Alden Terrace Convalescent Hospital

REVIEWEDBased on interview and record review, the facility failed to develop a comprehensive care plan for one of seven sampled residents (Resident 9) in accordance with the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered with review date of 5/20/2025, by failing to have a care plan for Resident 9's schizoaffective (a mental health condition that combines symptoms of both schizophrenia [a chronic brain disorder that affects how a person thinks, feels, and behaves, making it difficult to distinguish reality from imagination] and a mood disorder, such as bipolar [a mental health condition characterized by unusual and extreme shifts in mood, energy, and activity levels, which include periods of intense highs (mania) and lows (depression - a common, serious medical illness that affects how a person feels, thinks, and acts, characterized by a persistent sad or low mood and a loss of interest in activities once enjoyed)] disorder and bipolar disorders.This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 9.A review of Resident 9's admission Record indicated the facility admitted Resident 15 on 4/6/2011 and readmitted Resident 9 on 9/25/2025 with diagnoses including schizoaffective disorder, bipolar disorder, and hypertension (HTN -high blood pressure). A review of Resident 9's Minimum Data Set (MDS - a resident screening tool) dated 10/7/2025, indicated Resident 9 was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 9 required substantial/maximal assistance to dependency on staff with activities of daily living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 9's Multidisciplinary Progress Record (a team of professionals from different fields who are all working on the same project or for the same person) dated 10/20/2025, indicated .assessment -schizophrenia. During a concurrent interview and record review, on 11/20/2025, at 8:58 A.M., with Licensed Vocational Nurse (LVN) 2, Resident 9's electronic and paper chart was reviewed. LVN 2 stated that a care plan identifies a problem, has a goal, and the interventions as to what staff will do to help reach that goal. LVN 2 stated that if the care plan for a resident is missing for an identified problem, it may put the resident at risk for not receiving care for that problem properly to prevent the condition from worsening. LVN 2 stated that Resident 9 had an active diagnoses of schizoaffective disorder and bipolar disorder, however, there was no care plan noted in Resident 9's electronic or paper chart for both diagnoses. During an interview, on 11/20/2025, at 12:51 P.M., with the Director of Nursing (DON), the DON stated that a care plan is used to follow the plan for the residents' care so that the appropriate interventions and care regarding the resident's condition can be given. The DON stated that a care plan is initiated as soon as a condition occurs. The DON stated that if the resident does not have a specific care plan for schizoaffective and bipolar disorders then behaviors may not be addressed specifically and cause the condition to worsen. A review of the facility policy and procedures (P&P), titled Care Plans, Comprehensive Person-Centered with review date of 5/20/2025 indicated, Policy Statement: 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.2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REVIEWEDBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of her individuality for three (3) out of the 6 sampled residents (Resident 78, Resident 111 and Resident 180). This deficient practice had the potential to affect the Residents self-esteem and self-worth. During a meal observation on 9/29/2025 at 12:00 p.m., in the facility common dining room, Certified Nursing Assistant (CNA) 4, CNA5 and CNA6, were observed standing while feeding lunch to Resident 78, Resident 111 and Resident 180. The 3 residents, Resident 78, Resident 111 and Resident 180, were observed extending their necks up at CNA 4, CNA5 and CNA6 as they were being fed lunch. A review of Resident 78's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] , with diagnoses including but not limited to, dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning), dysphagia (difficulty or discomfort when swallowing), protein calorie malnutrition (a nutritional deficiency caused by a lack of sufficient protein calories in the diet), type 2 diabetes (chronic condition where the body either doesn't produce enough insulin to regulate blood sugar levels), difficulty walking, abnormal gait mobility (unusual/abnormal walking pattern) and hypertension (high blood pressure). A review of Resident 78's Quarterly Minimum Data Set (MDS - a resident assessment tool) dated 10/16/2025, indicated the resident had severely impaired cognitive skills for daily decision-making. The MDS indicated that the resident needed setup or clean up assistance with eating, partial moderate assistance with oral hygiene, and supervision with bed mobility, transfers and upper body dressing. A review of Resident 111's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] , with diagnoses including but not limited to, dementia, type 2 diabetes, chronic gastritis (the inflammation, irritation, or swelling of the stomach lining), dysphagia, anxiety disorder (excessive worry, fear, and nervousness that is out of proportion to the situation and interferes with daily life), bipolar disorder ( a mental health condition that causes significant and extreme shifts in mood, energy, activity levels, and concentration), abnormal gait mobility and hypertension. A review of Resident 110's MDS dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision-making. The MDS indicated that the residents needed supervision or touching assistance with eating, partial moderate assistance with oral hygiene, and supervision with bed mobility, transfers and substantial maximum assistance with upper and lower body dressing. A review of Resident 180's admission Record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including but not limited to, dementia, dysphagia, failure to thrive concerning food and fluid intake (clinical decline, primarily caused by inadequate nutrition), difficulty walking, abnormal gait mobility and hypertension. A review of Resident 180's MDS dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision-making. The MDS indicated that the resident needed supervision or touching assistance with eating, partial moderate assistance with oral hygiene, and supervision with bed mobility, transfers and partial moderate assistance with upper body dressing. During an interview with CNA4 on 9/29/2025 at 12:09 PM, CNA4 stated she had a lot of Residents (number not provided), and she had no chair to sit on. During an interview with CNA5 on 9/29/2025 at 12:10 PM, CNA5 stated she usually feeds the Residents while standing up. During an interview with CNA6 on 9/29/2025 at 12:11 PM CNA6 stated he usually feeds the Residents while standing up. During an interview with the Director of Nursing (DON) on 11/20/2025 at 12:47PM, the DON stated staff should sit down at eye-to-eye level with the Residents, talk to the Resident and encourage the Resident and monitor the Resident while the Resident eats, chews and properly swallows their food for dignity, DON stated Residents feel more comfortable and engaged resulting in positive outcomes. DON stated feeding Residents while standing looks hurried, is impersonal, there is no connection with the Resident. A review of the facility policy and procedures titled Assistance with Meals, dated 5/5/2025, indicated, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example, not standing over residents while assisting them with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ReviewedBased on observation, interview and record review the facility failed to ensure that one of 57 residents rooms (room [ROOM NUMBER]/320) accommodated no more than 4 residents per room. Five residents were observed residing in room [ROOM NUMBER]/320. room [ROOM NUMBER]/320 could accommodate six residents.This deficient practice had the potential to result in inadequate space for the residents and for the staff to provide safe nursing care and privacy to the residents in room [ROOM NUMBER]/320.During a tour on 9/29/2025 at 9:59 AM, room [ROOM NUMBER]/320 was observed to have six beds. At the time, none of the residents residing in the room were present. The room had access to the hallway via one door. Outside of the door was two nameplates that indicated the room was for room [ROOM NUMBER] and 320.During an concurrent interview and observation on 9/29/2025 2:40 PM with the Maintenance Staff (MS) 1, MS 2 and MS 3, room [ROOM NUMBER]/320 were observed and measured. room [ROOM NUMBER]/320 measured 507 square feetDuring an interview on 9/30/2025 at 7:05 AM, MS 1 stated they were employed at the facility since 1977. MS 1 further stated room [ROOM NUMBER]/320 were never separated and the rooms never had separated entrances.A review of the facility's Client Accommodation Analysis, dated 9/29/2025, indicated there was a room [ROOM NUMBER] and a room [ROOM NUMBER]. The form also indicated room [ROOM NUMBER] measured 252 square feet and the approved capacity was for three residents. The form also indicated room [ROOM NUMBER] measured 247 square feet and the approved capacity was for three residentsA review of facility map indicated room [ROOM NUMBER] was located between room [ROOM NUMBER] and room [ROOM NUMBER]. A review of the facility map also indicated there was no room [ROOM NUMBER]. During an observation with the Administrator (ADM) on 9/30/2025 at 1:20 PM, room [ROOM NUMBER]/320 was observed. The ADM stated the room319/320 is one room and has never been two separate rooms. The ADMIN further stated he did not know why the rooms are considered two separate rooms.During an interview on 11/20/2025 at 8:43 AM Interview inside room [ROOM NUMBER]/320, Resident 106 stated they currently resided in room [ROOM NUMBER]/320. Resident 106 stated the room contained adequate space for the resident's personal items and self when all residents of the room were present at the same time. Resident 106 further stated they would prefer for the facility to erect a partition or block off one side of room [ROOM NUMBER]/320 to make two separate rooms that could accommodate three residents each in order to provide Resident 106 with more privacy. Yes directions toA review of Resident 106's face sheet indicated the resident resided in room [ROOM NUMBER].During an interview on 11/20/2025 at 8:53 AM, Certified Nursing Assistant (CNA) 1, stated room [ROOM NUMBER]/320 provided enough room to complete her duties.During an interview on 11/20/2025 at 12:41 PM, the ADM stated six residents could reside within room [ROOM NUMBER]/320 at one time. The ADM stated he has requested a copy of the original facility plans but was unable to get them at this time.A review of the facility policy and procedures (P&P) titled, Bedrooms, reviewed 5/20/2025, indicated, All residents are provided with clean, comfortable and safe bedrooms that meet federal and state requirements. Bedrooms accommodate no more than two residents at a time. The P&P further indicated all resident rooms have: a. Direct access to an exit door;b. At least one window to the outside; andc. a floor above grade level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 4 protected one of three residents (Resident 13) identifiable personal information displayed on a computer screen when LVN 4 was walking away from the computer. This deficient practice violated Resident 13's right for privacy and confidentiality. Findings: A review of Resident 13's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses: type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness (lack of physical or muscle strength), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), essential (primary) hypertension (abnormally high blood pressure not caused by a medical condition), and cardiomegaly (an enlarged heart; a condition that makes a heart use extra effort to pump blood). A review of Resident 13's History and Physical (H&P - a physician's complete patient examination) dated 8/18/2025 indicated, Resident 13 was able to make decisions 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 13's Minimum Data Set (MDS - a resident assessment tool) dated 10/07/2025, indicated, Resident 13 made poor decisions, and required cues and supervision. The MDS also indicated, Resident 13 was dependent on staff with her Activities of daily Living (ADL). A review of Resident 13's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) on impaired ambulation (act of walking) dated 3/25/2025, indicated, Resident 13 had a diagnosis of self-care deficits. The CP goal indicated Resident 13 will be clean, dry, and well-groomed daily. A review of the facility's In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) sign-in sheet dated 8/08/2025 indicated, LVN 4 signed in and received HIPAA (Health Insurance Portability and Accountability Act - is a federal law that sets a national standard to protect medical records and other personal health information) education. During a concurrent observation on 9/29/2025 at 10:58 AM, at nurses' station 2, the surveyor observed a facility computer with the screen open on (medication(med) cart 2. There was no staff at the nurses' station or at med cart 2. The surveyor touched the track pad on the computer and the computer's screen instantly opened to Resident 13's personal information which included the resident's name, date of birth , social security number, address, and medical diagnoses. Approximately two minutes later, LVN 4 came to nurses' station 2. During a concurrent interview, LVN 4 stated that she was assigned nurses' station 2. LVN 4 stated, I thought I left the screen (computer) hidden. LVN 4 stated, I am exposing [Resident 13's] privacy, personal information, you know, identity theft. A review of the facility policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled HIPAA Training Program with a review date of 5/20/2025 indicated, . To ensure the confidentiality or our resident's protected health information (PHI) and facility information (PHI) . A review of the facility's P&P titled Resident Rights with a review date of 5/20/2025 indicated, the facility will provide privacy and confidentiality to all of their residents. A review of the facility P&P titled Confidentiality of Information and Personal Privacy dated 5/20/25, indicated, Our facility will protect and safeguard resident confidentiality and persosonal privacy. I. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REVIEWEDBased on interview, and record review, the facility failed to ensure necessary care was provided consistently for a resident who was receiving hospice service (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) for one of one sampled residents (Resident 4), by failing to maintain the resident's current hospice certification of terminal illness in the resident chart. This deficient practice had the potential to lead to Resident 4 not receiving the needed and necessary services. A review of the admission record indicated the facility admitted Resident 4 on 9/13/2011 and readmitted on [DATE], with diagnoses that included cerebral atherosclerosis (the narrowing of the arteries in the brain due to build of a fatty deposits which can lead to a stroke), heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and atrial fibrillation (an irregular heartbeat that can lead to blood clots and increases the risk of stroke and other heart complications). A review of Resident 4's Physician's Order 4/17/2024, indicated to admit Resident 4 to the facility under the services of hospice care. A review of Resident 4's History and Physical, dated 4/15/2025 indicated the resident's condition declined during the past year and the resident remained on hospice care. A review of Resident 4's Hospice Certification of Terminal illness dated 8/14/2025 indicated Resident 4 was eligible for the hospice services effective 8/10/2025 to 10/8/2025. A review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 10/10/2025, indicated the resident had severely impaired cognitive skills for daily decision making. The MDS also indicated the resident received hospice care while a resident. A review of Resident 4's hospice binder on 11/20/2025 at 9:15 AM indicated there was no hospice certification of terminal illness after 10/8/2025. During a concurrent interview and record review on 11/20/2025 at 10:02 AM, with Licensed Vocational Nurse (LVN) 3, Resident 4's hospice chart was reviewed. LVN 3 stated Resident 4 was currently receiving hospice services. LVN 3 stated Resident 4's hospice chart did not have the hospice certification of terminal after 10/8/2025. LVN 3 stated the resident's hospice chart should contain the current certification of terminal illness and the hospice has to recertify Resident 4 every three months to ensure that the resident still qualifies for hospice. During an interview on 11/20/2025 at 12:55 PM, the Director of Nursing (DON) stated the hospice certification of terminal illness is completed every three months. The DON further stated the certification of terminal illness should be in the hospice chart to ensure the resident requires hospice services and so that the resident receives the care they require. A review of the hospice and facility contract, dated 7/31/2009, indicated, The patient medical records and documentation maintained by each party shall be available for review and inspection by the other party as necessary for the proper evaluation, screening, provision of services to patients under this agreement. A review of the facility policy and procedures (P&P), titled Hospice Program, reviewed 5/230/2025, indicate, In order for a resident to qualify for the Hospice benefit under Medicare, he or she must be certified as being terminally ill. The facility coordinates care provided to the resident by the facility staff and the hospice staff and the facility is responsible for obtaining the physician certification and recertification of the terminal illness specific to each resident.

Based on observation, interview, and record review, the facility failed to ensure dietary aides (DA) 1, DA 2 and DA 3 wore hairnets at all times while in the kitchen. This deficient practice had the potential for hair to fall in food resulting in food borne illness illness to residents who consume food prepared in the facility kitchen. Findings: During a concurrent observation and concurrent interview on 9/29/2025 at 9:51 AM, DA 1, DA 2 and DA 3, were not wearing hairnets while performing tasks in the kitchen. DA 3 stated, I thought there is one on my head. DA 1 stated I forgot. When asked why DA 2's hairnet was sitting on top of DA 2's hair bun instead of covering the entire head, DA 2 stated, Oh I didn't know. DA 1, DA2, and D3 all stated they (Residents) will get sick when asked the potential harm for not wearing hairnets and not cover the head with hairnets. DA 2 added, we are supposed to wear the hairnet while working here. A review of the facility policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Sanitation and Infection Control with a review date of 5/20/2205 indicated, A hair net or head covering which completely covers all hair should be worn at all times.

REVIEWING Based on interviews and concurrent record review, the facility failed to complete the annual performances evaluations and annual skills competencies for six out of six employees according to facility policies and procedures titled, Performance Evaluations and Competency Assessments.This failure had the potential to result in inadequate care, skills, and nursing services to the residents.Findings: During an interview on 10/1/25 at 8:42 AM, Director of Satff Development (DSD) stated the importance of staff annual skills competencies is to ensure the nurse skills are following the correct protocol and to make sure the nurses are capable of caring out the skills to complete their job efficiently. DSD stated performance evaluations are to be completed annually to so that the managers and supervisors can identify areas of improvement for all the staff. During an interview on 10/1/25 at 9:32 a.m., Certified Nursing Assistant (CNA) 3 stated she does not remember the last time she completed annual skills competency. CNA 3 stated she has not completed abuse training since hire. During an interview and concurrent record review on 10/1/25 at 10:09 a.m., seven out of seven employee files were reviewed with the Director of Staff Development (DSD) and the following were noted/identified:1. License Vocational Nurse (LVN) 4 was hired on 12/22/2022. There was no documented evidence that LVN 4 completed the annual performance for 2023, and no documented evidence LVN 4 completed the annual competencies for year 2023 and 2025. 2. LVN 5 was hired on 7/11/2012. There was documented evidence that LVN 5 completed annual competencies for 2023, 2024, and 2025, and no documented evidence that LVN 5 completed annual skills check for 2023, 2024, and 2025.3. The Assistant Director of Nursing (ADON) was hired on 5/14/2013. There was no documented evidence that the ADON completed annual competency for 2023.4. CNA 3 was hired on 2/25/2024. There was no documented evidence that CNA 3 completed annual competencies for 2025.5. CNA 4 was hired on 10/20/2004. There was no documented evidence that CNA 4 completed annual competencies for 2022, 2023, and 2024.6. CNA 5 was hired on 5/9, 2024. There was no documented evidence that CNA 5 completed annual performance evaluation for 2025. During an interview with the Director of Nursing (DON) on 11/20/25 12:46 PM, the DON stated all staff are supposed to complete annual competencies and annual performance evaluations upon hire and annually. DON stated if the staff do not complete annual competencies yearly, they can forget how to care for the residents and could make mistakes with certain skills. DON stated it is very important that all the staff training is completed on time to prevent harm to the residents and to ensure all the residents receive the best possible care and to see if there are any areas of improvement that are needed to ensure the staff provide good care to residents. During a review of the facility policy and procedures (P&P) titled Performance Evaluations with a revised date of 5/20/2025, indicated, Policy Statement: The job performance of each employee shall be reviewed and evaluated at least annually. A review of the facility P&P titled Competency Assessments with a revised date of 5/20/2025, indicated, Policy: Employees will be assessed for competency upon hire and annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow and implement their abuse policy for one of three sampled residents (Resident 1). On 3/15/25, Resident 1 alleged that Resident 2 hit Resident 1 on the left shoulder. Resident 1 stated, Resident 2 hit her on the left shoulder and as a result, Resident 1 stated she had pain on the left arm and unable to stretch her left arm. The facility failed to report Resident 1's allegation of abuse to the state survey agency within two hours of knowing about Resident 1's allegation.
This deficient practice had the potential for delay in investigation and determine if Resident 1 and Resident 2 felt safe.
Findings:
1.During a review of the admission Record indicated the facility admitted Resident 1 on 12/23/24 and re-admitted on [DATE] with diagnoses including diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) and depression.
During a review of Resident 1's care plan initiated on 12/25/24 indicated Resident 1 and/or responsible party have been made aware that the facility has stable systems to identify not only abuse but also those practices and omissions that lead to abuse, neglect and misappropriation of property. The care plan goal indicated the facility will promptly identify and take appropriate measures to protect residents from abuse. The care plan interventions included follow all reporting guidelines as required related to abuse reporting and inform the resident and/or responsible party of the facility policy for reporting abuse.
During a review of Resident 1's Change of Condition (COC) dated 3/15/25 at 4:30 p.m. indicated on 3/15/25 at 10:30 a.m., the occupational therapist (OT) informed the registered nurse supervisor (RNS 1) that while Resident 1 and Resident 2 were in the rehabilitation room, Resident 2 called the attention of Resident 1 by tapping Resident 1's left shoulder. The COC indicated the OT told Resident 2 to call Resident 1 by Resident 1's name instead of tapping Resident 1's shoulder. The same COC indicated on 3/15/25 at 4:30 p.m., Resident 1 complained of pain in her shoulder that she claimed where another resident (Resident 2) tapped her . RNS 1 assessed Resident 1 and found no bruising or discoloration. Resident 1's range of motion (ROM, the extent to which a part of the body can be moved around a joint or a fixed point) was intact. Resident 1 was given Tylenol 650 milligrams (mg. - metric unit of measurement, used for medication dosage and/or amount) for pain and warm compress was applied to the left shoulder. Resident 1's nurse practitioner (NP,) was notified and gave order for x-ray of the left shoulder. At 6:30 p.m., Resident 1's NP gave a telephone order that included to apply Voltaren Gel (medicated gel applied to the skin for relief from muscle and joint pain) three times a day to Resident 1's left shoulder.
During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 3/29/25, indicated Resident 1 was cognitively intact. Resident 1 needed moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe, upper/lower body dressing, putting on/taking off footwear and supervision with eating, oral and personal hygiene.
2.During a review the admission Record indicated the facility admitted Resident 2 on 3/9/22 and re-admitted on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).
During a review of the MDS dated [DATE] indicated Resident 2 had moderately impaired cognitive skills. Resident 2 needed supervision with oral/toileting hygiene, shower/bather self, upper/lower body dressing, putting on/taking off footwear, personal hygiene and set up with eating.
During an interview on 4/7/25 at 9:10 a.m., Resident 1 (certified nursing assistant [CNA 1] interpreting, stated she was in the rehabilitation room doing exercise when Resident 2 came and hit me in the left shoulder. Resident 1 stated after Resident 2 hit her on the left shoulder, Resident 1 stated she had pain nine out of 10 pain scale (measure of pain, zero -no pain, one to three - mild pain, four to six - moderate pain seven to nine severe pain and 10 - very severe pain) on the left shoulder and unable to stretch her left arm. Resident 1 stated she felt safe.
During an interview on 4/7/25 at 9:43 a.m., Resident 2 did not respond to simple questions.
During an interview on 4/7/25 at 9:54 a.m., the assistant director of staff development (DSD) stated for any allegations of abuse the administrator had to be notified and report the allegation to the state survey agency no more than two hours of knowing the allegation.
During an interview on 4/7/25 at 11:33 a.m., the OT stated Resident 1 was sitting on the exercise bicycle when Resident 2 tapped Resident 1 on the shoulder. OT stated Resident 1 was annoyed and OT pulled Resident 2. OT stated he informed Resident 2 to call Resident 1 by Resident 1's name instead of tapping Resident 1. OT stated no abuse and there was no yelling that occurred.
During a telephone interview on 4/7/25 at 11:40 a.m., RNS 1 stated on 3/15/25, the OT informed RNS 1 that Resident 2 was annoying Resident 1 in the rehabilitation room. RNS 1 stated she went to the rehabilitation room and informed Resident 2 to call Resident 1 by her name instead of tapping on Resident 1's shoulder. RNS 1 stated, later during the day, Resident 1 approached RNS 1 and informed RNS 1 that Resident 1 was having pain on the left shoulder after Resident 2 tapped Resident 1 on the left shoulder. RNS 1 stated she assessed Resident 1 and found no bruising and discoloration but complained of pain of the left shoulder. RNS 1 stated she gave Resident 1 Tylenol for pain and notified Resident 1's NP. The NP gave order for x-ray of the left shoulder and apply voltaren gel to the left shoulder. RNS 1 stated the x-ray result was negative.
During an interview on 4/7/25 at 12:25 p.m., with the director of nursing (DON) and administrator (ADM), the DON stated RNS 1 informed her that Resident 1 complained of pain of the left shoulder where Resident 1 claim that Resident 2 hit her on the left shoulder. DON and ADM stated they did not report the allegation to the state survey agency because the OT witnessed the incident. DON and administrator stated no abuse occurred.
During a review of the facility Policy titled Abuse & Mistreatment of Residents reviewed on 5/21/24 indicated facility shall ensure reporting of all alleged and substantiated violations to the state agency and all other agencies as required and take all necessary corrective action on the results of the investigation. The same Policy indicated it is the facility's policy for any mandated reporter working in a facility to report abuse to their supervisor as well as the state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor the resident, who had a change in condition in accordance with professional standard of practice for one of three sampled residents (Resident 1). For Resident 1, who had a seizure (a sudden, uncontrolled jerking, blank stares, and loss of consciousness) on 1/14/25, and a physician order to continue to monitor Resident 1, the facility failed to monitor Resident 1 during the night shift on 1/14/25.
This deficient practice had the potential for Resident 1 to have had a seizure and not given treatment as indicated to ensure Resident 1 was safe.
Findings:
During a review of the admission Record indicated the facility originally admitted Resident 1 on 2/1/23 and readmitted on [DATE] with diagnoses including epilepsy and diabetes mellitus.
During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 10/29/24 indicated Resident 1 had mild cognitive impairment. Resident 1 needed supervision with oral hygiene, toileting, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, personal hygiene, and setup with eating.
During a review of Resident 1's Orders-Administration Note dated 1/14/25 at 5:40 p.m., indicated Resident 1 had petit mal seizure (brief, sudden lapses of consciousness) of approximately 30 seconds. The Note indicated Resident 1's blood pressure was 76/47 millimeters of mercury (mm HG, unit of measurement, normal range is 120/60 mm HG). Resident 1's blood pressure was re-taken and indicated the blood pressure was 120/75 mm HG. The Note indicated Resident 1's nurse practitioner (NP, a registered nurse who had additional training and education in how to diagnose and treat disease) was notified and gave orders to monitor Resident 1. The Note further indicated .will continue to monitor as ordered . and notify the physician of any further changes or complications.
During a review of Resident 1's Care Plan initiated on 1/14/25 indicated Resident1 had an actual seizure of less than 30 seconds. The Care Plan goal included Resident 1 will have no injury until the next assessment. The Care Plan interventions included observe for seizure activity and notify the physician as indicated, assess for any change of condition, and notify the physician as indicated.
During a telephone interview on 1/17/25 at 10:17 a.m., licensed vocational nurse (LVN 1) stated Resident 1 had a seizure on 1/14/25. LVN 1 stated she notified Resident 1's NP and the NP gave order to continue to monitor Resident 1. LVN 1 stated she continued to monitor Resident 1 by taking Resident 1's vital signs (measure of the basic functions of the body), asked Resident 1 if Resident 1 was dizzy and continue to monitor Resident 1 for seizure to ensure Resident 1 was fine.
During a concurrent interview and record review on 1/17/25 at 11:46 a.m., Resident 1's vital signs and nursing documentation dated 1/14/25 was reviewed with the director of staff development (DSD). DSD stated Resident 1 had a seizure on 1/14/25 and the seizure was considered a change of condition. DSD stated Resident 1 should be monitored for seizure and monitoring would include vital signs. DSD agreed there were no vital signs taken and no nursing documentation on 1/14/25 during the night shift. DSD stated it was important to monitor Resident 1 for seizure and vital signs because Resident 1 may have changes and may need to transfer Resident 1 to the hospital for further evaluation.
During a review of the facility Policy titled Change of Condition reviewed on 5/21/24, indicated a change of condition is a sudden or marked difference in resident's that included vital signs and behavior (change to lethargy, agitated, non-responsive) and level of consciousness. The same Policy indicated documentation of change in condition shall be performed by the licensed nurse accordingly: (includes the following)
1. Documenting for at least 72 hours or longer if condition change warrants.
2. Documenting vital signs each shift.
3. Re-assess resident condition as needed.
During a review of the facility Policy titled Charting and Documentation reviewed on 5/21/24, 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. The same Policy indicated the following information is to be documented in the resident medical record that included objective observations and treatments or services performed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident medical records are accurate in accordance with professional standard of practice for one of three sampled residents, (Resident 1). For Resident 1, the facility failed to ensure the monitoring and documentation for seizure (a sudden, uncontrolled jerking, blank stares, and loss of consciousness) activity on 1/14/25 during the night shift was accurate.
This deficient practice resulted in incomplete and inaccurate medical record for Resident 1.
Findings:
During a review of the admission Record indicated the facility initially admitted Resident 1 on 2/1/23 and readmitted on [DATE] with diagnoses including epilepsy (sudden bursts of electrical activity in the brain cause seizure or fits) and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 10/29/24 indicated Resident 1 had moderately impaired cognitive skills. Resident 1 needed supervision with oral hygiene, toileting, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, personal hygiene, and setup with eating.
During a review of the Medication Administration Record (MAR, daily documentation record used by licensed nurse to document medications and treatments given to a resident) dated 1/25 indicated to monitor Resident 1 for seizure activity every shift. The MAR indicated to enter zero (0) if no seizure and one (1) if Resident 1 had a seizure. On 1/14/25, number one (1) was entered in the MAR during the night shift.
During a concurrent telephone interview and record review, on 1/17/25 at 9:38 a.m., the MAR was reviewed with licensed vocational nurse (LVN 2). The MAR indicated LVN 2 entered number 1 on the box dated 1/14/25 during the night shift, indicating Resident 1 had a seizure. LVN 2 stated Resident 1 did not have a seizure on 1/14/25 during the night shift. LVN 2 stated he made a mistake with his documentation.
During an interview on 1/17/25, at 11:06 a.m., registered nurse supervisor (RNS 1) stated Resident 1 did not have a seizure on 1/14/25 during the night shift. RNS 1 stated LVN 2 should have entered zero (0) for no seizure activity instead of the number one (1). RNS 1 stated LVN 2 made a mistake during the documentation on 1/14/25.
During a review of the facility Policy titled Charting and Documentation reviewed on 5/21/24 indicated the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The same Policy indicated documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff did not refer to two of three sampled residents (Residents 101 and 114) as feeders. Residents 101 and 114 required staff assistance with feeding.
This deficient practice had the potential for lowered self esteem and depression (a prolonged feeling of sadness, hopelessness, or loss of interest in activities) for Residents 101 and 114.
Findings:
A review of Resident 114's admission record, indicated Resident 114 was admitted to the facility on [DATE], with diagnoses that included, adult failure to thrive, (AFTT - a complex decline in physical and mental health that can affect the elderly, causing weight loss, decreased appetite, dehydration, and social isolation), chronic obstructive pulmonary disease (COPD) (a lung disease that damages the lungs and makes breathing difficult), hypertension (HTN- High or raised blood pressure), muscle weakness (a lack of physical or muscle strength, throughout the body).
A review of Resident 114's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/17/24, indicated Resident 114's cognition (the mental ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 114 required substantial/maximal assistance with bed mobility, transfer, eating, toilet use and personal hygiene.
During observation of Resident 114's lunch meal on 10/1/24 at 12:54 pm in Resident 114's room, Resident 114 was lying on his bed in an upright position and Licensed Vocational Nurse 3 (LVN 3) was assisting Restorative Nursing Assistant 2 (RNA 2) feed Resident 114. LVN 3 was encouraging the resident to eat the food.
During an interview on 10/1/24 at 1:08 pm, LVN 3 stated Resident 114 eats lunch at the bedside because the resident is a feeder. LVN 3 stated that the feeder residents were part of the RNA feeding program. When asked why the residents that need assistance with feeding are called feeders, LVN 3 stated because the residents are on the RNA feeding list.
During an interview on 10/1/24 at 1:22 pm, RNA 2 stated, that she was feeding Resident 114 because he is a feeder. RNA 2 stated that all feeders are brought to the dining room and put in one area so the residents can be fed. When asked why Resident 114 is called a feeder, RNA 2 stated because he is on the list to be fed.
A review of Resident 101's admission record, indicated Resident 114 was admitted to the facility on [DATE], with diagnoses that included HTN and depression.
A review of Resident 101's MDS, dated [DATE], indicated Resident 101's cognition was severely impaired. Resident 101 required substantial/maximal assistance with bed mobility, transfer, eating, toilet use and personal hygiene.
During observation of Resident 101's lunch meal on 10/1/24 at 1:11 pm in Resident 101's room, Resident 101 was lying on bed in an upright position and Certified Nursing Assistant 1 (CNA 1) was feeding Resident 101 lunch.
During an interview on 10/1/24 at 1:11 pm, CNA 1 stated Resident 101 is a feeder. When asked why CNA 1 called the residents feeders, CNA 1 stated because residents on RNA program are called feeders. CNA 1 stated the residents should not be called feeders because it is disrespectful to them and their family members.
During an interview on 10/3/24 at 3:20 pm, RNA 1 stated that the residents that need feeding assistance should treated with respect.
During an interview on 10/3/24 at 3:39 pm, the Director of Staff Development (DSD) stated that residents on RNA program are called feeders because they cannot eat independently.
During an interview on 10/4/24 at 5:17 pm, the Director of Nursing (DON) stated residents that need of eating assistance should be respected and treated equal to all other residents. The DON stated, residents that need eating assistance should not be addressed as feeders because it is a matter of treating the residents with respect and maintaining their individual dignity during the aging process.
During a record review of the facility's In-service lesson plan on Preserving Patient Dignity and Privacy dated 4/30/24 at 2:30 pm, indicated: II. Lesson Body 3. Respect & Dignity a. Every individual should be treated with courtesy and respect. Residents should be addressed with their proper names. You can call them by their first name when permission is given to do so. Never use Honey, Sweetie, or Gramps - they should never be treated like children.
During a record review of the facility's policy and procedures (P&P) titled Dignity revised 2/2021, indicated, Policy Interpretation and Implementation. 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. 5. When assisting with care, residents are supported in exercising their rights. For example, resident are: e. provided with a dignified dinning experience. 8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents 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) were complete and updated for three out of four sampled residents (Residents 189, 18 and 146) by failing to maintain an accurate and current copy of the resident's advance directives in the resident's clinical record.
This failure resulted had the potential to cause conflict with Residents 189, 18 and 146 wishes regarding health care.
Findings:
1. A review of Resident 189's admission record, indicated Resident 189 was admitted to the facility on [DATE], with diagnoses that included, chronic obstructive pulmonary disease (COPD - a lung disease that damages the lungs and makes breathing difficult), dementia (a condition characterized by progressive or persistent loss of intellectual functioning especially with loss of memory), hypertension (HTN - high or raised blood pressure), muscle weakness (a lack of physical or muscle strength, throughout the body).
A review of Resident 189's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/8/24, indicated Resident 189's cognition (a person's mental ability to think, learn, remember, use judgement, and make decisions) was severely impaired. The MDS indicated Resident 189 required supervision or touching assistance with bed mobility, transfer, eating, toilet use and personal hygiene.
2. A review of Resident 18's admission Record indicated the resident was admitted to the facility on [DATE], with the diagnosis of, but not limited to, anxiety disorder, (restlessness, worried, tense or afraid of what may happen in the future), dementia, HTN, and muscle weakness.
A review of Resident 18's MDS dated [DATE], indicated Resident 18's cognition was severely impaired and that was dependent on staff for most activities of daily living (ADL - they include bathing, showering, dressing, getting in and out of bed or chair, toileting, and eating).
3. A review of Resident 146's admission Record indicated the resident was admitted to the facility on [DATE], with the diagnosis of, but not limited to, dementia, HTN, and muscle.
A review of Resident 146's MDS dated [DATE], indicated Resident 146's cognition was moderately impaired and required supervision or touching assistance with ADL including bathing, showering, dressing, getting in and out of bed or chair, toileting, and eating).
During an interview on 10/3/24 at 0:06 am, the Social Services Director (SSD) stated that when a resident is unable to make life ending or medical decisions, the residen's representative will sign the acknowledgment for the advanced directive and not check the box. Once the resident representative signs the advance directive acknowledgment form, the SSD and the resident's physician wil sign the form. The SSD stated, if the form is not signed by the resident's representative it would be unclear as to the representative's wishes for the resident regarding end-of-life care.
During record review on 10/04/24 11:06 am, Residents 189, 18 and 146 advance directive acknowledgment forms did not have the residents representative signature.
During a review of the facility's policy and procedures titled Advance Directives undated, indicated, the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with the state law and facility policy. It further indicates prior to or upon admission of a resident, the social service 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 directive.

Based on observation, interview, and record review the facility failed to anchor the urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) per physicia's order for one of two sampled residents (Resident 14).
This deficient practice had the possibility for Resident 14 to suffer and discomfort pain from potential pulling and dislodgement of the urinary catheter.
Findings:
A review of the Resident 14's admission record indicated Resident 14 was originally admitted the resident on 4/2/2008 and was re-admitted the resident on 4/28/24 with diagnoses that included benign prostatic hyperplasia (BPH - enlargement of the prostate gland), obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from draining properly), and urinary retention (a condition in which urine does not empty completely from the bladder).
A review of Resident 14's Physician Orders, dated 4/28/24 indicated to secure the urinary catheter tubing with anchor every day shift to minimize dislodging of catheter.
A review of Resident 14's alteration in urinary elimination care plan, initiated 11/20/23, indicated Resident 14 was at risk for complications secondary to blood coming out from the indwelling urinary catheter due to BPH and urinary retention. The care plan goal indicated to empty the resident's bladder to empty adequately without complications. The care plan interventions indicated facility staff to monitor indwelling catheter and change catheter or bag as ordered, reposition for comfort and monitor skin for alteration and to provide urinary catheter care every shift or as ordered.
A review of the Quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/29/24 indicated Resident 14's cognition (process of acquiring knowledge and understanding) was moderately impaired. The MDS indicated Resident 14 had indwelling catheter and that the resident required supervision or touching assistance with oral and toileting hygiene and upper body dressing.
During a concurrent observation and interview on 10/3/24 at 2:03 PM at Resident 14's bedside, Resident 14's urinary catheter was not anchored/secured to the resident's leg to prevent excessive tension to the catheter. Resident 14 stated the urinary catheter used to be secured to his leg and had not been secured for the past two or three days.
During a concurrent observation and interview on 10/3/24 at 2:09 PM with Treatment Nurse 1 (TN 1) inside Resident 14's room, Resident 14's urinary catheter was observed. TN1 stated Resident 14's catheter was not anchored/secured to the resident's leg or to the bed. TN 1 also stated the catheter should have an anchor in place to prevent dislodgement or tugging. TN 1 further stated TN 1 will replace Resident 14's anchor.
During an interview on 10/4/24 at 2:44 PM, the Director of Nursing (DON) stated staff should ensure a resident's urinary catheter should be anchored to the residents leg. The DON stated, the anchor is in place to ensure the catheter is in place, does not tug and does not cause pain.
During a review of the Center for Disease Control and Prevention (CDC) guideline title, Indwelling Urinary Catheter Insertion and Maintenance, indicated one should use a catheter securement device to anchor the catheter and Catheter securement devices act as an anchor to prevent tugging and pulling which can cause irritation and inflammation. When catheters are not secured in male patients, the tugging and pulling can cause pressure sores on the penis tip. (https://www.cdc.gov/infection-control/media/pdfs/Strive-CAUTI104-508.pdf).
During a review of the facility's policy and procedures titled, Procedure: Foley Catheter Maintenance, reviewed 5/21/24, indicated, the objective was to maintain a closed drainage system; to prevent bacterial contamination; to prevent backflow. Staff to change the catheter every month as needed or ordered by the physician. Catheter remains secured to reduce friction and movement at the insertion site.

**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 one sampled residents (Resident 142) by failing to label Resident 142's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) with date, time and initials per the facility's Policy: Oxygen Administration.
This deficient practice had the potential to cause complications associated with oxygen therapy, including infection.
Findings:
A review of Resident 142's admission record indicated Resident 142 was originally admitted to the facility on [DATE] and re-admitted the resident on 9/6/24 with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral aneurysm (a balloonlike swelling in the wall of an artery in the brain), occlusion and stenosis of carotid artery (narrowing and blockage of arteries in the neck) and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs).
A review of Resident 142's Quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/27/24, indicated Resident 142 had modified independence (some difficulty in new situations only) with their cognitive skills for daily decision making and required supervision or touching assistance with oral and toileting hygiene, showering, dressing and personal hygiene.
A review of Resident 142's Physician Orders, dated 9/6/24, indicated the facility to administer oxygen at 2 liters per minute (lpm) via nasal cannula as needed for shortness of breath (SOB) to Resident 142.
During an observation on 10/1/24 at 9:24 am, an undated and exposed to air nasal cannula was attached to Resident 142's oxygen concentrator.
During a concurrent interview and observation on 10/3/24 at 8:17 AM at Resident 142's bedside, Resident 142's Family Member 1 (FM 1) stated the resident's urinal was attached to Resident 142's concentrator.
During a concurrent interview and observation on 10/3/24 at 8:15 am inside Resident 142's room, Licensed Vocational Nurse 1 (LVN 1) stated Resident 142's oxygen tubing was not labeled with the resident's name and was not dated. LVN 1 was not able to state when the oxygen tubing was attached to the concentrator. LVN 1 also stated the oxygen tubing should be dated as it was an infection control issue which could lead to an respiratory infection.
During an interview on 10/4/2024 at 2:42 PM, the Director of Nursing (DON) stated oxygen tubing is changed weekly. The DON stated the oxygen tubing should be labeled in order to know that it is clean and to know when to replace it in order to prevent infection.
A review of the facility's policy and procedures titled, Policy: Oxygen Administration, undated, indicated:
-The oxygen tubing should be changed weekly and as needed, including changing the mask, cannula, nebulizer equipment, etc. When not in use, the oxygen tubing should be stored in a clean bag; for example, a Ziplock bag, etc.
- The date, time and initials should be noted on oxygen equipment when it is initially used and when changed.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when:
1.There were 13 small containers of previously prepared mixed fruits with a use by date of 9/28/24 expired and stored in the walk-in refrigerator.
2. Resident cups that were removed from the dish machine had red color stains and were stored to air dry on the racks.
3.Wet kitchen wiping cloths/towel were stored on the kitchen counters and were reused to clean and wipe food contact surfaces and food preparation equipment such as the stove, blenders, and food storage carts.
These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 195 out of 195 residents who received food from the facility.
Findings:
1. During an observation in the kitchen on 10/1/24 at 9 am, there were 13 single containers of mixed fruits stored in the walk-in refrigerator with a date of 9/28/24.
During a concurrent interview with cook (cook1), cook1 stated the containers of mixed fruits was prepared to serve the residents on 9/28/24 and its now expired. Cook1 stated the containers of fruits should be discarded and cook1 removed the mixed fruits to discard.
Cook1 stated it is important to follow the dates on the food, to make sure expired food is not served to residents because residents can get sick.
During an interview with Dietary Supervisor (DS) on 10/1/24 at 10:35 am, DS stated food should be labeled and dated. DS stated the mixed fruit containers should be discarded following the use by date of 9/28/24 on the label to prevent expired food being served to residents.
A review of facility policy titled Refrigerator/Freezer Storage (undated) indicated, No food item that is expired or beyond the best buy date are in stock .Leftovers will be covered, dated, labeled, and discarded within 72hours.
2. During an observation in the kitchen on 10/1/24 at 11 am, clean resident cups were stored on racks. One cup on the rack was observed with red color stains.
During a concurrent interview with facility Registered Dietitian RD on 10/1/24 at 11 am, RD stated the cups are washed and disinfected, then they are stored on the racks for air drying. RD stated the red stain could be thickened cranberry juice stains. RD stated it should have been rewashed and not placed on racks for air drying. RD stated the cup is dirty and could cross contaminate resident beverage.
During an interview with Dishwasher (DW) on 10/1/23 at 11:05 am, DW stated when the dishes are removed from the dish machine, they are checked for cleanliness and rewashed if there are still stains. DW stated this cup was missed during the checking process.
A review of facility's policy and procedures (P&P) titled Dish washing Procedures-Dish Machine (undated) indicated, Remove gross particles by spraying, scraping and prerinsing in water, use appropriate chemicals to wash, sanitize, de-stain, and rinse dishes.
A review of facility's (P&P) titled Sanitizing equipment and surfaces (undated) indicated, Dietary staff should ensure that all equipment, shelves, serving utensils, and surface areas are clean and in good condition.
3. During an observation in the kitchen on 10/1/2024 at 10:15AM, Dietary Aide 2 (DA2) picked up a kitchen cloth that was on the counter. DA2 was using the kitchen wiping cloth/towel to wipe and clean the counter for food preparation. After DA2 was done with cleaning the counters, DA2 left the kitchen towel on the food preparation counter.
During the same observation, DA4 picked up the same kitchen towel and started wiping surface of the food blender, and the counters. DA4 then left the kitchen towel on the counter.
During an interview with DA2 on 10/1/2024 at 10:30AM, DA2 stated the kitchen towels are soaked with sanitizer. The kitchen towels are to clean and disinfect the counters and equipment after food preparation. DA2 stated the towels are from a red bucket with sanitizer solution. DA2 stated the red bucket is on a rack around the corner from the preparation area and DA2 got it out of the bucket but did not return it.
During a concurrent interview with DA2 and DA3 on 10/1/2024 at 10:35AM, DA3 stated the kitchen towels should be returned and stored in the red bucket with sanitizer, but there is no red bucket with sanitizer solution in the food preparation area and the kitchen towels are left on the counters and reused. DA3 stated the kitchen towels are not clean and it is contaminating the counters.
During an interview with DA1 on 10/1/2024 at 10:40AM, DA1 stated DA1 assists the other Dietary aides and cooks and fills the red bucket with sanitizer solution. DA1 stated there should be a red bucket in the food preparation area to store the kitchen towels. DA1 stated the red bucket is filled with sanitizer solution and it is changed every two hours.
During a concurrent observation and interview with RD on 10/1/2024 at 10:45AM, Cook2 had a kitchen towel in his pocket and was using to wipe the stove. There was another towel stored on the food cart next to the steam stable. RD stated kitchen towels should be stored in the sanitizer solution when not in use and the sanitizer solution is changed every two hours to prevent cross contamination of the counters and kitchen equipment.
A review of facility's policy and procedures titled Food Preparation (undated) indicated, Work surfaces are cleaned and sanitized after each use. (Red bucket is used for sanitizer). Wiping cloths are stored in an approved sanitizing solution and laundered daily.
A review of the 2022 U.S. Food and Drug Administration Food Code, Code 3-304.14 Wiping Cloths, use Limitation, indicated, (B) Cloths in-use for wiping counters and other EQUIPMENT surfaces shall be:
(1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114; and (2) Laundered daily as specified under 4-802.11(D).
(C) Cloths in-use for wiping surfaces in contact with raw animal FOODS shall be kept separate from cloths used for other purposes.

Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster areas was maintained in sanitary manner.
One of two garbage dumpster was overfilled with cardboard boxes and uncovered. The floor area around the trash dumpsters was not clean, there was plastic utensils, gloves, plastic bags, disposable lunch tray and plates.
This deficient practice had the potential for harborage and feeding of pests.
Findings:
During a concurrent observation and interview with Dietary Supervisor (DS) on 10/2/24 at 12 pm, there was one dumpster outside of the kitchen at the back exit that was not covered. The dumpster was overfilled with cardboard boxes and not covered. There was trash on the floor including plastic bags, Styrofoam cups, disposable paper trays, plates and paper including resident meal ticket (includes resident diet and food preferences).
During a concurrent interview with DS and Maintenance Supervisor (MS), DS stated the cardboard boxes should be made flat so they can fit in the dumpster and lids can close. DS stated the trash company picks up trash every day. MS stated the housekeeping staff clean the trash on the floor everyday at 2 pm. MS stated the trash should always be covered and the trash cleaned from the floors to prevent flies and other pests from coming around the trash and then to the facility.
During an interview with the facility Administrator (ADM) on 10/2/24 at 3 pm, ADM stated the trash should always be covered. ADM also stated facility will add locks on the trash to secure facility trash.
During a review of the facility's policy and procedures titled, Food-Related Garbage and refuse Disposal (revised 10/2017) indicated, Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.
During a review of Food and Drug Administration (FDA) Food Code 2022 dated 1/18/2023, code number 5-501.113 titled Covering receptacles, indicated: receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its infection control policy and procedures by failing to ensure a urinal (a contianer to pass/collect urine), was not hanging on the oxygen concentrator (is a medical device that gives extra oxygen) and did not touch the oxygen tubing for one of one sampled residents (Resident 142).
These deficient practice had the potential for cross contamination and infection.
Findings:
A review of Resident 142's admission record indicated Resident 142 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), cerebral aneurysm (a balloonlike swelling in the wall of an artery in the brain), occlusion and stenosis of carotid artery (narrowing and blockage of arteries in the neck) and peripheral vascular disease (PVD - narrowing of the blood flow to the arms and legs).
A review of Resident 142's Quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/27/24 indicated Resident 142 had modified independence (some difficulty in new situations only) with their cognitive skills for daily decision making and required supervision or touching assistance with oral and toileting hygiene, showering, dressing and personal hygiene.
A review of Resident 142's Physician Orders, dated 9/6/24, indicated the facility to administer oxygen at 2 liters per minute (lpm) via nasal cannula as needed for shortness of breath (SOB) to Resident 142.
During a concurrent interview and observation on 10/3/24 at 8:17 AM at Resident 142's bedside, Resident 142's Family Member 1 (FM 1) stated that Resident 142's urinal was attached to the resident's oxygen concentrator and was touching the oxygen nasal cannula.
During a concurrent interview and observation on 10/3/24 at 8:15 AM inside Resident 142's room, Licensed Vocational Nurse 1 (LVN 1) stated Resident 142's urinal was hanging from the resident's oxygen concentrator and nasal cannula. LVN 1 stated the urinal should not touch Resident 142's oxygen tubing. LVN 1 also stated the urinal should not touch the concentrator and the oxygen tubing should be dated as it was an infection control issue and can lead to an respiratory infection.
During an interview on 10/4/24 at 2:42 PM, the Director of Nursing (DON) stated urinals should not be attached to oxygen concentrator, it is also an infection control issue.
A review of the facility's policy and procedures titled, Policies and Practices - Infection Control, reviewed 5/21/24, indicated it was the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the resident ' s healthcare decision maker for one of one sampled resident (Resident 1). For Resident 1, who designated his family member (FM 1) as his decision maker for health, the facility failed to:
1.Inform and obtain consent from FM 1 that Resident 1 wanted to be discharged to Resident 1 friend ' s home on 9/9/24.
2.Inform Resident 1 ' s primary physician that the facility was unable to contact FM 1 regarding Resident 1 ' s discharge.
These deficient practices resulted in failing to include Resident 1 ' s healthcare decision maker regarding Resident 1 ' s discharge plan.
Findings:
During a review of the Power of Attorney for Healthcare (POA, legal document that allows an individual to empower another person to make decisions about their medical care) dated 1/18/20 indicated Resident 1 designated FM 1 to make health care decisions for Resident 1.
During a review of the admission Record indicated the facility originally admitted Resident 1 on 3/12/24 and was readmitted on [DATE] with diagnoses including diabetes (elevated levels of blood glucose or blood sugar), difficulty walking and vascular dementia (caused by a range of conditions that disrupt blood flow to the brain and affect memory, thinking and behavior).
During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 6/16/24 indicated Resident 1 was cognitively intact. Resident 1 needed supervision (helper provides verbal cues as resident completes activity) with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, personal hygiene and set up with eating.
During a review of the Social Service Note dated 9/9/24 at 8:46 a.m., indicated Resident 1 will be discharged home on 9/9/24. The Note indicated several phone call messages were made to FM 1, but FM 1 did not answer the calls. The Note indicated Resident 1 ' s FM 2 was notified and FM2 stated FM 1 do not want to be involved with Resident 1.
During a review of the Social Service Note dated 9/9/24 at 10:47 a.m., indicated Resident 1 was discharged to home with Resident 1 ' s friend.
During an interview on 9/11/24 at 8:28 a.m., the Registered Nurse Supervisor 1 (RNS 1) stated Resident 1 was discharged home because Resident 1 and his family requested to go home. RNS 1 stated prior to going home, instructions regarding the medications were given to Resident 1 and to Resident 1 ' s friend.
During an interview on 9/11/24 at 8:52 a.m., the social worker (SW) stated she (SW) received a call from FM 2 that Resident 1 wanted to be discharged home. The SW stated she made several calls to FM 1 but did not receive a call back. The SW stated Resident 1 was discharged on 9/9/24.
During an interview on 9/13/24 at 7:45 a.m., the Director of Nursing (DON) stated the facility tried calling Resident 1 ' s FM 1 but unable to reach FM 1. The DON stated FM 1 was Resident 1 ' s POA and should be notified. The DON further stated Resident 1 ' s primary physician was notified on 9/9/24 about Resident 1 ' s request for discharge. However, the DON stated there was no documentation that the primary physician was notified that the facility was unable to contact Resident 1 ' s FM 1 before Resident 1 was discharged .
During a review of the facility's Policy and Procedures (P&P) titled Discharging the Resident reviewed on 5/21/24, indicated, if the resident is being discharged home, ensure the resident and/or responsible party receive teaching and discharge instructions that included medication administration.
During a review of the facility P&P titled Transfer/Discharge reviewed on 5/21/24, indicated, notify the facility and or/surrogate decision maker of the reason and location of discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the correct information in the Notice of Proposed Transfer and Discharge for one of one sampled resident (Resident 1). For Resident 1, the facility issued the Notice of Proposed Transfer and discharge on [DATE] and failed to:
1. Provide the correct address and telephone number of the agency that handles the appeals for discharge.
2. Provide the reason why Resident 1 was discharged as outlined in requirements for discharge.
These deficient practices resulted in Resident 1 being given the wrong information about the agency in the event Resident 1 wants to appeal his discharge from the facility.
Findings:
During a review of the admission Record indicated the facility originally admitted Resident 1 on 3/12/24 and was readmitted on [DATE] with diagnoses including diabetes (elevated levels of blood glucose or blood sugar), difficulty walking and vascular dementia (caused by a range of conditions that disrupt blood flow to the brain and affect memory, thinking and behavior).
During a review of the Minimum Data Set (MDS, standardized care and health screening tool) dated 6/16/24 indicated Resident 1 was cognitively intact. Resident 1 needed supervision (helper provides verbal cues as resident completes activity) with oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, personal hygiene and set up with eating.
During a review of the Notice of Proposed Transfer and discharge date d 9/9/24 indicated if Resident 1 believe that the proposed transfer/discharge was inappropriate, Resident 1 had the right to appeal. The Notice indicated the address and telephone number of the state survey agency (SSA) instead of the correct agency that handles the discharge appeals. The Notice also did not indicate the reason why Resident 1 was discharged as outlined in the requirements for discharge.
During a review of Resident 1 ' s Care Plan initiated on 9/9/24, indicated Resident 1 had physician order to discharge home related to Resident 1 no longer needs the services provided by the facility. The care plan goal indicated Resident 1 will be discharged home. Interventions included to provide proper Notice of Proposed Transfer/Discharge.
During a concurrent interview and record review on 9/11/24 at 10:13 a.m., with the Medical Record Director (MRD) the Notice of Proposed Transfer and Discharge given to Resident 1 was reviewed. MRD confirmed the address written on the Notice for discharge appeals was the address of the SSA. MRD stated it is important to give the right address of the agency so that if Resident 1 have a concern with his discharge, Resident 1 can appeal to the right agency.
During an interview on 9/13/24 at 7:45 a.m., the Director of Nursing (DON) stated the reason for Resident 1 ' s discharge should be, because Resident 1 ' s health has improved and no longer need the services of the facility.
During a review of the facility's Policy and Procedures titled Transfer/Discharge reviewed on 5/21/24, indicated, the purpose of the Policy is to ensure proper information is sent with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan (CP: a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) that met resident's identified individual needs for one of four sampled residents (Resident 1). By failing to implement Resident 1's CP for scabies (a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash).
This deficient practice had the potential to result negative impact on residents' health, safety, spread infection, and negatively impact the quality of care and services received.
Cross reference: F880
Findings:
A review of Resident 1's admission Record indicated the resident was admitted on [DATE] with diagnoses that included benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream) and disturbance (conditions that disrupt a person's thinking, feeling, and general daily functioning).
During a review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 5/12/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired and the resident required maximal assistance from staff for activities of daily living (ADL- shower/bathing, lower body dressing and putting on/taking off footwear). The MDS indicated Resident 1 required supervision with repositioning such as sit to stand, toilet transfer, and walking.
A review of Resident 1's Order Audit Report order dated 6/3/2024, created on 6/4/2024 at 10:36 a.m. (late entry) indicated, Resident 1's physician ordered to isolate the resident from roommates when Elimite (medication used to treat scabies) was applied.
A review of Resident 1's Care Plan for scabies dated 6/3/2024 indicated an approach of contact isolation precautions (applies to any person with signs of an illness easily transmitted by direct patient contact or by indirect contact with items in the patient's environment) for 1 day for prophylaxis (an attempt to prevent disease) treatment.
A review of Resident 1's Change of Condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) dated 5/30/2024, indicated Resident 1 was noted with scattered rashes on the torso.
During an interview with Certified Nursing Assistant 1 (CNA1) on 6/4/2024 at 10:51 a.m., CNA1 stated Resident 1was showered in the morning (6/4/2024) and had multiple rashes on the torso and extremities. CNA1 stated Resident 1 was not on contact precautions (steps healthcare visitors and staff need to follow before going into a resident's room. It is intended to prevent transmission of infectious agents and includes use of personal protective equipment such as gloves and a gown before resident contact) and CNA1 did not wear any personal protective equipment (PPE: gowns, gloves, masks, googles) when giving resident 1 a shower. CNA1 stated Resident 1 had two roommates.
During a concurrent observation of Resident 1 and interview on 6/4/2023 at 11:03 a.m., Resident 1 was observed with reddish/pink raised bumps on the skin of both upper legs and knees and all around the torso and back. Resident 1's room did not have any contact precaution signage posted and no PPE cart observed outside the room. Resident 1 was observed scratching both knees and stated, it itches. Resident 1's palms of both hands and fingers were observed with dry, crusted, and scaly skin. Resident 1 appeared uncomfortable due to constant scratching.
During an interview on 6/4/2024 at 12:59 p.m., CNA4 stated, Resident 1 was scratching and had rashes all over the torso and legs. CNA4 stated, the Treatment Nurse 4 (TXN4) and another nurse applied a cream on Resident 1's body after the resident was showered the night before (6/3/2024). CNA4 stated Resident 1 was placed in a room with two roommates throughout the night and CNA4 did not see a PPE cart or isolation signage for isolation after the cream was applied.
During an interview with Infection Preventionist Nurse (IPN) on 6/4/2024 at 10:17 a.m., the IPN stated Resident 1 was first observed with scattered skin rashes on 5/30/2024 and was started on hydrocortisone cream (medication used to treat a variety of skin conditions such as insect bites, poison oak/ivy, eczema, dermatitis, allergies, rash, and itching). The IPN stated Resident 1 went out on pass on 6/3/2024 and went to an appointment at a General Acute Care Hospital 1 (GACH1) where Resident 1 was ordered to be given Elimite treatment for scabies. The IPN stated the facility applied the Elimite cream on Resident 1 on the night of 6/3/2024. The IPN confirmed by stating Resident 1 was not put on contact isolation during the prophylaxis (attempt to prevent) treatment of scabies because based on facility policy isolation precautions were not necessary for prophylactic treatment. When asked if Resident 1 showed signs and symptoms of scabies, the IPN stated, yes.
During a concurrent follow-up interview with the IPN and review of Resident 1's CP and Order Audit Report on 6/4/2024 at 1:55 p.m., the IPN stated Resident 1's order report indicated the resident was to be isolated from roommates when the Elimite was applied. The IPN stated the resident's care plan indicated Resident 1 was to be put on contact isolation. The IPN confirmed by stating Resident 1 was not isolated during the treatment of Elimite and was not put on contact isolation according to the CP. The IPN did not have a log/list of which facility staff were asked to monitor themselves in case they develop any rashes and shows s/sx of scabies. The IPN stated Resident 1 should have been placed on contact precautions as indicated in the CP. The IPN stated the facility staff should have been more vigilant and the IPN should have kept a log to monitor staff who were exposed to Resident 1.
During an interview with the Director of Nursing (DON) on 6/4/2024 at 2:35 p.m., the DON confirmed by stating Resident 1's CP was not implemented.
A review of the facility's policy and procedures (P&P) titled The Resident Care Plan reviewed on 5/21/2024, indicated The resident care plan shall be implemented for each resident on admission and developed throughout the assessment process. It is the responsibility of the Director of Nursing to ensure that each professional involved in the care of the resident is aware of the written plan of care, including its location, the current problems of the resident, and the goals or objectives of the plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of diseases for 2 sampled Residents (Resident1 and 2) in accordance with professional standards of practice by:
1. Failing to place Resident in isolation on 5/30/2024 when the resident was suspected of having scabies (a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash) and showed signs and symptoms (S/Sx).
2. Failing to ensure staff wore appropriate Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses, PPE may include respirators, gloves, overalls, boots, disposable gowns, and goggles) when providing care to residents with potential scabies exposure.
3. Failing to ensure nurses and other healthcare workers (HCW) were trained to recognize and report signs and symptoms compatible with scabies infestation according to the facility's policy and procedure (P&P) titled, Scabies Outbreak Control Plan reviewed on 5/21/2024.
These deficient practices had the potential to spread infection to the residents, visitors, and the community.
Cross Reference F656
Findings:
A review of Resident 1's admission Record indicated the resident was admitted on [DATE] with diagnoses that included benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream) and disturbance (conditions that disrupt a person's thinking, feeling, and general daily functioning).
During a review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 5/12/2024, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired and the resident required maximal assistance from staff for activities of daily living (ADL- shower/bathing, lower body dressing and putting on/taking off footwear). The MDS indicated Resident 1 required supervision with repositioning such as sit to stand, toilet transfer, and walking.
/4/2024 at 10:36 a.m. (late entry) indicated, Resident 1's physician ordered to isolate the resident from roommates when Elimite (medication used to treat scabies) was applied.
A review of Resident 1's Care Plan for scabies dated 6/3/2024 indicated an approach of contact isolation precautions (applies to any person with signs of an illness easily transmitted by direct patient contact or by indirect contact with items in the patient's environment) for 1 day for prophylaxis (an attempt to prevent disease) treatment.
A review of Resident 1's Change of Condition (COC, a sudden clinically important decline from a patient's baseline in physical, cognitive, behavioral, or functional abilities) dated 5/30/2024, indicated Resident 1 was noted with scattered rashes on the torso.
During an interview with Certified Nursing Assistant 1 (CNA1) on 6/4/2024 at 10:51 a.m., CNA1 stated Resident 1was showered in the morning (6/4/2024) and had multiple rashes on the torso and extremities. CNA1 stated Resident 1 was not on contact precautions (steps healthcare visitors and staff need to follow before going into a resident's room. It is intended to prevent transmission of infectious agents and includes use of personal protective equipment such as gloves and a gown before resident contact) and CNA1 did not wear any personal protective equipment (PPE: gowns, gloves, masks, googles) when giving resident 1 a shower. CNA1 stated Resident 1 had two roommates. CNA1 stated facility administration had not asked if CNA1 had any signs or symptoms of scabies.
During a concurrent observation of Resident 1 and interview on 6/4/2023 at 11:03 a.m., Resident 1 was observed with reddish/pink raised bumps on the skin of both upper legs and knees and all around the torso and back. Resident 1's room did not have any contact precaution signage posted and no PPE cart observed outside the room. Resident 1 was observed scratching both knees and stated, it itches. Resident 1's palms of both hands and fingers were observed with dry, crusted, and scaly skin. Resident 1 appeared uncomfortable due to constant scratching.
During an interview with Licensed Vocational Nurse 1 (LVN1) on 6/4/2024 at 11:12 a.m., LVN1 was assigned to care for Resident 1 and stated the resident was not on any contact precautions and there was no PPE cart outside the room. LVN1 confirmed by stating the resident was not on any isolation precautions and had two roommates. LVN1 stated facility administration had not asked if LVN1 had any signs or symptoms of scabies.
During an interview on 6/4/2024 at 12:06 p.m., CNA2 was assigned to care for Resident 1 on 5/30/2024. CNA2 stated she first observed Resident 1's rashes on the torso, hands, and back and Resident 1 was scratching all day and made himself (resident 1) bleed. CNA2 stated she (CNA2) was not asked by facility administration to report any new skin rashes or complaints of itching.
During an interview on 6/4/2024 at 12:59 p.m., CNA4 stated, Resident 1 was scratching and had rashes all over the torso and legs. CNA4 stated, the Treatment Nurse 4 (TXN4) and another nurse applied a cream on Resident 1's body after the resident was showered the night before (6/3/2024). CNA4 stated Resident 1 was placed in a room with two roommates throughout the night and CNA4 did not see a PPE cart or isolation signage for isolation after the cream was applied. CNA4 further stated she (CNA2) was not asked by facility administration to report any new skin rashes or complaints of itching.
During an interview with Infection Preventionist Nurse (IPN) on 6/4/2024 at 10:17 a.m., the IPN stated Resident 1 was first observed with scattered skin rashes on 5/30/2024 and was started on hydrocortisone cream (medication used to treat a variety of skin conditions such as insect bites, poison oak/ivy, eczema, dermatitis, allergies, rash, and itching). The IPN stated Resident 1 went out on pass on 6/3/2024 and went to an appointment at a General Acute Care Hospital 1 (GACH1) where Resident 1 was ordered to be given Elimite treatment for scabies. The IPN stated the facility applied the Elimite cream on Resident 1 on the night of 6/3/2024. The IPN confirmed by stating Resident 1 was not put on contact isolation during the prophylaxis (attempt to prevent) treatment of scabies because based on facility policy isolation precautions were not necessary for prophylactic treatment. When asked if Resident 1 showed signs and symptoms of scabies, the IPN stated, yes.
During a concurrent follow-up interview with the IPN and review of Resident 1's CP and Order Audit Report on 6/4/2024 at 1:55 p.m., the IPN stated Resident 1's order report indicated the resident was to be isolated from roommates when the Elimite was applied. The IPN stated the resident's care plan indicated Resident 1 was to be put on contact isolation. The IPN confirmed by stating Resident 1 was not isolated during the treatment of Elimite and was not put on contact isolation according to the CP. The IPN did not have a log/list of which facility staff were asked to monitor themselves in case they develop any rashes and shows s/sx of scabies. The IPN stated Resident 1 should have been placed on contact precautions as indicated in the CP. The IPN stated the facility staff should have been more vigilant and the IPN should have kept a log to monitor staff who were exposed to Resident 1.
During an interview with the Director of Nursing (DON) on 6/4/2024 at 2:35 p.m., the DON confirmed by stating Resident 1's CP was not implemented.
A review of the facility's policy and procedures (P&P) titled Scabies - Prevention and Control reviewed on 5/21/2024, indicated As soon as a case of scabies is confirmed or suspected, the following precautions should be implemented . place symptomatic resident on contact isolation precautions. Restrict resident to his/her room for the duration of the first treatment period, usually eight to twelve hours. Education will be provided to staff as soon as possible after identification of scabies and for residents/ family members and visitors regarding the control, prophylaxis, and prevention of the spread of scabies as soon as possible. The same P&P also indicated that, nurses and other HCW will be trained to recognize and report any patient, themselves or other HCW with S/Sx compatible with scabies infestation.
A review of the facility's P&P titled Infection Control reviewed on 5/21/2024, indicated gowns and gloves are to be worn when providing care or working with environmental surfaces.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and document a resident's wound to ensure the resident received treatment and care in accordance with the professional standards of practice for one of three sampled residents (Resident 1) as evidenced by failure to:
1. Ensure Licensed Nurses documented he current assessment and or any changes in the resident's medical condition.
On dated 5/12/2024 at 7:26 pm, 5/13/2024 at 4 am, 5/13/2024 at 1:07 pm, 5/13/2024 at 7:49 pm and 5/13/2024 at 11:28 pm written by five different nurses (Licensed Vocational Nurse 2 (LVN 2), LVNs 3, 5, and 6 and Registered Nurse 2 (RN 2), indicated the same exact verbiage.
2. Initiate a plan of care when a change of wound condition was identified on 5/12/2024. The Resident 1's care plan titled Blister, Skin Integrity Impairment Secondary to Fluid Filled Blister to Left Upper Extremity, and Risk for Infection. Resident is at: Moderate risk for infection secondary to: Fluid Filled Blister to LUE (left upper extremity), were created on 5/15/2024 when Resident 1 was no longer in the facility.
3.Ensure to inform Wound Care Specialist (WCS, a medical professional who specializes in treating wounds) pertinent information regarding Resident 1 which includes diagnosis of diabetes (high blood sugar) and presence of brown drainage from Resident 1's left arm wound on 5/12/2024.
4. Ensure Licensed Nurses comprehensively assess and document the resident's wound bed color, size, length, width, depth, presence of drainage and discoloration in Resident 1's change of condition assessment dated [DATE] and when there is a notable change in the left arm wound condition.
5.Ensure Licensed Nurses identify the presence of signs and symptoms of infection and report any suspicion of infection for Resident 1 to the attending physician and or to the Wound Care Specialist 1.
These deficient practices:
1.Resulted to Resident 1 being admitted to General Acute Care Hospital (GACH 1) with a diagnosis of cellulitis (a deep bacterial infection of the skin characterized by redness, swelling and tenderness) of the left arm and sepsis (a serious condition in which the body responds improperly to an infection). Resident 1 received three different types of antibiotics in the Emergency Department and was recommended to have wound debridement (the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue).
2.The potential for Resident 1 not to receive the appropriate treatment and care due to lack of comprehensive documentation by the facility staff regarding Resident 1's condition and response to care.
Findings:
A review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (high blood sugar), chronic kidney disease (progressive damage and loss of function in the kidneys), personal history of urinary tract infections (an infection in any part of the urinary tract system which is the system of organs that makes urine), dementia (impaired inability to remember, think, or make decisions that interferes with doing everyday activities), and benign prostatic hyperplasia (prostate gland enlargement) with lower urinary tract symptoms (such as urinating frequently (during the day and night), a weak urine stream, and leaking or dribbling of urine).
A review of Resident 1's care plan titled Risk for developing pressure sore (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin; usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time), and other types of skin breakdown related to fragile skin due to (d/t) aging process, dementia, diabetes mellitus type 2 (DM 2), initiated on 10/26/2023, indicated a goal to minimize the risk of skin breakdown / pressure sore daily through the next assessment of 7/28/2024. Interventions included to assess skin integrity during care and to notify the resident's medical doctor of any changes.
A review of Resident 1's care plan titled Bruising. At risk for skin discolorations, bruising secondary to: (fragile skin, aging process, poor fluid/dietary intakes, antiplatelet therapy (drugs that prevent blood clots), locomotion impairment (reduced mobility in arms and legs) , cognitive impairment (dementia), initiated on 10/26/2023 indicated a goal to reduce the risk of skin discolorations and injury through appropriate interventions daily through the next assessment. Interventions included to administer medications as ordered, assess skin condition daily during care and with weekly body checks, and notify the medical doctor as indicated.
A review of Resident 1's admission assessment, dated 2/19/2024, indicated Resident 1 was noted with bilateral (both) upper extremities (arm) bruising.
A review of Resident 1's Physician Order, dated 2/19/2024, indicated an order of (Treatment) apply Cetaphil (hypo-allergenic, medication for skin allergy) lotion every four hours as needed for skin dryness / itchiness.
A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment tool), dated 4/29/2024, indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 did not exhibit behaviors of hitting or scratching on self (Under Section E0200). The MDS indicated Resident 1 needed setup or clean up assistance with eating and staff supervision with oral hygiene, toileting hygiene, shower, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS also indicated Resident 1 has a diagnosis of diabetes mellitus and had no pressure injury (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices), venous ulcer (wounds that occur when the veins in the legs do not push blood back up to the heart as well as they should), arterial ulcer (a painful, deep sore or wound in the skin of the lower leg or foot) or other skin problems.
A review of Resident 1's Weekly Skin Report for May 2024 indicated Resident 1 did not have a pressure ulcer, vascular ulcer (wounds on the skin that develop because of problems with blood circulation), diabetic ulcer (open wound or sore that can be difficult to heal), or other acquired skin conditions in the first week of May 2024.
A review of Resident 1's Documentation Survey Report for May 2024, indicated Resident 1 received a shower on Thursday (5/9/2024) by Certified Nursing Assistant 2 (CNA 2) and on Saturday (5/11/2024) by CNA 1.
A review of Resident 1's Change of condition / Interact Assessment Form (COC Form), dated 5/12/2024 at 12:04 pm, indicated Resident 1 was identified with left upper extremity fluid filled blisters. The COC form indicated 1200 (12:00 pm): CNA was assisting resident to dining room for lunch. While assisting resident CNA calls attention of charge nurse because resident has bumps on his hand. Charge nurse calls attention of RN (Registered Nurse) Supervisor for a full head to toe assessment. Upon head-to-toe assessment, Resident is noted with fluid filled blisters on left upper extremity. Cleansed site with Normal Saline (NS, a cleansing solution made up of water and salt), pat dry, and covered with rolled gauze until further orders from MD (Medical Doctor). All vital signs (measurements of the body's most basic functions such as body temperature, pulse rate, respiration rate and blood pressure) are within normal range, awaiting MDs (Medical Doctor) orders. Will continue to monitor as ordered and notify MD of any further changes / complications. 1215 (12:15 pm): Received new orders from MD as follows: 1) Left Upper Extremity; Cleanse with NS, pat dry, apply Xeroform (A petrolatum-based fine mesh gauze containing 3% bismuth tribromophenate [Medication that has antimicrobial properties]), then wrap with rolled gauze, diagnosis (DX): Fluid Filled Blisters. 2) Have resident seen and evaluated by wound consultant on 5/16/24 for further evaluation of treatment plan of care. All orders noted and carried out, will notify MD of any further changes / complications.
A review of Resident 1's non-pressure sore skin problem report, dated 5/12/2024, indicated Resident 1 was identified with left upper extremity fluid filled blister (is a small pocket of fluid in the upper skin layers and is a common response to injury or friction) on 5/12/2024.
A review of Resident 1's Physician Order, dated 5/12/2024 at 12:15 pm, indicated an order of [Treatment] Left Upper Extremity: Cleanse with NS (normal saline), pat dry, apply Xeroform then wrap with rolled gauze, every day shift for fluid filled blisters for 21 days.
A review of Resident 1's Physician Order, dated 5/12/2024 at 12:15 pm, indicated an order to change dressing as needed when soiled or pulled out, monitor dressing integrity daily every day shift, monitor fluid filled blisters every day shift, and monitor for pain during treatment.
A review of Resident 1's Treatment Administration Record (TAR) for May 2024 indicated Resident 1 received wound treatments for his left arm on 5/12/2024, 5/13/2024 and 5/14/2024.
A review of Resident 1's TAR for April and May 2024, indicated an as needed treatment order of Apply Cetaphil (Hypo-allergenic) lotion every four hours as needed for skin dryness / itchiness. The TAR indicated Resident 1 did not receive an as needed dose in April and May 2024.
A review of Resident 1's Nurses Notes dated 5/12/2024 at 7:26 pm, 5/13/2024 at 4 am, 5/13/2024 at 1:07 pm, 5/13/2024 at 7:49 pm and 5/13/2024 at 11:28 pm, written by five different nurses (Licensed Vocational Nurse 2 (LVN 2), LVNs 3, 5, and 6 and Registered Nurse 2 (RN 2), indicated the same exact verbiage (statement) of Resident vital signs within in normal range. Awake. Alert and oriented times two with periods of confusion. Reality orientation provided. No acute distress noted. Skin is dry and warm to touch. Afebrile (no fever). On 72-hour monitoring for skin infection. No active bleeding. No verbalization of pain or any discomfort. Continue treatment as ordered. Maintained safety and hazard free environment. Call light within easy reach. All needs met and attended to promptly. Frequent visual check (by observing and looking using the eyes) rendered. Will continue to monitor. Notes on 5/13/2024 at 4 am, 5/13/2024 at 1:07 pm, 5/13/2024 at 7:49 pm and 5/13/2024 at 11:28 pm, had same statement/text f Resident on monitoring for skin infection Tx (treatment) ongoing tolerated well denies any pain or discomfort @ (at) this time. All needs met by staff call light win reach will continue to monitor for any changes.
A review of Resident 1's Nurses Notes, dated 5/14/2024 at 3 am, indicated that Resident 1's Overall health status has been stable with no change in condition noted in the past week.
A review of Resident 1's Change of Condition / Interact Assessment Form, dated 5/14/2024 at 9 am, indicated Resident 1 was identified of having behavior of refusing to eat, was stating he is very sad and does not want to be in the facility. The COC form also stated Resident 1 was noted picking on the blister on his skin despite it being wrapped with rolled gauze.
A review of Resident 1's Physician Order, dated 5/14/2024 at 10 am, indicated an order to transfer Resident 1 to GACH 1 due to generalized weakness and variable food intake.
A record review of Resident 1's GACH note titled ED Provider Assessment Note, dated 5/14/2024 at 1:19 pm by the emergency room Medical Doctor (EMRD), indicated Resident 1 arrived at the emergency department with Left upper extremity with maceration (A softening and breaking down of skin resulting from prolonged exposure to moisture) and ulceration (a break in the skin with loss of surface tissue) of the dorsal (back part) left forearm with erythema (redness) and induration (An area of hardness in the skin) circumferential with warmth and blistering extending up into the posterior shoulder. The ED Provider Assessment note indicated cefepime (Antibiotic), vancomycin (Antibiotic) and metronidazole (Antibiotic) were given based on empiric skin and soft tissue antibiotics (medication used to treat minor skin and soft-tissue infections ) per infection disease recommendations for severe skin infection. The note indicated CT scan (A computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) was consistent with cellulitis. The note indicated that because of the severity of left upper extremity wound, general surgery recommended operating room for debridement but Resident 1's responsible party was not ready to make that decision at this time. ERMD 1's note indicated diagnoses of severe sepsis (a serious condition in which the body responds improperly to an infection), cellulitis, and urinary tract infection (An illness in any part of the urinary tract, the system of organs that makes urine).
A record review of Resident 1's GACH Integumentary (the body's outer layer which includes skin, hair, nails and glands) / Skin Wound note, date 5/14/2024 at 3:30 pm, indicated Resident 1 had left arm draining wound / cellulitis with two upper arm closed blood blister (a blister that is filled with blood instead of clear liquid).
A review of Resident 1's CT of the left forearm without contrast (a substance taken by mouth or injected into an intravenous (IV) line that causes the particular organ or tissue under study to be seen more clearly) result from GACH 1, dated 5/14/2024 at 3:33 pm, indicated the reason for the CT scan was cellulitis and necrotizing soft-tissue infection (NSTI, diverse disease process characterized by extensive, rapidly progressive soft tissue inflammation and necrosis [cell death]). The impression of the scan indicated Findings compatible with known cellulitis.
A review of Resident 1's CT of the left elbow without contrast result from GACH 1, dated 5/14/2024 at 3;33 pm, indicated the reason for the CT scan was cellulitis and NSTI. The impression of the scan indicated Findings compatible with cellulitis.
A review of Resident 1's CT of the left humerus (upper arm bone) without contrast result from GACH 1, dated 5/14/2024 at 3:33 pm, indicated the reason for the CT scan of the humerus was cellulitis and NSTI. The impression of the scan indicated Findings compatible with known upper arm cellulitis.
A record review of Resident 1's Surgery Consult Notes from GACH 1, dated 5/14/2024 at 5:51 pm, indicated, Upon further workup, patient became febrile (with fever) in the ED (emergency department) up to 100.5 with labs demonstrating severe leukocytosis (white blood cells in the blood are higher than normal which usually indicates an infection) up to 20.5 with a unit of measurement of 10 x 3 [NAME] (unit of measurement with normal range of 4 to 11; 10 x 3 [NAME] means thousands per cubic millimeter - a unit of measurement) in addition to positive UA (Urinalysis, a test of urine that identifies range of disorders such as urinary tract infection) and chronic (worsening) appearing left forearm wound with open drainage. General surgery consulted for further evaluation to rule out necrotizing skin infection. The surgery consult notes further indicated CT scans of L (left) humerus, elbow, and forearm obtained consistent with cellulitis.
A review of Resident 1's care plan titled Blister, skin integrity impairment secondary to fluid filled blister to left upper extremity, created on 5/15/2024 by the MDSN (confirmed by Data History) but initiated on 5/12/2024 (backdated), indicated a goal to resolve the blister without complications through the next assessment. Interventions included to administer medications as ordered, apply pressure relief devices as appropriate and/or ordered, assess for causative factors that caused development and attempt to prevent recurrence, assess for s/s (signs and symptoms) of inflammation or infection i.e. Odor, pain, drainage, swelling, warm to touch, etc. and notify MD (medical doctor) as indicated / needed, assess skin condition daily during care and with weekly body checks, observe universal precautions (standard set of guidelines to reduce exposure to blood and body fluids through the use of protective barriers such as gloves, gown, masks and protective eyewear) while providing treatment, and provide treatment as ordered.
A review of the care plan titled Risk for infection. Resident is at: Moderate risk for infection secondary to: Fluid Filled Blister to LUE (left upper extremity), created on 5/15/2024 by the MDSN (confirmed by Data History) but initiated on 5/12/2024 (back-dated), indicated a goal to reduce the risk for Multidrug-Resistant Organisms (MDRO - group of bacteria that have become resistant to certain antibiotics so these antibiotics can no longer be used to control or kill the bacteria) transmission daily until the next assessment. Interventions included to administer antibiotics if ordered, monitor signs and symptoms of infection, notify medical doctor if any signs and symptoms of infections were observed, and perform wound care if indicated.
During an interview on 5/16/2024 at 11:07 am, LVN 1 stated CNA 2 alerted him about Resident 1's arm which prompted him to go and see Resident 1 in the dining room on 5/12/2024. LVN 1 stated he observed Resident 1's left arm was full of blisters from his forearm up to his upper arm. LVN 1 stated the biggest blister he observed was about five inches by five inches and about 10 inches of the outer side of Resident 1's arm was covered with blisters. LVN 1 stated Not sure how he (Resident 1) got it. Looks like a burn. There's fluid in it. LVN 1 stated fluid was dripping from the blisters. LVN 1 also stated he observed RN 1 and Treatment Licensed Vocational Nurse 1 (TLVN 1) applied Betadine (Used on the skin to treat or prevent skin infection in minor cuts, scrapes, or burns) on the blisters and wrap the arm with gauze. LVN 1 did not provide any evidence of documentation regarding the sizes of the blisters observed in Resident 1.
During an interview on 5/16/2024 at 11:36 am, RN 1 stated he was the Registered Nurse that assessed Resident 1 for his change of condition on 5/12/2024. RN 1 stated Resident 1 was observed with one to two small blisters on his left forearm that he (RN 1) described as fluid filled watery on top of the skin surface. RN 1 stated that the facility took a photo of Resident 1's arm to send to the wound specialist. RN 1 stated Two blisters, one is dime size and the other one is small than dime size. When asked if Resident 1's arm looked infected, RN 1 responded I would say it looked irritated. It is hard for me to say, I am not a wound infection expert, looks blisterous because of the fluid like it is possible infection. When asked why he thinks there is possible infection, RN 1 responded, Anything is possible infection just like all patients are fall risk and can fall, I say all wounds are also possibly infected.
During an interview on 5/16/2024 at 12:05 pm, TLVN 1 stated and confirmed he was called by LVN 1 to look at Resident 1's left arm on 5/12/2024. TLVN 1 stated he observed Resident 1's left forearm with multiple blisters, with the biggest one measuring about 10 x 12 inches. TLVN 1 stated light brown fluid mixed with clear liquid was coming out of Resident 1's wound. TLVN 1 stated he noted discoloration around Resident 1's left forearm including redness around the blister. TLVN 1 stated Resident 1's wound was unusual as he has never seen anything like it before. TLVN 1 stated he asked Resident 1 what happened but Resident 1 doesn't remember how he got the blisters. TLVN 1 stated he cleaned the wound, patted it dry, applied Betadine and wrapped it with gauze prior to reporting the blisters to Wound Care Specialist Medical Doctor 1 (WCS 1). TLVN 1 stated he described the blister and drainage to Wound Care Specialist 1 (WCS 1) and he also sent a photo to her on 5/12/2024. TLVN 1 stated WCS 1 ordered to apply xeroform and to cover the arm with rolled gauze once a day. TLVN 1 stated he did not think Resident 1's forearm was infected because besides the drainage from the blister, Resident 1 did not have a fever and the area was not warm. TLVN 1 stated It was slight redness, not red as an infection. No Pain. If there was infection, would believe he would have pain. TLVN 1 stated that for wound infection, xeroform will not do much but an antibiotic would. No documentation evidence provided by the TLVN 1 regarding the sizes of the blisters and the description skin around the blisters.
During an interview on 5/16/2024 at 12:36 pm, RN 2 stated she transferred Resident 1 on 5/14/2024 to GACH 1 due to his poor appetite and behavior of picking on his skin. RN 2 stated she saw Resident 1's left upper arm was red but not blistered anymore. RN 1 stated she observed the arm red and drying. RN 2 stated It was also alarming it was red, so I referred to the doctor. RN 2 stated Resident 1 was picking his skin.
During an interview on 5/16/2024 at 1:06 pm, CNA 1 stated she showered Resident 1 on 5/11/2024 (Saturday) and noticed Resident 1 had a bandage, described as white, rectangle and taped, on one arm, but cannot recall which arm. CNA 1 stated the gauze had brown drainage just in the corner of the gauze and redness around the dressing. CNA 1 stated this is the first time she noticed Resident 1's arm like this. CNA 1 stated Resident 1 gets showers every other day except Sundays. CNA 1 stated Resident 1 complained of pain in his legs and arms. CNA 1 stated that she did not know what was under the dressing and she figured it was already reported since there was a dressing.
During an interview on 5/16/2024 at 1:40 pm, CNA 2 stated the last time she took care of Resident 1 was on 5/12/2024 and on 5/9/2024 (Thursday). CNA 2 stated that on 5/9/2024 she gave Resident 1 a shower where she observed him with a skin tear on his left arm. CNA 2 stated she informed LVN 1 on 5/9/2024 of Resident 1's skin tear. CNA 2 further stated the same area where Resident 1 had the skin tear on 5/9/2024 was the same area she saw him with blisters on 5/12/2024. CNA 2 further stated I didn't notice until close to lunch (on 5/12/2024), he was scratching a little bit on his arm. I noticed he had blister on his skin. He took off his jacket and noticed full of redness and blisters. He has a lot of discoloration before, but these blisters were new. CNA 2 further stated the blisters looked infected and nasty with lots of drainage that looked like pus (Thick fluid caused by infection that includes white blood cells and cellular debris). His room usually smells but it smelled bad that day. CNA 2 stated she informed LVN 1 regarding the observation on 5/12/2024.
During a follow up interview on 5/16/2024 at 2:04 pm, LVN 1 stated he did not see Resident 1 with a skin tear prior to 5/12/2024.
During a follow up interview on 5/16/20224 at 2:33 pm, TLVN 1 stated Resident 1's wound had slight redness and brown drainage. TLVN 1 stated he relayed the observed redness and brown drainage to Wound Care Specialist 1 (WCS 1) on 5/12/2024. TLVN 1 stated that although the change of condition for Resident 1's wound was done on 5/12/2024 (Sunday), he did not do a care plan because Minimum Data Set (MDS) nurses do the care plans in the facility. TLVN 1 stated and confirmed MDS nurses are only in the facility on Mondays to Fridays.
During an interview on 5/16/2024 at 2:49 pm, TLVN 2 stated he performed Resident 1's wound care treatment on 5/13/2024 and he observed Resident 1's forearm with a lot of blisters. TLVN 2 stated he followed the treatment order and cleaned the arm with normal saline, applied xeroform and wrapped the wound with kerlix. TLVN 2 stated Resident 1's wound was unusual because it was the first time, he has seen it. TLVN 2 stated Resident 1's blisters were oozing with brown fluid, and he assumed the blister popped because it was oozing. TLVN 2 further stated Resident 1 did not have any skin issues before. TLVN2 stated he did not report the changes to the attending physician.
During an interview on 5/16/2024 at 3:06 pm, TLVN 3 described Resident 1's arm with yellowing and red and with serous drainage (a clear to yellow fluid that leaks out of a wound) when he saw the wound on 5/13/2024. TLVN 3 thought the redness on Resident 1's arm was due to irritation.
During an interview on 5/16/2024 at 3:35 pm, TLVN 4 stated that on 5/10/2024, he was alerted by staff that Resident 1 was scratching his arm, so he washed Resident 1's arms, trimmed Resident 1's nails and put a patch of bordered dressing on Resident 1's upper arm. TLVN 4 stated there was no skin breakdown, but the skin was red. TLVN 4 stated he did not do a change of condition assessment and documentation on Resident 1's scratching because he did not observe any skin breakdown. TLVN 4 stated he placed a four-by-four gauze (4 inches by 4 inches medical fabric used in wound care) on the area to prevent skin breakdown. TLVN 4 stated he observed Resident 1's arm on 5/12/2024 with maybe three fluid filled blisters with the biggest size of 2.5 by 2.5 inches. TLVN 4 stated the blisters had no drainage on Sunday (5/12/2024). TLVN 4 stated that what he saw on Resident 1 on that Sunday was unusual because when a resident scratches, what appears is usually a tear and not a blister. TLVN 4 stated the following day, on 5/13/2024, he went to see Resident 1's left arm together with TLVN 2 where he observed redness with clear liquid coming out of the blister. TLVN 4 further stated it may be bolus pemphigoid (a rare skin condition that mainly affects older people. Starts with itchy, raised rash followed by blisters that forms on the skin) based on what TLVN 4 said. No documented evidence was provided by the TLVN 4 regarding the status of the blisters which include the size of the blister and the surrounding tissues for 5/12/2024 and 5/13/2024 as he described during the interview.
During an interview on 5/16/2024 at 4:10 pm, CNA 3 stated she observed Resident 1 with a white bandage on his arm on 5/13/2024. CNA 3 stated Resident 1 informed her that he was not feeling good, so she informed LVN 3 and LVN 3 checked on Resident 1.
During an interview on 5/16/2024 at 4:23 pm, CNA 4 stated that on 5/12/2024, he observed one of Resident 1's forearm with a bandage. CNA 4 stated he also observed the forearm with redness, so he informed LVN 2 and LVN 2 informed him Resident 1's arm was being treated for Cellitis (he means cellulitis).
During an interview on 5/16/2024 at 4:45 pm, LVN 2 stated he observed Resident 1's left arm covered with gauze on 5/12/2024. LVN 2 stated he has observed Resident 1 scratch his skin before and Resident 1 stated he was itchy.
During an interview on 5/16/2024 at 5:01 pm, the Director of Nursing (DON), stated she was made aware of Resident 1's blisters on 5/12/2024 on the telephone but she never saw Resident 1's arm on 5/12/2024. The DON stated she has never seen a patient with a blister in the arm. The DON stated she was informed Resident 1's skin is fragile, and Resident 1 always had discoloration on his arms.
During an interview on 5/17/2024 at 1:49 pm, TLVN 5 stated that brown fluid inside a blister on 5/12/2024 would mean a mixture of blood and water.
During an interview on 5/17/2024 at 2:05 pm, TLVN 4 stated Wound Care Specialist 1 said Resident 1's arm did not look infected based on the picture of the wound (photograph) sent by the facility to WCS 1. TLVN 4 stated the photograph (provided by the facility's administrator to the State Department) was the only photograph WCS 1 received. TLVN 4 confirmed and stated the photograph does not do what he observed justice because it does not show the blisters. TLVN 4 stated on 5/13/2024, together with TLVN 2, he observed drainage from the blister.
During a follow up interview on 5/17/2024 at 2:26 pm, CNA 3 identified and confirmed that the arm on the photograph was Resident 1's arm. CNA 3 stated that Resident 1 usually has dry skin and redness but not like the photograph. CNA 3 stated Resident 1's usual redness is more like sunburn redness. CNA 3 stated she has never seen Resident 1's arm this red before and it is not normal for Resident 1. CNA 3 stated if she sees a resident's arm like the photograph, she will report it immediately to the charge nurse.
During a follow up interview on 5/17/2024 at 2:32 pm, TLVN 3 stated that on 5/13/2024, he observed Resident 1's arm with blisters that were open because there was drainage. TLVN 3 described the drainage as clear reddish describing it as serosanguinous (presence of both blood and the liquid part of blood). TLNV 3 stated Resident 1's arm had redness from the elbow area to the forearm, but he was not sure if the wound was infected. When asked if he wound have done anything differently, TLVN 3 stated he would have sent Resident 1 to the ER (Emergency Room) out of precaution because it could be something more serious. No documentation evidence provided by the TLVN 3 regarding the status of the blisters as he described during the interview.
During a follow up interview on 5/17/2024 at 2:54 pm, LVN 1 stated he observed TLVN 1 clean the blisters of Resident 1 on 5/12/2024 with normal saline. LVN 1 stated he observed TLVN 1 squeeze the blister to clean out the drainage. LVN 1 stated the blister was probably open because it was dripping. LVN 1 stated he thought it was infected because it spread all over the arm.
During an interview on 5/17/2024 at 3:42 pm, the WCS 1 stated she was informed by the treatment nurse (TLVN 1) that called her on 5/12/2024 that Resident 1 was noted with bruising a day or two before and was observed with lesions (an area in the skin that is abnormal compared to the surrounding skin) in the arm that looked like blisters. WCS 1 confirmed the facility sent her a photograph of Resident 1's arm on 5/12/2024. WCS 1 stated she wanted to do a video call with Resident 1 but Resident 1 refused. WCS 1 stated the facility never reported to her that there was drainage from the blister, so she did not think the blister was ruptured. WCS 1 stated she was not concerned of the redness because the treatment nurse explained to her about Resident 1's prior history of bruising so it may have been residual bruising and likely hyperpigmentation (patches of the skin are darker than the surrounding skin) or senile purpura (benign condition characterized by the recurrent formation of purple ecchymoses (bruises) on the exterior surfaces of forearms). WCS 1 stated she did not suspect cellulitis because to her knowledge, Resident 1 did not have diabetes or vascular disease. WCS 1 stated the facility did not inform her Resident 1 had diabetes. WCS 1 stated the facility did not report any drainage. WCS 1 further stated that if drainage was colored, she would have suspected infection and placed resident on prophylactic antibiotics (medications given to prevent infection). WCS 1 stated a brown drainage may suggest a murky drainage and any drainage that is murky is not good because it is bacteria making it that color. WCS 1 further stated if she had known that Resident 1 was diabetic, she may have treated him with prophylaxis Bactrim (an antibiotic).
During a follow up interview on 5/17/2024 at 4:17 pm, the Director of Nursing (DON) stated the description of the wound in the change of condition assessment was not thorough because it failed to note how many blisters were present, what was the size of the blister, if there was any drainage or not and whether the blisters were intact or busted. The DON stated it is important to describe the wound in the change of condition assessment to help the doctor have more information in the chart.
During a concurrent interview and record review of the care plans titled Blister, skin integrity impairment secondary to fluid [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide adequate supervision to ensure one out of two sampled residents (Resident 1), who was admitted to a secured unit (a specific area of the facility that has a restricting device separating the residents in the unit from the residents in the remainder of the facility) located inside the facility due to being a high risk of elopement (when a resident leaves/escapes from a facility without a physician ' s order and without the staff knowing) was not left alone in a room with a door that had a malfunctioning lock.
As a result, on 02/04/24 Resident 1 left the facility through a door inside the dining room which led to an exit door in the facility kitchen. Resident 1 was not found and returned to the facility until 02/07/24. This deficient practice placed Resident 1 at risk for dehydration, malnutrition, hypothermia, uncontrolled medical and/or mental conditions, and placed the resident at risk for being assaulted, hit by a car, seriously injured resulting in death.
Findings:
On 2/9/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident (FRI) about Resident 1 eloping from the facility.
A review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facilityon 9/28/2023 with medical history including benign prostatic hyperplasia (enlarged prostate), hypertension (elevated blood pressure), osteoarthritis (joint pain and stiffness), solitary pulmonary nodule (a small single mass in the lungs), altered mental status (a change in mental function), and bipolar disorder (a disorder associated with episodes of mood swings).
A review of Resident 1 ' s Minimum Data Set (MDS - standardized assessment and care planning tool), dated 1/2/2024, indicated Resident 1 had moderately impaired cognition (problems with reasoning, memory, knowledge and understanding). The MDS indicated Resident 1 required supervision with oral hygiene, toileting, showering, dressing, and personal hygiene.
A review of Resident 1 ' s History and Physical dated 10/1/2023, indicated Resident 1 was unable to care for himself, but had the capacity to understand and make decisions.
A review of Resident 1 ' s Psychosocial assessment dated [DATE], indicated Resident 1 had bipolar disorder (a disorder associated with episodes of mood swings), and altered mental status. The assessment indicated Resident 1 required 24- hour skilled nursing care (care provided by trained registered nurses in a medical setting under a doctor ' s supervision) and assistance with activities of daily (ADL ' s: activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) living due to generalized weakness and impaired cognition due to bipolar disorder and altered mental status.
A review of Resident 1 ' s care plan titled, Elopement Risk dated 10/04/2023, indicated Resident was at risk for leaving safe area without authorization, and leaving premises without authorization secondary to wandering behavior, AWOL Resident 1 will have no elopement until the next assessment date. Interventions included to monitor at frequent intervals, elopement risk evaluation, provide 1:1 if indicated to redirect behavior, and notify physician and responsible party of change of condition.
A review of Resident 1 ' s care plan titled, Secured Unit dated 10/4/2023, indicated Resident 1 was at risk for purposeless [no set destination] wandering and potential for self-injury with actual placement in secured unit secondary to wandering behavior, AWOL risk, and cognitive deficits. The goals indicated included safe wandering and no self-injury. Interventions outlined in the care plan included a physician order to admit to the secured unit, psychiatric evaluation, avoidance of antipsychotic drugs as possible, and to notify the physician and responsible party of a change of condition.
A review of Resident 1 ' s Elopement Risk Evaluation form dated 1/2/2023, indicated Resident 1 was at risk for elopement/wandering. The evaluation indicated that the facility had to always monitor Resident 1 ' s whereabouts.
A review of Resident 1 ' s Change of Condition form dated 2/4/2024 at 1:40 AM, indicated, Recap of events: as per interview with 11PM-7AM charge nurse, the resident went to her station at around 3AM ' ish and was talking to her about his [Resident 1 ' s] medication and that he [Resident 1] doesn ' t like and need any medication. Resident was seen walking around the unit at that time as his usual behavior, noted going inside the activity room. 6:30 AM- Charge nurse was doing rounds in the morning and endorsing with outgoing shift nurse. 7:00 AM charge nurse was assisting in the dining room to assist resident for breakfast. CNA for the resident called his attention that resident has not eaten his breakfast. Resident is alert, oriented X3. RN supervisor and CNA checked his room and interviewed roommates, checked the bathroom and rooms adjoining his room, after searching for a few minutes and unable to locate the resident. RN supervisor called CODE GREEN RM [Resident 1 ' s room] to alert the facility staff that we have a missing resident. Head count was done all resident is accounted for at the time except the resident [Resident 1] in question. All staff assisted in looking at all the places including all rooms, dining room, closets, bathrooms, cabinets, garage, basements, and sheds. Several staff drove around the facility to look at the street Some staff are walking around on foot. Resident was unable to be located. 8:30 AM-Administration was informed about the incident. Police department was called. Nearest ER was called. MD and RP sister was informed that the resident was unable to be located at this time inside the facility.
A review of Resident 1 ' s Conclusion Investigation Report provided by the facility on 2/9/2023, indicated through the investigation process, the resident was discovered to successfully elope from the facility through the kitchen which had direct access to the street. The resident was able to get inside the kitchen through a door malfunction that did not properly latch. The doorknob and latch were immediately replaced to ensure that it properly closes to prevent reoccurrence. A daily door security check was created to ensure door remained properly closed and latched done every shift. In addition, on February 7, 2024, the facility received a call from a security manager of a Department Store, stating that Resident 1 instructed him to call the facility as he wanted to go home. Facility staff immediately went to pick up the resident. Resident 1 was readmitted to the facility.
During an interview with the Administrator (ADMIN) on 2/9/2023 at 2:00 PM, ADMIN stated, Resident 1 was back in the secured unit of the facility. ADMIN stated Resident 1 was found on February 7th at a Department Store. ADMIN stated, the activities room had a door access to the facility ' s kitchen which had an exit door to the street. ADMIN stated that on the day (2/04/24) Resident 1 left the facility, the door that accessed the kitchen in the activities room did not properly latch and it did not lock. ADMIN stated, the activity room door had to always remain locked because it was inside a secured unit within the facility. ADMIN stated, not locking the door posed a risk for residents to leave the facility. ADMIN stated he had in serviced the staff to make sure the door was always locked. ADMIN state he would speak to maintenance about placing an alarm by the activity room door.
During an interview with Licensed Vocational Nurse 1 (LVN1) on 2/9/2024 at 4:00PM, LVN1 stated she saw Resident 1 at 3:30 AM walk by the nurse ' s station. LVN1 stated she asked the resident if he was going to take his morning medication and that was the last time LVN1 saw Resident 1. LVN1 stated she was passing medications at around 6:00 AM and saw Resident 1 ' s CNA inside the resident ' sroom so LVN1 did not go inside the room. LVN1 stated she did not go inside the room because Resident 1 ' s refused morning medications. LVN1 stated she did not know Resident 1 was missing.
During a telephone interview with Certified Nurse Assistant (CNA 1) on 2/9/2023 at 5:00PM, CNA 1 stated he worked 11PM to 7 AM shift with Resident 1, and that around 1:00 AM he saw the resident leave his room. CNA 1 stated Resident 1 enjoyed going to the activities room and this was his (Resident 1 ' s)usual behavior. CNA 1 did not remember seeing any staff in the activities room that night (2/03/24 to 2/04/24). CNA 1 stated around 6:00 AM (2/14/24)he went inside Resident 1 ' s room to change the bed linen. CNA 1 stated he did not see Resident 1 in bed, and he figured Resident 1 was in the activities room. CNA 1 stated he did not check the activities room to see if the resident was in there before he clocked out from his shift.
During an interview with Director of Nurses (DON) on 2/9/2024 at 3:24 PM, DON stated residents in the locked unit were at risk for elopement. The DON stated on 02/04/24 when Resident 1 eloped from the facility the door in the activities room did not latch. The DON stated whenever residents were in the activity room a staff member had to be supervising. The DON stated there was no one in the activities room supervising Resident 1, and that is why Resident 1 eloped from the facility. The DON stated could not give an exact time frequency of how often residents should be supervised in the secured unit. The DON stated at least every four hours. The DON stated the exit door in the activities room should always remainedlocked for the resident ' s safety.
A review of the facility ' s policy and procedure titled, Policy: Care of Wandering Residents dated 5/17/2023, indicated the purpose to protect the wandering resident from injury. Residents who wander shall have their picture taken and placed in the medial record. A plan of care shall address the wandering. Wanderers are to be checked on a regular basis. Nursing and care duties include explaining procedures and their purposes to the resident, continuously reorienting resident to room and belongings, and monitoring the resident ' s location with visual checks as needed.
During an interview with the Administrator on 2/9/2024 at 5:00 PM, ADMIN stated the facility did not have any policy on monitoring the exit doors in their secured unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure:
1. Call lights were within reach for three of 10 (Resident 74, Resident 108 and Resident 123)
2. Soap was available and accessible for hand hygiene for one of three residents (Resident 93).
These deficient practices had a potential to result in Resident 108 and Resident 123 not able to communicate their needs to staff and their needs not met. Also, prevented Resident 93 from washing his hands with soap to prevent potential spread of infection which could negatively impact on Resident 93's health and wellbeing.
Findings:
1. A review of Resident 74's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 74's diagnoses included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), anxiety and tabaco use.
A review of Resident 74's Minimum Data Set (MDS- a standardized screening and assessment tool for nursing house residents), dated 12/16/2022, indicated the resident's cognition (the process of knowing in the broadest sense, including perception, memory, and judgment) was intact. Resident 74 required supervision and setup help only assistance for bed mobility, transfer, dressing, eating, toilet use and person hygiene.
A review of Resident 108's admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including but not limited to osteoarthritis (loss of protective cartilage that cushions the ends of your bones) and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain).
A review of Resident 108's MDS dated [DATE] indicated Resident 108 had moderately impaired cognition and usually was able to make herself understood. The MDS also indicated Resident 108 required limited staff assistance (requires minimal amount of assistance from another person to perform task) with bed mobility, eating, and transfers.
A review of Resident 108's care plan revised 4/11/2022, indicated Resident 108 was at risk for unavoidable declines related to arthritis/osteoarthritis, general weakness, muscular weakness, seizure disorder (abnormal electrical activity in the brain). The care plan intervention included call light within reach and attend needs promptly.
A review of Resident 123's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 123's diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), Alzheimer (a progressive disease that destroys memory and other important mental functions), cognitive communication deficit and difficulty in walking.
A review of Resident 123's MDS, dated [DATE], indicated the resident's cognition (the process of knowing in the broadest sense, including perception, memory, and judgment) was intact. Resident 123 required extensive assistance with one person physical assist from staff for bed mobility, transfer, dressing, eating, toilet use and person hygiene.
During a concurrent observation and interview with Resident 74 on 10/10/23 at 1:53 PM, Resident 74 was lying in bed, awake. The call light was observed on the floor tangled with one of the wheels of roll away nightstand and was not within Resident 74's reach. Resident 74 stated he did not know where to find the call light.
During a concurrent observation and interview on 110/11/23 at 9:34 AM, Resident 123 was lying in bed, alert. The call light was observed on the floor, partially under roll away bedside table and was not within Resident 123's reach. Resident 123 did not verbally respond when asked about call light.
During an interview Certified Nurse Assistant 4 (CNA 4) on 10/11/23 at 3:38 PM, CNA 4 stated call light should not be on floor and should be within residents' reach.
During an interview the Director of Nursing (DON) on 10/13/23 at 9:50 AM, the DON stated call light should be within residents' reach always and should not be on the floor.
During an observation and interview in Resident 108's room on 10/11/2023 at 8:27 AM, Resident 108 was sitting up in bed with the head of bed up raised around 45 degrees. Resident 108 stated she would like to get out of bed and had never used the call light button because she could not reach it. A cord with a red button at the end was clipped on the bed sheet to the left side of the resident above the resident's left shoulder. Resident 108 attempted to turn to the left side and reach for the call light with the right arm but could not reach it and stated, I cannot reach it, it is really hard to reach. I cannot even see it. Restorative Nursing Assistant 1 (RNA 1) entered Resident 108's room and stated the call light was too high and that Resident 108 could not reach the call light. RNA 1 unclipped the call light and brought it down lower and closer to Resident 108's left elbow and arm area. Resident 108 was able to reach the call light and push the red button. RNA 1 stated that a call light should be within a resident's reach at all times in case of an emergency or if the resident would like water, needed to be changed, or not feeling well so that they could call the staff for help.
During an interview the DON on 10/12/2023 at 3:33 PM, the DON stated that call lights should be within a resident's reach at all times so that the resident could call the attention of staff if the resident had any needs. The DON stated if the resident's call light was not within reach, the resident would not be able to ask for help from staff.
A review of the facility's policy and procedures titled Call Lights, reviewed by the facility on 5/16/23, indicated, To assure residents receive prompt assistance .ensuring that the call light is within the resident's reach when in his/her room or when on the toilet.
A review of the facility's policy and procedures titled Accommodation of Needs, reviewed by the facility on 5/16/23, indicated Residents will receive services in this facility with reasonable accommodation of individual needs and preferences.A review of Resident 108's admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including but not limited to osteoarthritis (loss of protective cartilage that cushions the ends of your bones) and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain).
A review of Resident 108's MDS dated [DATE] indicated Resident 108 had moderately impaired cognition and usually was able to make herself understood. The MDS also indicated Resident 108 required limited staff assistance (requires minimal amount of assistance from another person to perform task) with bed mobility, eating, and transfers.
A review of Resident 108's care plan revised 4/11/2022, indicated Resident 108 was at risk for unavoidable declines related to arthritis/osteoarthritis, general weakness, muscular weakness, seizure disorder (abnormal electrical activity in the brain). The care plan intervention included call light within reach and attend needs promptly.
During an observation and interview in Resident 108's room on 10/11/2023 at 8:27 AM, Resident 108 was sitting up in bed with the head of bed up raised around 45 degrees. Resident 108 stated she would like to get out of bed and had never used the call light button because she could not reach it. A cord with a red button at the end was clipped on the bed sheet to the left side of the resident above the resident's left shoulder. Resident 108 attempted to turn to the left side and reach for the call light with the right arm but could not reach it and stated, I cannot reach it, it is really hard to reach. I cannot even see it. Restorative Nursing Assistant 1 (RNA 1) entered Resident 108's room and stated the call light was too high and that Resident 108 could not reach the call light. RNA 1 unclipped the call light and brought it down lower and closer to Resident 108's left elbow and arm area. Resident 108 was able to reach the call light and push the red button. RNA 1 stated that a call light should be within a resident's reach at all times in case of an emergency or if the resident would like water, needed to be changed, or not feeling well so that they could call the staff for help.
During an interview the DON on 10/12/2023 at 3:33 PM, the DON stated that call lights should be within a resident's reach at all times so that the resident could call the attention of staff if the resident had any needs. The DON stated if the resident's call light was not within reach, the resident would not be able to ask for help from staff.
A review of the facility's policy and procedures titled Call Lights, reviewed by the facility on 5/16/23, indicated, To assure residents receive prompt assistance .ensuring that the call light is within the resident's reach when in his/her room or when on the toilet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, when one of four Licensed Vocational Nurse 1 (LVN 1) did not know how to check/interpret blood pressure parameters as per physician's order to determine whether to administer or hold pressure medications for one of seven residents (Resident 120).
This failure placed the residents at risk for incorrect blood pressure monitoring/interpretation which could lead to adverse reactions, hospitalization, or death.
Cross Reference F759
Findings:
A review of Resident 120's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of, hypertension (HTN- high blood pressure), cerebral atherosclerosis (fat and cholesterol build up in the arteries, or blood vessels, causing the arteries to narrow), and history of transient ischemic attack (when blood supply to part of the brain is briefly interrupted).
A review of Resident 120's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/2/2023 indicated the resident has severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated the resident needed limited staff assistance for eating and extensive to total assistance for with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive), dressing, transfer into and out of bed, and toileting.
A review of Resident 120's Orders Summary Report active as of 10/1/2023 indicated the following physician's orders:
1. Amlodipine 5 milligrams (mg - unit of measurement of mass) give one tablet by mouth daily for HTN. Hold if SBP (systolic pressure [SBP], the pressure when the heart beats) is less than 110 mmHg (millimeters of mercury), order date 8/8/2022.
2. Lisinopril 10 mg, give one tablet by mouth one time a day for HTN. Hold for SBP less than 110 mmHg, order date 8/8/2022.
During a concurrent medication pass observation and interview with LVN 1 on 10/11/2023 at 9:41 AM, LVN 1 was observed placing a blood pressure cuff on Resident 120's contracted (muscles tighten up and difficult to move or stretch out fully) right upper arm then placed the stethoscope (a medical instrument for detecting sounds produced in the body that are conveyed to the ears of the listener) tips in her ears. LVN 1 completely covered the diaphragm and bell portion of the stethoscope with the blood pressure cuff. LVN 1 stated Resident 120's blood pressure reading (blood pressure is recorded as two numbers, the systolic pressure [SBP], the pressure when the heart beats over the diastolic pressure [DBP], the pressure when the heart relaxes between beats) was 110 over 60 millimeters of mercury(mmHg- [110/60mmHg]). LVN 1 stated that she will hold (not administer) Resident 120's two blood pressure medications.
During an interview with LVN 1 on 10/11/2023 at 9:53 AM, LVN 1 stated that she usually covers the stethoscope with the blood pressure cuff because it is easier to hear the beats (Korotkoff sounds are the sounds of blood flow through the artery as you are listening to blood pressure).
During an observation and interview with LVN 1 on 10/11/2023 at 9:54 AM, LVN 1 rechecked Resident 120's blood pressure on the left upper arm, LVN 1 was asked not to place the stethoscope completely under the blood pressure cuff. LVN 1 stated Resident 120's blood pressure measured was 118/60 mmHg. LVN 1 stated that she will still hold the resident's blood pressure medications.
During an interview with the Director of Nursing (DON) on 10/12/23 at 12:00 PM, the DON stated the licensed nurse should measure the resident's blood pressure by placing the stethoscope over the resident's brachial artery (a major blood vessel supplying blood to the upper arm, elbow, forearm, and hand) to listen to blood flow. The DON stated the license nurse should not put the stethoscope completely under the blood pressure cuff, which will make the cuff too tight, and the blood pressure reading may not be accurate. The DON stated the facility does not conduct in-services or trainings on how to measure residents blood pressure.
A review of the facility's undated policy and procedures titled, Blood Pressure - Prior to Administration of Medications, indicated, Follow procedures for taking blood pressure in Nursing Procedure Manual. Check physician orders for parameters, if ordered, and administer and/or hold medication as per parameters as ordered.
A review of the facility's undated policy and procedures titled, Taking Blood Pressure, indicated, Extend the resident's arm, palm side up. Wrap the cuff . around the upper arm, just above the bend in the elbow. Do not wrap too tightly or too loosely, should be able to insert finger between cuff and skin. Put the stethoscope tips in ears. Hold the bulb in the left hand and place it over the brachial artery (blood vessel in the arm that carries blood from the heart to the arm and hand). Find the resident's pulse by feeling the center of the arm with your fingers, then place the diaphragm of the stethoscope on the resident's arm where you feel the resident's pulse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their policy and procedures (P&P) titled, Medication Administration-General Guidelines, and MedPass, to ensure four (4) out of 10 residents (Residents 94, 46, 24, and 74) observed during medication pass were positively identified prior to medication administration.
This deficient practice had the potential for medication errors and increase of the risk that Residents 94, 46, 24, and 74 would not receive prescribed medications as ordered to meet their needs.
Findings:
a. During an observation on 10/11/2023 at 9:33 AM, with Licensed Vocational Nurse (LVN 1) on Nursing Station 1, LVN 1 was observed preparing and administering to Resident 94's two seizure medications, Levetiracetam 750 mg, one tablet and Aptiom 200 mg, one tablet. Resident 94 was not observed wearing an identification (ID) band. LVN 1 was not observed verifying Resident 94's identity prior to administering the medications to the resident.
A review of Resident 94's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 94's diagnoses included but were not limited to epilepsy (a condition that causes a sudden, uncontrolled shaking or movements).
A review of Resident 94's History and Physical (H&P) dated 11/15/2022, indicated the resident had the capacity to understand and make decisions.
A review of Resident 94's Orders Summary Report active as of 10/1/2023 indicated the following physician's orders:
1. Levetiracetam 750 milligrams (mg - unit of measurement of mass) give one tablet by mouth every 12 hours for seizure disorder, order date 10/12/2020
2. Aptiom 200 mg, give one tablet by mouth two times a day for seizure disorder
During an interview on 10/11/2023 at 1:18 PM with LVN 1, LVN 1 stated for Resident 94, I did not say out loud, but I used his photograph on the eMAR (Electronic Medication Administration Record), and I stated his name. I usually ask his name, but I forgot to ask his name this time.
b. During an observation on 10/11/2023 at 12:04 PM, with LVN 4 on Nursing Station 3, LVN 4 prepared one tablet of Quetiapine 50 mg for Resident 46. LVN 4 entered Resident 46 room, stated the resident's name, and administered the medication to the resident. Resident 46 was not observed wearing an ID band. LVN 4 was not observed verifying Resident 46's identity prior to administering the medications to the resident.
A review of Resident 46's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 46's diagnoses included but were not limited to, Paranoid Schizophrenia (a serious mental disorder in which people interpret reality abnormally).
A review of Resident 46's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 9/2/2023 indicated the resident had moderate cognitive (relating to mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated the resident required supervision and limited assistance for dressing and personal hygiene.
A review of Resident 46's Orders Summary Report active as of 10/1/2023 indicated a physician's order for Quetiapine (a psychotropic [relating to or denoting drugs that affect a person's mental state] medication used to treat some types of mental distress/disorders) 50 mg, give one tablet by mouth three times a day for Paranoid Schizophrenia m/b (manifested by) inability to process internal stimuli causing anger/stress, order date 1/9/2023.
During an interview on 10/11/2023 at 12:15 PM with LVN 4, LVN 4 stated the residents in Nursing Station 3 do not wear identification bands. LVN 4 stated regarding Resident 46, I know the residents for many years. I do not need to identify the residents with another nurse because I know the residents. Usually, we call another nurse to identify them. I know the residents well and do not have to call another nurse.
c. During a medication pass observation on 10/11/2023 between 12:26 PM to 12:48 PM, with LVN 3 on Nursing Station 4, LVN 3 prepared and administered residents' (Resident 24 and Resident 74) medications as follow:
1. On 10/11/2023 at 12:28 PM LVN 3 prepared one tablet of Divalproex (used to treat epilepsy and certain mood disorders, like bipolar disorder [a mental disorder]) 250 mg for Resident 24. LVN 3 entered Resident 24's rooms, stated the resident's name and administered the medication. Resident 24 was not observed wearing an ID band. LVN 3 was not observed verifying Resident 24's identity prior to administering the medication to the resident.
A review of Resident 24's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses including bipolar disorder.
A review of Resident 24's Orders Summary Report active as of 10/1/2023 indicated a physician's order for Divalproex 250 mg, give one tablet by mouth four times a day for bipolar disorder uncontrollable extreme mood swings causing anger interfering with daily living activities, order date 4/21/2023.
A review of Resident 24's H&P dated 4/24/2023, indicated the resident did not have the capacity to understand and make decisions.
2. On 10/11/2023 at 12:40 PM, LVN 3 prepared one tablet of Gabapentin (used for seizures [sudden changes in the body due to unusual brain activity] and nerve pain) 600 mg for Resident 74. LVN 3 entered Resident 74's rooms, stated the resident's name and administered the medication. Resident 94 was not observed wearing an ID band. LVN 3 was not observed verifying Resident 24's identity prior to administering the medication to the resident.
A review of Resident 74's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses including, epilepsy and bipolar disorder.
A review of Resident 74's Orders Summary Report active as of 10/1/2023 indicated a physician's order for Divalproex 250 mg, give one tablet by mouth two times a day for bipolar disorder m/b recurrent fluctuations from depressed behaviors to manic behaviors, order date 9/18/2023.
A review of Resident 24's H&P dated 4/5/2023, indicated the resident did not have the capacity to understand and make decisions.
During an interview on 10/11/2023 at 12:50 PM with LVN 3, LVN 3 stated, that she did not call another nurse to verify Resident 24 or Resident 74's identities prior to administering the medications. LVN 3 stated that she only called each resident by name.
During an interview on 10/12/2023 at 11:53 AM with the Director of Nursing (DON), the DON stated the facility's nurses must use two forms of identification before administering medication to ensure the right resident is receiving the right medication. The DON stated nurses may use the picture of the resident on the electronic Medication Administration Record (MAR) with a second identification method that may include verification with another staff that knows the resident. The DON stated using the resident's picture is not sufficient by itself.
A review of the facility's Policy and Procedures (P&P) titled Medication Administration - General Guidelines, dated 10/2017, indicated, Residents are identified before medication is administered.
A review of the facility's P&P titled MedPass, dated 10/2017, indicated, Make sure that during the course of med pass: The resident is identified by ID band, photo, or by verification with another staff member, resident should NEVER just be called out by name, or asked for name.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent (%) or greater as evidenced by two medication errors out of 25 opportunities for error to yield a medication error rate of 8 percent (%), for one of ten residents (Residents 120) observed during medication administration (Med Pass). The facility failed to ensure Resident 120 was administered blood pressure (BP) medications in accordance with the physician's parameters for medication administration. (Ref. F726)
This deficient practice had the potential for Resident 120 to experience adverse consequences that were not limited to hypertension (high blood pressure), hospitalization, and increase of the risk for a stroke (blood flow to the brain is blocked).
Findings:
A review of Resident 120's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of, hypertension ([HTN] high blood pressure), cerebral atherosclerosis (fat and cholesterol build up in the arteries, or blood vessels, causing the arteries to narrow), and history of transient ischemic attack (when blood supply to part of the brain is briefly interrupted).
A review of Resident 120's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 9/2/2023, indicated the resident had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS indicated Resident 120 needed limited assistance for eating and extensive to total assistance for with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive), dressing, transfer into and out of bed, and toileting.
A review of Resident 120's Orders Summary Report active as of 10/1/23 indicated the following physician's orders:
1. Amlodipine (medication to treat high blood pressure) 5 milligrams (mg - unit of measurement of mass) give one tablet by mouth daily for HTN. Hold if SBP (systolic pressure [SBP], the pressure when the heart beats) is less than 110 mmHg (millimeters of mercury), order date 8/8/2022.
2. Lisinopril (medication to treat high blood pressure) 10 mg, give one tablet by mouth one time a day for HTN. Hold for SBP less than 110 mmHg, order date 8/8/2022.
During a concurrent medication pass observation and interview on 10/11/2023 at 9:41 AM with LVN 1, LVN 1 was observed placing a blood pressure cuff on Resident 120's right arm then placed the stethoscope tips in her ears. LVN 1 completely covered the diaphragm and bell portion of the stethoscope with the blood pressure cuff. LVN 1 stated Resident 120's blood pressure reading (blood pressure is recorded as two numbers, the systolic pressure [SBP], the pressure when the heart beats over the diastolic pressure [DBP], the pressure when the heart relaxes between beats) was 110 mmHg (millimeters of mercury) /60 mmHg. LVN 1 stated that she will hold (not administer) Resident 120's two blood pressure medications.
During a concurrent observation and interview on 10/11/2023 at 9:54 AM with LVN 1, LVN 1 rechecked Resident 120's blood pressure on the left upper arm, LVN 1 was asked not to place the stethoscope completely under the blood pressure cuff. LVN 1 stated Resident 120's blood pressure measured was 118/60 mmHg. LVN 1 stated that she would still hold the resident's blood pressure medications.
A review of the nursing progress notes dated 10/11/2023 documented the following:
- Note Text: Lisinopril Oral Tablet 10 mg, Give 1 tablet by mouth one time a day for HTN. Hold for SBP less than 110. BP (blood pressure) 118/60, per parameter hold medication at this time, will continue to monitor. e-Signed by LVN 1.
- Note Text: Amlodipine Besylate Oral Tablet 5 mg, Give 1 tablet by mouth one time a day for HTN. Hold if SBP less than 110. BP 118/60, hold medication at this time. e-Signed by LVN 1.
During an interview on 10/12/2023 at 12:02 PM with the Director of Nursing (DON), the DON stated she was made aware that Resident 120's blood pressure medication was withheld on 10/11/2023 when the resident's blood pressure medication should have been administered. The DON acknowledged that on 10/11/2023 that Resident 120's SBP was 118 mmHg which was greater than the hold parameter of less than a SBP of 110 mmHg. The DON stated Resident 120 could experience hypertensive episodes (a sudden, severe increase in blood pressure that can lead to a heart attack, stroke, or other life-threatening health problems) if the blood pressure medications were held when the SBP was within the ordered parameter to administer the medications to the resident.
A review of the facility's undated policy and procedure (P&P) titled, Blood Pressure - Prior to Administration of Medications, indicated, Check physician orders for parameters, if ordered, and administer and/or hold medication as per parameters as ordered.
A review of the facility's policies and procedures titled Medication Administration - General Guidelines, dated 10/2017 indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain timely and accurate resident medical records for three of 35 sampled residents (Resident 108, 82, and 148) when:
a. Resident 108's annual Physical Therapy Joint Mobility Screen dated 3/20/2023 was completed on 10/11/2023 (about seven months later).
b. Resident 82's annual Physical Therapy Joint Mobility Screen dated 12/20/2022 and annual Occupational Therapy Joint Mobility Screen dated 12/20/2022 was completed on 10/11/2023 (about 10 months later).
c. Resident 148's annual Physical Therapy Joint Mobility Screen dated 11/4/2022 was completed on 10/11/2023 (about 11 months later).
These deficient practices had the potential for inaccurate medical documentation and reporting of joint range of motion limitations for Residents 108, 82, and 148, which could cause a delay in appropriate interventions.
Findings:
a. A review of Resident 108's admission Record indicated Resident 108 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to osteoarthritis (loss of protective cartilage that cushions the ends of your bones) and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain).
A review of Resident 108's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 9/16/2023, indicated Resident 108 had moderately impaired cognition (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) and usually was able to make herself understood. The MDS also indicated Resident 108 required limited assistance (requires minimal amount of assistance from another person to perform task) with bed mobility, eating, and transfers. The MDS also indicated Resident 108 did not have any impairments in functional limitations in range of motion (ROM, full movement potential of a joint) in both upper and lower extremities.
A review of Resident 108's medical records indicated the annual Physical Therapy Joint Mobility Screen dated 3/20/2023 was completed on 10/11/2023.
During a concurrent record review of Resident 108's Joint Mobility Screen and interview with Physical Therapist (PT 1) on 10/12/2023 at 1:03 PM, PT 1 confirmed the annual Physical Therapy Joint Mobility Screen was dated on 3/20/2023 but was not completed until 10/11/2023. PT 1 stated she completed the Joint Mobility Screen yesterday (10/11/23). PT 1 stated it was standard of practice to complete any medical documentation the day of the assessment to ensure it was accurate. PT 1 stated the Joint Mobility Screen was considered late and had the potential to not be accurate.
b. A review of Resident 82's admission Record indicated resident 82 was admitted to the facility on [DATE] with diagnoses including but not limited to Type 2 Diabetes Mellitus (condition in which the body does not metabolize blood sugar correctly) without complication, hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (stroke-blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right side, osteoarthritis of hip, and muscle wasting and atrophy.
A review of Resident 82's MDS, dated [DATE], indicated Resident 82 had severely impaired cognition and had the ability to express wants. The MDS also indicated Resident 82 required extensive assist (requires significant amount of assistance from another person to perform task) with bed mobility, transfers, dressing, toileting. The MDS indicated Resident 82 had functional limitation in range of motion on one side of the upper extremity and no limitations in both lower extremities.
A review of Resident 82's medical records indicated the annual Physical Therapy Joint Mobility screen dated 12/20/2022 was completed on 10/11/2023 and the annual Occupational Therapy Joint Mobility screen dated 12/20/2022 was completed on 10/11/2023.
During a concurrent record review of Resident 82's annual Physical Therapy Joint Mobility Screen dated 12/20/2022 and annual Occupational Therapy Joint Mobility Screen dated 12/20/2022 and interview with PT 1 on 10/12/2023 at 1:17 PM, PT 1 confirmed both the Physical Therapy Joint Mobility Screen dated 12/20/2022 and the Occupational Therapy Joint Mobility Screen dated 12/20/2022 were completed and signed on 10/11/2023. PT 1 stated the Joint Mobility Screens were considered late and could be inaccurate because of the length of time between assessment date (12/20/2022) and the completion date (10/11/2023).
c. A review of Resident 148's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to hemiplegia affecting left nondominant side, lack of coordination, and difficulty in walking.
A review of Resident 148's MDS, dated [DATE], indicated Resident 148 had intact cognition. The MDS also indicated Resident 148 required extensive assistance with bed mobility, transfers, dressing, and toileting. The MDS also indicated Resident 148 did not have any functional limitations in range of motion of the upper extremities and had impairment on one side of the lower extremity.
A review of Resident 148's medical records indicated the annual Physical Therapy Joint Mobility Screen dated 11/4/2022 was completed on 10/11/2023.
During a concurrent record review of Resident 148's annual Physical Therapy Joint Mobility Screen dated 11/4/2022 with PT 1 on 10/12/2023 at 1:29 PM, PT 1 confirmed the annual PT Joint Mobility Screen dated 11/4/2022 was completed and signed on 10/11/2023. PT 1 confirmed that the Joint Mobility Screen was completed late and could be inaccurate because of the length of time between the assessment date (11/4/2022) and the completion date (10/11/2023).
During an interview on 10/12/2023 at 3:50 PM, the Director of Nursing (DON) stated all documentation should be completed timely so that staff know what the plan of care is for the resident and provide treatment according to the plan of care. The DON stated if staff completed documentation very late, then no one would remember what they had assessed a long time ago and it would not be accurate.
A review of the facility's undated policy and procedures titled, Standards Expected by Rehab Providers, indicated annual screenings and joint mobility assessment are to be completed by licensed therapist.

Based on observation, interview and record review, the facility failed to observe infection control measures by failing to follow the manufactures instructions when using of Micro-kill (a disinfectant cleaning wipe). Two (2) minutes of drying time (the time after the object is cleaned with the disinfectant wipe) was not observed after using a Micro-kill disinfectant wipe on a medication tray and stethoscope (a medical device for listening to internal sounds of an animal or human body) for 1 of 3 sampled residents (Resident 90).
This deficient practice had the potential to result in cross contamination (the process by which bacteria or other microorganisms are transferred from one substance or object to another) between the residents and staff.
Findings:
During an observation and concurrent interview on 10/11/2023 at 10:56 AM with Licensed Vocational Nurse (LVN 3), LVN 3 disinfected a mediation tray and stethoscope with Micro-Kill disinfectant wipes and stated that the contact time (how long the disinfectant needs to stay wet on a surface in order to be effective) for Micro-Kill disinfectant wipes was 30 seconds. Two (2) minutes of drying time was not observed.
During an interview and concurrent review of the manufacture label of Micro-kill disinfectant wipes on 10/11/2023 at 12:57 PM with LVN 5, LVN 5 stated that the manufacture label of Micro-kill disinfectant wipes indicated that the dwell time (the amount of time a disinfectant needs to sit on a surface, without being wiped away or disturbed, to effectively kill germs) is 2 minutes for bacteria and 5 minutes for suspected fungus (any of a group of spore-producing organisms feeding on organic matter, including molds, yeast, mushrooms).
During an interview with the Director of Nursing (DON) on 10/12/2023 at 12:15 PM, the DON stated per the manufacturer label of Micro-Kill disinfected wipes, the correct contact time is 2 minutes. The DON stated if the correct contact time is not observed the area, it would not be completely sanitized or disinfected, which could lead to skin infection, and transmission of disease also could occur. The DON further stated, if not used per the manufacturer label, the wipe may not provide protection from covered microorganisms listed on the containers. The DON also stated the resident may get sick.
A review of the manufacture label of Micro-kill disinfectant wipes with a revision date of 11/18/2022, indicated that the dwell time is 2 minutes at room temperature for bacteria and 5 minutes for fungal organisms.
A review of the facility policy and procedure titled Infection Control, not dated, indicated The Centers of Disease Control (CDC) considers tier 1 precautions as Standard Precautions (minimum infection prevention practices that apply to all patient care, including cleaning and disinfecting environmental surfaces) and this applies to all residents, regardless of known infected status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure joint mobility screens were completed by rehabilitation staff for seven of eight sampled residents (Residents 126, 120, 108, 82, 148, 128, and 15) to monitor joint range of motion (ROM, full movement potential of a joint) in residents at high risk for developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) or worsening current contractures.
These deficient practices had the potential to contribute to worsening contractures and development of contractures and had the potential to prevent Residents 126, 120, 108, 82, 148, 128, and 15 from receiving appropriate services and treatments to address any changes in the residents' joint ROM.
Cross Reference F842
Findings:
a. A review of Resident 126's admission Record indicated Resident 126 initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including but not limited to bilateral primary osteoarthritis of hip (loss of protective cartilage that cushions the ends of your bones on both hips), bilateral primary osteoarthritis of knee, bilateral primary osteoarthritis of left shoulder, muscle wasting and atrophy, multiple sites.
A review of Resident 126's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 8/3/2023 indicated Resident 126 had severely impaired cognition (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) and had the ability to express wants and had the ability to understand others. The MDS indicated Resident 126 required limited assistance (requires minimal amount of assistance from another person to perform task) with bed mobility, extensive assistance (requires significant amount of assistance from another person to perform task) with transfers and dressing and the activity of walking did not occur. The MDS also indicated Resident 126 had no impairment in functional limitation in range of motion (ROM, full movement potential of a joint) in upper and lower extremities.
A review of Resident 126's care plan revised 2/17/2023 indicated Resident 126 had an alternation in joint mobility as evidenced by limitations noted to left lower extremity and left hip. The goal of the care plan indicated to minimize the risk for further loss of range of motion daily. The care plan intervention indicated for initial, quarterly, annual assessment of joint mobility or as needed, provide ROM exercises if ordered, and therapy intervention as indicated.
A review of Resident 126's care plan revised 2/17/2023 indicated Resident 126 was at risk for further unavoidable decline in ROM secondary to polyneuropathy, osteoarthritis, use of geriatric chair and wheelchair as main sources of locomotion. The care plan goal was to minimize the risk for further loss of ROM daily. The care plan interventions included initial, quarterly, annual assessment of joint mobility or as needed.
A review of Resident 126's medical records did not indicate the annual physical therapy joint mobility screen was completed in 2023.
On 10/10/23 at 10:15 AM, during an observation and interview, Resident 126 was sitting up in a geriatric chair geriatric chair (a large, padded chair designed to help persons with limited mobility). Staff member was holding a cup with liquid and brought the cup to the resident's mouth for dependent assist with drinking liquid. Resident 126 was wearing a hospital gown and the resident's left hip was fully bent and knee was bent and leaning to the right side. Resident 126 was able to answer simple questions and able to open and close the right hand, move the right wrist, and lift the right arm up and down a little but not fully. Resident 126 was able to use the right arm and hands to scratch his lower chin.
During an interview on 10/11/2023 at 9:41 AM, Physical Therapist 1 (PT 1) stated it was important for residents who were at risk for contractures or who had contractures to maintain the resident's ROM and manage their current contractures. PT 1 stated if a resident had a loss of ROM, for example in the elbow, it would be harder for the resident to eat or groom themselves and make it more difficult for staff to care for them in bathing and dressing. PT 1 stated it was important for residents to maintain their ROM and to not lose their ROM. PT 1 stated rehabilitation staff completed admission screens and quarterly joint mobility screens.
During a concurrent interview and record review on 10/12/2023 at 12:26 PM, Resident 126's joint mobility screens were reviewed. PT 1 stated an annual physical therapy joint mobility screen was not completed in 2023. PT 1 stated an annual joint mobility screen should have been completed in February 2023.
b. A review of Resident 120's admission Record indicated Resident 120 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (stroke-blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side, aphasia (any loss of ability to understand or express speech, caused by brain damage), and muscle wasting and atrophy (gradual decline).
A review of Resident 120's MDS dated [DATE] indicated Resident 120 had unclear speech, rarely made herself understood, and rarely understood others. The MDS also indicated Resident 120 required extensive assistance with transfers, dressing, and the activity of walking did not occur. The MDS also indicated Resident 120 had impairments in functional range of motion on one side of the upper extremity and one side of the lower extremity.
A review of Resident 120's care plan revised 3/20/2023 indicated resident had limitations in range of motion and contractures related to cerebral vascular accident (blood flow stops to a part of the brain, brain damage due to blocked blood flow), muscle wasting and atrophy. The care plan goal indicated resident would not develop complications related to decreased mobility or contractures and would not decline. The care plan interventions included restorative nursing referral by Rehabilitation Department and Restorative Nursing Treatment.
A review of Resident 120's medical records did not indicate an annual physical therapy joint mobility screen was completed in 2023.
During an observation on 10/11/2023 at 8:23 AM, Resident 120 was lying in bed with eyes closed. Resident 120's left elbow was bent, left wrist was straight, and the left fingers relaxed. Resident 120's right elbow was bent, right wrist slightly bent forward, and right hand was in a fist.
During a concurrent interview and record review on 10/12/2023 at 12:57 PM, Resident 120's joint mobility screens were reviewed. PT 1 stated an annual physical therapy joint mobility screen was not completed in March 2023.
c. A review of Resident 108's admission Record indicated Resident 108 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to osteoarthritis and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain).
A review of Resident 108's MDS dated [DATE] indicated Resident 108 had moderately impaired cognition and usually was able to make herself understood. The MDS also indicated Resident 108 required limited assistance with bed mobility, eating, and transfers. The MDS also indicated Resident 108 did not have any impairments in functional limitations in range of motion in both upper and lower extremities.
A review of Resident 108's care plan revised 4/3/23 indicated Resident 108 was at risk for further unavoidable decline in ROM secondary to osteoporosis (condition in which the bones become brittle) and osteoarthritis. The goal of the care plan indicated to minimize the risk for further loss of ROM daily. The care plan interventions included initial, quarterly, annual assessment of joint mobility or as needed, provide ROM exercises if ordered, and therapy interventions as indicated.
A review of Resident 108's medical records indicated the annual Physical Therapy Joint Mobility Screen dated 3/20/2023 was completed on 10/11/2023.
During an observation and interview in Resident 108's room on 10/11/2023 at 8:27 AM, Resident 108 was sitting up in bed with the head of bed up around 45 degrees. Resident 108 stated she would like to get out of bed and had never used the call light button because she could not reach it. Resident 108 attempted to turn to the left side and reach for the call light with the right arm but was not able to reach it.
During a concurrent record review of Resident 108's Joint Mobility Screen and interview with PT 1 on 10/12/2023 at 1:03 PM, PT 1 confirmed the annual Physical Therapy Joint Mobility Screen dated 3/20/2023 was not completed until 10/11/23.
d. A review of Resident 82's admission Record indicated resident 82 admitted to the facility on [DATE] with diagnoses including but not limited to Type 2 Diabetes Mellitus (a chronic disease that affects how the body processes sugar) without complication, hemiplegia and hemiparesis following cerebral infarction affecting right side, osteoarthritis of hip, and muscle wasting and atrophy.
A review of Resident 82's MDS dated [DATE] indicated Resident 82 had severely impaired cognition and had the ability to express wants. The MDS also indicated Resident 82 required extensive assistance with bed mobility, transfers, dressing, toileting. The MDS indicated Resident 82 had functional limitation in range of motion on one side of the upper extremity and no limitations in both lower extremities.
A review of Resident 82's care plan revised 6/21/2023 indicated Resident 82 was at risk for further unavoidable decline in ROM secondary to hemiplegia and hemiparesis following cerebral infarction affecting unspecified side. The care plan goal indicated to minimize the risk for further loss of ROM daily. The care plan interventions indicated initial, quarterly, annual assessment of joint mobility or as needed, monitor for pain and stiffness.
A review of Resident 82's medical record indicated the annual Physical Therapy Joint Mobility Screen dated 12/20/2022 was completed on 10/11/2023 and the annual Occupational Therapy Joint Mobility Screen dated 12/20/2022 was completed on 10/11/2023.
During an observation and interview in Resident 82's room on 10/10/2023 at 10:45 AM, Resident 82 was laying on the back in bed wearing a hospital gown. Resident 82 stated he did not perform any exercises with staff. Resident 82 was able to move the right arm up a little and was able to open and close the right hand a little and could not fully straighten the third and fourth fingers on the right hand. Resident 82 was able to open and close the left hand, lift the right leg up a little and mov ethe left leg up and down and bend a little at the left hip. Resident 82's knees were straight.
During a concurrent record review of Resident 82's annual Physical Therapy Joint Mobility Screen dated 12/20/2022 and annual Occupational Therapy Joint Mobility Screen dated 12/20/2022 and interview with PT 1 on 10/12/2023 at 1:17 PM, PT 1 confirmed both the Physical Therapy Joint Mobility Screen dated 12/20/2022 and the Occupational Therapy Joint Mobility Screen dated 12/20/2022 were completed and signed on 10/11/2023.
e. A review of Resident 148's admission Record indicated initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to hemiplegia affecting left nondominant side, lack of coordination, and difficulty in walking.
A review of Resident 148's MDS dated [DATE] indicated Resident 148 had intact cognition. The MDS also indicated Resident 148 required extensive assistance with bed mobility, transfers, dressing, and toileting. The MDS also indicated Resident 148 did not have any functional limitations in range of motion of the upper extremities and had impairment on one side of the lower extremity.
A review of Resident 148's care plan revised 11/11/2021 indicated Resident 148 had an alteration in joint mobility as evidenced by limitations noted to left upper extremity and left lower extremity. The care plan goal indicated to minimize the risk for further loss of ROM daily. The care plan intervention included initial, quarterly, annual assessment of joint mobility or as needed, provide ROM exercises if ordered, and therapy intervention as indicated.
A review of Resident 148's medical records indicated the annual Physical therapy Joint Mobility screen dated 11/4/2022 was not completed until 10/11/2023.
During an observation on 10/10/2023 at 2:33 PM, Resident 148 was sitting in a wheelchair outside the activities room. Resident 148 was able to self-propel in the wheelchair using the right leg. Resident 148's left fingers were bent, and the wrist was straight. Resident 148 was able to straighten the left fingers using the right hand. Resident 148's left foot was resting on the wheelchair footrest. Resident 148 was able to move the right arm and leg with no limitations.
During a concurrent record review of Resident 148's annual Physical Therapy Joint Mobility Screen dated 11/4/2022 with PT 1 on 10/12/2023 at 1:29 PM, PT 1 confirmed the annual Physical Therapy Joint Mobility Screen dated 11/4/2022 was completed on 10/11/2023.
f. A review of Resident 128's admission Record indicated Resident 128 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to bilateral primary osteoarthritis of knee, obesity (disorder involving excessive body fat that increased risk for health problems), and chronic pain syndrome (persistent pain that can last weeks to years).
A review of Resident 128's MDS dated [DATE] indicated Resident 128 had intact cognition, required extensive assist with bed mobility, transfers, dressing, and toileting. The MDS also indicated Resident 128 did not have any functional limitations in range of motion in the upper extremities and had limitations on both sides of the lower extremities.
A review of Resident 128's care plan revised 6/5/2023 indicated Resident 128 was at risk for limitations in range of motion and contractures. The care plan goal was to maintain or show improvement in range of motion. The care plan intervention included restorative nursing treatment as ordered.
A review of Resident 128's medical record did not indicate an annual physical therapy joint mobility screen was completed in 2023.
During an observation and interview on 10/10/2023 at 10:52 AM, Resident 128 was sitting up in bed wearing a hospital gown with the head of bed up more than 45 degrees. Resident 128 was holding a personal mirror and putting on makeup. Resident 128 proceeded to put away the mirror and makeup inside the bedside table drawer to the left of the resident. Resident 128 stated she had pain in her knees and shoulders, and it was hard for her to move her legs and walk.
During a concurrent record review of Resident 128's joint mobility screens with PT 1 on 10/12/23 at 1:32 PM, PT 1 confirmed an annual physical therapy joint mobility screen was not completed in May 2023.
g. During a review of Resident 15's admission Record, indicated the facility originally admitted Resident 15 on 2/16/2004, 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]), dysphagia (difficulty swallowing food or liquid) and osteoporosis (a condition in which bones become weak and brittle).
During a review of Resident 15's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 7/13/2023, the MDS indicated Resident 15's cognitive skill for daily decision-making was severely impaired and one-person assist for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene).
During a review of Resident 15's Order Summary Report (OSR), dated 4/1/2021, indicated a physician order to have rehabilitation screening upon admission and quarterly; physical therapy (PT) and occupational therapy (OT) evaluation and treatment as indicated. OSR also indicated on 5/15/2023, an order for restorative nursing assistance (RNA) program for bilateral upper extremity (BUE) passive range of motion (PROM) daily five times a week as tolerated.
During a review of Resident 15's at risk for further unavoidable decline in range of motion (ROM) care plan, revised on 11/1/2022, indicated under interventions that an initial, quarterly and annual assessment of joint mobility or as needed will be provided to Resident 15.
During a review of Resident 15's self-care deficit care plan, revised on 11/1/2022, indicated that rehabilitation screening will be done upon admission, quarterly and as needed will be provided to Resident 15.
During a concurrent observation and interview on 10/10/2023 at 2:21 p.m., with Certified Nursing Assistant 1 (CNA 1), observed Resident 15 sitting on the wheelchair with bilateral legs limitations. CNA 1 stated that Resident 15 was not able to move her (Resident 15) legs.
During an interview on 10/12/2023 at 12:26 PM, PT 1 stated rehabilitation staff's role was to complete quarterly and annual screens on all residents. PT 1 stated the joint mobility screens were completed annually or upon admission. PT 1 stated if rehabilitation staff noted any issues with ROM or mobility, rehabilitation staff could modify the RNA program or add the resident on skilled therapy services. PT 1 stated it was important for rehabilitation staff to monitor residents with contractures to see if they were tolerating their splints and monitor residents to see if their ROM was getting worse, better, or the same. During the same interview PT 1 reviewed Resident 15's rehabilitation joint mobility screening. PT 1 verified and stated Resident 15 had an OT joint mobility screening done on 1/19/2022 and missing PT joint mobility screening since re-admission. PT 1 stated that OT joint mobility should have been done around January 2023. PT 1 stated that Resident 15 had been refusing to do any PT joint mobility screening and she (PT 1) did not document attempts that was provided. PT 1 also stated that Resident 15 has some limitation in bilateral lower extremities (BLE) and not been able to know if Resident 15 had declined in ROM in BLE.
During an interview on 10/12/2023 at 3:36 PM, the Director of Nursing (DON) stated therapy staff were required to complete an assessment for joint mobility so that therapy staff could determine the appropriate intervention such as an RNA program or skilled therapy services. DON stated therapy staff should do the joint mobility assessment quarterly, because therapy staff was the discipline that was appropriate to monitor if there was any difference in the resident's ROM to see if it changed from the prior quarter. DON stated nursing staff was not trained to assess if a joint ROM worsened, was the same, or was better. DON stated nursing staff could see if there were obvious changes such as if a resident was walking and now was not walking, but if there was a contracture in a joint, a nurse could not know if there were changes in the contracture. DON stated that the rehabilitation annual joint mobility screen was not enough to monitor joint mobility ROM changes in residents because the time between the assessments were too long and that it should be completed quarterly.
A review of the facility's undated policy and procedures titled, Joint Mobility Assessment, indicated, the purpose of the joint mobility assessment was to determine a resident's range of motion for all major joints and to implement plans of care to increase, maintain or reduce decline in joint mobility. It also indicated, it is the policy of this facility that all residents shall be assessed for joint mobility limitation in joint mobility upon admission and reviewed every three months thereafter. Physical therapist and/or occupational therapist shall assess each joint for range of motion and document findings on the Joint Mobility Assessment Sheet annually.

Based on observation, interview and record review the facility failed to review and revise a comprehensive person-centered care plan for one of seven sampled residents (Resident 125) by failing to ensure Resident 125's care plan for pain was updated with the specific location for pain.
This deficient practice had the potential to result in negative impact on Resident 125's quality of care and services received.
Findings:
During a review of Resident 125's admission Record, indicated the facility admitted Resident 125 on 3/21/2023, with diagnoses including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), osteoarthritis (inflammation of the bone) and hypertension (HTN - elevated blood pressure).
During a review of Resident 125's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/23/2023, the MDS indicated Resident 125's cognitive skill for daily decision-making was moderately impaired and set up to one-person assist for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene).
During a review of Resident 125's potential for alteration in comfort/pain care plan, revised 6/13/2023, indicated no specific location for pain. Care plan also indicated under interventions to assess characteristics of pain: location, duration, quality, aggravating/alleviating factors, radiation, intensity, and document.
During a concurrent observation and interview with Resident 125 on 10/10/2023 at 2:54 PM, observed Resident 125 lying in bed, unable to move and was moaning. Resident 125 stated he was having too much pain in his lower back.
During a concurrent interview and record review with the Director of Nursing (DON) on 10/11/2023 at 3:25 PM, Resident 125's care plan was reviewed. The DON verified and stated Resident 125 was missing a care plan that was specific for the low back pain. The DON further stated, it should have been updated with the location of the pain. The DON also stated Resident 125 had issues with lower back pain, and needed to be seen by a pain management specialist.
During a review of the facility's policy and procedures (P&P) titled, The Resident Care Plan, reviewed by the on 5/16/2023, indicated, the resident care plan shall be implemented for each resident on admission and developed throughout the assessment process.
During a review of the facility's P&P, titled, Procedure: The Resident Care Plan, reviewed by the facility on 5/16/2023, indicated, Resident care plan provides an individualized nursing care plan that promotes continuity of resident care.
During a review of the facility's P&P, titled, Pain Management, reviewed by the on 5/16/2023, indicated, facility will provide guidelines for the consistent assessment, management, and documentation of pain of resident, in order to provide maximum comfort and quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for one of seven sampled residents (Resident 129) by failing to ensure Resident 129 had a care plan for the diagnosis of basal cell carcinoma of the nose (type of skin cancer [abnormal cell]).
This deficient practice had the potential to result negative impact on Resident 129's quality of care and services received.
Findings:
During a review of Resident 129's admission Record, indicated the facility originally admitted Resident 129 on 10/2/2020 and was re-admitted on [DATE], with diagnoses including basal cell carcinoma of skin nose, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe) and dysphagia (difficulty swallowing food or liquid).
During a review of Resident 129's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/26/2023, the MDS indicated Resident 129's cognitive skill for daily decision-making was severely impaired and with one-person assist for activities of daily livings (ADLs- bed mobility, dressing, toilet use, and personal hygiene).
During a concurrent interview and record review with the Director of Nursing (DON) on 10/12/2023 at 9:45 AM, Resident 129's care plan was reviewed. DON verified and stated Resident 129 was missing a care plan specific for the basal cell carcinoma of the nose. DON stated that care plan should be develop, and updated specific on resident's care areas and needs.
During a review of the facility's policy and procedures (P&P) titled, The Resident Care Plan, reviewed on 5/16/2023, P&P indicated that the resident care plan shall be implemented for each resident on admission and developed throughout the assessment process.
During a review of the facility's P&P, titled, Procedure: The Resident Care Plan, reviewed on 5/16/2023, P&P indicated that Resident care plan provides an individualized nursing care plan that promotes continuity of resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess and code the functional limitations in joint range of motion (ROM, full movement potential of a joint) and locomotion (how a resident moves between locations) for one of 35 sampled residents' (Resident 126) Minimum Data Set assessment (MDS, a standardized assessment and care-screening tool).
This deficient practice had the potential to cause inaccurate care planning and inadequate provision of rehabilitation and nursing services for Resident 126.
Findings:
A review of Resident 126's admission Record indicated Resident 126 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to bilateral primary osteoarthritis of hip (loss of protective cartilage that cushions the ends of your bones on both sides of the hip), bilateral primary osteoarthritis of knee, bilateral primary osteoarthritis of left shoulder, muscle wasting and atrophy, multiple sites.
A review of Resident 126's MDS dated [DATE] indicated Resident 126 had severely impaired cognition (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) and had the ability to express wants and had the ability to understand others. The MDS indicated, in Section G for Functional Status, Resident 126 required limited assistance (resident is highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person for locomotion on unit (how a resident moves between locations in his/her room. If in wheelchair, self-sufficiency once in chair) and limited assistance of one person for locomotion off unit (how resident moves to and returns from off-unit locations (i.e. areas set aside for dining, activities or treatments), if in wheelchair, self-sufficiency once in chair). The MDS also indicated Resident 126 had no impairment in functional limitation in range of motion in both the upper and lower extremities.
A review of Resident 126's Order Summary Report dated 9/25/2023 indicated a physician's order dated 5/15/23 to begin Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) for active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) with both upper extremities (BUE, shoulder, elbow, wrist, hand) across all 3 planes as tolerated once a day five times a week. The Order Summary Report also indicated a physician's order dated 3/31/23 for RNA program for PROM exercise on both lower extremities (BLE, hip, knee, ankle, feet) once a day five times a week as tolerated.
A review of Resident 126's care plan revised 2/17/2023 indicated Resident 126 had an alteration in joint mobility as evidenced by limitations noted to left lower extremity and left hip. The goal of the care plan indicated to minimize the risk for further loss of range of motion daily. The care plan intervention included staff to not force movement of joints and do not move resident by contracted limbs (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and to position the resident to prevent further contractures with pillow or splints as needed.
A review of Resident 126's care plan revised 2/17/2023 indicated Resident 126 had self-care deficits and resident required up to extensive assistance with ADLs. The care plan goal indicated to minimize the risk of decline daily. The care plan intervention included for staff to assist with ADLs as needed.
On 10/10/2023 at 10:15 AM, during an observation and interview, Resident 126 was sitting up in a geriatric chair (a large, padded chair designed to help persons with limited mobility) that was stationary. A staff member was holding a cup with liquid and brought the cup to Resident 126's mouth for dependent assistance with drinking the liquid. Resident 126 was wearing a hospital gown and the resident's left hip was fully bent and knee was bent and leaning to the right side. Resident 126 was able to answer simple questions and able to open and close the right hand, move the right wrist, and lift the right arm up and down a little but not fully. Resident 126 was able to use the right arm and hands to scratch his lower chin. Resident 126 did not move the left arm.
On 10/10/2023 at 12:11 PM, during an observation of Resident 126 in the dining room, Resident 126 was sitting in a geriatric chair and staff fed Resident 126 lunch. Resident 126 did not attempt to feed himself and required full staff assist to eat and drink food for lunch.
On 10/11/2023 at 2:02 PM, during an interview with Licensed Vocational Nurse (LVN 2), LVN 2 stated Resident 126 was on RNA program for feeding and ROM. LVN 2 stated that Resident 126 could not move around or get around on his own and required a geriatric chair. LVN 2 stated that Resident 126's legs were contracted.
On 10/12/2023 at 9:33 AM, during an observation, interview, and concurrent record review of Resident 126's MDS assessment dated [DATE], with Minimum Data Set Nurse (MDS 1), MDS 1 stated it was important for an MDS assessment to be accurate because the MDS assessment represented what the resident was capable of doing and the type of care the resident received at the facility. MDS 1 reviewed Resident 126's MDS dated [DATE] and stated Resident 126 was coded as requiring limited assistance with locomotion on unit and off unit. MDS 1 stated that locomotion meant if the resident was using a wheelchair or geriatric chair and if the resident could move the WC or geriatric chair on their own but not the whole distance, then it was considered limited assistance. MDS 1 stated Resident 126 was bedbound. MDS 1 stated that Resident 126 could not assist at all in moving the geriatric chair and required staff to fully assist pushing him in the geriatric chair from one place to another. MDS 1 stated the MDS dated [DATE] for locomotion on unit and off unit was coded and assessed incorrectly.
During the same observation, interview, and record review, MDS 1 stated the MDS dated [DATE] indicated that Resident 126 had no functional limitations in ROM in either upper or lower extremities. MDS 1 subsequently went to Resident 126's room. Resident 126 was sitting up in a geriatric chair and there was a pillow underneath Resident 126's left arm and elbow. Resident 126's left hand was in a fist, both legs were bent and crossed over each other. MDS 1 attempted to straighten Resident 126's left fingers and stated the left fingers could not fully open. MDS 1 attempted to straighten Resident 126's left knee but Resident 126 stated he had pain and MDS 1 could not straighten Resident 126's left knee. MDS 1 stated he would not move Resident 126's left leg anymore due to pain. MDS 1 stated that in the case where a resident had difficulty moving a resident's extremities, the MDS nurse would refer to the rehabilitation department and their joint mobility screen to indicate if there were any range of motion limitations.
On 10/12/2023 at 10:36 AM, during an interview with Minimum Data Set Coordinator (MDS 3), MDS 3 stated Resident 126 should not have been coded as limited in locomotion because the resident could not move himself in the geriatric chair. MDS 3 stated Resident 126 should have been coded as an impairment in range of motion in the extremities because the limited range of motion in the legs prevented Resident 126 from walking. MDS 3 stated it was important for the MDS assessments to be accurate because it affected the care planning and the services the resident was provided at the facility. It also ensured that the staff were all on the same page regarding the resident's care and address any resident needs.
On 10/12/2023 at 12:26 PM, during an interview with Physical Therapist (PT 1), PT 1 stated Resident 126 had contractures in the left leg for a while now and Resident 126 could not self-propel or try to move himself in a geriatric chair.
On 10/12/2023 at 3:36 PM, during an interview with the Director of Nursing (DON), the DON stated Resident 126 had contractures in his upper and lower extremities and was not able to move himself in the geriatric chair. DON stated that Resident 126's MDS was assessed and coded incorrectly for locomotion on and off the unit and for functional limitations in range of motion.
A review of the facility's undated policy and procedures titled, Resident Assessment, indicated the completion of the MDS will be completed as per the RAI instructions/guidelines and accuracy of transcription of the data and computer data entry are important and special attention must be given to correct these errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a clean, safe, and sanitary environment and a building in good repair when:
1. Holes were found on wall and window screen in residents' rooms.
2. One handrail in hallway was found loose with loosing and missing screw.
These deficient practices had the potential to result in incidents from loose handrails and pest invasion from a hole in the window screen.
Findings:
1. A review of Resident 93's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and tobacco use (smoking).
A review of Resident 93's Minimum Data Set (MDS- a standardized screening and assessment tool for nursing house residents), dated 7/24/2023, indicated the resident's cognition (the process of knowing in the broadest sense, including perception, memory, and judgment) was intact. Resident 93 required supervision and setup help only assistance for bed mobility, transfer, dressing, eating, toilet use and person hygiene.
During an observation on 10/10/23 at 11:53 AM, there were holes observed in wall between the mirror and paper towel dispenser in Resident 93's bathroom.
A review of Resident 649's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia, mood disorder and sepsis (body's extreme reaction to an infection).
The MDS for Resident 649 was not available for review as the resident was newly admitted .
During a concurrent observation and interview on 10/10/23 at 12:24 PM, a sizable hole was observed on the window screen in Resident 649 room. Resident 649 stated he felt cold during the night.
During a concurrent observation and interview the Maintenance Supervisor (MS) on 10/11/23 at 1:55 PM, the MS confirmed the holes in the wall between the mirror and paper towel dispenser in Resident 93's bathroom. The MS stated the holes were from the soap dispenser that was pulled off and no staff had reported this to him. The MS further stated insects could come in the room from the holes in the wall.
During a concurrent observation and interview on 10/11/23 at 1:58 PM, the MS confirmed the sizable hole on window screen in Resident 649's room. The MS further stated, if not fixed, ants could come into the room from the hold in window screen.
2. During a concurrent observation and interview with Environmental Services staff 1 (ES 1) on 10/13/23 at 8:50 AM, the handrail in the hallway nearby station four (4) drinking fountain was observed as loose with one missing screw and one loose screw which anchored the handrail to wall. ES 1 confirmed and stated the handrail was loose. ES 1 then attempted to push the loosing screw back in place. ES 1 stated she will report the issue [loose handrail] to the MS.
During a concurrent observation and interview with the MS on 10/13/23 at 10 :34 AM, the MS stated he was checking on all handrails and would fix them.
A review of the facility's policy and procedures titled Maintenance Service, revised 2009, indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment .2. Functions of maintenance personnel include but are not limited to .b. maintaining the building in good repair and free from hazard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide proper feeding tube care as per manufacturer's instructions related to dilution of Pro-Stat (Protein supplement for wound healing) before administration through a gastrostomy tube (]G-tube] a tube inserted through the belly that brings nutrition directly to the stomach) and sufficient water flush after administration for one of one resident (Resident 90) observed with a G-tube during medication pass (medication administration).
Finding:
A review of Resident 90's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included non-pressure chronic ulcer (an open sore on the skin) of right ankle, severe protein-calorie malnutrition, and gastrostomy status.
A review of Resident 90's History and Physical dated 8/21/2023 indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 90's Medication Administration Record (MAR) for the months of 8/2023, 9/2023, and 10/2023 indicated Resident was administered Pro-Stat daily from 8/21/2023 through 10/11/2023.
A review of Resident 90's Order Summary Report dated 9/25/2023 and signed 9/27/2023, indicated orders for Pro-Stat Sugar Free Oral Liquid with instructions to give 30 ml via G-tube one time a day for wound healing, physician orders dated 8/21/2023, with order to discontinue on 9/6/2023. Resident 90's order for Pro-Stat was renewed on 9/6/2023. There were no instructions on Resident 90's orders dated 8/21/2023 and 9/6/2023 to mix the Pro-Stat with 30 to 60 ml of water prior to G-tube administration or to flush the G-tube with 30 to 60 ml of water before and after the administration of Pro-Stat.
During an observation on 10/11/2023 at 10:05 AM, Licensed Vocational Nurse 3 (LVN 3) was observed preparing to administer Resident 90's medications that included Pro-Stat Liquid Protein through the resident's G-tube. LVN 3 washed her hands, donned gloves, after checking Resident 90's G-tube placement, LVN 3 attached the syringe into the G-tube flushed the G-tube with 30 milliliters (ml) of water, then poured the 30 ml of Pro-Stat directly into the syringe. LVN 3 flushed the G-tube with 10 ml of water before administering the next medication to Resident 90.
During an interview on 10/11/2023 at 11:06 AM with LVN 3, LVN 3 reviewed Pro-Stat manufacturer's label that indicated:
1. Flush G-tube with 30 ml water
2. Pour one fluid ounce (fl oz, a unit of volume) or 30 ml of Pro-Stat into a four (4) to six (6) fl oz container
3. Add one (1 fl oz = 30 ml) to two (2 fl oz = 60 ml) fl oz of water and mix well
4. Administer Pro-Stat via syringe
5. Flush with 30 to 60 ml of water
LVN 3 stated that she did not mix Pro-Stat with water before administration through the G-tube and she should have. LVN 3 stated she did not flush Resident 90's G-tube with 30 to 60 ml of water after administering the Pro-Stat and only flushed with 10 ml of water. LVN 3 stated she was not aware of the water requirements for administering Pro-Stat through the G-tube.
During an interview on 10/12/2023 at 12:09 PM with the Director of Nursing (DON), DON stated she was not aware how Pro-Stat was to be administered through the G-tube. DON stated the directions for Pro-Stat will be changed to mix with 30 ml of water and to follow the manufacturer's instructions.
A record review of a facility's undated policy (P&P) and procedure titled Policy & Procedure: Med Pass, indicated, Supplements: Adequate fluids are to be supplied with medications and supplements.
A record review of a facility's P&P titled Physician Orders and Telephone Orders dated 1/2004, indicated, All orders must be specific and complete with all necessary details to carry out the prescribed order without any questions.

Based on interview, and record review, the facility failed to immediately seek advanced medical level of care for one of three sampled residents (Resident 1) after the facility identified Resident 1 with significant change of condition (COC - a deterioration in health, mental, or psychosocial status in either life-threatening circumstances or clinical complications) on 4/29/2023 at 7 a.m. in accordance with the facility's policy and procedures, titled Change of Condition, revised on1/24/2017.
This deficient practice resulted in three hours delayed care with the potential for acute (sudden onset) respiratory distress for Resident 1.
Findings:
A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 10/26/2022 with diagnoses including chronic obstructive respiratory disease (a group of diseases that cause airflow blockage and breathing related problems), hypertension (HTN-elevated blood pressure) and schizophrenia (a serious mental disorder in which people interpret reality abnormally).
A review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 1/29/2023, indicated Resident 1 had impaired cognitive skills (the mental ability to make decisions of daily living). The MDS indicated Resident 1 required limited staff assist with transfers, dressing, toilet use and is independent with dressing, and bed mobility and eating.
On 5/3/2023 at 9:25 a.m., during an interview, LVN 2 stated he was familiar with Resident 1 and that he provided care to the resident on 4/29/2023. LVN 2 stated if a resident developed a COC, he would notify the nursing supervisor and monitor resident. LVN 2 stated, on 4/29/2023, he noticed Resident 1's face was swollen when he was administering morning medications to Resident 1. LVN 2 stated, I don't remember which side, and that he notified the nursing supervisor right away and continued to monitor Resident 1.
On 5/2/2023 at 9:35 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated she was familiar with Resident 1 and that she provided care to Resident 1 on 4/29/2023. CNA 1 stated that on 4/29/2023, she started her shift at 7 a.m. and that Resident 1 was in the dining room. CNA 1 further stated noticed that Resident 1's face was swollen. CNA 1 stated Resident 1 told her No when she asked him if he was in any pain. CNA 1 stated Resident 1 did not appear to have any trouble breathing, and that she immediately notified Licensed Vocational Nurse 2 (LVN 2) at about maybe 7:30 a.m. about the swelling on Resident 1's face. CNA 1 stated Resident 1 picked up his breakfast tray which he does every day, went to his room, and ate his ate 100 percent (%). CNA 1 stated she later showered Resident 1 at around 9 a.m. on 4/29/2023, and Resident 1's face swelling had not changed since the start of the shift. CNA 1 stated around 11 a.m. on 4/29/2023, she heard Resident 1 was going to the hospital and that Resident 1's face swelling, has become a little bit more. CNA 1 stated during an inservice, she was instructed to care of the resident, don't ignore.
On 5/2/2023 at 11:50 a.m., during a concurrent interview and record review with Registered Nurse Supervisor (RNS), the RNS stated Resident 1, has never had this type of reaction (swollen face) before. He has no history of medication/food allergies. The RNS stated Resident 1's reaction was from an unknown agent and that Resident 1, should have been referred to the hospital, I should have called 911. There are different types of reactions, some may be meals, others may cause respiratory response.
On 5/3/2023 at 10:05 a.m., during a telephone interview, the primary medical doctor (PMD) stated the facility notified him of the incident with Resident 1 that happened on 4/29/2023. The PMD stated he ordered Benadryl and to transfer Resident 1 to the hospital for further evaluation. The PMD further stated he ordered Resident 1 to be transferred to the hospital because, I was concerned about the [Resident 1] breathing and the resident going into distress. That's the thing we have to address right away. Benadryl is to bring down the swelling due to allergic reaction could be from anything.
A review of the facility's policy and procedures, titled Change of Condition, revised on1/24/2017, indicated, the purpose for the policy is to ensure proper assessment and follow through for any resident with a change in condition . if no physician is available, arrangements are to be made for physician services that may include transfer to ER for appropriate care.