deficient practice had the potential for residents not being unable to summon health care workers for assistance as needed. a. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) affecting left dominant side, stiffness of left shoulder, elbow, and hand, and history of falling.
During a review of Resident 7's Minimum Data Set (MDS: a resident assessment tool) dated [DATE], the MDS indicated Resident 7 was cognitively intact. The MDS indicated Resident 7 was dependent on chair/bed-to-chair transfer, lying to sitting, required maximal assistance (provide more than half the effort) for toileting hygiene, bathing, lower body (waist below) dressing, required moderate assistance (provide less than half the effort) for oral/personal hygiene, upper body (waist above) dressing, and required setup for eating. The MDS indicated Resident 7 had an impairment on one side of the upper (arms/shoulders) and lower extremity (legs/hips) and utilized a wheelchair.
During a concurrent observation and interview on [DATE] at 11:13 a.m., with Resident 7, Resident 7 stated he did not have a call light and did not know where it was. Resident 7 stated he calls for help by raising his hand. The call light was observed behind the resident's bed.
During a concurrent observation and interview on [DATE] at 11:15 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 7's call light was behind his bed and brought the call light to Resident 7's right side. LVN 2 stated call lights are important as when a resident requires assistance, it notifies the staff they need assistance. LVN 2 stated call lights should be placed in a reachable position. LVN 2 stated if a call light was behind the bed and not reachable, the residents may try to get up on their own to get help and increasing their risk for falls.
During an interview on [DATE] at 12:42 p.m. with the Director of Nursing (DON), the DON stated call lights are important as if a resident needs assistance, the staff can respond right away, and the call light should be placed in a reachable position. The DON stated if the call light is not in a reachable position, the residents cannot use it.
b. During a review of Resident 100's admission Record, the admission Record indicated Resident 100 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including history of falling, epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) .
During a review of Resident 100's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 100 did not have the capacity (ability) to understand and make decisions.
During a review of Resident 100's MDS, dated [DATE], the MDS indicated Resident 100 required maximal assistance (Helper does more than half the effort) from one staff for bed mobility, bathing/shower, toilet hygiene, moderate assistance (Helper does less than half the effort) from one staff for dressing, and set up assistance (Helper sets up or cleans up) from one staff for eating.
During a concurrent observation and interview on [DATE], at 10:28 a.m., with Resident 100 in her room, Resident 100's call light was placed between left side foam padding and the left side siderails, and the call light button was dangling near the floor. Resident 100 stated, she knew how to use the call light, but she could not find it. Resident 100 stated, she would yell for help if she could not find the call light.
During an interview on [DATE], at 10:31 a.m., with Certified Nurse Assistant (CNA) 2 in Resident 100's room, CNA 2 stated, the call light should be placed within reach of the resident to accommodate the needs of the resident. CNA 2 stated, she did not know why the call light was placed between the foam padding and siderail where Resident 100 could not reach. CNA 2 stated, if the call light was not within reach, Resident 100 might be at risk for fall or accident.
During an interview on [DATE], at 2:28 p.m., with the Director of Staff Development (DSD), the DSD stated, the call light was the resident's lifeline (a thing on which someone or something depends, or which provides a means of survival) for emergency situations. The DSD stated, it should be within reach at all times to prevent falls and injuries.
During an interview on [DATE], at 3:52 p.m., with the Director of Nursing (DON), the DON stated, the call light should be within reach of the residents at all times to provide the assistance they needed. fall stated, Resident 100 was at risk for falls due to history of falling and the staff should have ensured that the call light was within reach to prevent injuries.
During a review of Resident 100's Care Plan Report (CPR), initiated on [DATE] and next review date on [DATE], the CPR Focus indicated, Resident 100 was at risk for fall related to balance problem during transition, and assistance needed during walking and bed mobility. The CPR Interventions indicated, explain or educate the resident to use the call light to ask for assistance because she could injure herself if she transfers herself without calling for help.
c) During a review of Resident 121s admission Record, the admission Record indicated Resident 121 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 121's MDS, dated [DATE], the MDS indicated Resident 121 had severe cognitive impairment. The MDS indicated Resident 121 was dependent on staff for all Activities of Daily Living (activities such as bathing, dressing and toileting a person performs daily).
During a concurrent observation and interview on [DATE] at 12:30 p.m., Resident 121's call light was not within Resident 121's reach and was on the left side of the bed. Certified Nurse Assistant (CNA) 1 stated the call light was not in reach and needed to be in reach.
During an interview on [DATE] at 12:42p.m. with the Director of Nursing (DON), the DON stated call lights are important as if a resident needs assistance, the staff can respond right away, and the call light should be placed in a reachable position. The DON stated if the call light is not in a reachable position, the residents cannot use it.
During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 12/2016, the P&P indicated communicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to be treated with respect, kindness, and dignity.
During a review of the facility's P&P titled, Answering the Call Light, revised 1/2010, the P&P indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Some residents may not be able to use their call light. Be sure you check these residents frequently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician when Resident 113's ambulation (walking or moving from one place to another) distance declined. This failure had the potential to result in a delay of care and further decline of ambulation. Findings: During a review of Resident 113's admission Record, the admission Record indicated Resident 113 was initially admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty in walking, and pressure induced deep tissue damage (discolored skin over a bony prominence caused by prolonged, unrelieved pressure) of the sacral (base of the spine) region. During a review of Resident 113's History and Physical (H&P), dated 6/19/2025, the H&P indicated Resident 113 had the capacity to understand and make decisions. During a review of Resident 113's Minimum Data Set (MDS - a resident assessment tool), dated 9/23/2025, the MDS indicated Resident 113's cognitive (ability to learn, reason, remember, understand, and make decisions) ability was intact, required setup assistance when eating and oral hygiene, required for upper body dressing, moderate assistance (helper does less than half the effort) for toileting and lower body dressing, and required maximal assistance (helper does more than half the effort) for bathing. During an interview on 11/18/2025 at 10:01 a.m., with Resident 113, Resident 113 stated they used to walk with a walker with the staff, but has gotten weaker and does not walk with the staff anymore. During a review of Resident 113's physician orders, the orders indicated: 6/26/2025 - 11/4/2025 Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) to provide ambulation program with front wheel walker ([FWW]) a tool that helps people walk more safely that has two wheels in the front and two legs in the back)3x/week or as tolerated and document walking distance 11/4/2025 RNA to provide bilateral(both) upper extremity (BUE)/Bilateral lower extremity (BLE) active range of motion (AROM- resident can move independently with instruction) 3x/week or as tolerated. During a concurrent interview and record review on 11/19/2025 at 2:21p.m., with RNA 1 , Resident 113's daily and weekly RNA documentation from June 2025 to November 2025 was reviewed. RNA 1 stated the daily documentation indicated: In July 2025, Resident 113 ambulated 150 feet (ft- a unit of measurement of distance) with the RNA every week The week of 8/3/2025 - 8/9/2025, Resident 113 ambulated 80 ft with the RNA The week of 8/10/2025 - 8/16/2025, Resident 113 ambulated 40 ft with the RNARNA 1 stated if a resident refuses or there are changes such as a decline, the RNA reports the change to the Licensed Vocational Nurse (LVN) or the Director of Nursing (DON) who would report it to the physician. During a concurrent interview and record review on 11/21/2025 at 10:07 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 113's medical record was reviewed. The MDSC stated the physician was notified on 10/20/2025 that Resident 113 had lower back pain and right leg weakness and was notified on 10/24/2025 that Resident 113 refused to ambulate. The MDSC stated if a resident's ambulation declines from 150 ft to less than 100 ft, the decline should be communicated to the physician. During a concurrent interview and record review on 11/21/2025 at 11:27 a.m. with LVN 1, Resident 113's medical record was reviewed. LVN 1 stated if there is a decrease in distance ambulated, they would expect the RNA to report the change to the LVN who would initiate a Change of Condition (COC) and notify the physician. LVN 1 stated they would have expected the physician to be notified by 8/11/2025 when the distance ambulated was trending down. During an interview on 11/21/2025 at 3:00 p.m., with the Director of Nursing (DON), the DON stated it is important to notify the physician when there is a change of condition such as a decline in ambulation so the provider is aware of the resident's condition, and so that the resident gets proper treatment. During an interview on 11/21/2025 at 4:17 p.m. with the Medical Director (MD), the MD stated if there is a decline in ambulation the facility should notify the provider. During a review of the facility's policy and procedure (P/P), titled Change in a Resident's Condition or Status, revised December 2016, the P/P indicated The nurse will notify the residents attending physician or physician on call when there has been a: .d. significant change in the residence physical/emotional/mental condition.f. Refusal of treatment or medication two or more consecutive times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a consent form for the use of an abdominal binder (belt used to support the abdomen after surgery, improve physical function), complete the restraint assessment, and monitor the use of abdominal binder for one of 26 sample residents (Resident 121). These deficient practices resulted in unnecessary restraint and placed the residents at risk of physical harm, skin injuries, or entrapment.During a review of Resident 121s admission Record, the admission Record indicated Resident 121 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities).During a review of Resident 121's Minimum Data Set ([MDS] a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 121 had severe cognitive impairment. The MDS indicated Resident 121 was dependent on staff for all Activities of Daily Living (activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 121's Admit/RE-Admit Nursing Evaluation, dated 11/12/2025 at 10:30 p.m., the evaluation indicated Resident 121 had a gastrostomy tube ([G- tube] 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 concurrent observation and interview, on 11/19/2025 at 3:45 p.m., at Resident 121's bedside, with Registered Nurse Supervisor (RNS) 1, Resident 121 was noted with an abdominal binder (wide compression belt that encircles the abdomen) in place covering the G-tube site. RNS 1 1 stated that Resident 121 had the abdominal binder in place to prevent Resident 121 from pulling out the G-tube. RNS 1 stated Resident 121 cannot remove the abdominal binder easily and the abdominal binder prevents Resident 121 from pulling the G-tube.During a concurrent interview and record review on 11/19/2025 at 3:45 p.m., with RNS 1, Resident 121's medical records were reviewed. RNS 1 stated there was no assessment for abdominal binder use and there was no informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) obtained from the resident or responsible party. During an interview on 11/21/2025 at 2:56 p.m. with the Director of Nursing (DON), the DON stated a restraint was a device that restricts residents' movements. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, revised 12/2007, the P&P indicated:1) Physical restraints were defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.2) Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions (programs, devices, referrals, etcetera) that may improve the symptoms.3) Residents and/or responsible parties shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for three of nine sampled residents (Resident 13, Resident 101, and Resident 113) when:a. Restorative Nursing Aide (RNA 1) documented he provided RNA feeding program (staff provide feeding assistance) assistance to Resident 13 for two meals, when he did not. b. RNA 1 documented Resident 101 wore both knee splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for two hours during Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment on 11/18/2025 when Resident 101 wore both knee splints for 40 minutes to one hour.c. RNA weekly documentation did not accurately reflect Resident 113's ambulation distance from 8/3/2025 - 10/4/2025. These deficient practices resulted in inaccurate medical documentation for Resident 13, Resident 113, and Resident 101 and had the potential for delayed assessment of both knee splints for Resident 101.
Findings:
a. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of hemiplegia (unable to move one side of the body) and a contracture (a permanent tightening of muscles, tendons, or skin that causes joints to become stiff and short, restricting movement) of the left hand.
During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 13 had severe cognitive impairment (a significant loss of mental ability, such as memory, thinking, and reasoning, that prevents a person from living independently and often requires substantial supervision) and had an impairment on one upper extremity (left). The MDS indicated Resident 13 required supervision or touching assistance (helper provides verbal cues and/or touching/ steadying assistance during the task).
During a review of Resident 13's Order Summary Report dated 11/21/2025, the Order Summary Report indicated Resident 13 had an order placed 9/30/2024 for RNA feeding program with breakfast and lunch.
During an observation on 11/20/2025 at 8:01 a.m., Resident 13 was sat up in bed, the meal tray was set up and placed in front of her, but staff (unknown) did not stay with her during the meal. Resident 13 fed herself.
During an observation on 11/20/2025 at 12:22 p.m., Resident 13 was feeding herself lunch. Resident 13 ate the vegetables on the plate and did not consume the meat or potatoes. RNA 1 came into the room and picked up Resident 13's meal tray.
During an interview on 11/20/2025 at 2:33 p.m., the Quality Assurance Nurse (QAN) stated Resident 13 had an order for the RNA feeding program and the RNA staff were supposed to assist the resident with feeding and sit with her while she ate. The QAN stated RNA staff were not supposed to leave Resident 13 unattended until she finished her meals. The RNA staff is supposed to supervise that she was eating safely and encourage her to eat.
During an interview on 11/21/2025 at 10:56 a.m., RNA 1 stated he was assigned to Resident 13 the day prior (11/20/2025) for the RNA feeding program (breakfast and lunch). RNA 1 stated to be honest he only set up the meal tray for Resident 13 but then left the room because he had other residents to attend to. RNA 1 stated Resident 13 could feed herself, the staff must monitor her while she was eating.
During a concurrent interview and record review on 11/21/2025 at 11:53 a.m., RNA 1 stated he reviewed Resident 13's Task Documentation for the RNA Feeding Program Task for 11/20/2025, question 1 was marked as the task was completed for breakfast and lunch and question 2 for the number of minutes spent with the resident was marked 20 minutes at both meals. RNA 1 confirmed he did not feed Resident 13 at breakfast or lunch on 11/20/2025 and he did not spend 20 minutes with the resident at mealtime. RNA 1 stated the documentation was not correct and he should not have documented something he did not do,
During an interview on 11/21/2025 at 3:37 p.m., the Director of Nursing (DON) stated if a resident was on the RNA feeding program the RNA should be in the room with the resident throughout the meal. The DON stated that even though the residents were on the RNA feeding program for encouragement and queuing, the staff should still be in the room throughout the meal. The staff need to motivate the resident to eat and be there if resident needed anything. The DON stated there was a possibility for weight loss if the resident was not encouraged to eat. The DON stated if a task was not completed, then it should not have been documented as done in the resident record. The DON stated setting up the tray and taking it away was not considered completing the RNA Feeding Program Task.
During a review of the facility's policies and procedures (P&P) revised 7/2017, titled, Charting and Documentation, the P&P indicated documentation in the medical record will be complete and accurate.
b. During a review of Resident 101's admission Record (AR), the AR indicated Resident 101 was admitted to the facility on [DATE] with diagnoses including but not limited to primary osteoarthritis (OA, a progressive disorder of the knee joint, caused by a gradual loss of cartilage) of right hip and left shoulder, polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), and morbid obesity due to excess calories (disorder involving excessive body fat that increases risk for health problems).
During a review of Resident 101's Minimum Data Set (MDS, resident assessment tool) dated 8/20/2025, the MDS indicated Resident 101 had no cognitive impairment (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 101 required setup assistance with eating, supervision for oral hygiene, and substantial assistance for toileting hygiene, showering, lower body dressing and sit to lying. The MDS indicated Resident 101 required dependent assistance for bed to chair transfers and walking was not attempted. The MDS indicated Resident 101 did not have any functional limitations in range of motion (ROM, full movement potential of a joint) in the upper extremities (UE, shoulder, elbow, wrist/hand) and had functional limitations in ROM on both sides of the lower extremities ([NAME], hip, knee, ankle/foot).
During a review of Resident 101's Care Plan Report (CP), the CP initiated on 1/3/2023 and with a target date of 2/17/2026 indicated Resident 101 was at risk for decline in Activities of Daily Living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) functions, mobility and joint mobility related to OA, severe obesity, and right knee contracture (loss of motion of a joint. The CP goal indicated Resident 101 will minimize potential declines in joint mobility. The CP interventions indicated to observe for pain or joint stiffness while providing RNA/ROM, RNA to provide both knee extension splints (splints to help keep the knee in a straight position) two to four hours three times a week or as tolerated, RNA to provide both UE active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) three times a week or as tolerated, RNA to provide both [NAME] passive range of motion (PROM, movement at a given joint with full assistance from another person) three times a week or as tolerated.
During a review of Resident 101's Order Summary Report (OSR) dated 11/20/2025, the OSR indicated an order dated 9/23/2025 for RNA to provide both knee extension splints for two to four hours three times a week or as tolerated.
During a review of Resident 101's November 2025 Documentation Survey Report (DSR) for RNA tasks, the DSR indicated on 11/18/2025, both knee extension splints were applied and tolerated for two hours.
During an observation and interview on 11/18/2025 at 10:35 a.m. in Resident 101's room, Resident 101 was lying in bed to the left side. Resident 101's knees were bent and rotated to the left side. Resident 101 stated she was supposed to have splints on her legs and staff put on the splints about 40 minutes at a time. There were no knee splints observed on Resident 101.
During an observation and interview on 11/18/2025 at 2:54 p.m. in Resident 101's room, Resident 101 was lying in bed to the left side. Resident 101's knees were bent and rotated to the left side. Resident 101 stated RNA 1 came to put on the leg splints today and Resident 101 wore the leg splints for about 40 minutes. There were no knee splints observed on Resident 101.
During an interview on 11/19/2025 at 9:28 a.m. with RNA 1, RNA 1 stated he completed RNA treatment with Resident 101 yesterday 11/18/2025 and RNA 1 put on the knee splints for only 45 minutes yesterday.
During an interview and record review on 11/20/2025 at 10:00 a.m. with RNA 1, RNA 1 reviewed RNA daily documentation on 11/18/2025. RNA 1 stated he documented on 11/18/2025 that Resident 101 wore and tolerated both splints for two hours. RNA 1 stated Resident 101 put on the splint for one hour, because Resident 101 could not tolerate it anymore and told RNA 1 to take off the splint. RNA 1 stated he documented two hours because that was what the order indicated. RNA 1 stated he should have documented one hour. RNA 1 stated the 11/18/2025 RNA documentation was not accurate, because the documentation did not reflect what happened during RNA treatment on 11/18/2025. RNA 1 stated staff should document accurately because the documentation showed what happened with Resident 101 and told staff how Resident 101 was progressing with wearing the knee splints. RNA 1 stated Resident 101 has not tolerated two hours of wearing the knee splints except for possibly two previous times.
During an interview on 11/20/2025 at 3:52 p.m. with the Director of Nursing (DON), the DON stated the purpose of documentation was to indicate what the resident did and what happened during treatment. DON stated all documentation needed to be accurate so that whatever happened to the resident, every shift and staff member would know what happened to the resident. DON stated RNA documentation should be accurate and indicate what happened during the RNA treatment session so that if the resident could not tolerate the splint for the time ordered, RNA should let nursing and therapy staff know and have therapy look into or recommend how much a resident could tolerate the splint.
During a review of the facility's policies and procedures (P&P) revised 7/2017, titled, Charting and Documentation, the P&P indicated documentation in the medical record will be complete and accurate.
c. During a review of Resident 113's admission Record, the admission Record indicated Resident 113 was initially admitted to the facility 6/16/2025 with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty in walking, and pressure induced deep tissue damage (discolored skin over a bony prominence caused by prolonged pressure)of sacral (base of the spine) region.
During a review of Resident 113's History and Physical (H&P), dated 6/19/2025, the H&P indicated Resident 113 had the capacity to understand and make decisions.
During a review of Resident 113's MDS, dated [DATE], the MDS indicated Resident 113's cognitive (ability to learn, reason, remember, understand, and make decisions) ability was intact, required setup assistance when eating and oral hygiene, required for upper body dressing, moderate assistance (helper does less than half the effort) for toileting and lower body dressing, and required maximal assistance (helper does more than half the effort) for bathing.
During an interview on 11/18/2025 at 10:01 a.m., with Resident 113, Resident 113 stated they used to walk with a walker with the staff, and but has gotten weaker and does not walk with the staff anymore.
During a review of Resident 113's physician orders, the orders indicated:
6/26/2025 – 11/4/2025 Restorative Nursing Aide (RNA) to provide ambulation program with front wheel walker (FWW) 3x/week or as tolerated and document walking distance.
During a concurrent interview and record review on 11/19/2025 at 2:21p.m., with RNA 1, Resident 113's daily and weekly RNA documentation from June 2025 to November 2025 was reviewed. RNA 1 stated the Daily RNA documentation is completed daily and indicated the distance a resident ambulates in feet (ft – a unit of measurement). RNA 1 stated the Weekly RNA documentation is a summary RNA services for a week including the total distance in feet ambulated in a week. RNA 1 stated the Weekly RNA documentation indicated the week of:
8/3/2025 – 8/9/2025 Resident 113 ambulated 150 ft, the Daily RNA documentation indicated Resident 113 ambulated 80 ft
8/10/2025 – 8/16/2025 Resident 113 ambulated 150 ft, the Daily RNA documentation indicated Resident 113 ambulated 40 ft
8/17/2025 to 8/23/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 70 ft
8/24/2025 – 8/30/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 30 ft
9/1/2025 – 9/6/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 30 ft
9/7/2025 – 9/13/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 70 ft
9/14/2025 – 9/20/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 30 ft
9/21/2025 – 9/27/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 30 ft
9/28/2025 – 10/4/2025 Resident 113 ambulated 300 ft, the Daily RNA documentation indicated Resident 113 ambulated 30 ft
RNA 1 stated the weekly RNA documentation should accurately reflect the daily RNA documentation, but they do not match. RNA 1 stated it was important for the Weekly RNA documentation to accurately reflect the resident's status to see if the resident is improving or declining.
During an interview on 11/20/2025 at 3:52 p.m. with the DON, the DON stated the purpose of documentation was to indicate what the resident did and what happened during treatment. DON stated all documentation needed to be accurate so that whatever happened to the resident, every shift and staff member would know what happened to the resident. DON stated RNA documentation should be accurate and indicate what happened during the RNA treatment session.
During a review of the facility's policies and procedures (P&P) revised 7/2017, titled, Charting and Documentation, the P&P indicated documentation in the medical record will be complete and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store and prepare food under safe and sanitary conditions in one of one kitchen, by failing to:a) Ensure no staff personal belongings were in the kitchen preparation area.b) Ensure the sanitizer bucket was not in the food preparation sink while food was being prepared. c) Ensure the pancake, breakfast meat, and waffles holding temperature (temperature at which food is kept) on the steam table (specifically made for holding prepared foods at a consistent temperature) were checked prior to meal service.d) Ensure the ice machine was clean.e) Ensure two of three residents' (Resident 101 and 112) refrigerated personal food items were dated on when it was opened or procured.These deficient practices had the potential to result in contamination of food items that placed residents in high risk for food borne illness (any illness resulting from eating contaminated/spoiled foods) that can lead to hospitalization and a decline in health.Findings: During a concurrent observation and interview on 11/18/2025 at 8:32 a.m., with the Dietary Supervisor (DS), in the kitchen, staff personal belongings were observed on a kitchen cart in the food preparation area. The DS stated staff's personal items do not belong in the kitchen.During an observation and interview with the Registered Dietician (RD) on 11/19/2025 at 6:45 a.m., the sink had a sign that indicated food preparation only. The food preparation sink had a red bucket labeled sanitizer. The RD stated the sanitizer should not be in the food preparation sink when food was being prepared.During an observation and interview on 11/19/2025 at 6:50 a.m., [NAME] 1 (CK 1) checked the pancake temperature and it was 130.8 degrees Fahrenheit.During an interview and record review on 11/19/2025 at 7:00 a.m., with the Dietary Supervisor (DS), the Daily Food temperature Log was reviewed, and the DS confirmed the temperature of the pancake should have been 140 degrees Fahrenheit as indicated in the log.During a concurrent observation and interview on 11/19/2025 at 8:19 a.m., with the Maintenance Supervisor (MS) the facility ice machine was observed with black colored unidentified substance on the inside of the machine. The MS stated the inside of the ice machine was dirty.During a review of Resident 101's admission Record, the admission record indicated the facility admitted Resident 101 on 12/30/2022 with the diagnosis including gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest).During a review of Resident 101's Minimum Data Set ([MDS] resident assessment tool), dated 8/20/2025, the MDS indicated Resident 101 had intact cognition and needed set-up assistance when eating.During a review of Resident 112's admission Record, the admission record indicated the facility admitted Resident 112 on 9/2/2025 with the diagnosis including gastroesophageal reflux disease.During a review of Resident 112's MDS, dated [DATE], the MDS indicated Resident 112 had moderate cognitive impairment and needed set-up assistance when eating.During a concurrent observation and interview on 11/19/2025 at 11:40 a.m., with the RD, the Residents refrigerator was noted with Resident 101's personal food items including an opened and undated, 8-ounce pack of sliced cheese and 16-ounce pack of deli meat. During a concurrent interview and record review on 11/19/2025 at 11:40 a.m., with the RD, the food package instructions were reviewed, and the instructions indicated the cheese slices, and the deli meat was best if used within seven days of opening. During a concurrent observation and interview on 11/19/2025 at 11:45 a.m., with the Registered Dietician (RD), the Residents' refrigerator was noted with Resident 112's box of fried chicken with food that was undated. During a concurrent interview and record review on 11/19/2025 at 2 p.m., with the RD, the menus and Food temperature Logs for 11/2/2025 to 11/19/2025 were reviewed and the logs indicated there were days that the breakfast meat, pancakes, or waffles were not checked. The RD stated prior to serving, food temperatures for pancake/toast/ breakfast meat should be checked to ensure food was warm when resident gets the food and to prevent foodborne illness. Pancake temperature should be at least 140 degrees Fahrenheit.During an interview on 11/19/2025 at 2 p.m. with the RD, the RD stated the following: 1. Residents' food should be dated so residents will not acquire food borne illnesses. 2. The sanitizer bucket should not be in the sink designated only for food preparation during food prepping to prevent contamination of food items.3. The ice machine should be clean to prevent infection.4. Staff personal belongings should not be in the kitchen area to prevent contamination.During a review of the facility's policy and procedure (P&P) titled, Bringing in food for a Resident, 2023, the P&P indicated food should be labeled and dated with the date food was opened to monitor for food safety.During a review of the facility's P&P titled, Food for Residents from Outside Sources, undated, the P&P indicated if food is opened, the food will be dated with the date opened and disposed of in 2 days after opening.During a review of the facility's P&P titled, Storage of Food and Supplies, 2023, the P&P indicated items such as bleach, soap and other cleaning supplies should be stored in entirely separate and specific areas. During a review of the facility's P&P titled, Employee Personal Items, 2023, the P&P indicated personal items brought in by staff from the outside will not be kept in the kitchen area.During a review of the facility's P&P titled, Ice machine Cleaning Procedures, 2023, then P&P indicated the ice machine needs to be cleaned and sanitized.During a review of the facility's P&P titled, Meal Service, 2023, the P&P indicated the staff member will take the food temperatures prior to meal service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one out of six sampled residents (Resident 13) was provided with a puree diet as ordered by the physician. This deficient practice had the potential for Resident 13 to aspirate (when something other than air gets into your airways) or for Resident 13 to lose weight because she was provided with a diet consistent with her physician's orders. Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of hemiplegia (unable to move one side of the body) and a contracture (a permanent tightening of muscles, tendons, or skin that causes joints to become stiff and short, restricting movement) of the left hand.During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool) dated 9/11/2025, the MDS indicated Resident 13 had severe cognitive impairment (a significant loss of mental ability, such as memory, thinking, and reasoning, that prevents a person from living independently and often requires substantial supervision) and had an impairment on one upper extremity (left). The MDS indicated Resident 13 was receiving a mechanically altered (change in texture of food) and therapeutic diet (a meal plan designed to treat a medical condition by controlling specific nutrients, textures, or calories).During a review of the facility's Diet Type Report dated 11/20/2025, Resident 13 had a current physician's order for a fortified (adding extra vitamins, minerals, protein, or calories to foods to increase their nutritional content) pureed (foods that are blended, mashed, or whipped to a smooth, lump-free, pudding-like consistency, which is easier to swallow and does not require chewing) diet.During an observation on 11/20/2025 at 8:01 a.m., Resident 13 was sat up in bed, the meal tray was set up and placed in front of her by Certified Nursing Assistant (CNA) 3. Resident 13's meal tray contained eggs that were scrambled but not pureed.During an interview on 11/20/2025 at 12:23 p.m., CNA 3 stated she set up the meal tray this morning for Resident 13 and described Resident 13's eggs on the meal tray as soft, looked like normal scrambled eggs but they were not pureed.During an interview on 11/20/2025 at 12:55 p.m., [NAME] (CK) 1 stated a puree diet had to be completely smooth and no chunks so the residents would not choke. CK 1 stated that morning they served scrambled eggs with cheese sprinkled on top and if it was a puree plate it would have been very smooshed and not look the same as regular scrambled eggs. CK 1 stated it was important to follow the physician's diet order for patient safety. CK 1 stated after the meal was plated and placed on the meal carts, the meal cart was sent to the nursing unit where nursing staff were supposed to verify the diet provided matched the physician's order, as second verification because everyone makes mistakes. That second check was supposed to keep the improper diet from reaching the resident.During a concurrent interview and record review on 11/21/2025 at 8:37 a.m., Registered Nurse Supervisor (RNS) 4 stated he reviewed Resident 13's Nurses Progress Notes for 10/31/2025, the day the Dentist recommended Resident 13's previous diet (minced and moist diet [a texture-modified diet where all foods are chopped or mashed into soft, moist, small pieces, typically no larger than 4mm wide for adults, and must be easy to swallow with little to no chewing]) be discontinued and changed to the puree diet due to Resident 13's dental status. RNS 4 stated it was very risky to serve the improper diet to the residents because there was a risk for aspiration.During an interview on 11/21/2025 at 3:37 p.m., the Director of Nursing (DON) stated if a resident was provided with the incorrect diet consistency, the resident may not be able to swallow the food correctly leading to negative outcomes such as aspiration.During a review of the facility's policy and procedure (P&P) titled Therapeutic Diets revised a November 2015, the P&P indicated diets must be prescribed by the resident's attending physician and the food services manager would develop a tray identification system to ensure each resident received his or her diet as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to serve regular texture toast to one of three sampled residents (Resident 98).The deficient practice had the potential to result in loss of appetite and cause unplanned weight loss.Findings:During a review of Resident 98's admission Record, the admission Record indicated Resident 98 was readmitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 98's Minimum Data Set ([MDS] a resident assessment tool), dated 9/1/2025, the MDS indicated Resident 98 had intact cognition. The MDS indicated Resident 98 needed set-up assistance when eating.During a review of Resident 98's Order Summary Report, the report indicated, starting on 11/11/2025, Consistent Carbohydrate (diet used for managing blood sugar in diabetics) diet and No added salt, regular texture diet.During an interview on 11/19/2025 at 2:20 p.m., Resident 98 stated she wanted regular toast, but she receives it chopped up and mushy.During a concurrent interview and record review on 11/19/2025 at 2:45 p.m., with the Dietary Supervisor, (DS) Resident 98's Diet Profile card was reviewed and the card notes indicated mechanical soft, toast not toasted. The DS stated the notes were wrong because her diet order was for Regular diet texture and not mechanical soft. The DS stated she will update the notes immediately.During an interview on 11/21/2025 at 2:26 p.m., with the Registered Dietician (RD), the RD stated staff should follow the menu They are supposed to follow the diet texture ordered for good tolerance so they can eat it and prevent weight loss.During a review of the facility policy and procedure titled, Menu Planning, 2023, the policy indicated the facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to serve food that was at the correct temperature to one of three sampled residents (Resident 131).This deficient practice had the potential to result in loss of appetite and cause unplanned weight loss.Findings:During a review of Resident 131's admission Record, the admission Record indicated Resident 131 was admitted to the facility on [DATE] with diagnoses including hypoglycemia (low blood sugar), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastroesophageal reflux disease (digestive disorder most often causes a burning and sometimes squeezing sensation in the mid-chest), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 131's Admit/Re-Admit Nursing Evaluation, dated 11/10/2025, the Evaluation indicated Resident 131 was alert and oriented. The Evaluation indicated Resident 131 needed assistance with all Activities of daily living (activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 131's Order Summary Report, dated 11/19/2025, the report indicated, starting on 11/10/2025, a diet order for Consistent Carbohydrate (diet used for managing blood sugar in diabetics) and No Added Salt (NAS) regular texture diet.During an interview on 11/18/2025 at 10:04 a.m., with Resident 131, Resident 131 stated the food was not always delivered warm. During a concurrent observation and interview on 11/19/2025 at 6:50 a.m., at the kitchen tray line, with [NAME] 1 (CK 1), CK 1 checked the pancake temperature and stated it was 130.8 degrees Fahrenheit.During a concurrent interview and record review on 11/19/2025 at 7:00 a.m., with the Dietary Supervisor (DS), the Daily Food temperature Log and Menus for 11/2025 were reviewed. The DS stated the temperature of the pancake should have been 140 degrees Fahrenheit as indicated in the log. The DS stated that the temperature of waffles or pancakes were not checked as indicated in the log and today the temperature was below recommended temperature.During a concurrent interview and record review on 11/19/2025 at 2:00 p.m., with the Registered Dietician (RD), the Daily Food temperature Log and Menus for 11/2025 were reviewed. The RD stated the temperature of the pancake should have been 140 degrees Fahrenheit as indicated in the log.During a review of the facility policy and procedure titled, Meal Service, 2023, the policy indicated pancakes service temperature should be 140 F or higher. The policy indicated the goal was to serve hot foods hot.

Based on interview and record review, the facility failed to ensure [NAME] (CK) 1 was competent in preparing pureed (foods that are blended, mashed, or whipped to a smooth, lump-free, pudding-like consistency, which is easier to swallow and does not require chewing) scrambled eggs and oatmeal.As a result of this deficient practice 27 residents who were on a puree diet were placed at risk for receiving eggs and oatmeal that were not completely smooth and without lumps which could lead to aspiration (when something other than air gets into your airways). Findings:During a review of the facility's Recipe titled, Pureed Eggs by Healthcare Menus Direct, LLC.2025, the recipe indicated to prepare eggs per recipe for eggs) and then puree the eggs on low speed (food processor or blender) to a paste consistency before adding any liquid then gradually add warm milk. The finished puree item should be smooth and free of lumps, hold its shape, while not being too firm or sticky. During a review of the facility's Recipe titled, Pureed Hot Cereal (Hot Cereal of Choice i.e. Oatmeal) by Healthcare Menus Direct, LLC. 2025, the recipe indicated to prepare the hot cereal as usual, puree the hot cereal and gradually add warm milk until the hot cereal was smooth and free of lumps. During an interview on 11/20/2025 at 12:55 p.m., CK 1 stated pureed foods needed to be smooshed and free of lumps. CK 1 stated when he prepared scrambled eggs with cheese that morning he did not put the eggs in the food processor or blender and just mashed them up by hand and for the oatmeal, he just prepared it as usual without any modification. CK1 stated to be honest they never puree the oatmeal, it is very liquidy and they have not had any problems up to this point. CK 1 stated while preparing food he was supposed to check the spreadsheet for the meal of the day versus the recipe to ensure it was the correct texture. CK1 stated it was important to follow the physician's order for food texture for the resident's safety. During an interview on 11/21/2025 at 10:33 a.m., the Dietary Supervisor (DS) stated she expected her cooks to prepare the proper food texture according to the recipe and pureed foods should be put in the blender or food processor to ensure the texture was smooth and free of lumps. The DS stated she spoke with CK 1 and he confirmed he was not pureeing the oatmeal and mashed the scrambled eggs by hand on 11/20/2025. The DS stated that was incorrect and a food processor or blender should have been utilized. The DS stated it was important to prepare the proper consistency because it placed the residents at risk for choking. During a review of the facility's Job Description: Dietary [NAME] dated 3/8/2025, the job description indicated the cook was to prepare meals and cook food according to standardized recipes and special diet orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor the valproic acid level (a lab value used to determine the effectiveness of certain medications used to treat seizures) related to the use of Depakote (a medication used to treat seizure disorder) per the physician's order in one of five residents sampled for unnecessary medications (Resident 9.)The deficient practice of failing to monitor valproic acid levels for the use of Depakote according to the physician's instructions increased the risk that Resident 9 could have experienced seizures or adverse effects related to the use of Depakote possibly leading to medical complications resulting in hospitalization.A review of Resident 9's admission Record (a record containing diagnostic and demographic resident information), dated 11/20/25, indicated she was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including anxiety disorder (a mental illness characterized by excessive worry, fear, or panic strong enough to interfere in everyday activities) and seizure disorder (a medical condition caused by uncontrolled electrical activity in the brain.)A review of Resident 9's History and Physical (a record of a physician's comprehensive medical examination), dated 6/9/25, indicated she had fluctuating capacity to understand and make decisions.A review of Resident 9's Order Summary Report (a summary of all active physician's orders), dated 11/20/25, indicated, on 9/15/25, she was prescribed Depakote DR 500 mg (milligrams - a unit of measure for mass) by mouth twice daily for seizure disorder.A review of the Medication Regimen Review (a monthly list of medication-related recommendations from the consultant pharmacist), dated 10/7/25, indicated the consultant pharmacist recommended to monitor the valproic acid level related to the use of Depakote with the next scheduled lab draw.A review of Resident 9's Order Summary Report, dated 11/20/25, indicated, on 10/30/25, Resident 9's attending physician ordered routine laboratory monitoring, including the valproic acid level, to be drawn every three months in November, February, May, and August on the second Tuesday of the month. Further review of the Order Summary Report indicated there were no other physician's orders to hold, cancel, or delay the valproic acid level.A review of the final lab report, dated 11/19/25, indicated that all other lab tests ordered by the physician were drawn for Resident 9 on 11/19/25 and results were reported the same day. Further review of the lab report indicated there was no requisition made for a valproic acid level, despite the physician order, and no indication that the valproic acid level was canceled by the attending physician. During an interview on 11/20/25 at 10:46 AM with the Director of Nursing (DON), the DON stated the facility failed to monitor Resident 9's valproic acid level as required by the physician's order from 10/30/25. The DON stated all the other laboratory orders from the physician order were drawn on 11/19/20 and reported the same day. The DON stated the valproic acid was not taken with the others as required in the physician order. The DON stated that failure to monitor the valproic acid level for a resident on Depakote for seizure disorder increases the risk that the resident may experience seizures or adverse effects related to the use of Depakote possibly leading to medical complications requiring hospitalization. A review of the facility's policy Lab and Diagnostic Test Results - Clinical Protocol, revised September 2012, indicated The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process test requisitions and arrange for tests. The laboratory. will report test results to 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 113) was assessed by a neurologist and wound doctor as ordered by the physician. This deficient practice had the potential to result in delay in the delivery of care and services. Findings: During a review of Resident 113's admission Record, the admission Record indicated Resident 113 was initially admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty in walking, and pressure induced deep tissue damage (discolored skin over a bony prominence caused by prolonged, unrelieved pressure) of sacral (base of the spine) region. During a review of Resident 113's History and Physical (H&P), dated 6/19/2025, the H&P indicated Resident 113 had the capacity to understand and make decisions. During a review of Resident 113's Minimum Data Set (MDS - a resident assessment tool), dated 9/23/2025, the MDS indicated Resident 113's cognitive (ability to learn, reason, remember, understand, and make decisions) ability was intact, required setup assistance when eating and oral hygiene, required for upper body dressing, moderate assistance (helper does less than half the effort) for toileting and lower body dressing, and required maximal assistance (helper does more than half the effort) for bathing. During a concurrent interview and record review on 11/21/2025 at 11:27 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 113's medical record was reviewed. LVN 1 stated there is a physician order dated 6/23/2025 indicating a consult to neurology. LVN 1 stated the physician order dated 6/30/2025 indicated Resident 113 was scheduled for an appointment with a neurologist on 10/28/2025 at 9:00 a.m. LVN 1 stated there is no documentation indicating that Resident 113's transportation was arranged or that Resident 113 went to the scheduled neurologist appointment. During a concurrent interview and record review on 11/21/2025 at 12:29 p.m., with the Social Services Director (SSD), Resident 113's medical record was reviewed. The SSD stated there was no documentation that Resident 113's transportation was set up for the scheduled appointment with the neurologist on 10/28/2025. The SSD stated there is no documentation that the neurologist saw Resident 113. During a concurrent interview and record review on 11/21/2025 at 1:02 p.m., with the Treatment Nurse (TN), Resident 113's medical record was reviewed. The TN stated there is a physician order dated 10/6/2025 indicating a consult with the wound doctor for bilateral (both) heel intact, blood filled blisters. The TN stated there was no documentation that the wound doctor saw Resident 113. During an interview on 11/21/2025 at 3:00 p.m., with the Director of Nursing (DON), the DON stated If a resident does not get their consultation as ordered, there was a risk for delay of care, treatment, or services. During a review of the facility's policy and procedure (P/P), titled Referrals, Social Services, revised December 2008, the P/P indicated 1. Social Services shall coordinate most resident referrals and or consultations. Exceptions might include emergency or specialized services that are arranged directly by a physician or the nursing staff. Two referrals for medical services must be based on physician evaluation of resident need and related physician order. 3 social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the position. For social services we'll document the referral in the residence medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility did not adequately provide pharmaceutical services to meet the needs of both sampled residents (Resident 1 and Resident 2) by failing to:
a. Follow the order as prescribed when the physician discontinued a Hydrocodone-Acetaminophen (used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated) 10-325miligram (mg-unit dose) and ordered 5-325mg dose for Resident 1.
b. Follow the facility's policy requiring the controlled substances to be stored in the medication room in a locked container, separate from non-controlled medications. Instead, a bottle of Lorazepam Intensol (knowns as Ativan, is used to treat anxiety disorders) for Resident 2 was found stored unlocked in the refrigerator.
c. Properly dispose of the discontinued narcotic medication from the refrigerator for Resident 2.
These failures had the potential to result in unmet needs of residents, misuse, or diversion of controlled substances.
Findings:
a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/13/2025 with diagnoses including low back pain (discomfort in the lower part of your back) and difficulty in walking.
During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/20/2025, indicated Resident 1 was cognitively (functions your brain uses to think, pay attention, process information, and remember things) intact. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort to complete the task) with eating, oral hygiene, persona hygiene, maximal assistance (helper does more than half the effort to complete task) with toileting hygiene, showing, upper body dressing, lower body dressing, and was dependent (helper does all of the effort) with putting on/taking off footwear.
During a review of Resident 1's Order Summary Report (OSR), as of 6/6/2025, indicated an order to give one tablet of Hydrocodone-Acetaminophen 5-325mg by mouth every six hours as needed for moderate to severe pain 4-10/10(o means no pain and 10 means the worst pain imaginable), hold if respiratory rate is less than 12 per minute(/m), and not to exceed three grams acetaminophen in 24 hours.
During a review of Resident 1's narcotic and hypnotic record (narcotic log) for Hydrocodone-Acetaminophen 10-325mg, dated from 5/19/25, to 6/5/2025, it was indicated that a total of 22 doses of Hydrocodone-Acetaminophen 10-325mg were dispensed during this period for Resident 1.
During a concurrent observation and interview on 6/6/2025 at 11:55 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that staff retrieved the 10-325mg tablets to administer the ordered dose of Hydrocodone-Acetaminophen 5-325mg. He was uncertain whether the entire 10-325mg tablet was administered or if the tablets were cut, as there was no documentation indicating the tablets were split, nor that the unused portions were properly discarded each time. LVN 2 also mentioned that the medication could not be cut. He stated that there had been a discrepancy between the physician's order and medication available and being pulled for administration for the past few weeks.
During an interview on 6/6/2025 at 2:00 p.m. with Resident 1, Resident 1 stated that she had taken the whole table of Hydrocodone-Acetaminophen without cutting it, including the day before the observation.
During an interview on 6/6/2025 at 4:12 p.m., the Director of Nursing stated that staff must follow physicians' orders for residents.
During a review of the facility's policy and procedure (P&P) titled, administering pain medications, revised 10/2010, the P&P indicated that staff have to administer pain medications as ordered, document the following in the resident's medical record: medication and dose. The P&P also indicated that residents are not at risk for addition to narcotic analgesics if used as prescribed for moderate to severe pain.
b. During a concurrent observation and interview conducted on 6/6/2025, at 10:35 a.m. with the Assistant Director of Nursing (ADON) in the East medication room, a narcotic container labeled 'Narcotic only' was observed in an unlocked refrigerator. Inside, there was one unopened 30 milliliter (ml-unit dose) bottle of Lorazepam Intensol for Resident 2. The ADON stated that they believed it was unnecessary to lock the narcotic container since the refrigerator itself was locked.
During an interview on 6/6/2025 at 2:30 p.m., Licensed Vocational Nurse (LVN) 1 stated that Lorazepam Intensol, a controlled narcotic medication, requires a lock to limit access to assigned staff, preventing theft.
During an interview on 6/6/ 2025, at 4:12 p.m. with the Director of Nursing (DON), the DON stated that staff should lock the narcotic medication cart or container because the medications are controlled substances.
During a review of the facility's policy and procedure (P&P) titled, Controlled Substances, revised 12/2012, the P&P indicated that controlled substances must be stored in the medication room in a locked container separate from containers for any non-controlled medications. This container must always remain locked, except when it is accessed to obtain medications for residents. The P&P also stated that the charge nurse on duty will maintain the keys to controlled substance containers.
c. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/28/2022 and readmitted on [DATE] with diagnoses including functional quadriplegia(someone is completely unable to move their arms and legs, not because of a spinal cord injury, but because of a severe medical condition that makes it impossible for them to move or control their body) and encounter for palliative care (specialized care that focuses on improving the quality of life for people facing serious illness, both physically and emotionally).
During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 5/6/2025, indicated, Resident 2's cognitive (functions your brain uses to think, pay attention, process information, and remember things) was severely impaired. The MDS indicated,
Resident 2 was dependent with oral hygiene, toileting hygiene, showering, upper body dressing, lower body dressing, putting on/ taking off footwear and personal hygiene.
During a review of Resident 2's Order Summary Report, dated 11/6/2024, the Order Summary Report indicated an order to give Lorazepam oral concentrate 0.25milliliter (ml-unit dose) by mouth every four hours as needed for anxiety manifested by agitation, restlessness for 14 days and the physician discontinued the Lorazepam order on 11/12/2024.
During a concurrent observation and interview on 6/6/2025 at 10:35 a.m. with the Assistant Director of Nursing (ADON) in the East Medication room, one unopened 30ml bottle of Lorazepam Intensol was observed in the refrigerator for Resident 2.
During a concurrent interview and record review on 6/6/2025 at 2:30 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's Order Summary, as of 6/6/2025 was reviewed. LVN 1 stated that the physician discontinued the lorazepam order in November 2024 and leaving no active order for Resident 2. LVN 1 stated that staff should have removed the lorazepam when it was discontinued six months ago.
During an interview on 6/6/2025 at 4:12 p.m. The Director of Nursing (DON) stated that when a narcotic is discontinued, it should be properly removed from the premises to prevent it from being accidentally administered to a resident.
During a review of the facility's P&P titled, Discarding and Destroying medications, revised 10/2014, the P&P indicated all unused controlled substances shall be retained in a securely locked are with restricted access until disposed of.
During a review of the facility's P&P titled, Disposal of medications, syringes, and needleless, undated, the P&P indicated that unused doses of controlled substances wasted for any reason should be destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions ([EBP] involve gown and glove use during high contact resident care activities for residents at risk for Multidrug-Resistant Organisms ([MDRO, bacteria that have become resistant to certain antibiotics]) for one of three sampled residents (Resident 1), who had a left thigh wound and required daily dressing (sterile pad or material placed directly on a wound to protect it from infection and to promote healing ) changes. The facility failed to:
1. Ensure the Treatment Nurse (TN) had the proper understanding of EBP and put on the appropriate personal protective equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) prior to conducting Resident 1 ' s dressing change.
2. Ensure proper signage was placed outside Resident 1 ' s room indicating Resident 1 was on EBP.
These deficient practices resulted in the TN not applying a gown prior to starting Resident 1 ' s dressing change. These deficient practices had the potential for all other staff not wearing the appropriate PPE when providing high contact resident care activities due to not having a sign indicating Resident 1 was on EBP. These deficient practices also had the potential to increase the risk of transmitting disease-causing organisms to Resident 1 and all other residents, staff, and/or visitors in the facility which could potentially lead to illness.
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] and readmitted on [DATE] with diagnoses including left femur (thigh) fracture (broken bone), multiple pelvic (bowl shaped structure formed by bones on the top of legs) fractures, and muscle weakness.
During a review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 5/2/2025, the MDS indicated Resident 1 ' s cognition (ability to register and recall information) was intact and had the ability to understand and be understood by others.
During a review of Resident 1 ' s Order Summary Report (Physician ' s Orders), dated 5/30/2025, indicated an order was written to cleanse Resident 1 ' s left medial (towards the middle) thigh extending to the left medial knee ruptured blood blister daily and as needed, with normal saline (mixture of water and salt), gently pat dry, apply Santyl (prescription medication used to remove dead tissue from wounds to promote healing) ointment to wound bed, then cover with non-woven gauze.
During an observation on 5/30/2025 at 10 a.m., outside Resident 1 ' s room, there were no EBP signs posted outside Resident 1 ' s room indicating Resident 1 was on EBP.
During an observation on 5/30/2025, at 10:10 a.m., in Resident 1 room, Resident 1 was observed lying in bed and the TN was observed setting up supplies to perform Resident 1 ' s left thigh dressing change then walked to the side of Resident 1 ' s bed and stated she was going to start Resident 1 ' s dressing change. The TN was observed not wearing a gown when she was going to start Resident 1 ' s dressing change.
During an interview on 5/30/2025 at 10:15 a.m., the TN stated Resident 1 did not require EBP because Resident 1 did not have an indwelling device (medical device that is inserted into the body and left in place for an extended period). The TN stated she did not think Resident 1 ' s wound dictated the need for implementing EBP. The TN stated there was no EBP signage on or around Resident 1 ' s door indicating the need for EBP. The TN stated there should be a sign outside Resident 1 ' s room upon entrance so it could remind staff to implement EBP prior to entering Resident 1 ' s room.
During a concurrent observation and interview on 5/30/2025 at 11:15 a.m., with the Infection Preventionist (IP) Nurse, the IP was observed placing an EBP sign outside of Resident 1 ' s room. The EPB sign indicated providers, and staff must also wear gloves, and a gown for high-contact activities which included dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care. The IP stated she just placed a sign outside Resident 1 ' s room indicating the need for EBP. The IP nurse stated she overlooked Resident 1 ' s need for EBP because she thought Resident 1 ' s wound was already healed. The IP nurse stated EBP must be implemented to prevent the spread of disease to Resident 1 whom has a wound that is currently being treated.
During an interview on 5/30/2025 at 4 p.m., with the Director of Nursing (DON), the DON stated she was aware of facility ' s policy on EBP but did not realize Resident 1 ' s wound was open and being treated. The DON stated residents with open wounds and who require dressing changes must have an EBP sign on or around entrance to the room indicating what precautions and/or PPE are required prior to entering the resident ' s room. The DON stated staff should also be properly educated on the understanding the rationale for EBP and when it is required. The DON stated staff must don (apply) the proper PPE when providing care to prevent the spread of any disease-causing microorganisms. The DON stated failure to ensure staff understood and implemented EBP put Resident 1 and all other residents, staff, and/or visitors in the facility for infections that could lead to unnecessary hospitalizations and/or death.
During a review of the facility ' s undated policy and procedure (P&P) titled, Enhanced Barrier Precautions, the P&P indicated it is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of MDROs. The P&P indicated EBP are recommended for residents with indwelling medical devices or wounds because wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO. The P&P indicated the facility will have discretion on how to communicate with staff which residents require the use of EBP. CMS supports facilities in using creative (e.g. subtle) ways to alert staff when EBP use is necessary to help maintain a homelike environment as long as staff are aware which resident require the use of EBP prior to providing high-contact care activities.

Based on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 10/6/2024 when:
1.Facility failed to ensure 16 residents on puree diet (The pureed diet provides foods that do not require chewing and are easily swallowed. All foods should be smooth and pureed to the consistency of pudding.) received spaghetti texture in form that meet their needs when the texture of the puree spaghetti was lumpy, not smooth and had large pieces of pasta present requiring chewing before swallowing.
2.The facility failed to follow lunch menu and portion sizes as written for residents on pureed diet. 16 residents on pureed diet received ½ cup of pureed meat sauce instead of 2/3 of cup per the food portion and serving guide. Residents on pureed diet did not receive the pureed garlic bread per the menu.
These deficient practices had the potential to result in meal dissatisfaction, decreased nutritional intake, wight loss and increased choking risk for 16 residents who were on puree diet.
Findings:
1.During an observation of the tray line service for lunch on 10/06/2024 at 11:45AM, the pureed spaghetti looked dry and not smooth. During the serving of the pureed spaghetti observed pieces of pasta on the plate.
During an interview and taste test of the pureed spaghetti with DS and Registered Dietitian (RD) on 10/06/2024 at 12:45PM, the pureed spaghetti was thick with lumpy texture. The pureed spaghetti had pieces of noodles resembling rice. There were chunky pieces of pasta that required chewing and moving around in the mouth before swallowing. DS stated the consistency of the pureed spaghetti is chunky and there are pieces of the noodles requiring chewing before swallowing. DS stated pureed diet should not require chewing. RD stated the texture of the pureed spaghetti is not smooth.
During an interview with cook1 on 10/06/2024 at 1:05PM, cook1 stated the spaghetti is not smooth. Cook1 stated he should blend the spaghetti longer and add more broth for a smooth consistency. Cook1 stated he was rushing, and he did not prepare the pureed spaghetti correctly. Cook1 stated it is important for the pureed food to be smooth because it can cause choking in residents.
A review of the facility policy titled IDDSI pureed (dated 2018) indicated, this diet is usually eaten with a spoon, does not require chewing and falls off a spoon in a single spoonful when tilted and continues to hold shape on a plate, does not have any lumps, is not sticky.
2.According to the facility lunch menu for pureed diet on 10/06/2024, the following items will be served: Wheat spaghetti pureed ½ cup; zesty meat sauce pureed #6 scoop (2/3 cup); cauliflower and peas pureed 1/3 cup; garlic bread 1 slice pureed; ice cream and milk.
During an observation of the tray line service for lunch on 10/06/2024, at 11:45AM, residents who were on puree diet the cook served pureed zesty meat sauce using #8 scoop yielding ½ cup instead of 2/3 cup per menu.
During the same lunch service observation, the residents on pureed diet did not receive pureed garlic bread with their lunch per menu.
During a review of the menu and interview with cook1 and DS on 10/06/2024 at 1:05PM, cook1 stated he served the wrong scoop and served less meat sauce to residents who were on pureed diet. Cook1 stated he forgot to prepare the pureed garlic bread. Cook1 stated its important to make sure the correct amount is served because serving less food residents can lose weight. DS stated it is important for cooks to follow the menu and the spreadsheet (food portion and serving guide) so residents can receive the correct portion and meet their nutrition needs.
During the same interview RD stated she will provide in-service on portion sizes, food textures and following the menu.
A review of facility menu and spreadsheet (portion and serving guide) on 10/07/2024 indicated serve 2/3 cup of pureed zesty meat sauce and 1 slice of pureed garlic bread.
A review of facility policy titled Menu Planning (dated 2018) indicated, The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physicians' orders and .most recent recommended dietary allowances .the menus provide a variety of foods in adequate amount each meal.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when:
1. There was no soap available in the handwashing sink.
2. One plastic bag of sliced raw meat, and two logs of ground beef thawing on the rack with no thaw date. One open container of cottage cheese and one container of juice with no open date and previously prepared house shake stored in a large one-gallon milk container.
3. Food brought to residents from outside of the facility, were stored in the resident food refrigerator with no use by date. There were four tv dinners with manufactures instruction to store frozen was stored in the refrigerator with no use by date.
These deficiencies 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 food borne illness in 109 out of 111 residents who receive food from facility, including 28 residents who received house shake and residents who had food stored in the resident refrigerator.
Findings:
1.During an observation in the kitchen on 10/06/2024 at 8:40AM one cook (Cook1) was washing hands in the handwashing sink, there was no soap and cook1 proceeded to wash and dry hands with paper towel. During the same observation there was no soap for surveyor to wash hands.
During a concurrent interview, cook1 stated there is no soap, cook1 stated he does not know when the soap was finished. Cook1 stated he informed housekeeping to bring the soap. Cook1 then left the kitchen.
During the same observation and interview with dietary supervisor (DS) on 10/06/2024 at 8:40AM DS stated I informed the house keeping staff to bring soap. DS stated it is important to have soap for handwashing to prevent germ from contaminating hands, infection control and food borne illness.
During an observation on 10/06/2024 at 8:50AM housekeeping staff replaced the soap dispenser.
A review of facility policy titled Hand washing procedure (dated 2018), indicated, Hand washing is important to prevent the spread of infection, use warm running water and soap, preferably from a dispenser .special considerations: soap and paper towel must be readily available.
2. During an observation in the kitchen on 10/06/2024 at 9:00AM, there was one medium size plastic bag with soft and thawed raw sliced beef with date of 10/1/2024 and two large logs of raw ground beef that were still frozen with receive date of 10/1/2024.
During a concurrent observation and interview on 10/06/2024 at 9:00AM, DS stated DS is not sure when the sliced beef was pull out of the freezer to thaw. DS stated DS is not sure because the date does not indicated thaw or use by date. DS removed the beef from the walk-in refrigerator to discard. DS stated the ground beef logs were pulled out of the freezer this morning and will be cooked for lunch. DS stated there should be a thaw date to make sure food is adequately cooked or discarded.
During an observation and interview with DS in the kitchen on 10/06/2024 at 9:10AM, there was one box of prune juice with no open date and one gallon of milk bottle with a brown color beverage labeled shake with a preparation date of 10/5/24 was stored in the reach in refrigerator (refrigerator #2).
DS stated prune juice should have an open date to know when to discard expired items. DS stated the shake stored in the milk gallon is a high calorie beverage prepared in the kitchen. DS stated staff should not store the house shake inside the milk gallon because there is risk of contamination. DS stated DS does not know if the gallon of the milk was cleaned to store the shake.
During a concurrent observation and interview with Dietary Aide (DA1) on 10/6/2024 at 9:15AM, DA1 stated the house shake is prepared by mixing milk with other ingredients. DA1 stated the mixture of house shakes is stored in a clean pitcher and should not be refilled in the milk gallon. DA1 stated using an empty milk gallon can cause cross contamination of the shake.
During a concurrent observation and interview with DS on 10/06/2024 at 9:20AM there was one open container of cottage cheese that was more than half full with dates 9/30/24-12/30/24 and no open date stored in the reach in refrigerator (refrigerator #1). DS stated the cottage cheese is stored for 3 days, DS stated the container is labeled wrong and removed the container to discard. DS stated items should be dated so they are discarded when expired.
A review of facility policy titled Procedure for Refrigerated Storage (dated 2018) indicated, Frozen food should be left in the refrigerator to thaw. Once thawed, uncooked meat is to be used within 2 days. Leftovers will be covered labeled and dated.
A review of facility policy titled Food Preparation (dated 2018) indicated, Label defrosting meat with pull and use by date.
A review of facility Refrigerated storage guide (dated 2018) indicated for cottage cheese follow expiration date or 7 days after opening whichever comes first.
3. During an observation in the resident refrigerator located in the conference room on 10/07/2024 at 09:50AM. The thermometer inside the refrigerator read 39 degrees Fahrenheit. There were two plastic containers of leftover food labeled with resident name and date of 9/29/2024 stored in the refrigerator.
During the same observation there was another bag with four TV dinners with manufacture instruction to keep frozen were stored in the refrigerator with a date of 10/2/24.
During a concurrent observation and interview with DS on 10/7/2024 at 10:00AM, DS stated the food is not labeled with the use by date per policy and should be discarded. DS stated the tv dinners should be stored frozen in the freezer per manufactures guidance and should be discarded because it was not stored safely.
A review of facility policy titled Foods Brought by family/Visitors (revised February 2018) indicated, Perishable foods must be stored in a resealable container with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. The nursing staff will discard perishable foods on or before the use by date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess the mental capacity (ability to make decisions) of one of three sampled residents (Resident 65) to sign a legaly binding document before indicating the Arbitration agreement (a contract indicating any disputes would be resolved within the facility rather than in court) was signed by Resident 65.
This failure had the potential to result in Resident 65 not fully understanding their rights, to limit opportunity to initiate judicial proceedings that challenge unfavorable decisions.
During a review of Resident 65's admission Record, the admission Record indicated, Resident 65 was admitted to the facility on [DATE] with diagnoses including unspecified sequalae (condition resulting from a prior disease or injury) of cerebral infarction (a loss of blood flow to part of the brain), bipolar disorder (mental disorder that causes extreme shifts in mood, energy, and activity levels), anxiety disorder (uncontrollable feelings of fear and anxiety), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 65's Minimum Data Set [(MDS) a Federally mandated assessment tool], dated 8/12/2024, the MDS indicated Resident 65's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. The MDS indicated Resident 65 was dependent on toilet transfer, chair/bed to chair transfer, and bathing, required maximal assistance for oral and toilet hygiene, and required moderate assistance in personal hygiene. The MDS indicated Resident 65 utilized a wheelchair for mobility and does not have impairments on both the upper and lower extremities (arms and legs).
During a review of Resident 65's History and Physical (H&P), dated 3/14/2022, the H&P indicated, Resident 66 does not have the capacity to understand and make decisions for herself.
During a review of Resident 65's Arbitration Agreement dated 1/13/2023, the Arbitration Agreement indicated Resident 65 had officially signed the agreement.
During a concurrent interview and record review on 10/8/2024 at 2:15p.m., with Resident 65, Resident 65 stated she does not recall getting informed about the Arbitration Agreement and does not recognize her signature.
During an interview on 10/8/2024 at 2:33p.m., with Resident 65's family, Resident 65's family member stated she does not recall being informed regarding an Arbitration Agreement and confirmed Resident 65 cannot sign for herself ever since she had had a stroke (loss of blood flow to a part of the brain).
During a concurrent interview and record review on 10/8/2024 at 2:49 p.m., with the Admissions Assistant (AA), the AA stated Arbitration Agreements are voluntary and a part of the admission packet. The AA stated she is not sure if Resident 65 was able to decide whether to sign the Arbitration Agreement or not. The AA stated a facility staff (unknown) signed the document and indicated it was Resident 65's signature. The AA stated if a resident does not have the capacity to sign a legal document, she will contact the Residents legal representative (family member, power of attorney), explain the Arbitration Agreement, and let the representative decide whether to sign the document or not. The AA stated in Resident 65's case, she would have to ask the family member to review the Arbitration Agreement again and obtain a new agreement and will always check whether the resident is alert and oriented.
During a review of the facility's Arbitration Agreement, undated, the agreement indicated by signing this arbitration agreement below, the parties agree ot be bound by the provisions of this Arbitration Agreement. Further the Resident (or Resident's Legal Representative and/or Agent on behalf of Resident) acknowledges that: (A) the agreement has been explained to the Resident (or Resident's Legal Representative and/or Agent on behalf of Resident) by a representative of the Facility in the form and manner that the Resident understands, including the language .and (B) the Resident (or Resident's Legal Representative or Agent on behalf of Resident) understands this agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the antibiotic stewardship program policy for four of five sampled residents (Resident 39,96, 37 and 42) when an antibiotic (a substance used to kill bacteria and to treat infections) did not meet McGeer Criteria (criteria used to determine appropriate use of antibiotics) for administration.
This deficient practice had the potential to increase antibiotic resistance and provide antibiotics to the residents without justification.
1.During a review of Resident 39's admission record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including Parkinsonism (condition that affects movement), Bullous Pemphigoid (rare skin disorder that causes large fluid filled blisters on the skin), and Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 39's Minimum Data Set [(MDS) a Federally mandated assessment tool], dated 8/20/2024, the MDS indicated Resident 39's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS indicated Resident 39 required maximal assistance in toilet transfer, chair/bed-to-chair transfer, oral hygiene, dressing the upper and lower body, bathing, and required moderate assistance for oral and personal hygiene. The MDS indicated Resident 39 did have an impairment on one side of the upper extremities (arms/shoulders) and did not have any impairments on both of the lower extremities (arms and legs) and utilized a walker and a wheelchair.
During a review of the McGeer's Criteria for Infection Control Surveillance (a document to identify whether the symptoms meet the criteria for definitive infection) dated 5/18/2024, the McGeer's criteria indicated Resident 39 had skin, soft tissue, and mucosal infections, cellulitis (bacterial skin infection that spreads rapidly), soft tissue, or wound infection. The surveillance document did not indicate an onset date and the section for indicating new or increasing presence of at least four (4) of the following sign or symptom of an infection, sub criteria indicated 'heat' at the affected site. Resident 39 was prescribed Doxycycline (an antibiotic) 100 milligram (mg: unit of mass) tablet by mouth. Resident 39 was admitted from the hospital with an order of Doxycycline 100mg for Bullous Pemphigoid.
During a review of the McGeer's Criteria for Infection Control Surveillance for Resident 39, dated 7/30/2024, the surveillance documents indicated the McGeer's criteria indicated (Resident 39 had a) urinary tract infections (UTI: infection in the urinary system) and no other sub criteria (signs and symptoms of a UTI infection) were selected. Resident 39 was ordered an antibiotic to treat the UTI called Amikacin Sulfate Injection Solution (Amikacin Sulfate: used to treat severe or serious bacterial infections) 250mg Intravenous (IV: device inserted into vein to provide medication or fluid) in the evening for UTI for seven (7) days.
During a concurrent interview and record review of Resident 39's McGeer's Criteria form on 10/8/2024 at 4:08p.m. with Infection Preventionist Nurse (IPN), the IPN stated the antibiotic stewardship is a process to minimize the increase of infections, minimize the use of antibiotic to prevent antibiotic resistance, and ensure residents are not on antibiotics unnecessarily. The IPN stated the McGeer's Criteria is a tool that is used to determine whether the resident has a true infection or not and or whether the resident qualifies to receive antibiotics. The IPN stated Resident 39 is currently on Doxycycline 100 mg three times a day for Bullous Pemphigoid, the IPN indicated the dermatologist (medical doctor who treats and diagnose skin disorders) would like to do laboratory tests (medical tests usually done on the resident's blood) every month until 11/12/2024 and decide whether to discontinue the antibiotics or not on 11/24/2024. The IPN stated Resident 39 has been on Doxycycline since admission on [DATE]. The IPN stated the McGeer's Criteria documentation dated 5/18/2024 for the skin infection did not meet the criteria for the use of antibiotics because only one out of four indicated subcriteria were met. The IPN stated the McGeer's Criteria documentation dated 7/30/2024 for the UTI did not indicate any sub criteria were met to justify use of antibiotics.
2. During a review of Resident 96's admission Record, the admission Record indicated Resident 96 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including UTI, infection and inflammatory reaction due to indwelling urethral catheter (thin tube inserted into the bladder to drain urine), and extended spectrum beta lactamase (ESBL: enzyme produced by bacteria that are resistant to common antibiotics) resistance.
During a review of Resident 96's MDS dated [DATE], the MDS indicated Resident 96's cognitive skills were intact. The MDS indicated Resident 96 is dependent on toilet hygiene, bathing toilet transfer, required maximal assistance dressing the lower body and required moderate assistance for oral hygiene, personal hygiene, and upper body dressing. The MDS indicated Resident 96 had impairments the lower extremities bilaterally and utilized a wheelchair and walker for mobility.
During a review of Resident 96's McGeer's Criteria for Infection Control Surveillance dated 9/24/2024, the McGeer's criteria indicated Resident 96 had a urinary tract infection without an indwelling catheter. The McGeer's Criteria indicated both criteria one (1) and two (2) must be present with at least one of the following sign or symptom subcriteria, but there were no sub criteria's indicated on the surveillance form. Resident 96 came from the hospital with an order to continue the antibiotic Cephalexin (generic name: Keflex) (medication is used to treat a wide variety of bacterial infections) 500mg for UTI due to the presence of Escherichia coli (E. Coli: bacteria found in food, water, and intestines) and ESBL taken from the catheter.
During a concurrent interview and record review on 10/8/2024 at 4:28 p.m., of Resident 96's McGeer's Criteria dated 9/27/2024 on with the IPN, the IPN stated the sub criteria: in the absence of fever or leukocytosis (a blood test result indicating infection), then two (2) or more of the sub criteria indicating infection should have been selected. The IPN stated Resident 96 was on the Cephalexin from 9/26/2024 to 10/6/2024.
3. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 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) and hemiparesis (partial weakness on one side of the body) affecting right dominant side, hypertension (high blood pressure), and anxiety (excessive worry, fear) disorder.
During a review of Resident 37's MDS dated [DATE], the MDS indicated Resident 37's cognitive skills were intact. The MDS indicated Resident 37 required maximal assistance for chair/bed to chair transfer, toilet transfer, bathing, toilet hygiene, and required moderate assistance for personal hygiene, oral hygiene, and dressing the upper and lower body. The MDS indicated Resident 37 did not have any impairments on both the upper and lower extremity and utilized a wheelchair and walker.
During a review of the McGeer's Criteria for Infection Control Surveillance dated 9/29/2024, the McGeer's criteria indicated Resident 37 had skin, soft tissue, and mucosal infections, cellulitis (bacterial skin infection that spreads rapidly), soft tissue, or wound infection. The onset date was 9/27/2024 and the section indicating new or increasing presence of at least four (4) signs or symptoms of infection, the surveillance documents indicated only two of the required four subcriteria were selected.
Resident 37 was prescribed Bactrim double strength (DS) (used to treat various bacterial infections) oral tablet 800-160mg for 10 days for folliculitis (inflamed hair follicle due to infection) and redness on the nose to forehead.
During a concurrent interview and record review of Resident 37's McGeer's Criteria on 9/27/2024 at 4:39 p.m., with the IPN, the IPN stated the use of antibiotics to treat folliculitis did not meet the McGeer's criteria since only two of four subcriteria were selected.
4. During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including pneumonia (infection in one or both of the lungs), UTI, and dysphagia (difficulty swallowing).
During a review of Resident 42's MDS dated [DATE], the MDS indicated Resident 42's cognitive skills were moderately impaired. The MDS indicated Resident 42 required maximal assistance for most of the activities of daily living (ADL: bathing, chair/bed-to-chair transfer, oral hygiene) and required moderate assistance in dressing the upper body and eating. The MDS indicated Resident 42 did not have any impairments for both the upper and lower extremities and utilized a wheelchair.
During a review of Resident 42's McGeer's Criteria for Infection Control Surveillance dated 7/31/2024, the McGeer's criteria indicated Resident 42 had a respiratory tract infection. The Surveillance form did not indicate any sub critera to justify administering antibiotics. Resident 42 was prescribed Ceftriaxone (used to treat bacterial infections in many different parts of the body) Sodium Intravenous Solution Reconstituted (process of adding a liquid to a dry ingredient to make a specific concentration of liquid) 1gm intravenously every 24 hours for bronchitis (inflammation in the airway of the lungs) for seven days.
During a concurrent interview and record review of Resident 42's McGeer's Criteria on 7/31/2024 at 4:47p.m. with the IPN, the IPN stated there are no subcriteria selected, tIPN stated the subcriteria can identify the type of infection the resident has and the treatment can change depending on the infection. IPN stated Resident 42 ended her antibiotics on 8/6/2024 and does not know whether her symptoms have cleared up at that time. IPN stated she would know if an antibiotic was effective if the resident does not show anymore signs and symptoms (s/s) of the infection but reiterated she has not documented any notes post antibiotic use. IPN stated following up can determine whether the antibiotics were effective or not since without a follow up, the resident may still have an infection and would be monitored from the moment they start until they finish the antibiotic.
During a review of the facility's P&P titled, Antibiotic Stewardship-Orders for Antibiotics, revised 12/2016, the P&P indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for medication Utilization and Prescribing. Appropriate indications for use of antibiotics include criteria met for clinical definition of active infection or suspected sepsis .the staff and practitioner will document the specific criteria that support the suspicion in the resident's clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents' medical records were up to date as per the facility's policy and procedure (P&P) regarding advance directives (a legal document indicating resident preference on end-of-life treatment decisions) for two of seven sampled residents (Residents 18 and 83).
These deficient practices violated the residents' right to be fully informed of the option to formulate an Advance Directive and had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff.
Findings:
A. During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of heart failure (a heart disorder which causes the heart to not pump the blood efficiently), chronic obstructive pulmonary disease ([COPD] a chronic lung disease that makes it difficult to breathe), atrial fibrillation (an irregular and fast heartbeat in the upper part of the heart), depression (sad mood disorder), difficulty walking, and muscle wasting.
During a review of Resident 18's Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 4/23/2024, the MDS indicated Resident 18 was moderately impaired in cognitive (though process) skills for daily decision-making and needed maximal assistance with self-care abilities such as oral hygiene, toileting, shower/bathing, dressing and functional abilities such as rolling left and right, sitting, and transferring.
During a concurrent observation and interview on 10/06/2024 at 11:10 a.m., with Resident 18 in her room, Resident 18 was resting in bed. Resident 18 was alert and oriented to person and place, the resident knew who she was and what city she was in but did not know the name of the facility she was in or why she was in the facility, and what time of day it was.
During a concurrent interview and record review on 10/08/2024 at 11:28 a.m., with the Social Service Director (SSD), the Advance Directive Acknowledgement form, dated 11/19/2022 was reviewed. The SSD stated Resident 18 does not have the capacity to execute an Advance Directive. The SSD stated the Advance Directive acknowledgement form was filled out in 2022 and the SSD stated she was not aware of who filled out the form. The SSD also stated the Advance Directive acknowledgement form was not valid the way it was and should have been discussed with Resident 18's responsible party (RP). The RP would need to fill out the Advance Directive acknowledgement form.
B. During a review of Resident 83's admission Record, the admission Record indicated Resident 83 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension ([HTN], high blood pressure), and anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation).
During a review of Resident 83's MDS dated [DATE], the MDS indicated Resident 83 was severely impaired in cognitive skills for daily decision making and was dependent on staff for self-care abilities such as oral hygiene, toileting, shower, and dressing and on functional abilities such as rolling left and right, sitting, and transferring.
During a concurrent observation and interview on 10/7/2024 at 9:13 a.m., with Resident 83 in her room, Resident 83 was lying in bed with eyes closed. Resident 83 did not open eyes when asked how the resident was doing today and the resident did not respond back.
During a concurrent interview and record review on 10/10/2024 at 11:28 a.m., with the SSD, the Advance Directive acknowledgement form for Resident 83, dated 9/11/2024 was reviewed. The SSD stated the Advance Directive acknowledgement form indicated the resident or RP had not executed an Advance Directive and do not wish to do so at this time. The Advance Directive acknowledgment form indicated verbal consent by a family member, but the facility does not know which family member it that the SSD spoke to. The SSD stated she does not know if the consent was a verbal consent over the phone or verbal consent in person as the form did not indicate so. The SSD stated the AD acknowledgement form was incomplete and not valid and another form would need to be completed.
During an interview and record review on 10/10/2024 at 3:44 p.m., with the Director of Nursing (DON), the DON stated if a resident is not able to fill out the Advance Directive acknowledgement form, the RP would fill it out. The DON stated the importance for residents to have an AD so the facility will know what the resident's or family wants in terms of treatment for end-of-life care.
During a review of the facility's policy and procedure (P&P), titled Advance Directive, revised in December 2016, indicated The resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .if resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative . prior to or upon admission of the resident, the Social Service Director or designee will inquire of the resident, his/her family members and/or his or her legal representative about the existence of any written advance directive . information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS], a federally mandated resident assessment tool) assessment for two of three sampled residents (Resident 81, and Resident 83).
This deficient practice had the potential to result in inaccurate care and services for the residents due to inappropriate MDS assessment and care screening tool practices.
Findings:
A. During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was originally admitted on [DATE] with a re-admission date on 5/31/2023 with diagnoses of atrial fibrillation (a condition that causes irregular and fast heartbeat in the heart), congestive heart failure ([CHF], when the heart cannot pump enough blood to meet the body's needs), type 2 diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing) , depression (sad mood disorder), dementia (a gradual decline in cognitive abilities such as thinking, remembering and reasoning), obstructive sleep apnea ([OSA], common sleep disorder that causes the upper airway to partially or completely collapse during sleep), and obesity (a disease when a person has too much body fat).
During a review of Resident 81's MDS, dated [DATE], the MDS indicated Resident 81 was moderately impaired in cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making and was maximal assistance (helper does more than half the effort in assisting to complete the task) on self-care abilities such as oral hygiene, toileting, shower, and dressing and on functional abilities such as rolling left and right, sitting, and transferring. The MDS also indicated that the bedrails were not being used.
During an observation on 10/6/2024 at 12:24 p.m., in Resident 81's room, Resident 81 was resting in bed watching television. The two upper side rails were up.
During a concurrent interview and record review on 10/9/2024 at 10:40 a.m., with the MDS Coordinator (MDSC), Resident 81's order summary report dated 10/8/2024 was reviewed. The order summary report indicated both upper quarter rails were up to aid in turning and repositioning, informed consent obtained by Medical Doctor (MD) from responsible party (RP), risks and benefits explained. The MDSC stated the two upper side rails were being used for aiding and turning in bed and does not meet the criteria of restraint. The MDSC stated the side rails and consent for the side rails does not affect how the MDS was coded on the MDS assessment.
During a review of the facility's policy and procedure (P/P) titled, Resident Assessments, revised November 2019, indicated the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessment and reviews.
B. During a review of Resident 83's admission Record, the admission Record indicated Resident 83 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus, hypertension ([HTN], high blood pressure), anemia (a condition where the body does not have enough healthy red blood cells), anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), insomnia (difficulty sleeping at night), and muscle weakness.
During a review of Resident 83's MDS dated [DATE], the MDS indicated Resident 83 was severely cognitively impaired for daily decision making and was dependent (helper does all the effort in assisting to complete the task) on self-care abilities such as oral hygiene, toileting, shower, and dressing and on functional abilities such as rolling left and right, sitting, and transferring. The MDS also indicated the side rails were not being used in the bed.
During an observation on 10/7/24 at 9:04 a.m. in Resident 83's room, Resident 83 was lying in bed with eyes closed. The two upper side rails were up.
During a concurrent interview and record review on 10/9/2024 at 10:31 a.m. with the MDS Coordinator (MDSC), Resident 83's order summary report dated 9/9/2024 was reviewed. The order summary report indicated both upper quarter rails up, to aid in turning and repositioning, informed consent obtained by Medical Doctor (MD) from responsible party (RP), risks and benefits explained. The MDSC stated the two upper side rails were being used for aiding and turning in bed and does not meet the criteria of restraint. The MDSC stated the side rails and consent for the side rails does not affect how the MDS was coded on the MDS assessment.
During a review of the MDS 3.0 Section P guidance, the guidance indicates that if the use of bed rails (quarter-, half- or three-quarter, one or both, etc.) meets the definition of a physical restraint even though they may improve the resident's mobility in bed, the nursing home must code their use as a restraint.
During a review of the facility's Resident Assessment/Care Plan Coordinator (MDS) job description, no date, indicated, general duties and responsibilities included conduct or coordinate the interviewing of each resident for the resident's assessment ensure that all members of the assessment team are aware of the importance of competences and accuracy in their assessment functions and that they are aware of the penalties, including civil money penalties, for false certification inform all assessment team members of the requirements for accuracy and completion of the resident assessment (MDS).
During a review of the facility's policy and procedure (P/P) titled, Resident Assessment, revised November 2019, indicated a change in status assessment is required when a resident begins to use a restraint of any type, when it was not used before.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the nursing staff failed to update and revise a fall risk care plan for two of three sampled residents (Resident 106 and 170).
This deficient practice had the potential to place Residents 106 and 170 to be at risk for recurrent falls.
Findings:
a. During a review of Resident 106's admission record, the admission record indicated Resident 106 was initially admitted to the facility on [DATE] with a diagnoses of acquired absence of the right leg above the knee (amputation), Lack of coordination, and difficulty walking.
During a review of Resident 106 's history and physical (H&P) dated 9/13/202 4, the H&P indicated resident 106 had the capacity to understand and make decisions.
During a review of Resident 106's Minimum Data Set (MDS), a Federally mandated assessment tool, dated 7/31/2024, the MDS indicated Resident 106 required substantial /maximum assistance (helper lifts and hold the trunk or limbs, but provides less than half the effort) with upper and lower body dressing, and sit to stand.
During a review of the Fall Risk Assessment (an evaluation of the likelihood of someone falling) dated 7/25/2024, the Fall Risk Assessment indicated Resident 106 had a score of 7 according to the Fall Risk Assessment Resident 106 was not a fall risk.
During a review of the post Fall Risk assessment dated 9/ 21/2024, the Fall Risk Assessment indicated Resident 106 had a score of 7 according to the Fall Risk Assessment Resident 106 was not a fall risk.
During a review of the Change in Condition Evaluation (COC a form used to document a significant change in a person's health) form, the COC indicated Resident 106 had a fall on 9/21/2024 at 11:30 a.m.
b. During a review of Resident 170's admission record, the admission record indicated Resident 170 was initially admitted to the facility on [DATE], with diagnoses of dementia (loss of memory, language, problem solving and other thinking abilities that interfere with daily life), Alzheimer's disease (a decline in memory, thinking, learning and organizing skills over time) and hypertension (high blood pressure ).
During a review of Resident 170's MDS dated [DATE], the MDS indicated Resident 170 had severe cognitive impairment.
During a review of Resident 170's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 170 had a score of 13 according to the Fall Risk Assessment Resident 170 is a high risk for falls.
During a record review of Resident 170's COC form, the COC indicated Resident 170 had a fall on 1/8/2024.
During a review of the Post Fall Risk assessment dated [DATE], the Post Fall Risk Assessment indicated Resident 106 had a score of 10 according to the Fall Risk Assessment Resident 170 was at risk for fall.
During an interview on 10/10/2024 at 11:51 a.m. with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated we enter an incident into Residents care plan if a concern is already there, we update the care plan.
During a concurrent interview and record review on 9/10/2024 at 1:30 p.m., with the DSD (Director of Staff Development ) Resident106's untitled care plan was initiated on 8/8/2024, the care plan indicated resident 106 is at risk for falls related to a balance problem during transition and assistance needed during walking and bed mobility. The DSD verified Resident 106's care plan was not revised to reflect the fall incident on 9/21/2024.
During a concurrent interview and record review on 10/10/2024 at 4:30 p.m., with the Director of Nursing (DON), the DON verified Resident 106 and 170's care plans was not updated to reflect recent fall of Resident 106 on 9/21/2024 and Resident 170 on 1/8/2024. The DON stated it is important to update a resident's care plan to monitor which intervention is not working.
During a review of the facility's policies and procedures (P&P) revised December 2016, titled Care Plans Baseline indicates the resident and their representatives will be provided a summary of a baseline care plan that includes but not limited to: Any updated information based on the details of the comprehensive care- plan, as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure following up with an optometrist (health care providers who examine, diagnose, treat, and manage diseases and disorders of the visual system, the eye and associated structures as well as diagnose related systemic conditions) visit in six months as recommended by the optometrist and referring to ophthalmologist (a specialist who can treat complex medical issues related to your eyes, and can perform corrective procedures or surgeries including cataracts [tissue that forms over the eye, causing vision loss) and glaucoma [built up pressure in the eye that causes gradual vision loss]) for one of six sampled residents (Resident 55).
This failure had the potential to result in Resident 55 not receiving proper care to maintain and/or improve his vision.
Findings:
During a review of Resident 55's admission Record, the admission Record indicated, Resident 55 was initially admitted to the facility on [DATE] and last readmission was 4/2/2024 with diagnosis including end stage renal disease (irreversible kidney failure), diabetes mellites (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), left eye blindness, and glaucoma (a disease that damages your eye's optic nerve. It usually happens when fluid builds up and increases pressure inside the eye).
During a review of Resident 55's History and Physical (H&P), dated 1/4/2024, the H&P indicated, Resident 55 had the capacity to understand and make decisions.
During a review of Resident 55's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/16/2024, the MDS indicated Resident 55 required dependent assistance (Helper does all of the effort) from two or more staff for shower/bathe self, toilet transfer, maximal assistance (Helper does more than half the effort) from one staff for toileting hygiene, upper/lower body dressing, personal hygiene, bed mobility, moderate assistance (Helper does less than half the effort) from one staff for oral hygiene, and set up or clan up assistance (Helper sets up or cleans up) from one staff for eating.
During a concurrent observation and interview on 10/6/2024, at 11:55 a.m., with Resident 55 in his room, Resident 55 was looking for his eyeglasses. Resident 55 stated, he was left eye blind because of glaucoma and diabetes and he wore special eyeglasses to adjust with lights and glare. Resident 55 stated, he was worried about losing his vision on the right side because he was seen by an ophthalmologist a long time ago. Resident 55 stated, the optometrist came to see him in March, but there was no follow up visit after that, and his right eye was getting blurry.
During a concurrent interview and record review on 10/8/2024, at 11:33 a.m., with Social Service Director (SSD), Resident 55's Eye Doctor Consultation Notes, dated 3/26/2024 was reviewed. The Eye Doctor Consultation Notes indicated, Resident 55 was diagnosed with glaucoma, presbyopia (the gradual loss of your eyes' ability to focus on nearby objects), dry eye, and pseudophakia (an artificial lens implanted after the natural eye lens has been removed). The Eye Doctor Consultation Notes indicated, next exam in six months. The SSD stated, she should have arranged Resident 55's follow up appointment in September and referred to specialist to prevent glaucoma and DM related complication such as diabetic retinopathy (a condition that may occur in people who have?diabetes, from getting worse. It causes progressive damage to the retina, the light-sensitive lining at the back of the eye).
During an interview on 10/8/2024, at 3:00 p.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated, Resident 55 should have been seen by the specialist (ophthalmologist) to prevent further vision loss because his diagnoses of glaucoma and DM. RNS 2 stated, Resident 55's concerns regarding his right eye should have been addressed sooner since he lost his vision on left side due to same issue.
During an interview on 10/10/2024, at 12:43 p.m. with Director of Nursing (DON), the DON stated, the SSD should have followed up with the optometry visit in September to ensure Resident 55 was seen by the optometrist and referred to the ophthalmologist regarding blurry vision. The DON stated, if the follow ups and referrals were not done in a timely manner, Resident 55 might lose his vision on right eye, and this will greatly affect his ability to do Activities of Daily Living (ADL).
During a review of Resident 55's Order Summary Report (OSR), dated 10/8/2024, the OSR indicated a physican's order dated 4/2/2024 for Brimonidine Tartrate (a medication to lower pressure in the eyes) Ophthalmic Solution (liquid eye drop) 0.2 percent (%) one drop in both eyes every eight hours for glaucoma. The OSR indicated, Dorzolamide HCL (a medication to treat high pressure inside the eyes) Ophthalmic Solution 2% one drop in both eyes two times a day for glaucoma was ordered on 5/16/2024.
During a review of Resident 55's Interdisciplinary (IDT- a group of health care professionals working collaboratively toward a common goal) Team Meeting Notes, dated from 3/2024 to 9/2024, the IDT Notes indicated, there was no discussion regarding Resident 55's follow-up visit with Optometry and Ophthalmologist referral.
During a review of Resident 55's untitled Care Plan (CP), initiated 1/3/2024, the CP Focus indicated, Resident 55 was at risk for injury due to impaired visual functioning secondary to glaucoma, left eye blindness, and DM. The CP Interventions indicated, provide medications (Brimonidine and Dorzolamide) as ordered and monitor for eye pain/problem. The CP interventions indicated; Optometry referral as indicated.
During a review of the facility's Policy and Procedure (P&P) titled, Ancillary Services, dated 5/2019, the P&P indicated, Policy: it is the policy of this facility to obtain dental, optometry, ophthalmology, podiatry, audiology (ENT) and psychological/psychiatric services for residents who present with or request a need for these ancillary services. RATIONALE: Ancillary services help residents attain and maintain healthy psychosocial functioning through their ability to interact with their environment. PROCEDURE: All residents will be assessed for ancillary needs upon admission, and reassessed quarterly and as needed. Dental evaluation should be done at least annually . Social Services will maintain records indicating when services (routine and non-routine) are due and when provided . Social Services will coordinate efforts with the ancillary service providers on recommended follow up until the need is met.
During a review of the facility's Policy and Procedure (P&P) titled, Social Service Department Role &Function, dated 11/2019, the P&P indicated, POLICY: It is the policy of this facility to provide medically related social services to all residents in an effort to help them achieve and maintain their highest practicable level . PROCEDURE: Medically-related social services means services provided by the facility's staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs. These services might include, for example: of physical, mental, and psychosocial functioning, within scope of accepted social work practice . Making referrals and obtaining services from outside entities (e.g., talking books, absentee ballots, community wheelchair transportation . Finding options which most meet their physical and emotional needs -Factors with a potentially negative effect on physical, mental, and psychosocial wellbeing include an unmet need for: Dental /denture care; Podiatry care; Eye Care; Hearing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow through Registered Dietitian (RD-a health professional who has special training in diet and nutrition)'s recommendations in a timely manner and failed to assess, monitor, and evaluate interventions to prevent two of nine sampled residents (Resident 42 and 79) from further weight loss by:
A. Failing to ensure to monitor and assess Resident 42's weekly weights and intake of supplements, and obtain an order for Megestrol Acetate (a medication to treat loss of appetite and weight loss) in a timely manner as recommended by the RD.
B. Failing to ensure Resident 79 received the boost glucose control (a nutritional drink designed to help people with type 2 diabetes [uncontrolled blood sugar] increase their nutrient consumption while maintaining their blood sugar levels) as recommended by the RD due to a significant weight loss.
This failure resulted in placing Resident 42 and 79 at risk for continued weight loss.
Findings:
A. During a review of Resident 42's admission Record, the admission Record indicated, Resident 55 was initially admitted to the facility on [DATE] and last readmission was 7/26/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), lack of coordination, and Pressure induced deep tissue damage (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of sacral region (the portion of the spine between lower back and tailbone).
During a review of Resident 42's History and Physical (H&P), dated 7/29/2024, the H&P indicated, Resident 42 did not have the capacity to understand and make decisions.
During a review of Resident 42's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/21/2024, the MDS indicated Resident 42 required maximal assistance (Helper does more than half the effort) from one staff for toileting hygiene, lower body dressing, personal hygiene, bed mobility, and moderate assistance (Helper does less than half the effort) from one staff for eating. The MDS section K (swallowing/Nutritional Status) indicated, Resident 42 had a weight loss of five percent (%) or more in the last month or a weight loss of 10 % or more in last six months and Resident 42 was not on physician prescribed regimen to improve Resident 42's weight loss.
During a concurrent observation and interview on 10/7/2024, at 12:35 p.m., with Licensed Vocational Nurse (LVN) 4 in the dining room, LVN 4 was assisting Resident 42 with feeding. Resident 42 was yelling and very confused. LVN 4 stated, Resident 42 ate 75 % of the meal, but she took a few sips of Boost Plus (a nutrient -packed, high calorie nutritional supplement drink) only because she was too full. LVN 4 stated, she did not document the amount of Boost Plus that Resident 42 drank during lunch. LVN 4 stated, she told Certified Nurse Assistant (CNA) to record the percentage of meal that Resident 42 consumed.
During a concurrent interview and record review on 10/7/2024, at 3:08 p.m., with the RD, Resident 42's Dietary Notes, dated from 7/16/2024 to 9/17/2024 were reviewed. The DN indicated, Resident 42's calorie requirement was 1762 kilocalories (kcal- The term used to represent the amount of energy required to raise the temperature of a liter of water one degree centigrade at sea level) on 7/16/2024 and 1713 kcal on 9/17/2024. The RD stated, Resident 42 was continuing to lose weight, and calorie requirements were getting less because she calculated based on the resident's current weight, not based on the resident's ideal weight.
During a concurrent interview and record review on 10/7/2024, at 3:15 p.m., with the RD, Resident 42's Dietary Notes, dated 7/16/2024 to 9/17/2024 were reviewed. The RD stated, she recommended an appetite stimulant (Megestrol Acetate) on 8/6/2024 during the weight variance meeting (an interdisciplinary team meeting to discuss and evaluate the residents' weight changes), but the physician ordered it on 8/29/2024. The RD stated, Nursing staff should have contacted physician to get an order for the appetite stimulant and carried out her recommendation right away. The RD stated, nursing staff should have measured Resident 42's weekly weight and recorded the amount of supplement drinks (Boost plus and health shakes- supplements for adding dietary calories and protein) consumed by Resident 42 to assess and evaluate interventions for effectiveness.
During a concurrent observation and interview on 10/8/2024, at 12:26 p.m., with the Quality Assurance Nurse (QA), in the dining room, the QA was assisting Resident 42 with feeding. Resident 42 ate 75% of the meal and drank four ounces of juice. Resident 42 took a sip of Boost Plus and spat it out right away. The QA stated, Resident 42 took few sips of Boost Plus because she was too full. The QA stated, it would be better if she could get the Boost Plus between meals, not with the meals.
During a concurrent interview and record review on 10/8/2024, at 3:10 p.m., with Registered Nurse Supervisor (RNS) 2, Resident 42's Medication Administration Record (MAR), dated 10/2024 was reviewed. The MAR indicated, health shakes, eight ounces were given at 10:00 a.m., 2:00 p.m., and 8:00 p.m. daily. The MAR did not indicate how much of each health shake Resident 42 consumed. RNS 2 stated, staff only document whether it was given or not, but staff did not document the amounts that Resident 42 consumed. RNS 2 stated, he would document it as 'given' (the whole drink consumed) even though Resident 42 took only a few sips of the health shakes. RNS 2 stated, there was no order to measure Resident 42's weekly weight. RNS 2 stated, staff should have followed up and notified the physician to order weekly weights and to document percentage of intake of the supplements to evaluate the progress of weight changes.
During an interview on 10/9/2024, at 11:52 a. m. with Director of Staff Development (DSD), the DSD stated, RD recommendation should have been carried out as soon as possible to prevent delay of care and provided Boost plus between meals to increase the consumption. DSD stated, weight variance meeting should have evaluated outcomes from interventions by using weekly weight and the amounts of Resident 42's intakes.
During an interview on 10/10/2024, at 3:44 p.m., with the Director of Nursing (DON), the DON stated, staff should have documented the portion of supplements Resident 42 consumed. The DON stated, there was no data recorded to be able to evaluate the effectiveness of the interventions since there was no weekly weight and amount of intake documented. The DON stated, the RD should have provided more calories and should have used ideal weight (a person's estimated weight that is associated with a healthy weight range for their height, ages, sex and frame size [Resident 42's goal weight-130 pounds]) instead of Resident 42's current weight to calculate the caloric requirements to improve weight status. The DON stated, RD's recommendation should have been carried out in timely manner to prevent a delay in treatment, and this could place the resident at risk for further weight loss. The DON stated, excessive weight loss could worsen the pressure injury (skin and tissue damage especially around bony areas due to continuous pressure) and serious complications.
During a review of Resident 42's Order Summary Report (OSR), dated 10/8/2024, the OSR indicated:
-Boost Plus with nectar thick liquid (liquids that has been altered to a thicker consistency than water) eight ounce three times with meals for supplement ordered on 8/31/2024.
-Health shakes with nectar thick liquid eight ounce three times a day between meals for supplement ordered on 9/19/2024.
-Megestrol Acetate 400 milligram/10 milliliter by mouth two times a day for appetite stimulant was ordered on 8/29/2024.
During a review of Resident 42's Weights and Vitals Summary (WVS), dated 10/8/2024, the WVS indicated, Resident 42 weighed 122 pounds (lbs) on 5/2/2024 and weighed 112 lbs on 10/04/2024, which was 8.20 % weight loss in six months. The WVS indicated as following:
On 5/2/2024 weight was 122 Lbs.
On 6/3/2024 weight was 118 Lbs.
On 6/19/2024 weight was 118 Lbs.
On 6/26/2024 weight was 118 Lbs.
On 7/3/2024 weight was 121 Lbs.
On 7/10/2024 weight was 117 Lbs.
On 7/28/2024 weight was 115 Lbs.
On 8/5/2024 weight was 115 Lbs.
On 8/13/2024 weight was 113 Lbs.
On 8/19/2024 weight was 111 Lbs.
On 8/26/2024 weight was 112 Lbs.
On 9/10/2024 weight was 111 Lbs.
On 10/4/2024 Resident 42's weight was 112 lbs. which was the last recorded weight at the facility.
During a review of Resident 42's untitled Care Plan (CP), initiated on 4/5/2024, the CP Focus indicated, Resident 42 was at risk for altered nutritional status as evidenced by history of weight loss. The CP Interventions indicated, monitor weight per protocol, provide Megestrol Acetate, health shakes, and Boost Plus supplement as ordered.
During a review of Resident 42's untitled CP, initiated 7/27/2024, the CP Focus indicated, Resident 42 exhibits poor oral intake and refuses to take food for all mealtimes. The CP Interventions indicated, assess for risk for impaired nutrition less than body requirement, feeder during mealtime, and monitor oral intake for every meals.
B. During a review of Resident 79's admission Record, the admission Record indicated Resident 79 was initially admitted to the facility on [DATE] and last readmission was 3/9/2024 with diagnoses including muscle wasting on the upper right and left arm, congestive heart failure (CHF: occurs when the heart cannot pump enough blood to meet the body's needs), Type II Diabetes Mellitus and unspecified protein-calorie malnutrition (lack of proper nutrition).
During a review of Resident 79's MDS dated [DATE], the MDS indicated Resident 79's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were intact. The MDS indicated Resident 79 required maximal assistance for chair-bed to chair transfer, toilet transfer, toilet hygiene and bathing. Required moderate assistance for lower body dressing, and required supervision for oral and personal hygiene, and upper body dressing. The MDS indicated, Resident 79 had a loss of five percent (%) or more weight in the last month or loss of 10 % or more in last six months was on a physician prescribed regimen to improve Resident 79's weight loss.
During a review of Resident 79's untitled CP initiated on 3/11/2024, the CP Focus indicated Resident 79 was at risk for altered nutritional status, dehydration electrolyte (a substance in the body that facilitate functions in the body) imbalance, and significant weight changes related to (r/t) fluid accumulation (CHF) and malnutrition. The CP Interventions indicated to monitor weight per protocol and Boost Glucose Control as ordered. The CP Initiated on 6/12/2024 indicated Resident 79 had a weight loss of seven (7) lbs. in one (1) month (three percent) with a resolve date of 9/12/2024. The CP Interventions indicated to monitor weights and report a five lb weight loss to the medical doctor (MD) and dietitian promptly.
During a review of Resident 79's OSR, the OSR indicated an active order of Boost Glucose Control three times a day for supplement with meals dated 10/4/2024. The OSR initially indicated a Boost Glucose Control two times a day on 8/15/2024.
During a review of Resident 79's WVS, the WVS indicated Resident 79 weighed 251 lbs. on 4/2/2024 and weighed 223 lbs. on 10/4/2024, which was 11.16 % weight loss in six months. The WVS indicated as following:
On
10/4/2024: 223.0 Lbs.
On
9/10/2024: 225.0 Lbs.
On
8/6/2024: 228.0 Lbs.
On
7/2/2024: 234.0 Lbs.
On
6/11/2024: 240 Lbs.
On
5/7/2024: 247.0 Lbs.
On
4/2/2024: 251.0 Lbs.
During a concurrent interview and record review on 10/7/2024 at 1:29 p.m., with Registered Dietitian (RD), RD stated if a resident has significant weight changes, the Interdisciplinary Team (IDT - Resident's healthcare team consisting of various specialties) will determine if a resident needs to be on weekly weights to monitor, review, and assess if their interventions are working. The RD stated since Resident 79 continued to lose weight she recommended on 8/13/2024 to add boost glucose control twice a day and to discontinue diuretics (medication used to remove excess fluids from the body). The RD stated Resident 79's weight has been trending down having lost 28 lbs. in 6 months, which is considered a significant weight loss, and indicated Resident 79 would have benefited from having a weekly weight done compared to being weighed monthly.
During a concurrent interview and record review on 10/10/2024 at 4:30 p.m., with QA, QA stated the Dietary Note dated 8/13/2024 indicated the recommendation was to discontinue fluids, order labs, and start boost glucose control twice a day with lunch and dinner. QA stated when there is a recommendation, they will inform the doctor, and once the doctor agrees with the recommendation, an order will be placed. QA stated they had an updated order regarding the boost glucose control on 10/5/2024. QA stated the order for boost control glucose was initiated on 8/15/2024 but was discontinued on 8/15/2024. QA stated based on the progress note on 8/15/2024, the doctor agreed to do the labs since it was completed on 8/15/2024 but is not sure what occurred regarding the order for the boost glucose control. QA stated there are no documentation regarding the boost glucose control and there are no indicating rational as to why the boost glucose control was discontinued on 8/15/2024. The QA stated Resident 79 should have gotten the boost glucose control back in August as recommended by the RD.
During a review of the facility's Policy and Procedure(P&P) titled, Weight Assessment and Intervention, revised 9/2008, the P&P indicated, Policy Statement: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Weight Assessment .3. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends overtime. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met . Analysis:1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range (including rationale if different from ideal body weight); b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake; c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; and d.Whether and to what extent weight stabilization or improvement can be anticipated .Care planning: individualized care plans shall address, to the extent. Possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . Interventions: I. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice and preference: b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating: d.
Environmental factors that may inhibit appetite or desire to participate in meals: e. Chewing and swallowing abnormalities and the need for diet modifications: f. Medications that may interfere with appetite, chewing, swallowing, or digestion; g. The use of supplementation and/or feeding tubes; and h. End of life decisions and advance directives.
During a review of the facility's Policy and Procedure(P&P) titled, Nutritional Assessment, revised 9/2011, the P&P indicated, Policy Statement: A nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. Policy Interpretation and Implementation . 3. Dietitian: a. An estimate of calorie, protein, nutrient and fluid needs; b. Whether the resident's current intake is adequate to meet his or her nutritional needs; and c. Special food formulations. 4. The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, that place the resident at increased risk for impaired nutrition.
During a review of the facility's Policy and Procedure(P&P) titled, Job Description: Dietary Consultant, dated 2011, the P&P indicated, Responsibilities: 1. Evaluates the nutritional needs of residents/patients and documents in the nutritional record.

Based on observation, interview, and record review, the facility failed to accurately account for one dose of a controlled medication (medications with a high potential for abuse) affecting Residents 10 in one of two inspected medication carts (West Station Cart 1.)
This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and the risk that Resident 10 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.
Findings:
During an observation and concurrent interview of [NAME] Station Cart 1, on 10/7/24 at 1:12 PM, with the Licensed Vocational Nurse (LVN 1) the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication):
1.
Resident 10's Narcotic and Hypnotic Record for morphine sulfate ER (a medication used to treat pain) 15 milligrams (mg - a unit of measure for mass) indicated there were two doses left, however, the medication card contained one dose.
During a concurrent interview, LVN 1 stated she administered the missing dose of Resident 10's morphine earlier this morning but failed to sign the Narcotic and Hypnotic Record at that time. LVN 1 stated she is required to sign the log before the medication is administered to ensure accountability for narcotics. LVN 1 stated failing to sign the log may result in the resident receiving a controlled substance more often than prescribed which could lead to medical complications.
A review of the facility's policy Controlled Substances, revised April 2019, indicated .Controlled substances are reconciled upon . administration . Upon administration, the nurse administering the medication is responsible for recording: .time of administration .quantity of the medication remaining, and signature of the nurse administering medications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician responded to the consultant pharmacist's recommendation from 8/3/24 to consider a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Depakene solution (a medication used to treat mood swings) in one of five sampled residents (Resident 65.)
The deficient practice of failing to ensure the physician evaluated and responded to medication irregularities (potential issues with a resident's medication regimen) identified by the consultant pharmacist during the Medication Regimen Review (MRR - a monthly report from the consultant pharmacist identifying any medication irregularities in a resident's current medication regimen) increased the risk that Resident 65 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.
Findings:
During a review of Resident 65's admission Record (a document containing diagnostic and demographic information), dated 10/8/24, indicated she was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental illness characterized by mood swings from manic highs to depressive lows.)
During a review of Resident 65's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 4/15/24, confirmed this resident's diagnosis of bipolar disorder.
During a review of Resident 65's Order Summary Report (a summary of all currently active physician orders), dated 10/8/24, indicated on 8/22/22, Resident 65 was prescribed Depakene 250 milligrams (mg - a unit of measure for mass) per 5 milliliters (ml - a unit of measure for volume) to take 10 ml by mouth one time a day for bipolar disorder manifested by yelling/screaming.
During a review of the consultant pharmacist's recommendation, dated 8/3/24, indicated the consultant pharmacist asked the physician to consider reducing the dose of Resident 65's Depakene solution or to indicate a clinical rationale as to why an attempt would be clinically contraindicated.
During a review of Resident 65's clinical record, no documentation was found indicating the physician responded to the consultant pharmacist's request to consider a GDR for Depakene solution.
During an interview on 10/08/24 at 10:03 AM, the Director of Nursing (DON) stated the facility failed to ensure the physician responded to the consultant pharmacist's request to decrease the dose of Depakene for Resident 65. The DON stated the GDR request addressed two different medications, but the GDR was only performed on one of them. The DON stated there is no record of a specific response to the pharmacist's request or any other record that addresses the dosage of Depakene specifically and the resident has been on the same dose since August of 2022. The DON stated the facility failed to decrease the dose or document a dosage reduction would be contraindicated for resident-specific reasons. The DON stated the failure to consider a GDR or respond to the pharmacist's request for GDR increased the risk that Resident 65 may have experienced adverse effects of Depakene, such as increased sedation, due to using a higher dose than necessary which could have negatively impacted her quality of life.
During a review of the facility's policy Pharmacy Services - Role of the Consultant Pharmacist, revised April 2019, indicated Upon receipt of the pharmacy recommendation, the facility will assign a licensed nurse or nurses to contact the prescribers and address the specific recommendations . The prescriber's response will be documented on the recommendations or in the resident's medical record. In the event the prescriber does not respond within 10 business days, the prescriber will be contacted again for follow-up. Record of the follow-up will be kept in a binder for review, or in the specific resident's medical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to discontinue hydroxyzine (a medication used to treat itching and allergies) per the physician's order due to non-use in one of five residents sampled for unnecessary medications (Resident 40.)
The deficient practice of failing to discontinue the use of hydroxyzine when Resident 40 was simultaneously using another medication to treat itching effectively could have increased the risk that Resident 40 may have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to the use of hydroxyzine possible resulting in a decline in her quality of life.
Findings:
During a review of Resident 40's admission Record (a document containing diagnostic and demographic information), dated 10/8/24, indicated she was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (a neurological condition causing muscle weakness.)
During a review of Resident 40's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 2/22/24, indicated she had the capacity to understand and make decisions.
During a review of Resident 40's Order Summary Report (a summary of all currently active physician orders), dated 10/8/24, indicated on 10/5/24, Resident 40 was prescribed hydroxyzine 50 milligrams (mg - a unit of measure for mass) by mouth every six hours as needed for itching for 14 days.
During a review of Resident 40's Order Summary Report, dated 10/8/24, indicated on 6/11/24, Resident 40 was prescribed Benadryl (a medication used to treat itching and allergies) 50 mg by mouth every six hours as needed for itching or allergies.
During a review of Resident 40's Medication Administration Report (MAR - record of all medications administered to a resident) between 8/1/24 and 10/8/24 indicated that, although Resident 40 has continually had an active physician order for hydroxyzine, she had never been administered a dose in that time frame.
During a review of the consultant pharmacist's recommendation, dated 8/3/24, indicated the consultant pharmacist made a recommendation to the physician to consider discontinuing Resident 40's order for hydroxyzine due to non-use and the fact that itching was being effectively treated with Benadryl. Further review of the pharmacist's recommendation indicated the physician agreed to discontinue hydroxyzine if it was not being used but the facility documented that the resident declined to have it discontinued because she still uses this.
During an interview on 10/08/24 at 10:17 AM, the Director of Nursing (DON) stated the facility failed to discontinue Resident 40's hydroxyzine despite an order from the physician to discontinue if it was not being used. The DON stated the MAR indicated this resident has not used any doses of hydroxyzine since August 2024 as it seems that the resident's itching is adequately controlled with the Benadryl. The DON stated there is a risk of increased side effects, such as sedation, if both Benadryl and hydroxyzine are used together which could negatively impact Resident 40's quality of life. The DON stated, because of the risk of adverse effects and non-use, the hydroxyzine should have been discontinued in August per the physician's order.
A review of the facility's policy Medication Therapy, revised April 2007, indicted Each resident's medication regimen shall include only those medication necessary to treat existing conditions and address significant risks . all medication orders will be supported by appropriate care process and practices .the physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example . when a medication is being given . in the absence of a valid clinical rationale .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Depakene solution (a medication used to treat mood swings) or document a clinical rationale as to why an attempt would be contraindicated in one of five sampled residents (Resident 65.)
The deficient practice of failing to perform or consider an GDR increased the risk Resident 65 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to Depakene therapy possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.
Findings:
During a review of Resident 65's admission Record (a document containing diagnostic and demographic information), dated 10/8/24, indicated she was admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental illness characterized by mood swings from manic highs to depressive lows.)
During a review of Resident 65's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 4/15/24, confirmed this resident's diagnosis of bipolar disorder.
During a review of Resident 65's Order Summary Report (a summary of all currently active physician orders), dated 10/8/24, indicated on 8/22/22, Resident 65 was prescribed Depakene 250 milligrams (mg - a unit of measure for mass) per 5 milliliters (ml - a unit of measure for volume) to take 10 ml by mouth one time a day for bipolar disorder manifested by yelling/screaming.
During a review of the consultant pharmacist's recommendation, dated 8/3/24, indicated the consultant pharmacist asked the physician to consider reducing the dose of Resident 65's Depakene solution or to indicate a clinical rationale as to why an attempt would be clinically contraindicated.
During a review of Resident 65's clinical record, no documentation was found indicating the physician responded to the consultant pharmacist's request to consider a GDR for Depakene solution or any other indication the dose of Depakene has changed since August 2022.
During an interview on 10/08/24 at 10:03 AM, the Director of Nursing (DON) stated the facility failed to ensure the physician responded to the consultant pharmacist's request to decrease the dose of Depakene for Resident 65. The DON stated the GDR request addressed two different medications, but the GDR was only performed on one of them. The DON stated there is no record of a specific response to the pharmacist's request or any other record that addresses the dosage of Depakene specifically and the resident has been on the same dose since August of 2022. The DON stated the facility failed to decrease the dose or document a dosage reduction would be contraindicated for resident-specific reasons. The DON stated the failure to consider a GDR or respond to the pharmacist's request for GDR increased the risk that Resident 65 may have experienced adverse effects of Depakene, such as increased sedation, due to using a higher dose than necessary which could have negatively impacted her quality of life.
During a review of the facility's policy Tapering Medication and Gradual Drug Dose Reduction , revised April 2007, indicated The physician will review periodically whether current medication are still necessary in their current doses; for example, whether an individual's conditions or risk factors are sufficiently prominent or enduring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medication, or with a lower dose . The physician will order appropriate tapering of medication, as indicated .

Based on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency related to their duties when:
1.Dietary Aid (DA2) and Dishwasher (DW) did not know the concentration strength of the chlorine sanitizer used in the dish machine (chlorine sanitizer a product that is used to reduce or eliminate pathogenic agents on surfaces).
2. Cook1 did not follow standardized recipes when preparing pureed diet and did not prepare enough zesty meat sauce to meet facility residents need.
These deficient practices had the potential to result in unsafe and unsanitary food production that could place 109 residents in the facility who received food at risk for foodborne illness and 16 residents who received lumpy pureed spaghetti at risk for choking and meal dissatisfaction in 12 residents who did not receive the spaghetti and meat sauce.
Findings:
1.During an observation in the dishwashing area on 10/6/2024 at 9:45AM, Dishwasher (DW) was wearing gloves and rinsing the dirty dishes then loading them inside the dishwasher. When asked about the sanitizer, DW attempted to test the sanitizer concentration in the dish machine. DW removed one dirty glove and kept the other then proceeded to take the test strip from its container and check the sanitizer effectiveness on the clean and sanitized dish surfaces.
During the same observation and interview with DW and Dietary Aide (DA2) on 10/6/2024 at 9:50AM, DW emersed the test strip on the dish surface with dirty gloves on, then compared to the color chart for chlorine sanitizer range. When asked DW stated the acceptable range for chlorine sanitizer is 200PPM. DW stated the test strip is not showing 200PPM, it is showing 50PPM.
During the same observation and interview DA2 who was standing next to DW, DA2 stated the acceptable range for chlorine sanitizer is 200PM, then stated maybe its 120PPM.
During a review of in-service records and interview with Dietary Supervisor (DS) on 10/06/2024 at 10:00AM DS stated the acceptable range for chlorine sanitizer is between 50-100PPM, DS stated staff was provided in service regarding sanitizers but both DW and DA2 were absent during the in-service day. DS stated DW and DA2 are confused between the two different sanitizers chlorine and quaternary sanitizer (quat, a type of sanitizing solution) used in the kitchen. DS sated they need to know the acceptable range so they can inform supervisor if something is wrong.
A review of Food and Nutrition Services in -service dated 9/23/24 on dish machine-chlorine level/temperature indicated DA2 and DW were not present for the in service.
A review of facility policy titled Dish washing (dated 2018) indicated, The chlorine should read 50-100PPM on dish surface final rinse.
A review of facility policy titled Sanitation (dated 2018) indicated, The Food service director is responsible for instructing Food and Nutrition Services personnel in the use of equipment. Each employee shall know how to operate and clean all equipment in his specific work area .
2. During an observation and a concurrent interview with Cook1 on 10/6/2024 at 1:05PM, the pureed spaghetti was not smooth and was chunky. The zesty meat sauce was not enough for all the residents. Cook1 stated he was rushing and did not add enough liquid to blend the spaghetti until the mixture was smooth. Cook1 stated he added water but should have added more water.
During the same interview, cook1 stated he didn't realize some residents are now double portion and he miscalculated the amount of meat to cook. Cook1 stated he did not notify DS when he ran out of the meat sauce to provide comparable alternatives.
During an interview with DS on 10/6/2024 at 1:05PM, DS stated cooks should notify DS and Registered Dietitian when there is an issue during food production and service. DS stated not receiving the food on the menu can cause meal dissatisfaction and residents can be upset.
During a review of the facility recipe for the Spaghetti with zesty meat sauce, it indicated puree the pasta and use milk for liquid.
A review of cook's job description (dated 2018), indicated, Duties and responsibilities: attend menu conference and plan food quantities to meet serving needs of the residents, report to food service director any problems with staff, food needs or any other irregularities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect one of one resident (Resident 1) from misappropriation of property (deliberate misplacement exploitation, or wrongful, temporary, or permanent use of a resident ' s belongings or money without the resident ' s consent) when Housekeeper 1 (HK 1) was running several personal errands procuring personal items, bringing the items to Resident 1, and cashing personal checks from Resident 1.
This deficient practice placed Resident 1 at risk for misappropriation of property.
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 end stage renal disease (kidney [organ that filters wastes and extra fluid from the body] failure), hemiplegia (paralysis of one side of the body), type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel) and heart failure (heart cannot pump as it should).
During a review of Resident 1 ' s Minimum Data Set (MDS), an assessment and care screening tool), dated 9/11/2023, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was moderately impaired.
During a review of Resident 1 ' s history and physical (H&P), dated, 7/14/2023, the H&P indicated Resident 1 recognized family, staff, and routines 75 to 90 percent of the time and needed occasional prompting. The H&P indicated Resident 1 was pleasant and slightly confused.
During a review of Resident 1 ' s Report of Suspected Dependent Adult/ Elder Abuse (SOC 341), completed 11/1/2023, the SOC 341 indicated family member 1 (FM 1) alleged an employee was involved in questionable bank transactions with Resident 1.
During a review of the facility ' s Investigation Summary for Resident 1 ' s abuse allegations, dated 11/6/2023, the summary indicated HK 1 confirmed that HK 1 made purchases for Resident 1.
During an interview with the Social services director (SSD) on 11/20/2023 at 12:02 p.m. HK 1 should not have run any errands for Resident 1. SSD stated HK 1 should have notified the activity director in charge of running errands to pick up personal items. The SSD stated when we handle finances everything is logged, and we give them a receipt for transactions.
During an interview with HK 1 on 11/20/2023 at 12:20 p.m., HK 1 stated Resident 1 was HK 1 ' s best friend and Resident 1 always asked HK 1 for personal favors during working hours. HK 1 stated he ran errands, like buying water, soda, food, clothes, and shoes, for Resident 1 for over a year. HK 1 stated Resident 1 wrote him personal checks which HK 1 deposited to his personal bank account. HK 1 stated he would then purchase items and bring it to Resident 1. HK 1 stated Resident 1 told him (HK 1) to keep the change for gas or extra cost. HK 1 stated he was unaware that he should not have been running errands or receiving any money from the residents. HK 1 stated he was unaware that it was illegal, and he should have referred Resident 1 to the social worker, the director of Nursing (DON), or the administrator (ADM).
During a phone interview with the ADM and record review of facility in service, dated 11/1/2023, titled Prohibiting staff from running errands for residents involving the handling of money, on 11/28/2023 at 3:45p.m., the in-service was reviewed. The in-service indicated staff was prohibited from running personal errands for residents involving the handling of money. The ADM stated the facility conducted in-services with all the staff as soon as the facility found out about HK 1 cashing checks issued by Resident 1 and running personal errands for Resident 1 because it was inappropriate. The ADM stated the facility social services was equipped to handle personal requests/ transactions needed by the residents, especially matters involving money.
During a review of the faculty policy and procedure titled Abuse policy and Procedure, revised 2/2018, the policy indicated:
a. Resident must not be subjected to abuse by anyone including facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.
b. To ensure resident rights are protected by providing a method for the prevention of alleged resident abuse.

Based on interview and record review, the facility failed to ensure the facility's Certified Nursing Assistants (CNAs) were provided mandatory (required by law or rules) minimum 12 hours per year in-service training of Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) Care and Abuse (treat a person with cruelty or violence, especially regularly or repeatedly).
This failure had the potential to result in the residents being subject to abuse, and residents who had dementia improperly cared for.
Findings:
During a concurrent interview and record review on 10/6/2023, at 4:38 p.m., with Director of Staff Development (DSD), CNA 8's In-Service Attendance Log for Abuse and Dementia Care (IALAD), dated from 1/2022 to 10/2023 was reviewed. The IALAD indicated, there were four abuse in-service trainings done on 2/17/2022, 5/18/2022, 7/7/2022, 12/5/2022 and three dementia care in-service trainings done on 3/15/2022, 4/21/2022, 9/8/2022. The IALAD indicated, there were five abuse in-service trainings done on 1/19/2023, 4/6/2023, 5/4/2023, 6/15/2023,7/13/2023 and one dementia care in-service training done on 1/12/2023. DSD stated abuse and dementia care in-service trainings were mandatory for CNAs and CNAs must receive two to four hours of both trainings per year. DSD stated, CNAs had an option to attend both trainings beyond four hours per year if they wanted to. DSD stated each session was done for one hour. DSD stated total mandatory trainings totaled 7 for the year 2022.
During a concurrent interview and record review on 10/6/2023, at 5:52 p.m., with DSD, the facility's In-Service Calendar (IC) for 2023 was reviewed. The IC indicated, abuse in-service was scheduled for 7/13/2023, 8/17/2023, 10/5/2023,11/9/2023 and dementia care in-service was scheduled for 1/12/2023. DSD stated, she noticed she did not follow the in-service calendar, but it would be ok if she completed 4 hours per year mandatory trainings. DSD stated, she found abuse and dementia care training records on 10/11/2017, but she could not find any records from 2018 to 2021. DSD stated, she had no evidence to prove the facility provided abuse and dementia care training from 2018 to 2021 to CNA 8. DSD stated those mandatory trainings were essential to provide better care for the residents.
During an interview on 10/6/2023, at 6:42 p.m., with Administrator (ADM), the ADM stated, he was not sure how many hours were required for abuse and dementia care training, but he believed it should be more than four hours. ADM stated the mandatory trainings were very important because all residents were being subjects to abuse and many of them were diagnosed with dementia.
During a review of the facility's Facility Assessment (FA), dated 4/21/2023, the FA indicated, Individual Staff Assignment .Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year. Include dementia management training and resident abuse prevention training.

Based on observation and interview, the facility failed to ensure the electric hi-low therapy mat (therapy mat, electric and adjustable padded mat table used for therapy treatments) was in safe, operating condition.
This deficient practice had the potential to cause injury to any resident or staff member who used this equipment as part of therapy treatment.
Findings:
During an observation on 10/4/2023 at 2:55 pm, in the rehab gym, a padded therapy mat was observed against the window of the rehab gym. The button controls to adjust the therapy mat height up and down were centered and attached to the base of the therapy mat frame.
During an observation and interview on 10/5/2023 at 10:00 am, in the rehab gym, the Director of Rehabilitation (DOR) who was also a Physical Therapist(PT- movement experts who improve quality of life through prescribed exercise, hands-on care, and patient education) confirmed the height of the therapy mat could not be adjusted because it was broken. The DOR stated the therapy mat was always left unplugged because the motor that controlled the height of the mat did not work. The DOR stated maintenance tried to fix the therapy mat several times, but it still did not work.
During an interview on 10/5/2023 at 11:24 am, the Maintenance Supervisor (MS) stated the therapy mat was broken. The MS stated the motor that powered the therapy mat to go up and down was broken. The MS stated he tried to fix the therapy mat multiple times, but it was still broken and did not know why the facility did not throw it away. The MS stated the facility decided to use the therapy mat as a standard mat table (static platform with a padded surface used for therapy treatments) since the motor was broken instead of trying to fix it or replace it.
During a follow up interview on 10/5/2023 at 12:43 pm, the DOR stated the therapy mat was still used for therapy treatments despite being broken because it was the only therapy mat the facility had. The DOR stated it was important to have equipment that was maintained in safe, operating order for patient safety, staff safety, and injury prevention.
During an interview on 10/5/2023 at 1:54 pm, the Occupational Therapist (OT 1) stated she was told the therapy mat was broken and could only use the therapy mat as a standard, non-adjustable mat for therapy treatments. OT 1 stated hi-low therapy mats were useful in therapy treatments because they allowed the therapist to adjust the height of the mat to assist with different types of transfers (an act of moving something or someone to another place) and improved staff safety.
During a follow up interview on 10/6/2023 at 11:45 am with the MS, the MS stated the therapy mat tilted and became unstable if the motor was turned on. The MS stated the therapy mat had been broken for almost one year and should have been replaced if it was broken and unfixable. The MS stated there could be potential harm to the staff and residents if the facility continued to use broken equipment during therapy treatments.
A review of the facility's undated Policy and Procedure (P/P) titled, Therapy Rooms, Equipment and Supplies, indicated Therapists are responsible for maintaining assigned equipment in a safe, clean, and usable manner.
A review of the facility's undated P/P titled, Assistive Devices and Equipment, indicated device condition would be addressed to decrease the risk of avoidable accidents associated with equipment. The P/P indicated Defective or worn devices will be discarded or repaired.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:
1.Cooked eggs, cooked bacon and ready to eat tofu were stored on the same shelf next to raw eggs and a carton of raw liquid eggs. Raw chicken was stored to thaw on shelf above raw marinated ground beef. This had the potential to cross contaminate food and result in food borne illness in 100 residents who received food from the kitchen.
2.Kitchen wash cloths/towel were stained and discolored, and dishware were chipped. Staff using discolored and stained wash cloths to clean food contact surfaces.
3.Cook1 did not wash hands after removing soiled gloved and returned to food prepare vegetables and rice. Dishwasher staff working in the dish machine area did not wash hands after changing gloves and when removing the clean and sanitized dishes from the dish machine.
4.Ice machine was not maintained in a sanitary manner and the inside compartment of ice machine was stained and dirty.
5. Food brought to residents from outside of the facility, including leftovers were stored in the resident food refrigerator were not labeled and dated.
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 illness in 100 out of 104 residents who received food and ice from the facility and including three residents who had food stored in the resident refrigerator.
Findings:
1.During an observation in the kitchen on 10/3/23 at 8:30AM, there was a container of hard-boiled eggs stored on same shelf next to raw shelled eggs and a carton of open liquid eggs in the reach in refrigerator. Cooked bacon on a tray and ready to eat tofu was also stored on the same shelf. During a concurrent observation and interview with Dietary Supervisor (DS), DS said it was left over from breakfast and cooked food should be stored separately to prevent cross contamination.
During and observation in the walk-in refrigerator on 10/3/23 at 8:40AM, there was raw chicken thawing on top of marinated ground beef. The ground beef was in a large bowl and loosely covered with a plastic wrap. During a concurrent observation and interview DS said chicken should be thawing on the bottom shelf to prevent juices from contaminating other meat products. DS reviewed the facility policy for food storage and said chicken should be stored on bottom shelf to prevent cross contamination and removed the meats.
A review of facility policy titled Food Preparation (Dated 2018), indicated, keep raw and cooked foods separate. Store raw meat, poultry, and fish in the order from top to bottom .a. whole fish, b. whole cuts of beef and pork, c. Ground meat and fish, d. whole and ground poultry.
2.During an observation in the kitchen on 10/3/23 at 9:15AM, Cook1 was using kitchen dish cloths to wipe and clean the counter for food preparation. The dish cloths were wet and were stored on the food preparation counters, Cook1 was using the same dish cloth to repeatedly wipe the counter after food preparation. The kitchen cloths looked stained and discolored grey in color. During concurrent observation and interview, cook1 said that the dish cloths are used to clean surfaces, [NAME] 1 said that he dips the dish cloth in the sanitizer bucket and wipes the surfaces. Cook1 said it should be inside the red sanitizer bucket, but he left them outside on the counter because he uses them often. During the same interview, Dietary Supervisor (DS) said that some of the kitchen wash cloths are discolored and will be replaced. DS said the dish cloth should always be stored in the sanitizer bucket inside the sanitizer solution when not in use for adequately sanitizing surfaces.
During a tray line lunch service observation on 10/3/23 at 11:50AM, observed 5 dishes were chipped and cracked on the sides. Cook1 continued to serve food to residents on chipped dishes. During a concurrent observation and interview DS removed the chipped dishes from service and said chipped dishes should be discarded because it can not be cleaned and sanitized.
A review of facility policy titled sanitation (dated 2018) indicated, all utensils, counters, shelves and equipment shall be kept clean, maintained in a good repair and free from .cracks and chipped areas.
A review of the 2022 U.S. Food and Drug Administration Food Code, Code 4-202.11 Food-Contact Surfaces, indicated, A) Multiuse FOOD-CONTACT SURFACES shall be:
(1) Smooth
(2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections
A review of the 2022 U.S. Food and Drug Administration Food Code, Code 3-304.14 Wiping Cloths, use Limitation, indicated, (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be:
(1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114; and (2) Laundered daily as specified under 4-802.11(D).
(C) Cloths in-use for wiping surfaces in contact with raw animal FOODS shall be kept separate from cloths used for other purposes.
3.During an observation in the food preparation area on 10/3/23 at 9:30AM, Cook1 was marinating and adding seasoning to raw chicken in a bowl. Cook1 had gloves on his hands and was mixing the chicken with hands. After finishing the chicken preparation, cook1 removed the soiled gloves and returned to the food preparation counter without washing his hands. [NAME] 1 proceeded to place the chicken in a pan and in the oven. Then Cook1 continued to prepare other food items. During a concurrent observation and interview, Cook1 said that he forgot to wash his hands after he removed the gloves. He said that he could contaminate everything that he touched after removing the gloves.
During an observation in the dishwashing area on 10/3/23 at 9:40AM, Dishwasher (DW1) was rinsing soiled dishes and loading the dirty dishes in the dish machine. DW1 had gloves on his hands, and after the dish machine stopped DW1 wore new gloves without washing hands and proceeded to remove the clean and sanitized dishes from the dish machine without washing hands. During a concurrent interview, DW1 stated he didn't wash his hands after removing gloves and before touching the clean dishes. DW1 sated not washing hands can contaminate clean dishes.
During an interview with DS on 10/3/23 at 9:50AM, DS said that in the afternoon there is two Dishwasher, and one handles the soiled dishes, and the other dishwasher assists with removing sanitized dishes.
A review of facility policy titled sanitation (dated 2018), indicated, A minimum of two employees will be used when dishes are machine washed. One will handle soiled area and ne will handle the clean side. If an employee does need to go from soiled end to clean end, a strict hand washing routine must be followed.
A review of the 2022 U.S. Food and Drug Administration Food Code, Code 2-301.14 When to Wash. Indicated, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and E) After handling soiled EQUIPMENT or UTENSILS.
(F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.
(G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD.
(H) Before donning gloves to initiate a task that involves working with FOOD.
4.During an observation of the facility ice machine on 10/3/23 at 1:05PM, located in the small dining room, a clean paper towel swipe of the ice storage bin ceiling produced small amounts of black residue. The residue was located under the baffle (plastic board that hold the ice from falling out of the ice storage bin). The baffle also had black color stains and discoloration.
During a concurrent interview with Maintenance Supervisor (MS), MS stated that it's his responsibility to clean the filters and outside of the ice machine. MS stated that an ice machine vendor cleans the inner compartments of the ice machine. During a concurrent review of the ice machine cleaning log, it indicated that outside vendor had cleaned on 8/9/23. MS verified that there was black residue inside the ice machine and said he will contact the vendor.
A review of facility policy titled sanitation (dated 2018), indicated, Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner.
5.During an observation in the resident refrigerator located in the conference room on 10/4/23 at 10:30AM, there was chicken and vegetable in a plastic container, a plastic bag full of several different soups, sandwiches, and snack with only resident room number on the bag, there was no date. There were several bags of food with no name and date and There was another container of food for a resident who is no longer at facility. During a concurrent interview with LVN5, she stated that nurses check the food brought from visitors for diet compatibility. LVN5 said that facility stores food for 3 days and then discard. LVN5 said it's important to label and date to know when to discard food. LVN5 didn't know when the food was stored in this refrigerator and said food will be discarded because there is no date on them.
A review of facility policy titled Foods brought by family/visitors (revised 10/2017) indicated, Perishable foods must be stored in resealable containers with tightly fitting lids in a refrigerator container will be labeled with the resident name, the item and the use by date. The nursing staff will discard perishable foods on or before the use by date.

Based on observation, interview, and record review, the facility failed to provide proper adaptive eating utensils (AE, eating equipment such as forks, knives, and spoons that are modified to increase independence with eating) for one of seven sampled residents (Resident 69) by failing to:
1.
Follow physician's orders for AE.
2.
Perform an assessment to determine the AE provided to Resident 69 was suitable and effective.
These deficient practices resulted in Resident 69 being issued built-up utensils (eating utensils with large handles made from hard plastic or soft foam to allow a person with limited grasp or hand strength to hold utensils with more ease) instead of weighted utensils (eating utensils with large handles with weights inside that help reduce tremors and improve control while eating) per physician's order for meals and had the potential to cause weight loss, decreased independence with self-feeding, and decreased quality of life.
Findings:
A review of Resident 69's admission Record indicated the facility admitted Resident 69 on 7/20/2021. Resident 69's diagnoses included right sided hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage), and muscle weakness.
A review of Resident 69's Minimum Data Set (MDS, a comprehensive assessment used as a care planning tool), dated 7/27/2023, indicated Resident 69 was severely impaired for cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 69 required extensive assistance with eating, dressing, personal hygiene, and bed mobility and was totally dependent with transfers (how resident moves between surfaces including to or from bed, chair, wheelchair and standing position), toileting, and bathing. The MDS also indicated Resident 69 had range of motion (full movement potential of a joint) limitations in one arm (shoulder, elbow, wrist, hand) and one leg (hip, knee, ankle, foot).
A review of Resident 69's Order Summary Report, dated 3/3/2022, indicated for Resident 69 to have weighted utensils every meal to improve independence with self-feeding.
A review of Resident 69's Comprehensive Care Plan, initiated 3/3/2023, indicated Resident 69 was at risk for altered nutritional status and significant weight changes. The interventions included providing weighted utensils with every meal to improve independence with self-feeding.
1.
During an observation and interview on 10/5/2023 at 12:22 pm, in Resident 69's room, Resident 69 was observed sitting in a recliner chair with a bedside table and meal tray placed directly in front of the body and at waist level. Certified Nursing Assistant 7 (CNA 7) was sitting in a chair to the left of Resident 69. The meal tray contained a plate divided into three sections with rice, meat, and an orange mashed potato like food. Three utensils (one fork, one spoon, and one knife) with red, thick handles were on the meal tray. Resident 69 drank fluid from a sippy cup (cup with a lid and a spout designed to reduce spills) using the left hand. CNA 7 handed Resident 69 the spoon with the red, thick handle and Resident 69 scooped the food from the tray with the left hand and fed self with assistance from CNA 7. The meal ticket on the tray indicated Resident 69's meal tray should have included built up utensils, a divided plate, and a sippy cup. CNA 7 confirmed Resident 69 was using built up utensils to eat, not weighted utensils.
During an interview and record review of Resident 69's Physician's Orders on 10/5/2023 at 2:03 pm, Licensed Vocational Nurse 3 (LVN 3) confirmed Resident 69 had a physician's order for weighted utensils for every meal. LVN 3 stated Resident 69 should have received weighted utensils instead of built-up utensils because the physician ordered weighted utensils. LVN 3 stated the CNA or LVN was supposed to compare and ensure the meal ticket items matched the physician's order prior to feeding the resident. LVN 3 stated that if the meal ticket items did not match the physician's order, nursing must always follow the physician's orders regardless of what the kitchen provided. LVN 3 confirmed the AE on Resident 69's meal ticket for built up utensils did not match the physician's order for weight utensils and should not have been given to Resident 69. LVN 3 stated it was important residents receive the correct AE because it could decrease their independence with self-feeding.
During an interview on 10/5/2023 at 2:20 pm, the Director of Nursing (DON) stated nursing must follow the physician's orders for AE. The DON stated it was important for residents to receive the correct AE during meals because it affected their level of independence with feeding.
During an interview on 10/6/2023 at 11:36 am, the Dietary Supervisor (DS) confirmed the kitchen staff did not follow physician's orders when providing Resident 69 with AE for all meals. The DS confirmed the utensils with the red, thick handles were built up utensils and the utensils with the thick grey handles were weighted utensils. The DS stated the kitchen had been providing Resident 69 with built up utensils, not weighted utensils per physician's order for a very long time because the type of AE manually inputted onto the meal ticket was incorrect.
2.
During an interview on 10/5/2023 at 10:00 am, the Director of Rehabilitation (DOR) stated Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) assessed the resident's need for AE. The DOR stated the OT notified the Director of Nursing (DON), Assistant Director of Nursing, or Quality Assurance Nurse of the specific type of AE recommended based on the resident's needs and nursing called the doctor to write an order.
During an interview on 10/5/2023 at 2:20 pm, the DON stated a clinical assessment for AE must be completed by an OT prior to issuing AE to any resident in the facility. The DON stated no other service in the facility would be able to complete an assessment and provide recommendations for the type of AE a resident needs because it was OT's specialty area. The DON stated that if AE was no longer suitable for a resident, OT would need to complete another assessment, update the recommendations for the proper AE for the resident, and obtain a new physician's order. The DON stated that if a resident received AE without a clinical assessment to ensure it was suitable for their needs, the AE may not be effective and would make the resident more dependent on others for care.
During an interview on 10/6/2023 at 8:45 am, the DOR stated he could not find any documented evidence from OT to indicate that Resident 69 was assessed for AE and did not know who recommended Resident 69 use weighted utensils for all meals. During a follow up interview with the DOR on 10/6/2023 at 9:25 am, the DOR stated if a resident was not assessed for the proper AE or used AE other than what was recommended by OT, it could potentially cause weight loss, agitation, depression, deconditioning (decline in physical function due to physical inactivity) due to malnutrition (lack of sufficient nutrients in the body), decreased quality of life, and decreased fine motor skills (ability to make precise movements using small muscle groups).
During an interview on 10/6/2023 at 9:38 am, the Administrator stated the facility did not have a policy for AE.
A review of the facility's Policy and Procedure (revised March 2018) titled, Activities of Daily Living (ADL), Supporting indicated residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. The P/P further indicated residents who were unable to carry out their ADLs independently would receive the necessary services to maintain good nutrition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident 55 was assisted and provided with additional nutritive packets to have a therapeutic diet (a prescribed meal plan that controls certain aspects of nutrients and/or foods as part of a treatment plan) as ordered by the physician during Restorative Nurse Assistant (RNA) feeding program (a feeding assistant program to restore residents to a former capacity or to improve their level of independence and thereby promote improved nutrition status) for one of three sampled residents (Resident 55).
This failure had the potential to result in preventing Resident 55 from receiving benefit of a therapeutic diet.
Findings:
During a review of Resident 55's admission record, the admission record indicated Resident 52 was admitted to the facility on [DATE]. Resident 55's diagnosis included atrial fibrillation (an irregular and often very rapid heart rhythm), dysphagia (difficulty swallowing), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and cerebral infarction (a loss of blood flow to part of the brain).
During a review of Resident 55's History and Physical (H&P), dated 8/17/2023, the H&P indicated, Resident 55 did not have the capacity to understand and make decisions.
During a review of Resident 55's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 8/17/2023, the MDS indicated Resident 55 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from one staff with bed mobility, transfer, dressing, toilet use, personal hygiene, and supervision and setup help for eating.
During a review of Resident 55's Order Summary Report , Order Summary Report dated 10/5/2023, theOrder Summary Report indicated, fortified diet with pureed texture, thin liquid consistency and large portion diet was ordered on 9/25/2023. Order Summary report also indicated RNA feeding program with breakfast and lunch ordered on 9/7/2023.
During a review of Resident 55's Care Plan (CP), dated 9/7/2023, the CP focus indicated, Resident 55 required RNA feeding program with breakfast and lunch. The CP interventions indicated, RNA provide verbal cues such as take a bit or pick up the spoon.
During a review of Resident 55's Care Plan (CP), dated 8/15/2023, the CP focus indicated, Resident 55 was at risk for altered nutritional status. The CP intervention indicated, provide diet as ordered: fortified diet, pureed texture, thin liquid consistency, large portion diet.
During a concurrent observation and interview on 10/4/2023, at 12:12 p.m., with RNA 1, at Rehabilitation RNA dining room, Resident 55 was sitting on chair and waiting for his tray. RNA 1 brought tray for Resident 55. The tray ticket indicated, fortified (The addition of nutrients to food, food constituents, or supplements) puree (foods that are smooth and lump free) diet. There was one sugar packet and two margarine packets on the tray. RNA 1 did not add any of them into Resident 55's food. There was no gravy on mashed potatoes, and no melted butter on pureed spinach. Resident 55 grabbed the spoon and started eating with his left hand. Resident 55 stated, all items on tray were dry. RNA 1 was observed to got up from her chair and left. RNA 1 stated, she left because Resident 55 was able to feed himself. RNA 1 stated, she did not know what the fortified diet was. RNA 1 stated, she did not add sugar packet and margarine packets into Resident 55's food because he did not ask to add. RNA 1 stated, she did not know where to get the list of residents who were receiving RNA feeding assistance.
During an interview on 10/5/2023, at 12:51 p.m., with Assistant Director of Nursing (ADON), ADON stated, she oversaw RNA feeding program. ADON stated, RNA should know the different types of physicians prescribed diets (therapeutic diet). ADON stated, if there were items to add such as butter packets or margarine packets to increase calorie on food, RNA should be able to recognize fortified items and add to the resident's food. ADON stated, RNA should stay with the resident entire mealtime and should not leave the resident during mealtime. ADON stated, if the resident did not get the fortified diet as ordered, it would affect the resident with undesired weight loss.
During a concurrent interview and record review on 10/4/2023, at 2:45 p.m., with Registered Dietitian (RD), Resident 55's Clinical Recommendations (CR), dated 9/5/2023, was reviewed. The CR indicated, Resident 55 lost seven pounds in three weeks and RD recommended RNA feeding program for breakfast and lunch. RD stated she recommended RNA feeding program so Resident 55 could get proper diet to gain back the weight he lost.
During a review of the facility's Lesson Plan for RNA Feeding Program (LP RNA FP), undated, the LP RNA FP indicated, RNA supervised, monitored, and assisted residents who needed feeding assistance to ensure that they consume the required calories and to prevent weight loss.
During a review of the facility's Fortified Menu Plan (FMP), undated, the FMP indicated, fortified diet plan added from 300 to 400 calories and from three to four grams of protein per day. The FMP indicated, fortified items for starch menu (such as mash potatoes) were extra half ounce melted margarine, one table spoon of puree shredded cheese, and 1 table spoon of sour cream. The FMP indicated, fortified items for vegetable menu were extra half ounce melted margarine or one table spoon of puree shredded cheese.
During a review of the facility's policy and procedure (P&P) titled, Fortification of Food: Increasing Calories and/or Protein in the diet, dated 2018, the P&P indicated, Purpose: The goal is to increase the calorie and /or protein density of the foods commonly consumed by the resident to promote improvement in their nutrition status .General considerations .Residents usually eat the same amount of food whether it is fortified or not. Therefore, fortification should increase nutrient density without increasing the amount of food sent.
During a review of the facility's policy and procedure (P&P) titled, RNA Feeding Program, undated, the P&P indicated, Policy . A restorative feeding/dining program, as part of the Facility Restorative program will be provided in order to restore residents to a former capacity or to improve their level of independence and thereby promote improved nutrition status.
During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, undated, the P&P indicated, Policy Statement: Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Policy Interpretation and Implementation . 4. A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure five vials of pens of insulin (a type of medication used to treat high blood sugar) requiring refrigeration were stored according to the manufacturer's requirements affecting Residents 5, 14 and 17 in one of two inspected medication carts (West Station Cart 2.)
The deficient practices of failing to store medications per the manufacturers' requirements increased the risk that Residents 5, 14 and 17 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization.
Findings:
During a concurrent observation and interview on [DATE] at 1:37 PM of [NAME] Station Cart 2 with the Licensed Vocational Nurse (LVN 2), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:
1.
One unopened vial of Humulin R (a type of insulin used to treat high blood sugar) for Resident 5 was found stored at room temperature.
According to the manufacturer's product labeling, unopened Humulin R vials must be stored in the refrigerator.
2.
One unopened vial of insulin glargine (a type of insulin used to treat high blood sugar) for Resident 14 was found stored at room temperature.
According to the manufacturer's product labeling, unopened vials of insulin glargine should be stored in the refrigerator.
3.
One unopened vial of Humulin R for Resident 17 was found stored at room temperature.
According to the manufacturer's product labeling, unopened vials of Humulin R should be stored in the refrigerator.
4.
One unopened vial of Lantus (a type of insulin used to treat high blood sugar) was found stored at room temperature.
According to the manufacturer's product labeling, unopened vials of Lantus should be stored in the refrigerator.
5.
One unopened Humulin N KwikPen (a type of insulin used to treat high blood sugar) for Resident 5 was found stored at room temperature.
According to the manufacturer's product labeling, unopened Humulin N KwikPens should be stored in the refrigerator.
LVN 2 stated the insulin for Residents 5, 14, and 17 are not stored properly according to the manufacturer's requirements. LVN 2 stated when insulin in unopened, it must remain in the refrigerator. LVN 2 stated she does not know why the insulin for Residents 5, 14, and 17 are stored in the medication cart. LVN 2 stated if insulin is stored at room temperature, the expiration date is shortened significantly and needs to be discarded much sooner. LVN 2 stated when insulin is stored improperly at room temperature, there is a risk of administering it to the resident once it has expired. LVN 2 stated administering expired insulin to residents could result in poor blood sugar control which could cause medical complications possibly leading to hospitalization.
A review of the facility's undated policy Medication Storage in the Facility, indicated Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations . mediations requiring 'refrigeration' . are kept in a refrigerator with a thermometer to allow temperature monitoring .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to enter or clarify a prescriber's order to reduce the dose of Seroquel (a medication used to treat mental illness) between 9/20/23 and 10/5/23 for one of five sampled residents (Resident 52.)
As a result of this deficient practice, Resident 52 received a higher than necessary dose of Seroquel between 9/20/23 and 10/5/23 which increased the risk that he could have experienced adverse effects (unwanted side effects of medication therapy like drowsiness or constipation) related to the use of Seroquel leading to a decline in his quality of life.
Findings:
A review of Resident 52's admission Record (a document containing a resident's demographic and diagnostic information), dated 10/5/23, indicated he was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality.)
A review of Resident 52's Order Summary Report (a document summarizing a resident's current, active physician orders), dated 10/5/23, indicated on 3/16/23, Resident 52's prescriber ordered Seroquel 25 milligrams (mg - a unit of measure for mass) by mouth at bedtime every other day (every 48 hours) for psychosis manifested by visual hallucinations i.e., seeing insects in his food.
A review of Resident 52's Medication Administration Record (MAR - a record of all medications administered to a resident) between 9/20/23 and 10/5/23 indicated Resident 52's was receiving Seroquel 25 mg every other day.
A review of the consultant pharmacist's Medication Regimen Review (MRR - a monthly report completed by the consultant pharmacist to identify irregularities in a resident's medication regimen) recommendation, dated 9/3/23, indicated the consultant pharmacist made a recommendation to consider a gradual dosage reduction (GDR - a periodic attempt to reduce the dosage of a medication to the lowest effective dose or to discontinue the medication) for Resident 52's Seroquel and pimavanserin (a medication used to treat mental illness). Further review of this MRR recommendation indicated the prescriber responded on 9/20/23 indicating a GDR was clinically contraindicated (not recommended) because target symptoms returned or worsened after a past GDR and to reduce the dose of Seroquel to 25 mg by mouth every 72 hours.
A review of Resident 52's psychiatric progress note (a document containing an assessment and plan for a resident's mental healthcare), dated 9/18/23 indicated the plan was to decrease Seroquel 25 mg every 72 hours.
During an interview on 10/05/23 at 10:41 AM, the Director of Nursing (DON) stated when a GDR is performed due to a MRR request, the facility staff enters the new order in the MAR, discontinues the old order, and transmits the order to the pharmacy to be filled. DON stated the MRR, dated 9/3/20, received via fax from the prescriber on 9/20/23 indicated that the prescriber wanted to decrease the dose of Seroquel to 25mg every 72 hours. The DON stated the psychiatric progress note from 9/18/23 also indicated the plan was also to decrease the dose of Seroquel 25 mg from every 48 hours to every 72 hours. The DON stated when the prescriber indicates a plan to change a resident's dose of medication, that change should be entered into the system immediately and the MAR should reflect the new dosage. The DON stated the facility failed to enter the new dosage for Resident 52's Seroquel on 9/20/23 or 9/26/23 (when the psychiatric progress note was received by the facility) and as a result Resident 52 is currently still receiving the old dosage of Seroquel 25 mg every 48 hours. The DON stated if Resident 52 received a higher dose of a Seroquel than necessary, it increases the risk that he may experience more adverse effects from that medication, like drowsiness, dizziness, or constipation, which could lead to a decline in his quality of life.
During an interview on 10/05/23 at 10:48 AM, the Quality Assurance Nurse (QA) stated when new orders from a MRR recommendation come in via fax, she or other licensed staff is responsible to put the order into the resident's MAR right away. QA stated neither she nor any other licensed staff entered Resident 52's new order for a reduction in the dose of Seroquel into the MAR. QA stated there was some confusion concerning the prescriber's response to the MRR recommendation, dated 9/3/23, indicating that a decrease in dosage was contraindicated while also providing instructions to decrease the dosage of Seroquel which may explain why it was not entered. QA stated since the MRR recommendation addressed two medications, it is likely that the prescriber intended to maintain the dose of one and reduce the dose of the other, but it would need to be clarified with the prescriber. QA stated she and other licensed staff failed to clarify the order to understand the prescriber's intent.
A review of the facility's undated policy Medication Orders, indicated Orders faxed (from the physician's office) . the following steps are initiated to complete the documentation: clarify the order . when a new order changes the dosage of a previously prescribed medication, discontinue(DC'd) the previous entry by writing DC'd and the date . enter the new order on the MAR .

Based on observation, interview, and record review, the facility failed to accurately account for the use of one dose of a controlled substance (medications with a high potential for abuse) affecting Resident 17 in one of two inspected medication carts (West Station Cart 2).
This deficient practice increased the risk that Resident 17 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.
Findings:
During an observation and concurrent interview of [NAME] Station Cart 2, on 10/4/23 at 1:37 PM, with the Licensed Vocation Nurse (LVN 2), the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication):
1.
Resident 17's Narcotic and Hypnotic Record for clonazepam (a medication used to treat mental illness) 0.5 milligrams (mg - a unit of measure for mass) indicated there was one dose left, however, the medication card was missing from the medication cart.
LVN 2 stated she administered the missing dose of clonazepam for Resident 17 around 9:00 AM today. LVN 2 stated she failed to sign the Narcotic and Hypnotic Record at that time because she was distracted by other tasks. LVN 2 stated it is important to sign the Narcotic and Hypnotic Record immediately after a controlled medication is administered to a resident to ensure accountability of the controlled substances, prevent diversion (transfer of a medication for any use other than what the prescriber intended), and ensure that the resident does not receive it more often than intended. LVN 2 stated if a resident receives a controlled medication like clonazepam more often than prescribed, it could cause medical complications.
A review of the facility's policy Controlled Substances, revised April 2019, indicated Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift . Upon administration, the nurse administering the medication is responsible for recording . time of administration, quantity of medication remaining, and signature of the nurse administering the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, the resident, who was assessed as being a moderate risk for falls, did not fall for one of one sampled resident (Resident 89).
The facility failed to:
1. Ensure a Certified Nurse Assistant (CNA 6) did not leave Resident 89 unsupervised when Resident 89 needed his soiled incontinence brief changed and left the resident's room to collect items for incontinence care.
2. Ensure CNA 6 followed the facility's policy and procedure (P&P) titled Answering the Call Light to summon other staff help by using the call light for assistance to get incontinence care items when CNA 6 was in the Resident 89's room.
3. Ensure Resident 89's room was changed closer to the nursing station for a closer observation/visibility as care planned.
These deficient practices resulted in Resident 89 attempting to remove his soiled incontinence brief (diaper) himself and fall out of bed sustaining a left hip fracture and subsequent transfer to a General Acute Care Hospital (GACH) for evaluation and treatment on 8/8/2023. At the GACH Resident 89 was diagnosed with closed left basicervical (area located at the junction between the femoral [the bone of the thigh] neck [part of the bone that connects the head of the bone with the middle part of the bone] and intertrochanteric region [area where the femur changes from a vertical bone to a bone angling at a 45° angle]) femur fracture requiring left hip open reduction internal fixation ([ORIF]-a type of surgery used to hold the broken bone together) with cephalomedullary nail (a surgical devise to stabilize the fracture). Resident 89 returned to the facility on 8/11/2023 with 11 staples on the incision (surgical cut) measured 5.0 centimeters [(cm) a unit of measure] by 0.1 cm to superior (top) surgical site of left hip, seven staples on the incision measured 4.0 cm by 0.1cm to inferior (bottom) surgical site of a left hip.
Findings:
During a review of Resident 's 89 admission Record (Face Sheet), the Face Sheet indicated Resident 89 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including difficulty in walking, unspecified dementia (impaired ability to remember, think, or make decisions), spinal stenosis (space inside the backbone is too small) of lumbar region (lower part of the back) type 2 diabetes (a disease that occurs when a person's blood glucose, also called blood sugar, is too high) and transient ischemic attack [(TIA) a condition when blood supply to part of the brain was briefly interrupted).
During a review of Resident 89's History and Physical (H/P), dated 8/12/2023, the H/P indicated, Resident 89 had the capacity to understand and make decisions.
During a review of Resident 89's Minimum Data Set [(MDS), a standardized assessment and care-screening tool], dated 6/07/2023, the MDS indicated Resident 89's cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making were mildly impaired. The MDS indicated, Resident 89 required extensive physical assistance from staff for bed mobility, transfer, walk in room, toilet use, and personal hygiene. The MDS indicated Resident 89 was frequently (seven or more episodes) incontinent with urinary continence and frequently (two or more episodes) incontinent of bowel.
During a record review of Resident 89's Fall Risk Evaluation dated 6/07/2023 and timed at 5:00 p.m., the Fall Risk Evaluation indicated Resident 89 was scored seven (0-5 low risk, 6-20 medium risk, 21-45 high risk) which indicated moderate risk for falls. The Fall Risk Evaluation indicated to provide Resident 89 with safe environment, clutter free, necessary belonging within reach, and attend needs in a timely manner.
During a review of Resident 89's GACH Emergency Department (ED) notes, dated 8/08/2023, and timed at 10:51 a.m., the ED notes indicated Resident 89 presented to the ED after rolling out of bed and landing on his left hip. The ED notes indicated Resident 89 was diagnosed with a nondisplaced intertrochanteric left hip fracture. The ED notes indicated Resident 89 undergo ORIF of the left hip.
During a review of Resident 89's GACH Computerized tomography [(CT) computerized x-ray {a photographic or digital image of the internal composition of something}] scan dated 8/08/2023, CT scan indicated the resident had an acute nondisplaced intertrochanteric fracture of the proximal left femur neck fracture.
During a review of the facility's Licensed Nurses Progress Note (LNPN), dated 8/07/2023, and timed at 9:56 p.m., the LNPN indicated Resident 89 was found lying on the floor in the resident's room. The LNPN indicated Resident 89 was complaining of pain of the left hip and the resident had a purple discoloration on the forehead. The LNPN indicated 911 (emergency number) was called and Resident 89 was transferred to GACH.
During a review of Situation Background Assessment and Recommendation [(SBAR) communication framework that can help teams share information about the conditions of the resident] form and LNPN dated 8/07/2023, and timed at 9:51 p.m., the SBAR indicated, at around 8:30 p.m., clinical nurse (CN) summoned the registered nurse supervisor (RNS) to Resident 89's room. The CN observed Resident 89 lying on the floor. SBAR indicated Resident 89 complained of pain level five out of 10 on a zero to ten pain rating scale (0 is no pain and 10 is worse possible pain) of the left hip. SBAR indicated Resident 89 was transferred to the GACH for further evaluation at 8:45 p.m.
During a review of Resident 89's Care Plan (CP) titled, Risk for fall related to balance problem during transition (sit to stand) initiated on 6/1/2023, the CP indicated the resident required assistance with walking and bed mobility. The CP indicated the goal for Resident 89 was to decrease significant injury as a result from falls and to minimize the risk for potential for fall related to resident's getting out of bed without waiting for staff assistance. The CP interventions included to provide Resident 89 with the adequate support from staff during activities of daily living (ADL) and transfers. The CP also indicated to move Resident 89 to a room close to the nursing station for a better visibility.
During an interview on 10/05/2023 at 11:42 a.m. with Resident 89, the resident stated he called for assistance by using the call light and waited for a long time and no one came to help. Resident 89 stated he needed his soiled diaper changed. Resident 89 stated it felt like he was waiting for more than an hour. Resident 89 stated he just kept on pressing the call light and no one was responding to his call for help. Resident 89 stated, when CNA 6 came in response to his (Resident 89's) call light, CNA 6 saw his soiled diaper needed to be changed. Resident 89 stated CNA 6 did not change his diaper and told him (Resident 89) to wait until he (CNA 6) comes back and left the room. Resident 89 stated, he had been waiting for a long time, so he decided to remove his diaper by himself. Resident 89 stated, when he attempted to sit up in bed, he felt dizzy and rolled out of his bed to the floor. Resident 89 stated, he had severe pain to his left side and screamed in pain.
During a phone interview on 10/05/2023, at 3:01 p.m., with CNA 6, CNA 6 stated on 8/07/2023 around 8:20 p.m., he answered Resident 89's call light and found Resident 89 trying to remove his diaper while in bed. CNA 6 stated to Resident 89 to leave the diaper on and left the room. CNA 6 stated he explained to Resident 89 that he would grab some towels and water to clean him. When CNA 6 came back, Resident 89 was on the floor adjacent to his bed laying on his back complaining of left-side pain.
During an interview on 10/5/2023 at 3:24 p.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated Resident 89 can make his needs known to staff. LVN 3 stated Resident 89 was assessed as moderate risk for fall and should not be left alone and provided the care needed. LVN 3 stated the Director of Rehabilitation (DOR) assess the residents upon admission and staff should provide the residents with assistance based on the DOR assessment.
During a concurrent interview and record review on 10/06/2023, at 8:41 a.m., with the DOR, the DOR reviewed Physical Therapy (PT) Discharge Summary, and stated, Resident 89 was able to safely ambulate using front-wheeled walker (assistive device) with supervision or touching assistance for proper sequencing (correct way of walking with assistive device) Physical Therapy Discharge summary dated from 6/20/2023 to 8/7/2023 indicated, Resident 89 required supervision or touching assistance with bed mobility, transfer, and ambulation. The DOR stated, there was a great possibility that Resident 89 could fall if Resident 89 gets out of bed by himself and/or walks by himself. The DOR stated, he did not recommend at all for Resident 89 to walk or get out of bed by himself.
During a review of Resident 89's PT Discharge summary dated from 6/20/2023 to 8/7/2023, the PT Discharge Summary indicated, Resident 89 required supervision or touching assistance with bed mobility (roll left and right), transfer from bed to chair, ambulation, and picking up object.
During a phone interview on 10/6/2023 at 8:54 a.m. with LVN 4, LVN 4 stated he remembered that on 8/7/2023 during 3 p.m. to11 p.m. shift at around 8 p.m. he heard a loud scream coming from Resident's 89's room when he (LVN 4) was attending to another resident. LVN 4 stated he walked to Resident 89's room and saw Resident 89 was lying on the floor, on his left side. LVN 4 stated, he remembers that Resident 89 needed moderate to maximum physical assistance from one staff. Resident 89's room was located about 40 feet away from the nursing station. LVN 4 stated, CNA 6 told him that CNA 6 walked out of Resident 89's room to get water and towel and when CNA 6 came back to Resident 89's room, Resident 89 was found on the floor. LVN 4 stated, Resident 89 was not supposed to be left alone when the resident needed help because Resident 89 has been trying to stand up by himself and tried to be independent.
During an interview on 10/06/2023, at 12:11 p.m., with the Director of Nursing (DON), the DON stated, if a resident was at moderate risks for falls, she educated a resident to use a call light for assistance. The DON stated after Resident 89's fall on 8/8/2023 we moved the resident in a room closer to the nursing station. The DON stated the facility staff should answer a call light promptly especially when a resident is at the risk for fall. The DON sated the facility staff discuss and communicate with each other to identify the residents who were at a moderate to high risk for fall. The DON stated the facility staff should not left Resident 89 alone since CNA 6 noticed Resident 89 felt uncomfortable with having on a soiled diaper. The DON stated if staff noticed that the resident would try to clean himself or herself up, staff should stay with the resident and ask other staff (CNA/LVN) to get the needed supply. The DON stated CNA 6 should have used the call light to ask for staff assistance and not leave resident 89's room.
During a review of the facility's undated P&P titled, Fall Prevention Program, revised 12/2007, the P&P indicated to assist resident with toileting needs upon rising before and after meals, before and after bed and as needed.
During a review of the facility's P&P titled, Safety and Supervision of Residents revised 7/2017, the P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.
During a review of the facility's undated P&P titled, Answering the Call Light. (undated) the P&P indicated staff to answer the resident's call as soon as possible. The P&P indicated, if assistance is needed when staff enter the room, summon help by using the call signal.
During a review of the facility's P&P, titled Care Plans-Comprehensive, revised 09/2010, the P&P indicated, the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representatives (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain a physician's order for foot care for one of one sample resident (Resident 97).
This deficient practice had the potential for placing the resident at risk for complications such as infection or bleeding of the feet.
Finding:
During a review of Resident 97's Face Sheet (admission record), the Face Sheet indicated Resident 97 was admitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis (paralysis and partial weakness on one side of the body) following a cerebral infarction (impaired blood flow to the brain) affecting the left non-dominant side, atrial fibrillation (irregular heart rhythm), cerebral aneurysm (bulging of the vessel that supplied to the brain) nonruptered, muscle weakness, contracture on the left hand, abnormalities of gait and mobility, Type II Diabetes Mellitus (high blood sugar without complications), and anxiety.
During a review of Resident 97's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 8/21/2023, the MDS indicated Resident 97's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS indicated Resident 97 required extensive assistance for dressing, toilet use, and personal hygiene and is totally dependent, transfer from bed, chair, wheelchair and move between one place to another. The MDS indicated Resident 97 was not steady transferring from sit to standing position and surface to surface transfers and is able to stabilize with staff assistance. The MDS indicated Resident 97 used a wheelchair for mobility and have an impairment on the upper extremities (arm, hand, shoulder).
During review of Resident 97's untitled CP initiated on 5/16/2023, the CP indicated Resident 97 had potential for bleeding, bruise, skin treat secondary to aspirin, Plavix, and apixaban.
During a concurrent interview and record review on 10/6/2023 at 1:44p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated Resident 97 does not have any podiatry consultation and social service is usually the one that makes the appointments for these services. RNS 1 stated Resident 97 had gotten her toenails cut once since she had been here in May 2023.
During a concurrent observation and interview on 10/6/2023 at 1:54p.m. with RNS 1, RNS 1 stated Resident 97's toenails are long on the right foot, but it is still okay as it is not digging in to her skin. Resident 97 stated it is not okay when she goes to physical therapy (PT) and her toenails are going in to skin. RNS 1 observed Resident 97's left big toe and stated that it was long. Resident 97 stated that she had asked three times to get her toenails cut but no one had attended to her request. RNS 1 stated if a Certified Nursing Assistant (CNA) observed that a resident's finger nail was long, or if they have a small cut, or if the resident wants a haircut, a CNA should notify the nurses. RNS 1 stated Resident 97 does not have an order for podiatry at this time and should have had one as it is the facilities protocol to put in a podiatry request for residents who are diabetic. RNS 1 stated if toenails are not cut on a timely manner, the toenails will become hard and would be difficult to cut, which may lead to bleeding and cause complications as diabetic residents are more prone to cuts.
During a review of the facility's P&P titled, Quality of Life-Dignity revised on August 2009, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).
During a review of the facility's P&P titled, Ancillary Services revised on May 2019, the P&P indicated it is the policy of this facility to obtain dental, optometry, ophthalmology, podiatry, audiology (ENT: Ears Nose Throat) and psychological/psychiatric services for residents who present with or request a need for these ancillary services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 14, and Resident 57) were provided with a communication board and language translating service were readily available.
These deficient practices lead the potential Resident 14 and 57 not communicating her needs effectively with staff and delay in care and services being rendered for Resident 14 and 57.
Findings:
a. During a record review of Resident 14's admission Record (Face Sheet), the Face Sheet indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage), and apraxia (loss of ability to carry out skilled movement and gestures).
During a record review of Resident 14's History and Physical (H/P), dated 8/28/2023, the H/P indicated Resident 14 does not have the capacity to understand and make decisions.
During a record review of Resident 14's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/09/2023, the MDS indicated Resident 14's cognitive (mental process by which knowledge is acquired, including perception, intuition, and reasonings) skills for daily decision making was severely impaired. The MDS indicated Resident 14 required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene.
During a concurrent observation and interview on 10/04/2023, at 9:37 a.m., with Certified Nurse Assistant 4 (CNA 4), Resident 14 continued saying [NAME], [NAME] and CNA 4 stated, he is not sure what she is saying. CNA 4 stated, Resident 14 cannot say any other words, except [NAME], and he usually assumed what Resident 14 asked. CNA 4 stated, he does not use communication board when he talked to the resident. CNA 4 stated, he did not know where he can find the communication board and it is not readily available in Resident 14's room.
During an interview on 10/06/2023, at 12:11 p.m., with Director of Nurse (DON), the DON stated, residents with aphasia, nurse should communicate with those residents by using communication boards for their needs and it should be located in the resident's room.
During a record review of Resident 14's Care Plan (CP), the CP indicated Resident 14 has communication problem difficulty communicating words or finishing thoughts unclear speech. The CP intervention indicated assist resident in decision making by giving simple choices.
During a review of facility's undated, policy and procedure (P/P), tilted Residents who present with Communication Barriers, the P/P indicated, communication boards will be provided at no charge to the resident so that non-English speakers, or aphasic residents can use pictograms to communicate needs and desires.
B. During a record review of Resident 57's Face Sheet, the admission record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including cerebral infarction on left side of brain (blood supply to the left side of the brain is stopped. The left side of the brain controls the right side of the body. It also controls the ability to speak and use language.), dementia (a loss of thinking ability, memory, attention, logical reasoning, and other mental abilities), hemiplegia of right side (right sided muscle paralysis or weakness), and hemiparesis of right side (weakness or the inability to move on right side of the body).
During a review of Resident 57's H&P, dated 10/5/2023, the H&P indicated, Resident 57 had no capacity to understand and make decisions.
During a record review of Resident 57's MDS, dated [DATE], the MDS indicated, Resident 57 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from one staff for bed mobility, dressing, personal hygiene, total dependence (full staff performance every time) from two or more staff for transfer, toilet use, and supervision and set up help for eating.
During an observation on 10/3/2023, at 2:12 p.m., in Resident 57's room, Resident 57 started yelling in her primary language (native language or mother tongue) and there was no communication board in her room.
During a concurrent observation and interview on 10/3/2023, at 2:22 p.m., with CNA 2, in Resident 57's room, Resident 57 was still yelling in her primary language. CNA 2 stated, Resident 57 was able to speak limited Spanish, but she did not understand what the resident was saying. CNA 2 stated, she did not know Resident 57's primary language, so she could not find out why the resident was yelling. CNA 2 stated, she could not find the communication board in Resident 57's room and did not know if there was any language translating service line available at the facility. CNA 2 stated, there should be a way to communicate with the Resident 57, because Resident 57 might need help for emergency and feel isolated.
During an interview on 10/4/2023, at 10:23 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 57 was able to communicate with limited Spanish, but the resident could not understand medical procedure or complex content. LVN 1 stated, it was important to provide information in Resident 57's primary language and to accommodate the resident's needs by communicating with the resident. LVN 1 stated, there was no language translating service number available at the facility.
During an interview on 10/6/2023, at 10:55 a.m., with DON, the DON stated the facility utilized staff who was able to speak different language other than English to communicate with the residents who were unable to speak English. DON stated, Resident 57 was speaking Cantonese, but there was no staff that could speak Cantonese. DON stated, it was important to provide communication board that way of communication for the residents to accommodate their needs and to provide proper treatment.
During a review of Resident 57's CP, dated 7/19/2021, the CP Focus indicated, Resident 57 had potential language barrier. Resident 57 was able to speak Cantonese and some Spanish. The CP Interventions indicated, use communication board, and use interpreters as possible.
During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised 3/2018, the P&P indicated, Policy Interpretation and Implementation .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with .e. Communication (speech, language, and any functional communication systems).
During a review of the facility's policy and procedure (P&P) titled, Residents Who Present with Communication Barriers, undated, the P&P indicated, Policy: It Is the policy of this facility to meet the needs of residents who present with communication barriers. RATIONALE: Communication supports psychosocial well-being by enabling residents to participate in their care. Procedure . Communication boards will be provided at no charge to the resident so that non-English speakers, or aphasic residents can use pictograms to communicate needs and desires.
During a review of the facility's policy and procedure (P&P) titled, Translation and /or Interpretation of Facility Services, revised 11/2020, the P&P indicated, Policy Interpretation and Implementation . 12. Interpreters and translators must be appropriately trained in medical terminology, confidentiality of protected health information, and ethical issues that may arise in communicating health-related information. 13. Family members and friends shall not be relied upon to provide interpretation services for the resident, unless explicitly requested by the resident. If family or friends are used to interpret, the resident must provide written consent for disclosure of protected health information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update and implement the comprehensive care plan for one of one sampled resident (Residents 73) who sustained a fall from his wheelchair.
This failure resulted in Resident 73 sustaining an injury from the actual fall.
Findings:
During a review of Resident 73's Face Sheet (admission record), the Face Sheet indicated Resident 73 was admitted to the facility on [DATE] with diagnosis including dementia with behavioral disturbance (impaired ability to think or make decisions accompanied by behaviors such as agitation and depression), Type II Diabetes Mellitus (high blood sugar) with diabetic chronic kidney disease (CKD: long term condition where the kidneys do not work as well), anxiety, repeated falls and hypertension (high blood pressure) .
During a review of Resident 73's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 9/8/2023, the MDS indicated Resident 73's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS indicated Resident 73 required extensive assistance for dressing, toilet use, and personal hygiene, transfer from bed, chair, wheelchair, moving between one place to another, dressing, walking, and required supervision for eating. The MDS indicated Resident 73 was not steady transferring from sit to standing position and surface to surface transfers and is able to only stabilize with staff assistance. The MDS indicated Resident 73 used a wheelchair and walker for mobility and have no impairments on both the upper and lower extremities (arms and legs).
During review of Resident 73's untitled Care Plan (CP) initiated on 6/6/2023, the CP indicated Resident 73 is at risk for fall related to balance problems during transition with contributing factors of history of falling, unsteady gait, and confusion. The CP goal indicated to decrease significant injury as a result from falls in the next three months. The CP intervention initiated on 6/7/2023 indicated Resident 73 can have a floormat, have perimeter mattress (a long triangular padding) applied to help resident define the edge of the bed with informed consent (IC) obtained by the medical director (MD) and responsible party with risk and benefits explained, and a pommel cushion while on the wheelchair due to Resident 73 having episodes of sliding down with IC obtained by the MD and responsible party.
During a review of Resident 73's untitled CP initiated on 6/30/2023 indicated Resident 73 had an actual fall with no injury. Additionally, it indicated Resident 73 had a fall on 9/29/2023 and sustained a hematoma (an abnormal collection of blood outside of the blood vessel) on the right side of his forehead. The CP intervention initiated on 6/30/2023 indicated to do neurological checks every shift for any unusual loss of consciousness, monitor for pain, transfer to acute hospital, and may use a pommel cushion while on the wheelchair due to Resident 73 having episodes of sliding down with IC obtained by the MD and responsible party.
During a review of the Order Summary Report (Physician Order) indicated a perimeter mattress to help resident define the edge of the bed was initiated on 6/29/2023. An order for the pommel cushion while on a wheelchair due to Resident 73 having episode of sliding down was initiated on 10/2/2023.
During a review of Resident 73's Situation, Background, Assessment, and Recommendation (SBAR) Communication Form and progress note dated 9/29/2023, documented by Minimum Data Set Coordinator (MDSC), the SBAR indicated Resident 73 had an actual fall by the hallway. Resident 73 was sitting up right on the wheelchair by the hallway when a staff that was at the nursing station suddenly heard a bang. The staff observed Resident 73 on the floor and upon assessment noted a bump on the right side of his forehead. Resident 73 was applied ice packs every 15 minutes to the bump. Resident 73 stated he stood up to walk but lost his balance and fell to the floor.
During a review of Resident 73's SBAR Communication Form and progress note dated 6/29/2023, documented by Licensed Vocational Nurse 4 (LVN 4), the SBAR indicated resident was observed on the floor on the left side of the bed. Additional note documented in the progress note on 6/29/2023 by Registered Nurse Supervisor 2 (RNS 2) indicated a Certified Nursing Assistant (CNA) had observed Resident 73 on the floor to the left side of the bed sitting on his buttocks leaning onto his palms trying to go home to his wife.
During a review of Resident 73's Computerized Tomography (CT: a series of X-ray images taken from different angles of the body) of the head without contrast (a substance used to enhance to visibility of certain structures) Radiology Report completed on 9/30/2023 indicated there was a large right soft tissue hematoma.
During a concurrent interview and record review on 10/5/2023 at 11:31a.m. with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated when a resident is a fall risk, some of the prevention method include moving residents close to the nursing station, have perimeter mattress, floor mat (for residents who had falls), and bed alarms. LVN 6 stated if a resident fell, they will do an assessment, do a change of condition (COC), take vital signs, notify family and doctor, monitor the resident for 72 hours, do a fall risk assessment, and assess for pain. LVN 6 stated Resident 73 fell on 9/29/2023 at night by the hallway in his wheelchair with a bump on his forehead. LVN 6 stated Resident 73 stood up and tried to walk but lost his balance and fell to the floor. LVN 6 stated there is a CP for a previous fall that occurred on 6/30/2023 with no injury and underneath the initial fall, the CP was updated with Resident 73's recent fall on 9/29/2023 which resulted in a hematoma on his right forehead with an injury. LVN 6 stated there should have been a separate CP created for the actual fall on 9/30/2023 instead of adding this information onto a previous fall CP. LVN 6 stated every COC has to have a CP the same day to know when the resident actually fell and add new interventions to prevent another incident from occurring.
During a concurrent interview and record review on 10/05/2023 at 4:29p.m. with MDSC, MDSC stated Resident 73 recently had a fall on 9/29/2023 and had a CP for at risk for fall and one for an actual fall with no injury when Resident 73 sustained an injury. MDSC stated the CP should have been updated the same day and if it revised, it should reflect Resident 73's current fall. MDSC stated a CP is initiated at admission and is revised quarterly, annually, or when there are any significant changes. MDSC stated it is important to follow up on the CP to see if the interventions are effective as the resident might not get the proper treatment or care if the CP is not updated.
During a concurrent interview and record review on 10/6/2023 at 2:06p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated an order for the perimeter mattress was placed on 6/29/2023 and Resident 73 was initially admitted on [DATE]. RNS 1 stated Resident 73 had a risk for fall CP that was done on 6/6/2023 since he had a history of falls. RNS 1 stated interventions are a plan and indicated the facility may apply the perimeter mattress and pommel cushion for Resident 73. RNS 1 stated nursing CPs have to be followed and the use of perimeter mattress and pommel cushion needs a consent from the family member and the doctor prior to being initiated. RNS 1 stated since Resident 73's admission, it does not indicate Resident 73 had the perimeter mattress or cushion based on the nursing progress notes and the perimeter mattress was ordered on 6/29/2023. RNS 1 stated all of the interventions in the CP have to be done as much as possible to prevent the resident from repeated falls.
During a review of the facility's P&P titled, Care Plans--Comprehensive revised on September 2010, the P&P indicated assessments of residents are ongoing and are plans are revised as information about the residents and the residents' condition change.
During a review of the facility's P&P titled Safety and Supervision of Residents revised on July 2017, the P&P indicated implementing interventions to reduce accident risks and hazards shall include the following: ensuring that interventions are implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to initiate a care plan for one of three sampled residents (Resident 13) who has decreased hearing.
This deficient practice had the potential to negatively affect the delivery of necessary care and services.
Findings:
During a review of Resident 13's admission record (face sheet), the face sheet indicated resident 13 was initially admitted to the facility on [DATE] with a diagnosis of diabetes mellitus with other specified complications (high blood sugar ) , hypertension ( high blood pressure), bilateral osteoarthritis of the knee ( when the cartilage that lines your joints is worn down ).
During a review of Resident 13's history and physical (H&P) report dated 6/3/2015, the H&P indicated Resident 13 had the capacity to understand and make decisions.
During a review of Resident 13's Minimum Data Set ( MDS -a standardized assessment and care planning tool) dated 1/1/2023, the MDS indicated Resident 13 requires limited assistance ( physical help in guided maneuvering of limbs or other non- weight bearing assistance ) with transfers, Dressing and toilet use.
During a review of Resident 13's Order Summary Report (OSR), the OSR indicated an order was placed on 6/14/2023 for Resident 13 to have an ENT (Ears , nose, and throat) consult with follow up treatment as indicated.
During a review of Resident 13's ENT physical exam appointment on 6/15/2023 , the physical exam indicated Resident 13 had moderate hearing loss bilaterally.
During an observation at the resident council meeting (is an organized group of residents who meet regularly to discuss and address concerns about their rights) on 10/4/2023 at 2:00 p.m., Resident 13 stated to the audience I cannot hear what everyone is saying.
During an Interview on 10/5/2023 at 1:08 p.m., with Licensed Vocational Nurse 6 (LVN), LVN 6 stated when speaking to Resident 13 we need to get close to her or stand where she can see and hear when we are speaking to her. LVN stated there was no care plan and should have been a care plan to address Resident 13's decreased hearing. LVN 6 stated a care plan help to assure that a resident's need are being met.
During an interview on 10/4/2023 at 10:09 a.m., with Social Service Designee (SSD), SSD stated I am aware of Resident 1,s hearing deficit and there is no care plan addressing this. SSD stated the reason we do care plans is to make sure a resident's needs are being met.
During an interview on 10/5/2023 at 1:18 p.m., with Director of Nursing (DON), the DON stated if there is a problem with a Residents hearing we need start a care plan this outline what needs to be done to manage the residents needs.
During a review of the policy and procedure (P&P) titled , Comprehensive Assessment and the Care Delivery Process, revised 11/2019 indicates, comprehensive assessments will be conducted to assist in developing person-centered care plans. Information analysis steps include.
b. define conditions and problems that are causing, or could cause, or could cause problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR is guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness) ) screening was completed for two of five sampled residents (Resident 14 and Resident 22) who were diagnosed with mental disorder (MD).
This deficient practice had the potential for Resident 14 and 22, not receiving appropriate behavioral services
Findings:
During a record review of Resident 14's admission Record (Face Sheet), the Face Sheet indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including anxiety (feeling of fear, and uneasiness) disorder, bipolar disorder (mental illness that cause unusual shifts in a person's mood, energy, activity levels, and concentration), and major depressive disorder (loss of pleasure or interest in activities).
During a record review of Resident 14's History and Physical (H/P), dated 8/28/2023, the H/P indicated Resident 14 does not have the capacity to understand and make decisions.
During a record review of Resident 14's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/09/2023, the MDS indicated Resident 14's cognitive (mental process by which knowledge is acquired, including perception, intuition, and reasoning) skills for daily decision making was severely impaired. The MDS indicated Resident 14 required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene.
During a concurrent interview and record review on 10/06/2023, at 1:54 p.m., with MDS Coordinator (MDSC), MDSC confirmed that Resident 14's PASSAR Level I screening, was not done correctly due to missing the assessment on Section V-Mental Illness because Resident 14 was admitted to the facility with MD. The MDSC stated, MDSC was responsible for following up with PASSAR Level I screening was done correctly upon admission and quarterly.
During a record review of Resident 22's Face Sheet, the Face Sheet indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing daily activities), anxiety disorder, and schizoaffective disorder (mental illness that can affect your mood and behavior).
During a record review of Resident 22's History and Physical (H/P), dated 5/30/2023, the H/P indicated Resident 22 does not have the capacity to make decisions.
During a record review of Resident 22's MDS, dated [DATE], the MDS indicated Resident 22's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 22 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene.
During a concurrent interview and record review on 10/06/2023, at 1:43 p.m., with MDSC, MDSC confirmed that PASSAR Level I was not done for Resident 22 upon admission, or prior to the admission. The MDSC stated, previous MDSC should have conduct Resident 22's PASSAR assessment if they did not receive one prior to the admission and follow up on it within 48 hours. The MDSC stated, if PASSAR screen was not done or was not completed correctly, we cannot treat residents necessary care for those residents.
During an interview on 10/06/2023, at 12:19 p.m., with Director of Nursing (DON), the DON stated the MDSC should be responsible person to check PASARR Level I was completed correctly. The DON stated, it was important to complete the level I because it gives us specific guidelines regarding specialized care to residents with MD.
During a record review of the undated, facility's policy and procedure (P/P) titled, Behavioral Assessment, Intervention, and Monitoring, the P/P indicated the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder. The P/P indicated all residents will receive a Level I PASARR screen prior to admission.

**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 57) was reviewed for Preadmission Screening and Resident Review (PASARR) in a timely manner.
This failure had the potential to result in the resident not receiving appropriate care or delay in treatment.
Findings:
During a review of Resident 57's admission Record (Face sheet) indicated Resident 57 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder (a mental health disorder including schizophrenia and mood disorder symptoms) encephalopathy (brain disease that alters brain function or structure) unspecified dementia (dementia without a specific diagnosis), and anxiety (persistent worry and fear about everyday situations).
During a review of Resident 57 Minimum Data Set (MDS, a standardized comprehensive assessment and care-screening tool, dated 7/20/2023, indicated Resident 57 has schizoaffective disorder, encephalopathy, unspecified dementia, and anxiety.
During a review of Resident 57's Preadmission Screening and Resident Review (PASARR) Level 1 Screening dated 9/03/ 2019, indicated resident 57 Level I PASARR was negative and the form was incompletely filled out.
During interview with MDS Coordinator (MDSC), on 10/04/2023, the MDSC stated PASARR should be done upon admission, when new psychiatric medication was added to care plan, and when resident has a change of condition (COC). The MDSC indicated Resident 57's PASARR was incomplete on 9/3/2019. Resident 57 had a new diagnosis of schizoaffective disorder on 09/2021, but the PASARR was not reevaluated.
During an interview with the Director of Nursing (DON) on 10/06/2023, at 10:55 a.m., the DON stated the MDSC was in charge of PASARR and should be done upon admission and if there any change of condition. The DON stated if the PASARR was not done correctly or not done in a timely manner, there would be a delay in treatment.
During a review of the facility's Policy and Procedure (P&P) titled, Resident Behavior and Facility Practices- Resident Behavior dated 3/2019, indicated New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR Level II evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to appropriately assess and monitor one of one sampled resident (Resident 73) during the use of a pommel cushion (blue cushion placed on a wheelchair) to prevent the resident from sliding.
This deficient practice had the potential to result in entrapment and injury.
Findings:
During a review of Resident 73's Face Sheet (admission record), the Face Sheet indicated Resident 73 was admitted to the facility on [DATE] with diagnosis including dementia with behavioral disturbance (impaired ability to think or make decisions accompanied by behaviors such as agitation and depression), Type II Diabetes Mellitus (high blood sugar) with diabetic chronic kidney disease (CKD: long term condition where the kidneys do not work as well), anxiety, repeated falls, hypertension (high blood pressure) and cognitive communication deficit.
During a review of Resident 73's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 9/8/2023, the MDS indicated Resident 73's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS indicated Resident 73 required extensive assistance for dressing, toilet use, and personal hygiene, transfer from bed, chair, wheelchair, moving between one place to another, dressing, walking, and required supervision for eating. The MDS indicated Resident 73 was not steady transferring from sit to standing position and surface to surface transfers and is able to only stabilize with staff assistance. The MDS indicated Resident 73 used a wheelchair and walker for mobility and have no impairments on both the upper and lower extremities (arms and legs). The MDS indicated Resident 73 did not have any physical restraints, which are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom or movement or normal access to one's body.
During review of Resident 73's untitled Care Plan (CP) initiated on 6/6/2023, the CP indicated Resident 73 is at risk for fall related to balance problems during transition with contributing factors of history of falling, unsteady gait, and confusion. The CP intervention initiated on 6/7/2023 indicated Resident 73 can have a floormat, have perimeter mattress (a triangular mattress) applied to help resident define the edge of the bed with informed consent (IC- is a principle in medical ethics and medical law and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) obtained by the medical director (MD) and responsible party with risk and benefits explained, and a pommel cushion while on the wheelchair due to Resident 73 having episodes of sliding down with IC obtained by the MD and responsible party.
During a review of Resident 73's Situation, Background, Assessment, and Recommendation (SBAR) Communication Form and progress note dated 9/29/2023, documented by Minimum Data Set Coordinator (MDSC), the SBAR indicated Resident 73 had an actual fall by the hallway. Resident 73 was sitting upright on the wheelchair by the hallway when a staff that was at the nursing station suddenly heard a bang. The staff observed Resident 73 on the floor and upon assessment noted a bump on the right side of his forehead. Resident 73 was applied ice packs every 15 minutes to the bump. Resident 73 stated he stood up to walk but lost his balance and fell to the floor.
During a review of Resident 73's SBAR Communication Form and progress note dated 6/29/2023, documented by Licensed Vocational Nurse 4 (LVN 4), the SBAR indicated resident was observed on the floor on the left side of the bed. Additional note documented in the progress note on 6/29/2023 by Registered Nurse Supervisor 2 (RNS 2) indicated a Certified Nursing Assistant (CNA) had observed Resident 73 on the floor to the left side of the bed sitting on his buttocks leaning onto his palms trying to go home to his wife.
During a review of the Order Summary Report (Physician Order) indicated a perimeter mattress to help resident define the edge of the bed was initiated on 6/29/2023. An order for the pommel cushion while on a wheelchair due to Resident 73 having episode of sliding down was initiated on 10/2/2023.
During a review of Resident 73's Fall Risk Evaluation, it indicated the fall intervention placed was to have a pommel cushion while the resident is up in the wheelchair and a perimeter mattress while in bed.
During an observation on 10/3/2023 at 10:50a.m. with Resident 73, Resident 73 had pillows on his right side of the back and had wedges on the left side. Resident 73 was observed unable to move.
During a concurrent observation and interview on 10/3/2023 at 1:01p.m. with Quality Assurance Nurse (QA), QA showed me a blue cushion in which Resident 73 was sitting on while in the patio. QA stated this cushion was the pommel cushion and attempted to show that the cushion was in place and cannot be moved by pulling on the cushion.
During a concurrent observation, interview, and record review on 10/6/2023 at 2:02p.m. with Registered Nursing Supervisor 1 (RNS 1), RNS 1 stated a restraint can be described as putting a belt on the arms, mittens for residents who try to pull out their gastrostomy tube (G-tube: surgically placed device to provide nutrients in the stomach) or if a resident is sitting and placing an object so they cannot move. RNS 1 stated Resident 73 had an order for a perimeter mattress on 6/29/2023. RNS 1 stated a perimeter mattress is kind of like a restraint but is also used to define the edge of the bed and would require a consent prior to applying the mattress. RNS 1 stated when the resident is on a wheelchair, a pommel cushion is used to prevent them from sliding in the wheelchair that was ordered on 10/2/2023. RNS 1 stated when the resident goes to activities, the pommel cushion is placed in the wheelchair. RNS 1 initially stated a consent is not required for the pommel cushion since it is only to prevent the resident from sliding, but later stated a consent is needed for a pommel cushion as it can be considered a restraint. RNS 1 stated any object or device that can be used as a restraint would require an order and the consent of the doctor and family member prior to the mattress or cushion being placed. RNS 1 stated since Resident 73's admission on [DATE], there is no indication that Resident 73 had the perimeter mattress or the pommel cushion until the perimeter mattress was ordered on 6/29/2023. RNS 1 stated whatever service that was provided or ordered for the resident is supposed to be documented in the progress note or as a weekly summary in the progress note since it is a form of communication between the staffs. RNS 1 stated Resident 73 had anxiety and dementia and cannot say that Resident 73's fall would have been prevented but stated the interventions (perimeter mattress and pommel cushion) for Resident 73 is a restraint and the doctor may not want the perimeter mattress. RNS 1 stated the perimeter mattress is placed on both sides of the bed, but even with the perimeter mattress, the resident would need frequent visual checks as they can still fall out of bed as it is only to help define the end of the bed. It was noted the perimeter mattress is not fully attached to the bed and was loose, indicating the resident can still fall out of the bed.
During a concurrent interview and record review of Resident 73's physician's order and consent form on 10/6/2023 at 6:17p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated residents are assessed quarterly and indicated there are different types of restraints such as physical and chemical restraint. MDSC stated a restraint is used to limit the movement of an individual, but it would not be considered a restraint if they are able to move freely. MDSC stated if a restraint is required, they would get an order from the doctor, get an IC, do an assessment, do a CP, and have an Interdisciplinary Team (IDT: a meeting with various department heads to discuss resident's plan of care) meeting. MDSC stated if a resident is able to stand up, but a table is placed in front of them and they cannot push the table, it would depend on the nurse's assessment on whether or not it would be considered a restraint. MDSC stated they do not use restraints at the facility and if a resident is a high risk for fall, they use a pommel cushion to prevent the resident from sliding out of the chair. MDSC stated if a resident had a pommel cushion and is unable to remove it, the resident would need to be assessed if they are able to take it out. MDSC stated a pommel cushion does not need an IC as it is not a restraint. MDSC stated in the MDS Section P: Restraints and Alarms indicated physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom or movement or normal access to one's body MDSC stated this is the only assessment at this time for safety on the fall risk for Resident 73's recent fall on 9/29/2023 MDSC stated there were no consent forms in Resident 73's chart for both the pommel cushion and the perimeter mattress. MDSC stated on the order, it indicated the doctor got an IC from the family, but there are no consent forms in the chart. MDSC stated an IC is important and is needed to notify the family for new interventions so that the family won't be surprised if they came to visit the resident.
During a review of the facility's P&P titled Resident Assessments revised on November 2019, the P&P indicated a significant change in status assessment (SCSA: comprehensive assessment of the resident) is required when a resident begins to use a restraint of any type when it was not used before.
During a review of the facility's P&P titled Use of Restraints revised on April 2017, the P&P indicated restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: how the restraint will be used to benefit the resident's medical symptoms and the type of restraint, and period of time for the use of the restraint. Documentation regarding the use of restraints shall include the length of effectiveness of the restraint time and observation, range of motion and repositioning flow sheets.
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During a review of the facility's P&P titled Behavioral Assessment, Intervention and Monitoring revised on March 2019, the P&P indicated if any devices (restraints) are prescribed, the IDT will monitor the situation to ensure that they are beneficial to the individual (for example, enhancing function and improving symptoms) and are not causing complications or disabling the individual. Over time, the staff will reduce the use or remove such devices or will document why such attempts are not feasible.

**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 96) was reviewed for changes in Medicare (federal health insurance for people 65 or older) coverage were provided with the Notice of Medicare Non-Coverage (NOMNC) appeal process in a timely manner.
This failure had the potential to result in Resident 96 and/or responsible party not being able to exercise their right to file an appeal.
Findings:
During a review of Resident 96's admission Record (Face sheet), the admission Record indicated Resident 96 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), hypertension (a condition in which the force of the blood against the artery walls is too high), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety (persistent worry and fear about everyday situations).
During a record review of Resident 96's Beneficiary Protection Notification Review form (for residents who receive Medicare Part A services) indicated the resident last coverage day for Medicare Part-A Skilled Service was 9/26/2023.
During a review of Resident 96's Beneficiary Protection Notification Review Notice of Medicare Non-Coverage (NOMNC) for appeal process, page 2 was not signed. The NOMNC page 2 contained address information on where the resident and/or resident's responsible party can file an appeal of the NOMNC.
During an interview with Social Service Designee (SSD 2), on 10/052023, at 9:04 a.m., the SSD 2 stated residents and/or responsible parties should receive NOMNC appeal process information upon discontinuation of services. SDD2 stated she did not mail the notice or give the copy to resident or resident representative. SSD 2 stated the importance of providing the notice in a timely manner was so that the resident and family to were aware of their right to appeal.
During a telephone interview with Resident 96's family member (FM 1), FM 1 stated she was not informed by the SSD 2 regarding NOMNC. FM 1 stated she was worried about receiving a bill.
During a review of the facility's Policy and Procedure (P&P) titled, Medicare Advance Beneficiary Notice, dated March 2019, the P&P indicated, If the director of admissions or benefits coordinator believes (upon or during the resident's stay) that Medicare (Part A of the Fee for Service Medicate Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s).
During a review of the facility's P&P titled, Resident Rights, dated December 2016, the P&P indicated, Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be informed about his or her rights and responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure advance directives (written statement of a person's wishes regarding medical treatment made to sure those wishes are carried out should the person be unable to communicate) was discussed and written information was provided to the residents /or responsible parties for one of five sampled residents (Resident 22).
This deficient practice violated the resident's right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care.
Finding:
During a record review of Resident 22's admission Record (Face Sheet), the Face Sheet indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness), dementia (impaired ability to remember, think, or make decisions), hypertension (high blood pressure), and schizoaffective (mental health disorder affect mood, behavior, and thoughts).
During a record review of Resident 22's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/30/2023, the MDS indicated Resident 22's cognitive (mental process by which knowledge is acquired, including perception, intuition, and reasoning) skills for daily decision making was severely impaired. The MDS indicated Resident 22 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene.
During a concurrent interview and record review of Resident's 22 medical chart on 10/05/2023, at 1:07 p.m., with Social Services Director 2 (SSD 2), the SSD 2 confirmed there was no advance directive acknowledgement form was completed for Resident 22. The SSD 2 stated, she is not sure if the advance directives was discussed, and written information was provided to Resident 22 and/or responsible party because there is missing signature on the form. The SSD 2 stated the acknowledgement form was important because the form informed the resident and her responsible party regarding the right to formulate an advance directive.
During a record review of the facility's policy and procedure (P/P), revised 07/2021 and titled, Advance Directives for Healthcare, the P/P indicated upon admission, all residents and their representatives are presented with written information about their rights to accept or refuse medical or surgical treatment and their right to formulate an advance directive. This information is found in the resident rights portion of the admission packet, Advance Directive Acknowledgement, and upon presentation of a valid Physician Order for Life Sustaining Treatment(POLST).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure:
A. call light was functioning properly for one of five sampled residents (Resident 76).
B. Call light was within reach for Resident 52 while up in Geriatric Chair(([Geri Chair]- a large, padded chair that is designed to help seniors with limited mobility)
C. care was provided in a manner that maintain or enhanced a resident's dignity and respect for Resident 63.
This deficient practice had the potential for Resident 76 and Resident 52 not receiving necessary assistance when needed, experience loss of dignity, and loss of self-esteem due to inability to summon help with call lights.
This deficient practice has the potential to affect Resident's 63 sense of self-worth and self-esteem.
Findings:
A. During a record review of Resident 76's admission Record (Face Sheet), the Face Sheet indicated Resident 76 was admitted to the facility on [DATE] with diagnoses with fracture of right humerus (your upper arm bone is broken), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), pneumonitis (general inflammation in your lungs that affect how you breathe and cause other bodily symptoms), chronic bronchitis (inflammation of the airways in the lungs), and dysphagia (difficulty in swallow).
During a record review of Resident 76's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 8/18/2023, indicated Resident 76's cognitive (process of acquiring knowledge and understanding) and decision-making skills were severely impaired. The MDS indicated, Resident 76 required extensive assistance from two staff for transfer, and extensive assistance from one staff for dressing, toilet use, and personal hygiene.
During an observation and interview on 10/03/2023 at 9:23 a.m. with Resident 76, Resident 76 was lying in her bed and stated, she needed to call her nurse for her medication. Resident 76 pushed her call light a few times but her call light was not working with no alert sound or no light outside of the resident's room.
During a concurrent observation and interview with Certified Nurse Assistant 3 (CNA 3) on 10/04/2023, at 9:50 a.m., CNA 3 stated Resident 76's call light is not working at all upon pushing the call light. The CNA 3 stated, it is very important to make sure all residents' call lights are working properly because call light is their lifeline to bring nurse's attention.
During an interview on 10/04/2023, at 9:52 a.m., with License Vocational Nurse 2 (LVN 2), the LVN 2 stated, she did not know Resident 76's call light has not been working and she or other nursing staff should have checked Resident 76's call light when they did rounds. LVN 2 stated she forgot to check it today.
During an interview on 10/06/2023, at 11:57 a.m., with Director of Nursing (DON), the DON stated, nurses should check their residents every 2 hour and at that time they should check if their residents' call lights are working properly or within accessible reach. DON stated, call light are important device to assist the resident's need and help residents during emergency situations.
During a record review of Resident 76's Care Plan (CP) with initiated date 7/01/2022, the CP indicated Resident 76 has assistance daily living (ADL) self-care performance deficits. The CP intervention indicated, assist ADL's as needed, and attend to resident's needs promptly.
B. During a review of Resident 52's admission record, the admission record indicated Resident 52 was admitted to the facility on [DATE]. Resident 52's diagnosis included dementia (a group of symptoms affecting memory, thinking and social abilities), parkinsonism (brain conditions that cause slowed movements, rigidity (stiffness) and tremors), and muscle atrophy (loss of muscle tissue).
During a review of Resident 52's History and Physical (H&P), dated 5/3/2023, the H&P indicated, Resident 1 was able to make simple decisions, but did not have the capacity to make complex medication decisions.
During a review of Resident 52's MDS dated [DATE], the MDS indicated Resident 52 required extensive assistance (resident involved in activity, staff provide weight-bearing support) from one staff with bed mobility, dressing, toilet use, personal hygiene, eating, and total dependence (full staff performance required) from two or more persons for transfer.
During a concurrent observation and interview on 10/3/2023, at 1:54 p.m., with Resident 52, in Resident 52's room, Resident 52 was sitting on GeriChair between two beds. The call light was placed on left side of bed (Resident 52's bed) close to the left side rail. Resident 52 stated, he was not able to reach his call light because his left side was weak, and the call light was placed too far. Resident 52 stated, he wanted to go back to his bed which was located on his left side, but he could not call his nurse because the call light was unreachable. Resident 52 stated, he felt helpless and disrespected because he could not do anything but wait for his nurse to come in.
During an interview on 10/3/2023, at 2:05 p.m., with CNA 1, in Resident 52's room, CNA 1 stated, Resident 52's call light was unreachable because it was placed too far. CNA 1 stated, the call light should have placed on either Geri-chair or on Resident 52's hand. CNA 1 stated, it was important to place the call light within reach, so Resident 52 could get the help he needed.
During an interview on 10/4/2023, at 10:23 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, it was nursing staff's responsibility to ensure placing the call light within reach to accommodate the resident's needs and in case of emergency. LVN 1 stated, if the resident could not get the help they needed in a timely manner, this could affect their dignity and their self-esteem.
During an interview on 10/6/2023, at 10:55 a.m., with Director of Nursing (DON), DON stated, resident's call light should be within reach at all times to meet the resident's needs. DON stated, residents had rights to get the help they needed. DON stated, all staff should respect the residents' dignity and their rights.
During a review of Resident 52's CP, dated 5/25/2021, the CP Focus indicated, Resident 52 is at risk for fall related to balance problem. The CP intervention indicated, call lights will be answered promptly and place the call light within reach.
During a review of Resident 52's CP, dated 8/26/2021, the CP Focus indicated, Resident 52 had a communication problem related to hearing loss. The CP Intervention indicated, ensure/provide a safe environment: call light within reach.
C. During a review of Resident 63's face sheet, the face sheet indicated Resident 63 was admitted to the facility on [DATE] with diagnosis of muscle weakness generalized, hypertension (high blood pressure ), and peripheral vascular disease ( a circulatory condition in which narrowed blood Vessels reduce blood flow to the limbs).
During a review of Resident 63's MDS a dated 7/31/2023 indicated Resident 63 has moderate cognitive impairment. The MDS indicated Resident 63 needs limited assistance (Hands on assistance ) with bed mobility( moving in bed ), transfer, and walk in the room.
During an observation on 10/3/2023 at 2:22 p.m. CNA 4 enters Resident 63's room and saw Resident 63 sitting at the edge of the bed. Resident 63 stated to the CNA she needs to go to the bathroom . CNA 4 was observed undresses Resident 63 from the waist down without closing the privacy curtain, CNA 4 placed Resident 63 in the shower chair and rolled Resident 63 to the bathroom without a blanket, CNA 4 placed Resident 63 on the toilet and kept the bathroom door open. There was one Roommate present inside the room.
During an interview on 10/3/2023 at 2:30 p.m., CNA 4 stated I forgot to pull Resident 4's curtain to provide privacy and when I placed Resident 63 in the bathroom , I did not close the door. CNA 4 stated it is important to always provide the Resident with privacy.
During an interview on 10/4/2023 at 10:13 a.m., with the LVN 4 stated Resident 63 should have been covered with a bath blanket when transferring her from the bed to the bathroom . LVN 4 stated the curtain should have been pulled to provide Residents with privacy and the bathroom door closed LVN 4 stated we should always provide privacy this is the Resident's home and it's their rights.
During a review of facility's undated, policy and procedure (P/P) titled, Quality of Life-Dignity, the P/P indicated residents shall be treated with dignity and respect at all times.
During a review of facility's undated, policy and procedure (P/P) titled, Answering the Call light, the P/P indicated the followings:
Be sure that the call light is plugged in at all times.
Report all defective call lights to the nurse supervisors promptly.
Answer the resident's call as soon as possible.
During a review of the facility's P&P titled, Answering the Call Light, undated, indicated, General Guidelines .5. When the resident is in bed or confined to a chair be sure the call light is within reach of the resident.
During a review of the facility's P&P titled, Quality of Life-Dignity, undated, indicated, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Policy Interpretation and Implementation . 2Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.
1.Residents should be treated with dignity and respect at all times,
2.Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.
3. Staff shall promote, maintain, and protect residents' privacy, including bodily privacy during assistance with personal care and during treatment procedures.