La Brea Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2) who were admitted in the facility with pressure ulcer/injury (damaged skin caused by staying in one position for too long) received care and services to promote wound healing by failing to:1. Ensure the wound care treatment were documented with complete assessments in Resident 1 and Resident 2's medical record as indicated in the facility's policy and procedures (P&P) titled, Dressings, Dry/Clean, and Wound Care.2. Ensure the medication Calcium Alginate (a natural, seaweed-derived dressing used for heavily draining wounds) was in place for Resident 1's skin treatment.3. Follow-up on wound care specialist (WCS) order and plan of care with Resident 2's skin treatment and wound management.These deficient practices placed the residents at risk of poor wound healing and deterioration of current pressure ulcers/injury.Findings:During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection), malignant neoplasm of breast (a group of diseased cells that have grown out of control within the breast tissue, forming a tumor that can invade surrounding tissues or spread to other parts of the body) and cellulitis (a skin infection that causes swelling and redness) of right upper limb (right arm).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/16/2026, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 was totally dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's WCS Progress Notes, dated 2/13/2026, the Progress Notes indicated that Resident 1 has an advanced breast cancer with fungating malignant chest wall mass (a type of advanced cancer growth that breaks through the skin), right heel unstageable pressure injury (a deep, severe skin wound where the base is completely covered by dead tissue), right buttock unstageable pressure injury and right scapula (shoulder blade) unstageable pressure injury. The Progress Notes by WCS also indicated plan treatment to apply silver alginate dressing on the fungating chest wall mass and right gluteal (buttock), right heel and right scapulaDuring a review of Resident 1's Order Summary Report (OSR), as of 3/6/2026, there was no order in place for Calcium Alginate for wound dressing and there was no order in place for wound dressing treatment as needed.During an interview with Treatment Nurse 2 (TXN 2) on 3/6/2026 at 11:57 a.m., TXN 2 stated, Resident 1's wound dressing would be soaking with blood and with drainage when he comes during the start of his shift (morning). TXN 2 stated, he changes Resident 1's wound dressing once daily.During a review of Resident 1's Wound Care Form, dated 2/13/2026 and 2/20/2026, there was no assessment of the wound documented and recorded in Resident 1's medical record.During a review of Resident 1's Treatment Administration Record (TAR) for the month of 2/2026, there was no treatment order for Calcium Alginate and there was no skin treatment order as needed when wound dressing gets soiled/dirty.During an interview with Director of Nursing (DON) on 3/9/2026 at 1:45 p.m., DON stated, when a wound dressing gets soiled and dirty, they must change the dressing as needed. DON stated, they should also follow up on WCS's skin treatment order, and the medications must be in place. DON further stated, they don't have a complete document of Resident 1's wound assessment during wound care management as indicated in the P&Ps.During a review of the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cellulitis of buttock, hidradenitis suppurativa (chronic, non-contagious skin condition that causes painful, recurring lumps, boils, or abscesses), and candidiasis (a yeast infection that occurs when a type of yeast called Candida albicans grows out of control).During a review of the MDS dated [DATE] indicated Resident 2's cognitive skills for daily decisions were intact. The MDS indicated Resident 2 was totally dependent on staff for ADLs.During a review of Resident 1's Order Summary Report dated, 1/24/2026, the OSR indicated skin treatment order of:pack bilateral hips with saline (NS - a sterile mixture of salt and water designed to gently clean wounds, remove debris, and flush out bacteria without irritating tissues) moistened kerlix (a specialized, highly absorbent, and breathable, fluffy gauze bandage roll used to wrap wounds, burns, or pack deep wounds) then cover with ABD pads (Abdominal Pad or Army Battle Dressing) is a large, thick, highly absorbent, and sterile bandage used for covering deep or heavily draining wounds), one time a day for wound managementxeroform oil emulsion (a sterile, non-adhering wound dressing consisting of fine-mesh gauze) gauze external pad - apply to sacrum (a large, triangular bone located at the base of the spine, just above the tailbone) topically one time a day for wound management, cleanse with NS, pat dry, apply xeroform and cover with dry dressing (DD).During a review of Resident 2's WCS Progress Notes dated 1/30/2026, the Progress Notes indicated that, Resident 2's plan treatment for wound management to change dressing twice daily (BID) or as needed if soiled.During a review of Resident 2's Treatment Administration Record (TAR) dated, there was no treatment order for Calcium Alginate and there was no skin treatment order as needed when wound dressing gets soiled/dirty.During a review of Resident 2's Wound Care Form, dated 1/30/2026, 2/6/2026, 2/13/2026 and 2/20/2026, there was no assessment of the wound documented and recorded in Resident 2's medical record.During a review of Resident 2's OSR as of 3/6/2026, the wound management skin treatment order was only for daily wound dressing and there was no order for skin treatment as needed if the wound dressing is soiled.During an interview with TXN 2 on 3/6/2026 at 12:10 p.m., TXN 2 stated, Resident 2 has multiple wounds that constantly drain with yellowish, pinkish discharge color that were visible in the wound dressing. TXN 2 stated, he changes the wound dressing once daily and when he comes to work in the morning, the ABD wound dressing will have drainage and wet.During an interview with DON on 3/9/2026 at 1:45 p.m., DON stated they are not following the WCS plan of treatment for wound management. DON further stated, they don't have a complete document of Resident 2's wound assessment during wound care management as indicated in the P&Ps.During a review of the facility's policy and procedures (P&P) titled, Dressings, Dry/Clean, revised on 1/2026, the P&P indicated that, The following information should be recorded in the resident's medical record, treatment sheet or designated wound form: the date and time the dressing was changed, wound appearance, including wound bed, edges, presence of drainage. all assessment data obtained when inspecting the wound, how the resident tolerated the procedure .During a review of the facility's P&P titled, Pressure Ulcers/Skin Breakdown, revised on 1/2026, the P&P indicated that, the staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleaning and debridement approaches, dressings, and application of topical agents.During a review of the facility's P&P titled, Wound Care, revised on 1/2026, the P&P indicated that, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The following information should be recorded in the resident's medical record:The type of wound care givenThe date and time the wound care was given.The position in which the resident was placed.The name and title of the individual performing the wound care.Any change in the resident's conditionAll assessment data obtained when inspecting the wound.How the resident tolerated the procedure.Any problems or complaints made by the resident related to the procedureIf the resident refused the treatment and the reason(s) why.The signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed as high risk for falls and dependent in Activities of Daily Living (ADLs), did not experience multiple falls, one resulting in injury, by failing to: 1. Initiate an individualized plan of care upon admission on [DATE] when Resident 1 was identified as having a high fall risk. 2. Update the care plan and interventions when Resident 1 had an unwitnessed fall on 11/16/2025. 3. Ensure staff adhered to the facility's policy and procedure titled Falls - Clinical Protocol (revised 12/2024), which requires staff and physicians to identify and implement interventions to prevent falls and mitigate clinically significant consequences. 4. Evaluate and analyze hazards and risks following repeated unwitnessed falls. As a result of these failures, Resident 1 had multiple unwitnessed falls (11/16/2025, 11/23/2025) and on 12/1/2025 Resident 1 slid from the bed, landing face down on the floor, resulting in a three cm laceration to the left forehead. Resident 1 was transferred to a General Acute Care Hospital (GACH) 1 on 12/2/2025 for generalized pain following the fall, with diagnoses of thoracic spine strain (discomfort in the mid-back, between the shoulder blades and lower ribs, often caused by muscle strain, poor posture, overuse, or joint issues, though more serious causes like nerve compression or fractures exist) and left shoulder contusion (bruise from direct impact, causing pain, swelling, stiffness, and discoloration [black-and-blue] as blood vessels leak under the skin). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnosis that included acute respiratory failure with hypoxia (severe, sudden condition where the lungs can't get enough oxygen into the blood), other lack of coordination, and other abnormalities of gait (a manner of walking or moving the foot) and mobility (ability to move arounds freely and easily). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills were severely impaired. The MDS indicated Resident 1 was dependent on oral hygiene, toileting, bathing and dressing. The MDS indicated Resident 1 was also dependent with mobility, helper does all of the effort, with Resident 1 laying on back to roll left and right side, sit on side of bed to lying flat on the bed, lying on the back to sitting on the side of the bed and with no back support, come to a standing position from sitting and transfer to and from a bed to chair. The MDS also indicated Resident 1's ability to get on and off a toilet commode was not attempted due to medical conditions or safety concerns. During a record review of Resident 1's fall risk assessment dated [DATE], the fall risk assessment indicated score of 14. According to the falls assessment tool, if the total score is above 10, the resident should be considered high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. During a record review Resident 1's admission care plan, for the admission date 11/11/2025, unable to locate documentation of a high risk for fall care plan, no care plan initiated and no intervention in place. During a review of Resident 1's Situation, Background, Assessment, Request (SBAR-communication framework widely used in healthcare to ensure clear, concise, and organized information exchange among team members.) Communication Form, dated 11/16/2025 timed at 4:16 a.m., the SBAR indicated Resident 1 slid out of bed and found sitting on the floor at bedside with no visible injuries or bruises noted and Resident 1 denied any acute pain. During a record review of Resident 1's fall risk assessment dated [DATE], indicated score of 19.During a review of review of the care plan titled Resident 1 noted sliding out of bed, dated 11/16/2025, the care plan intervention indicated fall precautions implemented such as bed at lowest locked position and frequent visual checks done by staff to ensure safety and monitoring. During review of Resident 1's care plan titled, Risk for fall initiated 11/17/2025, the care plan indicated anticipate and meet Resident 1's needs, Resident 1 needs prompt response to all request for assistance and follow facility fall protocol. During review of Resident 1's Occupational Treatment (OT) Encounter Notes, dated 11/17/2025, the notes indicated Resident 1's functional status as total dependence with dressing, toileting and bathing and unable to sit or stand during ADL. The notes indicated Resident 1 required extra time to initiate and complete given task. The notes also indicated that Resident 1's cognitive status and nursing care required were complexities and barriers impacting OT therapy session. During a review of Resident 1's SBAR Communication Form, dated 11/23/2025 timed at 9:06 p.m., the SBAR indicated Resident 1 was found on the floor by his bedside. During a review of Resident 1's SBAR Communication Form, dated 12/1/2025 timed at 10:30 p.m., the SBAR indicated a loud sound came from Resident 1's room and Resident 1 was found lying on the floor on his left side faced down. The SBAR further indicated Resident 1 had been attempting to use urinal on the edge of his bed until he slipped off the bed. The SBAR also indicated Resident 1 sustained a laceration on his left forehead above the eyebrow and reported a pain level of 7/10 and when assessed using the two-finger test, stated he were seeing 4 fingers(double). During an interview on 12/16/2025 at 4:02 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 depends totally on assistance with ADL's including toileting. LVN 1 stated Resident 1 was incontinent and able to tell the staff when he is wet. LVN 1 stated Resident 1's uses the urinal only when his spouse is present. LVN 1 stated that after Resident 1 fell on [DATE], the care plan should be floor mat, frequent (every hour and a half) visual checks and addressing why Resident 1 fell. Since there is no care plan done none of this intervention was implemented. LVN 1 said when Resident 1 fell again, the nurse needed to determine why he fell, review his medications, and assess whether confusion, attempts to get up, or anxiety caused the fall. LVN 1 said finding the cause of the second fall is necessary to change the care plan and prevent more falls. LVN 1 said, If the care plan stays the same with no changes to interventions Resident 1 can get hurt and it means we are not doing our job properly. LVN 1 said the LVN assigned to the resident initiates care plan changes, and the RN completes the assessment, follows up with the physician, and revises the care plan further. LVN 1 said the goal is to prevent Resident 1 from falling again and getting injured. During an interview on 12/17/2025 at 11:06 a.m. with LVN 2, LVN 2 stated Resident 1 responds verbally with episodes of confusion, especially at night. LVN 2 stated Resident 1 tries to get out of bed by pulling his upper body using the side rails. LVN 2 stated while assisting CNA 1 with another resident room, LVN 2 and CNA 1 heard a loud bang sound that came from Resident's 1 room. When they went to Resident 1's room, they found Resident 1 on the floor with the urinal next to him and urine on the floor. LVN 2 stated that Resident 1 told him, on 12/1/2025 after Resident 1 fell, he was at the edge of the bed trying to use the urinal and slipped out of bed. LVN 2 said he cannot confirm if Resident 1 slipped as described because Resident 1's cognition is impaired. LVN 2 said he forgot to update the care plan after the fall on 12/1/2025 and learned about it from Medical Records staff the next day. LVN 2 said he completed the care plan on paper the day after the fall and gave it to Medical Records. LVN 2 said he did not verify whether Medical Records received the care plan he submitted. During a concurrent interview and record review on 12/17/2025 at 12:07 p.m., with RN 1, Resident 1's care plan dated 11/10/2025 and 11/17/2025 and fall risk assessment dated [DATE] and 11/16/2025 were reviewed. The fall risk assessment dated [DATE] showed a score of 14. The admission care plan dated 11/10/2025 indicated no documented safety concern and did not address the risk of falls. RN 1 stated Resident 1 was high risk for falls based on fall assessment on 11/10/2025 and staff should have initiated a care plan for risk for falls. The fall risk assessment dated [DATE] S/P fall showed a score of 19. RN 1 said staff did not initiate care plan for actual fall on 11/16/2025. RN 1 stated she was the RN on duty when Resident 1 had another fall on 12/1/2025. RN 1 stated care plan should have been revised with changes in the interventions based on findings why Resident 1 keeps falling. RN 1 stated there should be a care plan addressing Resident 1's behavior with interventions such as frequent safety reminders and hourly check on Resident 1. RN stated it is important to have an updated, current care plan to prevent falls from recurring of which could result in injury or possible death. During an interview on 12/17/2025 at 2:40 p.m., with Director of Nursing (DON), DON stated a care plan is done on admission and reviewed and revise it as needed. The DON stated staff should have revised Resident 1's care plan after the fall on 11/23/2025 and completed a fall risk assessment. The DON stated it is important to assess what was missing from the initial care plan and change or add interventions based on their effectiveness. The DON stated staff must determine why the fall occurred and identify factors that explain the resident's behavior that increases fall risk so they can address them. The DON stated after a fall, staff must review the care plan, identify needed changes, and determine additional interventions. The DON said the care plan guides the care provided to the residents, and if staff fail to update it, the facility is not taking steps to prevent another fall. The DON further stated the plan of care becomes ineffective when staff do not update the care plan. The DON said failing to include a known issue in the care plan can lead to more falls and potentially cause injuries. During review of the GACH 1 records titled Emergency Department Reports (EDR) dated 12/2/2025, the EDR indicated Resident 1's presented for the GACH Emergency Department with generalized body pain after a fall and laceration to the left eyebrow. The EDR indicated Resident 1's visit diagnosis as forehead laceration, closed injury, cause of injury - accidental fall, thoracic spine strain and left shoulder contusion. During a review of the facility's policy and procedure (P&P) titled, Falls - Clinical Protocol, dated 2/2024, the P&P indicated, For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. If the fall is unclear.or if the individual continuous to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. The P&P also indicated, Based on preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls to address the risks of clinically significant consequences of falling.The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. During a review of the facility's fall prevention potential intervention dated 12/2024 nursing measures indicated toileting schedule, proper positioning, and use of non-slip material to prevent sliding. During a review of facility's P&P titled, Care Plans - Baseline, dated 12/2024, the P&P indicated, to assure that a resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of admission. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 12/2024, the P&P indicated, The Care Planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care. During a review of the facility's P&P titles, Care Planning - Interdisciplinary Team, dated 12/2024, the P&P indicated, our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow professional standards of practice by failing to manage, assess and monitor resident and implement the facility policy and procedure (P&P) titled, Nursing Care of the Older Adult with Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), for one of three sampled residents (Resident 2), when resident had a hyperglycemia (high blood sugar, occurs when there's too much glucose in the blood, often because the body lacks enough insulin or can't use it properly).This deficient practice placed Resident 2 at risk of developing complications due to inadequate monitoring of blood glucose.Findings:During a review of the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type II DM, DM, End Stage Renal Disease (ESRD - irreversible kidney failure), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 9/27/2025, indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 2 required supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 2's Order Summary Report (OSR), dated 11/25/2025, the OSR indicated, insulin glargine (a long-acting insulin used to manage blood sugar levels) subcutaneous (SQ - a shot given into the fatty layer right under the skin, not into a muscle, using a small needle for slow, steady medicine absorption) solution 100 unit/millimeter (ml - unit of measurement) - inject four unit SQ in the morning.During a review of Resident 2's Medication Administration Record (MAR), dated 11/26/2025 at 6:30 a.m., the MAR indicated, Resident 2's blood sugar (BS) level was 348 milligram per deciliter (mg/dl - unit of measurement).During a review of Resident 2's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 11/26/2025 at 1:05 p.m., the SBAR indicated, Resident 2 was found unresponsive, lethargic (decrease in consciousness), not easily arose, breathing noted to be labored. blood pressure (BP - measures the force of blood against artery walls) 156/90 (a BP of 156/90 is considered high BP), pulse (heart beat counted per minute) 86 beats per minute (bpm), temperature 97.2 degrees Fahrenheit (F - temperature scale) and respiration (RR - breathing rate) 20.During a concurrent interview and record review with Licensed Vocational Nurse (LVN 3) on 12/16/2025 at 1:23 p.m., LVN 3 stated, in the morning of 11/26/2025, Resident 2 was sleeping and did not touch his (Resident 2) breakfast, but he usually was up early in the morning and would eat his breakfast. LVN 3 stated, Resident 2 struggled waking up and he was unable to open his eyes. LVN 3 reviewed Resident 2's MAR on 11/26/2025 at 6:30 a.m., and stated, she was not made aware of Resident 2's BS of 348 mg/dl. LVN 3 stated, there was no report given to her during hands-off from Licensed Vocational Nurse 6 (LVN 6) in the morning of 11/26/2025. LVN 3 further stated, she checked Resident 2's BS upon assessment that he was lethargic, and he had a BS of 70 mg/dl which means hypoglycemic (low blood sugar). LVN 3 reviewed SBAR on 11/26/2025 and stated, she did not document the BS of 70 mg/dl and she should have documented it.During an interview with LVN 6 on 12/16/2025 at 3:12 p.m., LVN 6 stated, she checked Resident 2's BS on 11/26/2025 at 6:30 a.m. and he had a high BS. LVN 6 stated, she administered glargine insulin, but she did not recheck his BS after administering the insulin. LVN 6 stated, she also did not give any hand-off report to the oncoming nurse regarding Resident 2's high BS and she did not document what her interventions upon assessing Resident 2's high BS. LVN 6 further stated, I honestly don't remember what I did but I should have rechecked his (Resident 2's) BS and notify the physician and the oncoming nurse and documented it.During an interview with Director of Nursing (DON) on 12/17/2025 at 2:26 p.m., DON stated, if resident has a high BS and license nurse administered insulin, they need to recheck the BS because residents who are given insulin are at risk of hypoglycemia. DON stated, Resident 2's had symptoms of hypoglycemia on 11/26/2025 as he was lethargic, unable to be aroused and unresponsive. DON further stated, the facility staff failed to document the interventions and did not notify the physician upon assessment of BS of 348 mg/dl.During a review of the facility's P&P titled, Nursing Care of the Older Adult with Diabetes Mellitus, revised on 12/2024, the P&P indicated that, The target range for healthy older adults is considered 90-130 mg/dl. The provider will order the frequency of glucose monitoring and establish appropriate glycemic targets for individual residents. Establish provider notification protocols, for example:a. Call provider immediately if resident is hypoglycemic {<70 mg/dL).b. Call as soon as possible when:(1) blood glucose values are regularly 70-100 mg/dL (for possible regimen adjustment);(2) blood glucose values are >250 mg/dL more than once within a 24-hr period;(3) blood glucose values are >300 mg/dL more than once over two consecutive days;(4) reading is too high for glucometer; or(5) the resident is vomiting, has symptomatic hyperglycemia or poor oral intake.Medication Management:5. Closely monitor the diabetes management of cognitively impaired residents.Documentation:b. Level of consciousness, change in orientation;c. Dose and time of most recent anti-hyperglycemic given;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop an individual written baseline care plan with interventions within 48-hours of admission when residents were identified as having a high fall risk for four of five sample residents (Resident 7, Resident 8, Resident 9 and Resident 10).This deficient had the potential to place the residents at risk of avoidable falls and injury.Findings:During a review of the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), difficulty in walking, and lack of coordination.During a review of the Minimum Data Set (MDS - resident assessment tool) dated 12/16/2025, indicated Resident 7's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 7 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 7's Fall Risk Assessment (FRA), dated 11/19/2025, the FRA indicated Resident 7 had a score of 17 (total score above 10 represents high risk [of fall]). During a review of Resident 7's Baseline Care Plan (BCP), dated 1/3/2026, the BCP indicated Resident 7 had a history of falls/at risk of falls for safety precautions. The BCP did not include any interventions related to safety issues of history of falls/at risk of falls. During a review of Resident 7's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/30/2025, the SBAR indicated, Resident 7 had an unwitnessed fall and was found on the floor beside the bed.During a review of Resident 7's SBAR dated 2/3/2026, the SBAR indicated, Resident 7 had unwitnessed fall with dark blue/purple discoloration on left hand, right and left forearms, and middle of forehead with skin tear on right forearm.During a review of the admission Record indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including myasthenia gravis (MG - is an autoimmune disease causing fluctuating weakness in voluntary muscles, like those for eyes, face, swallowing, and limbs), lack of coordination and seizure (abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control and behavior).During a review of the MDS dated [DATE], the MDS indicated Resident 8's cognitive skills for daily decisions were intact. The MDS indicated Resident 8 required set-up assistance from staff for ADLs. During a review of Resident 8's FRA, dated 11/29/2025, the FRA indicated, Resident 8 had a score of 16 (total score above 10 represents high risk [of fall]). During a review of Resident 8's BCP, dated 6/12/2021, the BCP indicated Resident 8 safety precautions information was blank and no information if resident have any safety precautions CP in placed.During a review of Resident 8's SBAR dated 1/24/2026, the SBAR indicated, Resident 8 was observed sitting on the floor. Resident (8) stated that he sled on the floor and landed on his buttocks. During a review of the admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including abnormalities of gait and mobility, type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and heart failure (a condition in which the heart does not pump blood as well as it should).During a review of the MDS dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 9 was totally dependent from staff for ADLs. During a review of Resident 9's FRA, dated 1/25/2026, the FRA indicated, Resident 9 had a score of 17 (total score above 10 represents high risk [of fall]). During a review of Resident 9's BCP, dated 12/15/2025, the BCP indicated Resident 9 safety precautions information was blank and no information if resident have any safety precautions such as history of falls/or at risk of falls CP in placed. During a review of Resident 9's SBAR dated 1/25/2026, the SBAR indicated, Resident (9) was found sitting on floor outside bathroom door.During a review of the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy, heart failure and lack of coordination.During a review of the MDS dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decisions were mildly impaired. The MDS indicated Resident 10 required maximal assistance from staff for ADLs. During a review of Resident 10's FRA, dated 2/1/2026, the FRA indicated Resident 10 had a score of 10 (total score above 10 represents high risk [of fall]). During a review of Resident 10's BCP, dated 2/1/2026, the BCP indicated Resident 10's safety precautions information was blank and no information if resident have any safety precautions such as history of falls/or at risk of falls CP in placed. During a review of Resident 10's SBAR dated 1/23/2026, the SBAR indicated, Found Resident (10) on the floor next to the bed, on the left side.During a concurrent interview and record review with Minimum Data Set Nurse 1 (MDSN 1) and Minimum Data Set Nurse 2 (MDSN 2) on 2/4/2026 at 2:06 p.m., MDSN 1 stated, resident's BCP must be developed and completed when residents get admitted and/or readmitted which is completed by the whole IDT team.During a concurrent interview and record review with Director of Nursing (DON) on 2/4/2026 at 3:32 p.m., DON reviewed Resident 7, Resident 8, Resident 9 and Resident 10's BCP and stated, the BCP were not completed and were not documented accurately. DON stated, if the BCP were not accurate, they would not know if residents were at risk for fall or not. DON stated, Residents 7, 8, 9 and 10 were evaluated as high risk of falls during their readmission assessment but the BCP were not developed, and no interventions were included to address their history of fall and/or risk of accidents due to falls.During a review of facility's policy and procedure (P&P) titled, Care Plans - Baseline, revised 1/2026, the P&P indicated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. The interdisciplinary team will review the healthcare practitioner's orders and implement a baseline care plan to meet the resident's immediate needs including, but not limited to the following: a. initials goals based on admission orders; physician's orders, dietary orders; therapy services; social services; and PASARR recommendation, if applicable.During a review of facility's P&P titled, admission Assessment and Follow Up: Role of the Nurse, revised 1/2026, the P&P indicated, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS. Conduct an admission assessment including: a summary of the individual's recent medical history, including hospitalizations, acute illnesses, and overall status prior to admission; relevant medical, social, and family history; a list of active medical diagnoses and patient problems (such as recurrent falling or impaired mobility).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the residents were free of unnecessary physical and chemical restraints (use of medication to manage a person's behavior or restrict their movement) with a medication Haloperidol (Haldol- is a first-generation or typical antipsychotic medication used to treat psychotic disorders and severe behavioral issues), for one of three sampled residents (Resident 3). This deficient practice resulted in unnecessary restraint and placed the resident at risk of potentially life-threatening results, including physical injury, cognitive decline, psychological trauma, and even death.During a review of the admission record for Resident 3 indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), history of falling, and Hyperlipidemia (HLD- a condition in which there are abnormally high levels of lipids [fats] in the blood) During a review of history and physical (H&P- is a thorough assessment a doctor does to understand a patient's health. It involves asking about the patient's past and current health problems [the history] and then examining the patient's body to look for signs of illness [the physical examination], dated 8/18/2025, indicated Resident 3 Family Member (FM) 1 as the responsible party. During a review of Resident 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated 8/5/2025, indicated Resident 3 had severe cognitive impairment (a person has great difficulty with thinking, learning, remembering, and making decisions, to the point where they can't live independently). The same MDS indicated Resident 3 mostly required substantial/maximal assistance for his Activities of Daily Living such as: (ADLs routine tasks/activities such as oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of the physician order dated 8/18/2025 indicated, Haloperidol 1 mg (milligram) tablet, take 1 tablet by mouth every 6 hours for psychosis for 14 days (stop 9/1/2025). Hold if sedation/RTC (difficult to arouse and return to clinic for follow up). During a review of Resident 3's care plan (a written, personalized document that details a person's health and personal needs, the goals of care, and how that support will be provided. It serves as a guide and a communication tool for the individual, their family, and healthcare providers to ensure consistent, coordinated, and personalized care that meets the person's specific needs, goals, and preferences) initiated 8/23/2025 indicated a focus of Actual incident of fall: UNWITNESSED FALL, with interventions including:- Apply restraint as ordered- Frequent visual monitoring- Place call light within easy reachDuring an interview with Resident 4 on 9/5/2025 at 10:34 am, Resident 4 stated that he was concerned for Resident 3 who was his roommate of the numerous falls and fell at least twice a day. Resident 4 stated that facility staff not only restrained Resident 3 with an unknown object but also, drugged him like a zombie, to prevent him (Resident 3) from falling. During an observation of Resident 3 on 9/5/2025 at 10:38 am, Resident 3 was observed lying down in a Geri chair (a large, padded, often wheeled chair designed to help seniors or individuals with limited mobility) at the foot of his bed against the wall and was asleep. Resident 3 did not arouse a call of his name and a gentle shake. Resident was noted to have bruises and scab to both arms and legs During an interview with Family Member (FM) 1 on 9/11/2025 at 1:55 pm, FM 1 stated that facility staff ad called her to get her consent about applying a restraint for Resident 3 because he was too aggressive and striking staff and was attempting to get up and had fallen on multiple occasions. FM 1 stated that she (FM 1) gave the facility consent to apply the restraint and had observed Resident 3 during one of her visits to the facility. FM 1 stated that the restraint was tied around Resident 3 abdomen and secured to his (Resident 3) bed. FM 1 stated that Resident 3 was unable to remove the restraint.During a concurrent observation and interview of Resident 3's medication bubble packs (blister pack/multi-dose pack, is a sealed card that organizes medications by dose, date, and time. Each dose is contained in its own transparent, plastic bubble or compartment, which is sealed with a foil or paper backing) with the Director of Nursing (DON) on 9/11/2025 at 3:35 pm, the DON confirmed that there were two bubble packs one marked for evening which contained 3 Haldol tablets and a bedtime one which contained 2 Haldol tablets. The DON confirmed that there was no physician's order for the Haldol and that Resident 3 should not have had the Haldol among his medications. The DON stated that Resident 3 had returned from General Acute Care Hospital with an order for Haldol on 8/18/2025 which should have been discontinued on 9/1/2025. The DON stated that only active medications are kept in the medication cart meaning that those medications are being administered to the resident. During a concurrent interview and record review of Resident 3's care plan for actual fall initiated on 8/23/2025 with the DON on 9/11/2025 at 4:15 pm, the DON confirmed that the care plan included an intervention which indicated to apply restraints. The DON stated that a care plan's intervention guides the staff on what type of care to provide for a resident. The DON stated that restraints may not be applied as a preventative measure for falls or behavior monitoring unless ordered as a safety measure for the resident. The DON stated that restraints must have a physician order after careful monitoring. During a review of the Policy and Procedure (P&P) titled Use of Restraints, revised 12/2024, indicated, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. 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. The same P&P indicated under policy interpretation the followingi. 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 symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.ii 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:a. The specific reason for the restraint (as it relates to the resident's medical symptom);b. How the restraint will be used to benefit the resident's medical symptom; andc. The type of restraint, and period of time for the use of the restraint. iii. Documentation regarding the use of restraints shall include:a. Full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to create an individualized care for one of three sampled residents (Resident 3) with specific goals and interventions for Resident 3's fall risk. This deficient practice could have potentially resulted in Resident 3's continued falls.During a review of the admission record for Resident 3 indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), history of falling, and Hyperlipidemia (HLD- a condition in which there are abnormally high levels of lipids [fats] in the blood) During a review of history and physical (H&P- is a thorough assessment a doctor does to understand a patient's health. It involves asking about the patient's past and current health problems [the history] and then examining the patient's body to look for signs of illness [the physical examination], dated 8/18/2025, indicated Resident 3 Family Member (FM) 1 as the responsible party. The same H&P indicated Resident 3 had been admitted to General Acute Care Hospital (GACH) due to an unwitnessed fall and suffered a 1.5-centimeter (cm) laceration above the right eyebrow. During a review of Resident 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated 8/5/2025, indicated Resident 3 had severe cognitive impairment (a person has great difficulty with thinking, learning, remembering, and making decisions, to the point where they can't live independently). The same MDS indicated Resident 3 mostly required substantial/maximal assistance for his Activities of Daily Living such as: (ADLs routine tasks/activities such as oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of the physician's order dated 8/18/2025, the order indicated Resident 3 may have low bed and floor mats for fall risk both left and right side. During a review of Resident 3's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 8/23/2025 at 2:10 pm, indicated, Resident is Alert & orient (a medical term used to describe a person's level of consciousness and cognitive function) x2 (oriented to person and place: Knows their own name and where they are) respiration Even. Resident had unwitnessed fall. During a review of Resident 3's SBAR dated 8/31/2025 at 8:50 pm, indicated, Supervisor was called to room A by CN (Charge Nurse). Upon entering the room, found resident (Resident 3) sitting on the floor inside the bathroom facing the sink. Initial assessment made. Assisted back to bed by 2 person assist and made comfortable. During a review of Resident 3's care plan initiated 8/23/2025 indicated a focus of Actual incident of fall: UNWITNESSED FALL, with interventions including:- Frequent visual monitoring- Place call light within easy reach- Apply restraint as ordered- Encourage resident not to get up without assistance- Monitor for changes in LOC and report to MD promptly During a review of Resident 3's care plan initiated 8/31/2025 indicated a focus of un-witnessed fall, with interventions including:- Provide a safe environment, free of clutters, floor kept dry and non-slippery, rooms with adequate lighting and document changes in gait to MD- Report and document changes in gait to MD During a concurrent observation and interview of Resident 3 with Certified Nursing Assistant (CNA) 1 on 9/5/25 at 10:40 am, Resident 3 was noted to be fast asleep in a reclining chair which was at the foot of his bed against the wall. The resident was noted to have several bruises and scabs to both his arms and legs. CNA 1 confirmed that Resident 3 was a fall risk and had previously fallen in the past. CNA 1 stated that interventions to prevent residents who were at high risk for falls included frequent checks, placing the call light within reach, placing bed in the lowest position, and placing floor mats on both sides of the bed. CNA 1 confirmed that there were no floor mats on either side of Resident 3's bed. During an interview with the Director of Nursing (DON) on 9/5/2025 at 2:30 pm, the DON stated that Resident 3 was at high risk for falls and had fallen twice since his admission. She stated that when residents are at a fall risk, the interventions must include frequent visual monitoring, call light within reach, floor mats in place. The DON confirmed that there was a physician's order to place floor mats besides but that the order was not carried out nor was it included in the care plan. The DON stated that the facility should have developed an individualized care plan for fall prevention which should have included Resident 3's specific interventions such as floor mats and frequent monitor checks. The DON stated that care plans help health care staff be uniform in carrying out interventions to prevent falls. During a review of the Policy and Procedure (P&P) titled Care Plans - Comprehensive, revised 12/2024, indicated the following policy statement, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The same P&P policy interpretation and implementations included:Each resident's comprehensive care plan is designed to:a. Incorporate identified problem areas.b. Incorporate risk factors associated with identified problems.c. Build on the resident's strengths.d. Reflect the resident's expressed wishes regarding care and treatment goals.e. Reflect treatment goals, timetables and objectives in measurable outcomes.f. Identify the professional services that are responsible for each element of care.g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels.h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; [NAME]. Reflect currently recognized standards of practice for problem areas and conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedures for change in condition for one of four sampled residents (Resident 3) when the resident refused their hemodialysis treatments three days in a row on 5/6/25, 5/7/25, 5/8/25. This failure resulted in the resident refusing their hemodialysis treatments and having no follow up or interventions made until his hospitalization on 5/9/25. During a review of Resident 3's admission Record, dated 7/15/25 indicated, the resident was admitted to the facility on [DATE] with diagnoses including; End Stage Renal Disease (ESRD-irreversible kidney failure), dependence on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), anemia (a condition where the body does not have enough healthy red blood cells), and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 3/23/25, the MDS indicated, Resident 3 had mild cognitive (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) impairment, and required supervision or touching assistance for oral hygiene, toileting, showering/bathing, and transfers. During a review of Resident 3's Oder Summary Report dated 7/15/25 indicated an order for dialysis every Monday, Wednesday, Friday time 12:30pm. During a review of Resident 3's General Note dated 5/5/25 at 3:54 pm (Monday) indicated Resident 1 missed his dialysis appointment that day due to another appointment that morning. During a review of Resident 3's IDT (interdisciplinary) meeting note dated 5/6/25 (Tuesday) indicated, Resident 3 refused to go to dialysis that day on due to not feeling well that day and was explained the risks and benefits. During a concurrent interview and record review on 7/15/25 at 2:40 pm with the Director of Nursing (DON), Resident 3's Nurses Notes and Change of Condition forms were reviewed for the days of Monday 5/5/25 - Friday 5/9/25 where there was no Change of Condition forms or nurses notes documented for the residents dialysis treatments being missed or refused on Tuesday 5/6/25, Wednesday 5/7/25 or Thursday 5/8/25. The DON verified there were no nurses notes of Change of Condition forms indicating the doctor was called for any of the three days Resident 3 missed or refused dialysis, DON stated the doctor should have been called and a note should have been documented, because if it is not documented it is not done. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, reviewed December 2024, the P&P indicated Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical /mental condition and / or status. The nurse will notify the resident's attending physician or physician on call when there has been a (an). refusal of treatment. The nurse will record the resident's medical record information relative to changes in the resident's medical/mental condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 126) would not be allowed to keep ear drops (Debrox drops, earwax removal kit) medication at the bedside without a physician's order.
This failure had the potential to result in unsafe medication application and/or over medicating for Resident 126.
Findings:
During a review of Resident 126's admission Record, the admission Record indicated the facility admitted the resident on 3/1/2025 and readmitted on [DATE] with diagnoses that include lack of coordination, bed confinement, and history of falling.
During a review of Resident 126's Care Plan Report, date initiated 3/3/2025, the Care Plan Report indicated the resident was at risk for adverse reaction (harmful reaction to a medicine) related to polypharmacy (is when you take several medications [five or more] each day). The Care Plan Report indicated the intervention was to ensure each physician had the full list of medications available, including OTC (over the counter) and PRN (as needed) medications.
During a review of Resident 126's Minimum Data Set (MDS, a resident assessment tool) dated 4/27/2025, the MDS indicated the resident had an intact cognitive function (impairment in the ability to think, understand and reason).
During a review of Resident 126's History and Physical (H&P), dated 4/28/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 126's Order Summary Report, dated 6/19/2025, the Order Summary Report indicated the resident had an audiology (study of hearing) consult PRN (as needed) hearing problems.
During an interview on 6/16/2025 at 12:07 PM with Resident 126, Resident 126 stated he (Resident 126) currently had a build up of ear wax which would make it hard to hear. Resident 126 stated the ear wax medicated drops were on bedside table.
During an observation and an interview on 6/19/2025 at 12:30PM with Resident 126, the resident was resting in bed, Debrox ear wax medication box noted at bedside. The resident stated a friend(unidentified) who visited him gave him the ear wax medication. Resident 126 stated he (Resident 126) could not remember when his friend brought the ear wax medication.
During an interview and an observation on 6/19/2025 at 12:57 PM with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated he (LVN6) gave Resident 126's morning medications and did not notice the Debrox ear wax medication box at bedside. LVN6 was holding medication box in his hand. LVN 6 stated friends and family needed to be educated on bringing medication into the facility because it could negatively interact with medication that were prescribed by the doctor. LVN6 stated all residents (in general) at the facility could not self-administer medications. LVN 6 stated he (LVN6) would call the doctor and ask if Debrox ear wax medication could be added to Resident 126's current medications to be administered by licensed staff.
During an interview on 6/19/2025 at 2:18 PM with the Director of Nursing (DON), the DON stated medications need to be confined and ordered from the MD (Medical Doctor). It is dangerous if medications are at the resident's bedside because we do not know if the medication was properly sealed, if they are contraindicated or have negative interactions with medications they are currently taking.
During a review of the facility's undated policy and procedure titled Identification of Medications Brought In At Admission, indicated Identification of medications, which are brought in form the acute care hospital, other nursing centers, Intermediate Care Center (ICF), or those medications dispensed by an outside pharmacy after admission and brought directly to the center, s not required by Del's Pharmacy. It is however, the responsibility of the center to assure correct identification of those medicines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide an emergency kit (a special kit placed at the resident's bedside used in emergency situations such as bleeding from a dialysis fistula [surgically created connection between an artery and a vein, usually in the arm, that makes it easier to access your bloodstream for dialysis]) for two of five sampled residents (Resident 124 and Resident 491).
This failure had the potential for Resident 124 and Resident 491 to experience uncontrollable bleeding.
Findings:
a. During a review of Resident 124's admission Record, the admission Record indicated Resident 124 was admitted on [DATE] with diagnoses that included diabetes mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), ESRD (End Stage Renal Disease-irreversible kidney failure, and 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.
During a review of Resident 124's Care Plan Report dated 3/31/2025, the Care Plan Report indicated the resident was on anticoagulant therapy (medications that stop your blood from clotting too easily) and was at risk for bleeding. The Care Plan Report indicated Resident 124 would be monitored by the facility for signs and symptoms of bleeding.
During a review of Resident 124's History and Physical (H&P) dated 5/21/2025, the H&P indicated Resident 124 had the capacity to understand and make decisions.
During a review of Resident 124's Minimum Data Set (MDS - a resident assessment tool) dated 5/13/2025, the MDS indicated Resident 124 had the ability to understand others and had the ability to make himself understood.
During a review of Resident 124's Order Summary Report dated 6/19/2025, indicated Resident 124 was prescribed Heparin Sodium (a medication to prevent blood clots and could cause bleeding) 5000 units (a unit of measurement) and Clopidogrel (a medication to prevent blood clots and could cause bleeding) 75 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount). The Order Summary Report indicated Resident 124 had a fistula.
During a concurrent observation and interview on 6/17/2025 at 12:15 PM with Licensed Vocational Nurse 11 (LVN 11) in Resident 124's room, the resident did not have an emergency kit at the resident's bedside. LVN 11 stated Resident 124 did not have an emergency kit at the bedside and would be at risk for bleeding without the emergency kit.
b. During a review of Resident 491's admission Record, the admission Record indicated Resident 491 was admitted on [DATE] with diagnoses that included diabetes mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), ESRD (End Stage Renal Disease-irreversible kidney failure, and 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.
During a review of Resident 491's Care Plan Report dated 6/13/2025, the Care Plan Report indicated the resident needed hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) related to renal (kidney) failure. The Care Plan Report indicated the nursing interventions would be to monitor Resident 491 for bleeding
During a review of Resident 491's Order Summary Report dated 6/19/2025 indicated Resident 491 had a renal shunt (also known as a dialysis fistula).
During a concurrent observation and interview on 6/16/2025 at 1:16 PM with LVN 12 in Resident 491's room, the resident's emergency kit was observed to be missing and not at the resident's bedside. LVN 491 stated the emergency kit was missing and the facility would need the emergency kit case Resident 491 bled.
During an interview on 6/17/2025 at 12:19 PM with the Director of Nursing (DON), the DON stated Resident 124 and Resident 491 would be at risk for bleeding continuously from their dialysis fistula if they did not have an emergency kit at the bedside to help stop the bleeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the correct enteral tube feeding (way to get nutrients into the body through a tube that's inserted into the stomach or small intestine, bypassing the mouth) rate of 65 milliliter (mL, a unit of measure) per hour for one of three sampled residents (Resident 21).
This failure had the potential for Resident 21 to experience malnutrion (is a serious condition that happens when a person's diet does not contain the right amount of nutrients).
Findings:
During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy (a condition where the brain does not function properly), dysphagia (difficulty swallowing), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).
During a review of Resident 21's History and Physical (H&P) dated 2/3/2025, the H&P indicated Resident 21 had a diagnosis of aspiration pneumonia (a lung infection caused by inhaling food, liquid, vomit, or saliva into the lungs instead of swallowing them properly) and dementia (a progressive state of decline in mental abilities). The H&P indicated Resident 21 had a g-tube (gastrostomy). The H&P indicated Resident 21 lacked the capacity to make and understand decisions (a person has the mental ability to understand and make choices about their own life and affairs).
During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 5/31/2025, the MDS indicated Resident 21 sometimes understood others and sometimes could make himself understood.
During a review of Resident 21's Order Summary Report dated 6/19/2025, the Order Summary Report indicated Resident 21's physician wrote an order on 6/11/2025 for enteral tube feeding to run at 65 mL per hour.
During a review of Resident 21's Progress Note dated 6/1/2025 created by Dietician 1 (DT 1), the Progress Note indicated Resident 21 was NPO (nothing by mouth). The Progress Note indicated Resident 21 had gradual weight loss in one, three, and six months. The Progress Note indicated Resident 21 recently lost five pounds and could benefit from more kcal (a unit of energy, and it's essentially the same thing as what's commonly referred to as a calorie on food labels and in discussions about diet) and protein from his tube feeding.
During a concurrent observation and interview on 6/16/2025 at 12:35 PM with Licensed Vocational Nurse 9 (LVN 9) and Registered Nurse 1 (RN 1), Resident 21's enteral tube feeding was observed to be running at 45 ml per hour on the machine and the label on the tube feeding indicated the feeding should be running at 65 mLs per hour. LVN 9 stated the enteral tube feeding label was wrong and the tube feeding machine was set correctly to 45 ml per hour. RN 1 checked the order and stated the machine should be set to 65 mL per hour. RN 1 stated when the machine was set to 45 mL per hour and the resident was at risk for malnutrition and skin breakdown. RN 1 was observed setting the machine to the correct setting of 65 mLs per hour.
During an interview on 3/19/2025 at 10:59 AM with the Director of Nursing (DON), the DON stated Resident 21 could be at risk for malnutrition and skin breakdown if Resident 21's enteral tube feeding was set to 45 mL per hour instead of the 65 mL per hour that was ordered by the resident's physician.
During a review of the facility ' s policy and procedure (P&P) titled Enteral Feedings - Safety Precautions, dated 12/2024, the P&P indicated the purpose of the P&P was to ensure the safe administration of enteral nutrition. In the section of the P&P titled preventing errors in administration, the P&P indicated the staff should check the enteral nutrition label against the order before administration. Check the following information:
a. Resident name, ID and room number;
b. Type of formula;
c. Date and time formula was prepared;
d. Route of delivery;
e. Access site;
f. Method (pump, gravity, syringe); and
g. Rate of administration (mL/hour).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 105's admission Record, the admission Record indicated the facility admitted the resident on 11-6-2024 with diagnosis that included bed confinement status (a state where an individual is unable to leave their bed without assistance due to a medical condition, injury, or physical limitation), human immunodeficiency virus disease (HIV- a viral infection that weakens the immune system and can lead to one getting life-threatening infections), end stage renal disease (irreversible kidney failure), and actinic keratosis (a rough, scaly patch or bump on the skin caused by damage from ultraviolet (UV) radiation).
During a review of Resident 105's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 4/14/2025 for a LALM every shift for wound management.
During a review of Resident 105's MDS dated [DATE], the MDS indicated the resident was cognitively intact (had the ability to think, understand, and reason). The MDS indicated Resident 105 required partial/moderate assistance with eating. The MDS indicated Resident 105 required substantial/maximal assistance with oral hygiene, toileting hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 105 was dependent on help for lower body dressing and putting on and taking off footwear. The MDS indicated Resident 105 was at risk of developing pressure ulcers/injuries. The MDS indicated Resident 105 had one Stage 4 (a pressure ulcer characterized by full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) pressure ulcer. The MDS indicated Resident 105 utilized a pressure reducing device for bed.
During a review of Resident 105's Weight Summary, the Weight Summary indicated the resident weighed 140 lbs. on 6/1/2025.
During a concurrent observation and interview on 6/19/2025 at 11:25 AM, with the DON, Resident 105's was observed on a Protekt Aire 6000 LALM. Resident 105's LALM was observed on the 230 lbs., setting. The DON stated based on Resident 105's weight of 140 lbs. the LALM settings of 230 lbs., were incorrect. The DON stated the LALM settings should be based on the resident's weight. The DON stated since Resident 105 weighed 140 lbs. his LALM setting should be at 140 lbs. The DON stated there was a potential for Resident 105 to re-develop a pressure ulcer with the LALM on the wrong settings.
During a review of the undated operational manual titled Operation Manual for Protekt Aire 6000, the operational manual indicated Operation .It is recommended to press Auto Firm on the panel when the mattress is first inflated. Users can then easily adjust the air mattress to a desired firmness according to the patient's weight and comfort.
Based on observation, interview, and record review, the facility failed to maintain the appropriate Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries [PU/PI, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device]) settings for three of three sampled residents (Resident 42, Resident 93 and Resident 105).
This failure had the potential to place Resident 42, Resident 93 and Resident 105 at risk for discomfort, slow wound healing, and the development of pressure ulcers/injuries
Findings:
a. During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of pressure ulcer stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) left hip, pressure ulcer stage 4 right upper back, dementia (a progressive state of decline in mental abilities), and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).
During a review of Resident 42's History and Physical (H&P) dated 11/2/2024, the H&P indicated Resident 42 was immobile (unable to move) and had multiple wounds in her upper back and left hip stage 4 wound. The H&P indicated a specialty mattress. The H&P indicated Resident 42 lacked the capacity to make and understand decisions (a person has the mental ability to understand and make choices about their own life and affairs).
During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool) dated 5/31/2025, the MDS indicated Resident 42 rarely/never understood others and rarely/never had the ability to make herself understood. The MDS indicated Resident 42's ability to make daily decisions was severely impaired. The MDS indicated Resident 42 was dependent for toileting, showering/bathing, rolling left and right, and for personal hygiene (keeping your body clean to stay healthy and avoid spreading germs).
During a review of Resident 42's Order Summary Report dated 6/19/2025, indicated Resident 42's physician wrote an order for Low Air Loss Mattress for wound management. Firmness: Resident current weight. Mode: Normal Pressure Check Daily every day shift for pressure relieving mattress for decub (bed sore) mgt (management).
During an concurrent observation and interview on 6/16/2025 at 11:30 AM with Licensed Vocational Nurse 6 (LVN 6), Resident 42's LALM setting was observed to be set at 350. LVN 6 immediately noted the setting and was observed turning the nob to a lower setting. The surveyor asked LVN 6 if he (LVN6) knew what the resident's weight was and LVN 6 stated he (LVN 6) would have to check Resident 42's electronic medical record (EMR). LVN 6 stated Resident 42's weight was 142 lbs (weight was later rechecked on 6/19/2025 and Resident 42's actual weight was 162 lbs). LVN 6 stated Resident 42's LALM was not set to the correct weight when it was set to 350 and the LALM should have been set to the resident's correct weight.
During a concurrent interview and record review on 6/19/2025 at 11:05 AM with the Director of Nursing (DON), Resident 42's Care Plan dated 10/14/2024 was reviewed. The DON stated the resident had a Stage 4 PI and was at risk to develop PIs and the nursing interventions were for the resident to have the LALM for skin maintenance. The DON stated the nursing staff did not follow the resident's care plan when they set Resident 42's LALM to 350 and the setting was too high because Resident 42 weighed 162 lbs. The DON stated when staff set the LALM to 350 it defeated the purpose of the LALM, the LALM was too hard, and could make the resident's (Resident 42) bedsores/wounds worse.
During a concurrent interview and record review on 6/19/2025 at 11:05 AM wih the DON, the product manual for Resident 42's LALM titled Med-Aire Melody Alternating Pressure Low Air Loss Mattress Replacement System Operator's Manual, (manual not dated) was reviewed. The DON stated the Operator's Manual indicated Step 6 Determine the patient's weight and set the control knob to that weight setting on the control unit. The DON stated the facility did not have a policy for LALM and the facility used the manufacturer guidelines for the LALM setting. The DON stated staff were not following the manufacturer guidelines.
b. During a review of Resident 93's admission Record, the admission Record indicated the facility admitted the resident on 12/1/2023 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), severe-protein calorie malnutrition (a serious condition resulting from inadequate intake of both protein and calories), and a pressure ulcer of an unspecified site.
During a review of Resident 93's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognition (some impairment in the ability to think, understand, and reason). The MDS indicated Resident 93 was dependent on help for eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on and taking off footwear, and personal hygiene.The MDS indicated Resident 93 was at risk for developing pressure ulcers/injuries.The MDS indicated Resident 93 utilized a pressure reducing device for bed.
During a review of Resident 59's Weight Summary, the Weight Summary indicated the resident weighed 159 pounds (lbs., a measurement of weight) on 6/2/2025.
During a review of Resident 59's Order Summary Report, the Order Summary Report indicated the resident dated 6/18/2025, the Order Summary Report indicated the resident had a physician order for a Low Airloss Therapy bed (LALM) for prophylaxis of pressure ulcers. The Order Summary Report indicated to monitor the mode of the LALM. The Order Summary Report indicated the LALM was to be on normal pressure with firmness set per Resident 93's comfort or weight.
During a concurrent observation and interview on 6/16/2025, at 3:32 PM, with the DON, in Resident 93's room, the resident was observed on a Protekt Aire 2000/3000 LALM. Resident 93's LALM was observed with a label that indicated the LALM settings were to be on 120 - 160 lbs. Resident 93's LALM was observed on the 200 lbs., setting. The DON stated and verified Resident 93's LALM was set at 200 lbs. The DON stated the LALM settings were incorrect. The DON stated the purpose of the LALM was to help prevent pressure ulcers from developing. The DON stated that the purpose of the LALM was defeated if it was not placed on the correct settings. The DON stated there was a potential for Resident 93 to develop a pressure ulcer with the LALM on the wrong settings.
During a review of the undated operational manual titled Operation Manual for Protekt Aire 3000/3500/3600/3600AB, the operation manual indicated Operating Instructions .Step 6 Determine the patient's weight and set the control knob to that weight setting on the control unit.

Based on interview and record review, the facility failed to rotate the insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection (the act of putting a liquid, especially a drug, into a person's body using a needle ) administration sites for one of one sampled residents (Resident 109).
This failure had the potential for Resident 109 to develop skin infection.
Findings:
During a review of Resident 109's admission Record, the admission Record indicated the facility admitted the resident on 1/3/2025 with diagnoses that included type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of Resident 109's Minimum Data Set (MDS, a resident assessment tool) dated 4/19/2025, the MDS indicated the resident had moderate cognitive impairment (some impairment in the ability to think, understand, and reason). The MDS indicated Resident 109 received insulin injections.
During a review of Resident 109's Order Summary Report dated 6/18/2025, the Order Summary Report indicated the resident had a physician order to receive Lispro Insulin (a medication used to manage type 2 diabetes by lowering blood sugar levels) per sliding scale (a chart with preestablished insulin doses used to determine the dose to be administered to an individual based on blood sugar levels) subcutaneously (a method of administering medication by injecting it into the fatty layer of tissue just beneath the skin) before meals and at bedtime for DM.
During a review of Resident 109's Medication Administration Report (MAR) dated 5/1/2025 - 5/31/2025, the MAR indicated the resident consecutively received insulin in the right arm on 5/1/2025 at 11:30 AM and 4:30 PM; 5/25/2025 at 11:30 AM and 4:30 PM; and 5/28/2025 at 11:30 AM and 4:30 PM. The MAR indicated Resident 109 consecutively received insulin in the left arm on 5/2/2025 at 11:30 AM and 4:30 PM.
During a review of Resident 109's MAR dated 6/1/2025 to 6/17/2025, the MAR indicated Resident 109 consecutively received insulin in the left arm on 6/2/2025 at 11:30 AM and 4:30 PM; and on 6/6/2025 at 4:30 PM and 9:00 PM. The MAR indicated Resident 109 consecutively received insulin in the right arm on 6/3/2025 at 11:30 AM and 4:30 PM.
During a concurrent interview and record review on 6/18/2025 at 4 PM, with Licensed Vocational Nurse 5 (LVN 5), Resident 109's MAR dated 5/1/2025 to 5/31/2025 and MAR dated 6/1/2025 to 6/17/2025 were reviewed. LVN 5 stated Resident 109 did not have his insulin administration sites rotated on 5/1/2025 at 11:30 AM and 4:30 PM, 5/2/2025 at 11:30 AM and 4:30 PM, 5/25/2025 at 11:30 AM and 4:30 PM, 5/28/2025 at 11:30 AM and 4:30 PM, 6/2/2025 at 11:30 AM and 4:30 PM, 6/3/2025 at 11:30 AM and 4:30 PM, and on 6/6/2025 at 4:30 PM and 9:00 PM. LVN 5 stated when insulin was administered the injection sites should have been rotated to prevent infection.
During a concurrent interview and record review on 6/19/2025 at 11:45 AM, with the Director of Nursing (DON), Resident 109's MAR dated 5/1/2025 - 5/31/2025 and MAR dated 6/1/2025 to 6/17/2025 were reviewed. The DON stated Resident 109 did not have his insulin administration sites rotated on 5/1/2025 at 11:30 AM and 4:30 PM, 5/2/2025 at 11:30 AM and 4:30 PM, 5/25/2025 at 11:30 AM and 4:30 PM, 5/28/2025 at 11:30 AM and 4:30 PM, 6/2/2025 at 11:30 AM and 4:30 PM, 6/3/2025 at 11:30 AM and 4:30 PM, and on 6/6/2025 at 4:30 PM and 9:00 PM. The DON stated the injection sites needed to be rotated when administering insulin injections. The DON stated there was a potential for Resident 109 to develop cellulitis (skin infection) from repeated injections in the same area.
During a review of the facility's Policy & Procedure (P&P) titled Insulin Administration dated
12/2024, the P&P indicated Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes .Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

Based on observation, interview, and record review, the facility failed to reassess and reevaluate to identify residents' needs and/or change in conditions, for two of four observed residents (Resident 45 and Resident 89).
This failure had the potential for medication error and/or delay in treatment that may or may not affect Resident 89 and Resident 45' conditions.
(Cross Reference F759)
Findings:
a. During a med pass observation on 6/18/2025 at 8:49 AM, LVN 3 applied diclofenac sodium external gel 1 % to Resident 45's both knees. During a review of Resident 45's diclofenac order, the order (dated 8/24/2024) indicated apply to both [hands] topically two times a day for pain management.
During a review of Resident 45's care plan and a concurrent interview on 6/18/2025 at 3:40 PM, with the Director of Nursing (DON) Resident 45's care plan was reviewed. The DON stated the care plan did not specify which joints required pain management. The DON stated there was no mention of pain in hands or knees. The DON stated there was no documented assessment regarding Resident 45's pain in the knees.
b.During a medication administration (med pass) observation on 6/18/2025 at 8:27 AM Licensed Vocational Nurse (LVN 4) did not administer Resident 89's medication order (dated 7/16/2024) for diclofenac sodium (a medication used to relieve pain and inflammation in certain joints) external gel 1 %, with an instruction to apply to the right shoulder two times a day for pain management.
During an interview on 6/18/2025 at 11:11 AM, LVN 4 stated Resident 89 did not ask for [diclofenac gel] .
During an observation and a concurrent interview on 6/18/2025 at 1:10 PM, Resident 89 moved his right upper arm and shoulder in a circle and stated he had not been having any pain in the right shoulder, thus, he did not feel he needed the gel anymore.
During an interview on 6/18/2025 at 1:30 PM LVN 4 stated Resident 89 had not needed diclofenac gel for at least two weeks. LVN 4 referred to Resident 89's MAR and stated Resident 89's pain level had been zero (no pain) for his shoulders.
During an interview on 6/18/2025 at 1:38 PM, the DON stated nurses (in general) should reassess resident 89's right shoulder and notify the doctor for the change in condition. The DON reviewed Resident 89's care plan and stated there was no change in Resident 89's care plan regarding the shoulder pain.
During a review of the facility policy and procedures, Care Plans, Comprehensive Person-Centered (dated December 2024), the policy indicated . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . The comprehensive, person-centered care plan will . incorporate identified problem areas; . identify the professional services that are responsible for each element of care; . reflect currently recognized standards of practice for problem areas and conditions . interventions address the underlying source(s) of the problem area(s) . The interdisciplinary team must review and update the care plan . when there has been a significant change in the resident's condition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 45's order for diclofenac sodium (a medication used to relieve pain and inflammation in certain joints) external gel 1 %, the order (dated 8/24/2024) indicated apply to both [hands] topically two times a day for pain management.
During an observation on 6/18/25 at 8:49 AM, Licensed Vocational Nurse (LVN 3) applied the diclofenac gel to both of Resident 45's knees.
During an interview on 6/18/2025 at 11:32 AM, the Director of Nursing (DON) stated Resident 45's diclofenac gel order was written for the application to the hands and the nurse should contact doctor if Resident 45 had pain in the knees.
During an interview, and a concurrent review of Resident 45's medication administration record (MAR) of June 2025, on 6/18/2025 at 12 PM, the DON reviewed Resident 45's MAR for the diclofenac gel. The DON stated the hans in the order was misspelled and should be hands. The MAR indicated that at least four of 17 morning applications of diclofenac with the sites of applications noted as BLE (both lower extremeties/legs) and there was no documented site of evening applications. The DON stated BLE meant bilateral lower extremities. The DON stated nurses (in general) should only apply the medication to the area stipulated in the order, otherwise, nurses needed to contact the doctor for changes in order and evaluation of resident's new pain area.
During a review of Resident 45's care plan (initiated on 10/9/2023) did not specific which joints required pain management.
During an interview on 6/18/25 at 3:37 PM, the DON presented a clarification order (dated 6/18/2025) and a revised care plan (dated 6/18/25) for Resident 45, however, during a concurrent review of the care plan, the DON stated there was no new interventions added to the care plan.
3. During a review of Resident 44's admission Record, the admission Record indicated the facility admitted the resident on 9/16/2024 and readmitted on [DATE] with diagnoses that include hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body) following cerebral infarction affecting right dominant side, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastrostomy (Gtube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dysphagia (difficulty swallowing), gastro-esophageal reflux disease (when the stomach acid frequently flows back into the esophagus, causing heartburn and other issues) and muscle weakness.
During a review of Resident 44's Care Plan Report, date initiated 12/27/2024, the Care Plan Report indicated the resident has a Gt (Gtube) site on upper abdomen. Target date: 4/11/2025
During a review of Resident 44 ' s Order Summary Report, with an order date of 4/3/2025, the Order Summary Report indicated for the resident to receive enteral (also referred to as tube feeding, is the delivery of nutrients through a feeding tube directly into the stomach) feeding with Glucerna 1.5 (nutrition formula) at 60 milliliters (mL, a unit of measurement) per hour for 20 hours to equal 1,200 mL / 1800 kilocalorie (Kcal, a unit of energy measurement commonly used in nutrition to express the energy content of food) via the ePump machine (a system is intended for when patients require nutrition through continuous feeding, intermittent feeding or feeding and flushing) two times a day at 12 PM and off at 8 AM or until total desired volume was infused.
During a review of Resident 44's MDS dated [DATE], the MDS indicated the resident had a moderate cognitive impairment (impairment in the ability to think, understand and reason). The MDS indicated the resident was not assessed for eating ability due to medical condition or safety concerns.
During a concurrent interview and record review on 6/18/2025 at 12:21 PM with the Director of Nursing (DON) Resident 44's care plans for g-tube were reviewed. The DON stated Resident 44's care plans needed to be revised so the nursing staff would know how to care for the resident.
4. During a review of Resident 68's admission Record, the admission Record indicated the facility admitted the resident on 8/2/2021 and readmitted on [DATE] with diagnoses that include seizures, altered mental status, depression (a mental health disorder characterized by a persistent feeling of sadness and loss of interest in activities, impacting how someone feels, thinks and behaves), schizophrenia (a mental illness that is characterized by disturbances in thought), mild cognitive impairment (impairment in the ability to think, understand and reason), epilepsy (a neurological condition characterized by recurrent, unprovoked seizures), and encephalopathy (a condition where the brain does not function properly).
During a review of Resident 68's MDS dated [DATE], the MDS indicated the resident had a moderate cognitive impairment (impairment in the ability to think, understand and reason). The MDS indicated the resident also had fluctuating disorganized thinking and altered level of consciousness.
During a review of Resident 68's Care Plan Report, date initiated 5/15/2025, the Care Plan Report indicated, the resident has a seizure disorder (Epilepsy) and is to have the following medication(s): Levetiracetam (medication to help treat seizures) oral tablets 1000 milligrams (mg, a unit of measurement) to be given BID (twice a day). The Care Plan Report indicated Resident 68 had three episodes of seizure activity. Revised on 1/16/2025.
During an interview on 6/18/2025 at 12:15PM with LVN charge nurse, LVN stated, Resident 68 was on seizure precautions, the bed was always in the lowest position.
During an interview on 6/18/2025 at 12:20 PM with the DON, DON stated, Resident 68's care plans for falls, behaviors and seizure precautions were important to be revised so that we know how to care for the patient and revise as needed.
During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered dated December 2024, indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' condition change.
Based on observation, interview, and record review, the facility failed to revise the care plans for four of ten sampled residents (Resident 42, Resident 44, Resident 45, and Resident 68) by failing to revise:
1.Resident 42's low air loss mattress (LALM - a specialized air mattress designed to prevent pressure injuries (PI, injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) care plan.
2. Resident 45's new pain area care plan.
3.Resident 44's gastrostomy tube (g-tube - a surgical opeing fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) care plan.
4.Resident 68's behavioral and seizure (a sudden, uncontrolled electrical disturbance in the brain) precaution care plan.
These failures had the potential to negatively affect the provision of care and services for Resident 42, Resident 44, Resident 45, and Resident 68.
Findings:
1.During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of pressure ulcer stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) left hip, pressure ulcer stage 4 right upper back, dementia (a progressive state of decline in mental abilities), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).
During a review of Resident 42's History and Physical (H&P) dated 11/2/2024, the H&P indicated Resident 42 was immobile (unable to move) and had multiple wounds in her upper back and left hip stage 4 wound. The H&P indicated a specialty mattress.The H&P indicated Resident 42 lacked the capacity to make and understand decisions (a person has the mental ability to understand and make choices about their own life and affairs).
During a review of Resident 42's Minimum Data Set (MDS - a resident assessment tool) dated 5/31/2025, the MDS indicated Resident 42 rarely/never understood others and rarely/never had the ability to make herself understood. The MDS indicated Resident 42's ability to make daily decisions was severely impaired. The MDS indicated Resident 42 was dependent for toileting, showering/bathing, rolling left and right, and for personal hygiene (keeping your body clean to stay healthy and avoid spreading germs).
During a review of Resident 42's Order Summary Report dated 6/19/2025 indicated Resident 42's physician wrote an order for Low Air Loss Mattress for wound management. Firmness: Resident current weight. Mode: Normal Pressure Check Daily every day shift for pressure relieving mattress for decub (bed sore) mgt (management).
During an concurrent observation and interview on 6/16/2025 at 11:30 AM with Licensed Vocational Nurse 6 (LVN 6), Resident 42's LALM setting was observed to be set at 350. LVN 6 immediately noted the setting and was observed turning the knob to a lower setting. The surveyor asked LVN 6 if he knew what the resident's weight was and LVN 6 stated he would have to check Resident 42's electronic medical record (EMR). LVN 6 stated Resident 42's weight was 142 lbs (weight was later rechecked on 6/19/2025 and Resident 42's actual weight was 162 lbs). LVN 6 stated Resident 42's LALM was not set to the correct weight when it was set to 350 and the LALM should have been set to the resident's correct weight.
During a concurrent interview and record review on 6/19/2025 at 11:05 AM with the Director of Nursing (DON), Resident 42's Care Plan dated 10/14/2024 was reviewed. The DON stated the resident had a Stage 4 PI and was at risk to develop PIs and the nursing interventions were for the resident to have the LALM for skin maintenance. The DON stated the nursing staff did not follow the resident's care plan when they set Resident 42's LALM to 350 and the setting was too high because Resident 42 weighed 162 lbs. The DON stated when staff set the LALM to 350 it defeated the purpose of the LALM, the LALM was too hard, and could make the resident's (Resident 42) bedsores/wounds worse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatment) to meet the resident's needs for one of three sampled residents (Resident 44) by failing to create an appropriate care plan for Resident 44's tube feeding (a method of providing nutrition directly into the stomach or small intestine through a tube, when a person is unable to eat or drink enough to meet their nutritional needs).
This failure had the potential for Resident 44 to receiving inadequate care.
Findings:
During a review of Resident 44's admission Record, the admission Record indicated the facility admitted the resident on 9/16/2024 and readmitted on [DATE] with diagnoses that include hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body) following cerebral infarction affecting right dominant side, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dysphagia (difficulty swallowing), gastro-esophageal reflux disease (when the stomach acid frequently flows back into the esophagus, causing heartburn and other issues) and muscle weakness.
During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool) dated 4/4/2025, the MDS indicated the resident had a moderate cognitive impairment (impairment in the ability to think, understand and reason). The MDS indicated the resident was not assessed for eating ability due to medical condition or safety concerns.
During a review of Resident 44's Care Plan Report, date initiated 12/27/2024, the Care Plan Report indicated the resident had a Gt site on upper abdomen.
During a review of Resident 44 ' s Order Summary Report, with an order date of 4/3/2025, the Order Summary Report indicated for the resident to receive enteral (also referred to as tube feeding, is the delivery of nutrients through a feeding tube directly into the stomach) feeding with Glucerna 1.5 (nutrition formula) at 60 milliliters (mL, a unit of measurement) per hour for 20 hours to equal 1,200 mL /1800 kilocalorie (Kcal, a unit of energy measurement commonly used in nutrition to express the energy content of food) via the ePump machine (a system is intended for when patients require nutrition through continuous feeding, intermittent feeding or feeding and flushing) two times a day at 12PM and off at 8AM or until total desired volume was infused.
During an interview on 6/18/2025 at 9:38 AM with the Licensed Vocational Nurse (LVN) charge nurse, LVN stated he was searching for g-tube care plans related to the g-tube feeding and stated he (LVN charge nurse) was having difficulty finding them.
During a concurrent interview and record review on 6/18/2025 at 12:21 PM with the Director of Nursing (DON), the DON stated Resident 44's care plan for g-tube was important so that staff would know how to care for the resident. The DON stated the Care plan for g-tube on upper abdomen was printed and was searching for another care plan regarding g-tube regarding feeding.
During an interview on 6/19/2025 at 3:01 PM with the DON, the DON presented another careplan for Resident 44, the resident requires tube feeding (G-TUBE) related to dysphagia (difficulty swallowing). Date initiated 6/19/2025, today's date.
During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered dated December 2024, 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.

**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) discharge (the formal release from a facility) assessment was accurately performed for one of seven sampled residents (Resident 138).
This failure had the potential to result in the inadequate care of Resident 138 during her discharge from the facility.
Findings:
During a review of Resident 138's admission Record, the admission Record indicated the facility admitted the resident on 3/5/2025 with diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), lack of coordination (inability to smoothly and accurately control body movements), difficulty in walking, a history of falling, and a displaced fracture of the greater trochanter of the left femur (a broken left upper thigh bone).
During a review of Resident 138's MDS dated [DATE], the MDS indicated Resident 138 was discharged to a Short-Term General Hospital (a medical center that specializes in the short-term medical treatment of patients).
During a review of Resident 138's Order Summary Report dated 3/22/2025, the Order Summary Report indicated the resident was to be discharged to a Senior Living Facility 1 (SLF 1) on 3/22/2025 with Home Health Services (HHS, health care services that you can get in your home for an illness or injury) for nursing, physical therapy (treatment that helps improve how the body performs physical movements), occupational therapy (health care services that help improve the ability to perform daily tasks), and Durable Medical Equipment (DME, reusable medical devices used to manage health conditions, aid in recovery from injuries, or help individuals maintain independence).
During a review of Resident 138's Discharge summary dated [DATE] at 1:16 PM, the Discharge Summary indicated Resident 138 was discharged by a private car to SLF 1 with all her medicine accompanied by her family member.
During a concurrent interview and record review on 6/18/2025 at 2:06 PM, with MDS Assistant (MDS 1), Resident 138's MDS dated [DATE] and Order Summary Report dated 3/22/2025 were reviewed. MDS 1 stated Resident 138 was discharged to SLF 1 on 3/22/2025. MDS 1 stated the MDS dated [DATE] was inaccurate because it indicated Resident 138 was discharged to a short-term hospital. MDS 1 stated the MDS assessment must be accurate and reflect the resident's status. MDS 1 stated there was a potential for Resident 138 to not have her needs met at discharge if the MDS assessment was inaccurate.
During a concurrent interview and record review on 6/19/2025 at 11:50 AM, with the Director of Nursing (DON), Resident 138's MDS dated [DATE] and Order Summary Report dated 3/22/2025 were reviewed. The DON stated Resident 138 was discharged to SLF 1 not a hospital. The DON stated the MDS dated [DATE] did not reflect that Resident 138 was discharged to a SLF. The DON stated a resident might not receive the appropriate care when discharged from the facility if the MDS assessment was inaccurate.
During a review of the facility's Policy & Procedure (P&P) titled Resident Assessments dated 12/2024, the P&P indicated A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements .The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements .Discharge Assessment - Conducted when a resident is discharged from the facility .A comprehensive assessment includes: Completion of the Minimum Data Set (MDS); Completion of the Care Area Assessment (CAA) Process; and Development of the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide care in a manner that promoted or enhanced a resident's dignity for two of three sampled residents (Resident 6 and Resident 492) by failing to ensure to:
1. Provide Resident 6 with a privacy curtain (cloth barriers that surround a patient's bed) of adequate length.
2. Provide a cover for Resident 492's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) bag.
These failures had the potential to cause emotional distress, affect the Resident 6's and Resident 492's self-esteem (how we value and perceive ourselves), and cause a loss of dignity (he quality or state of being worthy, honored, or respected) and decline in psychosocial (social factors and individual thought and behavior) wellbeing.
Findings:
1. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 6/24/2024 with diagnoses that included encephalopathy (brain damage that causes severe confusion and forgetfulness), dysphagia (difficulty swallowing), schizophrenia (a mental illness that is characterized by disturbances in thought), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), and lack of coordination (inability to smoothly and accurately control body movements).
During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool) dated 4/30/2025, the MDS indicated the resident had severely impaired cognition (a significant decline in mental abilities, affecting a person's ability to think, remember, learn, make decisions, and solve problems). The MDS indicated Resident 6 required partial/moderate assistance for eating, oral hygiene, and upper body dressing. The MDS indicated Resident 6 was dependent on help for toileting hygiene, showering and bathing herself, lower body dressing, putting on and taking off footwear, and personal hygiene.
During a concurrent observation and interview on 6/19/2024 at 8:57 AM, with Restorative Nurse Assistant 2 (RNA 2), in Resident 6's room, RNA 2 was observed pulling Resident 6's privacy curtain to assist the resident to perform Range of Motion (ROM, exercises designed to maintain or improve the flexibility of joints and muscles) exercises. Resident 6's privacy curtain was observed short and unable to fully provide the resident with privacy. RNA 2 stated Resident 6's privacy curtain was too short. RNA 2 stated Resident 6's privacy curtain needed to be longer to provide the resident with adequate privacy.
During a concurrent observation and interview on 6/19/2024 at 9:10 AM, with Maintenance Director 1 (MAD 1), in Resident 6's room, the resident's privacy curtain was observed. MAD 1 stated Resident 6's privacy curtain was too short and would not fully cover the resident when needed. MAD 1 stated Resident 6's privacy curtain needed to be longer to provide the resident with adequate privacy.
During an interview on 6/19/2025 at 11:40 AM, with the Director of Nursing (DON), the DON stated each resident should have a privacy curtain to maintain dignity. The DON stated the curtain should be of adequate length to cover the resident's living area and space. The DON stated there was a potential for Resident 6's dignity to not be maintained if the privacy curtain was not an adequate length.
During a review of the facility's Policy and Procedure (P&P) titled Dignity dated 12/2024, the P&P indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
2. During a review of Resident 492's admission record, the admission Record indicated the facility originally admitted Resident 492 on 11/13/2018 and readmitted the resident on 6/12/2025 with diagnoses of infection and inflammatory (the body's response to injury or infection) reaction due to indwelling urethral catheter (a thin, hollow tube inserted through the that lets urine leave the body into the urinary bladder [part of the body that stores urine] to collect and drain urine), dementia (a progressive state of decline in mental abilities), urinary tract infection (UTI- an infection in the bladder/urinary tract), and benign prosthetic hypertrophy (BPH - also known as an enlarged prostate, is a common condition where the prostate gland grows larger than normal as men age).
During a review of Resident 492's Order sheet dated 6/12/2025, the Order sheet indicated an order for a foley catheter (a thin, flexible tube that's inserted into the bladder to drain urine).
During a review of Resident 492's History and Physical (H&P) dated 6/14/2025, the H&P indicated Resident 492 was getting an intravenous (IV - through a vein), Ceftriaxone (antibiotic) 1 gram (a unit of measurement) for a UTI until 6/19/2025.
During a review of Resident 492's MDS dated [DATE], the MDS indicated Resident 492 had the ability to understand others and make himself understood. The MDS indicted Resident 492 needed maximum assistance for toileting.
During a review of Resident 492's Care Plan dated 6/16/2025, the Care Plan indicated Resident 492 had an indwelling catheter and the catheter bag and tubing should be positioned away from the entrance room door.
During a concurrent observation and interview on 6/16/2025 at 1:26 PM with Certified Nursing Assistant 1 (CNA 1) in Resident 492's room, the resident's urinary catheter bag was observed hanging on the bed without a cover. CNA 1 stated the urine bag was not covered and the resident's dignity (the quality or state of being worthy, honored, or respected) may be affected.
During an interview on 6/19/2025 at 11:28 AM with the Director of Nursing (DON), the DON stated if a resident's urine bag is not covered (in general), the resident's dignity could be affected.
During a review of the facility's policy and procedure (P&P) titled Dignity, dated 12/2024, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P also indicated Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example:
a. helping the resident to keep urinary catheter bags covered.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program (is the practice of managing and regulating undesirable organisms, commonly known as pests, that pose threats to human health) for 136 residents who resided in the facility to destroy and prevent cockroaches in the facility
This failure resulted in the presence of one live cockroach in the utility room (a room where medical supply is stored and the location of the resident refrigerator for outside food and the unit ice machine) and placed 136 residents at risk of serious disease that can be transmitted through various routes (direct contact or inhalation) and by contaminating human food with germs (small living things/cells, especially one which cause diseases) that pests pick up from drains, garbage dumps and outside grounds.
Findings:
During a concurrent observation of the facility's utility room and interview with the Nurse Supervisor (RN2) on 6/18/2025, at 9 AM, one small brown cockroach was observed traveling from under the counter and went under the resident refrigerator for outside food. RN2 stated while observing the brown pest and stated that was cockroach and would contact the maintenance supervisor.
During a concurrent observation of the facility's utility room and interview with the Director of Staff development (DSD) on 6/18/2025, at 9:30AM, one small brown cockroach was observed coming out from under the residents' (in geneneral) refrigerator, it was moving slowly and stopped moving then went under the residents' refrigerator. DSD stated the insect was a cockroach and stated would contact the maintenance supervisor and housekeeping to clean it up.
During an interview with Maintenance and housekeeping Director (MAD1) on 6/18/2025 at 10 AM, MAD1 stated pest control services would go in once a month for services. MAD1 stated it was important to not have roaches to prevent cross contamination and for infection control for residents, so the residents would not get sick from it.
During an interview with Infection prevention nurse (IP, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment) on 6/18/2025 at 2:30PM, the IP nurse stated she (IP nurse) would make rounds every day in residents' rooms, offices and the utility room. The IP nurse stated she (IP nurse) had not observed any pests inside the facility and in resident rooms.
During an interview with the MAD1 on 6/18/2025 at 3:00PM, MAD1 stated pest control services were every month. MAD1 stated pest control started the rounds outside of the facility parameters then would go inside the building to monitor the traps for pest activity, added and replaced the traps. MAD1 stated every month pest control would go in and check inside the facility in resident rooms, kitchen, offices and utility room.
During a review of monthly pest control records from 2/17/2025 to 5/27/2025, it indicated for the month May on 5/27/2025 pest control only provided service outside of the building parameter and garage and did not come inside the building for monthly rooms inspection.
During a review of pest control report dated 6/18/2025, it indicated one dead German cockroach (most common species of cockroach and its infestations most often seen in restaurant, food processing facilities, hotels and nursing homes.) was found in the utility room. The report also indicated Food debris found in employee lounge and the utility room. The report indicated food debris sitting over night or few days can be a condition that is conducive for pest.
During a review of facility's policy titled Pest Control (revised 12/2024) indicated, Facility shall maintain an effective pest control program . an ongoing pest control program to ensure that the building is kept free of insects and rodents .maintenance series assist, when appropriate and necessary, in providing pest control services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a review of Resident 101's admission Record, the admission Record indicated the facility admitted Resident 101 on 11/5/2024 with diagnoses that included seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), HIV (Human Immunodeficiency Virus Disease (a virus that attacks the body's immune system), weakness, and anxiety disorder (mental health conditions that cause fear, dread and other symptoms)
During a review of Resident 101's History and Physical (H&P) dated 11/7/2024, the H&P indicated Resident 101 had lack of coordination and needed safety precautions.
During a review of Resident 101's MDS dated [DATE], the MDS indicated Resident 101 sometimes understood others and sometimes had the ability to understand others.
During a review of Resident 101's general progress note dated 6/19/2025 at 7:42 AM, indicated Licensed Vocational Nurse 5 (LVN 5) instructed Resident 101 to use her call light for assistance.
During a concurrent observation and interview on 3/16/2025 at 1:16 PM with CNA 3, Resident 101 was observed asleep in her wheelchair next to her bed with the call light positioned on the bed out of the reach of Resident 101. CNA 3 stated the call light should be within Resident 101's reach so she could call for assistance if needed. CNA 3 repositioned the call light next to Resident 101 within the resident's reach.
During a review of the facility's policy and procedure (P&P) dated 12/2024, indicated the purpose of this procedure is to ensure timely responses to the resident's requests and needs. The P&P indicated when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. The P&P indicated some residents may not be able to use their call light. Be sure you check these residents frequently.
Based on observation, interview, and record review, the facility failed to ensure the call lights (a device used by a patient to signal his or her need for assistance) were within reach for two of 27 sampled residents (Residents 69 and Resident 101).
This failure had the potential not to meet the needs of Resident 69 and Resident 101.
Findings:
During a review of Resident 69's admission Record, the admission Record indicated the facility originally admitted Resident 69 on 2/10/2023 and readmitted the resident on 4/8/2025 with diagnoses of end stage renal disease (a condition where the kidneys are so damaged that they can no longer filter waste and excess fluid from the blood effectively), need for assistance with personal care, history of falling, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle wasting and atrophy (the gradual wasting away or shrinking of an organ, tissue, or muscle), encephalopathy (a condition where the brain does not function properly) and dementia (a progressive state of decline in mental abilities).
During a review of Resident 69's Minimum Data Set (MDS - a resident assessment tool) dated 4/29/2025, the MDS indicated Resident 69 sometimes was able to make herself understood and sometimes was able to understand others. The MDS indicated Resident 69's vision was highly impaired. The MDS indicated Resident 69 was always incontinent of urine and stool (inability to control when you urinate or have a bowel movement).
During a concurrent observation and interview on 6/18/2025 at 12:03 PM with Licensed Vocational Nurse 2 (LVN2), Resident 69 was observed sleeping in her bed with her call light dangling off of the bed, not within her reach. LVN2 stated Resident 69 was blind and the call light was out of the resident's reach.
During an interview on 6/18/2025 at 12:08 PM with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 69's call light could have been pinned to the resident's gown so Resident 69 could reach it.
During an interview on 6/18/2025 at 12:55 PM with the Director of Nursing (DON), the DON stated Resident 69 was blind in one eye. The DON stated Resident 69's call light should have been within her reach and could have been pinned to the resident's pillow on the side where the resident could see. The DON stated the call light should be within the resident's reach so the resident could call for assistance.

Based on observation, interview, and record review the facility failed to ensure safe and sanity food storage practices in the kitchen for124 of 135 residents who received food from the facility and including residents who had food stored in the resident refrigerator when:
1. One opened container of cottage cheese was observed unlabeled in the refrigerator. A plastic bag that contained a staff member's (unidentified) lunch was observed in the refrigerator.
2. The temperature of TCS foods (Time/Temperature control for safety food) checked was above 41 degrees Fahrenheit (F). TCS foods are foods that can support bacterial growth than can result in food borne illness unless stored, prepared and served safely. The temperature of a previously cooked rice from 6/16/2025 stored in the walk-in refrigerator checked using the facility thermometer was 45.5 degrees Fahrenheit (F). There was one tray of previously cooked breakfast sausage stored on the same shelf and next to raw chicken and beef thawing. This had the potential to cross contaminate food and result in food borne illness in 124 out 135 residents who received food from the kitchen.
3. The floor and shelving in the dry storage area were dirty, there was one plate of cookies covered with plastic wrap with expiration date of 6/3/25 expired stored on the shelf in the dry storage. The bottles and containers of cooking sauces was covered with the sauce and was sticky to touch. One toaster oven was not clean and covered with breadcrumbs.
4. Cook1 did not follow cleaning and sanitizing procedure after preparing raw chicken in the food preparation sink and then one Dietary Aide DA2 used the same sink to wash vegetables.
5. One Dietary Aide (DA4) working in the dish machine area did not wash hands and change gloves when removing the clean and sanitized dishes from the dish machine.
6. Food brought to residents (unidentified) from outside of the facility, were stored in the resident's food refrigerator with no date and not monitored for the expiration date. The refrigerator temperature log was missing for the month of June. There were seven plastic bags with food inside not dated and one unopen package of cheese that was expired stored in the refrigerator.
7. One unlabeled plastic bag with five pre-packaged meals, four gelatin snack packs, and two sandwich bags filled with pastries were observed unlabeled in the dry storage room.
These failures 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 124 out of 135 residents who received food from the facility and including residents who had food stored in the resident refrigerator.
Findings:
1. During a concurrent observation and interview on 6/16/2025 at 8:01 AM, with the Dietary Supervisor (DS), in the facility kitchen, the refrigerator was observed. In the refrigerator one opened container of cottage cheese without an open date label and a knotted plastic bag dated 6/16/2025 were observed. The DS stated the open container of cottage cheese was unlabeled. The DS stated the plastic bag dated 6/16/2025 was a dietary staff's (unidentified) lunch. The DS stated that all food containers and items should be dated and labeled. The DS stated food containers that were opened should be labeled with the open date so dietary staff know if the food quality was still good. The DS stated dietary staff should not store their personal lunch in the kitchen refrigerator.
2. During an observation in the kitchen on 6/17/2025 at 9:15AM One medium deep pan of cooked rice dated 6/16/2025 was noted in the walk-in refrigerator. The temperature of the rice was checked with facility thermometer. The temperature of the rice in the middle of the pan registered at 45.5 degrees F.
During a concurrent observation and interview on 6/17/2025 at 9:15AM with the Dietary Supervisor (DS), the DS stated cold food should be held at 41 degrees or lower and the rice was not held at the right temperatures and would be discarded. The DS stated this was a mistake because the facility did not store left over food.
During a review of facilities' policy titled Procedure for Refrigerated Storage (dated 2023), the policy indicated Refrigerator 41F or lower .to keep food at a specific temperature, the air temperature in the refrigerator usually must be about 2 degrees F lower. for example, to hold chicken at 41F, the air temperature must be 39F
During a review of the 2022 U.S. Food and Drug Administration Food Code 3-501.16 titled Time/Temperature control for safety food, hot and cold holding indicated, except during preparation, cooking or cooling, time/temperature control for safety food shall be maintained at 135degrees F or above, and at 41 degrees F or below.
During an observation in the walk-in refrigerator on 6/17/2025 at 9:15AM there was one tray of previously cooked breakfast sausage stored on the same shelf and next to raw chicken and beef that were thawing. The tray of cooked sausage had a date of 6/17/2025.
During a concurrent observation and interview on 6/17/2025 at 9:15AM with the DS, the DS stated the sausages were left over from the morning breakfast on 6/717/2025. The DS stated the sausages were ready to eat and should not be stored next to raw beef and chicken that are thawing. The DS stated there was a potential for cross contamination of raw chicken or beef drippings on the cooked product.
During a review of the 2022 U.S. Food and Drug Administration Food Code 3-301.11 titled Packaged and unpackaged Food-Separation, segregation indicated, (A)Food shall be protected from cross contamination by: (1) Separating raw animal foods during storage, preparation, holding and display: (b) Cooked Ready-To-Eat Food.
3. During an observation in the dry storage area on 6/17/2025 at 9:20AM, the floor behind the shelf was dirty with food particles. Bags of macaroni stored in a large container and there was food debris and dust inside it. There was one plate of cookies wrapped with plastic bag and dated 6/3/2025 exceeding storage period for the cookies and had food debris inside.
During the same observation on 6/17/2025 at 9:20AM, there were bottles of soy sauce, teriyaki sauce, and tother seasoning sauces for cooking stored on the bottom shelf. The seasoning and sauce bottles were covered with brown color sticky substance and drippings.
During a concurrent observation and interview with the Dietary Supervisor (DS) on 6/17/2025 at 9:20AM, the DS stated staff sweep everyday but did not do a good job because there were food debris on the floor under the shelves and in the corners. The DS stated there were some flour and sugar like dust on top of the lids and it could attract pests to the dry food storage area.
During the same observation and interview on 6/17/2025 at 9:20AM the DS stated any leftover and open food was stored for three days. The DS discarded the plate of cookies that was in the dry storage area and asked staff to wipe the bottles of sauces and condiments. The DS stated sticky bottles could attract flies.
During an observation in the kitchen on 6/17/2025 at 11 AM, the countertop bread toaster (conveyor toaster oven for bread) the conveyor tray was covered with crumbs. The crumbs were stuck on the stainless-steel rotating (conveyor) wire and tray, inside the toaster oven and outside under the toaster oven and on the counter.
During an observation and interview with Dietary Aide (DA1) on 6/17/2025 at 11 AM, DA1 stated the toaster oven was for toasting bread and breadcrumbs were stuck on the racks and inside the oven. DA1 stated we clean it but can't remember last time it was cleaned. DA1 stated the staff should clean it to prevent attracting pests.
During an observation and interview with the DS on 6/17/2025 at 11 AM, the DS stated there was a lot of breadcrumbs and the breadcrumbs was not from today, (6/17/2025) alone. The DS stated he did not know when the inside of the oven was cleaned.
During a review of facility cleaning schedule and check list, the schedule indicated a weekly cleaning of the storeroom. The schedule did not indicate cleaning the conveyor toaster for bread.
During a review of facility's policy titled Storage of Food and Supplies (dated 2023) the policy indicated, The storeroom should be .clean at all times.; routine cleaning and pest control procedures should be developed and followed; liquid foods such as syrup, oil, vinegar, Worcestershire sauce .which have been opened will be tightly closed, labeled and dated.
During a review of facility's policy titled Sanitation (dated 2023) the policy indicated, All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam .
During a review of the 2002 U.S. Food and Drug Administration Food Code, code 3-304.11 titled Food Contact with Equipment and Utensils code indicated, Food shall only contact surfaces of: (A) Equipment and utensils that are cleaned and sanitized .Pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized.
4. During an observation in the food preparation area on 6/17/2025 at 9:10AM, observed [NAME] (cook1) washing the raw chicken inside the two-compartment food preparation sink. Cook1then removed the chicken and placed it inside a large round pan and began to add seasonings to the chicken and proceeded to cooking process. Cook1 did not wash and sanitize the sink after finishing with the raw chicken preparation.
During a food preparation observation on 6/17/2025 at 9:30AM, observed DA2 holding the lettuce and cucumber and rinsing them under running water in the same sink that was used to wash the chicken. DA2 then started chopping the lettuce on a cutting board next to the sink.
During the same observation on 6/17/2025 at 9:30AM observed pieces of the raw chicken inside the sink and near the faucet.
During an observation and interview with DA2 on 6/17/2025 at 9:30AM, DA2 stated once the lettuce and cucumber was chopped then it would be thoroughly washed and drained in the sink. DA2 stated the sink was clean but still the lettuce and cucumber would not be placed directly inside the sink. DA2 stated the chopped lettuce, and cucumber would be washed inside a pan in the sink. DA2 stated when everyone was finished with their work with the sink, it was expected to wash and sanitize the sink using detergent for washing then the sanitizer solution to sanitize the sink. DA2 stated she did not know the sink was used for the washing of raw chicken and not cleaned after.
During an interview with cook1 and the DS on 6/17/2025 at 9:45AM, Cook1 stated he did not wash and sanitize the sink after washing and marinating the raw chicken. Cook1 stated we always wash and sanitize sink when working with raw meat. Cook1 stated he forgot and made a mistake. Cook1 stated this could cross contaminate the vegetables that was going to be used for salad.
During the same interviewon 6/17/2025 at 9:45AM the DS instructed to clean the sink and discard ready to eat vegetables that were rinsed in the sink.
During a review of facility's policy titled Sanitation (dated 2023) the policy indicated, Each employee shall know how to operate and clean all equipment in his specific work area.
During a review of facility's cleaning procedure titled Shelves, counters and other surfaces including sinks (handwashing, Food Preparation.) (dated 2023) the policy indicated remove any large debris and wash surface with warm detergent solution .rinse with clear water .spray with a sanitizer.
During a review of the job description for cooks, it indicated demonstrated knowledge of how to clean and sanitize equipment and counter tops
5. During an observation in the dishwashing area on 6/17/205 at 10:15AM, Dietary Aide (DA4) was rinsing soiled dishes and loading the dirty dishes in the dish machine. DA4 had gloves on hands, DA4 rinsed hands with gloves in the manual ware washing sink dried the gloved hands with a kitchen cloth stored on the counter and proceeded to remove the clean and sanitized dishes from the dish machine without washing hands and replacing gloves. DA4 repeated the same process of loading dirty dishes, rinsing gloved hands then picking up clean dishes twice during the observation.
During a concurrent interview with DA4, DA1 and DS on 6/17/2025 at 10:30AM, DA4 stated he was rushing to finish the work, and he did not remove gloves, wash hands and replace gloves. DA4 stated usually there were two people working in the dish machine area to help remove the clean dishes but on 6/17/2025 the dishes were heavily soiled with sticky food item and the other staff was busy with soaking and rinsing dishes and then send the dishes to be loaded in the dishwashing machine. DA4 stated not washing hands can contaminate clean and sanitized dishes. DS stated all dishes would be rewashed and sanitized.
During a review of facility's policy titled, Glove Use Policy (dated 2023) indicated, When gloves need to be changed: 2. Before beginning a different task
During a review of facility's policy titled Sanitation (dated 2023) the policy indicated, A minimum of two employees will be used when dishes are machine washed. One will handle the soiled area, and one 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 .Note that hands must be thoroughly washed and clean before handling lean dishes and utensils. Cup.
6. During an observation in the resident refrigerator located in the facility's Utility Room on the 3rd floor on 6/18/2025 at 9 AM, the refrigerator temperature log for the month of June was missing.
During a concurrent observation and interview on 6/18/2025 at 9 AM with the nurse supervisor (RN2), RN2 stated she did not know what happened to the temperature monitoring log for the month of June. RN2 stated the residents' family (in general) would bring food, or the residents (in general) would order food and leftovers are stored in the resident refrigerator, labeled and dated for the time it was brought in.
During the same observation on 6/18/2025 at 9 AM in the resident refrigerator there were seven plastic bags with resident leftover food stored with resident room number and no date. There was one unopened package of cheese with no label and manufactures expiration date of 6/7/2025 expired and stored in the refrigerator. The refrigerator was dirty with food debris and there were sticky stains. The freezer was empty but was covered in ice.
During a concurrent interview with the Director of Staff Development (DSD) on 6/18/2025 at 9:30AM, the DSD stated family hands over the food to the nursing staff. The DSD stated any leftovers were labeled and dated then stored in the refrigerator for 72 hours. The DSD stated housekeeping was responsible to check the temperature of the resident refrigerator and discard any food that was beyond 72 hours. The DSD stated dates were important because food expires and needed to know when to discard. The DSD stated temperature monitoring was also important to make sure food was kept at safe temperature. The DSD stated everything would be discarded because there was no temperature log since 5/31/2025, no dates, and the facility did not know when the food was brought in.
During an interview with Maintenance and Housekeeping Director (MAD1) on 6/18/2025 at 10 AM, MAD1 stated housekeeping and maintenance staff were not assigned to check the resident food refrigerator temperatures. MAD1 stated housekeeping did not monitor temperature or discarded the resident food.
During a review of facility's policy titled, Foods Brought by Family/Visitors (revised 12/2024) indicated, Food brought by family/visitors that is left with the resident to consume later will be labeled and stored .Perishable foods must be stored in resealable containers with tightly fitting lids in a refrigerator container will be labeled with residents name, the item and the use by date. The nursing staff will discard perishable foods on or before the Use By date.
7. During a concurrent observation and interview on 6/16/2025 at 8:10 AM, with the DS, in the facility kitchen, the dry storage room was observed. In the dry storage room an unlabeled plastic bag with five pre-packaged meals, four gelatin snack packs, and two sandwich bags filled with pastries were all observed unlabeled. The DS stated the plastic bag contained food that was brought in by family for one of the facility residents (unidentified). The DS stated the food in the plastic bag were all kosher (food and beverages that are permissible for consumption according to Jewish dietary laws). The DS stated the food in the plastic bag was not labeled for the resident or labeled as kosher. The DS stated all food in the kitchen should be labeled, especially if they are kosher or for a certain resident. The DS stated food stored in the kitchen should be labeled and dated to prevent the residents from foodborne illness.
During an interview on 6/19/2025 at 11:30 AM with the Director of Nursing (DON), the DON stated opened food in the kitchen should be dated and labeled with the open date. The DON stated food that was brought into the facility by family (in general) should be dated and labeled for the resident. The DON stated that facility staff had an employee refrigerator in the employee lounge. The DON stated staff lunch should not be stored in the kitchen. The DON stated staff lunch should be put and stored in the employee lounge refrigerator. The DON stated the improper storage and labeling of food in the kitchen could potentially lead to infection control issues and foodborne illness amongst the facility residents.
During a review of the facility's Policy and Procedure (P&P) titled Procedure for Refrigerated Storage dated 2023, the P&P indicated Food items should be arranged so that older items will be used first. Dating the packages or containers will facilitate this practice .Leftovers will be covered, labeled, and dated .Individual packages of refrigerated or frozen food taken from the original packing box need to labeled and dated.
During a review of the facility's P&P titled Storage of Food and Supplies dated 2023, the P&P indicated Food and supplies will be stored properly and in a safe manner.
During a review of the facility's Policy and Procedure (P&P) titled Foods Brought by Family/Visitors dated 12/2024, the P&P indicated Food brought by family/visitors that is left with the resident to consume later will labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Non-perishable foods will be stores in re-sealable contains with tight-fitting lids. Intact fresh fruit may be stored without a lid. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date.

Based on observation, interview and record review, the facility failed to ensure two of 27 sampled residents (Resident 54 and Resident 39) were served food preferences listed on the lunch meal ticket (physician ordered diet with resident food preferences) when:
1.Resident 54 who had lactose intolerance (lactose a sugar found in dairy products such as milk) was served chocolate flavored ice cream, despite lactose being listed as an intolerance on the resident's lunch meal ticket/tray care.
2. Resident 39 was served pork despite cultural preferences for no pork or ham.
These failures had the potential to result in decreased meal satisfaction, decrease caloric intake, Resident 54 and Resident 39 being upset and for Resident 54 to experience symptoms associated with lactose intolerance.
Findings:
1. During a review of Resident 54's Dietary Quarterly Progress Notes dated 3/11/25 and 6/13/25 indicated Resident 54's current diet was regular NAS (no added salt) and CCHO (diet for people to control blood sugar levels). The Dietary Quarterly Progress Notes indicated Resident 54 did not like milk or soy milk. The Dietary Quarterly Progress Notes indicated Resident 54 was ok with cheese. The Dietary Quarterly Progress Notes did not indicate Resident 54 dislike for sweets and chocolate.
During a review of resident 54's meal ticket (lists residents' physician ordered diet with resident's food preferences and intolerances) for lunch dated 6/17/2025, the meal ticket indicated resident food intolerances included lactose intolerance and ok with cheese.
During an observation in the kitchen on 6/17/2025 at 11:50AM, the dessert was prepared for service. Dietary Aide 5 (DA5) was looking at the resident's meal tickets on the tray and placing ice cream on resident's lunch tray.
During an observation of lunch service in the kitchen on 6/17/2025 at 12 PM, Dietary Aide (DA5) served a chocolate flavored ice cream on Resident 54's lunch tray.
During a concurrent observation and interview with the DS on 6/17/2025 at 12:05PM, DS stated residents' preferences are recorded on the meal ticket. The DS sated Staff would look at the meal tickets and serve beverages or ice cream according to the resident's preferences.
During a dining observation on 6/17/2025 at 12:45PM, Resident 54's tray was on the bed side table. Resident 54 had not started eating lunch. There was one chocolate flavored ice cream on the tray.
During a concurrent interview on 6/17/2025 at 12:45PM with Resident 54, Resident 54 was upset and stated the facility did not listen to his food preferences. Resident 54 stated the facility was aware that the resident had dairy intolerance. Resident 54 stated I can eat yogurt and cheese, but I don't like milk. Resident 54 stated I don't like sweets either and I will not eat the chocolate ice cream on the tray. Resident 54 stated most of the time the facility would make mistakes and would bring me sweets and desserts and I often return them back to the kitchen.
During an observation of lunch service by the nurses' station on 6/18/2025 at 12:30 PM, one meal cart was delivered. Staff started distributing the trays before checking for diet accuracy.
During an observation of lunch service by the nurse's station on 6/18/2025 at 12:35 Licensed Vocational Nurse10 (LVN10) arrived and started checking rest of the trays.
During an interview on 6/18/2025 at 12:35 with LVN10, LVN10 stated the trays were checked for diet accuracy. LVN10 stated arrived late today because was busy with resident. LVN10 stated the Director of Staff Development (DSD) would also assist in checking the trays when a nurse was busy.
During an interview with DSD on 6/18/2025 at 12:45PM, the DSD stated nurses would check the diets for accuracy before delivering to the resident. The DSD stated did not see if LVN10 checked the trays on the first meal cart before it was distributed. The DSD did not know why Resident 54 received the chocolate flavored ice-cream despite lactose intolerance was listed on the meal ticket.
During an interview with DA5 on 6/18/2025 at 1 PM, DA5 stated on 6/17/2025 the dessert was ice cream. DA5 stated lactose intolerance was someone who could not have dairy products like milk, cheese yogurt and ice cream. DA5 stated there were some residents who did not like dairy and the facility offered them non diary ice cream or sherbert. DA5 stated he made a mistake serving chocolate ice cream on the Resident's 54 tray.
During an interview with Registered Dietitian (RD) on 6/18/2025 at 1:30PM, the RD stated any person with intolerance to dairy products could have upset stomach, bloating, and diarrhea when eating ice-cream.
During a review of facility's policy titled Food and Nutrition Services (Revised 12/2024) indicated, Easch resident is provided with .well balanced diet .taking into consideration the preferences of each resident, Reasonable efforts will be made to accommodate resident choices and preferences, Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident .If an incorrect meal is provided toa resident .nursing staff will report it to the food service manager.
2. During a review of Resident 39's admission Record, the admission Record indicated the facility admitted the resident on 6/11/2025 with diagnoses that include type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), iron deficiency anemia (a condition where the body does not have enough healthy red blood cells), vitamin D deficiency (the body does not have enough vitamin D to function properly), gastro-esophageal reflux disease (stomach acid frequently flows back into the esophagus, causing heartburn and other issues), and acute kidney failure (a sudden and rapid loss of kidney function).
During a review of Resident 39's Nutritional Screening, dated 6/12/2025, the Nutritional Screening indicated Resident 39's ethnic, religious, cultural preferences were no pork or ham.
During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool) dated 6/13/2025, the MDS indicated the resident had an intact cognitive function (impairment in the ability to think, understand and reason).
During a review of Resident 39's Order Summary Report, dated 6/18/2025, the Order Summary Report indicated, Resident 39 diet: NAS (No-Added Salt), CCHO (Consistent or Controlled Carbohydrate) diet, regular texture, regulars consistency three times a day.
During a review of Resident 39's CNA/STNA Function Abilities Flow Sheet, undated, the CNA/STNA Function Abilities Flow Sheet indicated Resident 39's meal percentage consumed 100% of breakfast since admission.
During a review of Resident 39's Dietary Slip, dated 6/19/2025, the Dietary Slip indicated that Resident 39 had dislikes to ham and pork for breakfast, lunch, and dinner.
During a review of Resident 39's Nursing Care Plan, dated 6/13/2025, the Nursing Care Plan indicated Resident 39 is refusing to eat - did not like the food served. Interventions include: Dietary supervisor will follow up to ensure his food preferences are strictly noted on his meal ticket to avoid unnecessary mistakes. Dietary supervisor will re-educate his staff on adherence of food preferences & restrictions.
During an interview on 6/16/2025 at 12:38 PM with Resident 39, Resident 39 stated he needed to stay on his diet and eat healthy foods like vegetables, salad, and a little bit of fruit and toast.
During an interview on 6/16/2025 at 12:44 PM with the Dietary Supervisor (DS) in Resident 39's bedroom, Resident 39 stated he was Muslim and did not want to be served pork. Resident 39 stated he wanted chicken or fish. The DS stated his apologies for his new staff's mistake when the resident was served pork.
During an interview on 6/18/2025 at 1:14 PM with Resident 39, Resident 39 stated there was only one incident that he was served a sausage for breakfast but unsure of exactly when.
During an interview on 6/18/2025 at 3:01 PM with the Registered Dietitian (RD), the RD stated she spoke with Resident 39 in regards to his diet. RD stated she spoke about current diet plans, educated on what it means to have carbs but spread out and sugar free desert. The RD stated Resident 39 verbalized understanding but had his own ideas on what foods were good and bad for diabetes. The DS stated Resident 39 mentioned having toast for breakfast and being okay with breakfast.
During an interview on 6/19/2025 at 1:50 PM with the DS, the DS stated Resident 39 claimed to be Muslim and requested chicken and fish. The DS stated the facility was doing their best to accommodate the resident's preferences.
During an interview on 6/19/2025 at 2:28 PM with the Director of Nursing (DON), the DON stated that it was important the diet given to the resident was not contraindicated to their preferences so that they could enjoy their meal according to the prescribed diet from the Medical Doctor (MD).
During a review of the facility's policy and procedure (P&P) titled, Menus dated December 2024, the P&P indicated, Menu items and available snacks reflect the religious, cultural and ethnic preferences of the residents, whenever reasonable.

Based on observation, interview, and record review, the facility failed to ensure the label on a bubble pack (a card that packages doses of medication within small, clear plastic bubbles or blisters) matched the physician's order for one of four sampled residents (Resident 114).
This failure had the potential of medication error that may or may not affect resident's condition.
(Cross Reference F759)
Findings:
During an observation and concurrent interview on 6/17/2025 at 12:30 PM at the Station A medication cart 3, the Licensed Vocational Nurse (LVN 1) found Resident 114's doxazosin (generic for Cardura, used to treat high blood pressure and prostate condition) 2 milligrams (mg, unit to measure mass) bubble pack in a drawer that stored evening medications. LVN 1 pointed to the label on the bubble pack and stated the label indicated take one tablet by mouth at bedtime. During a concurrent review of the medication administration record (MAR) of Resident 114's doxazosin, LVN 1 stated the scheduled time was at 9 AM.
During a review of Resident 114's medication orders, the orders indicated there was an order not given. The order was doxazosin (generic for Cardura, used to treat high blood pressure and prostate condition) 2 mg one time a day at 9 AM started on 5/25/2025.
During an interview on 6/17/2025 at 12:36 PM, the Director of Nursing (DON) stated Resident 114's doxazosin was scheduled at 9 AM and the pharmacy should have notified the facility if there was any change made to the order.
During a review of an email sent from the pharmacy to the DON, dated 6/17/2025 at 9:32 PM, the email indicated Resident [114] had an order for doxazosin 2 mg daily at 9 am on 5/25/25. The order from the pharmacy was found to be doxazosin 2 mg at bedtime. It is the practice of the pharmacy to verify any changes to the prescription order with the prescriber, and to communicate this change to the facility (either with a phone call to a licensed nurse or via fax). Since the paper trail of this communication for this specific order is not found, the pharmacy staff will be inserviced to ensure this procedure is being followed and also to ensure to continue to document all communications with the facility regarding any changes of orders.
During a review of the facility policy and procedures, Medication and Treatment Orders (dated December 2024), the policy indicated . Only authorized, licensed practitioners, . shall be allowed to write orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure its medication error rate was less than five (5) percents (%). Three medication errors out of 33 total opportunities yielded a medication error rate of 9.09%, in 3 of 4 sampled residents (Resident 114, Resident 89, and Resident 45) observed during medication administration (med pass).
This failure of med pass error rate exceeded the 5 % threshold had the potential of adverse effects that may or may not affect Resident 114, Resident 89, and Resident 45's health condition.
(Cross Reference F757 and F761)
Findings:
a.During a medication administration (med pass) observation on 6/17/2025 9:06 AM, outside Resident 114's room, the Licensed Vocational Nurse1 (LVN 1) prepared a total of three medications: vitamin C mg (also known as ascorbic acid, is a water-soluble vitamin essential for various bodily functions, including immune system support, wound healing, and collagen formation) 500 milligrams (mg, unit to measure mass), aspirin (a drug often used to prevent blood clots and heart attacks in low dose), and finasteride (generic for Propecia, used to treat hair loss and/or prostate condition).
During a review of Resident 114's medication orders, the orders indicated there was an order not given. The order was doxazosin (generic for Cardura, used to treat high blood pressure and prostate condition) 2 mg one time a day at 9 AM started on 5/25/2025.
During an interview on 6/17/2025 at 12:20 PM LVN 1 stated Resident 114's doxazosin 2 mg was not given because it was not in the medication cart earlier.
During an observation and concurrent interview on 6/17/2025 at 12:30 PM with the Director of Nursing (DON) and LVN 1 at Station A medication cart 3, LVN 1 found Resident 114's doxazosin 2 mg bubble pack (a card that packages doses of medication within small, clear plastic bubbles or blisters) in a drawer that kept evening medications. (see also F761)
During a medication administration (med pass) observation on 6/18/2025 at 8:27 AM the Licensed Vocational Nurse (LVN 4) prepared eight oral medications for Resident 89.
b. During a review of Resident 89's medication orders, the orders indicated there was an order dated 7/16/2024 for diclofenac sodium (a medication used to relieve pain and inflammation in certain joints) external gel 1 %, with an instruction to apply to the right shoulder two times a day for pain management, which was not administered.
During an interview on 6/18/2025 at 11:11 AM, when asked about Resident 89's diclofenac sodium external gel that was due at 9 AM but was not seen during the med pass earlier, LVN 4 stated Resident 89 did not ask for it . However, the order did not mention as needed.
c. During a med pass observation on 6/18/2025 at 8:49 AM, LVN 3 prepared 15 medications for Resident 45. One of the 15 medications was diclofenac external gel 1 %. LVN 3 applied the gel to Resident 45's knees, both left and right.
During a review of Resident 45's medication orders, the order for diclofenac sodium external gel 1% (dated 8/24/2024) indicated apply to both [NAME] [hands] topically two times a day for pain management.
During an interview on 6/18/2025 at 10:38 AM, LVN 3 reviewed Resident 45's MAR for diclofenac and stated the order was to apply to both hands, however, on the morning of 6/18/2025 Resident 45 wanted the gel to apply to the knees. (Refer to 757)
During a review of the facility's policy and procedures, Administering Medications (dated December 2024), the policy indicated Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame . The individual administering the medication checks the label THREE (3) times to verify the right . dosage, right time . before giving the medication .

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 45) did not receive medication without a physician order and/or without adequate indication of use.
This failure had the potential for medication error and delay in proper treatment that may or may not affect Resident 45's condition negatively.
(Cross Reference 759)
Findings:
During an observation on 6/18/2025 at 8:49 AM, Licensed Vocational Nurse 3 (LVN 3) applied the diclofenac sodium (a medication used to relieve pain and inflammation in certain joints) external gel 1 %, to Resident 45's both knees. (Refer to F-759)
During an interview on 6/18/2025 at 10:38 AM, LVN 3 reviewed Resident 45's Medication Administration Record (MAR) and the physician's order for diclofenac and LVN3 stated the order was to apply to resident's both hands, however, Resident 45 wanted the gel to be applied to the knees.
During an interview on 6/18/2025 at 3:40 PM, the Director of Nursing (DON) stated the applications of diclofenac gel to the Resident 45's knees were administered without a physician's order and evaluation.
During a review of the facility's policy and procedures, Unnecessary Drugs (revised January 2025), the policy indicated . Unnecessary drugs include . used . without adequate indications for its use .
During a review of the facility policy and procedures, Medication and Treatment Orders (dated December 2024), the policy indicated . Medication shall be administered only upon the written order of a person duly licensed and authorized to prescribe .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Ensure nursing staff would document medication administrations properly for two of four sampled residents (Resident 89 and Resident 86).
This failure had the potential for medication error and/or drug diversion (refers to the illegal and unauthorized transfer of legally obtained drugs from their intended use to an unintended use or recipient).
2.Ensure home medications brought in by one of one discharged sampled resident (Resident 900) were returned to the resident.
This failure had the potential for drug diversion (involving the transfer of a legally-prescribed controlled substance from the individual for whom it was prescribed to another person) and/or misuse of personal property.
Findings:
1.During a medication administration (med pass) observation on 6/18/2025 at 8:27 AM Licensed Vocational Nurse4 (LVN 4) did not administer Resident 89's medication order (dated 7/16/2024) for diclofenac sodium (a medication used to relieve pain and inflammation in certain joints) external gel 1 %, with an instruction to apply to the right shoulder two times a day for pain management. (Refer to 759, F658)
During an interview on 6/18/2025 at 1:30 PM LVN 4 stated Resident 89 had not needed diclofenac gel for at least two weeks.
During a review of the Resident 89's Medication Administration Record (MAR) of June 2025, the MAR indicated there were 35 of 35 administrations of the diclofenac gel. There was no indication the gel was not administered.
During an interview on 6/18/2025 at 1:38 PM, the Director of Nursing (DON) reviewed Resident 89's MAR and stated nurses (in general) should circle their initials and document in the back of the MAR if they did not administer the medication. The DON stated the back of the MAR was empty.
During a concurrent interview on 6/18/2025 at 1:38 PM LVN 4 stated she (LVN4) forgot to document diclofenac as not given or refused.
During a review of Resident 86's Dilaudid (hydromorphone, a potent narcotic and controlled substance to treat pain) on 6/18/2025 at 2:38 PM, Resident 86's Dilaudid count sheet (inventory accountability sheet) indicated the last dose taken out was on 6/10/2025 at 8 PM.
During a concurrent interview on 6/18/2025 at 2:38 PM LVN 2 reviewed Resident 86's MAR and stated there was no administration documentation of Resident 86's Dilaudid on 6/10/2025.
During an interview on 6/18/2025 at 3 PM, the DON stated the nurses (unidentified) forgot to document the administration of Dilaudid on Resident 86's MAR.
During a review of the facility policy and procedures, Administering Medications (dated December 2024), the policy indicated . The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones .
2.During an observation and interview on 6/17/2025 at 12:45 PM at the Director of Nursing's (DON) office, the DON opened a locked drawer and stated the drawer stored narcotics (pain relief medication) to be disposed or destructed with the facility's pharmacist. Inside the drawer, there were twelve (12) counts of lorazepam (generic for Ativan, a controlled substance to treat anxiety [nervousness]) 2 milligrams (mg, unit to measure mass) per (/) milliliters (ml, unit to measure volume) oral syringes. The DON stated a nurse (unidentified) brought those syringes to her on 6/17/2025 for disposition (is the process of returning and/or destroying unused medications). The DON reviewed the labels on the aforementioned oral syringes and stated those were for a resident (Resident 900) who had been discharged to a hospital on 1/21/2025. The DON stated those aforementioned oral syringes were home medications brought into the facility by the resident. The DON reviewed the discharged resident's medication list and stated lorazepam oral syringes were not part of the resident's discharge medications. The DON stated she was not sure why the syringes were still at the facility.
During an interview on 6/17/2025 at 12:49 PM, the DON stated personal medication were considered resident's personal properties and should be returned to the resident or family member at the time of discharge.
During an interview on 6/17/2025 at 1:02 PM, the DON stated the facility did not have a policy on how to handle medications that residents brought in from home; however, there was a policy on personal property.
During a review of the facility's policy and procedures, Personal Property (dated [DATE]), the policy did not denote what to do with personal property when resident was discharged .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure accident and hazard free environment for one of three sampled residents (Resident 1). The facility failed to ensure:
1. Resident 1 ' s bed footboard was not broken and left on the floor for several hours.
2. Resident 1 ' s feet (at ankle level) were not dangling at the foot of the bed.
3. Staff did report and request maintenance for the broken footboard.
This deficient practice had the potential for Resident 1 to sustain fall and injury.
Findings:
A review of Resident 1 ' s admission record indicated Resident 1 was initially admitted to the facility on [DATE] with a diagnosis of not limited to unspecified abnormalities of gait and mobility, encephalopathy (a disease damaged the functions of the brain), myocardial infarction (heart attack, happens when blood flow to the heart muscle is blocked).
A review of Resident 1 ' s Minimum Data Set (MDS, a assessment tool) dated 3/9/2025 indicated, Resident 1 had a cognitive (mental action or process of acquiring knowledge and understanding) loss, unclear speech, has difficulty communicating to make self-understood, is wheelchair bound for mobility, requires maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) to sit and stand, to transfer from bed to chair.
During an observation on 5/19/2025 at 10:35 AM, Resident 1 ' s bed footboard was broken and left on the floor. Resident 1 ' s feet at ankle level hanging at the foot of the bed. Resident 1 was observed lying in bed, right hand and lower extremities weakness. Resident 1 was unable to verbalize how long the footboard was left on the floor and the last time he was seen by a staff member.
During an interview on 5/19/2025 at 12:15 PM with Licensed Vocational Nurse 1(LVN1) stated, Resident 1 is dependent on staff for mobility, to turn in bed right or left. LVN1 observed Resident 1 ' s footboard broken and lying on the floor, Resident 1 ' s feet dangling. LVN1 stated, I saw the footboard on the floor this morning, not sure of the exact time. Stated, it might have been broken, it was not supposed to be left on the floor. It is a safety hazard. Resident 1 could potentially slide down and fall.
During an interview on 5/19/2025 at 12:29 PM with Restorative Nursing Assistant (RNA) stated, I saw Resident 1 ' s footboard on the floor while passing by the resident ' s room. I went into the room and tried to remove the broken piece because it is a safety hazard. I called for help and pulled Resident 1 up in bed because he was sliding down, the footboard is not in place to keep him from falling.
During an interview on 5/19/2025 at 12:35 PM with Certified Nursing Assistant 1 (CNA1) stated, I am the assigned CNA for Resident 1. He has seen Resident 1 ' s bed footboard was broken and left on the floor since the beginning of his shift. CNA1 did not report to charge nurse, did not request for maintenance. CNA1 acknowledged observing Resident 1 ' s feet dangling because the footboard was not in place. CNA1 acknowledged the broken footboard is a safety hazard, could lead to Resident 1 ' s falling from bed.
During an interview on 5/19/2025 at 12:55 PM with Facility Maintenance manager (FM), FM stated maintenance request log is checked every morning, there was no request for Resident 1 ' s room till moments ago. FM stated, I just found out about the repair requests. Resident 1 ' s footboard was missing a screw and broken piece. The footboard needed to be replaced. Stated, any broken equipment is a safety risk potentially leading to accidents and falls.
During an interview on 5/19/2025 at 1:10 PM with Registered Nurse supervisor (RN), RN stated, I conduct room rounds every two hours. I have not seen Resident 1 ' s bed broken. I have not seen Resident 1 dangling on bed. Staff are trained and expected to report environmental and resident safety risks immediately and request for maintenance. RN stated likely outcome for Resident 1 to slide down and fall.
During an interview on 5/19/2025 at 1:47 PM with the Director of Staffing Development (DSD), DSD stated, facility staff is trained, and in-serviced, and daily reminders are provided to provide a safe environment for residents. Staff watch safety videos to prevent and report unsafe environmental issues. Staff are trained and expected to report on environmental hazards, resident safety concerns immediately and request for maintenance. Leaving Resident 1 dangling in bed is a fall risk. The broken piece should have been removed immediately and reported to supervisor and maintenance.
During an interview on 5/19/2025 at 2:21 PM, the Director of Nursing (DON) stated, it is a resident neglect and safety concern not to report a broken bed and leaving a fall risk resident unattended. Licensed staff are expected to conduct room rounds, leaving a broken footboard for several hours is not according to the nursing standard of care. The time frame the broken footboard was not reported and Resident 1 left unattended is concerning, it should have been caught by the licensed staff during the rounds.
A review of the facility ' s Policy and Procedures (P&P) titled Staffing, Sufficient and Competent Nursing revied December 2024, the P&P indicated Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: assuring resident safety; attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident.
A review of the facility ' s P&P titled Maintenance Service revised December 2024 indicated, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review, the facility failed to treat one of three sampled residents (Resident 1) with dignity and respect by failing to safeguard Resident 1 ' s personal belongings.
This failure resulted in the loss of Resident 1 ' s shoes which caused his feelings of being upset.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/18/2025, and readmitted the resident on 5/7/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest and changes in thoughts, behavior, and physical well-being) and schizophrenia (a mental illness that is characterized by disturbances in thought).
During a review of Resident 1 ' s Inventory of Personal Effects, dated 2/18/2025, the Inventory of Personal Effects indicated Resident 1 had one pair of shoes (unidentified description).
During a review of Resident 1 ' s History and Physical (H&P) dated 2/21/2025, the H&P indicated the resident had the capacity to make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 2/25/2025, the MDS indicated the resident had moderate impairment, meaning the individual may need assistance with daily activities or specific tasks due to cognitive (ability to think, understand and reason) decline. The MDS indicated Resident 1 did not have difficulty in normal conversation, social interaction, listening to TV, distinct intelligible words and clear comprehension.
During a review of Resident 1 ' s Inventory of Personal Effects, dated 5/7/2025, the Inventory of Personal Effects did not indicate Resident 1 had shoes.
During an interview on 5/14/2025 at 11:19 AM with the Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 had a pair of shoes on 5/1/2025.
During a concurrent observation and interview on 5/15/2024 at 2:30 PM with CNA 1 in Resident 1 ' s bedroom closet, CNA 1 stated she (CNA1) could not find the resident ' s shoes.
During an interview on 5/15/2024 at 2:31 PM with Resident 1, Resident 1 stated that the tennis shoes were black and red and would wear a size 13. Resident 1 was stated he was upset that the shoes were lost and that he did not have any shoes to wear.
During an interview on 5/15/2025 at 2:46 PM with the Director of Nursing (DON), the DON stated that on 5/1/2025 Resident 1 had shoes on his feet and the laces were tied.
During an interview on 5/15/2025 at 2:57 PM with the DON, the DON stated that Resident 1 ' s rubber shoes were the colors orange and yellow and did not find them in the resident ' s room. The DON stated that Resident 1 likely left them in the hospital but never told anyone.
During an interview on 5/15/2025 at 2:59 PM with the DON, the DON stated that they could try and call the hospital and inquire about his shoes but that they would likely need to replace Resident 1 ' s shoes. The DON stated she (DON) saw a lot of non-skid hospital socks in Resident 1 ' s drawer that he would wear.
During an interview on 5/15/2025 at 4:01 PM with the DON, the DON stated it was important to get an account on what was brought in by the resident because any missing items were to be accounted for if there was a theft or loss.
During a review of the facility ' s policy and procedure titled, Personal Property, dated December 2024, indicated, The resident ' s personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished.
During a review of the facility ' s policy and procedure titled, Personal Property, dated December 2024, indicated, The resident ' s personal belongings and clothing are inventoried and documented upon admission and updated as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to timely document administered medications per facility policy to three of four sampled residents (Residents 6, 7 and 8).
This deficient practice had the potential to result in unsafe, and improper medication administration per facility policy.
Findings:
a. A review of Resident 6's admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid), congestive heart failure (CHF-a chronic condition in which the heart does not pump blood as well as it should) and gastrostomy (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration).
A review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 1/26/2025, indicated Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was severely impaired and dependent from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use).
A review of Resident 6's Medication Administration Record (MAR), dated 3/25/2025 at 12:32 p.m., indicated an unsigned scheduled administration medication at 9:00 a.m. for the following medications:
· Amlodipine Besylate (antihypertensive medication) 5 milligram (mg, unit of measurement) one tablet via GT one time a day (QD)
· Lasix (medication to treat fluid retention) 20 mg via GT QD
· Losartan Potassium (antihypertensive medication) 100 mg; give half a tablet via GT QD
· Ocusoft Lid Scrub (eye cleanser medication) apply to eyes QD
· Ferrous Sulfate (iron medication) liquid give 7.5 millimeter (ml) via GT two times a day
· Keppra (anti-seizure medication) 5 ml via GT two times a day
· Artificial Tears ophthalmic (eye lubricant) solution instill one drop to both eyes three times a day
b. A review of Resident 7's admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), lack of coordination and gastrointestinal (GI) bleed.
A review of Resident 7's MDS, dated [DATE], indicated Resident 7's cognitive skills for daily decision-making was severely impaired and dependent from staff for ADLs.
A review of Resident 7's MAR, dated 3/25/2025 at 12:32 p.m., indicated an unsigned scheduled administration medication at 9 a.m. for the following medications:
· Amlodipine Besylate 5 mg one tablet via mouth (PO) QD
· Citalopram (anti-depression medication) 20 mg PO QD
· Ferrous Sulfate tablet give 325 mg PO QD
· Losartan Potassium 50 mg PO QD
· Multivitamin (MVI) 1 tablet PO QD
· Eliquis (medication to prevent blood clots) 5 mg PO twice a day
· Mesalamine (anti-inflammatory medication) 400 mg, give two capsule three times a day
c. A review of Resident 8's admission Record indicated Resident 8 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including multiple sclerosis (MS- a disabling disease of the brain and spinal cord [ central nervous system]), COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) and lack of coordination.
A review of Resident 8's MDS, dated [DATE], indicated Resident 8's cognitive skills for daily decision-making was severely impaired and needing maximal assistance from staff for ADLs.
A review of Resident 8's MAR, dated 3/25/2025 at 12:32 p.m., indicated an unsigned scheduled administration medication at 9:00 a.m. for the following medications:
· Haldol (medication to treat mental disorders) 5 mg PO QD.
· Docusate Sodium (DSS-stool softener) 100 mg PO twice a day
· Lactobacillus (probiotic medication) one capsule PO twice a day
· Magnesium (vitamin ) 400 mg PO twice a day
During a concurrent observation and interview with Registered Nurse 2 (RN 2) on 3/25/2025 at 12:32 p.m., observed RN2 sitting in the nursing station about to sign Resident 6, 7 and 8's MAR for the medications scheduled at 9:00 a.m. RN2 stated and validated that the scheduled 9 a.m. medications were already administered on time and RN2 was barely about to sign the MAR that was administered. RN2 stated that she (RN 2) was supposed to sign the MAR right after administering the medication given to the resident.
During an interview with the Quality Assurance Nurse (QAN) on 3/25/2025 at 3:13 p.m., QAN stated that facility staff nurse should sign the MAR right after administering the medication to the resident. QAN also stated that it was unacceptable to administer medication at 9:00 a.m., and then sign MAR at around 12:00 p.m.
A review of the facility's policy and procedures (P&P), titled, Documentation of Medication Administration, reviewed on 12/2024, P&P indicated that Administration of medication must be documented immediately after it is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to develop and implement a comprehensive care plan that meet the care/services based on the resident ' s individual assessed needs for one of nine sampled residents (Resident 1) by failing to ensure Resident 1 ' s episodes of refusal of basic care were care planned.
This deficient practice had the potential to result negative impact on Resident 1 ' s health and safety, as well as the quality of care and services received.
Cross Referenced F580.
Findings:
A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses including carcinoma (cancer cells) in the rectum (final section/ part of the lower gastrointestinal tract [GI tract-organ system of the body from the mouth to the anus [part of the GI tract where the stool or feces are being eliminated from the body], colostomy (opening of the large intestine [abdominal area] to the outside of the body for passing of stool and gas) and abnormalities of gait (ambulation) and mobility.
A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/6/2024, indicated Resident 1 has an intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and needing moderate assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene).
A review of Resident 1 ' s medical record indicated missing care plan that Resident 1 had multiple episodes of refusals of basic care.
During an interview with Certified Nursing Assistant 3 (CNA 3), on 3/25/2025 at 12:59 p.m., CNA3 stated that Resident 1 had been refusing basic care. CNA 3 also stated that she (CNA 3) notified the charge nurse via Stop and Watch (a warning tool that identify any change while caring for a resident).
During an interview with CNA 4 on 3/25/2025 at 1:13 p.m., CNA 4 stated that Resident 1 had also been refusing basic care during the night shift. CNA4 also stated that he (CNA 4) notified the charge nurse.
During an interview with the Director of Staff Development (DSD), on 3/25/2025 at 2:52 p.m., DSD stated and validated that Resident 1 had multiple episodes of refusals of care. DSD also stated that when a resident refuses any care, the CNAs should notify the charge nurse and charge nurse must report to the MD and document via COC/CIC and start a care plan so they are able to monitor the resident ' s issue and plan a solution to assist the resident.
During an interview with the Quality Assurance Nurse (QAN), on 3/25/2025 at 3:13 p.m., QAN stated and validated missing care plan with Resident 1 ' s refusals of basic care. QAN also stated that a care plan must be initiated for any refusals of care.
A review of the facility ' s policy and procedures (P&P), titled, Care Plans, Comprehensive Person-Centered reviewed on 12/2024, the P&P indicated that interdisciplinary team reviews and updates the care plan when there has been a change in resident ' s condition and refusals are documented in the resident ' s clinical record in accordance with established policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to ensure physician (MD) notification was done for one of nine sampled residents (Resident 1's) change of condition (COC/CIC) by failing to notify MD when Resident 1 had multiple episodes of refusal of basic care.
This deficient practice had the potential to result in possible delayed provision of necessary care and services to Resident 1.
Cross Referenced F656
Findings:
A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses including carcinoma (cancer cells) in the rectum (final section/ part of the lower gastrointestinal tract [GI tract-organ system of the body from the mouth to the anus [part of the GI tract where the stool or feces are being eliminated from the body], colostomy (opening of the large intestine [abdominal area] to the outside of the body for passing of stool and gas) and abnormalities of gait (ambulation) and mobility.
A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 12/6/2024, indicated Resident 1 has an intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and needing moderate assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene).
A review of Resident 1's medical record indicated missing documentation that Resident 1 had multiple episodes of refusals of basic care.
During an interview with Certified Nursing Assistant 3 (CNA 3) on 3/25/2025 at 12:59 p.m., CNA 3 stated that Resident 1 had been refusing basic care. CNA 3 also stated that she (CNA3) notified the charge nurse via Stop and Watch (a warning tool that identify any change while caring for a resident).
During an interview with CNA 4 on 3/25/2025 at 1:13 p.m., CNA 4 stated that Resident 1 had also been refusing basic care during the night shift. CNA 4 also stated that he (CNA 4) notified the charge nurse.
During an interview with the Director of Staff Development (DSD), on 3/25/2025 at 2:52 p.m., DSD stated and validated that Resident 1 had multiple episodes of refusals of care and was made aware by the CNAs. DSD also stated that when a resident refuses any care, the CNAs should notify the charge nurse and charge nurse must report to the MD and document via COC/CIC so they are able to monitor the resident's issue.
During an interview with the Quality Assurance Nurse (QAN), on 3/25/2025 at 3:13 p.m., QAN stated and validated missing documentation with Resident 1's refusals of basic care. QAN also stated that a COC/CIC documentation must be done for any refusals of care.
A review of the facility's policy and procedures (P&P), titled, Change in Resident's Condition or Status, reviewed on 12/2024, P&P indicated that facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition and/or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary treatment and service to one of three sampled residents (Resident 4) consistent with the resident's needs and professional standard of care by failing to ensure low air loss (LAL) mattress was set up properly for Resident 4.
This deficient practice can place Resident 4 at risk of poor wound healing of the current pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) and possibly development of a new pressure injury.
Findings:
A review of Resident 4's admission Record indicated Resident 4, was admitted to the facility on [DATE] with diagnoses including paraplegia (paralysis of the legs and lower body), diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and osteomyelitis (bone infection).
A review of Resident 4's Minimum Data Set (MDS-a resident assessment tool), dated 10/21/2024, indicated Resident 4 was moderately impaired in cognitive skill (thought processes) for daily decision making and needing one to two-person assistance with staff on activities of daily living (ADLs-bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene). Resident 4's MDS indicated Resident 4 has currently has pressure ulcer, high risk for developing pressure ulcers with treatment to provide pressure reducing device for bed.
A review of Resident 4's Order Summary Report (OSR), dated 11/13/2024, OSR indicated a physician (MD) order LAL therapy bed for treatment and management of pressure ulcer and monitor every shift.
A review of Resident 4's monthly weight report, indicated Resident 4 weighed at 149 pounds (lbs.) in March 2024.
During a concurrent observation and interview with the Treatment Nurse 1 (TX1) on 3/25/2025 at 10:31 a.m., observed Resident 4's LAL mattress was currently set at weight 200 lbs. TX1 stated and validated that Resident 4's LAL mattress was supposed to be set according to Resident 4's current weight, not at 200 lbs.
During an interview with the Director of Staff Development (DSD) on 3/25/2025 at 2:52 p.m., DSD stated that LAL mattress should be set based on resident's weight.
A review of the facility's policy and procedures (P&P), titled, Support Surface Guidelines reviewed on 12/2024, P&P indicated that Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one of two sampled residents (Resident 2) by failing to ensure the nasal cannula (NC -a connector attached to oxygen) tubing and humidifier (a device used to make supplemental oxygen moist) for oxygen (O2) therapy was changed per facility ' s policy.
This deficient practice had the potential to cause complications associated with oxygen therapy.
Findings:
A review of the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including pneumonia (lung infection that inflames air sacs with fluid or pus), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), and acute on chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide).
A review of the Minimum Data Set (MDS – a resident assessment tool) dated 10/8/2024, indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 2 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
A review of Resident 2 ' s Order Summary Report as of 6/8/2024, the Order summary indicated, O2 at 2 liters per minute (lpm – unit of measurement) via NC continuously to maintain O2 saturation (sat) between 88 – 92 percent (% - unit of measurement).
During an observation with Resident 2 on 12/24/2024 at 1:21 p.m., Resident 2 was receiving O2 supplement via NC, connected to an oxygen concentrator machine and humidifier at bedside. Observed Resident 2 ' s NC tubing and humidifier bottle labeled with date 12/11/2024. The humidifier bottles was empty and no liquid observed.
During a concurrent observation and interview with Licensed Vocational Nurse (LVN 1) on 12/24/2024 at 1:24 p.m., LVN 2 observed Resident 2 ' s NC and humidifier bottle and stated and confirmed, Resident 2 ' s humidifier bottle was dated 12/11/2024 which was about two weeks ago. LVN 1 stated, the NC tubing and humidifier bottle needs to be changed. LVN 1 further stated, this puts resident at risk of infection.
During an interview with Registered Nurse 1 (RN 1) on 12/26/2024 at 1:39 p.m., RN 1 stated, the NC tubing and humidifier is to be replaced once a week and as needed if soiled and empty. DON stated, if not changed per policy, this puts residents at risk of infection and respiratory issue.
A review of the facility ' s policy and procedure (P&P) titled, Department (Respiratory Therapy) Prevention of Infection, revised 2/2024, the P&P indicated, Check water level of any pre-filled reservoir every 48 hours. Change pre-filled humidifier when the water level becomes low. Change the oxygen cannula and tubing every seven days, or as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to effectively and timely manage/treat/assess the pain for two of three sampled residents (Resident 2 and Resident 3) .
Resident 2 was experiencing severe pain of the left knee in the facility for two days
Resident 3 was admitted to the facility for pain management (The process of providing medical care that alleviates or reduces pain).
This deficient practice resulted in:
Resident 2 was sent to a general acute care hospital (GACH) emergency room after the resident's family intervened and requested for the transfer to GACH.
Resident 3 experiencing unnecessary pain affecting the resident's appetite and ability to sleep.
Findings:
1. During a review of the admission record for Resident 2 indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection (UTI- an infection in the bladder/urinary tract), dementia (a progressive state of decline in mental abilities), and hyperlipidemia (a condition where there are high levels of fats or lipids in the blood).
During a review of Resident 2's skin assessment dated [DATE] indicated the skin was intact, with no abnormalities.
During a review of Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 10/31/2024 at 1:16 pm, the SBAR indicated: Resident 2 had complaint of leg pain and skin discoloration to RUA (right upper extremity [right arm]). The SBAR indicated Resident [Resident 2] C/O (complained of) of pain on her left leg, upon assessment no s/s (signs and symptoms) of edema (swelling) or inflammation (a localized physical condition in which part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection) observed in the left leg. Upon admission patient have right upper arm skin discoloration no open skin noted on her left leg and right upper arm I request an X-ray (X-rays are a type of radiation called electromagnetic waves. X-ray imaging creates pictures of the inside of your body) for her left leg and continue to monitor for change of conditions and V/S (vital signs-measurements of the body's basic functions, such as breathing rate, temperature, pulse rate, and blood pressure).
During a review of an X-ray imaging report of Resident 2's Left tibia and fibula (two bones in your lower leg, also known as the shin bone [tibia] and the calf bone [fibula]) dated 10/31/2024, the indicated the X-ray report indicated there was no fracture (a break or a crack in a bone).
During a review of an SBAR dated 11/2/2024 at 3:49 pm indicated, Left knee pain - Resident is noted with mild pain on Left knee with minor swelling. The SBAR indicated Resident 2 c/o mild pain while touched or moved. The SBAR indicated, It [left knee] is Warm to touch. Resident is kept clean, dry, and comfortable. Bed is at lowest position; call light is placed within easy reach. No fever or chills. No s/sx infection noted. [Family member (FM)] at bedside concerned the resident's condition. MD (medical doctor/Np (nurse practitioner) made aware by RN (registered nurse) supervisor and received new order x-ray and lidocaine 4% patch (a targeted pain medication used in areas such as arms, legs, back) to left knee daily for pain management. Order noted and carried out. [FM] at bedside notified of the new order and she verbalized understanding it.
During a review of Resident 2's Nurse Progress note dated 11/2/2024 at 7:29 pm, the nurse progress note indicated, Resident [Resident 2] family called 911 (number called in the United States to contact the emergency services such medical, fire etc.) to transfer resident to ER (emergency room [the department of a hospital that provides immediate treatment for acute illnesses and trauma]) due to pain and swelling of right knee. Paramedics (a person specially trained to provide emergency medical services, as in or from an ambulance) came and transferred resident to the ER.
During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/2/2024, indicated Resident 2 had severe cognitive impairments (a condition that makes it difficult for a person to remember things, learn, concentrate, or make decisions). The same MDS indicated Resident 2 was dependent for all her Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During an interview with Licensed Vocational Nurse 1 (LVN 1) on 11/21/2024 at 1:34 pm, LVN 1 stated that while Resident 2 's FM was visiting Resident 2 on 10/31/2024, Resident 2's FM informed LVN 1 that Resident 2 had pain to the left knee. LVN 1 stated LVN 1 assessed Resident 2's left leg and that Resident 2 was guarding her left leg when moving her left leg away from LVN 1. LVN 1 stated tried to touch Resident 2's left leg and the resident started crying in pain. LVN 1 stated [NAME] called the physician and requested an x-ray which indicated that Resident 2 did not have any fractures.
During the same interview, LVN 1 stated that on 11/2/2024, Resident 2's FM was upset and told LVN 1 that Resident 2 had severe pain and that Resident 2's left knee was very swollen. LVN 1 stated that upon assessment, Resident 2's left knee was warm to touch, swollen, and painful. LVN 1 stated Resident 2's FM insisted that Resident 2 be sent to the ER. LVN 1 stated and admitted that Resident 2's situation should have been escalated given that Resident 2's condition was progressing to health conditions such as infection or DVT (Deep Vein Thrombosis- a condition where a blood clot forms in a large vein in the body, usually in the lower limbs).
During an interview with the Interim Director of Nursing (IDON) on 11/22/2024 at 2:05 pm, the IDON stated that given that Resident 2's X-ray was negative for a fracture and that Resident 2 was still presenting with worsening symptoms (increased swelling, pain, and was warm to touch to the left knee), the situation should have been promptly escalated and notify a medical doctor (MD) and request an X-ray of the affected area (left knee) instead of the lower leg.
During a review of a Policy and Procedures (P&P) titled Change in a Resident's Condition or Status, revised 2/2024, indicated Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The same P&P indicated under policy interpretation and implementation.
1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):
a. accident or incident involving the resident.
b. discovery of injuries of an unknown source.
c. adverse reaction to medication.
d. significant change in the resident's physical/emotional/mental condition.
e. need to alter the resident's medical treatment significantly.
f. refusal of treatment or medications two (2) or more consecutive times).
g. need to transfer the resident to a hospital/treatment center,
h. discharge without proper medical authority; and/or
i. specific instruction to notify the physician of changes in the resident's condition.
During a review of the P&P titled Pain - Clinical Protocol, revised 2/2024 indicated:
-The staff and physician will identify the characteristics of pain such as location, intensity,
frequency, pattern, and severity.
a. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.
- The staff and physician will evaluate how pain is affecting mood, activities of daily living,
sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls. The same P&P indicated, The physician will help identify causes of pain; for example, by examining the resident directly, reviewing the resident's history, and via discussion with the resident and staff.
2. During a review of the admission record for Resident 3 indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including multiple myeloma (a type of blood cancer that affects plasma cells in the bone marrow), neoplasm (an abnormal mass of tissue, also known as a tumor, that forms when cells grow and divide too much or don't die when they should) related pain (pain may arise from a tumor compressing or infiltrating tissue), and essential hypertension (HTN-high blood pressure).
During a review of the MDS dated [DATE], indicated Resident 3 had moderate cognitive impairments. The same MDS indicated Resident 3 required substantial/maximal assistance for most of his ADL such as: (routine tasks/activities such as bathing, dressing, toileting hygiene).
During a record review of Resident 3's SBAR dated 11/21/24 at 2:09 pm indicated, Pain is not relieved by Prn (as needed) narcotics (a substance used to treat moderate to severe pain). Asked Dr. to change Prn medications Norco Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen - a combination medication that contains hydrocodone (an opioid) and acetaminophen (an analgesic). It's used to manage pain for people who've tried non-opioid medications but haven't gotten enough relief) *Controlled Drug*
Give 1 tablet orally every 6 hours as needed for severe pain for 90 Days NTE 3gm/24 hrs. To Routine medications.
During a review of Resident 3's SBAR dated 11/21/2024 at 11:25 pm, indicated, Abnormal labs elevated the WBC (White blood cells are part of the blood and are an important part of the immune system, which helps to detect and deal with infections). The same SBAR indicated, Labs [laboratory] results came with abnormality WBC 17.9 (range 4,500 and 11,000 per microliter of blood), MD (Medical Doctor) aware with order to send General Acute Care Hospital.
During a concurrent observation and interview with Resident 3 on 11/21/24 at 9 am, Resident 3 was observed lying down in bed, positioned on 2 pillows. The resident appeared to be uncomfortable and was restless. Resident 3 was constantly trying to reposition himself at least every 30 seconds, was guarding his abdomen, and taking shallow rapid breaths. Resident 3 stated he had severe pain to his back but had recently received some pain medications. The resident stated that the pain causes him to lose his appetite.
During an interview with Family Member 1 (FM )1 on 11/21/24 at 11:12 am, FM 1 stated Resident 3 was afraid to ask staff for pain medication for fear of retaliation. FM 1 stated Resident 1 is constantly pain which was the reason he was sent to the facility. FM 1 stated Resident 3 manifests pain by getting quiet, readjusting position, withdrawals, loses appetite and sleep.
During a concurrent interview and record review of Resident 3's medical chart with Registered Nurse 1 (RN )1 on 11/22/24 at 11 am, RN 1 stated that Resident 3 was admitted to the facility for pain management due to neoplasm pain. RN 1 stated, It was very important that his [Resident 3] pain was treated. A review of the physician's order for Norco 10/325mg with RN 1 indicated to administer 1 tablet by mouth every 6 hours prn for severe pain to Resident 3. A review of the Norco administration log indicated Resident 3 received Norco as follows for the month of 11/2024:
11/2024 - once
11/3/2024 - twice
11/4/2024 - twice
11/5/2024- twice
11/6/2024 - once
11/7/2024 - once
11/12/2024 - once
11/14/2024 - once
11/20/2024 - once
During a review of the SBAR dated 11/21/24 at 2:09 pm for Resident 3, the SBAR indicated RN 1 had completed/documented that the pain medications were not sufficient for Resident 3. RN 1 stated and confirmed that Resident 3 did not receive the targeted dose daily as ordered for Norco to determine if the Norco was effective or not. RN 1 stated that inadequate management of pain may lead to problematic symptoms for the resident such as insomnia, loss of appetite, and severe pain. Resident 3's oral intake was reviewed with RN 1. The oral intake indicated that Resident 3 was consuming between 0-to-25% of all meals.
During a concurrent interview and record review of Resident 3's medical chart with the Director of Nursing (DON) on 11/25/24 at 10:40 am, the DON stated that Resident 3 was admitted for treatments which included pain management due to the neoplasm related pain. The DON admitted that even though pain is subjective, a faces pain scale would have been appropriate for Resident 3 that the pain scale given did not match his presentation.
During a review of the facility's P&P titled Administering Medications,' revised 2/2024, indicated under policy interpretation and implementation:
- Medications are administered in accordance with prescriber orders, including any required time frame.
-Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include:
a. enhancing optimal therapeutic effect of the medication.
b. preventing potential medication or food interactions.
During a review of the P&P titled Pain - Clinical Protocol, revised 2/2024 indicated:
-The staff and physician will identify the characteristics of pain such as location, intensity,
frequency, pattern, and severity.
a. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.
- The staff and physician will evaluate how pain is affecting mood, activities of daily living,
sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls.

**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 2), who had severe left knee pain was appropriately assessed in a timely manner.
This failure resulted in the delay of care for Resident 2 who had to suffer from pain and discomfort for two days.
Findings:
During a review of the admission record for Resident 2 indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection (UTI- an infection in the bladder/urinary tract), dementia (a progressive state of decline in mental abilities), and hyperlipidemia (a condition where there are high levels of fats or lipids in the blood).
During a review of Resident 2's skin assessment dated [DATE] indicated the skin was intact, with no abnormalities.
During a review of Situation, Background, Assessment, Recommendation (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 10/31/2024 at 1:16 pm, the SBAR
and symptoms) of edema (swelling) or inflammation (a localized physical condition in which part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection) observed in the left leg. Upon admission patient have right upper arm skin discoloration no open skin noted on her left leg and right upper arm I request an X-ray (X-rays are a type of radiation called electromagnetic waves. X-ray imaging creates pictures of the inside of your body) for her left leg and continue to monitor for change of conditions and V/S (vital signs-measurements of the body's basic functions, such as breathing rate, temperature, pulse rate, and blood pressure).
During a review of an X-ray imaging report of Resident 2's Left tibia and fibula (two bones in your lower leg, also known as the shin bone [tibia] and the calf bone [fibula]) dated 10/31/2024, the indicated the X-ray report indicated there was no fracture (a break or a crack in a bone).
During a review of an SBAR dated 11/2/2024 at 3:49 pm indicated, Left knee pain - Resident is noted with mild pain on Left knee with minor swelling. The SBAR indicated Resident 2 c/o mild pain while touched or moved. The SBAR indicated, It [left knee] is Warm to touch. Resident is kept clean, dry, and comfortable. Bed is at lowest position; call light is placed within easy reach. No fever or chills. No s/sx infection noted. [Family member (FM)] at bedside concerned the resident's condition. MD (medical doctor/Np (nurse practitioner) made aware by RN (registered nurse) supervisor and received new order x-ray and lidocaine 4% patch (a targeted pain medication used in areas such as arms, legs, back) to left knee daily for pain management. Order noted and carried out. [FM] at bedside notified of the new order and she verbalized understanding it.
During a review of Resident 2's Nurse Progress note dated 11/2/2024 at 7:29 pm, the nurse progress note indicated, Resident [Resident 2] family called 911 (number called in the United States to contact the emergency services such medical, fire etc.) to transfer resident to ER (emergency room [the department of a hospital that provides immediate treatment for acute illnesses and trauma]) due to pain and swelling of right knee. Paramedics (a person specially trained to provide emergency medical services, as in or from an ambulance) came and transferred resident to the ER.
During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/2/2024, indicated Resident 2 had severe cognitive impairments (a condition that makes it difficult for a person to remember things, learn, concentrate, or make decisions). The same MDS indicated Resident 2 was dependent for all her Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During an interview with Licensed Vocational Nurse 1 (LVN 1) on 11/21/2024 at 1:34 pm, LVN 1 stated that while Resident 2 's FM was visiting Resident 2 on 10/31/2024, Resident 2's FM informed LVN 1 that Resident 2 had pain to the left knee. LVN 1 stated LVN 1 assessed Resident 2's left leg and that Resident 2 was guarding her left leg when moving her left leg away from LVN 1. LVN 1 stated tried to touch Resident 2's left leg and the resident started crying in pain. LVN 1 stated [NAME] called the physician and requested an x-ray which indicated that Resident 2 did not have any fractures.
During the same interview, LVN 1 stated that on 11/2/2024, Resident 2's FM was upset and told LVN 1 that Resident 2 had severe pain and that Resident 2's left knee was very swollen. LVN 1 stated that upon assessment, Resident 2's left knee was warm to touch, swollen, and painful. LVN 1 stated Resident 2's FM insisted that Resident 2 be sent to the ER. LVN 1 stated and admitted that Resident 2's situation should have been escalated given that Resident 2's condition was progressing to health conditions such as infection or DVT (Deep Vein Thrombosis- a condition where a blood clot forms in a large vein in the body, usually in the lower limbs).
During an interview with the Interim Director of Nursing (IDON) on 11/22/2024 at 2:05 pm, the IDON stated that given that Resident 2's X-ray was negative for a fracture and that Resident 2 was still presenting with worsening symptoms (increased swelling, pain, and was warm to touch to the left knee), the situation should have been promptly escalated and notify a medical doctor (MD) and request an X-ray of the affected area (left knee) instead of the lower leg.
During a review of a Policy and Procedures (P&P) titled Change in a Resident's Condition or Status, revised 2/2024, indicated Our facility promptly notifies the resident, his or her attending physician and the resident representative
of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The same P&P indicated under policy interpretation and implementation.
1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):
a. accident or incident involving the resident.
b. discovery of injuries of an unknown source.
c. adverse reaction to medication.
d. significant change in the resident's physical/emotional/mental condition.
e. need to alter the resident's medical treatment significantly.
f. refusal of treatment or medications two (2) or more consecutive times).
g. need to transfer the resident to a hospital/treatment center,
h. discharge without proper medical authority; and/or
i. specific instruction to notify the physician of changes in the resident's condition.

Based on interview and record review the facility failed to ensure one for three sampled residents (Resident 1), Resident 1's Responsible Party (RP) was made aware of the reason Resident 1 was being discharged from the facility .
This failure resulted in Resident 1's Responsible Party (RP) not being notified of the transfer and reasons why the Resident 1 was not to be readmitted to the facility.
Findings:
During a review of Resident 1's admission Record , dated 11/1/24 indicated, Resident 1 was admitted to the facility originally on 7/19/24 and had a readmission date of 10/15/24. The same record further indicated Resident 1 had diagnosis including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), cerebral palsy (a group of neurological disorders that affect a person's ability to move, maintain balance, and posture), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (a condition that causes excessive and persistent feelings of fear, worry, dread, and uneasiness).
During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 9/23/24, the MDS indicated, Resident 1 had mild memory problems and continuously had behaviors of inattention and disorganized thinking. The same MDS further indicated Resident 1 was independent with self-care, indoor mobility and functional cognition (ability to assist in planning regular tasks such as shopping or remembering to take medications), but required partial/moderate assistance with toileting, showering/bathing dressing, personal hygiene.
During a review of Resident 1's census report dated 11/1/24, indicated Resident 1 had been transferred out to hospital and readmitted to facility as follows: 10/9/24 readmission, 10/13/24 discharge to hospital, 10/15/24 readmission, 10/19/24 1:10 am transfer to hospital, 10/19/24 10:05 pm readmission, 10/20/24 discharge to hospital.
During a review of Resident 1's Physicians' Orders , dated 10/20/24, the physician's orders indicated, an order for transfer to emergency room via 911 (emergency number) due to suicidal ideation manifested by get in to cross traffic of car also attempting to choking and putting hands around neck . banging head against wall & and poking her wrist with silverware knife and sharp ball pen.
During a review of Resident 1's SBAR (situation, background, assessment, recommendation) Communication Form and progress note date 10/20/24 at 2:55 pm, indicated Resident 1 had suicidal ideation manifested by get into cross traffic of car also attempting to choking and putting hands around neck . banging head against wall & and poking her wrist with silverware knife and sharp ball pen. MD and psychiatrist Physician's Assistant (PA) notified. And order to transfer out via 911 to ER (emergency room).
During a review of Resident 1's Nursing progress note dated 10/20/24 at 2:49 pm, indicated the resident was aggressive trying to go out to smoke by herself . she started yelling and hitting everyone . 911 called police came and detained resident in the lobby . waiting or 51-50 hold approval.
No indication Resident 1's responsible party (RP) was notified.
During an interview on 11/1/24 at 10:58 am with Activities Assistant (AA), the AA stated at first the resident was not violent but the day that she left on 10/20/24 she ended up getting upset because it was not time to smoke and she was insisting upon smoking. She trying to wheeling herself out on to the street with oncoming traffic. She was trying to push him out of the way and started hitting him in the chest then yelled I am not letting you have kids anymore and kicked him groin. She was then removed from the premises by police in handcuffs and has not seen her since.
During a telephone interview on 11/5/24 at 9:25 am with Hospital Social Worker (HSW), the HSW stated the understands it may be difficult for the nursing home to take back the resident and the resident may need a different type of facility.
During a telephone interview on 11/5/24 at 4:35 pm with Resident 1's RP, the RP stated she doesn't mind if the resident goes elsewhere but they don't know the vendor and the level of care and it needs to be vetted by a nurse at her office. The RP further stated she would sign off on it (the transfer/discharge to a different facility), but she has to know where the resident will be going beforehand (which was not done).
During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated , revised February 2024, the P&P indicated, facility-initiated and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation and documentation as specified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were free from physical abuse (deliberately aggressive or violent behavior by one person toward another that results in bodily injury) from Resident 3. Resident 3 slapped Resident 2 in the arm and assaulted Resident 1 in the activity room where facility staff was present and there was no documented monitoring of Resident 3, per the Mood Problem care plan interventions. This deficient practice resulted in Resident 1 sustaining a bloody lip with jaw pain, and was transferred to the General Acute Care Hospital for evaluation.
Findings:
a.A review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE] with a diagnoses including peripheral vascular disease (a condition that occurs when blood vessels narrow or become blocked, reducing blood flow to the limbs or other organ), and cellulitis (a bacterial infection that affects the skin and tissues beneath it).
A review of Resident 3's Mood Problem related to admission care plan, dated 8/7/23, indicated Resident 3 had a history of non-compliance and the interventions indicated to monitor / record / report to the physician acute episodes of feeling sad, loss of pleasure and interest in activities.
A review of Resident 3's Progress notes indicated there was no monitoring of episodes for feeling sadness, loss of pleasure and interest in activities.
A review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/13/24, indicated the resident had no issues with feeling down, depressed, or hopeless. The MDS indicated Resident 3 did not present with little interest or pleasure in doing things. This indicated a discrepancy and inaccurate assessment when compared to the Mood Problem care plan date 8/7/23.
A review of Resident 3's Situation, Background, Assessment, and Recommendation (SBAR - a framework that can assist in communication quickly and clearly in the healthcare setting), dated 10/30/24, indicated the resident had an altercation with other residents (Resident 1 and Resident 2).
A review of the Social Services note dated 10/30/24, indicated Resident 3 was visited once a day for two days for evaluation after the incident with Resident 1 and Resident 2. The Social Services note, indicated Resident 3 did not want to talk about the incident but Resident 3 stated, All I can say is that I'm sorry. I was just mad. The social service note dated 11/1/24, indicated Resident 3 was discharged to a board and care facility (a lower level of care).
b.A review of Resident 1's SBAR dated 10/30/24, indicated the resident had soreness to the right jaw, neck, back, and left knee due to an altercation with Resident 3 on 10/29/24. The SBAR indicated Resident 1's primary physician was notified.
A review of Resident 1's Progress notes, dated 11/1/24, indicated the resident was transferred to the General Acute Care Hospital (GACH) for evaluation due to complaints of neck, jaw, and left knee pain. The Progress note indicated the resident returned to the facility on [DATE] with no new orders, the facility continued monitoring Resident 1.
A review of Resident 1's psychiatrist consult, dated 11/1/24, indicated Resident 1 was calm, cooperative, and able to verbalize needs. The psychiatrist consult indicated staff to continue to monitor and report any changes.
During an interview on 11/6/24 at 11:54 AM, with Resident 1 in his room, Resident 1 stated that Resident 3 was beating on Resident 2 and I got involved. Resident 1 stated he and Resident 3 got into it. Resident 1 stated he sustained an injury to his right cheek, a bloody lip, and right neck and shoulder pain. Resident 1 stated he felt safe at the facility and liked living there. Resident 1 stated he had no prior interaction with Resident 3. Resident 1 stated the psychiatrist conducted a visit.
During an interview on 11/6/24 at 11:24 AM, the Administrator (ADM) stated the residents were watching the TV in the activities room. Resident 3 got upset and went into the activities room and hit Resident 2. Resident 2 stated that another resident, Resident 1, was assaulted by Resident 3. The ADM stated supervision was in the room and witnessed by the assistant activities director.
c.A review of Resident 2's admission record indicated the resident was admitted to the facility on [DATE], with a diagnoses including hemiplegia (the partial or total loss of movement to one side of the body) following cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked) and altered mental status.
A review of Resident 2's MDS, dated [DATE], indicated Resident 2 did not have feelings of depression or hopelessness, or little interest or pleasure in doing things.
A review of Resident 2's SBAR, dated 10/30/24, indicated the resident had an altercation with another resident (Resident 3) while watching TV in the activity room. The SBAR indicted the resident's primary physician was notified.
A review of Resident 2's Progress note, dated 10/30/24, indicated the resident was involved in an altercation with Resident 3.
During an interview on 11/6/24 at 12:04 PM, with Resident 2 in the activities room, Resident 2 stated, everyone was watching tv in the activities room. Resident 2 stated Resident 3 slapped him on the right arm on 10/29/24. Resident 2 stated the assistant activities director was in the room. Resident 2 stated the incident was not an accident and that his doctor came to see him. Resident 2 stated he felt safe at the facility.
During an interview on 11/6/24 at 1:06 PM, with the Activities Director (AD) and the Assistant Activities Director (AAD), the AD interpreted for the AAD. The AAD stated at around 7 pm, the residents finished dinner, and were watching TV. Resident 3 was not watching TV but came into the activity room, went to speak to Resident 2, and pushed him in the right side of the chest. The AAD stated Resident 3 then pushed Resident 1 in the chest. Resident 1 fell back into his chair. Resident 1 got up and pushed Resident 3 and the AAD stepped in front of Resident 2 and was telling Resident 1 and Resident 3 to stop. Resident 1 and Resident 3 pushed each other two more times. The AAD asked a staff member from the kitchen to help separate the two residents. The AAD assisted Resident 2, and the other staff told Resident 3 to go wait outside his room. The AAD stated she did not know why Resident 3 was upset and that Resident 1 had a scratch to the right side of his neck, and she saw that Resident 1 had a little blood in his mouth.
During an interview on 11/6/24 at 3:40 PM, the Administrator (ADM) and the Director of Nursing (DON) stated upon admission the residents were instructed on resident rights which included freedom from abuse. The ADM stated on the day of the incident he received a text at 8:45 PM, he came to the facility, conducted the investigation, and reported the abuse to the ombudsman, California Department of Public Health, and the Police Department. The ADM stated his investigation concluded the attack was incidental, abuse did occur, but supervision was there.
During an interview on 11/6/24, the Abuse Policies were requested from the medical records staff. The medical records staff provided the policy Abuse Investigation and Reporting, and Charting and Documentation but there was no reference to Abuse Prevention.
A review of the facility's policy and procedures titled, Resident Rights, dated 2/2024, indicated federal and state laws guarantee basic rights at the facility which include to be free from abuse, neglect, and exploitation. The resident had the right to a dignified existence and have the facility respond to his or her grievances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement the comprehensive care plan interventions for two of three sampled residents (Resident 2 and Resident 3). Both residents were not monitored after an altercation with another resident, per the care plan interventions. This deficient practice had the potential to result in missed opportunity for any changes in the residents.
Findings:
a.A review of Resident 2's admission record indicated the resident was admitted to the facility on [DATE], with a diagnoses including hemiplegia (the partial or total loss of movement to one side of the body) following cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked) and altered mental status.
A review of Resident 2's MDS, dated [DATE], indicated Resident 2 showed no delirium issues and did not have feelings of depression or hopelessness, or little interest or pleasure in doing things.
A review of Resident 2's SBAR, dated 10/29/24, indicated Resident 2 had an altercation with another resident while watching TV in the activity room, no injuries sustained. The SBAR indicated Resident 2 did not have a mental, functional status change, respiratory, abdomen or urine changes. The SBAR indicted the resident's primary physician was notified.
A review of Resident 2's Alteration in Mood/Behavior Care plan, dated 10/30/24, indicated the goal that the resident must not have an injury for 30 days with a reevaluation date of 1/25. The progress note indicated the resident should be monitored for changes in conduct.
A review of Resident 2's Progress note, dated 10/30/24, indicated Resident 2 was involved in an altercation with another resident (Resident 3). No other nurses note indicated in progress notes monitoring of resident's conduct after 10/30/24.
A review of Resident 2's psychiatrist consult, dated 11/1/24, indicated Resident 2 was calm and cooperative. The consult note indicated Resident 2 denied any history of mental health issues, feelings of depression, anxiety, or hallucinations. The consult indicated the staff to continue to monitor Resident 2 and report any changes.
A review of the physician's visit note, dated 11/1/24, indicated Resident 2 stated he was okay. The physician's visit note indicated Resident 2 appeared comfortable.
During an interview on 11/6/24 at 12:04 pm, with Resident 2 in the activities room, Resident 2 stated Resident 3 slapped him on the right arm and the assistant activities director was in the room. Resident 2 stated he did not want to see anyone from psychiatry after the incident. Resident 2 stated the incident was not an accident.
During a concurrent interview and record review on 11/6/204 at 3:40 pm with the Director of Nursing (DON), Resident 2's Progress notes, dated 10/30/24 was reviewed. The Progress notes indicated the resident was monitored on 10/30/24 at 11:04 pm for altercation with another resident while watching TV in the activity room. No other progress notes noted after the date of 10/30/24 for monitoring the resident. The DON confirmed that Resident 2 was not monitored every shift after the incident. The DON stated the result to the resident without proper monitoring per the care plan would be that there is a missed opportunity for any changes.
b.A review of Resident 3's admission record indicated the resident was admitted to the facility on [DATE] with a diagnoses of peripheral vascular disease (a condition that occurs when blood vessels narrow or become blocked, reducing blood flow to the limbs or other organ), and cellulitis (a bacterial infection that affects the skin and tissues beneath it).
A review of Resident 3's Mood Problem related to admission care plan, dated 8/7/23, indicated Resident 3 had a history of non-compliance. The goal indicated Resident 3 would have improved mood stated happier, calmer appearance, no signs or symptoms of depression, anxiety, or sadness through the review date. The goal was revised on 10/8/24.
A review of Resident 3's Progress notes indicated no monitoring for episodes of feeling sadness, loss of pleasure and interest in activities.
A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had no issues with feeling down, depressed, or hopeless. The MDS indicated Resident 3 did not present with little interest or pleasure in doing things.
A review of the Social Services note indicated Resident 3 was visited once a day for two days for evaluation after the incident. A review of Resident 3's Social Services note, dated 10/30/24, indicated Resident 3 did not want to talk about the incident. A review of Resident 3's Social Services note, dated 11/1/24, indicated Resident 3 was discharged to a board and care facility.
During concurrent interview and record review on 11/6/24 at 3:40 pm, with the DON, Resident 3's Mood Problem related to Admission, History of Noncompliant Medication Care Plan, dated 8/7/23 were reviewed. The care plan dated, 8/7/23, was revised on 10/8/24. The DON stated it was time for the yearly revision which was 10/8/24. The DON stated the nurses were not monitoring Resident 3 for this care plan due to no psychiatric diagnosis.
A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 6/2024, indicated the care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs, and was developed and implemented for each resident.
A review of the facility's policy and procedure titled, Charting and Documentation, dated 2/2024, indicated, all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide social services to one of three sample residents (Resident 1) by failing to follow up on an order for ophthalmology (eye care specialist) evaluation appointment.
This deficient practice had the potential for delay in the delivery of care and services.
Findings:
A review of Resident 1 ' s admission record indicated, Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), acute kidney failure(a rapid loss of the kidneys' ability to remove waste and help balance fluids and electrolytes in the body.), diabetes mellitus(a chronic metabolic disease that occurs when the body is unable to regulate blood glucose levels), and depression (a mental disorder characterized by loss of pleasure or interest in activities for long periods of time),
A review of the Minimum Data Set (MDS – a standardized assessment and care screening tool) dated 6/18/2024, indicated Resident 1 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact for daily decision making. Resident 1 requires partial to moderate assistance with eating, oral and personal hygiene, needs substantial/maximal assistance with upper body dressing and is totally dependent for lower body dressing.
During an interview on 07/17/2024, at 10:55 am, Resident 1 indicated she had a scheduled eye care specialist appointment in September 2024 (unable to recall exact date), Resident 1 stated she missed the scheduled appointment because the facility failed to schedule her transportation to the appointment.
A review of the Ophthalmology order dated 07/29/ 2024, indicated Resident 1 had a scheduled appointment for cataract eval and surgery on 9/13/2024.
During an interview on 09/17/2024 at 11:15 am, the Social Services Director (SSD) stated Licensed Vocational Nurse 1 (LVN1) scheduled the appointment for Resident 1for 09/13/2024 at 10:00 am but failed to inform SSD via the facility process of completing a Social Services referral transportation request form that Resident 1 had a scheduled appointment therefore. The SSD did not make transportation arrangements to get Resident 1 to the eye specialist appointment and Resident 1 subsequently missed the ophthalmology appointment.
During an interview on 9/17/2024 at 12:18 pm, LVN1 stated she (LVN1) scheduled the appointment on Resident 1 ' s medical record and completed a Social Services referral transportation request form for Resident 1 and placed it in the transportation folder for SSD to arrange transportation. LVN1 stated she did not document the transportation request in her nursing notes.
During an interview on 9/17/2024 at 1:40 pm, the Director of Nursing (DON) stated the DON was unaware Resident 1 had missed a scheduled ophthalmology appointment. The DON further stated failure to communicate and follow-up between LVN1 and the SSD created a missed opportunity for transportation arrangement that resulted in Resident 1 missing the eye appointment.
A review of the facility's social services undated Job Description, indicated, SSD duties and responsibilities as Directs and coordinates resident ' s appointments including transportation.
A review of facility's policy and procedure (P&P) undated indicated, it is the policy of the facility to provide assistance to residents with appointments for outside consultation (e.g. Clinic, visits), whenever possible and necessary. Forms of assistance include but are not limited to arrangement of transportation , policy further states, any appointments for outside consultation or visits to clinics shall be coordinated with Department of Social Services . Social services shall provide assistance with securing transportation for the scheduled appointments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary treatment and services for two of five sampled residents (Resident 3 and Resident 5) consistent with the residents' needs and professional standards of practice, by failing to:
-Ensure Resident 3 received wound treatment for right posterior hip unstageable (full-thickness skin and tissue loss in which actual depth of the ulcer is completely obscured by slough-yellow, tan, green or brown and/or eschar-tan, brown, or black, in the wound bed) pressure injury (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear-layers are laterally shifted in relation to each other, and or friction-surfaces sliding against each other).
-Ensure Resident 5 received wound treatment for coccyx (tailbone) Stage IV pressure injury (full thickness skin loss extended to muscle, tendon, or bone). These deficient practices had the potential for Resident 3 and Resident 5 to have further skin breakdown, to develop a new pressure injury, and possible infection.
Findings:
a. A review of Resident 3's admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including encephalopathy (a change in your brain function due to injury or disease), and Type II diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/25/2024, indicated Resident 3's cognitive skills for daily decision making (ability to think, remember and make decisions) was severely impaired (never/rarely made decisions). The MDS indicated Resident 3 required partial/moderate assistance for oral hygiene, toileting hygiene, upper and lower body dressing, showering/bathing, and personal hygiene. The MDS further indicated Resident 3 had one Stage II (skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) pressure injury, two unstageable pressure injuries, and two Stage III (full thickness ulcer that might involve the subcutaneous [under all layers of skin] fat) pressure injuries that were present upon admission.
A review of the Physician's Order Summary dated 8/7/2024, indicated to apply santyl external ointment (a topical medication used to remove damaged or burned skin) to right posterior hip topically (used on the outside of the body) every day shift for unstageable pressure injury for 21 days. The order further indicated to clean the wound with Normal Saline (NS-sterile salt solution), pat dry, apply Santyl and cover with foam dressing.
A review of Resident 3's Treatment Administration Record (TAR) for August 2024, indicated Santyl external ointment was not documented to be administered to Resident 3's right posterior hip pressure injury on 8/21 and 8/23/2024.
b. A review of Resident 5's admission Record indicated the facility originally admitted the resident on 8/16/2007, and readmitted on [DATE], with diagnoses including Type II diabetes mellitus and Stage IV pressure ulcer of sacral region (the portion of spine between lower back and tailbone).
A review of the MDS dated [DATE], indicated Resident 5's cognitive skills for daily decision making (ability to think, remember, and make decisions) was severely impaired (never/rarely made decisions). The MDS indicated Resident 5 was dependent for rolling left and right, oral hygiene, toileting hygiene, upper and lower body dressing, showering/bathing, and personal hygiene. The MDS further indicated Resident 5 had one Stage IV pressure injury that was present upon admission.
A review of Resident 5's Care Plan dated 5/28/2024, indicated the resident had a Stage IV pressure ulcer at her coccyx and had the potential for pressure ulcer development related to history of ulcers and immobility. The care plan goal was for the resident to show signs of healing and remain free from infection. The care plan interventions were to administer medications as ordered by the physician. Administer wound treatment as ordered by the physician. Monitor for effectiveness of the treatment, assess/monitor/record wound healing and healing process and to report improvements and declines to the physician.
A review of the Physician's Order Summary dated 8/11/2024, indicated to apply Medi honey external paste (gel made from honey for wound management) to both buttocks-coccyx area of Resident 5 topically every day shift, for pressure injury Stage IV for 21 days. Cleanse with Normal Saline (NS-sterile salt solution), pat dry, apply Medi honey and cover with bordered gauze.
A review of Resident 5's TAR for August 2024, indicated Medi honey external paste was not documented to be administered to Resident 5's buttocks-coccyx Stage IV pressure injury on 8/23, 8/26, 8/28, and 8/31/2024.
During a concurrent interview and record review on 9/12/2024 at 10:52 AM, with the facility's Treatment Nurse (TN), Resident 3 and Resident 5's TARs were reviewed. The TN stated staff did not document that they provided wound treatment for Resident 3's right posterior hip pressure injury on 8/21, and 8/23/2024. The TN stated, If it is not documented, it is not done. The TN stated staff did not document they provided wound treatment to Resident 5's coccyx Stage IV pressure injury on 8/23, 8/26, 8/28, and 8/31/2024. The TN further stated the potential outcome of not performing wound treatment for residents with pressure injuries as per physician order was worsening of the wound and infection.
During an interview on 9/12/2024 at 1:26 PM, with the Interim Director of Nursing (IDON), the IDON stated there were missing documentations for wound treatment in Resident 3 and Resident 5's TARs. The IDON stated there were occasions that nurses were performing the wound treatment, but they were forgetting to document it in the resident's medical record. The IDON stated, If the task is not documented then it is considered not done. Seems like Resident 3 did not receive wound care for his pressure injury on 8/21 or 8/23/2024. Resident 5 did not receive wound care for her coccyx Stage IV pressure injury on 8/23, 8/26, 8/28 or 8/31/2024. The IDON stated the potential outcome of not performing wound treatment as per physician order was worsening of the wound and infection.
A review of the facility policy and procedure titled, Wound Care, revised February 2024, indicated the purpose of this procedure was to provide guidelines for the care of wounds to promote healing. Verify that there was a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. Record the type of wound care given, the date and time the wound was given, the position in which the resident was placed, the name and title of the individual performing the wound care, the signature and title of the person recording the data.
A review of the facility policy and procedure titled, Charting and Documentation, revised February 2024, indicated all services provided to the resident, progress forward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The following information was to be documented in the residents medical records: treatment or services performed. Documentation of procedures and treatments will include care specific details including the date and time the procedure /treatment was provided and the name and title of the individual who provided the care.
A review of the facility policy and procedure titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised February 2024, indicated the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents.

Based on interview and record review, the facility failed to develop a complete baseline care plan for one of five sampled residents (Resident 3) within 48 hours of resident's admission.
This deficient practice had the potential for delayed administration of necessary care and services.
Findings:
A review of Resident 3's admission Record (Face Sheet) indicated the facility admitted the resident on 7/18/2024, with diagnoses including encephalopathy (a change in your brain function due to injury or disease) and type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).
A review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/25/2024, indicated the resident's cognitive skills for daily decision making (ability to think, remember, and make decisions) was severely impaired (never/rarely made decisions). The MDS indicated Resident 3 required partial/moderate assistance for oral hygiene, toileting hygiene, upper and lower body dressing, showering/bathing, and personal hygiene.
During a concurrent interview and record review on 9/12/2024 at 8:15 AM with Licensed Vocational Nurse (LVN) 1, Resident 3's baseline care plan was reviewed. LVN 1 stated staff initiated Resident 3's base line care plan on 7/19/2024. However, there were sections of the base line care plan that were not completed. LVN 1 further stated Resident 3's base line care plan for skin care and bowel/bladder needs, discharge goals, ethical/cultural preferences, nail care, equipment, meal location preference, and special treatments/procedures sections were not completed. LVN 1 stated licensed nurses were required to complete a resident's base line care plan thoroughly within 72 hours of the admission to the facility. LVN 1 stated the potential outcome of not completing the base line care plan thoroughly was the inability to meet Resident 3's immediate care needs.
During an interview on 9/12/2024 at 1:15 PM, the Interim Director of Nursing (IDON) stated a Resident 3's base line care plan was required to be completed within 48 hours of admission to the facility, and that Resident 3's base line care plan was not completed thoroughly as some parts were missing. The IDON further stated the potential outcome of not developing a complete base line care plan upon admission was the inability to meet resident's care needs and the inability to delivery necessary services to the resident.
A review of the facility's policy and procedure titled, Care Plans-Baseline, revised February 2024, indicated a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident. The baseline care plan was used until the staff conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan. The baseline care plan was updated as needed to meet the resident's needs until the comprehensive care plan was developed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure (P&P) of incident reporting for unusual occurrence for one of one sampled resident (Resident 1) by failing to report an unusual occurrence to the State Survey Agency and send a written report within 24 hours of Resident 1 ' s death.
This deficient practice resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place other residents during an COVID-19 (an infectious disease that can cause respiratory illness in humans) outbreak.
Findings:
During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and hypertension (HTN - elevated blood pressure).
During a review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated [DATE], indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were mildly impaired.
During a review of facility ' s COVID-19 Outbreak Notification Letter and Health Officer Order (HOO) sent by the Los Angeles County Department of Public Health (LACDPH), dated [DATE] indicated, A COVID-19 outbreak is a reportable situation that requires investigation and follow-up as specified by the Acute Communicable Disease Control Program.
During a review of Resident 1 ' s Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations), dated [DATE] indicated, (Resident 1) tested COVID-19 positive.
A review of Resident 1 ' s Nurse ' s Note indicated the following:
i. Dated [DATE] at 7:11 a.m., (Resident 1) monitored throughout the night shift, (at) 2 a.m., Resident (1) appeared comfortable, noted with rise/fall of chest, oxygen saturation (02 sat) 96 – 97 percent (% - unit of measurement). No shortness of breath (SOB) observed, no distress . At 5:15 a.m., CAN noted patient having difficulties breathing, vital sign (V/S) checked and observed . Called 911 (a phone number used to contact the emergency services), resident (1) was non-responsive but was noted with [NAME]-stroke breath (a breathing disorder that involves a pattern of breathing that alternates between deep breathing and shallow breathing, or apnea) pattern. 911 took over and resident expired at 5:45 a.m.
ii. dated [DATE] at 7:47 a.m., indicated, Patient (Resident 1) expired at 5:45 a.m., Nurse Practitioner 1 (NP 1) notified, Los Angeles Police Department (LAPD) came at 7:20 a.m.
During an interview with Registered Nurse 1 (RN 1) on [DATE] at 3:07 p.m., RN 1 stated, Resident 1 was alert and oriented and did not show any respiratory distress on [DATE]. RN 1 stated, the day before she passed, Resident 1 asked when she can come back to her previous room and she explained their protocol that because she tested positive for COVID-19, they need to temporarily place her to a different room until the isolation period is complete. RN 1 stated, she was surprised the next morning that Resident 1 passed away because she did not show any impending death.
During an interview with Licensed Vocational Nurse 1 (LVN 1) on [DATE] at 3:54 p.m., LVN 1 stated, on [DATE] at around 10:30 p.m., Resident 1 did not show any respiratory distress or any signs of impending death. LVN 1 stated, Resident 1 was alert and oriented and vitals signs were within normal limit.
During a review of the facility ' s P&P titled, Unusual Occurrence Reporting, revised on 6/2024 indicated, as required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Our facility will report the following events to appropriate agencies: an outbreak of any communicable disease; death of a resident, employee or visitor because of unnatural causes (example: suicide, homicide, accidents, etc.) Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within 24 hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency within 48 hours of reporting the event or as required by federal and state regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to:
a. Ensure the physician ' s order for transmission-based precaution are implemented for three of five sampled residents (Resident 4, Resident 5, and Resident 6) who tested positive for coronavirus (COVID-19 - an infectious disease that can cause respiratory illness in humans).
b. Ensure the Dietary Staff 1 (DS 1) wear fit-tested for National Institute for Occupational Safety and Health (NIOSH - federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness) approved N95 or higher-level respiratory protection (mask that protect used by filtering out contaminants in the air) in the facility.
These deficient practices had the potential to transmit infectious diseases and increase the risk of infection to the residents, staff, and visitors.
Findings:
1a. A review of Resident 4 ' s admission Record indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra) and unspecified asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing).
A review of Resident 4 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated 7/14/2024, indicated Resident 3's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were moderately impaired. The MDS indicated Resident 4 required maximal assistance from staffs for activities of daily living (ADL – toileting hygiene, shower/bathe self, lower body dressing and toilet transfer).
A review of Resident 4 ' s Physician ' s Order Summary Report (POSR), dated 8/7/2024 indicated, droplet isolation precaution (separation of an infected individual from the healthy until that individual is no longer able to transmit the disease) times (x) 10 days.
A review of Resident 4 ' s Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations), dated 8/7/2024 indicated, Resident (3) tested positive for COVID-19.
A review of Resident 4 ' s Care plan for COVID-19, initiated on 8/8/2024, indicated an intervention that included droplet isolation precaution.
1b. A review of Resident 5 ' s admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including Cerebrovascular disease (CVA - also known as stroke-when a blood flow to a part of your brain is stopped either by a blockage or rupture of a blood vessel), epileptic seizures (a disorder in which nerve cell activity in the brain is disturbed causing seizures) related to external causes.
A record review of Resident 5 ' s MDS dated [DATE], indicated Resident 5's cognitive for daily decision-making were intact. The MDS indicated Resident 6 required moderate from staffs for ADL – oral hygiene, toileting, and upper and lower body dressing and personal hygiene.
A review of Resident 5 ' s POSR, dated 8/7/2024 indicated, droplet isolation precaution x10 days.
A review of Resident 5 ' s SBAR, dated 8/7/2024 indicated, Resident (4) tested positive for COVID-19.
1c. A review of Resident 6 ' s admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including DM and pulmonary embolism (a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung).
A review of Resident 6 ' s MDS dated [DATE], indicated Resident 6's cognitive for daily decision-making were intact.
A review of Resident 6 ' s Physician ' s Order Summary, dated 8/7/2024 indicated, droplet isolation precaution x10 days.
A review of Resident 6 ' s SBAR dated 8/7/2024 indicated, Resident (6) tested positive of COVID-19.
A review of Resident 6 ' s Care plan for COVID-19 was initiated on 8/8/2024.
During a concurrent observation and interview with Registered Nurse 1 (RN 1) on 8/14/2024 at 11:16 a.m., observed Resident 4, Resident 5 and Resident 6 ' s room with no signage outside the door what type of transmission-based precaution the residents are on. RN 1 stated, Resident 4, Resident 5 and Resident 6 all tested positive for COVID-19 and should be placed under droplet isolation precaution per physician ' s order. RN 1 stated residents who tested positive for COVID-19 should have signages outside the door that indicates the type of transmission based precaution they have so that the staff and visitors know the precautions needed before entering residents ' room.
During a review of the facility ' s policy and procedure (P&P) titled, Coronavirus Disease (Covid-19) – Infection Prevention and Control Measures, revised 1/2023 indicated, signage on the use of specific PPE (for staff) is posted in appropriate locations in the facility (example: outside of a resident ' s room, wing, or facility-wide).
2. A review of facility ' s COVID-19 Outbreak Notification Letter and Health Officer Order (HOO) sent by the Los Angeles County Department of Public Health (LACDPH), dated 8/5/2024 indicated, A COVID-19 outbreak is a reportable situation that requires investigation and follow-up as specified by the Acute Communicable Disease Control Program.
During an observation of DS 1 on 8/14/2024 at 10:48 a.m., DS 1 was observed wearing a KN95 mask (a type of particulate mask not approved in the United States for healthcare use). DS 1 was observed walking along the hallway of the facility and was delivery cart trays to the residents.
During an interview with Dietary Supervisor (DS) on 8/14/2024 at 11:47 a.m., DS stated, all staff in the kitchen must wear an N95 respirator because the facility is in current COVID-19 outbreak.
During an interview with DS 1 on 8/14/2024 at 12:30 p.m., DS 1 stated, he was not fit-tested for the KN95 that he was currently wearing and should be wearing the N95 respirator that he was fit tested for. DS 1 was then observed removing the KN95 from his face and took out an N95 respirator from his pocket.
During an interview with RN 1 on 8/14/2024 at 12:41 p.m., RN 1 stated, they are currently in outbreak and all staff must wear N95 respirators in which they were fit tested for.
During a review of the facility ' s P&P titled, Coronavirus Disease (COVID-19) – Source Control, revised 6/2024 indicated, source control measures are utilized as part of the infection prevention and control measures during the COVID-19 pandemic. Source control options for staff include: a NIOSH-approved particulate respiratory with N95 filters or higher . When SARS-CoV-2 community transmission levels are high, source control is used by all staff and visitors in the facility when they are in areas of the facility where they could encounter residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents, (Resident 1) ' s clinical record was updated per facility ' s policy and procedure by failing to ensure resident's clinical records were updated regarding Physician Orders for Life-Sustaining Treatment (POLST - is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency).
This deficient practice violated resident ' s and/or representatives ' right to be fully informed of the option to formulate advance directive and POLST and had the potential to cause conflict with resident's wishes regarding health care.
Findings:
During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and hypertension (HTN - elevated blood pressure).
During a review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated [DATE], indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were mildly impaired. The same MDS also indicated, Resident 1 ' s POLST was in the chart and was not completed.
A review of Resident 1 ' s Nurse ' s Note indicated the following:
i. Dated [DATE] at 6:51 a.m., found patient (Resident 1) hypoxic (An absence of enough oxygen in the tissues to sustain bodily functions) and unresponsive at 5:15 a.m., with oxygen saturation (o2 sat) 87 percent (% -unit of measurement) . cardiopulmonary resuscitation (CPR – this can help save a life during cardiac arrest, when the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs) done.
During a concurrent interview and record review of Resident 1 ' s POLST with Registered Nurse 1 (RN 1) on [DATE] at 3:10 p.m., RN 1 reviewed Resident 1 ' s POLST with surveyor. RN 1 stated and confirmed, Resident 1 ' s POLST was not complete as it was not signed by the physician. RN 1 stated, the POLST should be signed by the physician as without physician ' s signature, they won ' t know if the POLST form is correct and accurate.
During a review of the facility ' s policy and procedure (P&P) titled, Advanced Directive/POLST, undated, indicated, It is the policy of this facility to assure that all residents have the right to a dignified existence and self-determination. The Social Service Department, in conjunction with nursing, will assure that each resident ' s desires regarding having CPR or no CPR are addressed and documented . The resident ' s physician will also sign the POLST and write an order in the Physician ' s Orders the code status of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for three of five sampled residents (Resident 1, Resident 2, and Resident 4) by failing to ensure that a comprehensive (CP) was implemented for refusals of vaccinations (a medical treatment that helps body's immune system to recognize and fight disease).
This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received.
Findings:
1. During a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and hypertension (HTN - elevated blood pressure).
During a review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and screening tool), dated 5/24/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were mildly impaired.
During a review of Resident 1's Vaccine Informed Consent, the record indicated Resident 1 refused (declined) coronavirus (COVID-19 - an infectious disease that can cause respiratory illness in humans) vaccine, pneumonia (PNA-infection that inflames air sacs in one or both lungs and can be life-threatening to anyone but particularly to infants, children, and people over [AGE] years old) vaccine, and influenza (flu shots, are vaccines that protect against infection by influenza viruses) vaccine dated 10/27/2023. Additionally, Resident 1 also refused COVID-19 vaccines on 10/30/2022 and 6/6/2024.
During a review of Resident 1 ' s CP as of 8/14/2024 indicated, there was no CP initiated and developed regarding Resident 1 ' s refusal of COVID-19, PNA and influenza vaccines.
2. A review of Resident 2 ' s admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type two diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]) and osteomyelitis (inflammation or swelling that occurs in the bone).
During a review of Resident 2 ' s MDS dated [DATE], indicated Resident 2's cognitive skill for daily decision-making were intact.
During a review of Resident 2's Vaccine Informed Consent, the record indicated Resident 2 refused (declined) COVID-19 vaccine dated 3/5/2024.
During a review of Resident 2 ' s CP as of 8/14/2024 indicated, there was no CP initiated and developed regarding Resident 1 ' s refusal of COVID-19 vaccine.
3. During a review of Resident 4 ' s admission Record indicated Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra) and unspecified asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing).
During a review of Resident 4 ' s MDS dated [DATE], indicated Resident 3's cognitive skill for daily decision-making were moderately impaired.
During a review of Resident 4's Vaccine Informed Consent, the record indicated Resident 4 refused (declined) COVID-19 vaccine, PNA vaccine and influenza vaccine dated 10/27/2023.
During a review of Resident 4 ' s CP as of 8/14/2024 indicated, there was no CP initiated and developed regarding Resident 4 ' s refusal of COVID-19 vaccine, PNA vaccine and influenza vaccines.
During a concurrent record review and interview with Registered Nurse 1 (RN 1) on 8/14/2024 at 3:07 p.m., RN 1 reviewed Resident 1, Resident 2, and Resident 4 ' s vaccine records, consents, and CP with the surveyor. RN 1 stated and confirmed, there were no CP initiated and developed regarding Resident 1, Resident 2, and Resident 4 ' s refusals of vaccinations. RN 1 stated, a CP should be developed so that the licensed nurses know that plan of care and signs and symptoms of diseases that residents are more prone to for refusing vaccines.
During a review of the facility ' s policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 6/2024 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to ensure one of five sampled residents (Resident 8) was free from significant medication error by failing to ensure the Ativan (lorazepam – used to relieve anxiety) 0.5 milligram (mg-unit of measurement) one tablet by mouth every 12 hours as needed for anxiety was not administered after 14 days ([DATE]) when the order expired.
This deficient practice has the potential to result in Resident 8 in unintended complications related to the management of medication.
Findings:
A review of Resident 8 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses including major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one ' s daily activities), and Alzheimer ' s disease (a progressing brain disorder that destroys memory and other important mental function).
A review of Resident 8 ' s Minimum Data Set (MDS-standardized assessment and screening tool), dated [DATE], indicated resident had severely impaired cognition (ability to think and make decisions).
A review of Resident 8 ' s Order Summary Report (OSR) dated [DATE], indicated physician ordered Ativan 0.5 milligram (mg-unit of measurement) give one tablet by mouth every 12 hours as needed for anxiety for 14 days.
A review of Resident 8 ' s Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) for Ativan 0.5 mg indicated the medication was removed from the narcotic storage on the following days:
i. [DATE] at 10 a.m.,
ii. [DATE] at 10 a.m.,
iii. [DATE] at 9 p.m.,
iv. [DATE] at 9 a.m.
During a concurrent interview and record review on [DATE] at 1:16 p.m., Licensed Vocational Nurse (LVN 2) stated she administered Ativan to Resident 8 on [DATE] at 9 a.m.
A review of Resident 8 ' s Medication Administration Record (MAR) with LVN 2 indicated, there was no MAR for Ativan 0.5 mg. LVN 2 stated, the order for Ativan on [DATE] was only for 14 days and she did not notice that the Ativan order had expired and is no longer active. LVN 2 further stated, she did not look at the physician's order and she did not document in the MAR after administering Ativan to Resident 8.
During an interview on [DATE] at 4:34 p.m., the Director of Nursing (DON) stated there had be an active order by the physician for medications. The DON stated staff had to check the five rights of medication administration (right patient, the right drug, the right time, the right dose, and the right route) and physician ' s order before administering medications. The DON stated not verifying a physician ' s order could put residents at risk of adverse effects (negative) of medications.
A review of the facility ' s policy and procedure (P&P) titled Administering Medications revised 6/2024, indicated the individual administering medications checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication . The individual administering the medication initials the resident ' s MAR on the appropriate line after giving each medication and before administering the next ones.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for four of five sampled residents (Resident 7, 9, 11 and 13).
This deficient practice had the potential to result in medication errors and/or drug diversion (illegal distribution or abuse of prescription drugs).
Findings:
A review of Resident 7 ' s admission Record indicated the facility originally admitted the resident on 5/9/2024 and readmitted on [DATE] with diagnoses including cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety or fear that are strong enough to interfere with one ' s daily activities), and type two diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 7 ' s Minimum Data Set (MDS-standardized assessment and screening tool) dated 7/9/2024, indicated resident had intact cognition (ability to think and make decisions).
A review of Resident 7 ' s Order Summary Report (OSR) dated 7/3/2024, indicated an order for hydrocodone-acetaminophen (Norco – used to relieve moderate to severe pain) 10-325 (mg-unit of measurement) one tablet by mouth every four hours as needed for moderate to severe pain.
A review of Resident 7 ' s Medication Administration Record (MAR), dated 8/1/2024, indicated Norco was administered and given to Resident 7 at 9 a.m. on 8/1/2024.
A review of Resident 7 ' s CDR for Norco HCL 10-325 mg, give one tablet by mouth every four hours, indicated the medication was not removed from the narcotic storage on 8/1/2024 at 9 a.m.
During a concurrent interview and record review with Licensed Vocational Nurse (LVN 2) on 8/1/2024 at 12:54 p.m., LVN 2 stated she administered Resident 7 ' s Norco that morning (8/1/2024) but forgot to sign the Norco out on the CDR. LVN 2 was then observed signing the CDR in front of the surveyor. LVN 2 stated the Norco had to be signed out and counted at the time of administration, so that it would reflect the correct narcotic count.
A review of Resident 9 ' s admission Record indicated the facility originally admitted the resident on 5/23/2023 and readmitted on [DATE] with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), cognitive social or emotional deficit following cerebral infarction (impairment of different domains of cognition).
A review of Resident 9 ' s MDS dated [DATE], indicated resident had moderately impaired cognition.
A review of Resident 9 ' s OSR dated 7/3/2024, indicated an order for Ativan (lorazepam – used to relieve anxiety) oral tablet 0.5 mg –1/2 tablet two times a day for anxiety.
A review of Resident 9 ' s MAR, dated 8/1/2024, indicated Ativan was administered and given to Resident 9 at 9 a.m. on 8/1/2024.
A review of Resident 9 ' s CDR for Ativan 0.5 mg, indicated the medication was not removed from the narcotic storage on 8/1/2024 at 9 a.m.
During a concurrent interview and record review with LVN 2 on 8/1/2024 at 1 p.m., LVN 2 stated she administered Resident 7 ' s Ativan that morning (8/1/2024) but forgot to sign the Ativan out on the CDR. LVN 2 was then observed signing the CDR in front of the surveyor. LVN 2 stated the Ativan had to be signed out and counted at the time of administration, so that it would reflect the correct narcotic count.
A review of Resident 11 ' s admission Record indicated the facility originally admitted the resident on 6/12/2012 and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side, neuralgia and neuritis (are nerve conditions that often result in pain, numbness, and tingling sensations) and DM.
A review of Resident 11 ' s MDS dated [DATE], indicated resident had severely impaired cognition.
A review of Resident 11 ' s OSR dated 7/3/2024, indicated an order for Lyrica capsule 50 mg (Pregabalin – can treat nerve and muscle pain) –50 mg by mouth three times a day.
A review of Resident 11 ' s MAR, dated 8/1/2024, indicated Lyrica was administered and given to Resident 11 at 9 a.m. and 1 p.m. on 8/1/2024.
A review of Resident 11 ' s CDR for Lyrica 50 mg, indicated the Lyrica doses for 9 a.m. and 1 p.m. were not removed from the narcotic storage on 8/1/2024 at 9 a.m. and 1 p.m.
During a concurrent interview and record review on 8/1/2024 at 1:56 p.m., LVN 3 stated she administered Resident 9 ' s Lyrica on 8/1/2024 at 9 a.m. and at 1 p.m. but forgot to sign the Lyrica out on the CDR because LVN 3 was in a rush.
A review of Resident 13 ' s admission Record indicated the facility admitted the resident on 11/8/2022 with diagnoses including cerebral infarction, encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), and anxiety disorder.
A review of Resident 13 ' s MDS dated [DATE], indicated resident had intact cognition.
A review of Resident 13 ' s OSR dated 7/3/2024, indicated a physician order for Ativan 1 mg – give 1 tablet by mouth every 12 hours as needed for anxiety.
A review of Resident 13 ' s MAR, dated 8/1/2024, indicated Ativan was administered and given to Resident 13 at 9 a.m. on 8/1/2024.
A review of Resident 13 ' s CDR for Ativan 1 mg, indicated the Ativan was not removed from the narcotic storage on 8/1/2024 at 9 a.m.
During a concurrent interview and record review on 8/1/2024 at 1:59 p.m., LVN 3 stated she administered Resident 13 ' s Ativan on 8/1/2024 at 9 a.m. but forgot to sign the Ativan out on the CDR because LVN 3 was in a rush.
During an interview on 8/2/2024 at 4:34 p.m., the Director of Nursing (DON) stated medication administration had to be documented at the time of administration and the narcotics had to be counted and documented on the CDR at the time of removing the narcotics from the narcotic storage.
A review of the facility ' s policy and procedure (P&P) titled, Administering Medications revised 6/2024, indicated the individual administering the medication was to initial the resident ' s MAR on the appropriate records in the resident ' s medical record with the date and time the medication was administered.
A review of the facility ' s P&P titled Controlled Drugs undated, indicated the nurse had to enter the following information on the narcotic drug record immediately after a dose of a controlled drug is administered: date and time of administration, dose administered, signature of the nurse that administered the dose.

Based on observation, interview and record review, the facility failed to ensure the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift were accurate for two of two sampled days (8/1/2024 and 8/2/2024).
This deficient practice resulted in incorrect actual hours staffing information and had the potential to cause inadequate staffing.
Findings:
During an observation of the facility on 8/1/2024 at 10:44 a.m., Direct Care Services Hours Per Patient Day (DHPPD) were observed posted on a wall indicating actual PPD hours of 3.58 in the DHPPD posting. The DHPPD included the information of total staff and starting census for 7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift and 11 p.m. to 7 a.m. shift.
During an observation of the facility on 8/2/2024 at 10:43 a.m., observed Direct Care Services Hours Per Patient Day (DHPPD) posted on the wall with an actual PPD hours of 3.61 indicated in the DHPPD posting. The DHPPD included the information of total staff and starting total census for 7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift and 11 p.m. to 7 a.m. shift.
During an interview with Director of Staff and Development (DSD) on 8/2/2024 at 3:37 p.m., DSD stated, the DHPPD was posted daily in the morning with the number of staff assigned to work that day and the actual hours included in the posting. DSD stated the posting was for the projected hours. When asked if the actual number of staff working was calculated within two hours of the beginning of each shift, DSD stated, no, only the projection hours are calculated and posted. DSD stated the actual hours were not accurate.
During an interview on 8/2/2024 at 4:45 p.m., the Director of Nursing (DON) stated the DHPPD hours posted on the wall was inaccurate. The DON stated the actual number of staff and total census had to be calculated and added within two hours of the beginning of each shift, so that the correct hours were reflected on the posting.
A review of the facility ' s policy and procedure (P&P) titled Posting Direct Care Daily Staffing Numbers revised on 6/2024 indicated, within two hours of the beginning of each shift, the charge nurse or designee computes the number of direct staff and completes the Nurse Staffing Information form. The charge nurse completes the form and posts the staffing information in the location(s) designated by the administrator.

Based on observation, interview, and record review, the facility failed to honor the rights of one of 32 (Resident 58) sampled residents shower preferences.
This deficient practice resulted in Resident 58 feeling dirty and uncomfortable.
Findings:
A review of Resident 58's admission Record indicated the facility admitted Resident 58 on 6/7/2020 and readmitted the resident on 4/19/2023 with diagnoses that included acute kidney failure (condition in which one's kidney's suddenly stop working), diabetes (high blood sugar), and heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen).
A review of Resident 58's History and physical, dated 4/21/2023 indicated Resident 58 had the capacity to understand and make decisions.
A review of Resident 58's quarterly Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/18/2024, indicated Resident 58 was cognitively intact (ability to acquire and understand knowledge). The MDS indicated Resident 58 was dependent upon staff for bathing, and shower. The MDS also indicated Resident 58 had not rejected care.
During a concurrent interview and observation on 5/20/2024 at 11:05 AM, Resident 58 was observed in bed with the head of bed elevated into a sitting position. Resident 58's hair appeared oily. Resident 58 stated she had not received a shower in two months. Resident 58 stated today (a Monday) the certified nursing assistant (CNA) gave the resident a bed bath after asking and Resident 58 agreed to have a shower. Resident 58 stated she did not know why she hadn't received a shower. Resident 58 stated My hair is not clean, and worse it makes me itch and I have to scratch.
During an interview on 5/21/2024 at 1:19 PM, Certified Nursing Assistant 2 (CNA 2) at first stated Resident 58 received a bed bath and CNA 2 washed Resident 58's hair the day prior (5/20/2024). Upon further questioning, CNA 2 confirmed by stating she did not wash Resident 58's hair. CNA 2 stated she did not give Resident 58 a shower because there was no one to help transfer the resident with the Hoyer lift (an assistive device that allows patients in hospitals and nursing homes and people receiving home health care to be transferred between a bed and a chair or other similar resting places). CNA 2 stated she did not ask for anyone to assist in transferring Resident 58 with a Hoyer lift. CNA 2 was unaware of how long it had been since Resident 58 last received a shower. CNA 2 stated, I would feel bad if I had not received a shower in two months.
During an interview on 5/22/2024 at 1:57 PM, the Director of Nursing (DON) stated residents had to be showered unless the resident had a medical condition that prevented a shower.
A review of the facility's policy and procedure titled, Resident Rights, reviewed 9/2023, indicated Employees shall treat all residents with kindness, respect, and dignity. 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:
a. A dignified existence.
b. Be treated with respect, kindness, and dignity.
c. Be free from abuse, neglect, misappropriation of property, and exploitation.
d. Be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms.
e. Self-determination;.
A review of the facility's P&P titled, Dignity, reviewed 9/2023, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated when assisting with care, residents are supported in exercising their rights. For example, residents are:
a. Groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).
b. Encouraged to attend the activities of their choice, including religious, political, civic, recreational, or social activities.
c. Encouraged to dress in clothing that they prefer.
d. Allowed to choose when to sleep, eat and conduct activities of daily living; and
e. Provided with a dignified dining experience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to schedule the urology (medical conditions of the urinary tract) and gastroenterology (all the organs in the digestive system, including the GI tract (esophagus, stomach, and intestines) and biliary organs (your liver, bile ducts, pancreas and gallbladder) consults as ordered by the physician on 5/10/2024, for one of four sampled residents (Resident 99) in a timely manner.
As a result, as of 5/22/2024 Resident 99's appointments had still not been scheduled. This deficient practice placed the resident at risk for worsening of symptoms, infections, organ failure, and death.
Findings:
A review of Resident 99's admission record indicated Resident 99 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder and benign prostatic hyperplasia (BPH - condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream) and diverticulitis (small bulging sacs or pouches that form on the inner wall of the intestine) of the large intestine with perforation (a hole that develops through the wall of a body organ) and abscess (a collection of pus that has built up within the tissue of the body).
A review of Resident 99's undated History and Physical (H&P), indicated Resident 99 had the capacity to understand and make decisions.
A review of Resident 99's quarterly Minimum Data Set (MDS- a standardized assessment and screening tool) dated 3/13/2024 indicated Resident 99 was cognitively (ability to think, read, learn, remember, reason, express thoughts, and make decisions) intact. The MDS indicated Resident 99 was dependent upon staff for toileting hygiene, lower body dressing and personal hygiene. The MDS indicated Resident 99 had an indwelling catheter (a catheter that's inserted into the bladder through the urethra or stomach wall and left in place to drain urine).
A review of Resident 99's physician order, dated 4/12/2024, indicated Resident 99 was to receive a urology (medical doctor that specializes in diseases and medical conditions of the urinary tract) consult for his neurogenic bladder (a urinary tract condition that prevents the bladder from emptying properly due to a neurological issue or spinal cord injury).
A review of Resident 99's physician order dated 5/10/2024, indicated Resident 99 was to receive a urology and gastroenterology consult.
A review of Resident 99's progress note dated 5/11/2024, indicated Resident 99's primary physician was in the facility and gave a new order for a urology and a gastroenterology consult. The progress note indicated (night shift) staff communicated with the morning shift to follow up for appointment on Monday (5/13/2024) due to clinic being closed on Saturday (5/11/2024).
A further review of Resident 99's progress notes between 5/11/2024 and 5/22/2024 indicated the urology and gastroenterology consults were not followed up on.
A review of Resident 99's progress note dated 5/22/2024, indicated staff contacted the urologist.
During an interview on 5/20/2024 at 10:39 AM, Resident 99 stated the resident has been waiting for over a month for a consult appointment. Resident 99 stated he required surgery prior to being discharged from the facility and has been waiting for over a month for a consult appointment.
During an interview on 5/21/2024 at 1:12 PM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 99 required certain doctor's appointments prior to leaving the facility. LVN 1 further stated the facility was still working on the resident's doctor's appointments.
During an interview on 5/22/2024 at 9:01 AM, LVN 2 stated Resident 99 required a urology and gastroenterology (GI) appointment which had not yet been scheduled. LVN 2 stated she was aware the appointment needed to be made on 5/8/24. LVN 2 stated 13 days was way to long to wait to make an appointment. LVN 2 stated Resident 99 was at risk for suffering a change in condition due to the appointment not being made.
During an interview on 5/23/2024 at 1:41 PM, with the Director of Nursing (DON), the DON stated resident appointments were required to be made by facility staff within 24 hours of the written order. The DON stated a delay in scheduling the appointment could adversely (negatively) affect the health of the resident.
A review of the facility's policy and procedure (P&P) titled Referrals, Social Services, reviewed 9/2023, indicated Referrals for medical services must be based on physician evaluation of resident need and a related physician order. The P&P also indicated social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.

Based on observation, interview, and record review the facility failed to store and label food in accordance with professional standards and the facility's policy and procedure (P&P) titled Labeling and Dating of Foods reviewed 9/202 by failing to label food with the open date (date indicating packaging opened; used to determine amount of time food can be safely consumed).
This deficient practice placed all 127 facility residents at risk for foodborne illnesses.
Findings:
During a concurrent observation and interview of the facility kitchen on 5/20/2024 at 8:40 AM, the following were observed:
1. A box containing 13 potatoes with no label or date in the dry storage section of the kitchen.
2. One opened and two unopened packages of frozen breaded fish with no label or open date in freezer 1.
3. One opened bottle of creamer with no label or open date in refrigerator
The Dietary Supervisor (DS) confirmed the box of potatoes, frozen breaded fish, and creamer were all unlabeled and undated. The DS stated food had to be dated and labeled with a received by, use by, and open date. The DS stated food labeling was done to prevent food borne illness.
During an interview on 5/23/2024 at 1:40 PM, the Director of Nurses (DON) stated all food stored in the kitchen had to be labeled and dated. The DON stated food labeling was done to ensure kitchen staff knew which foods were safe for the residents to eat and to prevent food poisoning and food borne illness.
A review of the facility's P&P titled Food Receiving and Storage reviewed 9/2023, indicated Food shall be received and stored in a manner that complies with safe food handling practices .Dry foods that are stored in bins are removed from original packaging, labeled, and dated (use by date). Such food is rotated using a First in-first out system .All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date) .Refrigerated foods are labeled, dated, and monitored so that are used by their use-by date, frozen, or discarded .Beverages are dated when opened and discarded after twenty-four (24) hours. Other opened containers are dated and sealed or covered during storage.
A review of the facility's P&P titled Labeling and Dating of Foods reviewed 9/2023, indicated All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Food delivered to the facility needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the delivery date for the product. Newly opened items will need to be closed and labeled with an open date and used by date that follow the various storage guidelines with this section- specifically the Dry Goods Storage Guidelines (page 6.9), Refrigerated Storage Guidelines (page 6.16), Produce Storage Guidelines (page 6.18), and Freezer Storage Guidelines (page 6.20).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to manage pain on the hands, legs, and stomach for one of three sampled residents (Resident 436) by failing to:
1. Address the Resident 436's request for adequate pain management,
2. Evaluate the effectiveness of the resident's pain medication,
3. Notify the resident's physician that pain management intervention was unsuccessful and for consultation.
This failure resulted in Resident 436's to continue experiencing severe, unrelieved and uncontrolled pain from 5/11/2024 to 5/22/2024. Resident was unable to walk due to leg pain, felt her pain was stressful, could not perform usual activities (decline in performing daily activities).
Findings:
During a concurrent observation and interview on 5/20/2024 at 10 AM, Resident 436 was lying in bed, with facial grimacing, and taking long and deep breaths. Resident 436 stated, I need pain medication, it takes hours to get my pain medications, my legs and arms hurt. The resident stated pain medication delays were reported to the head staff but was unable to recall any staff names.
During an interview on 5/21/2024 at 11:29 AM with Resident 436, the resident stated feeling pain on both hands, legs, and abdomen. Resident 436 stated he was unable to walk as usual because of the leg pains and the pain was stressful.
During an interview on 5/21/2024 at 11:35 AM with Licensed Vocational Nurse (LVN) 6, LVN 6 stated, Resident 436 had pain medication (oxycodone-acetaminophen, a controlled pain medication that treats moderate to severe pain) ordered every six hours, but resident asks for medication at least every two to three hours. LVN 6 stated, the resident's pain was not controlled but the resident's uncontrolled pain had not been reported to a physician nor had been discussed with interdisciplinary team (IDT, a team of professionals from different fields).
During an interview on 5/21/2023 at 12:20 PM with Certified Nursing Assistant (CNA) 6, CNA 6 stated, staff assisted Resident 436 with activities of daily living. CNA 6 stated Resident 436 liked to get up, but the resident complains of pain and did not do much activity.
During a concurrent observation and interview on 5/22/2024 at 9:57 AM, with Resident 436, Resident 436 was in bed, grimacing, asking for pain medication. The resident stated, I am in a lot of pain on my hands and legs, my legs are numbed, I cannot walk, my stomach hurts. I am just waiting for my pain medications.
During an interview on 5/22/2024 at 10 AM with LVN 3, LVN 3 stated Resident 436 asked for more pain medication at least once or twice a day. LVN 3 stated the resident could decline psychosocially (mind and behavior) and decline from participating with activities if pain was not managed.
During an interview on 5/22/2024 at 10:30 AM with LVN 3, LVN 3 stated Resident 436's physician was called and updated on the resident's pain status.
During an interview on 5/23/2024 at 8:30 AM with Resident 436, the resident stated, I am still in pain on my legs, it is affecting my mobility, I like to walk with my walker but unable to do it more than a couple of steps because of the pain.
During a concurrent interview and record review on 5/23/2024 at 8:35 AM with LVN 3 at Resident 436's room, Resident 436's Pain Assessment Flowsheet dated from 5/12/2024 to 5/20/20224 and Medication Administration Record (MAR) dated May 1 to May 31, 2024 were reviewed. The MAR indicated when oxycodone-acetaminophen 5-325 milligrams (mg, a unit of measure) one tablet by mouth was administered, the resident's pain was 8 out of 10 (a numeric pain scale with zero meaning no pain and 10 meaning the worst pain imaginable) from 5/11/2024 to 5/15/2024, on 5/17/2024, from 5/19 to 5/22/2024, and 7 out of 10 on 5/16/2024 and 5/18/2024. LVN 3 stated Resident 436 was given pain medication on an average of two or three times a day out of the four times maximum allowed for her pain medication order (oxycodone-acetaminophen).
During a concurrent interview and record review on 5/23/2024 at 8:55 AM with LVN 7, Resident 436's Pain Assessment Flow Sheet for the month of May 2024 was reviewed. The record indicated the pre (prior) pain medication administration assessment was a pain rating of 8 out of 10 on the pain scale. LVN 7 stated, the resident was not getting adequate pain medication. LVN 7 stated there was no prior pain management reported to the resident's physician, and no pain consultation was initiated. LVN 7 stated the resident was likely to decline if the pain was not managed.
During an interview on 5/23/2024 at 1:15 PM with the Director of Nursing (DON), the DON stated, the licensed staff was expected to notify residents' changes in condition to the charge nurses and physicians. The DON stated Resident 436 was likely to decline physically and psychosocially if pain was not controlled.
During a telephone interview on 5/23/2024 at 3 PM with Resident 436's physician (MD, medical doctor)1, MD 1 stated, Resident is drug seeking, has neuropathic pain (a condition that affects the nerves in the body). MD 1 stated the facility staff did not notify him of the resident's pain status until the morning of 5/22/2024. MD 1 stated, the resident can benefit from better pain management.
During a review of Resident 436's admission Record, indicated the resident was admitted to the facility on [DATE] with diagnoses that included but not limited to unspecified cirrhosis (a disease condition that scars and damages liver), anxiety disorder, and abnormalities of gait and mobility.
During a review of Resident 436's physician's order dated 5/9/2024, indicated the following orders:
1. Oxycodone-acetaminophen oral tablet 5-325 mg give one tablet by mouth every six hours as needed for severe pain for 3 months using pain rating scale 7-10.
2. Acetaminophen oral tablet (a medication that treats minor pain and lowers fever), give 650 mg every four hours as needed for mild pain, using pain rating scale 1-3.
During a review of Resident 436's Baseline Care Plans, dated 5/9/2024 indicated, the resident was alert and oriented.
During a review of Resident 436's History and Physical (H&P) dated 5/10/2024 indicated the resident had the capacity to make and understand decisions.
During a review of Resident 436's Care Plan, dated 5/22/2024 indicated the resident was at risk for acute (sudden) or chronic (persisting for a long time) pain related to disease process with interventions including to monitor, record, report to nurse resident's complaints of pain or requests for pain treatment; and notify the resident's physician if interventions were unsuccessful or if current complaint was a significant change from resident's experience of pain.
During a review of the facility's policy and procedure titled Change in a Resident's Condition and Status dated September 2023, indicated, the nurse will notify the resident's attending physician or physician on call except in medical emergencies, notifications will be made within twenty-four (24) hours of change occurring in the resident's medical/mental condition or status.
During a review of the facility's policy and procedure titled Pain-Clinical Protocol, dated September 2023, indicated, the staff will evaluate and report the resident/patient's use of standing and PRN (when necessary or as needed) analgesics (a medication to relieve pain) .If the resident's pain is complex or not responding to standard interventions, the attending physician may consider additional consultative support .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide one to one (1:1) feeding assistance as indicated in the care plan one of three residents (Resident 62) when:
Restorative Nursing Assistant (RNA) 1 and (RNA) 2 (staff who provides care to help to restore and maintain function) did not provide 1:1 feeding assistance to Resident 62 during lunch on 5/21/24 and 5/22/2024.
These deficient practices had the potential for Resident 62 and other 1:1 feeder at the facility to experience poor oral intake and be at risk for weight loss.
Findings:
During a review of Resident 62's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including cachexia (involuntary weight loss and muscle loss), adult failure to thrive, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
During a review Resident 62's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 4/17/2024, indicated Resident 62 had moderate cognitive impairment. The MDS indicated Resident 62 required supervision or touching assistance while eating.
During a review of Resident 62's Nutritional assessment dated [DATE] indicated Resident 62 was on a regular diet and recommendations were to add Boost (nutritional supplement) twice a day at medication pass, 1:1 RNA feeder and multivitamins with minerals.
During a review of Resident 62's Physician Order dated 1/30/2024, indicated for 1:1 RNA feeder.
During a review of Resident 62's care plan initiated on 1/28/2024 indicated that the resident was at risk for nutritional problem or potential nutritional problems and interventions included 1:1 RNA feeder.
During a concurrent observation and interview on 5/20/2024 at 12:59 PM, with Certified Nursing Assistant (CNA) 7, CNA 7 was observed in Resident 62's room assisting another resident. CNA 7 stated Resident 62 only needed set up assistance and some supervision. CNA 7 she knew what the resident needs were from the report given by the licensed nurse.
During a concurrent observation and interview on 5/21/2024 at 12:35 PM, with Certified Nursing Assistant (CNA) 8, CNA 8 was observed in the third-floor dining room with Resident 62. CNA 8 was assisting Resident 62 by cutting the resident's food into small pieces, giving the resident utensils, and opening the resident's drink. CNA 8 stated Resident 62 was able to feed herself and just needed assistance with meal set up. CNA 8 stated 1:1 RNA feeder meant the resident needed staff assistance, but the need can be feeding assistance, supervision, or just meal set up. CNA 8 stated when a resident who needed one to one feeding assistance but was not receiving the assistance, could be at risk for weight loss.
During an interview on 5/22/24 at 3:24 PM with Registered Dietician (RD), the RD stated Resident 62 needed only supervision, encouragement and set up assistance. The RD stated instead of 1:1 feeder, Resident 62's order should indicate supervision and set up assistance and resident should be reassessed to confirm the resident's need. RD stated that if facility staff failed to properly supervise Resident 62 during the resident's meals then the resident could be at risk for weight loss.
During an interview on 05/23/24 01:28 PM with the Director of Nursing (DON), the DON stated 1:1 RNA feeder meant the resident will need to be fed by an RNA. The DON stated the order for 1:1 RNA feeder should have been changed to the resident's specific need such as supervision or meal set up. DON stated there was no policy or procedure indicating what was meant by 1:1 feeder. The DON stated the facility was currently working with the rehabilitation and dietary department to implement a new policy to prevent any type of misinterpretation and confusion.

Based on observation, interview and record review, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and per the physician's orders for one of three sampled residents (Resident 131) at risk for developing pressure ulcers by failing to ensure the resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) was set at the appropriate level.
This deficient practice placed Resident 131 at risk for developing new pressure injuries and complications resulting from untreated or improperly treated pressure injuries which could result in systemic infections that could lead to death.
Findings:
A review of Resident 131's admission Record indicated the facility admitted the resident on 2/29/2024 with diagnoses that included encephalopathy (a change in your brain function due to injury or disease) atrial flutter (a condition in which the heart's upper chambers (atria) beat too quickly), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), abnormalities (a condition that is not normal) of gait (refers to how a person walks) and mobility (refers to how a person moves), and hypertension (when the pressure in the blood vessels are too high).
A review of Resident 131's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 3/6/2024, indicated the resident had severely impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 131 required partial moderate assistance for eating and oral hygiene. The MDS indicated Resident 131 required substantial/maximal assistance for toileting hygiene, upper body/lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 131 was at risk for developing pressure ulcers.
A review of Resident 131's Care Plan dated 3/7/2024, indicated the resident had a potential/actual impairment to skin integrity related to disease process. The care plan indicated a goal for Resident 131 to maintain or develop clean and intact skin by the review date. The care plan indicated interventions that included a LALM for skin maintenance.
A review of Resident 131's Physician Order dated 3/28/2024 indicated the resident was to have a LALM for skin maintenance.
A review of Resident 131's weight dated 5/12/2024 indicated the resident weighed 191 pounds (lbs.).
During a concurrent observation and interview on 5/20/2024 at 11:20 AM, in Resident 131's room, Resident 131 was observed lying in bed on a LALM. Resident 131's LALM was observed on the 400 lbs. setting. Licensed Vocational Nurse (LVN) 8 confirmed Resident 131's LALM settings were set at 400 lbs. The LVN 8 stated the 400 lbs. setting was incorrect. LVN 8 stated the LALM settings were to be based on Resident 131's weight (191 lbs.).
During a concurrent observation and interview on 5/22/2024 at 10:11 AM, in Resident 131's room, the resident's LALM was observed with Treatment Nurse (TN) 2. TN 2 stated Resident 131 was on a LALM to prevent wounds from forming. Resident 131's LALM was observed with settings of 400 lbs. TN 2 stated the settings (400 lbs.) were incorrect. TN 2 stated LALM settings were to be based on Resident 131's weight. TN 2 stated there was a potential for Resident 131 to develop wounds if the LALM was on the wrong settings.
During an interview on 5/23/2024 at 1:40 PM, the Director of Nursing (DON) stated LALM settings were based on the resident's weight. The DON stated a LALM was to help prevent pressure ulcers. The DON stated if settings were incorrect there was a potential for the resident to develop pressure ulcers or worsening existing pressure ulcers.
A review of the undated LALM manual titled Operation Manual for Protekt Aire 4000DX/4600DX/5000DX/4600DXAB, indicated Weight range/pressure level is set at 80 kilograms (kg)/30 millimeters of mercury (mm Hg) initially. Press the up/down buttons on panel to adjust the weight/pressure level to the patient's specific requirements .Users can adjust air mattress to a desired firmness according to patient's weight or the suggestion from a health care professional.
A review of the facility's policy and procedure titled, Support Surface Guidelines, reviewed 9/2023, indicated Redistributing support surfaces are to promote comfort for all bed - or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction.

Based on observation, interview, and record review, the facility failed to follow their infection prevention and control procedure by not displaying the proper isolation-based precaution sign and posting the specific type of isolation outside the door for one of one sampled resident (Resident 106).
This failure resulted in posting incorrect isolation precaution instructions, incorrect personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious illnesses) outside the resident's door and had the potential for staff donning incorrect PPE and contracting and spreading infections to other residents.
Findings:
During a review of Resident 106's admission Record, dated 5/22/2024 indicated, the resident was admitted to the facility with diagnoses including but not limited to acute kidney failure (when the kidneys suddenly become unable to filter waste products from the blood, anemia (low red blood cells), cardiac arrhythmia (irregular heart rate) and cellulitis (bacterial infection of the skin) of right and left lower limb.
During a review of Resident 106's Progress Notes from the medical doctor (MD) 1, dated 5/18/2024, indicated the resident had methicillin-resistant staphylococcus aureus (MRSA, group of bacterial infections that are difficult to treat) likely secondary to chronic wounds.
During a review of resident 106's care plan dated 5/18/2024 indicated the resident had MRSA to bilateral lower extremities (legs) wounds with interventions including Contact Isolation: wear gowns and masks when changing contaminated linens, instruct family/visitors/ caregivers to wear disposable gowns and gloves when in the resident's room and during physical contact with resident and to wear mask/face shield during procedures with risk of splashes or droplet contamination of bodily fluids.
During an observation on 5/20/2024 at 10:15 AM outside Resident 106's room, a Covid-19 (a highly contagious type of viral disease) infection precaution sign with instructions was posted indicating Please Report to Nursing Station Prior To Entering This Room. The posted isolation precaution sign displayed the type of infection.
During an interview on 5/20/2024 at 10:17 AM with Registered Nurse (RN) 1, RN 1 stated, the facility does not have suspected or positive Covid-19 residents, the posted isolation precaution must be an error.
During an interview on 5/20/2024 at 10:20 AM with Certified Nursing Assistant (CNA) 9, CNA 9 was unaware whether Resident 106 was Covid-19 positive or not and utilized the available PPE placed outside Resident 106's room. CNA 9 stated the likely outcome of wearing incorrect PPE was contracting infections and spreading to residents and staff.
During a concurrent interview and record review on 5/20/2024 at 11:00 AM with the Infection Prevention nurse (IP), the isolation precaution sign at Resident 106's door was reviewed. The isolation precaution sign indicated isolation for Covid-19 infection-based precaution. The IP stated Resident 106 had MRSA. The IP stated the policy was to post the appropriate infection-based precaution sign and not to disclose residents' type of infection. The IP stated the likely outcome was utilizing incorrect PPE, resulting in contracting infections and spreading to residents and staff.
During a review of the facility's policy and procedure titled, Infections- Clinical Protocol, dated September 20223, it indicated, In the interest of public health, posting the resident's isolation status or transmission-based precautions is permissible as long as the type of infection remains confidential.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of two sampled residents (Resident 37) received colostomy (an opening in the abdominal wall that's made during surgery, and it is used to move waste out of the body) care in accordance with the resident's comprehensive person-centered care plan (a set of instructions for providing individualized care to a resident for an identified area of concern) by failing to provide colostomy care during every shift and as needed, and monitor skin irritation as per the plan of care.
This deficient practice had the potential for Resident 37 to suffer from infection, skin breakdown, and pain.
Findings:
A review of Resident 37's admission Record (Face Sheet) indicated the facility originally admitted Resident 37 on 4/17/2017, and readmitted on [DATE], with diagnoses including colostomy, and lack of coordination.
A review of Resident 37`s Care Plan dated 8/1/2023, indicated Resident 37 had colostomy bag. The care plan goal for the resident was to be free from infection and skin breakdown in the area through the review date. The care plan interventions were to change the colostomy bag as needed, cleanse the skin with normal saline (salt solution), and to inform the physician for any changes of condition.
A review of Resident 37's most recent Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 2/9/2024, indicated the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated Resident 37 required partial/moderate staff assistance (helper does less than half the effort) with personal hygiene, dressing lower body, showering/bathing, and toileting hygiene. The MDS indicated Resident 37 had ileostomy.
A review of Resident 37`s Physician`s Orders dated 3/9/2024, indicated facility staff was to change the colostomy bag every Wednesday and Saturday, and as needed, if leaking or soiled.
A review of Resident 37`s Care Plan dated 2/6/2024, indicated Resident 37 had an alteration (a change resulting in something that is different from the original) in gastro-intestinal status (related to stomach and intestines) and had a colostomy. The care plan goal for the resident was to remain free from complications. The care plan interventions were to provide colostomy care during every shift and as needed, monitor skin irritation, and call the physician as needed.
A review of Resident 37`s Treatment Administration Record (TAR) for the months of January, February, March, April, and May 2024, indicated there was no documentation regarding providing colostomy care to Resident 37 or for monitoring Resident 37's skin for irritation.
During a concurrent interview and record review on 5/21/2024 at 2 PM, with Registered Nurse Supervisor 1 (RN1), Resident 37`s care plans for colostomy and TARs were reviewed. RN1 stated Resident 37`s colostomy care plan interventions were to provide colostomy care for Resident 37 during every shift and to monitor the skin for irritation. RN1 confirmed by stating the licensed staff did not document anywhere in Resident 37`s medical records the interventions were done. RN1 stated licensed staff were required to monitor resident`s skin surrounding the stoma (a surgically made hole in the abdomen that allows body waste to be removed from the colostomy site) for redness, swelling and irritation. RN1 stated the potential outcome of not implementing care plan interventions for colostomy care was insufficient care and a potential for skin breakdown and injury for the resident.
During an interview on 5/23/2024 at 1:37 PM, with the facility`s Director of Nursing (DON), the DON stated licensed nurses were required to implement all interventions specified in the residents` care plans. The DON stated Resident 37`s colostomy care plan interventions of providing colostomy care and monitoring the skin for irritation were not documented by licensed staff. The DON stated, If it is not documented, it is not done. The DON further stated the potential outcome of not implementing care plan interventions for colostomy is skin breakdown, infection, and harm to the resident.
A review of facility`s policy and procedure titled Colostomy and Ileostomy Care, reviewed September 2023, indicated The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident`s skin to fecal matter. Review the resident`s care plan to assess for any special needs of the resident. When evaluating the condition of the resident`s skin, note the breaks in the skin, excoriation, and signs of infection (heat, swelling, pain, redness .). The following information should be recorded in the resident`s medical records: the date and time the colostomy care was provided, the name and title of the individual who provided the care, any breaks in resident`s skin, signs of infection.

Based on interview and record review, the facility failed to develop a comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for Apixaban (Eliquis, an anticoagulant medication [medication that help prevent blood clots]) 5 milligrams (mg) by mouth twice a day for anticoagulant (medication used to treat and prevent blood clots) one of four sampled residents (Resident 7).
This deficient practice had the potential for Resident 7 to not be provided personalized care and experience negative effects from the anticoagulant medication such as bruising, internal bleeding, and uncontrolled bleeding.
Findings:
A review of Resident 7's admission Record indicated the facility re-admitted the resident on 4/22/2024 with diagnoses that included dysphagia (difficulty swallowing), hypoxia (low levels of oxygen in the body tissues), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), schizophrenia (a serious mental health condition that affects how people think, feel and behave), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Post-Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and anxiety (a feeling of fear, dread, and uneasiness).
A review of Resident 7's Physician order dated 4/22/2024, indicated Resident 7 was to receive Apixaban (Eliquis, an anticoagulant medication [medication that help prevent blood clots]) 5 milligrams (mg) by mouth twice a day for anticoagulant.
A review Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 4/29/2024, indicated Resident 7 had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated Resident 7 was dependent on facility staff for help for eating, oral hygiene, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 7 was taking anticoagulant medication.
A review of Resident 7's Medication Administration Record (MAR) for 4/2024 and 5/2024, indicated Resident 7 was receiving Apixaban twice a day.
A review of Resident 7's complete care plans indicated Resident 7 did not have a care plan for Apixaban.
During a concurrent interview and record review on 5/23/2024 at 1:40 PM, Resident 7's physician order for Apixaban and care plan was reviewed with the Director of Nursing (DON). The DON confirmed Resident 7 was receiving Apixaban. The DON confirmed Resident 7 did not have a care plan for Apixaban. The DON stated care plans should be created for all diagnoses, medication, and whatever was in the resident's record. The DON stated if there was a physician order, the care plan had to reflect the physician order. The DON stated there was a potential for Resident 7 to have a delay in care and not receive personalized care if the care plan was not developed. The DON stated there was a potential for Resident 7 to experience adverse effects from the Apixaban if there was no care plan developed for the medication.
A review of the facility's policy and procedures titled Care Plans, Comprehensive Person-Centered reviewed 9/2023, 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: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; builds on the resident's strengths; and reflects current recognized standards of practice for problem areas and conditions.

Based on interview and record review, the facility failed to provide mandatory information on the Nursing Facility (SNF) must issue this notice to a resident when it believes that Medicare may not cover their care or stay. The SNF must provide the notice to the resident before providing the non-covered care.) appeal process in a timely manner for one of three randomly selected residents (Resident 7).
This deficient practice denied Resident 2 the right to accept or decline non covered specific skilled services or file an appeal. This placed Resident 7 at risk for an unexpected financial burden/crisis.
Findings:
A review of Resident 7's admission Record indicated the facility re-admitted the resident on 4/22/2024 with diagnoses that included dysphagia (difficulty swallowing), hypoxia (low levels of oxygen in the body tissues), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), schizophrenia (a serious mental health condition that affects how people think, feel and behave), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Post-Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and anxiety (a feeling of fear, dread, and uneasiness).
A review Resident 7's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 4/29/2024, indicated the resident had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated Resident 7 was dependent on facility staff for help with eating, oral hygiene, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene.
A review of Resident 7's SNFABN Review Form indicated Resident 7's last covered Medicare Part A Skilled Services was 12/13/2024. The SNFABN Review form indicated the facility initiated the discharge form Medicare Part A when benefit days were not exhausted and indicated a SNFABN was not provided.
During an interview on 5/23/2024 at 2:20 PM, the Business Office Manager (BOM) stated Resident 7 was on Medicare part A and no longer needed skilled services and remained in the facility. The BOM stated Resident seven had Medicare days remaining. The BOM stated the residents were not provided SNFABN to inform them of services that were no longer covered under Medicare Part. The BOM stated the facility did not provide the SNFABN form to Resident 7.
During an interview on 5/23/2024 at 2:40 PM, the Director of Nursing (DON) stated she could not answer which beneficiary forms should be provided to residents or why the forms were given.
A review of the facility's policy and procedures (P&P) titled, Medicare and Medicaid Benefits reviewed 9/2023, indicated Residents are provided with information, verbally and in writing, about how to apply for and use Medicare and Medicaid benefits. The P&P also indicated Upon admission, and when a resident becomes eligible for Medicare/Medicaid benefits, the benefits coordinator or admissions coordinator informs the resident verbally and in writing of:
a. The services and items covered under the facility's Medicare/Medicaid payment rates; and
b. The charges for non-covered items or services that are available to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two out of 12 sampled residents (Resident 1 and 15) had Advance Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) or Advanced Directives Acknowledgement forms (a signed acknowledgment indicating the resident and/or resident representative were provided with information regarding creating an Advanced Directive) documented in the residents' active medical record.
This deficient practice had the potential for Residents 90 and Resident 96 to be denied the right to request or refuse medical care and treatment or have those options honored in the event of an emergency.
Findings:
A review of Resident 1's admission Record indicated the facility initially admitted Resident 1 on 11/27/2023 and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), essential hypertension (a type of high blood pressure that has no clear cause) and schizophrenia (a serious mental illness involves the breakdown of thought, emotion, and behavior, with negative actions and feelings).
A review of Resident 1's quarterly Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/5/2024, indicated Resident 1 had severe cognitive (ability to acquire and understand knowledge) impairment. The MDS indicated Resident 1 required partial/moderate assistance for eating, dressing, showering and oral hygiene.
During a concurrent interview and record review on 5/20/2024 at 2:44 PM, with Registered Nurse Supervisor 1 (RN Sup 1), Resident's 1 chart was reviewed. RN Sup 1 confirmed there was no Advance Directive or Advanced Directive Acknowledgement form in Resident 1's chart. RN Sup 1 stated it was important for residents to have an advance directive in case the resident had a critical condition to find out residents' wishes towards the end of life.
During concurrent interview and record review on 5/21/2024 at 3:57 PM, with Social Services Director (SSD), the facility's advance directive binder was reviewed. The SSD stated the Advance Directive was to be offered within seven days of admission. The SSD stated the Advance Directive form, or the Advance Directive Declination Form was provided to the residents or responsible party if the resident did not have the capacity to understand to make decisions. The SSD stated the Advance Directive and/or the Advance Directive Acknowledgement Form was to be kept in the active medical chart. The SSD stated the Advance Directive Acknowledgment Form should have been provided to the resident or responsible party. The SSD stated the Advance Directive Form for Resident 1 was not found in the binder or Resident 1's chart.
A review of Resident 15's admission Record (Face Sheet) indicated the facility originally admitted the resident on 5/2/2017, and readmitted on [DATE], with diagnoses that included parkinsonism (a brain disorder that causes unintended [happening by accident] or uncontrollable movements, such as shaking, stiffness [being firm], and difficulty with balance and coordination) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 15's MDS dated [DATE], indicated Resident 15's cognitive skills for daily decision making was intact. The MDS indicated Resident 15 was dependent on staff for toileting, hygiene, lower body dressing, and putting on and taking off footwear. The MDS indicated that Resident 15 required staff supervision for eating, oral hygiene, and personal hygiene.
A review of Resident 15's History and Physical dated 5/12/2024, indicated Resident 15 had the capacity to make medical decisions.
During a concurrent interview and record review on 5/21/2024 at 12 PM, with the MRD, Resident 15's medical chart was reviewed. The MRD stated the Advance Directive Acknowledgment form for Resident 15 was not completed and was blank with no entries. The MRD stated the social service department was responsible for completing the advance directive acknowledgment forms for residents upon admission or readmission to the facility.
During a concurrent interview and record review on 5/21/2024 at 12:07 PM, with the SSA, Resident 15's medical chart was reviewed. The SSA stated social service department was responsible for completing advance directive acknowledgment forms for residents upon admission or readmission to the facility. The SSA stated the Advance Directive Acknowledgment form for Resident 15 was not completed. The SSA stated the potential outcome of not having a complete Advanced Directive acknowledgement form was that Resident 15 would not have his choices for medical treatment honored.
During an interview on 5/23/2024 at 1:30 PM, the DON stated the Advance Directive Acknowledgment Form was required to be completed upon admission. The DON stated the Advance Directive Acknowledgment form for Residents 15 was not completed. The DON stated the potential outcome was that the resident`s wishes would not be honored.
A review of the facility's policy and procedures (P&P) titled, Advance Directives dated 9/2023, indicated Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The resident or representative is 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. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or the representative. Written information includes a description of the facility's policies to implement advance directives and applicable state law. If the 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 residents' legal representative.

Based on observation, interview, and record review, the nursing staff failed to revise the tube feeding (also known as enteral nutrition, is a way to provide nutrition, fluids, and medicines through a feeding tube placed into the stomach or small intestine) care plan to meet the individual needs for one of two sampled residents (Resident 76).
This deficient practice had the potential to prevent Resident 76 from receiving care to address specific needs, which could lead to a decline in emotional and physical health.
Findings:
A review of Resident 76's admission Record indicated the facility originally admitted the resident on 1/27/2021 and readmitted the resident on 1/15/2024 with diagnoses that included dysphagia (difficulty swallowing), stroke affecting the left side and type 2 diabetes mellitus (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood).
A review of Resident 76's tube feeding care plan, initiated 5/23/2023, indicated Resident 76 required tube feeding related to diagnoses of dysphagia and diabetes. The care plan indicated interventions included to provide GT feeding of Glucerna 1.2 at 60 ml per hour x 20 hours. The care plan indicated the intervention was revised on 1/3/2024 but the care plan did not include the resident's current enteral feeding order.
A review of the Order summary report, dated 4/1/2024, indicated on 1/16/2024, the physician ordered the facility to administer to Resident 76, Glucerna (a meal replacement or supplement made specifically for individuals with diabetes) 1.5 at 60 milliliters (ml) per hour (hr), to total 1200 ml every day.
A review of Resident 76's Nutritional Assessment, dated 1/17/2024, indicated the resident had a three-pound (lbs.) weight loss in 7 days. The Nutritional Assessment indicated Resident 76 was receiving Glucerna 1.5 at 60ml/hr for 20 hours for a total of 1200 ml per day. The nutritional assessment indicated the plan was to continue to monitor.
A review of Resident 76's Nutritional Assessment, dated 5/8/2024, indicated Resident 76 gained five pounds (lbs.) in 30 days. The Nutritional Assessment indicated Resident 76 was receiving Glucerna 1.5 at 55ml/ hr for 20 hours for a total of 1100 ml. The nutritional assessment indicated the recommendation was for the current enteral feed order to be stopped and a new order of Glucerna 1.5 at 40cc/hr for 20 hours to give a total of 800 ml per day.
A review of Resident 76's physician's order, dated 5/9/2024, indicated to administer Glucerna 1.5 via gastrostomy tube via feeding pump at 40 milliliters (ml) per hour for 20 hours to yield 800 ml per day or until desired volume was infused. The physician order indicated the feeding as to start at 12 PM and off 8 AM.
A review of Resident 76's Nutritional Assessment, dated 5/22/2024, indicated the resident's enteral feeding order was Glucerna 1. 5 at 40 ml/hour for 20 hours per day to administer a total of 800 ml per day.
During an interview on 5/22/2024 at 1:21 PM, Licensed Vocational Nurse 4 (LVN 4) stated Resident 76 had enteral feeding and ate with assistance. LVN 4 stated Resident 76's prior enteral feeding rate was 60 ml/hr and was lowered to 40 ml/hr. LVN 4 reviewed Resident 76's tube feeding care plan, LVN 4 stated the care plan was not updated with the current enteral feeding. LVN 4 stated the care plan should have been updated because the care plan directed the care for the resident. LVN 4 stated by not updating the care plan Resident 76's nutritional status could be negatively affected.
During an interview on 5/23/2024 at 1:42 PM, the Director of Nursing (DON) stated care plans had to be updated with the current physician orders. The DON stated care plans were updated to reflect the resident's current care.
A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, reviewed 9/2023, indicated, The comprehensive care plan will include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P indicated 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 provide a bed hold notification (written notice of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) at the time of transfer to the hospital for one of two sampled residents (Resident 133).
This deficient practice denied Resident 133 and/or the Responsible Party (RP) the right to be informed of their right to have the facility hold and reserve Resident 133's bed while absent from the facility.
Findings:
A review of Resident 133's admission Record (Face Sheet) indicated the facility originally admitted the resident on 2/9/2021, and readmitted on [DATE], with diagnoses that included type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen).
A review of Resident 133's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 11/29/2023, indicated Resident 133's cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated Resident 133 required partial/moderate assistance (helper does less than half the effort) from staff for oral hygiene, toileting hygiene, showering/bathing and upper and lower body dressing.
A review of Resident 133`s Physician orders dated 2/11/2024, indicated to transfer Resident 133 to General Acute Care Hospital 1 (GACH 1) for further evaluation and management of gross hematuria (blood in urine that can be seen by naked eye because the urine is pink, red, purplish-red, brownish-red, or tea-colored).
During a concurrent interview and record review on 5/22/2024 at 8:23 AM, with the Medical Record Director (MRD), Resident 133`s bed hold notifications were reviewed. The MRD stated Resident 133 and/or the RP were not provided with bed hold notification upon transfer to the hospital on 2/11/2024. The MRD stated the facility was required to provide a bed hold notification upon admission, re-admission, and transfer to the hospital.
During an interview on 5/23/2024 at 1:35 PM, with the Director of Nursing (DON), the DON stated the facility was required to provide a bed hold notification to residents or their RPs upon admission and transfer to the hospital. The DON stated Resident 133 and/or the RP were not provided a bed hold notification when the resident was transferred to hospital on 2/11/2024. The DON stated the potential outcome was resident`s unawareness of the bed hold policy.
A review of the facility's policy and procedure titled, Bed-Holds and Returns, reviewed September 2023, indicated All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident`s bed during periods of absence (hospitalizations or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: notice 1: well in advance of any transfer (e.g., in the admission packet) and notice 2: at the time of transfer (or, if the transfer was emergency, within 24 hours).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 4) received care and services when providing parenteral fluids (intravenous [IV-a small, flexible tube placed into a small vein for intravenous therapy such as medication fluids] infusion of various solutions to maintain hydration, restore and/ or maintain fluid volume, reestablish lost electrolytes [substance that help regulate chemical balance in the body] or maintain nutrition) consistent with professional standards of practice by failing to ensure Resident 4 ' s Peripheral Inserted Central Catheter (PICC line- a type of a Central Venous Catheter [CVC-a catheter placed into a large vein]) was flushed with 10 milliliter (mL - unit of measurement) 0.9 percent (%) sodium chloride (NS-normal saline) prior to administering an antibiotic medication per facility policy.
This deficient practice had the potential to result in Resident 4 ' s PICC line catheter site to develop complication such as infection and catheter occlusions or rupture.
Findings:
A review of Resident 4 ' s admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including left lower extremity infection, osteomyelitis (bone infection) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 4 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/3/2024, indicated Resident 4 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was intact. The MDS indicated Resident 4 required moderate assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use).
A review of Resident 4 ' s IV Medication Record dated 4/22/2024, indicated to provide Zosyn (antibiotic -medication to treat infection) 3.375 milligram (mg) via IV every eight hours and to provide maintenance flushes to the right upper arm PICC line.
During a concurrent observation and interview with the Registered Nurse 2 (RN2) on 4/22/2024 at 2:25 p.m., RN2 observed aspirating (pull back/withdraw) 2.5 ml of NS from the IV Zosyn bag and flushed the PICC line using the same syringe prior to administering IV Zosyn. RN2 stated unable to flush 10 ml NS since the facility ran out of the pre-filled 10 ml NS syringes. RN2 stated importance of flushing the PICC line with 10 ml NS was due to risk of the PICC line being clotted.
During an interview with Director of Nursing (DON) on 4/23/2024 at 4:37 p.m., DON stated that prior to administering IV medication, the licensed nurse should flush the PICC line with a pre-filled 10 ml NS syringe for patency. DON also stated the facility had plenty of pre-filled 10 ml NS syringes.
A review of facility ' s policy and procedures (P&P), titled, Implanted Venous Port-Flushing and Locking, reviewed on 9/2023, P&P indicated, the facility should maintain patency of the implanted venous port, to prevent mixing of incompatible medications and solutions; and to ensure entire dose of solution or medication is administered into the venous system. The volume of flushing solution should be at least twice the volume of the catheter system. When administering an intermittent medication, to flush the 10 ml prefilled syringe containing NS to catheter access device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document medication administration immediately after dose were administered for three of five sampled residents (Residents 1, 2, and 3).
This deficient practice had the potential to result in medication administration error and risk for unsafe, improper medication administration use for Residents 1, 2, and 3.
Findings:
1. A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including cholecystitis (inflammation of gallbladder [a small organ under the liver]) and neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet).
A review of Resident 1's Minimum Data Set (MDS - a standardized comprehensive assessment and care screening tool), dated 3/24/2024, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was intact and required moderate assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, and toilet use).
2. A review of Resident 2's admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), fracture of right femur (a break, crack, or crush injury of the thigh bone) and head injury.
A review of Resident 2's MDS, dated [DATE], indicated Resident 1's cognitive skills for daily decision-making was moderately impaired and required supervision to moderate assistance from staff for ADLs.
3. A review of Resident 3's admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including encephalopathy, pneumonia (PNA-infection that inflames air sacs in one or both lungs which may fill with fluid) and urinary tract infection (UTI-infection in the urinary system [kidneys, bladder, or urethra]).
A review of Resident 3's MDS, dated [DATE], indicated Resident 3's cognitive skills for daily decision-making was severely impaired and dependent from staff for ADLs.
During a concurrent observation, interview, and record review with Licensed Vocational Nurse 2 (LVN2) on 4/22/2024 at 1:55 p.m., LVN2 was observed signing Residents 1, 2, and 3's medication administration record (MAR). Residents1, 2, and 3's MAR indicated unsigned scheduled morning (9 am) medications for 4/22/2024. LVN2 stated and verified that LVN2 had administered Residents1, 2, and 3's scheduled morning medications and was barely documenting on the MAR that Resident 1, 2, and 3 had received medications. LVN2 stated LVN2 documents administered medications towards the end of LVN2's shift (shift ends at 3 p.m.). LVN2 was unable to answer when asked if it was LVN2's usual process when administering medications to the residents.
During an interview with Director of Nursing (DON) on 4/23/2024 at 4:37 p.m., DON stated, the medication nurse is supposed to do Pour, Pass and Sign. DON stated that the medication nurses are supposed to sign the MAR immediately after administering medications to the residents. DON also stated that signing the MAR at around 2 p.m. after administering medications in the morning, was unacceptable.
A review of facility's policy and procedures (P&P), titled, Administering Medications, reviewed on 9/2023, P&P indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all drugs and biologicals to meet the needs of each resident for one of six sampled residents (Resident 2) by failing to ensure that Resident 2 ' s medications were not left unattended at the bedside.
This deficient practice had the potential to result in Resident 2 in unintended complications related to the management of medications.
Findings:
A review of Resident 2 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses including encephalopathy (a chemical imbalance in the blood affecting the brain), human immunodeficiency virus (HIV - a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases, It is spread by contact with certain bodily fluids of a person with HIV, most commonly during unprotected sex [sex without a condom or HIV medicine to prevent or treat HIV], or through sharing injection drug equipment), schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly) and cellulitis of right lower limb (bacterial skin infection).
A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 3/5/2024, indicated Resident 2 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was mildly impaired for daily decision-making and required supervision to set-up assistance from staff for activities of daily living (ADL- eating, oral hygiene, personally hygiene).
A review of Resident 2 ' s Order Summary Report, dated 8/28/2023 indicated, physician ordered, Dextromethorphan-guaifenesin (used to treat cough and chest congestion caused by the common cold or allergies) oral syrup – give 10 ml by mouth every 4 hours as needed for cough.
During a concurrent observation and interview with Resident 2 on 4/10/2024 at 10:53 a.m., Resident 2 was observed with a medicine cup with a liquid in Resident 2 ' s bedside table. Resident 2 stated, it was his cough medicine which was given to him this morning. Resident 2 stated the nurse left it at his bedside table and he takes it little by little.
During a concurrent interview with Licensed Vocational Nurse 1 (LVN 1) on 4/10/2024 at 11:06 a.m. and observation of Resident 2, LVN 1 observed Resident 2 ' s medicine cup on top Resident 2 ' s bedside table. LVN 1 stated, it was Resident 2 ' s cough medication that she administered this morning. LVN 1 stated, she should have not left the medication at bedside, and they must observe residents taking the medication before leaving the room. LVN 1 stated, if medications are left at bedside, other residents might take it.
During an interview with Registered Nurse 1 (RN 1) on 4/10/2024 at 2:00 p.m., RN 1 stated, nurses should not leave medications at bedside, and they have to observe residents taking the medication before the leaving the room.
A review of the facility ' s policy and procedures (P&P) titled, Documentation of Medication Administration, reviewed on 9/2023 indicated, Administration of medication must be documented immediately after (never before) it is given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the residents have the right to be free from sexual abuse for one of seven sampled residents (Resident 3).
This deficient practice resulted in residents being subject to neglect and sexual abuse.
Cross Reference F609 and F610.
Findings:
A review of Resident 2 ' s admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including encephalopathy (a chemical imbalance in the blood affecting the brain), human immunodeficiency virus (HIV - a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases, It is spread by contact with certain bodily fluids of a person with HIV, most commonly during unprotected sex [sex without a condom or HIV medicine to prevent or treat HIV], or through sharing injection drug equipment), schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly) and cellulitis of right lower limb (bacterial skin infection).
A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 3/5/2024, indicated Resident 2 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was mildly impaired for daily decision-making and required supervision to set-up assistance from staff for activities of daily living (ADL- eating, oral hygiene, personally hygiene).
A review of Resident 3 ' s admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including cellulitis of right and left lower limb, altered mental status, and hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side.
A review of Resident 3's MDS dated [DATE], indicated Resident 3 ' s cognition was mildly impaired for daily decision-making and required moderate to maximal assistance from staff for ADL- eating, oral hygiene, toileting hygiene, and personal hygiene.
During an interview with Resident 2 on 4/10/2024 at 10:53 a.m., Resident 2 stated, he has a partner and in a relationship with another resident, Resident 3. Resident 2 stated, Resident 3 is a black descent, and he is his boyfriend. Resident 2 further stated the staffs are allowing them to have a relationship and they are aware of their situation before but lately; they are not letting them go to the same Activity Room and they separate them. Resident 2 stated, he is to go to the Activity room [ROOM NUMBER] only (3rd floor) away from Resident 3.
During an interview with Licensed Vocational Nurse 1 (LVN 1) on 4/10/2024 at 11:06 a.m., LVN 1 stated, sometime last week, Restorative Nursing Assistant 1 (RNA 1) reported to her that Resident 2 was found sitting on the lap of Resident 3 inside Resident 2 ' s room. LVN 1 stated, they reported it to the Director of Nursing (DON) and she was made aware of the incident. LVN 1 stated, she did not document the incident reported to her in Resident 2 and Resident 3 ' s chart.
During an interview with RNA 1 on 4/10/2024 at 11:12 a.m., RNA 1 stated, she witnessed Resident 2 and Resident 3 in Resident 2 ' s room, Resident 2 was on top of Resident 3 ' s lap while sitting on the wheelchair. RNA 1 stated, she did not witness how it started but she reported it to LVN 1 RNA 1 stated, she separated and reoriented both residents. RNA 1 further stated, they both reported the incident to the DON.
During an interview with Licensed Vocational Nurse 2 (LVN 2) on 4/10/2024 at 11:19 p.m., LVN 2 stated, Licensed Vocational Nurse 3 (LVN 3) mentioned to him on 4/5/2024 that Resident 2 and Resident 3 was observed in the Activity room [ROOM NUMBER] (AR 2) by the Activity Assistant 1 (AA 1) having intercourse. LVN 2 stated, DON and the Administrator (ADM) were aware of the incident and did not do any investigation. LVN 2 stated, DON and ADM did not report it to the State Agency and the Police because they want to hide the situation and the incident. LVN 2 stated, he talked to the DON about it and DON just shrugged it off. LVN 2 further stated, Resident 2 was diagnosed with HIV and the management did not try to do any testing for Resident 3.
During an interview with Resident 3 on 4/10/2024 at 12:03 p.m., Resident 3 stated, he is friend with Resident 2. When asked if he (Resident 3) knows the current date, Resident 3 was unable to answer correctly, as Resident 3 answered, today was the 12th. When asked how long he (Resident 3) has been in the facility, Resident 3 stated, 3 years.
During an interview with Activity Director (AD) on 4/10/2024 at 2:25 p.m., AD stated, AA 1 notified him that Resident 2 was found touching Resident 3 inappropriately sometime last week in the Activity room [ROOM NUMBER] in 3rd floor. AD stated, he told the managements including DON, ADM and Human Resources (HR) and they had a meeting about it. AD stated, they were told to keep an eye on both residents. AD stated all staffs are mandated reporter that is why he reported it to the managements. AD stated, he did not document the incident reported to him in Resident 2 and Resident 3 ' s chart.
During an interview with DON on 4/10/2024 at 4:27 p.m., DON stated, she was not aware of the sexual abuse allegation incident for Resident 2 and Resident. DON stated, they did not do any investigation of the sexual allegation.
A review of the facility's policy and procedures (P&P) titled, Abuse and Neglect - Clinical Protocol, reviewed on 9/2023 indicated, The nurse will assess the individual and document relevant findings. Assessment date will include: injury assessment, pain assessment, current behavior, patient ' s age and sex, all current medications . vital signs, behavior over last 24 hours . all avtive diagnoses; and any recent labs . The nurse will report findings to the physician . The physician will help identify individuals with history of having been abused or neglected . The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of six sampled residents, (Resident 1) received treatment and care accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to ensure the physician ' s order was carried out.
This deficient practice resulted to failure in the delivery of necessary care and services and resulted in Resident 1 ' s hospitalization.
Findings:
A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including aftercare following joint replacement surgery (a procedure in which a surgeon removes a damaged joint and replaces it with a new, artificial part), abnormalities of gait and mobility, and hypertensive heart disease (problems with heart that can develop if a person have high blood pressure and not treated for years).
A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 3/30/2024, indicated Resident 1 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact for daily decision-making and required moderate assistance from staff for activities of daily living (ADL- oral hygiene, toileting hygiene, shower/bathe self, and upper and lower body dressing).
A review of Resident 1 ' s Licensed Nurses Weekly Summary dated 4/4/2024 indicated, Resident 1 was coughing and had runny nose.
A review of Resident 1 ' s laboratory (lab) test, collected on 4/4/2024 and reported on 4/5/2024 indicated, the result of white blood count (WBC - measures the number of white cells in the blood, white blood cells are part of the immune system that helps body fight off infection) indicated, 33.3 (normal range: 4.0 – 10.0: high WBC occurs when a person have infection or inflammation in the body).
A review of Resident 1 ' s Progress Notes dates 4/5/2024 at 5:45 a.m., indicated, MD (MD 1) was notified of Resident 1 ' s WBC result with no new orders.
A review of the notification text message sent to MD 1 on 4/5/2024 at 5:24 a.m., indicated staff nurse reported Resident 1 ' s WBC is 33.3 with MD 1 ' s reply, OK.
A review of the notification text message sent to MD 1 on 4/6/2024 at 5:17 a.m. by the staff nurse, indicated a notification was sent to MD 1 regarding Resident 1 ' s WBC of 33.3 and MD 1 ordered to, start intravenous (IV - medications being given through a vein) fluid of normal saline (a fluid and electrolyte replenisher used as a source of water and electrolytes) at 75 millimeter/hour (ml/hr – unit of measurement) x 1 liter.
A review of Resident 1 ' s Order Summary Report as of 4/10/2024 indicated, there was no physician order was entered regarding physician ' s order of IV fluid of normal saline.
A review of Resident 1 ' s Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations), dated 4/5/2024 indicated, Resident 1 ' s laboratory (lab) test result of white blood count (WBC - measures the number of white cells in the blood, white blood cells are part of the immune system that helps body fight off infection) was 33.3 (normal range: 4.0 – 10.0: high WBC occurs when a person have infection or inflammation in the body).
A review of Resident 1 ' s Progress Notes dated 4/6/2024 at 1:23 p.m., indicated, Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) due to abnormal lab result . and increased general body weakness.
During an interview with Registered Nurse 1 (RN 1) on 4/10/2024 at 11:27 a.m., RN 1 stated, Resident 1 did not look good when she came to work on the morning of 4/6/2024. RN 1 stated, it was endorsed to her by the Registered Nurse 2 (RN 2) that MD 1 ordered an IV fluid to be administered but RN 2 was unable to start a peripheral IV (PIV - a tiny, short, flexible tube, called a catheter to give medication or fluids through the vein) line. RN 1 stated, RN 2 also did not put the order in Resident 1 ' s medical chart. RN 1 stated, Resident 1 was getting worse, so she called MD 1 ordered Resident 1 to be transferred to GACH 1.
During an interview with RN 2 on 4/10/2024 at 2:18 p.m., RN 2 stated, she tried to start an PIV for Resident 1 but unable to do so. RN 2 also stated, she is a new nurse. RN 2 stated, she waited for the oncoming nurse to help her start the PIV line so they can start the IV fluid of normal saline. RN 2 further stated, she did not write the telephone order in Resident 1 ' s medical chart and she does not know how to put the physician ' s order in the electronic medical chart as well.
During an interview with Director of Nursing (DON) on 4/10/2024 at 4:38 p.m., DON stated, nurses should carry out the physician ' s order by writing it in through paper charting and entering in the electronic chart. DON stated, since the medication was not given to Resident 1, it puts him at risk of dehydration. DON further stated, if medications was unable to be given to the resident, they need to notify the physician.
A review of the facility ' s policy and procedures (P&P) titled, Medication Orders, revised 9/2023 indicated, When recording orders for medication, specify the type, route, dosage, frequency, strength and the reason for administration .
A review of the facility ' s P&P titled, Medication and Treatment Orders, revised 9/2023 indicated, Orders for medications and treatments will be consistent with principles of safe and effective order writing . all drug and biological shall be written, dated, and signed by the person lawfully authorized to give such an order . verbal orders must be recorded immediately in the resident ' s chart by the person receiving the order and must include prescriber ' s last name, credentials, the date and the time of the order.
A review of the facility ' s P&P titled, Telephone Orders, revised 9/2023 indicated, Verbal telephone orders may only be received by licensed personnel, orders must be reduced to writing, by the person receiving the order, and recorded in the resident ' s medical record . The entry must contain the instructions from the physician ' s, date, time and the signature and title of the person transcribing the information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prevention policy by failing to report an allegation of sexual abuse within 2 hours or in accordance with state or federal law for two of seven sampled residents (Resident 2 and Resident 3).
This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further sexual abuse for Resident 2 and Resident 3.
Cross Reference F609.
Findings:
A review of Resident 2 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses including encephalopathy (a chemical imbalance in the blood affecting the brain), human immunodeficiency virus (HIV - a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases, It is spread by contact with certain bodily fluids of a person with HIV, most commonly during unprotected sex [sex without a condom or HIV medicine to prevent or treat HIV], or through sharing injection drug equipment), schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly) and cellulitis of right lower limb (bacterial skin infection).
A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 3/5/2024, indicated Resident 2 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was mildly impaired for daily decision-making and required supervision to set-up assistance from staff for activities of daily living (ADL- eating, oral hygiene, personally hygiene).
A review of Resident 3 ' s admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including cellulitis of right and left lower limb, altered mental status, and hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side.
A review of Resident 3's MDS dated [DATE], indicated Resident 3 ' s cognition was mildly impaired for daily decision-making and required moderate to maximal assistance from staff for ADL- eating, oral hygiene, toileting hygiene, and personal hygiene.
During an interview with Resident 2 on 4/10/2024 at 10:53 a.m., Resident 2 stated, he has a partner and in a relationship with another resident, Resident 3. Resident 2 stated, Resident 3 is a black descent, and he is his boyfriend. Resident 2 further stated the staffs are allowing them to have a relationship and they are aware of their situation before but lately; they are not letting them go to the same Activity Room and they separate them. Resident 2 stated, he is to go to the Activity room [ROOM NUMBER] only (3rdfloor) away from Resident 3.
During an interview with Licensed Vocational Nurse 1 (LVN 1) on 4/10/2024 at 11:06 a.m., LVN 1 stated, sometime last week, Restorative Nursing Assistant 1 (RNA 1) reported to her that Resident 2 was found sitting on the lap of Resident 3 inside Resident 2 ' s room. LVN 1 stated, they reported it to the Director of Nursing (DON) and she was made aware of the incident.
During an interview with RNA 1 on 4/10/2024 at 11:12 a.m., RNA 1 stated, she witnessed Resident 2 and Resident 3 in Resident 2 ' s room, Resident 2 was on top of Resident 3 ' s lap while sitting on the wheelchair. RNA 1 stated, she did not witness how it started but she reported it to LVN 1 RNA 1 stated, she separated and reoriented both residents. RNA 1 further stated, they both reported the incident to the DON.
During an interview with Licensed Vocational Nurse 2 (LVN 2) on 4/10/2024 at 11:19 p.m., LVN 2 stated, Licensed Vocational Nurse 3 (LVN 3) mentioned to him on 4/5/2024 that Resident 2 and Resident 3 was observed in the Activity room [ROOM NUMBER] (AR 2) by the Activity Assistant 1 (AA 1) having intercourse. LVN 2 stated, DON and the Administrator (ADM) were aware of the incident and did not do any investigation. LVN 2 stated, DON and ADM did not report it to the State Agency and the Police because they want to hide the situation and the incident. LVN 2 stated, he talked to the DON about it and DON just shrugged it off. LVN 2 further stated, Resident 2 was diagnosed with HIV and the management did not try to do any testing for Resident 3.
During an interview with Resident 3 on 4/10/2024 at 12:03 p.m., Resident 3 stated, he is friend with Resident 2. When asked if he (Resident 3) knows the current date and his location, Resident 3 was unable to answer correctly, Resident 3 answered, today was the 12th and he is in Angeles.
During an interview with Activity Director (AD) on 4/10/2024 at 2:25 p.m., AD stated, AA 1 notified him that Resident 2 was found touching Resident 3 inappropriately sometime last week in the Activity room [ROOM NUMBER] in 3rdfloor. AD stated, he told the managements including DON, ADM and Human Resources (HR) and they had a meeting about it. AD stated, they were told to keep an eye on both residents. AD stated all staffs are mandated reporter that is why he reported it to the managements.
During an interview with DON on 4/10/2024 at 4:27 p.m., DON stated, she was not aware of the sexual abuse allegation incident for Resident 2 and Resident. DON stated, they did not do any investigation of the sexual allegation.
A review of the facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, reviewed 9/2023 indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported . The Administrator or individual making the allegation immediately reports his or her suspicion to the following persons or agencies:
A. the state licensing/certification agency responsible for surveying/licensing the facility
b. the local/state ombudsman
c. The resident ' s representative
d. Adult protective services (where state law provides jurisdiction in long-term care);
e. Law enforcement officials;
f. The resident ' s attending physician; and
g. The facility medical director.
Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy regarding reporting of residents ' allegation of sexual abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for two of seven sampled residents (Resident 2 and Resident 3).
This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further sexual abuse for Resident 2 and Resident 3.
Findings:
A review of Resident 2 ' s admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including encephalopathy (a chemical imbalance in the blood affecting the brain), human immunodeficiency virus (HIV - a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases, It is spread by contact with certain bodily fluids of a person with HIV, most commonly during unprotected sex [sex without a condom or HIV medicine to prevent or treat HIV], or through sharing injection drug equipment), schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly) and cellulitis of right lower limb (bacterial skin infection).
A review of Resident 2's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 3/5/2024, indicated Resident 2 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was mildly impaired for daily decision-making and required supervision to set-up assistance from staff for activities of daily living (ADL- eating, oral hygiene, personally hygiene).
A review of Resident 3 ' s admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including cellulitis of right and left lower limb, altered mental status, and hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right dominant side.
A review of Resident 3's MDS dated [DATE], indicated Resident 3 ' s cognition was mildly impaired for daily decision-making and required moderate to maximal assistance from staff for ADL- eating, oral hygiene, toileting hygiene, and personal hygiene.
During an interview with Resident 2 on 4/10/2024 at 10:53 a.m., Resident 2 stated, he has a partner and in a relationship with another resident, Resident 3. Resident 2 stated, Resident 3 is a black descent, and he is his boyfriend. Resident 2 further stated the staffs are allowing them to have a relationship and they are aware of their situation before but lately; they are not letting them go to the same Activity Room and they separate them. Resident 2 stated, he is to go to the Activity room [ROOM NUMBER] only (3rd floor) away from Resident 3.
During an interview with Licensed Vocational Nurse 1 (LVN 1) on 4/10/2024 at 11:06 a.m., LVN 1 stated, sometime last week, Restorative Nursing Assistant 1 (RNA 1) reported to her that Resident 2 was found sitting on the lap of Resident 3 inside Resident 2 ' s room. LVN 1 stated, they reported it to the Director of Nursing (DON) and she was made aware of the incident.
During an interview with RNA 1 on 4/10/2024 at 11:12 a.m., RNA 1 stated, she witnessed Resident 2 and Resident 3 in Resident 2 ' s room, Resident 2 was on top of Resident 3 ' s lap while sitting on the wheelchair. RNA 1 stated, she did not witness how it started but she reported it to LVN 1 RNA 1 stated, she separated and reoriented both residents. RNA 1 further stated, they both reported the incident to the DON.
During an interview with Licensed Vocational Nurse 2 (LVN 2) on 4/10/2024 at 11:19 p.m., LVN 2 stated, Licensed Vocational Nurse 3 (LVN 3) mentioned to him on 4/5/2024 that Resident 2 and Resident 3 was observed in the Activity room [ROOM NUMBER] (AR 2) by the Activity Assistant 1 (AA 1) having intercourse. LVN 2 stated, DON and the Administrator (ADM) were aware of the incident and did not do any investigation. LVN 2 stated, DON and ADM did not report it to the State Agency and the Police because they want to hide the situation and the incident. LVN 2 stated, he talked to the DON about it and DON just shrugged it off. LVN 2 further stated, Resident 2 was diagnosed with HIV and the management did not try to do any testing for Resident 3.
During an interview with Resident 3 on 4/10/2024 at 12:03 p.m., Resident 3 stated, he is friend with Resident 2. When asked if he (Resident 3) knows the current date and his location, Resident 3 was unable to answer correctly, Resident 3 answered, today was the 12th and he is in Angeles.
During an interview with Activity Director (AD) on 4/10/2024 at 2:25 p.m., AD stated, AA 1 notified him that Resident 2 was found touching Resident 3 inappropriately sometime last week in the Activity room [ROOM NUMBER] in 3rd floor. AD stated, he told the managements including DON, ADM and Human Resources (HR) and they had a meeting about it. AD stated, they were told to keep an eye on both residents. AD stated all staffs are mandated reporter that is why he reported it to the managements.
During an interview with DON on 4/10/2024 at 4:27 p.m., DON stated, she was not aware of the sexual abuse allegation incident for Resident 2 and Resident. DON stated, they did not do any investigation of the sexual allegation.
A review of the facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, reviewed 9/2023 indicated, all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported . The Administrator or individual making the allegation immediately reports his or her suspicion to the following persons or agencies:
A. the state licensing/certification agency responsible for surveying/licensing the facility
b. the local/state ombudsman
c. The resident ' s representative
d. Adult protective services (where state law provides jurisdiction in long-term care);
e. Law enforcement officials;
f. The resident ' s attending physician; and
g. The facility medical director.
Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury . Within five business days of the incident, the administrator will provide a follow-up investigation report. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified.

Based on interview and record review the facility failed to ensure four of six sampled Certified Nursing Assistant staff (CNA 1, CNA 2, CNA 4, and CNA 5) had a performance review every 12 months to provide in-service training based on the outcome of their performance review.
This failure resulted in CNA 1, 2, 4 and 5 being denied a yearly performance review as required by the federal regulation.
Findings:
During a concurrent interview and record review on 4/2/23 at 3:55 pm with Director of Staff Development (DSD) the personnel files of CNA 1, 2, 4, and 5 were reviewed. The files indicated no evidence of a performance review to have been done in the last 12 months for the CNAs employed at the facility. The DSD confirmed the performance reviews were not done and stated they should be done to know where we need further education and if we are up to par, to know where we are lacking so we can improve.
A review of facility's Job Descriptions and Performance evaluation, dated 9/2023, indicated, I. The primary purpose of job descriptions is to provide uniform standards for the implementation of job requirements. Performance evaluations measure the standards against job performance . lt is the responsibility of the director of human resources and/or the respective department director to review with each employee a copy of the employee's job description prior to or upon employment, or upon assignment of duties, to determine if the essential functions of the job can be performed, or if modification of the job position needs to be made.

Based on interview and record review, the facility failed to ensure one of six sampled Certified Nursing Assistant staff (CNA 6) had an active license when employed at the facility.
This failure resulted in CNA 6 not meeting the requirements of the federal regulation for nurse aide registry (certification) verification.
Findings:
A review CNA 6 ' s employee file indicated CNA 6 ' s hire date as 1/12/23 and termination date as 6/9/23.
During a concurrent interview and record review on 4/4/24 at 3:55 pm with Director of Staff Development (DSD) CNA 6 ' s L & C (Licensing & Certification) Verification Detail Page, undated, from CNA 6 ' s personnel file was reviewed. The L& C Verification Detail Page, indicated CNA 6 ' s license status was active, employable with expiration date of 3/19/25. The DSD verified the information and expiration date.
During a concurrent interview and record review on 4/4/24 at 3:55 pm with Director of Staff Development (DSD) CNA 6 ' s L & C (Licensing & Certification) Verification Detail Page, dated 3/28/24, from the California Department of Public Health (CDPH) website, indicated, CNA 6 ' s license status was revoked, not employable with expiration date of 7/12/22. The DSD verified the information and expiration date.
A review of the facilities Certified Nursing Assistant, Job Description, undated, indicated, Qualifications – Currently enrolled in a school for nursing assistants or have a license as a certified nursing assistant.

Based on observation, interview, and record review the facility failed to implement its policies and procedures on infection control to prevent the spread of coronavirus disease 2019 (COVID-19, a highly contagious infection affecting the respiratory system caused by a virus that can spread from person to person) by failing to:
1. Ensure all staff were tested for the COVID-19 before the start of each shift as recommended by the local health department.
2. Ensure certified nursing assistant (CNA 1) wore protective gown and gloves when providing care and when in close contact with the resident who was potentially exposed to COVID-19.
3. Ensure the cleaning cart were sanitized and used exclusively for the rooms that house the COVID-19 positive residents.
These deficient practices had the potential for COVID-19 and other transmissible diseases to spread to residents and staff.
Findings:
1.During a review of the Site Visit Recommendation dated 1/4/24 indicated the local health department provided the facility with several recommendations to stop the spread of COVID-19 in the facility that included all staff to test for the COVID-19 before each shift.
During an interview on 2/7/24 at 9:25 a.m. the restorative nursing assistant 1 (RNA 1, a nursing assistant trained to help nurses in restoring mobility to residents) stated she test for the COVID-19 two times a week. RNA 1 stated she was not aware that she had to test for the COVID-19 daily before each shift.
During an interview on 2/7/24 at 12:44 p.m., the director of rehabilitation (DOR) stated the physical therapy (PT, medical professional that help restore functional movements such as standing, walking, and moving body parts) department test for the COVID-19 two times a week, on Mondays and Thursdays only.
During an interview on 2/7/24 at 2:03 p.m., the infection preventionist (IP) stated due to the COVID-19 outbreak in the facility, the local health department recommended that all staff test for the COVID-19 daily at the beginning of the shift. IP stated it is important to test for the COVID-19 because some staff have no symptoms of the COVID-19 but maybe positive. IP stated the COVID-19 testing helps prevent the spread of the COVID-19.
2. During observation on 2/7/24 at 11:15 a.m., CNA 1, in the presence of the IP, was observed inside Room B assisting a resident. CNA 1 was observed not wearing gloves and protective gown. Outside Room B, a sign was observed that indicated STOP, Novel Respiratory Precautions. The sign posted indicated to wear that included protective gown and gloves on entry. CNA 1 was also observed handling dirty linen with bare hands (without gloves) and walked out of Room B carrying the dirty linen.
During interview on 2/7/24 at 1:35 p.m., CNA 1 stated she should wear protective gown, gloves, and eye shield because she may contract something from the resident: CAN 1 stated the protective personal equipment (PPE, protective clothing, equipment designed to protect wearer's body from injury or infection) will help protect her and the resident from infection.
During an interview on 2/7/24 at 2:03 p.m., the IP stated she was aware that CNA 1 did not wear the appropriate PPE. IP stated CNA 1 should wear PPE because PPE helps prevent the transmission of infection from one resident to another and as a protection for .yourself and the resident.
3. During an interview on 2/7/24 at 10:06 a.m., Housekeeper 1 (HSK 1) stated she cleans the area with no COVID19 positive residents first and clean the COVID19 unit last. HKP 1 stated she uses the same cleaning cart for cleaning the COVID19 unit.
During observation on 2/7/24 at 2:27 p.m., two cleaning carts were observed inside the janitor's room. During concurrent interview, the maintenance supervisor (MS) stated he does not know which cleaning cart was used to clean the COVID-19 unit. MS stated the cleaning carts were disinfected after use. MS stated he does not have any documentation to show that the cleaning carts were disinfected after use.
During a review of the facility's Policy and Procedures (P&P) titled Coronavirus (COVID-19) - Infection and Control Measures reviewed on 9/23, indicated, The facility follows infection prevention and control practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. Implementation included source control measures, universal use of PPE for staff, and performing testing as recommended by current guidelines.
During a review of the facility's P&P titled Coronavirus Disease (COVID-19)- Testing Staff reviewed on 9/23, indicated the facility will, follow all recommended infection prevention and control practices, including wearing well-fitting source control, monitoring themselves for fever and symptoms associated with COVID-19. Viral testing for all staff (regardless of vaccination status) is conducted if there is an outbreak in the facility.
During a review of the facility's P&P titled Standard Precautions reviewed on 9/23, indicated, Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Gloves are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material. Gowns are worn to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions or cause soiling of clothing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a clean, free of odor, safe and home like environment for two of four sampled residents (Residents 1 and 4).
This deficient practice resulted in Resident 1 feeling dizzy from the strong distinct odors and had also the potential of placing other residents at risk of cross contamination, spread of disease-causing organism, and accident/incidents.
Findings:
A review of the admission Record (FS) for Resident 1 indicated that Resident 1 originally admitted on [DATE], and was re-admitted on [DATE] with diagnoses including heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), and morbid (severe) obesity (abnormal or excessive fat accumulation that presents a risk to health).
A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 11/1/2023, indicated Resident 1 was cognitively intact (mental ability to make decisions of daily living) and required partial assistance for upper and lower body dressing, toileting, and putting on/or taking off footwear. The MDS further indicated Resident 1 required set up assistance for eating and oral hygiene.
A review of the FS for Resident 4 indicated was initially admitted on [DATE] and re-admitted [DATE] with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality, which can be distressing for them and for their family and friends), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and morbid obesity.
A review of his MDS dated [DATE] indicated Resident 4 was moderately impaired cognitively (observable delays in the development of speech or motor skills, which may be accompanied by physical impairments) and that he (Resident 4) was dependent for toileting hygiene, lower body dressing, and putting on/taking off footwear. It also indicated that Resident 4 required partial/moderate assistance for personal hygiene. It further indicated that he required that he required supervision or touch assistance for eating and oral hygiene.
During an observation and interview with Resident 1 on 11/21/2023 at 11:15 a.m., Resident 1 ' s room was noted to have a strong body odor. His side of the bed was observed to be cluttered with his personal belongings all over the floor. Resident 1 stated his roommate (Resident 4) stinks and refuses to be showered or bathed. He further stated that Resident 4 refuses to be cleaned whenever he had a bowel movement in his diaper. He also stated that one early morning on 11/17/2023 around 2 a.m., the smell got so bad in the room that it (smell) reached the nurse ' s station. The nurses couldn ' t stand it they close my room door. Resident 1 stated that he could sleep because the fan was not effective in blowing out the smell since the door was closed. He tried wearing a mask, covering his nose with his blanket, and mouth breathing with no luck. He started to feel dizzy and left the room to go outside on the patio to get fresh air for 2 hours.
During an interview with Licensed Vocational Nurse (LVN) 1 on 11/21/2023 at 12:52 p.m., LVN 1 stated that Resident 1 is non-compliant about his personal hygiene (shaving, shower, cleaning clutter around his side of the bed) even though he had been complaining about Resident 4 ' s non-compliance of getting changed and taking showers. He admitted that Resident 1 and 4 ' s room does have some strong odors and that nurses do close the door when it gets bad. He stated that the potential effect of having cluttered room would result falls, injuries, and infections. He agreed that having bad odors is not home like.
A review of the facility's policy and procedures titled Homelike Environment, which was reviewed 1/2023 indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The same policy indicated, the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:
a. clean, sanitary and orderly environment;
b. comfortable {minimum glare) yet adequate {suitable to the task) lighting;
c. inviting colors and decor;
d. personalized furniture and room arrangements;
e. clean bed and bath linens that are in good condition;
f. pleasant, neutral scents;
g. plants and flowers, where appropriate;
h. comfortable and safe temperatures {71 °f - 81 °f); and
i. comfortable sound levels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to adequately assess stage Pressure Ulcers (PU-are skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin) for two of three sampled residents (Residents 2 and 3).
This deficient practice had the potential to result in improperly treating the wound which may lead to the wound getting worse for Resiednts 2 and 3.
Findings:
A review of Resident 2 's admission Record (FS) indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus 2 (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), dysphagia (swallowing difficulties where some people have problems swallowing certain foods or liquids, while others can't swallow at all), and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
A review of the Interdisciplinary team (IDT- an essential part of collaborative care, where physicians, nurses, therapists, social workers, and other professionals work together to plan and coordinate patient care) notes dated 11/1/2023 indicated, Resident 2 had been admitted with a left heel blood blister.
A review of the history and physical (a term used to describe a physician's examination of a patient in an H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) dated 7/28/2023 indicated that Resident 2 did not have the capacity to understand and make decisions. It further indicated that Resident 2 had a chronic stage II left heel PU.
A review of Resident 3 ' s FS indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a group of conditions that cause brain dysfunction. Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form), Cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of right lower limb, and pneumonia (an infection that inflames your lungs' air sacs (alveoli). The air sacs may fill up with fluid or pus, causing symptoms such as a cough, fever, chills, and trouble breathing).
A review of Resident 3 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 9/4/2023, indicated Resident 3 had some severe cognitive impairment (people with severe cognitive impairment have a very hard time remembering things, making decisions, concentrating, or learning) and required set up assistance for eating and personal hygiene. It further indicated that Resident 3 required 1-person physical assistance for bed mobility, transfer, locomotion on and off the unit, dressing, and toilet use.
During a concurrent interview and record review of the Treatment Administration Record (TAR-a legal and accurate record of the treatments received by the patient, including details such as the date, time, dosage, route of administration) with the treatment nurse (TN) 1 on 11/21/23 at 11:30 a.m., TN 1 confirmed that Resident 3 has Moisture Associated Skin Damage (MASD- inflammation, and erosion of the skin, result from prolonged exposure to different sources of moisture such as feces, urine, sweat, saliva, wound exudate, mucus, perspiration, digestive secretions, and other bodily fluids) to his sacrococcyx (the joint formed between the oval surface at the apex of the sacrum [triangle shaped bone just below the vertebrae], and the base of the coccyx [tail bone]) extending to the perinium (the thin layer of skin between your genitals [vaginal opening or scrotum] and anus) with an open area. She stated that the treatment was to cleanse with normal saline, pat dry and apply xerofoam and foam dressing.
During a concurrent interview and record review of Residents 2 and 3 's charts with the Director of Nursing (DON) on 11/21/23 at 3:30 p.m., the DON confirmed that Resident 3 was admitted from General Acute Health Care (GACH) with a stage 2 PU to the left heel. The DON stated that the initial skin assessment was their own and what they saw at the time. The DON stated that Resident 3 was admitted with MASD extending to the perineum with open skin to the sacroccoyx area. She confirmed that the initial assessment had indicated that the Resident 3 was admitted with a stage 4 PU alongside the MASD which extended to his perineum.
During an interview with the Wound Care Specialist (WCS) on 11/22/2023 at 11:30 a.m., WCS confirmed that Resident 3 had a PU on admission. WCS stated that PU must never be downgraded because it does not precisely reflect what's happening in a healing wound.
A review of the facility's policy and procedure (P&P) titled Staffing, Sufficient and Competent Nursing reviewed 1/2023 indicated a policy statement Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The P&P defined competent staff as a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. The same P&P indicated that licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting, and reporting resident changes of condition consistent with their scope of practice and responsibilities.
A review of the facility's P&P titled Pressure Injuries Overview reviewed 1.2023 defined pressure Ulcer/Injury (PU/PI) as localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device.
- A pressure injury will present as intact skin and may be painful.
- A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful.
- Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft
tissue.
The same policy indicated the following stages:
Stage 1 Pressure Injury: Non-blanchable erythema of intact skin.
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis.
Stage 3 Pressure Injury: Full-thickness skin loss.
Stage 4 Pressure Injury: Full-thickness skin and tissue loss.
Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss.
Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple
Discoloration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for two of the four sampled residents (Resident 1 and 4) by failing to ensure Residents 1 and 4 Activities of Daily Living (ADL -which included showers and incontinence care [assistance with bladder and/or bowel function which includes supporting a person to maintain continence and manage incontinence]) care refusals were care planned and addressed during Interdisciplinary team meetings.
These deficient practices resulted in Resident 1 and 4 ' s room to cause a strong odor that spread to the nursing station. The nurses shut the door which made Resident 1 feel dizzy from smelling the odor that he had to leave the room at 2 a.m.
Findings:
A review of the admission Record (FS) indicated the Resident 1 originally admitted on [DATE], and was re-admitted on [DATE] with diagnoses including heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), and morbid (severe) obesity (abnormal or excessive fat accumulation that presents a risk to health).
A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 11/1/2023, indicated Resident 1 was cognitively intact (mental ability to make decisions of daily living) and required partial assistance for upper and lower body dressing, toileting, and putting on/or taking off footwear. The MDS further indicated Resident 1 required set up assistance for eating and oral hygiene.
A review of the FS for Resident 4 indicated was initially admitted on [DATE] and re-admitted [DATE] with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality, which can be distressing for them and for their family and friends), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and morbid obesity.
A review of his MDS dated [DATE] indicated Resident 4 was moderately impaired cognitively (observable delays in the development of speech or motor skills, which may be accompanied by physical impairments) and that he (Resident 4) was dependent for toileting hygiene, lower body dressing, and putting on/taking off footwear. It also indicated that Resident 4 required partial/moderate assistance for personal hygiene. It further indicated that he required that he required supervision or touch assistance for eating and oral hygiene.
During an observation and interview with Resident 1 on 11/21/2023 at 11:15 a.m., Resident 1 ' s room was noted to have a strong body odor. His side of the bed was observed to be cluttered with his personal belongings all over the floor. Resident 1 stated his roommate (Resident 4) stinks and refuses to be showered or bathed. He further stated that Resident 4 refuses to be cleaned whenever he had a bowel movement in his diaper. He also stated that one early morning on 11/17/2023 around 2 a.m., the smell got so bad in the room that it (smell) reached the nurse ' s station. The nurses couldn ' t stand it they close my room door. Resident 1 stated that he could sleep because the fan was not effective in blowing out the smell since the door was closed. He tried wearing a mask, covering his nose with his blanket, and mouth breathing with no luck. He started to feel dizzy and left the room to go outside on the patio to get fresh air for 2 hours.
During an interview with Licensed Vocational Nurse (LVN) 1 on 11/21/2023 at 12:52 p.m., LVN 1 stated that Resident 1 is non-compliant about his personal hygiene (shaving, shower, cleaning clutter around his side of the bed) even though he had been complaining about Resident 4 ' s non-compliance of getting changed and taking showers. He admitted that Resident 1 and 4 ' s room does have some strong odors and that nurses do close the door when it gets bad. LVN 1 confirmed that the non-compliance was not care planned and admitted that one (care plan) should have been initiated to address the problem. He stated that care planning is important in that other nurses would be aware about what interventions to provide for both Residents 1 and 4. LVN 1, further confirmed that there was no documented evidence about education provided to both residents.
During an interview and record review of Residents 1 and 4 ' s charts with the Director of Nursing (DON) on 11/21/2023 at 2:45 p.m., The DON confirmed that there was no documented evidence of the education regarding the noncompliance of personal hygiene provided to both residents 1 and 4. She also confirmed that there were no care plans initiated, nor Interdisciplinary team (IDT- an essential part of collaborative care, where physicians, nurses, therapists, social workers, and other professionals work together to plan and coordinate patient care) meetings held to address the noncompliance. She stated that education could have helped improve the outcomes and care planning directs nurses on how to care for the residents.
A review of the facility's policy and procedures titled Care Plans. Comprehensive Person-Centered reviewed 1/2023 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. It further indicated the policy interpretation which included:
-The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.
-The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.
-If the participation of the resident and his/her resident representative in developing the resident's care plan is determined to not be practicable, an explanation is documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative in the process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received the care and supervision to prevent falls as evidenced by:
-Failing to correctly assess Resident 1 as indicated on the Fall Risk Assessment and identify Resident 1 was at high risk for falls.
-Failing to care plan for Resident 1's non-compliance with the front wheel walker and the resident's refusal of staff assistance with ambulation.
As a result, on 11/7/2023, Resident 1 fell and sustained a hematoma (an abnormal collection of blood outside of the blood vessel) to the head and a femoral neck fracture (broken upper thigh bone) and an impacted subcapital right femoral neck fracture (break in the upper thigh bone).
Findings:
A review of the admission Record indicated the facility admitted Resident 1 on 6/22/2020 and re-admitted the resident on 11/15/2023 with diagnoses including encephalopathy (brain dysfunction that can appear as confusion, memory loss, personality changes and/or coma in the most severe form), dementia (impaired ability to remember, think, or make decisions that interferes with doing every day activities), heart failure (when heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), rhabdomyolysis (a condition in which damaged muscle breaks down rapidly), adult failure to thrive (a decline in older adults that manifests as a downward spiral of health and ability), abnormalities of gait (a person's manner of walking) and mobility, and lack of coordination.
A review of the History and Physical (H&P) dated 4/6/2023, indicated Resident 1 did not have the capacity to understand and make decisions due to the reason of Alzheimer's (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). The H&P further indicated Resident 1 had a history of Alzheimer's, gait disorder, and poor memory.
A review of the Physician's Order dated 4/28/2023, indicated Resident 1 could ambulate (walk) using a front wheel walker (FWW) ad lib (as desired) around the facility as tolerated.
A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 10/27/2023, indicated Resident 1 had moderately impaired cognition (decisions poor; cues/supervision required), had impaired vision, and had delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 1 had no impairment to the upper/lower extremities and utilized a walker and required partial/moderate assistance for showering/bathing, and required supervision or touching assistance for personal hygiene, putting on/taking off footwear, lower body dressing, and upper body dressing. The MDS indicated Resident 1 required set up or clean up assistance for toileting, oral hygiene, eating, rolling left and right, sitting to lying, lying to sitting on the side of the bed, toilet transfer, walking 10 feet, walking 50 feet with two turns, and walking 150 feet. The MD further indicated Resident 1 was continent of bowel and bladder.
According to a review the Interdisciplinary Plan of Care Review Form dated 7/27/2023, Resident 1 was provided safety education to continue use of the FWW when ambulating. The Interdisciplinary Plan of Care Review Form indicated Resident 1 was explained the risk of fall/injury if their gait had imbalance and of the non-compliance of using a FWW. The Plan of Care Review form indicated Resident 1 understood the risk and benefits of preventing falls.
A review of the Care Plan initiated on 7/31/2023, indicated Resident 1 was at risk for falls related to the disease processes of lack of coordination, dementia, and abnormalities of gait and mobility. The care plan indicated the goals for Resident 1 to be free of falls, free of minor injury, and to not sustain serious injury through the review date. The care plan interventions indicated to anticipate and meet Resident 1's needs, to be sure the resident's call light was within reach, and to encourage the resident to use it for assistance as needed. The care plan interventions indicated Resident 1 needed prompt response to all requests for assistance, needed to be evaluated for and supplied appropriate adaptive equipment or devices as needed; to re-evaluate as needed for continued appropriateness; and to ensure least restrictive devices.
The care plan interventions indicated Resident 1 needed a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in low position at night, a front wheel walker, a wheelchair or side rails as ordered, had rails on walls, personal items within reach, and bilateral upper side rails.
A review of the Fall Risk assessment dated [DATE], indicated Resident 1 had a fall risk score of 8 (a total score above 10 represents a high risk for falls). The Fall Risk Assessment indicated Resident 1 had intermittent confusion or poor safety awareness, no falls in the past three months, was ambulatory, had adequate vision (with or without glasses), had a balance problem while standing, had a balance problem while walking, required the use of an assistive device, no noted drop of systolic blood pressure (top number) between lying and standing, took 1-2 medications currently and/or within the last seven days, and had no predisposing disease present (from the list of hypotension, vertigo (dizziness), cerebral vascular accident [CVA], Parkinson's disease, loss of limb, seizure, arthritis, osteoporosis, or fractures). The Fall Risk Assessment did not indicate whether Resident 1 was low or moderate risk for falls.
A review of the Interdisciplinary Plan of Care Review Form dated 10/23/2023, indicated Resident 1 was able to walk independently with the FWW ad lib. The Plan of Care Review Form indicated Resident 1 did not have a fall incident for three months and had no behavioral issues. The Plan of Care Review Form indicated Resident 1 had a FWW available at bedside, was stable to ambulate in and out of bed and the rest room, had socks and a FWW within reach, and the assistive device was working properly without issues in maintenance.
A review of the Fall Risk assessment dated 10/27 (no documentation of year), indicated Resident 1 had a fall risk score of 6 (a total score above 10 represents high risk for fall). The Fall Risk Assessment indicated Resident 1 had intermittent confusion or poor safety awareness, no falls in the past three months, was ambulatory, had normal gait and balance, no noted drop of systolic blood pressure between lying and standing, takes 1-2 medications currently and/or within the last seven days, and had no predisposing disease present (from the list of hypotension, vertigo, CVA, Parkinson's disease, loss of limb, seizure, arthritis, osteoporosis, or fractures). The Fall Risk Assessment indicated the vision status portion of the assessment was not completed. The Fall Risk Assessment did not indicate whether Resident 1 was low or moderate risk for falls.
According to a review of the Joint Mobility assessment dated [DATE], there were no problems noted in the summary for Resident 1 and Resident 1 was to continue ad lib ambulation.
A review of the Physician's Order dated 11/7/2023, indicated to send Resident 1 to the General Acute Care Hospital (GACH)'s emergency room (ER) for evaluation of hematoma (an abnormal collection of blood outside of a blood vessel) on the right forehead.
A review of the Progress Note dated 11/7/2023 at 1:31 PM, indicated at 1:20 PM the Certified Nursing Assistant (CNA) was passing by and noted that Resident 1 was sitting on the floor leaning towards the door with blood on the face and some drops on the floor. The Progress Note indicated the CNA alerted the Licensed Nurse (LN) immediately, an assessment was done and Resident 1 was able to verbalize what happened stating Resident 1 tried to pick up something on the floor. The Progress Note indicated the floor was free from scattered belongings and was dry. Resident 1's bilateral lower extremity and upper extremity range of motion was conducted and indicated there was no limitation, no pain, and no facial grimacing.
The Progress Note indicated Resident 1 was assisted back to bed with a two-person assist, had no complaints of pain or discomfort during the transfer. A body re-assessment was done, and indicated Resident 1 had no pain and no swelling on both hips, knees, or part of the body. The Progress Note indicated Resident 1 was noted with a hematoma on the right side of the forehead, first aid was rendered and an ice pack was applied. Resident 1 was noted with a five-centimeter skin tear which was cleansed with normal saline, applied with steri-strips, and covered with a dry dressing. The Progress Note indicated Resident 1 had an elevated blood pressure of 195/110 (normal blood pressure between 90/60 millimeters of mercury (mmHg) and 120/80 mmHg), the paramedics and Resident 1's physician were notified. The Progress Note further indicated the paramedics arrived at 1:45 PM and transferred Resident 1 to the GACH.
A review of the Situation Background Assessment and Recommendation (SBAR) Communication Form and Progress Note dated 11/7/2023 at 1:51 PM, indicated Resident 1 had an unwitnessed fall in the room and sustained a large hematoma to the right side of the forehead with bleeding. The SBAR note indicated Resident 1 remained awake and responsive during the transfer to the Emergency Department. The SBAR note indicated Resident 1's blood pressure was 195/110, pulse 88, respirations 22, temperature 97.2, and oxygen saturation 97%.
A review of the Computed Tomography (CT, an imaging exam that takes pictures of the inside of the body) of the brain without contrast (refers to a substance taken by mouth or injected into a vein that causes the particular organ under study to be seen more clearly) result dated 11/7/2023 at 3:24 PM, indicated Resident 1 had a right frontal soft tissue hematoma.
A review of the right hip x-ray (an imaging procedure that takes pictures of the inside of the body using radiation) results dated 11/7/2023 at 3:57 PM, indicated Resident 1 had a concern for a fracture of the femoral neck/head junction on the right side (break in the upper thigh bone).
A review of the GACH History and Physical (H&P) dated 11/8/2023 at 10:42 AM, indicated Resident 1 was admitted to the GACH on 11/7/2023. The H&P indicated Resident 1 was brought to the GACH after having had a fall and per nursing home documentation Resident 1 missed the rail and fell with hematoma to the right upper forehead. The H&P indicated Resident 1 was seen and evaluated in the ER by the ER physician and neurosurgery (specializes in the diagnosis and surgical treatment of disorders of the central and peripheral nervous system). The H&P indicated a subsequent brain imaging was done which showed a small contusion (type of hematoma). The H&P indicated Resident 1 had a laceration (deep cute or tear in the skin) on the right upper forehead that was repaired using prolene sutures (sterile sutures).
The H&P indicated a CT of the brain was obtained which showed Resident 1 had a 6 millimeter (mm, a measure of length) right temporal hemorrhage/cortical contusion (brain bruise). The H&P indicated a CT of the hip was also done which showed Resident 1 had an impacted subcapital right femoral neck fracture (break in the upper thigh bone).
A review of the CT of the brain without contrast imaging result dated 11/8/2023 at 2:04 AM, indicated Resident 1 had the second CT due to head trauma with worsening mental status and concern for delayed hemorrhage. The CT indicated Resident 1 had interval development of 6 mm right temporal hemorrhagic cortical contusion.
According to a review of the x-ray of the right femur dated 11/8/2023 at 2:38 AM, redemonstrated Resident 1 had an impacted subcapital femoral neck fracture.
A review of the GACH Orthopedic Surgery (physicians who specialize in surgery of bones and joints) Note dated 11/14/2023 at 2:04 PM, indicated Resident 1 was to be on strict non-weight bearing to the right lower extremity. The note further indicated Resident 1 had non-operative fractures and was to receive Eliquis 2.5 mg by mouth twice daily due to the resident's high risk for deep vein thrombosis (DVT, blood clot formation in a deep vein).
During an observation on 11/20/2023 at 10 AM, Resident 1 was observed with a bump to the right upper side of the forehead and a small laceration above their right eye. Resident 1 was observed with the bed in low position with floor mats to the left and right side of the bed. Resident 1's FWW was observed at bedside. During a concurrent interview, Resident 1 stated he got the bump on the forehead when he Turned the corner a little too fast, and hit his head on the corner. Resident 1 stated he did not remember the date or the time the fall happened. Resident 1 stated he did not call the nurses for help because he did not need help. Resident 1 stated, I don't need to call for help to the bathroom, if I need to go I will go by myself.
On 11/20/2023 at 10:29 AM, during an interview, CNA 1 stated she was walking past Resident 1's room when she saw the resident sitting on the floor by the door with blood. CNA 1 stated there was blood on the floor and on Resident 1's head. CNA 1 stated Resident 1 was confused and was not able to say what happened. CNA 1 stated there was a lot of blood on the floor. CNA 1 stated she called the charge nurse to report what she saw.
During an interview on 11/20/2023 at 10:37 AM, CNA 2 stated she was assigned to take care of Resident 1 the day the resident had the fall. CNA 2 stated she was with another resident when Resident 1 was found and indicated staff had called for her. CNA 2 stated when she went to Resident 1's room, the resident was already on the floor and the charge nurse was with them. CNA 2 stated prior to Resident 1 having the fall, the resident would get up and go to the bathroom by themselves. CNA 2 stated Resident 1 had moments of confusion. CNA 2 stated Resident 1 had a FWW next to him but never used it. CNA 2 stated sometimes Resident 1 would call out for help if he saw someone walking by, but stated the resident was reluctant to have assistance, stating that when staff would offer help the resident would refuse. CNA 2 stated prior to Resident 1 having the fall, the resident did not have a bed alarm or floor mats.
During an interview on 11/20/2023 at 11:40 AM, Resident 2 stated Resident 1 was his roommate. Resident 2 stated prior to Resident 1 having the fall, Resident 1 would walk to the bathroom on his own. Resident 2 stated sometimes Resident 1 would not use the FWW. Resident 2 stated Resident 1 often refused staff help and stated staff would even tell the resident it might be better to use diapers. Resident 2 stated Resident 1 refused staff help a lot.
During an interview on 11/20/2023 at 2:03 PM, Licensed Vocational Nurse (LVN) 1 stated she had been taking care of Resident 1 since the resident had been in the facility in 2022. LVN 1 stated the day Resident 1 fell she saw the resident on the floor with his back against the door. LVN 1 stated she saw a hematoma on the side of Resident 1's head that was slightly bigger than a tennis ball. LVN 1 stated Resident 1 had dementia, was confused, would recognize you but could not remember your name and would start talking about random things. LVN 1 stated Resident 1 would not come out of the room but would go back and forth to the bathroom.
LVN 1 stated Resident 1 did not like to use the FWW and would forget he was a little unsteady. LVN 1 stated Resident 1 would refuse help. LVN 1 stated Resident 1 had a shuffle kind of step. LVN 1 stated Resident 1 had orders that he was free to walk around the facility with the walker. LVN 1 stated Resident 1 was required to use the FWW which he refused to use. LVN 1 stated Resident 1 did not have a bed alarm or floor mats prior to the resident having the fall.
On 11/21/2023 at 9:48 PM, during an interview, the Director of Rehab (DOR) stated Resident 1 had a quarterly check-up for physical therapy (PT) and indicated the resident no longer needed assistance from the Restorative Nursing Assistant (RNA) and was able to walk ad-lib with a FWW. The DOR stated Resident 1 was stable on his feet, needed some close level assistance but after several months RNA was stable, stronger, and able to walk on his own.
During an interview on 11/21/2023 at 10:04 AM, RNA 1 stated Resident 1 was discharged from RNA services before the resident had the fall. RNA 1 stated Resident 1 was walking by themselves with a FWW. RNA 1 stated prior to the fall, Resident 1 was walking to the bathroom from his bed with the FWW. RNA 1 stated Resident 1 could walk on his own but would tell the resident to always call for help before he got up. RNA 1 stated Resident 1 would always refuse and say, No I can do it. Don't bother me, so staff let him do it but would watch him to make sure the resident got back to bed ok.
During a concurrent interview and record review, on 11/21/2023 at 11:40 AM, Resident 1's Fall Risk assessment dated 10/27 and MDS dated [DATE] was reviewed with Registered Nurse (RN) 1. RN 1 stated he was working as RN supervisor the day Resident 1 fell, and indicated he was called to come and see the resident after he fell. RN 1 stated he saw Resident 1 was bleeding profusely and needed to be sent out. RN 1 stated the fall risk assessment was done incorrectly. RN 1 stated Resident 1's fall risk assessment was not complete and indicated the score should be 13 not 8. RN 1 stated based on the MDS, Resident 1 had intermittent confusion or poor safety awareness, was ambulatory/continent, required the use of an assistive device, had a poor (with or without glasses-unable to read regular print) vision status, takes 1-2 medications and had three or more predisposing disease based on the active diagnoses in the MDS. RN 1 stated Resident 1 was supposed to be a high risk for falls, and would have required a bed alarm, low bed, a room closer to the station, and a more visual eye on the resident. RN 1 stated the day Resident 1 fell the resident did not have floor mats or a bed alarm, and indicated he did not see a FWW at bedside.
During a concurrent interview and record review, on 11/21/2023 at 12 PM, Resident 1's Fall Risk assessment dated 10/27 and MDS dated [DATE] were reviewed with Minimum Data Set Assistant (MDSA). MDSA stated she usually did the fall risk assessments and indicated sometimes the licensed nurses help her to do them as well. MDSA stated the fall risk assessments were done quarterly. MDSA stated Resident 1's Fall Risk assessment dated 10/27 was conducted this year 2023. MDSA stated the Fall Risk Assessment was not done completely. The MDSA stated the vision status portion was not completed, the gait/balance portion was done incorrect and should have indicated Resident 1 required the use of an assistive device. The MDSA stated the predisposing disease response on the fall risk assessment was based on whether Resident 1 had hypotension, vertigo, CVA, Parkinson's Disease, Loss of Limb, seizure, arthritis, osteoporosis, fractures. The MDSA stated when looking at Resident 1's active diagnoses on the MDS, the resident had three or more predisposing diseases that would contribute to the resident's risk of falls.
A review of Resident 1's Care Plan on 11/21/2023 at 12:15 PM, indicated there was no specific care plan for Resident 1's non-compliance of ambulating with a FWW or refusal of staff assistance with ambulation.
During a concurrent interview and record review, on 11/21/2023 at 12:32 PM, Resident 1's Fall Risk assessment dated 10/27, MDS dated [DATE], and care plan were reviewed with LVN 1. LVN 1 stated the fall risk assessment was done incorrectly. LVN 1 stated Resident 1's fall risk assessment was not complete and indicated the score should be 13 not 8. LVN 1 stated based on the MDS, Resident 1 had intermittent confusion or poor safety awareness, was ambulatory/continent, required the use of an assistive device, had a poor (with or without glasses-unable to read regular print) vision status, takes 1-2 medications, and had three or more predisposing diseases based on the active diagnoses in the MDS. LVN 1 stated Resident 1 was a high risk for falls, and needed more interventions such as floor mats, bed alarm, and visual monitoring. LVN 1 stated Resident 1 did not have a specific care plan for the refusal of FWW or refusal of staff assistance to prevent falls. LVN 1 stated the fall risk assessment and care plans were important to prevent falls and to provide appropriate interventions. LVN 1 stated the day Resident 1 fell, the resident did not have floor mats or a bed alarm.
During a concurrent interview and record review, on 11/21/2023 at 1:33 PM, Resident 1's Fall Risk assessment dated 10/27, MDS dated [DATE], and Care Plan were reviewed with the Director of Nursing (DON). The DON stated fall risk assessments were done on admission, quarterly, annually, and with change of condition. The DON stated the purpose of a fall risk assessment was to determine the interventions a resident may need to prevent falls. The DON stated the fall risk assessment dated 10/27 was done incorrectly. The DON stated the vision status portion was not completed, the gait/balance portion was done incorrect and should have indicated Resident 1 required the use of an assistive device. The DON stated the MDSA's predisposing disease response on the fall risk assessment was based on whether Resident 1 had hypotension, vertigo, CVA, Parkinson's Disease, loss of limb, seizure, arthritis, osteoporosis, or fractures.
The DON stated when looking at Resident 1's active diagnoses on the MDS, the resident had three or more predisposing diseases that would contribute to the resident's risk of falls. The DON stated Resident 1 had cognitive impairment, heart failure, anemia, neurological disorders, and balance and gait disorders which according to facility policy were conditions that may contribute to the risk of falls. The DON stated there was no care plan that specifically addressed Resident 1's refusal for staff assistance to the bathroom or refusal of use of FWW to prevent falls. The DON stated the care plan should be specific to the resident and indicated Resident 1 had issues with non-compliance before. The DON stated Resident 1's refusal of staff assistance when ambulating to the bathroom and refusal of the FWW should have been care planned. The DON indicated there was no care planning for non-compliance for Resident 1's refusal of staff assistance with ambulation or the refusal to use the FWW with ambulation. The DON indicated identifying a resident was at high risk for falls and through care planning could have prevented falls.
A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, reviewed 1/2023, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological, and functional needs was developed and implemented for each resident. Assessments of residents were ongoing and care plans were revised as information about the resident and resident's conditions change.
A review of the facility's policy and procedure titled, Goals and Objectives, Care Plans, reviewed 1/2023, indicated care plan goals and objectives were defined as the desired outcome for a specific resident problem. Care plan goals and objectives were derived from information contained in the resident's comprehensive assessment and were resident oriented, were behaviorally stated, were measurable, and contain timetables to meet the resident's needs in accordance with the comprehensive assessment.
A review of the facility's policy and procedure titled, Fall Risk Assessment, reviewed 1/2023, indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered fall prevention plan based on relevant assessment information. The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as decreased vision and peripheral neuropathy) that may predispose to falls. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis).
The staff with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living capabilities, activity intolerance, continence and cognition. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that were not modifiable.
A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing reviewed 1/2023, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to the risk of falls include fever, infection, delirium and other cognitive impairment, pain, lower extremity weakness, poor grip strength, medication side effects, orthostatic hypotension, functional impairments, visual deficits and incontinence. Medical factors that contribute to the risk of falls include arthritis, heart failure, anemia, neurological disorders and balance and gait disorders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to re admit one of three sampled resident (Resident 1) after hospitalization on 11/9/2023 at a General Acute Care Hospital (GACH) as indicated in the facility's policy and procedure (P&P) titled Bed-holds and Returns.
As a result, Resident 1 remained in GACH 1 since 11/16/2023 and had the potential to cause psychosocial harm.
Findings:
A review of Resident 1 ' s admission Record indicated resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest in life).
A review of Resident 1 ' s History and Physical, dated 10/29/2023, physician indicated, resident does not have the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/25/2023 indicated the resident required supervision from staff for activities of daily living (ADLs-bed mobility, transfers, dressing, eating, toilet use, and personal hygiene).
A review of Resident 1 ' s care plan for risk for falls related to disease process, revised on 11/8/2023, indicated interventions including, anticipate and meet the resident ' s needs, be sure the resident ' s call light (a device used to notify the nurse that the resident needs assistance) within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance .
A review of Resident 1 ' s Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Record, dated 11/9/2023 indicated, Resident (1) observed in supine (lying horizontally with the face and torso facing up) position, right side of bed in between the space of bedside tablet and bed . transfer to hospital for further evaluation.
A review of Resident 1 ' s Physician Note from General Acute Care Hospital 1 (GACH 1), dated 11/12/2023, indicated, Anticipate discharge back to skilled nursing facility tomorrow (11/13/2023).
During an interview with admission Director (AD) on 11/16/2023 at 10:27 a.m., AD stated, they received readmission request and clinical record from GACH 1 indicating Resident 1 was ready to be readmitted on [DATE]. AD stated, they have beds available for Resident 1 to be readmitted on [DATE]. AD stated, the Case Manager from GACH 1 sent over the clinical record on 11/13/2023 which required to be reviewed by the Director of Nursing (DON). AD stated, he sent over the GACH 1 ' s medical record to DON on 11/13/2023 and DON replied to him on 11/14/2023 indicating that before they can readmit Resident 1, they will need safety equipment including padded bedside full rails, low bed, floor mats and soft helmet. AD stated, he notified Maintenance Supervisor (MS) to order the equipment.
During an interview with DON on 11/16/2023 at 10:46 a.m., DON stated, she was able to review the GACH 1 ' s Clinical Record on 11/14/2023 in which she had determined to readmit Resident 1 but need safety equipment prior to readmitting which was a full bed side rails, soft helmet, low bed, and floor mat. DON stated, Resident 1 was transferred to GACH 1 for further evaluation after Resident 1 was found on the floor. DON stated, they don ' t have a full bed siderails at the facility and a soft helmet, so she requested more time from GACH 1 to readmit Resident 1.
During an interview with MS on 11/16/2023 at 11:11 a.m., MS stated, they don ' t have any bedside full rails in the facility. MS stated he tried to order them from the company that provides them supplies in which he was told that full siderails no longer exist as it is considered a physical restraint (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body) and therefore, no longer available. MS further stated, he even looked on Amazon to order the equipment but did not find any full siderails. MS stated, he was aware the full side bedrails are considered physical restraints.
During a follow-up interview with DON on 11/16/2023 at 12:59 p.m., DON stated, they were not able to find a full bed siderails, but soft helmet arrived today. When asked regarding Resident 1 ' s fall risk care plan and intervention, DON stated, Resident 1 ' s needs should be met by providing patient care and staffs assistance to prevent injury if Resident 1 had another fall incident. DON stated, she was aware that a bed full siderails are considered physical restraints. When asked if Resident 1 is on physical restraints, DON stated, no. When asked if preventing injury during a residents ' fall was being relied upon equipment, DON stated no. DON further stated, they will readmit Resident 1 today. When asked if Resident 1 should have been readmitted since 11/13/2023 as ordered by the physician, DON did not answer.
A review of the facility ' s policy and procedure (P&P) titled, Bed-Holds and Returns, reviewed on 1/2023 indicated, The resident will be permitted to return to an available bed in the collation of the facility that he or she previously resided.
A review of the facility ' s P&P titled, Bed Safety and Bed Rails, revised on 1/2023 indicated, The use of bed rails is prohibited unless the criteria for use of bed rails have been met . Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eight lengths.
A review of the facility ' s P&P titled, Use of Restraints, revised on 1/2023 indicated, Restraints shall only be used to treat the resident ' s medical symptom(s) and never for discipline or staff convenience, or for the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accommodate residents' needs were met by failing to ensure:
1. That the call light (A device used by a patient to signal his or her need for assistance from professional staff) for one of four sampled residents (Resident 3) was within reach per facility protocol.
2. Resident 1's who was incontinent (inability of the body to control the evacuative functions of urination or defecation) care was provided incontinence care in a timely manner.
This failure resulted in Resident 3 feeling isolated and unable to call for assistance whenever she needed help.
Findings:
During an initial tour on an unannounced visit to the facility on [DATE] at 5:10 p.m., Resident 3 was observed lying down with her right arm which she was unable to move herself was positioned on a pillow. She stated that staff always take her call light away and most of the times finds it hard to call for assistance and leaves her feeling isolated. The call light was observed to be underneath Resident 3's bed towards the wall behind her.
A record review of the admission record (Facesheet) indicated the Resident 3 was initially admitted on [DATE] with diagnoses that included hemiparesis (weakness or inability to move on one side of the body) and hemiplegia (one-sided muscle paralysis or weakness) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and history of falling.
A review of Resident 3's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 8/18/23, indicated the resident 3 had some moderate cognitive impairment. It further indicated that the resident required 1-person limited assistance for most of her Activities of Daily Living (ADLs- Bed mobility, eating, walk in room, locomotion on & off unit, dressing, toilet use, and personal hygiene). Resident required 2 plus person assistance for transfers.
During a concurrent observation and interview with the Director of Nursing (DON) on 10/24/23 at 5:10 p.m., the DON confirmed that the call light was out of Resident 3's reach. She stated that the potential effect is that the resident would be unable to reach or notify staff whenever she needed assistance which would include emergency call. She further stated that the resident may also get injured if she tried to climb out of bed and fall.
A record review of the Facesheet indicated the Resident 1 was initially admitted on [DATE] with diagnoses that included metabolic encephalopathy (a problem in the brain that is caused by a chemical imbalance in the blood. The imbalance is caused by an illness or organs that are not working as well as they should and can lead to personality changes), multiple sclerosis (a long-lasting chronic disease of the central nervous system. It is thought to be an autoimmune disorder, a condition in which the body attacks itself by mistake. MS is an unpredictable disease that affects people differently), and urinary tract infection (common infections that happen when bacteria, often from the skin or rectum, enter the urethra [a hollow tube that lets urine leave your body], and infect the urinary tract).
A review of Resident 1's MDS dated [DATE], indicated the Resident 1 was cognitive intact. It further indicated that the resident required 1-person limited assistance for most of her ADLs- Bed mobility, locomotion on & off unit, dressing, toilet use, and personal hygiene). Resident required 2 plus person assistance for transfers and eat independently.
During a concurrent observation and interview with Resident 1 on 10/24/23 at 4:55 p.m., Resident 1 stated that when she was assigned to work with Certified Nursing Assistant (CNA) 2 last week, Resident 1 had pushed the call light for some incontinence care. CNA 2 came in and told her that he was going on break and asked if she could wait for 30 minutes after his break was over. She further stated that he returned more than 30 later and cleaned her from the back to the front, causing the feces in her vagina and urethra. She stated this had happened on three other occasions.
During a phone interview with CNA 2 on 10/25/23 at 7:00 p.m., CNA 2 stated that a few days ago recalls a time where she had called, and he responded to the call right away. Resident 1 asked him if he could clean her up as she had a bowel movement. He stated that he asked her if she could wait because he was going on break. When asked what the protocol is when one must go on break of which he stated that staff are expected to ask their co-workers to assist with their assigned residents. He admitted that he did not ask anyone to assist and kept insisting I am a human being too and needed to eat and go to the bathroom!
He did admit that if urine or bowels left uncleaned for a long time, it would cause skin break down and or infections such as UTIs.
He further stated that Resident 1 had excessive bowel movement which caught him off guard. He stated that female residents are to be cleaned from the front to back to prevent infection from feces going into the urethra and vaginal. However, he would not answer when he was asked if he had cleaned her from back to front or front to back.
During an interview with the DON on 10/26/2023 at 3:20 p.m., the DON stated that the protocol in the facility for when staff need to go on break then other staff through a buddy system where staff are paired up. The potential effect is delay in care and potential for skin breakdown is residents are not attended to timely. She further stated that the potential for infection such as UTI when a female resident is cleaned from the back to the front.
A review of the policy titled Answering the Call Light, reviewed January 2023 indicated, the purpose of the procedure is to ensure timely responses to the resident's requests and needs. It further indicated the following general guidelines:
l. Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident.
2. Ask the resident to return the demonstration.
3. Explain to the resident that a call system is also located in his/her bathroom.
4. Be sure that the call light is plugged in and functioning at all times.
5. Ensure that tile call light is accessible to the resident when in bed. from the toilet. from the shower or bathing facility and from the floor.
6. Report all defective call lights to the nurse supervisor promptly.
A review of the policy titled Perinea! Care, revised January 2023 indicated, the purpose of the procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. It further indicated the steps in the procedure for a female resident as follows:
a. Wet washcloth and apply soap or skin cleansing agent.
b. Wash perineal area, wiping from front to back.
(I) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.)
(2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth.
(3) If the resident has ??indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.
(4) Gently dry perineum.
c. Ask the resident to tum on her side with her top leg slightly bent, if able.
d. Rinse wash cloth and apply soap or skin cleansing agent.

**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 5 Residents (Resident 4) was free from significant medication error by failing to administer the morning dose of Risperdal (a medication that works in the brain to treat schizophrenia. It is also known as a second-generation antipsychotic (SGA) or atypical antipsychotic), Aricept (used to treat dementia (memory loss and mental changes) associated with mild, moderate, or severe Alzheimer's disease), potassium chloride (a mineral supplement used to treat or prevent low amounts of potassium in the blood. A normal level of potassium in the blood is important), and Namenda (used to treat dementia associated with Alzheimer's disease [most common type of dementia. It is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment]).
This deficient practice had a potential to place Resident 1 at risk for worsening symptoms of dementia, psychosis when you perceive or interpret reality in a very different way from people around you), and unbalanced levels of fluid inside the cells.
Findings:
A review of the admission record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including unspecified dementia, hypokalemia (a lower-than-normal potassium level in your bloodstream), and Alzheimer's disease.
A review of Resident 1's Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 8/23/2023, indicated Resident 4 had some mild cognitive impairment and required assistance with one-person physical assist for dressing, toilet use, and personal hygiene.
During a concurrent observation and interview with the Director of Nursing on 10/25/23 at 5:53 p.m., a clear medication cup containing four tablet was noted on the bedside table of Resident 4, who was not in her room at the time. The DON confirmed that the medications were Resident 4's morning dosages which were signed as administered on her Medication Administration Records (MARs-record where medications are documented when administered). The DON further stated that medications must never be left at the bedside. She stated that licensed nurses must observe residents take their medications, then proceed to document. She stated that the potential effect would be worsening of symptoms such as psychosis and hypokalemia. She also stated that another resident might consume those medications and placing them at risk for adverse reactions.
A review of Resident's 4 physician's orders dated 8/16/2023, indicated the following orders:
1. Namenda Oral Tablet 5 MG (Memantine HCI) Give 1 tablet by mouth one time a day for dementia.
2. Potassium Chloride ER Oral Tablet Extended Release 10 MEQ (Potassium Chloride) Give 1 tablet by mouth one time a day for hypokalemia.
3. Aricept Oral Tablet 5 MG (Donepezil Hydrochloride) Give 1 tablet by mouth two times a day for Dementia.
A review of Resident's 4 physician's orders dated 9/27/2023, indicated Risperdal Oral Tablet 0.5 MG (Risperidone) Give 1 tablet by mouth two times a day for schizophrenia (a chronic brain disorder that affects less than one percent of the U.S. population. When schizophrenia is active, symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation) manifested by continuous pacing.
A review of the policy titled Administering Oral Medications, revised January 2023 indicated the purpose was to provided guidelines for the safe administration of oral medications. It further indicated steps which included the following:
-Confirm the identity of the resident.
- Explain the procedure to the resident.
- Perform any pre-administration assessments.
- Allow the resident to swallow oral tablets or capsules at his or her comfortable pace.
- Remain with the resident until all medications have been taken.
- Notify the supervisor if the resident refuses the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient preparation to ensure a safe discharge for one of two sampled residents (Resident 1) who had dementia (loss of memory, thinking and reasoning), secondary bone cancer, gait and mobility abnormalities and muscle weakness. On 8/1/2023, the facility discharged Resident 1 to her home where her medical and nursing needs could not be met, as Resident 1 required extensive assistance with activities of daily living (ADLs - eating, toileting, bathing, and walking).
As a result, on 8/15/2023 (two weeks after leaving the facility), Resident 1 was found in her home, by emergency services, covered in feces, after having fallen and sustaining a fracture. Resident 1 required transfer to a general acute care hospital (GACH) where she was admitted the same day for failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function) and sternum (breastbone) fracture.
Cross Reference: F622 and F623
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident, on 5/9/2023 with diagnoses including dementia (loss of memory, thinking and reasoning), secondary bone cancer (cancer that started somewhere else in the body has spread to the bones), gait and mobility abnormalities and muscle weakness. The admission record listed both Resident 1 and Family Member 1 (FM 1) as a Responsible Party and FM 1 as the Medical Power of Attorney (POA).
A review of Resident 1's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 5/10/2023, indicated the resident felt unsteady when standing and walking, and was worried about falling. The PT Evaluation indicated Resident 1 had decreased coordination, decreased strength, decreased functional mobility, reduced ADL participation, and increased physical exertion during daily living task and an increased need for assistance from others.
A review of Resident 1's Skilled Nursing Facility Follow-Up Visit, dated 5/11/2023 indicated the resident's anticipated discharge arrangement was either custodial care at the facility (non-medical care that assists one with activities of daily living [including walking, getting in and out of bed, bathing, dressing, eating, and using the toilet]), home with home health, or another long-term care facility. The Follow Up Visit form indicated Resident 1 had chronic pain and Stage IV breast cancer with extensive vertebral metastases status post-surgery and radiation.
A review of Resident 1's ADLs Care Plan, initiated 5/11/2023 indicated the resident had a self-care performance deficit related to her gait disorder, a history of falls, lack of coordination and gait abnormalities. The care plan interventions included to discuss with resident/family/POA any concerns related to the loss of independence or the decline in function, to encourage the resident to use the call bell for assistance and PT and Occupational Therapy (OT) evaluation and treatment per Physician's Order.
According to a review of the Care Plan, initiated 5/11/2023, Resident 1 was at risk for a pathological bone fracture (break in a bone that is caused by an underlying disease) related to osteoporosis (a bone disease when bone mass / density decreases) and the resident had a previous pathological fracture. The care plan interventions included Physical Therapy / Occupational Therapy to evaluate and treat as indicated, handle gently when moving or positioning, maintain body alignment and to support injured area with pillows and immobilize part as appropriate.
A review of Resident 1's Cognitive (thinking, reasoning, remembering) Function Care Plan, initiated 5/11/2023, indicated the resident had impaired cognitive function or impaired thought processes related to diagnosis of dementia. The interventions included to communicate with the resident/family/caregivers regarding resident's capabilities and needs. The interventions also included to cue, reorient, and supervise as needed.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/16/2023 (five days after the Cognitive Function Care Plan), indicated the resident's cognition was intact (able to understand and make decisions). This indicated a discrepancy from the Cognitive Function Care Plan. The MDS indicated Resident 1 had a planned discharge and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance with one-person physical assist with bed mobility, transfer, walking, dressing and toilet use. The MDS indicated Resident 1 required limited assistance with one-person physical assist for personal hygiene, was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, getting on or off the toilet and when transferring between bed and chair or wheelchair.
A review of the Physician's Orders, dated 6/6/2023 indicated Resident 1 was to continue:
-Skilled Physical Therapy (PT) services daily 5 times a week for four weeks for treatment diagnosis of gait abnormality with current plan of care.
-Skilled Occupational Therapy (OT) services daily five times a week for four weeks with treatment diagnosis of lack of coordination. Treatment plan includes therapeutic exercises, therapeutic activities, self-care training and safety awareness training.
A review of Resident 1's Detailed Explanation of Non-Coverage Letter from the GACH, dated 6/28/2023, indicated why the current Medicare coverage should end. The GACH letter indicated according to the medical doctor, nurse practitioner, case management assessment and facility team, the resident was medically stable for discharge to custodial care or home, with 24-hour caregiver support. The letter indicated Resident 1's therapist reported the resident had reached new levels in bed mobility with caregiver assistance and transfers with caregiver assistance. The letter indicated if Resident 1 was discharged home with a 24-hour caregiver, she would receive home health skilled nursing, Physical/Occupational Therapy services with close follow up from the primary care physician. The letter indicated continued recuperation from Resident 1's illness could be safely provided with custodial care or home health services, if discharge to home with caregiver.
According to a review of Resident 1's PT Discharge summary, dated [DATE], the resident previously was living home alone with a couple of steps to enter, was using a front wheel walker and wheelchair, and the discharge recommendation was to discharge home with home health services.
A review of the History and Physical (H&P), dated 7/20/2023, indicated Resident 1 had the capacity to understand and make some decisions but may not be able to participate in complex decision making (such as for discharge planning).
A review of the Physician's Order, dated 7/27/2023, indicated Resident 1 was to discharge home today with home health nurse, physical therapy (PT) and occupational therapy (OT) for safety.
A review of the Post Discharge Plan of Care, dated 8/1/2023, indicated Resident 1 was to receive home health service and there was a phone number for the home health agency.
A review of the Discharge Summary/Comprehensive Assessment form dated 8/1/2023, indicated Resident 1 required assist with bathing, dressing, eating, personal hygiene, transfers, bed mobility, toilet use and ambulation. Further review indicated the white resident copy remained attached to the yellow chart copy and remained in Resident 1's physical chart.
According to a review of Resident 1's Notice of Transfer / Discharge form, dated 8/1/2023, the resident was self-responsible and the effective date of discharge was 8/1/2023 to the resident's home address. The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. The Notice of Transfer was not signed by Resident 1 or the Medical POA and was not provided 30 days prior.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/1/2023, indicated the resident's cognition was intact., Resident 1's discharge was planned and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, moving between locations, toileting and personal hygiene.
A review of Resident 1's GACH Emergency Department (ED) Provider Note, dated 8/15/2023 (two weeks after leaving the facility), indicated Resident 1 was brought in by rescue services, unclothed and covered in excrement (waste matter discharged from the bowels). The ED Note indicated Resident 1's housing condition was deplorable (shockingly bad in quality) and she fell at home. The GACH ED Note indicated Resident 1's Blood Urea Nitrogen Level was elevated at 38.6 (normal is 9.8 - 20.1, an indication that either the resident's kidneys are not functioning well or dehydration [losing more fluids than you take in]) and Resident 1 sustained a sternum fracture (the breastbone, the long flat bone located in the central part of the chest, most commonly results from blunt, anterior chest-wall trauma,, patients typically experience a sudden onset of sharp and intense chest pain at the time of injury and may increase during deep breathing, coughing, laughing or sneezing, results in an increased risk in pulmonary injuries). The ED Note indicated Resident 1 was admitted to the GACH for failure to thrive and sternum fracture.
During a phone interview on 8/17/2023 at 3:56 PM, GACH Social Worker 1 (SW 1) stated there were concerns from an outside health agency that Resident 1's discharge from the facility was unsafe due to the resident's home had a lot of safety concerns. SW 1 stated the resident was unable to transfer herself or care for herself and Resident 1 was found covered in her feces. SW 1 further stated Resident 1 had a fall at home and was now admitted to the GACH with a sternum fracture.
During a phone interview on 8/17/2023 at 4:11 PM, Registered Nurse Case Manager (RNCM) stated Resident 1 lived alone, did not have the income to pay caregivers and Resident 1's Family Member 1 (FM 1) had her own medical problems. RNCM stated Resident 1 was unable to transfer herself and during her visit to the resident, she was bedbound. She further stated during her visit on 8/3/2023, Resident 1 had water at her bedside and had not had food for 24 hours. The RNCM also stated during each visit, Resident 1 was found each time in urine and feces.
During an interview on 8/18/2023 at 10:40 AM, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was incontinent and required someone to clean her lower body and to change her incontinence brief. CNA 1 stated Resident 1 required two people to transfer her to a wheelchair and if Resident 1 was to go home she would need a caregiver to cook, clean and perform personal care.
On 8/18/2023 at 12:14 PM, during an interview, the Director of Rehabilitation (DOR) stated Resident 1 was living alone prior to her admission. Our assessment indicated Resident 1 would never reach full independence and it was imperative for Resident 1 to go home with a caregiver. A caregiver was needed. I mean she can't function. She would basically be homebound as she can't go up and down those three steps without assistance.
During a phone interview on 8/18/2023 at 12:47 PM, Resident 1 stated, If I could have stayed at the facility I would have wished to stay. Resident 1 also stated she did not receive any discharge instructions prior to being discharged and did not recall any conversations with facility staff asking her about home health or about having a caregiver upon discharge. Resident 1 further stated she fell at home and was now hospitalized with a broken chest.
During an interview on 8/18/2023 at 3:30 PM, Resident 1's Family Member 1 (FM 1) stated when the resident was discharged from the facility the resident lived alone and was unable to walk up the stairs to her apartment. FM 1 stated no one at the facility spoke to her about Resident 1 needing a caregiver at home and They [the facility staff] didn't tell me anything about discharge, they only talked with me about the finances. FM 1 stated Resident 1 was feeling so weak she could not change her incontinence brief and she stood and slipped in her own urine and was now hospitalized .
During an interview on 8/21/2023 at 8:32 AM, Case Manager (CM) 1 stated Resident 1 was cleared by the Rehabilitation Department to go home, but CM 1 failed to indicate 'with home health services.' CM 1 informed Nurse Practitioner (NP) 1 and NP 1 ordered the discharge of Resident 1. CM 1 further stated the rehabilitation department recommended Resident 1 to receive 6 to 8 hours of caregiving services from FM 1. CM 1 further stated she discussed the resident's caregiver needs with Resident 1 and FM 1 but she did not document it in the resident's medical chart. CM 1 also stated she did not clarify the type of caregiving services and the quantity of services to be provided with the resident or FM 1.
On 8/21/2023 at 10:37 AM, during an interview, Nurse Practitioner 1 (NP 1) stated the facility told her Resident 1 was safe to go home with whatever her home situation was and she ordered the resident to go home with home health. NP 1 stated, I gave them the home health agency and generally the social worker contacts the home health. I feel like they (the facility staff) didn't give me the full picture. I trusted them and I shouldn't have.
During an interview on 8/21/2023 at 11:20 AM, Social Services Assistant (SSA) stated it was important to make sure Resident 1's discharge was safe prior to her discharge. The SSA stated she did not know if Resident 1's discharge was safe because I don't know what kind of help she was going to get at home. The SSA also stated she did not follow-up with Resident 1 post discharge and home health services were not arranged.
During an interview on 8/22/2023 at 10:36 AM, Director of Nursing (DON) stated Resident 1 should have been discharged with a 24-hour care giver support, this should have been communicated to the resident and family and this communication should have been documented. The DON also stated if a resident needs in home support it should be arranged prior to discharge and a possible outcome of not having a caregiver was injury to the resident.
A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised 3/2021, indicated residents were notified in writing, at least thirty (30) days prior to a transfer or discharge. The policy indicated residents were permitted to stay in the facility and not be transferred or discharge unless the transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility. The policy indicated the notice is given as soon as it is practicable but before the transfer or discharge.
A review of the facility's P&P titled, Discharge Summary and Plan, revised 12/2016, indicated when a resident's discharge was anticipated, a discharge summary and post discharge plan will be developed to assist the resident to adjust to his/her new living environment. Every resident would be evaluated for his discharge needs and will have an individualized post discharge plan. The discharge plan will include arrangements that have been made for follow-up care and services. It also indicated a member of the Interdisciplinary Team (IDT) will review the final post-discharge plan with the resident and family at least 24 hours before the discharge is to take place.
A review of the facility's policy and procedure (P&P) titled, Transfer and Discharge Documentation revised 12/2016, indicated each resident would be permitted to remain in the facility and not be transferred or discharged unless - the transfer or discharge was necessary for the resident's welfare and the resident needs cannot be met in this facility. The policy indicated when a resident is transferred or discharged from the facility, the following information will be documented in the medical record: the specific resident needs that cannot be met, and that an appropriate notice was provided to the resident and / or legal representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of two sampled residents (Resident 1) the facility failed to ensure:
-Resident 1 or the responsible party was notified at least 30 days before the resident was transferred or discharged or as soon as practicable before the discharge and the reasons for the move in writing and in a manner the resident understands.
A review of the Notice of Transfer / Discharge form dated 8/1/2023 indicated Resident 1 was self-responsible and the effective date of discharge was 8/1/2023 to the resident's home address. The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. The Notice of Transfer was not signed by Resident 1 or the Medical Power Of Attorney (POA) and was not provided 30 days prior.
As a result, on 8/15/2023 (two weeks after leaving the facility), Resident 1 was found in her home, by emergency services, covered in feces, after having fallen and sustaining a fracture. Resident 1 required transfer to a general acute care hospital (GACH) where she was admitted the same day for failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function) and sternum (breastbone) fracture.
Cross Reference: F622 and F624
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident, on 5/9/2023 with diagnoses including dementia (loss of memory, thinking and reasoning), secondary bone cancer (cancer that started somewhere else in the body has spread to the bones), gait and mobility abnormalities and muscle weakness. The admission record listed both Resident 1 and Family Member 1 (FM 1) as a Responsible Party and FM 1 as the Medical Power of Attorney (POA).
A review of Resident 1's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 5/10/2023, indicated the resident felt unsteady when standing and walking, and was worried about falling. The PT Evaluation indicated Resident 1 had decreased coordination, decreased strength, decreased functional mobility, reduced ADL participation, and increased physical exertion during daily living task and an increased need for assistance from others.
A review of Resident 1's Skilled Nursing Facility Follow-Up Visit, dated 5/11/2023 indicated the resident's anticipated discharge arrangement was either custodial care at the facility (non-medical care that assists one with activities of daily living [including walking, getting in and out of bed, bathing, dressing, eating, and using the toilet]), home with home health, or another long-term care facility. The Follow Up Visit form indicated Resident 1 had chronic pain and Stage IV breast cancer with extensive vertebral metastases status post-surgery and radiation.
A review of Resident 1's Activities of Daily Living (ADLs) Care Plan, initiated 5/11/2023 indicated the resident had a self-care performance deficit related to her gait disorder, a history of falls, lack of coordination and gait abnormalities. The care plan interventions included to discuss with resident/family/POA any concerns related to the loss of independence or the decline in function, to encourage the resident to use the call bell for assistance and PT and Occupational Therapy (OT) evaluation and treatment per Physician's Order.
According to a review of the Care Plan, initiated 5/11/2023, Resident 1 was at risk for a pathological bone fracture (break in a bone that is caused by an underlying disease) related to osteoporosis and the resident had a previous pathological fracture. The care plan interventions included Physical Therapy/Occupational Therapy to evaluate and treat as indicated, handle gently when moving or positioning, maintain body alignment and to support injured area with pillows and immobilize part as appropriate.
A review of Resident 1's Cognitive (thinking, memory, concentrating) Function Care Plan, initiated 5/11/2023, indicated the resident had impaired cognitive function or impaired thought processes related to diagnosis of dementia. The interventions included to communicate with the resident/family/caregivers regarding resident's capabilities and needs. The interventions also included to cue, reorient, and supervise as needed.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/16/2023, indicated the resident's cognition (able to understand and make decisions) was intact. This indicated a discrepancy from the Cognitive Function Care Plan. The MDS indicated Resident 1 had a planned discharge and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance with one-person physical assist with bed mobility, transfer, walking, dressing and toilet use. The MDS indicated Resident 1 required limited assistance with one-person physical assist for personal hygiene, was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, getting on or off the toilet and when transferring between bed and chair or wheelchair.
A review of the Physician's Orders, dated 6/6/2023 indicated Resident 1 was to continue:
-Skilled Physical Therapy (PT) services daily 5 times a week for four weeks for treatment diagnosis of gait abnormality with current plan of care.
-Skilled Occupational Therapy (OT) services daily five times a week for four weeks with treatment diagnosis of lack of coordination. Treatment plan includes therapeutic exercises, therapeutic activities, self-care training and safety awareness training.
A review of Resident 1's Detailed Explanation of Non-Coverage Letter from the GACH, dated 6/28/2023, indicated why the current Medicare coverage should end. The GACH letter indicated according to the medical doctor, nurse practitioner, case management assessment and facility team, the resident was medically stable for discharge to custodial care or home, with 24-hour caregiver support. The letter indicated Resident 1's therapist reported the resident had reached new levels in bed mobility with caregiver assistance and transfers with caregiver assistance. The letter indicated if Resident 1 was discharged home with a 24-hour caregiver, she would receive home health skilled nursing, Physical/Occupational Therapy services with close follow up from the primary care physician. The letter indicated continued recuperation from Resident 1's illness could be safely provided with custodial care or home health services, if discharge to home with caregiver.
According to a review of Resident 1's PT Discharge summary, dated [DATE], the resident previously was living home alone with a couple of steps to enter, was using a front wheel walker and wheelchair, and the discharge recommendation was to discharge home with home health services.
A review of the History and Physical (H&P), dated 7/20/2023, indicated Resident 1 had the capacity to understand and make some decisions but may not be able to participate in complex decision making (such as for discharge planning).
A review of the Physician's Order, dated 7/27/2023, indicated Resident 1 was to discharge home today with home health nurse, physical therapy (PT) and occupational therapy (OT) for safety.
A review of the Post Discharge Plan of Care, dated 8/1/2023, indicated Resident 1 was to receive home health service and there was a phone number for the home health agency.
A review of the Discharge Summary/Comprehensive Assessment form dated 8/1/2023, indicated Resident 1 required assist with bathing, dressing, eating, personal hygiene, transfers, bed mobility, toilet use and ambulation. Further review indicated the white resident copy remained attached to the yellow chart copy and remained in Resident 1's physical chart.
According to a review of the Resident 1's Notice of Transfer / Discharge form, dated 8/1/2023, the resident was self-responsible and the effective date of discharge was 8/1/2023 to the resident's home address. The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. The Notice of Transfer was not signed by Resident 1 or the Medical POA and was not provided 30 days prior.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/1/2023, indicated the resident's cognition was intact., Resident 1's discharge was planned and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, moving between locations, toileting and personal hygiene.
A review of Resident 1's GACH Emergency Department (ED) Provider Note, dated 8/15/2023, indicated Resident 1 was brought in by rescue services, unclothed and covered in excrement (waste matter discharged from the bowels). The ED Note indicated Resident 1's housing condition was deplorable, and she fell at home. The GACH ED Note indicated Resident 1's Blood Urea Nitrogen Level was elevated at 38.6 (normal is 9.8 - 20.1, an indication that either the resident's kidneys are not functioning well or dehydration) and Resident 1 sustained a sternum fracture (the breastbone, the long flat bone located in the central part of the chest, most commonly results from blunt, anterior chest-wall trauma,, patients typically experience a sudden onset of sharp and intense chest pain at the time of injury and may increase during deep breathing, coughing, laughing or sneezing, results in an increased risk in pulmonary injuries). The ED Note indicated Resident 1 was admitted to the GACH for failure to thrive and sternum fracture.
During a phone interview on 8/17/2023 at 3:56 PM, GACH Social Worker 1 (SW 1) stated there were concerns from an outside health agency that Resident 1's discharge from the facility was unsafe due to the resident's home had a lot of safety concerns. SW 1 stated the resident was unable to transfer herself or care for herself and Resident 1 was found covered in her feces. SW 1 further stated Resident 1 had a fall at home and was now admitted to the GACH with a sternum fracture.
During a phone interview on 8/17/2023 at 4:11 PM, Registered Nurse Case Manager (RNCM) stated Resident 1 lived alone, did not have the income to pay caregivers and Resident 1's Family Member 1 (FM 1) had her own medical problems. RNCM stated Resident 1 was unable to transfer herself and during her visit to the resident, she was bedbound. She further stated during her visit on 8/3/2023, Resident 1 had water at her bedside and had not had food for 24 hours. The RNCM also stated during each visit, Resident 1 was found each time in urine and feces.
During an interview on 8/18/2023 at 10:40 AM, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was incontinent and required someone to clean her lower body and to change her incontinence brief. CNA 1 stated Resident 1 required two people to transfer her to a wheelchair and if Resident 1 was to go home she would need a caregiver to cook, clean and perform personal care.
On 8/18/2023 at 12:14 PM, during an interview, the Director of Rehabilitation (DOR) stated Resident 1 was living alone prior to her admission. Our assessment indicated Resident 1 would never reach full independence and it was imperative for Resident 1 to go home with a caregiver. A caregiver was needed. I mean she can't function. She would basically be homebound as she can't go up and down those three steps without assistance.
During a phone interview on 8/18/2023 at 12:47 PM, Resident 1 stated, If I could have stayed at the facility I would have wished to stay. Resident 1 also stated she did not receive any discharge instructions prior to being discharged and did not recall any conversations with facility staff asking her about home health or about having a caregiver upon discharge. Resident 1 further stated she fell at home and was now hospitalized with a broken chest.
During an interview on 8/18/2023 at 3:30 PM, Resident 1's Family Member 1 (FM 1) stated when the resident was discharged from the facility the resident lived alone and was unable to walk up the stairs to her apartment. FM 1 stated no one at the facility spoke to her about Resident 1 needing a caregiver at home and They [the facility staff] didn't tell me anything about discharge, they only talked with me about the finances. FM 1 stated Resident 1 was feeling so weak she could not change her incontinence brief and she stood and slipped in her own urine and was now hospitalized .
During an interview on 8/21/2023 at 8:32 AM, Case Manager (CM) 1 stated Resident 1 was cleared by the Rehabilitation Department to go home, but CM 1 failed to indicate 'with home health services.' CM 1 informed NP 1 and NP 1 ordered the discharge of Resident 1. CM 1 further stated the rehabilitation department recommended Resident 1 to receive 6 to 8 hours of caregiving services from FM 1. CM 1 further stated she discussed the resident's caregiver needs with Resident 1 and FM 1 but she did not document it in the resident's medical chart. CM 1 also stated she did not clarify the type of caregiving services and the quantity of services to be provided with the resident or FM 1.
On 8/21/2023 at 10:37 AM, during an interview, Nurse Practitioner 1 (NP 1) stated the facility told her Resident 1 was safe to go home with whatever her home situation was and she ordered the resident to go home with home health. NP 1 stated, I gave them the home health agency and generally the social worker contacts the home health. I feel like they (the facility staff) didn't give me the full picture. I trusted them and I shouldn't have.
During an interview on 8/21/2023 at 11:20 AM, Social Services Assistant (SSA) stated it was important to make sure Resident 1's discharge was safe prior to her discharge. The SSA stated she did not know if Resident 1's discharge was safe because I don't know what kind of help she was going to get at home. The SSA also stated she did not follow-up with Resident 1 post discharge and home health services were not arranged.
During an interview on 8/22/2023 at 10:36 AM, Director of Nursing (DON) stated Resident 1 should have been discharged with a 24-hour care giver support, this should have been communicated to the resident and family and this communication should have been documented. The DON also stated if a resident needs in home support it should be arranged prior to discharge and a possible outcome of not having a caregiver was injury to the resident.
A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised 3/2021, indicated residents were notified in writing, at least thirty (30) days prior to a transfer or discharge. The policy indicated residents were permitted to stay in the facility and not be transferred or discharge unless the transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility. The policy indicated the notice is given as soon as it is practicable but before the transfer or discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit one of two sampled (Resident 1) to remain in the facility and not transfer or discharge her unless the transfer / discharge was necessary and appropriate. The facility failed to:
-Ensure the reason for discharging Resident 1 was because of one of the following: the resident's welfare and the resident's needs could not be met in the facility; her care needs could not be met at the facility, her health had improved and no longer needed the services provided by the facility, for the safety of individuals in the facility due to Resident 1's clinical or behavioral status, because of Resident 1's lack of payment, or because the facility ceased operation.
-Provide and document sufficient preparation and orientation to Resident 1 or responsible party for a safe and orderly transfer or discharge from the facility.
On 8/1/2023, the facility discharged Resident 1 to her home where her medical and nursing needs could not be met, as Resident 1 required extensive assistance with activities of daily living (ADLs, eating, toileting, bathing, walking).
As a result, on 8/15/2023 (two weeks after leaving the facility), Resident 1 was found in her home, by emergency services, covered in feces, after having fallen and sustaining a fracture. Resident 1 required transfer to a general acute care hospital (GACH) where she was admitted the same day for failure to thrive (a syndrome of weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function) and sternum (breastbone) fracture.
Cross Reference: F623 and F624
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident, on 5/9/2023 with diagnoses including dementia (loss of memory, thinking and reasoning), secondary bone cancer (cancer that started somewhere else in the body has spread to the bones), gait and mobility abnormalities and muscle weakness. The admission record listed both Resident 1 and Family Member 1 (FM 1) as a Responsible Party and FM 1 as the Medical Power of Attorney (POA).
A review of Resident 1's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 5/10/2023, indicated the resident felt unsteady when standing and walking, and was worried about falling. The PT Evaluation indicated Resident 1 had decreased coordination, decreased strength, decreased functional mobility, reduced ADL participation, and increased physical exertion during daily living task and an increased need for assistance from others.
A review of Resident 1's Skilled Nursing Facility Follow-Up Visit, dated 5/11/2023 indicated the resident's anticipated discharge arrangement was either custodial care at the facility (non-medical care that assists one with activities of daily living [including walking, getting in and out of bed, bathing, dressing, eating, and using the toilet]), home with home health, or another long-term care facility. The Follow Up Visit form indicated Resident 1 had chronic pain and Stage IV breast cancer with extensive vertebral metastases status post-surgery and radiation.
A review of Resident 1's Activities of Daily Living (ADLs) Care Plan, initiated 5/11/2023 indicated the resident had a self-care performance deficit related to her gait disorder, a history of falls, lack of coordination and gait abnormalities. The care plan interventions included to discuss with resident/family/POA any concerns related to the loss of independence or the decline in function, to encourage the resident to use the call bell for assistance and PT and Occupational Therapy (OT) evaluation and treatment per Physician's Order.
According to a review of the Care Plan, initiated 5/11/2023, Resident 1 was at risk for a pathological bone fracture (break in a bone that is caused by an underlying disease) related to osteoporosis (a bone disease when bone mass / density decreases) and the resident had a previous pathological fracture. The care plan interventions included Physical Therapy/Occupational Therapy to evaluate and treat as indicated, handle gently when moving or positioning, maintain body alignment and to support injured area with pillows and immobilize part as appropriate.
A review of Resident 1's Cognitive (thinking, reasoning, and memory) Function Care Plan, initiated 5/11/2023, indicated the resident had impaired cognitive function or impaired thought processes related to diagnosis of dementia. The interventions included to communicate with the resident/family/caregivers regarding resident's capabilities and needs. The interventions also included to cue, reorient, and supervise as needed.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/16/2023, indicated the resident's cognition (able to understand and make decisions) was intact. This indicated a discrepancy from the Cognitive Function Care Plan. The MDS indicated Resident 1 had a planned discharge and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance with one-person physical assist with bed mobility, transfer, walking, dressing and toilet use. The MDS indicated Resident 1 required limited assistance with one-person physical assist for personal hygiene, was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, getting on or off the toilet and when transferring between bed and chair or wheelchair.
A review of the Physician's Orders, dated 6/6/2023 indicated Resident 1 was to continue:
-Skilled Physical Therapy (PT) services daily 5 times a week for four weeks for treatment diagnosis of gait abnormality with current plan of care.
-Skilled Occupational Therapy (OT) services daily five times a week for four weeks with treatment diagnosis of lack of coordination. Treatment plan includes therapeutic exercises, therapeutic activities, self-care training and safety awareness training.
A review of Resident 1's Detailed Explanation of Non-Coverage Letter from the GACH, dated 6/28/2023, indicated why the current Medicare coverage should end. The GACH letter indicated according to the medical doctor, nurse practitioner, case management assessment and facility team, the resident was medically stable for discharge to custodial care or home, with 24-hour caregiver support. The letter indicated Resident 1's therapist reported the resident had reached new levels in bed mobility with caregiver assistance and transfers with caregiver assistance. The letter indicated if Resident 1 was discharged home with a 24-hour caregiver, she would receive home health skilled nursing, Physical/Occupational Therapy services with close follow up from the primary care physician. The letter indicated continued recuperation from Resident 1's illness could be safely provided with custodial care or home health services, if discharge to home with caregiver.
A review of Resident 1's PT Discharge summary, dated [DATE], indicated the resident previously was living home alone with a couple of steps to enter, was using a front wheel walker and wheelchair, and the discharge recommendation was to discharge home with home health services.
According to a review of the History and Physical (H&P), dated 7/20/2023, Resident 1 had the capacity to understand and make some decisions but may not be able to participate in complex decision making (such as for discharge planning).
A review of the Physician's Order, dated 7/27/2023, indicated Resident 1 was to discharge home today with home health nurse, physical therapy (PT) and occupational therapy (OT) for safety.
A review of the Post Discharge Plan of Care, dated 8/1/2023, indicated Resident 1 was to receive home health service and there was a phone number for the home health agency.
A review of the Discharge Summary/Comprehensive Assessment form dated 8/1/2023, indicated Resident 1 required assist with bathing, dressing, eating, personal hygiene, transfers, bed mobility, toilet use and ambulation. Further review indicated the white resident copy remained attached to the yellow chart copy and remained in Resident 1's physical chart.
According to a review of Resident 1's Notice of Transfer / Discharge form, dated 8/1/2023, the resident was self-responsible and the effective date of discharge was 8/1/2023 to the resident's home address. The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. The Notice of Transfer was not signed by Resident 1 or the Medical POA and was not provided 30 days prior.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/1/2023, indicated the resident's cognition was intact., Resident 1's discharge was planned, and the facility did not anticipate her return. The MDS further indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, moving between locations, toileting, and personal hygiene.
A review of Resident 1's GACH Emergency Department (ED) Provider Note, dated 8/15/2023, indicated Resident 1 was brought in by rescue services, unclothed and covered in excrement (waste matter discharged from the bowels). The ED Note indicated Resident 1's housing condition was deplorable, and she fell at home. The GACH ED Note indicated Resident 1's Blood Urea Nitrogen Level was elevated at 38.6 (normal is 9.8 - 20.1, an indication that either the resident's kidneys are not functioning well or dehydration [losing more fluids than you take in]) and Resident 1 sustained a sternum fracture (the breastbone, the long flat bone located in the central part of the chest, most commonly results from blunt, anterior chest-wall trauma,, patients typically experience a sudden onset of sharp and intense chest pain at the time of injury and may increase during deep breathing, coughing, laughing or sneezing, results in an increased risk in pulmonary injuries). The ED Note indicated Resident 1 was admitted to the GACH for failure to thrive and sternum fracture.
During a phone interview on 8/17/2023 at 3:56 PM, GACH Social Worker 1 (SW 1) stated there were concerns from an outside health agency that Resident 1's discharge from the facility was unsafe due to the resident's home had a lot of safety concerns. SW 1 stated the resident was unable to transfer herself or care for herself and Resident 1 was found covered in her feces. SW 1 further stated Resident 1 had a fall at home and was now admitted to the GACH with a sternum fracture.
During a phone interview on 8/17/2023 at 4:11 PM, Registered Nurse Case Manager (RNCM) stated Resident 1 lived alone, did not have the income to pay caregivers and Resident 1's Family Member 1 (FM 1) had her own medical problems. RNCM stated Resident 1 was unable to transfer herself and during her visit to the resident, she was bedbound. She further stated during her visit on 8/3/2023, Resident 1 had water at her bedside and had not had food for 24 hours. The RNCM also stated during each visit, Resident 1 was found each time in urine and feces.
During an interview on 8/18/2023 at 10:40 AM, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was incontinent and required someone to clean her lower body and to change her incontinence brief. CNA 1 stated Resident 1 required two people to transfer her to a wheelchair and if Resident 1 was to go home she would need a caregiver to cook, clean and perform personal care.
During an interview on 8/18/2023 at 12:14 PM, Director of Rehabilitation (DOR) stated Resident 1 was living alone prior to her admission. Our assessment indicated Resident 1 would never reach full independence and it was imperative for Resident 1 to go home with a caregiver. A caregiver was needed. I mean she can't function. She would basically be homebound as she can't go up and down those three steps without assistance.
On 8/18/2023 at 12:47 PM, during a phone interview, Resident 1 stated, If I could have stayed at the facility I would have wished to stay. Resident 1 also stated she did not receive any discharge instructions prior to being discharged and did not recall any conversations with facility staff asking her about home health or about having a caregiver upon discharge. Resident 1 further stated she fell at home and was now hospitalized with a broken chest.
During an interview on 8/18/2023 at 3:30 PM, Resident 1's Family Member 1 (FM 1) stated when the resident was discharged from the facility the resident lived alone and was unable to walk up the stairs to her apartment. FM 1 stated no one at the facility spoke to her about Resident 1 needing a caregiver at home and They [the facility staff] didn't tell me anything about discharge, they only talked with me about the finances. FM 1 stated Resident 1 was feeling so weak she could not change her incontinence brief and she stood and slipped in her own urine and was now hospitalized .
During an interview on 8/21/2023 at 8:32 AM, Case Manager (CM) 1 stated Resident 1 was cleared by the Rehabilitation Department to go home, but CM 1 failed to indicate 'with home health services.' CM 1 informed Nurse Practitioner (NP) 1 and NP 1 ordered the discharge of Resident 1. CM 1 further stated the rehabilitation department recommended Resident 1 to receive 6 to 8 hours of caregiving services from FM 1. CM 1 further stated she discussed the resident's caregiver needs with Resident 1 and FM 1 but she did not document it in the resident's medical chart. CM 1 also stated she did not clarify the type of caregiving services and the quantity of services to be provided with the resident or FM 1.
During an interview on 8/21/2023 at 10:37 AM, Nurse Practitioner 1 (NP 1) stated the facility told her Resident 1 was safe to go home with whatever her home situation was and she ordered the resident to go home with home health. NP 1 stated, I gave them the home health agency and generally the social worker contacts the home health. I feel like they (the facility staff) didn't give me the full picture. I trusted them and I shouldn't have.
During an interview on 8/21/2023 at 11:20 AM, Social Services Assistant (SSA) stated it was important to make sure Resident 1's discharge was safe prior to her discharge. The SSA stated she did not know if Resident 1's discharge was safe because I don't know what kind of help she was going to get at home. The SSA also stated she did not follow-up with Resident 1 post discharge and home health services were not arranged.
On 8/22/2023 at 10:36 AM, during an interview, the Director of Nursing (DON) stated Resident 1 should have been discharged with a 24-hour care giver support, this should have been communicated to the resident and family and this communication should have been documented. The DON also stated if a resident needs in home support it should be arranged prior to discharge and a possible outcome of not having a caregiver was injury to the resident.
A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised 3/2021, indicated residents were notified in writing, at least thirty (30) days prior to a transfer or discharge. The policy indicated residents were permitted to stay in the facility and not be transferred or discharge unless the transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility. The policy indicated the notice is given as soon as it is practicable but before the transfer or discharge.
A review of the facility's P&P titled, Discharge Summary and Plan, revised 12/2016, indicated when a resident's discharge was anticipated, a discharge summary and post discharge plan will be developed to assist the resident to adjust to his/her new living environment. Every resident would be evaluated for his discharge needs and will have an individualized post discharge plan. The discharge plan will include arrangements that have been made for follow-up care and services. It also indicated a member of the Interdisciplinary Team (IDT) will review the final post-discharge plan with the resident and family at least 24 hours before the discharge is to take place.
A review of the facility's policy and procedure (P&P) titled, Transfer and Discharge Documentation revised 12/2016, indicated each resident would be permitted to remain in the facility and not be transferred or discharged unless - the transfer or discharge was necessary for the resident's welfare and the resident needs cannot be met in this facility. The policy indicated when a resident is transferred or discharged from the facility, the following information will be documented in the medical record: the specific resident needs that cannot be met, and that an appropriate notice was provided to the resident and / or legal representative.

Based on interview and record review, the facility failed to ensure a resident's discharge summary was completed and was provided to the resident prior to discharge from the facility for one of 25 sample residents (Resident 1). This deficient practice had the potential to result in an unsafe discharge.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident, on 5/9/2023 with diagnoses including dementia, secondary bone cancer (when a cancer that started somewhere else in the body has spread to the bones), gait and mobility abnormalities and muscle weakness. The admission record listed both Resident 1 and Family Member 1 (FM 1) as the Responsible Party.
A review of the Interdisciplinary Team (IDT) Conference Notes, dated 5/10/2023, indicated Resident 1 received Physical and Occupational therapy and the goals were to return the resident to her prior level of functioning, assess functional ability, and enhance fall recovery abilities. The IDT Conference Notes indicated Resident 1 was living at home alone prior to hospitalization and was determined by a physician to lack the capacity for medical decision making. The Conference Notes also indicated the facility will arrange home health follow up and durable medical equipment (DME - equipment and supplies ordered by a health care provider for everyday or extended use) as required once the resident rehabilitated to maximum level of function and can safely discharge home.
A review of Resident 1 ' s Skilled Nursing Facility Follow-up Visit, dated 5/11/2023, indicated the resident had a history of stage IV breast cancer with extensive spinal metastases and was admitted to GACH for failure to thrive was now transferred to SNF for continuation of care.
A review of Resident 1 ' s Physician ' s Order, dated 7/27/2023, indicated the resident was to discharge home with home health, physical therapy (PT) and occupational therapy (OT).
A review of Resident 1 ' s Discharge Summary/Comprehensive Assessment, dated 8/1/2023, located inside the resident ' s physical chart indicated the white resident copy remained attached to yellow chart copy and inside the physical chart.
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/1/2023, indicated the resident ' s cognition (able to understand and make decisions) was intact, the resident ' s discharge was planned and the facility did not anticipate her return. The MDS also indicated Resident 1 required extensive assistance with transfer, moving between locations, toileting and personal hygiene.
During an interview, on 8/18/2023 at 11:52 AM, Licensed Vocational Nurse 2 (LVN 2) stated the discharge summary/comprehensive assessment form was part of the discharge paperwork she prepared when a resident was to discharge. LVN 2 further stated she completed the discharge summary/comprehensive assessment for Resident 1 and I have never sent this home with the patient. To be honest, I ' m not sure I ' m supposed to.
During a phone interview, on 8/18/2023 at 12:47 PM, Resident 1 stated she did not receive any discharge instructions prior to being discharged .
During an interview on 8/22/2023 at 10:36 AM, the Director of Nursing (DON) stated the purpose of the discharge summary was to summarize the resident ' s care at the facility, to assist with the resident ' s discharge planning, and should be given to the resident. The DON further stated a potential outcome of Resident 1 not knowing which healthcare provider to contact post discharge.
A review of the facility ' s policy and procedure titled, Discharge Summary and Plan, revised 12/2016, indicated when a resident ' s discharge was anticipated, a discharge summary and post discharge plan will be developed to assist the resident to adjust to his/her new living environment. It also indicated a copy of the discharge summary will be provided to the resident and a copy will be filed in the resident ' s medical records.

Based on interview and record review, the facility failed to review and revise the High Risk for Skin Breakdown Care Plan for one of five sampled residents (Resident 5). This deficient practice had the potential to result in Resident 5 receiving inadequate care and services at the facility.
Findings:
A review of Resident 5 ' s admission Record indicated the facility re-admitted the resident on 8/14/2022 with diagnoses that included, but were not limited to, Type II Diabetes (a condition in which the body does not use insulin properly, resulting in abnormally high blood sugar levels), Paraplegia (paralysis that affects the lower part of the body), Hypertension (high blood pressure), and an unspecified stage pressure ulcer (a wound caused by prolonged pressure of the skin causing tissue damage).
A review of Resident 5 ' s High Risk for Skin Breakdown Care Plan dated 12/1/2022, indicated the resident was at high risk for pressure injuries and skin breakdown due to shearing. The care plan further indicated Resident 5 preferred to lay in a supine (laying on the back facing up)/sitting position at all times. The care plan indicated it was due to be re-evaluated on 3/1/2023.
A review of Resident 5 ' s Minimum Data Set (MDS – an assessment and care screening tool) dated 6/25/2023 indicated the resident had moderately impaired cognition (decisions poor, cues/supervision required). The MDS indicated Resident 5 required total dependence and two-person physical assistance for transferring; and extensive assistance and one-person physical assistance for bed mobility dressing, toilet use, eating, and personal hygiene. The MDS further indicated Resident 5 was at risk for developing pressure ulcers and injuries.
A review of Resident 5 ' s Braden Scale (a tool to assess and document an individual ' s risk for developing pressure ulcers) dated 6/25/2023, indicated the resident was at moderate risk for developing a pressure ulcer.
During an interview and concurrent record review on 7/5/2023 at 12:17 PM, Resident 5 ' s High Risk for Skin Breakdown Care Plan was reviewed with Registered Nurse Supervisor (RNS) 1. The RNS 1 stated the care plan did not look updated. The RNS 1 stated the High Risk for Skin Breakdown Care Plan was due to be updated 3/1/2023. The RNS further stated care plans were updated as needed, with a change in condition, and every three months.
During a concurrent interview and record review on 7/5/2023 at 1:38 PM, Resident 5 ' s High Risk for Skin Breakdown Care Plan was reviewed with the Director of Nursing (DON). The DON stated Resident 5 ' s High Risk for Skin Breakdown Care Plan was not reviewed and should have been reviewed and re-evaluated on 3/1/2023. The DON stated the care plans were reviewed quarterly, annually, and with a change in condition. The DON further stated the purpose of reviewing and re-evaluating the care plans were to check and make sure the plan of care reflects the resident ' s current conditions and needs so adequate care to the resident can be provided.
A review of the facility ' s policy and procedure titled, Goals and Objectives, Care Plans, reviewed 1/23/2023, indicated goals and objectives were reviewed and/or revised when there had been a significant change in the resident ' s condition; when the desired outcome had not been achieved, the resident had been readmitted to the facility from a hospital/rehabilitation stay; and at least quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is a repeated deficiency from 1/25/2023.
Based on interview and record review, the facility, with more than 120 beds, failed to employ a qualified social worker on a full-time basis. This deficient practice had the potential for the residents not to attain the highest practicable physical, mental, and psychosocial well-being, and delay in the delivery of care and services.
Findings:
A review of the facility's Centers for Medicare and Medicaid Services- Statement of Deficiencies and Plan of Correction (CMS-2576) form dated 1/25/2023, with completion date of 2/25/2023, indicated that the facility posted an online advertisement to recruit a qualified candidate for the Director of Social Services (DSS) position. Currently, the facility employs two social service employees along with an assistant.
During an interview on 6/21/2023 at 9:40 AM, the facility's Administrator (ADM) stated that today the facilitys census was 123. The ADM stated the facility did not have a licensed Director of Social Services and the facility received a deficiency because of this practice. The ADM stated the previous plan of correction was to hire a qualified social worker through advertisement that was placed online and he interviewed a good candidate yesterday. The ADM stated currently the facility had a Social Service Assistant (SSA) with its assistant.
A review of the facility's census dated 6/20/2023, indicated the total number of in-house residents was 123.
A review of the admission Record indicated the facility admitted Resident 1 on 3/21/2023, with diagnoses including epilepsy (a brain disease where nerve cells do not signal properly, which causes uncontrolled muscle movements) and encounter for palliative care (a type of medical care that helps relieve symptoms and stress associated with serious illnesses).
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/28/2023, indicated Resident 1 had moderately impaired cognition (decisions poor, cues/supervision required) and the resident was total dependent with one-person physical assist for bed mobility, transfer, dressing, personal hygiene, and toilet use.
A review of the admission Record indicated the facility admitted Resident 5 on 3/16/2023, with diagnoses including cerebral infarction ( damage to tissues in the brain due to loss of oxygen to the area) and gastrostomy ( a tube inserted through the wall of the abdomen directly into the stomach).
A review of the MDS dated [DATE], indicated Resident 5 had severely impaired cognition (never/rarely made decisions) was total dependent with one-person physical assist for bed mobility, transfer, dressing, eating, personal hygiene, and toilet use.
A review of the medical charts for Resident 1 and Resident 5 on 6/22/2023 at 1:20 PM, did not indicate any Social Service Assessment forms.
During an interview and concurrent record review on 6/22/2023 at 1:43 PM, the Social Service Assistant (SSA) stated the facility currently did not have a DSS, and that she did not have a bachelor ' s degree but a certificate for social work. The SSA stated sometimes she felt overwhelmed with the amount of work she needs to do in the facility. The SSA stated she was backed up on resident assessments and paperwork and she was trying to catch up as much as she can. The SSA stated once a resident was admitted to the facility, the social service staff were required to initiate an assessment. SSA stated, I do not have any Social Service Assessment for Resident 1. The SSA stated, I met Resident 1, but I do not have his assessment. The SSA stated, I do not have an assessment for Resident 5 either in his file or on the computer either. The SSA stated the social service assessment included all the necessary information about the resident in assisting them with their needs. The SSA stated, This is one of the outcomes of not having a director to assist me in completing social service`s tasks. The SSA stated, I do not know the potential outcome of not completing a social service assessment for the residents.
During an interview on 6/22/2023 at 2:10 PM, The Director of Nursing (DON) stated the SSA was required to perform a social service assessment upon residents ' admission. The DON stated the potential outcome of not performing a social service assessment was the inability to be informed of the resident's psychosocial needs and the inability to initiate resident's discharge planning upon admission.
During an interview on 6/22/2023 at 2:20 PM, the facility's Administrator (ADM) stated he just hired a Director of Social Services (DSS) today and the new DSS will start working in two weeks. The ADM stated the SSA was required to complete the social service assessment for each resident admitted to the facility. The ADM stated he did not know the time frame within which the social service assessment needs to be completed for the residents.
A review of the facility ' s policy and procedure titled, Social Services program, revised January 2017, indicated the facility provided medically related social services based on each resident`s comprehensive assessment to ensure that each resident archives and maintains his/her highest practicable physical , mental, and psycho-social well-being. The social service staff provides the following: comprehensive documentation of socials service assessment and interventions for each resident and assistance in meeting the individual assessed needs of the residents. The social service staff is responsible for maintaining regular progress note and follow up notes indicating the resident`s response to the resident centered care plan and implementation of interventions.
A review of the facility's policy and procedure titled, Social Assessment, revised April 2012, indicated the social assessment shall be completed within 14 days of resident`s admission to the facility. A social assessment will be done to help identify the residents personal and social situation, needs and problems. Social services staff will obtain information during the initial interview of the family and upon the resident`s admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the nursing staff failed to follow the facility's policy titled, Answering the Call Light policy for two of five sampled residents (Residents 4 and 5). This deficient practice had the potential to result in a delay in care and services and the resident`s inability to ask for assistance.
Findings:
a.A review of the admission Record indicated Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including osteoarthritis (a condition in which the tissues in the joint break down over time), and cataract ( a condition in which the lens of the eye becomes cloudy).
A review of the Physician's History and Physical dated 11/30/2022, indicated Resident 4 was alert and oriented but had moments of forgetfulness.
A review of the Quarterly Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 4/27/2023, indicated Resident 4 had moderately impaired cognition (decisions poor, cues/supervision required) and required extensive assistance with one-person physical assist for bed mobility, transfer, walking, dressing, and toilet use. The MDS further indicated Resident 4 was totally dependent for personal hygiene.
During an observation on 6/21/2023 at 1:37 PM, Resident 4 was in her bed with food on her face and gown. Resident 4 had food pieces on her neck fold as well. There was a dirty towel in front of Resident 4. During a concurrent interview, Resident 4 stated, I wonder why the nurses are here in the facility. Sometimes I use the call light but sometimes I call the nurses by their names to help me. It works better when I call their names. I do not know why we have call lights when the nurses do not answer them. The nurses come inside the room when the light is on, but they do not change me, and they leave. They say they will come back to change me but they never come back. I remain dirty for long periods of time. Resident 4 stated she was able to use the call light, but the facility was unlike a hospital setting because the nurses in the facility do not show up until much later. Resident 4 stated, When the nurses see the call light on, they do not get excited. They overlook it. That makes me upset because the call light was on, and I needed their help.
During an observation on 6/21/2023 at 2:17 PM, there was an activated call light for one of the residents on the second floor. Licensed Vocational Nurse 2 (LVN 2) walked by the activated call light, without responding to the resident. When the surveyor brought the activated call light to LVN 2's attention, he stated, I am sorry, I did not see the call light. LVN 2 stated all staff were required to answer the call light as soon as they see it. LVN 2 further stated the potential outcome of not answering a resident's call light was the resident's needs would not be timely met.
During an observation on 6/22/2023 at 11:01 AM, there was an activated call light in the hallway next to the nursing station on the third floor. LVN3 who was present at the nursing station, walked through the hallway and did not answer the call light. LVN 3 returned using the same hallway, and once again passed by resident's room with the activated call light without responding. The Director of Nursing (DON) and the Administrator (ADM) were present next to the surveyor and witnessed LVN 3's actions. The Administrator answered the call light at 11:02 AM. The DON confirmed that LVN 3 did not answer the call light and stated all staff were required to answer the call lights immediately.
b.A review of the admission Record indicated Resident 5 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area) and gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach).
A review of the MDS dated [DATE], indicated Resident 5 had severely impaired cognition (never/rarely made decisions) and was totally dependent with one-person physical assist for bed mobility, transfer, dressing, eating, personal hygiene, and toilet use.
During an observation on 6/22/2023 at 12:45 PM, Resident 5 was in his bed, the call light was not within his reach and the cord was nowhere to be seen.
During an observation on 6/22/2023 at 12:47 PM, LVN 4 who was present at the bedside stated he was not able to see Resident 5`s call light within his reach. LVN 4 started searching for the call light. At 12:48 PM, the Director of Staff Development (DSD) walked inside Resident 5's room. LVN 4 found Resident 5's call light which was placed underneath two towels next to Resident 5's head. During a concurrent interview, LVN 4 and the DSD both stated the call light needs to be visible and accessible for the residents when in bed so they can call staff for assistance.
During an interview on 6/22/2023 at 2:10 PM, The Administrator (ADM) stated all staff were required to answer the call lights as soon as they see them. The ADM further stated residents` call lights need to be within their reach. He stated the potential outcome of not paying attention to call lights and not answering them on time is that resident needs will not be timely attended.
A review of the facility`s policy and procedure titled, Answering the Call Light, revised September 2022, indicated the purpose of this procedure was to ensure timely responses to the residents' requests and needs. Be sure that the call light was plugged in and functioning at all times. Ensure that the call light was accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. Answer the resident call system immediately. When answering an auditory request for assistance, identify yourself and politely respond to the resident by his/her name. If the resident needs assistance, indicate the approximate time it will take for you to respond. If the resident`s request if something you can fulfill, complete the task within five minutes if possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and Resident 2) received treatment and care in accordance with physician's orders by failing to ensure:
-Resident 1 received treatment for right lateral malleolus (the bone outside of the right ankle joint) reopened surgical incision (a cut made in the body to perform surgery).
-Resident 1's blood sugar was checked as ordered by the physician.
-Resident 2 received treatment for left anterior (situated to the front of the body) knee abscess (pocket of a think yellowish or greenish liquid produced in infected tissue).
These deficient practices had the potential for Resident 1 and 2 to have further skin breakdown and infection. These deficiencies also had the potential for Resident 1 to suffer from hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar).
Findings:
a.A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 3/21/2023, with diagnoses including epilepsy (a brain disease where nerve cells don't signal properly, which causes uncontrolled muscle movements) and encounter for palliative care ( a type of medical care that helps relieve symptoms and stress associated with serious illnesses).
A review of Resident 1 ' s Quarterly Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 3/28/2023, indicated Resident 1 had moderately impaired cognition (decisions poor, cues/supervision required) and was totally dependent with one-person physical assist for bed mobility, transfer, dressing, personal hygiene, and toilet use.
A review of the Physician's Orders dated 4/7/2023 indicated to cleanse Resident 1's right lateral malleolus reopened surgical incision with normal saline (a type of fluid), pat dry, apply Medi honey (a wound and burn gel made with a special honey), cover with dry dressing daily, every day shift for 30 days.
A review of the Physician's Orders dated 4/23/2023 indicated to check fasting blood sugar (FBS- a test to determine how much sugar is in a blood sample after an overnight fast) two times a day for diabetes (a disease when blood sugar is too high). The order also indicated to call the physician if BS level was greater than 200.
A review of Resident 1's Medication Administration Record (MAR) dated April 2023, indicated no entry for BS check on 4/24/2023 at 6:30 AM. A review of Resident 1's MAR dated May 2023, indicated no entry for BS check on 5/4/2023 at 4:30 PM.
A review of Resident 1's Treatment Administration Record (TAR) dated April 2023, indicated no wound treatment on Sunday 4/2/2023.
A review of Resident 2 ' s admission Record indicated the facility admitted Resident 2 on 4/6/2023, with diagnoses including cataract ( a condition in which the lens of the eye becomes cloudy), and diabetes mellitus.
A review of Resident 2 ' s Quarterly MDS dated [DATE], indicated Resident 2 had intact cognition (decisions consistent/reasonable). The MDS indicated Resident 2 required supervision with bed mobility, transfer, walking, dressing, personal hygiene, and toilet use.
A review of the Physician's Order dated 5/17/2023 indicated to cleanse the left anterior knee abscess with normal saline, pat dry, apply lodosorb gel ( a gel that kills bacteria and is used to treat infected wounds), cover with dry dressing daily, and as needed every day shift for 30 days.
A review of Resident 2's Treatment Administration Record (TAR) dated June 2023, did not indicate any wound treatment on Friday 6/2/2023.
During an interview and concurrent record review on 6/21/2023 at 10:18 AM, Treatment Nurse 1 (TN 1) stated he was a charge nurse and since the facility was short on staff, he also worked as a treatment nurse. TN 1 confirmed that Resident 2`s wound treatment, if any, was not documented for 6/2/2023. TN 1 stated he did not know why the entry was missing.
During an interview and record review on 6/22/2023 at 1:15 PM, the Director of Nursing (DON) stated Resident 1's FBS level was not documented on 4/24/2023 at 6:30 AM, and 5/4/2023 at 4:30 PM in his MAR. During a record review of Resident 1's TAR, the DON stated Resident 1's wound treatment was not documented on 4/2/2023. The DON stated, Maybe the staff checked Resident 1's blood sugar and provided wound treatment but they did not document it. The DON stated if it was not documented, it was not done. The DON stated the potential outcome of not checking a resident`s blood sugar level when ordered by the physician was the inability to detect hypoglycemia or hyperglycemia. The DON further stated the potential outcome of not providing wound care to a resident was the worsening of a wound and possible infection.
A review of facility's undated document titled, Charge Nurse Job Description, indicated the general duties and responsibilities of the charge nurses are as follows: reviewing medication sheet for completeness of the information, accuracy in transcription of the physician orders and adherence to stop order policies. Performing routine charting as required. Administering professional services such as applying and changing dressing/bandages. Charting blood pressure and blood glucose as required, and preparing/administering medications as ordered by the physician.
A review of the facility's policy and procedure titled, Quality of Care, Routine Resident Monitoring and Scope of Service, revised 1/2017, indicated it was the policy of the facility that each resident receives, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient staffing in order to accommodate resident needs for three of five sampled residents (Resident 3, 4, and 5). This deficient practice resulted in residents not receiving timely and efficient care and needed services.
Findings:
a.A review of the Certified Nursing Assistant's (CNA) Assignments for the month of April 2023, indicated that on 4/1/2023, three CNAs worked in station B during the 3PM-11PM shift attending to 62 residents. On 4/23/2023, three CNAs worked in station B during the 3PM-11PM shift, each CNA was assigned to 20 residents. On 4/29/2023, three CNAs worked in station A during the 3PM-11PM shift. Two of the CNAs were each assigned to 21 residents and the third CNA was assigned to 20 residents.
A review of CNA's Assignments for the months of May 2023, indicated that on 5/3/2023, three CNAs worked in station B during the 11PM-7AM shift, each CNA was assigned to 20 residents. On 5/27/2023, two CNAs worked in station B during the 3PM-11PM shift, one of the CNAs was assigned to 28 residents and the second CNA was assigned to 29 residents. On 5/27/2023, two CNAs worked in station B during the 11PM-7AM shift attending 57 residents.
A review of CNA's Assignments for the months of June 2023, indicated that on 6/1/2023, three CNAs worked in station B during the 11PM-7AM shift, each CNA was assigned to 18 residents. On 6/3/2023, two CNAs worked in station B during the 11PM-7AM shift, one CNA was assigned to 27 residents and the other one was assigned to 28 residents. On 6/5/2023, three CNAs worked in station B during the 11PM-7AM shift attending 53 residents.
During an interview on 6/21/2023 at 10:46 AM, CNA 2 stated she was assigned to 12 residents today but yesterday she was assigned to 13 residents. CNA 2 stated it was very stressful to work when she was assigned to more than 8-9 residents in the morning shift. CNA 2 stated she was required to clean 12 residents, shower scheduled residents and feed the ones who require feeding assistance all in one shift. CNA 2 stated, As a result of all the tasks I am required to perform for 12 residents, I am unable to provide the most thorough and complete care for them. CNA 2 stated this was the reason a lot of the CNAs have recently left this facility.
During an interview on 6/21/2023 at 12: 44 PM, the Director of Staff Development (DSD) stated, We try to schedule six-seven CNAs for the 7AM-3PM shift. The problem was the call offs. There are so many call offs every day in this facility. When the nurses call off, we try to get somebody. Sometimes we are successful and sometimes we are not. Today we have five CNAs working in station B and we have six CNAs in station A. The DSD stated, I wish we could have more CNAs scheduled to work today but we had a call off today as well.
During an interview on 6/21/2023 at 1:17 PM, CNA 4 stated she was assigned to ten residents today. CNA 4 stated, I get really tired when I take care of more than nine residents during my shift. All CNAs in station A complained a lot about the staffing shortage in the facility, but what can we do. That ' s why my last day of work will be end of the month. I am leaving and I will work somewhere else because I will get paid more over there. CNA 4 stated, Yesterday I was scheduled to shower four residents during my shift, but I only gave two showers because I could not complete my tasks and I am not going to kill myself. Sometimes my back is hurting badly. CNA4 stated, We had a meeting with the union regarding being overworked and understaffed. They did nothing. We are already tired of talking to higher management about staffing shortage. The facility stopped utilizing registry nurses ( temporary nursing staff from outside the facility) because they had to pay more for registry staff.
b.A review of the admission Record indicated the facility admitted Resident 3 on 1/4/2023, with diagnoses including back pain, lack of coordination, and depression (mood disorder with feeling of sadness and lack of interest).
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 4/14/2023, indicated Resident 3 had intact cognition (decisions consistent/reasonable) and required supervision with bed mobility, transfer, walking, dressing, and personal hygiene.
A review of the Physician's History and Physical of dated 1/8/2023, indicated Resident 3 had the capacity to understand and make decisions.
During an interview on 6/22/2023 at 10:38 AM, Resident 3 stated the issue in this facility was that there was never enough staff working, especially over the weekends and during the 11PM-7AM shift. Resident 3 stated, Last night there were only three CNAs working on the third floor and that was not enough. Resident 3 stated when there are not enough CNAs on the floor, CNAs are unable to timely answer the call lights to provide the necessary care.
c.A review of Resident 4 ' s admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including osteoarthritis (a condition in which the tissues in the joint break down over time), and cataract ( a condition in which the lens of the eye becomes cloudy).
A review of the MDS dated [DATE], indicated Resident 4 had moderately impaired cognition (decisions poor, cues/supervision required) and required extensive assistance with one-person physical assist for bed mobility, transfer, walking, dressing, and toilet use. The MDS further indicated Resident 4 was totally dependent for personal hygiene.
A review of the Physician's History and Physical dated 11/30/2022, indicated Resident 4 was alert and oriented but had moments of forgetfulness.
During an observation and concurrent interview on 6/21/2023 at 1:37 PM, Resident 4 was in her bed with food on her face and gown. Resident 4 had food pieces on her neck fold as well. There was a dirty towel in front of Resident 4. Resident 4 stated, After I had finished my lunch the nurse came in to take away my tray. The nurse saw that I had food on my face and neck and did nothing about it. It seemed like the nurse was in a hurry and wanted to just take my [NAME] and leave. Resident 4 stated, I wonder why the nurses are here in the facility. Sometimes I use the call light but sometimes I call the nurses by their names to help me. It works better when I call their names. I do not know why we have call lights when the nurses do not answer them. The nurses come inside the room when the light is on, but they do not change me, and they leave. They say they will come back to change but they never come back. I remain dirty for long periods of time. Resident 4 stated she was able to use the call light, but the facility was unlike a hospital setting because the nurses in the facility do not show up until much later. Resident 4 stated, When the nurses see the call light on, they do not get excited. They overlook it. That makes me upset because the call light was on, and I needed their help.
d.A review of the admission Record indicated the facility admitted Resident 5 on 3/16/2023, with diagnoses including cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area) and gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach).
A review of the Physician's History and Physical dated 3/18/2023, indicated Resident 5 did not have the capacity to understand and make decisions.
A review of the MDS dated [DATE], indicated Resident 5 had severely impaired cognition (never/rarely made decisions). The MDS indicated Resident 5 was total dependent with one-person physical assist for bed mobility, transfer, dressing, eating, personal hygiene, and toilet use.
During an observation and concurrent interview on 6/22/2023 at 10:21 AM, Family 1 was observed standing in the hallway close to Resident 5`s room. Family 1 stated, I do not come here every day. I do not know how well the staff are taking care of my father, but when I arrived at the facility a few minutes ago, my father was in a bad shape. His brief and linens were soiled, and there was strong odor of feces in his room. Family 1 stated, They are cleaning him right now after I had to ask the staff to clean him.
During an interview on 6/22/2023 at 1:04 PM, the Director of Nursing (DON) stated that the facility had a new Administrator, and We are aware of the staffing shortage in the facility. The DON stated, Although we have placed adds on indeed for CNAs we have yet to hear for qualified candidates. The DON stated the facility had a union and we had a few meetings discussing our shortage issues, however, nothing has been done about it as of yet. The DON stated There is nursing staff shortages everywhere. The staff started to call off and we started to write them up. The DON stated there was a lot of call offs at this facility.
During an interview on 6/22/2023 at 2:10 PM, The Administrator (ADM) stated, I am aware of the staffing issues in the facility. We have placed advertisements out to hire more staff specially CNAs. It is my second week of working in the facility. One CNA is coming for an interview this week. There are staffing shortages throughout our industry. I also reached out to nursing schools to see if I could recruit anyone. The ADM stated the potential outcome of insufficient staffing in the facility was that the residents will not receive proper care and services.
A review of the facility policy and procedure titled, Staffing, Sufficient and Competent Nursing, revised August 2022, indicated our facility provides sufficient numbers of nursing staff with the appropriate skills and competency to provide nursing related care and services in accordance with resident care plans and the facility assessment. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident`s care plan, the residents ' assessments, and the facility assessment. Inquiries or concerns relative to our facility's staffing should be directed to the Director of Nursing Services or his/her designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate the needs of one of three sampled residents (Resident 2) by failing to provide the resident with a call device he was able to use.
This deficient practice had the potential for Resident 2 not to be able to call the facility staff for help when needed, which could lead to accidents including falls and injuries.
Findings:
A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including but not limited to quadriplegia (partial or complete paralysis of both the arms and legs), blindness and anoxic brain injury (death of brain cells caused by the complete lack of oxygen to the brain).
A review of Resident 2's Minimum Data Set (MDS, a standardized comprehensive assessment tool, and care-screening tool) dated 3/23/2023, indicated the resident's speech was unclear and his cognitive (ability to remember, understand, make decisions, and learn) skills were mildly impaired. It also indicated the resident was totally dependent upon staff for bed mobility, transferring, dressing eating, personal hygiene and toilet use.
A review of Resident 2's risk for fall care plan initiated 3/17/2023, indicated Resident 2 was at risk for falls due to blindness, generalized weakness and a gait disturbance. The interventions included to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed.
A review of Resident 2's limited physical mobility care plan initiated 3/17/2023, indicated the goal was for the resident to not have complications related to immobility, including contractures, skin break down and fall.
During a concurrent observation and interview on 5/11/2023 at 1:05 PM with Resident 2 and Resident 2's representative inside his room, Resident 2's call bell was observed. The call bell was hanging down from the resident's right side bed rail out of reach of Resident 2. The call bell has a red button to activate the device. Resident 2 stated that he is unable to press the button on the call bell and he tries not to call the staff a lot.
During an interview on 5/11/2023 at 1:15 PM, Resident 2's representative stated Resident 1 cannot use his hands and is unable to use the call bell.
During an interview on 5/11/2023 at 2:02 PM, Certified Nursing Assistant 1 (CNA 1) stated Resident 2 is not able to use spoon, I feed him every time I work, and he has difficulty using his arms. CNA 1 further stated Resident 2 calls for help by yelling CNA 1's name and Resident 2 has never used his call bell to his knowledge.
During an interview on 5/11/2023 at 2:17 PM, Licensed Vocational Nurse 1 (LVN 1) stated if a resident is unable to use the push button call bell the facility has flat call bells. LVN 1 also stated it is very important for residents to have a call light, so they are able to use if there is an emergency.
During an interview on 5/11/2023 at 3:03 PM, LVN 1 stated Resident 2 would benefit from an adaptive call device because his (Resident 2) hands aren't able to grab objects or things. LVN 1 also stated Resident 2 just yells when he needs help. When asked what happens if staff are not near, LVN 1 replied, If no one is around his roommate comes out.
During an interview on 5/12/2023 at 2:46 PM, Director of Nursing (DON) stated it is important for Resident 2 to have a usable call device so that he can ask for help. He doesn't need to scream.
A review of the facility's policy titled, Answering the Call Light revised 9/2022, indicated upon admission staff will explain and demonstrate use of the call light to the resident and staff will ask the resident to return demonstration.
A review of the facility's policy titled, Call System, Residents, revised 9/2022, indicated if the resident has a disability that prevents him from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pain management treatment consistent with professional standards of practice for one of three sampled residents (Resident 1) by:
1. Failing to document when as needed pain medication was given; and
2. Failing to assess the intensity and location of the resident's pain prior to administering pain medication and evaluate the effectiveness of pain medication after the administration.
These deficient practices had the potential to for Resident 1's pain not to be effectively manage.
Findings:
A review of the admission Record indicated the facility admitted Resident 1 on 1/31/2023 with diagnoses including paraplegia (paralysis that affects the legs but not the arms), lung cancer and spinal cord compression (condition that puts pressure on your spinal cord which may cause pain, numbness or weakness in the limbs).
A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/7/2023, indicated Resident 1 had intact cognition (decisions consistent/reasonable). The MDS also indicated that Resident 1 was totally dependent upon staff for bed mobility, transferring and toileting. It further indicated the resident required extensive supervision with one-person physical assist for eating and personal hygiene.
A review of Resident 1's Physician's orders dated 4/11/2023, indicated to administer Oxycodone (a narcotic pain medication) 10 milligrams (mg) by mouth every three hours as needed for severe pain (8-10/ pain rating scale of zero being no pain and 10 being the worst pain possible).
A review of Resident 1's Risk for Discomfort and Pain Care Plan initiated on 4/12/2023, indicated the resident was at risk for pain due to the resident's diagnoses of lung cancer and spinal cord compression. The care plan interventions included to anticipate the resident's need for pain relief and respond immediately to any compliant of pain and to evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedule, resident satisfaction with results and the impact on functional ability and cognition.
A review of Resident 1's Medication Count Sheet for Oxycodone (strong pain medication) 10 milligrams (mg, unit of measurement) tablet indicated Resident 1 received as needed doses of Oxycodone twice on following date and time: 4/15/2023 at 12 AM, 4/19/2023 at 12 PM and 9 PM, 4/20/2023 at 1 PM, 4/21/2023 at 1 PM and 4 AM, 4/22/2023 at 1 PM and 9PM, 4/23/2023 at 2 PM, 4/24/2023 at 7:30 AM, 4/25/2023 at 7:15 AM and 1 PM, 4/26/2023 at 1 AM, 1 PM, 4/27/2023 at 2 AM and 5 AM, and 4/29/2023 at 2 AM.
A review of Resident 1's Medication Count Sheet for Oxycodone 5 mg tablet indicated Resident 1 received as needed doses of Oxycodone on 4/24/2023 at 8 PM and 10 PM, on 4/28/2023 at an unspecified time, on 4/29/2023 at 12 PM.
A review of Resident 1's Medication Administration Record (MAR) for April 2023, indicated the above listed doses were not documented as given.
A review of Resident 1's Pain Assessment Flow Sheet for April 2023 indicated its purpose is to evaluate the safety and effectiveness of pain medications. It also indicated Resident 1's pain location and/or intensity was not assessed prior to and after pain medication administration for the above listed dates and times.
A review of Resident 1's Nursing Discharge summary, dated [DATE], indicated the resident stated he called the paramedics, and the resident was transferred to a general acute hospital (GACH).
During an interview on 5/12/2023 at 10:33 AM, Resident 1 stated that on 4/30/2023 he called 911 (A telephone number in the US that links the public to the police and mobile rescue units to provide emergency care) because the staff were not coming in all night. Resident 1 stated, I had to get out of there .I was in excruciating pain. He further stated I have stage 4 cancer. I am a paraplegic (The inability to voluntarily move the lower parts of the body), and I can't do anything. I can't use my hands. I was dying over there.
During an interview on 5/11/2023 at 2:17 PM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was always asking for oxycodone. He (Resident 1) had a lot of medical problems and would basically get it every three hours.
During a concurrent interview and record review of Resident 1's medical chart on 5/12/2023 at 2:10 PM, LVN 3 stated Resident 1's pain assessment flow sheet and medication count sheet showed that there were doses of oxycodone not documented and the resident's pain was not assessed pre and post medication administration. LVN 3 stated a pain assessment is done because pain is subjective, we must find out where the pain is, what their pain level is and how much of the pain medication to give and if we should notify the doctor.
During an interview and concurrent record review on 5/12/2023 at 2:32 PM, the Director of Nursing (DON) stated staff are required to assess resident's pain including pain quality, intensity, and location for all as needed (prn) pain medications. The DON stated staff are required to re-assess and evaluate resident's pain after administering pain medication to monitor the effectiveness of the medication. The DON stated, the MAR should match the narcotic count sheets.
A review of the facility's policy and procedure titled Pain Management, reviewed 9/2/2022, indicated the facility must ensure that pain management is provided to residents who require such services, consistent with professional standard of practice, the comprehensive person-centered care plan and the resident's goals and preferences. It also indicated the facility will use a pain assessment tool to assist staff in consistent assessment of a resident's pain.

Based on interview and record review, the facility failed to review and revise the care plan for one of two residents (Resident 1), as evidenced by failing to revise Resident 1's care plan potential for recurrence of urinary tract infection related (UTI - an infection in any part of the urinary system [kidneys, bladder or urethra]) to UTI, incontinence of bladder and bowel function (loss of control with urine or stool).
This deficient practice had the potential to result in a delay in the current treatment plan, to lead to inadequate care, and cause injury to Resident 1.
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 8/18/2022 and re-admitted the resident on 4/15/2023 with urinary tract infection site not specified, Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and unspecified dementia (decline in mental ability severe enough to interfere with daily functioning/life)
A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 4/22/2023, indicated Resident 1's cognitive skills was severely impaired (never/rarely made decisions). The MDS indicated the resident was dependent and required one to two people assist for dressing, eating, and personal hygiene.
A review of Resident 1's assessment for incontinence, dated 8/18/2022, indicated a score of 22, meaning Resident 1 was not a good candidate for bowel and bladder training.
A review of Resident 1's laboratory urinalysis (a test of urine often done to check for a urinary tract infections), dated 9/5/2022, indicated Resident 1 had Klebsiella pneumoniae (a type of bacterium that can cause infection).
A review of Resident 1's change of condition, dated 9/7/2022, indicated Resident 1 had a urinary tract infection of extended-spectrum beta-lactamases in urine (ESBL - enzymes that confer resistance to most beta-lactam antibiotics and requires contact isolation).
A review of Resident 1's Care Plan initiated 8/18/2022, for potential for recurrence of UTI related to UTI, incontinence of bladder and bowel function, indicated resident will be free of bladder infection daily for 90 days. The care plan was re-evaluated but not revised on 11/2022.
During a concurrent interview and record review, on 5/11/2023 at 4:34 PM, with Licensed Vocational Nurse 1 (LVN 1), Resident 1's care plan for potential for recurrence of urinary tract infection related to UTI, incontinence of bladder and bowel function, initiated 8/18/2022, was reviewed. LVN 1 confirmed the care plan was re-evaluated on 11/2/2022 but was not revised to include any additional new interventions to prevent Resident 1 from developing further UTI. LVN 1 stated the potential outcome of failing to revise the care plan was that Resident 1 was at further risk for recurrence of UTI.
During a concurrent interview and record review, on 5/10/2023 at 4:42 PM, with the Director of Nursing (DON), Resident 1's Care Plan was reviewed. The DON confirmed and stated the care plan for potential for recurrence of UTI related to UTI, incontinence of bladder and bowel function, was initiated 8/18/2022 and re-evaluated but not revised on 11/2022. The DON stated the care plan was not revised to include new interventions to prevent Resident 1 from developing further UTIs. The DON stated Resident 1 had UTI on 9/7/2022 and the care plan to prevent recurrence of UTI was not effective. The DON stated when a care plan is not effective, the care plan must be reviewed and revised to include additional effective intervention to prevent the recurrence of Resident 1's UTI. The DON stated by failing to revise her care plan, it placed Resident 1 at continued risk to develop UTIs.
A review of the facility's Policy and Procedures titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated, the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly monthly MDS assessment. The policy and procedure further indicated care plans are revised as information about the resident and the resident's conditions change.

Based on interview and record review, the facility failed to update the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) within 14 days for significant change in status for one of 25 sampled residents (Resident 60).
This deficient practice had the potential to affect the provision of necessary care and services for Resident 60.
Findings:
A review of Resident 60's admission Record, indicated the facility originally admitted Resident 60 was originally on 5/16/2019, and readmitted the resident on 5/28/2020, with diagnoses that included, but were not limited to, Type II Diabetes (DM-a disorder which the body does not produce enough or respond normally to insulin causing blood sugar levels to be abnormally high), and Coronavirus disease 2019 (COVID-19, a contagious severe respiratory illness).
A review of Resident 60's Minimum Data Sheet (MDS- a standardized assessment and care-screening tool) dated 10/9/2021, indicated Resident 45 had severe cognition (ability to make decisions for daily living) impairment, and was dependent on staff for activities of daily living (ADL-bed mobility, dressing, eating and personal hygiene). MDS also indicated, Resident 60 is receiving hospice care.
A review of Resident 60's Physician Order dated 10/5/2021, indicated facility to disenroll Resident 60 from hospice effective 10/4/2021.
During an interview with Minimum Data Set Nurse (MDSN) on 12/8/2021 at 9:39 a.m., the MDSN stated Resident 60 had a significant change on 10/4/2021. The MDSN did not answer when asked if the MDS transmitted to The Centers for Medicare and Medicaid Services (CMS- a federal agency that administers the nation's major healthcare programs including Medicare, Medicaid) accurately reflected Resident 60's significant change in status.
During an interview with Director of Nursing (DON) on 12/9/2021 at 12:32 p.m., the DON stated and acknowledged, the facility did not accurately complete the MDS after Resident 60 had a significant change on care and treatment.
A review of facility's policy and procedures titled Resident Assessment Instrument, revised September 2010, indicated the Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen days of the resident's admission to the facility. b. When there has been a significant change in the resident's condition, c. At least quarterly, d. Once every twelve months.
A review of the CMS's Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Version 3.0 dated 10/2019, indicated A Significant Change in Status Assessment (SCSA) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care).

Based on interview and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) accurately reflected the resident's hospice status for one of 25 sampled residents (Resident 60).
This deficient practice resulted in incorrect data transmitted to Centers for Medicare and Medicaid Services (CMS- a federal agency that administers the nation's major healthcare programs including Medicare, Medicaid) regarding resident's hospice status.
Findings:
A review of Resident 60's admission Record, indicated the facility originally admitted Resident 60 was originally on 5/16/2019, and readmitted the resident on 5/28/2020, with diagnoses that included, but were not limited to, Type II Diabetes (DM-a disorder which the body does not produce enough or respond normally to insulin causing blood sugar levels to be abnormally high), and Coronavirus disease 2019 (COVID-19, a contagious and severe respiratory illness).
A review of Resident 60's Minimum Data Sheet (MDS- a standardized assessment and care-screening tool) dated 10/9/2021, indicated Resident 60 had severe cognition (ability to make decisions for daily living) impairment, and was dependent on staff for activities of daily living (ADL-bed mobility, dressing, eating and personal hygiene). The MDS also indicated, Resident 60 was on hospice care.
A review of Resident 60's Physician Order dated 10/5/2021, indicated facility to disenroll Resident 60 from hospice effective 10/4/2021.
During an interview with Minimum Data Set Nurse (MDSN) on 12/8/2021 at 9:39 a.m., the MDSN stated Resident 60 had a significant change on 10/4/2021. The MDSN did not answer when asked if the MDS transmitted to The Centers for Medicare and Medicaid Services (CMS) accurately reflected Resident 60's significant change in status.
During an interview with Director of Nursing (DON) on 12/9/2021 at 12:32 p.m., the DON stated and acknowledged, the facility did not accurately complete the MDS after Resident 60 had a significant change on care and treatment.
A review of facility's policy and procedure titled, Resident Assessment Instrument, revised September 2010, indicated, the Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews according to the following schedule: a. Within fourteen days of the resident's admission to the facility, b. When there has been a significant change in the resident's condition, c. At least quarterly, d. Once every twelve months.
A review of the CMS's Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual Version 3.0, dated 10/2019, indicated, A Significant Change in Status Assessment (SCSA) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement care plans on safety and peripherally (away from the center of the body) inserted central catheter (PICC- is a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart to administer intravenous [IV-inside a vein] fluids, blood transfusions, chemotherapy [medication to treat cancer], and other drugs) line care for two of 25 sampled residents (Resident 58 and 67).
A review of facility's policy and procedures (P&P) titled Care Planning- Interdisciplinary Team, revised 1/2017, indicated that it is the policy of the facility that the interdisciplinary team is responsible for the development of an individualized resident centered comprehensive care plan for each resident.
A review of facility's P&P titled admission Policy, revised 1/2017, indicated that the care plan will be developed to address minimum healthcare information required to properly care for each resident, including goals and objectives and the care plan must address effective and person-centered care that meets professional standards for quality of care.
These deficient practices placed Resident 58 at higher risk for fall, and a risk for serious complication associated with PICC line for Resident 67.
Findings:
1. A review of Resident 58's admission Record, indicated the facility readmitted Resident 58 on 2/13/2020, with diagnoses not limited to hemorrhage (bleeding) of the rectum (final section/ part of the lower gastrointestinal tract [GI tract-organ system of the body from the mouth to the anus [part of the GI tract where the stool or feces are being eliminated from the body]), dementia (loss of cognitive functioning-thinking, remembering, and reasoning), gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) and glaucoma (increase in eye pressure that can cause blindness).
A review of the Resident 58's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 10/20/2021, indicated Resident 58 had severe cognitive skills impairment for daily decision making. The MDS also indicated Resident 58 was dependent on staff for activities of daily living (ADL-bed mobility, dressing, eating, toilet use, personal hygiene, and bathing).
A review of Resident 58's fall risk assessment dated [DATE], indicated Resident 58 was a high risk for fall.
A review of Resident 58's care plan titled Baseline Care Plan: Safety developed on 11/3/2021, indicated Resident 58 was at risk for fall. Interventions included to place Resident 58's bed in low position.
During a concurrent observation and interview with Licensed Vocational Nurse 4 (LVN 4) on 12/7/2021 at 6:31 a.m., Resident 58's bed was observed in a high position level. LVN 4 stated Resident 58's bed should be at the lowest position because the resident was at risk for fall.
During a concurrent interview and record review with the Director of Nursing (DON) on 12/8/2021 at 11:22 a.m., the DON stated Resident 58 was a high risk for fall and should have the bed in the lowest position for safety.
2. A review of Resident 67's admission Record, indicated the facility re-admitted Resident 67 on 12/18/2018, with diagnoses that included, but not limited to hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, ischemic heart disease (also called coronary heart disease [CHD-heart problems caused by a narrowed heart arteries which can cause less blood and oxygen circulation to the heart]), and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 67's MDS dated [DATE], indicated Resident 67 cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated Resident 67 required limited staff supervision with ADL (bed mobility, surface transfer, walk in room, dressing, toileting, and personal hygiene).
A review of Resident 67's Order Summary Report dated 6/15/2021, indicated Resident 67 was started on Intravenous (IV-inside a vein) therapy of D5W 0.45 % NaCL (5 percent dextrose and 0.45 percent sodium chloride IV solution) with KCL (potassium chloride) 20 meq/L (milliequivalent per liter-unit of measurement) at 100 ml/ per hour (milliliter per hour) for 10 hours twice a week every Monday and Thursday.
A review of Resident 67's Care Plan for IV therapy hydration and medication re-evaluated on 8/2021, indicated the goal was the facility would handle appropriately the IV site with good aseptic (preventing or not involving infection) technique, maintain IV access, and be free of serious local or systemic complications. The care plan interventions included to observe the IV site frequently for signs and symptoms of complications such as redness, swelling, pain, drainage, leakage, temperature, and tape burns.
During a concurrent observation and record review with Registered Nurse 1 (RN 1) on 12/5/2021 at 8:58 a.m., Resident 67's IV medication sheet after administering the IV therapy medication did not have documentations PICC line site checks every 8 hours for Resident 67 on the following dates:
12/2/2021 at 11-7 shift
12/3/2021 at 11-7 shift
12/4/2021 at 3-11 and 11-7 shifts
12/5/2021 at 3-11 and 11-7 shifts
During a concurrent interview with RN 1 on 12/5/2021 at 8:58 a.m., RN 1 confirmed and stated the IV medication sheet for Resident 67 did not have any documentation on PICC line site checks every 8 hours. RN 1 further stated that nurses should check Resident 67's the PICC line sites for any complications and document per care plan and standard of practice.
During an interview with the Director of Nursing (DON) on 12/8/2021 at 10:05 a.m., the DON stated staff should monitor Resident 67's PICC line every shift and documented in the IV medication sheet per facility policy because of high risk of possible complications associated with PICC line.
A review of the facility's undated Nursing Supervisor Job Description, indicated that the general duties and responsibilities of the nursing supervisor is to perform resident assessments as condition warrants and develops, implements, and evaluates plans of care to promote desired outcomes.
A review of facility's policy and procedures (P&P) titled Care Planning- Interdisciplinary Team, revised 1/2017, indicated that it is the policy of the facility that the interdisciplinary team is responsible for the development of an individualized resident centered comprehensive care plan for each resident.
A review of facility's P&P titled admission Policy, revised 1/2017, indicated that the care plan will be developed to address minimum healthcare information required to properly care for each resident, including goals and objectives and the care plan must address effective and person-centered care that meets professional standards for quality of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an low air loss mattress (LAL-a mattress designed to prevent and treat pressure wounds) settings were consistent with weight and physician's order for five of 25 sampled residents (Residents 45, 49, 60, 66 and 100) who had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment, and dependent on staff for activities of daily living (ADL, bed mobility, locomotion, surface transfer, eating, grooming, persional hygiene, toileting and or dressing)
These deficient practice increased the risk for poor and or delayed pressure ulcer (also called pressure ulcers and decubitus ulcers -are injuries to skin and underlying tissue resulting from prolonged pressure on the skin) wound healing, and increased the risk to develop pressure ulcers /wounds for (Residents 45, 49, 60, 66 and 100).
Findings:
1. A review of Resident 45's admission Record, indicated the facility originally admitted Resident 45 on 2/2/2018, and was readmitted on [DATE], with diagnoses that included, but were not limited to, multiple sclerosis (a disease that impacts the brain and spinal cord which make up the central nervous system and controls everything a person does) and anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues).
A review of Resident 45's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 10/8/2021, indicated Resident 45 had severe cognitive impairment for daily decision-making. The MDS indicated Resident 45 needed extensive staff assist for bed mobility, dressing and personal hygiene.
During an initial tour of the facility on 12/6/2021 at 9:34 a.m., Resident 45 observed in bed on a LAL mattress bed, alert and calm. The LAL mattress machine knob indicated the LAL mattress was set at 80 pounds (lbs-unit of measurement) body weight. In a concurrent interview with Resident 45, the resident stated it's okay when the writer asked if the mattress was comfortable. Resident 45 further stated she was could not to get out of bed on her own.
A review of Resident 45's Vital Report dated 12/3/2021, indicated Resident 45 weighed 135 lbs.
A review of Resident 45's Physician's Order Report dated 6/25/2021, indicated Low air loss mattress for wound management firmness: resident current weight. Mode: Normal pressure Check: daily every shift for Resident 45.
2. A review of Resident 49's admission Record, indicated the facility originally admitted Resident 49 on 1/30/2018, and was readmitted on [DATE], with diagnoses that included, but were not limited to, Type II diabetes (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), and Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination).
A review of Resident 49's MDS dated [DATE], indicated Resident 49 had severe cognitive impairment for daily decision-making. The MDS indicated Resident 49 was dependent on staff for bed mobility, dressing, eating and personal hygiene).
During an initial tour of the facility on 12/6/2021 at 9:25 a.m., Resident 45 was observed in bed on a LAL mattress bed with eyes closed. The LAL mattress machine knob was set at 400 lbs body weight.
A review of Resident 49's Vital Report dated 12/3/2021, indicated Resident 49 weighed 109 lbs.
A review of Resident 49's Physician's Order Report dated 7/12/2021, indicated Low air loss mattress for wound management firmness: resident current weight. Mode: Normal pressure Check: daily every shift for skin maintenance for Resident 49.
3. A review of Resident 60's admission Record, indicated the facility originally admitted Resident 60 on 5/16/2019, and was readmitted on [DATE], with diagnoses that included, but were not limited to, Type II DM, and Coronavirus disease 2019 (COVID-19- a contagious severe respiratory illness).
A review of Resident 60's MDS dated [DATE], indicated Resident 45 had severe cognitive impairment for daily decision-making. The MDS indicated Resident 45 was dependent on staff for bed mobility, dressing, eating and personal hygiene.
During an initial tour of the facility on 12/6/2021 at 9:17 a.m., Resident 60 was observed in bed on a LAL mattress bed with eyes closed. The LAL mattress machine was on 4th LED light, and the LAL mattress was set at 170 lbs to 205 lbs body weight.
A review of Resident 60's Vital Report dated 12/3/2021, indicated Resident 60 weighed 133 lbs.
A review of Resident 60's Physician's Order Report dated 6/24/2021, indicated Low air loss mattress for wound management firmness: resident current weight. Mode: Normal pressure Check: daily every shift for Resident 60.
5. A review of Resident 100's admission Record, indicated the facility originally admitted Resident 100 on 6/9/2014, and was readmitted on [DATE], with diagnoses that included, but were not limited to, Parkinson's disease and chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should).
A review of Resident 100's MDS dated [DATE], indicated Resident 100 had severe cognitive impairment for daily decision-making. The MDS indicated Resident 100 was dependent on staff for bed mobility, dressing, eating and personal hygiene.
During an initial tour of the facility on 12/6/2021 at 9:13 a.m., Resident 100 was observed lying on a LAL mattress bed, eyes closed. The LAL mattress machine setting knob on bed indicated the bed mattress was set for weight of 200 lbs.
A review of Resident 100's Vital Report dated 12/6/2021, indicated Resident 100 weighed 166 lbs.
A review of Resident 100's Physician's Order Report dated 6/24/2021, indicated Low air loss mattress for wound management firmness: resident current weight. Mode: Normal pressure Check: daily every shift for wound management for Resident 100.
During a concurrent observation and interview with the Registered Nurse/Treatment Nurse (RN/TX 4) on 12/7/2021 at 9:47 a.m., the RN/TX 4 confirmed and stated LAL mattress settings were not correct for Residents 45, 49, 60, 66 and 100. The RN/TX 4 further stated Residents 45, 49, 60, 66, and 100, were at risk to develop pressure injury if the LAL mattresses were not at the correct settings.
A review of facility's policy and procedures (P&P) titled Low Air Loss Mattress revised 03/2017, indicated It is the policy of the facility to provide for the proper placement and management of a low air loss mattress when utilized by a resident.
A review of facility's undated P&P titled Skin wound management, indicated Use a pressure reduction device on the bed and chair.
4. A review Resident 66's admission Record, indicated the facility admitted Resident 66 on 10/15/21, with diagnoses not limited to quadriplegia, lack of coordination, and other symptoms and signs involving the musculoskeletal system.
A review of Resident 66's MDS dated [DATE], indicated Resident 66 cognition was intact. The MDS further indicated Resident 66 was dependent on staff for bed mobility, transfers, locomotion on unit and off, dressing, toilet use, personal hygiene, and bathing.
A review of Resident 66's active Order Summary Report dated 11/10/21, indicated for Low Air Loss Mattress for skin maintenance Firmness: Resident current weight. Mode: normal pressure, Check: Daily every shift for Resident 66.
A review of Resident 66's care plan on Risk for Skin Breakdown / Pressure Ulcer dated 11/10/21, intervention included Low Air Loss Mattress for skin maintenance Firmness: Resident current weight. Mode: Normal Pressure Check: Daily for Resident 66.
During an observation on 12/06/21 at 10:12 a.m., Resident 66's low air loss mattress was noted at the max setting number eight for 350 lbs body weight. Further observation of the LAL mattress, had a handwritten white sticker next to the setting dial of the LAL mattress pump that indicated 38 B, [DATE] lbs.
During an interview with Resident 66 on 12/06/21 at 10:17 a.m., Resident 66 stated I weigh around 120 lbs.
During an interview with Certified Nursing Assistant 4 (CNA 4) on 12/06/21 at 10:20 a.m., CNA 4 stated I am not supposed to touch the dial on Resident 66's LAL mattress bed.
During an interview with Licensed Vocation Nurse 1 (LVN 1) on 12/06/21 at 10:22 a.m., LVN 1 stated the dial should be on setting two for his (Resident 66) weight.
A review of facility's undated P&P titled Skin/Wound Management, indicated Moderate and Strict Pressure ulcer precautions shall include the following: Use a pressure reduction device on the bed and chair.
A review of facility's P&P titled Low Air Loss Mattress revised 03/2017, indicated It is the policy of the facility to provide for the proper placement and management of a low air loss mattress when utilized by a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A record review of the admission record indicated Resident 58 was re-admitted to the facility on [DATE]. Resident 58 diagnoses included but were not limited to hemorrhage (bleeding) of the rectum (the terminal part of the intestine from the sigmoid colon to the anus), dementia (loss of cognitive functioning-thinking, remembering, and reasoning), gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) and glaucoma (eye condition that can cause blindness).
A record review of the Resident 58's MDS, dated [DATE], indicated Resident 58 had severe impairment in cognitive skills for daily decision making. The MDS also indicated Resident 58 was totally dependent on staff for help in bed mobility, dressing, eating, toilet use, personal hygiene, and bathing.
A record review of Resident 58's fall risk assessment, dated 11/3/2021, indicated Resident 58 was a high risk for fall.
A record review of Resident 58's care plan titled Baseline Care Plan: Safety, developed on 11/3/2021, indicated Resident 58 was at risk for fall with interventions for low bed.
During a concurrent observation and interview on 12/7/2021 at 6:31 a.m., Resident 58's bed was observed in a high position level. Licensed Vocational Nurse 4 (LVN 4) stated Resident 58's bed should be at the lowest position due to possible risk for fall.
During a concurrent interview and record review with Director of Nursing (DON) on 12/8/2021 at 11:22 a.m., the DON stated Resident 58 had a high risk for fall and should be at the lowest bed position for safety.
A review of the facility's policy and procedures (P&P), titled, Fall and Prevention Reduction Program, undated, indicated that it is the facility's policy to prevent falls to the extent possible and within the control of the facility.
A review of the facility's Nursing Supervisor and Charge Nurse Job Description, undated, indicated that staff will follow safety policies in performing nursing care.
A review of the facility's Certified Nursing Assistant (CNA) Job Description, undated, indicated that CNAs will assist to walk with or without self-help devices as instructed.
Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards in preventing avoidable accidents by failing to:
1. Lock Resident 33's bed during incontinence (loss of bladder control) care.
2. Ensure Resident 58's bed was in the lowest position per care plan.
3. Provide non-skid socks to Resident 90 when walking from the bed to the restroom unassisted.
These deficient practices had the potential to place Resident 33, 58 and 90 at an increased risk for fall and injury.
Findings:
1. A review of the admission record, dated 12/6/2021, indicated Resident 33 was admitted to the facility on [DATE]. Resident 33's diagnoses included Parkinson's disease (a chronic disorder characterized by tremors and stiffness) and functional quadriplegia (paralysis of all four limbs).
A review of the Minimum Data Set (MDS, a standardized resident screening and assessment tool), dated 9/27/2021, indicated Resident 33 had severe impairment in cognitive (thinking, understanding, learning, and remembering) skills for daily decision making. The MDS also indicated Resident 33 was totally dependent on staff for help in bed mobility, dressing, eating, toilet use, personal hygiene, and bathing.
A review of the fall risk assessment, dated 10/13/2021, indicated Resident 33 was a high risk for fall.
A review of the care plan titled Resident Care Plan: Risk for fall/injury, developed on 10/14/2021, indicated Resident 33 was a high risk for fall related to aspiration pneumonia (a condition where there is inflammation or infection in the lungs due to food, saliva, liquids or vomit going into the lungs instead of being swallowed into the stomach), recurrent urinary tract infection (UTI, infection of the urine), acute encephalopathy (a problem in the brain caused by chemical imbalances in the blood that may lead to altered mental status) and Parkinson's. The care plan indicated a goal of that Resident 33 will minimize risk for falls and recurrence of falls daily till next review and interventions including to provide a safe environment, free of clutters ,floor kept dry and non slippery, rooms with adequate lighting.
During an observation on 12/8/2021 at 2:04 p.m., Certified Nursing Assistant 9 (CNA 9) and Certified Nursing Assistant 10 (CNA 10) performed incontinent care on Resident 33 while the wheels of the bed were unlocked. The bed moved side to side several times during care.
During an interview on 12/8/2021 at 2:18 p.m., CNA 9 stated and confirmed she and CNA 10 failed to lock the wheels of the bed during the incontinent care of Resident 33. CNA 9 stated they should have locked the wheels of the bed before starting incontinent care for the safety of the resident.
3. A review of the admission record indicated Resident 90 was admitted to the facility on [DATE]. Resident 90's diagnoses included toxic encephalopathy (brain dysfunction caused by toxic exposure), sepsis (when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body); Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar); chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), Paranoid Schizophrenia (mental disorder in which people interpret reality abnormally), bipolar disorder (a mental condition marked by alternating periods of elation and depression), Dementia (A group of thinking and social symptoms that interferes with daily functioning), hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), Anemia (a condition marked by a deficiency of red blood cells or hemoglobin in the blood), hyperlipidemia (an abnormally high concentration of fats or lipids in the blood) and hypertension (a condition in which the force of the blood against the artery walls is too high).
A review of Resident 90's MDS, dated [DATE], indicated resident had severely impaired cognition (Mental action or process of acquiring knowledge and understanding) and requires limited assistance with activities of daily living (ADLs), such as, walking in corridor, and toilet use.
During an observation on 12/06/202, at 9:13 a.m., Resident 90 was noted walking, in her room, from the bed to the restroom unassisted and without wearing non-skid socks (socks that have a grip added to the bottom).
During an interview on 12/08/21 at with Licensed Vocational Nurse 6 (LVN 6), she stated Resident 90 was a high fall risk and should have been wearing non-skid socks.
A review of the care plan initiated on 11/12/21 indicated Resident 90 was a high risk for fall and injury related to unsteady gait (to not walk in a steady way). The goal indicated that the facility will minimize risk for falls and recurrence of falls daily. The care plan interventions indicated to provide adequate assistance during transfers.
A review of the facility's policy and procedures titled, Fall and Prevention Reduction Program undated, indicated it is the facility's policy to prevent falls to the extent possible and within the control of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and document Peripherally Inserted Central Catheter (PICC-a thin, soft tube that is inserted into a vein in the arm, leg or neck for long-term intravenous [IV] antibiotics, nutrition, medications, and blood draws) site for one of two sampled residents (Resident 67).
This deficient practice had a potential for Resident 67's PICC line site not being properly monitored for possible infection.
Findings:
A review of Resident 67's admission Record indicated the resident was re-admitted to the facility on [DATE]. Resident 67'3 diagnoses included, but were not limited to hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, ischemic heart disease (also called coronary heart disease [CHD-heart problems caused by a narrowed heart arteries which can cause less blood and oxygen circulation to the heart]), and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 67's Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 11/1/2021, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding), and required limited supervision with activities of daily living (ADLs-bed mobility, surface transfer, walk in room, dressing, toileting, and personal hygiene).
A review of Resident 67's Order Summary Report, indicated on 6/15/2021, Resident 67 was started on an IV therapy of D5W 0.45 % NaCL (5 percent dextrose and 0.45 percent sodium chloride) with KCL (potassium chloride) 20 meq/L (milliequivalent per liter) at 100 ml/ per hour (milliliter per hour) for 10 hours twice a week every Monday and Thursday.
A review of Resident 67's Care Plan for IV therapy hydration and medication, re-evaluated on 8/2021, indicated the goals included that IV site will be handled appropriately with good aseptic technique (aseptic means the absence of germs, such as bacteria, viruses, and other microorganisms that can cause disease), IV access will be maintained and be free of serious local or systemic complications. Resident 67's care plan also indicated the interventions including to observe the site frequently for signs and symptoms of complications such as redness, swelling, pain, drainage, leakage, temperature, and tape burns.
During a concurrent observation, and record review on 12/5/2021 at 8:58 a.m., Registered Nurse 1 (RN 1) was observed documenting on Resident 67's IV medication sheet after administering the IV therapy medication. A review of the IV medication sheet, indicated missing documentation for Resident 67's PICC line site checks every 8 hours on the following dates:
12/2/2021 at 11-7 shift
12/3/2021 at 11-7 shift
12/4/2021 at 3-11 and 11-7 shifts
12/5/2021 at 3-11 and 11-7 shifts
During a concurrent interview with the RN 1 on 12/5/2021 at 8:58 a.m., RN 1 stated there were missing documentation in the IV medication sheet for PICC line site monitoring. RN 1 further stated the nurses should be checking the PICC line sites for any complications and document per care plan and standard of practice.
During an interview with Director of Nursing (DON) on 12/8/2021 at 10:05 a.m., the DON stated the PICC line should be monitored every shift and documented in the IV medication sheet per facility policy due to high risk of possible complication if not being monitored.
A review of the facility's policy and procedure titled Nursing Supervisor Job Description, undated, indicated the general duties and responsibilities of the nursing supervisor is to maintain documentation as required by federal and state regulations and facility policy. The policy and procedure also indicated to review medication cards for completeness of information, accuracy in the physician orders.
A review of facility's Care of PICC lines policy and procedure (P&P), undated, indicated the purpose of the P&P, is to minimize the possibility of local and systemic infection and making sure to document any procedure in the resident's medical record, including appearance of site and tolerance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to communicate the consultant pharmacist's recommendation, in the Medication Regimen Review (MRR), to the attending physician for one of five sampled residents (Resident 96).
This deficient practice had the potential for unnecessary medication use, resulting in an adverse drug reaction to affect the health and wellbeing of Resident 96.
Findings:
A review of the admission record indicated Resident 96 was admitted to the facility on [DATE]. Resident 96's diagnoses included cellulitis (a serious bacterial skin infection), Type I Diabetes (a chronic condition that affects the way the body processes blood sugar), venous insufficiency (failure of the veins to adequately circulate blood), anemia (a condition marked by a deficiency of red blood cells or hemoglobin in the blood), gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints), hypertension (a condition in which the force of the blood against artery walls is too high).
A review of Resident 96's Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 11/17/2021, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding) and required extensive assistance with activities of daily living (ADLs), such as, dressing toilet use, and personal hygiene.
A review of the Consultant Pharmacist's Medication Regiment Review, dated 10/13/2021, indicated that Resident 96 was currently on Benedryl (a medication treats pain and itching) for itching with strong anticholinergic properties ( agents that block the action of acetylcholine, a type of neurotransmitter) and caution for drowsiness/sedation and risk for fall; Clarify for a stop date.
During an interview on 12/09/21 at 10:00 a.m., the Director of Nursing (DON) stated that there was no documentation supporting that the Medical Director was notified of pharmacist's recommendation to clarify for a stop date.
A review of the facilities policy titled Drug Regimen Review, indicated the center (the facility) is responsible for documenting the follow-through of each monthly consultant pharmacist report. The center is not required to agree with the pharmacist's recommendation, but a follow-through is required. The Director of Nursing is responsible for ensuring proper follow-through.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a concurrent observation and interview on 12/7/2021 at 7:53 a.m., unlabeled opened dietary supplements were found in the drawer of Station A medication cart (Cart 2). Licensed Vocational Nurse 5 (LVN 5) stated that all opened medication bottles should have labels with date and initials when it was opened so staff could know when to dispose (get rid of) medications for safety and effectiveness.
4. During a concurrent observation and interview on 12/7/2021 at 7:55 a.m., unlabeled opened foil pack of DuoNeb were found in the drawer of Cart 2. LVN 5 stated that when opening DuoNeb, foil pack should be labeled with date and should be discarded within a week per manufacturer's policy.
A review of manufacturer's product labeling, undated, indicated DuoNeb should be used within a week.
5. During a concurrent observation and interview on 12/07/21 at 11:15 a.m., three (3) bottles of Magnesium Citrate with an expiration date of 11/2021 were found in the in-house storage room. Registered Nurse 2 (RN 2) stated that expired medications should not be found in the medication storage.
A review of the facility policy titled Medications requiring notation of date opened indicate that to insure potency, maintain efficacy, and avoid cross contaminations, certain medications must be dated when first opened and discarded when the designated expiration time period or the manufacturer's expiration date elapses.
Based on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to:
1. Ensure Resident 358's Insulin Pen was properly stored prior to opening.
2. Ensure an opened bottle Acetaminophen (a medication treats minor aches and pains, and reduces fever) was labeled with the date opened.
3. Ensure proper labeling of opened dietary supplement bottles.
4. Ensure proper labeling of an opened foil pack of ipratropium bromide and albuterol sulfate (Duoneb-medication being given via inhalation [inhaling medication in the form of gas or vapor] used to treat and prevent symptoms of wheezing [a high pitched whistling sound made while breathing] and shortness of breath caused by an ongoing lung disease).
5. Remove of three (3) bottles of Magnesium Citrate (a liquid laxative that can help with occasional constipation) from the medication storage room prior to expiration.
6. Conduct the emergency crash cart check on a daily basis.
These deficient practices had the potential to compromise the safety and effectiveness of medications, resulting in medication errors and missing medical supplies in the event of emergency.
Findings:
1. A review of the admission record indicated Resident 358 was admitted to the facility on [DATE]. Resident 358's diagnoses included metabolic encephalopathy (a problem in the brain caused by chemical imbalance in the blood), sepsis (when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body), urinary tract infection (UTI-an infection in any part of the urinary system), Type 2 Diabetes Mellitus (A chronic condition that affects the way the body processes blood sugar), and hypertension (high blood pressure).
A review of Resident 358's Minimum Data Set Assessment (MDS- a comprehensive assessment and care screening tool), Section N: Medications, dated 11/24/2021, indicated Resident 358 required insulin injections for medical treatment.
During a concurrent observation and interview on 12/07/21, at 11:27 a.m., an unopened Resident 358's Insulin Pen (Basaglar KwikPen) was found in the drawer of Station B medication cart (Cart 1). Licensed Vocational Nurse 1 (LVN 1) stated Resident 358's Insulin Pen should be stored in the refrigerator prior to opening.
A review of Resident 358's physician order, dated 11/17/21, Indicated for the administration of Insulin Glargine (type of insulin) Solution 100 UNIT/100 ML (milliliter) to inject 11 unit subcutaneously (under the skin) at bedtime for Diabetes Mellitus.
A review of the Basaglar KwikPen (insulin pen) Instructions for use indicated to store unused Pens in the refrigerator at 36 degrees Fahrenheit to 46 degrees Fahrenheit.
2. During a concurrent observation and interview on 12/07/2021 at 11:41 a.m., an opened bottle of Acetaminophen was found in the drawer of Station B med cart (Cart 1), however, the bottle was not labeled with the date opened. LVN 1 stated that the Acetaminophen bottle should be labeled with the date opened.
A review of the facility policy titled IV Drug Storage and Labeling indicated that drugs will be labeled in accordance with state and federal laws. The pharmacist is the only person allowed to change information on a prescription (RX) label. All prescription drug labels shall include the following information:
a). Brand or generic name of drug. If a generic drug is dispensed, the label will show the generic name, manufacturer name, and an explanatory note
b). Strength of Drug, quantity, expiration date, resident's name, directions for use, date of dispensing, name, address and phone number of pharmacy dispensing; prescription number, any applicable auxiliary labels.
c). Improperly labeled containers will not be allowed for use and will be returned to the pharmacy as soon as possible.
6. On 12/7/2021 at 12:05 p.m., during a concurrent observation and interview, RN 1 confirmed the Emergency Crash Cart A binder had missing check dates for the months of September, October, and November 2021. RN 1 stated the blank boxes in the calendar days represented either the cart was not being checked or the staff had forgotten to document that the cart had been checked. RN 1 stated Registered Nurses were responsible for checking all crash carts. RN 1 also stated that if carts were not checked, it could be an issues because supplies might be missing during an emergency event.
On 12/9/2021 at 11:05 a.m., during a concurrent observation, interview and record review, RN 3 confirmed the Emergency Crash Cart A binder had missing check marks for September, October, and November 2021. RN 3 stated blank check marks represented the staff not checking the cart or forgetting to document the carts being checked. RN 3 stated if the crash cart was not checked, medication or equipment might not be readily available during an emergency. Crash carts include oxygen equipment, back boards, medications such as epinephrine (a medication used in emergencies to treat very serious allergic reactions) pen, and other medical supplies.
A record review of the facility's undated policy and procedure titled Emergency Cart Supplies and Equipment indicated, Staff shall check the emergency cart on a daily basis for completeness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe and sanitary food distribution and hand hygiene practice when:
1. One staff working in the dish machine area did not wash hands and change gloves when removing the clean and sanitized dishes from the dish machine.
2. Two certified nursing assistants (CNAs) did not perform hand hygiene during delivery of food and drink to Resident 41 and Resident 102.
These failures had the potential to cross contaminate (transfer of harmful bacteria from one place to another) dishes and cause food borne illness in 95 out of 109 residents who received food from the facility's kitchen, exposing residents to infectious microorganisms (bacteria, virus, or fungus).
Findings:
1. During an observation in kitchen on 12/6/21 at 7:55 a.m., Dishwasher (DW) was working alone in the dish machine area. DW was rinsing soiled dishes with gloves on. After rinsing soiled dishes, DW loaded dirty dishes in the dish machine. DW proceeded to wash, then to wipe the food carts with sanitizer. When the dish machine stopped, DW proceeded to remove the clean and sanitized dishes from the dish machine. DW did not wash hands and change gloves prior to removing the clean dishes.
During a concurrent observation and interview on 12/6/21 at 8:30 a.m., DW stated he usually changed gloves when he moved from one task to another. Upon request, DW demonstrated changing gloves: he removed the soiled gloves and there was another layer of gloves under them. DW stated that when he removed the soiled first layer of gloves, he could then move to clean task and remove the clean dishes from the dish machine because the second layer of gloves were clean. DW also stated that today he forgot to remove the soiled first layer of gloves before touching the clean dishes.
During the same interview with DW on 12/6/21 at 8:30 a.m., the Dietary Supervisor (DS), who was in presence, stated that staff should not wear multiple layers of gloves, adding that staff should wear one layer of gloves then wash hands and change gloves when moving from dirty task to clean task. DS also stated that he would provide in-service on hand hygiene and Dishwashing policy.
A review of facility policy titled Sanitation and Infection Control (Dishwashing Procedures), dated 2018, indicated, if only one employee is available to wash and handle clean and soiled dishes, the employee must wash hands thoroughly before handling clean dishes, trays and carts.
A review of facility policy titled Sanitation and Infection Control (Handwashing), dated 2018, indicated, 2. When to wash hand .B. After handling carts, soiled dishes and utensils.
2. During an observation on 12/07/21 at 07:35 a.m., CNA 5 was observed leaving Resident 41's room (after having delivered a cup of coffee) and not performing hand hygiene. CNA 6 was also observed leaving Resident 102's room (after delivering food tray) and not performing hand hygiene after handling the meal tray.
During a concurrent interview with CNA 6 and CNA 5 on 12/07/21 at 07:35 a.m., both stated they should perform hand hygiene after leaving any resident's room.
During an interview with Registered nurse (RN 2) and Licensed Vocational Nurse (LVN 2), on 12/09/21 at 08:27 a.m., both stated staff should be performing hand hygiene every time before and after they provide care for residents.
A review of facility policy and procedures, titled Infection Control - Enhanced Standard Precautions with revision date of 03/16, indicated Standard Precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions include the following practices: 1. Hand hygiene: a. Hand hygiene refers to hand washing with soap; b. Or using alcohol-based hand rubs; d. in the absence of visible soiling of hands, alcohol-based hand rubs are preferred for hand hygiene.
A review of Resident 41's admission Record indicated the resident was admitted to the facility on [DATE]. The admission Record further indicated Resident 41 had diagnoses including malignant neoplasm (cancerous tumor) of lung, chronic obstructive pulmonary disease ([COPD] a group of lung diseases that block airflow and make it difficult to breath) and congestive heart failure (a condition where the heart muscle doesn't pump blood as well as it should).
A review of Resident 102's admission Record indicated the resident was admitted to the facility on [DATE]. The admission Record further indicated Resident 102 had diagnoses including rheumatoid arthritis (a chronic inflammatory disorder affecting joints), morbid obesity (a condition involving excessive body fat that increases the risk of health problems) and type two diabetes mellitus (a condition that affects the way the body processes blood sugar).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to observe infection control measures for two of six sampled residents (Resident 31 and Resident 46) by failing to ensure:
1. The Hoyer lift (a mechanical lift that allows a person to be lifted and transferred with minimum physical effort) was cleaned after its use on Resident 31.
2. Licensed Vocational Nurse 7 (LVN 7) wore a Non-oil 95% mask (N95 - a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) and eye protection (goggles or face shields) during oral suctioning (use of a rigid plastic suction catheter to remove pharyngeal secretions through the mouth) of Resident 46.
These deficient practices had the potential to spread infection in the facility and place residents at risk for infection.
Findings:
1. A review of Resident 31's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 31's diagnoses included, but were not limited to, anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues) and paraplegia (a term used to describe the inability to voluntarily move the lower parts of the body).
A review of Resident 31's Minimum Data Set (MDS - a comprehensive standardized assessment and care screening tool), dated 9/20/2021, indicated Resident 31 had an intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and requires total dependence from staff with transfer, eating and toilet use.
During an observation on 12/6/2021 at 8:48 a.m., Resident 31 was observed being transferred from bed to shower chair using a mechanical lift (are used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) by two staffs. After used, observed Certified Nursing Assistant 1 (CNA 1) took the mechanical lift in the hallway did not clean or sanitize the equipment.
During an interview on 12/6/2021 at 8:56 am, CNA 1 stated, after using mechanical lift, she returns them to the hallway where it can be charged. When asked if she clean the mechanical lift before and after using, CNA 8 stated, no, housekeeping is supposed to clean it. When asked how does she know it is clean prior to use, CNA 1 did not answer.
During an interview on 12/8/2021 at 3:30 p.m., with Infection Preventionist (IPN), IPN stated, shared equipment such as mechanical lift should be clean by staff before and after use, to prevent infection. IPN further stated, if shared equipment's are not being cleaned before and after use, it can cause a spread of infection to other residents and staffs.
A review of facility's policy and procedures titled, Infection Control Program, revised 10/2011, indicated, The facility shall establish an infection control program designed to provide a safe, sanitary and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection.
A review of facility's policy and procedures titled, Care of the Shared Resident Equipment, undated, indicated, Ensure that the reusable and shared equipment such as Hoyer lift (mechanical lift), shower chair, etc is properly cleaned and disinfected with the use of EPA approved disinfectant .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to conduct Coronavirus - 19 (COVID-19 or COVID, a virus that causes respiratory illness that can spread from person to person) testing practices consistent with the current standard of practice and state guidelines as evidenced by failing to:
1) Label Resident 80's COVID-19 test specimen collection tube (culturette package) with Resident 80's identification.
2) Monitor the percentage of their residents and health care providers (HCPs, facility staff) that are fully vaccinated on a daily basis.
These deficient practices had the potential resulting in transmission and spread of COVID-19 within the facility.
Findings:
1) A review of admission record, dated 12/8/2021, indicated Resident 80 was admitted to the facility on [DATE]. Resident 80's diagnoses included epilepsy (a group of related disorders characterized by a tendency for recurrent seizures) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning).
A review of the Minimum Data Set (MDS, a standardized resident screening and assessment tool), dated 11/9/2021, indicated Resident 80 had intact cognitive (thinking, reasoning, or remembering) response. The same MDS also indicated Resident 80 needed supervision in transfer, walking in corridor, toilet use and personal hygiene.
A review of Resident 80's physician order, dated 8/2/2021, indicated may do COVID test as directed by public health or facility protocol.
A review of Resident 80's care plan, titled Resident at risk for COVID-19 secondary to being unvaccinated, developed on 8/2/2021, indicated a goal of that resident will minimize the risk for COVID-19. The care plan indicated interventions including may do COVID test as directed by public health or facility protocol.
During an observation on 12/8/2021 at 1:10 p.m., the Infection Preventionist (IP) performed a polymerase chain reaction (PCR, gold standard test for detecting the COVID-19 virus) nasal swab test on Resident 80. The IP did not label the specimen tube before or after collection.
During an interview on 12/8/2021 at 1:10 p.m., the IP stated and confirmed she did not label Resident 80's specimen tube prior to storing it in the specimen refrigerator. The IP stated she should have labeled the tube with Resident 80's name, date of birth (DOB), specimen collection date and time so the specimen could be identified as Resident 80's and would not get mixed up with other residents' specimens.
During an interview on 12/9/2021 at 4:00 p.m., the Director of Nursing (DON) stated and confirmed that all specimen containers collected from a resident is expected to have the resident's name, room #, DOB, date of collection, person who collected and time of collection. The DON stated correct labeling is important for timely processing and identification to prevent mixing the sample with other residents' samples.
A review of the facility's policy titled Nasal Culture, undated, indicated that after collection, the procedure includes to write the resident's identification information on the culturette package and return swab to package.
2) During an interview on 12/10/2021 at 11:45 a.m., the Infection Preventionist (IP) stated and confirmed the facility did not monitor or keep a daily log to monitor the percentage of residents and HCPs who were fully vaccinated.
A record review of the All Facilities Letter 20-53.5 (AFL 20-53.5) issued by California Department of Public Health (CDPH), dated 8/3/2021, indicated SNFs (Skilled Nursing Facilities) must daily monitor the percentage of their residents and HCP that are fully vaccinated and resume routine diagnostic screening testing of all HCP (regardless of vaccination status) within one week if percentage of residents and HCP fully vaccinated drops below 70%.

Based on interview and record review, the facility failed to reimburse one of one sampled resident (Resident 47) for a missing mouthguard (is a protective device for the mouth that covers the teeth and gums to prevent and reduce injury to the teeth, arches, lips, and gums).
This deficient practice the potential to compromise the dental health for Resident 47.
Findings:
A review of Resident 47's admission Record, indicated the facility admitted Resident 47 on 7/3/2019, with diagnoses that included rheumatoid arthritis (when the body's infection defense system is attacking its own tissue, internal organs, and joints that can cause bone destruction and deformity), cervical (neck bone) disc disorder (a condition when one or more cushioning discs in the cervical spine starts to break down due to wear and tear causing neck and arm pain), and fibromyalgia (a condition that causes pain all over the body, sleep problems and emotional distress).
A review of Resident 47's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 10/7/2021, indicated Resident 47 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 47 was only able to stabilize with staff assist when moving from seated to standing position, walking, moving on and off the toilet, and transfer between bed and char or wheelchair.
During an interview with Resident 47 on 12/6/2021 at 9:35 a.m., Resident 47 stated one facility Certified Nurse Assistant (CNA) had accidentally flushed the resident's mouthguard in the toilet. Resident 47 further stated the facility's Social Services Director (SSD), and Facility Administrator (FA) gave the resident a check for the lost mouthguard, however, the reimbursement was not the correct amount. Resident 47 stated she returned the check back to the facility and continued to be dissatisfied with the outcome of her missing mouthguard.
During an interview with Resident 47 on 12/6/2021 at 11:57 a.m. during an interview, Resident 47 requested the writer to follow-up on the resident's missing mouthguard. Resident 47 further stated the facility offered her the facility's dental provider but refused and wanted a dental provider of her choice.
During an interview with SSD on 12/8/2021 at 9:04 a.m., SSD stated that she recently (did not to provide the date) spoke with a dental office regarding Resident 47's mouthguard and about the original receipt for the mouthguard for 2010. SSD stated the dental office was attempting to locate the original receipt. SSD stated this was the first time the facility had attempted to retrieve the original receipt and get a quote for a mouthguard for Resident 47.
During an interview and concurrent record review with SSD on 12/9/2021 at 9:00 a.m., SSD stated the facility did not record the value of Resident 47's clear retainer (night guard) on the resident's document titled Inventory of Personal Effects dated 7/3/2019. SSD stated CNAs are responsible to fill out the inventory of personal effects document during a resident's admission at the facility, and do not indicate the value of a belonging if unknown.
During an interview and concurrent record review with the FA on 12/9/2021 at 9:06 a.m., the FA stated the facility staff do not indicate the value amount on the Inventory list if the value of the item was unknown. The FA stated the facility contacted the dental office where Resident 47 obtained the mouthguard because the resident did not provide the facility with a copy receipt of the missing mouthguard. The FA stated the quoted amount for a mouthguard was $1500. The FA further stated the facility requested for estimate quotes for a mouthguard from neighboring dental offices. The FA stated the facility offered Resident 47 the facility's dental services and a check of $450 but the resident refused both offers. The facility did not offer the resident dental services from the dental office where the mouthguard was created nor offer the resident $1500 as quoted from the dental office where Resident 47 obtained the missing mouthguard.
A review of the Social Services Notes dated 9/13/21, indicated SSD met with Resident 47 about reimbursement check for lost night guard (mouthguard) in the amount of $450. The social services notes indicated Resident 47 verbalized to SSD that it is unacceptable will not accept the check again and continued to verbalize dissatisfaction.
A review of Resident 47's Golden Age Dental Care Dental Progress Notes dated 4/30/2021, indicated the facility notified a doctor about the night guard pricing for Resident 47 compared to outside dentistry (the treatment of diseases and other conditions that affect the teeth and gums, especially the repair and extraction of teeth and the insertion of artificial ones) offices. The golden age dental progress notes indicated the doctor recommended Resident 47 to use a dentist of the resident's choice.
A review of Resident 47's signed document titled Release of Facility Liability dated 8/20/2019, indicated Resident 47 would release the facility from any liability whatsoever if such valuable should be misplaced, lost or stolen by anyone under any circumstances.
During an interview with Resident 47 on 12/9/2021 11:15 a.m., Resident 47 stated she signed the release of facility liability document, however, the facility asked the resident to sign the document, but the resident was not able to read the document. Resident 47 stated the facility presented the document to her during a late-night admission, was distracted, tired and was in pain. Resident 47 further stated she would take a few days to read documents prior to signing them.
A review of Resident 47's document titled, California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities dated 05/11, under title VII Personal Property and Funds, indicated our facility has a theft and loss prevention program as a required by state law.
A review of the facility's undated policy and procedures (P&P) titled Theft and Loss Prevention Program, indicated the facility will make reasonable efforts to safeguard patient property, shall reimburse a patient for or replace stolen or lost patient property at its then current value. The facility shall be presumed to have made reasonable efforts to safeguard patient property if the facility has shown clear and convincing evident of its efforts to meet each of the requirements. The P&P indicated that the theft and loss program shall include the following: Its estimated value, a written patient personal property inventory is established upon admission and retained during the resident's stay in the long-term health care facility.
A review of the facility's policy and procedures dated 1/2017, indicated the facility has developed a theft and loss prevention system to ensure that resident's property will be safeguarded. After completing the admission section of this form, the resident and facility will sign the form. The Theft and Loss Log will indicate the type of losses and quantify the value of losses during a specific period of time. Any loss that is reimbursable to the resident must have a copy of or the original receipt or proof of reimbursements which must be attached to the Theft and Loss Report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a clean, free of odor, and home like environment for three of 25 sampled residents (Resident 25, 49 and 56).
These deficient practices had the potential for cross contamination, spread of disease-causing organism, and negatively impact the quality of life for Residents 25, 49 and 56.
Findings:
1. A review of Resident 25's admission Record, indicated the facility originally admitted Resident 25 on 6/7/2012, and readmitted the resident on 6/4/2021, with diagnoses that included, but were not limited to, dysphagia (occurs when there is a problem with the neural control or the structures involved in any part of the swallowing process), and thrombocytopenia (a condition in which you have a low blood platelet count (Platelets [thrombocytes] are colorless blood cells that help blood clot).
A review of Resident 25's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/17/2021, indicated Resident 25 had severe cognition (mental action or process of acquiring knowledge and understanding) impairment for daily decision-making. The MDS indicated Resident 25 was dependent on staff for activities of daily living (ADL- dressing, eating, toilet use and personal hygiene).
2. A review of Resident 49's admission Record, indicated the facility originally admitted Resident 49 on 1/30/2018, and readmitted the resident on 8/11/2020, with diagnoses that included, but were not limited to, Type II diabetes (a chronic condition that affects the way the body processes blood sugar [glucose]) and Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination).
A review of Resident 49's MDS, dated [DATE], indicated Resident 45 had severe cognition impairment for daily decision-making. The MDS indicated Resident 49 was dependent on staff for bed mobility, dressing, eating and personal hygiene.
3. A review of Resident 56's admission Record, indicated the facility originally admitted Resident 56 on 2/26/2020, and readmitted the resident on 11/12/2021, with diagnoses that included, but were not limited to, sepsis (body's extreme response to an infection, it is a life-threatening medical emergency) and chronic obstructive pulmonary disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems).
A review of Resident 56's MDS dated [DATE], indicated Resident 56 had severe cognition impairment for daily decision-making. The MDS indicated Resident 56 was dependent on staff for transfer, eating and toilet use.
During an initial tour of the facility on 12/6/2021 at 9:30 a.m., room [ROOM NUMBER] noted with urine like pungent odor. Residents 25, 45 and 56, were inside room [ROOM NUMBER]
During an observation of the room [ROOM NUMBER] on 12/6/2021 at 11:50 am with another surveyor, a pungent smell of urine can still be detected upon entrance of the room.
During a concurrent observation and interview with Certified Nursing Assistant 11 (CNA 11) on 12/7/2021 at 9:21 a.m., CNA 11 confirmed and stated room [ROOM NUMBER] had a pungent odor of urine. CNA 11 further stated, Resident 25 always urinated on his incontinent brief, and CNA 11 had not changed Resident 25 incontinent brief on 12/7/2021.
During a concurrent observation and interview with Registered Nurse 1 (RN 1) on 12/7/2021 at 11:04 a.m., Resident 56's urinary catheter bag (a thin, flexible tube placed in your bladder to drain your urine) was leaking fluid. RN 1 stated he would change Resident 56's catheter bag as it tended to leak. RN 1 confirmed and stated room [ROOM NUMBER] had a pungent odor of urine and would ask housekeeping staff to clean and sanitize the room.
A review of facility's policy and procedures titled, Infection Control Program revised 10/2011, indicated The facility shall establish an infection control program designed to provide a safe, sanitary and comfortable environment for residents and staff to help prevent the development and transmission of disease and infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 8's admission Record, indicated the facility re-admitted Resident 8 on 11/22/2020, with diagnoses not limited to embolism (a sudden blocking of an artery or vein [blood vessels that deliver oxygen-rich blood from the heart to the tissues of the body] and thrombosis (blood clot in the deep vein, usually in the legs) of left lower leg, myasthenia gravis (a weakness and rapid fatigue of muscles under voluntary control), abnormality of gait (ambulation) and mobility, lack of coordination and seizure (a sudden, uncontrolled electrical disturbance in the brain).
A review of Resident 8's MDS dated [DATE], indicated Resident 8 had intact cognition, and needed limited to extensive staff assist with bed mobility, surface transfer, walk in room, dressing, toileting, and personal hygiene.
During an interview with Resident 8 on 12/05/21 at 9:40 a.m., Resident 8 stated he would push the call light on for staff to assist with ADL, but would wait for more than 30 minutes before staff responded to the call light.
A review of Resident 8's care plan on high risk for fall and injury dated 12/5/2021, indicated the facility will implement fall precautions such as keep call light within reach and answer promptly for Resident 8.
4. A review of Resident 101's admission Record, indicated the facility re-admitted Resident 101 on 12/21/2020, with diagnoses not limited to transient cerebral ischemic attack (TIA-a temporary blockage of blood flow to the brain), end stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis), diabetes mellitus, and morbid obesity (a disorder involving excessive body fat that increases the risk of health problems)
A review of Resident 101's MDS dated [DATE], indicated Resident 101 had intact cognition, and needed limited to extensive staff assist with ADLs.
During an interview with Resident 101 on 12/07/21 at 6:45 a.m., Resident 101 stated he would push the call light on and had to wait for almost an hour to get assistance to use a urinal (a portable container for urination [release of urine]). Resident 101 further stated that he was at risk for urinary tract infection (UTI) due holding urine for a long time.
A review of Resident 101's care plan on high risk for fall and injury dated 11/19/2021, indicated the facility will implement fall precautions such as keep call light within reach and answer promptly for Resident 101.
During an interview with the Director of Nursing (DON) on 12/9/2021 at 11:57 a.m., the DON stated staff should answer residents' call lights promptly, no more than 5 minutes since it can cause resident frustrations from waiting, cause a delay in resident care, and possible resident safety.
A review of facility's policy and procedures titled, Call lights revised on 1/2017, indicated Call lights should be answered promptly.
Based on observation, interview, and record review, the facility failed to answer the call light promptly per facility policy for four of 25 sampled residents (Residents 6, 8, 10 and 101).
This deficient practice resulted in a delay for staff to answer the call light and had the potential to not address the needs for Residents 6, 8, 10 and 101 timely.
Findings:
1. A review of Resident 6's admission Record, indicated the facility admitted Resident 6 on 8/27/2019, with diagnoses that included chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problem), heart failure (when the heart muscle does not pump blood as well as it should and fluid builds up in the lungs, causing shortness of breath), and transient cerebral ischemic attack (a brief episode during parts of the brain do not receive enough blood).
A review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening and tool) dated 9/3/2021, indicated Resident 6 had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and Resident 6 required staff supervision with bed mobility, personal hygiene and locomotion on/off unit.
During an interview with Resident 6 on 12/6/2021 9:00 a.m., Resident 6 stated the staff did not respond to call lights at night. Resident 6 further stated he would call out and yell for staff to assist and this caused other residents to wake up. Resident 6 continued to state that the lack of fcaility staff to respond to call lights was brought up to the facility's attention, including the Resident Council, however, the facility did not follow up.
During an observation on 12/7/2021 6:15 a.m., the writer turned on the call light in Resident 6's room. The writer observed two facility staff members walk by and not answer the call light. A third staff member addressed the call light after 10 minutes.
A review of Resident 6's care plan on risk for fall/injury dated 9/3/21, indicated Resident 6 was a high risk for fall and injury related to unsteady gait, use of anti-hypertensives, use of seizure medications, requires assistance on ambulation. The interventions included to implement fall precautions such as keeping call light within reach and answer promptly for Resident 6.
3. A review of Resident 10's admission Record, indicated the facility admitted Resident 10 on 3/2/2021, with diagnoses that included Seizures (a sudden, uncontrolled electrical disturbance in the brain), Diabetes Mellitus (DM-a disorder which the body does not produce enough or respond normally to insulin causing blood sugar levels to be abnormally high), and hypertension (HTN-a condition which the long term force of blood against artery walls is high enough that may cause heart problems).
A review of Resident 10's MDS dated [DATE], indicated Resident 10 had intact cognition, and required staff supervision with bed mobility, transfers, dressing and toilet use.
A review of Resident 10's care plan on risk for fall/injury dated 12/5/21, indicated Resident 10 was a high risk for falls related to unsteady gait, weakness, use of anti-hypertensive medication, and has history of falls. Interventions included to implement fall precautions such as keeping call light within reach and answer promptly for Resident 10.
During an interview with Resident 10 on 12/7/2021 2:10 p.m., Resident 10 stated the facility had issues with the call light especially on the night shift. Resident 10 further stated the night shift took a long time to answer call lights, the facility was aware, and the call light concern was mentioned in Resident Council Meetings.

Based on observation, interview and record review, the facility failed to ensure staff did not stand over one of 10 sampled Residents (Resident 91) while assisting Resident 91 to eat at lunch time.
This deficient practice violated the right to be treated with dignity and respect, and had the potential for psychosocial harm for Resident 91.
Findings:
A review of Resident 91's admission Record, indicated the facility admitted Resident 91 on 8/6/2019, with diagnoses that included, but not limited to diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), abnormalities of gait and mobility, lack of coordination and dementia (loss of cognitive functioning-thinking, remembering, and reasoning).
A review of Resident 91's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/13/2021, indicated Resident 91 had severe impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required extensive assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene).
A review Resident 91's Order Summary Report dated 8/16/2021, indicated Resident 91 was on RNA (Restorative Nursing Assistance) feeding program.
A review of Resident 91's Nutritional Care Plan dated 8/13/2021, indicated that one of the goals was for Resident 91 to consume 75% (percent) of meals for 90 days and resident will not have a significant weight loss for 90 days. Interventions included for Resident 91 to be in RNA feeding program.
During a concurrent observation and interview on 12/6/2021 at 12:48 p.m., Certified Nursing Assistant 7 (CNA 7) was observed standing up while feeding Resident 91. CNA 7 stated that she should be seated when feeding Resident 91 to promote dignity.
During an interview with the Director of Nursing (DON) on 12/9/2021 at 11:57 a.m., the DON stated that all staff should be seated and at an eye level when feeding residents to allow social interaction with residents, and better observation of residents for any swallowing difficulties.
A review of facility's policy and procedures (P&P) titled, Feeding the Dependent Resident, revised on 1/2017, indicated that the facility will ensure adequate nutrition for residents who are unable to feed themselves. The P&P also indicated staff to sit at eye level of the resident which allows for social interaction and better observation if any swallowing difficulty arises.