Ararat Nursing Facility

Based on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) was maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:1. Ensure Registered Nurse (RN) 1 documented the level of care provided to Resident 1 while the resident was in the facility. RN 1 documented the level of care and assessment she provided to Resident 1 on 2/10/2026. Resident 1 had a change of condition (COC) on 2/9/2026.2. Ensure social service staff documented the level of care provided to Resident 1 while the resident was in the facility. Social service staff documented Resident 1 was transferred to the General Acute Care Hospital (GACH) 1 on 2/9/2026. Resident 1 was transferred to GACH 1 on 2/10/2026. 3. Ensure Licensed Vocational Nurse (LVN) 1 documented the Tylenol oral tablet (a medication taken by mouth used to temporarily relieve minor aches, pain, and reduce fever) 650 milligrams (mg - unit of measurement) given to Resident 1 in the resident's medication administration record (MAR).These deficient practices resulted in incomplete and inaccurate information on Resident 1's medical records and had the potential for delayed medical interventions.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 3/3/2025 with diagnoses including age-related osteoporosis (a disease that makes bones thin, weak, and brittle, increasing the risk of fractures [broken bones]), unspecified dementia (a decline in brain function including memory, language, reasoning, and behavior severe enough to interfere with daily life but the specific type had not been identified), and essential hypertension (high blood pressure that is not due to another medical condition). During a review of Resident 1's Physician Orders, dated 3/3/2025, the Physician Orders indicated Tylenol oral tablet 325 mg, give two tablets every four hours as needed for mild pain or general discomfort. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was severely impaired. During a review of Resident 1's COC Evaluation, dated 2/9/2026, the COC Evaluation indicated Resident 1 complained of right hip pain. The COC Evaluation indicated Resident 1 was given Tylenol for the right hip pain. The COC Evaluation indicated on 2/9/2026 at 2:45 p.m., Resident 1's Attending Physician (MD) 1 was notified and ordered a right hip x-ray (a medical imaging that uses radiation to take pictures of the inside of a body). During a review of Resident 1's COC Evaluation, dated 2/10/2026, the COC Evaluation indicated the facility received Resident 1's x-ray results. The COC Evaluation indicated on 2/10/2026 at 8:05 a.m., Resident 1's Attending Physician (MD) 1 was notified and ordered to transfer the resident to GACH 1. During an interview on 2/24/2026 at 3:15 p.m., and concurrent record review of Resident 1's Progress Notes, dated 2/9/2026 to 2/10/2026, reviewed with RN 1, RN 1 stated she assessed Resident 1 after the resident's COC on 2/9/2026. RN 1 stated Resident 1's Progress Notes indicated she documented her assessment of the resident's COC on 2/10/2026. RN 1 stated Resident 1's Progress Notes did not indicate the assessment documented on 2/10/2026 was a late entry for the assessment done on 2/9/2026. RN 1 stated the documented assessment on Resident 1's Progress Notes was not timely and was not accurate. RN 1 stated Resident 1's Progress Notes, dated 2/10/2026, indicated social services documented the resident was transferred to GACH 1 on 2/9/2026. RN 1 stated Resident 1 was transferred to GACH 1 on 2/10/2026. RN 1 stated the social services documentation on Resident 1's transfer to GACH 1 was inaccurate. RN 1 stated on 2/9/2026, she witnessed LVN 1 giving Resident 1 two tablets of Tylenol 325 mg. RN 1 stated there was no documented evidence on Resident 1's MAR, dated 2/1/2026 to 2/28/2026, that Resident 1 received two tablets of Tylenol 325 mg on 2/9/2026. During an interview on 2/25/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated RN 1 did not timely document Resident 1's assessment after the COC on 2/9/2026. The DON stated Resident 1's Progress Notes, dated 2/10/2026, should indicate RN 1's documented assessment was a late entry for 2/9/2026. The DON stated Resident 1 was transferred to GACH 1 on 2/10/2026. The DON stated the social services documentation should indicate the correct date of Resident 1's transfer to GACH 1. The DON stated inaccurate documentation had the potential to cause confusion amongst the care team that may negatively affect resident care. The DON stated inaccurate documentation of Resident 1's transfer to GACH 1 had the potential to cause confusion on the resident's 7-day bed hold. The DON stated Resident 1's MAR did not indicate the two tablets of Tylenol 325 mg were given to Resident 1 on 2/9/2026. The DON stated another licensed nurse may give another dose of Tylenol that may potentially cause Resident 1 to overdose. The DON stated the facility failed to provide safe care to Resident 1 by failing to document the resident assessment timely. The DON stated the facility failed to document accurately the date Resident 1 was transferred to GACH 1. The DON stated the facility failed to ensure the pain medication given to Resident 1 was documented in the resident's MAR. During a review of the facility's policy and procedure (PnP) titled, Documentation - Nursing, last reviewed on 1/26/2026, the PnP indicated the purpose to provide documentation of resident status and care given by nursing staff. The PnP indicated . F. nurse's notes are dated, timed, and signed when written. H. medication administration records and treatment administration records are completed with each medication or treatment completed. K. documentation will be completed by the end of the assigned shift. During a review of the facility's PnP titled, Medication - Administration, last reviewed on 1/26/2026, the PnP indicated the purpose to provide standards for safe administration of medications for residents in the facility. The PnP indicated the time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment. During a review of the facility's PnP titled, Completion & Correction, last reviewed on 1/26/2026, the PnP indicated the purpose to ensure that medical records are complete and accurate. The PnP indicated . II. entries will be recorded promptly as the events or observations occur, III. Entries will be complete, legible, descriptive and accurate. V. when adding an entry at a later date, the entry is to be clearly identified as a late entry, late entries should be documented as soon as possible. VII. Documentation will reflect medically relevant information concerning the resident and will be documented in a professional manner.

Based on observation, interview, and record review, the facility failed to ensure confidential personal information for one of four sampled residents (Resident 4) was protected. The medical records of Resident 4 were left unattended on the medication cart computer. This deficient practice had the potential to violate Resident 4's rights for privacy and confidentiality of personal and medical records.Findings: During a review of Resident 4's admission Record (undated), the admission Record indicated the facility admitted the resident on 2/19/2026 with diagnoses including atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls), gastroesophageal reflux disease (a condition in which the stomach contents leak backward from the stomach into the esophagus [the tube connecting the mouth and stomach]), and age-related osteoporosis (a disease that makes bones thin, weak, and brittle, increasing the risk of fractures [broken bones]). During an observation on 2/25/2026 at 9:58 a.m., observed the medication cart computer at nurse station 1 was open with Resident 4's medical record on the computer screen. Resident 4's visible medical records included the resident's name, picture, and medication list. Observed facility staff walked past the medication cart computer with Resident 4's medical information on it. During a concurrent observation and interview on 2/25/2026 at 10:02 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 4's medical records were observed on the medication cart computer. LVN 2 stated she did not lock the medication cart computer before she left to assist another resident. LVN 2 stated Resident 4's medical information was visible to the people walking on station 1 hallway. LVN 2 stated Resident 4's medical records left unattended had the potential to violate resident confidentiality. During an interview on 2/25/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated Resident 4's medical records should not be left unattended. The DON stated facility staff not involved in Resident 4's care, other residents, and visitors had the potential for unauthorized access to Resident 4's medical records. The DON stated the facility failed to ensure private information in Resident 4's medical records was safe from unauthorized access. During a record review of the facility's policy and procedure (PnP) titled, General Provisions, last reviewed on 1/26/2026, the PnP indicated protected health information contained in the record is confidential and will only be released accordance with the facility's HIPPA policies. The PnP indicated active records are to be located in an area not accessible to unauthorized persons.

Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1) was created and implemented. The facility failed to develop and implement an individualized care plan with interventions addressing Resident 1's change of condition (COC) on 2/9/2026. This deficient practice had placed Resident 1 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition such as worsening of Resident 1's right hip fracture and pain.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 3/3/2025 with diagnoses including age-related osteoporosis (a disease that makes bones thin, weak, and brittle, increasing the risk of fractures [broken bones]), unspecified dementia (a decline in brain function including memory, language, reasoning, and behavior severe enough to interfere with daily life but the specific type had not been identified), and essential hypertension (high blood pressure that is not due to another medical condition). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was severely impaired. During a review of Resident 1's COC Evaluation, dated 2/9/2026, the COC Evaluation indicated Resident 1 complained of right hip pain. The COC Evaluation indicated Resident 1 was given Tylenol for the right hip pain. The COC Evaluation indicated on 2/9/2026 at 2:45 p.m., Resident 1's Attending Physician (MD) 1 was notified and ordered a right hip x-ray (a medical imaging that uses radiation to take pictures of the inside of a body). During an interview on 2/24/2026 at 3:15 p.m., and concurrent record review of Resident 1's Care Plans, reviewed with Registered Nurse (RN) 1, RN 1 stated Resident 1 complained of right hip pain on 2/9/2026. RN 1 stated there was no care plan created for Resident 1's COC on 2/9/2026. RN 1 stated a care plan should be initiated to address Resident 1's right hip pain. RN 1 stated if Resident 1's care plan was not created, the facility staff will not be aware of the interventions to address the resident's COC. During an interview on 2/25/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated a care plan was a list of care and services to be provided for the residents. The DON stated a care plan should be created after Resident 1's COC on 2/9/2026. The DON stated Resident 1 did not have a care plan that included Resident 1's right hip pain. The DON stated Resident 1's care had the potential to lack interventions to prevent further injuries and manage the resident's pain. The DON stated the facility failed to ensure Resident 1 had a care plan after the resident's COC on 2/9/2026 that addressed the resident's right hip pain. During a review of the facility's policy and procedure (PnP) titled, Care Planning, last reviewed on 1/26/2026, the PnP indicated the purpose to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The PnP indicated each resident's comprehensive care plan will describe the. services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. During a review of the facility's PnP titled, Change of Condition Notification, last reviewed on 1/26/2026, the PnP indicated a licensed nurse will. update the Care Plan to reflect the resident's current status.

Based on interview and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 1) by failing to:1. Ensure licensed nurses monitored Resident 1's medical status after the resident's change of condition (COC) on 2/9/2026. Resident 1's COC status was not monitored on 2/9/2026, 11 p.m. to 7 a.m. shift.2. Ensure Registered Nurse (RN) 1 assessed Resident 1's right lower extremity after the resident complained of right hip pain. These deficient practices had the potential to place Resident 1 at risk for undetected and worsening medical conditions which could negatively impact the residents' health and safety.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 3/3/2025 with diagnoses including age-related osteoporosis (a disease that makes bones thin, weak, and brittle, increasing the risk of fractures [broken bones]), unspecified dementia (a decline in brain function including memory, language, reasoning, and behavior severe enough to interfere with daily life but the specific type had not been identified), and essential hypertension (high blood pressure that is not due to another medical condition). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was severely impaired. During a review of Resident 1's COC Evaluation, dated 2/9/2026, the COC Evaluation indicated Resident 1 complained of right hip pain. The COC Evaluation indicated Resident 1 was given Tylenol for the right hip pain. The COC Evaluation indicated on 2/9/2026 at 2:45 p.m., Resident 1's Attending Physician (MD) 1 was notified and ordered a right hip x-ray (a medical imaging that uses radiation to take pictures of the inside of a body). During an interview on 2/24/2026 at 3:15 p.m., and concurrent record review of Resident 1's medical records, reviewed with RN 1, RN 1 stated Resident 1's COC Evaluation, dated 2/9/2026, indicated on 2/9/2026 at 2:40 p.m., Resident 1 complained of right hip pain. RN 1 stated Resident 1's COC should be monitored every shift for 72 hours. RN 1 stated Resident 1's Progress Notes indicated there was no documented evidence that the resident was monitored on 2/9/2026 (11 p.m. to 7 a.m. shift). RN 1 stated she did not document her full assessment of Resident 1's right lower extremity on the resident's Progress Notes. RN 1 stated a resident care that was not documented was considered as not done. RN 1 stated incomplete documentation of Resident 1's health status had the potential for the resident's health condition to worsen. During an interview on 2/25/2026 at 3:30 p.m. with the Director of Nursing (DON), the DON stated Resident 1 should be monitored every shift for at least 72 hours after the resident's COC. The DON stated there was no documented evidence that Resident 1 was monitored on 2/9/2026, 11 p.m. to 7 a.m. shift. The DON stated RN 1 did not document the assessment done on Resident 1's lower extremities that included pain on palpation and the appearance of the right lower extremity. The DON stated that if resident care was not documented it meant the resident care was not done. The DON stated not assessing and monitoring the resident after a COC had the potential for the resident's progress or decline to be missed. The DON stated the facility failed to provide safe resident care by failing to ensure Resident 1 was assessed and monitored after a COC. During a review of the facility's policy and procedure (PnP) titled, Change of Condition Notification, last reviewed on 1/26/2026, the PnP indicated the licensed nurse will assess the resident's change of condition and document the observations and symptoms. The PnP indicated a licensed nurse will document the. date, time, and pertinent details of the incident and the subsequent assessment in the nursing notes. The PnP indicated a licensed nurse will document each shift for at least seventy-two (72) hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had a history of multiple falls in the facility (12/20/2024 and 9/30/2025) and required partial/moderate assistance (helper does less than half the effort) from facility staff with bed mobility (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), remained free from accidents by failing to:1. Initiate the facility's Falling Star Program (a resident safety initiative that uses a visual symbol, like a falling star, to identify residents at high risk for falls in healthcare settings) on 6/24/2025 when Resident 1 was identified as being at higher risk for falls following a fall incident on 12/20/2024. A fall risk assessment was completed for Resident 1 on 12/20/2024, however Resident 1 was not added to the facility's Falling Star Program until 11/1/2025 (nearly one year later).2. Ensure Certified Nurse Assistant (CNA) 1 requested additional support from another facility staff when providing morning care (changing bed linens and resident's incontinence briefs (disposable, underwear designed for managing bladder or bowel incontinence [having no or insufficient voluntary control over urination or defecation]) to Resident 1 on 11/1/2025. These deficient practices resulted to Resident 1's fall on 11/1/2025 at 6:15 a.m., during morning care, when CNA 1 rolled Resident 1 to her (Resident 1) left side of the bed and Resident 1, unable to hold self (Resident 1) on the side of her bed, fell to the floor. Resident 1 sustained a laceration (a deep cut or tear in the skin) on the left eyebrow, skin tear (wounds caused by friction or shear that separates skin layers) on the left forehead, skin tear on the left wrist, and bleeding. Registered Nurse (RN) 4 cleaned the laceration site with normal saline (a sterile solution used to clean and treat wounds) and applied a dressing (a pad or cover applied to an injury or wound to protect it, promote healing and prevent infection) to control the bleeding. Resident 1 complained of headache with level of three (mild pain) out of 10 on the numeric pain rating scale (a pain assessment tool that uses a scale ranging from zero [0 - no pain] to 10 [worst pain imaginable], to quantify pain intensity). RN 4 administered Tylenol (a brand of medication used to treat mild to moderate aches and pains) 325 milligrams (mg - unit of measurement) two (2) tablets to Resident 1 on 11/1/2025 at 6:15 a.m. On 11/1/2026 at 7:19 a.m., the facility transferred Resident 1 to the General Acute Care Hospital (GACH) for further evaluation due to head injury where Resident 1 received seven (7) sutures (sterile medical devices (threads and needles) used to hold body tissues together after injury) on the left eyebrow laceration. 3. Ensure Resident 1's bilateral floor mats (high-impact, shock-absorbing pads placed beside beds to minimize injury from falls, fractures, and head trauma) were placed next to Resident 1's bed.4. Ensure facility staff completed Resident 1's Fall Risk Assessment after Resident 1 had an episode of fall on 11/1/2025. 5. Ensure Resident 1's Care Plan was revised after Resident 1's fall incident on 12/20/2025. These deficient practices had the potential to increase the chances of Resident 1 incurring accidents such as falls with injury.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 6/27/2019 and readmitted on [DATE] with diagnoses including chronic diastolic (congestive) heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), right shoulder rotator cuff tear or rupture (damage to the muscles/tendons, causing pain, weakness, and limited motion), wedge compression fracture (a type of spinal injury where the front part of a vertebra [the individual bones of the spine] collapses while the back remains intact, causing the bone to take on a wedge shape) of T11-T12 vertebra sequela (the long-term or lasting effects resulting from a previous injury to the eleventh [11th] and twelfth [12th] thoracic vertebrae), and muscle weakness. During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 7/1/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Fall Risk Assessment form, dated 12/20/2024, the Fall Risk Assessment form indicated Resident 1 had a fall risk score of 28 (a total score above 10 represents a high risk for falls). During a review of Resident 1's Interdisciplinary (or Interdisciplinary Team [IDT] - is a collaborative, team-based approach where professionals from different specialties work together to create and implement a single, unified, and comprehensive care plan for a resident) Care Conference Review form, dated 12/20/2024, the IDT Care Conference Review form indicated that on 12/20/2024 Resident 1 had an episode of fall. The IDT Care Conference Review form indicated that while ambulating (walking) to the restroom, Resident 1 slipped and was assisted to the floor by a facility staff (name not indicated).During a review of Resident 1's Care Plan for functional abilities of everyday activities, initiated on 5/19/2025, the Care Plan indicated that Resident 1 required assistance with bed mobility (movement). The Care Plan interventions indicated that as needed, two or more facility staff will assist Resident 1 with bed mobility. During a review of Resident 1's Fall Risk Assessment form, dated 10/22/2025, the Fall Risk Assessment form indicated Resident 1 had a fall risk score of 20. The Fall Risk Assessment form indicated Resident 1 had one or two falls in the past 90 days. During a review of Resident 1's Incident Report (an objective, written account of an unexpected event such as falls or injuries affecting residents) for a witnessed fall, dated 11/1/2025, the Incident Report indicated on 11/1/2025, at 6:15 a.m., RN 4 received a report from Licensed Vocational Nurse (LVN) 1 that Resident 1 was observed on the floor next to her (Resident 1) bed during the morning care. The Incident Report indicated that while CNA 1 turned Resident 1 to her (Resident 1) side on the bed to place a bed protector (waterproof, and absorbent barrier placed over sheets to protect the mattress from incontinence, fluids, and damage), Resident 1 was unable to hold herself (Resident 1) and fell. The Incident Report indicated there was no floor mat (high-impact, shock-absorbing pads placed beside beds to minimize injury from falls, fractures, and head trauma) present on the floor. The Incident Report indicated RN 4 observed a laceration on the left side of the left eyebrow with bleeding, skin tear on the left side of the forehead, and skin tear on the left wrist. The Incident report indicated Resident 1 complained of pain level of three out of 10 on the numeric pain rating. The Incident Report indicated an ice pack was applied to Resident 1's forehead and Resident 1 received Tylenol 325 mg 2 tablets. During a review of Resident 1's Progress Note, dated 11/1/2025, timed at 2 p.m., the Progress Note indicated Resident 1 returned to the facility from GACH at 12 p.m. (on 11/1/2025). The Progress Note indicated Resident 1 had seven sutures and skin tear on the left forearm (skin tear measurement not indicated). During a review of Resident 1's Progress Note, dated 11/1/2025, timed at 2:28 p.m., the Progress Note indicated that on 11/1/2025, at 12 p.m., Resident 1 returned to facility from GACH. The Progress Note indicated Resident 1's laceration site measured six (6) centimeters (cm - unit of measurement) in length, 1.5 cm in width, and 0.1 cm in depth. During a review of Resident 1's Physician Orders, the Physician Orders indicated the following:- 11/1/2025: Transfer Resident 1 via 911 (phone number used to contact the emergency services) for further evaluation related to fall. - 11/1/2025: Amoxicillin (a medication used to treat infections caused by bacteria such as skin infection) Capsule 500 milligram (mg-unit of measurement). Give one capsule by mouth every eight hours prophylactically (to prevent infection) for sutures. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 11/2025, the MAR indicated Resident 1 received Tylenol 325 mg two tablets at 6:15 a.m. for a pain level of five (5 - moderate) out of 10 on the numeric pain rating scale (the Incident Report dated 11/1/2025 indicated pain level of 3, while MAR indicated pain level of 5).During a review of Resident 1's Interdisciplinary Care Conference Record, dated 11/3/2025, the IDT Care Conference Record indicated that Resident 1 had stated she (Resident 1) was feeling weak and was not able to hold herself (Resident 1) trying to turn and fell from the bed. The IDT Care Conference Record indicated that Resident 1 stated that she (Resident 1) was not comfortable for CNA 1 to care for her (Resident 1) again. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/27/2025, the MDS indicated Resident 1 had intact cognitive functioning (resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions). The MDS indicated Resident 1 was dependent (helper does all of the effort) on facility staff for toileting hygiene, showers, and lower body dressing. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) from facility staff for moving from sitting on the side of the bed to lying flat on the bed, moving from lying on the back to sitting on the side of the bed, upper body dressing, and personal hygiene. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) from facility staff for rolling from lying on back to left and right side on the bed. The MDS indicated Resident 1 was frequently incontinent (having no or insufficient voluntary control) of bowel and bladder. During a review of CNA 1's Performance Correction Notice, dated 2/17/2026, the Performance Correction Notice indicated that CNA 1 was receiving a final written warning related to Resident 1's fall on 11/1/2025 and was suspended until further notice. The Performance Correction Notice indicated that CNA 1 must follow safety, health, and security rules and procedures when providing care to residents. The Performance Correction Notice indicated that CNA 1 should have gotten additional help or have requested assistance from a Charge Nurse (LVN) while providing care to Resident 1. During an interview on 2/12/2026 at 4:10 p.m. with Resident 1, Resident 1 stated that few months ago (could not recall exact date) while CNA 1 was changing bed linens and turned Resident 1 to left side, Resident 1 lost hold of the bed and fell on the floor. Resident 1 stated her face touched the floor and she sustained a cut on the left side of the forehead. During a concurrent observation and interview on 2/12/2026 at 4:30 p.m. with RN 2 in Room A (Resident 1's room), there was no floor mat (high-impact, shock-absorbing pads placed beside beds to minimize injury from falls, fractures, and head trauma) observed next to Resident 1's bed. RN 2 stated it was the responsibility of the RN and charge nurse to ensure that Resident 1's Care Plan interventions were followed. RN 2 stated failure to provide bilateral floor mats to Resident 1 had the potential to increase Resident 1's risk of injury such as fractures if Resident 1 fell again.During a concurrent interview and record review on 2/12/2025 at 4:46 p.m. with RN 2, Resident 1's Care Plan for witnessed fall initiated on 11/3/2026, was reviewed. The Care Plan interventions indicated Resident 1 would have bilateral floor mats. RN 2 stated it was the responsibility of the RN and charge nurse to ensure that Resident 1's Care Plan interventions were followed. RN 2 stated failure to provide bilateral floor mats to Resident 1 had the potential to increase Resident 1's risk of injury such as fractures if Resident 1 fell again.During an interview on 2/13/2026 at 12:16 p.m. with RN 4, RN 4 stated that on 11/1/2026, at approximately 6:15 a.m. (per progress note), she (RN 4) received a call from LVN 1 regarding a fall incident at Station A (Resident 1's nursing station). RN 4 stated she immediately entered Resident 1's room and found Resident 1 lying supine (lying flat on the back with face and torso facing upward) on the floor next to Resident 1's bed. RN 4 stated that there was blood visible on Resident 1's forehead near the left eyebrow (cannot recall the exact location) and approximately one milliliter (ml - unit of measurement) blood was visible on the floor next to Resident 1's head. RN 4 stated she assessed Resident 1 and cleaned Resident 1's forehead wound with normal saline and gauze (bleached cotton cloth of plain weave used for bandages and dressing). RN 4 stated that CNA 1 had told her (RN 4) that during cleaning Resident 1 was weak and was not able to hold herself (Resident 1) in bed. RN 4 stated that facility staff should consider safety of residents before starting care and ask for assistance if needed. During an interview on 2/13/2026 at 1:05 p.m. with LVN 4, LVN 4 indicated there was no documented evidence that Resident 1 was added to the Falling Star Program prior to 11/1/2025.During a concurrent interview and record review on 2/17/2026 at 11:14 a.m. with LVN 2, Resident 1's Fall Risk Assessment forms, dated 7/25/2025 to 10/22/2025 were reviewed. LVN 2 stated the facility failed to complete a fall risk assessment after Resident 1 had an episode of fall on 11/1/2025. LVN 2 stated a fall risk assessment should be completed upon residents' admission, quarterly and after a fall incident. LVN 2 stated since Resident 1's fall risk was not assessed after a fall episode there was a potential for Resident 1's fall prevention intervention to be incomplete or inaccurate. LVN 2 stated failure to compete a fall risk assessment after Resident 1's fall episode on 11/1/2025 had the potential to increase Resident 1's risk of recurrent falls.During an interview on 12/17/2026 at 12:04 p.m. with RN 1, RN 1 stated a fall risk assessment should have been completed after Resident 1's fall episode on 11/1/2025. RN 1 stated based on the post fall risk assessment facility staff will identify appropriate interventions to prevent falls. RN 1 stated failure to assess Resident 1 had the potential to increase Resident 1's risk for falls.During an interview on 2/17/2026 at 12:29 p.m. with RN 1, RN 1 stated it was the responsibility of the licensed facility staff to update Resident 1's Care Plan after post fall IDT meeting on 12/20/2024. RN 1 stated Care Plan was a guide for the facility staff to provide care to residents. RN 1 stated failure to update Resident 1's Care Plan with fall prevention interventions had the potential to increase Resident 1's risk for fall.During a concurrent interview and record review on 2/17/2026 at 3:02 p.m. with LVN 3, Resident 1's Care Plan was reviewed. LVN 3 stated the information discussed during the IDT meeting after Resident 1's fall episode on 12/20/2024 should have been addressed in Resident 1's Care Plan. LVN 3 stated there was no documented evidence that Resident 1's Care Plan was updated after the fall incident on 12/20/2024. LVN 3 stated the failure to revise Resident 1's Care Plan post fall had the potential for Resident 1 not to receive appropriate fall prevention interventions possibly leading to a recurrent incident of fall.During an interview on 2/18/2026 at 11:22 a.m. with CNA 1, CNA 1 stated that she was the CNA assigned to Resident 1 on 11/1/2025 for 11 p.m. to 7 a.m. shift (work schedule). CNA 1 stated on 11/1/2025, at approximately 6 a.m., she (CNA 1) entered Resident 1's room to provide morning care prior to end of the shift. CNA 1 stated that when she (CNA 1) entered Resident 1's room Resident 1 was sleeping. CNA 1 stated she explained to Resident 1 that she (CNA 1) will change Resident 1's bed linens and incontinent briefs. CNA 1 stated she (CNA 1) could not recall asking Resident 1 if she (Resident 1) was able to move and hold herself (Resident 1) on the side of the bed prior to initiating care on 11/1/2025 at 6 a.m. CNA 1 stated that after cleaning Resident 1 while Resident 1 was supine, she (CNA 1) turned Resident 1 to her (Resident 1) left side to place the bed protector. CNA 1 stated she was holding Resident 1 with right hand from Resident 1's right arm while trying to place the bed protector with left hand. CNA 1 stated that approximately 10 to 15 minutes after initiation of care, while lying on her (Resident 1) left side at the edge of the bed, Resident 1 slipped from her (CNA 1) hand and fell on floor. CNA 1 stated she (CNA 1) immediately approached Resident 1 who was lying next to the bed, on the floor. CNA 1 stated she (CNA 1) immediately screamed for assistance and LVN 1 entered Resident 1's room. CNA 1 stated that Resident 1 had visible blood on the left side of her face near the forehead, approximately equal to the size of her (CNA 1) palm. CNA 1 stated that prior to the fall incident on 11/1/2025, CNA 1 had noticed that Resident 1 was less active and was having more difficulty moving in bed. CNA 1 stated that she should have asked for assistance from facility staff before providing care to Resident 1. CNA 1 stated Resident 1's fall on 11/1/2025 could have been prevented if another facility member was assisting her (CNA 1) during Resident 1's morning care on 11/1/2025. During an interview on 2/18/2026 at 11:54 a.m. with the Director of Nursing (DON), the DON stated that Resident 1's fall on 11/1/2025 could have been prevented if CNA 1 had asked for additional assistance from facility staff during Resident 1's as it was indicated in Resident 1's Care Plan. The DON stated that CNA 1 had received a performance correction notice and training related to poor care provided to Resident 1. During an interview on 2/18/2026 at 1:36 p.m. with LVN 1, LVN 1 stated that on 11/1/2025, at approximately 6 a.m. (cannot recall exact time), while in Station A (nursing station where Resident 1's room was located), she (LVN 1) heard CNA 1 call for assistance in Resident 1's room. LVN 1 stated that upon entering Resident 1's room, she (LVN 1) observed Resident 1 on the floor next to the bed, lying on her (Resident 1) back. LVN 1 stated Resident 1's bed was high at approximately half of her (LVN 1) height of 5 feet (ft - unit of measurement) and 4 inches (in-unit of measurement). LVN 1 stated there was visible blood on Resident 1's forehead. LVN 1 stated there was blood on the floor next to Resident 1's head approximately equal to a large drink and required 3 face towels to clean. LVN 1 stated that Resident 1 told her (LVN 1) that she (Resident 1) was not young and could not sustain herself (Resident 1) on the bed. During a concurrent interview and review on 2/18/2026 at 12:29 p.m., the facility-provided policy and procedure (P&P) titled, Falling Star Program, reviewed on 7/28/2025, was reviewed with RN 1. The P&P indicated, The Facility will ensure that staff is aware of resident who is at high risk for falls. I. The Facility's Interdisciplinary Team (IDT) will determine the need to place resident in 'Falling Star' Program. II. The 'Falling Star' program will be used as a post-fall intervention to prevent falls and injuries. RN 1 stated that Resident 1 should have been added to the facility's Falling Star Program after Resident 1 was identified as having high risk for fall and experiencing a fall episode in the facility. RN 1 stated the staff failed to follow facility's Falling Star Program P&P. RN 1 stated the failure to add Resident 1 to the Falling Star Program had the potential to increase Resident 1's risk of falls.During a review of the facility-provided P&P titled, Fall Management Program, last reviewed on 7/28/2025, the P&P indicated, it is the policy of this facility to provide the highest quality care in the safest environment for the residents residing in the facility. The Facility has developed a Fall Management Program that strives to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. I. Assessment: A. The Licensed Nurse will assess each resident for their risk of falling upon admission, quarterly, with significant change in condition, and as needed. C. Based on the information gathered from the history and assessment of the resident, the Nursing staff, and Interdisciplinary Team (IDT), with input from the Attending Physician, will identify the implement interventions to reduce the risk of falls. II. Care Planning: A. The Nursing Staff will develop a plan of care specific to the residents' needs with interventions to reduce the risk of falls. B. The Interdisciplinary Team will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall. Interventions will be implemented or changed based on the resident's condition and response. During a review of the facility-provided policy and procedure titled, Response to Falls, last reviewed on 1/26/2026, the P&P indicated, To ensure the Facility responds quickly and appropriately to resident falls in a manner that addresses both the resident's immediate needs and longer-term fall prevention. V. The Interdisciplinary Team (IDT) will review the investigation reports on a regular bases, as they may occur and make systemic changes to reasonably limit future occurrences, consider change in POC interventions, system changes, etc. Documentation: A. Licensed Nurse . vii. Revise resident's Care Plan as necessary.During a review of the facility-provided policy and procedure titled, Care Planning, last reviewed on 1/26/2026, the P&P indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. V. The IDT will revise the Comprehensive Care Plan as needed at the following intervals.B. As indicated by changes in the resident's condition; (care plans must be updated for any change in condition, regardless of physician's orders promptly).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical records for one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure accurate documentation of Fall Risk Assessment (a tool to identify residents at high risk of falling by evaluating factors such as medical conditions, vision, balance, mobility, medications) form. This deficient practice had the potential for inaccurate medical interventions for Resident 1. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 6/27/2019 and readmitted on [DATE] with diagnoses including chronic diastolic (congestive) heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), right shoulder rotator cuff tear or rupture (damage to the muscles/tendons, causing pain, weakness, and limited motion), wedge compression fracture of T11-T12 vertebra sequela (lasting effects of a collapsed, wedge-shaped thoracic vertebra), and muscle weakness. During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 7/1/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/21/2026, the MDS indicated Resident 1 had intact cognitive functioning (resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions). The MDS indicated Resident 1 was dependent (helper does all of the effort) on facility staff for toileting hygiene, showers, and lower body dressing. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) from facility staff for rolling from lying on back to left and right side on the bed, moving from sitting on the side of the bed to lying flat on the bed, moving from lying on the back to sitting on the side of the bed, upper body dressing, and personal hygiene. During a concurrent interview and record review on 2/18/2026 at 12:29 p.m. with Registered Nurse (RN) 1, Resident 1's Fall Risk assessment dated [DATE], 10/1/2025, and 10/22/2025 were reviewed. The Fall Risk Assessments dated 7/29/2025, 10/1/2025, and 10/22/2025 indicated that section F (Assessment of resident's systolic blood pressure variation when changing positions between lying and standing) was not assessed. RN 1 stated Resident 1's Fall Risk Assessment for the months of July (2025) and October (2025) were incomplete. RN 1 stated the assessment did not describe Resident 1's condition correctly which could potentially lead to lower score level. RN 1 stated failure to complete the fall assessment correctly had the potential to affect Resident 1's care leading to higher risk for falls. During a review of the facility-provided policy and procedure titled, Documentation Nursing, last reviewed on 1/26/2026, the P&P indicated, Nursing documentation will be concise, clear, pertinent, and accurate. Alert Charting: A. Alert charting is documentation done to track a medical event for a period of 72 hours or B. Alert charting is completed by professional staff rather than non-professional staff. D. Alert charting describes what is going on. (a) Describe the resident's condition, include what you see, hear, smell, feel, etc . (c) Describe what you have done in response to what is going on with the resident.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of three sample residents (Resident 1) to address the use of restraints when on 1/14/2026 at 3 a.m. Certified Nursing Assistant (CNA) 1 who was assigned to Resident 1 tied Resident 1's hands together at the wrist with a scarf while Resident 1 was in bed in her (Resident 1) room.This deficient practice had the potential to negatively affect the care and services provided to Resident 1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/16/2025 with diagnosis including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness (general), and abnormalities of gait (manner of walking) and mobility (ability to move). During a review of Resident 1's Physician History and Physical (H&P- a process used by doctors to understand residents' health which combines medical history and a physical examination), dated 9/5/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Fall Risk Assessment (a process used by healthcare providers to determine a resident's likelihood of falling), dated 12/8/2025, the Fall Risk Assessment indicated Resident 1's fall risk score was 21 meaning Resident 1 was a high risk for fall. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 1 rarely understood and was rarely understood. The MDS indicated Resident 1 was dependent on staff for showering, required substantial assistance (helper does more than half the effort) with upper body dressing, and required partial assistance (helper does less than half the effort) with eating, oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and personal hygiene.During a review of Resident 1's Care plan (CP), initiated on 1/14/2026 and revised on 2/4/2026, the CP indicated educate staff about type of abuse, including physical restraint, prevention measures, how and when to report it, resident safety and rights are respect and psychiatrist consult.During a review of Resident 1's Progress Note, dated 1/15/2026 timed at 8:45 a.m., the Progress Note indicated that during the night shift on 1/14/2026 (time not indicated), Resident 1 was restless, yelling on and off and LVN 1 asked CNA 1 to check on Resident 1. The Progress Note indicated that CNA 1 came out from Resident 1's room and stated that Resident 1 was okay and always behaves like this but after approximately 10 minutes later, Resident 1 was again yelling in her language. The Progress Note indicated LVN 1 entered Resident 1's room, saw Resident 1's blanket on the floor, picked up the blanket, and was about to place the blanket on Resident 1 when LVN 1 saw Resident 1's wrist tied in front of her (Resident 1) by what looked like to be a long scarf. The Progress Note indicated LVN 1 untied the scarf and quickly assessed Resident 1 with no visible injury noted. During a concurrent interview and record review on 2/4/2026 at 4:22 p.m. of Resident 1's Care plan for abuse with the RMN, the RMN reviewed Care plan and stated it was updated on 2/4/2026 but the way it is printed does not show the updated date. The RMN stated there was no previous care plan for the use of restraints for Resident 1 as Resident 1 was not using restraints. The RMN stated the use of the scarf was used as a restraint for Resident 1, should have had a care plan.During a review of the facility's policy and procedure (P&P) titled, Change of Condition Notification, last reviewed on 7/28/2025, the P&P indicated to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. II. The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to:b. A significant change in the resident's physical, cognitive, behavioral or functional statusDocumentationA. A Licensed Nurse will document the following:i. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes.ii. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received. iii. The time the family/responsible person was contactediv. Update the Care Plan to reflect the resident's current statusv. The incident and brief detail in the 24-hour report C. A Licensed Nurse will document each shift for at least seventy-two (72) hours.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) receive treatment and care in accordance with professional standards of practice when on 1/14/2026 at 3 a.m. Certified Nursing Assistant (CNA) 1 who was assigned to Resident 1 tied Resident 1's hands together at the wrist with a scarf while Resident 1 was in bed in her (Resident 1) room, the facility failed to:1. Failed to create a Change of Condition (COC) Evaluation for the alleged physical abuse2. Failed to start 72-hour monitoring (a watch period where staff closely observe a resident for three days to make sure the new health problem does not get worse) after Resident 1 had a COC.This deficient practice had the potential to negatively affect Resident 1's plan of care and delivery of necessary care and services.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/16/2025 with diagnosis including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness (general), and abnormalities of gait (manner of walking) and mobility (ability to move).During a review of Resident 1's Physician History and Physical (H&P- a process used by doctors to understand residents' health which combines medical history and a physical examination), dated 9/5/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Fall Risk Assessment (a process used by healthcare providers to determine a resident's likelihood of falling), dated 12/8/2025, the Fall Risk Assessment indicated Resident 1's fall risk score was 21 meaning Resident 1 was a high risk for fall. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 1 rarely understood and was rarely understood. The MDS indicated Resident 1 was dependent on staff for showering, required substantial assistance (helper does more than half the effort) with upper body dressing, and required partial assistance (helper does less than half the effort) with eating, oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and personal hygiene.During a review of Resident 1's Care plan (CP), initiated on 1/14/2026 and revised on 2/4/2026, the CP indicated educate staff about type of abuse, including physical restraint, prevention measures, how and when to report it, resident safety and rights are respect and psychiatric consult.During a review of Resident 1's Progress Note, dated 1/15/2026 timed at 8:45 a.m., the Progress Note indicated that during the night shift on 1/14/2026 (time not indicated), Resident 1 was restless, yelling on and off and LVN 1 asked CNA 1 to check on Resident 1. The Progress Note indicated that CNA 1 came out from Resident 1's room and stated that Resident 1 was okay and always behaves like this but after approximately 10 minutes later, Resident 1 was again yelling in her language. The Progress Note indicated LVN 1 entered Resident 1's room, saw Resident 1's blanket on the floor, picked up the blanket, and was about to place the blanket on Resident 1 when LVN 1 saw Resident 1's wrist tied in front of her (Resident 1) by what looked like to be a long scarf. The Progress Note indicated LVN 1 untied the scarf and quickly assessed Resident 1 with no visible injury noted. During a review of Resident 1's Health Status Note created on 1/16/2026 at 7:25 a.m. with an effective date of 1/15/2026 at 2:50 p.m., the Health Status Note indicated Resident 1 on monitoring status post abuse incident. During a review of Resident 1's Interdisciplinary Care Conference (IDT- a meeting where a patient's health team such as doctors, nurses, therapists, and social workers-collaborates to review progress, share expertise, and create a unified, personalized treatment plan) dated 1/16/2026 at 11 a.m., the IDT indicated following an alleged abuse report IDT recommendations MD was contacted and orders were received for Urinary Analysis (UA-test that examines a urine sample's color, chemical makeup, and microscopic content to detect infections, kidney disease, diabetes, and overall health issues), Culture and Sensitivity (C&S- identifies the specific germ [bacteria or fungus] causing an infection and determines which medication best kills it), Complete Blood Count (CBC- blood test that measures the types, numbers, and health of cells in your blood), Comprehensive Metabolic Panel (CMP- a routine blood test that checks 14 different substances to assess your overall health, organ function, and chemical balance) and Thyroid Stimulating Hormone (TSH- checks how well your thyroid gland is working) related to any infection. As an infection can be a contributing factor to restless.During a review of Resident 1's COC Evaluation dated 1/16/2026 at 11:54 a.m. the COC indicated restlessness as discussed during IDT. Resident 1 reported with having restless behavior at night that was discussed during IDT meeting. MD notified and ordered UA with C&S, CBC, CMP and TSH. During a review of Resident 1's Order Audit Report dated 1/16/2026 at 11:59 a.m. the Order Audit Report indicated:- CBC, CMP, TSH, one time only for one day.- UA, C&S one time only for one day.During a review of Resident 1's COC dated 1/17/2026 at 10:39 a.m. the COC indicated UTI. Abnormal UA result noted by RN supervisor. Reported to MD and received order for Macrobid orally 100 milligrams (mg- a unit of measurement) two times a day for urinary tract infection (UTI- an infection in the bladder/urinary tract) for one week. Resident 1 has no pain or discomfort and no fever noted. Family notified. During a review of Resident 1's Order Audit Report dated 1/17/2026 at 10:13 a.m. the Order Audit Report indicated Macrobid oral capsule 100 mg give 100 mg by mouth every 12 hours for UTI for one week. During an interview on 1/28/2026 at 1:02 p.m. with the RMN, the RMN stated when she saw the picture of Resident 1 tied up, RMN stated Resident 1's hands were tied in front on top of each other like a cross, cannot say if the scarf was tight or not. RMN stated when a resident is tied up it can prevent the resident from getting up, the resident would not be able to use the call light. RMN stated Resident 1 is a fall risk, can result in the resident attempting to get up and hurt themselves because their hands are tied, would not be able to catch themselves if falling. The RMN stated can be a potential for Resident 1 not to be able to drink as well. The RMN stated a COC was conducted during IDT on 1/16/2026 and that is when we notified the MD regarding the restlessness and that is when we obtained and order for labs and Resident 1 and was later noted with a UTI. The RMN stated COC form is to note a change in condition in the residents and to conduct and assessment on the resident. The RMN stated there is no COC for 1/14/2026.During an interview on 2/2/2026 at 3:19 p.m. with the DON stated was informed by LVN 1 on 1/14/2026 at 7:30 a.m. she had something important to tell them, LVN 1 stated let me show you a picture of a resident who was bound on her wrist and that is when LVN1 showed us the picture. The DON stated the picture showed Resident 1 bound by her wrist side by side with a greenish scarf, to me (DON) could not tell how tight it was but it looked solid there was no way the Resident 1 could have pulled arms apart. The DON stated this is physical abuse, used as a physical restraint, Resident 1 could have encouraged the potential for an injury from a fall due to her lack of mobility as her wrist were tied. The DON stated alleged abuse is considered a COC. The DON stated COC is a communication is a form that communicates with all staff, would have been given to nurses then, communicate to MD, IDT and family. The DON stated if there is no COC for 1/14/2026 allegation of abuse documented then we cannot say the MD, or family were notified of the COC.During a concurrent interview and record review on 2/3/2026 at 9:52 a.m. of Resident 1's Health Status Note with the RMN, the RMN stated there is no COC for Resident 1 on 1/14/2026. The RMN stated the COC would have been specifically for abuse and include the restlessness the restlessness was addressed on the OCC dated 1/16/2026. The RMN stated COC identity the COC, then will initiate 72- hour monitoring. The RMN stated the RN supervisor should have started the COC on 1/14/2026. The RMN reviewed Resident 1's Health Status Note dated 1/16/2026 at 7:25 a.m. and the RMN stated that is when the 72-hour monitoring was started. The RMN stated 72-hour monitoring should have started on 1/14/2026. The RMN stated the 72 hour monitoring is to ensure residents are being checked for their psychosocial wellbeing and any new skin issues like bruising from the restraint and the resident's overall status. The RMN stated there was a delay in Resident 1's restlessness, RMN stated on 1/16/2026 when she spoke to MD1 asked if it was possible for Resident 1 to have a UTI. The RMN stated MD1 was notified but he had no orders at the time and 1/14/2026. The RMN stated basic nursing if not documented cannot say MD was notified, the RMN stated there is no documentation MD was notified on 1/14/2026.During a review of the facility's policy and procedure (P&P) titled, Change of Condition Notification, last reviewed on 7/28/2025, the P&P indicated to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. II. The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to:b. A significant change in the resident's physical, cognitive, behavioral or functional statusDocumentationA. A Licensed Nurse will document the following:i. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes.ii. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received. iii. The time the family/responsible person was contactediv. Update the Care Plan to reflect the resident's current statusv. The incident and brief detail in the 24-hour report C. A Licensed Nurse will document each shift for at least seventy-two (72) hours.

Based on interview and record review, the facility failed to implement its Abuse Prevention and Prohibition Program Policy and Procedures (P&P) by failing to report the alleged abuse to the State Survey Agency (SSA), and local law enforcement, in accordance with the facility's policy no later than two (2) hours after the allegation occurred for one of three sampled residents (Resident 1) when on 1/14/2026 at 2:50 a.m. Licensed Vocation Nurse (LVN) 1, observed Resident 1 with her wrists bound.This deficient practice had the potential to result in unidentified abuse and placed Resident 1 at risk for further abuse.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/16/2025 with diagnosis including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness (general), and abnormalities of gait (manner of walking) and mobility (ability to move).During a review of Resident 1's Physician History and Physical (H&P- a process used by doctors to understand residents' health which combines medical history and a physical examination), dated 9/5/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's Fall Risk Assessment (a process used by healthcare providers to determine a resident's likelihood of falling), dated 12/8/2025, the Fall Risk Assessment indicated Resident 1's fall risk score was 21 meaning Resident 1 was a high risk for fall. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 1 rarely understood and was rarely understood. The MDS indicated Resident 1 was dependent on staff for showering, required substantial assistance (helper does more than half the effort) with upper body dressing, and required partial assistance (helper does less than half the effort) with eating, oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and personal hygiene.During a review of CNA 1's Timecard, dated 1/13/2026, the Timecard indicated CNA 1 clocked into work on 1/13/2026 10:46 p.m. and clocked out on 1/14/2026 at 7:16 a.m. During a review of Resident 1's Progress Note, dated 1/15/2026 timed at 8:45 a.m., the Progress Note indicated that during the night shift on 1/14/2026 (time not indicated), Resident 1 was restless, yelling on and off and LVN 1 asked CNA 1 to check on Resident 1. The Progress Note indicated that CNA 1 came out from Resident 1's room and stated that Resident 1 was okay and always behaves like this but after approximately 10 minutes later, Resident 1 was again yelling in her language. The Progress Note indicated LVN 1 entered Resident 1's room, saw Resident 1's blanket on the floor, picked up the blanket, and was about to place the blanket on Resident 1, who was lying in her bed, when LVN 1 saw Resident 1's wrist tied in front of her (Resident 1) by what looked like to be a long scarf. The Progress Note indicated LVN 1 untied the scarf and quickly assessed Resident 1 with no visible injury noted. During an interview on 1/28/2026 at 1:02 p.m. with the RMN, the RMN stated she saw the picture of Resident 1's hands tied up in the front (of Resident 1) on top of each other like a cross, but she cannot say if the scarf was tight or not. The RMN stated that when a resident is tied up it can prevent the resident from getting up and, also, the resident would not be able to use the call light. The RMN stated Resident 1 was a fall risk and this can result in Resident 1 attempting to get up and hurt herself because her hands were tied and would not be able to catch herself if falling. The RMN stated this can be a potential for Resident 1 not to be able to drink water, as well. The RMN stated LVN 1 should have reported immediately to the Adm because LVN 1 notified the DON and RMN at around 7:15 a.m. to 7:20 a.m. (on 1/14/2026) causing a delay of about three hours in reporting the abuse. The RMN stated CNA 1 completed her shift and continued to work with Resident 1 on 1/14/2026. The RMN stated LVN 1 should have removed CNA 1 immediately from the assignment and should have left the premises of the facility.During an interview on 1/28/2026 at 2:49 p.m. with LVN 1, LVN 1 stated she worked on 1/13/2026 during the 11 p.m. to 7 a.m. shift. LVN 1 stated on 1/13/2026 at around 1:30 a.m. to 2 a.m. she heard Resident 1 making sounds like Resident 1 was chanting in a different language. LVN 1 stated she (LVN 1) does not speak that language and was unable to understand what Resident 1 was saying. LVN 1 stated she asked CNA 1, who was Resident 1's assigned CNA and speaks the same language as Resident 1, what Resident 1 was saying and CNA 1 responded that Resident 1 always did that. LVN 1 stated that a few minutes later (did not indicate exact time) Resident 1's chanting got louder and increased in frequency. LVN 1 stated she asked CNA 1 to check on Resident 1, so CNA 1 went into Resident 1's room, talked with Resident 1, and left Resident 1's room. LVN 1 stated Resident 1's chanting got worse and getting louder and around 2:50 a.m. (on 1/14/2026) LVN 1 went into Resident 1's room and saw Resident 1's blanket on the floor and thought Resident 1, who was lying in her bed, might be cold. LVN 1 stated she bent down to get the blanket, shook the blanket, and noted Resident 1's hands were bound. LVN 1 stated Resident 1's hands were firmly bound at the wrist with a scarf, in front of Resident 1 with no way of getting out and no wiggle room. LVN 1 stated Resident 1's hands were hog tied tied at the wrist with a figure eight at least three times. LVN 1 stated that prior to removing the scarf she took a picture of Resident 1's tied hands to show to her supervisors and untied Resident 1 around 3 a.m. LVN 1 stated that when she initially came into Resident 1's room Resident 1 looked relieved and became wiggly as she was moving around wanting LVN 1 to see she (Resident 1) was bound. LVN 1 stated that after that she looked for CNA 1 and she saw CNA 1 at the desk in the Nursing Station sleeping and snoring (woke up at unknown time to continue her shift). LVN 1 stated CNA 1 completed her (CNA 1) shift taking care of Resident 1.During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, last reviewed on 7/28/2025, the P&P indicated each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, an/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. ProtectionA. The facility protects residents during investigation of abuse, neglect or mistreatment.B. Facility staff members accused of committing abuse, neglect or mistreatment against a resident are suspended until the investigation is complete and the findings have been reviewed by the Administrator. Reporting/Response B. The Administrator is the Abuse Coordinatorii. Facility Staff will report known or suspected instance of abuse to the Administer, or his/her designee.C. All mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be financial abuse, physical abuse, neglect, abandonment, isolation, abduction, or other treatment resulting in physical harm or pain or mental suffering, deprivation of goods or services that are necessary to avoid physical harm or mental suffering.i. Immediately, by telephone, but no later than 2 hours after forming the suspicion if the alleged violation involves abuse or results in serious bodily injury to the SSA, adult protective services, law enforcement, and the Ombudsmen.During a review of the facility's P&P titled, Restraints, last reviewed on 7/28/2025, the P&P indicated residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measure shall be used.Physical Restraint is defined as any manual method or physical or mechanical devise, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. ii. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. The Facility will ensure that restraints will not be imposed for purpose of discipline or convivence.VII. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to:A. Treat the medical symptom;B. Protect the resident's safety; andC. Help the resident attain the highest level of his/her physical or psychological well-beingX. Except in emergency situation, a physical restraint shall be used only after the interdisciplinary tea, (IDT) has performed an assessment, attempted to determine and alleviate precipitating factors, determined the need for restraint and identified the least restrictive device.Assessment- An assessment will be completed by a Licensed Nurse prior to the application of any device that restricts movement or access to one's body. The assessment will be repeated quarterly thereafter. If a resident is admitted with a restraint, the assessment will be completed upon admission.VI. Physician order- There must be a physician's order for the use of the restraint which include:A. Medical symptoms for the use:B. Frequency of use;C. Type of restraint;D. Release protocols; andE. Plan of reduction, when applicableVII. Informed consentA. Before any type of restraint is used, the Licensed Nurse will verify that informed consent has been obtained form the resident/responsible party and that the resident/responsible party was educated regarding the risks and benefits of restraint use.X. Care Planning-Care plans for resident with restraints will reflect:A. the type of restraint to be used;B. the medical symptoms requiring the use of restraints;C. The treatment team's goals in using the restraint;D. Interventions that address the immediate medical symptom(s) and the underlying problem that may be causing the symptom(s);E. Systemic and gradual approaches for minimizing or eliminating the concerning behavior and restraint use, and F. Frequency observation and release every 2 hours for toileting and/or repositioning and checking the condition of skin and impaired circulation if indicated.G. The use of postural support and the method of application will be specified in the resident's Care Plan.

Based on interview and record review, the facility failed to take precautionary measures to provide protection to one of three sampled Residents (Resident 1) when, on 1/14/2026 at 3 a.m. Certified Nursing Assistant (CNA) 1 who was assigned to Resident 1 tied Resident 1's hands together at the wrist with a scarf while Resident 1 was in bed in her (Resident 1) room. CNA 1 was able to continue to work with Resident 1 and all other residents in the facility until she clocked out on 1/14/2026 at 7:16 a.m.This deficient practice had the potential to place Resident 1 and other residents at risk for further abuse.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/16/2025 with diagnosis including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness (general), and abnormalities of gait (manner of walking) and mobility (ability to move). During a review of Resident 1's Physician History and Physical (H&P- a process used by doctors to understand residents' health which combines medical history and a physical examination), dated 9/5/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Fall Risk Assessment (a process used by healthcare providers to determine a resident's likelihood of falling), dated 12/8/2025, the Fall Risk Assessment indicated Resident 1's fall risk score was 21 meaning Resident 1 was a high risk for fall. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 1 rarely understood and was rarely understood. The MDS indicated Resident 1 was dependent on staff for showering, required substantial assistance (helper does more than half the effort) with upper body dressing, and required partial assistance (helper does less than half the effort) with eating, oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of CNA 1's Timecard, dated 1/13/2026, the Timecard indicated CNA 1 clocked into work on 1/13/2026 10:46 p.m. and clocked out on 1/14/2026 at 7:16 a.m. During a review of Resident 1's Progress Note, dated 1/15/2026 timed at 8:45 a.m., the Progress Note indicated that during the night shift on 1/14/2026 (time not indicated), Resident 1 was restless, yelling on and off and LVN 1 asked CNA 1 to check on Resident 1. The Progress Note indicated that CNA 1 came out from Resident 1's room and stated that Resident 1 was okay and always behaves like this but after approximately 10 minutes later, Resident 1 was again yelling in her language. The Progress Note indicated LVN 1 entered Resident 1's room, saw Resident 1's blanket on the floor, picked up the blanket, and was about to place the blanket on Resident 1 when LVN 1 saw Resident 1's wrist tied in front of her (Resident 1) by what looked like to be a long scarf. The Progress Note indicated LVN 1 untied the scarf and quickly assessed Resident 1 with no visible injury noted. During a concurrent interview and record review on 1/28/2026 at 9 a.m. with the Adm, CNA 1's Timecard on 1/13/2026 was reviewed. The Adm stated CNA 1 clocked in on 1/13/2026 at 10:46 p.m. and clocked out on 1/14/2026 at 7:16 a.m. During an interview on 1/28/2026 at 11:25 a.m. with CNA 1, CNA 1 stated she worked on 1/13/2026 during the 11 p.m. to 7 a.m. shift (work schedule) and was the CNA for Resident 1. CNA 1 stated she continued to work with Resident 1 until the end of her (CNA 1) shift. CNA 1 stated she was not taken off Resident 1's care. During an interview on 1/28/2026 at 1:02 p.m. with the RMN, the RMN stated she saw the picture of Resident 1's hands tied up in the front (of Resident 1) on top of each other like a cross, but she cannot say if the scarf was tight or not. The RMN stated that when a resident is tied up it can prevent the resident from getting up and, also, the resident would not be able to use the call light. The RMN stated Resident 1 was a fall risk and this can result in Resident 1 attempting to get up and hurt herself because her hands were tied and would not be able to catch herself if falling. The RMN stated this can be a potential for Resident 1 not to be able to drink water, as well. The RMN stated LVN 1 should have reported immediately to the Adm because LVN 1 notified the DON and RMN at around 7:15 a.m. to 7:20 a.m. (on 1/14/2026) causing a delay of about three hours in reporting the abuse. The RMN stated CNA 1 completed her shift and continued to work with Resident 1 on 1/14/2026. The RMN stated LVN 1 should have removed CNA 1 immediately from the assignment and should have left the premises of the facility. During an interview on 1/28/2026 at 2:49 p.m. with LVN 1, LVN 1 stated she worked on 1/13/2026 during the 11 p.m. to 7 a.m. shift. LVN 1 stated on 1/13/2026 at around 1:30 a.m. to 2 a.m. she heard Resident 1 making sounds like Resident 1 was chanting in a different language. LVN 1 stated she (LVN 1) does not speak that language and was unable to understand what Resident 1 was saying. LVN 1 stated she asked CNA 1, who was Resident 1's assigned CNA and speaks the same language as Resident 1, what Resident 1 was saying and CNA 1 responded that Resident 1 always did that. LVN 1 stated that a few minutes later (did not indicate exact time) Resident 1's chanting got louder and increased in frequency. LVN 1 stated she asked CNA 1 to check on Resident 1, so CNA 1 went into Resident 1's room, talked with Resident 1, and left Resident 1's room. LVN 1 stated Resident 1's chanting got worse and getting louder and around 2:50 a.m. (on 1/14/2026) LVN 1 went into Resident 1's room and saw Resident 1's blanket on the floor and thought Resident 1 might be cold. LVN 1 stated she bent down to get the blanket, shook the blanket, and noted Resident 1's hands were bound. LVN 1 stated Resident 1's hands were firmly bound at the wrist with a scarf, in front of Resident 1 with no way of getting out and no wiggle room. LVN 1 stated Resident 1's hands were hog tied tied at the wrist with a figure eight at least three times. LVN 1 stated that prior to removing the scarf she took a picture of Resident 1's tied hands to show to her supervisors and untied Resident 1 around 3 a.m. LVN 1 stated that when she initially came into Resident 1's room Resident 1 looked relieved and became wiggly as she was moving around wanting LVN 1 to see she (Resident 1) was bound. LVN 1 stated that after that she looked for CNA 1 and she saw CNA 1 at the desk in the Nursing Station sleeping and snoring. LVN 1 stated CNA 1 completed her (CNA 1) shift taking care of Resident 1. During an interview on 1/28/2026 at 3:32 p.m. with the RMN, the RMN stated this is abuse, because Resident 1 was unable to move due to being tied down. The RMN stated there was no way to determine how long Resident 1 was tied down. The RMN stated having CNA 1 still work after allegation of abuse placed Resident 1 at further risk and other residents at risk of abuse. During an interview on 2/2/2026 at 4:44 p.m. with the Adm, the Adm stated he is the facility's abuse coordinator. The Adm stated Resident 1 being tied with a scarf is a form of restraint and it falls under abuse. The Adm stated this would be physical abuse. The Adm stated he believed CNA 1 was the one that tied Resident 1, and it was for the convenience of CNA 1 because Resident 1 was restless during that time. The Adm stated CNA 1 should have been removed immediately from the work schedule once LVN 1 found Resident 1 was bound because there was a potential for CNA 1 to do it to other residents, and can get in the way of the investigation, as well. During a review of the facility's P&P titled, Abuse Prevention and Prohibition Program, last reviewed on 7/28/2025, the P&P indicated, Each resident has the right to be free from abuse, neglect, mistreatment. The facility has zero-tolerance for abuse, neglect, mistreatment. Staff must not permit anyone to engage in . physical abuse, neglect, mistreatment. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff. A. The facility protects residents during investigation of abuse, neglect or mistreatment. B. Facility staff members accused of committing abuse, neglect or mistreatment against a resident are suspended until the investigation is complete and the findings have been reviewed by the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the right of one of three sampled residents (Resident 1) to be free from physical restraint (is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body). On 1/14/2026 at 3 a.m., Licensed Vocational Nurse (LVN) 1 found the hands of Resident 1, who had severe cognitive impairment (is a profound, often irreversible loss of mental capacity involving a major inability to think, remember, learn, communicate, or make decisions, requiring daily assistance with basic tasks like eating, dressing, or safety) and was dependent on staff (helper does all of the effort) for care, were firmly tied together at the wrist with a scarf with no way of getting out, no wiggle room, and with no ability to move or release her hands while Resident 1 was in bed in her (Resident 1) room. The facility failed to: 1. Ensure that a licensed nurse completed an assessment prior to the application of a physical restraint restricting Resident 1's freedom of movement in accordance with the facility's policy and procedure (P&P) titled, Restraints, last reviewed on 7/28/2025, indicating, . a physical restraint shall be used only after the interdisciplinary team (IDT - a collaborative group of healthcare professionals who work together to create, implement, and evaluate a personalized, comprehensive care plan for residents) has performed an assessment, attempted to determine and alleviate precipitating factors, determined the need for restraint and identified the least restrictive device. 2. Ensure Certified Nursing Assistant (CNA) 1, who was assigned to Resident 1, was suspected of tying Resident 1's hands, and was caught sleeping during that time, was immediately removed from duty on 1/14/2026 at 3 a.m. CNA 1 remained on schedule and continued providing care to Resident 1 until clocking out at 7:16 a.m. on 1/14/2026. This failure allowed potential continued or further abuse. The facility failed to follow its P&P titled, Abuse Prevention and Prohibition Program, last reviewed on 7/28/2025, indicating, Facility staff members accused of committing abuse, neglect or mistreatment against a resident are suspended until the investigation is complete and the findings have been reviewed by the Administrator. 3. Follow the facility's P&P titled, Restraints, dated 11/1/2017, indicating, Residents shall be provided an environment that is restraint-free. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. The facility will ensure that restraints will not be imposed for purposes of discipline or convenience. 4. Follow the facility's P&P titled, Abuse Prevention and Prohibition Program, last reviewed on 7/28/2025, indicating, Each resident has the right to be free from abuse, neglect, mistreatment. The Facility has zero-tolerance for abuse. Staff must not permit anyone to engage in . physical abuse, neglect, mistreatment. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff. As a result, on 1/14/2026, CNA 1 allegedly subjected Resident 1 to a physical restraint while under the care of the facility. On 1/14/2026 at 2 a.m., LVN 1 heard Resident 1 chanting which became louder, increased in frequency, and getting worse. On 1/14/2026 at around 2:50 a.m., LVN 1 entered Resident 1's room and found Resident 1's blanket on the floor and Resident 1 who was lying in her bed making wiggly (quick, irregular shaking or twisting motion from side to side or up and down) body movements to show LVN 1 her hands were bound with a scarf. Also, based on the reasonable person concept (refers to a tool to assist the survey team's assessment of the severity level of negative, or potentially negative, psychosocial [relating to the interrelation of social factors and individual thought and behavior] outcome the deficiency may have had on a reasonable person in the resident's position), due to Resident 1's severe impaired cognitive skills and medical condition, an individual subjected to abuse may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation. On 2/3/2026 at 12 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participations has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (Adm), the Director of Nursing (DON), and the Risk Management Nurse (RMN) due to the facility's failure to protect Resident 1's right to be free from physical restraint beginning on 1/14/2026 at 3 a.m., when LVN 1 found the hands of Resident 1 firmly tied together at the wrist with a scarf with no way of getting out, no wiggle room, and with no ability to move or release her hands while under the care of the facility. On 2/4/2026 at 4:26 p.m., the RMN provided an acceptable IJ removal plan (a detailed plan to address the IJ findings) for the facility's failure to protect Resident 1's right to be free from physical restraint on 1/14/2026 at 3 a.m. On 2/4/2026 at 4:50 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to protect Resident 1's right to be free from physical restraint was no longer present. The SSA removed the IJ situation, while onsite, on 2/4/2026 at 4:50 p.m., in the presence of the DON and the RMN. The immediate jeopardy was removed on 2/4/2026, but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that is not IJ (noncompliance causing minimal discomfort or potential to compromise resident functioning). The acceptable IJ Removal Plan included the following summarized actions: 1. On 1/14/2026 at about 7:20 a.m., LVN 1 reported to the facility's Human Resources (HR) and the DON the alleged abuse incident. Upon reporting to the DON, LVN 1 stated that Resident 1 was found with her (Resident 1) hands bound by a scarf, and she (LVN 1) immediately removed the scarf and notified the Ombudsman (OMB- an advocate for residents of nursing homes, board and care centers, and assisted living facilities). 2. On 1/14/2026 at 7:45 a.m. the facility suspended CNA 1 pending HR's investigation. 3. On 1/15/2026 at 7:45 a.m. LVN 1 was provided with written warning due to her failure to report the incident to the RN Supervisor on duty, who would have suspended CNA 1 immediately. 4. On 1/16/2026, the facility terminated CNA 1. 5. On 1/28/2026 at 1:58 p.m., the Director of Staff Development (DSD) reported CNA 1 to the CNA Licensing Board. 6. On 2/3/2026, Registered Nurse (RN) Supervisors 1, 2, and 3 conducted rounds on all units to visually observe all residents in-house for any signs of physical restraints, inappropriate use of devices that could function as restraints, or any signs of abuse or neglect. No other residents were identified. 7. On 2/3/2026 at 9 :30 p.m., RN Supervisors 4, 5, 6, and 7 conducted another facility-wide sweep of all residents to screen for restraints. No other residents were identified. 8. On 2/3/2026 at 2 p.m., the facility's HR and Adm suspended LVN 1 due to failure to follow facility's policy (did not indicate which policy). 9. On 2/3/2026, the Assistant DSD initiated an in-serviced facility staff regarding restraints and the Assistant DSD and DSD will continue to provide in-services until completion by 2/6/2026. During orientation, facility will in-service newly hired staff on abuse and physical restraints. The in-service will include: a. Review of facility's Abuse Prevention and Prohibition Program policy, with emphasis on Residents being free from physical restraints, regulatory requirements and facility policy regarding physical restraints, including the definition of physical restraint, prohibition of restraints for discipline or convenience, and requirement for physician orders and assessments. b. Resident rights including the right to be free from restraints and abuse. c. Immediate reporting requirements. d. Facility's zero-tolerance policy for abuse and requirement to report suspected abuse immediately. e. Documentation requirements. 10. On 2/4/2026 at 12 p.m., the DON created a root cause analysis (a structured, team-based, and non-punitive process used to investigate and to uncover underlying system, process, or human factor [NAME] rather than assigning individual blame). 11. On 2/4/2026, the Adm and DON instructed staff that there will be immediate removal of staff from duty when abuse/neglect is suspected. 12. Effective 2/4/2026, shift to shift report (handover process where the nurse ending his/her shift transfers responsibility, accountability, and essential resident information to the incoming staff member) will include report of any suspected abuse and immediate suspension of staff involved. 13. Department Managers, Managers of the Day, and RN Supervisor on duty will conduct daily rounds inclusive of every shift, weekends and holidays to validate no restraints observed weekly for four weeks, then monthly for two months, to ensure residents feel safe and are free from restraints.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/16/2025 with diagnosis including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness (general), and abnormalities of gait (manner of walking) and mobility (ability to move). During a review of Resident 1's Physician History and Physical (H&P- a process used by doctors to understand residents' health which combines medical history and a physical examination), dated 9/5/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Fall Risk Assessment (a process used by healthcare providers to determine a resident's likelihood of falling), dated 12/8/2025, the Fall Risk Assessment indicated Resident 1's fall risk score was 21 meaning Resident 1 was a high risk for fall. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 1 rarely understood and was rarely understood. The MDS indicated Resident 1 was dependent on staff for showering, required substantial assistance (helper does more than half the effort) with upper body dressing, and required partial assistance (helper does less than half the effort) with eating, oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of CNA 1's Timecard, dated 1/13/2026, the Timecard indicated CNA 1 clocked into work on 1/13/2026 10:46 p.m. and clocked out on 1/14/2026 at 7:16 a.m. During a review of Resident 1's Progress Note, dated 1/15/2026 timed at 8:45 a.m., the Progress Note indicated that during the night shift on 1/14/2026 (time not indicated), Resident 1 was restless, yelling on and off and LVN 1 asked CNA 1 to check on Resident 1. The Progress Note indicated that CNA 1 came out from Resident 1's room and stated that Resident 1 was okay and always behaves like this but after approximately 10 minutes later, Resident 1 was again yelling in her language. The Progress Note indicated LVN 1 entered Resident 1's room, saw Resident 1's blanket on the floor, picked up the blanket, and was about to place the blanket on Resident 1, who was lying in her bed, when LVN 1 saw Resident 1's wrist tied in front of her (Resident 1) by what looked like to be a long scarf. The Progress Note indicated LVN 1 untied the scarf and quickly assessed Resident 1 with no visible injury noted. During a concurrent interview and record review on 1/28/2026 at 9 a.m. with the Adm, CNA 1's Timecard on 1/13/2026 was reviewed. The Adm stated CNA 1 clocked in on 1/13/2026 at 10:46 p.m. and clocked out on 1/14/2026 at 7:16 a.m. During an interview on 1/28/2026 at 11:25 a.m. with CNA 1, CNA 1 stated she worked on 1/13/2026 during the 11 p.m. to 7 a.m. shift (work schedule) and was the CNA for Resident 1. CNA 1 stated she continued to work with Resident 1 until the end of her (CNA 1) shift. CNA 1 stated she was not taken off Resident 1's care. During an interview on 1/28/2026 at 1:02 p.m. with the RMN, the RMN stated she saw the picture of Resident 1's hands tied up in the front (of Resident 1) on top of each other like a cross, but she cannot say if the scarf was tight or not. The RMN stated that when a resident is tied up it can prevent the resident from getting up and, also, the resident would not be able to use the call light. The RMN stated Resident 1 was a fall risk and this can result in Resident 1 attempting to get up and hurt herself because her hands were tied and would not be able to catch herself if falling. The RMN stated this can be a potential for Resident 1 not to be able to drink water, as well. The RMN stated CNA 1 completed her shift and continued to work with Resident 1 on 1/14/2026. The RMN stated LVN 1 should have removed CNA 1 immediately from the assignment and should have left the premises of the facility. During an interview on 1/28/2026 at 2:49 p.m. with LVN 1, LVN 1 stated she worked on 1/13/2026 during the 11 p.m. to 7 a.m. shift. LVN 1 stated on 1/13/2026 at around 1:30 a.m. to 2 a.m. she heard Resident 1 making sounds like Resident 1 was chanting in a different language. LVN 1 stated she (LVN 1) does not speak that language and was unable to understand what Resident 1 was saying. LVN 1 stated she asked CNA 1, who was Resident 1's assigned CNA and speaks the same language as Resident 1, what Resident 1 was saying and CNA 1 responded that Resident 1 always did that. LVN 1 stated that a few minutes later (did not indicate exact time) Resident 1's chanting got louder and increased in frequency. LVN 1 stated she asked CNA 1 to check on Resident 1, so CNA 1 went into Resident 1's room, talked with Resident 1, and left Resident 1's room. LVN 1 stated Resident 1's chanting got worse and getting louder and around 2:50 a.m. (on 1/14/2026) LVN 1 went into Resident 1's room and saw Resident 1's blanket on the floor and thought Resident 1, who was lying in her bed, might be cold. LVN 1 stated she bent down to get the blanket, shook the blanket, and noted Resident 1's hands were bound. LVN 1 stated Resident 1's hands were firmly bound at the wrist with a scarf, in front of Resident 1 with no way of getting out and no wiggle room. LVN 1 stated Resident 1's hands were hog tied tied at the wrist with a figure eight at least three times. LVN 1 stated that prior to removing the scarf she took a picture of Resident 1's tied hands to show to her supervisors and untied Resident 1 around 3 a.m. LVN 1 stated that when she initially came into Resident 1's room Resident 1 looked relieved and became wiggly as she was moving around wanting LVN 1 to see she (Resident 1) was bound. LVN 1 stated that after that she looked for CNA 1 and she saw CNA 1 at the desk in the Nursing Station sleeping and snoring (woke up at unknown time to continue her shift). LVN 1 stated CNA 1 completed her (CNA 1) shift taking care of Resident 1. During an interview on 1/28/2026 at 3:32 p.m. with the RMN, the RMN stated this is abuse, because Resident 1 was unable to move due to being tied down. The RMN stated there was no way to determine how long Resident 1 was tied down. The RMN stated having CNA 1 still work after allegation of abuse placed Resident 1 at further risk and other residents at risk of abuse. During an interview on 2/2/2026 at 3:19 p.m. with the DON, the DON stated LVN 1 showed a picture of Resident 1 whose hands were bound by her wrists, side by side, with a greenish scarf. The DON stated she could not tell how tight it was, but it looked solid that there was no way Resident 1 could have pulled her arms apart. The DON stated the scarf would inhibit Resident 1 from grabbing the handrails and thinks that was why it was done to prevent Resident 1 from pulling herself up and getting out of the bed. The DON stated Resident 1 would not be able to use the call light and the way her wrists were bound she would not be able to drink water or even scratch her face. The DON stated that because Resident 1's hands were tied Resident 1 was at a higher risk for falling due to not being able to balance. The DON stated she thought CNA 1 bound Resident 1's hands to prevent Resident 1 from getting up out of bed. The DON stated there was no assessment specifically for the use of the scarf as a restraint. The DON stated the scarf was used as a restraint. The DON stated the scarf was used as convenience for CNA 1 because CNA 1 knew Resident 1 would not be able to get out of bed. The DON stated this was physical abuse and use of physical restraint because Resident 1 could have the potential for an injury from a fall due to her lack of mobility as her wrists were tied. The DON stated because she (Resident 1) was bound, Resident 1 was restricted, and this would impact Resident 1's sleep. The DON stated that psychosocially this would affect Resident 1's mental status because Resident 1 would be confused why she was unable to move. The DON stated Resident 1's increased chanting was indicative of Resident 1 being agitated because she was bound. The DON stated the scarf was used as a restraint on Resident 1. The DON stated it was not a proper way of using scarf as a restraint. The DON stated there is no policy where the facility can use a scarf as a restraint. The DON stated when a restraint is used, the facility must conduct a total assessment to ensure the resident is able to remove the restraint, must be documented and signed off, and there must be a consent for the use of the restraint. The DON stated there was no assessment and/or consent for the use of a scarf as a restraint for Resident 1. During an interview on 2/2/2026 at 4:44 p.m. with the Adm, the Adm stated he is the facility's abuse coordinator. The Adm stated Resident 1 being tied with a scarf is a form of restraint and it falls under abuse. The Adm stated this would be physical abuse. The Adm stated he believed CNA 1 was the one that tied Resident 1, and it was for the convenience of CNA 1 because Resident 1 was restless during that time. The Adm stated CNA 1 should have been removed immediately from the work schedule once LVN 1 found Resident 1 was bound because there was a potential for CNA 1 to do it to other residents, and can get in the way of the investigation, as well. During a review of the facility's P&P titled, Abuse Prevention and Prohibition Program, last reviewed on 7/28/2025, the P&P indicated, Each resident has the right to be free from abuse, neglect, mistreatment. The facility has zero-tolerance for abuse , neglect, mistreatment. Staff must not permit anyone to engage in . physical abuse, neglect, mistreatment. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff. A. The facility protects residents during investigation of abuse, neglect or mistreatment. B. Facility staff members accused of committing abuse, neglect or mistreatment against a resident are suspended until the investigation is complete and the findings have been reviewed by the Administrator. During a review of the facility's P&P titled, Restraints, last reviewed on 7/28/2025, the P&P indicated, Residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measure shall be used. The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. The facility will ensure that restraints will not be imposed for purposes of discipline or convenience. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to: A. Treat the medical symptom (something a person feels or experiences that may indicate they have a disease or condition); B. Protect the resident's safety; and C. Help the resident attain the highest level of his/her physical or psychological well-being. Except in emergency situation, a physical restraint shall be used only after the interdisciplinary team (IDT) has performed an assessment, attempted to determine and alleviate precipitating factors, determined the need for restraint and identified the least restrictive device. Assessment - An assessment will be completed by a Licensed Nurse prior to the application of any device that restricts movement or access to one's body.

Based on interview and record review, the facility failed to ensure the Medical Doctor (MD) and the Resident Representative (RR) of one of three sampled residents (Resident 1) were notified when on 1/14/2026 at 3 a.m. Certified Nursing Assistant (CNA) 1 who was assigned to Resident 1 allegedly tied Resident 1's hands together at the wrist with a scarf while Resident 1 was in her bed in her (Resident 1) room.This deficient practice had the potential to negatively affect the care and services provided to Resident 1.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/16/2025 with diagnosis including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), muscle weakness (general), and abnormalities of gait (manner of walking) and mobility (ability to move). During a review of Resident 1's Physician History and Physical (H&P- a process used by doctors to understand residents' health which combines medical history and a physical examination), dated 9/5/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Fall Risk Assessment (a process used by healthcare providers to determine a resident's likelihood of falling), dated 12/8/2025, the Fall Risk Assessment indicated Resident 1's fall risk score was 21 meaning Resident 1 was a high risk for fall. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 1 rarely understood and was rarely understood. The MDS indicated Resident 1 was dependent on staff for showering, required substantial assistance (helper does more than half the effort) with upper body dressing, and required partial assistance (helper does less than half the effort) with eating, oral hygiene, toileting, lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 1's Care plan (CP), initiated on 1/14/2026 and revised on 2/4/2026, the CP indicated to educate staff about type of abuse, including physical restraint, prevention measures, how and when to report it, resident safety and rights are respect and psychiatric consult.During a review of Resident 1's Progress Note, dated 1/15/2026 timed at 8:45 a.m., the Progress Note indicated that during the night shift on 1/14/2026 (time not indicated), Resident 1 was restless, yelling on and off and LVN 1 asked CNA 1 to check on Resident 1. The Progress Note indicated that CNA 1 came out from Resident 1's room and stated that Resident 1 was okay and always behaves like this but after approximately 10 minutes later, Resident 1 was again yelling in her language. The Progress Note indicated LVN 1 entered Resident 1's room, saw Resident 1's blanket on the floor, picked up the blanket, and was about to place the blanket on Resident 1, who was lying in her bed, when LVN 1 saw Resident 1's wrist tied in front of her (Resident 1) by what looked like to be a long scarf. The Progress Note indicated LVN 1 untied the scarf and quickly assessed Resident 1 with no visible injury noted. During a review of Resident 1's Interdisciplinary Care Conference (IDT- a meeting where a patient's health team such as doctors, nurses, therapists, and social workers-collaborates to review progress, share expertise, and create a unified, personalized treatment plan) dated 1/16/2026 at 11 a.m., the IDT indicated following an alleged abuse report IDT recommendations MD was contacted and orders were received for Urinary Analysis (UA-test that examines a urine sample's color, chemical makeup, and microscopic content to detect infections, kidney disease, diabetes, and overall health issues), Culture and Sensitivity (C&S- identifies the specific germ [bacteria or fungus] causing an infection and determines which medication best kills it), Complete Blood Count (CBC- blood test that measures the types, numbers, and health of cells in your blood), Comprehensive Metabolic Panel (CMP- a routine blood test that checks 14 different substances to assess your overall health, organ function, and chemical balance) and Thyroid Stimulating Hormone (TSH- checks how well your thyroid gland is working) related to any infection. As an infection can be a contributing factor to restless.During a review of Resident 1's COC Evaluation dated 1/16/2026 at 11:54 a.m. the COC indicated restlessness as discussed during IDT. Resident 1 reported with having restless behavior at night that was discussed during IDT meeting. MD notified and ordered UA with C&S, CBC, CMP and TSH. During a review of Resident 1's Order Audit Report dated 1/16/2026 at 11:59 a.m. the Order Audit Report indicated:- CBC, CMP, TSH, one time only for one day.- UA, C&S one time only for one day.During a review of Resident 1's COC dated 1/17/2026 at 10:39 a.m. the COC indicated UTI. Abnormal UA result noted by RN supervisor. Reported to MD and received order for Macrobid orally 100 milligrams (mg- a unit of measurement) two times a day for urinary tract infection (UTI- an infection in the bladder/urinary tract) for one week. Resident 1 has no pain or discomfort and no fever noted. Family notified. During a review of Resident 1's Order Audit Report dated 1/17/2026 at 10:13 a.m. the Order Audit Report indicated Macrobid oral capsule 100 mg give 100 mg by mouth every 12 hours for UTI for one week. During an interview on 1/28/2026 at 11 a.m. with the DON and the RMN, the DON stated on 1/14/2026 LVN 1 stated she (LVN 1) took a picture showing Resident 1's tied with a silk scarf.During an interview on 1/28/2026 at 11:25 a.m. with CNA 1, CNA 1 stated worked on 1/13/2026 the 11 p.m. to 7 a.m. shift and was the CNA for Resident 1. CNA 1 stated Resident 1 was confused, incontinent, sometimes is quiet and sometimes is not, Resident 1 will try to get out of bed. CNA 1 stated she did not see Resident 1's wrist tied, not sure what happened CNA 1 stated did not tie Resident 1's hands. CNA 1 stated continued to work with Resident 1 until the end of her (CNA 1) shift, was not taken off Resident 1's care. During an interview on 1/28/2026 at 1:02 p.m. with the RMN, the RMN stated when she saw the picture of Resident 1 tied up, RMN stated Resident 1's hands were tied in front on top of each other like a cross, cannot say if the scarf was tight or not. RMN stated when a resident is tied up it can prevent the resident from getting up, the resident would not be able to use the call light. RMN stated Resident 1 is a fall risk, can result in the resident attempting to get up and hurt themselves because their hands are tied, would not be able to catch themselves if falling. The RMN stated can be a potential for Resident 1 not to be able to drink as well. The RMN stated a COC was conducted during IDT on 1/16/2026 and that is when we notified the MD regarding the restlessness and that is when we obtained and order for labs and Resident 1 and was later noted with a UTI. The RMN stated COC form is to note a change in condition in the residents and to conduct and assessment on the resident. The RMN stated there was no COC for 1/14/2026.During an interview on 1/28/2026 at 2:49 p.m. with LVN 1, LVN 1 stated worked on 1/13/2026 11 p.m. to 7 a.m. and on 1/13/2026 around 1:30 a.m. to 2 a.m. heard Resident 1 making sound like Resident 1 was chanting in a different language, LVN 1 stated she (LVN 1) does not speak that language was unable to understand what Resident 1 was saying. LVN 1 stated she asked CNA 1 who was Resident 1's CNA and speaks the same language as Resident 1 what Resident 1 was saying and CNA 1 responded with she (Resident 1) always does that. LVN 1 stated a few minutes later Resident 1 got louder and the chanting increased in frequency then asked CNA 1 to check on Resident 1, CNA1 went into Resident 1's room and Resident 1 got worse, Resident 1 louder and the chanting was constant, CNA 1 then left Resident 1's room. LVN 1 stated around 2:50 a.m. went into Resident 1's room and saw Resident 1's blanket on the floor and thought Resident 1 might be cold. LVN 1 stated she bent down to get the blanket shook the blanket and noted Resident 1's hands were bound. LVN 1 stated Resident 1's hands were bound at the wrist with a scarf, in front of Resident 1 real firm, the resident had no way of getting out there was no wiggle room, Resident 1 would not be able to move hands. LVN 1 stated Resident 1 was tied with a figure eight (8) at least three times, Resident 1 was hog tied. LVN 1 stated prior to removing the scarf took a picture of Resident 1 to show her supervisors, then called the OMB as she untied Resident 1 around 3 a.m. LVN 1 stated when she initially came into Resident 1's room Resident 1 looked relieved and became wiggly she was moving around wanting LVN 1 to see Resident 1 was bound. LVN 1 stated after that looked for CNA1 and she was at the desk, CNA 1 was asleep was snoring.During an interview on 2/2/2026 at 11:35 a.m. with MD1, MD 1 stated was notified a few weeks ago, one of the staff found Resident 1 with a scarf like thing over her wrist tied. MD 1 stated was told the next morning after the incident occurred and tis when he was told about Resident 1's restlessness, it was reported there was no skin issues and MD 1 ordered labs to ensure nothing was going on. MD 1 stated ordered UA and blood test because Resident 1 was more confused than usual. MD 1 stated if Resident 1 is more confused than normal then that would be a new COC. During an interview on 2/2/2026 at 3:19 p.m. with the DON stated was informed by LVN 1 on 1/14/2026 at 7:30 a.m. she had something important to tell them, LVN 1 stated let me show you a picture of a resident who was bound on her wrist and that is when LVN1 showed us the picture. The DON stated the picture showed Resident 1 bound by her wrist side by side with a greenish scarf, to me (DON) could not tell how tight it was but it looked solid there was no way the Resident 1 could have pulled arms apart. The DON stated this is physical abuse, used as a physical restraint, Resident 1 could have encouraged the potential for an injury from a fall due to her lack of mobility as her wrist were tied. The DON stated alleged abuse is considered a COC. The DON stated COC is a communication is a form that communicates with all staff, would have been given to nurses then, communicate to MD, IDT and family. The DON stated if there is no COC for 1/14/2026 allegation of abuse documented then we cannot say the MD, or family were notified of the COC.During a concurrent interview and record review on 2/3/2026 at 9:52 a.m. of Resident 1's Health Status Note with the RMN, the RMN stated there is no COC for Resident 1 on 1/14/2026. The RMN stated the COC would have been specifically for abuse and include the restlessness the restlessness was addressed on the OCC dated 1/16/2026. The RMN stated COC identity the COC, then will initiate 72- hour monitoring. The RMN stated the RN supervisor should have started the COC on 1/14/2026. The RMN reviewed Resident 1's Health Status Note dated 1/16/2026 at 7:25 a.m. and the RMN stated that is when the 72-hour monitoring was started. The RMN stated 72-hour monitoring should have started on 1/14/2026. The RMN stated the 72 hour monitoring is to ensure residents are being checked for their psychosocial wellbeing and any new skin issues like bruising from the restraint and the resident's overall status. The RMN stated there was a delay in Resident 1's restlessness, RMN stated on 1/16/2026 when she spoke to MD1 asked if it was possible for Resident 1 to have a UTI. The RMN stated MD1 was notified but he had no orders at the time and 1/14/2026. The RMN stated basic nursing if not documented cannot say MD was notified, the RMN stated there is no documentation MD was notified on 1/14/2026. During a review of the facility's policy and procedure (P&P) titled, Change of Condition Notification, last reviewed on 7/28/2025, the P&P indicated to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. II. The facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition caused by, but not limited to:b. A significant change in the resident's physical, cognitive, behavioral or functional statusDocumentationA. A Licensed Nurse will document the following:i. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes.ii. The time the Attending Physician was contacted, the method by which he was contacted, the response time, and whether or not orders were received. iii. The time the family/responsible person was contactediv. Update the Care Plan to reflect the resident's current statusv. The incident and brief detail in the 24-hour report C. A Licensed Nurse will document each shift for at least seventy-two (72) hours.

Based on interview and record review, the facility failed to ensure interventions to prevent falls were in place for one of three sampled residents (Resident 3) when Resident 3 had a fall on 11/19/2025 by failing to: 1. Ensure the Situational Background Assessment Recommendation (SBAR - a structured communication tool used primarily in healthcare for concise, clear updates, especially during handoffs or critical situations, ensuring all team members understand the resident's status and needs) Communication Form, dated 11/19/2025, was complete and accurate for Resident 3's Fall. 2. Ensure the Incident Note (IN - a formal, factual document that records any unplanned or unusual event that affects a resident, visitor, or staff member's safety or well-being) for Resident 3's fall on 11/19/2025 was complete and accurate. 3. Ensure Resident 3's Interdisciplinary Care Conference (IDT - a formal meeting where a team of healthcare professionals, along with the resident and their family, come together to discuss, plan, and coordinate the resident's overall care and treatment goals) was accurate to Resident 3's fall on 11/19/2025. These deficient practices had the potential to place Resident 3 at risk for more falls in the facility.Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted Resident 3 on 2/7/2020 and readmitted the resident on 10/29/2025 with diagnoses including age-related osteoporosis (a bone disease that makes bones weak and brittle, like a honeycomb with too many holes, increasing the risk of fractures from even minor falls), glaucoma (a group of eye diseases that damage the optic nerve, often due to increased pressure inside the eye from fluid buildup, leading to gradual, permanent vision loss, usually starting with peripheral [side] vision and potentially causing blindness if untreated), and muscle weakness (generalized). During a review of Resident 3's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling), dated 10/29/2025, the Fall Risk Evaluation indicated Resident 3's fall risk score was 24 (a total score of 10 or greater, the resident should be considered at high risk for potential falls). During a review of Resident 3's Care plan for risk for fall secondary to fall assessment score above 10 representing a high risk, initiated on 10/31/2025, the Care plan indicated interventions that included to keep Resident 3's bed in lowest degree of elevation while in bed, place floor mat next to Resident 3's bed to prevent the resident from injuries and keep environment free of hazards such as wet spots and keep pathways free of clutter. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 11/5/2025, the MDS indicated Resident 1 sometimes understood and was sometimes understood. The MDS indicated Resident 1 was dependent (helper does all the effort) on facility staff for oral hygiene, showering, lower body dressing, putting on and taking off footwear and personal hygiene and required substantial assistance (helper does more than half the effort) from facility staff for toileting and upper body dressing. During a review of Resident 3's SBAR Communication Form, dated 11/19/2025, the SBAR Communication Form indicated Resident 3 had a fall. The SBAR Communication Form Appearance section indicated Resident 3 was awake, verbally responsive, able to make needs known and able to follow commands. The SBAR Communication Form indicated Resident 3 had no change in level of consciousness noted, was able to move all extremities with no pain within previous limitations, offered fluids, and toilet needs met promptly. The SBAR Communication Form Review and Notify section indicated the physician (MD) was notified on 11/19/2025 at 11:15p.m. The SBAR Communication Form indicated the recommendation by the MD was left blank. During a review of Resident 3's Care plan for un-witnessed fall/at risk for injuries, initiated on 11/20/2025, the Care plan indicated interventions included falling star program (initiative used to identify and protect residents at high risk for falls), bilateral floor mats (specialized mats used to cushion falls for at-risk residents who get up unexpectedly to reduce serious injury) next to bed, and continue with rehab evaluation and treatment. During a review of Resident 3's IN, dated 11/20/2025, the IN indicated Resident 3 had an unwitnessed fall on 11/19/2025 at 11:07 p.m. The IN indicated Resident 3 was awake, alert and verbally responsive, able to make needs known and follow commands, able to move all extremities within previous limitation, and with no reported pain or discomfort. The IN indicated Resident 3 had no skin issues or impairment, nor discoloration noticed, all needs met toilet needs assisted promptly, neurological check (assessments of the brain, spinal cord, and nerves to evaluate the nervous system's function, checking mental status, motor skills, balance, reflexes, and senses) started, and will be placed on 72-hour post fall monitoring. The IN indicated to not proceed with Restorative Nurse Assistant (RNA) morning exercise. The MD and family were made aware with no order for transfer to hospital at this time, bed in low position, call light within reach and encouraged to use it for assistance. During a review of Resident 3's IDT, dated 11/20/2025, at 11:25 a.m., the IDT indicated Resident 3 had an unwitnessed fall. The IDT indicated per the report on 11/19/2025 at 11:07 p.m., the charge nurse (CN) observed Resident 3 slide from the bed. The IDT indicated recommendations included placing Resident 3 on the Falling Star Program, placing bilateral floor mats next to the bed, and continue rehab evaluation and treatment. During a review of Resident 3's Fall Risk Assessment, dated 11/24/2025, the Fall Risk Assessment indicated Resident 3's fall risk score was 29 (High Risk). During a concurrent interview and record review on 12/8/2025 at 3 p.m. with the Director of Nursing (DON), Resident 3's SBAR, IN, and IDT were reviewed. The DON reviewed Resident 3's SBAR and IN and stated the reports do not indicate how Resident 3 had the fall. The DON reviewed Resident 3's IDT and stated the IDT looks like the fall was witnessed by the CN but we did not get the correct information for the IDT. The DON stated the SBAR, IN, and IDT should match and be accurate, should be specific to who, what, where, and when. The DON stated if the documentation was not accurate, the staff assigned to the resident will not be able to know how to treat the resident and implement the changes to the care plan. During a review of the facility's policy and procedure (P&P) titled, Documentation, Nursing, last reviewed on 1/2972025, the P&P indicated nursing documentation will be concise, clear, pertinent, and accurate. During a review of the facility's P&P titled, Response to falls, last reviewed on 1/2972025, the P&P indicated investigation will help to identify circumstances or factors contributing to the resident's fall.

Based on interview and record review, the facility failed to report an allegation of an employee-to-resident verbal abuse (harsh and insulting language directed at a person) and physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) within two hours to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). Certified Nursing Assistant (CNA) 1 reported an allegation of abuse to the Director of Nursing (DON) that allegedly occurred on 8/5/2025, committed by Life Enrichment Coordinator (LEC) 1 towards Resident 1. The facility reported the allegation of abuse to the SSA on 8/29/2025, 24 days after the allegation of abuse was made.This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse.Findings:During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 2/10/2023 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the right dominant side, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and dysphagia (a condition that makes it difficult to swallow).During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool), dated 6/25/2025, the MDS indicated Resident 1's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired. During an interview on 9/9/2025 at 12:04 p.m. with RNA 1, RNA 1 stated he saw LEC 1 threw a towel or sweater at Resident 1's face in the dining room. RNA 1 stated he heard LEC 1 yelling at Resident 1. RNA 1 stated LEC 1's actions were considered an alleged verbal and physical abuse. RNA 1 stated he reported the alleged verbal and physical abuse to the DON on 8/29/2025. During an interview on 9/9/2025 at 4:05 p.m. with the Assistant Administrator (AADM), the AADM stated he was the facility's Abuse Coordinator. The AADM stated on 8/29/2025, RNA 1 reported the allegations of verbal and physical abuse that allegedly happened on 8/5/2025. The AADM stated RNA 1 should have reported the allegations of abuse within two hours. The AADM stated he was aware allegations of abuse must be reported within two hours to the SSA, Ombudsman, and law enforcement. During an interview on 9/9/2025 at 4:34 p.m. with the Director of Nursing (DON), the DON stated on 8/29/2025, RNA 1 informed her about the allegation of abuse by LEC 1 to Resident 1 on 8/5/2025. The DON stated not reporting allegations of verbal and physical abuse had the potential for the abuse to continue. The DON stated RNA 1 failed to report the allegation of abuse within 2 hours that led to the facility reporting the allegations on 8/29/2025. During a review of the facility's policy and procedure (PnP) titled, Abuse Prevention and Prohibition Program, last reviewed on 7/23/2025, the PnP indicated, the facility will report allegations of abuse . immediately. no later than two hours after forming the suspicion.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care to attain or maintain the highest practicable physical well-being, when the facility failed to: 1. Complete Resident 1's admission Assessment upon his re-admission to the facility after being transferred to the General Acute Care Hospital (GACH) 1 due to a fall incident. 2. Complete Resident 1's neurological checks for 72 hours post-fall in accordance with the facility's policy and procedure.These deficient practices had the potential to result in Resident 1 receiving inadequate care.Findings: a. During a review of Resident 1's admission Record, dated 8/28/2025, the admission Record indicated Resident 1's diagnoses included atrial fibrillation (a condition where the upper chambers of the heart beat irregularly and too fast), chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe due to damage to the lungs and airways), and vascular dementia (a condition where a lack of blood flow to the brain causes damage, leading to a decline in memory, thinking, and problem-solving skills). During a review of Resident 1's History and Physical Examination (H&P - when a doctor obtains a patient's medical history, performs a physical exam, and documents his/her findings in the patient's medical record), dated 8/14/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/13/2025, the MDS indicated Resident 1 needs substantial assistance with personal hygiene, toileting, and dressing the upper and lower body (a helper does more than half the effort in completing the activity). The MDS indicated Resident 1 needed supervision for eating (a helper provides verbal cues or contact assistance as the resident completes the activity).During an interview on 8/28/2025 at 10:13 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had moments of confusion. LVN 1 stated he found Resident 1 lying on the floor in his room at approximately 2:30 p.m. on 8/25/2025. LVN 1 stated when he asked Resident 1 why he was on the floor, Resident 1 stated that he was trying to go to the bathroom but fell. LVN 1 stated he notified the RN supervisor.During a concurrent interview and record review on 8/28/2025 at 10:33 a.m. with Registered Nurse (RN 1), an Incident Note, dated 8/25/2025, was reviewed. RN 1 stated that on 8/25/2025, LVN 1 notified RN 1 of Resident 1's fall at approximately 2:30 p.m. RN 1 stated that she and a physical therapist entered Resident 1's room and began assessing Resident 1, who was lying on the floor on his left side. RN 1 stated it was determined that Resident 1 should not be moved and that an ambulance should be called. RN 1 reviewed Incident Note dated 8/25/2025, which indicated emergency personnel arrived at 2:55 p.m., and Resident 1 was then transferred to GACH 1 for further evaluation.During a review of Resident 1's Order Summary Report, dated 8/28/2025, the Order Summary Report indicated that on 8/26/2025, Resident 1's doctor ordered for Resident [to] return to the facility and to resume all previous orders. During a concurrent interview and record review on 8/29/2025 at 1:57 p.m. with the Director of Nursing (DON), Resident 1's electronic medical record was reviewed. DON stated that when a resident is transferred to a hospital and subsequently returns to the facility, an admission assessment is done and the assigned nurse must also do a progress note. The DON stated that an admission assessment is important because a baseline status is needed since the facility don't know what was done to the patient in the hospital. The DON reviewed Resident 1's electronic record and could not locate a completed admission assessment related to Resident 1's return to the facility on 8/26/2025. The DON stated an admission assessment should have been done.During a review of the facility's policy and procedure (P&P) titled, admission Assessment, dated 8/30/2019, the P&P indicated the following: Upon admission, a Licensed Nurse will conduct an admission assessment of the resident using NP - 102 - Form A - Resident admission Assessment or alternate form available on the electronic health record platform.b. During a concurrent interview and record review on 8/28/2025 at 10:33 a.m. with RN 1, Resident 1's medical record was reviewed. RN 1 stated that for any unwitnessed fall, the nurses must assess the resident's neurological status for 72 hours after the fall occurs. RN 1 stated the resident's neurological status is to be checked every 15 minutes for 1 hour; followed by every 30 minutes for 1 hour; followed by every hour for 2 hours; and then, every 4 hours until 72 hours have been reached. RN 1 stated the neurological checks are documented on a paper form that is titled, Neurological Assessment Flowsheet. RN 1 reviewed Resident 1's Neurological Assessment Flowsheet, which indicated that Resident 1's neurological status was assessed on 8/25/2025 at 2:20 p.m. and 2:35 p.m. RN 1 stated when Resident 1 was re-admitted to the facility, the assessment of his neurological status resumed on 8/26/2025 at 1:05 a.m. but stopped after 4:05 a.m. RN 1 stated that Resident 1's neurological status was not assessed for 72 hours after he had an unwitnessed fall. During a concurrent interview and record review on 8/29/2025 at 1:57 p.m. with the DON, Resident 1's Neurological Assessment Flowsheet that was initiated on 8/25/2025 was reviewed. The DON stated Resident 1's neuro checks should have been done for 72 hours. The DON stated neurological assessments are important for an unwitnessed fall because we don't know if they hit their head or not, and two days later we could have a bleed [in the brain]. The DON stated if something did happen, we can catch it right away by performing neurological checks. During a review of the facility's policy and procedure (P&P) titled, Neurological Assessment, dated 8/1/2014, the P&P indicated the nurses will perform a neurological assessment.[f]ollowing an unwitnessed fall.for a combined total of 72 hours.

Based on interview and record review, the facility failed to complete a background check for three of three sampled employee files (Licensed Vocational Nurse 1 or LVN1, Registered Nurse 1 or RN1, and Certified Nurse Assistant 1 or CNA1).This deficient practice has the potential to place residents at risk for abuse, neglect, exploitation, or misappropriation of resident property.Findings:During a review of LVN 1's Employee file, Employee file indicated LVN 1 was hired on 6/5/2021. The employee file indicated no documented evidence of criminal background checks. LVN 1 is currently employed in the facility. During a review of RN 1's Employee file, Employee file indicated RN 1 was hired on 3/18/1997. The employee file indicated no documented evidence of a criminal background check. RN 1 is currently employed in the facility. During a review of CNA 1's Employee file, the Employee file indicated CNA 1 was hired on 2/16/1998. The employee file indicated no documented evidence of a criminal background check. CNA1 is currently employed in the facility. Durin an interview with the Director of Staff Development (DSD) on 8/12/2025 at 9:10 a.m., the DSD stated, LVN 1, RN 1, and CNA 1 did not have a background check in their employee files because prior to 2014, the facility did not require new hires to have a background check. DSD stated, she was not working in the facility at that time and does not know what happened prior to 2014. The DSD stated she will submit a background check for the staff. The DSD stated all staff in the facility should have a background check because they need to be cleared from any abuse prior to start of work in the facility.During an interview with the Administrator (ADMIN) on 8/12/2025, ADMIN stated the Facility did not conduct any background checks prior to the year 2014 but was not able to provide a policy to corroborate his statement. During an interview with Director of Nurses (DON) on 8/13/2025 at 4:10 p.m., the DON stated a background check was immediately ordered for LVN 1, RN 1, and CNA 1. The DON stated it is important to have background checks on all staff working in the facility because they need to be cleared of any criminal findings and also be cleared from any abuse.A record review of the facility's policy and procedure titled, Staff Screening, dated August 1, 2023, indicated the facility will utilize reasonable and prudent criminal background screening and reference checks for prospective staff, contractors/consultants, registry/temporary staff, and volunteers. Prior to employment or commencement of a contract, the Facility will verify and document or obtain a copy, if applicable, of the following information that may include, but is not limited to: criminal background checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of six sampled residents (Resident 1) when on 7/25/2025 at approximately 2:30 p.m., Resident 2 threw a four-ounce (oz - a unit of measurement) thickened flavored water cup at Resident 1, inside Room A (Resident 1 and Resident 2's shared room), hitting Resident 1 on the left lower lip. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. On 7/25/2025, Resident 1 sustained a three (3) centimeter (cm - unit of measurement) scratch (a type of wound characterized by damage on the surface of the skin) to Resident 1's left lower lip with bleeding that needed first aid (initial assistance and care given to a resident who has been injured). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 8/19/2024 with diagnoses including cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis [loss of ability to move] of the arm, leg, and trunk on the same side of the body), and dysphagia (difficulty swallowing). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 8/20/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/6/2025, the MDS indicated Resident 1 had moderately impaired cognitive functioning (a decline in a resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions). The MDS further indicated Resident 1 required maximal assistance (helper does more than half of the effort) from staff with oral hygiene, upper body dressing, and was dependent (helper does all of the effort) on staff for toileting hygiene, showers, and personal hygiene. During a review of Resident 1's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form, dated 7/25/2025, timed at 3:51 p.m., the COC form indicated that on 7/25/2025 (time not indicated), CNA 1 entered Room A after hearing shouting between two residents (Resident 1 and Resident 2). The COC form indicated that Resident 1 was observed with blood on the lower lip, resulting from a three cm scratch on Resident 1's left side of the lip. The COC form further indicated that Resident 2 admitted to throwing a four-ounce thickened flavored water cup at Resident 1. The COC form indicated that the scratch on Resident 1's lower lip was cleansed and left open to air (uncovered). The COC form indicated Resident 1 was placed on monitoring for discoloration (change in the skin's natural color) of the affected area, monitoring for the condition of the scratch on the left lower lip, and for signs of emotional distress (a state of significant psychological discomfort or suffering, impacting a person's ability to function normally) related to receiving aggression (behaviors intended to cause harm) from Resident 2. During a review of Resident 1's CP (untitled), initiated on 7/28/2025, the CP indicated that Resident 1 sustained a skin tear (a type of wound where the outer layers of skin separate from each other due to friction, shear or blunt force) on the left side of the mouth due to roommate (Resident 2) throwing a cup of thickened liquid at Resident 1 on 7/25/2025. (Resident 1's COC indicated the injury as scratch.) The CP interventions included cleansing the affected area (Resident 1's left lower lip) with normal saline (a mixture of water and salt). During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/10/2025 with diagnoses including CVA, hemiplegia, and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's H&P dated 2/12/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognitive functioning (the state where a resident's mental processes, including memory, attention, language, reasoning, and executive functions, are working at a normal or expected level for their age and background). The MDS further indicated Resident 2 required moderate assistance (helper does less than half of the effort) from staff with oral hygiene and upper body dressing. The MDS further indicated Resident 2 required maximal assistance from staff with toileting hygiene, showers, and lower body dressing. During a review of Resident 2's COC form, dated 7/25/2025, timed at 2:48 p.m., the COC form indicated that on 7/25/2025 (time not indicated), CNA 1 entered Room A after shouting was heard between two residents (Resident 1 and Resident 2). The COC form indicated Resident 1 was observed with blood on the lip, resulting from a three cm scratch on the left side of Resident 1's lower lip. The COC form further indicated that Resident 2 admitted to throwing a four-ounce thickened flavored water cup at Resident 1. During a review of Resident 2's CP (untitled), initiated on 7/28/2025, the CP indicated that on 7/25/2025, Resident 2 was involved in an incident in which he (Resident 2) threw an object at his roommate (Resident 1). During a review the facility's five-day conclusion report titled, Abuse Investigation Reporting Form, dated 7/28/2025, the report indicated Resident 2 threw a four-ounce thickened flavored cup at Resident 1 on 7/25 2025 at 2:30 p.m. The report indicated Resident 1 had blood on his lip from a three-centimeter scratch on the left side of the lower lip. The report indicated Resident 1's left lower lip scratch was cleaned and left open to air. During an interview on 8/1/2025 at 10:18 a.m., with Resident 2, Resident 2 stated that during an argument with his roommate (Resident 1), in Room A , Resident 1 used profanity (offensive language) towards him (Resident 2) after which Resident 2 threw a cup at Resident 1, hitting Resident 1 in the face (left lower lip). Resident 2 was unable to recall the exact date and time of the incident. During an interview on 8/1/2025 at 1:18 p.m., with LVN 1, LVN 1 stated the incident (Resident 2 threw a cup at Resident 1) happened at approximately 2:30 p.m., (unable to recall the exact date of the incident). LVN 1 stated LVN 2 requested assistance from her (LVN 1) to provide translation in Room A. LVN 1 stated that during the interview with Resident 1, Resident 1 stated that he (Resident 1) had asked Resident 2 to lower the television volume, at which point Resident 2 threw a cup at Resident 1. LVN 1 further stated that during a separate interview (on 7/25/2025) with Resident 2, Resident 2 admitted to throwing an object (cup) from his (Resident 2's) meal tray at Resident 1 to scare him (Resident 1). LVN 1 further stated Resident 1 was observed to have a scratch on the lower lip. LVN 1 stated that the incident between Resident 1 and Resident 2 was physical abuse. LVN 1 further stated that Resident 2 could potentially hit Resident 1 in the head, which could result in a hematoma (a localized collection of blood outside of blood vessels, often resulting in a swollen, painful lump or bruise [an injury where blood vessels under the skin break, causing blood to leak into surrounding tissues]), or other serious injuries. During an interview on 8/1/2025 at 1:28 p.m., with LVN 2, LVN 2 stated that on 7/25/2025 (unable to recall the exact time of the incident), he (LVN 2) observed CNA 1 exiting Room A and requesting assistance. LVN 2 stated upon entering Room A, LVN 2 observed Resident 1 with bleeding from a scratch on the mouth. LVN 2 stated that during an interview (on 7/25/2025), with LVN 1 providing translation services, Resident 2 admitted to throwing a cup at Resident 1. LVN 2 further stated that the incident between Resident 1 and Resident 2 was a resident-to-resident physical abuse (refers to situations where one resident intentionally inflicts physical harm on another resident). During an interview on 8/4/2025 at 12:05 p.m., with the Director of Nursing (DON), the DON stated that the incident between Resident 1 and Resident 2 was a resident-to-resident physical abuse resulting in Resident 1 sustaining a scratch on his (Resident 1) mouth (left lower lip). The DON further stated that the incident had the potential to negatively affect Resident 1's psychosocial (refers to the interplay between psychological factors [thoughts, feelings, behaviors] and social factors [relationships, environment, culture]) well-being. During an interview on 8/4/2025 at 12:40 p.m., with the Administrator, the Administrator stated that the incident between Resident 1 and Resident 2 was a physical abuse that resulted in Resident 1 sustaining a scratch on his mouth (left lower lip). During a review of the current facility-provided policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, last reviewed on 7/28/2025, the P&P indicated, To ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to . protect residents, and to ensure a standardized methodology for the prevention . of abuse . in accordance with federal and state requirements. Each resident has the right to be free from abuse. The facility has zero-tolerance for abuse . Staff must not permit anyone to engage in . physical abuse. The Facility is committed to protecting residents from abuse by anyone, including but not limited to . other residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of 13 sampled residents (Resident 21 and Resident 20) were provided care in accordance with professional standards of practice. For Resident 21 (who was dependent on staff for eating), after the breakfast dining observation, the head-of-bed (HOB) was not elevated which caused an increased risk to Resident 21 for aspiration (when food or liquid goes into the airway instead of the esophagus). For Resident 20, the 72-hour daily shift charting was incomplete when the resident had a change in condition regarding weight loss which caused a potential for Resident 20's oral intake to go unmonitored and further weight loss. Cross reference F726 Findings:a. During a review of Resident 21’s admission Record (AR), the AR indicated the facility admitted Resident 21 on 11/9/2024 with diagnoses including subdural hemorrhage (collection of blood between the brain's outer membrane and the brain itself) without loss of consciousness, Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills, a progressive decline in mental abilities), dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), muscle weakness, and dysphagia (difficulty swallowing).
During a review of Resident 21’s care plan titled, “Therapeutic Diet Secondary to Dysphagia,” initiated on 2/2/2024, the care plan interventions indicated to follow safe swallowing precautions and to have Resident 21 participate in the Restorative Nursing Assistant ([RNA] nursing aide program to help residents maintain their function and joint mobility) dining program for breakfast and lunch.
During a review or Resident 21’s Speech Language and Pathology ([SLP] profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) Evaluation, dated 4/14/2025, the SLP Evaluation indicated recommendations for a puree diet (food altered into a smooth and creamy texture for people with difficulty chewing or swallowing) and all liquids. The SLP Evaluation indicated strategies to facilitate safety including upright posture for more than 30 minutes after meals.
During a review of Resident 21’s Minimum Data Set (MDS- a resident assessment tool), dated 5/25/2025, the MDS indicated Resident 21 had difficulty communicating words or finishing thoughts, usually understood verbal content, and was moderately impaired for daily decision making. The MDS indicated Resident 21 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for eating.
During a review of the Physician’s Order, dated 5/27/2025, the Physician’s Order indicated to provide passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) to both arms as tolerated every day shift for Resident 21. The Physician’s Order indicated to provide Resident 21 active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to both legs as tolerated every day shift, and ambulation with assistance daily as tolerated every day shift.
During an observation on 7/16/2025 at 8:28 a.m. in Resident 21’s room, Resident 21 was lying flat while asleep in bed. Resident 21’s breakfast tray was on top of the bedside table and appeared untouched.
During an observation on 7/16/2025 at 8:59 a.m. in Resident 21’s room, Resident 21’s HOB was elevated in an upright posture while Restorative Nursing Assistant 5 (RNA 5) was sitting in a chair next to Resident 21’s bed. Resident 21 drank milk from an open cup which RNA 5 brought to Resident 21’s mouth. Resident 21 then ate a spoonful of food. RNA 5 stated Resident 21 was holding liquids in the mouth and did not swallow. RNA 5 stated Resident 21 ate 10 percent [%] of the food tray.
During a concurrent observation and interview on 7/16/2025 at 9:13 a.m. in Resident 21’s room, RNA 5 lowered Resident 21’s HOB and positioned the bed completely flat. RNA 5 stated the HOB should be slightly elevated after eating but Resident 21 ate almost nothing. RNA 5 proceeded to provide ROM exercises for both arms and legs while Resident 21 lay flat in bed. RNA 5 completed Resident 21’s exercises on 7/16/2025 at 9:30 a.m. Resident 21 continued to lay flat with the HOB lowered completely. RNA 5 stated Resident 21’s HOB should be elevated after eating but did not eat much today. RNA 5 proceeded to slightly elevate Resident 21’s HOB.
During an interview on 7/16/2025 at 9:33 a.m., RNA 5 stated the HOB was lowered to a flat position to make Resident 21 more comfortable while providing ROM exercises. RNA 5 stated Resident 21 could choke or vomit if the bed was flat after eating. RNA 5 stated Resident 21 ate a few spoons of food and basically ate nothing.
During a review of Resident 5’s SLP Evaluation, dated 7/16/2025, the SLP Evaluation indicated recommendations for a puree diet and thin liquids. The SLP Evaluation also indicated strategies to facilitate safety including upright posture for more than 30 minutes after meals.
During a telephone interview on 7/18/2025 at 8:26 a.m. with Speech Language Pathologist (SLP) SLP 1 stated Resident 21’s recommendations for upright posture during meals and more than 30 minutes after meals were to ensure safety, including ensuring the food did not come up the throat and into the trachea (tube-like structure that connects the larynx (voice box) to the lungs) and lungs. SLP 1 stated any type of material that entered the lungs could build up bacteria and result in infection. SLP 1 stated the HOB should be slightly elevated even if Resident 21 ate a small amount. SLP 1 stated Resident 21 should not lay flat after eating because the body did not have time to digest the food, can increase the risk of the food coming back up the throat to aspirate into the lungs, and can increase the risk of aspiration.
During an interview on 7/18/2025 at 3:36 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated a resident (in general) should have the HOB raised completely while eating. The DON stated the HOB should remain elevated for at least 30 minutes after eating, even a small amount, to prevent aspiration. The DON stated that placing a resident flat in bed after eating increased the risk of aspiration. The DON stated Resident 21’s ROM exercises could have been completed with the head-of-bed elevated.
During a review of the facility’s policy and procedure (P&P) titled, “Eating and Swallowing: Nursing Manual – Restorative Nursing Program,” revised 3/1/2015 and reviewed 4/28/2025, the P&P indicated the RNA would promote safe swallowing through proper positioning and have knowledge of aspiration.
During a review of the facility’s P&P titled, “Care and Services: Nursing Manual – Nursing Care,” revised 7/1/2016 and reviewed 4/28/2025, the P&P indicated the residents were provided with the necessary care and services to maintain the highest level of functioning in an environment that enhances quality of life.
b. During a review of Resident 20’s AR, the AR indicated the facility originally admitted Resident 20 on 3/8/2021 and readmitted the resident on 11/29/2024 with diagnoses including dementia, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dysphagia, and generalized muscle weakness.
During a review of Resident 20’s History and Physical (H&P) dated 5/14/2025, the H&P indicated Resident 20 did not have the capacity to understand and make decisions.
During a review of Resident 20’s CP titled, “Therapeutic Diet Secondary to Dysphagia,” last revised on 5/14/2025, the CP indicated to monitor tolerance of food, monitor oral intake by percentage for breakfast, lunch, and dinner, and setup, prompt, supervise, and/or assist resident at mealtime as a few of the interventions in place to prevent further weight loss.
During a review of Resident 20’s MDS, dated [DATE], the MDS indicated Resident 20 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding), was able to make her needs known and usually had the ability to understand others. The MDS indicated Resident 20 required setup or clean-up assistance with eating and substantial / maximal assistance to totally dependent on staff with all other activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 20’s Change of Condition (COC -major decline or improvement in a resident’s status that will not resolve itself without intervention) form dated 7/10/2025, the COC form indicated to monitor Resident 20 for 72 hours for weight loss of 16 pounds (lbs – a unit of measurement) over 180 days.
During a review of Resident 20’s progress notes from 7/10 - 7/13/2025, there was no documented evidence of a 72 hour monitoring addressing Resident 20’s weight loss.
During a concurrent interview and record review on 7/18/2025 at 10:57 a.m., Resident 20’s COC form and progress notes were reviewed with the Risk Management Nurse (RMN). The RMN stated if a resident had a change in condition, licensed nurses would do a shift charting for 72 hours and should include what happened or what was the problem, vital signs, family and physician notification, and the response from the physician. The RMN stated at each station there was a paper on a clipboard to list the name of residents who had a COC or require special charting, and the charting should be done every shift for 72 hours. The RMN stated the RN supervisor or whoever wrote the COC on the resident would write the resident’s name on the form which would serve as a form of communication between the outgoing and incoming charge nurse. The RMN stated there was no documented evidence Resident 20 was monitored every shift for 72 hours addressing the resident’s weight loss of 16 lbs. in 180 days. The RMN stated the last progress note documented for Resident 20 in the electronic health record was 7/5/2025 at 8:39 p.m. for behavioral changes. The RMN stated the shift charting monitoring Resident 20’s weight loss should have been done for 72 hours to ensure Resident 20’s intake was monitored, resident was encouraged to eat, assisted with eating, and offered alternatives if refusing meals which could lead to further weight loss.
During an interview on 7/18/2025 at 2:30 p.m., the ADON stated for any change in resident's condition, charting the resident's name was placed on a clipboard at the nurses’ station on the list of residents who needed shift charting for 72 hours. The ADON stated the RN supervisors also had their own list in their binder. The ADON stated the purpose of the charting list was to remind the charge nurse of the residents that had a recent COC or residents who required special charting and were supposed to be documented every shift for 72 hours under the progress notes in the electronic health record. The ADON stated Resident 20’s 72-hour charting was not done from 7/10 to 7/13/2025 addressing the resident’s weight loss. The ADON stated Resident 20’s 72-hour shift charting should have been done to ensure the amount of Resident 20’s oral intake was monitored, offered assistance when needed, and offered alternatives if refusing meals. The ADON stated if Resident 20 was not monitored properly, it could lead to further weight loss.
During a review of the facility’s P&P titled, “Documentation – Nursing, last reviewed on 4/28/2025, the P&P indicated a purpose to provide documentation of resident status and care given by the nursing staff. The P&P further indicated alert charting was documentation done to track a medical event for a period of 72 hours or longer. Events may include but are not necessarily limited to suspected or actual change in condition. Alert charting describes what was going on such as the resident's condition, use the resident's own words if needed, describe what was done in response to what was going on with the resident, and describe how the resident responded to the actions.
During a review of the facility’s P&P titled, “Change of Condition,” last reviewed on 4/28/2025, the P&P indicated an acute change of condition was a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. A licensed nurse would document each shift for at least 72 hours. Documentation pertaining to change in the resident's condition would be maintained in the resident's medical record and on the 24-hour report.

Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to one of five sampled residents (Resident 6) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760 Findings: During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 1/27/2017, with diagnoses including long term use of insulin, type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic chronic kidney disease (a kidney disease caused by diabetes), and hyperglycemia (high blood sugar). During a review of Resident 6's History and Physical (H&P), dated 3/15/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 6/3/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and sometimes had the ability to understand others and had severely impaired cognition (a significant and noticeable decline in a person's thinking abilities, making it difficult for them to perform everyday tasks and live independently). The MDS indicated Resident 6 was on a high-risk drug class hypoglycemic medication (a group of drugs used to help reduce the amount of sugar present in the blood). During a review of Resident 6's Order Review History Report, the Order Review History Report indicated an order for: - 3/15/2025 Admelog SoloStar Subcutaneous Solution Pen-injector 100 unit per milliliters (unit/ml, the amount of insulin in a specific volume of liquid) (Insulin Lispro). Inject as per sliding scale (a customized guide that tells someone with diabetes how much insulin to inject before meals or at specific times, based on their current blood sugar level): if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals related to type 2 diabetes mellitus with hyperglycemia (E11.65). Call MD if fingerstick blood sugar (a blood glucose test mainly screens for diabetes by measuring the level of glucose [sugar] in your blood) is above 400 or below 70. -6/15/2025 Basaglar KwikPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine). Inject 60 units subcutaneously in the morning related to type 2 diabetes mellitus with hyperglycemia (E11.65) before meals (AC) breakfast. During a review of Resident 6's Care Plan (CP) Report titled Diabetes Mellitus: At risk for hyper/hypoglycemia (low blood sugar) episodes, initiated on 1/27/2017, the CP indicated an intervention to administer Lispro insulin per sliding scale and Basaglar Kwik pen sq in the morning as ordered. During a review of Resident 6's Location of Administration Report of insulin for 5/2025 to 7/2025, the Location of Administration Report indicated that insulin: -Admelog Solostar Subcutaneous Solution Pen-injector 100 unit/ml was administered on, 5/6/2025 at 4:23 p.m. on the Abdomen-Left Lower Quadrant (LLQ) 5/7/2025 at 6:28 a.m. on the Abdomen-LLQ 5/10/2025 at 4:15 p.m. on the Abdomen-LLQ 5/11/2025 at 6:58 a.m. on the Abdomen-LLQ 5/16/2025 at 4:27 p.m. on the Abdomen-Right Lower Quadrant (RLQ) 5/17/2025 at 6:37 a.m. on the Abdomen-RLQ 5/18/2025 at 4:13 p.m. on the Abdomen-LLQ 5/19/2025 at 6:14 a.m. on the Abdomen-LLQ 6/7/2025 at 4:20 p.m. on the Abdomen-LLQ 6/8/2025 at 4:11 p.m. on the Abdomen-LLQ 6/20/2025 at 4:01 p.m. on the Abdomen-LLQ 6/21/2025 at 5:47 a.m. on the Abdomen-LLQ 6/23/2025 at 4 p.m. on the Abdomen-Left Upper Quadrant (LUQ) 6/24/2025 at 4:42 p.m. on the Abdomen-LUQ 7/8/2025 at 6:33 a.m. on the Abdomen-Right Upper Quadrant (RUQ) 7/8/2025 at 4:28 p.m. on the Abdomen-RUQ -Basaglar KwikPen Subcutaneous Solution Pen-injector 100 unit/ml was administered on, 5/4/2025 at 7:05 a.m. on the Abdomen-RLQ 5/5/2025 at 7:03 a.m. on the Abdomen-RLQ 5/6/2025 at 7:24 a.m. on the Abdomen-RLQ 5/7/2025 at 6:29 a.m. on the Abdomen-LLQ 5/8/2025 at 6:55 a.m. on the Abdomen-LLQ 5/11/2025 at 6:59 a.m. on the Abdomen-LLQ 5/12/2025 at 6:13 a.m. on the Abdomen-LLQ 5/17/2025 at 6:38 a.m. on the Abdomen-RLQ 5/18/2025 at 7:21 a.m. on the Abdomen-RLQ 5/21/2025 at 7:13 a.m. on the Abdomen-RLQ 5/22/2025 at 7:24 a.m. on the Abdomen-RLQ 5/26/2025 at 6:54 a.m. on the Abdomen-LLQ 5/27/2025 at 6:32 a.m. on the Abdomen-LLQ 5/28/2025 at 6:26 a.m. on the Abdomen-RLQ 5/29/2025 at 6:41 a.m. on the Abdomen-RLQ 6/13/2025 at 6:51 a.m. on the Abdomen-LLQ 6/14/2025 at 6:22 a.m. on the Abdomen-LLQ 6/20/2025 at 6:33 a.m. on the Abdomen-RLQ 6/21/2025 at 5:50 a.m. on the Abdomen-RLQ During a concurrent interview and record review on 7/17/2025, at 3:59 p.m., with Licensed Vocational Nurse (LVN) 12, reviewed Resident 6's Medical Diagnosis, Order Review History Report, Medication Administration Record (MAR), Location of Administration of insulin for 5/2025 to 7/2025, and Care Plan. LVN 12 stated there were multiple instances where the licensed nurses did not rotate insulin administration sites to the resident. LVN 12 stated the licensed nurses should rotate insulin administration sites to prevent tissue damage such as lipodystrophy. LVN 12 stated injecting insulin on the sites of lipodystrophy affects the absorption of the medication that can cause the resident to have hypo/hyperglycemia. During an interview on 7/18/2025, at 10 a.m., with Registered Nurse (RN) 4, RN 4 stated the licensed staff should rotate insulin administration sites on Resident 6. RN 4 stated they rotate injection sites to prevent the tissues of frequented sites of administration from hardening, lipodystrophy, and the absorption of insulin will not be effective, causing the residents to have a high blood sugar level. During an interview on 3/18/2025, at 1:39 p.m., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated the licensed staff should have rotated the sites of insulin administration to Resident 6 to prevent infection, skin irritation, big purple areas on the skin, and lipodystrophy. The DON stated injecting insulin on the sites with lipodystrophy can predispose the resident to hypoglycemia. During a review of the facility's recent policy and procedure (P&P) titled Subcutaneous Injection/Insulin or Heparin, last reviewed on 4/28/2025, the P&P indicated injection sites will be rotated to avoid unnecessary trauma to tissues and aid in medication absorption. Hardened or painful areas will not be used for injection. To establish more consistent blood insulin levels, rotate insulin injection sites within anatomic regions. Preferred insulin injection sites are the arms, abdomen, thighs, and buttocks. During a review of the facility-provided Highlights of Prescribing Information on the use of Admelog (insulin lispro) injection, for subcutaneous or intravenous use, with initial U.S. approval in 2017, the Highlights of Prescribing Information indicated to administer ADMELOG by subcutaneous injection into the abdominal wall, thigh, upper arm, or buttocks within 15 minutes before a meal or immediately after a meal. Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility-provided Highlights of Prescribing Information on the use of Basaglar (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2015, the Highlights of prescribing Information indicated to rotate injection sites into the abdominal area, thigh, or deltoid to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.

**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 (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for four of the five sampled residents (Residents 117, and 106, 72 and 224) by failing to: 1. Ensure a care plan was developed for Resident 117's diagnosis of pneumonia (lung infection). 2. Ensure a care plan was developed for Resident 106's use of azithromycin (antibiotic medication used to treat infection). 3. Ensure a care plan was developed for Resident 72's refusal to remove the wheelchair on top of the floor mat (a cushioned floor pad designed to help prevent injury should a person fall). 4. Ensure a care plan was developed timely for Resident 224's involvement on a resident-to-resident altercation. These failures had the potential to result in delays in the delivery of necessary care and services. Findings:1). During a review of Resident 117’s admission Record, the admission Record indicated the facility admitted Resident 117 on 5/29/2025, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and generalized muscle weakness.
During a review of Resident 117’s History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 6/6/2025, the H&P indicated Resident 117 had fluctuating capacity to understand and make decisions.
During a review of Resident 117’s Minimum Data Set (MDS-a resident assessment tool), dated 6/11/2025, the MDS indicated Resident 117’s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.
During a review of Resident 117’s Order Audit Report (Physician Order), dated 6/23/2025, the Order Audit Report indicated an order to administer amoxicillin potassium clavulanate (medication used to treat infection) tablet 875-125 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount), one tablet by mouth every 12 hours for bacterial infection/pneumonia for five days.
During a concurrent interview, and record review on 7/15/2025, at 9:52 a.m., with the IP, Resident 117’s Care Plans were reviewed. The IP stated there was no care plan developed for Resident 117’s pneumonia. The IP stated a care plan should have been created. The IP stated the care plan indicates the goals and intervention to be provided to the residents.
2). During a review of Resident 106’s admission Record, the admission Record indicated the facility admitted Resident 106 on 4/8/2025, with diagnoses that included Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia and generalized muscle weakness.
During a review of Resident 106’s H&P, dated 4/9/2025, the H&P indicated Resident 106 had fluctuating capacity to understand and make decisions.
During a review of Resident 106’s MDS, dated [DATE], the MDS indicated Resident 106’s cognitive skills for daily decisions were moderately impaired.
During a review of Resident 106’s Order Audit Report, dated 6/3/2025, the Order Audit Report indicated an order to administer azithromycin tablet 250 mg, two tablets by mouth in the afternoon for bronchitis (an inflammation of the bronchial tubes, the airways that carry air to your lungs) for one day and administer one tablet by mouth for four days on day two administer four.
During a concurrent interview, and record review on 7/15/2025, at 9:52 a.m., with the IP, Resident 106’s Care Plans were reviewed. The IP stated there was no care plan developed for Resident 106’s use of azithromycin on 6/3/2025. The IP stated care plan should have been created for the use of azithromycin.
During an interview on 7/16/2025, at 2:55 p.m., with the Assistant Director of Nursing (DON), the ADON stated a care plan should have been developed for Resident 117’s pneumonia and especially for Resident 106’s use of antibiotics. The ADON stated that without a care plan, it could exacerbate the signs and symptoms of pneumonia or bronchitis or whatever the infection. The ADON stated that without a care plan, nursing care would not be followed because there was no care plan to guide the nurses.
During an interview on 7/16/2025, at 4 p.m., with the Director of Nursing (DON), the DON stated a care plan should have been created for the diagnosis of pneumonia and the use of azithromycin. The DON stated the care plan helps the nurses for continuity of care. The DON stated the care plan guides the nurses on how to take care of the residents. The DON stated that without the care plan, infection could not be treated, and infection could prolong.
During a review of the facility’s policy and procedure (P&P), titled, “Care Planning” dated 10/24/2022, and last reviewed on 4/28/2025, the P&P indicated, “To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and interdisciplinary team (IDT- a coordinated group of experts from several different fields who work together) work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs…. Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. These subsequent changes will not need to be reflected through updates to the Baseline Care Plan….
IX. Each resident's Comprehensive Care Plan will describe the following:
A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.”
3). During a review of Resident 72’s admission Record, the admission Record indicated the facility admitted the resident on 1/6/2023, with diagnoses including Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), age-related osteoporosis (is a condition that weakens bones, increasing the likelihood of fractures), and repeated falls.
During a review of Resident 72’s Care Plan (CP) Report titled “At Risk for fall secondary to repeated falls/antihypertensive (medications used to treat high blood pressure, also known as hypertension) medication,” initiated on 1/9/2024, the CP indicated an intervention to keep the environment free of hazards such has wet spots and keep the pathway free from clutter.
During a review of Resident 72’s Order Review History Report, dated 2/26/2024, the Order Review History Report indicated an order that Resident 72 may have a floor mat next to the bed to prevent injuries every shift.
During a review of Resident 72’s History and Physical (H&P), dated 1/1/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 72’s Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated the resident required substantial to supervision assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 72’s Fall Risk Assessment, dated 6/3/2025, the Fall Risk Assessment indicated the resident was at a high risk for falls.
During a concurrent observation and interview on 7/14/2025, at 2:28 p.m., with Licensed Vocational Nurse (LVN) 7, while inside Resident 72’s room, Resident 72’s floor mat was observed at the right side of the bed with a wheelchair on top of them. LVN 7 stated the resident placed them himself despite explanation of the risks it may bring. LVN 7 stated it was care planned. LVN 7 stated she was aware of the dangers that it could bring to the resident such as a fall with injury.
During a concurrent interview and record review on 7/18/2025, with Registered Nurse (RN) 4, Resident 72’s Medical Diagnosis, Order Review History Report, and Care Plan were reviewed. RN 4 stated she cannot find the care plan of the resident refusing to remove the wheelchair on top of the resident’s floor mat. RN 4 stated the floor mat of Resident 72 should be clear of objects or furniture, because it could cause a fall with injury and has to be care planned if the resident refuses to remove the wheelchair on top of the mat. RN 4 stated the care plan serves as a “Bible” for healthcare providers on what interventions that are needed to be done to the resident to provide quality care.
During an interview on 7/18/2025, at 1:39 p.m., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated they use the floor mat to reduce the injury of a resident’s fall at the facility. The DON stated there should be no equipment or furniture on top of the fall mat as it causes instability of furniture placed on top of them and the furniture can land on the resident causing injury such as skin tears, trauma, and fracture. The DON also added that the furniture or equipment placed on top of the floor mat can damage the mat by creating a permanent dent, or tear on the mat compromising its ability to absorb the impact of the resident’s fall. The DON stated the refusal of the resident to remove the wheelchair on top of the floor mat should be care planned to communicate to the healthcare team that the resident is refusing despite explanation of the risks it could pose on Resident 72.
During a review of the facility's recent policy and procedure (P&P) titled Care Planning, last reviewed on 4/28/2025, the P&P indicated to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including comprehensive and quarterly review assessments.
During a review of the facility's recent P&P titled Safety-Environmental, last reviewed on 4/28/2025, the P&P indicated to ensure a safe, clean, and hazard-free environment for all residents, in compliance with Title 22 of the California Code of Regulations, promoting their well-being, dignity, and quality of life.
During a review of the undated facility-provided Floor Mat 1 Manufacturer’s Specification, the Manufacturer’s Specification indicated when moving equipment across the mat ensure that the wheels are not locked as “dragging wheels” may damage the mat. Avoid sharp materials from contacting the mat. Never leave heavy materials on the mat for an extended amount of time and they may cause a permanent indentation.
4). During a review of Resident 224’s admission Record, the admission Record indicated the facility originally admitted Resident 224 on 3/23/2022 and readmitted in the facility on 5/12/2024 with diagnoses including Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).
During a review of Resident 224’s H&P, dated 5/1/2025, the H&P indicated Resident 224 did not have the capacity to understand and make decisions.
During a review of Resident 224’s MDS, dated [DATE], the MDS indicated Resident 224 had severely impaired cognition (mental action or process of acquiring knowledge and understanding), and usually had the ability to make self-understood and to understand others. The MDS indicated Resident 224 required partial/moderate assistance with eating and was totally dependent on staff with all other activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 224’s Change of Condition (COC-(major decline or improvement in a resident’s status that will not resolve itself without intervention) form dated 6/28/2025, the COC form indicated Resident 224 was struck on the head and right lower extremity by another resident (Resident 45) with a cane.
During a review of Resident 224’s care plan (CP) titled, “Psychosocial: Altercation Peer to Peer,” was initiated on 6/29/2025.
During a concurrent interview, and record review on 7/18/2025, at 9:16 a.m. Resident 224’s electronic health record including care plans, and COC with Registered Nuse (RN) 4. RN 4 stated the resident-to-resident altercation happened on 6/28/2025 on a weekend. RN 4 stated the CP regarding the incident was developed on 6/29/2025. RN 4 stated RN 4 stated she did not develop the CP regarding the incident. RN 4 stated she should have developed the CP after the incident happened. RN 4 stated the purpose of the CP serves as the communication tool between staff to properly care for Resident 224 especially with an incident of physical abuse. RN 4 stated if the care plan was not developed in a timely manner, the staff would not be aware of the proper interventions to take care of the residents which could have affected Resident 224 psychosocially and physically which may lead to a delay in the care the residents needed.
During an interview on 7/18/2025 at 10:15 a.m. with the Risk Management Nurse (RMN), the RMN stated the care plan that Resident 224 was involved in a resident-to-resident altercation should have been created on the day of the incident to prevent delay in the delivery of care and services Resident 224 needed as the CP includes the proper intervention necessary to be able to take care of the resident properly.
During an interview on 7/18/2025 at 1:39 p.m., with the Director of Nursing (DON) and Assistant DON (ADON), the DON stated care plans should be developed immediately if an incident such as a fall incident and abuse happens even during the weekend. There is no need for the nurses to wait for the care planners to come on the following business day. The DON stated a care plan addressing Resident 224’s altercation with another resident was not developed timely. The ADON stated the care plan for Resident 224 addressing the altercation with another resident should have been developed immediately to ensure that all the interventions needed are in place, that the plan of care is followed, and that the team is aware of what interventions are in place to meet Resident 224’s needs. The DON stated if the care plan was not developed timely, the interventions would be delayed to ensure Resident 224 was protected from the altercation.
During a review of facility’s policy and procedure (P&P), titled, “Care Planning,” last reviewed on 4/28/2025, the P&P indicated a purpose to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The P&P further indicated:
- The care plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and interdisciplinary team (IDT- a coordinated group of experts from several different fields who work together) work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.
- Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay.
- Each resident’s care plan will describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and psychosocial well-being.

Based on interview and record review, the facility failed to report an allegation of staff to resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) immediately, but no later than two hours after the allegation was made to the State Survey Agency (CDPH - California Department of Public Health), the Ombudsman (a resident advocate), and local law enforcement (LLE) in accordance with federal and state law for one of three sampled residents (Resident 16) reviewed under the Abuse care area. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from harm from abuse. Findings:During a review of Resident 16's admission Record (AR), the AR indicated the facility originally admitted the resident on 9/12/2022 and most recently admitted the resident on 4/17/2025 with diagnoses that included congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). During a review of Resident 16's Minimum Data Set (MDS - resident assessment tool), dated 6/17/2025, the MDS indicated the resident sometimes was able to understand others and sometimes was able to make themself understood. The MDS further indicated that the resident required substantial/maximal assistance from staff with dressing; and was dependent on staff for toileting, oral and personal hygiene, and bathing. During a review of Resident 16's History and Physical (H&P), dated 6/12/2025, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 16's Change of Condition (COC) Progress Notes completed by Registered Nurse (RN) 3, dated 7/5/2025 at 4 p.m., the COC Progress Notes indicated Resident 16 reported an allegation of being pushed by a staff member. Monitoring for abuse, neglect, and emotional distress were started and the Director of Nursing (DON) was notified. During a review of Resident 16's Incident Note, dated 7/5/2025 at 4 p.m., completed by RN 3, the Incident Note indicated there would be an investigation of alleged abuse and the Administrator (ADM) was informed. During a review of Resident 16's Order Review History Report, dated 7/17/2025, the Order Review History Report indicated a physician's order to monitor for signs and symptoms of emotional distress, neglect, and abuse every shift for 14 days, dated 7/5/2025. During a review of the facility provided email titled, Allegation of Abuse, dated 7/8/2025, at 10:32 a.m., the email indicated on 7/7/2025 at 10:32 a.m. the ADM reported an allegation of abuse to CDPH, the Ombudsman, and LLE. During a review of the facility provided SOC 341 (a report of suspected dependent adult/elder abuse) form, dated 7/7/2025, the SOC 341 indicated an allegation of alleged abuse had begun for Resident 16. The SOC 341 indicated CDPH, Ombudsman, and LLE were notified. The SOC 341 indicated there were blank information boxes for the date and time CDPH, the Ombudsman, and LLE were notified. During a concurrent interview and record review on 7/16/2025 at 8:35 a.m. with the ADM, the SOC 341 form, dated 7/7/2025, was reviewed. The ADM stated the ADM is the facility abuse coordinator. The ADM stated the facility policy is to immediately, but not later than two hours from learning of the allegation, report an allegation of abuse to CDPH, the Ombudsman, and LLE. The ADM stated the proper authorities should be notified to investigate and ensure the resident is safeguarded. The ADM stated on 7/5/2025 at about 2:45 p.m., CNA 5 reported to LVN 6 that Resident 16 alleged that on 7/4/2025 CNA 7 grabbed Resident 16's hands, crossed the arms on the resident's chest, then pushed on the resident's chest. The ADM stated on 7/5/2025, the ADM was sent a text message that indicated Resident 16 made the allegation of abuse, but the allegation was not reported to CDPH, the Ombudsman, and LLE until 7/7/2025 due to confusion over who would report the allegation. The ADM stated all the facility staff caring for Resident 16 were mandated reporters (someone legally obligated to report suspected abuse or neglect to the appropriate authorities), and it was everyone's job to follow up to ensure the ADM reported Resident16's allegation of abuse at the time of the allegation, but they did not. The ADM stated the facility policy and procedure (P&P) was not followed when Resident 16's allegation of abuse was not reported within 2 hours of learning of the allegation. During an interview on 7/16/2025 at 9:40 p.m. with LVN 6, LVN 6 stated on 7/5/2025 in the morning, Resident 16 made an allegation of abuse. LVN 6 stated LVN 6 reported the allegation of abuse at 2:45 p.m. on 7/7/2025 to RN 3, the ADM, and the DON. LVN 6 stated LVN 6 waited until 2:45 p.m. to report the allegation because LVN 6 wanted to monitor Resident 16. LVN 6 stated the ADM did not respond to LVN 6's text message, but the DON did respond and was aware of the allegation. During an interview on 7/18/2025 at 11:53 a.m. with the DON, the DON stated the facility protocol is the staff notifies the DON and ADM of any allegation of abuse. The DON stated the ADM is the abuse coordinator and reports allegations of abuse to CDPH, the Ombudsman, and LLE. The DON stated on 7/5/2025 the DON notified the ADM via text message that Resident 16 made an allegation that needed to be reported as an allegation of abuse pending investigation. The DON stated the ADM did not respond. The DON stated on 7/5/2025, the DON did not follow up with the ADM to ask if the ADM reported the abuse allegation. The DON stated on 7/5/2025, the DON did not report the allegation. The DON stated on 7/7/2025 the ADM stated the ADM was not aware there was an allegation of abuse made on 7/5/2025. The DON stated the ADM reported the allegation of abuse on 7/7/2025 and the allegation was not reported within two hours of learning of the allegation. The DON stated all staff are mandated reporters and the role of the mandated reporter is to ensure allegations of abuse are reported. The DON stated LVN 6 also should not have waited until 2:45 p.m. to report Resident 16's allegation of abuse if the resident made the allegation in the morning because there is a small window of time to ensure timely reporting. The DON stated the facility P&P was not followed when Resident 16's allegation of abuse was not reported until two days after the allegation was made potentially resulting in continued abuse of the resident by the CNA. During a review of the facility P&P titled, Abuse Prevention and Prohibition Program, last reviewed 4/28/2025, the P&P indicated the purpose was to ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies and procedures. The Administrator may delegate the coordination and implementation of components of the Abuse Prevention Program to other staff. The Facility will report allegations of abuse, neglect, mistreatment, injuries of unknown source, misappropriation of resident property, or other incidents that qualify as a crime using Form - California Report of Suspected Dependent/Elder Abuse with the option of supplementing with the report with Form - Initial Report - Facility Reported Incidents.-Immediately, but no later than 2 hours after forming the suspicion -if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman. -Failure to file a report within the required time frames may result in disciplinary action, up to and including termination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents were free from unnecessary (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use of psychotherapeutic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures for three (3) of six (6) sampled residents (Residents 2, 19 and 27) by failing to ensure: 1. Resident 2 had specific, measurable target behaviors monitored related to the use of clonazepam (a psychotropic medication used to treat anxiety). As a result, Resident 2 was not monitored for specific behavior with the use of clonazepam, starting 7/11/2025. 2. The use of clonazepam was limited to the use of as needed for 14 days or indicate a specific duration of use. As a result, Resident 2's clonazepam order remained on the Medication Administration Record ([MAR] - a record of medications administered to residents) without a specific duration, starting 5/8/2025. 3. Resident 19 had specific, measurable target behaviors monitored related to the use of Ativan (a psychotropic medication used to treat anxiety [a mental health condition where excessive fear and worry interfere with daily life, causing significant distress]). As a result, Resident 19 was not monitored for specific behavior with the use of Ativan, starting 5/22/2025. 4. Resident 19's use of as needed Ativan was limited to 14 days or with a specific duration of use. As a result, Resident 19's Ativan order remained on the MAR without a specific duration, starting 5/2/2025 and 5/22/2025. 5. Resident 27 was monitored for pulse rate and adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) for the use of Remeron (a type of medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]. As a result, Resident 27 was not monitored for adverse effects and pulse rate and adverse effects for the use of Remeron. These deficient practices had the potential to place Residents 2, 19 and 27 at risk for significant adverse effects from the use of unnecessary psychotherapeutic drugs, which could result in impairment or decline in the residents' mental, physical condition, mental, functional, and psychosocial status. Cross reference F756 Findings:a). During a review of Resident 2’s admission Record (a document containing demographic and diagnostic information,) dated 7/17/2025, the record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnosis including psychosis, depression, anxiety, insomnia (difficulty sleeping) and dementia (a group of conditions that cause a decline in memory, thinking, language, and judgment).
During a review of the History and Physical (H&P) report completed on 7/31/2024, indicated Resident 2 had fluctuating capacity to understand and make decisions.
During a review of the Minimum Data Set (MDS - a resident assessment tool) dated April 15, 2025, the MDS indicated Resident 2 had moderately impaired cognition for daily decision making, had no symptoms of feeling down, depressed or hopeless, and was not marked for having trouble falling asleep, and was taking antipsychotic, antianxiety and antidepressant medications.
During a review of Resident 2’s MAR on 7/17/2025, for July 2025, the MAR indicated Resident 2 was prescribed the following medications:
1. Clonazepam 1 milligram ([mg – a unit of measure of mass]) to give one (1) tablet orally every 24 hours “as needed” for anxiety manifested by constantly getting out of bed at night, starting 5/8/2025 without a specific duration.
2. Clonazepam 0.5 mg to give one (1) tablet orally at bedtime for anxiety for 14 days manifested by impulsive behavior/agitation, at 9 p.m. starting 7/11/2025.
b). During a review of Resident 19’s admission Record, the admission Record indicated the facility admitted the resident on 2/24/2021 with diagnoses including Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress).
During a review of Resident 19’s Care Plan (CP) titled, “Antianxiety Drug Therapy as needed lorazepam” initiated on 5/2/2025, the CP indicated administer medication as ordered as one of the interventions to decrease episode of restlessness.
During a review of Resident 19’s H&P dated 5/4/2025, the H&P indicated Resident 19 did not have the capacity to understand and make decisions.
During a review of Resident 19’s MDS dated [DATE], the MDS indicated Resident 19 had minimal difficulty hearing, sometimes had the ability to make self-understood and understand others. The MDS indicated Resident 19 required supervision or touching assistance with eating; substantial/maximal to total assistance from staff with all activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 19’s Order Summary Report, the Order Summary Report indicated the following physician orders:
- 5/2/2025 with a discontinued date of 5/5/2025: lorazepam tablet 1 mg give 1 tablet by mouth every 12 hours as needed for manifested by restlessness and agitation
- 5/22/2025: Ativan oral tablet 0.5 mg (lorazepam) give 1 tablet by mouth every 12 hours as needed for anxiety.
During a review of Resident 19’s Consultant Pharmacist’s MRR created between 5/1/2025 and 5/4/2025, the Consultant Pharmacist’s MRR indicated to clarify the diagnosis with the physician and recommend adding 14 days duration of therapy if clinically indicated or appropriate.
During a review of Resident 19’s Consultant Pharmacist’s MRR created between 6/1/2025 and 6/4/2025, the Consultant Pharmacist’s MRR indicated the Ativan order dated 5/22/2025 was missing the behavior and clarify the current order, target behavior and monitoring to ensure behaviors are qualitatively and objectively documented.
c). During a review of Resident 27’s admission Record, the admission Record indicated the facility admitted the resident on 8/1/2023 with diagnoses including Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and depression.
During a review of Resident 27’s CP titled, “Antidepressant Drug Use,” initiated on 8/14/2023, the CP indicated to administer medication as ordered and monitor for common side effects as a few of the interventions to prevent injury from the medication side effects.
During a review of Resident 27’s H&P dated 8/16/2024, the H&P indicated Resident 27 did not have the capacity to understand and make decisions.
During a review of Resident 27’s MDS dated [DATE], the MDS indicated Resident 27 had minimal difficulty hearing, sometimes had the ability to make self-understood and understand others. The MDS indicated Resident 27 required substantial/maximal to total assistance from staff with all ADLs. The MDS indicated Resident 27 was taking an antidepressant medication.
During a review of Resident 27’s Order Summary Report dated 7/18/2025, the Order Summary Report indicated a physician’s order for Remeron oral tablet (mirtazapine) to give 15 by mg mouth at bedtime for depression manifested by insomnia and poor appetite.
During a review of Resident 27’s MAR for 6/2025, the MAR indicated that Resident 27 was not monitored for a pulse rate and adverse effects for the use of Remeron on 6/14/2025 on the night shift. The MAR further indicated the medication was administered on 6/14/2025 at 9 p.m.
During an interview on 7/16/2025 at 3:21 p.m., with the Director of Nursing (DON), the DON stated that when the consultant pharmacist emails the MRRs, the task to address the recommendations with the physicians are delegated between the care planners and the RN supervisors and addressed as soon as possible.
During a concurrent record review and interview on 7/17/2025 at 11:24 a.m., with Licensed Vocational Nurse (LVN) 15, LVN 15 reviewed Resident 2’s MAR for July 2025. LVN 2 stated Resident 2’s clonazepam 0.5 mg order prescribed at bedtime for anxiety for 14 days manifested by impulsive behavior/agitation does not have a specific type of impulsive behavior/agitation identified. LVN 15 stated there are many different types of impulsive behavior/agitation, such as pushing things, or constantly disrobing. LVN 15 stated psychotherapeutic medications should have specific target behaviors to ensure specific behavior monitoring, otherwise different licensed nursing staff will evaluate different behaviors, and as a result physicians make incorrect assessments for the clonazepam therapy.
During the same interview, LVN 15 stated psychotherapeutic medications should be used for short durations to prevent harm to residents by preventing adverse effects, and that “as needed” psychotherapeutic medications should have a specific duration indicated on the physician order. LVN 15 stated that the clonazepam 1 mg order for every 24 hours “as needed” for anxiety prescribed to Resident 2 does not have a specific duration identified.
During a concurrent record review and interview on 7/17/2025 at 12:03 p.m., with Registered Nurse (RN) 1, RN 1 reviewed Resident 2’s MAR for July 2025. RN 1 stated Resident 2’s clonazepam 0.5 mg order prescribed for anxiety manifested by impulsive behavior/agitation, does not have a specific type of impulsive behavior/agitation identified. RN 1 stated there are many different types of impulsive behavior/agitation, such as yelling, hitting, and screaming. RN 1 stated psychotherapeutic medications should have indications and monitoring for specific target behaviors to ensure specific behavior monitoring, evaluation of medication effectiveness for specific behavior, and to prevent adverse consequences caused by continuing unnecessary medications. RN 1 stated that without specific targeted behaviors of impulsive behavior/agitation different licensed nurses can interpret and document for different behaviors resulting in the physician making an inaccurate assessment of Resident 2’s medication therapy leading to the use of unnecessary psychotherapeutic medication causing adverse consequences and harming Resident 2.
During the same interview, RN 1 confirmed RN 1 was unable to locate a stop date or a specific duration for the clonazepam 1 mg “as needed” order for Resident 2, starting 5/8/2025. RN 1 stated that “as needed” orders for psychotherapeutic medications needed to have a specific duration to ensure that the medications were not causing more harm than good. RN 1 stated that the physician who prescribed the order and the licensed nursing staff who accepted the orders failed to include the duration for the clonazepam 1 mg “as needed” order for Resident 2, starting 5/8/2025.
During a concurrent interview and record review on 7/18/2025 9:25 a.m., Resident 19’s electronic health record, physician’s order, and MRR created between 5/1/2025 and 5/4/2025, and 6/1/2025 and 6/4/2025, were reviewed with the Risk Management Nurse (RMN). The RMN stated the MRR dated 5/1/2025 and 5/4/2025 indicated to clarify the diagnosis with the physician and recommend adding 14 days duration of therapy. The RMN stated the pharmacist recommendation created between 5/1/2025 and 5/4/2025 was not followed up and acted upon with the physician to clarify the diagnosis and to add the 14 days duration. The RMN stated the pharmacist recommendation created between 6/1/2025 and 6/4/2025 was not followed up and acted upon with the physician to indicate the behavior manifestation for the use of Ativan. The RMN stated she was unable to find documented evidence that the pharmacist recommendation was addressed with the physician. The RMN stated the monthly pharmacist recommendations are delegated to the care planners and/or RN supervisors to address with the physicians within 1 week. The RMN stated the care planners or RN supervisors assigned should have addressed the pharmacy recommendations with the physician timely. The RMN stated the Ativan order dated 5/2/2025 should have indicated the diagnosis and a duration of 14 days and the Ativan order dated 5/22/2025 should have indicated the specific behavior manifestation to ensure the use of the medication is necessary and not prolonged which placed Resident 19 at risk for adverse effects related to prolonged use of the Ativan.
During a concurrent interview and record review on 7/18/2025 at 11:44 a.m., Resident 27’s physician’s orders, MAR for 6/2025, and CP were reviewed with the RMN. The RMN stated Resident 27 was not monitored for pulse rate and adverse effects of the medication for 6/14/2025 night shift. The RMN stated residents are supposed to be monitored for adverse effects of Remeron and documented in the MAR to ensure Resident 27 is monitored appropriately and that the use of the medication is necessary. The RMN stated if Resident 27 was not monitored appropriately or accurately for any adverse effects resulting in the physician making an inaccurate assessment of the antianxiety therapy, leading to unnecessary use of the medication and placed the resident at risk for inaccurate, unmonitored side effects which could lead to risk of falls/injury.
During an interview on 7/18/2025 at 12:30 p.m., the Assistant Director of Nursing (ADON) stated that the licensed nurses are required to document in the MAR if the resident had adverse reactions including the pulse rate to ensure accurate assessment of the physician during an evaluation of the behavior episodes as well as notification of the physician for the presence of any adverse reactions. The ADON stated Resident 27’s monitoring of adverse effects and pulse rate for the use of Remeron were not documented in the MAR on 6/14/2025 at 9 p.m. when the medication was administered. The ADON stated the licensed nurse should have monitored Resident 27 for the adverse effects and pulse rate for the use of Remeron. The ADON stated if there was incomplete documentation of the adverse reactions including the pulse rate, the staff including the physician would not know if the resident had any adverse effects or abnormal pulse rate which may lead to inaccurate assessment of the antianxiety therapy. The ADON stated the inaccurate assessment, unmonitored side effects of the Remeron may lead to unnecessary use of the medication which could lead to risk of falls.
During an interview on 7/18/2025 at 12:54 p.m., with the DON, and ADON, and in the presence of RMN, the DON stated clonazepam was a psychotherapeutic medication, and that “as needed” psychotherapeutic medications needed to have a specific duration of therapy. The ADON stated the reason for limiting the duration of psychotherapeutic medications was to ensure the medications were re-evaluated for effectiveness of specific behaviors without causing additive side effects, such Tardive Dyskinesia (TD- a disorder characterized by involuntary, repetitive, and uncontrollable movements, often of the face and body, that develop after prolonged use of certain medications) Extra Pyramidal Symptoms ([EPS - a group of side effects that affect movement, often caused by certain medications,]) and not resulting in more harm than benefit leading to the unnecessary use of psychotherapeutic medications. The ADON and DON stated the clonazepam 1 mg “as needed” order for Resident 2 did not indicate a specific duration and needed to be limited to 14 days, placing Resident 2 at risk of receiving unnecessary psychotherapeutic medication. The DON stated the facility failed to identify a stop date or duration for clonazepam 1 mg “as needed” order for Resident 2, starting 5/8/2025.
During the same interview, the ADON and DON stated psychotherapeutic medications needed to have a specific behavior linked to the use of the medication for the licensed nursing staff to know exactly what behavior to monitor. The ADON, DON and RMN stated Resident 2’s clonazepam 0.5 mg order prescribed for anxiety manifested by impulsive behavior/agitation did not have a specific type of impulsive behavior/agitation identified. The DON stated that without specific targeted behavior monitoring, assessments and evaluations for the use of clonazepam will be inaccurate, preventing potential medication adjustments, such as lowering the dose or discontinuing the medication leading to unnecessary use and adverse consequences for Resident 2. The ADON and DON stated that the facility failed to identify a specific behavior related to the use of clonazepam 0.5 mg order, placing Resident 2 at risk of receiving unnecessary psychotherapeutic medications.
During an interview with the ADON on 7/18/2025 at 2:06 p.m., the ADON stated the care planners and/or RN supervisors are responsible in addressing the pharmacist recommendations with the physicians immediately. The ADON stated the MRR for Resident 19 created between 5/1/2025 and 5/4/2025 indicating to clarify the diagnosis with the physician and recommend adding 14 days duration of therapy and the MRR for 6/1/2025 and 6/4/2025 to indicate the behavior manifestation for the use of Ativan should have been addressed timely with the physician to ensure the use of the medication is necessary and not prolonged which placed Resident 19 at risk for adverse effects related to prolonged use of the Ativan. The ADON stated behavior manifestations should be specific and measurable. The ADON stated the facility policy titled, “Drug Regimen Review,” was not followed.
During a review of the facility’s policy and procedures (P&P), titled “Psychotherapeutic Drug Management,” last reviewed 4/28/2025, the P&P indicated:
I. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as medications can be utilized to meet the needs of the individual resident.
II. The facility will make every effort to comply with the state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits.
“Psychotropic medications’ – also described as …’psychotherapeutic’ medications, are drugs that affect brain activities associated with mental processes and behavior. They are divided into four broad categories: antipsychotic, antidepressant, antianxiety and hypnotic.
‘Tardive dyskinesia’ – refers to abnormal, recurrent, involuntary movements that may be irreversible and typically present as lateral movements of the tongue or jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing, and lip smacking, although the trunk and other parts of the body may also be affected.
‘Unnecessary drugs’ – are any drug used in excessive dose; for excessive duration, without adequate monitoring, or without adequate indications for its use, in the presence of adverse consequences which indicate the dose should be reduced or discontinues or any combinations of the afore listed reasons.
C. The psychotherapeutic medication order will include the following information.
III. Indications and manifestations of the disorder treated i.e. auditory hallucinations, hitting others, refusing to eat, etc.
M. Residents should not receive psychotropic drugs pursuant to a PRN (as needed) order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.
i. PRN orders for psychotropic drugs are limited to 14 days. If the Attending physician/LHP believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident’s medical record and indicate the duration for the PRN order.
Nursing responsibility:
B. Will monitor psychotropic drug use daily noting any adverse effects (such as EPS, tardive dyskinesia, excessive dose or distressed behavior).
H. The medication will be written on the MAR with the following information:
ii. manifestations for the drug i.e. hitting others etc. “
During a review of the facility’s P&P titled “Psychotherapeutic Drug Management in Residents with Dementia,” last reviewed 4/28/2025, the P&P indicated:
II. “To help promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being, promote resident safety and security, and to enhance the resident’s ability to interact positively with his/her environment
III. To ensure the resident receives only those medications, in doses and for the duration clinically indicated to treat the resident’s associated condition(s).
V. To ensure clinically significant adverse consequences are minimized.
B. to monitor psychotropic drug use daily noting any adverse effects (such as EPD, tardive dyskinesia, and excessive dose or distressed behavior as one of the nursing responsibilities.
E. The psychotherapeutic medication order will include the following information.
III. Indications and manifestations of the disorder treated i.e. auditory hallucinations, hitting others, refusing to eat, etc.”
During a review of the facility’s P&P titled, “Guidelines for Psychotherapeutic Medications,” last reviewed on 4/28/2025, the P&P indicated that “residents receiving antidepressant drugs shall have behaviors and side effects monitored on the MAR.”
During a review of facility P&P titled “Physician Orders,” last reviewed 4/28/2025, the P&P indicated:
III. “Medication orders will include the following:
D. Duration of order.”
During a review of the facility’s policy and procedure (P&P) titled, “Drug Regimen Review,” last reviewed on 4/28/2025, the P&P indicated:
- The facility maintains the residents’ highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences r/t medication therapy to the extent possible by providing oversight by a licensed pharmacist, attending physician (AP), medical director, and the DON.
- The consulting pharmacist will report any irregularities such as unnecessary drugs (which include but are not limited to excessive dosage, excessive duration, inadequate monitoring, inadequate indications for use or adverse consequences of use) to the medical director, DON, and the AP.
- Irregularities must be addressed in a separate, written report. The report will include the resident’s name, the relevant drug, and the irregularity the pharmacist identified.
- The AP will respond to any irregularities reported by the pharmacist by reviewing the irregularities and documenting in the resident’s medical record that the irregularity has been interviewed and what, if any, action has been taken to address it.
- If no action has been taken, the attending physician must document his/her rationale.
- Documentation by the attending physician must occur within 30 days of the issuance of the pharmacist’s report.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 224) when on 6/28/2025 at 2:45 p.m., Certified Nursing Assistant 11 (CNA 11) witnessed Resident 45 approached Resident 224 and hit Resident 224 on the head and right lower extremity (RLE - right side of the lower part of the human body) with a single point cane (a mobility aid with a single tip that provides basic support and balance assistance for individuals with minor mobility issues). This deficient practice resulted in Resident 224 being subjected to physical abuse by Resident 45 while under the care of the facility. On 6/28/2025, Resident 224 sustained bruising (discoloration of the skin caused by blood pooling beneath the surface) and swelling on the RLE, redness on top of the head, and pain level of two (mild pain) out of 10 on the numeric pain rating scale (a pain assessment tool that uses a scale ranging from zero [0 - no pain] to 10 [worst pain imaginable], to quantify pain intensity). Resident 224 complained of mild headache on 6/28/2025 at 3:15 p.m. and Tylenol (a brand of medication used to treat mild to moderate aches and pains) 325 milligrams (mg - unit of measurement) two (2) tablets were administered to Resident 224. Findings: a. During a review of Resident 224's admission Record, undated, the admission Record indicated the facility originally admitted Resident 224 on 3/23/2022 and readmitted in the facility on 5/12/2024 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 224's Order Summary Report dated 5/12/2024, the Order Summary Report indicated a physician's order for Tylenol oral tablet 325 mg, give two tablets by mouth every four hours as needed for mild pain or general discomfort not to exceed three (3) grams (gm - a unit of measurement) per 24 hours. During a review of Resident 224's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 5/1/2025, the H&P indicated Resident 224 did not have the capacity to understand and make decisions. During a review of Resident 224's Minimum Data Set (MDS - a resident assessment tool), dated 4/30/2025, the MDS indicated Resident 224 had severely impaired cognition (significant decline in a resident's mental abilities that profoundly impacts their daily life and independence), and usually had the ability to make self understood and understand others. The MDS indicated Resident 224 required partial or moderate assistance (helper does less than half of the effort) with eating and was totally dependent (helper does all of the effort) on staff with all other activities of daily living (ADLs - routine tasks or activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 224's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form, dated 6/28/2025, timed at 5 p.m., the COC form indicated on 6/28/2025 at 2:45 p.m., Resident 224 was in the hallway (across Room A) sitting in the wheelchair and was yelling. The COC indicated that CNA 11 observed Resident 45 exiting Room A, approaching Resident 224 and hitting Resident 224 on the head and RLE with a cane. During a review of Resident 224's Incident Note, dated 6/28/2025, timed at 5:15 p.m., the Incident Note indicated that on 6/28/2025 at 2:45 p.m., Resident 224 was in the hallway (across Room A) sitting in the wheelchair and was yelling. The Incident Note indicated that CNA 11 observed Resident 45 exiting Room A, approaching Resident 224 and hitting Resident 224 on the head and RLE with a cane and that upon further assessment, bruising and swelling were noted on Resident 224's RLE and redness on top of Resident 224's head. The Incident Note indicated Resident 224 complained of mild headache at 3:15 p.m. (on 6/28/2025) and Tylenol 325 mg two tablets were administered to Resident 224 as ordered. During a review of Resident 224's Progress Notes dated 6/29/2025 at 12:10 a.m., 6/29/2025 at 1:08 p.m., 6/30/2025 at 7:04 a.m., 6/30/2025 at 2:49 p.m., and 6/30/2025 at 9:05 p.m., the Progress Notes indicated Resident 224 had bruising present on Resident 224's RLE. During a review of Resident 224's Care Plan (CP) titled, Resident has been involved in an incident on 6/28/2025 (struck by another resident), initiated on 6/30/2025, the CP indicated to provide appropriate pain relief measures, including pharmacological (the use of medications to treat prevent a medical condition) and non-pharmacological (any health intervention that doesn't involve medications) interventions as one of the interventions to maintain resident's safety and comfort. During a review of Resident 224's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 6/2025, the MAR indicated Resident 224 received Tylenol 325 mg two tablets at 3:15 p.m. for a pain level of two out of 10 on the numeric pain rating scale. b. During a review of Resident 45's admission Record, undated, the admission Record indicated the facility originally admitted Resident 45 on 6/27/2023 and readmitted in the facility on 5/8/2025 with diagnoses including Alzheimer's disease, dementia, anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 45's H&P, dated 5/14/2025, the H&P indicated Resident 45 had the capacity to understand and make decisions. During a review of Resident 45's MDS, dated [DATE], the MDS indicated Resident 45 had moderately impaired cognition (slight decline in thinking and memory), and usually had the ability to make self understood and understand others. The MDS indicated Resident 45 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating and bed mobility and partial or moderate assistance to substantial/maximal assistance from staff with all other ADLs. During a review of Resident 45's COC form, dated 6/28/2025, timed at 4:56 p.m., the COC form indicated that on 6/28/2025 at 2:45 p.m., CNA 11 observed Resident 45 becoming agitated and annoyed at Resident 224 who was yelling from across the hall near his (Resident 45) room (Room A). The COC indicated that CNA 11 observed Resident 45 exiting Room A, approaching Resident 224 and hitting Resident 224 on the head and RLE with a cane. During a review of Resident 45's CP (untitled), initiated on 6/28/2025, the CP indicated Resident 45 was observed manifesting impulsive behavior (acting on a whim or urge without thinking through the potential consequences), physical aggression (refers to behavior that is intended to cause physical harm to another person) towards another resident (Resident 224), and being aggressive during afternoon breaks. During an interview on 7/17/2025 at 2:58 p.m. with CNA 11, CNA 11 stated that on 6/28/2025 at 2:45 p.m., as he (CNA 11) was walking past Room C, in the hallway, he (CNA 11) observed Resident 224 sitting in the wheelchair outside Room B, yelling. CNA 11 stated that he (CNA 11) saw Resident 45 exit Room A, which is directly across from Room B, approach Resident 224, and hit Resident 224 on the head and RLE with a single point cane. CNA 11 further stated that Resident 45 was speaking in a foreign language (did not state specific language) with an angry tone and appeared agitated prior to hitting Resident 224. CNA 11 stated Resident 224 and Resident 45 were separated immediately by the staff (CNA 11 and Licensed Vocational Nurse [LVN] 16). CNA 11 stated the incident between Resident 45 and 224 is physical abuse as he (CNA 11) witnessed Resident 45 physically hit Resident 224 and he (CNA 11) observed redness on Resident 224's right lower leg after being hit by Resident 45. During an interview on 7/18/2025 at 9:15 a.m. with Registered Nurse (RN) 4, RN 4 stated she was notified by the Charge Nurse (CN) that on 6/28/2025 at 2:45 p.m., CNA 11 observed Resident 45 became agitated and annoyed due to Resident 224 yelling from across the hall from his (Resident 45) room (Room A). RN 4 stated Resident 45 exited Room A approached Resident 224 and hit Resident 224. RN 4 stated that during an interview (on 6/28/2025) with Resident 45, Resident 45 stated that he (Resident 45) wanted Resident 224 to stop yelling. RN 4 further stated that the incident between Resident 224 and Resident 45 was a resident-to-resident physical abuse. RN 4 stated all residents in the facility should be free from any type of abuse. During an interview on 7/18/2025 at 12:28 p.m. with Social Services Designee (SS Designee), the SS Designee stated the SS Department follows up with the residents involved after an allegation of abuse for psychosocial support and to ensure the residents their safety while in the facility. The SS Designee stated during her (SS Designee) visit with Resident 45 on 6/30/2025, Resident 45 stated that Resident 224 was making too much noise, so he (Resident 45) hit Resident 224. The SS Designee stated the incident between Resident 224 and Resident 45 was a physical abuse and the facility should ensure that all residents are free from any type of abuse. During a concurrent interview and record review on 7/18/2025 at 10:05 a.m., with the Risk Management Nurse (RMN), Resident 224's COC, Incident Note, Progress Notes, and MAR were reviewed. The RMN stated the facility was able to substantiate that physical abuse happened between Residents 224 and 45 and that Resident 224 suffered bruising on the RLE and redness on the head. The RMN stated that all residents in the facility have the right to be free from any form of abuse, in order to ensure their safety and well-being at all times. During an interview on 7/18/2025 at 2:30 p.m. with the Director of Nursing (DON), the DON stated that all residents should be free from abuse. The DON stated that the provoking behavior was Resident 224 yelling and making noise in the hallway. The DON stated Resident 45 became agitated by Resident 224's yelling and, in response, hit Resident 224 on the head and RLE, resulting in bruising and swelling on Resident 224's RLE. The DON stated the incident is considered physical abuse and may have a negative psychosocial impact (refers to the negative effects that an incident has on a person's mental health, psychological well-being and social interactions) on Resident 224. The DON further stated that the facility failed to prevent the physical abuse between Residents 224 and Resident 45, as CNA 11 was unable to intervene in a timely manner to prevent the incident. During a review of the current facility-provided policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, last reviewed by the facility on 4/28/2025, the P&P indicated, To ensure the facility established, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to . protect residents, and to ensure a standardized methodology for the prevention . of abuse . in accordance with federal and state requirements. Each resident has the right to be free from abuse. The Facility has zero-tolerance for abuse. The staff must not permit anyone to engage in . physical abuse. The facility is committed to protecting residents from abuse by anyone, including but not limited to . other residents.

Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for one (1) of two (2) sampled residents (Resident 27) reviewed under the environmental task by failing to ensure Resident 27's floor mat (a cushioned floor pad designed to help prevent injury should a person fall) was free from rips and disrepair. This deficient practice had the potential to negatively affect the residents' quality of life. Additionally, the facility failed to honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for one of two sampled residents (Resident 187) reviewed under environment facility task by failing to ensure the resident's floor/fall mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have any peeling covers. The deficient practice violated the residents' right to a safe, clean, comfortable and homelike environment. Findings:a). During a review of Resident 27’s admission Record, the admission Record indicated the facility admitted the resident on 8/1/2023 with diagnoses including Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 27’s History and Physical (H&P), dated 8/16/2024, the H&P indicated Resident 27 did not have the capacity to understand and make decisions.
During a review of Resident 27’s Order Summary Report, the Order Summary Report indicated a physician’s order dated 12/4/2024 that Resident 27 may have a floor mat next to the bed to prevent injuries every shift.
During a review of Resident 27’s care plan (CP) risk for falls initiated on 7/25/2024 and last revised on 1/24/2025, the CP indicated to keep the environment free of hazards and floor mats next to the bed as a few of the interventions to minimize the potential for falls or injury.
During a review of Resident 27’s Minimum Data Set (MDS-a resident assessment tool), dated 4/1/2025, the MDS indicated Resident 27 had minimal difficulty hearing, sometimes had the ability to make self-understood and understand others. The MDS indicated Resident 27 required substantial/maximal to total assistance from staff with all activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a concurrent observation and interview on 7/14/2025, at 12:31 p.m. while inside Resident 27’s room with Licensed Vocational Nurse (LVN) 8. LVN 8 stated Resident 27’s floor mat with the right lower edges was peeling off and in disrepair. LVN 8 stated the floor mats should be replaced if the edges are peeling off or in disrepair, as it is not very homelike for Resident 27 and can affect her quality of life. LVN 8 stated the maintenance department should have been notified about the peeling fall mat cover edges and should be replaced.
During an interview on 7/18/2025, at 10:15 a.m. with Registered Nurse (RN) 4, RN 4 stated the charge nurses/Certified Nursing Assistants (CNAs) are required to check the integrity of the floor mats to ensure that they are not damaged or in disrepair. RN 4 stated it was not appropriate to have floor mats with peeling covers in the resident’s room because it can cause a fall, and it is not homelike to see the edges of the floor mats peeling off in the resident’s room.
During an interview on 7/18/2025, at 1:39 p.m., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated Resident 27’s floor mat should be free of wear and tear, and the mat should not have peeling covers on the edges as it compromises the integrity of the mat to prevent falls with injury. The DON also stated it is not homelike to see peeling covers on the floor mats of the residents.
During a review of the facility's recent policy and procedure (P&P) titled Resident Rights- Personal Property, last reviewed on 4/28/2025, the P&P indicated to ensure the quality of life of all residents by allowing residents to create a home-like environment.
During a review of the undated facility-provided Floor Mat 1 Manufacturer’s Specification, the Manufacturer’s Specification indicated when moving equipment across the mat ensure that the wheels are not locked as “dragging wheels” may damage the mat. Avoid sharp materials from contacting the mat. Never leave heavy materials on the mat for an extended amount of time because they may cause permanent indentation.
b). During a review of Resident 187’s admission Record, the admission Record indicated the facility admitted the resident on 10/13/2023, with diagnoses including a history of falling, abnormalities of gait (how a person walks) and mobility, and age-related osteoporosis (a common condition that affects older adults, making their bones weak and fragile).
During a review of Resident 187’s Care Plan (CP) Report titled “Psychosocial: Home like environment,” initiated on 10/20/2023, the CP indicated a goal of the facility will ensure resident’s room is a home like environment through 9/10/2025.
During a review of Resident 187’s Minimum Data Set (MDS, a resident assessment tool), dated 6/11/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had impaired vision. The MDS indicated the resident had moderately impaired cognition (a stage between normal aging and dementia [a progressive state of decline in mental abilities] where individuals experience noticeable cognitive decline but can still manage most of their daily activities, though they may need some assistance), upper extremity, and uses a walker and a wheelchair to mobilize. The MDS indicated the resident required substantial supervision assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated the resident had a fall with a major injury while a resident at the facility.
During a review of Resident 187’s Fall Risk Assessment, dated 6/11/2025, the Fall Risk Assessment indicated the resident was high risk for falls.
During a review of Resident 187’s History and Physical (H&P), dated 7/12/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a concurrent observation and interview on 7/14/2025, at 2:33 p.m. with the Director of Staff Development (DSD), while inside Resident 187’s room, Resident 187’s fall mat with had peeling covers at the edges. The DSD stated the fall mat should be replaced because the peeling covers had compromised the ability of the fall mat to reduce the impact of the fall if a resident lands on them. The DSD stated the peeling fall mat cover edges does not look homelike for a resident and should be replaced.
During a concurrent interview and record review on 7/18/2025, at 10 a.m., with Registered Nurse (RN) 4, RN 4 stated the charge nurses/Certified Nursing Assistants (CNAs) should be checking the integrity of the floor mats. The picture of the floor mat with peeling covers was reviewed with RN 4, RN 4 stated it was not appropriate to have floor mats with peeling covers in the resident’s room because it can cause a fall, it is not homelike to see peeling covers of the fall mat in the resident’s room.
During an interview on 7/18/2025, at 1:39 p.m., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated Resident 187’s floor mat should be free of wear and tear, the mat should not have peeling covers on the edges as it compromises the integrity of the mat to prevent falls with injury. The DON also stated it is not homelike to see peeling covers on the fall mats of the residents.
During a review of the facility's most recent policy and procedure (P&P) titled Resident Rights- Personal Property, last reviewed on 4/28/2025, the P&P indicated to ensure the quality of life of all residents by allowing residents to create a home-like environment.
During a review of the undated facility-provided Floor Mat 1 Manufacturer’s Specification, the Manufacturer’s Specification indicated when moving equipment across the mat ensure that the wheels are not locked as “dragging wheels” may damage the mat. Avoid sharp materials from contacting the mat. Never leave heavy materials on the mat for an extended amount of time because they may cause permanent indentation.

Based on observation, interview, and record review, the facility failed to notify the primary physician and responsible party of a significant change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of six sampled residents (Resident 21) reviewed under the Nutrition care area by failing to notify the physician and family regarding significant weight loss per the facility policy and procedure (P&P) when the resident had a weight loss of greater than 5 pounds (lbs. - a unit of measurement for mass) in 30 days. This failure had the potential to result in a delay in care and services and a further decline of Resident 21. Findings:During a review of Resident 21's admission Record (AR), the AR indicated the facility originally admitted the resident on 1/18/2024 and most recently admitted the resident on 11/9/2024 with diagnoses that included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells), carcinoma in situ of vulva (abnormal cells are found on the surface of the vulvar [external female genitals] skin), malignant neoplasm (cancer - disease in which abnormal cells divide uncontrollably and destroy body tissue) of unspecified site of female breast, dysphagia (difficulty swallowing), and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 21's History and Physical (H&P), dated 4/11/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set (MDS - resident assessment tool), dated 5/5/2025, the MDS indicated the resident usually was able to understand others and usually was able to make herself understood. The MDS further indicated that the resident was dependent on staff for eating, toileting, bathing, dressing, oral and personal hygiene, and mobility. During a review of Resident 21's Order Review History Report, the Order Review History Report indicated the following physician's orders:-Fortified, no salt added diet pureed texture, regular consistency liquids, three times a day, dated 11/9/2024. During a review of Resident 21's Weights and Vitals Summary report, the Weights and Vitals Summary report indicated the following:-On 6/16/2025 at 9:48 a.m., Resident 21 weighed 102 lbs. while sitting.-On 7/14/2025 at 9:32 a.m., Resident 21 weighed 92 lbs. while sitting.--A 10 lb. weight loss of 9.8 percent (% - a measurement) of previous comparison weight, over 30 days. During a review of Resident 21's Care Plan (CP) regarding the resident's history of malignant neoplasm of the right breast and carcinoma in situ of vulva, initiated 1/19/2025, the CP indicated the resident was at risk for weight loss. The CP indicated an intervention to report to the physician any weight loss. During a concurrent observation and interview on 7/15/2025 at 1:11 p.m. with Resident 21 and Resident 21's Family Member (FM) 1, observed FM 1 sitting at a table next to Resident 21. Resident 21 had a lunch tray placed in front of the resident containing pureed food. Resident 21 did not eat. FM 1 stated Resident 21 was not eating. FM 1 stated FM 1 thought Resident 21 did not like the texture of the food. During an interview on 7/17/2025 at 9:30 a.m. with Treatment Nurse (TN) 2, TN 2 stated residents are weighed monthly by the restorative nurse aides (RNA) and if there is a significant change in the resident's weight, the weight is reported to the charge nurse because it is considered a COC. TN 2 stated 10 lbs. weight loss is a significant change from the resident's baseline weight and is considered a COC. During a concurrent interview and record review on 7/17/2025 at 10:06 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 21's Weight Monitoring form for 2024 and 2025 were reviewed. LVN 6 stated on 7/14/2025, the RNA told LVN 6 that Resident 21 had a bit of weight loss. LVN 6 stated LVN 6 did not follow up to review Resident 21's weight loss. LVN 6 reviewed the Weight Monitoring form and stated Resident 21 had lost 10 lbs. in one month. LVN 6 stated if a resident loses too much weight the physician should be notified. LVN 6 stated on 7/14/2025 nobody told LVN 6 the Resident had gone from 102 lbs. to 92 lbs. During a concurrent interview and record review on 7/17/2025 at 10:17 a.m. with Registered Nurse (RN) 2, Resident 21's Weights and Vitals form for 6/2025 and 7/2025 and Progress Notes for 7/2025 were reviewed. RN 2 stated Resident 21's weight loss of 10 lbs. in one month was a big weight loss and is concerning. RN 2 stated the family and physician should have been immediately notified on 7/14/2025. RN 2 stated there was no documentation to indicate the family and physician were notified of Resident 21's COC. RN 2 stated when a COC for weight loss in Resident 21 was not reported, it could potentially result in abnormal vital signs (measurements of the body's most basic functions including temperature, heart rate, respiratory rate, and blood pressure), skin issues, or a failure to thrive (an inability to sustain weight due to poor nutrition). During a concurrent interview and record review on 7/17/2025 at 11:09 a.m. with the Assistant Director of Nursing (ADON), Resident 21's Weights and Vitals form for 6/2025 and 7/2025 and Progress Notes for 7/2025 were reviewed. The ADON stated a weight loss of 5% or more in one month is considered significant weight loss. The ADON stated that a significant weight loss in a resident is a COC and the physician and family should be notified. The ADON stated it is important to immediately report a COC because the physician needs to know what is happening with residents and there needs to be 72-hour monitoring of the resident's condition. During an interview on 7/17/2025 at 11:50 a.m. with the RD and the ADON, the RD stated the RD was not aware Resident 21 had significant weight loss on 7/14/2025 or the RD would have acted immediately. The RD stated the resident's physician should have been notified on 7/14/2025, but the physician was not notified. The ADON stated when the physician is not notified regarding weight loss it may cause a delay in addressing the weight loss resulting in further weight loss in the resident. During a follow-up interview on 7/18/2025 at 10:11 a.m. with the ADON, the ADON stated the facility's P&P indicates a weight loss of 5 lbs. or more in thirty days is a COC. The ADON stated LVN 6 did not follow the facility P&P when the COC was not reported to the family and physician. During a concurrent interview and record review on 7/18/2025 at 1:40 p.m. with the ADON and Director of Nursing (DON), the facility's P&P titled, Change of Condition, last reviewed 4/28/2025, was reviewed. The DON stated that when a weight loss COC is not reported the resident may not be closely monitored to determine why the weight loss occurred, and the physician may not evaluate the resident. The DON stated LVN 6 did not follow the facility P&P with a potential for further decline in the resident. During a review of the P&P titled Change of Condition, last reviewed 4/28/2025, the P&P indicated the purpose was to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. An acute change of condition is a sudden, clinically important deviation from a patient's baseline in physical, behavioral, cognitive, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. Members of the interdisciplinary team are expected to report and document signs and symptoms that might represent an acute COC. The facility will promptly inform the resident, consult with the physician, and notify the resident's legal representative when the resident endures a significant COC. The licensed nurse (LN) will notify the attending physician when there is a change in weight of five pounds or more in a 30-day period unless a different stipulation has been stated in writing by the resident's physician. The LN will assess the resident's COC and document the observation and symptoms. The LN will notify the resident's responsible party or family / surrogate decision maker of any changes in the resident's condition as soon as possible. A LN will document each shift for at least 72 hours. Documentation pertaining to a COC will be maintained in the resident's medical record.

Based an observation, interview, and record review, the facility failed to ensure that nine of nine residents (Residents 59, 73, 116, 119, 123, 131, 135, 150 and 232) who attended the Resident Council Meeting (gathering of residents, typically in a long-term care or public housing setting, where they discuss issues, concerns, and suggestions related to their living environment and quality of life) on 7/15/2025, were aware of the availability and location of the facility's latest survey results. This failure had the potential for the residents and their legal representatives not to be fully informed of the facility's deficient practices and how they were corrected. Findings:During the Resident Council Meeting on 7/15/2025 at 11:03 a.m., attended by nine residents (Residents 59, 73, 116, 119, 123, 131, 135, 150 and 232), in the presence of two Activity Staff (AC 1 and AC 2), Residents 116 stated they were not aware of the availability and location of the survey results and how the facility corrected the deficiencies that were identified in the past survey. During a concurrent observation and interview on 7/15/2025 at 11:03 a.m., with AC 2, inside the classroom, AC 2 translated the question into the language used by the residents and AC 2 stated all nine residents (Residents 59, 73, 116, 119, 123, 131, 135, 150 and 232) stated they were not sure where to find the survey result. During a concurrent observation, interview, and record review on 7/15/2025 at 11:29 a.m. with the Administrator (ADM), in the facility's hallway beside the consumer board, observed the survey result binder hooked on the wall. The ADM stated the survey result binder did not contain the latest (2024) survey result. During an observation on 7/16/2025 at 9:27 a.m. in the hallway beside the consumer board, the survey results binder was missing. During a concurrent interview and record review on 7/16/2025 at 9:29 a.m. with the ADM, the ADM stated the survey results binder was in his (ADM) office being updated. The ADM brought the survey result binder and showed the latest recertification survey result was attached. The ADM stated the survey result binder did not contain the plan of correction for the latest survey result. The ADM stated his (ADM) staff did not follow his (ADM) instructions. During an interview on 7/16/2025 at 2:55 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the purpose of the survey result binder was to inform the public that the facility had corrected the deficiencies or issues found during the latest survey. The ADON stated the survey result should be accessible to residents without asking any staff. During an interview on 7/16/2025 at 4 p.m. with the Director of Nursing (DON), the DON stated the survey results informs the residents and families of what's going on in the facility. The DON stated the survey binder contains the latest survey results and what the facility did to correct it. The DON stated the survey result binder should be accessible to residents, families, and staff. During a review of facility's policy and procedure (P&P) titled, Compliance with Laws and Professional Standards, dated 10/1/2017 and last reviewed on 4/28/2025, the P&P indicated, The Facility will post in place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the Facility.A. Readily Accessible means that the individual(s) wishing to examine the most recent survey results should not ask to see them (staff) (example given, posted on an accessible wall).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for three of the three sampled residents (Residents 125, 113 and 74) reviewed under the area of accommodation. The deficient practice had the potential to result in the residents being unable to summon health care workers for help as needed. Findings:1. During a review of Resident 125’s admission Record, the admission Record indicated the facility admitted the resident on 10/2/2018, and readmitted the resident on 8/14/2022, with diagnoses including age-related osteoporosis (a condition where bones become weak and fragile over time, primarily due to the natural aging process), history of traumatic fracture (a broken bone that happens because of a sudden, strong force or impact), and history of falling.
During a review of Resident 125’s History and Physical (H&P), dated 8/20/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions due to chronic delirium (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking).
During a review of Resident 125’s Fall Risk Assessment, dated 5/25/2025, the Fall Risk Assessment indicated the resident was at a high risk for falls.
During a review of Resident 125’s Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2025, the MDS indicated the resident had the ability to make self-understood and to understand others and had highly impaired vision. The MDS indicated the resident had moderate cognitive impairment (a noticeable decline in thinking skills that affects daily life), upper and lower extremity impairment, and uses a wheelchair to mobilize. The MDS indicated the resident was dependent on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 125’s Care Plan (CP) Report titled “Antipsychotic (medications used to treat conditions involving psychosis) drug therapy (Seroquel): At Risk for toxicity/At Risk for Fall,” initiated on 8/8/2023, the CP indicated an intervention to keep call light within easy reach and answer promptly.
During a concurrent observation and interview on 7/14/2025, at 1:11 p.m., with Certified Nursing Assistant (CNA) 9, while inside Resident 125’s room, Resident 125 was observed sitting in a wheelchair on the left side of the bed with the resident’s feet resting on top of the bed and the call light was placed on the foot part of the bed. CNA 9 stated the resident’s call light should be near the resident. CNA 9 stated the resident cannot reach the call light because it is not close to her and the resident can fall while reaching for it.
During an interview on 7/18/2025, at 10 a.m., with Registered Nurse (RN) 4, RN 4 stated the call light of Resident 125 should always be within the reach of the residents when they are in bed or on a chair. RN 4 stated the staff should have placed the call light within the reach of the resident while they are sitting in the wheelchair and answer promptly when the call light goes off to prevent falls or other injuries.
During an interview on 7/18/2025, at 1:39 p.m., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated the call light should be within reach of Resident 125 and the call lights should be answered right away to prevent falls.
During a review of the facility's recent policy and procedure (P&P) titled Communication- Call System, last reviewed on 4/28/2025, the P&P indicated to provide a mechanism for residents to promptly communicate with nursing staff.
I. The Facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities.
A. The call system should be accessible to a resident lying on the floor in toileting and bathing facilities.
Procedure
II. Call cords will be placed within the resident's reach in the resident's room.
2. During a review of Resident 113’s admission Record, the admission Record indicated the facility admitted the resident on 7/11/2022, with diagnoses including mild cognitive impairment (a condition where people experience more memory or thinking problems than other people their age, but it's not severe enough to interfere with their daily lives or be considered dementia), fracture (a broken or cracked bone) of left shoulder girdle, and age-related osteoporosis.
During a review of Resident 113’s CP Report titled “High risk for falls due to fall risk assessment score,” initiated on 7/25/2022, the CP included an intervention to keep the call light within easy reach and answer promptly.
During a review of Resident 113’s H&P, dated 7/24/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 113’s Fall Risk Assessment, dated 5/8/2025, the Fall Risk Assessment indicated the resident was high risk for fall.
During a review of Resident 113’s MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and to understand others and had moderate cognitive impairment. The MDS indicated Resident 113 had upper extremity impairment and used a walker and wheelchair to mobilize. The MDS indicated the residents were dependent on needing supervision with mobility and ADLs. The MDS indicated the resident had a fall without injury while a resident at the facility.
During a concurrent observation and interview on 7/14/2025, at 1:57 p.m., with CNA 8, while inside Resident 113’s room, Resident 113 was observed in a wheelchair, at the left side of the bed, with the resident’s feet resting on top of the bed and the call light was placed on the foot part of the bed. CNA 8 stated the resident’s call light should be near the resident. CNA 8 stated the resident could not reach the call light because it is not close to her and she could fall while reaching it. CNA 8 stated the resident goes to the bathroom by herself. CNA 8 stated the resident was not a fall risk.
During an interview on 7/18/2025, at 10 a.m., with RN 4, RN 4 stated the call light of Resident 113 should always be within the reach of the resident when they are in bed or on a chair. RN 4 stated the staff should have placed the call light within the reach of the resident while the resident was sitting in a wheelchair and answer promptly when the call light goes off to prevent falls or other injuries.
During an interview on 7/18/2025, at 1:39 p.m., with the DON and the ADON, the DON stated the call light should be within reach of Resident 113 and the call lights should be answered right away to prevent falls.
During a review of the facility's recent P&P titled Communication- Call System, last reviewed on 4/28/2025, the P&P indicated to provide a mechanism for residents to promptly communicate with nursing staff.
I. The Facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities.
 A. The call system should be accessible to a resident lying on the floor in toileting and bathing facilities.
Procedure
II. Call cords will be placed within the resident's reach in the resident's room.
3. During a review of Resident 74’s admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted the resident on 4/27/2023 and readmitted in the facility on 7/26/2024, with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and functional quadriplegia (complete inability to move due to severe disability or frailty [body’s inability ability to cope with minor illnesses] without physical injury).
During a review of Resident 74’s fall risk assessments dated 3/4/2025 and 6/2/2025, the fall risk assessments indicated Resident 74 was at a high risk for falls.
During a review of Resident 74’s History and Physical (H&P) dated 4/24/2025, the H&P indicated Resident 74 did not have the capacity to understand and make decisions.
During a review of Resident 74’s Minimum Data Set (MDS, a resident assessment tool), dated 6/1/2025, the MDS indicated Resident 74 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) but was able to understand and make her needs known. The MDS further indicated Resident 74 required supervision or touching assistance with eating; substantial/maximal assistance to total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 74’s care plan (CP) on potential for falls initiated on 4/17/2024 and last revised on 4/3/2025, the CP indicated to keep the resident's most frequently used personal items within easy reach and to keep call light within easy reach and answer promptly as a few of the interventions to minimize potential for fall or injury.
During a concurrent observation and interview on 7/14/2025 at 12:59 p.m. while inside Resident 74’s room with Certified Nursing Assistant (CNA) 3 in the presence of Licensed Vocational Nurse (LVN) 8, Resident 74 lay in bed awake, verbally responsive with the call light placed at the uppermost edge of the bed on the right side. CNA 3 stated the staff should ensure all residents’ call lights are placed within reach prior to leaving the room so the residents can call for assistance when needed. CNA 3 stated she forgot to ensure the call light was within Resident 74’s reach after she removed the resident’s lunch tray. CNA 3 stated she should have ensured Resident 74’s call light was within reach prior to leaving the room so the resident can call for assistance when needed, which placed Resident 74 at risk for a delay in meeting the resident’s needs.
During an interview on 07/18/2025 at 10 AM with Registered Nurse (RN) 4, RN 4 stated the call light should be within the reach of the residents when they are in bed or on a chair. RN 4 stated the staff should ensure the residents’ call lights are within reach prior to leaving the room. RN 4 stated Resident 74’s call light should have been placed within the resident’s reach as Resident 74 had limitations with her upper extremities and would be unable to call for assistance which may lead to a delay in meeting the resident’s needs.
During a review of the facility's recent policy and procedure (P&P) titled “Call Light,” last reviewed on 4/8/2025, the P&P indicated:
- All residents shall have immediate access to functioning call light at all times, ensuring they can easily signal for assistance whenever needed.
-The call light must be within the resident’s reach at all times, including when in bed, in a chair, or in the bathroom.
During a review of the facility’s P&P titled, Communication- Call System, last reviewed on 4/28/2025, the P&P indicated:
-The Facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities.
-The call system should be accessible to a resident lying on the floor in toileting and bathing facilities.
-Call cords will be placed within the resident's reach in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of five sampled residents (Resident 2, 19, 27) reviewed under unnecessary medication, were afforded the right to informed consent for the use of psychotherapeutic medications (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to: 1. Ensure an informed consent was obtained from Resident 2 or Resident 2's responsible party (RP) prior to starting doxepin (an antidepressant [against depression] medication classified as a psychotherapeutic drug {a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior} used to treat depression) ensuring that the risk and benefit of doxepin were explained to the resident or RP, and for a new dose of clonazepam (a psychotropic medication used to treat anxiety) and for the use of quetiapine (an antipsychotic medication used to treat serious mental health conditions such as psychosis]) after six (6) months. 2. Ensure informed consent was obtained from the resident and/or RP for Resident 19, prior to starting Ativan (a type of medication used to treat anxiety disorders [a mental health condition where excessive fear and worry interfere with daily life, causing significant distress], sleeplessness, nausea, and agitation) ensuring that the risk and benefit of Ativan were explained to the resident and/or RP. 3. Ensure informed consent was obtained from the resident and/or RP for the continued use of Remeron (a type of medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest] every six (6) months. These deficient practices violated Resident 2s', 19s' and 27s' right to be fully informed, to consent and to make decisions regarding the use of their psychotherapeutic medications. Findings: During a review of Resident 2's admission Record, the admission Record dated 7/17/2025, the record indicated Resident 2 was originally admitted to the facility on [DATE] with diagnosis including psychosis, depression, anxiety, insomnia (difficulty sleeping) and dementia (a group of conditions that cause a decline in memory, thinking, language, and judgment). During a review of Resident 2's History and Physical report, completed on 7/31/2024, the History and Physical Report indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of the Minimum Data Set ([MDS - a resident assessment tool]) dated April 15, 2025, the MDS indicated Resident 2 had moderately impaired cognition for daily decision making, had no symptoms of feeling down, was depressed or hopeless, and was not marked for having trouble falling asleep, and was taking antipsychotic, antianxiety, antidepressant medications. During a review of Resident 2's Medication Administration Record ([MAR] - a record of mediations administered to residents) on 7/17/2025, July 2025, the MAR indicated Resident 2 was prescribed the following: 1.Administer clonazepam 1 mg one (1) tablet orally every 24 hours as needed for anxiety manifested by constantly getting out of bed at night, starting 5/8/2025 until 7/10/2025. 2. Administer clonazepam 0.5 mg one (1) tablet orally at bedtime for anxiety for 14 days manifested by impulsive behavior/agitation, at 9 p.m. starting 7/11/2025. 3.Administer doxepin 6 mg one (1) tablet orally in the evening for depression manifested by insomnia, at 5 p.m. starting 7/30/2024. 4.Administer quetiapine 50 mg two (2) tablets orally at bedtime for psychosis manifested by hallucination/delusion (seeing/talking to people not present), at 9 p.m. starting 7/30/2024. During a further review of the same MAR for July 2025, the MAR indicated Resident 2 was administered the following: 1.Clonazepam 0.5 mg one (1) tablet orally at 9 p.m. for anxiety for 14 days manifested by impulsive behavior/agitation, between 7/11/2025 and 7/16/2025 2.Doxepin 6 mg one (1) tablet orally at 5 p.m. for depression manifested by insomnia, between 7/1/2025 and 7/16/2025. 3.Quetiapine 50 mg two (2) tablets orally at 9 p.m. for psychosis manifested by hallucination/delusion (seeing/talking to people not present), between 7/1/2025 and 7/16/2025. During a review of Resident 2's clinical record on 7/17/2025, the clinical record lacked documentation for the following: 1.Obtaining informed consent for the updated clonazepam order to 0.5 mg at bedtime for anxiety for 14 days manifested by impulsive behavior/agitation, starting 7/11/2025. 2.Obtaining informed consent for doxepin 6 mg in the evening for depression manifested by insomnia, starting 7/30/2024. 3.Providing written notice to the resident or RP for quetiapine 50 mg two (2) tablets at bedtime for psychosis manifested by hallucination/delusion (seeing/talking to people not present), beyond six (6) months after the last signed consent on 11/29/2024. b)During a review of Resident 19's admission Record, the admission Record indicated the facility admitted the resident on 2/24/2021 with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress). During a review of Resident 19's History and Physical (H&P), dated 5/4/2025, the H&P indicated Resident 19 did not have the capacity to understand and make decisions. During a review of Resident 19's MDS dated [DATE], the MDS indicated Resident 19 had minimal difficulty hearing, sometimes had the ability to make self-understood and to understand others. The MDS indicated Resident 19 required supervision or touching assistance with eating; substantial/maximal to total assistance from staff with all activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 19's Order Summary Report, the Order Summary Report indicated the following physician's order:- 5/2/2025 with discontinued date of 5/5/2025: lorazepam tablet 1 mg give 1 tablet by mouth every 12 hours as needed for restlessness and agitation.- 5/22/2025: Ativan oral tablet 0.5 mg (lorazepam) give 1 tablet by mouth every 12 hours as needed for anxiety. During a review of Resident 19's care plan (CP) titled, Antianxiety Drug Therapy as needed lorazepam initiated on 5/2/2025, the CP indicated to obtain and place the consent in the chart as an intervention for the use of the antianxiety medication. c)During a review of Resident 27's admission Record, the admission Record indicated the facility admitted the resident on 8/1/2023 with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and depression. During a review of Resident 27's care plan (CP) titled, Antidepressant Drug Use, initiated on 8/14/2023, the CP indicated to obtain consent and place in the chart as one of the interventions for the use of the antidepressant. During a review of Resident 27's H&P, dated 8/16/2024, the H&P indicated Resident 27 did not have the capacity to understand and make decisions. During a review of Resident 27's Informed Consent forms dated 5/11/2024 and 11/29/2024, the Informed Consent forms indicated Resident 27's RP signed the consent for the use of Remeron. During a review of Resident 27's MDS dated [DATE], the MDS indicated Resident 27 had minimal difficulty hearing, sometimes had the ability to make self-understood and to understand others. The MDS indicated Resident 27 required substantial/maximal to total assistance from staff with all activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 27 was taking an antidepressant medication. During a review of Resident 27's Order Summary Report dated 7/18/2025, the Order Summary Report indicated a physician's order for Remeron oral tablet (mirtazapine) give 155 milligrams (mg - a unit of measurement) by mouth at bedtime for depression manifested by insomnia (sleeplessness) and poor appetite. During an interview on 7/17/2025 at 12:37 p.m., with Care Planner (CP) 1 and CP 2, CP 1 and CP 2 stated care planners ensure informed consent forms are complete and available in the medical record. CP 1 and CP 2 stated for each new order of a psychotherapeutic medication a new informed consent form was required, as well as when a psychotherapeutic was continued to be used beyond six (6) months. CP 1 and CP 2 confirmed the informed consent forms for doxepin, continued use of quetiapine and new order of clonazepam for Resident 2 were not in the medical record. During an interview on 7/17/2025 at 2:30 p.m., with the Director of Nursing (DON,), the DON stated the DON was unable to provide documented evidence in the medical record that an informed consent was obtained from Resident 2 or RP prior to initiation of doxepin and that documented evidence that Resident 2 or RP was notified for continuing quetiapine after the last signed consent on 11/29/2024. During an interview on 7/17/2025 at 2:55 p.m., with Licensed Vocational Nurse (LVN) 14, LVN 14 stated informed consent forms should be verified in the medical record prior to administering psychotherapeutic medications. LVN 14 stated that without informed consent psychotherapeutic medications cannot be administered to residents. LVN 14 stated not having documentation of informed consent form in the medical record indicated informed consent was not obtained from the resident or RP. During an interview and concurrent record review, on 7/17/2025 at 3:15 p.m. with the Assistant Director of Nursing (ADON,) the ADON stated Resident 2's informed consent form for clonazepam 0.5 mg at bedtime for anxiety for 14 days prescribed on 7/11/2025 was not available in Resident 2's medical record. The ADON stated the form was stored in his desk since the form was not fully filled out and completed until 7/17/2025. During an interview and concurrent record review, on 7/17/2025 at 3:30 p.m. with the ADON, the ADON stated psychotherapeutic medications should not be administered to residents without consent from the resident or RP. The ADON stated that psychotherapeutic medications have a high risk for falls and can affect resident behaviors. The ADON stated clonazepam was a sedative (a medication that reduces anxiety, or induces sleep,) and when administered without informed consent implied clonazepam was used as a chemical restraint (use of medication to sedate someone, control or restrict their behavior or movement, rather than treating a medical condition). The ADON stated per law and facility policy and procedure, medications that affect behavior and cause adverse effects (unwanted, unintended results,) required residents or RP to be informed. The ADON stated that for any changes in psychotherapeutic medication order, new informed consent should be obtained, even if the medication was prescribed before. During a concurrent interview and record review on 7/18/2025 at 9:25 a.m., Resident 19's physician's orders, care plans, and informed consents were reviewed with the Risk Management Nurse (RMN). The RMN stated consent for the use of psychotropics is supposed to be obtained from the resident and/or RP prior to the start of administration of any psychotropics. The RMN stated the RN supervisors or the licensed nurse receiving the order are responsible for obtaining the informed consent and upon receipt of the order, will verify with the physician if an informed consent was obtained from the family and then the RN or licensed nurse will obtain the signature from the resident or family. The RMN stated there was no informed consent obtained from Resident 19 and/or RP for the Ativan order dated 5/2/2025 and 5/22/2025. The RMN stated the informed consent should have been obtained from Resident 19 and/or RP prior to start of Ativan on 5/2/2025 to ensure that the resident and/or RP were informed of the risks and benefits of the use of an antianxiety medication which cannot be used long term for the elderlies as it can cause potential adverse effects such as changes in behavior, confusion, and sleepiness to name a few which could lead to falls and/or injuries from the fall. During a concurrent interview and record review on 7/18/2025 at 11:44 a.m., Resident 27's physician's orders, care plans, and informed consents were reviewed with the Risk Management Nurse (RMN). The RMN stated consent for the use of psychotropics is supposed to be obtained every six months for the continued use of a psychotropic. The RMN stated the care planners are responsible for obtaining the consents from the resident and/or RP during the IDT meeting. The RMN stated there was no informed consent obtained from Resident 27 and/or RP for the continued use of the Remeron which was due on 5/2025. The RMN stated the informed consent should have been obtained from Resident 27 and/or RP on 5/2025 to ensure that the resident and/or RP were informed of the risks and benefits of continued use of the Remeron, and to be able to consent or decline continued use of the medications. During an interview on 7/18/2025 at 2:30 p.m., with the ADON, the ADON stated psychotropics are not to be started without consent from the resident and/or RP. The ADON stated psychotherapeutic drugs are not good for long term use, which could lead to potential adverse effects such as the risk of falls. The ADON stated Remeron is an antidepressant and if the facility continues to administer without the proper consent, it is considered a chemical restraint (use of medication to sedate someone, control or restrict their behavior or movement, rather than treating a medical condition). The ADON, stated per regulation and the facility's policy and procedure (P&P), psychotherapeutics requires obtaining a new informed consents every 6 months for continued use, as the resident or RP has the right to be informed of the risk and benefits of the medication and gives them the right too decline or accept the use of the medication. During an interview on 7/18/2025 at 2:30 p.m., the ADON stated psychotherapeutic drugs are not supposed to be started without a consent from the resident and/or RP. The ADON stated psychotherapeutic drugs are not good for long term use especially the Ativan which could lead to potential adverse effects such as risk of falls. The ADON stated Ativan is an antianxiety medication that cannot be used as needed without a date to discontinue the use and if the facility started administering the medication without the proper consent, it is considered a chemical restraint. The ADON, stated per regulation and the facility's policy and procedure (P&P), all psychotherapeutics require obtaining informed consents prior to starting the medication, as the resident or RP have the right to be informed of the risk and benefits of the medication and gives them the right to decline or accept the use of the medication. The ADON stated, the informed consent should have been verified with the physician first and a signature obtained from the RP prior to start of Ativan for Resident 19 as it placed Resident 19 at risk for developing adverse effects such as risk of falls or injuries. During a review of the facility's policy and procedures (P&P), titled Informed Consent, last reviewed 4/28/2025, the P&P indicated: to ensure that the Facility respects the resident's right to make an informed decision prior to deciding to undergo certain mediation therapies and procedures.I.The use of informed consent will be done for but not limited to the following: a. Psychotherapeutic drugs IV. The informed consent/Notice will be documented and placed in the resident's medical record. V. The Facility verifies that informed consent was obtained prior to the administration of a medical intervention or change in medical intervention that requires informed consent. II. Within six (6) months after the informed consent for a psychotherapeutic drug is signed, and every six (6) months thereafter during which the resident receives a psychotherapeutic drug, the Facility shall provide a written notice to the resident or the resident's representative, of any recommended dosage adjustment and the resident's right to revoke consent and to receive gradual dose reductions and behavioral interventions in an effort to discontinue the psychotherapeutic drug. VII. The Facility will maintain documentation of verification of Informed Consent/Notice in the resident's medical record. During a review of the facility's policy and procedures (P&P), titled Psychotherapeutic Drug Management, last reviewed 4/28/2025, the P&P indicated: Psychotropic medications' - also described as .'psychotherapeutic' medications, are drugs that affect brain activities associated with mental processes and behavior. They are divided into four broad categories: antipsychotic, antidepressant, antianxiety and hypnotic. 'Unnecessary drugs' - are any drug used in excessive dose; for excessive duration, without adequate monitoring, or without adequate indications for its use, in the presence of adverse consequences which indicate the dose should be reduced or discontinues or any combinations of the afore listed reasons. B. When changing the dosage of psychotherapeutic medications, the attending physician/licensed healthcare practitioner must obtain informed consent for changes in the dosage of psychotherapeutic medication. i. An updated informed consent is needed even if the medication change is from within the same class (ex. Antipsychotic). During a review of the facility's P&P titled Psychotherapeutic Drug Management in Residents with Dementia, last reviewed 4/28/2025, the P&P indicated: C. When changing dosage of psychotherapeutic medications, the attending physician/licensed healthcare practitioner must obtain informed consent for changes in dosage of psychotherapeutic medication. i. An updated informed consent is needed even if the medication change is from within the same class (ex. Antipsychotic). G. The licensed nurse will not administer the psychotherapeutic medication until an informed consent form has been obtained and documented by the attending physician from the resident and/or surrogate decision maker. During a review of the facility's P&P titled Behavior Management, last reviewed 4/28/2025, the P&P indicated: If the attending physician determines that the resident requires psychotherapeutic medications, the attending physician must obtain informed consent before psychotherapeutic medications may be ordered and administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the decision of the resident representative were given the same consideration as if the resident made the decision themselves for one of seven sampled residents (Resident 102) reviewed for accidents by failing to assess and implement Resident Representative (RR) 1's request for a least restrictive form of physical restraint (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for safety. This deficient practice had denied the right of the resident representative to advocate for the resident who was deemed incompetent to make medical decisions. Findings:During a review of Resident 102's admission Record, the admission Record indicated the facility admitted the resident on 5/6/2021, and readmitted the resident on 4/19/2023, with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), age-related osteoporosis (is a condition where bones become thin, weak, and brittle with age, making them more likely to break), and history of falling. During a review of Resident 102's History and Physical (H&P), dated 4/1/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 102's Minimum Data Set (MDS - a resident assessment tool), dated 6/11/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had impaired vision. The MDS indicated the resident had severe cognitive impairment (a significant decline in a person's ability to think, learn, remember, concentrate, or make decisions), upper and lower extremity impairment, and uses a walker and wheelchair to mobilize self. The MDS indicated that the resident required substantial to partial assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 102's Fall Risk Assessments, dated 3/13/2025, 6/11/2025, and 7/8/2025 status post-fall, the Fall Risk Assessments indicated the resident was high risk for falls. During a review of Resident 102's Progress Notes, dated 7/4/2025, the Progress Notes indicated that at 3:25 a.m., Certified Nursing Assistant (CNA) 6 observed Resident 102 getting out of bed unassisted, the resident lost balance and fell on the floor. Resident 102 stated she wanted to go to the bathroom. Resident 102 sustained 4 centimeters (cm - a unit of measurement) by (X) 1 cm skin tear on the left elbow. The physician and family member notified of resident transfer to general acute care hospital (GACH 1). During a review of Resident 102's Progress Notes, dated 7/7/2025, the Progress Notes indicated the resident was readmitted to the facility from GACH 1 status post (s/p) fall with fractures (a broken bone). The resident was observed with a skin discoloration on the right antecubital fossa (the area in front of your elbow, also known as the elbow pit) 2 cm X 0.5 cm, skin discoloration on the right arm, 2 cm X 2 cm skin discoloration on left forearm 3 cm X 0.5 cm. Resident 102 had a brace on her left wrist. During a review of Resident 102's Radiology Report, dated 7/11/2025, the Radiology Report of left wrist, 3 views, indicated findings of acutely complex impacted fracture (occurs when the broken ends of the bone are jammed together by the force of the injury) of distal radius (the larger forearm bone is broken near the wrist) with dorsal angulation (a bone is bent or angled towards the back). During a review of Resident 102's Post Fall Assessment/Intervention, dated 7/4/2025, the Post Fall Assessment/Intervention indicated the resident was observed attempting to get out of bed unassisted, lost balance and fell on the floor. The resident required supervision/touching assistance and determined the cause or pattern of the resident's fall was unsteady gait (the way a person walks), poor judgment, and dementia (a progressive state of decline in mental abilities). During a review of Resident 102's Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their clients) Notes, dated 7/11/2025, the IDT Notes indicated RR 1 had requested to have something at night to keep her in bed like a tie, but the facility told her that it was a physical restraint. During a review of Resident 102's Care Plan (CP) Report titled Resident had a witnessed fall incident, initiated on 7/4/2025, the CP indicated an intervention for 11-7 shift staff to check on resident from 2 a.m. to 4 a.m. to see if resident is asleep or needs assistance in ADLs. During an interview on 7/17/2025 at 8:45 a.m. with RR 1, on the phone, RR 1 stated her mom can wake up in the middle of the night confused and she does not remember anything, she can walk by herself and is not calling for assistance. RR 1 stated that she is [AGE] years old, and she is barely walking, and her mind is not working as it used to. RR 1 stated it is very hard for caregivers to monitor her. RR 1 stated she suggested to the facility to use some kind of bed alarm that can help the facility be alerted when the resident is getting out of bed without assistance or a bed railing to delay her from getting out of bed by herself, she is very much willing to sign an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for her safety. RR 1 stated the facility did not want to use any restraint because they are restraint-free. During an interview on 7/17/2025 at 8:55 a.m. with Certified Nursing Assistant (CNA) 6, on the phone, CNA 6 stated she heard a noise in Resident 102's room and when she checked on the resident, she saw the resident get out of bed and fall. CNA 6 stated Resident 102 was not using the call light (button or switch, typically located near a resident's bed, that allows residents to easily request assistance from the nursing staff) for a year to alert staff when she needed help to go to the bathroom. CNA 6 stated the facility does not have any pad/tab alarms (a device designed to alert caregivers when a patient or resident is attempting to leave a bed, chair, or wheelchair) in the facility. CNA 6 stated if the resident required constant supervision, the facility provides a 1:1 sitter (staff that are immediately at hand can help prevent a fall or redirect a resident from engaging in a harmful act) to a resident. CNA 6 stated she had attended a fall prevention education at the facility and the use of pad/tab alarms and 1:1 sitters were not mentioned during the education. CNA 6 stated it could have helped her monitor Resident 102's non-compliance to use the call light if the resident is trying to get out of bed unassisted. During an interview on 7/17/2025 at 11:07 a.m. with Registered Nurse (RN) 5, on the phone, RN 5 stated that Resident 102 was found on the floor, on her left side, and was complaining of wrist and knee pain. RN 5 stated CNA 6 reported to her that the resident was getting out of bed unassisted. RN 5 stated by the time CNA 6 reached the resident, the resident already had fallen to the floor. RN 5 stated the resident does not call for help when she goes to the bathroom. RN 5 stated the facility is not using any restraints because the facility is a restraint-free facility. RN 5 stated a pad/tab alarm or a 1:1 sitter could have helped with early notification of staff that the resident is getting out of bed without assistance. RN 5 stated that she was not aware of RR 1's request for restraint on the resident and the administration needed to approve its use. During an interview on 7/18/2025 at 10 a.m. with RN 4, RN 4 stated it is against their protocol to use restraints because they are a restraint free facility. RN 4 stated it is a violation of the resident's/resident representative's right to deny the treatment suggested by RR 1 on applying a least restrictive form of restraint for Resident 102's safety. During an interview on 7/18/2025 at 1:39 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated they had an IDT with the resident and explained the reason of not using the bed rails as a means of preventing falls to the resident, however they have not used a pad/tab alarm on the resident. The ADON stated they should have tried a least restrictive form of restraint to the resident to assess if the restraint will work on preventing falls to the resident as the resident was not using a call light to ask for help to go to the bathroom. During a review of the facility's recent policy and procedure (P&P) titled Resident Rights, last reviewed on 4/28/2025, the P&P indicated all residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility including those specified in this policy. Procedure: I. State and federal laws guarantee certain basic rights to all residents of the Facility. These rights include, but are not limited to, a resident's right to: C. Choose a physician and treatment and participate in decisions and care planning, including involving representatives and considering personal and cultural preference; D. Be fully informed and participate in his/her treatment, including being fully informed in a language that he or she can understand of his/her total health status, including his/her medical condition. During a review of the facility's recent P&P titled, Restraints, last reviewed on 4/28/2025, the P&P indicated residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used. Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. This may include bed rails, beds against walls, restrictive clothing, etc. Treatment restraint is a restraint used for the protection of the resident during treatment and diagnostic procedure. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: A. Treat the medical symptom; B. Protect the resident's safety; and C. Help the resident attain the highest level of his/her physical or psychological well-being. During a review of the facility's recent P&P titled, Informed Consent, last reviewed on 4/28/2025, the P&P indicated to ensure that the Facility respects the resident's right to make an informed decision prior to deciding to undergo certain medical therapies and procedures. Informed consent is defined as the voluntary agreement of a resident (or a representative of an incapacitated resident) to accept a treatment or procedure after receiving the following information: D. The resident's/representative's right to decline to consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen, reviewed during the Kitchen task by failing to: 1.Ensure food items in Walk-in Refrigerator 1 were labeled per facility policy. 2.Ensure food items in Walk-in Refrigerator 1, were properly covered with tight sealed lids per facility policy. 3.Ensure expired food items in Walk-in Refrigerator 1 and in the food preparation area were discarded per facility policy. 4.Ensure the sanitization buckets were maintained per the manufacturer guidelines with the recommended concentration level of chemicals. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs) in 240 of 241 medically compromised residents who received food and ice from the kitchen. Findings: a.During an Initial Kitchen Tour on 7/14/2025 at 9:55 a.m., with the Dietary Supervisor (DS), observed Walk-in Refrigerator 1 and the food preparation area. The DS stated the facility uses the First-In, First-Out method to ensure no expired or old food is served to residents. The DS stated all food items are labeled to indicate the date received, the date opened, and the use by or expiration date. The DS stated food is used or discarded by a date determined by the Food Storage Guidelines. The DS stated some foods are used within three days of opening and other foods, like vegetables, are used within seven days. The DS noted the following in Walk-in Refrigerator 1 and food preparation area: 1.In Walk-In Refrigerator 1: a.Observed a grey bin of apples labeled Product [NAME] (Apple), Date 5/4/25, Use By 5/15,. The DS stated apples are stored for two weeks and the label on the bin must be wrong. The DS stated staff should have labeled the bin when the new shipment of apples arrived, but they did not. The DS stated the apples were mislabeled and should not be stored and served to residents if the apples were received on 5/4/2025. The DS stated the DS cannot be sure when the apples in the bin were received because the bin is mislabeled. b.Observed a bag containing three heads of lettuce labeled with a received date of 7/2/2025. The DS stated lettuce is good for seven days after receipt. The DS stated the lettuce was not discarded or used within 7 days of receipt and the facility guidelines were not followed. Observed the DS removed the bag of lettuce from the refrigerator. c.Observed a box of sealed individually packaged sliced smoked ham labeled with a received by date of 5/28/25. The DS stated the box with sealed bags was removed from the freezer and the ham was partially thawed. The DS stated the facility process when removing food items from the freezer, is to label with the date removed from the freezer and indicate a use by date. The DS stated it was important to label items removed from the freezer because the use by date changes when the item is no longer frozen. The DS stated the packages of smoked ham should be used within three days after removal from the freezer. The DS stated the kitchen staff forgot to label the box when it was removed from the freezer. d.Observed a large, opened container of yogurt with the lid resting on top of the container and slightly pushed to the side exposing the yogurt inside. The DS stated the lid on the yogurt was not attached to the container, but it should have been to ensure that nothing falls inside and contaminates the yogurt. 2.In the Food Prep area: a.Observed a clear plastic bin with two pieces of sliced bread labeled with an open date of 7/10/2025 and a use by date of 7/13/2025. The DS stated the bread should have been removed and discarded from the prep area on 7/13/2025 and it was not. The DS stated it was important to remove the bread to ensure expired food was not served to residents. The DS stated the facility staff did not follow the facility process. During a follow up interview and record review on 7/18/2025 at 12:32 a.m. with the DS, the DS reviewed the facility policy and procedures (P&P) and guidelines regarding food storage and noted the following: a.Smoked ham deli meat should be used or discarded within five days of being thawed. The DS stated when the box of smoked ham was not immediately labeled when it was removed from the freezer, the staff did not follow the facility P&P. b.Lettuce should be used or discarded within five days. The DS stated the staff did not follow the P&P when the lettuce was stored in the refrigerator past five days. c.Apples should be used or discarded after two weeks when stored in the refrigerator. The DS stated staff did not follow the facility P&P when the bin of apples was stored in the refrigerator with a label indicating to discard 5/14/2025. The DS further stated the facility did not have a policy to ensure lids are tightly attached to containers, but it was a standard of practice to ensure that nothing enters the container and is then served to residents. The DS stated nonedible items could fall into the food and become a physical hazard to residents. The DS Stated when food is not properly labeled, not discarded when expired, and not covered with a tightly sealed lid there is the potential that food served to residents may result in food borne illnesses. During a review of the facility P&P titled, Food Storage, last reviewed 4/28/2025, the P&P indicated the purpose was to establish guidelines for storing, thawing, and preparing food. Food items will be stored, thawed, and prepared in accordance with good sanitary practice. Thaw foods at 41 For below in covered container in refrigerator. Date meat when taken out of freezer and with date of meal service. Refreezing defrosted food is not recommended because of the increase in growth of food bacteria and the deterioration in food quality. Fresh fruit should be ordered and delivered frequently to ensure freshness and rotate fruit so that oldest produce is used first. Fresh vegetables should be ordered and delivered frequently to ensure freshness. Rotate so that oldest produce is used first. Dry storage guidelines: any opened products should be placed in storage containers with tight fitting lids, label and date storage products, and rotate stock. During a review of the facility P&P titled, Receiving Food and Supplies, last reviewed 4/28/2025, the P&P indicated food and supply items will be received and handled in accordance with good sanitary practice. Items received should be dated with FIFO Rotation. Food stock should be rotated with each new order received. During a review of the facility provided Refrigerated Storage Guidelines, undated, the Refrigerated Storage Guidelines indicated the recommended maximum storage period for refrigerated luncheon meat is five days, apples is two weeks, all other vegetables five days. b. During an Initial Kitchen Tour on 7/14/2025 at 9:55 a.m., with the DS and Food and Nutrition Services worker (FNS) 1, observed the Dishwashing Area. The DS stated red buckets are filled with Sanitizer Solution (SS) 1 to clean the kitchen surfaces using disposable towels. The DS stated SS 1 is tested by staff every four hours to ensure the solution has the proper concentration of chemicals. The DS stated SS 1 Test Strips are placed in the bucket of SS 1 and the test strips turn different colors that are compared to the guidelines on the SS 1 Test Strip vial. The DS stated the SS 1 Test Strip vial indicates a range of chemical levels that are acceptable. The DS stated the acceptable level is 272 to 700 ppm (parts per million, a measurement). The DS stated if the test strip color is out of range, then SS 1 should be adjusted. FNS 1 stated there is a sanitizer bucket in the Dishwashing Area. Observed FNS 1 hand the DS a red sanitizing bucket. Observed the DS place a test strip in the solution, observed the test strip was a light green color, and observed the DS compared the test strip to the vial. The DS then stated the test strip indicated the solution did not have the correct concentration of chemicals and measured at 848 ppm. Observed the DS rechecked SS 1 with the same results. The DS stated SS 1 was not within the recommended range. The DS stated when the level of chemicals is too low then SS 1 may not sanitize the surfaces of the kitchen potentially resulting in food borne illness in residents. The DS stated when the level of chemicals in SS 1 is too high then it may result in chemicals contaminating the food of residents. During a review of the facility P&P titled, Cleaning and Sanitation Solutions, last reviewed 4/28/2025, the P&P indicated the purpose was to ensure that dietary staff follow the guidelines for different soap and sanitation solutions and their proper use in designated buckets. The dietary department is responsible for following the manufacturer's guidelines for cleaning and sanitation solution concentration and use, as well as proper use of buckets. Red buckets will be used for sanitizer solution. Test concentration range of sanitizer solution prior to use and adhere to minimum water temperature. Appropriate test strips must be used for sanitizer solutions. All hard, non-porous surfaces must be cleaned and sanitized. Dietary staff should discard solution when the solution goes out of compliance (as indicated by the indicator/test strip) Change these buckets at least three (3) times per day and test with the appropriate test strips each time the solution is changed to assure accurate levels of sanitizer. Sanitation Solution-test: A. Measurement must be taken above minimum water temperature, as indicated by manufacturer's guidelines B. To test, follow manufacturer's guidelines (for example, dip into test solution for 5 seconds and allow 10 seconds for color change to occur) C. Detailed instructions and a color change comparison chart found on the outside of the test strip bottle can be referenced. During a review of the facility provided SS 1 Manual, dated 2021, the SS 1 Manual indicated SS 1 is a contact cleaner sanitizer. SS 1 Test Strips measurement the concentration of lactic Acid and DDBSA (one of the two approved active ingredients) in SS 1. Detailed instructions and a color comparison chart can be found on the outside of the vial. Measurement can be taken at any temperature above 65 degrees Fahrenheit (a measurement of temperature). Measurement requires 5 second dip into the test solution. Allow 10 seconds for color change to occur and compare the strip against the color on the vial. Adjust the concentration of sanitizer accordingly. The blue box indicates the approved active range of SS 1. The color of the test strip should fall within the color range indicated. The approved active range is 272 to 700 ppm (parts per million, a measurement).

Based on observation, interview, and record review, the facility failed to provide range of motion ([ROM] full movement potential of a joint) exercises to one of five sampled residents (Resident 240) with positioning and mobility (ability to move) concerns by failing to provide active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) exercises to Resident 240's right ankle and left leg in accordance with the physician's order and care plan. This failure had the potential for Resident 240 to develop weakness and ROM limitations. Findings: During a review of Resident 240's admission Record, the admission Record indicated the facility admitted Resident 240 on 4/11/2024 with diagnoses including congestive heart failure (heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), age-related cognitive (ability to think, understand, learn, and remember) decline, and muscle weakness. During a review of Resident 240's physician's orders, dated 8/9/2024, the physician's orders indicated to provide AAROM to both arms daily as tolerated and Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) to apply the right-hand wrist/hand/finger orthosis ([WHFO] material secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist and prevent contractures) as tolerated daily. Another physician's order, dated 10/28/2024, indicated for Resident 240 to receive AAROM to both legs daily as tolerated and sit-to-stand using the handrail in the hallway with the right knee brace (medical device designed to provide support, stability, and protection to the knee joint) on daily as tolerated. During a review of Resident 240's care plan titled, Sit to Stand Transfers Using Handrail with R(ight) Knee Brace On/AAROM Exercises to Upper and Lower Extremities (arms and legs) Due to Limitations of Elbows, Shoulders, Hips, Knees, Ankles and Feet, initiated on 5/13/2025, the care plan interventions included to perform AAROM exercises to both arms and legs, eight to ten (8-10) repetitions, seven times per week as tolerated, apply the right WHFO for 45 minutes or as tolerated daily, and to assist resident to perform sit-to-stand transfers using the handrail with maximum assistance (required between 51 to 75% physical assistance to perform the task) using safety belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) and right knee brace. During a review of Resident 240's Restorative Nursing Program (RNP) Referral/Care Plan, dated 5/13/2025 by Physical Therapist 2 ([PT 2] professional aimed in the restoration, maintenance, and promotion of optimal physical function), the RNP Referral/Care Plan indicated Resident 240 was at risk for decreased ROM and weakness on both legs. The RNP Referral/Care Plan goal included to maintain ROM and strength to both legs with the provision of AAROM exercises on both legs and sit-to-stand transfers using the handrail with maximum assistance and the right knee brace as tolerated. During a review of Resident 240's Minimum Data Set ([MDS] a resident assessment tool), dated 6/30/2025, the MDS indicated Resident 240 had clear speech, expressed ideas and wants, understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 240 had functional ROM limitations (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and legs and required substantial/maximal assistance (helper does more than half the effort) for upper and lower body dressing, sit-to-stand transfers, and chair/bed-to-chair transfers. During an observation on 7/15/2025 at 1:11 p.m. in Resident 240's room, Resident 240's head-of-bed was elevated and was sleepy with difficulty opening both eyes. There was a green hand splint observed on the bedside table. During an observation on 7/15/2025 at 1:28 p.m. in Resident 240's room, Resident 240's RNA session with Restorative Nursing Assistant 4 (RNA 4) was observed. Resident 240 was drowsy and sleepy throughout the RNA session. RNA 4 performed ROM exercises to the right shoulder, elbow, wrist, hand and the right hip and knee. RNA 4 did not perform any ROM exercises to the right ankle. RNA 4 moved to the left side of Resident 240's bed and began performing left shoulder ROM. Resident 240 complained of left shoulder pain, and RNA 4 stopped providing ROM exercises. RNA 4 did not provide any ROM exercises to the left elbow, wrist, hand, hip, knee, and ankle joints. RNA 4 then applied Resident 240's right-hand WHFO. During an interview on 7/15/2025 at 1:38 p.m. with RNA 4, RNA 4 stated Resident 240 received AAROM exercises to the arms and legs and applied right-hand WHFO. RNA 4 stated Resident 240 had physician's order to perform sit-to-stand but was not awake enough today to perform sit-to-stand exercises. RNA 4 stated Resident 240 did not receive ROM to the left arm due to Resident 240's complaint of left arm pain. RNA 4 stated she forgot to provide ROM to the right ankle and the left leg. During a concurrent interview and record review on 7/18/2025 at 11:54 a.m. with PT 2, Resident 240's RNP Referral/Care Plan was reviewed. PT 2 stated Resident 240's RNP Referral/Care Plan included for the RNA to provide AAROM to both hip, knee, and ankle joints. PT 2 stated Resident 240 could develop weakness, stiffness, and contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) if the RNA did not provide AAROM to both legs at each joint. During an interview on 7/18/2025 at 3:43 with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated the purpose of ROM exercises included to maintain or improve joint mobility. The DON stated that a resident (in general) can develop contractures and decreased ability to use their arms and legs if ROM exercises were not provided in accordance with the physician's order. The DON stated Resident 240 should have received ROM exercises to both arms and legs. The DON stated not providing ROM exercise to Resident 240's legs could potentially cause weakness and affect Resident 240's ability to perform sit-to-stand transfers. During a review of the facility's policy and procedure (P&P) titled, Range of Motion Exercise Guidelines: Nursing Manual - Restorative Nursing Program, revised 3/1/2015 and reviewed 4/28/2025, the P&P indicated the purpose of the policy included to maintain/increase ROM of a joint, prevent/reduce deformity including contractures, and maintain/increase muscle strength with active range of motion ([AROM] performance of ROM of a joint without any assistance or effort of another person) and AAROM. The P&P also indicated the facility will provide ROM exercises per the physician order or PT.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received necessary care and services to prevent accidents for two of seven sampled residents (Resident 72 and 4). For Resident 72, who had repeated falls, the floor mat (a cushioned floor pad designed to help prevent injury should a person fall) had furniture or medical equipment on top of it. For Resident 4, who had a high risk of fall, there was no fall risk assessment completed after the resident fell on 4/24/2025. These deficient practices caused an increased the risk of accidents and fall with injury. Cross Reference F656 Findings:a. During a review of Resident 72’s admission Record, the admission Record indicated the facility admitted the resident on 1/6/2023, with diagnoses including Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), age-related osteoporosis (a condition that weakens bones, increasing the likelihood of fractures), and repeated falls.
During a review of Resident 72’s Care Plan (CP) Report titled “At Risk for fall secondary to repeated falls / antihypertensive medication (drugs used to treat high blood pressure, also known as hypertension),” initiated 1/9/2024, the CP indicated an intervention to keep environment free of hazards and keep the pathway free from clutter.
During a review of Resident 72’s Order Review History Report, dated 2/26/2024, the Order Review History Report indicated Resident 72 may have floor mat next to bed to prevent injuries every shift.
During a review of Resident 72’s History and Physical (H&P), dated 1/1/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 72’s Minimum Data Set (MDS, a resident assessment tool), dated 5/28/2025, the MDS indicated the resident had the ability to make self-understood, understood others, and had intact cognition (no problems with thinking, remembering or using judgment). The MDS indicated the resident required substantial to supervision assistance for mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily).
During a review of Resident 72’s Fall Risk Assessment, dated 6/3/2025, the Fall Risk Assessment indicated the resident was a high risk for falls.
During a concurrent observation and interview on 7/14/2025, at 2:28 p.m., with Licensed Vocational Nurse (LVN) 7, inside Resident 72’s room, Resident 72’s floor mat was at the right side of the bed with a wheelchair on top of it. LVN 7 stated the resident placed the wheelchair on top of the floor mat himself, despite explanation of the risks it may bring. LVN 7 stated she was aware of the dangers that it could bring to the resident.
During a concurrent interview and record review on 7/18/2025, with Registered Nurse (RN) 4, Resident 72’s Medical Diagnosis, Order Review History Report, and Care Plans were reviewed. RN 4 stated she could not find the care plan of the resident refusing to remove the wheelchair on top of the resident’s floor mat. RN 4 stated the floor mat of Resident 72 should be clear of objects or furniture because it could cause a fall with injury and had to be care planned if the resident refused to remove the wheelchair. RN 4 stated the care plan served as guidance for healthcare providers on what interventions were needed to provide quality care to Resident 72.
During an interview on 7/18/2025, at 1:39 p.m., the Director of Nursing (DON) stated they used the floor mat to reduce the injury of a resident’s fall at the facility. The DON stated there should be no equipment or furniture on top of the fall mat as it caused instability, and the furniture could land on the resident causing injury. The DON added that the furniture or equipment placed on top of the floor mat can damage the mat by creating a permanent dent, or tear on the mat compromising its ability to absorb the impact of the resident’s fall. The DON stated the refusal of Resident 72 to remove the wheelchair on top of the floor mat should be care planned to communicate to the healthcare team that the resident refused despite explanation of the risks it could pose.
During a review of the facility's recent policy and procedure (P&P) titled, Safety-Environmental, last reviewed on 4/28/2025, the P&P indicated to ensure a safe, clean, and hazard-free environment for all residents, in compliance with Title 22 of the California Code of Regulations, promoting their well-being, dignity, and quality of life.
During a review of the facility's recent P&P titled, Care Planning, last reviewed on 4/28/2025, the P&P indicated to ensure that a comprehensive person-centered Care Plan was developed for each resident based on their individual assessed needs. The Comprehensive Care Plan must be completed within 7 days after completion of the Comprehensive admission Assessment and must be periodically reviewed and revised by a team of qualified persons after each assessment, including the comprehensive and quarterly review assessments.
During a review of the facility-provided Floor Mat 1 Manufacturer’s Specification, undated, the Manufacturer’s Specification indicated when moving equipment across the mat, ensure the wheels were not locked as “dragging wheels” may damage the mat. Avoid sharp materials from contacting the mat. Never leave heavy materials on the mat for an extended amount of time as they may cause a permanent indentation.
b. During a review of Resident 4’s admission Record, the admission Record indicated the facility originally admitted the resident on 3/21/2023 and readmitted on [DATE] with diagnoses including chronic congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 4’s History and Physical (H&P), dated 2/26/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 4’s Fall Risk assessment dated [DATE], the assessment indicated the total score of 10 or above represents high risk for fall, and Resident 4 had a total score 24.
During a review of the Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 4/24/2025 the RN/LVN notes indicated Resident 4 was on the floor mat, the bed was in low position, and the resident was unable to explain what happened.
During a review of Resident 4’s MDS dated [DATE], the MDS indicated the resident had minimal difficulty hearing, clear speech, usually could make self-understood and had the ability to usually understand others. The MDS indicated the resident had moderately impaired cognitive skills (able to think, remember and use judgement) for decision-making that required cues or supervision. The MDS indicated the resident required maximal assistance with sit to stand and from lying to sitting on the side of bed.
During a review of Resident 4’s Fall Risk assessment dated [DATE] indicated the total score of 10 or above represents high risk for fall, and Resident 4 had a total score 24.
During a concurrent interview and record review on 7/17/2025 at 1:34 p.m., with the Assistant Director of Staff Development, Resident 4’s Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 4/24/2025 were reviewed. The ADSD stated the RN/LVN progress notes indicated the resident’s roommate stated Resident 4 was sitting on the edge of the bed and slid down from the bed to floor mat.
During a concurrent interview and record review on 7/17/2025 at 1:44 p.m., with the ADSD, the Fall Assessments were reviewed. The ADSD stated for Resident 4 there was no fall assessment completed after the 4/24/2025 fall incident.
During an interview on 7/18/2025 at 9:46 a.m., the ADSD stated Fall Risk Assessments were done to get a status on the resident’s fall risk level. The ADSD stated the score of 10 and above would be a high risk for fall. The ADSD stated the fall risk score shows what interventions would be implemented and discussed during the interdisciplinary (IDT) meetings. The ADSD stated the Fall Risk Assessment was completed upon admission, quarterly, and after fall incidents. The ADSD stated that when the Fall Risk Assessment was not completed, they could miss doing further evaluations for Resident 4 and Resident 4 could have a repeat fall and potential for decline.
During an interview on 7/18/2025 at 1:39 p.m., the Assistant Director of Nursing (ADON) stated there was no post-fall assessment completed after Resident 4’s fall incident on 4/24/2025 and the fall risk scores were used to identify all the residents that were high risk and have potential for falls.
During a review of the facility’s policy and procedure (P&P) titled, “Fall Risk Assessment,” last reviewed on 4/27/2025, the P&P indicated the facility would ensure the resident’s environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. The facility assesses all residents upon admission and periodically for their risk of falling. The P&P indicated the facility used this information to develop both individualized plans of care and facility-wide fall prevention measures. The P&P indicated the licensed nurse would use the fall risk assessment form to help identify individuals with a history of falls and risk factors for subsequent falling. The P&P indicated the assessment would be completed upon admission, quarterly, and with a significant change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided to residents consistent with professional standards of practice for three of four sampled residents (Resident 53, 72, and 114), reviewed for Respiratory care by failing to: -Ensure Resident 53's oxygen concentrator (a medical device that provides supplemental oxygen) was turned on to administer as needed (PRN) oxygen on 7/14 and 7/15/2025. -Ensure Resident 72's nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing and mask was off of the floor. -Ensure Resident 114's nasal cannula (a simple, two-pronged device that delivers extra oxygen to the nose) tubing was not touching the floor. These deficient practices had the potential for residents to develop breathing complications and respiratory infections. Findings:a. During a review of Resident 53’s admission Record, the admission Record indicated the facility admitted the resident on 5/15/2021 and readmitted the resident on 11/15/2024 with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart).
During a review of the Physician’s Order Review History Report dated 11/15/2024, the Order Review History Report indicated Resident 53 to receive Oxygen at three liters per minute (LPM, the liters of liquid moved in one minute) via nasal cannula (NC - a small plastic tube, which fits into the person’s nostrils for providing supplemental oxygen) as needed for shortness of breath (SOB).
During a review of Resident 53’s Care Plan (CP) titled, “COPD / Respiratory Disorder / Pulmonary Hypertension at Risk for Dyspnea (difficulty breathing) / wheezing: at risk for SOB,” initiated 11/20/2024, the CP indicated an intervention to have O2 available at all times and administered per protocol.
During a review of Resident 53’s Minimum Data Set (MDS, a resident assessment tool), dated 5/19/2025, the MDS indicated the resident had the ability to make self-understood and the ability to understand others. The MDS further indicated the resident required partial/moderate assistance with toileting, dressing, and personal hygiene.
During a review of Resident 53’s Medication Administration Record (MAR) Progress Notes for 7/2025, the MAR Progress Notes indicated the following:
-On 7/14/2024 at 9:43 a.m., Licensed Vocational Nurse (LVN) 13 administered PRN O2 to Resident 53 for SOB.
-On 7/14/2025 at 2:12 p.m. LVN 13 documented the PRN administration of O2 was effective.
-On 7/15/2024 at 8:15 a.m., LVN 13 administered PRN O2 to Resident 53 for SOB.
-On 7/15/2025 at 2:59 p.m. LVN 13 documented the PRN administration of O2 was effective.
During a concurrent observation and interview on 7/14/2025 at 1:18 p.m., Resident 53 was observed lying in bed with a NC administered at the resident’s nose. The resident groaned slightly and stated he (Resident 53) was breathing ok and needed the O2 via NC every day. Resident 53 was observed with the O2 concentrator turned off and the flow meter (measures and regulates the flow rate of O2 being delivered to a patient) indicated there was no supplemental O2 via NC being administered to Resident 53.
During a concurrent observation and interview on 7/15/2025 at 9:10 a.m., with Resident 53 and Certified Nursing Assistant (CNA) 10, Resident 53 was observed sitting in the Dining Room with a NC administered at the resident’s nose. CNA 10 stated Resident 53 had been in the Dining Room for a few minutes and the resident was always administered supplemental O2 via NC while in the Dining Room. Resident 53 stated his breathing was not good. During a concurrent observation, the O2 concentrator was not turned on and the flow meter indicated there was no supplemental O2 via NC being administered to Resident 53. CNA 10 stated the concentrator was not turned on and CNA 10 then turned on the concentrator and the flow meter indicated 3 LPM being administered to the resident. CNA 10 stated usually the Licensed Vocational Nurse (LVN) turns on the concentrator when the resident was brought to the Dining Room.
During an interview on 7/15/2025 at 9:23 a.m., LVN 13 stated when Resident 53 complained of SOB, LVN 13 administers PRN O2 via NC, and then LVN 13 reevaluated the effectiveness of the PRN O2 and removed the NC if the resident no longer complained of SOB. LVN 13 stated if Resident 13 had the NC on, then the O2 concentrator should be turned on. LVN 13 stated Resident 13 needed PRN O2 on and off. LVN 13 stated on 7/15/2025 during Resident 53’s breakfast, LVN 13 placed Resident 53 on PRN O2 because the resident complained of SOB. LVN 13 stated Resident 53 went to the Dining Room with PRN O2 due to SOB and the concentrator should have been turned on. LVN 13 stated it was the LVN’s responsibility to turn on the NC.
During a concurrent interview and record review on 7/18/2025 at 1:40 p.m. with the Assistant Director of Nursing (ADON) and Director of Nursing (DON), the ADON and DON reviewed the facility policy and procedure regarding O2 administration. The ADON stated it was important to ensure the O2 concentrator was turned on when administering PRN O2 to maintain the resident’s breathing and vital signs (measurements of the body's most basic functions including body temperature, heart rate, respiratory rate, oxygen saturation [measurement of oxygen in the blood], and blood pressure). The DON stated when a resident needs PRN O2 and the concentrator was not turned on it could potentially lead to an exacerbation (COPD respiratory symptoms become much more severe) potentially resulting in a transfer to the acute care hospital. The DON stated the P&P was not followed when Resident 53’s O2 concentrator was not turned on.
During a review of the facility P&P titled, “Oxygen Administration,” last reviewed 4/28/2025, the P&P indicated the purpose was to prevent or reverse hypoxemia (a condition characterized by low levels of oxygen in the blood) and provide oxygen to the tissues. The procedure indicated to attach oxygen tubing to the nozzle on the flowmeter, turn on the oxygen at the prescribed rate, and check that oxygen was flowing through the tubing.
b. During a review of Resident 72’s admission Record, the admission Record indicated the facility admitted the resident on 1/6/2023, with diagnoses including urinary tract infection (UTI, common infections that happen when bacteria, often from the skin or rectum, enter the urethra and infect the urinary tract), Escherichia coli (e. coli, is a type of bacteria that commonly lives in the intestines of humans and animals), and Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).
During a review of Resident 72’s MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (able to think, remember, and understand).
During a review of Resident 72’s Discontinued Order, dated 7/2/2025, the Discontinued Order indicated an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams per 3 milliliters (mg/ml, a way to express the concentration of a substance) (Ipratropium-Albuterol). 1 unit (refers to a single, pre-measured dose of the drug) inhale orally via nebulizer every 8 hours for metabolic acidosis (a condition where there is too much acid in the body, specifically in the blood and other body fluids) for two weeks.
During a review of Resident 72’s Resolved CP Report titled, “Bronchitis (an inflammation of the lining of your bronchial tubes) with cough: at risk for shortness of breath (SOB),” resolved on 4/9/2024, the CP indicated an intervention to administer hand held nebulization (HHN, deliver medicines in the form of aerosols to add moisture and help control your respiratory symptoms) treatment with Albuterol every (q) 6 hours for (X) 10 days as ordered and notify MD if ineffective.
During a concurrent observation and interview on 7/14/2025, at 2:28 p.m. with LVN 7, inside Resident 72’s room, observed Resident 72 had a nebulizer at the bedside with the tubing and mask on the floor. LVN 7 stated the tubing, and the mask should not be on the floor as the floor was dirty and it could contaminate the mask and the tubing that delivered the treatment via the mouth and the nose. LVN 7 stated the tubing and the mask if used could cause respiratory infection to Resident 72. LVN 7 stated the mask should be discarded and replaced with a new one.
During an interview on 7/18/2025, at 10 a.m., Registered Nurse (RN) 4 stated the treatment nurses were responsible for ensuring the tubing and the mask were stored inside a plastic bag and labeled with the name of the resident and the date it was last changed and kept off the floor to prevent infection to Resident 72. RN 4 stated using a contaminated tubing and mask in delivering an inhalation medication can cause respiratory infection to Resident 72.
During an interview on 7/18/2025, at 1:39 p.m., the ADON stated it was not acceptable for the nebulizer tubing and mask to be on the floor or touching the floor because it can cause respiratory infection to Resident 72. The ADON stated the bacteria can crawl into the tubing and into the mask that can cause respiratory infections such as pneumonia (an infection/inflammation in the lungs) and upper respiratory tract infection (URI, a viral or bacterial infection that affects the nose, throat, and sinuses).
c. During a review of Resident 114’s admission Record, the admission Record indicated the facility admitted the resident on 4/11/2025, with diagnoses including heart failure (occurs when the heart muscle does not pump blood as well as it should), chronic obstructive pulmonary disease (COPD, a group of lung conditions that make it hard to breathe), and Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).
During a review of Resident 114’s H&P, dated 4/15/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 114’s MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had severe cognitive impairment (a person has significant difficulties with thinking, learning, remembering, and making decisions). The MDS indicated the resident was on oxygen therapy.
During a review of Resident 114’s Order Review History Report, dated 4/11/2025, the Order Review History Report indicated an order for oxygen (O2) three liters per minute (L/min, measurement of how much liquid or gas flows past a certain point in one minute) via nasal cannula as needed for shortness of breath.
During a review of Resident 114’s CP Report titled, “COPD: At risk for shortness of breath,” initiated on 4/15/2025, the CP indicated an intervention to monitor for episodes of shortness of breath, measure pulse oximetry (a simple, non-invasive way to check how much oxygen is in the blood and the heart rate) as needed, administer oxygen via nasal cannula at 3 L/min as ordered, and to notify MD if ineffective.
During a concurrent observation and interview on 7/14/2025, at 2:45 p.m., with CNA 4, inside Resident 114’s room, Resident 114’s oxygen tubing via nasal cannula was touching the floor. CNA 4 stated the oxygen tubing should not be touching the floor to prevent respiratory infection, and the tubing was dated 7/6/2025. CNA 4 stated the tubing should have been changed as they change them weekly. CNA 4 stated he would report the incident to his Charge Nurse.
During an interview on 7/18/2025, at 10 a.m., RN 4 stated the treatment nurses were responsible for ensuring the tubing was stored inside a plastic bag, labeled with the name of the resident, the date it was last changed, and kept off the floor to prevent infection to Resident 114. RN 4 stated using a contaminated tubing in delivering an oxygen therapy can cause respiratory infection to Resident 114.
During an interview on 7/18/2025, at 1:39 p.m., the ADON stated it was not acceptable for the nasal cannula tubing to be touching the floor because it can cause respiratory infection to Resident 114. The ADON stated the bacteria can crawl to the tubing that can cause respiratory infections such as pneumonia and URI.
During a review of the facility's recent P&P titled, Oxygen Administration, last reviewed on 4/28/2025, the P&P indicated to prevent or reverse hypoxemia and provide oxygen to the tissues:
-All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen:
-Are for single resident use only.
-Will be changed weekly and when visibly soiled.
The P& P indicated oxygen items would be stored in a plastic bag at the resident's bedside which was labeled with the resident's name and date when O2 cannula was changed for correct identification and to protect the equipment from dust and dirt when not in use.

Based on observation, interview and record review, the facility failed to effectively manage a resident's pain for one of six sampled residents (Resident 21) reviewed during the nutrition care area by failing to ensure Treatment Nurse (TN) 2 assessed for pain before, during, and after indwelling catheter (a flexible tube placed in the bladder to drain urine) care (the act of cleaning) when the resident displayed facial grimacing/moaning on 7/17/2025. This deficient practice resulted in Resident 21's undetected pain after catheter care, potentially resulting in a negative effect on the resident's quality of life. Findings: During a review of Resident 21's admission Record (AR), the AR indicated the facility originally admitted the resident on 1/18/2024 and most recently admitted the resident on 11/9/2024 with diagnoses that included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), carcinoma in situ of vulva (abnormal cells are found on the surface of the vulvar [external female genitals] skin), malignant neoplasm (cancer) of unspecified site of female breast, and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 21's History and Physical (H&P), dated 4/11/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set (MDS - resident assessment tool) dated 5/5/2025, the MDS indicated the resident usually was able to understand others and usually was able to make herself understood. The MDS further indicated Resident 21 was dependent on staff for eating, toileting, bathing, dressing, oral and personal hygiene, and mobility. During a review of Resident 21's Order Review History Report, the Order Review History Report indicated the following physician's orders: 1. Indwelling catheter care, cleanse with ready bath bathing cloths (2 Licensed Vocational Nurses [LVN] required), every 12 hours and as needed, dated 7/11/2025. 2. Monitor for pain, every shift, dated 1/18/2025. 3. Acetaminophen Oral Tablet 325 milligrams (MG - a unit of measurement), give 2 tablets by mouth every 4 hours as needed, for mild pain or general discomfort, not to exceed 3 grams (GM - a unit of measurement) in 24 hours from all sources, dated 1/18/2025. During a review of Resident 21's Care Plan (CP) regarding the resident's history of malignant neoplasm of the right breast and carcinoma in situ of vulva, initiated 1/19/2025, the CP indicated the resident was at risk for pain with a goal that the resident would have no excessive pain. The CP indicated interventions to encourage the resident to verbalize feelings and concerns and try to resolve concerns. During a review of Resident 21's CP regarding excoriation (the mechanical removal or abrasion of the skin's surface layer, resulting in the skin appearing red, raw, or with irritated patches) in the perineal area (area of the body between the anus and the external genitalia), initiated 4/1/2025, the CP indicated interventions to provide perineal care after each episode of incontinence. During an interview on 7/17/2025 at 7:40 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated CNA 2 has been caring for Resident 21 for about two months. CNA 2 stated Resident 21's skin has redness in the perineal area where the nurses apply cream. CNA 2 stated it seems like Resident 21 has a problem in that area that causes pain when CNA 2 cleans the resident after having a bowel movement. During a concurrent observation and interview on 7/17/2025 at 9:30 a.m. with TN 2, LVN 5, LVN 6, and CNA 2; observed Resident 21's indwelling catheter care. TN 2 stated Resident 21 had a history of excoriation that had previously healed but had just returned. Observed TN 2 explained to Resident 21 that catheter care would be provided while Resident 21 lay in bed. Observed Resident 21 did not verbally communicate with TN 2, LVN 5, or CNA 2. Observed TN 2 used disposable cloths to clean the perineal area of Resident 21. Observed Resident 21 moaned with some facial grimacing throughout the care provided. Observed TN 2, LVN 5, and CNA 2 did not ask Resident 21 if the resident was having pain before or during indwelling catheter care. TN 2 then exited the area after completing the care and LVN 5 remained at bedside. The surveyor then asked Resident 21 if Resident 21 was having pain. LVN 5 stated Resident 21 speaks Armenian. LVN 5 stated the word for pain in Armenian to Resident 21 and Resident 21 responded yes. While in the hallway outside Resident 21's room, TN 2 stated TN 2 did not assess Resident 21's pain level before, during, or after providing catheter care. TN 2 stated Resident 21's skin looked red and painful, and TN 2 should have asked Resident 21 about pain but did not. Observed LVN 6 enter then exit Resident 21's room. LVN 6 stated LVN 6 was the medication nurse for Resident 21 and Resident 21 was complaining of pain. LVN 6 stated LVN 6 would administer pain medication to Resident 21. TN 2 stated it was important to address resident pain, so the resident did not have pain during the care. TN 2 stated when a resident has untreated pain it can result in a decreased quality of life for the resident. During an interview on 7/17/2025 at 11:09 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the facility process is for the nurse to assess for pain before and during any treatment or care provided. The ADON stated if a resident demonstrates or verbalized pain during a treatment, the nurse should stop the treatment and medicate the resident, wait for about a half an hour, then return and complete the treatment. The ADON stated TN 2 should have assessed Resident 21's pain level before and during providing care. The ADON stated when TN 2 did not assess Resident 21's pain level it was a quality-of-care issue potentially leading to psychosocial issues in the resident that may manifest physically resulting in a general decline in the resident. During a follow-up concurrent interview and record review on 7/18/2025 at 10:11 a.m. with the ADON, the ADON reviewed the facility P&P regarding pain management. The ADON stated the facility P&P indicates how to identify pain through verbal and facial expression. The ADON stated it was a standard of practice for nurses to assess for pain while providing care to a resident and TN 2 did not assess Resident 21's pain. The ADON stated that when a resident's pain is not assessed and dealt with right away, the delay in treatment may affect the resident's pain threshold and make pain more difficult to treat. The ADON stated residents have the right not to be in pain. During a review of the P&P titled Administration of Pain Medication, last reviewed 4/28/2025, the P&P indicated the purpose was to provide guidelines for assessing the resident's level of pain prior to administering analgesic medication. Residents who receive as needed medication routinely will be reassessed for around-the- clock (ATC) pain medication to ensure the highest level of comfort. During a review of the P&P titled Pain Management, last reviewed 4/28/2025, the P&P indicated the purpose of the P&P was to ensure accurate assessment and management of the resident's pain. A Licensed Nurse will assess residents for pain routinely as indicated by the resident's health and functional status. Facility Staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. If the resident cannot verbalize the intensity of their pain, the Licensed Nurse will assess the resident's pain based on non-verbal cues such as facial expressions. Nursing Staff will implement timely interventions to reduce the increase in severity of pain. During a review of the P&P titled Resident Rights, last reviewed 4/28/2025, the P&P indicated all residents have a right to a dignified existence. The facility must treat each resident with respect and dignity and care for each resident in a manner and environment that promotes maintenance and enhancement of his or her quality of life.

Based on observation, interview, and record review, the facility did not have sufficient staff to provide Restorative Nursing Assistant ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services to 244 residents, including Resident 159, on 7/15/2025. This deficient practice had the potential for the residents to develop limitations in range of motion ([ROM] full movement potential of a joint) and mobility (ability to move). Cross reference F842 Findings: During a review of the job description titled, Director of Clinical Services, revised 5/2011, the responsibilities of the Director of Clinical Services included to determine staffing needs and ensure scheduling was done accordingly. During a review of the RNA job description, revised 10/2011, the RNA job description indicated the Director of Clinical Services was the immediate supervisor. The RNA job description included providing restorative nursing care as directed and ordered, including feeding, active range of motion ([AROM] performance of ROM of a joint without any assistance or effort of another person), passive range of motion ([PROM] movement of a joint through the ROM with no effort from person), ambulation (the act of walking), and transfers. During a review of the facility census printed on 7/15/2025 at 7:08 a.m., the census indicated 244 residents resided in the facility. During a review of the RNA Assignment, dated 7/15/2025, the RNA Assignment indicated the facility had eight nursing stations and listed the corresponding beds in each nursing station. The RNA Assignment indicated six RNAs were scheduled to provide RNA services to the eight nursing stations. The RNA Assignment indicated RNA 1 and RNA 6 were each assigned one nursing station and divided the assignment of an additional nursing station. The RNA Assignment also indicated RNA 4 and RNA 9 were each assigned one nursing station and divided the assignment of additional nursing station. The RNA Assignment indicated RNA 1 had 43 residents, Resident 4 had 46 residents, RNA 5 had 44 residents, RNA 6 had 31 residents, RNA 9 had 47 residents, and RNA 10 had 33 residents for RNA services on 7/15/2025. During an interview on 7/15/2025 at 10:59 a.m. with the Director of Rehabilitation (DOR), the DOR stated the RNAs provided maintenance services including ROM, the application of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), sit-to-stand transfers, and ambulation. The DOR stated nursing unit referred residents to the RNA feeding program. During an interview on 7/16/2025 at 1:22 p.m. with RNA 2, RNA 2 stated she was responsible for the schedules and assignments of the RNA staff. RNA 2 stated eight RNAs scheduled per day was perfect, seven RNAs scheduled per day was okay, but six RNAs scheduled per day was tough to provide RNA services. RNA 2 stated six RNAs were scheduled on 7/15/2025 to provide RNA services to the eight nursing because some RNA staff had time off. RNA 2 stated additional RNAs were not contacted to cover the two nursing stations. RNA 2 stated RNA 1, RNA 4, RNA 6, and RNA 9 had residents added to their RNA assignments for 7/15/2025 to cover the two nursing stations. During an interview on 7/16/2025 at 1:25 p.m. with RNA 1 and RNA 6, RNA 1 and RNA 6 stated they were unable to provide RNA sessions to their assigned stations on 7/15/2025. RNA 1 stated Resident 159 did not receive RNA for ambulation since Resident 159 required the assistance of two people. RNA 1 stated there were no other available RNAs to assist with Resident 159. During an interview on 7/17/2025 at 11:15 a.m. with RNA 3, RNA 3 stated each of the eight nursing stations had one primary (main) RNA. RNA 3 stated there were five RNAs that floated to different nursing stations when the primary RNA was off. RNA 3 stated all residents admitted to the facility received RNA services. RNA 3 stated there was an RNA staffing shortage over the past two days, requiring assistance from the Activity Staff who were also Certified Nursing Assistants and RNAs to assist with the RNA feeding program for breakfast and lunch. During an observation on 7/17/2025 at 1:52 p.m. with RNA 1 and RNA 7, Resident 159 sat on a wheelchair in the hallway with a safety belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) placed around Resident 159's waist. RNA 1 stood on Resident 159's left side while RNA 7 stood on the right side to physically assist Resident 159 to stand from the wheelchair. Resident 159 was observed in half standing position with the buttocks approximately eight inches above the wheelchair seat's surface. Resident 159 shuffled some steps forward but sat back down onto the wheelchair. RNA 1 and RNA 7 again physically assisted Resident 159 from sitting on the wheelchair to the half standing position. RNA 1 and RNA 7 held onto Resident 159's safety belt while RNA 1 pushed the FWW to encourage Resident 159 to shuffle both feet forward and RNA 7 pulled the wheelchair behind Resident 159. Resident 159 sat back down into the wheelchair. During an interview on 7/17/2025 at 2:01 p.m. with RNA 1 and RNA 7, RNA 1 stated Resident 159 required maximum assistance of two people to walk five feet. RNA 1 stated Resident 159 needed two people for safety because of the way Resident 159 walked, Resident 159 was heavy, and Resident 159's inability to follow commands. During an interview on 7/18/2025 at 10:07 a.m. with the Director of Nursing (DON), the DON stated RNA 2 arranged the RNA staff schedule, and RNA 3 audited the RNA documentation. The DON stated RNA 2 and RNA 3 reported to the Administrator. The DON stated she started to supervise the RNA program, which included scheduling and following up on any change in condition identified during RNA services. During a concurrent interview and record review on 7/18/2025 with 10:26 with RNA 3 and the DON, the RNA Assignment was reviewed. RNA 3 stated the RNA assigned to each nursing station was expected to provide RNA services to all the residents present in the nursing station. The DON stated she was not aware the RNAs were providing services to at least 30 residents in each nursing station. During a concurrent interview and record review on 7/18/2025 at 3:56 p.m. with the DON, the RNA job description and RNA Assignment, dated 7/15/2025, was reviewed. The DON stated the RNA job description indicated the DON was the RNA's immediate supervisor. The DON stated the eight RNAs assigned to each nursing station provided RNA services to approximately 30 residents. The DON stated each RNA had more than 40 residents on 7/15/2025 since there were six RNAs assigned to provide RNA services to the eight nursing stations. The DON stated the facility did not have enough RNA staff on 7/15/2025 to provide RNA services to the residents. The DON stated the RNAs could have provided either inadequate or no RNA services to the residents on 7/15/2025.

Based on observation, interview, and record review, the facility failed to perform competency skills evaluations (systematic process that evaluated an individual's skill and knowledge) for three of 13 Restorative Nursing Assistants ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility [ability to move]; RNA 4, RNA 5, and RNA 6) prior to providing RNA services, including the provision of feeding assistance, the provision of range of motion ([ROM] full movement potential of a joint) exercises, application of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), and the provision of ambulation (the act of walking). This deficient practice had the potential for 244 residents receiving RNA services to develop ROM limitations, decline in mobility, and aspiration (when food or liquid goes into the airway instead of the esophagus). Cross reference F684 and F688. Findings: During a review of the facility census, dated 7/14/2025 at 9:48 a.m., the census indicated 244 resided in the facility. During an interview on 7/15/2025 at 10:59 AM with the Director of Rehabilitation (DOR), the DOR stated the RNAs provided maintenance services including ROM, the application of splints, sit-to-stand transfers, and ambulation. The DOR stated nursing unit referred residents to the RNA feeding program. During an interview on 7/15/2025 at 10:13 a.m. with Restorative Nursing Assistant 4 (RNA 4), RNA 4 stated she has been an RNA for two months. During an interview on 7/16/2025 at 8:09 a.m. with Restorative Nursing Assistant 5 (RNA 5), RNA 5 stated she has been an RNA for approximately four mouths. During an interview on 7/16/2025 at 1:13 p.m. with Restorative Nursing Assistant 6 (RNA 6), RNA 6 stated she was a new RNA along with RNA 4 and RNA 5. During an interview on 7/17/2025 at 11:15 a.m. with RNA 3, RNA 3 stated each of the eight nursing stations had one primary (main) RNA. RNA 3 stated there were five RNAs that floated to different nursing stations when the primary RNA was off. RNA 3 stated all residents admitted to the facility received RNA services. During a concurrent observation and interview on 7/17/2025 at 11:14 a.m. with RNA 5, RNA 5 stated she was not working today but had to come in to work. RNA 5 had a competency form on the table. During a review of the Restorative Nursing Skills Evaluation form, the Restorative Nursing Skills Evaluation included but was not limited to placing the front wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking) in front of the resident, supporting the resident during standing, coaching the resident during walking, passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) exercises, active range of motion ([AROM] performance of ROM of a joint without any assistance or effort of another person) exercises, active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) exercises, splint assistance, and feeding techniques. During a concurrent interview and review of employee files on 7/17/2025 at 11:45 a.m. with the Director of Staff Development (DSD), RNA 4, RNA 5, and RNA 6's employee files were reviewed. The DSD did not have the dates RNA 4, RNA 5, and RNA 6 transitioned from Certified Nursing Assistants (CNAs) to RNAs. The DSD stated the new RNAs were coupled with an experienced RNA for orientation. The DSD stated the facility did not have any documented evidence RNA 4, RNA 5, and RNA 6 received a competency evaluation to provide RNA services after orientation. The DSD stated the facility accepted their skills based on their RNA certification (additional training in restorative care techniques). The DSD stated an outside contractor, Therapy Regional Manager (TRM), completed the Restorative Nursing Skills Evaluations once per year. RNA 4's employee file included an RNA certification, dated 3/10/2023, and RNA 4's Restorative Nursing Skills Evaluation was completed on 6/26/2025. RNA 6's employee file included an RNA certification, dated 3/10/2023, and RNA 6's Restorative Nursing Skills Evaluation was completed on 6/26/2025. RNA 5's employee file included an RNA certification, dated 12/2017, and did not include a Restorative Nursing Skills Evaluation. The DSD stated RNA 5 did not complete the annual Restorative Nursing Skills Evaluation on 6/26/2025 because RNA 5 had time off. The DSD stated TRM was supposed to but did not complete RNA 5's Restorative Nursing Skills Evaluation today (7/17/2025). During an interview on 7/17/2025 at 4:23 p.m. with the DSD, the DSD provided the facility's RNA schedule to determine the dates RNA 4, RNA 5, and RNA 6 began providing RNA services. The DSD stated RNA 4 started on 5/19/2025, RNA 5 started on 2/24/2025, and RNA 6 started on 5/19/2025. During an interview on 7/18/2025 at 9:46 a.m. with the TRM, the TRM stated RNA 5's Restorative Nursing Skills Evaluation was started but was not completed. The TRM stated the RNAs (in general) were observed while providing RNA services to determine their skills competencies. The TRM stated RNA 5 provided ambulation with a resident (unknown) and had to leave for the day. The TRM stated RNA 5's skill competency was not completed for ROM exercises and feeding techniques. The TRM stated RNA 5 has never been observed for competency skills prior to 7/17/2025. During an interview and record review on 7/18/2025 at 3:46 p.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), RNA 4, RNA 5, and RNA 6's dates of hire as RNAs and Restorative Nursing Skills Evaluations were reviewed. The DON stated competency skills evaluations (in general) determined the staff member's capability of performing specific job functions. The DON stated the competency skills evaluations should be completed upon hire and then annually. The DON reviewed the RNA dates of hire and stated RNA 4 became an RNA on 5/19/2025, RNA 5 on 2/24/2025, and RNA 6 on 5/19/2025. The DON stated the facility should have completed competency skills evaluations during the transition from CNAs to RNAs. The DON and ADON stated they did not know RNA 4, RNA 5, and RNA 6 did not have any documented competency skills evaluations upon hire as RNAs. The DON and ADON reviewed the Restorative Nursing Skills Evaluation for RNA 4 and RNA 6, dated 6/26/2025, and stated RNA 4 and RNA 6's competency skills evaluations were completed late. The DON stated RNA 5's competency evaluation was not completed. The DON stated the absence of competency skills evaluations for RNAs could result in improper provision of ROM, improper application of splints, decline in feeding skills which could lead to a decline in function, and decline in mobility. During a review of the facility's policy and procedure (P&P) titled, Staff Competency Evaluations, implemented 8/9/2024 and reviewed 4/28/2025, the P&P defined competency as demonstrated ability of an employee to perform specific tasks and responsibilities in a manner that meets or exceeds the expected standards of practice, safety, and quality. The P&P also defined evaluation as formal assessment process conducted by a qualified evaluator to measure an employee's competency in specific areas of their job role. The P&P also indicated evaluations will be conducted using direct observation, skills demonstrations, written exams, and/or verbal assessments.

Based on interview and record review the facility failed to ensure sulfamethoxazole trimethoprim (antibiotic medication used to treat infection) was administered on 7/13/2025, at 9 a.m., per physician's order for one of five sampled residents (Resident 44). The facility also failed to reconcile (comparing medication activity to supporting documentation) six medication emergency kits (eKITs) for July 2025, in three of three medication rooms (Southwest Station, Southeast Station, East Station). These deficient practices had the potential for residents to experience medication errors, worsening of infection, and increased the opportunity for Controlled Medication diversion (CM - medications which have a potential for abuse, the transfer of a CM or other medication from a lawful to an unlawful channel of distribution or use). Findings:a.During a review of Resident 44’s admission Record, the admission Record indicated the facility admitted Resident 44 on 4/2/2025, with diagnoses including atherosclerotic heart disease (a condition where fatty deposits build up inside your arteries, making them narrow and stiff), generalized muscle weakness, and urinary tract infection (UTI- an infection in the bladder/urinary tract.
During a review of Resident 44’s History & Physical (H&P) dated 4/3/2025, the H&P indicated Resident 44 did not have the capacity to understand and make decisions.
During a review of Resident 44’s Minimum Data Set (MDS-a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 44’s cognitive skills (ability to think, reason and use judgement) for daily decisions were moderately impaired and required maximum assistance from staff for toileting, showering and personal hygiene.
During a review of Physician’s Order Audit Report dated 7/12/2025, the Order Audit Report indicated an order for Resident 44 to receive sulfamethoxazole-trimethoprim (antibiotic) tablet 800-160 milligrams (mg, unit of measurement) one tablet by mouth two times a day, for left thigh abscess (a localized collection of pus, usually caused by a bacterial infection, that forms within body tissue) for seven days.
During a review of Resident 44’s Medication Administration Record (MAR) dated 7/2025, the MAR indicated Resident 44 did not receive the sulfamethoxazole-trimethoprim on 7/13/2025, at 9 a.m.
During a concurrent interview, and record review on 7/15/2025, at 1:52 p.m. with the Risk Management Nurse (RMN), Resident 44’s MAR dated 7/2025 and Progress Notes dated 7/13/2025, were reviewed. The RMN stated Resident 44’s MAR dated 7/13/2025 timed at 9 a.m. indicated code five (5.), which means see progress notes. The RMN stated Resident 44’s Progress Notes, dated 7/13/2025, timed at 8:24 a.m., did not indicate if sulfamethoxazole-trimethoprim was administered to Resident 44. The RMN stated Licensed Vocational Nurse (LVN) 1 should have administered and documented that sulfamethoxazole-trimethoprim was administered to Resident 44 on 7/13/2025, at 9 a.m. following the physician’s order. The RMN stated if the medication was not documented it meant the medication was not administered. The RMN stated based on the MAR and Progress Notes, Resident 44 did not receive the complete dose of the ordered antibiotic. The RMN stated LVN 1 should have notified the physician if the medication was missed and get an order to continue if needed. The RMN stated Resident 44’s abscess would not be resolved because of the incomplete dose of antibiotic.
b.During an observation on 7/16/2025 at 11:10 a.m., with Licensed Vocational Nurse (LVN) 2, in Medication Room Southwest Station there was:
-One medication eKIT stored in the refrigerator labeled “REF562” containing CMs without an accountability log for the reconciliation of the CM inventory at every shift change for July 2025.
-One medication eKIT stored in the cabinet labeled “12” containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for July 2025.
During a concurrent interview, LVN 2 stated that all CMs, including the medication eKITs containing CMs, should be reconciled at every shift. LVN 2 stated that the two eKITs labeled “12” and “REF562” containing CMs in Medication Room Southwest Station were not reconciled at every shift in July 2025, and it was important to account for all CMs to ensure accountability and prevent CM diversion.
During an observation on 7/16/2025 at 11:21 a.m., with Registered Nurse (RN) 1, in Medication Room Southeast Station there was:
-One medication eKIT stored in the refrigerator labeled “REF207” containing CMs without an accountability log for the reconciliation of the CM inventory at every shift change for July 2025.
-One medication eKIT stored in the cabinet labeled “4” containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for July 2025.
During a concurrent interview, RN 1 stated that all CMs should be reconciled at every shift. RN 2 stated the two eKITs labeled “4” and “REF207” containing CMs in Medication Room Southeast Station were not reconciled at every shift in July 2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion, accidental exposure of harmful medications, and to prevent adverse effects to residents.
During an observation on 7/16/2025 at 11:30 a.m., with LVN 3, in Medication Room East Station there was:
-One medication eKIT stored in the refrigerator labeled “REF466” containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for July 2025.
-One medication eKIT stored in the cabinet labeled “9” containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for July 2025.
During a concurrent interview, LVN 3 stated that all CMs, including medication eKITs containing CMs, should be reconciled at every shift. LVN 3 stated that the two eKITs labeled “9” and “REF466” containing CMs in Medication Room East Station were not reconciled at every shift in July 2025. LVN 3 stated it was important to account for all CMs to ensure accountability, prevent CM diversion, and accidental exposure of harmful medications to residents.
During an interview on 7/16/2025, at 2:55 p.m., the Assistant Director of Nursing (ADON) stated nurses should administer medication and document in the MAR per the physician’s order. The ADON stated an incomplete dose of antibiotic could result in an increase in Resident 44’s bacteria and white blood cells (part of the blood that’s its main job is to fight off infections and illnesses caused by things like viruses, bacteria, and other foreign invaders) and placed Resident 44 at a high risk for kidney damage.
During an interview on 7/16/2025, at 4 p.m., the Director of Nursing (DON) stated nurses should medicate the resident according to the physician’s order and document in the residents MAR that the medication was administered. The DON stated a missed antibiotic dose could prolong Resident 44’s infection.
During an interview on 7/18/2025 at 12:54 p.m., with the DON, ADON, and RMN, the ADON stated that medication eKITs containing CMs needed to be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON acknowledged per facility policy, reconciliation of CMs at each shift change should include eKITs containing CMs. The ADON stated six eKITs labeled “2, 4, 9, REF207, REF 466, REF562” containing CMs in Medication Room Southwest, Southeast and East stations did not have accountability and reconciliation logs at each shift change for July 2025. The DON stated not reconciling eKITs containing CMs can lead to accountability failures, and CM diversion. The ADON acknowledged the facility failed to follow policy and procedure of reconciling eKITs containing CMs.
During a review of the facility’s Policy and Procedures (P&P) titled “Controlled Medication Storage,” last reviewed 4/28/2025, the P&P indicated “Medications included in the Drug Enforcement Administration classification as CSs are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.
A. The DON and the Consultant Pharmacist maintain the facility’s compliance with federal and state laws and regulations in the handling of CMs.
D. At each shift change, a physical inventory of all CMs, including the emergency supply, is conducted by two licensed nurses and is documented on the CM accountability record.
I. The director of nursing in conjunction with the consultant pharmacist or designee routinely monitors CM storage, records, and expiration dates during medication storage inspection.”
During a review of facility’s P&P titled, “Medication-Administration,” dated 7/1/2016, and last reviewed on 4/28/2025, the P&P indicated “Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner.” The Licensed Nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the MAR. The time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act upon the recommendations of the consultant pharmacist for two of six sampled residents (Residents 27 and 19) reviewed for Unnecessary Medications, Psychotropic (medications capable of affecting the mind, emotions, and behavior) Medications, and Medication Regimen Review (MRR-a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) care area by: 1. Failing to follow-up with Resident 27's physician regarding the consultant pharmacist's MRR recommendation to add Eliquis (also known as apixaban - a type of blood thinner medication to prevent blood clots). This deficient practice had the potential to place Resident 27 at risk for ineffective treatment or adverse effects. 2. Failing to follow up with Resident 19's physician regarding the consultant pharmacist's MRR recommendation to indicate an end date for the continued use of Ativan (also known as lorazepam, a type of medication primarily used for short term treatment of anxiety disorders [a mental health condition where excessive fear and worry interfere with daily life, causing significant distress] and insomnia [difficulty sleeping]). This deficient practice had the potential to place Resident 19 at risk for development of adverse side effects from the continued use of the medication. Findings: a. During a review of Resident 27's admission Record, the admission Record indicated the facility admitted the resident on 8/1/2023 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 27's History and Physical (H&P), dated 8/16/2024, the H&P indicated Resident 27 did not have the capacity to understand and make decisions. During a review of Resident 27's Minimum Data Set (MDS-a resident assessment tool), dated 4/1/2025, the MDS indicated Resident 27 had minimal difficulty hearing, sometimes had the ability to make self understood and understand others. The MDS indicated Resident 27 required substantial/maximal to total assistance from staff with all activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 27's Order Summary Report dated 7/18/2025, the Order Summary Report indicated the following physician's orders: -4/3/2024: Eliquis (apixaban) oral tablet 2.5 milligrams (mg - a unit of measurement) give 1 tablet by mouth 2 times a day related to atherosclerotic heart disease of native coronary artery without angina pectoris. -8/1/2023: Anticoagulant medication - monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, nose bleeds every shift. -7/9/2025: Anticoagulant medication/Eliquis - monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, nose bleeds every shift. During a review of Resident 27's care plan (CP) on risk for adverse reaction from Eliquis therapy initiated on 8/10/2023, the CP indicated to observe Resident 27 and report for any signs and symptoms of but not limited to bleeding gums, bruises on arms or legs, nose bleeds as one of the interventions so the resident will have no adverse reactions from the Eliquis therapy. During a review of Resident 27's Consultant Pharmacist's MRR created between 5/1/2025 and 5/4/2025, the Consultant Pharmacist's MRR indicated to add Eliquis to anticoagulant monitoring. During a concurrent interview and record review on 7/18/2025 11:44 AM, reviewed Resident 27's electronic health record, MRR created between 5/1/2025 and 5/4/2025, and medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 5/2025, 6/2025, and 7/2025 with the Risk Management Nurse (RMN). The RMN stated the MRR created between 5/1/2025 and 5/4/2025, indicated to add Eliquis to the anticoagulant monitoring. The RMN stated she was unable to find documented evidence that the pharmacist recommendation was addressed with the physician. The RMN stated the monthly pharmacist recommendations are delegated to the care planners and/or Registered Nurse (RN) supervisors to address with the physicians within 1 week. The RMN stated the care planners or RN supervisors assigned should have addressed the pharmacy recommendations with the physician timely. The RMN stated Eliquis was added to the anticoagulant monitoring on 7/9/2025. The RMN stated the pharmacist recommendation was not addressed timely. The MRN stated it is important to add the type of medicine that was being monitored so the staff would be aware which medication they are monitoring which could lead to unmonitored adverse effects or ineffective treatment for the specific medication. During an interview on 7/16/2025 at 3:21 p.m., with the Director of Nursing (DON), the DON stated that when the consultant pharmacist emails the MRRs, the task to address the recommendations with the physicians are delegated between the care planners and the RN supervisors and addressed as soon as possible. During an interview with the Assistant DON (ADON) on 7/18/2025 at 2:06 p.m., the ADON stated the care planners and/or RN supervisors are responsible in addressing the pharmacist recommendations with the physicians immediately. The ADON stated the MRR for Resident 27 created between 5/1/2025 and 5/4/2025 indicating to add Eliquis in the anticoagulant monitoring was not added until 7/9/2025. The ADON stated the pharmacist recommendation to add Eliquis should have been addressed timely with the physician so the staff would be aware of which medication they are monitoring for adverse reactions which may lead to unmonitored or undetected adverse reactions from the specific medication. The ADON stated the facility policy titled, Drug Regimen Review, was not followed. b. During a review of Resident 19's admission Record, the admission Record indicated the facility admitted the resident on 2/24/2021 with diagnoses including Alzheimer's disease, dementia, and anxiety disorder (a mental health condition where excessive fear and worry interfere with daily life, causing significant distress). During a review of Resident 19's H&P, dated 5/4/2025, the H&P indicated Resident 19 did not have the capacity to understand and make decisions. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 had minimal difficulty hearing, sometimes had the ability to make self-understood and understand others. The MDS indicated Resident 19 required supervision or touching assistance with eating; substantial/maximal to total assistance from staff with all ADLs. During a review of Resident 19's Order Summary Report, the Order Summary Report indicated the following physician's orders: -5/2/2025 with discontinued date of 5/5/2025: lorazepam tablet 1 mg give 1 tablet by mouth every 12 hours as needed for manifested by restlessness and agitation. -5/22/2025: Ativan oral tablet 0.5 mg (lorazepam) give 1 tablet by mouth every 12 hours as needed for anxiety. During a review of Resident 19's care plan (CP) titled, Antianxiety Drug Therapy as needed lorazepam initiated on 5/2/2025, the CP indicated administer medication as ordered as one of the interventions to decrease episode of restlessness. During a review of Resident 19's Consultant Pharmacist's MRR created between 5/1/2025 and 5/4/2025, the Consultant Pharmacist's MRR indicated to clarify the diagnosis with the physician and recommend adding 14 days duration of therapy if clinically indicated or appropriate. During a review of Resident 19's Consultant Pharmacist's MRR created between 6/1/2025 and 6/4/2025, the Consultant Pharmacist's MRR indicated the Ativan order dated 5/22/2025 was missing the behavior and clarify the current order, target behavior and monitoring to ensure behaviors are qualitatively and objectively documented. During a concurrent interview and record review on 7/18/2025 9:25 a.m., reviewed Resident 19's electronic health record, physician's order, and MRR created between 5/1/2025 and 5/4/2025, and 6/1/2025 and 6/4/2025, with the Risk Management Nurse (RMN). The RMN stated the MRR dated 5/1/2025 and 5/4/2025 indicated to clarify the diagnosis with the physician and recommend adding 14 days duration of therapy. The RMN stated the pharmacist recommendation created between 5/1/2025 and 5/4/2025 was not followed up and acted upon with the physician to clarify the diagnosis and to add the 14 days duration. The RMN stated the pharmacist recommendation created between 6/1/2025 and 6/4/2025 was not followed up and acted upon with the physician to indicate the behavior manifestation for the use of Ativan. The RMN stated she was unable to find documented evidence that the pharmacist recommendation was addressed with the physician. The RMN stated the monthly pharmacist recommendations are delegated to the care planners and/or Registered Nurse (RN) supervisors to address with the physicians within 1 week. The RMN stated the care planners or RN supervisors assigned should have addressed the pharmacy recommendations with the physician timely. The RMN stated the Ativan order dated 5/2/2025 should have indicated the diagnosis and a duration of 14 days and the Ativan order dated 5/22/2025 should have indicated the behavior manifestation to ensure the use of the medication is necessary and not prolonged which placed Resident 19 at risk for adverse effects related to prolonged use of the Ativan. During an interview on 7/16/2025 at 3:21 p.m., with the Director of Nursing (DON), the DON stated that when the consultant pharmacist emails the MRRs, the task to address the recommendations with the physicians are delegated between the care planners and the RN supervisors and addressed as soon as possible. During an interview with the Assistant DON (ADON) on 7/18/2025 at 2:06 p.m., the ADON stated the care planners and/or RN supervisors are responsible in addressing the pharmacist recommendations with the physicians immediately. The ADON stated the MRR for Resident 19 created between 5/1/2025 and 5/4/2025 indicating to clarify the diagnosis with the physician and recommend adding 14 days duration of therapy and the MRR for 6/1/2025 and 6/4/2025 to indicate the behavior manifestation for the use of Ativan should have been addressed timely with the physician to ensure the use of the medication is necessary and not prolonged which placed Resident 19 at risk for adverse effects related to prolonged use of the Ativan. The ADON stated behavior manifestations should be specific and measurable. The ADON stated the facility policy titled, Drug Regimen Review, was not followed. During a review of the facility's policy and procedure (P&P) titled, Drug Regimen Review, last reviewed on 4/28/2025, the P&P indicated: -The facility maintains the residents' highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences r/t medication therapy to the extent possible by providing oversight by a licensed pharmacist, attending physician (AP), medical director, and the DON. -The consulting pharmacist will report any irregularities such as unnecessary drugs (which include but are not limited to excessive dosage, excessive duration, inadequate monitoring, inadequate indications for use or adverse consequences of use) to the medical director, DON, and the AP. -Irregularities must be addressed in a separate, written report. The report will include the resident's name, the relevant drug, and the irregularity the pharmacist identified. -The AP will respond to any irregularities reported by the pharmacist by reviewing the irregularities and documenting in the resident's medical record that the irregularity has been interviewed and what, if any, action has been taken to address it. -If no action has been taken, the attending physician must document his/her rationale. -Documentation by the attending physician must occur within 30 days of the issuance of the pharmacist's report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (% - one per hundred). Two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69 % affecting two of three residents observed for medication administration (Residents 215 and 106). The medication errors were as follows: 1.Resident 215 did not receive Senna Plus (a combination medication containing senna [a laxative] with docusate [a stool softener] used for constipation) as ordered by Resident 215's physician. Instead, Resident 215 received senna tablet. 2.Resident 106 was not instructed to rinse out mouth with water and spit after the administration of Symbicort (a corticosteroid [an anti-inflammatory medication also known as steroid] medication used for wheezing [difficulty in breathing]) inhalation, as ordered by Resident 106's physician and manufacturer guidelines. These failures had the potential to result in Residents 215 and 106 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in their health and well-being to be negatively impacted. Findings: During an observation on 7/15/2025 at 8:44 a.m., in Medication Cart Southwest Cart 1, with Licensed Vocational Nurse (LVN) 4, LVN 4 was observed administering senna 8.6 milligram ([mg]-a unit of measure of mass) tablet orally to Resident 215. Resident 215 was observed swallowing senna 8.6 mg tablet with a sip of water. During an interview on 7/15/2025 at 12:45 p.m., with LVN 4, LVN 4 stated during the morning medication administration at 8:44 a.m. LVN 4 administered senna 8.6 mg tablet to Resident 215. LVN 4 acknowledged the physician's order specified to administer Senna Plus to Resident 215. LVN 4 stated that LVN 4 failed to administer Senna Plus and instead administered senna which did not match the physician's order. LVN 4 stated Senna Plus includes a laxative and stool softener and not administering Senna Plus could potentially harm Resident 215 by increasing the risk of having hard stools and constipation. LVN 4 stated this was considered a medication error and that LVN 4 needed to report the error. During an observation on 7/15/2025 at 10:05 a.m., in Medication Cart Southwest Cart 2, with LVN 2, LVN 2 was observed administering Symbicort 2 puffs oral inhalation to Resident 106. Resident 106 was observed inhaling Symbicort 2 puffs. During an interview on 7/15/2025 at 12:50 p.m., with LVN 2, LVN 2 stated during the morning medication administration at 10:05 a.m. LVN 2 did not instruct Resident 106 to rinse mouth and spit after the two puffs oral inhalation of Symbicort. LVN 2 stated that LVN 2 failed to follow the physician and manufacturer guidelines to instruct Resident 106 to rinse out mouth with water and spit after administering Symbicort inhalation. LVN 2 stated not rinsing the mouth after administering Symbicort can cause medication to remain in the mouth harming Resident 106 by irritating the oral mucosa (membrane that lines the inside of the mouth) and resulting in oral thrush (a fungal infection of the mouth that causes creamy white lesions on the tongue, inner cheeks, and sometimes the roof of the mouth, throat, or gums, that can be painful and may bleed.) During an interview on 7/18/2025 at 12:54 p.m., with the Director of Nursing (DON,) and Assistant Director of Nursing (ADON), and in the presence of Risk Management Nurse (RMN), the ADON stated that LVN 4 failed to administer Senna Plus to Resident 215, according to Resident 215's physician order. The ADON stated that Resident 215 may be at risk for experiencing constipation, and hard stools by not receiving Senna Plus. The ADON stated that LVN 2 failed to administer Symbicort to Resident 106 according to physician orders and manufacturer guidelines. The ADON stated LVN 4 failed to instruct Resident 106 to rinse with water and spit after the inhalation of Symbicort placing Resident 106 at risk of developing oral thrush. The ADON stated that licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and the five/seven rights of medication administration are followed to ensure residents receive the correct medications according to physician orders and manufacturer guidelines. During a review of Resident 106's admission Record (a document containing demographic and diagnostic information,) dated 7/16/2025, the record indicated Resident 106 was originally admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease ([COPD - a condition that makes it difficult to breathe.]) During a review of Resident 106's Order Summary Report, dated 7/16/2025, indicated Resident 106 was prescribed Symbicort 2 puffs to inhale orally twice a day related to COPD and rinse mouth with water after use, gargle and spit out, starting 4/9/2025. During a review of Resident 106's Medication Administration Record ([MAR] - a record of mediations administered to residents) for July 2025, the MAR indicated Resident 106 was prescribed Symbicort 2 puffs inhale orally twice a day related to COPD and rinse mouth with water after use, gargle and spit out, at 9 a.m. and 5 p.m. During a review of Resident 215's admission Record dated 7/16/2025, the record indicated Resident 215 was originally admitted to the facility on [DATE] with diagnosis including constipation. During a review of Resident 215's Order Summary Report dated 7/16/2025, indicated Resident 215 was prescribed Senna Plus 8.6-50 mg tablet twice a day related to constipation, starting 8/7/2024. During a review of Resident 215's Medication Administration Record for July 2025, the MAR indicated Resident 215 was prescribed Senna Plus 8.6-50 mg tablet to give 1 tablet orally twice a day related to constipation, at 9 a.m. and 5 p.m. During a review of the facility's policy and procedures (P&P), titled Medication Administration, last reviewed 4/28/2025, the P&P indicated To provide practice standards for safe administration of medications for residents in the facility. 1.Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner. 4.Nursing staff will keep in mind the seven rights of medication when administering medication: 1.The right medication 5.Additional considerations include: 3.The rule of 3 - The Licensed Nurse administering medications will perform 3 checks comparing the physicians order, pharmacy label, and MAR. During a review of the facility's P&P titled Medication Administration -General Guidelines, last reviewed 4/28/2025, the P&P indicated: Medications are administered as prescribed in accordance with good nursing principles and practices. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Preparation 3.Prior to administration of any medication, the medication ad dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different.the physician's orders are checked for the correct dosage schedule. Administration 2.Medications are administered in accordance with written orders of the attending physician. During a review of the facility's P&P, titled Medication Errors, last reviewed 4/28/2025, the P&P indicated: I.Definition - the preparation or administration of medications or biologicals which is not in accordance with: a.The prescriber's order b.Manufacturer's specifications regarding the preparation and administration of the medication or biological d.A medication error may be the administration or omission of medication: v.Which is not currently prescribed. During a review of manufacturer's guidelines titled Highlights of Prescribing Information for Symbicort, last revised February 2009, the document indicated: After inhalation, the patient should rinse the mouth with water without swallowing. Rinse your mouth with water and spit the water out after each dose (two puffs) of SYMBICORT. Do not swallow the water. This will help to lessen the chance of getting a fungus infection (thrush) in the mouth and throat.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of five sampled residents (Resident 6, Resident 106 and Resident 207) were free of significant medication errors. For Resident 6, the insulin administration sites were not rotated per standard of care. For Resident 106, the azithromycin (an antibiotic medication used to treat infections) was not administered timely, per physician's order on 7/16/2025, and Resident 207 received nine doses of expired fluticasone and salmeterol (a combination medication used to treat breathing disorders) inhalation powder Diskus (inhaler device used to deliver medication to the lungs). These deficient practices had the potential to cause Resident 6, 106 and 207 to experience significant adverse effects (unwanted, unintended results) and serious health complications, including tissue damage, difficulty breathing, and progression of infection. Cross Reference F658 and F761 Findings:a. During a review of Resident 6’s admission Record, the admission Record indicated the facility admitted the resident on 1/27/2017, with diagnoses including long term use of insulin, type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic chronic kidney disease (a kidney disease caused by diabetes), and hyperglycemia (high blood sugar).
During a review of Resident 6’s History and Physical (H&P) dated 3/15/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 6’s Minimum Data Set (MDS, a resident assessment tool), dated 6/3/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and sometimes had the ability to understand others. The MDS indicated Resident 6 had severely impaired cognition (unable to think, remember or us judgement) and was on a high-risk drug class hypoglycemic medication (a group of drugs used to help reduce the amount of sugar present in the blood).
During a review of the Physician’s Order Review History Report, the Order Review History Report indicated for Resident 6 was to receive:
- 3/15/2025, Admelog SoloStar Subcutaneous Solution Pen-injector 100 unit per milliliters (unit/ml, the amount of insulin in a specific volume of liquid) (Insulin Lispro). Inject as per sliding scale (a customized guide, the amount of insulin to inject before meals or at specific times, based on their current blood sugar level), subcutaneously (under skin) before meals related to type 2 diabetes mellitus with hyperglycemia. Call physician if above 400 or below 70.
-6/15/2025 Basaglar KwikPen Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine). Inject 60 units subcutaneously in the morning related to type 2 diabetes mellitus with hyperglycemia, before meals, breakfast.
During a review of Resident 6’s Care Plan titled, “Diabetes Mellitus: At risk for hyper/hypoglycemia (low blood sugar) episodes,” initiated on 1/27/2017, the care plan indicated an intervention to administer Lispro insulin per sliding scale and Basaglar Kwik pen under skin in the morning as ordered.
During a review of Resident 6’s Location of Administration Report of insulin for 5/4/2025 to 7/8/2025, the Location of Administration Report indicated that insulin:
-Admelog Solostar Subcutaneous Solution Pen-injector 100 unit/ml was administered four times on 5/6 – 5/11/2025 to Resident 6’s Abdomen-Left Lower Quadrant (LLQ), and on 5/18 -5/19/2025 to LLQ. On 6/7, 6/8, 6/20 and 6/21/2025, the insulin was again administered to Resident 6’s LLQ. On the morning and afternoon on 7/8/2025 the insulin was administered to Resident 6’s RUQ.
-Basaglar KwikPen Subcutaneous Solution Pen-injector 100 unit/ml was administered on 5/4, 5/5 and 5/6/2025 to Resident 6’s RLQ. On 5/7, 5/8, 5/11 and 5/12/2025 the insulin was administered to Resident 6’s the LLQ. On 5/17, 5/18, 5/21, 5/22/2025 the insulin was administered to Resident 6’s RLQ and on 6/20, and 6/21/2025 to the residents RLQ.
During a concurrent interview and record review on 7/17/2025, at 3:59 p.m., with Licensed Vocational Nurse (LVN) 12, Resident 6’s Medical Diagnosis, Order Review History Report, Medication Administration Record (MAR), Location of Administration of insulin for 5/2025 to 7/2025, and Care Plan was reviewed. LVN 12 stated there were multiple instances where the licensed nurses did not rotate insulin administration sites to Resident 6. LVN 12 stated the licensed nurses should rotate sites of administration of insulin to prevent tissue damage such as lipodystrophy. LVN 12 stated injecting the insulin on the sites of lipodystrophy affects the absorption of the medication that can cause the resident to have hypo/hyperglycemia. LVN 12 stated not rotating insulin administration sites was a medication error.
During an interview on 7/18/2025, at 10 a.m., Registered Nurse (RN) 4 stated the licensed staff should rotate insulin administration sites on Resident 6. RN 4 stated they rotate injection sites to prevent the tissues from hardening, lipodystrophy, and the absorption of insulin would not be effective, causing the residents to have a high blood sugar level. RN 4 stated they consider not rotating insulin administration sites as a medication error.
During an interview on 7/18/2025, at 1:39 p.m., the Director of Nursing (DON) stated the licensed staff should have rotated the sites of insulin administration to Resident 6 to prevent infection, skin irritation, big purple areas on the skin, and lipodystrophy. The DON stated injecting insulin on the sites with lipodystrophy can predispose the resident to hypoglycemia (low blood sugar). The DON stated not rotating insulin administration sites was a medication error.
b. During a review of Resident 106’s admission Record, the admission record indicated Resident 106 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease that makes it difficult to breathe).
During a review of Resident 106’s chest x-ray, dated 7/14/2025, the report indicated Resident 106 had mild bronchitis (inflammation of the airways that carry air to and from the lungs) with infective etiology (referring to the cause of disease by bacteria, viruses, fungi, or parasites).
During a review of the Physician’s Order Audit Report dated 7/16/2025, the audit report indicated on 7/14/2025 at 11:44 p.m. Resident 106’s physician prescribed azithromycin 250 mg, two tablets, one time only for infection for one day, and give one tablet once a day for infection for four days starting on day two.
During a review of Resident 106’s azithromycin Order Details, the document indicated:
-Order date 7/14/2025 11:44 p.m.
-Azithromycin 250 mg tablet, two tablets for infection starting 7/15/2025 at 9 a.m.
-Azithromycin 250 mg tablet orally, one tablet for infection starting 7/17/2025 at 9 a.m. for four days.
During a review of Resident 106’s Medication Administration Record (MAR) for July 2025, the MAR indicated Resident 106 was prescribed:
-Azithromycin 250 mg tablet, two tablets one time only for infection for one day, starting on 7/15/2025, and
-Azithromycin 250 mg tablet, one tablet once a day for infection for four days starting on day two, scheduled for 9 a.m. on 7/17, 7/18, 7/19, and 7/20/2025.
The MAR indicated there was no Azithromycin 250 mg dose scheduled for day two on 7/16/2025.
During an interview on 7/16/2025 at 10 a.m., the Assistant Director of Nursing (ADON) stated the ADON failed to correctly transcribe (converting spoken words into written text) the azithromycin order for Resident 106 in the July 2025 MAR, erroneously starting the second dose on 7/17/2025 at 9 a.m. and omitting the physician’s order to start the second dose on day two on 7/16/2025. The ADON stated the ADON would contact the physician to obtain a one-time order for 7/16/2025 since the dose should have been administered at 9 a.m. and was now considered late.
During an interview on 7/18/2025 at 12:55 p.m., the ADON and DON stated it was important to administer full antibiotic therapy as ordered by the physician to effectively treat infections and prevent worsening of infections. The ADON stated the inaccurate transcription of the azithromycin order for Resident 106 by the ADON, led to omitting a dose on the MAR on day two (7/16/2025) and starting the second dose on 7/17/2025. The ADON stated the dose was administered late on 7/16/2025 and that omitting a dose of antibiotic or administering late was considered a significant medication error as Resident 106 was at risk of worsening lung infection by not being treated timely.
c. During a review of Resident 207’s admission Record, the admission Record indicated Resident 207 was admitted to the facility on [DATE] with diagnoses including COPD.
During a review of the Physician’s Order Summary dated 7/16/2025, the summary indicated Resident 207 was prescribed Advair Diskus (brand name for fluticasone and formoterol,) 250-50 microgram per dose, one puff inhale orally twice a day related to COPD, starting 10/2/2024.
During a review of Resident 207’s MAR for July 2025, the MAR indicated Resident 207 was prescribed Advair Diskus 250-50 microgram per dose one puff to be inhaled orally twice a day related to COPD, at 9 a.m. and 5 p.m., and that Resident 207 received nine doses of fluticasone and formoterol from the following nurses on the following dates and times:
LVN 3 – five doses at 9 a.m. on 7/12, 7/13, 7/14, 7/15, and 7/16/2025.
LVN 9 – two doses at 5 p.m. on 7/14 and 7/15/2025.
LVN 10 – one dose at 5 p.m. on 7/13/2025.
LVN 11 – one dose at 5 p.m. on 7/12/2025.
During an observation on 7/16/2025 at 11:37 am, in East Station Medication Cart 1, in the presence of LVN 3, one open fluticasone and salmeterol inhalation powder Diskus (for Resident 207) was found stored at room temperature and marked with a black marker indicating storage began on 6/11/2025.
During a concurrent interview, LVN 3 stated the fluticasone and salmeterol inhalation powder Diskus for Resident 207 was stored in the medication cart and opened on 6/11/2025. LVN 3 stated according to the manufacturer guidelines printed on the carton box containing the fluticasone and salmeterol inhalation powder Diskus, to store the inhaler at room temperature and discard the inhaler one month after opening the foil pouch or when the counter (on the Diskus) reads “0”, whichever comes first. LVN 3 stated the inhalation powder expired on 7/11/2025 and needed to be removed the medication cart to prevent an administration error. LVN 3 stated expired fluticasone and salmeterol inhalation powder had lost potency and would not be effective in treating the COPD, potentially causing harm to resident 207, exacerbating (making worse) difficulty in breathing. LVN 3 stated several licensed nurses failed to remove the expired fluticasone and salmeterol inhalation powder Diskus from the medication cart and as a result, several licensed nurses, including LVN 3, administered nine doses of expired fluticasone and salmeterol inhalation powder to Resident 207 between 7/12/2025 and 7/16/2025.
During a review of the manufacturer’s product storage and labeling sheet, the sheet indicated fluticasone and salmeterol inhalation powder should be stored at room temperature and discarded one month after removal from the foil overlap packaging pouch.
During an interview on 7/18/2025 at 12:54 p.m., with the DON and ADON, and in the presence of Risk Management Nurse (RMN), the ADON stated fluticasone and salmeterol inhalation powder Diskus for Resident 207 expired on 7/11/2025. The ADON and DON stated expired medications need to be removed from use to prevent accidental use. The ADON and DON stated that expired inhalers have lost effectiveness and strength, and when administered would not treat the COPD, further causing respiratory distress and exacerbation or shortness of breath. The DON stated several licensed nurses failed to remove the expired Diskus from East Station Medication Cart 1 leading to the administration of nine doses of expired medications fluticasone and salmeterol, which were considered significant medication errors.
During a review of the facility’s policy and procedures (P&P) titled, “Medication Errors,” last reviewed 4/28/2025, the P&P indicated “to ensure the prompt reporting of errors in the administration of medications and treatments to residents.
I.Definition – the preparation or administration of medications or biologicals which is not in accordance with:
a. The prescriber’s order
b. Manufacturer’s specifications regarding the preparation and administration of the medication or biological.
c. Accepted professional standards and principles which apply to professionals providing services.
d. A medication error may be the administration or omission of medication:
ii. At the wrong time.”
During a review of the facility’s P&P titled, “Discontinued Medications,” last reviewed 4/28/2025, the P&P indicated when medication are expired, the medications are marked as “discontinued” or stored in a separate location and later destroyed.
A.If a medication expires, the discontinued drug container shall be marked or otherwise identified or shall be stored in a separate location designated solely for this purpose.
B.Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up by pharmacy. Medications are removed from the medication cart or storage area prior to expiration.
During a review of facility’s P&P titled, “Storage of Medications,” last reviewed 4/28/2025, the P&P indicated “Medications and biologicals ae stored safely, and properly, following manufacturer’s recommendations or those of the supplier.
-M. Outdated, contaminated, or deteriorated medications are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.
During a review of manufacturer’s guidelines titled, “Highlights of Prescribing Information,” for Advair Diskus, last revised April 2008, the document indicated “The Diskus should be discarded one month after removal from the moisture-protective foil overwrap pouch or when the dose indicator reads 0, whichever comes first. Safely discard ADVAIR DISKUS one month after you remove it from the foil pouch, or after the dose indicator reads 0, whichever comes first.”
During a review of facility’s P&P titled, “Guide for Special Handling of Medications,” last reviewed 4/28/2025, the guide indicated “Advair Diskus (fluticasone/formoterol) – Date the Diskus when removed from the foil pouch and discard one month after removal from foil pouch or when the dose counter reads 0, whichever comes first.”
During a review of the facility's P&P titled, Subcutaneous Injection/Insulin or Heparin, last reviewed on 4/28/2025, the P&P indicated injection sites will be rotated to avoid unnecessary trauma to tissues and aid in medication absorption. Hardened or painful areas will not be used for injection. To establish more consistent blood insulin levels, rotate insulin injection sites within anatomic regions. Preferred insulin injection sites are the arms, abdomen, thighs, and buttocks.
During a review of the facility-provided Highlights of Prescribing Information on the use of Admelog (insulin lispro) injection, for subcutaneous or intravenous use, with initial U.S. approval in 2017, the Highlights of Prescribing Information indicated to administer ADMELOG by subcutaneous injection into the abdominal wall, thigh, upper arm, or buttocks within 15 minutes before a meal or immediately after a meal. Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
During a review of the facility-provided Highlights of Prescribing Information on the use of Basaglar (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2015, the Highlights of prescribing Information indicated to rotate injection sites into the abdominal area, thigh, or deltoid to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing: a. To ensure there were no expired hand sanitizer on the resident's bedside table for one of two sampled residents (Resident 72) observed during resident screening. The expiration date of the hand sanitizer is 3/2021. This deficient practice had the potential for Resident 72 to use an alcohol-based hand sanitizer past its efficacy state decreasing the effect of killing bacteria or viruses on the resident's hands that can lead to resident illnesses. b. To remove and discard from use from one of six inspected medication carts (East Station Medication Cart 1) one expired fluticasone and salmeterol (a combination medication used to treat chronic obstructive pulmonary disease [COPD - a condition that makes it difficult to breathe]) inhalation (form of medication that is inhaled) powder Diskus (inhaler device used to deliver medication to the lungs), belonging to Resident 207, observed during medication storage and labeling facility task, in accordance with facility policy and procedures and manufacturer's requirements. This deficient practice resulted in Resident 207 receiving medication that had compromised (decreased) efficacy and potency (strength of a medication,) and not effectively treating Resident 207's COPD, increasing the risk of health complications such as difficulty in breathing, and potentially resulting in hospitalization or death. Findings:
a. During a review of Resident 72’s admission Record, the admission Record indicated the facility admitted the resident on 1/6/2023, with diagnoses including urinary tract infection (UTI, an infection in the bladder/urinary tract), Escherichia coli (e. coli, is a common type of bacteria that usually lives harmlessly in the intestines of humans and animals), and dementia (a progressive state of decline in mental abilities).
During a review of Resident 72’s History and Physical (H&P), dated 1/1/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 72’s Minimum Data Set, dated [DATE], the MDS indicated the resident had the ability to make self understood and understand others and had intact cognition (means having the mental abilities like thinking, remembering, and learning functioning effectively to handle the normal demands of daily life). The MDS indicated Resident 72 required substantial to supervision assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 72 had occasional urinary incontinence (the loss of bladder control).
During a review of Resident 72’s Order Review History Report, dated 1/6/2023, the Order Review History Report indicated an order for Resident 72 to be free from a communicable disease (an illness that can be spread from one person or animal to another, or even from contaminated surfaces or objects to a person).
During a review of Resident 72’s Care Plan (CP) Report titled “At Risk for fall secondary to repeated falls/antihypertensive medication (are medicines used to treat high blood pressure, also known as hypertension),” initiated on 1/9/2024, the CP indicated an intervention to keep environment free of hazards such has wet spots and keep the pathway free from clutter.
During a concurrent observation and interview on 7/14/2025, at 2:28 p.m., with Licensed Vocational Nurse (LVN) 7, inside Resident 72’s room, observed Resident 72 had 2 hand sanitizers on the bedside table of the resident located on the foot part of the bed, one of the hand sanitizers had an expiration date of 3/2021. LVN 7 stated the hand sanitizers should not be left at the bedside of the resident because the resident can ingest them and cause an adverse reaction (a harmful or unwanted effect that happens when a person take a medication, vaccine, or are exposed to some other substance, even when they are using it correctly) to the resident and it should have been discarded. LVN 7 stated the expired hand sanitizer will not be able to effectively disinfect the hand of the resident that can cause cross-contamination (when harmful bacteria or other microorganisms are unintentionally transferred from one substance or surface to another, potentially causing illness) and infection to Resident 72.
During an interview on 7/18/2025, at 10 a.m., with Registered Nurse (RN) 4, RN 4 stated all staff were not supposed to leave hand sanitizers inside the Resident 72’s room. RN 4 stated when the staff are doing their environment of safety rounds, they should remove all the hazards identified on the resident’s surroundings including expired sanitizing agents to prevent accidental ingestion of the sanitizers that can cause adverse effects of the residents. The expired alcohol-based hand sanitizer should be discarded per facility protocol.
During an interview on 7/18/2025, at 1:39 p.m., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the ADON stated the alcohol-based hand sanitizer should not be left at the bed side of Resident 72. The ADON stated that an alcohol-based hand sanitizer is a chemical and should be away from the residents due to potential accidental ingestion that can cause the resident to get ill. The ADON stated utilizing expired alcohol-based hand sanitizer will not be effective in sanitizing the hands of the staff and the residents that can predispose them to developing infection.
During a review of the facility's policy and procedure (P&P) titled, Pharmacy Services Committee- Composition & Duties, last reviewed on 4/28/2025, the P&P indicated the Facility has a Pharmacy Services Committee (PSC) to oversee pharmacy services in the delivery of resident care at the facility.
II. Duties and Responsibilities may consist of, but are not limited to the following:
A. Development and review of policies and procedure for:
i. Safe procurement, storage, distribution, use and disposal of drugs and biological.
b. During an observation on 7/16/2025 at 11:37 am, in East Station Medication Cart 1, in the presence of Licensed Vocational Nurse (LVN) 3, the following medication was found either stored in a manner contrary to facility policies and manufacturer’s requirements, and expired and not discarded: One (1) open fluticasone and salmeterol inhalation powder Diskus for Resident 207 was found stored at room temperature and marked with a black marker indicating storage or use at room temperature began on 6/11/2025.
According to the manufacturer’s product storage and labeling, fluticasone and salmeterol inhalation powder should be stored at room temperature between 68 and 77 degrees Fahrenheit and discarded one (1) month after removal from the foil (package made of foil protecting the inhalation powder from light and degradation) overlap (layer on the outside of the inhalation powder) pouch.
During a concurrent interview with LVN 3, LVN 3 stated that the fluticasone and salmeterol inhalation powder Diskus for Resident 207 was stored in the medication cart and opened on 6/11/2025. LVN 3 stated according to the manufacturer guidelines printed on the carton box containing the fluticasone and salmeterol inhalation powder Diskus, to store the inhaler at 68 and 77 degrees Fahrenheit and discard the inhaler one (1) month after opening the foil pouch or when the counter (on the Diskus) reads “0”, whichever comes first. LVN 3 stated the inhalation powder expired on 7/11 and needed to be removed the medication cart to prevent usage in error. LVN 3 stated expired fluticasone and salmeterol inhalation powder has lost potency and will not be effective in treating the COPD potentially causing harm to resident 207 exacerbating (making worse) the wheezing associated with COPD leading to difficulty in breathing and resulting in potential hospitalization. LVN 3 stated several licensed nurses failed to remove expired fluticasone and salmeterol inhalation powder Diskus from the medication cart and as a result, several licensed nurses including LVN 3 administered nine (9) doses of expired fluticasone and salmeterol inhalation powder to Resident 207 between 7/12/2025 and 7/16/2025.
During an interview on 7/18/2025 at 12:54 p.m., with the Director of Nursing (DON,) and Assistant Director of Nursing (ADON), and in the presence of Risk Management Nurse (RMN), the ADON stated fluticasone and salmeterol inhalation powder Diskus for Resident 207 expired on 7/11/2025. The ADON and DON stated expired medications needed to be removed from use to prevent accidental use. The ADON and DON stated that expired inhalers have lost effectiveness and strength, and when administered will not treat the COPD further causing respiratory (related to breathing) distress and exacerbation, shortness of breath, and stoppage of breathing, resulting in needing to contact the physician and potentially transferring Resident 207 to the hospital. The DON stated that several licensed nurses failed to remove expired Diskus from East Station Medication Cart 1 leading to the administration of nine (9) doses of expired medications fluticasone and salmeterol, which were considered significant medication errors.
During a review of the facility’s policy and procedures (P&P), titled “Discontinued Medications,” last reviewed 4/28/2025, the P&P indicated: “When medications are expired, …the medications are marked as “discontinued” or stored in a separate location and later destroyed.
A. If a medication expires…, the discontinued drug container shall be marked or otherwise identified or shall be stored in a separate location designated solely for this purpose.
B. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up by pharmacy. Medications are removed from the medication cart or storage area prior to expiration….”
During a review of facility’s P&P titled, “Storage of Medications,” last reviewed 4/28/2025, the P&P indicated: “Medications and biologicals ae stored safely, and properly, following manufacturer’s recommendations or those of the supplier.
M. Outdated, contaminated, or deteriorated medications…are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.”
During a review of manufacturer’s guidelines titled “Highlights of Prescribing Information” for Advair Diskus ((brand name for fluticasone and formoterol,) last revised April 2008, the document indicated: “The Diskus should be discarded 1 month after removal from the moisture-protective foil overwrap pouch or when the dose indicator reads “0”, whichever comes first. Safely discard ADVAIR DISKUS 1 month after you remove it from the foil pouch, or after the dose indicator reads “0”, whichever comes first.”
During a review of facility’s P&P, titled “Guide for Special Handling of Medications,” last reviewed 4/28/2025, the guide listed the following:
“Advair Diskus (fluticasone/formoterol) – Date the Diskus when removed from the foil pouch and discard 1 month after removal from foil pouch or when the dose counter reads “0”, whichever comes first.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical record in accordance with accepted professional standards for 11 of 75 sampled residents, including five of five sampled residents (Residents 44, 106, 117,188, and 96) reviewed for infection control, 6 of 244 sampled residents (Resident 48, 121, 140, 146, 159, and 240) receiving Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services, by failing to: 1. Ensure the Coronavirus Disease 2019 (COVID-19, respiratory illness and is spread through respiratory droplets) screening form and informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for COVID-19, influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) and pneumococcal (disease is caused by bacteria) vaccinations (the administration of a vaccine to help the immune system develop immunity from a disease) were completed prior to Residents 44, 106, 117, 188, and 96 signing and acknowledging the form. 2. Document Resident 159's actual ability to perform ambulation (the act of walking) in the RNA Weekly Progress notes, dated 6/20/2025, 6/24/2025, 6/27/2025, 7/4/2025, 7/11/2025. 3. Document Resident 159's missed RNA treatment on 7/15/2025 and 7/16/2025. 4. Document Resident 240's inability to participate in sit-to-stand transfers with RNA on 7/14/2025. 5. Document Resident 48, 121, 140, and 146's missed RNA treatment on 7/15/2025. These failures had the potential to result in confusion in the care and services rendered to residents and resulted in incomplete information entered in Residents 44, 106, 117, 188, and 96's medical record. These failures also resulted in inaccurate medical records for Resident 48, 121, 140, 146, 159, and 240 which could potentially cause an undetected decline in ROM and mobility. Findings:
a. During a review of Resident 44’s admission Record, the admission Record indicated the facility admitted Resident 44 on 4/2/2025, with diagnoses including atherosclerotic heart disease (a condition where fatty deposits build up inside your arteries, making them narrow and stiff), generalized muscle weakness and urinary tract infection (UTI-an infection in the bladder/urinary tract).
During a review of Resident 44’s History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/3/2025, the H&P indicated Resident 44 did not have the capacity to understand and make decisions.
During a review of Resident 44’s Minimum Data Set (MDS-a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 44’s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.
During a concurrent interview, and record review on 7/16/2025, at 8:13 a.m., with Registered Nurse 1 (RN 1), Resident 44’s COVID Screening Form dated 4/3/2025, did not indicate Resident 44’s temperature. RN 1 stated COVID Screening Form should indicate the resident’s temperature at the time the screening was performed. RN 1 stated if the resident’s temperature was not documented, then the screening form was not properly completed.
During a review of Resident 106’s admission Record, the admission Record indicated the facility admitted Resident 106 on 4/8/2025, with diagnoses including Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities) and generalized muscle weakness.
During a review of Resident 106’s H&P, dated 4/9/2025, the H&P indicated Resident 106 had fluctuating capacity to understand and make decisions.
During a review of Resident 106’s MDS, dated [DATE], the MDS indicated Resident 106’s cognitive skills for daily decisions were moderately impaired.
During a concurrent interview, and record review on 7/16/2025, at 8:13 a.m., with RN 1, Resident 106’s Influenza Vaccination Informed Consent/Refusal dated 4/8/2025, Pneumococcal Vaccination Informed Consent/Refusal dated 4/8/2025 and the COVID-19 Vaccination Informed Consent/Refusal dated 4/8/2025 were reviewed. RN 1 stated all three Vaccination Informed Consent did not indicate the name of the representative and the relationship of the representative to the resident. RN 1 stated the informed consent should be fully and properly filled out.
During a review of Resident 117’s admission Record, the admission Record indicated the facility admitted Resident 117 on 5/29/2025, with diagnoses including metabolic encephalopathy (a change in how your brain works due to an underlying condition), unspecified (unconfirmed) dementia and generalized muscle weakness.
During a review of Resident 117’s H&P, dated 6/6/2025, the H&P indicated Resident 117 had fluctuating capacity to understand and make decisions.
During a review of Resident 117’s MDS, dated [DATE], the MDS indicated Resident 117’s cognitive skills for daily decisions were severely impaired.
During a concurrent interview, and record review on 7/16/2025, at 8:13 a.m., with RN 1), Resident 117’s COVID Screening Form dated 4/3/2025 did not indicate Resident 117’s temperature. RN 1 stated the COVID Screening Form should indicate the resident’s temperature at the time the screening was performed. RN 1 stated if the resident’s temperature was not documented, then the screening form was not properly completed.
During a review of Resident 188’s admission Record, the admission Record indicated the facility initially admitted Resident 188 on 12/4/2024, and readmitted on [DATE], with diagnoses including atherosclerotic heart disease, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and benign prostatic hyperplasia (BPH-a common condition in older men where the prostate gland grows larger than normal) with lower UTI.
During a review of Resident 188’s H&P, dated 2/6/2025, the H&P indicated Resident 188 had fluctuating capacity to understand and make decisions.
During a review of Resident 188’s MDS, dated [DATE], the MDS indicated Resident 188’s cognitive skills for daily decisions were moderately impaired.
During a concurrent interview, and record review on 7/16/2025, at 8:13 a.m., with RN 1, Resident 188’s COVID Screening Form dated 2/5/2025, Influenza Vaccination Informed Consent/Refusal dated 2/5/2025, and the COVID-19 Vaccination Informed Consent/Refusal dated 2/5/2025, were reviewed. RN 1 stated Resident 188’s COVID Screening Form did not indicate Resident 188’s temperature. RN 1 stated the COVID Screening Form should indicate the resident’s temperature at the time the screening was performed. RN 1 stated if the resident’s temperature was not documented, then the screening form was not properly completed. RN 1 stated Resident 188’s Influenza Vaccination Informed Consent/Refusal and the COVID-19 Vaccination Informed Consent/Refusal forms did not indicate the name of representative and relationship of the representative to the resident. RN 1 stated informed consents should be fully and properly filled out.
During a record review of Resident 96’s admission Record, the admission record indicated the facility admitted Resident 96 on 5/16/2025 with diagnoses including Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities), dementia and generalized muscle weakness.
During a review of Resident 96’s H&P, dated 5/19/2025, the H&P indicated Resident 96 did not have the capacity to understand and make decisions.
During a review of Resident 96’s MDS, dated [DATE], the MDS indicated Resident 96’s cognitive skills for daily decisions were severely impaired.
During a concurrent interview, and record review on 7/16/2025, at 8:13 a.m., with RN 1, Resident 96’s COVID Screening Form dated 5/16/2025, COVID-19 Vaccination Informed Consent/Refusal dated 5/16/2025, Influenza Vaccination Informed Consent/Refusal dated 5/16/2025, and the Pneumococcal Vaccination Informed Consent/Refusal dated 5/16/2025, were reviewed. RN 1 stated Resident 96’s COVID Screening Form did not indicate Resident 96’s temperature. RN 1 stated the COVID Screening Form should indicate the resident’s temperature at the time the screening was performed. RN 1 stated if the resident’s temperature was not documented, then the screening form was not properly completed. RN 1 stated Resident 96’s COVID-19 Vaccination Informed Consent/Refusal, Pneumococcal Polysaccharide and Influenza Vaccination Informed Consent/Refusal form did not indicate the last name of the resident’s representative. RN 1 stated Resident 96’s Influenza Vaccination Informed Consent/Refusal did not indicate the name of Resident 96. RN 1 stated the informed consents should be fully and properly filled out including the name and last name of the resident and the resident’s representative and the representative’s relationship to the resident.
During an interview on 7/16/2025, at 2: 55 p.m., with the Assistant Director of Nursing (ADON), the ADON stated residents’ consent should be completely filled out including the name of the resident and their representative. The ADON stated a completed consent form ensures the appropriate representative provided consent for the vaccination. The ADON stated an incomplete consent form constitutes an incomplete resident medical record.
During an interview on 7/16/2025, at 4 p.m., with the Director of Nursing (DON), the DON stated the Medical Records department should have audited the consents to ensure they were completely filled out. The DON stated the informed consents should be fully and properly filled out including the name and last name of the resident and the resident’s representative and the representative’s relationship to the resident. The DON stated a consent is a legal paper and if it is incomplete, it means it is an incomplete medical record.
During a review of facility’s policy and procedure (P&P), titled “Documentation-Nursing” dated 1/1/2016, and last reviewed on 4/28/2025, the P&P indicated “Nursing documentation will be concise, clear, pertinent, and accurate.”
During a review of facility’s P&P, titled “Informed Consent” dated 4/1/2024, and last reviewed on 4/28/2025, the P&P indicated, “To ensure that the Facility respects the resident’s right to make an informed decision prior to deciding to undergo certain medical therapies and procedures. The informed consent must be signed by the resident or the resident's representative and the physician/LHP who provided the material information.”
During a review of facility’s P&P, titled “COVID-19 Vaccination” dated 5/19/2025, was reviewed. The P&P indicated, “Prior to administering the vaccination, a nursing staff member will complete COVID-19 Vaccine – Resident Consent/Refusal with the resident or the resident’s representative. The resident or resident’s representative must sign the consent form prior to vaccine administration.”
b. During a review of Resident 159’s admission Record, the admission Record indicated the facility admitted Resident 159 on 12/16/2023 with diagnoses including Alzheimer’s disease (disease characterized by a progressive decline in mental abilities), dementia (progressive state of decline in mental abilities), dysphagia (difficulty swallowing), aphasia (disorder that makes it difficult to speak), and obesity (high amount of body fat).
During a review of Resident 159’s physician’s orders, dated 2/22/2024, the physician’s orders indicated to provide ambulation with assistance daily as tolerated and passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) to both legs as tolerated. Another physician’s order, dated 2/24/2024, indicated active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to both arms as tolerated.
During a review of Resident 159’s care plan titled, “Ambulation with Assistance Due to Unsteady Gait and Balance/PROM Exercises to Lower Extremities (legs)/AAROM Exercises to Upper Extremities (arms) due to Limitations of Shoulders, Hips, and Knees,” initiated on 2/12/2025, the care plan interventions included to assist Resident 159 with ambulation with minimal assistance (requires less than 25 percent [%] physical assistance to perform the task) using the front wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking) and safety belt (assistive device placed around a person’s waist to assist with safe transferring between surfaces or while walking) for 150 to 200 feet (unit of measure) daily as tolerated. Another intervention included performing AAROM to both of Resident 159’s arms and legs for eight to ten (8-10) repetitions daily as tolerated.
During a review of Resident 159’s Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 5/11/2025, the MDS indicated Resident 159 did not have any speech, rarely/never expressed ideas and wants, did not understand verbal content, and was severely impaired for daily decision making. The MDS also indicated Resident 159 required partial/moderate assistance (helper does less than half the effort) for sit-to-stand transfers, chair/bed-to chair transfers, toilet transfers, and walking 160 feet.
1. During a review of Resident 159’s Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 6/13/2025, the PT Evaluation indicated Resident 159 was referred to PT services from RNA due to Resident 159’s decreased activity tolerance, poor balance, difficulty with ROM exercises to both arms and legs, and difficulty with ambulation. The PT Evaluation indicated Resident 159 had within functional limits ([WFL] sufficient joint movement without significant limitation) ROM in both legs and required maximum assistance (required between 51 to 75% physical assistance to perform the task) for sit-to stand transfers, bed/chair transfers, and walking 30 feet using the FWW.
During a review of Resident 159’s RNA Weekly Summary, dated 6/20/2025, the RNA Weekly Summary indicated Resident 159 maintained goals of restorative care including ambulation with minimal assistance with use of the FWW and safety belt for 150 to 200 feet, assisted to perform AAROM exercises to arms, and provided PROM to legs daily as tolerated.
During a review of Resident 159’s PT Treatment Encounter Note, date 6/20/2025, the PT Treatment Encounter Note indicated Physical Therapy Assistant 1 (PTA 1) attempted to perform transfers and gait training but Resident 159 was resistive and uncooperative.
During a review of Resident 159’s PT Treatment Encounter Note, dated 6/23/2025, the PT Treatment Encounter Note indicated Resident 159 stood with maximum assistance and walked five (5) feet in the therapy gym with maximum assistance of two people to support and push the FWW.
During a review of Resident 159’s RNA Weekly Progress Report, dated 6/24/2025, the RNA Weekly Progress Report indicated Resident 159 maintained goals of restorative care including ambulation with moderate assistance with use of the FWW for 70 to 80 feet and performed 8-10 repetitions of AAROM exercises to arms and legs.
During a review of Resident 159’s RNA Weekly Progress Report, dated 6/27/2025, the RNA Weekly Progress Report indicated Resident 159 maintained goals of restorative care including ambulation with minimal assistance with use of the FWW for 70 to 80 feet and performed 8-10 repetitions of AAROM exercises to arms and legs.
During a review of Resident 159’s PT Treatment Encounter Note, dated 6/27/2025, the PT Treatment Encounter Note indicated Resident 159 attempted to perform three sit-to-stand transfers with maximum assistance of two people but had difficulty due to Resident 159’s resistive behavior.
During a review of Resident 159’s RNA Weekly Progress Report, dated 7/4/2025, the RNA Weekly Progress Report indicated Resident 159 maintained goals of restorative care including ambulation with minimal assistance without an assistive device for 100 to 150 feet and performed 8-10 repetitions of AAROM and PROM exercises to arms and legs.
During a review of Resident 159’s PT Treatment Encounter Note, dated 7/8/2025, the PT Treatment Encounter Note indicated Resident 159 performed four sit-to-stand transfers in the therapy gym’s parallel bars (pair of bars placed a short distance apart to provide support and stability during exercises and gait [manner of walking] training) with maximum assistance of two people.
During a review of Resident 159’s RNA Weekly Progress Report, dated 7/11/2025, the RNA Weekly Progress Report indicated Resident 159 maintained goals of restorative care including ambulation with minimal assistance without an assistive device for 100 to 200 feet and performed 8-10 repetitions of AAROM and PROM exercises to arms and legs.
During a review of Resident 159’s RNA daily treatment record (record of RNA sessions) for 7/2025, the RNA daily treatment record indicated Restorative Nursing Assistant 8 (RNA 8) provided Resident 159 with AAROM to both arms, PROM to both legs, and ambulation with assistance on 7/14/2025.
During a review of Resident 159’s PT Treatment Encounter Note, dated 7/15/2025 by Physical Therapy Assistant 2 (PTA 2), the PT Treatment Encounter Note indicated Resident 159 performed three sit-to-stand transfers in the therapy gym’s parallel bars with maximum assistance of two people. The PT Treatment Encounter Note indicated Resident 159 was unable to achieve upright posture.
During a review of Resident 159’s RNA daily treatment record for 7/2025, the RNA daily treatment record indicated Restorative Nursing Assistant 1 (RNA 1) provided Resident 159 with AAROM to both arms, PROM to both legs, and ambulation with assistance on 7/15/2025.
During a review of Resident 159’s PT Treatment Encounter Note, dated 7/16/2025 by PTA 1, the PT Treatment Encounter Note indicated PROM was performed to both legs to maintain ROM and prevent loss of motion. The PT Treatment Encounter Note indicated Resident 159 required physical cues to improve participation with poor return demonstration due to cognition. The PT Treatment Encounter Note indicated Resident 159’s ability to perform sit-to-stand transfers and walking were not tested.
During a review of Resident 159’s RNA daily treatment record for 7/2025, the RNA daily treatment record indicated Restorative Nursing Assistant 6 (RNA 6) provided Resident 159 with AAROM to both arms, PROM to both legs, and ambulation with assistance on 7/16/2025.
During a concurrent interview and record review on 7/16/2025 at 3:16 p.m. with Physical Therapist 1 (PT 1), Resident 159’s PT Evaluation, dated 6/13/2025, was reviewed. PT 1 stated Resident 159 was referred from RNA to PT due to decreased activity tolerance, difficulty with both arms and legs ROM exercises, and difficulty with ambulation. PT 1 stated Resident 159 did not follow commands for strength testing and required maximum assistance for sit-to-stand transfers and walking 30 feet. PT 1 stated PTA 1 provided Resident 159’s PT treatment today.
During a concurrent interview and record review on 7/16/2025 at 3:23 p.m. with PTA 1, Resident 159’s PT Treatment Encounter Notes were reviewed for 7/16/2025. PTA 1 stated Resident 159 received PROM to both legs due to poor cognition and inability to follow commands. PTA 1 stated Resident 159 worked on trunk control while seated but resisted sit-to-stand transfers.
During an interview on 7/16/2025 at 3:42 p.m. with PTA 2, PTA 2 stated Resident 159 was confused and had difficulty following directions. PTA 2 stated Resident 159 required maximum assistance of two people to perform sit-to-stand transfers due to safety since Resident 159 was heavy and did not initiate movement. PTA 1 stated Resident 159 required maximum assistance of two people and physical cues to perform sit-to-stand transfers at the parallel bars. PTA 2 stated Resident 159 has not walked with PTA 2, and the most Resident 159 has walked with PT services was 30 feet during the PT Evaluation (on 6/13/2025).
During an observation on 7/17/2025 at 9:01 a.m. in Resident 159’s room, Resident 159 was observed lying in bed awake and slightly turned to the right side. Resident 159 did not have any expressive verbal language.
During an interview on 7/17/2025 at 10:58 a.m. with Restorative Nursing Assistant 8 (RNA 8), RNA 8 stated she floated to different nursing stations to provide RNA services. RNA 8 stated she provided RNA services to Resident 159 on Monday (7/14/2025). RNA 8 checked Resident 159’s care plan and stated Resident 159 walked 120 feet using a FWW and a safety belt, AAROM exercises for both arms, and PROM exercises for both legs.
During an observation on 7/17/2025 at 1:09 p.m. in Resident 159’s bedroom, Resident 159’s RNA session with Restorative Nursing Assistant 7 (RNA 7) was observed. Resident 159 was awake while sitting up in a wheelchair but did not respond to questions. RNA 7 sat in a chair next to Resident 159 and provided ROM exercises for both arms and legs.
During an observation on 7/17/2025 at 1:52 p.m., RNA 7 walked out of Resident 159’s room into the hallway and returned to the room with the FWW, safety belt, and Restorative Nursing Assistant 1 (RNA 1). RNA 7 wheeled Resident 159 into the hallway and placed the safety belt around Resident 159’s waist. RNA 1 stood on Resident 159’s left side while RNA 7 stood on the right side to physically assist Resident 159 to stand from the wheelchair. Resident 159 was observed in half standing position with the buttocks approximately eight inches above the wheelchair seat’s surface. Resident 159 shuffled some steps forward and sat back down into the wheelchair. RNA 1 and RNA 7 again physically assisted Resident 159 from sitting in the wheelchair to the half standing position. RNA 1 and RNA 7 held onto Resident 159’s safety belt while RNA 1 pushed the FWW to encourage Resident 159 to shuffle both feet forward and RNA 7 pulled the wheelchair immediately behind Resident 159. Resident 159 sat back down into the wheelchair.
During an interview on 7/17/2025 at 2:01 p.m. with RNA 1 and RNA 7, RNA 1 stated Resident 159 required maximum assistance of two people to walk five (5) feet. RNA 1 stated Resident 159 needed two people for safety because of the way Resident 159 walked, Resident 159 was heavy, and Resident 159’s inability to follow commands. RNA 1 and RNA 7 stated it was unsafe for one RNA to walk with Resident 159 to manage both the FWW and the wheelchair. RNA 1 and RNA 7 stated it was difficult for Resident 159 to walk even with two RNAs.
During an interview on 7/17/2025 at 2:06 p.m. with RNA 8, RNA 8 stated Resident 159 received ROM exercises but did not remember if Resident 159 walked on 7/14/2025. RNA 8 stated she may have walked with Resident 159 at the station but did not remember who assisted RNA 8 with walking Resident 159.
During an interview on 7/18/2025 at 4:03 PM with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated the medical record (in general) contained information on the residents including diagnoses, plan of care, medications, and treatments the residents’ received.
During a concurrent interview and record review on 7/18/2025 at 4:14 p.m. with the DON and ADON, Resident 159’s RNA daily treatment record for 7/2025 and RNA Weekly Summaries, including 7/11/2025, were reviewed. The DON reviewed the RNA daily treatment record for 7/2025 and stated it did not indicate Resident 159’s ambulation distance with the RNA. The DON reviewed Resident 159’s RNA Weekly Summary, dated 7/11/2025, and stated it indicated Resident 159 walked 100 to 200 feet with the RNA. The DON was informed Resident 159 walked five feet with two RNAs during an observation on 7/17/2025. The DON stated Resident 159’s RNA Weekly Summary, dated 7/11/2025, was not accurate since the RNA daily treatment record did not indicate the ambulation distance. The DON stated Resident 159 would not require PT services if Resident 159 could walk 100 to 200 feet. The DON stated Resident 159’s RNA Weekly Summary indicated the goal for ambulation and not the actual distance. The DON stated the facility would not catch a resident’s decline if the RNA Weekly Summary was not accurate.

2. During a review of Resident 159’s RNA daily treatment record for 7/2025, the RNA daily treatment record indicated Restorative Nursing Assistant 1 (RNA 1) provided Resident 159 with AAROM to both arms, PROM to both legs, and ambulation with assistance on 7/15/2025.
During a review of Resident 159’s RNA daily treatment record for 7/2025, the RNA daily treatment record indicated Restorative Nursing Assistant 6 (RNA 6) provided Resident 159 with AAROM to both arms, PROM to both legs, and ambulation with assistance on 7/16/2025.
During an interview on 7/16/2025 at 1:25 p.m. with RNA 1, RNA 1 stated Resident 159 did not receive RNA on 7/15/2025 since Resident 159 required the assistance of two people. RNA 1 stated there were no other available RNAs to assist with Resident 159.
During a concurrent interview and record review on 7/17/2025 at 2:14 p.m. with RNA 6, Resident 159’s RNA daily treatment record for 7/16/2025 was reviewed. RNA 6 stated Resident 159 received ROM exercises and sit-to-stand transfers but did not walk yesterday (7/16/2025) because the resident required two people for safety. RNA 6 stated Resident 159 required one person to physically assist with walking while the second person needed to follow behind with the wheelchair because Resident 159 would suddenly sit. RNA 6 stated Resident 159’s RNA daily treatment record for 7/16/2025 had a check mark for ambulation but did not provide ambulation. RNA 6 stated Resident 159’s RNA daily treatment record was inaccurate for 7/16/2025.
During a concurrent interview and record review on 7/17/2025 at 2:26 p.m. with RNA 1, Resident 159’s RNA daily treatment record for 7/15/2025 was reviewed. RNA 1 stated Resident 159 received ROM exercises but did not perform ambulation on 7/15/2025. RNA 1 stated Resident 159’s RNA daily treatment record was inaccurate for 7/15/2025.
During an interview on 7/17/2025 at 2:29 p.m. with RNA 1 and RNA 6, RNA 1 stated Resident 159’s electronic documentation record should have been marked “No” for ambulation and then put the reason ambulation was not completed. RNA 6 stated the electronic documentation record was a new process and did not know how to mark “No” for RNA sessions. RNA 1 and RNA 6 stated Resident 159’s RNA daily treatment record should be but was not accurate. RNA 1 and RNA 6 stated the medical record (in general) was a record of the services provided to the residents. RNA 1 and RNA 6 stated inaccurate medical records could potentially lead to the resident’s decline in mobility.
During a concurrent interview and record review on 7/18/2025 at 4:03 p.m. with the DON and ADON, Resident 159’s RNA daily treatment record for 7/2025 was reviewed. DON stated the medical record (in general) contained information on the residents including diagnoses, plan of care, medications, and treatments the residents’ received. The DON reviewed Resident 159’s RNA daily treatment record and stated the check marks indicated Resident 159 was seen for RNA services, including ambulation. The DON stated Resident 159’s RNA daily treatment record was inaccurate if ambulation was not actually provided to Resident 159.
During a review of the facility’s policy and procedure (P&P) titled, “Documentation: Nursing Manual – Restorative Nursing Program,” revised 3/1/2015 and reviewed 4/28/2025, the P&P’s purpose included to ensure that residents’ progress in the Restorative Nursing Program was documented accurately and timely.
c. During a review of Resident 240’s admission Record, the admission Record indicated the facility admitted Resident 240 on 4/11/2024 with diagnoses including congestive heart failure (heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), age-related cognitive (ability to think, understand, learn, and remember) decline, and muscle weakness.
During a review of Resident 240’s physician’s orders, dated 8/9/2024, the physician’s o[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement appropriate infection control practices for one of six sampled residents (Residents 21) reviewed under the Nutrition care area by failing to: 1. Implement Enhanced Barrier Precautions (EBP, sometimes referred to as enhanced standard precautions, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) for Resident 21 during indwelling catheter (a flexible tube placed in the bladder to drain urine) care (the act of cleaning the catheter and area around the catheter). 2. Ensure Certified Nursing Assistant (CNA) 1 performed hand washing who provided peri-care to Resident 62, who had an indwelling urinary catheter (a flexible plastic tube [a catheter] inserted into the bladder [a hallow organ that stores urine] to provide continuous urinary drainage). 3. Failing to implement EBP for Resident 62 when CNA 1 provided peri-care to the resident who had an indwelling urinary catheter. These deficient practices had the potential to spread infections and illnesses to other residents, visitors, and staff. Findings:
a. During a review of Resident 21’s admission Record (AR), the AR indicated the facility originally admitted the resident on 1/18/2024 and most recently admitted the resident on 11/9/2024 with diagnoses that included metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), carcinoma in situ of vulva (abnormal cells are found on the surface of the vulvar [external female genitals] skin), malignant neoplasm (cancer) of unspecified site of female breast, and Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).
During a review of Resident 21’s History and Physical (H&P), dated 4/11/2025, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 21’s Minimum Data Set (MDS – resident assessment tool) dated 5/5/2025, the MDS indicated the resident usually was able to understand others and usually was able to make herself understood. The MDS further indicated Resident 21 was dependent on staff for eating, toileting, bathing, dressing, oral and personal hygiene, and mobility.
During a review of Resident 21’s Order Recap Summary, the Order Recap Summary indicated the following physician’s orders:
-Indwelling catheter care, cleanse with ready bath bathing cloths (2 Licensed Vocational Nurses required), every 12 hours and as needed, dated 7/11/2025.
During a review of Resident 21’s Care Plan (CP) regarding the use of an indwelling catheter, initiated 4/11/2025, the CP indicated the resident was at risk for infection. The CP indicated a goal that the resident would have no signs or symptoms of infection with interventions that included providing catheter care per protocol.
During an observation on 7/17/2025 at 9:30 a.m. with Treatment Nurse (TN) 2, Licensed Vocational Nurse (LVN) 5, and Certified Nursing Assistant (CNA) 2; observed Resident 21’s indwelling catheter care. Observed TN 2, LVN 5, and CNA 2 enter Resident 21’s room wearing masks and gloves. Observed TN 2, LVN 5, and CNA 2 did not don (put on) gowns upon entering the room. Observed TN 2 provided indwelling catheter care to Resident 21 while LVN 5 and CNA 2 were at bedside assisting with moving the resident and adjusting the sheets. Observed TN 2, LVN 5, and CNA 2 did not wear gowns while providing and assisting with indwelling catheter care.
During a follow-up interview on 7/17/2025 at 12:57 p.m. with CNA 2, CNA 2 stated CNA 2 did not wear a gown when providing care to Resident 21 because Resident 21 was not on any kind of isolation precautions (preventative steps taken by healthcare team members and staff at healthcare facilities to prevent the spread of infections). CNA 2 stated CNA 2 did not wear a gown while assisting with Resident 21’s indwelling catheter care on 7/17/2025.
During a concurrent interview and record review on 7/17/2025 at 1:10 p.m. with TN 2, TN 2 stated for a short period of time EBP were implemented in the facility. TN 2 stated the facility stopped implementing EBP and TN 2 did not know why. TN 2 stated EBP includes wearing a gown, masks, and gloves when providing care for residents with foley catheters because residents with indwelling devices are vulnerable to the spread of infection. TN 2 stated TN 2 did not implement EBP and don a gown when providing indwelling care to Resident 21 on 7/17/2025.
During an interview on 7/17/2025 at 4:18 p.m. with the Infection Prevention Nurse (IP), the IP stated EBP was discontinued at the facility in 3/2025 because there was an Infection Prevention Education Series which recommended that EBP was only necessary for residents with MDROs. The IP stated the facility did not have EBP because the residents did not have any MDROs.
During an interview on 7/18/2025 at 9:55 a.m. with the IP, the IP stated she was unable to locate the Infection Prevention Education Series which recommended the discontinuation of EBP if residents did not have any MDROs. The IP stated she was mistaken regarding the EBP recommendations and did not know EBP should be implemented even if the resident did not have any MDROs. The IP stated residents requiring EBP do not have any infection and want to prevent an infection. The IP stated EBP will be implemented at the facility today (7/18/2025).
b. During a review of Resident 62’s AR, the AR indicated the facility admitted the resident on 3/12/2024 with diagnoses including Alzheimer’s disease, dementia (a progressive state of decline in mental abilities), and neuromuscular dysfunction of bladder (a condition where the nerves connecting the brain and bladder are damaged or not working properly, leading to problems with bladder control and emptying).
During a review of Resident 62’s H&P, dated 5/26/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 62’s MDS, dated [DATE], the MDS indicated the resident had adequate hearing, clear speech, usually makes self understood, and usually had the ability to understand others. The MDS indicated the resident was dependent on staff for toileting, personal hygiene, and shower/bathing self. The MDS indicated the resident had an indwelling catheter.
During a review of Resident 62’s Order Review History Report (ORHR), dated 5/26/2024, the ORHR indicated catheter care every shift.
During a review of Resident 62’s CP with focus on “Has Foley Catheter: Potential for infection,” dated 5/27/2024, the CP indicated interventions including provide peri care every shift per protocol and as needed.
During an observation on 7/17/2025 at 7:48 a.m., inside and outside of Resident 62’s room, no EBP signage and no personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) noted.
During a concurrent observation and interview on 7/17/2025 at 9:46 a.m. with CNA 1, at Resident 62’s bedside, CNA 1 without wearing a gown, put on gloves in a double-gloving technique. CNA 1 stated he will provide care to Resident 62 and get her ready for the day. CNA 1 cleansed the resident’s perineal area using a peri wash soap-soaked cloth and then dried with one towel. CNA 1 cleansed the resident’s bottom, noted with bowel movement, using a second periwash-soaked washcloth and dried using a second towel. CNA 1 removed the first layer of his gloves and continued with the care. CNA 1 applied adult pads and removed soiled chux (disposable under pads) and put on clean chux underneath the resident. CNA 1 secured the resident’s adult pads and then removed the resident’s heel protectors. CNA 1 removed his pair of gloves, continued with the care, placed pillows and blankets on resident and adjusted bed to level to low. CNA 1 applied new gloves and emptied the resident’s urinary drainage bag into a container. CNA 1 stated the resident’s urinary output is 425 milliliters (ml- a unit of measurement). CNA 1 emptied the container in the restroom and performed hand washing with soap and water.
During an interview on 7/17/2025 at 10:16 a.m. with CNA 1, CNA 1 stated when he is alone providing care to the resident he would wear double gloves. CNA 1 stated he did not have to leave the resident alone with her bed all the way up to wash his hands. CNA 1 stated they are supposed to take off the gloves and wash their hands in between. CNA 1 stated this is for infection control.

During an interview on 7/17/2025 at 10:51 a.m. with CNA 1, CNA 1 stated Resident 62 is not in any isolation. CNA 1 stated he does not know about EBP. CNA 1 stated for example contact isolation they would have a sign outside the room and a cart that would have the gown and gloves. CNA 1 stated the sign tells them what to wear and a trash bin inside the room for the disposal of the PPE. CNA 1 stated there is no isolation signage inside the room either.
During an interview on 7/18/2025 at 11:57 a.m. with the Infection Preventionist (IP), the IP stated she has been the IP of the facility since 12/2024. The IP stated staff are expected to wear only one pair of gloves and double gloving is not part of the facility’s policy. The IP stated the EBP P&P was discontinued and had it clarified and reinstated starting today, 7/18/2025. The IP stated they followed the local health department guidance but reviewed from the CDC to continue the EBP P&P. The IP stated the EBP are for residents with indwelling catheters, gastrostomy tubes, central lines, and residents with wounds. The IP stated the EBP is to prevent MDROs. The IP stated the potential for not implementing EBP are residents getting an infection that becomes an MDRO. The IP stated staff are to perform hand washing before and after care and when changing gloves.
During a concurrent interview and record review on 7/18/2025 at 1:40 p.m. with the ADON and the DON, the facility P&P regarding EBP was reviewed. The ADON stated the facility stopped implementing EBP after the facility IP took training with the local health department that indicated EBP was no longer necessary. The DON stated EBP should have been implemented, and they were not. The DON stated when EBP was not implemented there was a potential for infection in residents from exposure to MDROs.
During a concurrent interview and record review on 7/18/2025 at 1:47 p.m. with the DON, the DON stated staff are expected to wash their hands before, during, and after peri-care. The DON stated all staff are expected to change gloves in between and use only one pair. The DON stated that when this is not followed there is a potential transmission of infection.
During a concurrent interview and record review on 7/18/2025 at 1:40 p.m. with the Assistant Director of Nursing (ADON) and Director of Nursing (DON), the facility P&P regarding EBP was reviewed. The ADON stated the facility stopped implementing EBP after the facility IP took a training with the local Department of Public Health that indicated EBP was no longer necessary. The DON stated EBP should have been implemented, and they were not. The DON stated when EBP were not implemented there was a potential for infection in residents from exposure to MDROs.
During a review of the facility policy and procedure (P&P) titled, “Standard and Enhanced Barrier Precautions,” last reviewed 4/28/2025, the P&P indicated the purpose of the P&P was to ensure the use of appropriate personal protective equipment to improve infection control as required in the care of residents. The Facility will utilize current guidance from the Centers for Disease Control (CDC) and the Centers for Medicare & Medicaid Services (CMS) to determine the appropriate PPE to be utilized during the care of residents to minimize the risk of infection or spread of infection. EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of MDRO colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (e.g., indwelling urinary catheter). For residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities:
-Dressing
-Bathing/showering
-Transferring
-Providing hygiene
-Changing linens
-Changing briefs or assisting with toileting
-Device care or use: urinary catheter
EBP are intended to be in place for the duration of a resident's stay in the Facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at high-risk.
During a review of the facility P&P titled, “Hand Hygiene,” last reviewed 4/28/2025, the P&P indicated the facility considers hand hygiene the primary means to prevent the spread of infections. The P&P indicated facility staff must perform hand hygiene procedures by washing hands with soap and water in circumstances including after using the bathroom, when soiled with visible dirt or debris. The P&P indicated alcohol-based hand hygiene products can and should be used to decontaminate hands after removing PPE and before moving to another resident in the same room or exiting the room. The P&P indicated the use of gloves does not replace hand hygiene procedures.
During a review of the facility P&P titled, “Perineal Care,” last reviewed 4/28/2025, the P&P indicated perineal care is provided as part of a resident’s hygienic program. The P&P indicated the procedure included after after washing, rinsing, and drying the resident’s buttocks and peri-anal area without contaminating the perineal area to remove the wet linen, placing dry linens or briefs or both underneath the resident, reposition the resident, then remove gloves and wash hands or use alcohol-based hand sanitizer. The P&P indicated “do not touch anything with soiled gloves after procedure (ie. Curtain, side rails, clean linen, call bell, etc.).” The P&P indicated the facility staff to put on clean gloves, clean and return all equipment to its proper place and to place soiled linen in proper container, remove gloves, and then wash hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) program and infection prevention and control program for four of five sampled residents (Residents 188, 117, 60, and 44) by: 1.Failing to monitor Resident 188 for the adverse effects (undesired or harmful effects) of cefdinir (antibiotic medication used to treat infection) on the following dates and times: a. 7 a.m., to 3 p.m. on 6/26/2025, and 6/27/2025. b. 3 p.m., to 11 p.m., on 6/29/2025. c.11 p.m., to 7 a.m. on 6/27/2025, 67/28/2025, and 6/29/2025. 2.Failing to monitor Resident 117 for the adverse effects of amoxicillin potassium clavulanate (antibiotic medication used to treat infection) on the following dates and times: a. 7 a.m. to 3 p.m. on 6/24/2025. b. 11 p.m. to 7 a.m. on 6/24/2025, 6/25/2025, and 6/26/2025, 3.Failing to monitor Resident 106 for the adverse effects of azithromycin (antibiotic medication used to treat infection) on the following dates and times: a. 3 p.m., to 11 p.m. on 6/4/2025, and 6/6/2025. b. 11 p.m. to 7 a.m. on 6/3/2025, 6/4/2025, and 6/6/2025. 4.Failing to monitor Resident 44 for the adverse effects of sulfamethoxazole-trimethoprim (antibiotic medication used to treat infection) on the following dates and times: a. 7 a.m. to 3 p.m. on 7/13/2025. b. 3 p.m. to 11 p.m. on 7/13/2025. c. 11 p.m. to 7 a.m. on 7/12/2025, 7/13/2025, and 7/14/2025. 5. Failing to complete Infection Control Surveillance log (a document or system used to track and monitor infections within a specific setting, like a healthcare facility, to identify trends, outbreaks [a sudden increase in the number of cases of a disease], and potential areas for improvement in infection prevention and control practice) dated 6/2025. The Infection Control Surveillance log did not indicate Residents 188, 117, and 106's signs of infection, mental status (mental state), culture result ( a laboratory procedure where a sample of body fluid or tissue is tested to know what organism is growing), x-ray result (imaging test that can spot problems areas in the body) and if the infection is either community acquired (infection was from home or community) or nosocomial (infection from the hospital). These failures had the potential to increase antibiotic resistance (do not respond to a drug) from unnecessary or inappropriate antibiotic use and had the potential for Residents 188, 117, 106, and 44 to experience an adverse reaction. Cross reference to F882 Findings: a. During a review of Resident 188's admission Record, the admission Record indicated the facility initially admitted Resident 188 on 12/4/2024, and readmitted on [DATE], with diagnoses that included atherosclerotic heart disease (a condition where fatty deposits build up inside your arteries, making them narrow and stiff), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and benign prostatic hyperplasia (BPH-a common condition in older men where the prostate gland grows larger than normal) with lower urinary tract infection (UTI-an infection in the bladder/urinary tract). During a review of Resident 188's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 2/6/2025, the H&P indicated Resident 188 had fluctuating capacity to understand and make decisions. During a review of Resident 188's Minimum Data Set (MDS-a resident assessment tool), dated 5/7/2025, the MDS indicated Resident 188's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. During a review of Resident 188's Order Audit Report (Physician Order), dated 6/24/2025, the Order Audit Report indicated an order for cefdinir capsule 300 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount), one capsule by mouth every 12 hours for UTI for three days. During a review of Resident 188's Care Plan dated 6/24/2025 on at risk for adverse reaction, the Care Plan indicated an intervention to notify the physician if adverse reaction due to antibiotic occurs. During a review of Resident 188's Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/2025, the MAR indicated Resident 188 received cefdinir from 6/26/2025, at 9 a.m., to 6/28/2025, at 9 p.m. During a concurrent interview, and record review on 7/15/2025, at 9:52 a.m., with the Infection Preventionist (IP), Resident 188's Progress Notes, dated 6/26/2025, to 6/30/2025, were reviewed. The IP stated nurses monitor residents for the adverse effects of antibiotics every shift until one to two days after the completion of antibiotic dose. The IP stated the monitoring of adverse effects were documented in the residents Progress Notes. The IP stated if residents were not monitored for the adverse effects of antibiotics, residents could have adverse reaction, which could result in delay in physician notification and cause delay in resident care. The IP stated there was no documented monitoring for the adverse effects of cefdinir in Resident 188's Progress Notes on the following dates and times. a. 7 a.m., to 3 p.m. on 6/26/2025 and 6/27/2025. b. 3 p.m., to 11 p.m., on 6/29/2025. c. 11 p.m., to 7 a.m. on 6/27/2025, 67/28/2025, and 6/29/2025. b. During a review of Resident 117's admission Record, the admission Record indicated the facility admitted Resident 117 on 5/29/2025, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and generalized muscle weakness. During a review of Resident 117's H&P, dated 6/6/2025, the H&P indicated Resident 117 had fluctuating capacity to understand and make decisions. During a review of Resident 117's MDS, dated [DATE], the MDS indicated Resident 117's cognitive skills for daily decisions were severely impaired. During a review of Resident 117's Order Audit Report, dated 6/23/2025, the Order Audit Report indicated an order for amoxicillin potassium clavulanate tablet 875-125 mg, give one tablet by mouth every 12 hours for bacterial infection /pneumonia (lung infection) for five days. During a review of Resident 117's MAR, dated 6/2025, the MAR indicated Resident 117 received amoxicillin potassium clavulanate from 6/24/2025, at 9 a.m. to 6/28/2025, at 9 p.m. During a concurrent interview, and record review on 7/15/2025, at 9:52 a.m., with the IP, Resident 117's Progress Notes, dated 6/24/2025, to 6/29/2025, were reviewed. The IP stated there was no documented monitoring for the adverse effects of amoxicillin potassium clavulanate in Resident 117's Progress Notes on the following dates and times. a. 7 a.m. to 3 p.m. on 6/24/2025 b. 11 p.m. to 7 a.m. on 6/24/2025, 6/25/2025, and 6/26/2025 c. During a review of Resident 106's admission Record, the admission Record indicated the facility admitted Resident 106 on 4/8/2025, with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia and generalized muscle weakness. During a review of Resident 106's H&P, dated 4/9/2025, the H&P indicated Resident 106 had fluctuating capacity to understand and make decisions. During a review of Resident 106's MDS, dated [DATE], the MDS indicated Resident 106's cognitive skills for daily decisions were moderately impaired. During a review of Resident 106's Order Audit Report, dated 6/3/2025, the Order Audit Report indicated an order for azithromycin (antibiotic medication used to treat infection) tablet 250 mg, give two tablets by mouth in the afternoon for bronchitis (an inflammation of the bronchial tubes, the airways that carry air to your lungs) for one day and give one tablet by mouth for four days on day two to four. During a review of Resident 106's MAR, dated 6/2025, the MAR indicated Resident 106 received azithromycin from 6/3/2025, to 6/7/2025. During a concurrent interview, and record review on 7/15/2025, at 9:52 a.m., with the IP, Resident 106's Progress Notes dated 6/3/2025, to 6/8/2025, were reviewed. The IP stated there was no documented monitoring for the adverse effects of azithromycin in Resident 106's Progress Notes on the following dates and times. a. 3 p.m., to 11 p.m. on 6/4/2025, and 6/6/2025. b. 11 p.m. to 7 a.m. on 6/3/2025, 6/4/2025, and 6/6/2025. d. During a review of Resident 44's admission Record, the admission Record indicated the facility admitted Resident 44 on 4/2/2025, with diagnoses that included atherosclerotic heart disease, generalized muscle weakness and UTI. During a review of Resident 44's H&P, dated 4/3/2025, the H&P indicated Resident 44 did not have the capacity to understand and make decisions. During a review of Resident 44's MDS, dated [DATE], the MDS indicated Resident 44's cognitive skills for daily decisions was moderately impaired. During a review of Resident 44's Order Audit Report, dated 7/12/2025, the Order Audit Report indicated an order for sulfamethoxazole-trimethoprim (antibiotic medication used to treat infection) tablet 800-160 mg, give one tablet by mouth two times a day for left thigh abscess (a localized collection of pus, usually caused by a bacterial infection, that forms within body tissue) for seven days. During a review of Resident 44's MAR, dated 7/2025, the MAR indicated Resident 44 received sulfamethoxazole-trimethoprim on 7/13/2025, at 5 p.m. to 7/15/2025, at 9 a.m. During a concurrent interview, and record review on 7/15/2025, at 1:52 p.m. with the IP, Resident 44's Progress Notes, dated 7/13/2025, to 7/15/2025, were reviewed. The IP stated there was no documented monitoring for the adverse effects of sulfamethoxazole-trimethoprim in Resident 44's Progress Notes on the following dates and times. a. 7 a.m. to 3 p.m. on 7/13/2025. b. 3 p.m. to 11 p.m. on 7/13/2025. c. 11 p.m. to 7 a.m. on 7/12/2025, 7/13/2025, and 7/14/2025. e. During a concurrent interview, and record review on 7/15/2025, at 9:52 a.m., with the IP, facility's Infection Control Surveillance Log, dated 6/2025, was reviewed. The IP stated she (IP) did not completely fill up the Infection Control Surveillance Log. The IP stated she (IP) should have completed the Infection Control Surveillance Log to keep an accurate tracking of Residents 188, 117 and 106's infections. The IP stated for Residents 188, 117, and 106, the Infection Control Surveillance had missing information on the following: 1. signs and symptoms of infection, 2. residents' mental status, 3. organism or culture result 4. x-ray result 5. if the infection is community acquired 6. if the infection was nosocomial. During an interview on 7/16/2025, at 2:55 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the IP should completely fill up the Infection Control Surveillance Log. The ADON stated the importance of the Infection Control Surveillance Log was to track and prevent further infection. The ADON stated residents are monitored for the adverse effects of antibiotics, 72 hours after starting the antibiotic, every shift. The ADON stated the nurses should monitor residents for fever, adverse effects of antibiotics to prevent anaphylactic reaction (a severe, potentially life-threatening allergic reaction that can occur rapidly after exposure to an allergen). The ADON stated residents who were not monitored for adverse effects of antibiotic could be at risk for anaphylactic reaction. During an interview on 7/16/2025, at 4:00 p.m. with the Director of Nursing (DON), the DON stated it was the IP's responsibility to complete the Infection Control Surveillance Log. The DON stated every part of the Infection Control Surveillance Log should be answered if applicable to help the nurses track if the antibiotic was effective or not and to know if the resident was experiencing any adverse reaction. The DON stated it is important to know if residents are tolerating the antibiotic. The DON stated the nurses should check if the resident had any side effects or adverse effects from the antibiotic and the nurses need to document. The DON stated if residents are not monitored for the adverse effects of the antibiotic, infection could not heal and could worsen. During a review of facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program dated 12/1/2021, and last reviewed on 4/28/2025, the P&P indicated, The Antibiotic Stewardship Program (ASP) is designed to promote appropriate use of antibiotics while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use. II. Accountability C. The Infection Control Committee (ICC) will review infections and monitor antibiotic usage patterns on a regular basis. In addition, the ICC will obtain and review results from microbial cultures, resistant organisms, alerts and antibiograms from the laboratory for trends of resistance. F. The IP will collect and analyze infection surveillance data and monitor the adherence to the ASP and create a report for the Consultant Pharmacist identifying the number of residents on antibiotics that did not meet criteria for active infection and suggest appropriate overall changes to make it a successful, well-rounded program. V. Tracking A. The IP will be responsible for review of infection surveillance and multidrug-resistant organism (MDRO-bacteria that have become resistant to certain antibiotics) tracking. The IP will utilize.Antibiotic Tracking Sheet. During a review of facility's P&P titled, Infection Prevention and Control Program, dated 12/1/2021, and last reviewed on 4/28/2025, the P&P indicated, The IP is responsible for coordinating the development and monitoring of the facility's established infection control policies and procedures including but not limited to: . D. Collecting, analyzing and providing infection data and trends to nursing staff and Physicians. IV. Surveillance A. The Facility provides surveillance of Healthcare-Associated Infections (HAIs) and Community-Associated Infections (CAls) significantly affecting resident health outcomes. B. Healthcare-Associated Infection (HAI) - An infection contracted in a healthcare setting while receiving healthcare treatment for other conditions. i. For infection surveillance purposes, infections are HAI, if: . b. Onset of clinical manifestation occurs after two calendar days after admission. C. Community-Associated Infection (CAI) -An infection that is acquired outside of a healthcare setting or an infection present upon admission. E. Licensed nursing staff monitors residents for signs and symptoms that suggest infection, according to current criteria and definitions of infections, and documents and reports suspected infections to the Charge Nurse as soon as possible. V. Gathering Surveillance Data A. The Licensed Nurse will initiate the gathering of surveillance data for each resident and document on. Infection Control Surveillance. B. The IP will review the Infection Control Surveillance Form and Surveillance Data Collection Form initiated by the Licensed Nurse and determine if the infection is HAI or CAI. The Infection Preventionist will document accordingly on .Infection Control Surveillance. C. The IP will complete.HAI Infections Worksheet to determine specific sites and pathogen trends. D. In addition, the IP will collect and document data on the incidence of infections on.Monthly Infection Report for All Nursing Units. This surveillance system is designed to capture epidemiologically important data that influences how the overall surveillance data is interpreted. VII. Interpreting Surveillance Data A. The Medical Director and Infection Control Committee (ICC) will review data gathered by the IP to determine root cause for HAI or CAI. B. The surveillance may include a review of the following information to help identify possible root causes of HAIs: . v. Infection surveillance sheets. viii. Antibiotic review. During a review of facility's P&P titled, Monitoring for Efficacy and Adverse Drug Reactions dated 7/1/2016, and last reviewed on 4/28/2025, the P&P indicated, For the first 72 hours after starting a new medication the resident shall be assessed every shift related to the efficacy of the medication and the presence, if any, of untoward or adverse consequences of the new medication. I. Nursing Staff will assess the resident for any signs of untoward or adverse reaction to new medications. This includes any allergic reaction or side effect to the medication as described in the manufacturer's information or current literature. IV. Assessing the resident during the episode will be done in accordance with the physician's instruction, with all appropriate documentation done in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Infection Preventionist performed the duties of the position by failing to implement the antibiotic (medication used to treat infection) stewardship program (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) and the infection prevention and control program for four of five sampled residents (Residents 188, 117,106, and 44) by: 1.Failing to completely fill out the Infection Control Surveillance log (a documented record used to systematically track and analyze healthcare-associated infections and other infectious diseases within a healthcare facility), dated 6/2025, for Resident 188, 117 and 106. 2.Failing to ensure Resident 188, 117, 106, and 44 were monitored for the adverse effects (undesired or harmful effects) of antibiotic. These failures had the potential to increase antibiotic resistance (do not respond to a drug) from unnecessary or inappropriate antibiotic use and had the potential for Residents 188, 117, 106, and 44 to experience an adverse reaction. Cross reference to F881 Findings: a. During a concurrent interview, and record review on 7/15/2025, at 9:52 a.m., with the IP, facility's Infection Control Surveillance Log, dated 6/2025, was reviewed. The IP stated she (IP) works full time as the facility's IP and the Risk Management Nurse (RMN). The IP stated she (IP) did not completely fill out the Infection Control Surveillance Log. The IP stated she (IP) should have completed the Infection Control Surveillance Log to keep an accurate tracking of Residents 188, 117 and 106's infections. The IP stated for Residents 188, 117, and 106, the Infection Control Surveillance had the following missing information: 1. signs and symptoms of infection, 2. residents' mental status (mental state), 3. culture result (a laboratory procedure where a sample of body fluid or tissue is tested to know what organism is growing), 4. x-ray result (imaging test that can spot problems areas in the body), 5. if the infection is community acquired (infection started from home or community) 6. if the infection was nosocomial (infection started from the hospital). b. During a review of Resident 188's admission Record, the admission Record indicated the facility initially admitted Resident 188 on 12/4/2024, and readmitted on [DATE], with diagnoses that included atherosclerotic heart disease (a condition where fatty deposits build up inside your arteries, making them narrow and stiff), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and benign prostatic hyperplasia (BPH-a common condition in older men where the prostate gland grows larger than normal) with lower urinary tract infection (UTI-an infection in the bladder/urinary tract). During a review of Resident 188's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 2/6/2025, the H&P indicated Resident 188 had fluctuating capacity to understand and make decisions. During a review of Resident 188's Minimum Data Set (MDS-a resident assessment tool), dated 5/7/2025, the MDS indicated Resident 188's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. During a review of Resident 188's Order Audit Report (Physician Order), dated 6/24/2025, the Order Audit Report indicated an order for cefdinir (antibiotic medication used to treat infection) capsule 300 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount), one capsule by mouth every 12 hours for UTI for three days. During a review of Resident 188's Care Plan dated 6/24/2025 on at risk for adverse reaction, the Care Plan indicated an intervention to notify the physician if adverse reaction due to antibiotic occurs. During a review of Resident 188's Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/2025, the MAR indicated Resident 188 received cefdinir from 6/26/2025, at 9 a.m., to 6/28/2025, at 9 p.m. During a concurrent interview, and record review on 7/15/2025, at 9:52 a.m., with the Infection Preventionist (IP), Resident 188's Progress Notes, dated 6/26/2025, to 6/30/2025, were reviewed. The IP stated nurses monitor residents for the adverse effects of antibiotics every shift until one to two days after the completion of antibiotic dose. The IP stated the monitoring of adverse effects were documented in the residents Progress Notes. The IP stated if residents were not monitored for the adverse effects of antibiotics, residents could have adverse reaction, which could result in delay in physician notification and cause delay in resident care. The IP stated there was no documented monitoring for the adverse effects of cefdinir in Resident 188's Progress Notes on the following dates and times. a. 7 a.m., to 3 p.m. on 6/26/2025 and 6/27/2025. b. 3 p.m., to 11 p.m., on 6/29/2025. c. 11 p.m., to 7 a.m. on 6/27/2025, 67/28/2025, and 6/29/2025. During a review of Resident 117's admission Record, the admission Record indicated the facility admitted Resident 117 on 5/29/2025, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and generalized muscle weakness. During a review of Resident 117's H&P, dated 6/6/2025, the H&P indicated Resident 117 had fluctuating capacity to understand and make decisions. During a review of Resident 117's MDS, dated [DATE], the MDS indicated Resident 117's cognitive skills for daily decisions were severely impaired. During a review of Resident 117's Order Audit Report, dated 6/23/2025, the Order Audit Report indicated an order for amoxicillin potassium clavulanate (antibiotic medication used to treat infection) tablet 875-125 mg, give one tablet by mouth every 12 hours for bacterial infection /pneumonia (lung infection) for five days. During a review of Resident 117's MAR, dated 6/2025, the MAR indicated Resident 117 received amoxicillin potassium clavulanate from 6/24/2025, at 9 a.m. to 6/28/2025, at 9 p.m. During a concurrent interview, and record review on 7/15/2025, at 9:52 a.m., with the IP, Resident 117's Progress Notes, dated 6/24/2025, to 6/29/2025, were reviewed. The IP stated there was no documented monitoring for the adverse effects of amoxicillin potassium clavulanate in Resident 117's Progress Notes on the following dates and times. a. 7 a.m. to 3 p.m. on 6/24/2025. b.11 p.m. to 7 a.m. on 6/24/2025, 6/25/2025, and 6/26/2025. During a review of Resident 106's admission Record, the admission Record indicated the facility admitted Resident 106 on 4/8/2025, with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia and generalized muscle weakness. During a review of Resident 106's H&P, dated 4/9/2025, the H&P indicated Resident 106 had fluctuating capacity to understand and make decisions. During a review of Resident 106's MDS, dated [DATE], the MDS indicated Resident 106's cognitive skills for daily decisions were moderately impaired. During a review of Resident 106's Order Audit Report, dated 6/3/2025, the Order Audit Report indicated an order for azithromycin (antibiotic medication used to treat infection) tablet 250 mg, give two tablets by mouth in the afternoon for bronchitis (an inflammation of the bronchial tubes, the airways that carry air to your lungs) for one day and give one tablet by mouth for four days on day two to four. During a review of Resident 106's MAR, dated 6/2025, the MAR indicated Resident 106 received azithromycin from 6/3/2025, to 6/7/2025. During a concurrent interview, and record review on 7/15/2025, at 9:52 a.m., with the IP, Resident 106's Progress Notes dated 6/3/2025, to 6/8/2025, were reviewed. The IP stated there was no documented monitoring for the adverse effects of azithromycin in Resident 106's Progress Notes on the following dates and times. a. 3 p.m., to 11 p.m. on 6/4/2025, and 6/6/2025. b. 11 p.m. to 7 a.m. on 6/3/2025, 6/4/2025, and 6/6/2025. During a review of Resident 44's admission Record, the admission Record indicated the facility admitted Resident 44 on 4/2/2025, with diagnoses that included atherosclerotic heart disease, generalized muscle weakness and UTI. During a review of Resident 44's H&P, dated 4/3/2025, the H&P indicated Resident 44 did not have the capacity to understand and make decisions. During a review of Resident 44's MDS, dated [DATE], the MDS indicated Resident 44's cognitive skills for daily decisions was moderately impaired. During a review of Resident 44's Order Audit Report, dated 7/12/2025, the Order Audit Report indicated an order for sulfamethoxazole-trimethoprim (antibiotic medication used to treat infection) tablet 800-160 mg, give one tablet by mouth two times a day for left thigh abscess (a localized collection of pus, usually caused by a bacterial infection, that forms within body tissue) for seven days. During a review of Resident 44's MAR, dated 7/2025, the MAR indicated Resident 44 received sulfamethoxazole-trimethoprim on 7/13/2025, at 5 p.m. to 7/15/2025, at 9 a.m. During a concurrent interview, and record review on 7/15/2025, at 1:52 p.m. with the IP, Resident 44's Progress Notes, dated 7/13/2025, to 7/15/2025, were reviewed. The IP stated there was no documented monitoring for the adverse effects of sulfamethoxazole-trimethoprim in Resident 44's Progress Notes on the following dates and times. a. 7 a.m. to 3 p.m. on 7/13/2025. b. 3 p.m. to 11 p.m. on 7/13/2025. c. 11 p.m. to 7 a.m. on 7/12/2025, 7/13/2025, and 7/14/2025. During an interview on 7/16/2025, at 2:55 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the IP should completely fill up the Infection Control Surveillance Log. The ADON stated the importance of the Infection Control Surveillance Log was to track and prevent further infection. The ADON stated residents are monitored every shift for 72 hours for the adverse effects of antibiotics. The ADON stated residents should be monitored for fever and adverse effects of antibiotics to prevent anaphylactic reaction (a severe, potentially life-threatening allergic reaction that can occur rapidly after exposure to an allergen). The ADON stated residents who were not monitored for adverse effects of antibiotic could be at risk for anaphylactic reaction. The ADON stated the IP did not perform her responsibility in completing the Infection Control Surveillance Log and did not ensure residents are monitored for antibiotic adverse effect every shift. During an interview on 7/16/2025, at 4:00 p.m. with the Director of Nursing (DON), the DON stated it was the IP's responsibility to complete the Infection Control Surveillance Log. The DON stated every part of the Infection Control Surveillance Log should be answered if applicable to help the nurses track if the antibiotic was effective or not and to know if the resident was experiencing any adverse reaction. The DON stated it is important to know if residents are tolerating the antibiotic. The DON stated residents should be monitored for any side effects or adverse effects from the antibiotic and the nurses need to document. The DON stated if residents are not monitored for the adverse effects of the antibiotic, infection could not heal and could worsen. The DON stated the IP failed to perform her responsibility in completing the Infection Control Surveillance Log and the IP should make sure residents are monitored for antibiotic adverse effect. During a review of IP's/ Risk Management Nurse (IP/RMN) Job Description signed and dated on12/6/2024, the IP's Job Description indicated, The Infection Prevention/ Risk Management Nurse provides administrative, surveillance and consultative work in planning, developing, coordinating and administering an Infection Control Program. Work involves planning, organizing, implementing, and evaluating the infection control program to ensure the program is carried out properly, effectively and efficiently throughout the facility and educating staff regarding infection control practices. Duties and Responsibilities; Infection Prevention/Risk Management Nurse: -Provides surveillance of healthcare or industry practices to identify problem areas and determine any necessary interventions; gathers related data (reviews lab reports and patient charts, communicates with facilities and units), inputs data into various report documents for analysis; provides education and training to program areas requiring changes; evaluates and reports on data. Knowledge: -Infection prevention and control regulations and guidelines. -Assess and quantify risk, potential challenges. During a review of facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program dated 12/1/2021, and last reviewed on 4/28/2025, the P&P indicated, The Antibiotic Stewardship Program (ASP) is designed to promote appropriate use of antibiotics while optimizing the treatment of infections, and simultaneously reducing the possible adverse events associated with antibiotic use. II. Accountability C. The Infection Control Committee (ICC) will review infections and monitor antibiotic usage patterns on a regular basis. In addition, the ICC will obtain and review results from microbial cultures, resistant organisms, alerts and antibiograms from the laboratory for trends of resistance. F. The IP will collect and analyze infection surveillance data and monitor the adherence to the ASP and create a report for the Consultant Pharmacist identifying the number of residents on antibiotics that did not meet criteria for active infection and suggest appropriate overall changes to make it a successful, well-rounded program. V. Tracking A. The IP will be responsible for review of infection surveillance and multidrug-resistant organism (MDRO-bacteria that have become resistant to certain antibiotics) tracking. The IP will utilize.Antibiotic Tracking Sheet. During a review of facility's P&P titled, Infection Prevention and Control Program, dated 12/1/2021, and last reviewed on 4/28/2025, the P&P indicated, The IP is responsible for coordinating the development and monitoring of the facility's established infection control policies and procedures including but not limited to: . D. Collecting, analyzing and providing infection data and trends to nursing staff and Physicians. IV. Surveillance A. The Facility provides surveillance of Healthcare-Associated Infections (HAIs) and Community-Associated Infections (CAls) significantly affecting resident health outcomes. B. Healthcare-Associated Infection (HAI) - An infection contracted in a healthcare setting while receiving healthcare treatment for other conditions. i. For infection surveillance purposes, infections are HAI, if: . b. Onset of clinical manifestation occurs after two calendar days after admission. C. Community-Associated Infection (CAI) -An infection that is acquired outside of a healthcare setting or an infection present upon admission. E. Licensed nursing staff monitors residents for signs and symptoms that suggest infection, according to current criteria and definitions of infections, and documents and reports suspected infections to the Charge Nurse as soon as possible. V. Gathering Surveillance Data A. The Licensed Nurse will initiate the gathering of surveillance data for each resident and document on. Infection Control Surveillance. B. The IP will review the Infection Control Surveillance Form and Surveillance Data Collection Form initiated by the Licensed Nurse and determine if the infection is HAI or CAI. The Infection Preventionist will document accordingly on .Infection Control Surveillance. C. The IP will complete.HAI Infections Worksheet to determine specific sites and pathogen trends. D. In addition, the IP will collect and document data on the incidence of infections on.Monthly Infection Report for All Nursing Units. This surveillance system is designed to capture epidemiologically important data that influences how the overall surveillance data is interpreted. VII. Interpreting Surveillance Data A. The Medical Director and Infection Control Committee (ICC) will review data gathered by the IP to determine root cause for HAI or CAI. B. The surveillance may include a review of the following information to help identify possible root causes of HAIs: . v. Infection surveillance sheets. Viii. Antibiotic review. During a review of facility's P&P titled, Monitoring for Efficacy and Adverse Drug Reactions dated 7/1/2016, and last reviewed on 4/28/2025, the P&P indicated, For the first 72 hours after starting a new medication the resident shall be assessed every shift related to the efficacy of the medication and the presence, if any, of untoward or adverse consequences of the new medication. I. Nursing Staff will assess the resident for any signs of untoward or adverse reaction to new medications. This includes any allergic reaction or side effect to the medication as described in the manufacturer's information or current literature. IV. Assessing the resident during the episode will be done in accordance with the physician's instruction, with all appropriate documentation done in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of three sampled residents (Resident 15) by failing to ensure weekly wound assessment was done for Resident 15's stage 2 pressure injury (it involves a break in the skin's outer layer [epidermis] and some damage to the underlying layer [dermis] on the coccyx (the last bone at the bottom [base] of the spine). The deficient practices had the potential for delay of necessary care and services and worsening of pressure injury to residents. Findings: During a review of Resident 15's admission Record, the admission Record indicated the facility admitted the resident on 3/23/2021, with diagnoses including peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), muscle weakness, and functional urinary incontinence (a state in which an individual cannot get to or use a toilet in time to urinate). During a review of Resident 15's History and Physical (H&P), dated 4/15/2025, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool), dated 4/20/2025, the MDS indicated the resident usually had the ability to make self understood and understand others and had moderately impaired cognition (is a significant decline in mental abilities that noticeably affects daily life). The MDS indicated Resident 15 had impaired upper and lower extremities and uses a wheelchair to mobilize. The MDS indicated Resident 15 was dependent to requiring substantial assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 15 was always incontinent of urine and bowel movement. The MDS indicated Resident 15 had an unhealed stage 2 pressure injury and was on a skin and ulcer/injury treatments. During a review of Resident 15's Physician's Order Sheet, dated 4/4/2025, the Physician's Order Sheet indicated an order for low air loss (LAL) mattress (a type of specialized bed that helps prevent and treat pressure ulcers [bed sores] by circulating air through tiny holes in the mattress surface) every (q) shift for pressure injury. Cleanse Stage 2 pressure injury on coccyx with normal saline (NS, a simple solution of salt and water), apply Triad wound dressing (is a special kind of wound dressing that comes as a thick paste), cover with dry dressing (DD) and secure with tape daily (qd) for (X) 24 days for pressure injury. During a review of Resident 15's Braden Scale- For Predicting Pressure Sore Risk, dated 4/7/2025, the Braden Scale indicated the resident was high risk for pressure sore/injury development. During a review of Resident 15's Wound Assessment, the Wound Assessments indicated on: - 4/7/2025, the Wound Assessment indicated Resident 15 had a stage 2 pressure injury at the coccyx measuring 1.5 centimeters (cm, a unit of measurement) (length, L) X 1 cm (width, W) X 0.2 cm (depth, D) and indicated a plan of care to offload area, stable, continue treatment, prognosis is fair and follow up in 1 week. -4/8/2025 to 4/14/2025, no Wound Assessments found. (Second and third week of April 2025) -4/20/2025 to 4/26/2025, no Wound Assessment found. (Fourth week of April 2025) -4/27/2025 to 5/3/2025, no Wound Assessment found. (Fifth week of April to beginning of May 2025) -5/5/2025, the Wound Assessment indicated Resident 15 had a stage 2 pressure injury on the coccyx that had been resolved. During a review of Resident 15's Care Plan (CP) Report titled Pressure Injury Stage 2- Coccyx, initiated on 4/4/2025, the CP indicated interventions to monitor for signs and symptoms (s/s) of infection: swelling, redness, drainage, odor, notify MD promptly if occurs, monitor for pain/discomfort and provide pain management as needed- per protocol, and notify MD if treatment is ineffective. During a concurrent interview and record review on 7/16/2025, at 2:18 p.m., with Treatment Nurse (TN) 1, reviewed Resident 15's Medical Diagnoses, Physician's Order Sheet, Wound Assessments, Braden Scale, and Care Plan. TN 1 stated she does the Wound Assessments weekly with the Physician Assistant (PA). TN 1 stated she assesses the residents with pressure injury thoroughly including measuring the wounds length, width, and depth. TN 1 stated the pressure injury of Resident 15 was community acquired and was discovered on 4/4/2025 and was provided treatment by the physician. TN 1 stated the resident was hospitalized from [DATE] to 4/14/2025, and she was not able to do her Weekly Wound Assessment on the week of 4/20/2025 to 4/26/2025 and 4/27/2025 to 5/3/2025. TN 1 stated she had seen the resident on 5/5/2025 and the pressure injury on the coccyx was healed and they resolved the pressure ulcer. TN 1 stated she missed 2 weekly Wound Assessments on the resident. TN 1 stated it was important to do Weekly Wound Assessments to monitor the progress of the wound and to intervene if the treatment is not working properly on the resident. TN 1 stated the failure to do Weekly Wound Assessment had the potential for Resident 15's pressure injury to worsen. During an interview on 7/18/2025, at 10 a.m., with Registered Nurse (RN) 4, RN 4 stated TN 1 should have done the Wound Assessments of Resident 15 weekly to check if the wound is getting better or worse and to intervene appropriately. During an interview on 7/18/2025, at 1:39 p.m., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON stated it was the responsibility of the TNs to ensure the Wound Assessments were done weekly per facility policy together with the PAs. The DON and the ADON both stated the wound should be assessed weekly with measurements to determine if the wound is healing, if the treatment was effective, or if any signs of wound infection is occurring on Resident 15's pressure injury in the coccyx. The DON stated TN 1 did not follow their facility policy and procedure for assessing the wound weekly and the failure of TN 1 to assess the wound could potentially lead to worsening of the pressure injury. During a review of the facility's recent policy and procedure (P&P) titled Pressure Ulcer Prevention, last reviewed on 4/28/2025, the P&P indicated the facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development. I. Identification and Assessment: A. The Licensed Nurse will complete a Braden Scale Assessment upon admission and quarterly to identify residents at risk for skin breakdown. B. The Licensed Nurse will conduct a skin assessment for a resident upon admission, readmission, weekly, and as needed. Results of the weekly skin assessment will be documented in the medical record. (Results may be documented using the weekly Skin inspection form. See NP- 279-Form A- Weekly Skin Inspection).

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) for one of three sampled residents (Residents 1) by failing to:1. Provide ongoing re-evaluation of the need for psychotropic medication by failing to ensure PRN (given as needed or requested) risperidone (Risperdal-a psychotropic medication used to treat mental health conditions such as schizophrenia [(a mental illness that is characterized by disturbances in thoughts] ) was ordered with an end date (time at which a medication will no longer be dispensed and will be required to be re-prescribed).2. Provide ongoing re-evaluation of the need for psychotropic medication by failing to monitor for adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status) of risperidone. 3. Ensure as needed (PRN) risperidone was prescribed for a specific, diagnosed condition. These deficient practices had the potential to result in the administration of unnecessary psychotropic medication and placed Residents at risk for decline in physical functioning, and injury.Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 1/6/2023 with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), anxiety disorder (feeling of anxiousness that affects daily life), history of repeated falls.During a review of Resident 's M1inimum Data Set (MDS - resident assessment tool), dated 5/28/2025, the MDS indicated Resident 1 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS further indicated Resident 1was dependent on staff for bathing and required moderate assistance with personal hygiene, toileting hygiene, lower body dressing. During a review of Resident 1's Care Plan (CP), dated 7/2/2025, the CP indicated Resident 1 was receiving antipsychotic drug therapy (Risperdal/PRN) and was at risk for toxicity and falls. The CP interventions indicated to obtain consent, monitor resident for common side effects such as sedation (a state of sleepiness caused by certain drugs), confusion, restlessness, and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness).During a review of Resident 1's Care Plan (CP), dated 7/2/2025, the CP indicated Resident 1 was receiving PRN risperidone and was at risk for toxicity and falls. The CP interventions indicated to obtain consent, monitor resident for common side effects such as sedation (a state of sleepiness caused by certain drugs), confusion, restlessness, and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness).1.a During a concurrent interview and record review on 7/7/2025 at 11:48 a.m. with Registered Nurse (RN) 1, Resident 1's Order Summary Report was reviewed. The Order Summary indicated on 7/1/2025, Resident 1 was prescribed Risperidone tablet 1milligram (mg-unit of measurement), 1 tablet by mouth as needed for agitation manifested by aggressive behavior towards staff at bedtime. RN 1 stated the order for Risperidone did not have an end date. RN 1 stated antipsychotic medications such as Risperidone used in as needed bases should have an end date. RN 1 further stated the end date was indicated to stop the administration of the medication and allow the physician to review resident's progress and determine if the medication is necessary to continue. RN 1 stated the failure had the potential for Resident 1 to receive medication that was not indicated and experience side effects. During an interview on 7/2/2025 at 12:06 p.m. with the Director of Nursing (DON), the DON stated Resident 1's risperidone order should have had an end date after 14 days of the initiation of the order. The DON stated facility failed to obtain an end date for Resident 1's Risperidone order. The DON further stated the failure had the potential for Resident 1 to receive unnecessary medication negatively affecting Resident 1's well-being. During a review of the facility-provided policy and procedure (P&P) titled, Psychotropic Medication Use, last reviewed on 01/27/2025, the P&P indicated, Psychotropic also described as 'psycho-pharmacologic medication,' 'psychoactive,' or 'psychotherapeutic' medications are drugs that affect brain activities associated with mental processes and behavior. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the Attending Physician/LHP evaluates the resident, in person, for the appropriateness of that medication.1b. During a concurrent interview and record review on 7/7/2025 at 11:48 a.m. with Registered Nurse (RN) 1, Resident 1's Medication Administration Record (MAR), dated 7/2025 was reviewed. The Order Summary indicated on 7/1/2025, Resident 1 was prescribed a risperidone tablet 1milligram (mg-unit of measurement), 1 tablet by mouth as needed for agitation manifested by aggressive behavior towards staff at bedtime. RN 1 stated there was no order to monitor Resident 1 for side effects of risperidone. RN 1 it was important to monitor side effects of psychotropic medications to notify the physician and determine if the Resident is benefiting from the medication. RN 1 stated the failure to monitor Resident 1 for side effects of risperidone placed Resident 1 at risk to experience side effects such as tremors. During an interview on 7/2/2025 at 12:06 p.m. with the Director of Nursing (DON), the DON stated there should be an order for staff to monitor and record the side effects caused by antipsychotic medications to determine if the medication is beneficial for Residents. The DON stated the failure to monitor Resident 1 for side effects of risperidone placed Resident 1 at risk of receiving unnecessary medication. During a review of the facility-provided policy and procedure (P&P) titled, Psychotropic Medication Use, last reviewed on 01/27/2025, the P&P indicated, Psychotropic also described as 'psycho-pharmacologic medication,' 'psychoactive,' or 'psychotherapeutic' medications are drugs that affect brain activities associated with mental processes and behavior.Nursing Responsibilities: B. Will monitor psychotropic drug use daily noting any adverse effects1c. During a concurrent interview and record review on 7/2/2025 at 12:06 p.m. with the Director of Nursing (DON), Resident 1's Order Summary Report was reviewed. The Order Summary indicated on 7/1/2025, Resident 1 was prescribed a risperidone tablet 1milligram (mg-unit of measurement), 1 tablet by mouth as needed for agitation manifested by aggressive behavior towards staff at bedtime. The DON stated the facility failed to obtain the diagnoses for which Resident 1's Risperidone order was indicated for. The DON further stated facility would contact the ordering physician to clarify and update the risperidone order to include the diagnoses for which the medication was indicated for. The DON further stated this failure had the potential for Resident 1 to receive unnecessary medication negatively affecting Resident 1's well-being. During a review of the facility-provided P&P titled, Guidelines for Psychotherapeutic Medications, last reviewed on 01/27/2025, the P&P indicated, Antipsychotic Medications (OBRA F330).The diagnosis shall be noted on the physician order and the physician will be responsible for obtaining informed consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a care plan was created for a resident who was high risk for fall for one of four sampled resident (Resident 2). This deficient practice had the potential to a delay in/or lack of delivery of care and services to Resident 2. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 1/22/2021 and readmitted on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris and hypertension. During a review of Resident 2's Initial History and Physical, dated 1/30/2025, the Initial History and Physical indicated Resident 2 had fluctuating capacity to understand and make decisions due to dementia (decline in mental abilities, like memory and thinking, that is severe enough to interfere with daily life). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 5/25/2025, the MDS indicated Resident 2 was moderately impaired with thought process and required substantial to partial assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 2's Fall Risk Assessments, dated 3/4/2025, 6/2/2025, and 6/8/2025, the Fall Risk Assessments indicated Resident 2 on 3/4/2025 had a total score of 22, on 6/22/2025 had a total score of 22, and on 6/8/2025 a total score of 24. A total score above 10 represents high risk for falls. During a concurrent interview and record review on 6/26/2025 at 10:44 a.m. with Registered Nurse (RN) 2, Resident 2's Fall Risk assessment dated [DATE], 6/2/2025, and 6/8/2025 were reviewed. Resident 2's Care Plan was reviewed. RN 2 stated that Resident 2's Fall Risk Assessment score was 22 since 3/4/2025. RN 2 stated any score more than 10 means a resident is a high risk for fall. RN 2 stated that Resident 2 did not have a care plan on high risk for fall before Resident 2 had a fall incident last 6/8/2025. RN 2 stated Resident 2 should have a high risk for fall care plan and proper interventions like highlighted Resident 2's name by the door, low bed position, frequent visual check, call light within reach, and therapy so that the staff were aware that Resident 2 was a high risk for fall and proper fall preventions were in place. During a review of the facility policy and procedure titled, Care Planning, last review date 4/28/2025, the policy and procedure indicated, To ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sample residents (Resident 1), who had moderate impaired cognition (a stage where individuals experience noticeable and significant difficulties in functions like memory, language, and problem-solving, affecting their ability to manage daily activities independently), was free from sexual abuse (any sexual activity that occurs without consent [permission]), by Resident 2 (Resident 1's roommate) on 6/20/2025 by failing to: 1. Protect Resident 1 from Resident 2 when Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 witnessed Resident 2, topless with breasts uncovered, was at the head of Resident 1's bed leaning on top of Resident 1 who was lying on her (Resident 1) bed. Resident 2 was rubbing her (Resident 2) exposed breasts against Resident 1's chest while Resident 2 was sucking Resident 1's chin causing it (Resident 1's chin) to be red. 2. To identify the potential risks of Resident 2's sexually inappropriate behavior (masturbatory behavior) to other residents (in general). 3. Prevent sexual abuse by ensuring facility licensed staff monitored and documented Resident 2's sexually inappropriate behavior (masturbatory behavior) and develop interventions and implement interventions to prevent abuse to other residents (in general). 4. Identify and evaluate if Resident 1 had the capacity to consent (when someone understands what they are being asked to do, and they give their permission clearly and freely without being pressured) to perform sexual activity with Resident 2 or other residents to prevent sexual abuse. 5. Assess Resident 1 for possible injuries after the sexual abuse incident on 6/20/2025 at around 4:50 a.m. in accordance with the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, with review date of 4/28/2025, indicating, A Licensed Nurse assesses the resident (alleged victim) for possible injuries. 6. Follow its P&P titled, Abuse Prevention and Prohibition Program, with review date of 4/28/2025, indicating, Each resident has the right to be free from abuse. The Facility has zero-tolerance for abuse. Staff must not permit anyone to engage in . sexual . abuse. These deficient practices resulted in Resident 1 being subjected to sexual abuse by Resident 2 while under the care of the facility. CNA 1 stated Resident 1 looked in panic and in shock during the incident. CNA 3 went to Resident 1 to offer to change Resident 1 (who refused to be changed by CNA 1) after the sexual abuse incident stated Resident 1 started to become agitated, shaking, and looks nervous. On 6/20/2025 at 10:24 a.m., the facility sent Resident 2 to General Acute Care Hospital (GACH) 1 for psychological evaluation (a comprehensive assessment conducted by a mental health professional to understand an individual's psychological state, including their thoughts, feelings, behaviors, and personality). Based on the reasonable person concept (refers to a tool to assist the survey team's assessment of the severity level of negative, or potentially negative, psychosocial outcome of the deficiency may have had on a reasonable person in the president's position), due to Resident 1's moderately impaired cognitive skills, an individual subjected to abuse may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself). On 6/25/2025 at 5:14 p.m. while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.12 Freedom from Abuse, Neglect (failed to care for properly), and Exploitation (illegal or improper use of a person's resources) in the presence of the Administrator (ADM), Director of Nursing (DON), and the Risk Manager Nurse (RMN) due to the facility's failure to protect Resident 1's right to be free from sexual abuse on 6/20/2025 at around 4:50 a.m. On 6/27/2025 at 4:32 p.m., the ADM provided the SSA with an acceptable IJ Removal Plan (a detailed plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation). On 6/27/2025 at 5:12 p.m., while onsite at the facility and after verifying and confirming the facility's implementations of the IJ Removal plan through observations, interviews, and record reviews, the SSA removed the IJ situation in the presence of the ADM, DON, Assistant DON (ADON), RMN, and DSD (Director of Staff Development). The acceptable IJ Removal Plan included the following summarized actions: 1. On 6/20/2025 at 4:50 a.m., CNA 1 found Resident 2 on top of Resident 1 and CNA 1 separated Resident 1 and Resident 2 (both are still in the same room). LVN 2 monitored Resident 1 to prevent reoccurrence. 2. On 6/20/2025 at about 5 a.m., CNA 2 and CNA 3 alternated being in Resident 1 and Resident 2's room to assure the safety of Resident 1 and prevent recurrence until the end of their (CNA 2 and CNA 3) shift at 6:45 a.m. at which point CNA 4 was at Resident 1's bedside providing one-on-one supervision (a staff member is assigned to solely observe and attend to the needs of a specific resident) until Resident 2 was transferred by ambulance at 10:24 a.m. to GACH 1 for psychological evaluation. As of 6/27/2025, Resident 2 remains to be hospitalized and in no direct threat to any current residents. 3. On 6/20/2025 at 12:22 p.m., Resident 1 was transferred to a different room. 4. On 6/25/2025 at about 6 p.m., the DON, ADON, Social Services Director (SSD), and RMN completed an audit of all the residents and identified two residents (Resident 3 and Resident 4) with inappropriate behaviors. Room changes were offered to the roommates, but they (roommates) declined. 5. On 6/25/2025 at 6:30 p.m., the DSD initiated in-service trainings (ongoing education and training provided to staff to enhance their knowledge, skills, and competency in providing care) on staff focusing on abuse. 6. On 6/25/2025 at 7 p.m., Licensed Vocational Nurse (LVN) 3 updated Resident 1 and Resident 2's care plans with interventions including routine checks by CNAs. 7. On 6/25/2025 starting at 7 p.m., RN 3, RN 4, and RN 5, along with the assistance of the SSD, screened all residents to identify any other potential for abuse using the Resident's Psychological Well Being Questionnaire (formulated by the facility) which included questions of feeling safe or ever being sexually abused at the facility. During completion of the screening, there were no other residents identified to be affected. 8. On 6/25/2025 starting at 8 p.m., LVN 3 reviewed the care plans of two residents (Resident 3 and Resident 4) with a history of sexually inappropriate behaviors, as well as their roommates. Focus for Resident 3 included grabbing staff inappropriately with interventions to intervene as necessary to protect the rights and safety of others in a calm manner, divert attention, explain and reinforce appropriate behavior. Resident 4's focus is to prevent displaying inappropriate sexual behaviors towards other residents with interventions of monitoring every two hours during routine rounds (scheduled times when staff visits the residents to check on their well-being, assess their needs, and ensure their comfort and safety) for inappropriate sexual behavior, provide calm and non-shaming redirection if the resident initiates inappropriate behavior. CNAs are monitoring Resident 4 during the required rounds every two hours by RNs every shift. 9. The facility has implemented a new system for monitoring residents with sexually inappropriate behaviors. On 6/25/2025, the behavior monitoring tool was initiated on Electronic Health Record (EHR - a cloud based electronic health record platform) 1 and implemented on 6/26/2025. The CNAs are to monitor every two hours any residents with sexually inappropriate behavior. Licensed nurses are to document all sexual behaviors of residents. Interdisciplinary team (IDT - a group of healthcare professionals from various disciplines who collaborate to provide comprehensive and coordinated care to residents) will meet weekly to discuss sexually inappropriate behavior issues of residents. 10. On 6/26/2025 at 10:30 a.m. Resident 1 was seen by Psychologist 1 (a person who specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) with no changes in mood or depressive manner. Resident 2 remains hospitalized . Once Resident 2 is determined safe to return to the facility, a new care plan will be created focusing on her hypersexuality (an excessive and uncontrolled sexual behavior that causes significant distress or impairment in a person's life) with interventions including monitoring one-on-one indefinitely. Monitoring will be set for Resident 2's whereabouts, pattern in her activity and sexual behavior by a hash mark system (tally marks) on EHR. 11. On 6/26/2025 at 10:30 a.m., Psychiatrist 1 (a medical practitioner specializing in the diagnosis and treatment of mental illness) visited Resident 3 and Resident 4 who were identified with history of sexually inappropriate behaviors. Psychiatrist 1's evaluation of Residents 3 and 4 did not identify any potential harm to others. 12. On 6/26/2025 at 2:50 p.m., the DSD sent a message to all staff with instructions that any staff on vacation or leave cannot return to work on the floor until completion of in-service trainings on Abuse. As of 6/27/2025, 82 percent (% - one part in every hundred) of staff have been in-serviced. 13. For any new residents admitted to the facility, the DON/ADON will screen residents by checking their history and physical, medication regimen (a structured plan designed by a healthcare provider to manage a resident's medical condition or illness through the use of medication), conduct interview with the resident's responsible party if resident has any history of sexually inappropriate behavior. Room assignments will also be evaluated to ensure appropriate placement of residents. Monitoring will be set in place for residents, such as CNAs doing the required rounds every two hours to ensure resident safety. 14. Effective 6/26/2025, Performance Improvement Quality Improvement (PIQI - systematic, data driven approaches to enhance resident care and organizational efficiency) nurses conduct weekly audits of Resident 3 and Resident 4 who were identified with sexually inappropriate behaviors to ensure care planned prevention interventions are appropriate and implemented. 15. Effective 6/27/2025, RN supervisors conduct rounds every shift to ensure residents are not engaged in inappropriate behaviors related to sexual abuse. This will be documented on the facility's supervisor round form. 16. Effective 6/27/2025, the SSD or designee will interview random residents to ensure they feel safe and free from any abuse, including sexual abuse. This is to be done weekly for four weeks, then monthly for two months, using the social services weekly review. 17. The Quality Assurance Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) committee will meet on 6/30/2025 to discuss initiating a form for consenting to sexual activity basing on the regulatory guidelines. The QAPI Team plans to discuss determining factors, developing policy and procedures and how to determine a monitoring system. 18. The DON reports audit findings to the QAPI committee monthly for three months, then quarterly thereafter. The QAPI committee will evaluate the effectiveness of the plan and make changes as needed until substantial compliance is achieved and maintained. Findings:
During a review of Resident 1’s admission Record, the admission Record indicated the facility admitted Resident 1 on 4/18/2023 with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (clogged heart arteries without chest pain) and hypertension (high blood pressure).
During a review of Resident 1’s Initial History and Physical, dated 4/11/2025, the Initial History and Physical indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1’s Minimum Data Set (MDS – a resident assessment tool), dated 6/1/2025, the MDS indicated Resident 1 was moderately impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily).
During a review of Resident 1’s Progress Notes, dated 6/20/2025 at 10:22 a.m., the note indicated that at 4:50 a.m. CNA 1 reported to LVN 1 that Resident 2 was found on top of Resident 1 with Resident 2’s breasts exposed and rubbed against Resident 1 and Resident 2 was sucking Resident 1’s chin. The note indicated LVN 1 noted a red-mark color on Resident 1’s chin as a result from Resident 2’s sucking Resident 1’s chin. The note indicated RN 1 notified the Physician.
During a review of Resident 2’s admission Record, the admission Record indicated the facility originally admitted Resident 2 on 1/22/2021 and readmitted on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris and hypertension.
During a review of Resident 2’s Initial History and Physical, dated 1/30/2025, the Initial History and Physical indicated Resident 2 had fluctuating capacity to understand and make decisions due to dementia (decline in mental abilities, like memory and thinking, that is severe enough to interfere with daily life).
During a review of Resident 2’s MDS, dated [DATE], the MDS indicated Resident 2 was moderately impaired with thought process and required substantial to partial assistance from staff to complete ADLs.
During a review of Resident 2’s Care Plan Report, dated 9/17/2024, the Care Plan Report indicated Resident 2 exhibited masturbatory behavior.
During a review of Resident 2’s Progress Notes, dated 6/20/2025 at 4:50 a.m., the note indicated that at 4:50 a.m. CNA 1 reported to LVN 1 that Resident 2 was found on top of Resident 1 with Resident 2 breasts exposed and rubbed against Resident 1 and Resident 2 was sucking Resident 1’s chin. The note indicated LVN 1 noted a red-mark color on Resident 1’s chin as a result from Resident 2’s sucking Resident 1’s chin. The note indicated RN 1 notified the Physician. The note indicated on 6/20/2025 at 10:24 a.m., the Physician gave an order to transfer Resident 2 to GACH 1 for further evaluation.
During an interview on 6/23/2025 at 11:13 a.m., with LVN 1, LVN 1 stated that while LVN 1 was in nurse’s station on 6/20/2025 at “around 4:50 a.m.,” CNA 1 was standing at the door of Residents 1 and 2’s room (near the nurse’s station) and reported to LVN 1 that Resident 2 was on top of Resident 1. CNA 1 stated Resident 2’s blouse was down to her (Resident 2’s) waist, and Resident 2 rubbed her (Resident 2) uncovered breasts against Resident 1’s chest. LVN 1 stated CNA 1 reported Resident 2 was sucking Resident 1’s chin. LVN 1 stated she (LVN 1) immediately went to Resident 1 and 2’s room and observed that Resident 2 was still on top of Resident 1 and LVN 1 asked Resident 2 to get away from Resident 1 and to return to Resident 2’s bed. LVN 1 stated Resident 2 started to get a little agitated and Resident 2 started to give a hand gesture to LVN 1 to go away. LVN 1 stated Resident 1’s chin was red from Resident 2’s sucking. LVN 1 stated she notified RN 1 right away. LVN 1 stated that when she (LVN 1) got hired since 2/2025, LVN 1 already knew and observed Resident 2’s behavior of patting and touching her (Resident 2) own private area and touching her (Resident 2) own breasts. LVN 1 stated staff in the unit were aware of Resident 2’s behavior. LVN 1 stated this was considered as sexual abuse due to inappropriate behavior of Resident 2 towards Resident 1 by rubbing her (Resident 2) breasts to Resident 1’s chest and sucking Resident 1’s whole chin which left a redness on Resident 1’s chin.
During an interview on 6/23/2025 at 11:38 a.m. with CNA 1, CNA 1 stated that she (CNA 1) found Resident 2 on top of Resident 1 with Resident 2’s blouse down to her (Resident 2) waist, rubbing her (Resident 2) breasts against Resident 1, sucking Resident 1’s chin. CNA 1 stated she (CNA 1) reported the incident to LVN 1 right away. CNA 1 stated this was considered as sexual abuse because Resident 1 did not give any consent to Resident 2 because Resident 1 was confused.
During an interview on 6/23/2025 at 12:29 p.m. with CNA 4, CNA 4 stated Resident 2 usually touches herself and CNA 4 usually provides privacy to Resident 2.
During an interview on 6/24/2025 at 6:29 a.m. with CNA 1 in Resident 1 and 2’s room, CNA 1 stated she (CNA 1) was in another resident’s (name not indicated) room (a room across Residents 1 and 2’s room) and heard a bed-squishing noise prompting her (CNA 1) to check and go to the door of Residents 1 and 2’s room. CNA 1 was observed demonstrating how Resident 2 was standing on the right side on the top part of Resident 1’s bed. CNA 1 stated Resident 2 was rubbing her (Resident 2) exposed breasts to Resident 1’s chest and sucking Resident 1’s chin. CNA 1 stated during that time CNA 1 observed Resident 1 looked panic and shocked.
During an interview on 6/24/2025 at 6:39 a.m. with CNA 3, CNA 3 stated she was assigned to care for Resident 1 after the sexual abuse incident on 6/20/2025 at around 4:50 a.m. CNA 3 stated she (CNA 3) offered to change Resident 1 and observed Resident 1 was agitated holding her (Resident 1) hands close to her (Resident 1) chest, very nervous, shaking, and refusing to be changed. CNA 3 stated Resident 1 later on agreed to be changed after explanation that she (Resident 1) needed to be changed.
During a concurrent interview and record review on 6/25/2025 at 11:13 a.m. with RN 2, Resident 2’s care plan titled, “Exhibiting Masturbatory Behavior,” dated 9/17/2024, all other current care plans since admission, Medication Administration Record (MAR), and Progress Notes from 5/8/2024 to 6/20/2025 were reviewed. RN 2 stated there was no intervention to monitor Resident 2’s masturbatory behavior based on Resident 2’s care plan and no behavioral monitoring found in Resident 2’s MAR and progress notes. RN 2 stated Resident 2’s care plan was not assessed and revised to indicate how Resident 2’s masturbatory behavior will potentially affect other residents. RN 2 stated had the facility created a care plan on how Resident 2’s masturbatory behavior will potentially affect other residents; this incident could have been prevented. RN 2 stated that there was no assessment or documentation about Resident 2’s masturbatory behavior during a review of Resident 2’s progress notes from 5/8/2024 to 6/20/2025. RN 2 stated that as a result Resident 2’s behavior was not monitored, and Resident 2 sexually abused her roommate (Resident 1).
During a concurrent interview and record review on 6/25/2025 at 1:05 p.m. with Resident Care Planner (RCP) 1, Resident 2’s care plan titled, “Exhibiting Masturbatory Behavior,” dated 9/17/2024, was reviewed. RCP 1 stated she (RCP) was the author of the care plan, and a nurse (could not remember who the nurse was) reported that Resident 2 had an episode of masturbation behavior (cannot remember the date). RCP 1 stated monitoring Resident 2’s behavior was not included in Resident 2’s care plan interventions. RCP 1 stated Resident 2’s behavior should be monitored to know if the interventions are effective. RCP 1 stated there was no intervention included to identify the risk of Resident 2’s behavior to other residents. RCP 1 stated it was important to include how Resident 2’s behavior will affect other residents and possibly this sexual abuse incident could have been prevented if there was a proper intervention for Resident 2.
During a concurrent interview and record review on 6/24/2025 at 9:56 a.m. with Risk Manager Nurse (RMN), Resident 1’s Progress Notes dated between 6/20/2025 to 6/24/2025 and vital signs (measurements of the body’s most basic functions) dated 6/20/2025, were reviewed. Resident 2’s Progress Notes dated between 6/20/2025 and vital signs dated 6/20/2025, were also reviewed. RMN stated there was no documented evidence that assessment was done, and vital signs were taken after the sexual abuse incident on 6/20/2025 at “around 4:50 a.m.” for Resident 1 and Resident 2. RMN stated Resident 1’s condition must be monitored after the sexual abuse incident for 72 hours every shift, but it was not done.
During a telephone interview on 6/25/2025 at 10:11 a.m. with Family Member (FM) 1, FM 1 stated Resident 1 was a conservative person so this sexual abuse incident on 6/20/2025 at around 4:50 a.m. will destroy, traumatize, and mentally damage Resident 1. FM 1 stated Resident 1 will lose a lot of sleep, will not know what to do, feel victimize, and will feel her life will be ruined just like other sexual victims. FM 1 stated the family members (FM 1, FM 2, and FM 3) were shocked and traumatized. FM 1, FM 2, and FM 3 cried, felt angry and felt guilty by choosing this facility. FM 1 stated FM 1, FM 2 and FM 3 lost sleep, felt anxious, and uneasy when they found out about Resident 1’s sexual abuse incident on 6/20/2025 at around 4:50 a.m.
During a concurrent interview and record review on 6/25/2025 at 11:13 a.m. with Registered Nurse (RN) 2, Resident 1’s Progress Notes, dated between 6/20/2025 to 6/24/2025 and vital signs dated 6/20/2025 were reviewed. Resident 2’s Progress Notes dated between 6/20/2025 and vital signs dated 6/20/2025, were also reviewed. RN 2 stated there was no head-to-toe assessments (a systematic and comprehensive physical examination that evaluates all major body systems, from the head to the feet, to determine a resident’s overall health status) and no vital signs were taken for Resident 1 and Resident 2 after the sexual abuse incident last 6/20/2025 at 4:50 a.m. RN 2 stated that staff must do a head-to-toe assessment, check vital signs and monitor Resident 1 and Resident 2 (was discharged to GACH 1 on 6/20/2025 at 10:24 a.m.) every shift for 72 hours every shift to know how this incident could affect them (Resident 1 and Resident 2). RN 2 stated it was important to monitor Resident 1 closely.
During an interview on 6/25/2025 at 2:26 p.m. with CNA 6, CNA 6 stated she (CNA 6) was the regular CNA assigned in the morning for Resident 2 and had been taking care of her (Resident 2) since she (Resident 2) was admitted . CNA 6 stated she (CNA 6) observed Resident 2 will call her (CNA 6) inside Resident 2’s room and will start patting her (Resident 2) private area and this happened three times last week on different days before the incident that happened on 6/20/2025 at around 4:50 a.m. CNA 6 stated she (CNA 6) reported those observations to LVN 4 for LVN 4 to talk to Resident 2 to stop doing those inappropriate sexual behavior (patting the vagina).
During an interview on 6/25/2025 at 2:34 p.m. with LVN 4, LVN 4 stated she was the regular charge nurse for Resident 1 and Resident 2. LVN 4 stated CNA 6 reported about two to three times (dates not indicated) that Resident 2 was patting her abdomen but did not document anything or did not report to anyone because LVN 4 did not think it was a sexual behavior because Resident 2 was patting her abdomen. LVN 4 later on stated CNA 6 reported to her (LVN 6) that Resident 2 was patting her (Resident 2) private area (vagina) but cannot imagine Resident 2 doing that. LVN 4 stated she (LVN 4) did not document and did not report Resident 2’s inappropriate sexual behaviors (patting the vagina) to the RN and Physician.
During a concurrent interview and record review on 6/26/2025 at 4:01 p.m. with the DON and RMN, Resident 1’s admission record, history and physical, MDS (dated 6/1/2025), care plans (dated 4/11/2024 to 6/9/2025) and progress notes (dated 6/2/2025 to 6/23/2025) were reviewed. The DON stated Resident 1’s cognition was moderately impaired and was diagnosed with dementia. The DON stated Resident 1’s History and Physical, dated 4/11/2025, indicated Resident 1 did not have the capacity to make decisions. The DON stated she (DON) observed Resident 1 could nod her head for yes or no and could only answer a certain question (did not indicate what question). The DON and RMN stated Resident 1 was unable to give consent for any sexual activity.
During an interview on 6/26/2025 at 4:35 p.m. with the DON, the DON stated the facility failed to provide safety for Resident 1 and knowing that Resident 2’s behavior was exhibited since 9/2024. The DON stated there were no monitoring and no documentation of Resident 2’s sexually inappropriate behaviors (masturbatory behaviors). The DON stated there was lack of documentation and reporting. The DON stated this resulted to Resident 2 sexually assaulted Resident 1.
During a review of the current facility-provided policy and procedure titled, “Abuse Prevention and Prohibition Program,” with review date of 4/28/2025, the policy and procedure indicated, “The Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to … protect residents…. Each resident has the right to be free from abuse…. The Facility has zero-tolerance for abuse…. Staff must not permit anyone to engage in … sexual … abuse…. The Facility is committed to protecting residents from abuse by anyone, including but not limited to … other residents…. Resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict…. The Administrator then acts to ensure the following steps are taken: … ii. A Licensed Nurse assesses the resident (alleged victim) for possible injuries.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered care plan for four of five sampled residents (Residents 1, 2, 3 and 4) by:
1. Failing to ensure a care plan was develop timely for Resident 1 ' s impulsive behavior of getting up unassisted.
2. Failing to ensure a care plan was develop for Resident 2 ' s diagnosis of osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D).
3. Failing to ensure a care plan was develop for Resident 3 ' s behavior of throwing himself (Resident 3) on the floor.
4. Failing to ensure a care plan was develop for Resident 4 ' s diagnosis of osteoporosis.
5. Failing to ensure a care plan was timely develop for Resident 4 ' s behavior of banging the call light on the table.
6. Failing to ensure a care plan was timely develop for Resident 4 ' s refusal of activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) including shower.
These failures had the potential for delayed provision of necessary care and services and placed Residents 1, 2, 3, and 4 at risk for injury.
Findings:
a. During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 7/29/2024, with diagnoses that included unspecified (unconfirmed) heart failure (occurs when the heart can't pump enough blood to meet the body's needs), unspecified dementia, unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and history of falling.
During a record review of Resident 1 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) dated 7/31/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a review of Resident 1 ' s Psychiatry Progress Note dated 9/26/2024, the Psychiatry Progress Note indicated staff reported Resident 1 was observed with episodes of constantly getting up from the wheelchair or bed unassisted.
During a record review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool) dated 4/15/2025, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 was dependent to staff for toileting, needed moderate assistance from staff for sit to stand and needed maximum assistance for transfer and walking. The MDS indicated Resident 1 was frequently incontinent (unable to control) of bowel and bladder functions. The MDS indicated Resident 1 had history of fall since admission.
During an interview on 5/30/2025, at 12 p.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated Resident 1 when awake would start moving in bed or wheelchair. CNA 3 stated Resident 1 could stand up but did not have a good balance with walking. CNA 3 stated Resident 1 was a high risk and had history of fall.
During a concurrent interview, and record review on 6/3/2025, at 12:08 p.m., with Care Planner 1 (CP 1), Resident 1 ' s Care Plan for at risk for fall developed on 8/9/2024, was reviewed. The Care Plan Indicated Resident 1 was observed on the floor nine times on the following dates: 8/11/2024, 9/20/2024, 10/16/2024, 11/19/2024, 11/25/2024, 12/9/2024, 12/16/2024, 12/31/2024 and 2/17/2025. CP 1 stated Resident 1 was also observed on the floor on 12/27/2024, and 3/20/2025.
During an interview on 6/4/2025, at 11:16 p.m., with the Director of Staff Development (DSD), the DSD stated Resident 1 would always try to get up without calling for assistance.
During a concurrent interview, and record review on 6/6/2025, at 10:11 a.m., with CP 1, Resident 1 ' s Care Plan on at risk for fall manifested by constantly getting up from wheelchair or bed unassisted dated 3/7/2025 was reviewed. The Care Plan on 3/7/2025 indicated a goal that Resident 1 will have decreased episode of constantly getting up from wheelchair or bed unassisted.
During a concurrent interview, and record review on 6/6/2025, at 12:32 p.m. with the Director of Nursing (DON), Resident 1 ' s Care Plan on at risk for fall manifested by constantly getting up from wheelchair or bed unassisted dated 3/7/2025, was reviewed. The DON stated care plan should have been created when nurses first observed the behavior. The DON stated the facility failed to create a care plan timely.
b. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease (the arteries that supply blood to your heart become hardened and narrowed due to the buildup of plaque), Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities) and age-related osteoporosis.
During a review of Resident 2 ' s H&P dated 3/1/2025, the H&P indicated Resident 2 had no capacity to understand and make decisions.
During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decisions was moderately impaired. The MDS indicated Resident 2 needed maximum assistance from staff for oral hygiene, showering, dressing, personal hygiene and transfer. The MDS indicated Resident 2 needed supervision with walking.
During a concurrent interview, and record review on 6/3/2025, at 9:20 a.m., with CP 2, Resident 2 ' s admission Record, Physician Progress Notes dated 4/15/2025, and Care Plans was reviewed. The admission Record indicated a diagnosis of age-related osteoporosis on 9/14/2023. CP 2 stated care plan for osteoporosis was resolved on 3/23/2022. CP 2 stated care plan should still be active. CP 2 stated the Physician Progress Notes dated 4/15/2025, indicated the physician documented diagnosis of osteoporosis. CP 2 stated she (CP 2) missed developing a new care plan for osteoporosis. CP 2 stated the importance of developing a care plan was to guide and notify nurses that Resident 2 was at risk for fracture (break in the bone).
During an interview on 6/3/2025, at 11:14 a.m., with Risk Management Nurse (RMN), the RMN stated Resident 2 who had a history of osteoporosis should have a care plan. The RMN stated care plan help address resident needs.
During an interview on 6/4/2025, at 12:52 p.m., with the DON, the DON stated CP 2 should have developed a care plan for osteoporosis. The DON stated the facility failed to develop a care plan for the diagnosis of osteoporosis.
c. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 1/17/2025, with diagnoses that included Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), unspecified Alzheimer ' s, muscle weakness and age-related osteoporosis.
During a review of Resident 3 ' s H&P dated 4/18/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.
During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 ' s cognitive skills for daily decision making severely impaired. The MDS indicated Resident 3 was dependent to staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 3 had a fall incident in the last two to six months before admission.
During a review of Resident 3 ' s Post Fall Summary/Intervention dated 5/26/2025, the Post Fall Summary/Intervention indicated Resident 3 was observed on the floor on 5/25/2025 at 2 p.m.
During an interview on 5/30/2025, at 11:25 a.m., with CNA 10 and translated by Central Supply Coordinator (CSC), CNA 10 stated Resident 3 moves a lot in the bed. CNA 10 stated Resident 3 attempts to get out of the bed unassisted. CNA 10 stated nurses are aware that he (Resident 3) does want to get out of the bed.
During a concurrent interview, and record review on 6/3/2025, at 9:54 a.m., with CP 1, Resident 3 ' s Progress Notes dated 5/6/2025 to 5/24/2025 was reviewed. The Progress Notes indicated from 5/6/2025 to 5/10/2025, 5/13/2025, and 5/15/2025 to 5/24/2025, Licensed Vocational Nurse (LVN) ' s 5, 6, and 7 documented that Resident 3 was observed with behavior of throwing himself (Resident 3) on the floor and cannot stay in the room unattended. CP 1 stated there were no reported behavior that Resident 3 throws himself on the floor so care plan was not developed.
During an interview on 6/3/2025, at 10:20 a.m., with Performance Improvement Quality Improvement Nurse 1 (PIQIN 1), PIQIN 1 stated nurses should report Resident 3 ' s behavior of throwing himself (Resident 3) on the floor so the facility can develop a care plan with interventions to prevent fall for resident safety.
During a concurrent interview, and record review on 6/3/2025, at 11:14 a.m., with the RMN, Resident 3 ' s Progress Notes dated 5/6/2025 to 5/25/2025, was reviewed. The RMN stated LVNs 5, 6, and 7 documented Resident 3 ' s behavior of throwing himself (Resident 3) on the floor almost daily, 16 times from 5/6/2025 to 5/24/2025 and on 5/25/2025, Resident 3 had a fall. The RMN stated nurses should report any behavior or change in condition so care plan could be developed to address Resident 3 ' s behavior.
During an interview on 6/4/2025, at 12:52 p.m., with the DON, the DON stated care plan should have been developed when nurses first observed and documented the behavior of Resident 3 ' s throwing himself on the floor on 5/6/2025.
d. During a review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted Resident 4 on 4/19/2022, with diagnoses that included unspecified atrial fibrillation (irregular heartbeat), generalized idiopathic epilepsy (a type of epilepsy where seizures originate in both sides of the brain simultaneously) and age-related osteoporosis.
During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated Resident 4 ' s cognitive skills for daily decision making was moderately impaired.
During a review of Resident 4 ' s H&P dated 4/24/2025, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.
During a concurrent interview, and record review on 6/5/2025, at 9:27 a.m., with CP 1, Resident 4 ' s care plans were reviewed. CP 1 stated there was no care plan developed for Resident 4 ' s diagnosis of osteoporosis.
During an interview on 6/5/2025, at 10:47 a.m., with the DON, the DON stated care plan should have been developed for Resident 4 ' s diagnosis of osteoporosis.
e. During a review of Resident 4 ' s Registered Nurse (RN)/LVN Progress Notes dated 4/10/2025, the RN/LVN Progress Notes indicated on 4/10/2025, at 3:30 p.m., Resident 4 screamed and used the call light to hit the desk.
During a review of Resident 4 ' s RN/LVN Progress Notes dated 4/17/2025, at 11:45 a.m., Resident 4 complained of right-hand middle finger pain. The RN/LVN Progress Notes indicated Resident 4 ' s right middle finger appeared bruised and swollen. The RN/LVN Progress Notes also indicated even with bruised finger Resident 4 still bangs her (Resident 4) hand on the table to call for the nurse.
During an interview on 6/4/2025, at 10:59 a.m., with CNA 13, CNA 13 stated CNA 10 was the assigned regular CNA for Resident 4. CNA 13 stated Resident 4 would bang the call light every day but on 4/17/2025, it was out of control.
During an interview on 6/4/2025, at 3:46 p.m., with CNA 12, CNA 12 stated Resident 4 had a habit of banging her call light on the table. CNA 12 stated nurses were aware of her behavior.
During an interview on 6/5/2025, at 8:12 a.m., with LVN 8, LVN 8 stated since she (LVN 8) started four to five months ago, Resident 4 used her right hand to bang her call light on the table and that was her (Resident 4) way of calling for assistance. LVN 8 stated she (LVN 8) had reported to the RN but not familiar with RN names yet at that time.
During an interview on 6/5/2025, at 9:27 a.m., with CP 1, CP1 stated the nurses reported Resident 4 ' s behavior of using the call light to hit the table on 4/17/2025. CP 1 stated they were not informed of Resident 4 ' s behavior before 4/17/2025. CP 1 stated nurses where informed to monitor and observed a one-time behavior but if the behavior continued that nurses need to report to CP ' s so a care plan could be developed.
During an interview on 6/5/2025, at 10:47 a.m., with the DON, the DON stated if nurses had observed Resident 4 ' s behavior of hitting the table with the call light, nurses should have reported and documented so care plan could have been developed. The DON stated care plan should have been developed for any change in condition.
f. During a record review of Resident 4 ' s Interdisciplinary (IDT-a coordinated group of experts from several different fields who work together) Care Conference Review dated 2/7/2025, the IDT indicated Resident 4 refused CNA ' s assistance with ADL.
During a review of Resident 4 ' s Documentation Survey Report, dated 2/2025, to 5/5/2025, about ADL-hygiene and showering, the Documentation Survey Report indicated Resident 4 had refused shower on 2/3/2025, 2/14/2025, 2/28/2025, 3/3/2025, 3/28/2025, 4/23/2025 and 4/25/2025.
During an interview on 6/4/2025, at 10:59 a.m., with CNA 13, CNA 13 stated Resident 4 refused shower sometimes.
During an interview on 6/5/2025, at 8:44 a.m., with the DSD, the DSD stated Resident 4 had a tendency of refusing shower.
During a concurrent interview, and record review on 6/5/2025, at 9:27 a.m., with CP 1, Resident 4 ' s Care Plans, and IDT notes dated 2/7/2025, were reviewed. The IDT dated 2/7/2025, indicated Resident 4 ' s refusal with ADL. CP 1 stated a care plan for shower refusal was developed on 5/1/2025. CP 1 stated she (CP 1) was not informed of Resident 4 ' s refusal until 5/1/2025. CP 1 stated there were no care plan developed for Resident 4 ' s refusal with ADL. CP 1 stated care plans are reviewed quarterly (every three months). CP 1 stated she (CP 1) should have developed a care plan on refusal on 2/17/2025 when the IDT happened. CP 1 stated she (CP 1) should have caught that there was no care plan for ADL refusal on 4/2025 during the quarterly review of care plans.
During an interview on 6/5/2025, at 10:47 a.m., with the DON, the DON stated it was the CP ' s fault that they did not develop the care plan for Resident 4 ' s refusal with ADL and shower. The DON stated care plan should have been created on 2/2025 when Resident 4 had refused ADL and shower.
During an interview on 6/6/2025, at 12:03 p.m., with the RMN, the RMN stated care plan should have been developed timely when Resident 4 had a change of condition, when resident refused treatment or when resident had any behavior.
During a review of facility ' s policy and procedure (P&P) titled, Care Planning dated 3/7/2025, and last reviewed on 4/28/2025, the P&P indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs
II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.
III. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an ass needed bases.
VIII. A culturally competent and trauma-informed Comprehensive Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs.
A. In the event that the Comprehensive Care Plan identified a change in the resident's goals or functioning that was not identified in the Baseline Care Plan, these changes will be incorporated into an updated summary and provided to the resident and/or resident's representative.
B. Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. These subsequent changes will not need to be reflected through updates to the Baseline Care Plan.
IX. Each resident's Comprehensive Care Plan will describe the following·
A. Services that are to be furnished to attain or maintain the resident highest practicable. physical, mental and psychosocial well-being;
B. Any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment;

Based on interview and record review, the facility failed to ensure that one of the four sampled residents (Resident 4), who was unable to carry out activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) received the necessary services to maintain good grooming and personal hygiene.
This failure had the potential to negatively affect Resident 4' s self-esteem and wellbeing and placed Resident 4 at risk of infection.
Findings:
During a review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted Resident 4 on 4/19/2022, with diagnoses that included unspecified atrial fibrillation (irregular heartbeat), generalized idiopathic epilepsy (a type of epilepsy where seizures originate in both sides of the brain simultaneously) and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D).
During a review of Resident 4 ' s Minimum Data Set (MDS-a resident assessment tool) dated 1/28/2025, the MDS indicated Resident 4 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was moderately impaired. The MDS indicated Resident 4 needed maximum assistance from staff with shower and bathing.
During a review of Resident 4 ' s History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) dated 4/24/2025, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.
During a record review of Resident 4 ' s Interdisciplinary (IDT-a coordinated group of experts from several different fields who work together) Care Conference Review dated 2/7/2025, the IDT indicated Resident 4 refused CNA ' s assistance with ADL.
During a review of Resident 4 ' s Documentation Survey Report, dated 2/2025, to 5/5/2025, about ADL-hygiene and showering, the Documentation Survey Report indicated Resident 4 was not provided a shower from 2/1/2025, to 2/16/2025, and from 4/17/2025, to 4/28/2025.
During an interview on 6/4/2025, at 10:59 a.m., with Certified Nursing Assistant 13 (CNA 13), CNA 13 stated Resident 4 refuses shower sometimes and LVNs are informed.
During an interview on 6/5/2025, at 8:32 a.m., with CNA 14, CNA 14 stated Resident 4 refuses shower and only wanted shower with the assistance of CNA 15.
During an interview on 6/5/2025, at 8:44 a.m., with the DSD, the DSD stated Resident 4 had a tendency of refusing shower. The DSD stated Resident 4 was on shower schedule twice a week. The DSD stated CNA 15 was the regular assigned CNA but if CNA 15 was not on the schedule, Resident 4 had the tendency to refuse.
During a concurrent interview, and record review on 6/5/2025, at 9:58 a.m., with the Information System Staff (ISS), Resident 4 ' s Documentation Survey Report about ADL-hygiene and showering dated 2/2025 to 5/2025 was reviewed. The ISS stated Resident 4 did not receive a shower from 4/17/2025 to 4/28/2025.
During an interview on 6/5/2025, at 10:08 a.m., with the DSD, the DSD stated Resident 4 did not received a shower for two weeks on 4/2025.
During a concurrent interview, and record review on 6/5/2025, at 9:27 a.m., with Care Planner (CP) 1, Resident 4 ' s Care Plans, and Interdisciplinary Team (IDT) notes dated 2/7/2025, were reviewed. The IDT dated 2/7/2025, indicated Resident 4 ' s refusal with ADL. CP 1 stated a care plan for shower refusal was developed on 5/1/2025. CP 1 stated she (CP 1) was not informed of Resident 4 ' s refusal until 5/1/2025. CP 1 stated there were no care plan developed for Resident 4 ' s refusal with ADL. CP 1 stated care plans are reviewed quarterly (every three months). CP 1 stated she (CP 1) should have developed a care plan on refusal on 2/17/2025 when the IDT happened. CP 1 stated she (CP 1) should have caught that there was no care plan for ADL refusal on 4/2025 during the quarterly review of care plans.
During an interview on 6/5/2025, at 10:47 a.m., with the Director of nursing (DON), the DON stated Resident 4 had no shower for two weeks on 4/2025. The DON stated shower should be provided at least twice a week and if resident refused, physician should be notified. The DON stated the importance of bathing and showering was it removes dead skin cells, refreshes residents and gives opportunities for CNAs to check residents skin but mostly for hygiene purposes.
During a review of facility ' s policy and procedure (P&P) titled, Showering a Resident dated 8/1/2014 and last reviewed on 4/28/2025, the P&P indicated, A shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors. Residents are offered a shower at a minimum of once weekly and given per resident request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for two of four sampled residents (Resident 1 and Resident 2) by:
1. Failing to ensure vital signs (measurements that indicate the status of a person's body's vital functions and are used to assess overall health) were taken when Resident 1 fell on 5/21/2025.
2. Failing to ensure Resident 1 ' s neurochecks (neurological assessments that nurses perform to monitor a patient's neurological status, especially when a patient has a condition that could affect their brain or nervous system function) were assessed after the falls on 10/16/2024, 12/31/2024 and 5/21/2025 as indicated in the facility ' s Neurological Assessment policy.
3. Failing to ensure Resident 2 ' s neurochecks were assessed after the falls on 1/3/2025 and 5/21/2025 as indicated in the facility ' s Neurological Assessment policy.
These failures had the potential for a delay in care and services to Resident 1 and Resident 2.
Findings:
a. During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 7/29/2024, with diagnoses that included unspecified (unconfirmed) heart failure (occurs when the heart can't pump enough blood to meet the body's needs), unspecified dementia (a progressive state of decline in mental abilities), unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and history of falling.
During a record review of Resident 1 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) dated 7/31/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a record review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool) dated 4/15/2025, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 was dependent to staff for toileting, needed moderate assistance from staff for sit to stand and needed maximum assistance for transfer and walking. The MDS indicated Resident 1 was frequently incontinent (unable to control) of bowel and bladder functions. The MDS indicated Resident 1 had history of fall since admission.
During a review of Resident 1 ' s Progress Notes, dated 5/21/2025, the Progress Notes indicated on 5/21/2025, at 9:50 p.m., Resident 1 was seated in a wheelchair in front of the nurse ' s station when RN 1, LVN 1 and LVN 2 observed Resident 1 got out of the wheelchair and walked one step and fall. The Progress Notes indicated Resident 1 had 3 centimeters (cm- a unit of length in the metric system) in length by 0.5 cm in width right eyebrow laceration with bleeding.
During a concurrent interview, and record review on 6/3/2025, at 10:20 a.m., with Performance Improvement Quality Improvement Nurse (PIQIN 1), Resident 1 ' s Progress Notes dated 5/21/2025, and Weights and Vital Summary dated 5/21/2025, were reviewed. PIQIN 1 stated there were no documented vital signs when Resident 1 fell on 5/21/2025. PIQIN 1 stated vital signs is part of resident assessment and its necessary to check vital signs after a fall to find out the cause of a fall if it was from a low blood pressure or from low blood sugar. PIQIN 1 stated vital signs is necessary when calling the physician of a change in condition. During a concurrent record review, Resident 1 ' s neurocheck after the 5/21/2025, was reviewed with PIQI 1. The PIQI 1 stated Resident 1 ' s neurocheck after the 5/21/2025 fall was not in Resident 1 ' s medical record.
During an interview on 6/3/2025, at 11:14 a.m., with the Risk Management Nurse (RMN), the RMN stated vital signs is important to check after Resident 1 ' s fall to see if there were any contributing factors to the fall incident. The RMN stated vital signs is part of the assessment that should be relayed to the physician. The RMN stated nurses should check vital signs and document.
During a concurrent interview and record review on 6/4/2025, at 11:48 a.m., with the RMN, Resident 1 ' s neurocheck assessments dated 10/16/2024, 12/31/2024, and 5/21/2025 were reviewed. The RMN stated there were no documented neurochecks after Resident 1 ' s falls on 10/16/2024, 12/31/2024, and 5/21/2025. The RMN stated the importance of neurologic assessment was to find out if the neurological status of Resident 1 was affected after the fall incidents.
During a concurrent on 6/4/2025, at 12:52 p.m., with the Director of Nursing (DON), the DON stated Resident 1 ' s vital signs was not documented on 5/21/2025 fall. The DON stated the facility ' s Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together) team failed to catch that vital sign was missing on the 5/21/2025 fall. The DON stated vital signs is part of assessment after each change of condition. The DON stated a neurocheck is done when residents fall and hit their head and during an unwitnessed fall. The DON stated the importance of neurochecks was to help identify any significant change as a result of a fall. The DON stated if staff did not do a nuerocheck after the fall the staff would not be able to know if there was a change in residents ' condition that might cause a delay in care.
During a concurrent interview, and record review on 6/5/2025, at 10:47 a.m., with the DON, the facility ' s policy and procedure (P&P) titled, Fall Risk Assessment, last reviewed on 4/28/2025, was reviewed. The P&P indicated, The Licensed Nurse will use the Fall Risk Assessment Form to help identify individuals with a history of falls and risk factors for subsequent falling. The assessment will be completed upon admission, quarterly (every three months), and with a significant change in condition. The DON stated when residents fall, nurses should do a fall risk assessment. The DON stated the facility failed to assess Resident 1 ' s fall risk after the incident on fall. During a concurrent record review of the facility ' s P&P titled, Change of Condition Notification, dated and last reviewed on 4/28/2025, the P&P indicated, I. The Licensed Nurse will notify the resident's Attending Physician when there is an:
A. Incident/accident involving the resident;
B. An accident involving the resident which results injury and has the potential for requiring physician intervention;
II. The Licensed Nurse will assess the resident's change of condition and document the observations and symptoms.
III. Notifying the Attending Physician .
B. Notification to the Attending Physician will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required. The DON stated with any change of condition like fall, vital signs is included.
The DON stated without the vital signs the nurses would have an incomplete report to the physician. The DON stated the facility failed to check and document Resident 1 ' s vital signs after the fall on 5/21/2025.
b. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease (the arteries that supply blood to your heart become hardened and narrowed due to the buildup of plaque), Alzheimer ' s Disease and age-related osteoporosis (a condition where bone density and strength decrease as people age, primarily due to a decrease in bone-building cells and an increase in bone-resorbing cells).
During a review of Resident 2 ' s Licensed Nurses Progress Notes dated 1/3/2025, the Licensed Nurses Progress Notes indicated on 1/3/2025 at 3:20 a.m., heard a noise from Resident 2 ' s room and found Resident 2 lying on her (Resident 2) right side, on the floor between the toilet bowl and the bathroom wall. The Licensed NursesProgress Notes indicated Resident 2 had a skin tear on the right side of the face. The Licensed Nurses Progress Notes indicated physician was notified with order to transfer Resident 2 to a GACH via 911.
During a review of Resident 2 ' s H&P dated 3/1/2025, the H&P indicated Resident 2 had no capacity to understand and make decisions.
During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 2 needed maximum assistance from staff for oral hygiene, showering, dressing, personal hygiene and transfer. The MDS indicated Resident 2 needed supervision with walking.
During a review of Resident 2 ' s Progress Notes dated 5/21/2025, timed at 10:56 p.m., the Progress Notes indicated on 5/21/2025, at 9:30 p.m., CNA 5 reported that Resident 2 was found on the floor. The Progress Notes indicated Resident 2 complained of right hip pain and unable to move her (Resident 2) right leg. The Progress Notes indicated the physician was notified with order to transfer Resident 2 to GACH via 911.
During a concurrent interview and record review on 5/30/2025, at 11:35 a.m , with LVN 4, Resident 2 ' s Licensed Nurses Progress Notes and Nuerocheck assessment dated [DATE] and 5/21/2025 were reviewed. LVN 4 stated Resident 2 had fall incident on 1/3/2025, and 5/21/2025. LVN 4 stated there were no neurochecks on 1/3/2025 and 5/21/2025 in Resident 2 ' s medical record.
During an interview on 6/4/2025, at 11:48 a.m., with the RMN, the RMN stated the importance of neurologic assessment was to find out if Resident 2 ' s neurological status was affected after the fall incident. The RMN stated neurocheck is part of nurse ' s assessment after a fall.
During an interview on 6/4/2025 at 12:52 p.m. with the DON, the DON stated neurocheck is done when a resident fall and hit their head and during an unwitnessed fall. The DON stated the importance of neurocheck was to help identify any significant change as a result of a fall. The DON stated if staff did not do a nuerocheck after the fall the staff would not be able to know if there was a change in residents ' condition that might cause a delay in care. The DON stated neurocheck is basic nursing care that nurses forget.
During a review of the facility ' s P&P titled, Neurological Assessment, dated 8/1/2014, and last reviewed on 4/28/2025, the P&P indicated, To provide guidelines for the performance of a neurological assessment on residents.
I. Nursing Staff will perform a neurological assessment in the following circumstances .
B. Following an unwitnessed fall;
C. Following a fall or other accident/injury involving head trauma;
II. Neurological checks will be performed as follows or otherwise ordered by the Attending Physician:
A. Every 15 minutes for 1 hour, then;
B. Every 30 minutes for 1 hour, then;
C. Every hour for 2 hours, then;
D. Every 4 hours for a combined total of 72 hours
IX. Documentation
A. The following information will be documented in the resident's medical record:
i. The date and time the procedure was performed;
ii. The name and title of the individual(s) who performed the procedure;
iii. All assessment data obtained during the procedure, including:
a. Eye opening
b. Verbal response
c. Motor response
d. Pupillary (black circle in the center of the eye) response
e. Limb (arms or legs) response.
During a review of facility ' s P&P titled, Response to Fall dated 3/31/2025, and last reviewed on 4/28/2025, the P&P indicated, Post-Fall Assessment and Monitoring: The Licensed Nurse will also complete the Neurological Flow Sheet for any un-witnessed fall or witnessed fall with known head injury for 72 hours following the fall.
Documentation:
A. License Nurse .
v. Complete Neurological Flow Sheet for 72 hours following an un-witnessed fall or fall with known head injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 2) who had an indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services by failing to ensure Resident 2 ' s urine color and consistency was assessed per physician order.
This failure had the potential to result in urinary tract infection (UTI- an infection in the bladder/urinary tract) and had potential to lead to urosepsis (a potentially life-threatening complication of urinary tract infection).
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease (the arteries that supply blood to your heart become hardened and narrowed due to the buildup of plaque), Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities) and age-related osteoporosis (a condition where bone density and strength decrease as people age, primarily due to a decrease in bone-building cells and an increase in bone-resorbing cells).
During a review of Resident 2 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 3/1/2025, the H&P indicated Resident 2 had no capacity to understand and make decisions.
During a review of Resident 2 ' s Minimum Data Set (MDS- a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 2 needed maximum assistance from staff for oral hygiene, showering, dressing, personal hygiene and transfer.
During a concurrent observation, and interview on 5/30/2025, at 8:30 a.m., in Resident 2 ' s bedside, Resident 2 had a urinary catheter draining yellow urine with a privacy bag.
During a concurrent interview, and record review on 5/30/2025, at 12:10 p.m., with Treatment Nurse 1 (TN 1), Resident 2 ' s Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 5/2025 and Progress Notes, dated 5/28/2025 to 5/30/2025 were reviewed. TN 1 stated there were no documented assessment and monitoring of Resident 2 ' s urine color and consistency until today 5/30/2025. TN 1 stated Resident 2 ' s urine if not monitored could result to infection and kidney stones (hard object that is made from chemicals in the urine).
During a concurrent interview, and record review on 5/30/2025, at 12:43 p.m., with Registered Nurse 4 (RN 4), Resident 2 ' s Physician Order dated 5/28/2025 was reviewed. The Physician Order indicated to assess Resident 2 ' s urine for color and consistency (sedimentation-alert health care providers to the presence of kidney disease) every shift. RN 4 stated nurses, assess and document urine color and consistency in the Progress Notes or in MAR. RN 4 stated the facility failed to document assessment of urine for color and consistency. RN 4 stated not assessing urine might cause urinary infection.
During a concurrent interview, and record review on 6/3/2025, at 11:14 a.m., with the Risk Management Nurse (RMN), Resident 2 ' s MAR, dated 5/2025 was reviewed. The RMN stated Resident 2 was readmitted to the facility on [DATE], at 6:20 p.m. The RMN stated urine assessment should have been started at least the following day on 5/29/2025. The RMN stated there were no monitoring for urine assessment on 5/29/2025 and was just started today 5/30/2025. The RMN stated the facility failed to follow the physician order.
During an interview on 6/4/2025, at 12:52 p.m., with the Director of Nursing (DON), the DON stated the facility failed to follow physician order for assessing urine color and consistency every shift on 5/29/2025. The DON sated the nurses should have validated the order and follow the physician order to assess and document Resident 2 ' s urine. The DON stated the importance of urine assessment was to notify the physician immediately of any change in condition to prevent UTI.
During a concurrent interview, and record review on 6/5/2025, at 10:47 a.m., with the DON, facility ' s policy and procedure (P&P) titled, Care of Catheter, dated 9/1/2014, and last reviewed on 4/28/2025, the P&P indicated, To prevent catheter-associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary .
V. A resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible .
L. Report the following signs and symptoms to the Attending Physician:
i. Any sign or symptom of urinary tract infection (UTI): fever, change in urine, such as a foul odor or bloody/cloudy appearance.
ii. No urine output or decreased urine output
iii. Leakage of urine
iv. Hematuria (bloody urine) .
The DON stated the nurses should monitor Resident 2 ' s urine for color, clarity and consistency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer pain medication for one of four sampled residents (Resident 2) as per physician ' s order to administer Tylenol (medication used to treat pain) as needed for pain when Resident 2 had an incident of fall on 5/21/2025 and had a pain level of six out of ten using the pain scale (a tool used to help people describe and quantify their pain).
This failure had the potential to negatively affect the Resident 2 ' s physical comfort and had the potential to increase the pain level and result in an unmanageable pain.
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease (the arteries that supply blood to your heart become hardened and narrowed due to the buildup of plaque), Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities) and age-related osteoporosis (a condition where bone density and strength decrease as people age, primarily due to a decrease in bone-building cells and an increase in bone-resorbing cells).
During a review of Resident 2 ' s Physician Order dated 3/13/2021, the Physician Order indicated Tylenol oral tablet 326 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give two tablets by mouth every four hours as needed for mild pain or general discomfort.
During a review of Resident 2 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) dated 3/1/2025, the H&P indicated Resident 2 had no capacity to understand and make decisions.
During a review of Resident 2 ' s Minimum Data Set (MDS-a resident assessment tool) dated 4/9/2025, the MDS indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 2 needed maximum assistance from staff for oral hygiene, showering, dressing, personal hygiene and transfer.
During a review of Resident 2 ' s Progress Notes dated 5/21/2025, timed at 10:56 p.m., the Progress Notes indicated on 5/21/2025, at 9:30 p.m., Certified Nursing Assistant 5 (CNA 5) reported that Resident 2 was found on the floor. The Progress Notes indicated Resident 2 complained of right hip pain and unable to move her (Resident 2) right leg. The Progress Notes indicated the physician was notified at 9:56 p.m., and family informed at 10:05 p.m.
During a review of Resident 2 ' s Progress Notes dated 5/22/2025, timed at 10:31 a.m., the Progress Notes indicated on 5/21/2025, at 10:15p.m., Resident 2 was transferred to the General Acute Care Hospital (GACH).
During a review of Resident 2 ' s Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 5/2025, the MAR indicated no Tylenol was administered to Resident 2 on 5/21/2025.
During a review of Resident 2 ' s Weights and Vitals Summary dated 5/21/2025, the Weights and Vitals Summary indicated on 5/21/2025, at 9:45 p.m., Resident 2 had a pain level of six out of ten.
During an interview on 5/30/2025, at 9:13 a.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated on 5/21/2025, at 9:15 p.m., Resident 2 was observed in bed and at 9:30 p.m., Resident 2 was found on the floor. LVN 3 stated she (LVN 3) was with another resident when CNA 5 reported that Resident 2 was on the floor. LVN 3 stated Resident 2 complained of right hip pain. LVN 3 stated she (LVN 3) checked Resident 2 ' s vital signs (measurements that indicate the status of a person's body's vital functions and are used to assess overall health) and Registered Nurse 2 (RN 2) called 911 (emergency medical response). LVN 3 stated Resident 2 was not transferred back to bed due to pain and waited for the paramedics to transfer Resident 2 to GACH.
During an interview on 5/30/2025, at 9:21 a.m., with RN 2, RN 2 stated he (RN 2) was in a different nursing station when LVN 3 reported that Resident 2 was found on the floor. RN 2 stated when he (RN 2) came inside Resident 2 ' s room, Resident 2 was on the floor with no floor mat. RN 2 stated upon assessment, Resident 2 complained of right hip pain, Resident 2 could not move the right leg and Resident 2 was guarding her (Resident 2) right hip. RN 2 stated he (RN 2) called the physician, 911 and the family.
During an interview on 6/3/2025, at 8:35 a.m., with RN 2, RN 2 stated Resident 2 complained of pain after the 5/21/2025 fall and LVN 3 should have medicated Resident 2 for pain while waiting for the paramedics to pick up Resident 2. RN 2 stated pain medication help relieves pain and if not given when Resident 2 complained of pain, the pain could get worst and cause severe pain and discomfort.
During a concurrent interview, and record review on at 11:14 a.m., with the Risk Management Nurse (RMN), Resident 2 ' s Physician Order dated 3/13/2021, MAR dated 5/2025, and Weights and Vital Summary dated 5/21/2025 were reviewed. The RMN stated Resident 2 had a pain level of six out of ten on 5/21/2025 at 9:45 p.m. The RMN stated no pain medication was given to Resident 2 according to the MAR. The RMN stated Resident 2 had an order for Tylenol and LVN 3 should have offered the pain medicine and document if administered or if Resident 2 refused. The RMN stated not administering pain medicine can cause Resident 2 to experience unmanageable pain and discomfort.
During an interview on 6/4/2025, at 12:52 p.m., with the Director of Nursing (DON), the DON stated Resident 2 was not medicated for pain after the 5/21/2025 fall. The DON stated Tylenol could have help ease Resident 2 ' s pain and discomfort. The DON stated the facility failed to follow physician order for pain medication administration.
During a concurrent interview, and record review on 6/5/2025, at 10:47 a.m., with the DON, facility ' s policy and procedure (P&P) titled Pain Management, dated 8/1/2024, and last reviewed on 4/28/2025, the P&P indicated, The License Nurse will administer pain medication as ordered and document all the medication administered on the Medication Administration Record (MAR) Nursing Staff will implement timely interventions to reduce the increase in severity of pain. The DON stated nurses should have medicated Resident 2 for pain when Resident 2 complained of pain according to the physician order and if there was no order for pain medicine, nurses should be calling the physician to get an order and help relieve Resident 2 ' s pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of four sampled residents (Residents 1 and 4) by:
1. Failing to ensure Resident 1 ' s physician order to administer cephalexin (antibiotic medication that treats infection [harmful germs have entered your body and are causing problems]) for five days was followed.
2. Failing to ensure Resident 1 ' s physician order was followed for Humulin R (medication used to manage blood sugar level) administration.
3. Failing to ensure 12 medications of Resident 4 ' s were not provided to Family Member (FM 2) without a physician order.
These failures had resulted to incomplete dose of cephalexin that may potentially prolong infection, may potentially cause hypoglycemia (low blood sugar) and medication error to Resident 2. Also, this failure had the potential to had a negative outcome to Resident 4 if the medications were not given to Resident 4 as ordered by the physician.
Findings:
a. During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 7/29/2024, with diagnoses that included unspecified (unconfirmed) heart failure (occurs when the heart can't pump enough blood to meet the body's needs), unspecified dementia, unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a record review of Resident 1 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) dated 7/31/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a record review of Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool) dated 4/15/2025, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 was dependent to staff for toileting, needed moderate assistance from staff for sit to stand and needed maximum assistance for transfer and walking.
During a review of Resident 1 ' s Order Audit Report dated 5/22/2025, the Order Audit Report indicated cephalexin oral capsule 500 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one capsule by mouth every six hours for infection of laceration (a tear or cut in the skin or deeper tissues, often with jagged edges) on the right eyebrow for five days.
During a review of Resident 1 ' s Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 5/2025, the MAR indicated on 5/26/2025, at 12 a.m., and 6 a.m., MAR was left blank and on 5/26/2025 at 12 p.m., cephalexin was not administered.
During a review of Resident 1 ' s Progress Notes, dated 5/26/2025, timed at 12:24 p.m., the Progress Notes indicated cephalexin was not in the medication cart.
During a concurrent interview, and record review on 6/3/2025, at 10:20 a.m., with the Performance Improvement Quality Improvement Nurse 1 (PIQIN 1), Resident 1 ' s MAR dated 5/2025 was reviewed. PIQIN 1 stated according to the MAR, Resident 1 missed three doses of cephalexin. PIQIN 1 stated the physician needed to be notified when medication is not available, and pharmacy need to be informed so antibiotic could be obtained from the emergency kit (ekit- small supply of medication that can be used when pharmacy services are unavailable. Emergency kits are designed to help nursing facilities provide medication to their residents during emergencies) if available.
During a concurrent interview, and record review on 6/3/2025, at 11:14 a.m., with the Risk Management Nurse (RMN), Resident 1 ' s Order Summary Report dated 5/22/2025, was reviewed. The RMN stated the physician ordered cephalexin every six hours for five days and Resident 1 missed three doses of antibiotic cephalexin. The RMN stated nurses should have called the physician and the pharmacy. The RMN stated missing doses of antibiotic could result to unresolved infection.
During an interview on 6/4/2025, at 12:52 p.m., with the Director of Nursing (DON), the DON stated if MAR is blank, it means medication was not administered. The DON stated if medication was not available, nurses should have called the pharmacy and Registered Nurse Supervisor should have track why medication was not delivered. The DON stated the nurses did not follow through causing Resident 1 to received incomplete dose of antibiotic. The DON stated incomplete dose of antibiotic will not help fight Resident 1 ' s infection. The DON stated the facility failed to follow the physician order.
During a review of facility ' s policy and procedure (P&P), titled, Medication-Administration dated 7/1/2016, and last reviewed on 4/28/2025, the P&P indicated, Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner.
b. During a review of Resident 1 ' s Physician Order, dated 12/11/2024, the Physician Order indicated Humulin R injection 100 units per milliliter (ml- a unit of volume) give eight units subcutaneously (an injection administered into the fatty tissue just beneath the skin, between the skin and muscle) before meals related to DM and hold for blood sugar less than 120 mg/deciliter (dl- one tenth of a liter).
During a review of Resident 1 ' s MAR dated 5/2025, the MAR indicated Humulin R eight units was administered on the following dates and times.
1. 5/15/2025, at 11:30 a.m., with a blood sugar of 112 mg/dl.
2. 5/20/2025, at 5 p.m., with blood sugar of 110 mg/dl.
3. 5/24/2025, at 7 a.m., with a blood sugar of 103 mg/dl.
During a concurrent interview, and record review on 6/3/2025, at 10:20 a.m. with PIQIN 1, Resident 1 ' s MAR dated 5/2025 was reviewed. PIQIN 1 stated there were three incidences on 5/2025 MAR that Resident 1 received Humulin R eight units with a blood sugar below 120 mg/dl. PIQIN stated Humulin R should have been held as per physician order. PIQIN 1 stated Resident 1 can experience hypoglycemia (low blood guar) if physician order was not followed. PIQIN 1 stated nurses should read and follow the physician order.
During an interview on 6/3/2025, at 11:14 a.m., with the RMN, the RMN stated nurses should follow the physician order. The RMN stated Humulin R is an insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) that lowers blood sugar. The RMN stated Resident 1 could experience hypoglycemia with Humulin R administration.
During an interview on 6/4/2025, at 12:52 p.m., with the DON, the DON stated the facility failed to follow the physician order. The DON stated Resident 1 could have hypoglycemia because of the Humulin R administration and not following the physician order.
During a review of facility ' s P&P, titled, Medication- Administration dated 7/1/2016, and last reviewed on 4/28/2025, the P&P indicated, I. Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner
IV. The licensed nurse must know the following information about any medication they are administering:
A. The drug's name.
B. The drug's route of administration
C. The drug's action
D. The drug's indication for use and desired outcome
E. The drug's usual dosage
F. The drug's side effects and adverse effects
G. Any precautions and special consideration
VII. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record (blood pressure, pulse, finger stick blood glucose monitoring).
c. During a review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted Resident 4 on 4/19/2022, with diagnoses that included unspecified atrial fibrillation (irregular heartbeat), generalized idiopathic epilepsy (a type of epilepsy where seizures originate in both sides of the brain simultaneously) and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D).
During a review of Resident 4 ' s Physician Order dated 4/19/2022, the Physician Order indicated Resident 4 may go out on therapeutic leave (TL-referred to as a leave of absence, allows residents of long-term care facilities to temporarily leave for non-medical reasons, like family visits or outings) with medications.
During a review of Resident 4 ' s Physician Order, the Physician order indicated the following orders:
1. Gabapentin (medication used to treat epilepsy [muscle jerking, altered awareness, or changes in sensation or behavior] and nerve pain) capsule 100mg, give one capsule by mouth two times a day, ordered on 4/19/2022.
2. Lomotil (medication used to lower number of bowel movements) oral tablet 2.5 mg-0.025mg, one tablet by mouth three times a day, ordered on 11/3/2022.
3. Potassium chloride (KCL-medication used to prevent and treat low potassium levels in the body) 10 milliequivalent (meq-unit of measurement) by mouth daily, ordered on 11/23/2022.
4. Diltiazem extended release (ER-medication used to treat high blood pressure) capsule 120 mg, give one capsule by mouth daily, ordered on 3/20/2023.
5. Levothyroxine sodium (medication used to treat hypothyroidism [underactive thyroid]) 88 microgram (mcg-unit of measurement) by mouth daily, ordered on 4/1/2023.
6. Levetiracetam (medication used to treat epilepsy and seizures) oral tablet 250 mg, give two tablets by mouth every 12 hours, ordered on 4/14/2023.
7. Sulfasalazine (medication used to treat certain inflammatory conditions) tablet 1000 mg by mouth four times a day, ordered on 5/7/2024.
8. Lasix (medication that helps reduce excess fluid in the body) tablet 20 mg by mouth daily, ordered on 7/4/2024.
9. Metoprolol succinate (medication used to treat high blood pressure) extended release 100 mg every 12 hours, ordered on 7/11/2024.
10. Eliquis (medication used to treat blood clot) oral tablet 2.5 mg, give one tablet by mouth two times a day, ordered on 7/16/2024.
11. Ambien (medication that help individuals who have difficulty falling asleep or staying asleep) 5 mg, give one tablet by mouth at bedtime ordered on 12/21/2024.
12. Protonix (medication that reduces the amount of acid produced in the stomach) tablet 40mg, give one tablet by mouth in the morning, ordered on 4/11/2025.
During a review of Resident 4 ' s MDS dated [DATE], the MDS indicated Resident 4 ' s cognitive skills for daily decision making were moderately impaired.
During a review of Resident 4 ' s H&P dated 4/24/2025, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.
During a review of Resident 4 ' s Progress Notes dated 5/2/2025, timed at 2:19 p.m., the Progress notes indicated on 5/2/2025, Resident 2 left the facility with FM 2.
During a review of Resident 4 ' s Progress Notes dated 5/5/2025, timed at 6:06 a.m., the Progress Notes indicated on 5/5/2025, at 1:55 a.m., FM 2 arrived at the facility and took Resident 4 ' s belongings including all medications with narcotics (controlled substances [is a drug or chemical that is regulated by a government agency due to its potential for abuse and/or its impact on public health] that was used to treat pain). The Progress Notes indicated FM 2 refused to sign narcotic sheet out, and at 2:10 a.m., FM 2 left with all medications and narcotics against medical advice.
During an interview on 6/4/2025, at 12:52 p.m., with the DON, the DON stated FM 2 threatened the nurses to give her (FM 2) all of Resident 4 ' s medications. The DON stated LVN 8, and RN 3 should not give the controlled medication to FM 2 without the physician ' s order. The DON stated LVN 8, or RN 3 should have notified the physician.
During an interview on 6/4/2025, at 1:32 p.m., with the Administrator (ADM), the ADM stated nurses should not give the medication to FM 2 without a physician order. The ADM stated the nurses should have said no to FM 2.
During an interview on 6/5/2025, at 7:54 a.m., with RN 3, RN 3 stated on 5/5/2025, early morning, LVN 8 called and notified her (RN 3) that FM 2 wanted to discharge Resident 4 and FM 2 was taking all of Resident 4 ' s belongings. RN 3 stated FM 2 was asking for all of Resident 4 ' s medication. RN 3 stated she (RN 3) called the DON, but the DON did not answer the phone, so she (RN 3) had informed LVN 8 to give all of Resident 4 ' s medication. RN 3 stated all medication were given to FM 2 including Ambien.
During an interview on 6/5/2025, at 8:12 a.m., with LVN 8, LVN 8 stated on 5/5/2025 early am, FM 2 arrived in the facility and gathered all Resident 4 ' s belongings and requested all of Resident 4 ' s medication. LVN 8 stated she (LVN 8) notified RN 3 and RN 3 instructed her (LVN 8) to give FM 2 all of Resident 4 ' s medications. LVN 8 stated all of Resident 4 ' s medications were given to FM 2 without the physician order. LVN 8 stated she (LVN 8) cannot remember what medications were given and how many tablets were given. LVN 8 stated if she (LVN 8) had counted she (LVN 8) would have documented it. LVN 8 stated there were two controlled substances given to FM 2.
During an interview on 6/5/2025, at 10:47 a.m., with the DON, the DON stated she (DON) was not called on the morning of 5/5/2025, that FM 2 was at the facility taking all of Resident 4 ' s medications. The DON stated she (DON) was concerned when the nurses gave the medications to FM 2. The DON stated the nurses should have called the security or the police.
During a concurrent interview, and record review on 6/6/2025, at 10:08 a.m., with the Director of Staff Development (DSD), Resident 4 ' s Progress Notes dated 5/5/2025, was reviewed. The DSD stated there were no documented names of medications given to FM 2 in Resident 4 ' s medical record. The DSD stated there were two controlled drugs given to FM 2 which were Ambien and Lomotil. The DSD provided a list of itemized medication including number of tablets given to FM 2 as follows:
1. Diltiazem 120 mg- 10 capsules
2. Eliquis 2.5 mg- 20 tablets
3. Gabapentin 100 mg - 16 tablets
4. KCL 10 meq. - 1 tablet
5. Lasix 20mg. - 10 tablets
6. Levetiracetam 250 mg - 14 tablet
7. Levothyroxine 88 mcg- 2 tablet
8. Metoprolol succinate 100 mg - 20 tablet
9. Protonix 40 mg - 4 tablet
10. Sulfasalazine 100 mg—40 tablets
11. Lomotil 2.5 mg-0.025 mg - 25 tablets
12. Ambien 5 mg – 6 tablets
During an interview on 6/5/2025, at 10:47 a.m., with the DON, the DON stated the facility do not have a policy for therapeutic leave.
During a review of facility ' s P&P titled, Transfer and Discharge dated 9/1/2023, and last reviewed on 4/28/2025, the P&P indicated, Disposition of Resident Drugs Upon discharge.
A. Drugs which have been dispensed for individual resident use and are labeled in conformance with the state and federal law for outpatient use will be furnished to a resident by the Licensed Nurse upon discharge on the orders of the residents Attending Physician.
B. Controlled Substances should not be release upon discharge of the resident unless permitted by the current state law governing the release of controlled substances and as authorized in writing by the resident ' s Attending Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain accurate and complete medical records for three of five sampled residents (Residents 4, 3, and 2) by:
1. Failing to document 12 medications provided to Resident 4 ' s Family Member 2 (FM2) when FM 2 requested the medications on 5/5/2025.
2. Failing to accurately document Resident 3 ' s behavior of throwing himself on the floor from 5/6/2025 to 5/24/2025.
3. Failing to document Resident 2 ' s vital signs (basic measurements that indicate how well your body is functioning) when Resident 2 had a fall incident on 5/21/2025.
These failures had the potential to cause confusion in care and the medical records containing inaccurate documentation.
Findings:
a. During a review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted Resident 4 on 4/19/2022, with diagnoses that included unspecified (unconfirmed) atrial fibrillation (irregular heartbeat), generalized idiopathic epilepsy (a type of epilepsy where seizures originate in both sides of the brain simultaneously) and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D).
During a review of Resident 4 ' s Physician Order dated 4/19/2022, the Physician Order indicated Resident 4 may go out on therapeutic leave (TL-referred to as a leave of absence, allows residents of long-term care facilities to temporarily leave for non-medical reasons, like family visits or outings) with medications.
During a review of Resident 4 ' s Physician Order, the Physician order indicated the following orders:
1. Gabapentin (medication used to treat epilepsy [muscle jerking, altered awareness, or changes in sensation or behavior] and nerve pain) capsule 100 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one capsule by mouth two times a day, ordered on 4/19/2022.
2. Lomotil (medication used to lower number of bowel movements) oral tablet 2.5 mg-0.025mg, one tablet by mouth three times a day, ordered on 11/3/2022.
3. Potassium chloride (KCL-medication used to prevent and treat low potassium levels in the body) 10 milliequivalent (meq-unit of measurement) by mouth daily, ordered on 11/23/2022.
4. Diltiazem (medication used to treat high blood pressure) extended-release capsule 120 mg, give one capsule by mouth daily, ordered on 3/20/2023.
5. Levothyroxine sodium (medication used to treat hypothyroidism [underactive thyroid]) 88 microgram (mcg-unit of measurement) by mouth daily, ordered on 4/1/2023.
6. Levetiracetam (medication used to treat epilepsy and seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) oral tablet 250 mg, give two tablets by mouth every 12 hours, ordered on 4/14/2023.
7. Sulfasalazine (medication used to treat certain inflammatory conditions) tablet 1000 mg by mouth four times a day, ordered on 5/7/2024.
8. Lasix (medication that helps reduce excess fluid in the body) tablet 20 mg by mouth daily, ordered on 7/4/2024.
9. Metoprolol succinate (medication used to treat high blood pressure) extended release 100 mg, every 12 hours, ordered on 7/11/2024.
10. Eliquis (medication used to treat blood clot) oral tablet 2.5 mg, give one tablet by mouth two times a day, ordered on 7/16/2024.
11. Ambien (medication that help individuals who have difficulty falling asleep or staying asleep) 5 mg, give one tablet by mouth at bedtime ordered on 12/21/2024.
12. Protonix (medication that reduces the amount of acid produced in the stomach) tablet 40 mg, give one tablet by mouth in the morning, ordered on 4/11/2025.
During a review of Resident 4 ' s Minimum Data Set (MDS-a resident assessment tool), dated 1/28/2025, the MDS indicated Resident 4 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were moderately impaired.
During a review of Resident 4 ' s History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/24/2025, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.
During a review of Resident 4 ' s Progress Notes dated 5/2/2025, timed at 2:19 p.m., the Progress notes indicated on 5/2/2025, Resident 2 left the facility with FM 2.
During a review of Resident 4 ' s Progress Notes dated 5/5/2025, timed at 6:06 a.m., the Progress Notes indicated on 5/5/2025, at 1:55 a.m., FM 2 arrived at the facility and took Resident 4 ' s belongings including all medications with controlled substances (is a drug or chemical that is regulated by a government agency due to its potential for abuse and/or its impact on public health). The Progress Notes indicated FM 2 refused to sign the narcotic sheet (controlled substances sheet) out, and at 2:10 a.m., FM 2 left with all medication against medical advice.
During an interview on 6/5/2025, at 7:54 a.m., with RN 3, RN 3 stated on 5/5/2025, early morning, LVN 8 called and notified her (RN 3) that FM 2 wanted to discharge Resident 4 and FM 2 was taking all of Resident 4 ' s belongings. RN 3 stated FM 2 was asking for all of Resident 4 ' s medication. RN 3 stated she (RN 3) called the Director of Nursing (DON), but the DON did not answer the phone, so she (RN 3) had informed LVN 8 to give all of Resident 4 ' s medication. RN 3 stated all medication were given to FM 2 including Ambien.
During an interview on 6/5/2025, at 8:12 a.m., with LVN 8, LVN 8 stated on 5/5/2025 early am, FM 2 arrived in the facility and gathered all Resident 4 ' s belongings and requested all of Resident 4 ' s medication. LVN 8 stated she (LVN 8) notified RN 3 and RN 3 instructed her (LVN 8) to give FM 2 all of Resident 4 ' s medications. LVN 8 stated all of Resident 4 ' s medication was given to FM 2 without the physician order. LVN 8 stated she (LVN 8) cannot remember what medication was given and how many tablets was given. LVN 8 stated if she (LVN 8) had counted she (LVN 8) would have documented it. LVN 8 stated there were two controlled medications given to FM 2.
During a concurrent interview, and record review on 6/6/2025, at 10:08 a.m., with the Director of Staff Development (DSD), Resident 4 ' s Progress Notes dated 5/5/2025, was reviewed. The DSD stated there were no documented names of medications given to FM 2 in Resident 4 ' s medical record. The DSD stated there were two controlled drugs given to FM 2 which are Ambien and Lomotil. The DSD provided a list of itemized medication including number of tablets given to FM 2 as follows:
1. Diltiazem 120 mg- 10 capsules
2. Eliquis 2.5 mg- 20 tablets
3. Gabapentin 100 mg - 16 tablets
4. KCL 10 meq. - 1 tablet
5. Lasix 20mg. - 10 tablets
6. Levetiracetam 250 mg - 14 tablets
7. Levothyroxine 88 mcg- 2 tablets
8. Metoprolol succinate 100 mg - 20 tablets
9. Protonix 40 mg - 4 tablets
10. Sulfasalazine 100 mg—40 tablets
11. Lomotil 2.5 mg-0.025 mg - 25 tablets
12. Ambien 5 mg – 6 tablets
During a concurrent interview and record review on 6/5/2025 at 10:47 a.m., with the DON, facility ' s policy and procedure (P&P), titled, Documentation-Nursing, dated 3/20/2025, and last reviewed on 4/28/2025, the P&P indicated, Nursing documentation will be concise, clear, pertinent, and accurate. Nurse's notes addressing the resident leaving the facility will document when and with whom, and time of return, along with any medications sent. Documentation will be completed by the end of the assigned shift. The DON stated medication given to FM 2 should have been documented for completeness of medical record.
During a review of facility ' s P&P titled, Transfer and Discharge dated 9/1/2023, and last reviewed on 4/28/2025, the P&P indicated, Disposition of Resident Drugs Upon discharge.
A. Drugs which have been dispensed for individual resident use and are labeled in conformance with the state and federal law for outpatient use will be furnished to a resident by the Licensed Nurse upon discharge on the orders of the residents Attending Physician.
B. Controlled Substances should not be release upon discharge of the resident unless permitted by the current state law governing the release of controlled substances and as authorized in writing by the resident ' s Attending Physician.
b. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 1/17/2025, with diagnoses that included Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), unspecified Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities), muscle weakness and age-related osteoporosis.
During a review of Resident 3 ' s H&P, dated 4/18/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.
During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognitive skills for daily decision making severely impaired. The MDS indicated Resident 3 was dependent to staff for activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a review of Resident 3 ' s Progress Notes dated 5/25/2025, timed at 2:50 p.m., the Progress Notes indicated on 5/25/2025, at 2 p.m., Activity Staff reported that Resident 3 was sitting on the floor mat next to his (Resident 3) bed with no bruises, no changes in level of consciousness and vital signs was stable. The Progress Notes indicated at 2:10 p.m. FM 2 was informed and requested General Acute Care Hospital (GACH) transfer. The Progress notes indicated at 2:15 p.m., the physician was notified and agreed for GACH transfer.
During a concurrent interview, and record review on 6/3/2025, at 9:54 a.m., with Care Planner 1 (CP 1), Resident 3 ' s Progress Notes dated 5/6/2025 to 5/24/2025 was reviewed. The Progress Notes indicated from 5/6/2025 to 5/10/2025, 5/13/2025, and 5/15/2025 to 5/24/2025, LVN ' s 5, 6, and 7 documented that Resident 3 was observed with behavior of throwing himself (Resident 3) on the floor and cannot stay in the room unattended. CP 1 stated the were no reported behavior that Resident 3 throws himself on the floor.
During a concurrent interview, and record review on 6/3/2025, at 11:14 a.m., with the RMN, Resident 3 ' s Progress Notes dated 5/6/2025 to 5/25/2025, and IDT dated 5/26/2025 was reviewed. The RMN stated LVNs 5, 6, and 7 documented Resident 3 ' s behavior of throwing himself (Resident 3) on the floor almost daily, 16 times from 5/6/2025 until 5/24/2025 and on 5/25/20205, Resident 3 had a fall. The RMN stated she (RMN) was not informed of Resident 3 ' s behavior and knows that Resident 3 do not have that behavior. The RMN stated nurses were possibly copying and pasting other nurses ' documentation.
During an interview on 6/4/2025, at 12:52 p.m. with the DON, the DON stated Resident 3 had behavior of throwing himself (Resident 3) on the floor initially but not for 14 days in a row. The DON stated it was a major error on the nurse ' s part. The DON stated the nurses were lazy and not paying attention to their documentation. The DON stated the facility failed to follow policy for documentation and to not copy and paste other nurses ' documentation.
During an interview on 6/4/2025, at 3:02 p.m., with LVN 6, LVN 6 stated he (LVN 6) did not observe Resident 3 ' s behavior of throwing himself (Resident 3) on the floor. LVN 6 stated he (LVN 6) did copy and paste previous nurses ' documentation. LVN 6 stated it was his (LVN 6) fault that he (LVN 6) should have document only what was observed. LVN 6 stated the importance of accurate documentation was to record what happen and what was done for that shift.
During an interview on 6/4/2025, at 3:09 p.m., with LVN 7, LVN 7 stated she (LVN 7) sometimes copy and paste other nurses ' documentation. LVN 7 stated nurses should only documented what was observed and was what done for the resident.
c. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease (the arteries that supply blood to your heart become hardened and narrowed due to the buildup of plaque), Alzheimer ' s Disease and age-related osteoporosis.
During a review of Resident 2 ' s H&P, dated 3/1/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decisions was moderately impaired. The MDS indicated Resident 2 needed maximum assistance from staff for oral hygiene, showering, dressing, personal hygiene and transfer.
During a review of Resident 2 ' s Progress Notes dated 5/21/2025, timed at 10:56 p.m., the Progress Notes indicated on 5/21/2025, at 9:30 p.m., CNA 5 reported that Resident 2 was found on the floor. The Progress Notes indicated Resident 2 complained of right hip pain and unable to move her (Resident 2) right leg. The Progress Notes indicated the physician was notified with order to transfer Resident 2 to GACH via 911.
During an interview on 5/30/2025, at 9:13 a.m., with LVN 3, LVN 3 stated when she (LVN 3) responded to CNA 5 ' s report that Resident 2 was on the floor, she (LVN 3) took Resident 2 ' s vital signs. LVN 3 stated she must have forgotten to document Resident 2 ' s vital signs.
During an interview on 6/3/2025, at 8:35 a.m. with RN 2, RN 2 stated he (RN 2) did not check Resident 2 ' s vitals signs during the fall. RN 2 stated checking vitals signs was LVN ' s responsibility.
During an interview on 6/3/2025, at 11:14 a.m., with the RMN, the RMN stated Resident 2 ' s vitals signs on 5/21/2025 at 9:30 p.m., was not documented in Resident 2 ' s Progress Notes and Vital Signs Log. The RMN stated vitals signs should be documented in Resident 2 ' s medical record as it is part of an assessment after a change in condition.
During an interview on 6/4/2025, at 12:52 p.m., with the Director of Nursing (DON), the DON stated the facility failed to document Resident 2 ' s vital signs. The DON stated the nurses should check and documented vital signs every after change of condition.
During a concurrent interview and record review on 6/5/2025, at 10:467 a.m., with the DON, facility ' s P&P, titled, Documentation-Nursing, dated 3/20/2025 and last reviewed on 4/28/2025, the P&P indicated, Nursing documentation will be concise, clear, pertinent, and accurate. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures. Documentation for subsequent and/or routine care and procedures may be completed by exception. Checklists, flow charts, and other documentation tools will be used as appropriate. Documentation will be completed by the end of the assigned shift. The DON stated nurses should document accurately because it ' s the facility policy.
During a review of facility ' s P&P titled, Change of Condition Notification, dated 1/1/2017, and last reviewed on 4/28/2025, the P&P indicated, The Licensed Nurse will assess the resident's change of condition and document the observations and symptoms.
VI. Documentation
A. A Licensed Nurse will document the following:
i. Date, time, and pertinent details of the incident and the subsequent assessment in the Nursing Notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Director of Nursing (DON) has an active Registered Nurse (RN) License while working in the capacity as the full-time DON in the facility. On [DATE], during an onsite visit, the DON's license was expired since [DATE].
This deficient practice had the potential to affect the delivery of care and services to the residents.
Findings:
During a concurrent interview and record review with the Director of Staff Development (DSD) on [DATE] at 11a.m., the DON's Employee file had a copy of the California Board of Registered Nursing License with an expiration date of [DATE]. The DSD stated she typically does not check on the DON's file because her (DON) file is kept in the Administrator's (Admin's) office. The DSD stated she had no idea that the DON's license had expired back in February. The DSD stated the DON has been working as a Registered Nurse in the facility since [DATE]. The DSD stated the DON cannot practice as an RN and the DON needs to renew her (DON) license right away. DSD stated practicing as an RN with an expired license can have serious legal and professional consequences.
During an interview with the DON on [DATE] at 12 p.m., the DON stated it was a failure on not following up with the Licensing Board for verification. The DON stated she (DON) will call the Licensing Board to verify her (DON) license.
During an interview with the Admin on [DATE] at 12:30 p.m., The Admin stated, he was not aware the DON was practicing in the facility with an expired license. The Admin stated the DSD is usually responsible to verify that staff are working with active license. The Admin stated he will remove the DON from the floor because she cannot work at this time with an expired license.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, by failing to report a physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) to the State Survey Agency (SSA) no later than two hours for one of six sample residents (Resident 5) when on 5/18/2025 at 10:15 a.m. Resident 5 reported to Registered Nurse (RN) 1, that Certified Nursing Assistant (CNA) 2 had handled her roughly. The facility reported the allegation of abuse to the SSA on 5/18/2025 at 2:48 p.m.
This deficient practice had the potential to result in unidentified abuse and place Resident 5 at risk for further abuse.
Findings:
During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 5/16/2025 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), repeated falls, and respiratory failure (lungs are not working properly to get enough oxygen into your blood and/or remove enough carbon dioxide).
During a review of the facility-provided email titled, Accusation employee being rough with resident, dated 5/18/2025 at 2:48 p.m., the email indicated it was reported to the Assistant Administrator (AA) at 2:27 p.m. that Resident 5 reported to her family that her evening CNA (CNA 2) was rough to her.
During a review of Resident 5 Incident Note, dated 5/19/2025 at 11:58 a.m., the Incident Note indicated the family member (FM 1) of Resident 5 complained to RN 1 at 10:15 a.m. that the afternoon and night CNA (CNA 2) had handled Resident 5 unpleasantly. Resident 5's FM 1 wanted to ensure CNAs provide gentle care to Resident 5.
During a review of Resident 5's Incident Note, dated 5/19/2025 at 12:10 p.m., the Incident Note indicated RN 1 was informed that a verbal write-up will be issued due to the delayed report at 2:20 p.m. for the incident that occurred at 10:15 a.m.
During a review of Resident 5's Interdisciplinary Team (IDT- a group of people with different expertise working together to achieve a common goal) Notes, dated 5/19/2025 at 1:43 p.m., the IDT Note indicated on 5/18/2025 at 10:15 a.m. Resident 5 reported that the evening CNA (CNA 2), during Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily), changed the brief unpleasantly. The IDT Note indicated Resident 5 said that it was about 1:30 a.m. to 2 a.m. and Resident 5 was wet and pressed the call light to ask for assistance. The IDT Note indicated Resident 5 said that when CNA 2 arrived, Resident 5 asked to be changed, and CNA 2 started pushing her and Resident 5 thought that she might fall. The IDT Note indicated Resident 5 told CNA 2 she (Resident 5) might fall, and CNA 2 stated so what.
During an interview on 5/21/2025 at 1:37 p.m. with Resident 5, Resident 5 stated does not recall the date but it was around 1:30 a.m. Resident 5 needed to be changed and used the call light and CNA 2 came in. Resident 5 stated she asked CNA 2 to be changed in bed. Resident 5 stated CNA 2 began to push Resident 5. Resident 5 stated she was lying on her side and CNA 2 kept pushing her and she Resident 5 felt like she was going to be pushed off the bed because the pushing was rough. Resident 5 stated she asked CNA 2 to stop because she (Resident 5) was going to fall off the bed and CNA 2 responded with so what if you fall. Resident 5 stated the following morning she was telling FM 1 about the incident and the nurse (RN 1) overheard and went to report the incident. Resident 5 stated she told CNA 2 she (CNA 2) was pushing Resident 5 and Resident 5 was going to fall and CNA 2 stated so what. Resident 5 stated this made Resident 5 mad. Resident 5 stated she was scared if she (Resident 5) fell she would break a bone because you never know what could happen, and that was scary. Resident 5 stated if she fell, she would not be able to get up.
During an interview on 5/21/2025 at 2:17 p.m. with CNA 2, CNA 2 stated on 5/18/2025 at around 12:30 a.m. or 1 a.m. she was called by Resident 5 through the call light. CNA 2 stated Resident 5 refused to get up and wanted to be changed in bed. CNA 2 stated she turned Resident 5 and Resident 5 complained of pain. CNA 2 stated she asked Resident 5 if she was able to turn and Resident 5 turned on her own. CNA 2 stated Resident 5 stated she was going to fall and CNA 2 stated she responded with no you are not; I will be with you. CNA 2 stated at around 5 p.m. she was informed Resident 5 had complained that CNA 2 had provided care roughly.
During an interview on 5/21/2025 at 4:53 p.m. with the Director of Nursing (DON), the DON stated the incident occurred during 11 p.m. to 7:30 a.m. shift on 5/17/2025. The DON stated Resident 5 stated CNA 2 was rough with Resident 5. The DON stated Resident 5 stated CNA 2 kept pushing her and CNA 2 commented if she (Resident 5) fell it was Resident 5's problem, and Resident 5 said she (Resident 5) was not happy with the care. The DON stated there was a delay in reporting the alleged abuse. The DON stated staff were informed in the morning, and they did their investigation prior to contacting the Assistant Director of Nursing (ADON). The DON stated staff knew about the alleged abuse in the morning and did not report until three to four hours later on 5/18/2025, hence, there was a delay. The DON stated that they must report any allegations of abuse within two hours. The DON stated the potential for delay in the reporting can be that the facility staff would not be aware of alleged abuse and CNA 2 could have continued to work with Resident 5 and this could have caused Resident 5 and their family more anxiety.
During an interview on 5/22/2025 at 8 a.m. with RN 1, RN 1 stated on 5/18/2025 at 10 a.m. she was informed the family of Resident 5 was complaining about care. RN 1 stated she went to Resident 5's room and FM1 stated Resident 5 complained that CNA 2 was being rough during ADL and pushed Resident 5 to the side which was not gentle. RN 1 stated she went to investigate who worked with Resident 5. RN 1 stated then continued to work and did not report the alleged abuse to the Administrator (Adm). RN 1 stated another nurse reported the alleged abuse around 1 p.m. to the ADON. RN 1 stated allegations of abuse must be reported immediately to the Adm. RN 1 stated there was a potential the health department not to be informed. RN 1 stated the reporting was not done in a timely fashion. RN 1 stated because she did not report in a timely manner there was potential for further abuse. RN 1 stated she informed the 3 to 11 shift RNs not to assign CNA 2 to Resident 5 because there are concerns of abuse with CNA 2 and there is a potential for CNA 2 to abuse other residents.
During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention and Prohibition Program, last revised on 1/2025, the P&P indicated the purpose is To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to . protect residents . in accordance with federal and state requirements The Facility will report allegations of abuse .
i. Immediately, but no later than 2 hours - if the alleged violation involves abuse . to the state survey agency, law enforcement, and the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) and verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability) for two of six sampled residents (Resident 1 and Resident 3) when:
1. On 5/9/2025 at 1:30 p.m., Resident 1 and Resident 2, who were both inside Room A (Resident 1 and Resident 2's shared room), were observed by Certified Nursing Assistant (CNA) 1, when Resident 2 made a fist with his left hand and punched Resident 1 on Resident 1's lower right abdomen, then Resident 2 used verbal profanity towards Resident 1.
This deficient practice resulted in Resident 1 being subjected to physical and verbal abuse by Resident 2 while under the care of the facility.
2. On 5/9/2025 during lunch time, Resident 3 and Resident 4, who were sitting at the same table in the Staff Dinning (SD) room, were observed by Activities Staff (AS ) 1 and AS 2 having a verbal argument. Resident 3 and Resident 4 both stood up and walked to the end of the table where Resident 4 was observed using his left open hand to push Resident 3 on Resident 3's shoulder.
This deficient practice resulted in Resident 3 being subjected to physical abuse by Resident 4 while under the care of the facility.
Findings:
a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/10/2025 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified psychosis (when someone experiences a loss of contact with reality, often marked by hallucinations [seeing or hearing things that aren't there] and delusions [false beliefs]), and unspecified dementia (a progressive state of decline in mental abilities).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/17/2025, the MDS indicated Resident 1's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 1 required substantial to maximal assistance (helper does more than half the effort) with showering and required partial to moderate assistance (helper does less than half the effort) with toileting, upper and lower body dressing and putting on and taking off footwear.
During a review of the facility-provided record titled, Abuse Investigation Reporting Form, dated 5/14/2025, the Abuse Investigation Reporting Form indicated based on eyewitness accounts from CNA 1, the facility substantiated that Resident 2 made contact with Resident 1 after Resident 1 attempted to wake Resident 2 up with Resident 2 hitting Resident 1 in the stomach.
b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/15/2025 with diagnoses of atrial fibrillation (a condition where the upper chambers of the heart [atria] beat irregularly and rapidly, sometimes faster than normal), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness (generalized).
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated Resident 2 required substantial to maximal assistance with toileting, showering, upper and lower body dressing, and putting on and taking off footwear and required partial to moderate assistance with oral hygiene and personal hygiene.
During a review of Resident 2's Incident Note, dated 5/9/2025 at 2:41 p.m., the Incident Note indicated at 1:30 p.m. CNA 1 reported that Resident 1 told CNA 1 Resident 1 wanted to see her husband (Resident 2) and CNA 1 told Resident 1 Okay, but come back. CNA 1 stated she decided to follow Resident 1 and that was how CNA 1 saw Resident 2 hit Resident 1 for waking up Resident 2, then Resident 2 called Resident 1 names.
During an interview on 5/21/2025 at 10:36 a.m. with Resident 2, Resident 2 stated he cannot recall date of incident but must have occurred more than a week ago. Resident 2 stated he shared a room with wife (Resident 1) and Resident 1 kept waking Resident 2 up and around 1 p.m. Resident 1 woke Resident 2 up again and Resident 2 stated with his left-hand he (Resident 2) shoved or pushed Resident 1 back telling Resident 1 to go away. Resident 2 stated he said some bad words to Resident 1 like you stupid women and may have used profanity (offensive or vulgar language, often considered impolite, rude, or disrespectful).
During an interview on 5/21/2025 at 1:07 p.m. with CNA 1, CNA 1 stated recalls incident with Resident 1 and Resident 2 but does not recall the exact date and said it was around 1:30 p.m. after lunch. CNA 1 stated she was doing her charting (documentation) right outside of Room A, Resident 1 and Resident 2's shared room, with Resident 1 by her (CNA 1) side asking about Resident 2. CNA 1 stated she told Resident 1 that Resident 2 was sleeping but Resident 1 wanted to see Resident 2. CNA 1 stated she told Resident 1 she could take a look at Resident 2 but to leave Resident 2 alone. CNA 1 stated she followed Resident 1 into Room A. CNA 1 stated Resident 1 walked into Room A and walked in front of Resident 2 and shrugged Resident 2's shoulder and whispered to Resident 2 trying to wake Resident 2 up. CNA 1 stated Resident 2 was lying on his right side facing away from the door. CNA 1 stated she saw Resident 2 make a fist with his left hand and with the back of his hand Resident 2 punched Resident 1 on her lower abdomen and Resident 1 scooted back and Resident 2 was yelling at Resident 1 in their own language. CNA 1 stated she rushed to Resident 1 and Resident 2's side and told Resident 2 that was not okay, and Resident 2 said profanities toward Resident 1. CNA 1 stated based on what she witnessed it was physical and verbal abuse.
c. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 12/6/2024 with diagnoses including unspecified dementia, psychotic disturbance (when someone experiences a significant disconnect from reality), mood disturbance (someone is experiencing a significant or unusual shift in their emotional state), and anxiety (a feeling of fear, dread, and uneasiness).
During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was able to understand and be understood. The MDS indicated Resident 3 was dependent (helper does all of the effort) with showering, lower body dressing, putting on and taking off footwear, required substantial to maximal assistance with toileting, upper body dressing, and personal hygiene and required partial to moderate assistance with oral hygiene.
During a review of Resident 3's Incident Note dated 5/9/205 at 12:59 p.m., the Incident Note indicated Resident 3 received lunch which came with a Boost (doctor recommended oral nutritional supplement) from activities and Resident 4 grabbed Resident 3's Boost from Resident 3's tray. The Note indicated Resident 3 went to retrieve the Boost which angered Resident 4 making Resident 4 swing his left arm and made contact with Resident 3's right side of neck below the ear.
During a review the facility-provided record titled, Abuse Investigation Reporting Form, dated 5/13/2025, the Abuse Investigation Reporting Form indicated based on eyewitness accounts the facility substantiated that Resident 4 made contact with Resident 3 on the right side of his body shoulder and neck area below the ear.
d. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 1/6/2023 with diagnoses including major depressive disorder, unspecified dementia, and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).
During a review of Resident 4's MDS, dated [DATE], the MDS indicated that Resident 4 had the ability to understand and be understood. The MDS indicated that Resident 4 required substantial to maximal assistance with showering, and putting on and taking off footwear, and required partial to moderate assistance with toileting, lower body dressing and personal hygiene.
During an interview on 5/21/2025 at 10 a.m. with Resident 4, Resident 4 stated the incident with Resident 3 was about a week ago and does not recall exact date, but it was in the morning around 11 a.m. Resident 4 stated was in the SD room sitting at the table with Resident 3. Resident 4 stated Resident 3 wanted Resident 4's Boost.
During an interview on 5/21/2025 at 12:09 p.m. with AS 2, AS 2 stated the incident with Resident 3 and Resident 4 occurred on 5/9/2025 around lunch time. AS 2 stated Resident 3 and Resident 4 were sitting at the same table across from each other, both in their wheelchairs. AS 2 stated she was in the SD room far away from Resident 3 and Resident 4 assisting another resident when AS 2 observed Resident 3 stood up. AS 2 stated she ran to Resident 3 because she did not want Resident 3 to fall. AS 2 stated AS 1 was already standing next to Resident 3 when she got to Resident 3. AS 2 stated hearing Resident 3 saying that Resident 4 had taken his (Resident 3) Boost. AS 2 stated that Resident 3 and Resident 4 were both standing up and had moved to the front of the table now directly in front of each other and Resident 4 pushed Resident 3. AS 2 stated Resident 4 with an open hand (AS 2 stated cannot recall which hand Resident 4 used) pushed Resident 3 but because AS 2 and AS 1 were there they (AS 2 and AS 1) prevented Resident 3 from falling.
During an interview on 5/21/2025 at 12:34 p.m. with AS 1, AS 1 stated she does not recall date of the incident with Resident 3 and Resident 4, but it was between 11:30 a.m. and 12 p.m. during setting up the tables for lunch. AS 1 stated she was standing next to the table where Resident 3 and Resident 4 were sitting and heard Resident 3 and Resident 4 arguing, and they (Residents 3 and 4) were getting loud. AS 1 stated she heard Resident 3 said to Resident 4, You stole my Boost. AS 1 stated she approached Resident 3 and Resident 4 and that was when they (Residents 3 and 4) both got up and walked to the edge of the table (initially Resident 3 and Resident 4 were sitting across from each other in the same table in their wheelchairs). AS 1 stated she went to Resident 3 to support Resident 3 to avoid a fall, then saw AS 2 come to the other side of Resident 3. AS 1 stated she was standing on the left side of Resident 3 and AS 2 was standing on the right side of Resident 3 when Resident 4 with an opened hand pushed Resident 3, hitting Resident 3's right shoulder with enough force to push Resident 3 to fall back. AS 1 stated Resident 3 is not stable and does not have a good balance. AS 1 stated if AS 1 and AS 2 were not there Resident 3 would have fallen.
During an interview on 5/21/2025 at 4:14 p.m. with the Director of Nursing (DON), the DON stated Resident 4 punched Resident 3 around Resident 3's ear and neck area. The DON stated Resident 3 had no injuries but would consider this abuse because Resident 4 knew what he was doing and reacted physically and hit another resident. The DON stated abuse is a concern for the safety of other residents. The DON stated the facility does not allow abuse in the facility. The DON stated there are concerns for failing to provide protection for other residents. The DON stated it can cause death if Resident 4 hit Resident 3 hard enough and Resident 3 fell and hit the head.
During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention and Prohibition Program, last revised on 1/2025, the P&P indicated the purpose is To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to . protect residents . in accordance with federal and state requirements. Each resident had the right to be free from . abuse The facility has zero-tolerance for abuse Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse The facility is committed to protecting residents from abuse by anyone, including but not limited to . other residents
During a review of the facility's P&P titled, Definitions: Operational Manual- Abuse & Neglect, last revised on 1/2025, the P&P indicated, 'Abuse' means the willful infliction of injury . with resulting physical harm, pain, or mental anguish Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, . physical abuse, and mental abuse 'Physical Abuse' means assault, battery, assault with . force likely to produce great bodily injury 'Verbal Abuse' means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents ., or within their hearing distance, regardless of their age, ability to comprehend, or disability.

Based on interview and record review, the facility failed to ensure one of three sampled residents, Resident 1, had the right to be treated with dignity and respect by Restorative Nurse Assistant 1 (RNA 1) who was heard by Visitor 1 (V 1) telling Resident 1, Do you want to end up in the grave like your wife? This deficient practice placed Resident 1 at risk of feeling sad, hopeless or humiliated.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/16/2023 with diagnoses including atrial fibrillation (an irregular, often rapid heart rate), chronic obstructive pulmonary disease (a group of lung disease that block airflow), and dementia (loss of memory).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment and care screening tool), dated 2/24/2025, the MDS indicated Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with activities of daily living (ADLs - routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves).
During a review of Resident 1's Psychologist's (person who specializes in the treatment of mental, emotional, and behavioral disorders) Progress Notes (detailed records of a resident's therapy sessions [structure meetings with a trained professional]), dated 4/7/2025, the Progress Notes indicated Resident 1 presented with anxious mood/affect (is characterized by feelings of apprehension, worry, and unease often involving restlessness, difficulty concentrating, and a sense of impending danger). The Progress Notes indicated the Psychologist assessed Resident 1's because of an allegation that a staff made insensitive comments to Resident 1. The Progress Notes indicated that during the session Resident 1 denied any knowledge of such an incident and did not appear to recall any related events. Affect (refers to the outward expression of an emotion, like a facial expression or tone of voice) was calm and mood (the underlying internal state or feeling that persists over time) appeared anxious with Resident 1 stating, Some days I'm good and other days I'm not. The Progress Notes indicated Resident 1 may benefit from psychotherapy (also known as talk therapy, is a form of treatment that involves a trained mental health professional working with an individual to improve their mental health and well-being) to decrease anxiety.
During an interview with the ADON on 4/9/2025 at 1 p.m., the ADON stated one day (did not remember the date) V 1, who was visiting another resident, reported to him (ADON) hearing RNA 1 telling Resident 1, Do you want to end up in the grave like your wife? V 1 told the ADON the incident happened a couple of months prior but did not provide a specific date and occurred while Resident 1 was sitting in front of the Physical Therapy (PT) room. The ADON stated V 1 did not report the incident right away due to fear of retaliation (an act of revenge). The ADON stated the facility terminated RNA 1's employment.
During an interview with Licensed Vocational Nurse (LVN) 1 on 4/9/2025 at 3:28 p.m., LVN 1 stated that it was on 4/3/2025 when V 1 reported to the ADON that he (V 1) heard RNA 1 telling Resident 1, Do you want to end up in the grave like your wife?
During a telephone interview with V 1 on 4/9/2025 at 3:47 p.m., V 1 stated he (V 1) heard RNA 1 telling Resident 1, Do you want to end up in the grave like your wife? V 1 stated he was visiting a different resident and did not know the specific date. V 1 stated that comment from RNA 1 to Resident 1 was very inappropriate.
During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised on 5/1/2023, the P&P indicated, To promote and protect the rights of all residents at the Facility. All residents have a right to a dignified existence
During a review of the facility's P&P titled, Resident Rights - Quality of Life, revised 5/1/2023, the P&P indicated, To ensure that all residents are treated with the level of dignity they are entitled to while residing at the facility. Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of eight sampled residents (Resident 1) when on 3/12/2025, at around 5:45 p.m. Resident 2 scratched Resident 1's right upper nose during a physical altercation (refers to a confrontation or fight involving physical contact or force) in the dining room.
This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a skin scratch with bleeding on Resident 1's right upper side of nose and complained of moderate pain (a level of discomfort that is significant but not severe) with a score of four out of 10 using the pain scale (a score from zero [0] to ten where ten is the worst possible pain) on her (Resident 1) right upper nose.
Based on the Reasonable Person Concept (what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer because of the noncompliance), due to Resident 1's impaired cognition (mental action or process of acquiring knowledge and understanding), an individual subjected to physical abuse may have physical pain, psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself).
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 2/10/2021 and readmitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (is a group of lung diseases characterized by long-term breathing difficulty and airflow obstruction), dementia (a broad term describing a decline in memory, thinking, and reasoning skills, impacting daily life, and often caused by damage to brain cells that affects their ability to communicate), and Alzheimer's disease (a type of dementia marked by a decline in mental abilities severe enough to interfere with daily activities).
During a review of Resident 1's Order Summary Report, dated 2/18/2025, the report indicated to give two tablets of acetaminophen (a medication used to relieve pain) 325 mg (milligram - a unit of measurement) by mouth every four hours as needed for mild pain or general discomfort.
During a review of Resident 1's History & Physical (H&P - refers to a comprehensive assessment of a resident's medical history and a physical examination, used to gather information for diagnosis and treatment planning), dated 2/20/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (a resident assessment tool), dated 2/25/2025, the MDS indicated Resident 1 had moderately impaired (generally signifies a level of impairment that is between mild and severe, indicating noticeable difficulties or limitations in a specific area, but not to the extent that it renders someone completely unable to function) cognitive skills (the mental processes and abilities that enable individuals to acquire, process, and apply knowledge, encompassing functions like memory, attention, language, and problem-solving) for daily decision making. The MDS indicated Resident 1 used a manual wheelchair (a chair on wheels designed for mobility, propelled by the user's hands or by someone else, without the use of a motor) while in the facility. The MDS indicated Resident 1 needs substantial/maximal assistance (helper does more than half the effort) during shower, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 was dependent (helper does all the effort) on toileting and needed partial/moderate assistance (helper does less than half the effort) during oral (mouth) hygiene and upper body dressing.
During a review of Resident 1's Progress Notes dated 3/12/2025, the Progress Notes indicated that on 3/12/2025, at around 5:45 p.m., in the facility's dining station, a loud altercation (a noisy argument or disagreement) and yelling was heard from two residents (Resident 1 and Resident 2). Resident 1 was noted with a skin scratch in her (Resident 1) right upper nose. The progress notes indicated Resident 1's pain level was assessed at four out of ten and pain medication (acetaminophen) was given as ordered.
During a review of Resident 1's Order Summary Report dated 3/12/2025, the report indicated to cleanse Resident 1's right side upper nose scratch with normal saline solution (salt water, used for cleaning wounds), pat dry, apply antibiotic (a medication used to treat bacterial infections) ointment, cover with dry dressing, and secure with tape twice a day for ten days.
During a review of Resident 1's Medication Administration Record (MAR- a report detailing the drugs administered to a resident by a healthcare professional), dated 3/12/2025, two tablets of acetaminophen was given by mouth.
During a review of Resident 1's care plan titled, Skin scratch: upper right side of nose, dated 3/12/2025, the care plan indicated interventions including to monitor Resident 1's affected area of the nose every shift for one month and to apply antibiotic ointment to the affected area of nose twice a day for two weeks as ordered.
During a review of Resident 1's care plan titled, Resident has been substantially (to a great or significant) involved in a peer-to-peer (resident to resident) altercation on 3/12/2025, dated 3/13/2025, the care plan indicated goals for Resident 1 not to experience a repeat of the altercation.
During a review of Resident 1 Interdisciplinary Care Conference Review (is a meeting where healthcare professionals from different disciplines gather to discuss a resident's care plan, share information, and coordinate interventions to improve resident outcomes), dated 3/13/2025, the Care Conference Review indicated Resident 1 was able to verbalize what happened during the incident (altercation with Resident 2). The care conference review indicated Resident 1 stated that while in the dining room the other resident (Resident 2), who was on a wheelchair, was hitting and bumping into her (Resident 1) wheelchair. The Care Conference Review indicated Resident 1 stated Resident 2 scratched her (Resident 1) face.
During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the resident on 3/21/2023 and readmitted on [DATE], with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a problem with the body's metabolism or chemical processes, leading to issues with thinking, memory, and potentially even consciousness), dementia, and Alzheimer's disease.
During a review of Resident 2's H&P, dated 2/26/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.
During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 2 was dependent during oral hygiene, toileting hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 2 needed maximal assistance during upper body dressing and moderate assistance during eating.
During a review of Resident 2's Interdisciplinary Care Conference Review, dated 3/13/2025, the Care Conference Review indicated that the facility staff (name not indicated) updated Family Member 1 about the incident (altercation) with Resident 2 and another resident (Resident 1) that was witnessed by two activity staff (this is wrong information as the incident was witnessed by Certified Nursing Assistants [CNA] 1 and 2 who were present in the dining room).
During an interview on 3/25/2025 at 3:04 p.m., with Resident 1 together with the Activity Director, in Resident 1's room, the Activity Director acted as the interpreter translating Resident 1's statements in a foreign language to English who stated that Resident 2's wheelchair kept hitting her (Resident 1) wheelchair so Resident 1 told Resident 2 to not bother her (Resident 1) or Resident 1 will hit Resident 2. Resident 1 stated Resident 2 hit her (Resident 1) in her (Resident 1) nose.
During an interview on 3/25/2025 at 3:43 p.m., with CNA 2 (CNA 1 was not available for interview), CNA 2 stated she (CNA 2) heard two residents (Resident 1 and Resident 2) yelling in the dining room and when she checked, she (CNA 2) witnessed Resident 2 scratched Resident 1's face and observed bleeding in Resident 1's right upper nose. CNA 2 stated Resident 2 had a strong grip in Resident 1 face because Resident 2 broke a nail from scratching Resident 1's face. CNA 2 stated the incident between Resident 1 and Resident 2 was considered a physical abuse because Resident 1 got a skin scratch with bleeding from Resident 2.
During an interview on 3/26/2025 at 12:31 p.m., with the Director of Nursing (DON), the DON stated that Resident 2 got a little agitated (angry) and scratched Resident 1's skin. The DON stated this incident was considered as a physical abuse.
During a review of the current facility-provided policy and procedure titled, Abuse Prevention and Prohibition Program, last reviewed date of 1/27/2025, the policy and procedure indicated, Each resident has the right to be free from . abuse The facility has zero-tolerance for abuse Staff must not permit anyone to engage in . physical abuse The facility is committed to protecting residents from abuse by anyone, including but not limited to . other residents

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for one of eight sampled residents (Resident 4) by failing to ensure Resident 4 had a care plan regarding Resident 4's bluish discoloration below the knee and foot on 3/22/2025.
This deficient practice had the potential to result in a delay in or lack of delivery of care and services to Resident 4.
Findings:
During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 2/18/2025 with diagnoses including encephalopathy (a general disturbance in brain function).
During a review of Resident 4's History & Physical (H&P), dated 3/14/2025, the H&P indicated that resident had dementia (a decline in mental abilities), dry eyes, and depression (a persistent state of sadness) as an active problem.
During a review of Resident 4's Minimum Data Set (a resident assessment tool), dated 2/26/2025, was dependent during eating, oral hygiene, toileting, shower, upper and lower body dressing, putting on/off footwear, and personal hygiene.
During a concurrent interview and record review on 3/26/2025 at 12:31 p.m., Resident 4's Care Plans were reviewed with the Director of Nursing (DON). The DON stated that Resident 4 has a new skin discoloration below the knee and foot on 3/22/2025. The DON checked the care plans for Resident 4's discoloration and found that none existed. The DON stated that a care plan is important because it provides recommendations and interventions for Resident 4's skin discoloration. The DON stated that if there is no care plan, staff might not be aware of the issue.
During a review of the facility policy and procedure titled, Care Planning, last reviewed date 1/27/2025, the policy and procedure indicated to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain accurate and complete medical records for four of eight sampled residents (Residents 1, 2, 3, and 8) by failing to ensure monitoring for the use of an anticoagulant (medication used to treat and prevent blood clot) was documented in Residents 1, 2, 3 and 8 ' s Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/2025.
This deficient practice had the potential to cause confusion in the residents' (Residents 1, 2, 3, and 8) care and medical records containing inaccurate documentation.
Findings:
a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 8/8/2018, with diagnoses that included congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), unspecified (unconfirmed) atrial fibrillation (an irregular and often very rapid heart rhythm) and unspecified Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities).
During a review of Resident 1 ' s History and Physical (H&P-medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/23/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 2/2/2025, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent to staff for all activities of daily living (ADL-eating, toileting, shower and personal hygiene).
During a review of Resident 1 ' s Physician Order, dated 4/7/2019, the Physician Order indicated an order for an anticoagulant medication, to monitor for discolored urine, . bruising (forms when blood pools under your skin), sudden change in mentation, shortness of breath, and nose bleeds every shift.
During a review of Resident 1 ' s Physician Order, dated 4/26/2024, the Physician order indicated Eliquis (anticoagulant medication used to treat and prevent blood clot) oral tablet, give 2.5 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) by mouth two times a day related to unspecified atrial fibrillation.
During a review of Resident 1 ' s Progress Notes, dated 3/6/2025, the Progress Notes indicated Certified Nursing Assistant 9 (CNA 9) observed linear (something that is straight) bluish discoloration on Resident 1 ' s left lower calf (posterior portion of the lower leg), on 3/6/2025 at 10 p.m. and CNA 9 reported to Licensed Vocational Nurse 6 (LVN 6).
During a review of Resident 1 ' s Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/2025, the MAR indicated no documented signs of bruising.
During a concurrent interview and record review on 3/17/2025, at 10:18 a.m., with LVN 2, Resident 1 ' s MAR dated 3/2025 was reviewed. The MAR indicated no documented bruising. LVN 2 stated Resident 1 ' s monitoring for use of anticoagulant should be documented in the MAR. LVN 2 stated the importance of documentation was to indicate Resident 1's status.
During an interview on 3/18/2025, at 3:19 p.m., with the LVN 6, LVN 6 stated CNA 9 notified him (LVN 6) of Resident 1 ' s left calf bruise on 3/6/2025, at 10 p.m. LVN 6 stated he (LVN 6) should have documented in the MAR when he (LVN 6) had observed the bruise.
b. During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 6/19/2017, with diagnoses that included atherosclerotic heart disease (a condition where plaque [a buildup of fat, cholesterol, and other substances] hardens and narrows the arteries), Alzheimer ' s Disease and paroxysmal (occurring in sudden, intense bursts or episodes) atrial fibrillation.
During a review of Resident 2 ' s H&P, dated 6/7/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 2 was dependent to staff for ADL- eating, toileting, dressing and personal hygiene.
During a review of Resident 2 ' s Physician Order, dated 2/25/2020, the Physician Order indicated an order for an anticoagulant medication, to monitor for discolored urine, . bruising, sudden change in mentation, shortness of breath, and nose bleeds every shift.
During a review of Resident 2 ' s Physician Order, dated 4/3/2024, the Physician Order indicated an order for Eliquis oral tablet 2.5 mg., give one tablet by mouth two times a day related to paroxysmal atrial fibrillation.
During a review of Resident 2 ' s Progress Notes, dated 3/9/2025, the Progress Notes indicated on 3/9/2025 at 1:50 p.m., CNA 12 noted discoloration to Resident 2 ' s left calf measured as 5 centimeter (cm-unit of measurement) long and 5.5 cm wide.
During a review of Resident 2 ' s MAR, dated 3/2025, the MAR indicated signs of bruising was documented as follows:
1. Day shift (7 a.m., to 3 p.m.) daily from 3/9/2025 to 3/17/2025.
2. Evening shift (3 p.m., to 11 p.m.) daily from 3/12/2025 to 3/16/2025.
3. Night shift (11 p.m., to 7 a.m.) daily only on 3/10/2024 and 3/11/2025.
During an interview on 3/18/2025, at 12:59 p.m., with LVN 5, LVN 5 stated CNA 12 notified her (LVN 5) that Resident 2 had discoloration on the left calf. LVN 5 stated she had initially documented no bruising in the MAR but after CNA 12 notified her (LVN 5) she (LVN 5) changed her documentation and documented Resident 2 had bruising.
During a concurrent interview and record review on 3/19/2025, at 8:46 a.m., with the Risk Manager (RM), Resident 2 ' s MAR dated 3/2025 was reviewed. The RM stated the documentation of the monitoring for the side effect (undesirable effect of a drug) of anticoagulant was not accurate. The RM stated the MAR indicated bruising was present in the day shift and would be gone on the evening and night and re-exist again in the day shift.
c. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 2/16/2023, with diagnoses that included atherosclerotic heart disease, paroxysmal atrial fibrillation and Alzheimer ' s disease.
During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 ' s cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 3 was dependent to staff for oral hygiene, toileting and personal hygiene.
During a review of Resident 3 ' s H&P, dated 2/22/2025, the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions.
During a review of Resident 3 ' s Physician Order, dated 2/16/2023, the Physician Order indicated an order for an anticoagulant medication, to monitor for discolored urine, . bruising, sudden change in mentation, shortness of breath, and nose bleeds every shift.
During a review of Resident 3 ' s Physician Order, dated 2/16/2023, the Physician Order indicated Aspirin (medication used to help prevent blood clot) 81 mg., give one tablet by mouth in the evening related to atherosclerotic heart disease.
During a review of Resident 3 ' s Progress Notes, dated 3/7/2025, the Progress Notes indicated on 3/7/2025 at 6:30 p.m., Resident 3 ' s right hand had bluish discoloration.
During a review of Resident 3 ' s Physician Order, dated 3/7/2025, timed at 6:50 p.m., the Physician Order indicated to hold (temporary stop) aspirin fort two days for bleeding risk.
During a review of Resident 3 ' s MAR, dated 3/2025, the MAR indicated no documented signs of bruising.
During an interview on 3/18/2025, at 3:30 p.m., with CNA 10, CNA 10 stated she (CNA 10) was taking Resident 3 ' s blood pressure when she (CNA 1) had noticed Resident 3 ' s right hand bruise.
During an interview on 3/18/2025, at 3:52 p.m., with LVN 7, LVN 7 stated CNA 10 notified her (LVN 7) of Resident 3 ' s right hand bruise. LVN 7 stated the physician was notified and ordered to stop aspirin for two days. LVN 7 stated Resident 3 reported that he (Resident 3) had hit his (Resident 3) ' s hand on a sharp corner of the table. LVN 7 stated she (LVN7) documented no bruising because she (LVN 7) assumed the bruise was a result of the impact and not from the aspirin. LVN 7 stated she (LVN 7) should have documented the bruising in Resident 3 ' s MAR. LVN 7 stated the importance of documentation was to document Resident 3 ' s change in condition and notify the physician.
d. During a review of Resident 8 ' s admission Record, the admission Record indicated the facility admitted Resident 8 on 2/26/2021, with diagnoses that included atherosclerotic heart disease, diabetes mellitus (DM- disorder characterized by difficulty in blood sugar control and poor wound healing) and long-term use of aspirin.
During a review of Resident 8 ' s MDS, dated [DATE], the MDS indicated Resident 8 ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 8 needed maximum assistance from staff for oral hygiene, showering and personal hygiene.
During a review of Resident 8 ' s H&P, dated 3/14/2025, the H&P indicated Resident 8 had fluctuating capacity to understand and make decisions.
During a review of Resident 8 ' s Physician Order, dated 2/26/2021, the Physician Order indicated an order for an anticoagulant medication, to monitor for discolored urine, . bruising, sudden change in mentation, shortness of breath, and nose bleeds every shift.
During a review of Resident 8 ' s Progress Notes, dated 3/9/2025, the Progress Notes indicated on 3/9/2025, at 3:35 p.m., CNA 13 observed Resident 8 ' s left hand dorsal (the back of your hand, the part opposite the palm) discoloration measured as 5 cm long and 5 cm wide. The Progress Notes indicated the physician was notified and ordered to hold the aspirin for four days.
During a review of Resident 8 ' s MAR, dated 3/2025, the MAR indicated no documented signs of bruising.
During a concurrent interview and record review on 3/19/2025, at 8:46 a.m., with the RM, Residents 1, 2, 3 and 8 ' s MARs were reviewed. The RM stated the side effects of anticoagulant medication were bleeding and bruising. The RM stated the nurses failed to document signs of bruising as part of anticoagulant monitoring for Residents 1, 2, 3, and 8. The RM stated Residents 1,2, 3, and 8 ' s MAR should match the nurses' Progress Notes. The RM stated the nurses should be consistent with their assessment and documentation. The RM stated the facility ' s policy was to document accurately. The RM stated the facility ' s policy on use of anticoagulant was to document any existing bruising.
During a concurrent interview and record review on 3/19/2025, at 9:51 a.m., with the Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled, Documentation-Nursing, dated 1/1/2016, and last reviewed on 1/27/2025, the P&P indicated, Nursing documentation will be concise, clear, pertinent and accurate. The DON stated the nurses failed to document accurately in MAR. The DON stated the importance of monitoring and documenting any side effects of anticoagulant was to determine how effective the anticoagulant and to document if it healed or got worst. The DON stated nurses should have documented signs of bruising, call the physician and stop the anticoagulant as per physician order.
During a review of facility ' s P&P titled, Anticoagulant Therapy, dated 6/13/2018, and last reviewed on 1/27/2025, the P&P indicated, The facility will monitor residents receiving anticoagulant therapy. Complete a head-to-toe assessment of the resident and document any preexisting bruising.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the physician's order and follow pain management policy for three of eight sampled residents (Residents 1, 2, and 5) by:
1. Failing to ensure Licensed Vocational Nurse 10 (LVN 10) document the time Tylenol (medication used to treat pain and fever) was given to Resident 1 on 3/9/2025.
2. Failing to ensure LVN 10 document Resident 1 ' s pain level before Tylenol administration on 3/9/2025.
3. Failing to ensure LVN 5 document pain level and reassess Residents 2 ' s pain level after Tylenol administration on 3/9/2025 at 9 a.m.
4. Failing to ensure physician's order for Norco (medication used to treat pain) was followed for Resident 5.
These deficient practices had the potential to negatively affect the residents' (Residents 1, 2, and 5) physical comfort and had the potential to not manage residents' pain.
Findings:
a. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 8/8/2018, with diagnoses that included chronic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities) and unspecified (unconfirmed) polyosteoarthritis (the medical term for having arthritis [a condition characterized by inflammation or swelling of one or more joints, leading to pain, stiffness, and reduced range of motion] that affects five or more joints at the same time).
During a review of Resident 1 ' s History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 4/23/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 2/2/2025, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent to staff for all activities of daily living (ADL - eating, toileting, shower, and personal hygiene).
During a review of Resident 1 ' s Physician Order, dated 8/8/2018, the Physician Order indicated Tylenol 325 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) oral tablet, give two tablets by mouth every four hours as needed for mild pain or generalized discomfort.
During a review of Resident 1 ' s Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/9/2025, the MAR indicated on 3/9/2025 LVN 10 administered Tylenol to Resident 1 with no documented time Tylenol was administered.
During a review of Resident 1 ' s Pain Management Flowsheet, dated 3/9/2025, the Pain Management Flowsheet indicated LVN 10 reassessed Resident 1 for pain on 3/9/2025 at 9 a.m.
During a concurrent interview and record review on 3/17/2025, at 10:18 a.m., with LVN 2, Resident 1 ' s MAR dated 3/9/2025 was reviewed. The MAR indicated no documented time Tylenol was given on 3/9/2025. LVN 2 stated there were no documented time Tylenol was administered to Resident 1 on 3/9/2025. LVN 2 stated nurses should documented the time Tylenol was given in Resident 1 ' s MAR. LVN 2 stated the importance of documenting time Tylenol was given was to know when to reassess pain again to know if pain medication was effective.
During an interview on 3/19/2025, at 8:46 a.m., with the Risk Manager (RM), the RM stated LVN 10 did not document time Tylenol was given to Resident 1 on 3/9/2025. The RM stated LVN 10 should document time medication was given to Resident 1. The RM stated the importance of documenting time pain medication was given was to know when to reassess pain level if medication was effective.
During an interview on 3/19/2025, at 9:51 a.m. with the Director of Nursing (DON), the DON stated the importance of documenting time pain medication was administered was to know when to reassess the Resident 1 ' s pain level if effective or not.
b. During a review of Resident 1 ' s Physician Order dated 8/8/2018, the Physician Order indicated Tylenol 325 mg oral tablet, give two tablets by mouth every four hours as needed for mild pain or generalized discomfort.
During a review of Resident 1 ' s MAR dated 3/9/2025, the MAR indicated on 3/9/2025 LVN 10 administered Tylenol to Resident 1 with no documented pain level.
During a concurrent interview and record review on 3/17/2025, at 10:18 a.m., with LVN 2, Resident 1 ' s MAR dated 3/9/2025 was reviewed. The MAR indicated no documented pain level before Tylenol was given to Resident 1 on 3/9/2025. LVN 2 stated nurses should documented resident ' s pain level before medication administration. LVN 2 stated Resident 1 ' s Tylenol, dated 3/9/2025, had no documented pain level. LVN 2 stated the importance of documenting pain level before medication administration was to know how severe residents pain was and to know what medication to give depending on the pain level as per physician order.
During an interview on 3/17/2025, at 10:46 a.m. with the RM, the RM stated nurses should document pain level to find out if medication was effective or not and to justify reason for medication administration.
During an interview on 3/19/2025, at 9:51 a.m. with the DON, the DON stated the importance of documenting pain level before medication administration was to know if the medication was effective or not for Resident 1 ' s pain.
c. During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 6/19/2017, with diagnoses that included atherosclerotic heart disease (a condition where plaque [a buildup of fat, cholesterol, and other substances] hardens and narrows the arteries), Alzheimer ' s Disease and paroxysmal (occurring in sudden, intense bursts or episodes) atrial fibrillation (a common type of irregular heart rhythm).
During a review of Resident 2 ' s H&P, dated 6/7/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.
During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 2 was dependent to staff for ADL- eating, toileting, dressing and personal hygiene.
During a review of Resident 2 ' s Physician Order, dated 6/19/2017, the Physician Order indicated Tylenol oral tablet 325 mg, give two tablets by mouth every four hours as needed for mild pain and general discomfort.
During a review of Resident 2 ' s MAR, dated 3/2025, the MAR indicated from 3/3/2025 to 3/17/2025, Tylenol was administered daily to Resident 2 with no documented pain level.
During a review of Resident 2 ' s Pain Management Flowsheet, dated 3/2025, the Pain Management Flowsheet indicated on 3/3/2025 to 3/5/2025 at 9 a.m., Tylenol was administered to Resident 2 for a pain level of three out of ten. The Pain Management Flowsheet indicated from 3/7/2025 to 3/17/2025 at 9 a.m., Tylenol was administered to Resident 2 for a pain level of three out of ten. The Pain Management Flowsheet indicated no Tylenol was given to Resident 2 on 3/6/2025.
During a concurrent interview and record review on 3/18/2025, at 12:59 a.m., with LVN 5, Resident 2 ' s MAR dated 3/2025 was reviewed. The MAR indicated Resident 2 was given Tylenol daily from 3/3/2025 to 3/17/2025. LVN 5 stated she (LVN 5) had administered Tylenol to Resident 2. LVN 5 stated she (LVN 5) administered Tylenol to Resident 2 on 3/6/2025 at 9 a.m. but forgot to document the pain level and forgot to reassess Resident 2 ' s pain level after Tylenol administration. LVN 5 stated she (LVN 5) should have documented pain level to show that Tylenol was the appropriate pain medication based on resident ' s pain level as per physician order. LVN 5 stated she should have reassessed Resident 2 ' s pain level at 10 a.m., to know if medication was effective.
During an interview on 3/19/2025 at 8:46 a.m., with the RM, RM stated LVN 5 should have documented Resident 2 ' s pain level before Tylenol administration and reassess Resident 2 ' s pain level after the Tylenol administration on 3/6/2025. The RM stated the importance of documenting pain level and pain reassessment was to find out if medication had taken effect. The RM stated the facility ' s policy was to reassess pain after pain medication administration.
During an interview on 3/19/2025 at 9:51 a.m. with the DON, the DON stated the importance of documenting pain level before pain medication administration was to know if the medication was effective or not for resident ' s pain. The DON stated nurses should reassess residents after medication administration. The DON stated the nurse failed to document pain level before medication administration and failed to reassess residents ' pain if medication given was effective. The DON stated the nurse should have assessed and documented the pain level in residents' MAR.
d. During a review of Resident 5 ' s admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE], with diagnoses that included unspecified heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's need}, Alzheimer ' s Disease and displaced intertrochanteric fracture of the right femur (a break in the thighbone).
During a review of Resident 5 ' s H&P, dated 2/11/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.
During a review of Resident 5 ' s MDS, dated [DATE], the MDS indicated Resident 5 ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 5 needed maximum assist from staff for oral hygiene, upper body dressing, and transfers.
During a review of Resident 5 ' s Physician Order dated 2/26/2025, the Physician Order indicated Norco 5-325 mg, give one tablet by mouth every eight hours for one month as needed for severe pain.
During a review of Resident 5 ' s MAR dated 3/2025, the MAR indicated from 3/1/2025 to 3/18/2025, Norco 5-325 mg was administered to Resident 5 with a pain level between five to six.
During a review of Resident 5 ' s Pain Management Flowsheet, dated 3/2025, the Pain Management Flowsheet indicated the following pain severity:
0-no pain
1-3 mild pain
4-6 moderate pain
7-8 severe pain
9-10 very severe pain.
During an interview on 3/18/2025, at 4 p.m., with LVN 8, LVN 8 stated severe pain is any pain level between five to ten and medicated with Norco if with a physician order. LVN 8 stated if resident had a pain level between three to four then she (LVN 8) will administer Tylenol.
During a concurrent interview and record review on 3/19/2025, at 8:46 a.m., with the RM, Resident 5 ' s MAR dated 3/2025 was reviewed. The MAR indicated Norco was administered to Resident 5 with pain level between five to six. The RM stated severe pain are pain level between seven to ten. The RM stated nurses should have given other pain medication except for as Norco is indicated for severe pain. The RM stated nurses should have called the physician and clarify the order for the pain range. The RM stated the facility failed to clarify the order and failed to follow the physician's order. The RM stated Resident 5 can be overmedicated (excessive use of medications).
During an interview on 3/19/2025, at 9:51 a.m. with the DON, the DON stated severe pain is pain level ranging from seven to eight. The DON stated the nurses failed to follow the physician order to give Norco for severe pain. The DON stated nurses should have called and clarify order with the physician. The DON stated medicating resident with strong pain medicine like Norco can slow the healing process, affect residents ' vital signs (measurements of your body's basic functions, like temperature, pulse, breathing, and blood pressure) and affect residents ' mood.
During a review of facility ' s policy and procedure (P&P) titled, Pain Management, dated 8/1/2024 and last reviewed on 1/27/2025, the P&P indicated, II. Pain Management
A. The Licensed Nurse will administer pain medication as ordered and document all medication administered on the Medication Administration Record (MAR).
B. Nurses will complete the Pain Flow Sheet for residents receiving PRN (as needed) pain to evaluate the effectiveness of the medication regimen.
C. The Licensed Nurse will assess the resident for pain and document results on the MAR each shift using the 1-10 pain scale.
D. If there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician for a review of medications.E. Nursing Staff will implement timely interventions to reduce the increase in severity of pain.
F. Nursing Staff will provide education to residents and families as to appropriate expectations for pain management.
G. The Nursing Staff will attempt to become familiar with cognitive, cultural, familial, or gender-specific influences on the resident ' s ability or willingness to verbalize pain.
H. The Facility may utilize the Pain Monitor Tool to audit and assess the success of the Pain Management Program.
I. The shift pain score will indicate the highest pain level that occurred on the shift.
III. DocumentationA. Pain Assessments will be maintained in the resident's medical record.
i. Document the explanation to the resident/responsible party of how the pc in scale works.
B. The Licensed Nurse will document resident's pain and response to interventions in the medical record on the weekly summary and as indicated on the progress notes.

Based on interview and record review, the facility failed to ensure the medical records of one of four sampled residents (Resident 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:
1. Ensure Licensed Nurses documented the specific and detailed descriptions of Resident 3's left hip discoloration in the resident's medical records.
2. Ensure Licensed Nurses documented the level of care provided to Resident 3 after the resident's change of condition (COC).
3. Ensure Licensed Nurses' signatures were indicated on Resident 3's Medication Administration Record (MAR).
These deficient practices resulted in inaccurate information on Resident 3's medical records and had the potential for delayed and inaccurate medical interventions.
Findings:
During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 2/24/2021 with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and age-related osteoporosis (a disease that causes bones to become weak and brittle, making them more likely to break) without current pathological fracture (a broken bone in an area weakened by another disease, not by an injury).
During a record review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 12/30/2024, the MDS indicated Resident 3's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired.
During a record review of Resident 3's Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 1/26/2025, the RN/LVN Progress Notes indicated that on 1/26/2025 at 2:17 a.m., Restorative Nursing Assistant (RNA) 1 assisted Resident 3 to the toilet. The RN/LVN Progress Notes indicated RNA 1 reported Resident 3's left hip discoloration. The description of Resident 3's left hip discoloration was not indicated on the RN/LVN Progress Notes.
During a record review of Resident 3's Care Plan on left hip and buttocks discoloration, initiated on 2/26/2025, the Care Plan indicated an intervention to monitor Resident 3 for discoloration of the left hip and buttocks area for signs and symptoms of infection for one month.
During a concurrent interview and record review on 3/11/2025 at 11 a.m. with LVN 1, Resident 3's MAR, dated 2/1/2025 to 2/28/2025, was reviewed. The MAR indicated Resident 3 was on a 30-day monitoring, started on 2/26/2025, for left hip and buttocks area discoloration. LVN 1 stated there were no licensed nurses' signatures on Resident 3's MAR that identified the licensed nurses' signed initials. LVN 1 stated the licensed nurses' initial on Resident 3's MAR indicated the left hip and buttocks discoloration was present. LVN 1 stated the licensed nurses should document the specific and detailed description of Resident 3's left hip and buttocks discoloration at the narrative section of the MAR. LVN 1 stated Resident 3's MAR, dated 3/1/2025 to 3/31/202, that indicated the 30-day monitoring of the resident's left hip and buttocks discoloration was not in the resident's chart.
During a concurrent interview and record review on 3/11/2025 at 11:45 a.m. with RN 1, Resident 3's RN/LVN Progress Notes, dated 1/26/2025, was reviewed. RN 1 stated Resident 3's RN/LVN Progress Notes did not indicate the description of Resident 3's left hip and buttocks discoloration. The RN/LVN Progress Notes indicated Resident 3's last documented assessment of the left hip and buttocks discoloration was on 2/27/2025, 11 p.m. to 7 a.m. shift. RN 1 stated incomplete documentation on Resident 3's medical records had the potential to result in incorrect diagnosis and treatment of the left hip and buttocks discoloration.
During a follow up interview on 3/11/2025 at 1:30 p.m. and concurrent record review of Resident 3's MAR, dated 3/1/2025 to 3/31/2025, reviewed with RN 1 and LVN 1, the MAR indicated Resident 3 was on a 30-day monitoring, started on 2/24/2025, for right index finger discoloration and redness. LVN 1 stated Resident 3's right index finger monitoring on the MAR had a handwritten addition of 30-day monitoring of the left hip and buttocks discoloration. RN 1 stated Resident 3's 30-day monitoring for the left hip and buttocks discoloration that started on 2/26/2025 should be separated from Resident 3's right index finger monitoring that started on 2/24/2025. RN 1 stated there was no documented description of Resident 3's left hip and buttocks discoloration on the narrative section of Resident 3's MAR.
During an interview on 3/11/2025 at 2:31 p.m. with the Director of Nursing (DON), the DON stated licensed nurses' initials were not verified with the licensed nurses' signatures on Resident 3's MAR. The DON stated licensed nurses combined Resident 3's right index finger monitoring and Resident 3's left hip and buttocks monitoring documentation on Resident 3's MAR. The DON stated the licensed nurses did not document the specific and detailed description of Resident 3's left hip and buttocks discoloration. The DON stated incomplete and inaccurate documentation had the potential for Resident 3's condition to worsen. The DON stated the facility failed to provide complete and accurate documentation and monitoring of Resident 3's condition.
During a record review of the facility's policy and procedure (PnP) titled, Completion and Correction, last reviewed on 1/27/2025, the PnP indicated the purpose to ensure that medical records were complete and accurate. The PnP indicated entries will be complete, legible, descriptive, and accurate. The PnP indicated documentation will reflect medically relevant information concerning the resident and will be documented in a professional manner.
During a record review of the facility's PnP titled, Nursing Documentation, last reviewed on 1/27/2025, the PnP indicated the purpose to provide documentation of resident status and care given by nursing staff. The PnP indicated nursing documentation will be concise, pertinent, and accurate. The PnP indicated alert charting was a documentation done to track a medical event for a period of 72 hours or longer. The PnP indicated event may include suspected or actual change in condition. The PnP indicated documentation describes the resident's condition and include what the professional staff see, hear, smell, feel, etc.
During a record review of the facility's PnP titled, Resident Assessment, last reviewed on 1/27/2025, the PnP indicated reassessment must be conducted whenever there is a significant change in the resident's physical, mental, or emotional condition. The PnP indicated all assessments and reassessments must be thoroughly documented in the resident's medical record. The PnP indicated the documentation should include the date of assessment, findings, change in condition, and updates to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain accurate and complete medical records for four of four sampled residents (Resident 1, 2, 3, and 4) by failing to ensure monitoring for use of anticoagulant (medication used to treat and prevent blood clot) was documented in Residents 1, 2, 3, and 4's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 2/2025.
These deficient practices had the potential to cause confusion in care and the medical records containing inaccurate documentation.
Findings:
a. During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/10/2021, with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (weakness on one side of the body) following a cerebral infarction (a blockage of blood flow to the brain), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a record review of Resident 1's History and Physical (H&P-medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/17/2024, the H&P indicated Resident 1 did not have capacity to understand and make decisions.
During a record review of Resident 1's Physician Order, dated 9/17/2024, the Physician Order indicated anticoagulant aspirin medication, to monitor for discolored urine, black tarry stool (blood in the stool), sudden severe headache, nausea (urge to vomit), vomiting, diarrhea, muscle joint pain, lethargy (state of tiredness, sleepiness, weariness, fatigue, sluggishness, or lack of energy), bruising (a discolored mark on your skin that forms when blood vessels under your skin break and leak), sudden changes in mental status, shortness of breath and nose bleeds every shift.
During a record review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 12/17/2024, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.
During a record review of Resident 1's Progress Notes, dated 2/9/2025, the Progress Notes indicated on 2/9/2025, at 5 p.m., Certified Nursing Assistant 1 (CNA 1) reported that Resident 1 had a left shin (the front of the leg below the knee) discoloration measuring five centimeter (cm- unit of measurement) long and 1.5 cm wide.
During an interview on 2/18/2025, at 10:38 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 2/9/2025 at 5 p.m., she (CNA 1) notices the skin discoloration on Resident 1's left shin while changing Resident 1's incontinent brief and she (CNA 1) reported immediately to Licensed Vocational Nurse 8 (LVN 8).
During a concurrent interview and record review on 2/18/2025, at 11:30 a.m., with LVN 2, Resident 1's MAR, dated 2/2025, was reviewed. The MAR indicated from 2/9/2025 to 2/18/2025, no documented bruising or signs of bleeding. LVN 2 stated today, 2/18/2025, Resident 1 still had the left shin discoloration. LVN 2 stated she (LVN 2) documented zero sign of bruising in the MAR because Resident 1 had discoloration and not bruising.
b. During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/14/2020, with diagnoses that included atherosclerotic heart disease (a buildup of plaque [fatty deposits] in the arteries that supply blood to the heart), diabetes, and Alzheimer's.
During a record review of Resident 2's Physician Order, dated 2/25/2020, the Physician Order indicated anticoagulant aspirin medication, to monitor for discolored urine, black tarry stool, sudden severe headache, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath and nose bleeds every shift.
During a record review of Resident 2's Care Plan on at risk for low platelet (small, colorless cell fragments in our blood that form clots and stop or prevent bleeding) level, dated 2/3/2021, the care plan indicated an intervention to assess resident and notify the physician for pale skin, bleeding of gums and nose, brushing, petechia (tiny spots of bleeding under the skin), hematuria (bloody urine).
During a record review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were moderately impaired.
During a record review of Resident 2's H&P, dated 2/14/2025, the H&P indicated Resident 2 did not have capacity to understand and make decisions.
During a record review of Resident 2's Progress Notes, dated 2/10/2025, the Progress Notes indicated at 7:15 p.m., CNA 2 reported that Resident 2 had a right upper inner arm bruise. The Progress Notes indicated the physician was notified and ordered to monitor.
During a concurrent interview and record review on 2/18/2025, at 11:08 a.m., with LVN 1, Resident 2's MAR, dated 2/2025, was reviewed. The MAR indicated from 2/10/2025 to 2/18/2025, there was no documented bruising or signs of bleeding. LVN 1 stated the morning of 2/11/2025, CNA 2 reported that Resident 2 had discoloration. LVN 1 stated she (LVN 1) went to Resident 2 and saw quarter size petechia to right upper inner arm. LVN 1 stated Resident 1 takes aspirin and was monitored for signs of bleeding. LVN 1 stated petechia is not a bruise. LVN 1 stated petechia is not a sign of bleeding and not a change of condition.
c. During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 10/16/2023, with diagnoses that included displaced intertrochanteric fracture of the left femur, atherosclerotic heart disease and Alzheimer's.
During a record review of Resident 3's Physician Order, dated 10/16/2023, the Physician Order indicated anticoagulant aspirin medication, to monitor for discolored urine, black tarry stool, sudden severe headache, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath and nose bleeds every shift.
During a record review of Resident 3's Care Plan on aspirin and clopidogrel therapy (medication used to prevent blood clot), dated 10/26/2023, the Care Plan indicated an intervention to observe and report to the physician signs of bleeding gums, bruises on arms and legs, petechia, nose bleeds, melena (blood in the stool).
During a record review of Resident 3's Care Plan on at risk for anemia, dated 4/16/2024, the Care Plan indicated an intervention to assess resident for pale skin, pale gums, bruising.
During a record review of Resident 3's H&P, dated 10/11/2024, the H&P indicated Resident 3 did not have capacity to understand and make decisions.
During a record review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decisions were moderately impaired.
During a record review of Resident 3's Progress Notes, dated 2/9/2025, the Progress Notes indicated on 2/9/2025 at 8:35 p.m., CNA 5 while providing evening care, reported to LVN 9 that Resident 3 had a bruise on his (Resident 3)'s right hip. The Progress Notes indicated LVN 9 measured the right hip bruise to three cm in diameter and Resident 3 also had skin discoloration to both arms.
During a concurrent interview and record review on 2/18/2025, at 11:36 a.m., with LVN 3, Resident 3's MAR, dated 2/2025, was reviewed. The MAR indicated from 2/9/2025 to 2/18/2025 there was no documented bruising or signs of bleeding. LVN 3 stated Resident 3 was monitored for signs of bleeding every shift because of the clopidogrel medication. LVN 3 stated Resident 3 still had the bruising on his (Resident 3)'s hip but lighter in color. LVN 3 stated she (LVN 3) should have documented in the MAR that bruising was still present. LVN 3 stated documentation should be accurate.
d. During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 7/4/2023, with diagnoses that included atherosclerotic heart disease, history of falling and Alzheimer's Disease.
During a record review of Resident 4's Physician Order, dated 3/4/2024, the Physician Order indicated anticoagulant aspirin medication, to monitor for discolored urine, black tarry stool, sudden severe headache, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath and nose bleeds every shift.
During a record review of Resident 4's H&P, dated 7/5/2024, the H&P indicated Resident 4 did not have capacity to understand and make decisions.
During a record review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decisions were moderately impaired.
During a record review of Resident 4's Progress Notes, dated 2/11/2025, the Progress Notes indicated on 2/11/2025 at 10:55 a.m., CNA 3 while providing morning care, noticed Resident 4 had a chin discoloration.
During an interview on 2/18/2025 at 10:54 a.m., with CNA 3, CNA 3 stated on 2/11/2025 at 9:30 a.m., she (CNA 3) noticed Resident 4's bruised chin and she (CNA 3) reported to LVN 6.
During a concurrent interview and record review on 2/19/2025 at 11:10 a.m., with LVN 5, Resident 4's MAR, dated 2/2025, was reviewed. The MAR indicated from 2/11/2025 to 2/18/2025, there was no documented bruising or signs of bleeding. LVN 5 stated Resident 4 still had the bruised chin. LVN 5 stated nurses should have documented in MAR that Resident 4 still had the bruises. LVN 5 stated the importance of accurate documentation was to record change in resident's condition.
During an observation on 2/19/2025 at 11:52 am., at Resident 4's bedside. Observed Resident 4 with bruised right chin.
During an interview on 2/19/2025 at 12:19 p.m., with Risk Management Nurse (RMN), the RMN stated resident on anticoagulant should be monitored for signs of bleeding as a side effect of anticoagulant. The RMN stated discoloration and bruise are both skin changes and should be documented in the anticoagulant monitoring in residents MAR.
During an interview on 2/19/2025 at 12:54 p.m., with the Director of Nursing (DON), the DON stated skin discoloration can be a bruise, petechia or any change in skin color. The DON nurses should document any signs of bleeding if residents were on anticoagulant.
During a concurrent interview and record review on 2/19/2025 at 1:14 p.m. with the DON, facility's policy and procedure (PnP) titled, Documentation-Nursing, dated 1/1/2016 and last reviewed on 1/27/2025, the PnP indicated, Nursing documentation will be concise, clear, pertinent, and accurate. Documentation will be completed by the end of the assigned shift. The DON stated nurses' documentation has to be concise and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan for two of four sampled residents (Resident 1 and Resident 2) by:
1. Failing to ensure a care plan was created when Resident 1 had a left shin (on the front of the lower leg, between the knee and ankle joints) discoloration (a change to the original color) on 2/9/2025.
2. Failing to ensure a care plan was created when Resident 2 had a right upper inner arm bruise (discoloration of the skin that occurs when the small blood vessels break and leak blood) on 2/10/2025.
These deficient practices had the potential for delayed provision of necessary care and services.
Findings:
a. During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/10/2021, with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (a blockage of blood flow to the brain), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).
During a record review of Resident 1's History and Physical (H&P-medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 9/17/2024, the H&P indicated Resident 1 did not have capacity to understand and make decisions.
During a record review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 12/17/2024, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.
During a record review of Resident 1's Progress Notes, dated 2/9/2025, the Progress Notes indicated at 5 p.m., Certified Nursing Assistant 1 (CNA 1) reported that Resident 1 had a left shin discoloration measuring 5 centimeter (cm- unit of measurement) in length and 1.5 cm in width.
During a concurrent interview and record review on 2/18/2025, at 9:58 a.m., with Care Planner 1 (CP 1), Resident 1's Care Plans and Physician's Order, dated 2/9/2025, were reviewed. CP 1 stated care plan was not created for Resident 1's left shin discoloration because there was no new order from the physician on 2/9/2025.
During a concurrent interview and record review on 2/18/2025, at 10:11 a.m., with CP 2, Resident 1 Care Plans and Interdisciplinary Team (IDT - a coordinated group of experts from several different fields who work together) Care Conference Review, dated 2/10/2025, was reviewed. CP 2 stated no care plan was created for Resident 1's left shin discoloration because there was no new physician order on 2/9/2025. CP 2 stated the facility have 10 days after the incident to create a care plan. CP 2 stated today is the 11th day after the left shin discoloration. CP 2 stated the facility also creates and updates the care plan same day an IDT meeting was done. CP 2 stated IDT for Resident 1 was done on 2/10/2025 and as of today 2/18/2025, care plan was still not created for Resident 1's left shin discoloration. CP 2 stated CPs should have created a care plan to address Resident 1's left shin discoloration.
During an interview on 2/18/2025, at 11:30 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated care plan should have been created for Resident 1's left shin discoloration. LVN 2 stated care plan helps her (LVN 2) understand what is going on with Resident 1 and guides her (LVN 2) on how to take care of Resident 1 as care plan contains intervention to address a specific problem.
b. During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/14/2020, with diagnoses that included atherosclerotic heart disease (a buildup of plaque [fatty deposits] in the arteries that supply blood to the heart), diabetes and Alzheimer's.
During a record review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were moderately impaired.
During a record review of Resident 2's H&P, dated 2/14/2025, the H&P indicated Resident 2 did not have capacity to understand and make decisions.
During a record review of Resident 2's Progress Notes, dated 2/10/2025, the Progress Notes indicated at 7:15 p.m., CNA 2 reported that Resident 2 had a right upper inner arm bruise. The Progress Notes indicated the physician was notified and the physician ordered to monitor Resident 2.
During a concurrent interview and record review on 2/18/2025, at 9:58 a.m., with CP 1, Resident 2's Care Plans were reviewed. CP 1 stated Resident 2 did not have any care plan for right upper arm discoloration or bruise. CP 1 stated care plan lists the interventions for treatment. CP 1 stated since there was no new order from the physician, care plan was not created. CP 1 stated the facility just started implementing approximately two weeks ago (2/4/2025) to create a care plan even without physician order. CP 1 stated Resident 2's right upper arm bruise was reported on 2/10/2025 and that was only eight days ago, and care plan should have been created for Resident 2.
During a concurrent interview and record review on 2/18/2025, at 10:11 a.m., with CP 2, CP 2 stated a care plan was not created or updated for Resident 2 because there was no new physician order. CP 2 stated care plan helps address a resident's problem and lists the interventions to help Resident 2's right upper arm discoloration. CP 2 stated it has been eight days since the discoloration started and if care plan is created today (2/18/2025) discoloration might be resolved already.
During an interview on 2/18/2025, at 11:08 a.m. with LVN1, LVN 1 stated a care plan should have been created for Resident 2's right upper arm discoloration. LVN 1 stated care plan gives LVN information on what to do to address the discoloration.
During an interview on 2/19/2025, at 12:08 p.m., with the Director of Staff Development (DSD), the DSD stated Resident 1's left shin discoloration and Resident 2's right upper inner arm discoloration were considered a change of condition. The DSD stated any change of condition should have a care plan created.
During an interview on 2/19/2025, at 12:19 p.m. with the Risk Management Nurse (RMN), the RMN stated example of skin change of condition includes any discoloration, bruising, new pressure ulcer (PU - a localized area of skin damage that develops when prolonged pressure is applied to the same spot on the body) or new order for skin care. The RMN stated the importance of care plan was for continuity of monitoring the changes and guides the nurses on what to do to address the change of condition. The RMN stated care plans should have been created for Resident 1 and Resident 2's changes in skin condition.
During an interview on 2/19/2025, at 12:54 p.m. with the Director of Nursing (DON), the DON stated the Care Planners were instructed to create or update a care plan for any skin changes whether it be a bruise or just discoloration. The DON stated the Care Planners before did not update residents' care plan if there were no new physician orders. The DON stated the facility changed that until two weeks ago since care planning is a nursing intervention and does not require a physician order. The DON stated creating and updating care plans is a standard of practice. The DON stated CPs were informed that if there were any change of condition like discoloration or bruising, monitoring should be started, and care plan should be updated or created. The DON stated care plan guides the nurses on what needs to be done for the resident.
During a concurrent interview and record review on 2/19/2024, at 1:14 p.m., with the DON, facility's policy and procedure (PnP) titled, Care Planning, dated 10/24/2022 and last reviewed on 1/27/2025, was reviewed. The PnP indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with Omnis Budget Reconciliation Act (OBRA- federal law enacted in 1987 that regulates the quality of care in nursing homes and other long-term care facilities) or MDS guidelines and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgement on an as needed bases. The DON stated care plans should have been created or updated for Resident 1 and Resident 2's skin changes.

Based on interview and record review, the facility failed to ensure three of six sample residents (Resident 1, Resident 2, and Resident 3) were identified on the facility ' s fall prevention program by failing to complete the Shift Report and the Resident Transfers Audit Tool as indicated on the facility ' s previous Plan Of Correction (POC).
This deficient practice had the potential to increase the residents ' (Residents 1, 2, and 3) risks for falls that can lead to injuries.
Findings:
During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 8/23/2021 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side (the side of the body that is not used as much or is not as much effective as the same side on the other side of the body), hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
During a review of Resident 1 ' s Fall Risk Assessment, dated 1/16/2025, the Fall Risk Assessment indicated the resident had a total score of 17. A total score of above 10 represented high risk for falls.
During a review of Resident 1 ' s Care Plan on the resident ' s functional abilities of everyday activities, dated 1/23/2025, the Care Plan indicated an intervention for Resident 1 to have two or more persons physical assist on bed mobility, transfers, and bathing or showering.
During a record review of the Shift report form, dated 3/17/2025, the Shift Report form indicated during the 7 a.m. to 3 p.m. shift (day shift) and 11 p.m. to 7 a.m. shift (night shift), Resident 1 was not identified as a resident that required two-person assistance.
During a record review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted the resident on 6/21/2022 with diagnoses including Parkinson ' s disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), and dementia.
During a review of Resident 2 ' s Care Plan on the resident ' s functional abilities of everyday activities, dated 5/10/2024, the Care Plan indicated an intervention for Resident 2 to have two or more persons physical assist on bed mobility, transfers, and bathing or showering.
During a review of Resident 2 ' s Fall Risk Assessment, dated 1/20/2025, the Fall Risk Assessment indicated the resident had a total score of 18. A total score of above 10 represented high risk for falls.
During a record review of the Shift report form, dated 3/17/2025, the Shift Report form indicated during the day shift and night shift, Resident 2 was not identified as a resident that required two-person assistance.
During a record review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 7/15/2021 with diagnoses including Alzheimer ' s disease, dementia, and age-related osteoporosis (occurs as bones naturally lose density and strength with age, making the bones more prone to fractures).
During a review of Resident 3 ' s Care Plan on the resident ' s functional abilities of everyday activities, dated 11/29/2023, the Care Plan indicated an intervention for Resident 3 to have two or more persons physical assist on bed mobility, transfers, and bathing or showering.
During a review of Resident 3 ' s Fall Risk Assessment, dated 1/20/2025, the Fall Risk Assessment indicated the resident had a total score of 14. A total score of above 10 represented high risk for falls.
During a record review of the Shift report form, dated 3/17/2025, the Shift Report form indicated Resident 3 was not identified as a resident that required two-person assistance.
During an interview on 3/18/2025 at 9:55 a.m. and concurrent record review of the undated facility-provided Resident Transfers Audit Tool, reviewed with the Director of Staff Development (DSD), the Resident Transfers Audit Tool indicated the DSD or Assistant DSD (ADSD) will conduct random transfers of ten residents requiring two-person assists daily for two weeks, weekly for one month, then monthly for three months or until 100 percent compliance was achieved. The DSD stated she was able to complete the Resident Transfers Audit for ten residents on 3/11/2025 and 3/18/2025. The DSD stated she (the DSD) and the ADSD got busy with other facility tasks and were not able to observe ten resident transfers on 3/10/2025 and 3/12/2025 to 3/17/2025.
During an interview on 3/18/2025 at 10:28 a.m. and concurrent record review of the Shift Report forms, dated 3/9/2025 to 3/17/2025, reviewed with Registered Nurse (RN) 1, the Shift Report forms indicated to list all residents that required two-person assist for transfers to validate rounding (a regular, structured visits to patients to assess their needs and well-being) hand off. The Shift Report form indicated there were no documented list of residents that required two-person assist on the following dates:
a. On 3/9/2025 at day shift at the southwest station and on all shifts at the southeast station.
b. On 3/10/2025 on all shifts at the west station, southeast middle station, and southeast station.
c. On 3/12/2025 on day shift at the southwest station and west 1 station, on day shift, 3 p.m. to 11 p.m. (evening shift) at the west 2 station, and on day shift and night shift at the west station,
d. On 3/13/2025 on night shift at the west 2 station and southeast middle station, evening and night shift at the west 1 station, and on all shifts at the southwest station.
e. On 3/14/2025 on all shifts at the west station, east station, and southeast station, on night shift at the west 2 station.
f. On 3/15/2025 on evening shift at the east station, on day shift and night shift at the west station, and all shifts at the southwest station and southeast station.
g. On 3/16/2025 on all shifts at the west station, east station, and southeast station.
h. On 3/17/2025 on day shift and night shift at the west 1 station and on all shifts at the west station, east station, south middle station, and southeast station.
RN 1 stated incomplete Shift Report forms had the potential for residents to not receive two-person assistance that may lead to an accident or fall. RN 1 stated the facility failed to ensure residents requiring 2-person assistance were identified and documented on the Shift Report form.
During an interview on 3/18/2025 at 12:50 p.m. and concurrent record review of the undated facility-provided Resident Transfers Audit Tool and Shift Report dated 3/9/2025 to 3/17/2025, reviewed with the Assistant Director of Nursing (ADON), the ADON stated the Resident Transfers Audit Tool was used to ensure two-person assist resident transfer was done safely. The ADON stated the Resident Transfers Audit Tool was initiated on 3/10/2025 and the facility should audit ten resident every day for two weeks then weekly for one month, and monthly for three months. The ADON stated the Resident Transfers Audit Tool was incomplete on the following dates:
a. On 3/10/2025, one of ten residents was audited.
b. On 3/12/2025, three of ten residents were audited.
c. On 3/13/2025, one of ten residents was audited.
d. On 3/14/2025, two of ten residents was audited.
e. On 3/15/2025 and 3/16/2025, no residents were audited.
f. On 3/17/2025, eight of ten residents were audited.
The Shift Report, dated 3/9/2025 to 3/17/2025, was reviewed with the ADON. The ADON stated the Shift report did not indicate the room numbers of the residents that required two-person assistance. The ADON stated the Shift Report documentation was inconsistent. The ADON stated incomplete shift report documentation and incomplete resident transfer audits had the potential for residents ' increased risk for falls and injuries during transfers. The ADON stated fall risk residents not identified in the shift report had the potential to not receive the required two-person assistance. The ADON stated the facility failed to complete the Shift Report form to ensure the residents requiring two-person assistance were identified. The ADON stated the facility failed to complete the Resident Transfer Audit Tool as indicated on the previous POC.
During a record review of the facility ' s policy and procedure (PnP) titled, Fall Management Program, last reviewed on 1/27/2025, the PnP indicated the purpose to prevent resident falls and minimize complications associated with falls through the development of a fall management program. The PnP indicated residents at increased risk of fall may be placed under more frequent monitoring and supervision of staff throughout the day. The PnP indicated the facility may utilize a fall monitor tool to audit and assess the success of the fall prevention program.

Based on interview and record review, the facility failed to ensure that the physician and family or resident representative were notified for one of four sampled residents (Resident 1) when Resident 1 had a change in condition.
This deficient practice had the potential for delayed medical interventions for Resident 1.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 5/6/2024 with diagnoses including atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and age-related osteoporosis (a disease that causes bones to become weak and brittle, making them more likely to break) without current pathological fracture (a broken bone in an area weakened by another disease, not by an injury).
During a record review of Resident 1's Fall Risk Assessment, dated 11/1/2024, the Fall Risk Assessment indicated the resident had a total score on 20. A total score of above ten represented high risk for falls.
During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/4/2024, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were moderately impaired.
During a record review of Resident 1's Interdisciplinary Team (IDT, a team of healthcare professionals from different professional disciplines who work together to address and manage the needs of the resident) Care Conference Review, dated 1/27/2025, the IDT Care Conference Review indicated Resident 1 had discoloration on the right hand. The IDT Care Conference Review did not indicate Resident 1's physician and family were notified.
During an interview on 2/6/2025 at 12:59 p.m. and concurrent record review of Resident 1's Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 1/27/2025, reviewed with RN 1, the RN/LVN Progress Notes indicated that on 1/24/2025 at 8:15 a.m., Resident 1 had discoloration of the right hand. RN 1 stated LVN 1 did not document that Resident 1's physician and family were notified of the resident's change of condition (COC). RN 1 stated Resident 1's physician and family should be notified about the resident's COC and documented in Resident 1's medical records. RN 1 stated if notification of the physician and family was not documented, it meant it was not done.
During an interview on 2/7/2025 at 12:25 p.m. with the Director of Nursing (DON), the DON stated the licensed nurses should have documented that Resident 1's physician and family were notified about the resident's discoloration on the right hand. The DON stated no documentation that Resident 1's physician and family were notified had the potential for delay in care for Resident 1. The DON stated the facility failed to ensure Resident 1' s physician and family were notified about the resident's COC in accordance with the policy on COC.
During a record review of the facility's policy and procedure (PnP) titled, Change of Condition Notification, last reviewed on 1/27/2025, the PnP indicated the attending physician will be notified timely with a resident's COC. The PnP indicated the licensed nurse will notify the resident, the resident's responsible party, or the family or surrogate decision makers of any changes in the resident's condition as soon as possible. The PnP indicated the licensed nurse will document the time the attending physician was contacted, the method by which he or she was contacted, the response time, and whether orders were received. The PnP indicated the licensed nurse will document the time the family or responsible person was contacted.

Based on interview and record review, the facility failed to ensure one of four sampled resident's (Resident 3) medical records were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Medication Administration Record (MAR)s were not signed later. On 2/6/2025, the facility provided Resident 3's MAR, dated 1/1/2025 to 1/31/2025, the MAR indicated Resident 3's Tylenol (a brand name for acetaminophen [medication used to relieve mild to moderate pain]) 325 milligrams (mg - unit of measurement) did not have a licensed nurse signature on 1/24/2025. On 2/7/2025, Resident 3's MAR without a licensed nurse signature had later been signed.
This deficient practice had the potential for inaccurate information on Resident 3's medical record and had the potential for inaccurate medical interventions for Resident 3.
Findings:
During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 2/9/2020 with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and age-related osteoporosis (a disease that causes bones to become weak and brittle, making them more likely to break) without current pathological fracture (a broken bone in an area weakened by another disease, not by an injury).
During a record review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 11/20/2024, the MDS indicated Resident 3's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were moderately impaired.
During a record review of Resident 3's Physician Order, dated 12/6/2024, the Physician Order indicated Tylenol 325mg two tablets every four hours as needed for mild pain or general discomfort.
During a record review of Resident 3's Physician Order, dated 12/6/2024, the Physician Order indicated Tylenol 325mg two tablets every four hours as needed for elevated temperature over than 100 degrees Fahrenheit (°F - unit of measurement).
During a record review of Resident 3's Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 1/24/2025, the RN/LVN Progress Notes indicated that on 1/24/2025 at 9:30 a.m., Certified Nursing Assistant 1 (CNA 1) was inside the shower room with Resident 3. Resident 3 became agitated and pushed CNA 1 during the transfer of Resident 3 from the wheelchair to the shower bench. The RN/LVN Progress Notes indicated Resident 3's knee (side not specified) hit the shower bench and swelling was noted. The RN/LVN Progress Notes indicated Resident 3 received Tylenol for facial grimacing (a distorted, pained facial expression). The RN/LVN Progress Notes indicated Resident 3 was monitored. On 1/24/2025 at 6:30 p.m., Resident 3 had skin discoloration, swelling, and a nine out of ten pain (a numeric scale used to describe the pain with zero as no pain and 10 as the worst pain) on the right lower leg. Resident 3's physician was notified and ordered to send Resident 3 to General Acute Care Hospital 1 (GACH) 1 for further evaluation and treatment.
During a record review of Resident 3's MAR, dated 1/1/2025 to 1/31/2025, the MAR indicated there were no signatures on Tylenol 325mg for elevated temperature and for Tylenol 325mg for mild pain or generalized discomfort. On 2/6/2025, the facility provided a copy of Resident 3's medical records.
During an interview on 2/7/2025 at 11:22 a.m. and concurrent record review of Resident 3's MAR, dated 1/1/2025 to 1/31/2025, reviewed with LVN 4, the MAR indicated a signature on 1/24/2025 for Tylenol 325mg for elevated temperature. This document was initially reviewed on 2/6/2025 with no signatures and when presented with the same document again on 2/7/2025, the document now had a signature. LVN 4 stated the MAR should be signed immediately after giving the resident's medication and document the medication given on the narrative section of the MAR. LVN 4 stated the narrative section of the MAR should indicate the date and time the medication was given, the name of the medication, and the indication of the medication. LVN 4 stated she could not remember when she signed Resident 3's MAR. LVN 4 later stated she signed Resident 3's MAR on 1/24/2025 around 11 a.m. Resident 3's MAR in the resident's medical record was reviewed with LVN 4 and indicated there were no narrative documentations on the Tylenol 325mg for elevated temperature given to Resident 3 on 1/24/2025 and on Tylenol 325mg for mild pain. LVN 4 stated the signature on Resident 3's Tylenol 325mg for elevated temperature was supposed to be on Resident 3's Tylenol 325mg for mild pain or general discomfort. LVN 4 stated that she signed Resident 3's Tylenol 325mg after the resident was transferred to GACH 1. LVN 4 was not able to provide an answer when the facility-provided copy of Resident 3's MAR, received on 2/6/2025, was compared to Resident 3's MAR received on 2/7/2025. LVN 4 stated medications that were documented incorrectly had the potential for Resident 3 to be given another dose of the medication.
During an interview on 2/7/2025 at 12:25 p.m. and a concurrent record review of Resident 3's MAR, reviewed with the Director of Nursing (DON), the DON stated the facility-provided copy of Resident 3's MAR, received on 2/6/2025, did not have a signature on the Tylenol 325mg and was later signed on 2/7/2025. The DON stated the facility staff falsified Resident 3's medical records.
During a record review of the facility's policy and procedure (PnP) titled, Completion and Correction, last reviewed on 1/27/2025, the PnP indicated the purpose to ensure that medical records were complete and accurate. The PnP indicated entries should be written in chronological sequence and when adding an entry at a later date, the entry was to be clearly identified as a late entry. The PnP indicated late entries should be documented as soon as possible.
During a record review of the facility's Employee Conduct and Work Rules, dated 2023, the Employee Conduct and Work Rules indicated the company expects all employees to observe professional behavior while at work. The Employee Conduct and Work Rules indicated conduct that should not take place in the work environment included falsifying or making material omissions in any employment or company documents or record and dishonesty of any kind, including asking another employee to lie, withholding the truth from management, or falsifying time sheets or any company documents or files.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 3), who was assessed as high risk for falls, had intermittent (not happening regularly or continuously) confusion, and required two-person staff assistance was free from falls and injury in accordance with Resident 3's care plan (a document that outlines the specific healthcare and support needs of a resident, along with strategies and interventions to address those needs), by failing to:
1. Provide Resident 3 with the required two-person staff assistance for the use of a mechanical lift (a device used to assist with transfers of residents who require support for mobility) when on 1/24/2025 at 9:30 a.m. Certified Nursing Assistant 1 (CNA 1) transferred Resident 3, by himself, from the wheelchair to the shower bench.
2. Ensure CNA 1 did not move Resident 3 after the witnessed fall, from the shower room floor to the wheelchair before a registered nurse (RN) had assessed Resident 3 for injuries.
As a result, on 1/24/2025 at 9:30 a.m., Resident 3 fell from the wheelchair and hit his (Resident 3) right knee on the shower bench. Resident 3 sustained a mild displaced avulsion fracture (a small piece of bone attached to a tendon [a strong, flexible cord of strong fibrous tissue attaching a muscle to the bone] or ligament [a band of tough tissue that connects two bones or holds together a joint] gets pulled away from the main part of the bone) that involved the tibial tuberosity (the top of the tibia [shinbone] where the patellar [kneecap] tendon connects). Resident 3 was given pain medication and was transferred to General Acute Care Hospital 1 (GACH 1) on 1/25/2025 for further evaluation and treatment.
Findings:
During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 2/9/2020 with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and age-related osteoporosis (a disease that causes bones to become weak and brittle, making them more likely to break) without current pathological fracture (a broken bone in an area weakened by another disease, not by an injury).
During a record review of Resident 3's Physician Order, dated 6/14/2024, the Physician Order indicated Resident 3 may use a mechanical device (mechanical lift) for transfers.
During a record review of Resident 3's Fall Risk Assessment, dated 11/19/2024, the Fall Risk Assessment indicated Resident 3 had a total score of 16. A total score of above ten represented high risk for falls.
During a record review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 11/20/2024, the MDS indicated Resident 3's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were moderately impaired. The MDS indicated Resident 3 had a functional limitation in range of motion (ROM - extent of movement of a joint) on both sides of the upper extremity (shoulder, elbow, wrist, and hand) and the lower extremity (hip, knee, ankle, and foot). The MDS indicated Resident 3 was dependent (resident does none of the effort to complete the activity or the assistance of two or more helpers [staff] were required for the resident to complete the activity) on facility staff with mobility (movement) such as sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or the side of the bed), chair or bed-to-chair transfer (the ability to transfer to and from bed or chair to a chair or wheelchair), toilet transfers, and shower transfers.
During a record review of Resident 3's Physician Order, dated 12/6/2024, the Physician Order indicated Tylenol (a brand name for acetaminophen [medication used to relieve mild to moderate pain]) 325 milligrams (mg - unit of measurement) two tablets every four hours as needed for mild pain or general discomfort.
During a record review of Resident 3's Activities of Daily Living (ADLs - refers to everyday tasks that individuals need to care for our bodies and maintain overall well-being) Hygiene Task section, dated 1/24/2025, the ADL Hygiene Task indicated Resident 3 was provided a shower on 1/24/2025.
During a record review of Resident 3's ADL Transfer Task section, dated 1/24/2025, the ADL Transfer Task indicated Resident 3 was dependent on facility staff with shower transfers. The ADL Transfer Task indicated there was no mechanical device used in Resident 3's transfers on 1/24/2025.
During a record review of Resident 3's Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 1/24/2025, the RN/LVN Progress Notes indicated that on 1/24/2025 at 9:30 a.m., CNA 1 was inside the shower room with Resident 3 when Resident 3 became agitated (unable to relax and be still) and pushed CNA 1 (with no assistance from any other facility staff) during the transfer of Resident 3 from the wheelchair to the shower bench. The RN/LVN Progress Notes further indicated Resident 3's knee (side not specified in the progress notes) hit the shower bench and swelling was observed. The RN/LVN Progress Notes indicated Resident 3 received Tylenol for facial grimacing (a distorted, pained facial expression). The RN/LVN Progress Notes indicated on 1/24/2025 at 6:30 p.m., Resident 3 had skin discoloration (a change in the skin's natural skin tone), swelling, and a nine out of ten pain (a numeric scale used to describe the pain with zero as no pain and 10 as the worst pain) on Resident 3's right lower leg. The RN/LVN Progress Notes indicated Resident 3's physician was notified and ordered for stat (immediately and without delay) X-ray (a medical imaging procedure that captures images of the structures inside the body).
During a record review of Resident 3's Physician Order, dated 1/24/2025, the Physician Order indicated stat X-ray of the right tibia and fibula (the two bones in the lower leg), two views due to right leg pain.
During a record review of Resident 3's X-ray results of the right tibia and fibula, dated 1/24/2025, the X-ray results indicated Resident 3 had acute (recent onset) oblique coronal fracture (an angled break in a bone that occurs on a plane that cuts across the bone like a slice) through the base of the tibial tuberosity with approximately 7.8 millimeter (mm - unit of measurement) diastases (an abnormal separation of parts normally joined together). The X-ray indicated Resident 3 had joint subluxation (a partial dislocation of a joint).
During a record review of Resident 3's X-ray results, dated 1/24/2025, the X-ray result indicated Resident 3 had acute to subacute (rather recent onset or rapid change) mild displaced avulsion fracture involving the tibial tuberosity.
During a record review of Resident 3's Physician Order, dated 1/24/2025, the Physician Order indicated to transfer Resident 3 to GACH 1 for further evaluation.
During a record review of Resident 3's Interdisciplinary Team (IDT, a team of healthcare professionals from different professional disciplines who work together to address and manage the needs of the resident) Care Conference Review, dated 1/24/2025, the IDT Care Conference Review indicated on 1/24/2025, during shower transfer, Resident 3 became agitated, pushed CNA 1, and her (Resident 3) right knee hit the shower bench that resulted to Resident 3's right knee swelling. The IDT Care Conference Review indicated an ice pack was placed on Resident 3's right knee for 15 minutes every six hours and Resident 3 was given Tylenol for facial grimacing. The IDT Care Conference Review indicated on 1/24/2025 at 6:30 p.m., Resident 3 had skin discoloration and swelling on the right lower leg. Resident 3 had an X-ray of the right tibia and fibula done. Resident 3 had nine out of ten on the pain scale when Resident 3's right leg was moved. Resident 3's physician was notified and ordered to send Resident 3 to GACH 1 for further evaluation and treatment.
During an interview on 2/7/2025 at 10:19 a.m., with CNA 1, CNA 1 stated on 1/24/2025 at around 9:30 a.m., Resident 3 had an aggressive behavior. CNA 1 stated Resident 3 required two-person staff assistance with transfers. CNA 1 stated on 1/24/2025 between 9 a.m. to 10 a.m., he (CNA 1) transferred Resident 3 from the resident's bed to the resident's wheelchair without the use of a mechanical device for transfers. CNA 1 stated he (CNA 1) brought Resident 3 to the shower room utilizing a wheelchair. CNA 1 stated he stood in front of Resident 3, locked the wheelchair wheels and placed his arms under Resident 3's arms to transfer Resident 3 from the wheelchair to the shower bench. CNA 1 stated Resident 3 became agitated and pushed CNA 1. CNA 1 stated he (CNA 1) lost grip on Resident 3. Resident 3's right knee hit the shower bench before Resident 3's right knee landed on the floor. CNA 1 stated he sat Resident 3 on the shower room floor. CNA 1 stated he assisted Resident 3 back to the wheelchair without the use of a mechanical device for transfer and before a licensed nurse had assessed Resident 3. CNA 1 stated he brought Resident 3 (resident was on a wheelchair) to the nurse station and informed Licensed Vocational Nurse 4 (LVN 4) and Registered Nurse 1 (RN 1) about Resident 3's fall inside the shower room. CNA 1 stated if there were two staff that assisted Resident 3 on transfers, the fall would have been prevented. CNA 1 stated Resident 3 had the potential for more injury because Resident 3 was moved before RN 1 assessed Resident 3.
During a concurrent interview and record review on 2/7/2025 at 11:22 a.m., with LVN 4, Resident 3's care plan on Functional Abilities of Everyday Activities dated 12/22/2023 was reviewed. The care plan on Functional Abilities of Everyday Activities dated 12/22/2023 indicated a goal for the resident to be transferred safely as evidenced by no fall through the target date of 3/4/2025. The care plan intervention indicated to transfer Resident 3 in and out of bed or wheelchair daily as needed using a mechanical lift and provide two-person physical assist. The care plan intervention indicated Resident 3 required two-person physical assist as needed when bathing or showering. LVN 4 stated Resident 3's care plan was not followed and resulted in Resident 3's fall with injury on 1/24/2025. LVN 4 stated on 1/24/2025, after the fall incident, Resident 3 was observed with facial grimace. LVN 4 stated she (LVN 4) gave Resident 3 Tylenol 325 mg two tablets for pain.
During a concurrent interview and record review on 2/7/2025 at 12:25 p.m., with the Director of Nursing (DON), Resident 3's care plan on Functional Abilities of Everyday Activities dated 12/22/2023 was reviewed. The DON stated Resident 3 had a fall on 1/24/2025 and sustained a right leg fracture (break or crack in the bone). The DON stated Resident 3 should have been assisted by two facility staff during transfers and mobility as indicated in Resident 3's care plan. The DON stated CNA 1 should have not moved Resident 3 before RN 1 and the Physical Therapist (a health professional trained to evaluate and treat residents who have conditions or injuries that limit their ability to move and do physical activities) assessed Resident 3 for injuries. The DON stated moving Resident 3 before RN 1's assessment had the potential to cause more injury. The DON stated Resident 3's care plan was not followed and resulted to Resident 3's fracture. The DON stated the facility failed to follow the fall prevention interventions, Resident 3's care plan interventions, and Resident 3's physician order dated 6/14/2024 to use a mechanical device (mechanical lift) for transfers.
During a concurrent interview and record review on 2/7/2025 at 1:56 p.m., with LVN 4, Resident 3's RN/LVN Progress Notes, IDT Care Conference Review, and care plans from 1/1/2025 to 1/23/2025 were reviewed. LVN 4 stated there were no documented evidence found regarding Resident 3's agitation (a condition in which a person is unable to relax and be still) and aggressive (actions or conduct that are intended to cause harm, intimidate others) behavior in Resident 3's RN/LVN Progress Notes, IDT Care Conference Review, and care plans.
During a follow up interview on 2/7/2025 at 2:19 p.m., with the DON, the DON stated Resident 3's agitated and aggressive behavior should be documented for every occurrence and a plan of care should have been created to address Resident 3's aggression and agitation. The DON stated Resident 3's behaviors that were not communicated to Resident 3's care givers had the potential to affect the care provided for Resident 3.
During a record review of the current facility-provided policy and procedure (PnP) titled, Fall Management Program, last reviewed on 1/27/2025, the PnP indicated the facility will provide the highest quality in the safest environment for the residents residing in the facility. The PnP indicated upon completion of the resident care assessment upon admission, quarterly, with significant change in condition, and as needed, MDS nurse will assess how many persons assist was needed for the resident. The PnP indicated based on the information gathered from the history and assessment of the resident, the nursing staff . will identify and implement interventions to reduce the risk of falls.
During a record review of the current facility-provided PnP titled, Care Planning, last reviewed on 1/27/2025, the PnP indicated the purpose to ensure a comprehensive person-centered care plan was developed for each resident based on their individual assessed needs. The PnP indicated each resident's comprehensive care plan will describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial (relating to the interrelation of social factors and individual thought and behavior) well-being.
During a record review of the current facility-provided PnP titled, Transfer of Residents, last reviewed on 1/27/2025, the PnP indicated the purpose to provide the form of transfer best suited to the resident's needs and to maintain resident safety during the procedure. The PnP indicated a licensed nurse, or the Director of Rehabilitation services assess and determine lifting and transfer requirements, and the procedure used for each resident. The procedure is recorded in the resident's care plan. The PnP indicated residents must be lifted or transferred according to the determined procedure.
During a record review of the current facility-provided PnP titled, Response to Falls, last reviewed on 1/27/2025, the PnP indicated upon witnessing a fall or finding a resident in a position indicating a fall, stay with the resident and send another staff member to notify a licensed nurse if the first responder was not a licensed personnel. The PnP indicated do not move the resident initially until after an assessment has been completed. The PnP indicated to call for assistance.

Based on interview and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 2) by failing to ensure Resident 2 was included in the line list report (a table that organizes information about people or cases of disease during an outbreak investigation) submitted to the Public Health Nurse (PHN) for possible exposure to scabies (a contagious skin condition caused by microscopic [so small as to visible only with microscope] mites [tiny bugs] burrowing [made a hole] into the skin.
This deficient practice resulted to incomplete line listing report submitted to the PHN and had the potential for spread of infection among residents and staff.
Findings:
During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/7/2021, with diagnoses that included atherosclerosis heart disease (a condition that occurs when the walls of the arteries that supply blood to the heart thicken and narrow), history of falling and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities).
During a review of Resident 2's History and Physical (H&P), dated 4/29/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.
During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 11/11/2024, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 2 was dependent on staff for toileting, dressing, and hygiene.
During a review of Resident 2's Physician Order, dated 10/14/2024, the Physician Order indicated an order for skin scraping (a procedure that involves scraping the skin to collect a sample for examination under a microscope) to rule out (eliminate) scabies and an order for spinosad (medication used to treat head lice and scabies infestations [the state of being invaded or overrun by pests or parasites]) 0.9 percent (% - by a specified amount in or for every hundred) topical suspension (are liquid preparations that contain solid particles dispersed in a liquid vehicle intended for application to the skin), apply to neck to toes, allow to absorb in the skin and wash off after eight hours for scabies prophylaxis (an attempt to prevent disease).
During a review of Resident 2's Laboratory Result, dated 10/15/2024, the Laboratory Result indicated no sarcoptes scabei (an itch mite is a parasitic mite found in all parts of the world that burrows into skin and causes scabies).
During a review of Resident 2's Physician Order, dated 10/29/2024, the Physician Order indicated Elimite (medication used to treat head lice and scabies) 5% cream, apply from neck to toes, wash off eight to 12 hours after and repeat dose in one week for scabies prophylaxis.
During a review of Resident 2's Physician Order, dated 11/28/2024, the Physician Order indicated Elimite 5% cream, apply from neck to toes tonight only (11/28/2024) and give a shower tomorrow morning (11/29/2024) for scabies prophylaxis.
During a review of Resident 2's Physician Order, dated 12/20/2024, the Physician Order indicated Elimite 5% cream, apply from neck to toes tonight only (12/20/2024), and give a shower tomorrow morning (12/21/2024) and repeat dose in one week (12/27/2024), for scabies prophylaxis.
During a review of facility's Scabies Outbreak Line lists, dated 10/15/2024 and 10/21/2024, were reviewed. The Line Lists indicated Resident 2 was not on the list on 10/2024 and 12/2024.
During a concurrent interview and record review on 12/24/2024, at 10:11 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 2's Physician Orders dated 10/14/2024 and 12/20/2024 were reviewed. Resident 2's Physician Order, dated 10/14/2024, indicated contact isolation precaution (a set of steps that healthcare staff and visitors take to prevent the spread of germs to others by isolating patients with infections that can be spread through direct or indirect contact) for possible scabies. Resident 2's Physician Order, dated 12/20/2024, indicated contact isolation precautions for seven days. LVN 1 stated Resident 2 was on contact isolation for possible scabies. LVN 1 stated recent contact isolation order was dated 12/20/2024.
During an interview on 12/24/2024, at 11:32 a.m., the Infection Preventionist (IP) stated latest line list report emailed to PHN was on 12/18/2024. The IP stated Resident 2 was not in the line list report on 12/2024.
During an interview on 12/24/2024, at 11:56 a.m., the IP stated Resident 2 should be in the line list report on 12/20/2024 when the Physician ordered the Elimite cream and contact isolation.
During an interview on 12/24/2024, at 1:18 p.m., the IP stated, she (IP) should have notified PHN that Resident 2 had an order for Elimite and contact isolation on 12/20/2024. The IP stated it is important to notify PHN on any new updated line list to control the spread of infection. The IP stated the outbreak from 10/3/2024 was still open. The IP admitted it was her (IP) error of not notifying the PHN of Resident 2.
During an interview on 12/24/2024, at 2:48 p.m., the Director of Nursing (DON) stated the IP should have checked the line list report. The DON stated their policy only indicated notifying the Public Health of positive cases of scabies.
During an interview on 12/24/2024, at 3:07 p.m., the IP stated on 12/20/2024, Resident 2 complained of itching and the Physician ordered contact isolation and apply Elimite cream. The IP stated there were a total of 44 symptomatic residents who had Elimite cream for scabies prophylaxis and two residents tested positive for scabies from 10/3/2024. The IP stated she should have double checked that line list report was send out to PHN. The IP stated Resident 2 was not on the line list on 10/2024 and 12/2024. The IP stated line listing should be complete and accurate.
During a concurrent interview and record review on 12/24/2024, at 3:13 p.m., with the IP, facility's Rash/Scabies Outbreak Notification letter (OB letter), dated 10/15/2024 was reviewed. The OB letter indicated, Each scabies outbreak is unique and requires an individualized approached. PHN 1 will be working with you (the facility) to develop a plan specifically for your facility. However, listed below are the number of actions you (the facility) can take immediately:
13. Provide a line listing of symptomatic (showing symptoms) patients and health care workers and a separate list of their contacts to your assigned PHN. Please include date of onset, type of treatment or prophylaxis provided and date of such treatment.
14. Report any new symptomatic patients to your assigned PHN and send weekly updates on the facility regardless of any new cases.
The IP stated she should have reported to PHN when Resident 2 had symptoms of scabies on 12/20/2024.
During a review of facility's policy and procedure (PP) titled, Scabies, dated 8/1/2014 and reviewed on 1/23/2023, the PP indicated, The Facility works to prevent the spread of scabies in the facility by strictly adhering to the standards set out by the Centers for Disease Control and Prevention and State of California Department of Public Health.
IV. The Infection Control Coordinator will follow the guidance provided in the following publications to prevent and minimize the outbreak of scabies:
A. IC (Infection Control) -16 -Form A-Increased Scabies Outbreaks in Healthcare Facilities
B. IC -16 -Form B -Prevention and Control of Scabies in California Long-Term Care Facilities
C. IC -16 -Form C -Management of Scabies Outbreaks in California Healthcare Facilities.
During a record review of facility's Infection Control (IC)-16-Form B- Prevention and Control of Scabies in California Long Term Care Facilities, dated 3/2008, the Prevention and Control of Scabies in California Long Term Care Facilities indicated, As soon as a possible case of scabies is identified, the infection control practitioner should develop a contact identification list. This list should identify every resident, health care worker, visitor and volunteer who may have had direct, physical contact with the case within the previous month. Initially, the contact identification list should be limited to the nursing unit where the suspect or confirmed case resides. This list should contain the following:
1. Include the nursing unit, room number, name, date of onset of symptoms, results of skin scrapings, date of initial treatment, date of follow-up treatment, results of treatments (example given condition resolved or not resolved) and the date and results of repeat skin scrapings, if performed.
2. Identify roommates of the case. Include roommates who have been discharged , moved to other nursing units or to another health care facility within the previous month.
During a record review of facility's IC-16 Form C -Management of Scabies Outbreaks in California Healthcare Facilities, dated 2008, was reviewed. The Management of Scabies Outbreaks in California Healthcare Facilities indicated, The following information should be collected on all patients who are diagnosed, clinically symptomatic or who may have been exposed to a scabies case:
o Patient's name.
o Room and bed number.
o Nursing unit or other service e.g., chronic dialysis.
o Date of admission.
o Nursing units transfers including emergency department:
o Date(s) of transfer between nursing units.
o Diagnostic and therapeutic services utilized (radiology, physical therapy,).
o Date of previous admission if within past 1-8 weeks.
o Symptoms (rash, pruritus).
o Classified as typical (common), atypical (uncommon), or crusted scabies.
o Date of onset of symptoms.
o Date of skin scrapings.
o Results of skin scrapings (positive, negative, or not done).
o Date of first treatment.
o Treatment (permethrin or ivermectin (medication used to treat scabies).
o Date of second treatment if recommended.
o Follow-up treatment and/or evaluation and dates.
o Family members or visitors contacted and offered prophylaxis.
During a record review of facility's PP titled, Infection Prevention and Control Program, dated 10/24/2022, the PP indicated Surveillance data are provided to the Infection Control Coordinator (ICC or IP) regularly. The ICC communicates surveillance data to the Attending Physicians, the Administrator (ADM), Director of Nursing Services, and the local and state health department as necessary.
During a record review of facility's PP titled, Communicable Disease Outbreak, dated 3/6/2023, the PP indicated Outbreaks of communicable diseases within the facility are promptly identified and appropriately treated and reported.
I. Contact tracing between the infected individuals and other residents and staff is initiated.
II. Symptomatic residents and employees are to be considered potentially infected and are assessed for appropriate actions.
III. The Administrator will be responsible for:
C. Submitting periodic progress reports to the health department, as requested. Calling emergency meetings of the Infection Control Committee.
F. Updating the Department of Public Health, as required.
V. The Infection Preventionist (IP) and Director of Nursing Services are responsible for:
A. Receiving surveillance information and tabulating data.
B. Maintaining a line listing of identified cases on the appropriate Line Listing Reports (IC - 09 - Forms A- E - Outbreak of Communicable Disease - Line Listing Report).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) comprehensive, person-centered care plan with measurable objectives and interventions were implemented addressing:
1. Resident 1's fall risk status not identified by Certified Nursing Assistant 1 (CNA 1), CNA 2, and Restorative Nursing Assistant 1 (RNA 1).
2. Resident 1's need for an assistive device (a tool or piece of equipment that helps a person with disability perform tasks and activities) during ambulation (the ability to walk or move around independently).
3. Resident 1's unspecified abnormalities on gait and mobility as identified by the physical therapist (PT).
As a result, on 10/29/2024 at 7:08 a.m., Resident 1 had a fall and sustained a left hip fracture. Resident 1 was admitted to General Acute Care Hospital 1 (GACH 1) and underwent a major surgical intervention.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/31/2023 with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), and generalized muscle weakness.
During a review of Resident 1's History and Physical, dated 2/24/2024, the History and Physical indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/2/2024, the MDS indicated Resident 1's cognitive (the ability of the brain to think and reason) skills for daily decision making was moderately impaired. The MDS indicated Resident 1 required a walker and wheelchair for mobility (the ability to move freely). The MDS indicated Resident 1 required moderate assistance with toileting and personal hygiene. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or steadying as resident completes activity) while walking at least 10 feet (ft. - unit of measure), while walking 50 ft. with two turns and when walking 150 ft.
During a review of Resident 1's Fall Risk Assessment, dated 10/2/2024, the Fall Risk Assessment indicated Resident 1 had a total score of 22 (a total score above 10 represents a high risk for falls). The Fall Risk Assessment indicated Resident 1 had intermittent confusion (a medical condition that involves a sudden or worsening change in mental state), balance problem while standing and while walking, decreased muscular coordination, unsteady gait (a manner of walking) when walking through the doorway, unstable when making turns and requires use of assistive device.
During a review of Resident 1's Weekly Summary, dated 10/11/2024, the Weekly Summary under the functional status section indicated the resident (Resident 1) required assistance when walking. The Weekly Summary under the Special Treatment/ Procedures/ Programs section indicated Resident 1 required contact guard assist (CGA - a light touch or contact is made to help steady the body and help with balance), use of a front wheel walker (a device designed for people who are unstable to walk, has two wheels in front of the walker) and use of a walking belt (a device used to help safely transfer a person from a bed to a wheelchair, and assist with walking, sitting and standing) when walking 175 ft. to 200 ft. daily. The Weekly Summary further indicated to monitor Resident 1's balance for steadiness (refers to stability and balance while walking) during transitions (change from one position, step or movement to another) and walking and to provide assistance to Resident 1.
During a review of Resident 1's Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) Progress Notes, dated 10/29/2024, timed at 7:40 a.m., the RN/LVN Progress Notes indicated on 10/29/2024 at 7:08 a.m., Restorative Nursing Assistant 1 (RNA 1) informed LVN 1 that Resident 1 was found on the floor, next to Resident 1's bed, inside the resident's room. LVN 1 documented she (LVN 1) observed Resident 1 lying supine (lying on the back with the face and body facing up) on the floor with a small amount (exact amount not specified) of blood at the back of Resident 1's head. The RN/LVN Progress Notes indicated LVN 1 applied pressure on the small laceration at the back of Resident 1's head. LVN 1 documented Resident 1 was not able to move the left lower extremity (hip, thigh, knee, leg, ankle, and foot) and complained of left hip pain. The RN/LVN Progress Notes indicated Resident 1 stated the fall happened while walking on the way to the bathroom. The RN/LVN Progress Notes indicated at 7:36 a.m. (on 10/29/2024), Resident 1 was transferred to GACH 1.
During a review of Resident 1's Physician Order Sheet, dated 10/29/2024, the Physician Order Sheet indicated Attending Physician 1 (MD 1) ordered to transfer Resident 1 to GACH 1 via 911 (a phone number to contact the emergency services) after a fall for further evaluation.
During a review of Resident 1's Post Fall Summary and Intervention form, dated 10/29/2024, the Post Fall Summary and Intervention form indicated Resident 1 had a fall on 10/29/2024 at 7:08 a.m. inside Resident 1's room. The Post Fall Summary form indicated the cause of Resident 1's fall were unsteady gait (when a person is having trouble with their balance of the way they walk), poor judgment, non-compliant (inability or unwillingness to follow a prescribed treatment plan), and dementia.
During a review of Resident 1's Paramedics' (trained personnel that provides emergency medical care to people who are injured or ill) Patient Care Report, dated 10/29/2024, the Patient Care Report indicated the paramedics, who were on scene (at the facility) at 7:26 a.m. (on 10/29/2024), found Resident 1 lying supine on the ground and complained of left hip pain. The Patient Care Report under the narrative section indicated Resident 1 had a small abrasion (scrape on the skin) on the top of the head and had a possible left leg shortening with outward rotation and tender (painful) to touch.
During an interview on 11/12/2024 at 10:40 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she (CNA 1) observed Resident 1 use a walker at times. CNA 1 stated Resident 1 was observed unstable when walking to the bathroom independently without a walker. CNA 1 stated residents that were identified as a high fall risk had their names on the residents' room doors highlighted (colored) in yellow. CNA 1 stated Resident 1 was not identified as a fall risk because the resident's name on the room door was not highlighted in yellow.
During an interview on 11/12/2024 at 10:52 a.m. with CNA 2, CNA 2 stated Resident 1 required assistance with walking to the bathroom and was unstable when walking without a walker. CNA 2 stated Resident 1 did not have a yellow highlighted name outside Resident 1's room. CNA 2 stated that on 10/29/2024 she (CNA 2) observed Resident 1 lying on the floor by the resident bed's foot part with the Resident 1's head towards the door and the towards the bathroom. CNA 2 stated Resident 1 wanted to go to the bathroom. CNA 2 stated Resident 1 did not have a walker in the room.
During an interview on 11/12/2024 at 1:44 p.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN 2) did not see an assistive device or walker inside Resident 1's room.
During a concurrent interview and record review on 11/12/2024 at 2:50 p.m., with the Director of Rehabilitation (DOR), Resident 1's Physical Therapy (PT) Discharge summary, dated [DATE] was reviewed. The PT Discharge summary dated [DATE] indicated Resident 1 had a treatment diagnosis of unspecified abnormalities of gait and mobility (a diagnosis used when a resident has abnormal gait or mobility that does not fit into other categories). The DOR stated Resident 1's treatment diagnosis indicated the resident's gait was compromised and warranted therapy at the time of Resident 1's evaluation.
During a concurrent interview and record review on 11/12/2024 at 2:56 p.m. with the Director of Nursing (DON), the DON stated Resident 1's balance was not stable and stated Resident 1 was a fall risk. The DON stated Resident 1's strength and mobility was declining, and the resident was not safe to ambulate (walk) without assistance. Resident 1's Care Plan on ambulation, initiated on 10/3/2024 was reviewed. The DON stated Resident 1 required CGA on ambulation due to unsteady gait and balance. The Care Plan Intervention indicated to assist Resident 1 to ambulate 175 ft. to 200 ft. daily with CGA and with the use of a front wheel walker.
During a review of Resident 1's Care Plan on falls, initiated on 2/13/2023, indicated the resident was at risk for falls. The Care Plan Intervention indicated to remind Resident 1 to follow fall precaution and to ambulate with walker and with staff assistance. The DON stated Resident 1's name should have been highlighted in yellow (by the door outside Resident 1's room) to indicate Resident 1 was a high fall risk. The DON stated that on 10/29/2024, Resident 1 sustained a laceration on the head and a left femur fracture from a fall. The DON stated the walker should have been available for Resident 1's use. The DON stated the facility failed to provide Resident 1 with a walker as indicated on Resident 1's fall care plan. The DON stated the facility failed to ensure Resident 1's name (by the door outside Resident 1's room) was in yellow identifying Resident 1 as a high risk for fall.
During a review of Resident 1's GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the pelvis (the bony structure between the lower stomach and upper thighs that connects the spine to the legs), dated 10/29/2024, the CT indicated Resident 1 had angulated (tilts at an angle) and impacted (the broken ends of the bone were jammed together by the force of the injury) intertrochanteric fracture of the proximal (closer to the center of the body or to the point of attachment to the body) left femur.
During a review of Resident 1's undated GACH 1 clinical record (provided by the facility), the clinical record indicated on 10/29/2024 Resident 1 was admitted to GACH 1 after a fall resulting to the resident's left hip pain. The clinical records indicated Resident 1 had a fall and sustained a closed displaced intertrochanteric fracture of the left femur and traumatic (a sudden and severe physical injury that requires immediate medical attention) left intertrochanteric fracture. The clinical records indicated Resident 1 underwent a left femur IM nailing.
During a review of the facility's policy and procedure (P&P) titled, Care Planning, last reviewed on 1/29/2024, the P&P indicated the purpose is to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The PnP indicated the care plan served as a course of action where the resident, resident's family and/or guardian or other legally authorized representative, resident's attending physician, and interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental, and psychosocial needs. The PnP indicated each resident's comprehensive care plan will describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent a fall and injury for one of three sampled residents (Resident 1), who was identified as a high fall risk, with unsteady standing and walking balance, with decreased muscular coordination requiring use of assistive device (a tool or piece of equipment that helps a person with disability perform tasks and activities such as a walker [a device that helps a person maintain balance and stability while walking]) and needed supervision to prevent falls and injuries. The facility failed to:
a. Provide an assistive device for safe ambulation (the ability to walk from one place to another safely or move around independently).
b. Implement the facility's policy and procedure (P&P) titled Falling Star Program by failing to ensure Resident 1's name was printed on a brightly colored paper (yellow) by the door outside of Resident 1's room to ensure that staff is aware Resident 1 is at high risk for falls.
As a result, on 10/29/2024 at 7:08 a.m., Resident 1 fell while walking towards the bathroom unassisted and without a walker. Resident 1 sustained a laceration (a deep cut or tear in the skin) at the back of the head and required transfer to General Acute Care Hospital 1 (GACH 1) on 10/29/2024 at 7:36 a.m. where Resident 1 was diagnosed with closed displaced intertrochanteric fracture of left femur (the upper part of the thigh bone was broken, and the broken pieces were not aligned, without any open wounds on the skin around the break). Resident 1 underwent left femur (thigh bone) intramedullary nailing (IM nailing - a surgical procedure that involves inserting a metal rod into the center of a broken bone to stabilize and aid in healing) at GACH 1.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 1/31/2023 with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), and generalized muscle weakness.
During a review of Resident 1's History and Physical, dated 2/24/2024, the History and Physical indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/2/2024, the MDS indicated Resident 1's cognitive (the ability of the brain to think and reason) skills for daily decision making was moderately impaired. The MDS indicated Resident 1 required a walker and wheelchair for mobility (the ability to move freely). The MDS indicated Resident 1 required moderate assistance with toileting and personal hygiene. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or steadying as resident completes activity) while walking at least 10 feet (ft. - unit of measure), while walking 50 ft. with two turns and when walking 150 ft.
During a review of Resident 1's Fall Risk Assessment, dated 10/2/2024, the Fall Risk Assessment indicated Resident 1 had a total score of 22 (a total score above 10 represents a high risk for falls). The Fall Risk Assessment indicated Resident 1 had intermittent confusion (a medical condition that involves a sudden or worsening change in mental state), balance problem while standing and while walking, decreased muscular coordination, unsteady gait (a manner of walking) when walking through the doorway, unstable when making turns and requires use of assistive device.
During a review of Resident 1's Weekly Summary, dated 10/11/2024, the Weekly Summary under the functional status section indicated the resident (Resident 1) required assistance when walking. The Weekly Summary under the Special Treatment/ Procedures/ Programs section indicated Resident 1 required contact guard assist (CGA - a light touch or contact is made to help steady the body and help with balance), use of a front wheel walker (a device designed for people who are unstable to walk, has two wheels in front of the walker) and use of a walking belt (a device used to help safely transfer a person from a bed to a wheelchair, and assist with walking, sitting and standing) when walking 175 ft. to 200 ft. daily. The Weekly Summary further indicated to monitor Resident 1's balance for steadiness (refers to stability and balance while walking) during transitions (change from one position, step or movement to another) and walking and to provide assistance to Resident 1.
During a review of Resident 1's Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) Progress Notes, dated 10/29/2024, timed at 7:40 a.m., the RN/LVN Progress Notes indicated on 10/29/2024 at 7:08 a.m., Restorative Nursing Assistant 1 (RNA 1) informed LVN 1 that Resident 1 was found on the floor, next to Resident 1's bed, inside the resident's room. LVN 1 documented she (LVN 1) observed Resident 1 lying supine (lying on the back with the face and body facing up) on the floor with a small amount (exact amount not specified) of blood at the back of Resident 1's head. The RN/LVN Progress Notes indicated LVN 1 applied pressure on the small laceration at the back of Resident 1's head. LVN 1 documented Resident 1 was not able to move the left lower extremity (hip, thigh, knee, leg, ankle, and foot) and complained of left hip pain. The RN/LVN Progress Notes indicated Resident 1 stated the fall happened while walking on the way to the bathroom. The RN/LVN Progress Notes indicated at 7:36 a.m. (on 10/29/2024), Resident 1 was transferred to GACH 1.
During a review of Resident 1's Physician Order Sheet, dated 10/29/2024, the Physician Order Sheet indicated Attending Physician 1 (MD 1) ordered to transfer Resident 1 to GACH 1 via 911 (a phone number to contact the emergency services) after a fall for further evaluation.
During a review of Resident 1's Post Fall Summary and Intervention form, dated 10/29/2024, the Post Fall Summary and Intervention form indicated Resident 1 had a fall on 10/29/2024 at 7:08 a.m. inside Resident 1's room. The Post Fall Summary form indicated the cause of Resident 1's fall were unsteady gait (when a person is having trouble with their balance of the way they walk), poor judgment, non-compliant (inability or unwillingness to follow a prescribed treatment plan), and dementia.
During a review of Resident 1's Paramedics' (trained personnel that provides emergency medical care to people who are injured or ill) Patient Care Report, dated 10/29/2024, the Patient Care Report indicated the paramedics, who were on scene (at the facility) at 7:26 a.m. (on 10/29/2024), found Resident 1 lying supine on the ground and complained of left hip pain. The Patient Care Report under the narrative section indicated Resident 1 had a small abrasion (scrape on the skin) on the top of the head and had a possible left leg shortening with outward rotation and tender (painful) to touch.
During an interview on 11/12/2024 at 10:40 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she (CNA 1) observed Resident 1 use a walker at times. CNA 1 stated Resident 1 was observed unstable when walking to the bathroom independently without a walker. CNA 1 stated residents that were identified as a high fall risk had their names on the residents' room doors highlighted (colored) in yellow. CNA 1 stated Resident 1 was not identified as a fall risk because the resident's name on the room door was not highlighted in yellow.
During an interview on 11/12/2024 at 10:52 a.m. with CNA 2, CNA 2 stated Resident 1 required assistance with walking to the bathroom and was unstable when walking without a walker. CNA 2 stated Resident 1 did not have a yellow highlighted name outside Resident 1's room. CNA 2 stated that on 10/29/2024 she (CNA 2) observed Resident 1 lying on the floor by the resident bed's foot part with the Resident 1's head towards the door and the towards the bathroom. CNA 2 stated Resident 1 wanted to go to the bathroom. CNA 2 stated Resident 1 did not have a walker in the room.
During an interview on 11/12/2024 at 1:44 p.m. with Registered Nurse 2 (RN 2), RN 2 stated she (RN 2) did not see an assistive device or walker inside Resident 1's room.
During a concurrent interview and record review on 11/12/2024 at 2:50 p.m., with the Director of Rehabilitation (DOR), Resident 1's Physical Therapy (PT) Discharge summary, dated [DATE] was reviewed. The PT Discharge summary dated [DATE] indicated Resident 1 had a treatment diagnosis of unspecified abnormalities of gait and mobility (a diagnosis used when a resident has abnormal gait or mobility that does not fit into other categories). The DOR stated Resident 1's treatment diagnosis indicated the resident's gait was compromised and warranted therapy at the time of Resident 1's evaluation.
During a concurrent interview and record review on 11/12/2024 at 2:56 p.m. with the Director of Nursing (DON), the DON stated Resident 1's balance was not stable and stated Resident 1 was a fall risk. The DON stated Resident 1's strength and mobility was declining, and the resident was not safe to ambulate (walk) without assistance. Resident 1's Care Plan on ambulation, initiated on 10/3/2024 was reviewed. The DON stated Resident 1 required CGA on ambulation due to unsteady gait and balance. The Care Plan Intervention indicated to assist Resident 1 to ambulate 175 ft. to 200 ft. daily with CGA and with the use of a front wheel walker.
During a review of Resident 1's Care Plan on falls, initiated on 2/13/2023, indicated the resident was at risk for falls. The Care Plan Intervention indicated to remind Resident 1 to follow fall precaution and to ambulate with walker and with staff assistance. The DON stated Resident 1's name should have been highlighted in yellow (by the door outside Resident 1's room) to indicate Resident 1 was a high fall risk. The DON stated that on 10/29/2024, Resident 1 sustained a laceration on the head and a left femur fracture from a fall. The DON stated the walker should have been available for Resident 1's use. The DON stated the facility failed to provide Resident 1 with a walker as indicated on Resident 1's fall care plan. The DON stated the facility failed to ensure Resident 1's name (by the door outside Resident 1's room) was in yellow identifying Resident 1 as a high risk for fall.
During a review of Resident 1's GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the pelvis (the bony structure between the lower stomach and upper thighs that connects the spine to the legs), dated 10/29/2024, the CT indicated Resident 1 had angulated (tilts at an angle) and impacted (the broken ends of the bone were jammed together by the force of the injury) intertrochanteric fracture of the proximal (closer to the center of the body or to the point of attachment to the body) left femur.
During a review of Resident 1's undated GACH 1 clinical record (provided by the facility), the clinical record indicated on 10/29/2024 Resident 1 was admitted to GACH 1 after a fall resulting to the resident's left hip pain. The clinical records indicated Resident 1 had a fall and sustained a closed displaced intertrochanteric fracture of the left femur and traumatic (a sudden and severe physical injury that requires immediate medical attention) left intertrochanteric fracture. The clinical records indicated Resident 1 underwent a left femur IM nailing.
During a review of the current facility-provided P&P titled, Fall Management Program, last reviewed in 1/29/2024, indicated the facility to provide the highest quality care in the safest environment for the residents in the facility. The P&P indicated the facility strived to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. The Universal Fall Prevention Measures for all Residents section indicated to reassess resident's mobility status daily and encourage use of assistive devices such as walker or wheeled walker, as appropriate.
During a review of the current facility-provided P&P titled, Falling Star Program, last reviewed in 1/29/2024, indicated the facility will ensure that staff was aware of residents who were at high risk for falls. The P&P indicated the resident's name will be printed on brightly colored paper by the door outside of resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was free from physical restraint when he was placed on a wheelchair against the wall and placing a bed horizontally across in front of him. Resident 1 was noted with a white bed sheet across his stomach area and tied to the back of the wheelchair.
This deficient practice had the potential to inhibit Resident 1's freedom of movement or activity.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a brain disorder caused by a chemical imbalance in the blood that affects the brain), pneumonia (infection in the lungs), urinary tract infection (bladder infection), Alzheimer ' s disease (a progressive disease that destroys memory), dementia (memory loss), unspecified psychosis (a mental disorder characterized by a disconnection from reality), depression (a mood disorder that causes feelings of sadness), and history of falling.
During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/14/2024, indicated Resident 1 was unable to complete the interview. Resident 1 ' s behavior indicated potential indicators of psychosis (a mental disorder characterized by a disconnection from reality) including hallucinations (false perceptions), and delusions (a false belief). Resident 1 required supervision with eating, and required maximal assistance with oral hygiene, toileting, shower, and dressing.
During a review of Resident 1 ' s History and Physical, dated 4/11/20224, the History and Physical indicated the resident did not have capacity to understand and make decisions.
During a review of Resident 1 ' s Plan of Care, dated 10/11/2024, indicated resident had psychosocial (relating to the interrelation of social factors and individual thought and behavior) episodes of constant calling out for no apparent reason. The goal was to have less episodes of constant calling out for no reason per week with date initiation of 10/11/2024 and with target date of 1/202/2025. Intervention included to always approach the resident calmly and unhurriedly, attempt to refocus behavior to something positive when resident is exhibiting behavior of constant calling out for no apparent reason, be consistent, gently and firm when setting limits. Wear a smile and speak in a calm voice.
During a review of Resident 1's care plan, dated 4/16/2024, the care plan indicated resident had psychosocial episodes of hallucinations manifested by seeing talking to people or things that do not exist. Interventions included to assist Resident 1 in determining what is real and attempt to refocus behavior to something positive when the resident is delusional.
During a concurrent interview with Registered Nurse 2 (RN 2) and review of Resident 1 ' s Incident/ Accident Report dated 10/29/2024, indicated on 10/29/2024 at 5:10 p.m., Licensed Vocational Nurse 1 (LVN 1) reported to the Facility Manager that Resident 1 was restrained behind a bed in a different room. Resident 1 ' s restraint was immediately removed. Resident 1 was taken to his assigned room. Registered Nurse 1 (RN 1) was notified. RN 2 stated she conducted a skin assessment and head to toe assessment with no abnormal findings. RN 2 stated the Medical Doctor and family were notified. RN 2 stated Resident 1 did not complain of any pain or discomfort.
During an interview with the Facility Manager (FM) on 10/31/2024 at 1 p.m., the FM stated on 10/29/2024 at around 5 p.m. he was in his office when the LVN 1 asked him to come to the room where Resident 1 was located.The FM stated Resident 1 was placed into a different room, not his assigned room. The FM stated that when he went into the room, he noted Resident 1 sitting in a wheelchair against the wall with a bed placed horizontally in front of Resident 1. The FM stated the bed was positioned in a way that Resident 1 could not get out of his wheelchair. The FM stated he removed the bed away from Resident 1. The FM stated he noted Resident 1 grabbing his shirt, and noted the Resident had a bed sheet around his waist tied to the back of the wheelchair. The FM stated the bed sheet was removed from Resident 1. The FM stated he called RN 2 and a body assessment was done. The FM stated there were no visible injuries noted. The FM stated Resident 1 was very confused, disoriented, and was a fall risk. The FM stated the bedsheet that was used was taken to the laundry room. The FM stated he interviewed Certified Nursing Assistant 1 (CNA 1) and she told him that she was fearful for Resident 1 because he was being disruptive to other residents, and that was why CNA1 placed him in there. The FM stated CNA 1 thought this intervention was acceptable, but FM stated this is a form of neglect and abuse, and the facility is a restraint-free facility. The FM stated CNA 1 was immediately suspended.
During an interview with CNA 1 on 10/31/2024 at 1:30 p.m., CNA 1 stated Resident 1 was not assigned to her on 10/29/2024 during her 3 p.m. to 11 p.m. shift, but she was helping Resident 1 because he (Resident 1) was very agitated and screaming. CNA 1 stated Resident 1 was by the CNA ' s station around 4 p.m. CNA 1 stated LVN 1 and an Activities Assistant were trying to calm him (Resident 1) down. CNA 1 stated Resident 1 was uncontrollable so she went to notify the RN supervisor to see if she can put Resident 1 in an empty room because Resident 1 was being disruptive to other Residents. CNA 1 stated the RN Supervisor agreed to put Resident 1 in a different room. CNA 1 stated she put Resident 1 against the wall and moved the bed horizontally in front of him. CNA 1 stated, she placed the bed in front of him to prevent him from falling.
During an interview with the Director of Nurse (DON) on 10/31/204 at 2 p.m, the DON stated that around 5 p.m., the facility manager went to check on Resident 1, and he found the resident in a room restrained with bed sheet around his waist tied to the back of the wheelchair. The DON stated this is considered abuse, and she got the name of CNA 1. The DON stated the need to report immediately to the abuse coordinator. The DON stated the facility is a restraint-free facility, and the potential outcome could have been injury, such as skin breakdown and circulation issues. The DON stated CNA 1 should have called the charge nurse and RN supervisor to let them know that Resident 1 was uncontrollable, and they should have called the Medical Doctor and obtain and order for a medication intervention or send him out to the hospital. The DON stated CNA 1 was suspended pending investigation.
During an interview with LVN 1 on 10/31/2024 at 3 p.m., LVN 1 stated that on 10/29/2024 at around 4 p.m. she noticed Resident 1 was sitting at the CNA ' s station and extremely agitated, restless, and yelling, trying to get out of the wheelchair. The Activity personnel offered the resident juice/snacks, but it was not effective. LVN 1 stated she decided to medicate Resident 1 with his scheduled medications. At around 5 p.m. while passing medications she noticed Resident 1 was not in the station and started looking for him by following his voice and she found him in a room. LVN 1 stated the door closed. LVN 1 stated when she opened the door and saw Resident 1 in the room. LVN 1 stated she immediately notified the FM. LVN 1 stated the FM and herself walked towards Resident 1 ' s room. LVN 1 stated the FM walked into the room, he moved the bed away from the resident and untied him from the bed sheet around his (Resident 1) waist.
A review of the facility ' s Policy and Procedure titled, Restraints, dated 2/28/2019, indicated residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used. The facility honors the resident ' s right to be free from any restraints that are imposed for reasons other than that of treatment of the resident ' s medical symptoms. The facility will ensure that restraints will not be imposed for purposed of discipline or convenience.
A review of the facility ' s Policy and Procedure titled, Abuse Prevention and Prohibition Program, dated 8/1/2023, indicated to ensure the facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property.

Based on observation, interview and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 1), who tested positive for scabies (a contagious skin condition caused by microscopic [so small as to visible only with microscope] mites [tiny bugs] burrowing [made a hole] into the skin) by failing to ensure a contact isolation (a safety measure as certain germs can be spread by contact) signage was posted outside Resident 1's room.
This deficient practice had the potential for staff to be unaware of the necessary infection control measures to observe when caring for Resident 1 and increase the risk of the spread of infection among residents and staff.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/17/2023, with diagnoses that included fracture of right pubis (break in one of the three main bones that make up the pelvis), vascular dementia (occurs when blood vessels in the brain are damaged, which can reduce the brain's supply of oxygen and nutrients) and unspecified (unconfirmed) pruritus (itching).
During a record review of Resident 1's History and Physical (H&P) dated 8/17/2024, the H&P indicated Resident 1 had capacity to understand and make decisions.
During a record review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/23/2024, the MDS indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required maximum assistance from staff for dressing and personal hygiene.
During a record review of Resident 1's Physician Order dated 9/26/2024, the Physician Order indicated an order to apply permethrin cream (medication used to treat scabies) from neck to toes and leave for eight hours today (9/26/2024) and repeat application in one week (10/3/2024).
During a record review of Resident 1's Physician Progress Note dated 9/26/2024, the Progress Note indicated Resident 1 was diagnosed (the act of identifying a disease, illness, or problem by examining someone or something) with pruritus of unknown etiology (cause), rule out drug eruption (a skin reaction to a medication that can be ruled out by a physical exam, history, and other diagnostic tests), rule out scabies (a healthcare provider can examine your skin for symptoms and take a sample to look for mites or eggs under a microscope).
During a record review of Resident 1's Pathology Report (a medical report about a piece of tissue, blood, or body organ that has been removed from your body) dated 10/3/2024, the Pathology Report indicated Resident 1 tested positive for scabies.
During a concurrent observation and interview on 10/11/2024 at 8:34 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed an Enhanced Barrier Precaution (EBP-an infection control practice that involves wearing gowns and gloves during high-contact activities with residents in nursing homes) signage posted outside of Resident 1's room. LVN 1 stated Resident 1 was positive for scabies and was placed on contact isolation. LVN 1 stated the signage posted should have indicated contact isolation. LVN 1 stated the difference between EBP and contact isolation, is that for EBP, a gown is worn when providing direct care, whereas for contact isolation, a gown is worn before entering the room.
During an interview on 10/11/2024 at 10:47 a.m. with the Director of Staff Development (DSD), the DSD stated residents with scabies should be placed on contact isolation. The DSD stated the signage posted outside of Resident 1's room should be for contact isolation. The DSD stated the importance of correct signage is to remind nurses on what personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and or environments) to use to prevent the spread of infection.
During an interview on 10/11/2024 at 11:49 a.m., with the Director of Nursing (DON), the DON stated residents with scabies should be on contact isolation. The DON stated the importance of correct signage is to prevent the spread of infection among staff and residents.
During a review of facility's policy and procedure titled, Resident Isolation-Categories of Transmission Based Precautions, dated 7/1/2023, the PnP indicated, Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Examples of infections requiring Contact precautions include but are not limited to: .i. Scabies. The facility also ensures that the residents care plan indicates the type of precaution implemented for the resident.

Based on interview and record review, the facility failed notify the primary physician (PP) of a significant change of condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of three sampled residents (Resident 1) by:
1. Failing to ensure the PP was notified on 9/26/2024, when Resident 1 was prescribed (to tell somebody to take a particular medicine or have a particular treatment) with permethrin cream (medication used to treat scabies [a contagious skin condition caused by mites burrowing into the skin and laying eggs characterized by intense itching and a rash of small red bumps and blisters])by the dermatologist (a doctor who has special training to diagnose and treat skin problems).
2. Failing to ensure the PP was notified on 10/7/2024 when Resident 1 tested positive for scabies.
These deficient practices had the potential to result in the delay of obtaining appropriate treatment instructions from the physician and the spread of scabies among residents and staff.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/17/2023, with diagnoses that included fracture of right pubis (break in one of the three main bones that make up the pelvis), vascular dementia (occurs when blood vessels in the brain are damaged, which can reduce the brain's supply of oxygen and nutrients) and unspecified (unconfirmed) pruritus (itching).
During a record review of Resident 1's care plan (CP) on history of skin rashes and itching dated 8/2/2023, the CP indicated an intervention to assess skin and notify the physicianof any new outbreaks in skin and or if complaint of itching.
During a record review of Resident 1's History and Physical (H&P) dated 8/17/2024, the H&P indicated Resident 1 had capacity to understand and make decisions.
During a record review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/23/2024, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required maximum assistance from staff for dressing and personal hygiene.
During a record review of Resident 1's Physician Order dated 9/26/2024, the Physician Order indicated an order to apply permethrin cream from neck to toes and leave for eight hours today (9/26/2024) and repeat application in one week (10/3/2024).
During a record review of Resident 1's Physician Progress Note dated 9/26/2024, the Progress Note indicated Resident 1 was diagnosed (the act of identifying a disease, illness, or problem by examining someone or something) with pruritus of unknown etiology (cause), rule out drug eruption (a skin reaction to a medication that can be ruled out by a physical exam, history, and other diagnostic tests), rule out scabies (a healthcare provider can examine your skin for symptoms and take a sample to look for mites or eggs under a microscope).
During a record review of Resident 1's Nurses Progress Notes dated 9/26/2024, the Progress Notes indicated, on 9/26/2024, Resident 1 was picked up at 10:30 a.m., for 11 a.m., appointment with the Dermatologist (Derma-a medical doctor who specializes in treating the skin, hair, and nails). The Progress Notes indicated, on 9/26/2024 at 1:30 p.m., Resident 1 returned to the facility with new orders for skin care.
During a record review of Resident 1's Pathology Report (a medical report about a piece of tissue, blood, or body organ that has been removed from your body) dated 10/3/2024, the Pathology Report indicated Resident 1 tested positive for scabies.
During a concurrent interview and record review on 10/11/2024, at 9:25 a.m., with the Infection Preventionist (IP), Resident 1's Pathology Report dated 10/3/2024, and Progress Notes dated 9/26/2024, and 10/7/2024, were reviewed. The IP stated the Progress Notes dated 9/26/2024 and 10/7/2024, did not indicate the primary physician (PP) was notified on 9/26/2024 when the Dermatologist ordered permethrin cream for the resident and on 10/7/2024, when the Pathology Report received by the facility indicated the resident tested positive for scabies. The IP stated the PP should have been notified when the resident had a change in condition so the PP can give new orders.
During a concurrent interview and record review on 10/11/2024, at 11:49 a.m., with the Director of Nursing (DON), the facility's policy and procedure (PnP) titled, Change in Condition Notification dated 1/1/2017, was reviewed. The PnP indicated, An acute change in condition is a sudden, clinically important deviation from a patients baseline in physical, cognitive, behavioral or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. The Licensed Nurse will notify the residents Attending Physician when there is an: F. A need to alter treatment significantly (example given based on laboratory or Xray result, a need to discontinue an existing form of treatment due to a change in condition). The Attending Physician will be notified timely with a residents change in condition. A licensed nurse will document the following: .ii. time the attending physician was contacted, the method by which he was contacted, the response time and whether or not orders were received. The DON stated when Resident 1 came back from the Dermatologist appointment on 9/26/2024, with orders for permethrin cream, the nurse should have notified the physician because the resident was prescribed a new treatment. The DON further stated the nurse who received the Pathology Report on 10/7/2024, indicating Resident 1 tested positive for scabies, should have notified the physician to obtain further orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by failing to follow the physician's order for permethrin cream (medication used to treat scabies [a contagious skin condition caused by mites burrowing into the skin and laying eggs characterized by intense itching and a rash of small red bumps and blisters]) treatment to Resident 1.
This deficient practice resulted in the delay of Resident 1's treatment and had the potential for the spread of scabies (an itchy rash due to mites that live under your skin) among residents and staff.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/17/2023, with diagnoses that included other specified fracture of right pubis (break in one of the three main bones that make up the pelvis), vascular dementia (occurs when blood vessels in the brain are damaged, which can reduce the brain's supply of oxygen and nutrients) and unspecified (unconfirmed) pruritus (itching).
During a record review of Resident 1's History and Physical (H&P) dated 8/17/2024, the H&P indicated Resident 1 had capacity to understand and make decisions.
During a record review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/23/2024, the MDS indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required maximum assistance from staff for dressing and personal hygiene.
During a record review of Resident 1's Physician Order dated 9/26/2024, the Physician Order indicated an order to apply permethrin cream (medication used to treat scabies [an itchy rash due to mites that live under your skin] from neck to toes and leave for eight hours today (9/26/2024) and repeat application in one week (10/3/2024).
During a concurrent interview and record review on 10/11/2024, at 10:47 a.m., with the Director of Staff Development (DSD), Resident 1's Treatment Administration Record (TAR) dated 9/2024-10/2024 and the Progress Notes dated 10/4/2024 was reviewed. The TAR dated 9/27/2024 indicated permethrin cream was administered to Resident 1 on 9/27/2024 at 9 p.m. The TAR dated 10/2024, did not indicate the treatment order for permethrin. The DSD stated permethrin cream is a medication used to treat scabies. The DSD stated the second application of permethrin was due on 10/4/2024, one week after the first application. The DSD stated the TAR dated 10/2024 did not list permethrin as one of the resident's medications. The DSD stated if the medication or treatment is not documented it means it was not given. The DSD stated the Progress Notes dated 10/4/2024 did not indicate permethrin was applied to Resident 1.
During an interview on 10/11/2024, at 11:43 a.m., with Registered Nurse 1 (RN 1), RN 1 stated she worked on 10/7/2024 and when she checked Resident 1's TAR dated 10/2024, she found out that permethrin was not given to the resident on 10/4/2024. RN 1 stated she called the pharmacy and the pharmacy confirmed permethrin was not delivered to the facility on [DATE]. RN 1 stated she (RN 1) requested permethrin to be delivered that day, on 10/7/2024 and informed Treatment Nurse 1 (TN 1) to give the medication as soon as it is delivered because the resident did not receive the treatment on 10/4/2024.
During an interview on 10/11/2024, at 11:49 a.m., with the Director of Nursing (DON), the DON stated the nurses should have followed the physicians order to administer permethrin one week after the first application, to Resident 1.
During a review of facility's policy and procedure (PnP) titled, Medication Administration, dated 7/1/2016, the PnP indicated, Medication will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner.
During a record review of facility's PnP titled Scabies dated 8/1/2014, the PnP indicated, The Infection Control Coordinator will follow the guidance provided in the following publications to prevent and minimize the outbreak of scabies: B. Infection Control-16-Form B- Prevention and Control of Scabies in California Long Term Care Facilities.
During a record review of facility's PnP titled, Prevention and Control of Scabies in California Long Term Care Facilities dated 3/2008, the PnP indicated, The current recommended treatment for scabies is five percent (%- unit of measurement) permethrin cream, a synthetic pyrethroid (man-made chemical insecticides that are similar to the natural pesticide pyrethrins, which come from chrysanthemum flowers). When applied to the skin as directed, it is approximately 90 % effective after one application. Two applications may be required and is often recommended to assure compete eradication (the process of getting rid of something completely or of destroying something bad).

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1).
This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1's medical record.
Findings:
During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/17/2023, with diagnoses that included fracture of right pubis (break in one of the three main bones that make up the pelvis), vascular dementia (occurs when blood vessels in the brain are damaged, which can reduce the brain's supply of oxygen and nutrients) and unspecified (unconfirmed) pruritus (itching).
During a record review of Resident 1's History and Physical (H&P) dated 8/17/2024, the H&P indicated Resident 1 had capacity to understand and make decisions.
During a record review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/23/2024, the MDS indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 1 required maximum assistance from staff for dressing and personal hygiene.
During a record review of Resident 1's Physician Order dated 9/26/2024, the Physician Order indicated an order to apply permethrin cream (medication used to treat scabies [an itchy rash due to mites that live under your skin] from neck to toes and leave for eight hours today (9/26/2024) and repeat application in one week (10/3/2024).
During a concurrent interview and record review on 10/11/2024, at 10:47 a.m., with the Director of Staff Development (DSD), Resident 1's Treatment Administration Record (TAR) dated 9/2024-10/2024 and Progress Notes dated 10/4/2024 were reviewed. The TAR dated 9/27/2024 indicated permethrin cream was administered to Resident 1 on 9/27/2024 at 9 p.m. The TAR dated 10/2024, did not indicate the treatment order for permethrin. The DSD stated permethrin cream is a medication used to treat scabies. The DSD stated the second application of permethrin was due on 10/4/2024, one week after the first application. The DSD stated the TAR dated 10/2024 did not list permethrin as one of the resident's medications. The DSD stated if the medication or treatment is not documented it means it was not given. The DSD stated the Progress Notes dated 10/4/2024 did not indicate permethrin was applied to Resident 1.
During an interview on 10/11/2024, at 11:43 a.m., with Registered Nurse 1 (RN 1), RN 1 stated on 10/7/2024, pharmacy did not deliver the permethrin so she (RN 1) called and informed Treatment Nurse 1 (TN 1) to give the medication as soon as it is delivered.
During an interview on 10/11/2024, at 11:49 a.m., with the Director of Nursing (DON), the DON stated nurse should document medication or treatment given according to the physician's order.
During an interview on 10/11/2024, at 12:43 p.m., with Treatment Nurse 1 (TN 1), TN 1 stated she (TN 1) gave Resident 1 permethrin on 10/8/2024 at 8 p.m., because Resident 1 was due for shower the following day on 10/9/2024. TN 1 stated she (TN 1) forgot to document that she (TN 1) administered permethrin to Resident 1 on 10/8/2024.
During a record review of facility's policy and procedure (PnP) titled Nursing Documentation dated 1/1/2016, the PnP indicated, Nursing documentation will be concise, clear, pertinent and accurate. Medication administration record and treatment administration records are completed with each medication or treatment completed. Treatments completed and documented as per physician's order. Documentation will be complete by the end of the shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1).
This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1's clinical record.
Findings:
During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 7/31/2024, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition that can cause confusion, memory loss and loss of consciousness), paroxysmal (intermittent, stopping within 7 days, and often within 24 hours) atrial fibrillation (irregular heartbeat in the upper chambers of the heart) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities).
During a record review of Resident 1 ' s MDS, dated [DATE], the MDS indicated Resident 1 ' s cognitive skills for daily decision making was moderately impaired.
During a record review of Resident 1 ' s History and Physical (H&P), dated 9/26/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.
During an observation on 10/2/2024, at 8:16 a.m., Resident 1 was on oxygen at three liters per minute.
During a record review of Resident 1 ' s Medication Administration Record (MAR) dated 10/2024, the MAR indicated oxygen use was not signed on 10/1/2024.
During an interview on 10/2/2024, at 9:22 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 was on oxygen yesterday and she forgot to document the oxygen use. LVN 1 stated she should have checked her documentation before the end of her shift.
During an interview on 10/2/2024, at 9:57 a.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated LVN 1 should have documented on the same day.
During a concurrent interview and record review on 10/3/2024, at 8:42 a.m., with the Director of Nursing (DON), facility ' s policy and procedure titled, Documentation-Nursing, dated 1/1/2016, was reviewed. The PnP indicated, Nursing documentation will be concise, clear, pertinent and accurate. Medication administration records and treatment administration records are completed with each medication and treatment completed. Documentation will be completed by the end of the assigned shift. The DON stated documentation should be competed by the end of the shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by:
1. Failing to measure Resident 1 ' s pressure ulcer upon readmission on [DATE] and 9/25/2024.
2. Failing to assess and document Resident 1 ' s weekly wound assessment.
3. Failing to assess and complete Resident 1 ' s weekly Skin Integrity Sheet.
These deficient practices placed Resident 1 at risk for the development and worsening of pressure ulcers.
Findings:
During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 7/31/2024, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition that can cause confusion, memory loss and loss of consciousness), paroxysmal (intermittent, stopping within 7 days, and often within 24 hours) atrial fibrillation (irregular heartbeat in the upper chambers of the heart) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities).
During a record review of Resident 1 ' s MDS, dated [DATE], the MDS indicated Resident 1 ' s cognitive skills for daily decision making was moderately impaired. The MDs indicated Resident 1 was dependent to staff for all activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 1 had one stage 2 PU and two stage 3 PUs.
During a record review of Resident 1 ' s History and Physical (H&P), dated 9/26/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a concurrent interview and record review on 10/2/2024 at 9:22 a.m., with the Treatment Nurse 1 (TN 1), Resident 1 ' s Progress Notes, dated 9/25/2025, were reviewed. TN 1 stated Resident 1 was in the General Acute Care Hospital (GACH) from 9/19/2024 to 9/25/2024. TN 1 stated Resident 1 had a stage 3 PU but there was no wound measurement documented on 9/25/2024 when Resident 1 returned to the facility.
During a concurrent interview and record review on 10/2/2024 at 9:57 a.m., with Registered Nurse Supervisor 1 (RNS 1), Resident 1 ' s Progress Notes, dated 9/4/2024 and 9/25/2024, were reviewed. The Progress Note, dated 9/4/2024, indicated Resident 1 was readmitted at 7:10 p.m., with stage 3 PU to sacrococcyx and right buttocks, and a stage 2 PU to left buttocks. The Progress Notes, dated 9/25/2024, indicated Resident 1 was readmitted at 5:45 p.m., with stage 3 pressure injury to sacrococcyx. RNS 1 stated RN measures the wound and document in the Progress Notes upon admission and readmission. RNS 1 stated it is important to document wound measurement upon admission and readmission to find out if the wound or PU was worsening or getting bigger. RNS 1 stated RN 2 readmitted Resident 1 on 9/4/2024 and 9/25/2024.
During an interview on 10/2/2024 at 10: 15 a.m., RNS 1 provided the Skin Integrity Sheet and Wound Assessment Form. RNS 1 stated RN or TN should start the Skin Integrity Sheet and Wound Assessment Form upon admission and readmission then TN should complete and document weekly to track PU improvement.
During an interview on 10/2/2024 at 12:32 p.m., with RNS 1, RNS 1 stated she had looked in Resident 1 ' s record but unable to find the Skin Integrity Sheet and Wound Assessment Form for 9/2024. RNS 1 stated staff were not doing their job of skin assessment and documentation.
During an interview on 10/3/2204 at 8:26 a.m., with TN 2, TN 2 stated once resident is admitted or readmitted with PU, skin is checked and documented in the Skin integrity Sheet including the PU measurement. TN 2 stated the Wound Assessment Form is also completed weekly.
During a concurrent interview and record review on 10/3/2024 at 8:42 a.m., with the Director of Nursing (DON), facility ' s policy and procedure (PnP) titled, Pressure Ulcer Prevention dated 2/1/2015 was reviewed. The PnP indicated, Licensed Nurse will conduct a skin assessment for a resident upon admission, readmission, weekly and as needed. Results of the weekly skin assessment will be documented in the medical record. (Result may be documented using the Weekly Skin Inspection form). The DON stated it is important to assess and document PU or wound upon admission, readmission and weekly to find the appropriate treatment for the resident. The DON stated measuring wounds or PU was part of their policy for PU prevention. The DON stated RN or TN should have assess and document their observations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that two of eight residents (Resident 2 and Resident 1) who had a urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services by:
1. Failing to ensure Treatment Nurse 1 (TN 1) notified physician of sediments (urine becomes more concentrated, allowing substances like salts and minerals to precipitate and form) and blood in Resident 2 ' s urine on 10/2/2024 as per facility ' s policy and procedure.
2. Failing to ensure TN 1 obtain an order for urinary irrigation (flushing of the bladder with sterile fluid to prevent clots [gel-like clumps of blood] and blood retention) before flushing Resident 2 ' s urinary catheter.
3. Failing to ensure Resident 2 ' s indwelling catheter was secured to resident's leg as per facility ' s policy.
4. Failing to ensure Resident 1 ' s urinary catheter bag was changed weekly as per physician ' s order.
5. Failing to ensure Resident 2 and Resident 1 ' s urine was assessed for urine color and consistency as per physician ' s order.
These deficient practices had the potential to result in urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) and had a potential to lead to urosepsis (a potentially life-threatening complication of urinary tract infection).
Findings:
a. During a record review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 3/23/2022, with diagnoses that included unspecified encephalopathy, chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and obstructive (a condition in which the flow of urine is blocked) and reflex uropathy ( a condition in which the kidneys are damaged by the backward flow of urine into the kidney).
During a record review of Resident 2 ' s Order Summary Report, dated 5/12/2024, the Order Summary Report indicated the following order:
1. Assess urine for color every shift.
2. Assess urine for consistency (sedimentation) every shift.
During a record review of Resident 2 ' s H&P, dated 5/14/2024, the H&P indicated Resident 2 had no capacity to understand and make decisions.
During a record review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decision making were severely impaired.
During a record review of Resident 2 ' s Treatment Administration Record (TAR), dated 10/2024, the TAR indicated on 10/2/2024, TN 1 signed that Resident 2 ' s urine was assessed for urine color and consistency.
During an interview on 10/2/2204, at 11:53 a.m., with TN 1, TN 1 stated Resident 2 had blood and sediments in the urinary tubing. TN 1 stated she (TN 1) did not report to Registered Nurse Supervisor 1 (RNS 1) because Resident 2 had history of sediments and blood in the urine.
During an interview on 10/2/2024, at 12:14 p.m., with RNS 1, RNS 1 stated she (RNS 1) did not receive any report from the staff regarding Resident 2 ' s sediments and blood in the urine. RNS 1 stated TN 1 should have informed her (RNS 1) so she could have called and notified the physician and obtained an order for urinary irrigation.
During a concurrent interview and record review on 10/3/2024, at 8:42 a.m., with the Director of Nursing (DON), facility ' s policy and procedure (PnP) titled, Care of Catheter, dated 9/1/2014, was reviewed. The PnP indicated Report the following signs and symptoms to the Attending Physician: i. Any sign or symptom of urinary tract infection (UTI), fever, change in urine such as a foul odor (strong, unpleasant smell) or bloody cloudy appearance ii. No urine output or decreased urine output. Iii. Leakage of urine iv. Hematuria (blood in the urine) . The DON stated TN 1 should have reported changes in Resident 2 ' s urine to RNS 1 so RNS 1 could have notified the physician. The DON stated physician should be notified to prevent UTI.
b. During a record review of Resident 2 ' s Physician Order dated 9/6/2024, the Physician Order indicated the following:
Continuous urinary catheter irrigation every six hours until 9/20/2024.
1. Disconnect tubing from the catheter.
2. Instill bladder with 120 cubic centimeter (cc-unit of measurement) of normal saline (NS-salt water)
3. Withdraw 60 cc of flush.
4. Instill 60 of flush.
5. Withdraw 60 of flush.
6. Repeats steps four and five no clots or mucus.
7. Reconnect urinary catheter to tubing.
During an interview on 10/2/204, at 11:53 a.m. with TN 1, TN 1 stated when she (TN 1) saw Resident 2 ' s blood and sediments in the urinary tubing, she (TN 1) flushed it as per physician ' s order.
During a concurrent interview and record review on 10/2/204, at 12:14 p.m., with RNS 1, Resident 2 ' s Physician Order dated 9/6/2024, was reviewed. The Physician Order indicated to discontinue urinary catheter irrigation on 9/20/2024. RNS 1 stated TN 1 should not flushed the urinary catheter because there was no physician ' s order. RNS 1 stated TN 1 should have reported Resident 2 ' s changes in urine so RNS 1 could have called the physician and get an order for urinary irrigation.
During a concurrent interview and record review on 10/3/2024, at 8:42 a.m., with the DON, facility ' s PnP titled, Care of Catheter dated 9/1/2014, was reviewed. The PnP indicated Irrigation should be avoided unless obstruction is anticipated (example after prostatic or bladder surgery, or to relieve obstruction due to bleeding or other causes) When irrigation is necessary, intermittent irrigation should be used, and a physician order is required. The DON stated physician ' s order is needed before flushing the urinary catheter. The DON stated TN 1 should have checked the Physician ' s Order first before flushing the urinary catheter to prevent potential worsening of the urinary condition.
c. During a concurrent observation and interview on 10/2/2024, at 8:34 a.m., with Certified Nursing Assistant 3 (CNA 3), at Resident 2 ' s bedside. Observed Resident 2 ' s urinary catheter not secured to Resident 2 ' s leg. CNA 3 stated Resident 2 ' s urinary catheter was not secured to Resident 2 ' s leg.
During a concurrent observation and interview on 10/2/2024, at 8:40 a.m., with Licensed Vocational Nurse 1 (LVN 1), inside Resident 2 ' s room. LVN 1 stated Resident 2 ' s urinary catheter was not secured to the resident ' s leg. LVN 1 stated if not secured, urinary catheter can be accidentally pulled out.
During a concurrent interview and record review on 10/3/204, at 8:42 a.m., with the DON, facility ' s PnP titled, Care of Catheter, dated 9/1/2014, was reviewed. The PnP indicated, Anchor the catheter with a leg strap to prevent excessive tension on the catheter which can lead to urethral tears or dislodging (force out of position) the catheter. The DON stated it is the facility ' s policy to secure the catheter to prevent injury and prevent dislodgment.
d. During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 7/31/2024, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition that can cause confusion, memory loss and loss of consciousness), paroxysmal (intermittent, stopping within 7 days, and often within 24 hours) atrial fibrillation (irregular heartbeat in the upper chambers of the heart) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities).
During a record review of Resident 1 ' s MDS, dated [DATE], the MDS indicated Resident 1 ' s cognitive skills for daily decision making was moderately impaired.
During a record review of Resident 1 ' s History and Physical (H&P), dated 9/26/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.
During a record review of Resident 1 ' s Order Summary Report, dated 8/29/2024, the Order Summary Report indicated an order to change catheter bag weekly every Mondays in the morning.
During a record review of Resident 1 ' s Treatment Administration Record (TAR), dated 9/2024, the TAR indicated on 9/30/2024 the catheter bag change was left blank.
During a concurrent interview and record review on 10/3/2024, at 8:42 a.m., with the DON, Resident 1 ' s TAR dated 9/2024 and facility ' s PnP titled, Care of Catheter dated 9/1/2024, was reviewed. The TAR dated 9/30/2024 was not signed. The PnP indicated, Catheter and drainage bags will be changed based on clinical indications such as infections, obstructions or when the closed system is compromised. Documentation of the catheter care will be maintained in the resident ' s medical record. The DON stated catheter bag should be changed as per physician ' s order. The DON stated staff should have changed the catheter bag on 9/30/2024 and sign the TAR.
e. During a record review of Resident 1 ' s Order Summary Report dated 8/29/2024, the Order Summary Report indicated the following order:
1. Assess urine for color every shift.
2. Assess urine for consistency (sedimentation) every shift.
During an observation on 10/2/2024, at 8:16 a.m., inside Resident 1 ' s room. Observed Resident 1 ' s foley with sediments and appeared concentrated.
During a concurrent observation and interview on 10/2/2024, at 8:22 a.m., with LVN 1 inside Resident 1 ' s room. LVN 1 stated Resident 1 ' s urine was cloudy in color and was not sure of the white things in the urinary tubing if it were sediments.
During a concurrent interview and record review on 10/2/2024, at 10:19 a.m., with LVN 1, Resident 1 ' s Care Plan on potential for infection due to urinary retention dated 9/24/2024, was reviewed. The Care Plan indicated, Report to physician, changes in urine appearance, amount, color, clarity or if blood in the urine noted.
During an interview on 10/2/2024, at 11:53 a.m., with TN 1, TN 1 stated Resident 1 had no sediments, but the urine was concentrated. TN 1 stated she (TN 1) did not document the color and consistency in the Progress Note but just signed the TAR that Resident 1 ' s urine was assessed for color and consistency. TN 1 stated she (TN 1) only documents if there were abnormalities.
During a record review of Resident 2 ' s Order Summary Report dated 5/12/2024, the Order Summary Report indicated the following order:
1. Assess urine for color every shift.
2. Assess urine for consistency (sedimentation) every shift.
During a concurrent observation and interview on 10/2/2024, at 8:31 a.m., with CNA 3, inside Resident 2 ' s room. Observed Resident 2 ' s urinary tubing with sediments and small amount of blood. CNA 3 stated Resident 2 ' s urinary tubing had blood and white colored cloudy urine.
During an interview on 10/2/204, at 11:53 a.m., with TN 1, TN 1 stated she (TN 1) saw that Resident 2 ' s urine had sediments and blood. TN 1 stated she (TN 1) did not document that Resident 2 had sediments and blood because Resident 2 had prior history of bloody urine.
During an interview on 10/2/2024, at 12:14 p.m., with RNS 1, RNS 1 stated order for assessment of urine color and consistency was a facility ' s protocol. RNS 1 stated there were no report from the staff that Resident 1 and Resident 2 had abnormalities in their urine.
During a concurrent interview and record review on 10/3/2024, at 8:42 a.m., with the DON, facility ' s PnP titled, Care of Catheter dated 9/1/2014, was reviewed. The PnP indicated, A resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible. Documentation of the catheter care will be maintained in the resident ' s medical record. The DON stated RNS 1 should be notified and document changes in urine color and consistency like sediments and blood in urine. The DON stated nurses should document what they observe.
During a record review of facility ' s PnP titled, Nursing Documentation dated 1/1/2016, the PnP indicated, Treatments completed and documented as per physician ' s order. Alert charting is documentation done to track a medical event for a period of 72 hours or longer .Events may include but not necessarily limited to: b. suspected or actual change in condition. Alert charted describes what is going on.
a. Describe the resident ' s condition, include what you see, hear, smell, feel etcetera.
b. Use the residents ' own words if needed.
c. Describe what you have done in response to what is going on with the resident.
d. Describe how the resident responded to the actions.

**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 for three of eight sampled residents (Resident 3, 1, and 2) by:
1. Failing to ensure Physical Therapist Assistant (PTA 1) and Occupational Therapist (OT 1) wore gowns while repositioning Resident 3, who was placed on Enhanced Barrier Precautions (EBP- an infection control method that uses personal protective equipment [PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses] to reduce the spread of multidrug-resistant organisms [MDROs- microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents, such as antibiotics] between residents in skilled nursing facilities).
2. Failing to ensure Resident 1 ' s oxygen tubing did not touch the floor.
3. Failing to ensure Certified Nursing Assistant 3 (CNA 3) wore a gown while providing incontinent care to Resident 2 who was placed on EBP.
These deficient practices had the potential to result in an increased risk for MDRO transmission.
Findings:
a. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 3/14/2022 and readmitted the resident on 9/5/2024 with diagnoses that included urinary device (used to drain the bladder), benign prostatic hyperplasia (BPH- is a non-cancerous condition that causes the prostate gland to enlarge, which can lead to urinary problems) and history of urinary tract infection (condition in which bacteria invade and grow in the urinary tract [the kidneys, ureters, bladder, and urethra]).
A review of Resident 3 ' s Order Summary Report, dated 9/5/2024, indicated the following orders:
- Catheter (urinary catheter also known as Foley catheter, is a hollow flexible tube inserted in the bladder through the urethra to drain urine) care per shift every shift.
- Change catheter bag every week Monday in the morning.
- Change foley catheter 16 French (Fr- Catheters are just millimeters wide, with different sizes often being just fractions of a millimeter apart) as needed per month and as needed.
A review of Resident 3 ' s Care plan, developed on 9/5/2024 for enhanced barrier precautions secondary to foley catheter use. The interventions included to place EBP sign at the door entry, provide gowns, and gloves at door entry, and use gown and gloves during high contact resident care activities (dressing, bathing, transfer, hygiene, toileting, brief changes, changing linens, device care, wound care.
A review of Resident 3 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/13/2024, indicated resident was independent with making decision regarding tasks of daily life. The MDS further indicated Resident 3 was dependent (helper does all the effort) with toileting, showering, upper and lower body dressing and putting on or taking off footwear and required substantial assistance (helper does more than half the effort) with eating, oral hygiene, and personal hygiene. The MDs indicated Resident 3 had an indwelling catheter.
During an observation on 10/2/2024 at 10:47 a.m. in Resident 3 ' s room observed PTA 1 and OT 1 in Resident 3 room wearing a mask and gloves while assisting Resident 3 in his wheelchair. Registered Nurse Supervisor 1 (RNS 1) observed PTA 1 and OT 1 in Resident 3 ' s room and asked PTA 1 and OT 1 to place gown and gloves on, OT 1 stated was repositioning Resident 3.
During an interview on 10/2/2024 at 1:05 p.m. with PTA 1 stated EBP is to protect residents for whatever you may have and do not want the residents to get sick. PTA 1 stated any resident with wounds, catheter, or any other stuff that can make them susceptible to infection and need to be on EBP. PTA 1 stated if there is a sign on the door or a PPE cart outside of the room, one must wear gown, mask, and gloves. PTA 1 stated Resident 3 was already in his wheelchair and requested to be repositioned and OT 1 went in and repositioned Resident 3. PTA 1 stated normally we wear the appropriate PPE. PTA 1 stated at that time we were not wearing the appropriate PPE. PTA 1 stated should have been wearing a gown, had gloves and a mask, but no gown. PTA 1 stated can be a risk to cause the resident to get sick or infected.
During an interview n 10/2/2024 at 1:11 p.m. with OT 1 stated EBP is for resident who are at risk of infections or giving infection, for resident with tubes, and wounds. OT 1 stated there is a sign and PPE cart outside of each door to let us know which residents have EBP. OT 1 stated for Resident 3 has a catheter and that is why Resident 3 is on EBP. OT 1 stated went to speak to Resident 3 to see when he wanted to be seen for therapy. OT 1 stated Resident 3 wanted to be fixed, wanted to be repositioned, OT 1 stated Resident 3 was leaning, and she grabbed Resident 3 and helped Resident 3 reposition himself on the wheelchair. OT 1 stated when assisting Resident 3 was wearing gloves and mask, OT 1 stated should have been wearing gloves, mask and gown. OT 1 stated can be a risk for exposing resident with an infection from not wearing the gown and risk for contact for anything to touch Resident 3.
A review of the facility ' s policies and procedures titled, Standard and Enhanced Precautions, last revised on 4/1/2024, indicated Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs target gown and gloves use during high contact resident care activities that are associated with high risk of MDRO colonization when contact precaution do not otherwise apply and or transition such as presence of indwelling devices (urinary catheter, feeding tube, endotracheal or tracheostomy tube, vascular catheters) and wounds or presence of unhealed pressure ulcers.
b. During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 7/31/2024 with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition that can cause confusion, memory loss and loss of consciousness), paroxysmal (intermittent, stopping within 7 days, and often within 24 hours) atrial fibrillation (irregular heartbeat in the upper chambers of the heart) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities).
During a record review of Resident 1 ' s MDS, dated [DATE], the MDS indicated Resident 1 ' s cognitive skills for daily decision making was moderately impaired.
During a record review of Resident 1 ' s History and Physical (H&P), dated 9/26/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.
During an observation on 10/2/2024 at 8:16 a.m., Resident 1 ' s was on oxygen at two liters per minute and the oxygen tubing was touching the floor.
During a concurrent observation and interview on 10/2/2024 at 8:18 a.m., with CNA 2, inside Resident 1 ' s room. Observed Resident 1 ' s oxygen tubing touching the floor. CNA 2 stated Resident 1 ' s oxygen tubing slightly touched the floor. Observed CNA 2 raised Resident 1 ' s bed and stated oxygen tubing did not touched the floor anymore.
During an interview on 10/2/2024 at 9:57 a.m., RNS 1 stated oxygen tubing should not touch the floor for infection control. RNS 1 stated CNA 2 should have reported to Licensed Vocational Nurse 1 (LVN 1) and LVN 1 should have changed the oxygen tubing.
During a concurrent interview and record review on 10/3/2024 at 8:42 a.m., with the Director of Nursing (DON), facility ' s policy and procedure titled, Oxygen Administration, dated 8/1/2014, was reviewed. The policy and procedure indicated, All oxygen tubing, humidifiers, mask, and cannulas used to deliver oxygen: ii. Will be changed weekly and when visibly soiled. The DON stated oxygen tubing should not come in contact with the floor for infection control.
c. During a record review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 3/23/2022 with diagnoses that included unspecified encephalopathy, chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing)) and obstructive (a condition in which the flow of urine is blocked) and reflex uropathy ( a condition in which the kidneys are damaged by the backward flow of urine into the kidney).
During a record review of Resident 2 ' s H&P, dated 5/14/2024, the H&P indicated Resident 2 had no capacity to understand and make decisions.
During a record review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decision making was severely impaired.
During an observation on 10/2/2024 at 8:33 a.m., outside of Resident 2 ' s room. Observed an EBP signage posted by the right side of the door and an isolation cart (contains essential equipment outside of resident rooms that have been deemed an infection risk) noted by door.
During a concurrent observation and interview on 10/2/2024 at 8: 34 a.m., inside Resident 2 ' s room. Observed CNA 3, opened Resident 2 ' s incontinent brief and touched the urinary catheter without a gown. CNA 3 stated the urinary catheter leaked because the incontinent brief was wet on the left side.
During a concurrent observation and interview on 10/2/2024 at 8:40 a.m. with LVN 1, inside Resident 2 ' s room. LVN 1 stated CNA 3 should wear a gown before providing incontinent care.
During an interview on 10/2/2024 at 9:57 a.m., RNS 1 stated staff should wear personal protective equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when providing care like incontinent care to residents on EBP. RNS 1 stated CNA 3 should wear a gown for infection control.
During a concurrent interview and record review on 10/3/2024 at 8:42 a.m., with the DON, facility ' s policy and procedure titled, Standard and Enhanced Precautions, dated 4/1/2024, indicated, A gown is worn to protect the skin and prevent soiling of clothing during procedures and residuent care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions if causes soiling of clothing. For residents whom EBP are indicated, EBP should be used when performing the following high contact resident care activities .vi. Changing briefs or assisting with toileting. The DON stated staff should wear a gown when they touch incontinent brief, urinary catheter, to wound to protect the resident from infection.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan with measurable objectives and timeframes for one of three sampled residents (Resident 3) by failing to develop a care plan that addressed Resident 3's Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission [transfer] of multidrug-resistant organisms [MDRO- bacteria that have become resistant to certain antibiotics that can no longer be used to control or kill the bacteria]).
This deficient practice had the potential to negatively impact Resident 3's over-all health.
Findings:
During a record review of Resident 3's admission Record indicated the facility admitted Resident 3 on 1/31/2022 with diagnoses that included unspecified (unconfirmed) heart failure (occurs when the heart muscle doesn't pump blood as well as it should), diabetes mellitus (uncontrolled elevated blood sugar) and unspecified retention of urine.
During a record review of Resident 3's History and Physical, dated 11/28/2023, indicated Resident 3 had the capacity to understand and make decisions.
During a record review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/19/2024, indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 3 needed moderate assistance from staff for personal hygiene.
During an observation on 8/23/2024 at 8:43 a.m., outside Resident 3's room, it was observed an Enhanced Barrier Precaution signage was posted by Resident 3's right side of the door.
During an observation on 8/23/2024 at 8:44 a.m., with Registered Nurse 1 (RN 1) from Resident 3's door, it was observed that Resident 3 was seated on a wheelchair and RNA 1 standing in front of Resident 3 holding onto Resident 3's urinary drainage bag. It was observed that RNA 1 hang the urinary drainage bag to Resident 3's wheelchair.
During an interview on 8/23/2024 at 8:45 a.m., RNA 1 stated she (RNA 1) walked Resident 3 in the hallway. RNA 1 stated she (RNA 1) did not have to wear a gown because the Enhanced Barrier Precaution signage was only for Certified Nursing Assistant (CNA) who changes incontinent brief. RNA 1 stated she (RNA 1) transferred Resident 3 from bed to wheelchair and walked Resident 3 in the hallway.
During a concurrent interview and record review on 9/5/2024 at 12:42 p.m., with IP 1, the facility's policy and procedure (PnP) titled, Care Planning dated 10/24/2022 was reviewed. The PnP indicated, The Care Plan serves as a course of action where the resident (residents' family and or guardian or other legally authorized representative), residents Attending Physician, and Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together) work to help the resident move toward resident-specific goals that address the residents medical, nursing and mental and psychosocial needs. Each resident's comprehensive care plan will describe the following: A. Services that are to be furnished to attain and maintain the residents highest practicable physical, mental, and psychosocial well-being. IP 1 stated they do not create a care plan for Enhance Barrier Precaution. IP 1 stated the EBP signage should be enough to remind staff on what Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) to use.

Based on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 3) and four of five sampled staff (Director of Nursing [DON], Licensed Vocational Nurse 1 [LVN 1], Restorative Nursing Assistant 1 [RNA 1] and RNA 2) when the facility had Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) positive residents by;
a. Failing to ensure DON wore N95 mask (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) with lower strap secured behind the neck while walking in the hallway.
b. Failing to ensure LVN 1 wore N95 with upper strap behind the head and the lower strap behind the neck while speaking to the Surveyor.
c. Failing to ensure RNA 1 wore protective gown when transferring and walking Resident 3 in the hallway who was on Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission [transfer] of multidrug-resistant organisms [MDRO- bacteria that have become resistant to certain antibiotics that can no longer be used to control or kill the bacteria]).
d. Failing to ensure RNA 2 wore N95 with upper strap behind the head and the lower strap behind the neck while distributing coffee to residents in the dining room.
These deficient practices had the potential for spread of infection among residents and staff.
Findings:
a. During an observation on 8/23/2024 at 8:36 a.m., observed DON walking in the hallway wearing an N95 mask with the lower strap hanging in front of her (DON) neck.
During a concurrent observation and interview on 8/23/2024 at 8:38 a.m., with LVN 1 in the hallway, observed DON walking in the hallway with her (DON) N95 lower strap hanging in front of her (DON) neck. LVN 1 stated DON's N95 lower strap was not secure behind the neck.
During a concurrent observation and interview on 8/23/2024 at 8:39 a.m., with Compliance Officer (CO) in the hallway, CO witnessed DON's N95 lower strap in front of her (DON) neck. CO stated DON should secure the lower strap of the N95 behind the neck. Observed CO followed DON in the conference room and CO informed DON to put the N95 lower strap behind the neck.
During an interview on 8/23/2024 at 8:40 a.m., DON stated she (DON) was in a hurry to attend to the Surveyor and did not notice the N95 lower strap was not properly worn.
During an interview on 8/23/2024 at 10:46 a.m., Infection Preventionist 1 (IP 1) stated the facility had three COVID-19 positive residents and the facility's policy for masking was for all staff and visitors to wear N95 when inside the facility. IP 1 stated the proper way of wearing N95 was to put upper strap behind the head and the lower strap behind the neck. IP 1 stated the DON should wear the N95 properly to help prevent the spread of COVID-19 and to protect herself (DON).
During a record review of facility's policy and procedure titled, Personal Protective Equipment dated 7/1/2023 indicated, The facility may use National Institute for Occupational Safety and Health (NIOSH) certified N95 filtering facepiece respirators to prevent the risk of exposure to infectious respiratory illnesses. If the facility utilizes N95 mask, the facility will follow their respiratory protection program to include training, fit testing.
During a record review of the NIOSH's How to Use the N95 Respirator dated 5/16/2023, indicated, Pull the top strap over your head, placing it near the crown. Then, pull the bottom strap over and place it at the back of your neck, below your ears. Do not crisscross the straps. Make sure the straps lay flat and are not twisted.
b. During an observation on 8/23/2024 at 8:37 a.m., observed LVN 1 with N95 straps tied together and secured behind the ear.
During an interview on 8/23/2024 at 10:46 a.m., IP 1 stated LVN 1 was not allowed to customize their N95 mask. IP 1 stated N95 was fit tested to ensure it was well fitted and prevent the spread of COVID-19.
During a record review of facility's policy and procedure titled, Personal Protective Equipment dated 7/1/2023 indicated, The facility may use NIOSH certified N95 filtering facepiece respirators to prevent the risk of exposure to infectious respiratory illnesses. If the facility utilizes N95 mask, the facility will follow their respiratory protection program to include training, fit testing, etc.
During a record review of the NIOSH's How to Use the N95 Respirator dated 5/16/2023, indicated, Pull the top strap over your head, placing it near the crown. Then, pull the bottom strap over and place it at the back of your neck, below your ears. Do not crisscross the straps. Make sure the straps lay flat and are not twisted.
c. During a record review of Resident 3's admission Record indicated the facility admitted Resident 3 on 1/31/2022 with diagnoses that included unspecified (unconfirmed) heart failure (occurs when the heart muscle doesn't pump blood as well as it should), diabetes mellitus (uncontrolled elevated blood sugar) and unspecified retention of urine.
During a record review of Resident 3's History and Physical, dated 11/28/2023, indicated Resident 3 had the capacity to understand and make decisions.
During a record review of Resident 3's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/19/2024, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.
During an observation on 8/23/2024 at 8:43 a.m., outside of Resident 3's room, it was observed that an Enhanced Barrier Precaution signage was posted by Resident 3's right side of the door.
During a concurrent observation and interview on 8/23/2024 at 8:44 a.m., with Registered Nurse 1 (RN 1) from Resident 3's door, observed Resident 3 seated on a wheelchair, RNA 1 standing in front of Resident 3 wearing N95 and gloves while holding onto Resident 3's urinary drainage bag. Observed RNA 1 hanging the urinary drainage bag to Resident 3's wheelchair. RN 1 stated RNA 1 walked Resident 3 and was not providing care and did not need to wear a gown.
During an interview on 8/23/2024 at 8:45 a.m., RNA 1 stated she (RNA 1) walked Resident 3 in the hallway. RNA 1 stated she (RNA 1) did not have to wear a gown because the Enhanced Barrier Precaution signage was only for Certified Nursing Assistant (CNA) who changes incontinent brief. RNA 1 stated she (RNA 1) transferred Resident 3 from bed to wheelchair and walked Resident 3 in the hallway and transferred Resident 3 back to the wheelchair.
During an interview on 8/23/2024 at 10:46 a.m., IP 1 stated RNA 1 should wear the gown when transferring Resident 3 who was on Enhanced Barrier Precaution.
During a record review of facility's policy and procedure titled, Standard and Enhanced Precautions dated 4/1/2024, indicated, Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of MDRO colonization (the presence of bacteria on a body surface like on the skin, mouth, intestines or airway without causing disease in the person) when contact precautions do not otherwise apply and/or transmission such as presence of indwelling (inside the body) devices (urinary catheter [a flexible tube used to empty the bladder and collect urine in a drainage bag], feeding tube, endotracheal [is placed through the mouth to the windpipe to help assist breathing during surgery and medical emergencies] or tracheostomy tube [is inserted through the opening and into the windpipe to help you breathe], vascular catheters [adevice used to draw blood and give treatments, including intravenous fluids, drugs, or blood transfusions]) and wounds or presence of unhealed pressure ulcers (localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences). For residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities:
i. Dressing
ii. Bathing/showering
iii. Transferring
iv. Providing hygiene
v. Changing linens
vi. Changing briefs or assisting with toileting
vii. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator
viii. Wound care: any skin opening requiring a dressingOutside the resident's room, EBP are used when performing transfers or assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility for more than a brief amount of time.
d. During an observation on 8/23/2024 at 9:49 a.m., in the dining room, observed RNA 2 filling cups with coffee. RNA 2 was observed wearing an N95 with the upper and lower straps tied together and secured behind the ear.
During an interview on 8/23/2024 at 9:54 a.m., RNA 2 stated she (RNA 2) cut the N95 straps and tied it together to make it loose because the N95 was so tight on her. RNA 2 stated she was aware of the COVID-19 residents in the facility and aware that all staff needs to wear N95 mask to prevent the spread of COVID-19.
During an interview on 8/23/2024 at 10:46 a.m., IP 1 stated RNA 2 was not allowed to customize their N95 mask. IP 1 stated N95 was fit tested to ensure it was well fitted and prevent the spread of COVID-19.
During a record review of the NIOSH on how to use the N95 respirator dated 5/16/2023, indicated, Pull the top strap over your head, placing it near the crown. Then, pull the bottom strap over and place it at the back of your neck, below your ears. Do not crisscross the straps. Make sure the straps lay flat and are not twisted.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life by failing to ensure Certified Nursing Assistant 8 (CNA 8) sat at eye level while providing feeding assistance for one of one residents (Resident 109) reviewed under the Dignity care area.
This deficient practice had the potential to result in a decrease in psychosocial well-being and a lack of awareness of the resident's ability to safely swallow resulting in choking.
Findings:
During a review of Resident 109's admission Record, it indicated the facility admitted the resident on 3/11/2022 with diagnoses that included Alzheimer's dementia (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dysphagia oropharyngeal phase (difficulty initiating a swallow) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and muscle weakness.
During a review of Resident 109's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/2/2024, the MDS indicated the resident sometimes was able to understand others and sometimes was able to make herself understood. The MDS indicated the resident required partial/moderate assistance from staff while eating and rolling side to side; and was dependent on staff for oral hygiene, toileting, bathing, dressing, and moving from sit to stand and transfers.
During a review of Resident 109's history and physical dated 6/26/2024, it indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 109's physician orders indicated an order for a no salt added diet, pureed texture, regular consistency dated 6/25/2024.
During a review of Resident 109's Care Plan (CP) titled, Therapeutic Diet secondary to . Dysphagia: At Risk for Choking/Aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident) . Needs Assistance in Eating ., initiated on 3/14/2022, the CP indicated Resident 109 would tolerate food texture as evidenced by no choking or aspiration. The CP interventions indicated to do the following:
1.
Set up tray and assist resident at mealtime as necessary.
2.
Follow safe swallow precautions as ordered.
3.
Monitor for tolerance of food/liquid texture.
4.
Encourage the resident to consume at least 85 percent (a unit of measurement) of her dietary intake daily.
During an observation on 8/6/2024 at 8:07 a.m., observed CNA 8 standing in the hallway spooning food from Resident 109's breakfast tray into the resident's mouth CNA8 was not at eye level with the resident while providing feeding assistance.
During an observation on 8/6/2024 at 8:10 a.m. Licensed Vocational Nurse 8 (LVN 8) was observed to walk up to CNA 8 who was providing feeding assistance to Resident 109. CNA 8 stated that she could sit down. CNA 8 walked into Resident 109's room and exited, and then walked down the hallway toward the dining room. CNA 8 returned with a chair, placed the chair next to Resident 109 and continued to provide feeding assistance while seated.
During an interview on 8/6/2024 at 8:20 a.m., LVN 8 stated she asked CNA 8 if she would continue to provide feeding assistance to Resident 109 by standing or sitting and CNA 8 replied she would sit. LVN 8 stated CNAs are supposed to sit while providing feeding assistance out of respect to the residents and it was the right way to protect the resident. LVN 8 stated it was better to sit with a resident to speak with them and the resident also needs reminders to swallow the food in her mouth.
During an interview on 8/6/2024 at 9:40 a.m., CNA 8 stated she did not sit while providing feeding assistance to Resident 109 because she was nervous. CNA 8 stated she must sit face to face with the resident while providing feeding assistance to be able to see the resident's mouth and make sure they are receiving the food.
During an interview on 8/8/2024 at 11:31 a.m., Registered Nurse 2 (RN 2) stated CNAs should sit when assisting a resident with feeding for patient safety first. RN 2 stated CNAs must concentrate on what they are doing and be at eye level in case the resident has swallowing difficulties and to prevent choking. RN 2 stated CNAs also must make sure to have eye contact to encourage the resident, because if someone is standing over them it does not encourage the resident to eat.
During a review of the facility's policy and procedure titled, Eating and Swallowing, last reviewed on 1/29/2024, the policy indicated the certified nursing assistant will have knowledge of aspiration, be able to promote safe swallowing through proper positioning, and understand the sequence of food progression and its implications for safe swallowing. Environmental considerations include, create a calm atmosphere, provide ample time for the meal, and utilize consistent seating.
During a review of the facility's policy and procedure titled, Resident Rights, last reviewed on 1/29/2024, the policy indicated the purpose of the policy was to ensure that the facility provides an environment and services that meet each resident's individual needs. The policy further indicated the facility's environment is designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and wellbeing. Facility staff are to interact with the resident in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains each resident's dignity.
During a review of the facility policy and procedure titled, Privacy and Dignity, last reviewed on 1/29/2024, the policy indicated the facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality. Staff assists the resident in maintaining self-esteem and self-worth. The facility promotes dignity in dining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 227's admission Record, the admission record indicated the facility admitted Resident 227 on 12/26/2023, with diagnoses that included glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called optic nerve) and dysphagia (difficulty swallowing).
During a review of Resident 227's Care Plan titled, Family Education related to resident's safe feeding/eating precautions, initiated on 5/16/2024, indicated to instruct visitors that either feeding or resident eating with visitor should be under close supervision of staff.
During a review of Resident 227's H&P, dated 5/22/2024, indicated Resident 227 had the capacity to understand and make decisions.
During a review of Resident 227's MDS, dated [DATE], indicated Resident 227 had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision and had intact cognition (gaining of knowledge and understanding).
During a review of Resident 227's IDT, dated 6/26/2024, the IDT indicated Resident 227 was alert and oriented times 3 (alert and oriented to person, place, and time). Knows his vitamins and supplements and wanted to keep his medications at the bedside.
During an observation on 8/6/2024, at 8:45 a.m., inside Resident 227's room, Resident 227 was observed taking one tablet from a medication bottle labeled Areds 2.
During a review of Resident 227's Order Summary Report, (Date?) the report did not indicate a physician's order for Areds 2 (supplement for age-related macular degeneration [an eye disease that can blur the central vision]).
During a concurrent interview and record review on 8/6/2024, at 8:47 a.m., with LVN 3, a review of Resident 227's Order Summary Report and Medication Administration Record (MAR) was done. LVN 3 stated there was no order for the resident to self-administer medications and there was no okay to keep medications at the bedside on the Order Summary Report. LVN 3 also stated there was no order for the medication Areds 2 and she does not know how the bottle of Areds 2 was left at the resident's bedside. LVN 3 stated it must be the family member that gave the medication, Areds 2, to the resident.
During a concurrent interview and record review on 8/6/2024, at 9:05 a.m., with the Minimum Data Set Coordinator (MDSC), a review of Resident 227's Order Summary Report, Assessment for Self-Administration of Medication, and IDTs was done. The MDSC stated there was no order for Areds 2 or an okay to self-administer medications on the Order Summary Report. The MDSC also stated there was no Medication Self-Administration Assessment done on admission for Resident 227. The MDSC confirmed there was a desire from Resident 227 to keep supplements and vitamins at the bedside of the resident during an IDT done on 6/26/2024, but they failed to assess the resident for self-administration of medications. The MDSC stated it was important to assess the resident for their ability to self-administer their medications to honor the resident's rights. The MDSC stated after assessing the resident for their ability to self-administer medication they should get an order from the physician for the resident to self-administer medication to ensure safe use.
During an interview on 8/9/2024, at 4:52 p.m., with the DON, the DON stated an assessment for medication self-administration should be done on admission. The DON stated they should honor the resident's right to self-administer medications. The DON stated the resident was a researcher and was alert and oriented and was very much capable of taking his own medications. The DON stated the failure of the staff to perform an assessment for medication self-administration to the resident deprived the resident of his right to self-determination and the failure of the staff to ensure there was an order for the medication Areds 2 had predisposed the resident to taking unnecessary medications and to adverse effects of the medication that can cause harm to the resident.
During a review of the facility's most recent policy and procedure titled, Resident Rights, last reviewed on 1/29/2024, indicated to self-administer medication, if the Interdisciplinary Team determines it is safe.
During a review of the facility's recent policy and procedure titled, Medication- Self Administration, last reviewed on 1/29/2024, the policy indicated Residents who request to perform medication self-administration will be assessed for capacity. During the admission process, residents will be asked if they wish to self-administer medications. Those residents who wish to self-administer medications will be assessed during the admission process to ensure they have the necessary knowledge and skill(s) to safely self-administer medications.
A. Additional assessments will be completed at least quarterly based on OBRA timeframes.
If the resident is assessed as clinically appropriate for medication self-administration, by the IDT, the Licensed Nurse obtains a physician's order for self-administration of selected medications.
A. The resident's record should contain documentation that demonstrates that he/she was part of the IDT process in determining whether self-administration is safe and appropriate.
The IDT develops and implements a care plan for medication self-administration. The care plan will identify:
i. Where the medications are stored.
ii. Education for resident/family regarding medication self-administration process; specific medication information and safe, effective use of medications.
a. Obtaining medication.
b. Administering medication according to physician order.
iii. How Licensed Nurses will validate that medications are taken as ordered by the attending physician; and
iv. How non-compliance and/or refusal to take medications will be managed.
Based on observation, interview, and record review, the facility failed to ensure their medication self-administration was clinically appropriate and failed to honor the resident's right to self-administer medications for two of two sampled residents reviewed during general observations and investigations under residents' rights (Resident 177 and 227) by failing to:
1. Perform a medication self-administration assessment for Resident 177.
2. Perform a medication self-administration assessment on Resident 227 after the Interdisciplinary Team (IDT - professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) had determined the resident wanted to keep the medications at the bed side on 6/26/2024 to self-administer.
These deficient practices violated the residents' right to self-administer medications and had a potential to result in the resident to experience adverse effects (an undesired effect of a drug or other type of treatment) of the medication.
Cross-reference F656, F689, and F755.
Findings:
1. During a review of Resident 177's admission record, the admission record indicated Resident 177 was admitted to the facility on [DATE] with diagnoses that included, hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than the normal), hyponatremia (a condition that occurs when the level of sodium in the blood is too low), and allergic rhinitis (also known as seasonal allergies, a response causing itchy, watery eyes, sneezing, and other similar symptoms).
During a review of Resident 177's Order Summary Report, dated 6/28/2022, the order summary report indicated to administer to Resident 177 sodium chloride tablet one gram (a unit of measure for mass), two tablets by mouth two times a day related to hypo-osmolality and hyponatremia.
During a review Resident 177's History and Physical (H&P), dated 7/2/2023, the H&P indicated Resident 177 had fluctuating capacity to understand and make decisions.
During a review of Resident 177's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/26/2024, the MDS indicated Resident 177 was able to understand and make decisions, required setup assistance with eating, required touching assistance or supervision with walking up to 150 feet (a unit of measure for length), and required moderate assistance to total dependence on facility staff for surface-to-surface transfers, hygiene, bathing or showering, and dressing.
During a concurrent observation and interview with Resident 177, on 8/5/2024, at 10:26 a.m., inside Resident 177's room, Resident 177's bedside table contained a small clear plastic cup containing two white circular tablets and a saline spray bottle. Resident 177 stated the two white circular tablets in the medication cup were her sodium tablets and she takes the medications with food. Resident 177 stated the nurse gave her the tablets in the morning and she will take the tablets after eating lunch. Resident 177 further stated she uses the saline spray as needed to help her breathe.
During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on 8/8/2024, at 9:35 a.m., Resident 177's medical record was reviewed and LVN 1 confirmed Resident 177 did not have a medication self-administration assessment. LVN 1 stated Resident 177 is alert and oriented and told her to leave her sodium chloride tablets at the bedside so she can take it later. LVN 1 stated it is important to perform a medication self-administration assessment for resident safety, to accommodate the resident's needs, and respect the resident's rights. LVN 1 further stated, if a medication self-administration assessment is not performed, it is possible that staff would be unaware if residents are safe to take medications on their own.
During an observation on 8/8/2024, at 10:15 a.m., inside Resident 177's room, Resident 177's bedside table contained a small clear plastic cup with two white circular tablets.
During an interview with the Director of Nursing (DON), on 8/9/2024, at 8:55 a.m., the DON stated for better practices and safety, the facility chooses not to have residents self-administer medications. The DON stated medication self-administration assessments should be done on admission, quarterly, and as needed, such as during a significant change of condition. The DON further stated Resident 177 did not have a medication self-administration assessment performed.
During a review of Resident 177's medical record, the medical record did not indicate a medication self-administration assessment was performed.
During a review of Resident 177's Order Summary Report, (What date?) the order summary report did not indicate an order for saline solution nasal spray (a mixture of salt and water that is sprayed into the nose).
During a review of Resident 177's Order Summary Report, (What was the date of the summary report?) the order summary report did not indicate an order for self-administration for medication.
During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed 1/29/2024, the P&P indicated state and federal laws guarantee certain basic rights to all residents of the facility which include, but are not limited to, self-administer medication, if the IDT determines it is safe.
During a review of the facility's P&P titled, Medication - Self Administration, last reviewed 1/29/2024, the P&P indicated during the admission process, residents will be asked if they wish to self-administer medications. The P&P indicated residents who wish to self-administer medications will be assessed during the admission process to ensure they have the necessary knowledge and skills to safely self-administer medications. The P&P indicated if the resident is assessed as clinically appropriate for medication self-administration by the IDT, the licensed vocational nurse obtains a physician's order for self-administration of selected medications. The P&P indicated the resident's record should contain documentation that demonstrates that he/she was part of the IDT process in determining whether self-administration is safe and appropriate. The P&P further indicated the IDT develops and implements a care plan for medication self-administration and will identify where medications are stored, education for resident or family regarding medication self-administration process, specific medication information and safe, effective use of medications, obtaining medication, administering medications according to physician's order, how the licensed nurse will validate that medications are taken as ordered by the attending physician, and how non-compliance and/or refusal to take medications will be managed.
During a review of the facility's P&P titled, Medication Labels, last reviewed 1/29/2024, the P&P indicated when medication is ordered for use at the bedside, the medication label contains, in addition to the instruction for use, a notation that it may be self-administered and stored at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for two of two sampled residents (Resident 159 and 14) reviewed under the Environment task.
This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers.
Findings:
1. During a review of Resident 159's admission record, the admission record indicated the facility originally admitted Resident 159 on 10/14/2021 and readmitted the resident on 12/15/2021 with diagnoses that included generalized muscle weakness and a history of falling.
During a review of Resident 159's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/12/2024, the MDS indicated Resident 159 had mild cognitive impairment (difficulty understanding and making decisions) and was independent or required setup assistance to moderate assistance with activities of daily living, such as eating, hygiene, bathing, toileting, dressing, walking, and surface-to-surface transfers.
During a review of Resident 159's Care Plan, last reviewed 7/16/2024, the care plan indicated Resident 159 was at risk for fall secondary to impaired vision and unsteady balance during transitions and walking, has impairment of upper and lower extremities on both sides. The care plan further indicated interventions included keeping the call light within easy reach and answer promptly.
During a review of Resident 159's History & Physical (H&P), dated 7/20/2024, the H&P indicated Resident 159 had fluctuating capacity to understand and make decisions.
During a concurrent observation and interview with Resident 159, on 8/5/2024, at 9:22 a.m., inside Resident 159's room, Resident 159 was lying down in bed with the head of his bed elevated greater than 40 degrees, and the call light was on the floor, to the left of the resident's bed. Resident 159 stated he was unable to reach for his call light. Resident 159 attempted to get his call light from the floor but was unsuccessful.
During a concurrent observation and interview with Certified Nursing Assistant (CNA) 1, on 8/5/2024, at 9:25 a.m., inside Resident 159's room, CNA 1 confirmed Resident 159's call light was on the floor and outside of the resident's reach. CNA 1 stated she was assigned to Resident 159 and stated Resident 159 has difficulty grabbing items, needs assistance with using the bathroom, and is able to use the call light. CNA 1 stated when call lights are outside of a resident's reach, the resident has the potential to get out of bed on their own when they are not supposed to. CNA 1 further stated when residents are not able to reach the call light and call for help, the residents can potentially injure themselves from falling.
During an interview with the Director of Nursing (DON), on 8/9/2024, at 8:55 a.m., the DON stated call lights should be within easy reach of residents, regardless of whether the resident is in bed, wheelchair, or chair so that the facility can attend to the resident's needs. The DON further stated if the call light is not within reach, the resident's needs will not be met.
During a review of the facility's policy and procedure (P&P) titled, Communication, last reviewed on 1/29/2024, the P&P indicated to place the call light or call device close to the person.
During a review of the facility's P&P titled, Call Light, last reviewed on 1/29/2024, the P&P indicated all residents shall have immediate access to a functioning call light at all times, ensuring they can easily signal for assistance whenever needed. The P&P further indicated the call light must be within the resident's reach at all times, including when in bed, in a chair, or in the bathroom.
2. During a review of Resident 14's admission Record, the admission record indicated the facility admitted Resident 14 on 6/11/2021 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), age-related osteoporosis (a disease that causes bones to become weak and brittle), and sarcopenia (loss of muscle mass and strength that can affect older adults).
During a review of Resident 14's Care Plan titled, Minimal Difficulty Hearing: At Risk for Communication Deficit, initiated 5/19/2023, it indicated to keep the call light within easy reach and answer promptly.
During a review of Resident 14's Care Plan titled, Short- and Long-Term Memory/Moderately Impaired Decision Making ., initiated on 5/19/2023, the CP indicated to encourage the resident to use the call light for assistance and to keep the call light within easy reach and answer promptly.
During a review of Resident 14's H&P, dated 6/28/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 sometimes was able to understand others and sometimes was able to make herself understood. The MDS indicated Resident 14 was dependent on staff for oral hygiene, toileting, bathing, and personal hygiene; and the resident required substantial/maximal assistance with mobility.
During an observation on 8/9/2024 at 12:25 p.m., Resident 14 was observed sitting in a wheelchair (WC) between the resident's right side of the bed and the wall near the entrance door. The call light was resting on top of the resident's bed, not within reach of the resident. Resident 14 did not respond to the surveyor's questions and no staff were present in the room.
During an observation and interview on 8/9/2024 at 12:43 p.m., CNA 2 entered Resident 14's room and stated the resident was in the WC and the call light was on the resident's bed. CNA 2 stated Resident 14 was a total assist resident, and the call light was not within reach. CNA 2 stated the call light did not need to be within reach of the resident. CNA 2 exited the room. The call light remained on the bed out of reach of the resident.
During an observation and interview on 8/9/2024 at 12:45 p.m., Licensed Vocational Nurse 4 (LVN 4) entered Resident 14's room and stated all facility resident's need the call light within reach. LVN 4 stated all facility residents need to be able to call for help even if the resident is not always able to use the call light. LVN 4 exited the room and the call light remained on the bed out of reach of the resident.
During an interview on 8/9/2024 at 1:52 p.m., the DON stated all residents need to have the call light within reach and it does not matter if the resident can use it. The DON stated it is not up to the CNA to decide if the resident is able to use the call light or not. The DON stated the importance of the call light is for staff to be able to attend to the resident's needs. The DON stated when the call light is not within reach, there is the possibility that residents would not have their needs met resulting in the resident becoming restless and attempting to get up resulting in a fall.
During a review of the facility's policy and procedure titled, Call Light last reviewed on 1/29/2024, the policy indicated all residents shall have immediate access to a functioning call light at all times, ensuring they can easily signal for assistance whenever needed. The call light must be within the resident's reach at all times, including when in bed, in a chair, or in the bathroom.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report and monitor changes of condition ([COC] major decline or improvement in a resident's status that will not resolve itself without intervention) for two of four sampled residents (Resident 119 and Resident 139) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns by failing to:
1. Report Resident 119's decline in ROM to both arms and legs during Restorative Nursing Assistant ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) sessions in accordance with the facility's job description titled, Restorative Nursing Assistant, revised 10/2011, and policy tilted, Change of Condition Notification, revised 1/1/2017 and reviewed 1/29/2024.
2. Monitor Resident 139's decline in cognition and weakness indicated on the Registered Nurse (RN)/Licensed Vocational Nurse (LVN) Progress Notes, dated 7/24/2024, for 72 hours in accordance with the facility's policy titled, Change of Condition Notification, revised 1/1/2017 and reviewed 1/29/2024.
3. Report to Resident 139's physician and responsible party or family and monitor Resident 139's decline in ROM to both arms and legs from minimum ROM limitation (less than 25 percent [%] ROM loss) on the Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs), dated 3/5/2024 and 6/3/2024, to moderate ROM limitation (25-50% ROM loss) on the JMA, dated 8/6/2024, for 72 hours in accordance with the facility's policy titled, Change of Condition Notification, revised 1/1/2017 and reviewed 1/29/2024.
These failures prevented Resident 119 and 139 from receiving intervention to improve mobility and ROM, including intervention to prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness).
Cross reference F688 and F726.
a. During a review of Resident 119's admission Record, the facility admitted resident 119 on 5/11/2017 with diagnoses including Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life), dementia (decline in mental ability severe enough to interfere with daily life), age-related osteoporosis (medical condition in which the bones become brittle and fragile from loss of tissue), dysphagia (difficulty swallowing).
During a review of Resident 119's census (record of hospitalizations, room changes, and payor source changes), the census indicated Resident 119 resided at the facility since 5/11/2017 and was never hospitalized .
During a review of Resident 119's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 5/13/2024, the MDS indicated Resident 119 had unclear speech, rarely expressed ideas, and wants, rarely understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 119 had ROM impairments in both arms and legs and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for eating, toileting, showering/bathing, upper and lower body dressing, rolling to both sides in bed, and chair/bed-to-chair transfers.
During a review of Resident 119's physician orders, dated 11/9/2020, the physician orders indicated to provide Resident 119 with passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to both arms and legs, every day.
During a review of Resident 119's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 6/8/2022, the OT Evaluation indicated Resident 119's ROM to the right elbow, both wrists, and both hands were within functional limits (WFL, sufficient movement without significant limitation). The OT Evaluation indicated Resident 119's impaired ROM included right shoulder flexion (lifting the arm upward) 0 to 80 degrees (0-80 degrees, normal 0-180 degrees), right shoulder abduction (lifting the arm up and away from the body) 0-75 degrees (normal 0-180 degrees), left shoulder flexion 0-40 degrees, left shoulder abduction 0-40 degrees, and left elbow extension (straightened) was limited to 80 degrees (normal 0 degrees, positioned in 80 degrees of elbow flexion [bend]).
During a review of Resident 119's OT Treatment Encounter Notes, dated 8/19/2022, the OT Treatment Encounter Notes indicated Resident 119's ROM included right shoulder flexion 0-90 degrees (shoulder height), right shoulder abduction 0-80 degrees, right elbow extension to 20 degrees (elbow positioned in 20 degrees of flexion), left shoulder flexion 0-50 degrees, left shoulder abduction 0-50 degrees, and left elbow extension to 30 degrees (elbow positioned in 30 degrees of elbow flexion).
During a review of Resident 119's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 119 safely wore elbow splints to both elbows for two hours without signs of redness, swelling, discomfort, or pain. The OT Discharge Summary recommendations included to provide Resident 119 with a RNA program for PROM and to apply both elbow splints for two hours daily as tolerated.
During a review of Resident 119's Restorative Nursing Program (RNP) Referral/Care Plan, dated 8/19/2022, the RNP Referral/Care Plan indicated Occupational Therapist 2 (OT 2) reviewed Resident 119's program with Restorative Nursing Assistant 5 (RNA 5) for the application to both elbow splints for two hours.
During a review of Resident 119's physician orders, dated 8/19/2022, the physician orders indicated for the RNA to apply both elbow splints for two hours daily as tolerated.
During a review of Resident 119's Registered Nurse (RN)/Licensed Vacation Nurse (LVN) Progress Notes, dated 10/4/2022, the RN/LVN Progress Notes indicated Resident 119 was on RNA program for both PROM exercises to both arms and both legs and application of both elbow splints for two hours as tolerated. The RN/LVN Progress Notes indicated Resident 119 was noted with abnormal posture (position in which someone hold their body) while sitting up in the wheelchair and/or lying in bed and was at-risk for developing contractures. The RN/LVN Progress Notes indicated Resident 119 will continued to be monitored.
During a review of Resident 119's RN/LVN Progress Notes, dated 10/5/2022, the RN/LVN Progress Notes indicated Resident 119 continued to have abnormal posture while sitting up in the wheelchair and lying in bed and was at-risk for developing contractures. The RN/LVN Progress Notes indicated a discussion with family included providing Resident 119 with a Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) and OT Evaluation to ensure correct body alignment, positioning, and prevention of contractures.
During a review of Resident 119's Joint Mobility Screening (JMA completed by PT and OT), dated 10/6/2022, the Joint Mobility Screening indicated Resident 119's ROM included severe ROM limitation in the left shoulder, moderate ROM limitation in the right shoulder, minimum ROM limitation in both elbows and knees, and full ROM in both hands, hips, and ankles. The Joint Mobility Screening recommendations indicated for Resident 119 to receive PT and OT Evaluations and to continue with the RNA program.
During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 10/6/2022, the OT Evaluation indicated Resident 119 was seen for an Evaluation Only (no intervention recommended). The OT Evaluation indicated Resident 119's ROM was WFL in both wrists and hands but had impairment in both shoulders and elbows, including right shoulder flexion 0-90 degrees, right elbow extension to 20 degrees, left shoulder flexion 0-50 degrees, and left elbow extension to 30 degrees. The OT Evaluation Only indicated Resident 119 was recently provided with both elbow splints and did not have any significant change in condition requiring OT intervention.
During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 10/6/2022, the PT Evaluation indicated Resident 119 was referred to PT due to a new onset of decreased ROM, decreased postural alignment when sitting up in the wheelchair, and at-risk for contracture development. The PT Evaluation indicated Resident 119's ROM in both hips and ankles were WFL but hand impaired ROM to both knees, including right knee extension limited to 30 degrees (knee positioned in 30 degrees of knee flexion) and left knee extension limited to 15 degrees (knee positioned in 15 degrees of knee flexion).
During a review of Resident 119's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 119 tolerated sitting up in a standard wheelchair with a cushioned seat for four hours, had 20 degrees of extension on the right knee, and tolerated a right knee extension splint for two hours. The PT Discharge recommendations included for the RNA to provide PROM and apply the right knee extension splint.
During a review of Resident 119's RNP Referral/Care Plan, dated 10/28/2022, the RNP Referral/Care Plan indicated the Physical Therapist 3 (PT 3) reviewed RNA 5 Resident 119's program with RNA 5 for PROM and application of the right knee splint for two hours.
During an observation on 8/6/2024 at 3:45 p.m. in the bedroom, Resident 119 was being transferred from the bed to a gerichair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) using a mechanical lift (used to transfer residents between surfaces). Resident 119 was fully dressed, did not have any splints applied to either arm or leg. Resident 119's both knees were bent while sitting up in the gerichair.
During a concurrent observation and interview on 8/7/2024 at 9:10 a.m. in the dining room with Restorative Nursing Assistant 2 (RNA 2), Resident 119 was sitting upright in the gerichair without any splints applied to either arm or leg. RNA 2 stated Resident 119 was seen for ROM exercises to both arms and legs and the splints were applied this morning. RNA 2 stated Resident 119's Certified Nursing Assistant (CNA) may have removed the splints.
During an observation on 8/7/2024 at 12:40 p.m. in the bedroom, RNA 2 stated Resident 119's primary (routinely assigned) RNA was RNA 5. RNA 2 stood on the right side of Resident 119's bed. RNA 2 performed ROM exercises on Resident 119's right shoulder but could not lift the right arm to shoulder height. RNA 2 bent and extended the right elbow to perform ROM exercises but could not fully extend the right elbow, which remained in a bent position. RNA 2 performed wrist flexion (bent down) and wrist extension (bent up) exercises but did not perform any exercises to Resident 119's right hand. RNA 2 massaged Resident 119's right arm into extension prior to applying the right elbow splint upside down. RNA 2 bent and extended Resident 119's right hip and knee at the same time, causing Resident 119 to moan with a facial grimace (expression of pain or strong dislike). RNA 2 could not extend the right knee, which continued to have a bend of approximately 90 degrees. RNA 2 performed exercises to the right ankle into rotation, dorsiflexion (ankle bent with toes pointing toward the body), and plantarflexion (ankle bent with toes pointing away from the body). RNA 2 applied Resident 119's right knee splint, which was fixed in a nearly straight position, and fastened a strap over the right knee. RNA 2 stood on the left side of Resident 119's bed and performed ROM exercises on the left shoulder. RNA 2 lifted the left arm higher than the right shoulder joint but could not lift the left arm to shoulder height. RNA 2 bent and extended the left elbow to perform ROM exercises but could not fully extend the left elbow, which remained in a bent position. RNA 2 performed wrist flexion and extension exercises but did not perform any exercise to Resident 119's left hand. RNA 2 applied the left elbow splint. RNA 2 bent and extended Resident 119's left hip and knee at the same time. RNA 2 could not fully extend Resident 119's left hip and knee. RNA 2 then performed ankle exercises to Resident 119's left ankle into rotation, dorsiflexion, and plantarflexion.
During an interview on 8/7/2024 at 1:04 p.m. with RNA 2, RNA 2 stated the splints will be checked every 30 minutes and will remove the splints after 2 hours. RNA 2 stated ROM was not performed to Resident 119's hands because both hands were good and stated Resident 119 could straighten the fingers.
During a concurrent observation and interview on 8/7/2024 at 1:09 p.m. with the Director of Rehabilitation (DOR) and Physical Therapy Assistant 1 (PTA 1) in the bedroom, Resident 119 was observed lying in bed while wearing both elbow splints and the right knee splint. PTA 1 stated Resident 119's right knee splint was applied lower than the knee. PTA 1 checked the right knee splint and stated Resident 119's knee splint was set to 30 degrees of extension but Resident 119's right knee was bent to approximately 90 degrees. PTA 1 stated the right knee splint did not fit Resident 119 because the bend in the splint did not match the bend in Resident 119's knee. PTA 1 stated an inappropriately fitted splint could put pressure on the skin and bones of Resident 119's right knee, which could result in pressure sores (localized damage to the skin and underlying soft tissues over a bony prominence) and dislocation of the right knee.
During a concurrent observation and interview on 8/7/2024 at 1:19 p.m. with the DOR and PTA 1 in the bedroom, the DOR removed Resident 119's right knee splint. The skin on Resident 119's right knee, which was directly under the strap of the knee splint, had redness. PTA 1 stated Resident 119 had redness to the pressure sensitive area of the right kneecap. The DOR observed Resident 119's elbow splints, stated the right elbow splint was applied upside down, and adjusted both of Resident 119's elbow splints.
During a concurrent observation and interview on 8/8/2024 at 8:30 a.m. in the bedroom with RNA 5, Resident 119 was lying in bed awake with the head-of-bed (HOB) fully elevated and the elbow splint applied to the right arm. RNA 5 stated Resident 119 was usually nonverbal and that RNA 5 was Resident 119's primary RNA. Resident 119's right kneecap was observed with pink areas on the skin. RNA 5 stated Resident 119's splints were applied this morning at approximately 7:00 a.m. but the right knee and left elbow splints were removed after 15 minutes due to skin redness.
During a concurrent observation and interview on 8/8/2024 at 9:05 a.m. with Physical Therapist 1 (PT 1) in the bedroom, Resident 119's ROM in both knees and the right knee extension splint were observed. Resident 119 was lying in bed with the HOB fully elevated and both knees were in bent positions. PT 1 extended both knees and stated Resident 119 had contractures to both knees with right extension to 90 degrees (right knee positioned in 90 degrees of flexion) while the left knee extension to 55 degrees (left knee positioned in 50 degrees of flexion). PT 1 observed Resident 119's right knee extension splint, which was set to 30 degrees, and stated the right knee splint was not an appropriate fit because Resident 119's right knee was bent more than 30 degrees. PT 1 stated the right knee extension splint could cause injury to Resident 119's right leg if applied to the right knee.
During a concurrent observation and interview on 8/8/2024 at 9:16 a.m. with PT 1 and RNA 5 in the bedroom, RNA 5 applied Resident 119's knee extension splint. RNA 5 stated Resident 119's right knee extension splint did not fit because Resident 119's right knee ROM had worsened. RNA 5 stated she notified Licensed Vocational Nurse 2 (LVN 2) of Resident 119's worsening ROM in the right knee. PT 1 stated he was not notified regarding Resident 119's right knee ROM worsening and that inability to apply the right knee splint appropriately.
During an interview on 8/8/2024 at 9:30 a.m. with LVN 2, LVN 2 stated RNA 5 reported Resident 119's right knee skin redness today after putting on the right knee splint. LVN 2 stated RNA 5 reported Resident 119's skin redness from the splints two to three times per month but did not receive any reports of Resident 119's worsening ROM to the right knee. LVN 2 stated perhaps RNA 5 reported it to the Registered Nurse (RN) Supervisor.
During an interview on 8/8/2024 at 9:33 a.m. with RNA 5, LVN 2 and RN Supervisor 2 (RN 2), RN 2 stated Resident 119's had both knee contractures with the right knee bent more than the left knee. RN 2 and LVN 2 stated they were never told Resident 119's right knee ROM had worsened and that the right knee extension splint was not fitting. RN 2 stated worsening contractures could cause skin issues, positioning issues, pain, and injury, including bone fractures. RNA 5 stated she was supposed to but did not report Resident 119's worsening ROM immediately to the nurses.
During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 8/8/2024 completed by OT 2, the OT Evaluation indicated Resident 119 had ROM impairments in both shoulders, both elbows, and both hands. The OT Evaluation indicated Resident 119's ROM limitations included right shoulder flexion 0-50 degrees, right shoulder abduction 0-61 degrees, right elbow extension to 26 degrees, right hand with less than 25% loss of motion, left shoulder flexion 0-66 degrees, left shoulder abduction 0-61 degrees, left elbow extension to 43 degrees, and left hand with 25-50% loss of motion.
During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 8/8/2024 completed by Physical Therapist 2 (PT 2), the PT Evaluation indicated Resident 119 had ROM impairments in both hips, both knees, and the left ankle. The PT Evaluation indicated Resident 119's ROM limitations included right hip flexion (bending the leg at the hip joint toward the body, normal 0-120 degrees) 30-96 degrees, right hip abduction (moving the leg away from the body, normal 0-45 degrees) 0-13 degrees, right knee extension to 73 degrees, left hip flexion 26-70 degrees, left hip abduction 0-11 degrees, left knee extension to 17 degrees, and left ankle dorsiflexion 0-4 degrees (normal 0-20 degrees).
During a concurrent interview and record review, on 8/9/2024 at 8:09 a.m. with RNA 5, Resident 119's RNP Referral/Care Plan, dated 8/19/2022 and 10/28/2022, were reviewed. RNA 5 stated the therapists provided training to RNA 5 on providing ROM and applying splints on Resident 119 for two hours. RNA 5 stated she did not work for two months from 6/2024 to 7/2024 (unspecified dates) but another RNA provided Resident 119 with ROM and applied the splints when RNA was off. RNA 5 stated Resident 119's splints have not fit for the past two weeks since RNA 5 has been back to work. RNA 5 stated Resident 119's right knee splint did not fit her because Resident 119's knee was more contracted. RNA 5 stated Resident 119 has had skin redness from the right knee splint every day for the past two weeks after wearing the splint for 30 to 40 minutes. RNA 5 did not report Resident 119's right knee splint did not fit and just removed it since 30 to 40 minutes was the amount of time Resident 119 tolerated the right knee splint.
During a concurrent interview and record review on 8/9/2024 at 11:16 a.m. with the DOR and PT 2, Resident 119's PT Discharge summary, dated [DATE], and PT Evaluation, dated 8/8/2024, were reviewed. PT 2 stated Resident 119 did not have any ROM limitations in both hips upon PT discharge on [DATE]. PT 2 stated Resident 119 developed flexion contractures on both hips since both hips could not be extended to neutral (0 degrees) and were significantly limited in hip abduction. PT 2 stated Resident 119's right knee extended to 20 degrees upon PT discharge on [DATE] but currently had 73 degrees of right knee extension which was a significant decline in ROM. PT 2 stated Resident 119's development of and worsening contractures could limit the ability to reposition Resident 119 and increased Resident 119's risk for skin breakdown. The DOR and PT 2 stated Resident 119's decline in ROM on both legs were not reported to the therapy department.
During a concurrent interview and record review on 8/9/2024 at 11:37 a.m. with OT 2, Resident 119's OT Evaluation Only, dated 10/6/2022, and OT Evaluation, dated 8/8/2024, were reviewed. OT 2 stated Resident 119 had 0-90 degrees of right shoulder flexion and 0-80 degrees of left shoulder flexion during the OT Evaluation on 10/6/2022. OT 2 stated Resident 119 currently had 0-50 degrees of right shoulder flexion and 0-61 degrees of left shoulder flexion which was a significant decline in ROM. OT 2 stated Resident 119's ROM in both hands were WFL during the OT Evaluation on 10/6/2022. OT 2 stated Resident 119 currently hand loss of motion into extension. OT 2 stated Resident 11 developed contractures on both hands and had worsening contractures on both shoulders and elbows. OT 2 stated contractures could cause discomfort and pain. OT 2 stated it was important to prevent contractures to allow the staff to clean and dress Resident 119 more easily. OT 2 stated Resident 119's decline in ROM on both arms were not reported to the therapy department.
During an interview on 8/9/2024 at 2:06 p.m. with RNA 5, RNA 5 stated she did not but was supposed to report to the LVN charge nurse or the RN supervisor that the right knee splint did not fit. RNA 5 stated Resident 119 resisted ROM because Resident 119 was in pain and had facial expressions of pain whenever RNA 5 touched Resident 119.
During an interview on 8/9/2024 at 3:49 p.m. with the Director of Nursing (DON), the DON stated Resident 119's change of condition (COC) for a decline in ROM and joint mobility was not reported until yesterday (8/8/2024). The DON stated COCs needed to be reported to communicate with Resident 119's physician and family.
During an interview on 8/9/2024 at 4:30 p.m. with the DON, the DON stated Resident 119's room was located within the same physical area as the therapy department. The DON stated Resident 119's COC should have been reported to address the change.
During a review of the facility's job description titled, Restorative Nursing Assistant, revised 10/2011, the job description indicated the RNA will report and document any changes in the resident's condition and/or severity of limitation to the senior team leader immediately.
During a review of the facility's policy and procedure (P&P) titled, Change of Condition Notification, revised 1/1/2017 and reviewed 1/29/2024, the P&P indicated the residents, family, legal representative, and physicians were informed of changes in the resident's condition in a timely manner.
Cross reference F688 and F726.
b. During a review of Resident 139's admission Record, the facility admitted Resident 139 on 4/28/2021 with diagnoses including Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life), dementia (decline in mental ability severe enough to interfere with daily life), dysphagia (difficulty swallowing), and heart failure.
During a review of Resident 139's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 6/5/2024, the MDS indicated Resident 139 had clear speech, had difficulty communicating words, understood verbal content, and was moderately impaired (poor decisions) for daily decision making. The MDS also indicated Resident 139 had ROM limitations in both arms and legs, was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for eating, toileting, lower body dressing, and chair/bed-to-chair transfers, and required substantial/maximal assistance (helper does more than half the effort) for upper body dressing and rolling to both sides in bed.
1. During a review of Resident 139's Registered Nurse (RN)/Licensed Vocational Nurse (LVN) Progress Notes, dated 7/24/2024 written by Licensed Vocational Nurse 6 (LVN 6), the RN/LVN Progress Notes (pink colored sheet) indicated Resident 139 was observed with a decline in general condition, rarely understood, sometimes understood verbal content, and severely impaired for decision making. The RN/LVN Progress Notes did not indicate any monitoring of Resident 139's decline in general condition after 7/24/2024.
During an observation on 8/7/2024 at 10:30 a.m. in the bedroom with Restorative Nursing Assistant 4 (RNA 4), Resident 139 was awake, nonverbal, and sitting up in wheelchair. RNA 4 performed ROM exercises on both arms and both legs.
During an interview on 8/8/2024 at 11:25 a.m. with the Registered Nurse Supervisor (RN 1), Performance Improvement Quality Improvement Licensed Vocational Nurse (PIQI 1), and PIQI 2, PIQI 1 stated the pink-colored RN/LVN Progress Notes (in general) indicated any changes of condition (COCs) for the resident.
During a concurrent interview and record review on 8/8/2024 at 11:55 a.m. with LVN 6, LVN 6 stated Resident 139 had a COC on 7/24/2024 which should have been monitored every shift in the pink-colored RN/LVN Progress Notes. LVN 6 stated Resident 139's COC was not monitored but the physician and family were notified.
During a concurrent interview and record review on 8/9/2024 at 4:40 p.m. with the Director of Nursing (DON), the DON reviewed Resident 139's RN/LVN Progress Notes, dated 7/24/2024. The DON stated Resident 139's COC was identified on 7/24/2024 which should have been but was not monitored for 72 hours after identification.
During a review of the facility's policy and procedure (P&P) titled, Change of Condition Notification, revised 1/1/2017 and reviewed 1/29/2024, the P&P indicated the licensed nurse will document the resident's change in condition each shift for at least 72 hours.
2. During a review of Resident 139's JMA, dated 3/5/2024 and 6/3/2024, the JMA indicated Resident 139 had minimum ROM limitations (less than 25% ROM loss) in both shoulders, elbows, wrists, hips, knees, and ankles and full ROM in both hands.
During a review of Resident 139's JMA for a significant change of condition, dated 8/6/2024, the JMA indicated Resident 139 had moderate ROM limitations (25-50% ROM loss) in both shoulders, elbow, wrists, hips, knees, and ankles, full ROM in the right hand, and stiffness in the left hand.
During an interview on 8/8/2024 at 11:25 a.m. with the RN 1, PIQI 1, and PIQI 2, Resident 139's JMA, dated 3/5/2024, 6/3/2024, and 8/6/2024, and RN/LVN Progress Notes were reviewed. PIQI 1 stated the pink-colored RN/LVN Progress Notes (in general) indicated any changes of condition (COCs) for the resident. RN 1 stated Resident 139's JMAs indicated Resident 139 had a decline in ROM on 8/6/2024 compared to the JMAs dated 3/5/2024 and 6/3/2024. RN 1 stated Resident 139's COC for ROM decline was not documented and monitored on the RN/LVN Progress Notes.
During a concurrent interview and record review on 8/9/2024 at 4:40 p.m. with the Director of Nursing (DON), the DON reviewed Resident 139's JMA, dated 3/5/2024, 6/3/2024, and 8/6/2024 and RN/LVN Progress Notes were reviewed. The DON stated Resident 139 had a decline of ROM which should have been but was not documented and monitored for 72 hours after identification. The DON stated the COC was not completed; therefore, Resident 139's physician and family were not notified.
During a review of the P&P titled, Change of Condition Notification, revised 1/1/2017 and reviewed 1/29/2024, the P&P indicated the licensed nurse will assess the resident's change of condition and document observations and symptoms. The P&P indicated the physician will be notified timely and the resident's responsible party or family will be notified as soon as possible. The P&P also indicated the licensed nurse will document the resident's change in condition each shift for at least 72 hours.
Cross reference F688 and F726.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility's Registered Nurses (RNs) and Restorative Nursing Assistants ([RNA], certified nursing aide program that helps residents to maintain their function and joint mobility) were competent in providing assessments and services affecting four of four sampled residents (Residents 119, 139, 141, and 34) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move), by failing to:
1. Ensure the facility's system, which identified six RNs (Director of Nursing [DON], RN 1, RN 2, RN 3, RN 4, RN 5) who performed assessments of joint mobility at each major joint, had competency evaluations (systematic process that evaluated an individual's skill and knowledge) to perform the Joint Mobility Assessments (JMA, brief assessment of a resident's range of motion in both arms and both legs) in accordance with the facility's policy and procedure titled, Staff Competency Evaluations, upon admission, quarterly, annually, and for a change in condition for all 296 residents.
2. Ensure RNs were competent in the assessment of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) during the JMAs to ensure proper fit to prevent complications such as skin breakdown and contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness).
3. Ensure RNAs 3, 4, 5, 7, 9, 11, and 13 had competency evaluations for RNA duties and responsibilities, including ROM exercises, application of splints, and ambulation (the act of walking) in accordance with the facility's job description titled, Restorative Nursing Assistant, and policy and procedure titled, Range of Motion Exercise Guidelines.
4. Ensure RNAs 1, 2, 6, 8, 10, and 12 had competency evaluations completed by a qualified staff member with knowledge and experience to evaluate staff competency in accordance with the facility's policy and procedure titled, Staff Competency Evaluations.
These failures resulted in Resident 119's decline in ROM due to the facility-identified qualified personnels' (RNs) inability to identify ROM decline during JMAs, the RNAs' inability to correctly apply splints, and the RNAs' inability to identify and report a decline in ROM and mobility during the provision of care, including Resident 119's development of contractures (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) to both hands and hips and worsening contractures to both shoulders, elbows, and knees while residing at the facility. These failures also had the potential for Residents 139, 141, and 34, to experience a decline in ROM.
Cross reference F688.
Findings:
During an interview on 8/6/2024 at 9:34 a.m. with the Director of Rehabilitation (DOR) in the therapy gym, the DOR stated the RNA program was a maintenance program to maintain a resident's ROM and mobility. The DOR stated limitations in ROM could lead to limitations in function and the development of contractures, which could cause pain. The DOR stated ROM exercises and application of splints can assist in maintaining ROM and preventing contractures. The DOR stated Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) did not complete the residents' JMA quarterly or annually.
During an interview on 8/8/2024 at 9:41 a.m. with Registered Nurse Supervisor 2 (RN 2), RN 2 stated the RN Supervisor and the RNA assigned to the nursing station completed the JMAs for each resident upon admission and quarterly. RN 2 stated the facility did not provide any training on how to perform the JMA.
During an interview on 8/8/2024 at 10:40 a.m. with the Director of Nursing (DON), RN 1, Registered Nurse Supervisor 1 (RN 1) Performance Improvement Quality Improvement Licensed Vocational Nurse 1 (PIQI 1), and PIQI 2, RN 1 stated the RN, PIQI, and RNA assigned to each nursing station performed the JMA for each resident upon admission, quarterly, change of condition, and annually. The DON stated the previous DOR provided a training on how to perform the JMA to the DON, RN Supervisors, PIQI LVNs, and RNAs approximately five years ago. The DON stated there has not been any recent training on how to complete the JMAs. PIQI 2 stated the JMA assessed a resident's active or passive joint limitations depending on if the resident can move.
During an interview on 8/8/2024 at 1:15 p.m. with PIQI 1, PIQI 1 stated the JMA needed to be accurate because a change in a resident's ROM could be missed if the JMA was not accurate.
During an interview on 8/8/2024 at 1:47 p.m. with DOR and PT 1, the DOR stated the nursing staff were not provided with any recent in-service training for the completion of JMAs.
During an interview on 8/8/2024 at 3:21 p.m. with the DON, the DON stated the Supervising RN, PIQI, and RNA assigned to the nursing station were supposed to perform each resident's JMA. The DON stated the Supervising RN assessed the resident, the PIQI was present to gather information about each resident, and the RNA provided the ROM for the assessment. The DON stated competency evaluations ensured the nurse was knowledgeable in providing care. The DON stated the RNs, including the DON, did not have competency evaluations to perform the JMA. The DON stated she did not know the reason the facility did not have competency evaluations for RNs to perform the JMA. The DON stated the RNs should have a competency evaluation especially since ROM and joint mobility was not a nursing specialty. The DON stated there was no way to ensure the JMAs for all residents were accurate since the RNs did not have the competence to perform the JMA.
During an interview on 8/8/2024 at 3:43 p.m. with the DON, the DON stated the DON was provided education on performing the JMAs but stated RN 1, RN 2, RN 3, RN 4, and RN 5 performed the residents' JMAs.
During an interview on 8/9/2024 at 8:37 a.m. with PIQI 1 and PIQI 2, PIQI 1 and PIQI 2 stated the Supervising RN, PIQI, and the RNA assigned to the nursing station were supposed to be present during each resident's JMA. PIQI 1 and PIQI 2 stated the RNA moved the resident and applied the splints (if applicable), the RN assessed the resident's ROM and splints, and the PIQI recorded the resident's joint mobility limitations based on the RN's assessment.
During a review of the employee files for the DON, RN 1, RN 2, RN 3, RN 4, and RN 5, the employee files, the employee files included a performance appraisal (process that evaluates and records how well an employee performed their job) for the DON, dated 12/2023, and for RN 4, dated 4/14/2023. The employee files for the DON and RN 4 did not include a competency skills checklist. A review of the employee files included a competency skills checklist for RN 1, dated 5/2024, for RN 2, dated 1/22/2024, for RN 3 dated 7/2023, and for RN 5, dated 3/2024. The competency skills checklist did not include a competency for assessment of splints and performing the JMA.
During a concurrent interview and record review on 8/9/2024 at 3:24 p.m. with the DON, the DON, RN 1, RN 2, RN 3, RN 4, and RN 5's employee files on skill competency evaluations were reviewed. The DON stated skill competency evaluations were completed annually to ensure the RNs were knowledgeable in the necessary and appropriate care provided to the residents. The DON stated she evaluated the RNs for their annual skills competency but stated the facility never performed a skills competency for the DON. The DON stated RN 1, RN 2, RN 3, and RN 5, had skill competency evaluations for the provision of ROM exercises but did not have any competencies to assess ROM to perform the JMA. The DON stated RN 4 was a PIQI RN and did not have an annual competency evaluation since RN 4 did not provide any direct resident care. The DON stated the skills competency evaluations for the DON, RN 1, RN 2, RN 3, RN 4, and RN 5 did not include splint assessment and JMA assessment. The DON stated the JMAs for all residents would be inaccurate since the RNs did not have any competency skills to assess splints and perform the JMA.
During a review of the employee files for the RNAs, the employee files included a Restorative Nursing Skills Evaluation which included but was not limited to the provision of ROM, application of splints, transfers, and walking for RNA 1, dated 5/2024, for RNA 2, dated 6/1/2024, for RNA 6, dated 6/10/2024, for RNA 8, dated 7/26/2024, for RNA 10, dated 7/26/2024, and for RNA 12, dated 7/16/2024. A review of the employee files did not include a Restorative Nursing Skills Evaluation for RNA 3, RNA 4, RNA 5, RNA 7, RNA 9, RNA 11, RNA 13.
During a concurrent interview and record review on 8/9/2024 at 3:49 p.m. with the DON, 13 RNA employee files on competency skills evaluations were reviewed, including RNA 1, RNA 2, RNA 3, RNA 4, RNA 5, RNA 6, RNA 7, RNA 8, RNA 9, RNA 10, RNA 11, RNA 12, and RNA 13. The DON stated RNAs were important to maintain, improve, and prevent any decline in a resident's ROM, mobility, and overall physical condition. The DON stated seven of 13 RNAs, including RNA 3, RNA 4, RNA 5, RNA 7, RNA 9, RNA 11, and RNA 13, did not have any competency skills evaluations to determine appropriate provision of RNA services, including providing ROM, splint application, and mobility. The DON stated six of 13 RNAs, including RNA 1, RNA 2, RNA 6, RNA 8, RNA 10, and RNA 12, had Restorative Nursing Skills Evaluations completed by the Director of Staff Development (DSD) who was not competent in the provision of RNA services. The DON did not know why the skills competency evaluations for the RNAs were not provided by a facility staff member with knowledge of ROM, splint application, and mobility. The DON stated 13 of 13 RNAs did not have appropriate competency skills evaluations to determine whether the RNAs accurately performed their duties. The DON stated the residents could develop ROM limitations and contractures if the RNAs were not competent in the application of splints and provision of ROM and mobility. The DON stated the resident could develop undetected changes and declines in ROM since the RNAs were not competent in the provision of services and the RNs were not competent in performing the JMAs.
During an interview on 8/9/2024 at 4:30 p.m. with the DON, the DON stated contractures develop due to immobility and could be prevented with ROM exercises and application of splints. The DON stated contractures result in limited movement, and could cause discomfort, and pain, and increased a resident's risk of skin impairments. The DON stated contracture prevention was important for a resident's quality of life to prevent any restrictions in movement.
During a review of the facility's policy and procedures (P&P) titled, Staff Competency Evaluations, revised on 7/12/2018 and reviewed on 1/29/2024, the P&P indicated annual competency evaluations for all nursing and clinical staff ensured the facility maintained the highest standards of care and resident safety. The P&P indicated annual competency evaluations will be conducted by qualified personnel who have the appropriate knowledge and experience to assess staff competency.
During a review of the facility's job description titled, Restorative Nursing Assistant, revised 10/2011, the job description indicated RNAs performed restorative nursing procedures that maximized the resident's abilities and minimized the negative effects of disability. The RNA job description also indicated duties and responsibilities included providing restorative nursing care as directed and ordered, including ROM, ambulation, and transfers.
During a review of the facility's P&P titled, Restorative Nursing Program Guidelines, revised on 3/1/2015 and reviewed on 1/29/2024, the P&P indicated RNAs provide interventions to achieve or maintain optimal physical functioning, including providing ROM exercises, applying splints, transfer training, and walking.
During a review of the facility's P&P titled, Range of Motion Exercise Guidelines, revised on 3/1/2015 and revised reviewed on 1/29/2024, the P&P indicated the purpose of the policy included maintaining or increasing ROM of a joint and to prevent or reduce contractures. The P&P indicated ROM should be delivered by staff trained in the procedures.
1. During a review of Resident 119's admission Record, the admission Record indicated the facility admitted Resident 119 on 5/11/2017 with diagnoses including Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life), dementia (decline in mental ability severe enough to interfere with daily life), age-related osteoporosis (medical condition in which the bones become brittle and fragile from loss of tissue), and dysphagia (difficulty swallowing).
During a review of Resident 119's census (record of hospitalizations, room changes, and payor source changes), the census indicated Resident 119 resided at the facility since 5/11/2017 without any hospitalizations.
During a review of Resident 119's Minimum Data Set ([MDS], a comprehensive assessment and care planning tool), dated 5/13/2024, the MDS indicated Resident 119 had unclear speech, rarely expressed ideas and wants, rarely understood verbal content, and was severely impaired (never/rarely made decisions) for daily decision making. The MDS indicated Resident 119 had ROM impairments in both arms and legs and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for eating, toileting, showering/bathing, upper and lower body dressing, rolling to both sides in bed, and chair/bed-to-chair transfers.
During a review of Resident 119's physician orders, dated 11/9/2020, the physician orders indicated for Resident 119 to receive passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to both arms and legs, every day.
During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 6/8/2022, the OT Evaluation indicated Resident 119 was referred to OT due to a decline in ROM, decreased balance, and increased need for assistance from others. The OT Evaluation indicated Resident 119's ROM to the right elbow, both wrists, and both hands were within functional limits (WFL, sufficient movement without significant limitation). The OT Evaluation indicated Resident 119's impaired ROM included right shoulder flexion (lifting the arm upward) 0 to 80 degrees (0 to 80 degrees, normal 0 to180 degrees), right shoulder abduction (lifting the arm up and away from the body) 0 to 75 degrees (normal 0 to 180 degrees), left shoulder flexion 0 to 40 degrees, left shoulder abduction 0 to 40 degrees, and left elbow extension (straightened) was limited to 80 degrees (normal 0 degrees, positioned in 80 degrees of elbow flexion [bend]).
During a review of Resident 119's OT Treatment Encounter Notes, dated 8/19/2022, the OT Treatment Encounter Notes indicated Resident 119's ROM included right shoulder flexion 0 to 90 degrees (shoulder height), right shoulder abduction 0 to 80 degrees, right elbow extension to 20 degrees (elbow positioned in 20 degrees of flexion), left shoulder flexion 0 to 50 degrees, left shoulder abduction 0 to 50 degrees, and left elbow extension to 30 degrees (elbow positioned in 30 degrees of elbow flexion).
During a review of Resident 119's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 119 safely wore splints to both elbows for two hours without signs of redness, swelling, discomfort, or pain. The OT Discharge Summary recommendations included a Restorative Nursing Program ([RNP], nursing program that uses restorative nursing aides [RNAs] to help residents maintain their function and mobility) to provide Resident 119 with PROM and to apply both elbow splints for two hours daily as tolerated.
During a review of Resident 119's RNP Referral/Care Plan, dated 8/19/2022, the RNP Referral/Care Plan indicated Occupational Therapist 2 (OT 2) reviewed Resident 119's program with Restorative Nursing Assistant 5 (RNA 5) to apply both elbow splints for two hours.
During a review of Resident 119's Joint Mobility Screening (JMA completed by OT and PT), dated 10/6/2022, the Joint Mobility Screening indicated Resident 119's ROM included severe ROM limitation (more than 50 percent [%] loss of motion) in the left shoulder, moderate ROM limitation (25 to 50% loss of motion ) in the right shoulder, minimum ROM limitation (less than 25% loss of motion) in both elbows and knees, and full ROM in both hands, hips, and ankles. The Joint Mobility Screening indicated recommendations for Resident 119 to receive PT and OT Evaluations and to continue with the RNA program.
During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 10/6/2022, the OT Evaluation indicated Resident 119 was seen for an Evaluation Only (no intervention recommended). The OT Evaluation Only indicated Resident 119's ROM was WFL in both wrists and hands but had impairment in both shoulders and elbows, including right shoulder flexion 0 to 90 degrees (shoulder height), right elbow extension to 20 degrees, left shoulder flexion 0 to 50 degrees, and left elbow extension to 30 degrees. The OT Evaluation Only indicated Resident 119 was already provided with both elbow splints and did not have any significant change in condition requiring OT intervention.
During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 10/6/2022, the PT Evaluation indicated Resident 119 was referred to PT due to a new onset of decreased ROM, decreased postural alignment when sitting up in the wheelchair, and was at-risk for contracture development. The PT Evaluation indicated Resident 119's ROM in both hips and ankles were WFL but had impaired ROM to both knees. The PT Evaluation indicated Resident 119's right knee extension was limited to 30 degrees (normal 0 degrees, knee positioned in 30 degrees of knee flexion) and left knee extension was limited to 15 degrees (knee positioned in 15 degrees of knee flexion).
During a review of Resident 119's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 119 tolerated sitting up in a standard wheelchair with a cushioned seat for four hours, had right knee extension to 20 degrees, and tolerated a right knee extension splint for two hours. The PT Discharge recommendations included a RNP to provide Resident 119 with PROM and to apply the right knee extension splint.
During a review of Resident 119's RNP Referral/Care Plan, dated 10/28/2022, the RNP Referral/Care Plan indicated the Physical Therapist 3 (PT 3) reviewed Resident 119's program with RNA 5 to provide PROM to both legs and to apply the right knee splint for two hours.
During a review of Resident 119's JMA, dated 12/7/2022 and 3/3/2023, the JMA indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMA indicated Resident 119 received RNA for PROM to both arms and legs as tolerated. The JMA did not indicate the RNA applied both elbow splints and the right knee splint.
During a review of Resident 119's JMA, dated 6/1/2023, the JMA indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMA indicated Resident 119 received RNA for PROM to both arms and legs and application of both elbow splints and the right knee splint.
During a review of Resident 119's JMA, dated 8/23/2023 and 11/24/2023, the JMAs indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMA indicated Resident 119 received RNA for PROM to both arms and legs. The JMA did not indicate the RNA applied both elbow splints and the right knee splint.
During a review of Resident 119's JMA, dated 2/16/2024, 5/11/2024, and 8/4/2024, the JMAs indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMAs indicated Resident 119 received RNA for PROM to both arms and legs and application of both elbow splints and the right knee splint.
During an observation on 8/7/2024 at 12:40 p.m. with Restorative Nursing Assistant 2 (RNA 2) RNA 2 in the bedroom, RNA 2 stated Resident 119's primary (routinely assigned) RNA was RNA 5 who was off today that day (8/7/2024) but will return the next day tomorrow. RNA 2 stood on the right side of Resident 119's bed and performed ROM exercises on Resident 119's right shoulder. RNA 2 could not lift the right arm to shoulder height. RNA 2 bent and extended the right elbow to perform ROM exercises but could not fully extend the right elbow, which remained in a bent position. RNA 2 performed wrist flexion (bent down) and wrist extension (bent up) exercises but did not perform any exercises to Resident 119's right hand. RNA 2 massaged Resident 119's right arm into extension prior to applying the right elbow splint upside down. RNA 2 bent and extended Resident 119's right hip and knee at the same time, causing Resident 119 to moan with a facial grimace (expression of pain or strong dislike). RNA 2 could not extend the right knee, which continued to have a bend of approximately 90 degrees. RNA 2 performed exercises to the right ankle into rotation, dorsiflexion (ankle bent with toes pointing toward the body), and plantarflexion (ankle bent with toes pointing away from the body). RNA 2 applied Resident 119's right knee splint, which was fixed in a nearly straight position, and fastened a strap over the right kneecap. RNA 2 stood on the left side of Resident 119's bed and performed ROM exercises on the left shoulder. RNA 2 lifted the left arm higher than the right shoulder joint but could not lift the left arm to shoulder height. RNA 2 bent and extended the left elbow to perform ROM exercises but could not fully extend the left elbow, which remained in a bent position. RNA 2 performed wrist flexion and extension exercises but did not perform any exercise to Resident 119's left hand. RNA 2 applied the left elbow splint. RNA 2 bent and extended Resident 119's left hip and knee at the same time. RNA 2 could not fully extend Resident 119's left hip and knee. RNA 2 then performed ankle exercises to Resident 119's left ankle into rotation, dorsiflexion, and plantarflexion.
During an interview on 8/7/2024 at 1:04 p.m. with RNA 2, RNA 2 stated the splints will be checked every 30 minutes and will be removed remove the splints after 2 hours. RNA 2 stated ROM was not performed to Resident 119's hands because both hands were good and stated Resident 119 could straighten the fingers.
During a concurrent observation and interview on 8/7/2024 at 1:09 p.m. with the DOR and Physical Therapy Assistant 1 (PTA 1) in Resident 119's the bedroom, Resident 119 was observed lying in bed while wearing both elbow splints and the right knee splint. PTA 1 stated Resident 119's right knee splint was applied lower than the knee. PTA 1 checked the right knee splint and stated Resident 119's knee splint was set to 30 degrees of extension but Resident 119's right knee was bent to approximately 90 degrees. PTA 1 stated the right knee splint did not fit Resident 119 because the bend in the splint did not match the bend in Resident 119's knee. PTA 1 stated an inappropriately fitted splint could put pressure on the skin and bones of Resident 119's right knee, which could result in pressure sores (localized damage to the skin and underlying soft tissues over a bony prominence) and dislocation (injury caused when the normal position of a joint is disturbed) of the right knee.
During a concurrent observation and interview on 8/7/2024 at 1:19 p.m. with the DOR and PTA 1 in the bedroom, the DOR removed Resident 119's right knee splint. The skin on Resident 119's right knee, which was directly under the strap of the knee splint, was observed with redness. PTA 1 stated Resident 119 had redness to the pressure sensitive area of the right kneecap. The DOR observed Resident 119's elbow splints, stated the right elbow splint was applied upside down, and adjusted both of Resident 119's elbow splints.
During a concurrent interview and record review on 8/7/2024 at 1:45 p.m. with the DOR, Resident 119's census, OT Discharge summary, dated [DATE], OT Evaluation Only, dated 10/6/2022, PT Evaluation, dated 10/6/2022, and PT Discharge summary, dated [DATE], were reviewed. The DOR reviewed Resident 119's census and stated Resident 119 was admitted to the facility on [DATE] and did not leave the facility for any reason. The DOR stated Resident 119's ROM upon discharge from OT on 8/19/2022 was right shoulder flexion 0-90 degrees, right shoulder abduction 0-80 degrees, right elbow extension to 20 degrees, left shoulder flexion 0 to 50 degrees, left shoulder abduction 0 to 50 degrees, and left elbow extension to 30 degrees. The DOR stated OT 2 discharged Resident 119 on 8/19/2022 with recommendations for RNA to provide PROM to both arms and apply both elbow splints for two hours. The DOR stated Resident 119 received an OT Evaluation Only on 10/6/2022 but treatment was not Provided since Resident 119's ROM did not change from OT discharge on [DATE]. The DOR stated the OT Evaluation Only, dated 10/6/2022, indicated to continue RNA for PROM to both arms and application of both elbow splints. The DOR reviewed the PT Evaluation, dated 10/6/2022, and stated Resident 119's ROM in both hips and ankles were WFL but had ROM limitation in both knees, including right knee extension to 30 and left knee extension to 15 degrees. The DOR stated Resident 119 was discharged from PT on 10/28/2022 with right knee extension to 20 degrees. The DOR stated PT 3 (no longer works at the facility) discharged Resident 119 on 10/28/2022 with recommendations for RNA to provide PROM to both legs and apply the right knee extension splint. The DOR stated OT has not performed any treatment to Resident 119 since 10/6/2022 and PT has not performed any treatment to Resident 119 since 10/28/2022 (approximately 22 months ago).
During a concurrent observation and interview on 8/8/2024 at 8:30 a.m. in Resident 119's the bedroom with RNA 5, Resident 119 was lying in bed awake with the head-of-bed (HOB) fully elevated and the elbow splint applied to the right arm. RNA 5 stated Resident 119 was usually nonverbal and that RNA 5 was Resident 119's primary RNA. The skin on Resident 119's right kneecap was observed with pink areas. RNA 5 stated Resident 119's splints were applied this morning at approximately 7:00 a.m. but the right knee and left elbow splints were removed after 15 minutes due to skin redness.
During a concurrent observation and interview on 8/8/2024 at 9:05 a.m. with PT 1 Physical Therapist 1 (PT 1) in Resident 119's the bedroom, Resident 119's ROM in both knees and the right knee extension splint were observed. Resident 119 was lying in bed with the HOB fully elevated and both knees were in bent positions. PT 1 extended both knees and stated Resident 119 had contractures to both knees. PT 1 stated the right knee extended to 90 degrees (right knee positioned in 90 degrees of flexion) and the left knee extended to 55 degrees (left knee positioned in 55 degrees of flexion). PT 1 observed Resident 119's right knee extension splint, which was set to 30 degrees, and stated the right knee splint was not an appropriate fit because Resident 119's right knee was bent more than 30 degrees. PT 1 stated the right knee extension splint could cause injury to Resident 119's right leg if applied to the right knee.
During a concurrent observation and interview on 8/8/2024 at 9:16 a.m. with PT 1 and RNA 5 in Resident 119's the bedroom, RNA 5 applied Resident 119's knee extension splint. RNA 5 stated Resident 119's right knee extension splint did not fit because Resident 119's right knee ROM had worsened. PT 1 stated he was not notified of Resident 119's worsening ROM in the right knee and the inability to apply the right knee splint appropriately.
During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 8/8/2024, completed by OT 2, the OT Evaluation indicated Resident 119 had ROM impairments in both shoulders, both elbows, and both hands. The OT Evaluation indicated Resident 119's ROM limitations included right shoulder flexion 0 to 50 degrees, right shoulder abduction 0 to 61 degrees, right elbow extension to 26 degrees, right hand with less than 25% loss of motion, left shoulder flexion 0 to 66 degrees, left shoulder abduction 0 to 61 degrees, left elbow extension to 43 degrees, and left hand with 25 to 50% loss of motion.
During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 8/8/2024, completed by PT 2, Physical Therapist 2 (PT 2), the PT Evaluation indicated Resident 119 had ROM impairments in both hips, both knees, and the left ankle. The PT Evaluation indicated Resident 119's ROM limitations included right hip flexion (bending the leg at the hip joint toward the body) 30 to 96 degrees (normal 0 to 120 degrees), right hip abduction (moving the leg away from the body) 0 to 13 degrees (normal 0 to 45 degrees), right knee extension to 73 degrees, left hip flexion 26 to 70 degrees, left hip abduction 0 to 11 degrees, left knee extension to 17 degrees, and left ankle dorsiflexion 0 to 4 degrees (normal 0 to 20 degrees).
During an interview on 8/9/2024 at 10:36 AM with the DOR, the DOR stated contractures developed over time. The DOR stated performing ROM exercises, positioning and applying splints assisted in preventing contractures, which could cause pain, limited function, increased skin issues, and increased the potential for injury.
During a concurrent interview and record review on 8/9/2024 at 11:16 a.m. with the DOR and PT 2, Resident 119's PT Discharge summary, dated [DATE], and PT Evaluation, dated 8/8/2024, were reviewed. PT 2 stated Resident 119 did not have any ROM limitations in both hips per the PT Discharge Summary. PT 2 stated Resident 119 developed flexion contractures on both hips since both hips could not be extended to neutral (0 degrees) and were significantly limited in hip abduction. PT 2 stated Resident 119's right knee extended to 20 degrees per PT Discharge Summary but currently had 73 degrees of right knee extension per PT Evaluation which was a significant decline in ROM. PT 2 stated Resident 119's development of and worsening contractures could limit the ability to reposition Resident 119 and increased Resident 119's risk for skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure). The DOR and PT 2 stated Resident 119's decline in ROM on both legs from the PT Evaluation were not reported to the therapy department.
During a concurrent interview and record review on 8/9/2024 at 11:37 a.m. with OT 2, Resident 119's OT Evaluation Only, dated 10/6/2022, and OT Evaluation, dated 8/8/2024, were reviewed. OT 2 stated Resident 119 had 0-90 degrees of right shoulder flexion and 0-80 degrees of left shoulder flexion during the OT Evaluation on 10/6/2022. OT 2 stated Resident 119 currently had 0-50 degrees of right shoulder flexion and 0-61 degrees of left shoulder flexion per OT Evaluation on 8/8/2024, which was a significant decline in ROM. OT 2 stated[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for eight of ten sampled residents (Residents 227, 38, 14, 55, 148, 177, 213, and 43) investigated under care area accidents by failing to ensure:
1. Resident 227's Areds 2 (supplement for age related macular degeneration) was not left at the bedside for the resident to self-administer.
The deficient practice had the potential to place Resident 227 at risk for adverse effect (a harmful or abnormal result) of taking medications.
2. Residents 38 was not left in a wheelchair with a bedside table on top of a fall mat (used to cushion fall impact) to eat breakfast.
The deficient practice lessened the effectiveness of the fall mat to prevent falls with injury by placing a heavy equipment and furniture on top of the floor mat decreasing its effectiveness to lessen the impact of a fall due to permanent dented mat surface and potential of the residents hitting the hard surfaces of the heavy equipment and furniture causing fractures (break in bone) and even death.
3. Resident 14's wheelchair was not placed on top of floor mats while left unattended by staff.
This deficient practice had the potential to result in the resident's wheelchair becoming unstable and toppling over resulting in injury to the resident.
4. Certified Nursing Assistant 2 (CNA 2) did not leave the sit-to-stand assistive device (helps transfer residents from one seated surface to another) in Resident 55 and 148s shared room while Resident 55 was in the room unattended by staff.
This deficient practice had the potential to result in residents sustaining injury caused by a trip or fall over the unattended device.
5. Resident 177's two white circular tablets and a bottle of saline spray (a mixture of salt and water that is sprayed into the nose) was not left on the resident's bedside table.
This deficient practice had the potential for other residents to enter the resident's room and take the medication without the facility staff knowing.
6. Resident 213 was assessed for elopement risk quarterly per the facility policy for 7/19/2024.
7. Resident 43 was assessed for elopement risk upon readmission.
These deficient practices had the potential to affect resident safety and minimize injury in the event of elopement.
Findings:
1. During a review of Resident 227's admission Record, the admission record indicated the facility admitted the resident on 12/26/2023, with diagnoses that included glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called optic nerve) and dysphagia (difficulty swallowing).
During a review of Resident 227's Care Plan titled, Family Education related to resident's safe feeding/eating precautions, initiated on 5/16/2024, indicated to instruct visitors that either feeding or resident eating with visitor should be under close supervision of staff.
During a review of Resident 227's History and Physical (H&P), dated 5/22/2024, the H & P indicated Resident 227 had the capacity to understand and make decisions.
During a review of Resident 227's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/24/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision and had intact cognition (gaining of knowledge and understanding).
During a review of Resident 227's Order Summary Report, the report did not indicate a physician's order for Areds 2.
During a review of Resident 227's Interdisciplinary Team (IDT, is a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychosocial, and spiritual needs of the residents) note, dated 6/26/2024, indicated the resident was alert and oriented times 3 (alert and oriented to person, place, and time), knows his vitamins and supplements, and wanted to keep his medications at the bedside.
During an observation on 8/6/2024, at 8:45 a.m., while inside Resident 227's room, Resident 227 was observed taking one tablet from a medication bottle labeled Areds 2.
During a concurrent interview and record review on 8/6/2024, at 8:47 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 227's Order Summary Report and Medication Administration Record (MAR) was reviewed. LVN 3 stated there was no order for the resident to self-administer medications or an order that it was okay to keep medications at the bedside on the Order Summary Report. LVN 3 also stated there was no order for the medication Areds 2. LVN 3 stated she does not know how the bottle of Areds 2 was left at the resident's bedside. LVN 3 stated it must be the family member that gave the medication Areds 2 to the resident. LVN 3 stated leaving a medication at the bedside without a physician order can cause accidental ingestion of medication by other residents and had a potential for the resident to choke due to unsupervised administration of the medication.
During a concurrent interview and record review on 8/6/2024, at 9:05 a.m., with the Minimum Data Set Coordinator (MDSC), the Order Summary Report, Assessment for Self-Administration of Medication, and IDTs done for the resident were reviewed. The MDSC stated there was no order for Areds 2 or an order that it was okay to self-Administer medications on the Order Summary Report. The MDSC also stated there was no Medication Self-Administration Assessment done on admission for the resident. The MDSC confirmed there was a desire from the resident to keep supplements and vitamins at the bedside of the resident during an Interdisciplinary Team (IDT, professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) done on 6/26/2024, and they failed to assess the resident for self-administration of medications. The MDSC stated it was important to assess the resident for their ability to self-administer their medications to honor the resident's rights. The MDSC stated after assessing the resident for their ability to self-administer medication they should get an order from the physician for the resident to self-administer medication to ensure safe use.
During an interview on 8/9/2024, at 4:52 p.m., with the Director of Nursing (DON), the DON stated a self-administration medication assessment should be done on admission. The DON stated they should honor the resident's right to self-administer medications. The DON stated the resident was a researcher and was alert and oriented very much capable of taking his own medications. The DON stated the failure of the staff to do an assessment for medication self-administration to the resident deprived the resident of his right to self-determination and the failure of the staff to ensure there was an order for the medication Areds 2 had predisposed the resident to taking unnecessary medications and the adverse effect of the medication that can cause harm to the resident. The DON also stated some residents may have access to the medication and take the medication accidentally that can cause an accident of ingesting non-prescribed medication.
During a review of the facility's most recent policy and procedure titled, Physician Orders, last reviewed on 1/29/2024, the policy indicated the purpose of the policy was to ensure all physician orders are complete and accurate. Medication orders will include the following:
A. Name of the medication;
B. Dosage;
C. Frequency; and
D. Duration of order
E. The route and the condition/diagnosis for which the medication is ordered, if applicable.
Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline.
During a review of the facility's most recent policy and procedure titled, Medication- Self Administration, last reviewed on 1/29/2024, indicated Residents who request to perform medication self-administration will be assessed for capacity. During the admission process, residents will be asked if they wish to self-administer medications. Those residents who wish to self-administer medications will be assessed during the admission process to ensure they have the necessary knowledge and skill(s) to safely self-administer medications.
A. Additional assessments will be completed at least quarterly based on OBRA timeframes.
If the resident is assessed as clinically appropriate for medication self-administration, by the IDT, the Licensed Nurse obtains a physician's order for self-administration of selected medications.
A. The resident's record should contain documentation that demonstrates that he/she was part of the IDT process in determining whether self-administration is safe and appropriate.
The IDT develops and implements a care plan for medication self-administration. The care plan will identify:
i. Where the medications are stored;
ii. Education for resident/family regarding medication self-administration process; specific medication information and safe, effective use of medications;
a. Obtaining medication;
b. Administering medication according to physician order;
iii. How Licensed Nurses will validate that medications are taken as ordered by the attending physician; and
iv. How non-compliance and/or refusal to take medications will be managed.
2. During a review of Resident 38's admission Record, the admission record indicated the facility admitted the resident on 2/28/2023, with diagnoses including age-related osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue), ataxia (a loss of muscle control), and presence of right artificial shoulder joint (a metal or plastic part that is surgically implanted to replace a natural joint).
During a review of Resident 38's Care Plan titled, At risk for fall secondary to impairment of upper and lower extremities on both sides/presence of artificial shoulder joint, initiated on 3/15/2023, indicated an intervention to keep environment free of hazards such as wet spots or small objects below field of vision and to place a floor mat next to resident's bed to prevent the resident from injuries.
During a review of Resident 38's H&P, dated 1/27/2024, the H & P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 38's Order Summary Report, the report included the following orders:
-3/11/2024 Caution for sedation (a state of calmness, relaxation, or sleepiness caused by certain drugs), lethargy (a condition marked by drowsiness and an unusual lack of energy and mental alertness), drowsiness, dizziness, respiratory depression, and falls. Every shift.
-2/28/2023 May have floor mat next to bed to prevent injuries. Every shift.
During a review of Resident 38's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and to understand others. The MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident had impaired upper and lower extremity and required substantial to maximal assistance in mobility and activities of daily living (ADLs).
During a review of Resident 38's Fall Risk Assessment, dated 8/1/2024, indicated the resident was a high risk for falls.
During an observation on 8/5/2024, at 8:54 a.m., Resident 38 was eating breakfast at the bedside in a wheelchair with a bedside table on top of a fall mat.
During an interview on 8/5/2024, at 10:18 a.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated there should be no rolling equipment like a bedside table on top of the floor mat so the resident will not fall on them.
During a concurrent observation and interview on 8/8/2024, at 11:45 a.m., with Performance Improvement Quality Improvement Nurse 1 (PIQI 1), rounded the nursing stations and found multiple rooms with bedside tables and equipment on top of the fall mats. PIQI 1 stated there should be no equipment or furniture on top of fall mats as it forms a permanent dent on the mats decreasing the capability of the mat to lessen the impact of resident's fall on the floor. PIQI 1 also stated leaving equipment and furniture on the fall mat increases the risk of the resident sustaining falls with injury because they could hit the sharp edges and hard surfaces of the equipment or furniture that was left on the fall mat.
During an interview on 8/9/2024, at 5:12 p.m., with the DON, the DON stated the fall mats should be free of any furniture and device so that when residents fall on the mat they will not hit on the sharp edges and hard surfaces of the furniture that was left on top of them. The DON also added leaving equipment or furniture on top of the fall mat will leave a dent on the surface of the mat and will not serve its purpose to lessen the fall impact to the resident.
During a review of the facility provided undated, Manufacturer's Recommendation on the use of Landing Mat 1 (LM 1), indicated when moving equipment across the mat ensure that the wheels are not locked as dragging wheels may damage the mat. Avoid sharp materials from contacting the mat. Never leave heavy materials on the mat for an extended amount of time and they may cause a permanent indentation.3. During a review of Resident 14's admission Record, the admission record indicated the facility admitted Resident 14 on 6/11/2021 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), age-related osteoporosis (a disease that causes bones to become weak and brittle), and sarcopenia (loss of muscle mass and strength that can affect older adults).
3. During a review of Resident 14's admission Record, the admission record indicated the facility admitted Resident 14 on 6/11/2021 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), age-related osteoporosis (a disease that causes bones to become weak and brittle), and sarcopenia (loss of muscle mass and strength that can affect older adults).
During a review of Resident 14's physician orders indicated the following orders:
-May have floor mat next to bed to prevent injuries, dated 6/11/2021.
During a review of Resident 14's Care Plans titled, At Risk for Fall secondary to Impairment of Upper and Lower Extremities on both sides, initiated on 4/25/2024, indicated the resident's potential for fall/injury will be minimized, to place a floor mat at the resident's bed to prevent injuries, and to keep the environment free from hazards.
During a review of Resident 14's history and physical dated 6/28/2024, indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 14's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/10/2024, the MDS indicated the resident sometimes was able to understand others and sometimes was able to make herself understood. The MDS indicated Resident 14 was dependent on staff for oral hygiene, toileting, bathing, and personal hygiene, and required substantial to maximal assistance with mobility.
During an observation on 8/9/2024 at 12:25 p.m., Resident 14 was sitting in a wheelchair (WC) between the resident's right side of the bed and the wall near the entrance door. The resident's WC with the left wheel was on the wood floor surface and the right wheel was on top of the floor mat.
During an observation and interview on 8/9/2024 at 12:43 p.m., Certified Nursing Assistant 2 (CNA 2) entered Resident 14's room and stated the resident's WC was on top of the floor mat. CNA 2 stated Resident 14 was a total assist resident and was not able to move the WC. CNA 2 stated the resident's WC should not be on top of the floor mat for safety.
During an observation and interview on 8/9/2024 at 12:45 p.m., Licensed Vocation Nurse 4 (LVN 4) entered Resident 14's room and stated residents in WCs should never be left on top of the floor mat for safety. LVN 4 stated the WC could become unstable and fall over.
During an interview on 8/9/2024 at 1:52 p.m., the Director of Nursing (DON) stated WCs should not be on top of the floor mat because the resident must be free from hazards. The DON stated this was a safety issue and if the resident fell it could cause harm like a fracture (broken bone).
During a review of the facility policy and procedure titled, Safety - Environment, last reviewed on 1/29/2024, the policy indicated the purpose of the policy was to provide a safe, clean, and hazard free environment for all residents promoting their wellbeing, dignity, and quality of life. The facility shall maintain an environment that ensures the safety and security of all residents. This includes, but is not limited to, the prevention of accidents, hazards, and exposure to harmful conditions. All rooms shall be arranged in a manner that ensures safety. All furniture should be positioned to allow safe movement within the room. All rooms shall be free of clutter and any items that could pose a fall risk.
4.a. During a review of Resident 55's admission Record, the admission record indicated the facility admitted the resident on 11/21/2019 with diagnoses that included unspecified dementia, metabolic encephalopathy (a general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), Parkinson's disease (a brain disorder causing uncontrolled movements including shaking or difficulty with balance and coordination) with dyskinesia (uncontrolled, involuntary muscle movements), Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), and muscle weakness.
During a review of Resident 55's physician orders indicated the following orders:
-May use mechanical device for transfers and or weights, dated 6/14/2024.
During a review of Resident 55's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS indicated the resident required substantial/maximal assistance from staff for toileting, bathing, dressing, personal hygiene; and mobility.
During a review of Resident 55's history and physical dated 7/24/2024, the H & P indicated the resident had the capacity to understand and make decisions.
During an observation on 8/9/2024 at 12:15 p.m., Resident 55 was lying in bed. A sit-to-stand assistive device was inside the resident's room placed near the door next to Resident 148's bed. No staff were present in the room or hallway.
During an observation on 8/9/2024 at 12:30 p.m., CNA 2 exited the resident room, walked to the nursing station, and moved Resident 148 in the WC to the shared room with Resident 55 and closed the curtain. After assisting Resident 148 into bed, CNA 2 walked out of the room with the sit-to-stand assistive device.
During an interview on 8/9/2024 at 12:40 p.m., CNA 2 stated she used the sit-to-stand assistive device to assist Resident 148 into bed.
During an interview on 8/9/2024 at 2:02 p.m., the DON stated she was made aware by CNA 2 that the sit-to-stand assistive device was left unattended next to the resident's bed while there was a resident in the room. The DON stated equipment should not be left in the resident rooms if there is a resident present in the room. The DON stated it was an environmental hazard to leave equipment in a resident's room because residents may harm themselves on the equipment. The DON stated the facility CNAs have recently had in-services on not leaving equipment in the resident's room.
During a review of the facility provided In-Service Training Report for Mechanical Lifting Safety, dated 6/14/2024, the Inservice report indicated CNA 2 completed a Mechanical Lifting Post Test that indicated lifting machines may not be stored in the resident's room.
During an interview on 8/9/2024 at 2:40 p.m. the facility Administrator (ADM) stated equipment should not be left in resident rooms because it could create a hazard for residents, especially if they are ambulatory. The ADM stated there was a risk that ambulatory residents could trip and fall over the equipment that could result in an injury like a fracture.
During an interview on 8/9/2024 at 2:45 p.m., LVN 4 stated CNA 2 told her she brought and left the sit-to-stand assistive device in the residents' room. LVN 4 stated the resident should be brought into the room first, then the sit-to-stand machine should be brought to the room because there are other residents that may walk in the room when the equipment is unattended.
During a review of the facility policy and procedure titled, Resident Rooms and Environment, last reviewed 1/29/2024, the policy indicated its purpose is to provide residents with a safe, clean, comfortable, and homelike environment. The facility shall ensure residents can receive care and services safely and that the physical layout maximizes resident independence and does not pose a safety risk.
During a review of the facility policy and procedure titled, Sit-to-Stand Lift, last reviewed on 1/29/2024, indicated the purpose of the policy was to ensure safety of residents during transfers and to reduce the potential for injuries to residents.
During a review of the facility policy and procedure titled, Safety Environment, last reviewed on 1/29/2024, indicated the purpose of the policy was to provide a safe, clean, and hazard free environment for all residents promoting their wellbeing, dignity, and quality of life. The facility shall maintain an environment that ensures the safety and security of all residents. This includes, but is not limited to, the prevention of accidents, hazards, and exposure to harmful conditions. All rooms shall be arranged in a manner that ensures safety. All rooms shall be free of clutter and any items that could pose a fall risk.
4.b. During a review of Resident 55's admission Record, the admission record indicated the facility admitted the resident on 11/21/2019 with diagnoses that included unspecified dementia, metabolic encephalopathy (a general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), Parkinson's disease (a brain disorder causing uncontrolled movements including shaking or difficulty with balance and coordination) with dyskinesia (uncontrolled, involuntary muscle movements), Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), and muscle weakness.
During a review of Resident 55's physician orders indicated the following orders:
-May use mechanical device for transfers and or weights, dated 6/14/2024.
During a review of Resident 55's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS indicated the resident required substantial/maximal assistance from staff for toileting, bathing, dressing, personal hygiene; and mobility.
During a review of Resident 55's history and physical dated 7/24/2024, the H & P indicated the resident had the capacity to understand and make decisions.
During an observation on 8/9/2024 at 12:15 p.m., Resident 55 was lying in bed. A sit-to-stand assistive device was inside the resident's room placed near the door next to Resident 148's bed. No staff were present in the room or hallway.
During an observation on 8/9/2024 at 12:30 p.m., CNA 2 exited the resident room, walked to the nursing station, and moved Resident 148 in the WC to the shared room with Resident 55 and closed the curtain. After assisting Resident 148 into bed, CNA 2 walked out of the room with the sit-to-stand assistive device.
During an interview on 8/9/2024 at 12:40 p.m., CNA 2 stated she used the sit-to-stand assistive device to assist Resident 148 into bed.
During an interview on 8/9/2024 at 2:02 p.m., the DON stated she was made aware by CNA 2 that the sit-to-stand assistive device was left unattended next to the resident's bed while there was a resident in the room. The DON stated equipment should not be left in the resident rooms if there is a resident present in the room. The DON stated it was an environmental hazard to leave equipment in a resident's room because residents may harm themselves on the equipment. The DON stated the facility CNAs have recently had in-services on not leaving equipment in the resident's room.
During a review of the facility provided In-Service Training Report for Mechanical Lifting Safety, dated 6/14/2024, the Inservice report indicated CNA 2 completed a Mechanical Lifting Post Test that indicated lifting machines may not be stored in the resident's room.
During an interview on 8/9/2024 at 2:40 p.m. the facility Administrator (ADM) stated equipment should not be left in resident rooms because it could create a hazard for residents, especially if they are ambulatory. The ADM stated there was a risk that ambulatory residents could trip and fall over the equipment that could result in an injury like a fracture.
During an interview on 8/9/2024 at 2:45 p.m., LVN 4 stated CNA 2 told her she brought and left the sit-to-stand assistive device in the residents' room. LVN 4 stated the resident should be brought into the room first, then the sit-to-stand machine should be brought to the room because there are other residents that may walk in the room when the equipment is unattended.
During a review of the facility policy and procedure titled, Resident Rooms and Environment, last reviewed 1/29/2024, the policy indicated its purpose is to provide residents with a safe, clean, comfortable, and homelike environment. The facility shall ensure residents can receive care and services safely and that the physical layout maximizes resident independence and does not pose a safety risk.
During a review of the facility policy and procedure titled, Sit-to-Stand Lift, last reviewed on 1/29/2024, indicated the purpose of the policy was to ensure safety of residents during transfers and to reduce the potential for injuries to residents.
During a review of the facility policy and procedure titled, Safety Environment, last reviewed on 1/29/2024, indicated the purpose of the policy was to provide a safe, clean, and hazard free environment for all residents promoting their wellbeing, dignity, and quality of life. The facility shall maintain an environment that ensures the safety and security of all residents. This includes, but is not limited to, the prevention of accidents, hazards, and exposure to harmful conditions. All rooms shall be arranged in a manner that ensures safety. All rooms shall be free of clutter and any items that could pose a fall risk.
6. During a review of Resident 213's admission Record indicated the facility admitted the resident on 9/8/2023 with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).
During a review of Resident 213's History and Physical (H&P) dated 9/8/2023, the H & P indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 213's Elopement Risk Assessment form for 11/13/2023, 2/1/2024, and 4/25/2024, indicated a score of 8. The form did not indicate that the resident's quarterly assessment, which was due in 7/2024, was done. The form indicated to assess the residents according to the Resident Assessment Instrument (RAI) guidelines, upon admission, readmission, quarterly, and upon identification of a significant change of condition. The form indicated if the total score is eight or greater, the resident should be considered at risk for potential elopement from the facility.
During a review of Resident 213's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/10/2024 indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding), was independent with mobility, and ambulation, required set up/clean up assistance with eating and transfers, and supervision or touching assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 213 was always continent of bowel and bladder.
During a review of Resident 213's care plan on risk of elopement from the facility (Elopement Risk Assessment score 8 or greater initiated 9/24/2023 target date 11/6/2024, indicated a goal that resident safety will be maintained through the target date.
During a concurrent interview and record review on 8/8/2024 at 11:33 a.m., Resident 213's Elopement Risk Assessment, MDS assessment, and care plans were reviewed with the Minimum Data Set Coordinator (MDSC). The MDSC verified the most current MDS Assessment was submitted and accepted on 7/25/2024. The MDSC verified Resident 213's Elopement Risk Assessment was not done. The MDSC verified all assessments that were due for the resident were completed 7/19/2024 and stated the Elopement Risk Assessment was not completed. The MDSC stated it was important for the assessment to be completed quarterly so everyone would be aware of how the resident is and to keep the resident safe and provide the proper care needed.
During a concurrent interview and record review on 8/8/2024 at 4:30 p.m., Resident 213's Elopement Risk Assessment was reviewed with the Performance Improvement Quality Improvement Nurse 1 (PIQI 1). The PIQI 1 stated assessments are completed quarterly. PIQI 1 verified Resident 213's elopement risk assessment was not completed for 7/2024. The PIQI 1 stated she must have missed it.
During a concurrent interview and record review on 8/9/2024 at 5:34 p.m., the Director of Nursing (DON) stated assessments are completed upon admission, readmission, quarterly, and/or for a change of condition. The DON stated the assessment should have been completed as it was important for the facility to identify a resident's risk for elopement and develop a care plan and implement interventions to prevent such incidents.
During a review of the facility's policy and procedure titled, Wandering and Elopement, last reviewed on 1/29/2024 indicated:
The facility will identify residents at risk for elopement and minimize any possible injury because of elopement.
The Licensed Nurse (LN), in collaboration with the Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of then residents), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition.
The resident's risk for elopement and preventative interventions will be documented in the resident's medical record and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition according to the RAI guidelines.
7. During a review of Resident 43's admission Record, the admission record indicated the facility admitted the resident on 3/17/2021 and readmitted on [DATE] with diagnoses that included congestive heart failure (CHF - a long-term [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Residents 119, 139, 141, and 34) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) received treatment and services to prevent further decline in ROM, by failing to:
1. Accurately complete Joint Mobility Assessments (JMA, brief assessment of a resident's range of motion in both arms and both legs) for Residents 119, 139, 141, and 34 in accordance with the facility's policy titled, Joint Mobility Assessment, revised on 5/1/2018 and reviewed on 1/29/2024.
2. Assess both of Resident 119's elbow splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for proper fit during the JMAs, dated 12/7/2022, 3/3/2023, 8/23/2023, 11/24/2023, and 8/4/2024, after Resident 119's discharge from Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) on 8/19/2022 and 10/6/2022.
3. Assess Resident 119's right knee splint during JMAs, dated 12/7/2022, 3/3/2023, 8/23/2023, 11/24/2023, and 8/4/2024 for proper fit, after Resident 119's discharge from Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) on 10/28/2022.
4. Identify and report Resident 119's significant decline in ROM to both arms and legs on the JMA, dated 8/4/2024.
5. Provide passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to both of Resident 119's hands on 8/7/2024. The physician's order is to PROM to both arms every day.
6. Apply Resident 119's right elbow splint properly by applying the splint right-side up (not upside down) on 8/7/2024.
7. Identify and report Resident 119's right knee splint was not aligned with the right knee for at least two weeks, including on 8/7/2024 and 8/8/2024.
8. Identify and replace Resident 139's loose left hand compressive glove (worn after a burn or skin injury to provide consistent and even pressure to the healed skin to decrease the severity of scarring).
These failures resulted in Resident 119's undetected worsening contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to both elbows and knees and the development of contractures to both hips and hands. These failures resulted in inaccurate monitoring of ROM in both arms and legs for Resident 119, 34, 139, and 141. These failures had the potential for Resident 139 to experience a decline in ROM to the left hand.
Cross reference F726.
Findings:
a. During a review of Resident 119's admission Record, the facility admitted Resident 119 on 5/11/2017 with diagnoses including Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life), dementia (decline in mental ability severe enough to interfere with daily life), age-related osteoporosis (medical condition in which the bones become brittle and fragile from loss of tissue), and dysphagia (difficulty swallowing).
During a review of Resident 119's census (record of hospitalizations, room changes, and payor source changes), the census indicated Resident 119 resided at the facility since 5/11/2017 without any hospitalizations.
During a review of Resident 119's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 5/13/2024, the MDS indicated Resident 119 had unclear speech, rarely expressed ideas and wants, rarely understood verbal content, and was severely impaired (never/rarely made decisions) for daily decision making. The MDS indicated Resident 119 had ROM impairments in both arms and legs and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) with eating, toileting, showering/bathing, upper and lower body dressing, rolling to both sides in bed, and chair/bed-to-chair transfers.
During a review of Resident 119's physician orders, dated 11/9/2020, the physician orders indicated for Resident 119 to receive PROM exercises to both arms and legs, every day.
During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 6/8/2022, the OT Evaluation indicated Resident 119 was referred to OT due to a decline in ROM, decreased balance, and increased need for assistance from others. The OT Evaluation indicated Resident 119's ROM to the right elbow, both wrists, and both hands were within functional limits (WFL, sufficient movement without significant limitation). The OT Evaluation indicated Resident 119's impaired ROM included right shoulder flexion (lifting the arm upward) 0 to 80 degrees (0 to 80 degrees, normal 0 to 180 degrees), right shoulder abduction (lifting the arm up and away from the body) 0 to 75 degrees (normal 0 to 180 degrees), left shoulder flexion 0 to 40 degrees, left shoulder abduction 0 to 40 degrees, and left elbow extension (straightened) was limited to 80 degrees (normal 0 degrees, positioned in 80 degrees of elbow flexion [bend]).
During a review of Resident 119's OT Treatment Encounter Notes, dated 8/19/2022, the OT Treatment Encounter Notes indicated Resident 119's ROM included right shoulder flexion 0 to 90 degrees (shoulder height), right shoulder abduction 0 to 80 degrees, right elbow extension to 20 degrees (elbow positioned in 20 degrees of flexion), left shoulder flexion 0 to 50 degrees, left shoulder abduction 0 to 50 degrees, and left elbow extension to 30 degrees (elbow positioned in 30 degrees of elbow flexion).
During a review of Resident 119's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 119 safely wore splints to both elbows for two hours without signs of redness, swelling, discomfort, or pain. The OT Discharge Summary recommendations included a Restorative Nursing Program ([RNP] nursing program that uses restorative nursing aides [RNAs] to help residents maintain their function and mobility) to provide Resident 119 with PROM and to apply both elbow splints for two hours daily as tolerated.
During a review of Resident 119's Restorative Nursing Program (RNP) Referral/Care Plan, dated 8/19/2022, the RNP Referral/Care Plan indicated Occupational Therapist 2 (OT 2) reviewed Resident 119's program with Restorative Nursing Assistant 5 (RNA 5) to apply both elbow splints for two hours.
During a review of Resident 119's physician orders, dated 8/19/2022, the physician orders indicated for RNA to apply both elbow splints for two hours daily as tolerated.
During a review of Resident 119's Registered Nurse (RN)/Licensed Vocational Nurse (LVN) Progress Notes, dated 10/4/2022, the RN/LVN Progress Notes indicated Resident 119 was on RNA program for PROM exercises to both arms and both legs and application of both elbow splints for two hours as tolerated. The RN/LVN Progress Notes indicated Resident 119 was noted with abnormal posture (position in which someone holds their body) while sitting up in the wheelchair and/or lying in bed and was at-risk for developing contractures. The RN/LVN Progress Notes indicated Resident 119 will continue to be monitored.
During a review of Resident 119's RN/LVN Progress Notes, dated 10/5/2022, the RN/LVN Progress Notes indicated Resident 119 continued to have abnormal posture while sitting up in the wheelchair and lying in bed and was at-risk for developing contractures. The RN/LVN Progress Notes indicated a discussion with family included providing Resident 119 with PT and OT Evaluations to ensure correct body alignment, positioning, and prevention of contractures.
During a review of Resident 119's Joint Mobility Screening (JMA completed by PT and OT), dated 10/6/2022, the Joint Mobility Screening indicated Resident 119's ROM included severe ROM limitation (more than 50 percent [%] loss of motion) in the left shoulder, moderate ROM limitation (25 to 50% loss of motion ) in the right shoulder, minimum ROM limitation (less than 25% loss of motion) in both elbows and knees, and full ROM in both hands, hips, and ankles. The Joint Mobility Screening indicated recommendations for Resident 119 to receive PT and OT Evaluations and to continue with the RNA program.
During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 10/6/2022, the OT Evaluation indicated Resident 119 was seen for an Evaluation Only (no intervention recommended). The OT Evaluation Only indicated Resident 119's ROM was WFL in both wrists and hands but had impairment in both shoulders and elbows, including right shoulder flexion 0 to 90 degrees (shoulder height), right elbow extension to 20 degrees, left shoulder flexion 0 to 50 degrees, and left elbow extension to 30 degrees. The OT Evaluation Only indicated Resident 119 was already provided with both elbow splints and did not have any significant change in condition requiring OT intervention.
During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 10/6/2022, the PT Evaluation indicated Resident 119 was referred to PT due to a new onset of decreased ROM, decreased postural alignment when sitting up in the wheelchair, and at-risk for contracture development. The PT Evaluation indicated Resident 119's ROM in both hips and ankles were WFL but had impaired ROM to both knees. The PT Evaluation indicated Resident 119's right knee extension was limited to 30 degrees (normal 0 degrees, knee positioned in 30 degrees of knee flexion) and left knee extension was limited to 15 degrees (knee positioned in 15 degrees of knee flexion).
During a review of Resident 119's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 119 tolerated sitting up in a standard wheelchair with a cushioned seat for four hours, had right knee extension to 20 degrees, and tolerated a right knee extension splint for two hours. The PT Discharge recommendations included a RNP to provide Resident 119 with PROM and to apply the right knee extension splint.
During a review of Resident 119's RNP Referral/Care Plan, dated 10/28/2022, the RNP Referral/Care Plan indicated the Physical Therapist 3 (PT 3) reviewed Resident 119's program with RNA 5 to provide PROM to both legs and to apply the right knee splint for two hours.
During a review of Resident 119's physician orders, dated 10/28/2022, the physician orders indicated for the RNA to apply the right knee splint for two hours with skin checks every 30 minutes daily as tolerated.
During a review of Resident 119's JMAs, dated 12/7/2022 and 3/3/2023, the JMA indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMAs indicated Resident 119 received RNA for PROM to both arms and legs as tolerated. The JMAs did not indicate the RNA applied both elbow splints and the right knee splint.
During a review of Resident 119's JMAs, dated 8/23/2023 and 11/24/2023, the JMAs indicated Resident 119 had severe ROM limitation in both shoulders, moderate ROM limitation in both elbows, hips, knees, and ankles, minimum ROM limitation in both wrists, and full range of motion in both hands. The JMAs indicated Resident 119 received RNA for PROM to both arms and legs. The JMAs did not indicate the RNA applied both elbow splints and the right knee splint.
During an interview on 8/6/2024 at 9:34 a.m. with the Director of Rehabilitation (DOR) in the therapy gym, the DOR stated RNA was a maintenance program to maintain a resident's ROM and mobility. The DOR stated the DOR, RNA Team Lead (RNA 1), and the RNA assigned to each station had weekly meetings to discuss new admissions and any changes with residents. The DOR stated limitations in ROM (in general) can lead to limitations in function and the development of contractures, which could cause pain. The DOR stated ROM exercises and application of splints can assist in maintaining ROM and preventing contractures. The DOR stated PT and OT did not complete the JMA quarterly or annually.
During an observation on 8/6/2024 at 3:45 p.m. in the bedroom, Resident 119 was being transferred from the bed to a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) using a mechanical lift (used to transfer residents between surfaces). Resident 119 was fully dressed, did not have any splints applied to either arm or leg, but did have cushioned heel protectors (minimizes risk of injury to the heels) applied to both feet. Resident 119's both knees were bent while sitting up in the Geri chair.
During a concurrent observation and interview on 8/7/2024 at 9:10 a.m. in the dining room with Restorative Nursing Assistant 2 (RNA 2), Resident 119 was sitting upright in the Geri chair without any splints applied to either arm or leg but had cushioned heels protectors applied to both feet. RNA 2 stated Resident 119 was seen by RNA 2 for ROM exercises to both arms and both legs and the splints were applied this morning. RNA 2 stated Resident 119's Certified Nursing Assistant (CNA) may have removed the splints.
During an observation on 8/7/2024 at 12:40 p.m. in the bedroom, RNA 2 stated Resident 119's primary (routinely assigned) RNA was RNA 5. RNA 2 stood on the right side of Resident 119's bed and performed ROM exercises on Resident 119's right shoulder. RNA 2 could not lift the right arm to shoulder height. RNA 2 bent and extended the right elbow to perform ROM exercises but could not fully extend the right elbow, which remained in a bent position. RNA 2 performed wrist flexion (bent down) and wrist extension (bent up) exercises but did not perform any exercises to Resident 119's right hand. RNA 2 massaged Resident 119's right arm into extension prior to applying the right elbow splint upside down. RNA 2 bent and extended Resident 119's right hip and knee at the same time, causing Resident 119 to moan with a facial grimace (expression of pain or strong dislike). RNA 2 could not extend the right knee, which continued to have a bend of approximately 90 degrees. RNA 2 performed exercises to the right ankle into rotation, dorsiflexion (ankle bent with toes pointing toward the body), and plantarflexion (ankle bent with toes pointing away from the body), and then applied the cushioned heel protector. RNA 2 applied Resident 119's right knee splint, which was fixed in a nearly straight position, and fastened a strap over the right kneecap. Resident 119's knee splint was not applied directly on the right knee but toward the right ankle. RNA 2 stood on the left side of Resident 119's bed and performed ROM exercises on the left shoulder. RNA 2 lifted the left arm higher than the right shoulder joint but could not lift the left arm to shoulder height. RNA 2 bent and extended the left elbow to perform ROM exercises but could not fully extend the left elbow, which remained in a bent position. RNA 2 performed wrist flexion and extension exercises but did not perform any exercise to Resident 119's left hand. RNA 2 applied the left elbow splint. RNA 2 bent and extended Resident 119's left hip and knee at the same time. RNA 2 could not fully extend Resident 119's left hip and knee. RNA 2 then performed ankle exercises to Resident 119's left ankle into rotation, dorsiflexion, and plantarflexion and then applied the left cushioned heel protector.
During an interview on 8/7/2024 at 1:04 p.m. with RNA 2, RNA 2 stated the splints will be checked every 30 minutes and will remove the splints after 2 hours. RNA 2 stated ROM was not performed to Resident 119's hands because both hands were good and stated Resident 119 could straighten the fingers.
During a concurrent observation and interview on 8/7/2024 at 1:09 p.m. with the DOR and Physical Therapy Assistant 1 (PTA 1) in the bedroom, Resident 119 was observed lying in bed while wearing both elbow splints and the right knee splint. PTA 1 stated Resident 119's right knee splint was applied lower than the knee. PTA 1 checked the right knee splint and stated Resident 119's knee splint was set to 30 degrees of extension but Resident 119's right knee was bent to approximately 90 degrees. PTA 1 stated the right knee splint did not fit Resident 119 because the bend in the splint did not match the bend in Resident 119's knee. PTA 1 stated an inappropriately fitted splint could put pressure on the skin and bones of Resident 119's right knee, which could result in pressure sores (localized damage to the skin and underlying soft tissues over a bony prominence) and dislocation (injury caused when the normal position of a joint is disturbed) of the right knee.
During a concurrent observation and interview on 8/7/2024 at 1:19 p.m. with the DOR and PTA 1 in the bedroom, the DOR removed Resident 119's right knee splint. The skin on Resident 119's right knee, which was directly under the strap of the knee splint, was observed with redness. PTA 1 stated Resident 119 had redness to the pressure sensitive area of the right kneecap. The DOR observed Resident 119's elbow splints, stated the right elbow splint was applied upside down, and adjusted both of Resident 119's elbow splints.
During a concurrent interview and record review on 8/7/2024 at 1:45 p.m. with the DOR, Resident 119's census, OT Evaluation, dated 6/8/2022, OT Discharge summary, dated [DATE], OT Evaluation Only, dated 10/6/2022, PT Evaluation, dated 10/6/2022, and PT Discharge summary, dated [DATE], were reviewed. The DOR reviewed Resident 119's census and stated Resident 119 was admitted to the facility on [DATE] and did not leave the facility for any reason. The DOR stated Resident 119 received an OT Evaluation on 6/8/2022 due to a change of condition ([COC] major decline or improvement in a resident's status that will not resolve itself without intervention), including declining ROM, reduced balance, and increased need for assistance from others, but did not receive a PT Evaluation (unknown reason). The DOR stated Resident 119's ROM in both wrists and hands were WFL but had ROM limitations in both shoulders and elbows. The DOR stated Resident 119's ROM upon discharge from OT on 8/19/2022 was right shoulder flexion 0 to 90 degrees, right shoulder abduction 0 to 80 degrees, right elbow extension to 20 degrees, left shoulder flexion 0 to 50 degrees, left shoulder abduction 0 to 50 degrees, and left elbow extension to 30 degrees. The DOR stated OT 2 discharged Resident 119 on 8/19/2022 with recommendations for RNA to provide PROM to both arms and apply both elbow splints for two hours. The DOR stated Resident 119 received an OT Evaluation Only on 10/6/2022 but treatment was not provided since Resident 119's ROM did not change from OT discharge on [DATE]. The DOR stated the OT Evaluation Only, dated 10/6/2022, indicated to continue RNA for PROM to both arms and application of both elbow splints. The DOR reviewed the PT Evaluation, dated 10/6/2022, and stated Resident 119's ROM in both hips and ankles were WFL but had ROM limitation in both knees, including right knee extension to 30 and left knee extension to 15 degrees. The DOR stated Resident 119 was discharged from PT on 10/28/2022 with right knee extension to 20 degrees. The DOR stated PT 3 (no longer works at the facility) discharged Resident 119 on 10/28/2022 with recommendations for RNA to provide PROM to both legs and apply the right knee extension splint. The DOR stated OT has not performed any treatment to Resident 119 since 10/6/2022 and PT has not performed any treatment to Resident 119 since 10/28/2022 (approximately 22 months ago).
During a concurrent observation and interview on 8/8/2024 at 8:30 a.m. in the bedroom with RNA 5, Resident 119 was lying in bed awake with the head-of-bed (HOB) fully elevated and the elbow splint applied to the right arm. RNA 5 stated Resident 119 was usually nonverbal and that RNA 5 was Resident 119's primary RNA. The skin on Resident 119's right kneecap was observed with pink areas. RNA 5 stated Resident 119's splints were applied this morning at approximately 7:00 a.m. but the right knee and left elbow splints were removed after 15 minutes due to skin redness on both sites.
During a concurrent observation and interview on 8/8/2024 at 9:05 a.m. with Physical Therapist 1 (PT 1) in the bedroom, Resident 119's ROM in both knees and the right knee extension splint were observed. Resident 119 was lying in bed with the HOB fully elevated and both knees were in bent positions. PT 1 extended both knees and stated Resident 119 had contractures to both knees. PT 1 stated the right knee extended to 90 degrees (right knee positioned in 90 degrees of flexion) and the left knee extended to 55 degrees (left knee positioned in 55 degrees of flexion). PT 1 observed Resident 119's right knee extension splint, which was set to 30 degrees, and stated the right knee splint was not an appropriate fit because Resident 119's right knee was bent more than 30 degrees. PT 1 stated the right knee extension splint could cause injury to Resident 119's right leg if applied to the right knee.
During a concurrent observation and interview on 8/8/2024 at 9:16 a.m. with PT 1 and RNA 5 in the bedroom, RNA 5 applied Resident 119's knee extension splint. RNA 5 stated Resident 119's right knee extension splint did not fit because Resident 119's right knee ROM had worsened. PT 1 stated he was not notified of Resident 119's worsening ROM in the right knee and the inability to apply the right knee splint appropriately.
During a review of Resident 119's physician orders, dated 8/8/2024 timed at 9:30 a.m., the physician orders indicated to discontinue the right knee splint and both elbow splints. The physician orders also indicated for OT and PT to evaluate and treat.
During an interview on 8/8/2024 at 10:40 a.m. with the Director of Nursing (DON), Registered Nurse Supervisor 1 (RN 1), Performance Improvement Quality Improvement Licensed Vocational Nurse 1 (PIQI 1), and PIQI 2, RN 1 stated the facility process is that the RN, PIQI, and RNA assigned to each nursing station complete the JMA for each resident upon admission, quarterly, change of condition, and annually. The DON stated the previous DOR provided a training on how to complete the JMA to the DON, RN Supervisors, PIQI LVNs, and RNAs approximately five years ago. The DON stated there has not been any recent training on how to complete the JMAs. PIQI 2 stated the JMA assessed a resident's active or passive joint limitations depending on if the resident can move.
During a concurrent interview and record review on 8/8/2024 at 11:55 a.m. with RN 1, PIQI 1, PIQI 2, Resident 119's quarterly JMAs from 3/3/2023, 6/1/2023, 8/23/2023, 11/24/2023, 2/16/2024, 5/11/2024, and 8/4/2024. RN 1 stated the splints should be assessed for proper fit during the JMAs. RN 1 stated Resident 119's JMAs from 3/3/2023 to 8/4/2024 indicated Resident 119 had severe ROM limitations in both shoulders, moderate ROM limitations in both elbows, hips, knees, and ankles, and minimum ROM limitations in both wrists. RN 1 stated Resident 119's JMAs from 3/3/2023 to 8/4/2024 indicated Resident 119's ROM limitations remained the same and did not change.
During an interview on 8/8/2024 at 3:21 p.m. with the DON, the DON stated the Supervising RN, PIQI LVN, and RNA assigned to the nursing station were supposed to perform each resident's JMA. The DON stated the Supervising RN assessed the resident, the PIQI LVN was present to gather information about each resident, and the RNA provided the ROM movement as part of the assessment. The DON stated the RNs, including the DON, did not have competency assessments (systematic process that evaluated an individual's skill and knowledge) to perform JMAs. The DON stated there was no way to ensure the JMAs for all residents were accurate since the RNs did not have a competency to perform the JMAs.
During a review of Resident 119's OT Evaluation and Plan of Treatment, dated 8/8/2024 completed by OT 2, the OT Evaluation indicated Resident 119 had ROM impairments in both shoulders, both elbows, and both hands. The OT Evaluation indicated Resident 119's ROM limitations included right shoulder flexion 0 to 50 degrees, right shoulder abduction 0 to 61 degrees, right elbow extension to 26 degrees, right hand with less than 25% loss of motion, left shoulder flexion 0 to 66 degrees, left shoulder abduction 0 to 61 degrees, left elbow extension to 43 degrees, and left hand with 25 to 50% loss of motion.
During a review of Resident 119's PT Evaluation and Plan of Treatment, dated 8/8/2024 completed by Physical Therapist 2 (PT 2), the PT Evaluation indicated Resident 119 had ROM impairments in both hips, both knees, and the left ankle. The PT Evaluation indicated Resident 119's ROM limitations included right hip flexion (bending the leg at the hip joint toward the body) 30 to 96 degrees (normal 0 to 120 degrees), right hip abduction (moving the leg away from the body) 0 to 13 degrees (normal 0 to 45 degrees), right knee extension to 73 degrees, left hip flexion 26 to 70 degrees, left hip abduction 0 to 11 degrees, left knee extension to 17 degrees, and left ankle dorsiflexion 0 to 4 degrees (normal 0 to 20 degrees).
During an interview and record review on 8/9/2024 at 8:37 a.m. with RNA 5, PIQI 1 and PIQI 2, Resident 119's JMAs, dated 2/16/2024, 5/11/2024, and 8/4/2024, were reviewed. PIQI 1 and PIQI 2 stated the Supervising RN, PIQI LVN, and the RNA assigned to the nursing station were supposed to be present during each resident's JMA (in general). PIQI 1 and PIQI 2 stated the RNA moved the resident and applied the splints (if applicable), the RN assessed the resident's ROM and splints, and the PIQI recorded the resident's joint mobility limitations based on the RN's assessment. PIQI 1 stated PIQI 3 and RN 5 participated in Resident 119's JMA on 8/4/2024. RNA 5 stated she watched but did not move Resident 119 or apply any splints during Resident 119's JMAs on 2/16/2024, 5/11/2024, and 8/4/2024.
During a telephone interview on 8/9/2024 at 8:56 a.m. with PIQI 3, PIQI 3 stated RN 5 and PIQI 3 performed Resident 119's JMA on 8/4/2024 without RNA 5. PIQI 3 stated Resident 119's splints were not applied during the JMA on 8/4/2024 but should have been applied to assess whether the splints fit.
During an interview on 8/9/2024 at 10:36 AM with the DOR, the DOR stated contractures developed over time. The DOR stated performing ROM exercises, positioning and applying splints assisted in preventing contractures, which could cause pain, limited function, increased skin issues, and increased the potential for injury.
During a concurrent interview and record review on 8/9/2024 at 11:16 a.m. with the DOR and PT 2, Resident 119's PT Discharge summary, dated [DATE], and PT Evaluation, dated 8/8/2024, were reviewed. PT 2 stated Resident 119 did not have any ROM limitations in both hips upon PT discharge on [DATE]. PT 2 stated Resident 119 developed flexion contractures on both hips since both hips could not be extended to neutral (0 degrees) and were significantly limited in hip abduction. PT 2 stated Resident 119's right knee extended to 20 degrees upon PT discharge on [DATE] but currently had 73 degrees of right knee extension which was a significant decline in ROM. PT 2 stated Resident 119's development of and worsening contractures could limit the ability to reposition Resident 119 and increased Resident 119's risk for skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure). The DOR and PT 2 stated Resident 119's decline in ROM on both legs were not reported to the therapy department.
During a concurrent interview and record review on 8/9/2024 at 11:37 a.m. with OT 2, Resident 119's OT Evaluation Only, dated 10/6/2022, and OT Evaluation, dated 8/8/2024, were reviewed. OT 2 stated Resident 119 had 0 to 90 degrees of right shoulder flexion and 0 to 80 degrees of left shoulder flexion during the OT Evaluation on 10/6/2022. OT 2 stated Resident 119 currently had 0 to 50 degrees of right shoulder flexion and 0 to 61 degrees of left shoulder flexion which was a significant decline in ROM. OT 2 stated Resident 119's ROM in both hands were WFL during the OT Evaluation on 10/6/2022. OT 2 stated both of Resident 119's hands currently cannot extend completely. OT 2 stated Resident 11 developed flexion contractures on both hands and had worsening contractures on both shoulders and elbows. OT 2 stated contractures could cause discomfort and pain. OT 2 stated Resident 119's decline in ROM on both arms were not reported to the therapy department.
During an interview on 8/9/2024 at 2:06 p.m. with RNA 5, RNA 5 stated she did not report but was supposed to report to the LVN charge nurse or the RN supervisor that Resident 119's right knee splint did not fit. RNA 5 stated Resident 119 resisted ROM because Resident 119 was in pain and had facial expressions of pain whenever RNA 5 touched Resident 119.
During a concurrent interview and record review on 8/9/2024 at 3:49 p.m. with the DON, 13 RNA employee files were reviewed. The DON stated RNAs were important to maintain, improve, and prevent any decline in a resident's mobility, ROM, and overall physical condition. The DON stated 7 of 13 RNA staff did not have any competency evaluations for the provision of RNA services. The DON Stated 6 of 13 RNA staff were evaluated by the Director of Staff Development (DSD) who were not competent in the provision of RNA services. The DON stated 13 of 13 RNAs did not have the competency to accurately perform their duties, including providing ROM, applying splints, and detecting declines in ROM and mobility.
During a concurrent interview and record review on 8/9/2024 at 4:30 p.m. with the DON, Resident 119's quarterly JMAs from 3/3/2023 to 8/4/2024 were reviewed. The DON stated the JMA (in general) was completed to determine if there were any changes in a resident's joint mobility and ROM. The DON stated Resident 119's JMAs were the same because the RN Supervisors were not competent to assess joint mobility and therefore did not notice any changes in Resident 119's ROM. The DON stated contractures (in general) develop due to immobility and could be prevented with ROM exercises and application of splints. The DON stated contractures limited movement, could cause discomfort and pain, and increased a resident's risk of skin impairments. The DON stated contracture prevention was important for a resident's quality of life to prevent any restrictions in movement.
During a concurrent interview and record review on 8/9/2024 at 6:19 PM with the DON, Resident 119's JMA, dated 12/7/2022, 3/3/2023, 8/23/2023, and 11/24/2023, were reviewed. The DON stated the JMAs did not indicate Resident 119 had both elbow and the right knee splints. The DON stated the splints were not assessed during the JMAs for fit if the splints were not documented.
During a review of the facility's policy and procedure (P&P) titled, Joint Mobility Assessment, revised 5/1/2018 and reviewed on 1/29/2024, the P&P indicated all residents shall receive a joint mobility assessment upon admission, quarterly, and during a significant change in the resident's condition to identify any limitation in joint mobility and risk of contractures. The P&P indicated the DON or designee will monitor the completion and accuracy of joint mobility assessments.
During a review of the facility's P&P titled, Range of Motion Exercise Guidelines, revised 3/1/2015 and reviewed on 1/29/2024, the P&P indicated ROM should be delivered by trained staff to maintain or increase ROM of a joint and to prevent or reduce contractures.
b.1. During a review of Resident 139's admission Record, the facility admitted Resident 139 on 4/28/2021 with diagnoses including Alzheimer's disease (generalized brain deterioration that leads to progressive decline in

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 139's admission Record indicated the facility admitted the resident on 4/28/2021, with diagnoses that included pressure-induced deep tissue damage (condition that affects the underlying layers of skin, muscle, and other soft tissues) of the left heel, muscle wasting and atrophy (a wasting away or progressive decline, typically of a body part, organ, or tissue), and peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs).
During a review of Resident 139's History and Physical (H&P), dated 4/1/2024, the H & P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 139's MDS, dated [DATE], indicated the resident usually makes self-understood and understands others. The MDS indicated the resident had upper and lower extremity impairment and was totally dependent in the area of mobility and activities of daily living (ADLs). The MDS indicated the resident was incontinent (unable to control excretions, to hold urine in the bladder, or to keep feces in the rectum.) of urine and bowel (feces) and was at risk for developing pressure injuries. The MDS also indicated the resident had an unstageable pressure injury and was on a turning/repositioning program.
During a review of Resident 139's Order Summary Report, dated 7/2/2024, indicated an order to cleanse with normal saline (NSS, a mixture of water and salt for washing the wound), the left medial malleolus (the bony protuberance on either side of the ankle) arterial ulcer (a painful, deep sore or wound in the skin of the lower leg or foot), pat dry, apply Santyl ointment (used to help the healing of burns and skin ulcers), cover with dry dressing (DD), and secure with tape. One time a day for one month.
During a review of Resident 139's Braden Scale- For predicting Pressure Sore Risk, dated 8/6/2024, indicated Resident 139 was a high risk for developing or worsening of pressure injuries.
During a concurrent observation and interview on 8/7/2024, at 12:47 p.m., while inside Resident 139's room, with Certified Nursing Assistant 7 (CNA 7), Resident 139 was sitting on a wheelchair. CNA 7 stated the resident was in the wheelchair for four hours now. CNA 7 stated they do not reposition the resident in the wheelchair. CNA 7 stated they use a Hoyer lift (a patient lift used by caregivers to safely transfer patients) to transfer the resident from chair to bed and vice versa.
During an observation on 8/7/2024, at 1:28 p.m., Resident 139 was still in the wheelchair beside the resident's bed.
During an interview on 8/8/2024, at 9 a.m., with Registered Nurse 1 (RN 1), RN 1 stated residents can only sit in a wheelchair for two hours to prevent skin breakdown.
During an interview on 8/8/2024, at 9:15 a.m., with the Performance Improvement Quality Improvement Nurse 1 (PIQI 1), PIQI 1 stated the resident can only be in a wheelchair for a maximum of two hours to prevent pressure injury. PIQI 1 stated if the resident needed to stay in a wheelchair for a longer period, they need to reposition the resident every two hours.
During a concurrent interview and record review, on 8/8/2024, at 9:43 a.m., with the Administrator (ADM), the ADM stated they were repositioning residents in a wheelchair every two hours to prevent pressure injury. The Policy and procedure titled, Support Surface Guidelines, was reviewed with the ADM, the ADM confirmed they were not following their policy and procedure as it indicated to reposition the resident in a chair every hour and to encourage the resident to change position on their own every 15 minutes.
During a review of the facility's recent policy and procedure titled, Support Surface Guidelines, last reviewed on 1/29/2024, the policy indicated the purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing relieving devices for residents at risk of skin breakdown. Residents placed in chairs should be repositioned every hour and encouraged to change position on their own every 15 min.
Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI, injuries to the skin and underlying tissue resulting from prolonged pressure) by failing to:
1. Set the Low Air Loss Mattress (LALM or LAL mattress, designed to prevent and treat PIs) in accordance with the resident's weight and manufacturer's instructions for two of three sampled residents (Resident 23, 230) reviewed under the Pressure Ulcer/Injury care area.
2. Reposition a resident on a wheelchair every hour per facility policy for one of three sampled residents (Resident 139) reviewed under the Pressure Ulcer/Injury care area.
These deficient practices had the potential for the reoccurrence or development of new PIs.
Findings:
a. During a review of Resident 23's admission Record, it indicated the facility admitted the resident on 6/21/2022 with diagnoses that included Parkinsonism (a term that refers to brain conditions that cause unintended or uncontrollable movements), Alzheimer disease (a type of dementia [a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life]), and dementia, and muscle weakness.
During a review of Resident 23's Care Plan titled, Pressure Injury, Stage Two (the skin breaks open, wears away, or forms a wound which is usually tender and painful) Left Buttock and Right Buttock, initiated on 8/3/2023 and resolved on 9/22/2023, the CP indicated the resident had a history of pressure injuries and was placed on a LALM.
During a review of Resident 23's Care Plan titled, Functional Abilities of Everyday Activities Dependent in .bed mobility . At Risk for Skin Breakdown ., initiated on 12/8/2023, the CP indicated to apply a LALM for skin integrity as ordered.
During a review of Resident 23's history and physical dated 6/1/2024, it indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 23's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/18/2024, it indicated the resident was unable to complete the brief interview for mental status (BIMS, a brief cognitive screening measure that focuses on orientation and short-term word recall). The MDS indicated the resident was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, and mobility.
During a review of Resident 23's Weight Flow Sheet, the flow sheet indicated on 7/29/2024 that the resident weighed 141 pounds.
During an observation on 8/5/2024 at 9:40 a.m., Resident 23 lay in bed on top of a LALM, no staff were present in the room. The LALM pump was turned on and had the dial set to indicate a weight of 250 pounds (lbs).
During a concurrent observation and interview on 8/5/2024 at 9:45 a.m. Certified Nursing Assistant 10 (CNA 10) stated Resident 23 was on a LALM for preventative reasons because the resident has back pain and prefers to stay lying down. CNA 10 stated the charge nurse sets the LALM and she does not touch the settings. CNA 10 entered Resident 23's room and assessed the LALM settings and stated it was set to a resident weight of 250 lbs.
During a concurrent observation, interview, and record review on 8/5/2024 at 9:50 a.m., Licensed Vocational Nurse 2 (LVN 2) reviewed Resident 23's weights and physician's orders. LVN 2 stated LALM are set according to the resident's weight. LVN 2 stated Resident 23 had an order for a LALM and the resident's weight is 141 lbs. LVN 2 entered Resident 23's room and stated the mattress was set to 250 lbs and it was not the correct weight. LVN 2 adjusted the LALM setting to 180 lbs and stated the setting was the closest to the resident's weight. RN 2 stated when the LALM is set to a higher weight it makes the mattress harder. RN 2 stated the purpose of the LALM was to provide a softer surface to prevent PIs.
During an interview on 8/7/2024 at 12:53 p.m., Treatment Nurse 1 (TN 1) stated Resident 23's family wanted her to be on a LALM and they were trying to be nice by providing the LALM. TN 1 stated Resident 23 had a physician's order and a care plan for the LALM and if it was provided then it should be set to the correct setting. TN 1 stated it was not okay that the LALM was set to 250 lbs, but things happen. TN 1 stated it was more important to set the LALM so it doesn't have too little air because the resident would then be touching the bed frame. TN 1 stated she does not look at the LALM manufacture guidelines to set the LALM pumps. TN 1 stated she doesn't work for the manufacture and has never called them. TN 1 stated she knows how to set the LALM settings based on her 27 years of experience in the facility. TN 1 stated she did not think there was any harm in setting the LALM setting weight too high.
During an interview on 8/7/2024 at 1:50 p.m., LVN 2 stated if the LALM weight is set too high then the mattress will be harder resulting in the loss of the purpose of the mattress to prevent PIs. LVN 2 stated it was everyone's responsibility to monitor the LALM settings.
During an interview on 8/8/2024 at 9:17 a.m., the Director of Nursing (DON) stated the facility policy includes providing a LALM for PI prevention. The DON stated the LALM should be set to the resident's weight. The DON stated if the LALM mattress was set to a higher weight it would be firmer. The DON stated the LALM is a piece of equipment, and all equipment comes with manufacture instructions that are available to staff for reference. The DON stated when the LALM is set to too high of a weight and staff are not following the manufacture guidelines, it could potentially harm the resident by causing skin breakdown.
During a review of the facility policy and procedure titled, Support Surface Guidelines, last reviewed on 1/29/2024, the policy indicated pressure reducing support surfaces is a surface designed to prevent or promote the healing of pressure ulcers by distributing pressure over a larger surface area of the body in an effort to reduce or eliminate tissue pressure in a more circumscribed location. The facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development. LALM are giant air-permeable pillows that are continuously inflated with air, the air flow has a drying effect on tissue. An individual at risk for developing pressure ulcers will be placed on pressure reducing devices as recommended.
During a review of the facility provided LALM 2 Instruction Manual indicated to always read the operating instructions before use. According to the weight and height of the patient, adjust the pressure setting to the most comfortable level without bottoming out, then the pressure in the mattress will slowly increase to the intended value after the air mattress is ready to use. Users can adjust the pressure of air mattress to a desired softness by adjusting the comfort keys. Please consult physician for a suitable setting.
b. During a review of Resident 230's admission Record, the admission record indicated the facility admitted the resident on 3/29/2024 with diagnoses that included PU of the sacral region (located below the lumbar spine and above the tailbone) Stage 4 (Full thickness tissue loss with exposed bone, tendon, or muscle), protein-calorie malnutrition (a range of condition arising from lack of dietary protein and/or energy (calories), and cachexia (a wasting disorder that causes extreme weight loss and muscle wasting, and can include loss of body fat).
During a review of Resident 230's History and Physical (H&P) dated 3/29/2024, the H & P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 230's Order Summary Report dated 3/29/2024, indicated Resident 230 was ordered a pressure redistribution mattress - low air loss mattress for skin integrity every shift.
During a review of Resident 230's care plan initiated on 3/29/2024, the CP indicated Resident 230 had pressure injury Stage 4 to the coccyx area (also known as tailbone, a small bone at the bottom of the spine), with interventions including, but not limited to, place LALM on bed as ordered and use a pressure reducing pad when up in wheelchair.
During a review of Resident 230's Braden Scale - For Predicting Pressure Sore Risk dated 5/28/2024 and 6/26/2024, indicated resident was a high risk with a score of 1
A review of Resident 230's MDS, dated [DATE] indicated Resident 230 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance from staff with eating, was dependent with toileting, required partial to moderate assistance with oral hygiene, upper body dressing, sit to lying, lying to sit, and required substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 230 had one Stage 4 PU and used pressure reducing devices on the bed.
During a concurrent observation and interview on 8/5/2024 at 12:46 p.m., while inside Resident 230's room, Treatment Nurse 3 (TN 3) verified Resident 230 was lying on a LALM in supine position with the device's setting at 120 pounds (lbs. - a unit of measurement). TN 3 stated the LALM setting should be according to the resident's weight. TN 3 stated Resident 230's current weight was 80 lbs. TN 3 stated the setting should be at 80 lbs.
During an interview on 8/8/2024 at 2:30 p.m. while inside Resident 230's room, Resident 230 stated she felt a little uncomfortable at the buttock area when the LALM setting was at a little higher setting. Resident 230 stated the bed feels more comfortable and did not hurt the buttock area anymore.
During a concurrent interview and record review on 8/9/2024 at 11:13 a.m., Resident 230's medical records including the physician's orders, care plan, MDS, and weights flow sheet was reviewed with the Resident Assessment Coordinator (RAC). The RAC verified Resident 230's last weight dated 7/8/2024 was at 79 lbs., and a physician's order for LALM every shift for skin integrity. The RAC stated Resident 230's LALM should be set according to weight and the closest weight setting was at 80 lbs. The RAC stated the firmer setting for the LALM placed the resident at risk for worsening of the PU.
During an interview on 8/9/2024 at 5:23 p.m., the DON stated LALM setting should be set according to weight. The DON stated it can affect and possibly delay wound healing.
During a review of undated, manual provided by the facility for LALM 1 owner's manual, indicated:
Once the pump starts press the plus (+) and minus (-) buttons to input the patient's weight (80-35o lbs.) and the machine will automatically adjust the pressure to the ideal level of resistances for the person's weight.
The (+) and (-) increases or decreases the patient weight setting for the mattress in lbs. adjust this setting to fine tune the desired mattress firmness, lower weight for a softer setting and higher weight for a firmer setting.
The mattress is rated for a minimum weight of 80 lbs. and a maximum of 350 lbs. exceeding these limitations may result in damage to the product or personal injury.
During a review of the facility's policy and procedure titled, Support Surface Guidelines, last reviewed on 1/29/2024, indicated:
Provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk for skin breakdown.
The facility will identify residents at risk for PU and provide care and services to promote the prevention of PU development.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for two (2) out of 2 sampled residents (Residents 43 and 211) investigated under the insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (SQ - beneath the skin) insulin administration sites.
These deficient practices had the potential to result in adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).
Findings:
Cross Reference F760
a. During a review of Resident 43's admission Record, the admission record indicated Resident 43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included congestive heart failure (CHF - a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply), type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high), and aphasia (a language disorder that makes it hard for a person to read, write, and say what you mean to say).
During a review of Resident 43's History and Physical (H&P) dated 6/14/2024, the H & P indicated Resident 43 did not have the capacity to understand and make decisions.
During a review of Resident 43's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/1/2024 indicated Resident 43 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating, partial to moderate assistance with walking, was dependent with toileting, bathing, and lower body dressing and required substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 43 received insulin.
During a review of Resident 43's Order Summary Report indicated the following physician's order dated 6/13/2024:
Administer Insulin lispro-aabc injection solution 100 unit per milliliter (unit/ml - a unit of measurement). Inject as per sliding scale: if 150-200 unit; 201-250 = 4 unit; 251-300 = 6 unit; 301-350 = 8 unit; 351-400 = 10 unit, SQ before meals related to DM 2. Call physician if fingerstick blood sugar is above 400 or below 70.
During a review of Resident 43's Medication Administration Record (MAR) from 6/2024 to 7/2024, the MAR indicated insulin lispro injection solution was administered as follows:
06/23/24 11:30 subcutaneously Right Upper Arm (RUA)
06/23/24 17:00 subcutaneously - RUA
06/25/24 11:30 subcutaneously Left Upper Arm (LUA)
06/25/24 17:00 subcutaneously - LUA
06/27/24 17:00 subcutaneously - Left Deltoid (LD)
06/28/24 07:00 subcutaneously - LD
06/30/24 07:00 subcutaneously - RUA
06/30/24 11:30 subcutaneously - RUA
07/02/24 11:30 subcutaneously - RUA
07/02/24 17:00 subcutaneously - RUA
07/03/24 11:30 subcutaneously - LUA
07/03/24 17:00 subcutaneously - LUA
07/10/24 11:30 subcutaneously - LUA
07/10/24 17:00 subcutaneously - LUA
07/13/24 11:30 subcutaneously - RUA
07/13/24 17:00 subcutaneously - RUA
07/19/24 17:00 subcutaneously - RUA
07/20/24 17:00 subcutaneously - RUA
07/20/24 11:30 subcutaneously - LUA
07/20/24 17:00 subcutaneously - LUA
07/23/24 11:30 subcutaneously - RUA
07/23/24 17:00 subcutaneously - RUA
07/24/24 17:00 subcutaneously - RUA
07/28/24 11:30 subcutaneously - LUA
07/28/24 17:00 subcutaneously - LUA
07/29/24 07:00 subcutaneously - Right & Above Umbilicus
07/29/24 11:30 subcutaneously - Right & Above Umbilicus
07/30/24 11:30 subcutaneously - Right & Below Level of Umbilicus
07/30/24 17:00 subcutaneously - Right & Below Level of Umbilicus
During a concurrent interview and record review on 8/8/24 at 12:04 p.m., Resident 43's MAR for 6/2024 and 7/2024 was reviewed with Registered Nurse 1 (RN 1). RN 1 verified the insulin administration sites were not rotated by the licensed nurses. RN 1 stated the insulin administration sites should have been rotated as the residents could develop irritation on the site, possibly abscess, and lipodystrophy. RN 1 stated it was a standard of practice and considers not rotating insulin administration site as a medication error.
During a review of the undated, insulin lispro manufacturer's guideline provided by the facility, the manufacturers guidelines indicated to change (rotate) injection sites within the area you choose for each dose to reduce the risk of getting lipodystrophy and localized cutaneous amyloidosis at the injection sites.
b. During a review of Resident 211's admission Record, the admission record indicated the facility admitted Resident 211 on 8/22/2022, with diagnoses that included type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (a type of kidney disease caused by diabetes) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks).
During a review of Resident 211's History and Physical (H&P), dated 8/11/2023, indicated Resident 211 did not have the capacity to understand and make decisions.
During a review of Resident 211's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/8/2024, indicated Resident 211 had rarely or never had the ability to make self-understood and sometimes understand others. The MDS indicated the resident had highly impaired vision and was on a high-risk drug class hypoglycemic (occurs when the level of glucose in the blood drops below normal) medication insulin.
During a review of Resident 211's Order Summary Report, indicated an order for the following:
-7/17/2024 Novolin N FlexPen Subcutaneous Suspension Pen-injector 100 unit (the amount of insulin required to reduce the blood glucose)/milliliters (ml, a unit of volume) (Insulin NPH Human [Isophane]). Inject 4 unit subcutaneously in the morning related to type 2 diabetes mellitus with diabetic chronic kidney disease.
-6/14/2024 Novolog Injection Solution 100 unit/ml (Insulin Aspart). Inject as per sliding scale (varies the dose of insulin based on blood glucose level): if 150-200=2 unit; 201-250=4 unit; 251-300=6unit; 301-350=8 unit; 351-400=10 unit, subcutaneously before meals related to type 2 diabetes mellitus with diabetic chronic kidney disease. Call MD if fingerstick (a procedure in which a finger is pricked with a lancet to obtain a small quantity of capillary blood for testing) blood sugar (BS) is above 400 or below.
During a review of Medication Administration Record of insulin for 6/2024 to 7/2024 indicated Novolog insulin was administered on:
6/22/2024 at 7 am on (20) the left and above the level of umbilicus (navel).
6/22/204 at 11:30 am on (20) the left and above the level of umbilicus.
7/7/2024 at 7 am on (21) right and below level of umbilicus.
7/7/2024 at 11:30 am on (21) right and below level of umbilicus.
7/10/2024 at 7 am on (22) left and below level of umbilicus.
7/10/2024 at 11:30 am on (22) left and below level of umbilicus.
7/19/2024 at 11:30 am on (19) to right and above umbilicus.
7/20/2024 at 7 am on (19) to right and above umbilicus.
7/22/2024 at 11:30 am on (21) right and below level of umbilicus.
7/22/2024 at 5 pm on (21) right and below level of umbilicus.
7/24/2024 at 5 pm on (12) left upper arm.
7/25/2024 at 7 am on (12) left upper arm.
7/29/2024 at 7 am on (21) right and below level of umbilicus.
7/29/2024 at 11:30 am (21) right and below level of umbilicus.
During a concurrent interview and record review on 8/8/2024, at 12:04 p.m., with Registered Nurse 1 (RN 1), Resident 211's Order Summary Report and the Medication Administration Record for 6/2024 to 7/2024 was reviewed. RN 1 stated there was an order for Novolin insulin for the resident and on the MAR from 6/2024 to 7/2024 there were multiple instances where the insulin administration sites were not rotated by the licensed nurses. RN 1 stated the failure of the licensed nurse to rotate insulin administration sites could cause skin irritations such as abscess, necrosis, and lipodystrophy.
During an interview on 8/9/2024, at 5:03 p.m., with the Director of Nursing (DON), the DON stated it was common knowledge for licensed nurses to rotate insulin administration sites to prevent tenderness, discomfort, and lipodystrophy to the sites that was frequently administered with insulin.
During a review of the facility's undated, Novolog Manufacturer's Recommendation for Novolog (insulin aspart) injection 100 U/ml is an insulin analog indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus, indicated repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis have been reported to result in hyperglycemia; and a sudden change in the injection site (to an unaffected area) has been reported to result in hypoglycemia. Advise patients who have repeatedly injected into areas of lipodystrophy or localized cutaneous amyloidosis to change the injection site to unaffected areas and closely monitor for hypoglycemia.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not maintaining the trash area free from trash, soiled gloves, soiled tissue papers, a plastic bag of trash on the floor and other dirt debris.
This deficient practice had a potential to attract birds, flies, insects, pests and possibly spread infection to 239 of 239 facility residents.
Findings:
During a concurrent observation of the dumpster (a large metal trash container designed to be emptied into a truck) area outside of the facility and interview with the Dietary Supervisor (DS) on 8/6/2024 at 9:33 a.m., there were soiled gloves, tissue papers and a pile of trash around the dumpster area. The DS stated the trash surroundings were not clean. The DS stated the trash on the ground was not good, not sanitized, and cleaned. The DS stated it was important to maintain the cleanliness of trash surroundings to prevent pest in the area that could end up going in the facility and for infection control.
During concurrent observation of the trash area and interview with the Environmental Service Staff (EVSS) on 8/6/2024 at 9:35 a.m., the EVSS stated the truck driver who picked up the trash comes everyday around 6-6:30 a.m. and trash would fall from the transfer of the trash from the dumpster to the truck. The EVSS stated their vendor would tell the EVSS that the vendor did not have time for the facility to wait to clean the surroundings. The EVSS stated they must call their vendor to prevent this issue. The EVSS stated it was important to maintain the cleanliness of the trash area for infection control for the residents.
A review of facility's policies and procedures (P&P) titled Pest Control dated 1/29/2024, indicated General Practices B. Garbage and trash are not permitted to accumulate in any part of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. During a review of Resident 13's admission Record indicated the facility admitted the resident on 3/28/2020, with diagnoses that included paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts a few hours or days) and history of malignant neoplasm of the brain (a cancerous growth in the brain that grows quickly and invades healthy brain tissue).
During a review of Resident 13's History and Physical (H&P), dated 4/27/2024, the H & P indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 13's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision and was totally dependent on mobility and activities of daily living (ADLs).
During a review of Resident 13's Order Summary Report, dated 7/31/2024, indicated an order of Duoneb Inhalation Solution 0.5-2.5 (3) milligrams (mg, a unit of weight)/3 milliliters (ml, a unit of volume) (Ipratropium-Albuterol). 1 unit inhale orally every 8 hours as needed for wheezing (a high-pitched whistling sound made while breathing) for 2 weeks.
During a concurrent observation and interview on 8/6/2024, at 8:32 a.m., inside Resident 13's room, with Licensed Vocational Nurse 3 (LVN 3), the nebulizer mask and tubing was not labeled with the date it was last changed. LVN 3 stated the nebulizer mask and tubing should be changed weekly and labeled with the date it was last changed. LVN 3 stated the failure of the staff to label the nebulizer mask and tubing with the date it was last changed can predispose the resident to infection because they will not be able to know if the tubing was old and bacteria could have grown in the mask and tubing making the residents sick.
During an interview on 8/9/2024, at 5:03 p.m., with the Director of Nursing (DON), the DON stated the nebulizer mask and tubing should be labeled with the date it was last changed to have a reference of when to change them again. The DON stated the tubing, and the mask should be changed weekly. The DON added if the mask were used for a longer time, there was a potential for contamination/development of infection caused by bacteria that can make the residents sick.
During A review of the facility's recent policy and procedure titled, Oxygen Administration, last reviewed on 1/29/2024, indicated all oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen:
i. Are for single resident use only.
ii. Will be changed weekly and when visibly soiled.
F. During a concurrent observation and interview on 8/7/2023, at 10:35 a.m., with Certified Nursing Assistant 9 (CNA 9), observed Cart A covered with loosely woven/permeable material to protect the clean linens inside the cart. CNA 9 stated the cover was not totally protecting the clean linens as the covering lets air and water in that could allow external environmental contaminants in the clean linen. CNA 9 stated it was important to ensure that the linens were protected from environmental contaminants to prevent spread of infection to residents.
During a concurrent observation and interview on 8/7/2024, at 11:05 a.m., with Registered Nurse 1 (RN 1), observed Cart B covered with loosely woven/permeable material to protect the clean linens inside the cart. RN 1 stated the covers can allow air and water to come in contact with the linen and can transmit infection to the residents.
During a review of the facility's recent policy and procedure titled, Clean Linen Carts, last reviewed on 1/29/2024, indicated the purpose of this policy is to establish standardized procedures for the handling, storage, and transportation of clean linen carts to prevent contamination and ensure compliance with Title 22 regulations thereby maintaining high standards of hygiene and resident care.
G. During a concurrent interview and record review on 8/7/2024, at 3:01 p.m., with the Administrator (ADM), the Water Management System Binder of the facility was reviewed. The ADM stated they were following the CDC Guidelines for Legionella Water Management System. The ADM stated they have identified areas of water stagnation in the facility in the water heaters, water fountains, dead ends of the main water lines. The DON stated they intervened by flushing the system regularly monthly, draining water heaters quarterly, checking for water sedimentation and non-disturbing the dead ends of the waterlines. The DON stated they did in-service for staff for signs and symptoms of legionnaires disease, and they do water temperature monitoring daily. The DON stated they maintain the water temperature above 108 degrees to prevent Legionella.
During a review of Temperature Log for 5/7/2024 to 8/6/2024 indicated temperatures were below 108 degrees Fahrenheit on the following dates:
5/7/2024 RM [ROOM NUMBER]- 77 degrees
5/9/2024 RM [ROOM NUMBER]- 75 degrees
5/14/2024 RM [ROOM NUMBER]- 75 degrees
5/15/2024 RM [ROOM NUMBER]- 75 degrees
5/16/2024 RM [ROOM NUMBER]- not measured.
5/21/2024 RM [ROOM NUMBER]- 75 degrees
6/12/2024 RM [ROOM NUMBER]- 77 degrees
7/26/2024 RM [ROOM NUMBER]- 75 degrees
During a concurrent interview and record review on 8/7/2024, at 4:37 p.m., with the ADM, the ADM reviewed and confirmed the dates the water in the facility was below 108 degrees Fahrenheit on the Temperature Log. The DON stated it was important to ensure the temperatures were above 108 degrees to ensure Legionella doesn't grow in their water system that can cause the residents to get sick.
During a review of the facility's recent policy and procedure titled, Legionella, last reviewed on 1/29/2024, the policy indicated its purpose is to inhibit microbial growth in the facility's water systems to reduce the risk of growth and spread of legionella and other opportunistic pathogens in water. The facility will follow guidance issued by the Centers for Disease Control (CDC) as outlined in IC-03- Form A - Developing Water Management Program to Reduce Legionella.
A review of the facility provided Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, last reviewed on 1/29/2024, indicated factors internal to buildings that can lead to Legionella growth, water temperature fluctuations provide conditions where Legionella grows best (77 degrees to 108 degrees Fahrenheit); Legionella can still grow outside this range.
Based on observation, interview, and record review, the facility failed to maintain and infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to:
1. Ensure the nasal cannula (NC - tubing connected to a device that gives additional oxygen [O2] through the nose) was not resting on the floor for four of four sampled residents (Resident 217, 164, 221, and 13) reviewed under the Respiratory care area.
2. Ensure urinary drainage bag was inside the privacy bag and not laying flat touching the floor mat for one of five sampled residents (Residents 204) observed during a random observation.
3. Ensure nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can bebreathed directly into the lungs through a face mask or mouthpiece) tubing and mask was labeled with the last date it was changed for one of four sampled residents (Resident 13) reviewed under the respiratory care area.
4. Ensure the linen in the nursing stations were protected from external contaminants such as dust, viruses, and bacteria by using a permeable (having pores or openings that permit liquids or gasses to pass through)/ loosely woven material to cover the mobile linen carts to two out of two linen carts (Carts A and B) observed during infection control facility task.
5. Ensure the water temperature in the entire facility was above 108 degrees Fahrenheit (a scale for measuring temperature) per Centers for Disease Control and Prevention (CDC, a United States federal agency that works to protect the public's health) guidelines to prevent growth of Legionella (a severe form of pneumonia- lung inflammation usually caused by infection) in the water system.
These deficient practices had the potential for cross-contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and placed the residents at risk for acquiring infections.
Findings:
1. During a review of Resident 217's admission Record, it indicated the facility admitted the resident on 8/26/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and respiratory failure (serious condition when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues).
During a review of Resident 217's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/23/2024, it indicated the resident was dependent on staff for oral hygiene, toileting, bathing, personal hygiene, and mobility. The MDS further indicated the resident used oxygen therapy intermittently.
During a review of Resident 217's physician orders, it indicated and order for 2 three liter per minute (LPM, a unit of measurement) via nasal canula as needed for shortness of breath (SOB), dated 11/14/2022.
During a review of Resident 217's Care Plans titled, COPD with wheezing: At Risk for Shortness of Breath, initiated 8/29/2022, it indicated to monitor for episodes of shortness of breath and administer oxygen at three LPM via NC as needed for SOB.
was
During an observation on 8/5/2024 at 10:05 a.m., Resident 217 was awake and lying in bed, the resident did not respond to questions. Oxygen was infusing and administered to Resident 217 at 3 LPM via a NC. The NC tubing was resting on the floor.
During a concurrent observation and interview on 8/5/2024 at 12:15 a.m., Certified Nursing Assistant 11 (CNA 11) entered Resident 217's room while the surveyor was present. CNA 11 removed the NC tubing off the floor and placed the tubing on top of the blanket covering the resident. CNA 11 stated the NC tubing was on the floor and she placed it on the resident's bed.
During a concurrent observation and interview on 8/5/2024 at 10:20 a.m., Licensed Vocational Nurse 4 (LVN 4) entered Resident 217's room and stated the NC tubing should be off the floor. The surveyor informed LVN 4 that the CNA had placed the NC tubing from the floor onto the bed. LVN 4 stated the NC should be off the floor. LVN 4 exited the room.
During a follow up interview on 8/5/2024 at 10:30 p.m., LVN 4 stated the NC tubing should never be on the floor because of infection control. LVN 4 stated bacteria could go from the floor up the tubing to the resident and cause an infection. LVN 4 stated she did not understand the surveyor stated the NC tubing was moved from the floor to the bed. LVN 4 stated the NC tubing should be changed if it was on the floor.
During an interview on 8/8/2024 at 11:31 a.m., Registered Nurse 2 (RN 2) stated NCs are changed weekly and kept in bags at the bedside because NCs can get dirty from germs. RN 2 stated it was not okay for the NC tubing be touching the floor. RN 2 stated if the NC tubing was touching the floor, it should be removed, and a new NC provided. RN 2 stated CNA 11 should have notified the charge nurse to change the NC immediately because it could potentially lead to germs from the floor, like from dirty shoes, causing cross contamination resulting in an infection in the resident.
During a review of the facility policy and procedure titled, Infection Prevention and Control Program, last reviewed 1/29/2024, it indicated the purpose of the policy was to ensure the facility establishes and maintains an Infection Control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection
c. During a review of Resident 204's admission Record indicated the facility admitted the resident on 1/24/2023 and readmitted on [DATE] with diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), neuromuscular dysfunction of bladder (a condition in which a person lacks bladder control due to a brain, spinal cord, or nerve condition), and generalized muscle weakness.
During a review of Resident 204's History and Physical (H&P) dated 4/27/2024, indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 204's MDS, dated [DATE] indicated Resident 204 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance from staff with mobility, was dependent with toileting hygiene, and substantial maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 204 had an indwelling catheter (a catheter drains urine from the bladder into a bag outside the body) and diagnoses of neurogenic bladder and obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow).
During a review of Resident 204's Order Summary Report indicated the following physician's order:
o2/5/2023: Foley Catheter (FC - a thin, flexible tube placed into the bladder to allow urine to drain into a collection bag) to gravity drain Q shift every shift.
During a review of Resident 204's care plan for FC indicated:
oPotential for infection /At risk for dehydration initiated 2/6/2023 target date 10/23/2024, indicated resident will have no signs and symptoms of infection and/or complications of FC. The care plan indicated the following interventions but not limited to:
1. Provide catheter care per protocol.
2. Always keep catheter tubing placed below level of bladder.
3. Observe resident's FC, tubing, and bag frequently during the shift.
4. Report to physician any changes in urine appearance, amount, odor and clarity.
During a concurrent observation and interview on 8/6/2024 at 8:05 a.m. while inside Resident 204's room with Registered Nurse 1 (RN 1), Resident 204 was sitting at the edge of the bed in the lowest position with the urinary drainage bag not inside the privacy bag and laying flat on the floor mat. RN 1 stated the urinary drainage bag should not be touching the floor. RN 1 stated it was an infection control issue and the bag should be changed.
During an interview on 8/9/2024 at 10:45 a.m., the Resident Assessment Coordinator (RAC) stated Resident 204's urinary drainage bags should inside the privacy bag and should not be lying flat and touching the floor mat. The RAC stated it was an infection control issue and had the potential for the resident to acquire infection.
During a review of the facility's policy and procedure titled, Catheter - Care of, last reviewed 1/29/2024, indicated:
o A resident, with or without catheter receives the appropriate care and services to prevent infections to the extent possible.
o Ensure the collection bag should always be kept below the level of the bladder, avoiding contact with the floor.
o Catheters and drainage bags will be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised.
o The resident's privacy and dignity will be protected by placing a cover over the drainage bag when the resident is out of bed.
A review of the facility's policy and procedure titled, Infection Prevention and Control Program, last reviewed 1/29/2024, indicated the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. The policy indicated the facility has an Infection Control Committee (ICC) to provide oversight of all infection control practices in the delivery of resident care.
d. A review of Resident 221's admission Record indicated the facility admitted the resident on 1/23/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD - a group of lung conditions that make it hard to breathe and get worse over time.), congestive heart failure (CHF - a condition that develops when the heart doesn't pump enough blood for the body's needs), and difficulty walking.
During a review of Resident 221's History and Physical (H&P) dated 1/25/2024, the H & P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 221's MDS, dated [DATE] indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance from staff with eating, was dependent with toileting/hygiene, showers/bath, and transfers; and substantial maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 221 had a diagnosis of COPD and on oxygen (O2) therapy.
During a review of Resident 221's Order Summary Report indicated the following physician's order:
o1/23/2023: O2 three (3) liters per minute (L/Min - a unit of measurement) via nasal cannula (NC - a device that delivers extra oxygen through a tube and into the nose) as needed for shortness of breath (SOB).
During a review of Resident 221's care plan indicated:
1. Heart failure: At risk for SOB, chest pain, edema, elevated blood pressure initiated 2/3/2023 with a goal that all signs and symptoms will be addressed thoroughly thru 10/4/2024. The care plan indicated the following interventions but not limited to, have O2 available for use as needed and monitor pulse oximetry as needed and administer O2 per protocol.
2. At risk for SOB and wheezing initiated 5/3/2024 target date 10/4/2024 with a goal to relieve episodes of SOB within 5 minutes interventions. The care plan indicated to monitor for episodes of SOB and administer O2 as needed per protocol and notify physician if ineffective.
During a concurrent observation and interview on 8/6/2024 at 8:02 a.m. inside Resident 221's room with Restorative Nursing Assistant 2 (RNA 2). Resident 221 was receiving O2 at 3 L/Min via NC with the tubing touching the floor. RNA 1 stated Resident 221's oxygen tubing was not really touching the floor at the same time anchoring the tubing on the resident's grab bar. When asked again, RNA 2 stated the tubing was touching the floor.
During an interview on 8/6/2024 at 8:00 a.m., RN 1 stated she just changed the O2 tubing. RN 1 stated the tubing should not be touching as it was an infection control issue.
During an interview on 8/9/2025 at 10:37 a.m., the Minimum Data Set Coordinator (MDSC) stated the O2 tubing should not be touching the floor as it was already contaminated and placed the resident at risk for acquiring infection.
During a review of the facility's policy and procedure titled, Oxygen Administration, last reviewed 1/29/2024 indicated, all oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen will be changed weekly and when visibly soiled. The policy indicated oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt.
During a review of the facility's policy and procedure titled, Infection Prevention and Control Program, last reviewed 1/29/2024, indicated the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. The policy indicated the facility has an Infection Control Committee (ICC) to provide oversight of all infection control practices in the delivery of resident care.
2 .During a review of Resident 164's admission Record, the admission record indicated the facility admitted the resident on 8/8/2018 with diagnoses including, but not limited to, respiratory failure.
During a review of Resident 164's MDS, dated [DATE], the MDS indicated Resident 164 sometimes makes herself understood and sometimes understands others, was dependent on facility staff for activities of daily living such as eating, dressing, hygiene, bathing or showering, and surface-to-surface transfers, and was receiving oxygen therapy.
During a review of Resident 164's History and Physical (H&P), dated 4/23/2024, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 164's Order Summary Report, dated 8/23/2023, the order summary report indicated the resident was ordered oxygen three liters (a unit of measure for capacity) per minute via nasal cannula as needed for shortness of breath.
During a concurrent observation and interview with Certified Nursing Assistant (CNA) 12, on 8/5/2024, at 10:51 a.m., while inside Resident 164's room, CNA 12 confirmed Resident 164 was wearing a nasal cannula around her nose and the nasal cannula tubing was touching the floor. CNA 12 stated Resident 164's nasal cannula tubing should not be touching the floor due to possible contamination and can be a potential source for infection.
During an interview with the Director of Nursing (DON), on 8/9/2024, at 8:55 a.m., the DON stated no tubing should touch the floor because of the risk for contamination. The DON further stated when tubing touches the floor there is a potential for a break in infection control.
A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, last reviewed 1/29/2024, the P&P indicated oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen are for single resident use only and will be changed weekly and when visibly soiled. The P&P further indicated oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement its policy and procedure on influenza (an infection of the nose, throat and lungs, which are a part of the respiratory system) and pneumonia (an infection that affects one or both lungs) vaccine (a substance that stimulates the body's immune system to fight disease) administration by failing to provide documentation an informed consent was obtained from the resident or the resident representative and education was provided to the resident or the resident's representative regarding the benefits and potential side effects of the vaccine for two of five sampled residents (Residents 174 and 98) investigated under infection control task.
This deficient practice violated the resident or responsible party's right to make an informed decision.
Findings:
a. During a review of Resident 174's admission Record, it indicated the facility admitted the resident on 7/25/2019, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and dementia (a loss of brain function that occurs with certain diseases).
During a review of Resident 174's History and Physical (H&P), dated 7/2/2023, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 174's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/24/2024, the MDS indicated the resident sometimes had the ability to make self-understood and understand others.
During a review of Resident 174's Physician's Order Sheet, dated 9/18/2023, it indicated an order for influenza vaccine 0.5 milliliters (ml, a unit of volume) intramuscular injection (IM, into a muscle) injection.
During a concurrent interview and record review on 8/9/2024, at 4 p.m., with the Resident Assessment Coordinator (RAC), reviewed Resident 174's Influenza Vaccination Informed Consent/Refusal forms on file. The RAC stated there was no Influenza Vaccination Informed Consent/Refusal completed for the 9/8/2023 vaccine administration.
During an interview on 8/9/2024, at 2:05 p.m., with the Infection Preventionist (IP), the IP stated the Administrator (ADM) instructed the IP to only get a one-time consent for flu, pneumonia (infection that inflames air sacs, and COVID-19 (a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) vaccines.
During an interview on 8/9/2024, at 2:55 p.m., with the ADM, the ADM stated she instructed staff that the resident or the resident representative's consent should only be obtained once, on admission for administration of flu, pneumonia, and COVID-19 vaccine.
During an interview on 8/9/2024, at 3:07 p.m., with the Director of Nursing (DON), the DON stated the Influenza Vaccination Informed Consent/Refusal form should be completed each time a vaccine is given to ensure informed consent and honor the resident or the resident representative's right to refuse the vaccine if desired.
During a review of the facility's recent policy and procedure titled, Influenza Prevention & Control, last reviewed on 1/29/2024, indicated before offering the influenza vaccine, each resident or the resident representative receives education regarding the benefits and potential side effects of the vaccination. Residents are offered an influenza vaccine during flu season annually, unless the vaccination is medically contraindicated, or the resident has already been vaccinated during this time period. That the resident was given a copy of IC-14-Form A-Influenza Vaccination-Informed Consent/refusal which is to be placed in the resident's medical record.
b. During a review of Resident 98's admission Record, it indicated the facility admitted the resident on 3/3/2022, with diagnoses including Alzheimer's disease and dementia.
During a review of Resident 98's H&P, dated 3/27/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 98's MDS, dated [DATE], the MDS indicated the resident usually makes self-understood and understand others.
During a review of Resident 98's Physician's Order Sheet, dated 9/20/2023, it indicated an order of may have influenza vaccine 0.5 ml IM injection.
During a concurrent interview and record review on 8/9/2024, at 4 p.m., with the RAC, reviewed Resident 98's Influenza Vaccination Informed Consent/Refusal forms on file. The RAC stated there was no Influenza Vaccination Informed Consent/Refusal completed for the 9/20/2023 vaccine administration.
During an interview on 8/9/2024, at 2:05 p.m., with the Infection Preventionist (IP), the IP stated the Administrator (ADM) instructed the IP to only get a one-time consent for flu, pneumonia (infection that inflames air sacs, and COVID-19 (a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) vaccines.
During an interview on 8/9/2024, at 2:55 p.m., with the ADM, the ADM stated she instructed staff that the resident or the resident representative's consent should only be obtained once, on admission for administration of flu, pneumonia, and COVID-19 vaccine.
During an interview on 8/9/2024, at 3:07 p.m., with the Director of Nursing (DON), the DON stated the Influenza Vaccination Informed Consent/Refusal form should be completed each time a vaccine is given to ensure informed consent and honor the resident or the resident representative's right to refuse the vaccine if desired.
During a review of the facility's recent policy and procedure titled, Influenza Prevention & Control, last reviewed on 1/29/2024, indicated before offering the influenza vaccine, each resident or the resident representative receives education regarding the benefits and potential side effects of the vaccination. Residents are offered an influenza vaccine during flu season annually, unless the vaccination is medically contraindicated, or the resident has already been vaccinated during this time period. That the resident was given a copy of IC-14-Form A-Influenza Vaccination-Informed Consent/Refusal which is to be placed in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement its policy and procedure on Coronavirus Disease 2019 (COVID-19 -a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) vaccination (the act of introducing a vaccine [a substance that stimulates the body's immune system to fight disease]) by failing to provide documentation an informed consent was obtained from the residents or the resident's representative and education was provided on the risk and benefits of the vaccine prior to vaccination for three of five sampled residents (Residents 174, 80, and 98) investigated under the infection control task.
This deficient practice violated the resident or resident representative's right to make an informed decision.
Findings:
a. During a review of Resident 174's admission Record indicated the facility admitted the resident on 7/25/2019, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and dementia (a loss of brain function that occurs with certain diseases).
During a review of Resident 174's History and Physical (H&P), dated 7/2/2023, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 174's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/24/2024, the MDS indicated the resident sometimes had the ability to make self-understood and understand others.
During a review of Resident 174's Physician's Order Sheet, it indicated the following orders:
-On 5/9/2022, may have COVID-19 vaccine booster (am extra dose of a vaccine) # 2 per family request.
-On 10/6/2022, may have COVID-19 vaccine bivalent (contains both the original vaccine strain) X 1.
-On 7/2/2024, may have Moderna Spikevax COVID-19 vaccine X 1.
During a concurrent interview and record review on 8/9/2024, at 4 p.m., with the Resident Assessment Coordinator (RAC), reviewed Resident 174's COVID-19 Vaccination Informed Consent/Refusal forms on file. The RAC stated there was no COVID-19 Vaccination Informed Consent/Refusal form completed for the 5/9/2022, 10/6/2022, and 7/2/2024 vaccine administration.
During an interview on 8/9/2024, at 2:05 p.m., with the Infection Preventionist (IP), the IP stated the Administrator (ADM) instructed the IP to only get a one-time consent for flu, pneumonia (infection that inflames air sacs, and COVID-19 vaccines.
During an interview on 8/9/2024, at 2:55 p.m., with the ADM, the ADM stated she instructed staff that the resident or representative's consent should only be obtained once, on admission for administration of flu, pneumonia, and COVID-19.
During an interview on 8/9/2024, at 3:07 p.m., with the Director of Nursing (DON), the DON stated the COVID-19 Vaccination Informed Consent/Refusal form should be completed each time a vaccine is given to ensure informed consent and honor the resident or resident representative's right to refuse the vaccine if desired.
During a review of the facility's recent policy and procedure titled, COVID-19 Vaccination, last reviewed on 1/29/2024, indicated the infection preventionist, or designee, will ensure that the resident's medical record includes documentation that, at a minimum, the resident and/or resident representative was provided education regarding the vaccine they were offered, if they accepted and received the vaccine or refused, and each dose of the COVID-19 vaccine if administered.
i. Such documentation should include the date the education was offered.
b.During a review of Resident 80's admission record, it indicated the facility admitted the resident on 2/20/2024, with diagnoses including Alzheimer's disease and dementia.
During a review of Resident 80's H&P, dated 6/10/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 80's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others.
During a review of Resident 80's Physician's Order Sheet, dated 7/2/2024, it indicated an order for Moderna Spikevax COVID-19 vaccine X 1.
During a concurrent interview and record review on 8/9/2024, at 4 p.m., with the RAC, reviewed Resident 80's COVID-19 Vaccination Informed Consent/Refusal forms on file. The RAC stated there was no COVID-19 Vaccination Informed Consent/Refusal form completed for the vaccine administration on 7/2/2024.
During an interview on 8/9/2024, at 2:05 p.m., with the Infection Preventionist (IP), the IP stated the Administrator (ADM) instructed the IP to only get a one-time consent for flu, pneumonia (infection that inflames air sacs, and COVID-19 vaccine.
During an interview on 8/9/2024, at 2:55 p.m., with the ADM, the ADM stated she instructed staff that the resident or the resident representative's consent should only be obtained once, on admission for administration of flu, pneumonia, and COVID-19 vaccine.
During an interview on 8/9/2024, at 3:07 p.m., with the Director of Nursing (DON), the DON stated the COVID-19 Vaccination Informed Consent/Refusal form should be completed each time a vaccine is given to ensure informed consent and honor the resident or resident representative's right to refuse the vaccine if desired.
During a review of the facility's recent policy and procedure titled, COVID-19 Vaccination, last reviewed on 1/29/2024, indicated the infection preventionist, or designee, will ensure that the resident's medical record includes documentation that, at a minimum, the resident and/or resident representative was provided education regarding the vaccine they were offered, if they accepted and received the vaccine or refused, and each dose of the COVID-19 vaccine if administered.
i. Such documentation should include the date the education was offered.
c.During a review of Resident 98's admission Record, it indicated the facility admitted the resident on 3/3/2022, with diagnoses including Alzheimer's disease and dementia.
During a review of Resident 98's H&P, dated 3/27/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 98's MDS, dated [DATE], the MDS indicated the resident usually makes self-understood and understand others.
During a review of Resident 98's Physician's Order Sheet, it indicated the following orders:
-On 6/16/2022, may have COVID-19 vaccine booster # 2 per family request.
-On 10/11/2022, may have COVID-19 vaccine bivalent X 1.
-On 7/2/2024 may have Moderna Spikevax COVID-19 vaccine X 1.
During a concurrent interview and record review on 8/9/2024, at 4 p.m., with the RAC, reviewed Resident 98's COVID-19 Vaccination Informed Consent/Refusal forms on file. The RAC stated there was no COVID-19 Vaccination Informed Consent/Refusal completed for the for 6/16/2022, 10/11/2022, and 7/2/2024 vaccine administration.
During an interview on 8/9/2024, at 2:05 p.m., with the Infection Preventionist (IP), the IP stated the Administrator (ADM) instructed the IP to only get a one-time consent for flu, pneumonia (infection that inflames air sacs, and COVID-19 vaccines.
During an interview on 8/9/2024, at 2:55 p.m., with the ADM, the ADM stated she instructed staff that the resident or the resident representative's consent should only be obtained once, on admission for administration of flu, pneumonia, and COVID-19 vaccine.
During an interview on 8/9/2024, at 3:07 p.m., with the Director of Nursing (DON), the DON stated the COVID-19 Vaccination Informed Consent/Refusal form should be completed each time a vaccine is given to ensure informed consent and honor the resident or resident representative's right to refuse the vaccine if desired.
During a review of the facility's recent policy and procedure titled, COVID-19 Vaccination, last reviewed on 1/29/2024, indicated the infection preventionist, or designee, will ensure that the resident's medical record includes documentation that, at a minimum, the resident and/or resident representative was provided education regarding the vaccine they were offered, if they accepted and received the vaccine or refused, and each dose of the COVID-19 vaccine if administered.
ii. Such documentation should include the date the education was offered.

Based on observation, interview, and record review the facility failed to provide a safe environment for one of two sampled residents (Resident 41) investigated during review of the environment task by failing to ensure Resident 41 did not plug an extension cord (an electrical outlet that contains two wires: a neutral wire and a hot wire) into a two-prong wall outlet to charge Resident 41's cellphone.
This deficient practice had the potential to result in safety hazards including electrical shock and fire.
Findings:
During a review of Resident 41's admission Record, it indicated the facility admitted the resident on 10/3/2018, with diagnoses including atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls) and heart failure (occurs when the heart muscle does not pump blood as well as it should).
During a review of Resident 41's History and Physical (H&P) dated 6/5/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 41's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/16/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision.
During a review of Resident 41's Care Plan (CP) titled, Psychosocial: Home like environment, initiated on 2/11/2019, the CP indicated an intervention the facility will rearrange room as per resident's request permitting that new arrangement of the room does not create life safety and/or fire hazards.
During a concurrent observation and interview on 8/5/2024, at 11:32 a.m., inside Resident 41's room, with Licensed Vocational Nurse 5 (LVN 5), observed Resident 41 plug a two-prong extension cord into the wall outlet to charge the resident's cellphone. LVN 5 stated the resident should not use an extension cord that was not underwriter laboratories (UL, the product or service meets local and federal environmental and safety regulations) certified and not inspected by the Maintenance Staff (MS) to prevent fires.
During an interview on 8/9/2024, at 4:24 p.m., with the MS, the MS stated residents are not allowed to use a non-UL approved electrical extension cords without a ground. The MS stated the residents should use three prong extension cords (the third prong and grounded outlet were designed to help reduce the risk of electrical shocks and fires) to prevent electrical shocks and fire in the facility.
During an interview on 8/9/2024, at 5:03 p.m., with the Director of Nursing (DON), the DON stated two-prong extension cords should not be used in the resident's room because it could cause electrical accidents to residents.
During a review of the facility's recent policy and procedure titled, Electrical Equipment- Power Strips, last reviewed on 1/29/2024, indicated to ensure that power strips are used minimally and with general precaution. The facility will ensure safe usage of power strips within the resident care environment. Power strips will be used with general precaution and should not be utilized unless absolutely necessary. Power strips shall meet the UL 1363A or UL60601-1 standards. Staff will ensure personal electronics will not be plugged in to power strips in resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. During a review of Resident 38's admission Record, the admission record indicated the facility admitted the resident on 2/28/2023, with diagnoses that included age-related osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue), ataxia (involves a lack of muscle coordination and control), and the presence of right artificial shoulder joint (removes damaged areas of bone and replaces them with parts made of metal and plastic [implants]).
During a review of Resident 38's History and Physical (H&P), dated 1/27/2024, indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 38's MDS, dated [DATE], indicated Resident 38 had the ability to make self-understood and to understand others. The MDS indicated Resident 38 had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions) and had upper and lower extremity impairment. The MDS indicated the resident required substantial to maximal assistance with mobility and activities of daily living (ADLs).
During an observation on 8/5/2024, at 8:54 a.m., Resident 38's bed was placed against the wall on the left side of the resident's bed and a fall mat was at the right side of the bed with the wheelchair and the bedside table on top of the fall mat.
During a concurrent interview and record review on 8/7/2024, at 11:03 a.m., with Registered Nurse 1 (RN 1), Resident 38's Order Summary Report, Consents, Assessments, and Care Plans were reviewed. RN 1 stated there was no order, no assessment for entrapment (an event in which a patient is caught, trapped, or entangled in spaces in the spaces in or about the bed rail, mattress, or hospital bed frame), no consent from the resident or resident representative for the bed to be placed against the wall, and no CP for placing the bed against the wall for the resident. RN 1 stated the CP was important to communicate the interventions being done for the resident to mitigate the negative effects of using the restraint bed placed against the wall.
During an interview on 8/9/2024, at 4:56 p.m., with the DON, the DON stated the CP serves as the communication for all healthcare disciplines to standardize care. The DON stated the failure of staff to initiate and implement a CP for the use of restraint bed placed against the wall had predisposed the resident to possible bed entrapment.
During a review of the facility's recent policy and procedure titled, Care Planning, last reviewed on 1/29/2024, indicated the facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive CP for each resident in accordance with OBRA and MDS guidelines. The CP serves as a course of action where the resident (Resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.
e. During a review of Resident 190's admission Record indicated the facility admitted Resident 190 on 11/3/2020, and readmitted on [DATE], with diagnoses including muscle weakness, age-related osteoporosis, and displaced oblique fracture (the pieces of the bone moved so much that a gap formed around the fracture when the bone broke) of the shaft of the left ulna (a long bone in the forearm stretching from the elbow to the wrist).
During a review of Resident 190's H&P, dated 6/6/2024, indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 190's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had moderately impaired vision and required total dependence on mobility and activities of daily living (ADLs).
During a concurrent interview and record review on 8/5/2024, at 11:14 a.m., with Licensed Vocational Nurse 9 (LVN 9), Resident 190's Order Summary Report, Consents, Assessments, and Care Plans were reviewed. LVN 9 stated there was no order for restraints-bed placed against the wall and the wedge pillow tucked under the mattress. There was no assessment on the safety of the use of bed placed against the wall and the wedge pillow tucked under the mattress, no consent for the bed to be placed against the wall and the wedge pillow tucked under the mattress, and there was no CP on the use of restraints bed placed against the wall and the wedge pillow tucked under the mattress on the resident's medical chart. LVN 9 stated the CP was important as it serves as their guide on providing safe and appropriate care to the resident. LVN 9 stated the failure of the staff to create and implement a CP for restraints bed placed against the wall and wedge tucked under the mattress, placed the resident at risk for injury such as bed entrapment.
During an interview on 8/9/2024, at 4:56 p.m., with the DON, the DON stated the staff should have created a CP on the use of restraints bed placed against the wall and wedge tucked under the mattress, to serve as the communication for all healthcare disciplines to standardize care and prevent injury such as bed entrapment.
During a review of the facility's recent policy and procedure titled, Care Planning, last reviewed on 1/29/2024, indicated the facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive CP for each resident in accordance with OBRA and MDS guidelines. The CP serves as a course of action where the resident (Resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.
f. During a review of Resident 227's admission Record, indicated the facility admitted the resident on 12/26/2023, with diagnoses including glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called optic nerve) and dysphagia (difficulty swallowing).
During a review of Resident 227's History and Physical (H&P), dated 5/22/2024, indicated Resident 227 had the capacity to understand and make decisions.
During a review of Resident 227's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/24/2024, indicated Resident 227 had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision and had intact cognition (gaining of knowledge and understanding).
During a review of Resident 227's Order Summary Report, dated 12/26/2023, the report indicated an order indicating Resident 227 may have bilateral assist rails to assist the resident for turning and repositioning. The order summary report also indicated there was no physician's order for Areds 2 (supplement for age-related macular degeneration [an eye disease that can blur the central vision]) and may self-administer medications.
During an observation on 8/6/2024, at 8:45 a.m., inside Resident 227's room, Resident 227 was taking one tablet from a medication bottle labeled Areds 2. The resident also had grab bars on both sides of the bed.
During an interview and record review on 8/6/2024, at 8:47 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 227's Order Summary Report, Medication Administration Record (MAR), and Care Plan were reviewed. LVN 3 stated there was no order for the resident to self-administer medications indicating it was okay to keep medications at the bedside on the Order Summary Report. LVN 3 also stated there was no order for the medication Areds 2 and no CP on its use. LVN 3 stated she does not know how the bottle of Areds 2 was left at the resident's bedside. LVN 3 stated it must be the family member that gave the medication Areds 2 to the resident. LVN 3 stated it was important to have a CP on the safe use of Areds 2 at the bed side to ensure residents were free from its adverse effects.
During an observation, interview, and record review on 8/8/2024, at 10:16 a.m., with Licensed Vocational Nurse 10 (LVN 10), Resident 227's bed had grab bars on both upper parts of the bed. During a review of Resident 227's Care Plans, LVN 10 stated there was no CP for grab bars. LVN 10 stated the CP was important for the use of grab bars for the resident to ensure safe use of the equipment.
During an interview on 8/9/2024, at 9:43 a.m., with the DON, the DON stated there should be a CP on the use of Areds 2 self-administration by the resident to ensure the resident was safe to take the medication and to outline the interventions needed to ensure safe administration of the drug by the resident. The DON also stated there should be a CP on the use of grab bars as it was considered a bedrail to prevent accidents such as entrapment.
During a review of the facility's recent policy and procedure titled, Medication- Self Administration, last reviewed on 1/29/2024, the policy indicated Residents who request to perform medication self-administration will be assessed for capacity. During the admission process, residents will be asked if they wish to self-administer medications. Those residents who wish to self-administer medications will be assessed during the admission process to ensure they have the necessary knowledge and skill(s) to safely self-administer medications.
A. Additional assessments will be completed at least quarterly based on OBRA timeframes.
If the resident is assessed as clinically appropriate for medication self-administration, by the IDT, the Licensed Nurse obtains a physician's order for self-administration of selected medications.
A. The resident's record should contain documentation that demonstrates that he/she was part of the IDT process in determining whether self-administration is safe and appropriate.
The IDT develops and implements a CP for medication self-administration. The CP will identify:
i. Where the medications are stored.
ii. Education for resident/family regarding medication self-administration process; specific medication information and safe, effective use of medications.
a. Obtaining medication.
b. Administering medication according to physician order.
iii. How Licensed Nurses will validate that medications are taken as ordered by the attending physician; and
iv. How non-compliance and/or refusal to take medications will be managed.
During a review of the facility's recent policy and procedure titled, Side Rails, last reviewed on 1/29/2024, the policy indicated its purpose is to determine the appropriateness of bed rail use for individual residents. The resident's plan of care will be updated to reflect the use of side rails.
During a review of the facility's recent policy and procedure titled, Care Planning, last reviewed on 1/29/2024, the policy indicated the facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive CP for each resident in accordance with OBRA and MDS guidelines. The CP serves as a course of action where the resident (Resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.
Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered CP (CP, a written course of action that helps a patient achieve outcomes that improve their quality of life) by failing to:
1. Develop a CP for placing the resident's bed against the wall for three of five sampled residents (Resident 109, 38, and 190) reviewed during the Physical Restraint care area.
2. Develop a CP for medication self-administration for two of two sampled residents (Resident 177 and 227) reviewed during a general observation.
3. Develop and implement a CP for the use of nitrofurantoin (an antibiotic medication that is used for the treatment and prevention of uncomplicated lower urinary tract infections) for one of three sampled residents (Resident 385) reviewed under the Urinary Catheter or UTI care area.
4. Develop a CP for the use of grab bars for one of five sample residents (Resident 227) investigated under bedrails (a barrier attached to the side of a bed) reviewed during the Physical Restraint care area.
These deficient practices had the potential to result in a delay in the provision of necessary care and services for residents.
Findings:
a. During a review of Resident 109's admission Record, it indicated the facility admitted the resident on 3/11/2022 with diagnoses that included Alzheimer's dementia (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and muscle weakness.
During a review of Resident 109's physician orders, it indicated the following orders:
-Monitor behavior for constantly trying to get out of bed and wheelchair unattended, dated 6/22/2022.
During a review of Resident 109's CPs titled, Psychosocial: episode of constant trying to get up from bed and wheelchair unassisted, initiated 8/15/2023, it indicated to assure the environment is safe when episodes of repetitive movements occur, and to attempt to determine cause of movement and resolve as able. The CP did not indicate an intervention to move the bed against the wall.
During a review of Resident 109's physician orders, it indicated the following orders:
-May have wedge cushion on the sides of mattress to prevent from rolling down, dated 3/20/2024.
During a review of Resident 109's history and physical dated 6/26/2024, it indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 109's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/2/2024, the policy indicated the resident sometimes was able to understand others and sometimes was able to make herself understood. The MDS indicated the resident required partial/moderate assistance from staff with eating and rolling side to side; and was dependent on staff for oral hygiene, toileting, bathing, dressing, and moving from a sit to stand position and transfers.
During an observation on 8/5/2024 at 10:40 a.m., Resident 109 lay in bed with the lights off. The right side of the mattress was elevated by a wedge cushion placed under the mattress and observed the left side of the bed pushed up against the wall.
During a concurrent interview and record review on 8/6/2024 at 8:20 a.m., Licensed Vocational Nurse 8 (LVN 8) reviewed Resident 109's physician orders and care plans. LVN 8 stated she cares for Resident 109 and the resident is confused. LVN 8 stated the resident tries to stand but does not have the strength to walk. LVN 8 stated Resident 109 had a wedge under the mattress and the bed against the wall to prevent the resident from falling. LVN 8 stated there was no CP for placing Resident 109's bed against the wall.
During a concurrent interview and record review on 8/6/2024 at 9:15 a.m., the Resident Care Planner (RCP) reviewed Resident 109's CPs and stated the facility did not make CPs for placing resident beds against the wall.
During a concurrent interview and observation on 8/6/2024 at 1:16 p.m., LVN 8 entered Resident 109's room and stated the resident was lying in bed with the bed against the wall and a wedge cushion under the mattress.
During an interview on 8/8/2024 at 9:49 a.m., Licensed Vocational Nurse 4 (LVN 4) LVN 4 stated she cares for Resident 109 and the resident has had the bed placed against the wall ever since she was placed on the unit, months ago. LVN 4 stated there should have been a CP in place for the bed against the wall because the bed against the wall was a part of the care provided by the facility.
During an interview on 8/8/2024 at 11:31 a.m., Registered Nurse 2 (RN 2) stated a CP is used to identify resident problems and the interventions used to correct and prevent problems. RN 2 stated the facility does not have CPs for placing the beds against the wall. RN 2 stated the importance of a CP for placing the bed against the wall would be to identify the risks, like injuries from residents' extremities becoming stuck or from hitting their head, and the interventions to minimize the risks like close monitoring.
During an interview on 8/8/2024 at 1:38 p.m. with the facility Administrator (ADM) and Director of Nursing (DON), the DON stated there were no CPs for placing the bed against the wall. The DON stated the importance of CPs was that the CP is a tool that leads the staff, including the nurses, regarding the care of the resident. The ADM stated if Resident 109 had the bed against the wall for months, then there should have been a CP. The ADM stated the CP should include the risk and benefits for the resident, the alternatives attempted and explained to the resident and family. The ADM stated without a CP the resident potentially would not know the risk of having the bed against the wall and inadvertently put themselves at risk for entrapment (a condition in which a resident is caught or trapped in the spaces in or about the mattress or bed frame).
During a review of the facility policy and procedure titled, Care Planning, last reviewed on 1/29/2024, the policy indicated the purpose of the policy was to ensure that a comprehensive person-centered CP is developed for each resident based on their individual assessed needs. The facilities interdisciplinary team will develop a comprehensive CP for each resident. The CP serves as a course of action where the resident (resident's family), resident's attending physician, and IDT work to help the resident move toward resident specific goals that address the resident's medical, nursing, mental, and psychosocial needs. The CP will include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs. Changes may be made to the comprehensive CP on an ongoing basis for the duration of the resident's stay. The comprehensive CP must be completed within seven days after completion of the comprehensive admission assessment and must be periodically reviewed and revised by a team of qualified persons.
c. During a review of Resident 385's admission Record indicated the facility admitted the resident on 3/1/2022 and readmitted on [DATE] with diagnoses that included dementia, chronic urinary tract infections (UTI - an infection in any part of the urinary system), and generalized muscle weakness.
During a review of Resident 385's History and Physical (H&P) dated 6/25/2024, the H & P indicated Resident 385 had the capacity to understand and make decisions.
During a review of Resident 385's MDS, dated [DATE], the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance from staff with eating; substantial/maximal assistance with oral hygiene and mobility; and was dependent with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 385 was frequently incontinent of bowel and bladder.
During a review of Resident 385's Order Summary Report, the report indicated the following physician's order dated 11/30/2023:
o nitrofurantoin microcrystal oral capsule 50 milligrams (mg - a unit of measurement) one capsule by mouth one time a day for chronic UTIs with food.
During a concurrent interview and record review on 8/9/2024 at 1:23 p.m., Resident 385's H&P, physician's orders, and care plans were reviewed with the Minimum Data Set Coordinator (MDSC). The MDSC verified the resident was on nitrofurantoin for chronic UTI per physician's order. The MDSC verified the previous care plans for nitrofurantoin and chronic UTI were marked with a pink highlighter which means that there should have been another CP developed with a new target date.
During an interview on 8/9/2024 at 4:56 p.m., the DON stated the new CP regarding the use of nitrofurantoin and chronic UTI should have been developed when Resident 385 was readmitted on [DATE]. The DON stated the CP serves as the communication for all healthcare disciplines to standardize care for the residents.
During a review of the facility's policy and procedure titled, Care Planning, last reviewed on 1/29/2024, the policy indicated the following:
o The facility ensures that a CP is developed for each resident based on their individual needs.
o The CP serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), Attending Physician, Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the residents) work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental, and psychosocial needs.
o The CP will describe the services that are to be furnished to attain or maintain the resident's highest physical, mental, and psychosocial well-being, and the resident's goals for admission and desired outcome.
b. During a review of Resident 177's admission Record, the admission record indicated Resident 177 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than the normal), hyponatremia (a condition that occurs when the level of sodium in the blood is too low), and allergic rhinitis (also known as seasonal allergies, a response causing itchy, watery eyes, sneezing, and other similar symptoms).
During a review of Resident 177's Order Summary Report, dated 6/28/2022, the order summary report indicated Resident 177 was ordered sodium chloride tablet one gram (a unit of measure for mass), two tablets by mouth two times a day related to hypo-osmolality and hyponatrem
During a review Resident 177's History and Physical (H&P), dated 7/2/2023, the H&P indicated Resident 177 had fluctuating capacity to understand and make decisions.
During a review of Resident 177's MDS, dated [DATE], the MDS indicated Resident 177 was able to understand and make decisions, required setup assistance with eating, required touching assistance or supervision with walking up to 150 feet (a unit of measure for length), and required moderate assistance to total dependence on facility staff for surface-to-surface transfers, hygiene, bathing or showering, and dressing.
During a review of Resident 177's Order Summary Report of active orders as of 8/7/2024, the order summary report did not indicate an order for saline solution nasal spray (a mixture of salt and water that is sprayed into the nose).
During a review of Resident 177's Order Summary Report of active orders as of 8/7/2024, the order summary report did not indicate an order for self-administration for medication.
During a review of Resident 177's medical record, the medical record did not indicate a medication self-administration assessment was performed.
During a concurrent observation and interview with Resident 177, on 8/5/2024, at 10:26 a.m., while inside Resident 177's room, Resident 177's bedside table contained a small clear plastic cup containing two white circular tablets and a saline spray bottle. Resident 177 stated the two white circular tablets in the medication cup were her sodium tablets and she takes the medications with food. Resident 177 stated the nurse gave her the tablets in the morning and she will take the tablets after eating lunch. Resident 177 further stated she uses the saline spray as needed to help her breathe.
During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on 8/8/2024, at 9:35 a.m., Resident 177's medical record was reviewed and LVN 1 confirmed Resident 177 did not have a CP for medication self-administration. LVN 1 stated Resident 177 is alert and oriented and told her to leave her sodium chloride tablets at the bedside so she can take it later. LVN 1 stated it is important to have a CP for medication self-administration to provide information to the staff regarding the resident and the care to provide to them. LVN 1 stated care plans help guide the care for residents. LVN 1 further stated, without a CP the facility would not know how to care for the residents.
During an observation on 8/8/2024, at 10:15 a.m., while inside Resident 177's room, Resident 177's bedside table contained a small clear plastic cup with two white circular tablets.
During an interview with the DON, on 8/9/2024, at 8:55 a.m., the DON stated there should be a CP for medication self-administration and the resident and family should be involved with its creation. The DON stated the CP should include monitoring including checking where the medication will be stored, the medication the resident will be self-administering, and the frequency of administration.
During a review of the facility's policy and procedure (P&P) titled, Medication - Self Administration, last reviewed on 1/29/2024, the P&P indicated the interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the resident) develops and implements a CP for medication self-administration and will identify where medications are stored, education for resident or family regarding medication self-administration process, specific medication, information and safe, effective use of medications, obtaining medication, administering medications according to physician's order, how the licensed nurse will validate that medications are taken as ordered by the attending physician, and how non-compliance and/or refusal to take medications will be managed.
Cross-reference F554, F755 and F689.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess functional limitation (limited ability to move a joint that interferes with daily functioning) in range of motion ([ROM] full movement potential of a joint [where two bones meet]) for one of four sampled residents (Resident 34) with limited ROM and mobility (ability to move).
This failure provided inaccurate information to the Federal database.
Findings:
During a review of Resident 34's admission Record, the facility admitted Resident 34 on 6/26/2017 with diagnoses including Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life), dementia (decline in mental ability severe enough to interfere with daily life), dysphagia (difficulty swallowing), hemiplegia and hemiparesis (weakness or inability to move one side of the body) following a cerebral vascular infarct (brain damage due to a loss of oxygen to the area) affecting the left, non-dominant side (less often used during completion of daily living tasks).
During a review of Resident 34's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 3/31/2024 and 6/23/2024, the MDS indicated Resident 34 had clear speech, expressed ideas and wants, clearly understood verbal content, and had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 34 had functional ROM limitations in both arms and legs.
During a review of Resident 34's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 8/31/2022, the OT Evaluation indicated Resident 34's ROM in the right shoulder, elbow, wrist, and hand was within functional limits ([WFL] sufficient movement without significant limitation). The OT Evaluation indicated Resident 34 had impaired ROM in the left shoulder, elbow, wrist, and hand due to left-sided hemiplegia.
During a review of Resident 34's OT Discharge summary, dated [DATE], the OT Discharge Summary recommendations included for Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) to perform active range of motion ([AROM] performance of ROM of a joint without any assistance or effort of another person) on the right arm and active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) on the left arm.
During a review of Resident 34's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 10/26/2022, indicated Resident 34's ROM in both legs were WFL. The PT Evaluation indicated Resident 34 had more weakness in the left leg than the right leg.
During a review of Resident 34's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 34 walked 60 feet (unit of measure) with minimum assistance (requires less than 25 percent [%] physical assistance to perform the task). The PT Discharge Summary recommendation indicated for the RNA to provide AROM (unspecified) and ambulation (the act of walking) with Resident 34.
During a review of Resident 34's physician orders, dated 12/5/2022, the physician orders indicated to provide ambulation with assistance using the hemi-walker (assistive device that allows a person to lean on one side while walking for support) daily as tolerated.
During an observation on 8/7/2024 at 9:59 a.m. in the bedroom with Restorative Nursing Assistant 3 (RNA 3), Resident 34 was seated in a wheelchair. RNA 3 pushed Resident 34's wheelchair to the hallway to perform exercises. RNA 3 verbally and visually cued Resident 34 to perform AROM on the right leg and performed AAROM on Resident 34's left leg. RNA 3 verbally and visually cued Resident 34 to perform AROM on the right arm and performed AAROM on the left arm.
During an observation on 8/7/2024 at 10:10 a.m. in the hallway, RNA 3 placed a cloth gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) around Resident 34's waist while Resident 34 sat in the wheelchair. RNA 3 placed a hemi-walker on Resident 34's right side. Resident 34 required minimal assistance to stand from a seated position. RNA 3 was positioned on Resident 34's left side while Resident 34 walked using the right hand to maneuver the hemi-walker. Resident 34 walked more than 100 feet using the hemi-walker and RNA 3's assistance.
During a review of the MDS's Resident Assessment Instrument (RAI) Manual, published 10/2023, Page GG-7 of the RAI Manual indicated to avoid assessing ROM in isolation and to determine whether limited ROM had an impact on a resident's functional ability.
During a concurrent interview and record review on 8/9/2024 at 1:40 p.m. with the MDS Assistant (MDS 1), MDS 1 reviewed Resident 34's MDS, dated [DATE] and 6/23/2024, and the RAI Manual. MDS 1 stated Resident 34's MDS assessments, dated 3/31/2024 and 6/23/2024, were inaccurate for functional ROM limitations. MDS 1 stated both MDS assessments should have indicated Resident 34 had functional ROM limitations in one arm and one leg.
During an interview on 8/9/2024 at 2:14 p.m. with MDS 1, MDS 1 stated the MDS assessments should be accurate to provide accurate information to the Federal database.
During a review of the facility's policy and procedure (P&P) titled, Resident Assessment, revised 3/1/2015 and reviewed 1/29/2024, the P&P indicated the resident assessments should be conducted regularly and comprehensively to monitor a resident's health status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/12/2023 with diagnoses including, but not limited to, history of falling.
During a review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/16/2024, the MDS indicated Resident 2 had moderate cognitive impairment (difficulty understanding and making decisions) and requires supervision or touching assistance to total dependence on staff with activities of daily living such as eating, hygiene, showering or bathing self, dressing, repositioning, and surface-to-surface transfers.
During a review Resident 2's History and Physical (H&P), dated 4/23/2024, the H&P indicated Resident 2 does not have the capacity to understand and make decisions.
During a review of Resident 2's Order Summary Report, the report did not indicate an order to place the bed against the wall.
During a review of Resident 2's Care Plan, the care plan did not indicate a care plan related to placing the bed against the wall.
During a review of Resident 2's Medical Record, the medical record did not indicate a consent to place the bed against the wall.
During a review of Resident 2's Medical Record, the medical record did not indicate an assessment for entrapment risk.
During an observation on 8/5/2024, at 9:14 a.m., inside Resident 2's room, Resident 2 sat in a wheelchair parked to the left of the bed. Resident 2's bed was pushed against the wall opposite of the doorway into the room.
During an observation on 8/6/2024, at 8:00 a.m., inside Resident 2's room, Resident 2 was sleeping in bed with the bed pushed against the wall, opposite wall from the doorway, on Resident 2's left side.
During an interview with Certified Nursing Assistant (CNA) 6, on 8/8/2024, at 2:09 p.m., CNA 6 stated placing a resident's bed against the wall restricts the resident's movements. CNA 6 further stated placing beds against the wall makes it difficult for staff to provide care because staff are not able to provide space to reposition the resident.
During an interview with the Director of Nursing (DON), on 8/9/2024, at 8:55 a.m., the DON stated consents for placing the bed against the wall should be obtained. The DON stated risk assessments should be performed prior to placing beds against the wall. The DON further stated it is important to obtain a consent and perform a risk assessment prior to placing the bed against the wall because it is considered a restraint and might place the residents at risk for entrapment.
During a review of the facility's policy and procedure (P&P) titled, Restraints, last reviewed 1/29/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body, which may include bed against walls. The P&P indicated there must be a physician's order for the use of the restraint. The P&P further indicated documentation for residents with restraints shall include the following:
-
A comprehensive assessment
-
Rationale for physical restraint use
-
Restraint information
-
A signed consent form
-
A written physician's order for restraint use.
4. During a review of Resident 109's admission Record, the admission Record indicated the facility admitted the resident on 3/11/2022 with diagnoses that included Alzheimer's dementia (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and muscle weakness.
During a review of Resident 109's Minimum Data Set (MDS - an assessment and care screening tool) dated 7/2/2024, the MDS indicated the resident sometimes was able to understand others and sometimes was able to make herself understood. The MDS indicated the resident required partial/moderate assistance from staff with eating and rolling side to side; and was dependent on staff for oral hygiene, toileting, bathing, dressing, and moving from a sit to stand position and transfers. The MDS further indicated the resident did not have restraints.
During a review of Resident 109's History and Physical (H&P) dated 6/26/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 109's physician orders, the orders indicated the following orders:
-May have wedge cushion on the sides of mattress to prevent from rolling down, dated 3/20/2024.
-Monitor behavior for constant trying to get out of bed and wheelchair unattended, dated 6/22/2022
During a review of Resident 109's Care Plans titled, Psychosocial: episode of constant trying to get up from bed and wheelchair unassisted, initiated 8/15/2023, indicated to assure the environment is safe when episodes of repetitive movements occur, and to attempt to determine cause of movement and resolve as able.
During a review of Resident 109's Care Plans titled, Psychosocial: Home Like Environment, initiated 3/14/2022, indicated the facility will rearrange room as per resident request permitting that the new arrangement of room does not create life safety and/or fire hazards.
During a review of Resident 109's Care Plans titled, Plan of Care - Physical Therapy, initiated 6/26/2024, indicated the resident was a fall risk with decreased safety awareness and had decreased strength in the left and right upper and lower extremities.
During an observation on 8/5/2024 at 10:40 a.m., Resident 109 lay in bed with the lights off. Observed the right side of the mattress elevated by a wedge cushion placed under the mattress and observed the left side of the bed pushed up against the wall.
During a concurrent interview and record review on 8/6/2024 at 8:20 a.m., with Licensed Vocational Nurse 8 (LVN 8), LVN 8 reviewed Resident 109's physician orders, and informed consents. LVN 8 stated she cares for Resident 109 and the resident is confused. LVN 8 stated the resident tries to stand but does not have the strength to walk. LVN 8 stated Resident 109 had a wedge under the mattress and the bed against the wall to prevent the resident from falling. LVN 8 stated Resident 109 could not get out of bed on the left side because it was against the wall and Resident 109 could not get out of the bed on the right side due to the wedge. LVN 8 stated the bed was placed against the wall by using critical thinking and they did not need a physician's order. LVN 8 stated there was no informed consent form for placing Resident 109's bed against the wall when a wedge was in place. LVN 8 stated the wedge and the bed against the wall kept the resident in the bed and the resident was not able to remove the wedge or move the bed away from the wall.
During a concurrent interview and observation on 8/6/2024 at 1:16 p.m., with LVN 8, LVN 8 entered Resident 109's room and stated the resident was lying in bed with the bed against the wall and a wedge under the mattress on the opposite side. LVN 8 stated the resident could not get out of bed. LVN 8 stated a restraint was anything that keeps a resident from doing something. LVN 8 stated they were limiting Resident 109's freedom of movement. LVN 8 stated she was not sure if placing the bed against the wall with a wedge under the mattress was a restraint.
During an interview on 8/6/2024 at 3:38 p.m., with Registered Nurse 6 (RN 6), RN 6 stated if the resident's bed is against the wall, it is a restraint if they cannot get out of bed. RN 6 stated she informed staff in her area that resident beds should not be against the wall. RN 6 stated this has been an ongoing issue and maybe some family members have been communicating with certified nursing assistants to move the bed against the wall. RN 6 stated if a bed is against the wall with a wedge in place it really is a restraint. RN 6 stated when a restraint is used there is a possibility of psychological and emotional harm, and it may potentially be considered abusive. RN 6 stated because the facility considers itself to be restraint free, and there are no assessments completed for placing the bed against the wall.
During an interview on 8/8/2024 at 9:49 a.m., with LVN 4, LVN 4 stated she cares for Resident 109 and the resident has had the bed placed against the wall ever since she was placed on the unit, months ago. LVN 4 stated she was not aware resident beds should not be against the wall.
During an interview on 8/8/2024 at 1:38 p.m. with the facility Administrator (ADM) and Director of Nursing (DON), the DON stated the facility is restraint free. The DON stated the beds should not be pushed up against the wall, but some family members wanted it that way. The ADM stated the wedge under the mattress with the bed placed against the wall limits the resident's movement and it is considered a restraint. The ADM stated without informed consent there were no risk and benefits or alternatives attempted and explained to the resident and family. The ADM stated without consent the resident potentially would not know the risk of having the bed against the wall and inadvertently put themselves at risk for entrapment (a condition in which a resident is caught or trapped in the spaces in or about the mattress or bed frame).
During a follow up interview on 8/9/2024 at 8:58 a.m. with the DON, the DON stated when the resident's bed was against the wall it was a restraint and there should be a risk assessment and informed consent obtained prior to placing the bed against the wall, but it was not done.
During a review of the facility policy and procedure (P&) titled, Resident Rooms and Environment, last reviewed 1/29/2024, the P&P indicated to provide residents with a safe, clean, comfortable, and homelike environment. The facility shall ensure residents can receive care and services safely and that the physical layout maximizes resident independence and does not pose a safety risk.
During a review of the facility policy and procedure (P&P) titled, Restraints, last reviewed 1/29/2024, the P&P indicated residents shall be provided an environment that is restraint free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measure shall be used. The definition of a physical restraint is any manual method of physical or mechanical device material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. This may include beds against the wall. Postural support is defined as a method to assist patients to achieve proper body position and balance. Postural supports may include lateral supports. The facility honors the residents right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. The facility will ensure that restraints will not be imposed for purposes of convenience. Medical symptoms will be evaluated to determine if underlying causes may be eliminated. If underlying causes of medical symptoms cannot be eliminated, alternative measures must be tried before a restraint is used. If alternative measures are unsuccessful, the least restrictive form a restraining will be used. Every attempt must be made to avoid a decline in the resident's physical functioning. Except in emergency situations, a physical restraint shall be used only after the interdisciplinary team has performed an assessment, attempted to determine, and alleviate precipitating factors, determined the need for restraint and identified the least restrictive device. Postural supports will only be used to improve a resident's mobility and independent functioning, or for positioning, rather than to restrict movement. An assessment will be completed by a licensed nurse prior to the application of any device that restricts movement or access to one's own body. There must be a physician's order for the use of a restraint. Before any restraint is used, the licensed nurse will verify that informed consent has been obtained from the resident/responsible party and the party was educated regarding the risks and benefits of restraint use.
During a review of the facility policy and procedure (P&P) titled, Informed Consent, last reviewed 1/29/2024, the P&P indicated the facility respects the resident's right to make an informed decision prior to deciding to undergo certain medical therapies and procedures. The facility will have the Attending Physician/Licensed Healthcare Practitioner obtain informed consent for physical restraints and prolonged use of a device that may lead to inability to regain use of a normal bodily function. Informed consent is defined as the voluntary agreement of a resident (or a representative of an incapacitated resident) to accept a treatment or procedure after receiving the following information: the nature of the proposed treatment; material information concerning the risks, and complications and expected benefits or effects of the treatment. The informed consent will be documented and placed in the resident's medical record.
Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for four of five sampled residents (Residents 38, 190, 2, and 109) investigated during review of physical restraints care area by failing to:
1. Complete a Physical Restraint Assessment Form, obtain a physician order, and obtain an informed consent from the resident or the resident representative prior to placing the bed against the wall as a restraint for Residents 38, 109, 2, and 109.
2. Complete a Physical Restraint Assessment Form, obtain a physician order, and obtain an informed consent from the resident or the resident representative prior to using a wedge cushion (special triangle-shaped pillows that raise the top half of the body while sleeping) tucked under the mattress on one side of the bed and prior to placing the other side of the bed against the wall as restraints, for Residents 190 and 109.
These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from), and death of residents.
Findings:
1. During a review of Resident 38's admission Record, the admission record indicated the facility admitted the resident on 2/28/2023, with diagnoses including age-related osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue), ataxia (involves a lack of muscle coordination and control), and presence of right artificial shoulder joint (removes damaged areas of bone and replaces them with parts made of metal and plastic [implants]).
During a review of Resident 38's History and Physical (H&P), dated 1/27/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 38's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/13/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions) and had upper and lower extremity impairment. The MDS indicated the resident required substantial to maximal assistance on mobility and activities of daily living (ADLs).
During a review of Resident 38's Fall Risk Assessment, dated 8/1/2024, the assessment indicated the resident was high risk for falls.
During an observation on 8/5/2024, at 8:54 a.m., observed Resident 38's left side of the bed placed against the wall.
During an interview on 8/5/2024, at 10:16 a.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated the placement of the resident's bed against a wall is considered a restraint.
During a concurrent interview and record review on 8/7/2024, at 11:03 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 38's Order Summary Report, Consents, and assessments. RN 1 stated there was no physician's order, no assessment for entrapment (an event in which a patient is caught, trapped, or entangled in spaces in the spaces in or about the bed rail, mattress, or hospital bed frame), and no consent from the resident or resident representative for placement of bed against the wall. RN 1 stated placing the bed against the wall is considered a restraint. RN 1 stated the residents should be able to get out on both sides of the bed.
During a review of the facility's recent policy and procedure (P&P) titled, Restraints, last reviewed on 1/29/2024, the P&P indicated resident shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used. Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. This may include bed rails, bed against walls, restrictive clothing, etc. The Attending Physician must be notified of such use and reason for the order. Informed consent will be obtained from the resident or responsible party if a restraint will be used during a treatment or diagnostic procedures. An assessment will be completed by a Licensed Nurse prior to the application of any device that restricts movement or access to one's body. The IDT will discuss with the resident and/or resident representative the risk and benefits involved with bed rails and described alternatives that may be feasible prior to installing bed rails by utilizing NP-278-Form C- Potential Risk and Benefits of Bed Rails. There must be a physician's order for the use of the restraint which includes:
A. Medical symptoms for use;
B. Frequency of use;
C. Type of restraint;
D. Release protocols; and
E. Plan for reduction, when applicable.
Before any type of restraint is used, the Licensed Nurse will verify that informed consent has been obtained from the resident/responsible party and that the resident /responsible party was educated regarding the risks and benefits of restraint use. Care plans for residents with restraints will reflect:
A. The type of restraint to be used;
B. The medical symptoms requiring the use of restraints;
C. The treatment team's goals in using the restraint;
During a review of the facility's recent policy and procedure titled, Informed Consent, last reviewed on 1/29/2024, indicated to ensure that the facility respects the resident's right to make an informed decision prior to deciding to undergo certain medical therapies and procedures. The facility will have the Attending Physician/ Licensed Healthcare Practitioner (LHP) determine when material circumstances have changed so that an informed consent is required from the resident before providing treatment. The Attending Physician/LHP will then obtain an informed consent from the resident or authorized representative before administration of a therapy or procedure that requires an informed consent. The use of informed consent will be done for but not limited to the following:
B. Physical Restraints.
During a review of the facility provided Owner's Manual titled, Bed Frame 1 (BF 1), last revised on 6/1/2019, indicated an entrapment warning, entrapment issues can still arise when components and accessories are not properly installed. Accurate assessment of the resident and monitoring of correct maintenance and equipment use are required to prevent entrapment. On March 10, 2006, the U.S. Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled; Hospital bed System Dimensional and Assessment Guidance to Reduce Entrapment. This guidance document identifies potential entrapment areas within the bed frame, rails, and mattress and identifies those body parts most at risk for entrapment.
2. During a review of Resident 190's admission Record, the admission Record indicated the facility admitted the resident on 11/3/2020 and readmitted the resident on 6/5/2024, with diagnoses including muscle weakness, age-related osteoporosis, and displaced oblique fracture (the pieces of the bone moved so much that a gap formed around the fracture when the bone broke) of shaft of left ulna (a long bone in the forearm stretching from the elbow to the wrist).
During a review of Resident 190's H&P, dated 6/6/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 190's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had moderately impaired vision and required total dependence on mobility and activities of daily living (ADLs).
During a review of Resident 190's Fall Risk Assessment, dated 6/6/2024, the assessment indicated the resident was high-risk for falls.
During a concurrent observation and interview on 8/5/2024, at 10:50 a.m., with LVN 5, inside Resident 190's room, observed the resident's left side of the bed placed against the wall and a wedge cushion tucked under the mattress on the right side of the bed. LVN 5 stated placing the bed against the wall and tucking a wedge pillow under the mattress on the opposite side of the resident's bed are considered restraints.
During a concurrent interview and record review on 8/5/2024, at 11:14 a.m., with Licensed Vocational Nurse 9 (LVN 9), reviewed Resident 190's Order Summary Report, Consents, and Assessments. LVN 9 stated there was no physician's orders, no restraint assessments, and no consent from the resident or resident representative for placing the bed against the wall and using a wedge cushion tucked under the mattress. LVN 9 stated it is important to have a physician's order, an assessment for safe use of the restraints, and obtain a consent from the resident or resident representative to ensure safe use of the restraints and to honor the resident's right to agree or refuse the treatment.
During an interview on 8/9/2024, at 4:56 p.m., with the DON, the DON stated by placing a wedge cushion on Resident 190's right side of the bed, the height of the bed increased, and the wedge pillow restrained the resident from easily getting out on the right side of the bed. The DON stated the increased height of the bed increased the chances of falls with injury. The DON further stated placing the bed against the wall is a restraint. The DON stated it is important to get an order from the physician, assess the resident for safe use of the restraints and obtain a consent from the resident or resident representative to ensure appropriate and safe use of the restraints. The DON stated the consent honors the residents right to refuse or accept treatment.
During a review of the facility's recent policy and procedure titled, Restraints, last reviewed on 1/29/2024, indicated resident shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used. Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. This may include bed rails, bed against walls, restrictive clothing, etc. The Attending Physician must be notified of such use and reason for the order. Informed consent will be obtained from the resident or responsible party if a restraint will be used during a treatment or diagnostic procedures. An assessment will be completed by a Licensed Nurse prior to the application of any device that restricts movement or access to one's body. The IDT will discuss with the resident and/or resident representative the risk and benefits involved with bed rails and described alternatives that may be feasible prior to installing bed rails by utilizing NP-278-Form C- Potential Risk and Benefits of Bed Rails. There must be a physician's order for the use of the restraint which includes:
A. Medical symptoms for use;
B. Frequency of use;
C. Type of restraint;
D. Release protocols; and
E. Plan for reduction, when applicable.
Before any type of restraint is used, the Licensed Nurse will verify that informed consent has been obtained from the resident/responsible party and that the resident /responsible party was educated regarding the risks and benefits of restraint use. Care plans for residents with restraints will reflect:
A. The type of restraint to be used;
B. The medical symptoms requiring the use of restraints;
C. The treatment team's goals in using the restraint;
During a review of the facility's recent policy and procedure titled, Informed Consent, last reviewed on 1/29/2024, indicated to ensure that the facility respects the resident's right to make an informed decision prior to deciding to undergo certain medical therapies and procedures. The facility will have the Attending Physician/ Licensed Healthcare Practitioner (LHP) determine when material circumstances have changed so that an informed consent is required from the resident before providing treatment. The Attending Physician/LHP will then obtain an informed consent from the resident or authorized representative before administration of a therapy or procedure that requires an informed consent. The use of informed consent will be done for but not limited to the following:
B. Physical Restraints.
During a review of the facility provided Owner's Manual titled, Bed Frame 1 (BF 1), last revised on 6/1/2019, indicated an entrapment warning, entrapment issues can still arise when components and accessories are not properly installed. Accurate assessment of the resident and monitoring of correct maintenance and equipment use are required to prevent entrapment. On March 10, 2006, the U.S. Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled; Hospital bed System Dimensional and Assessment Guidance to Reduce Entrapment. This guidance document identifies potential entrapment areas within the bed frame, rails, and mattress and identifies those body parts most at risk for entrapment.

Based on observation, interview, and record review, the facility failed to have an updated policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption when the policy did not include the facility's responsibility for storing food brought in by family and other visitors.
This deficient practice had the potential to cause a decrease food intake resulting in unintentional (without trying) weight loss, frustrations, and psychosocial harm to 239 of 239 facility residents.
Findings:
A review of the facility's Policies and Procedures (P&P) titled Food Brought in by Visitors dated 6/6/2024, indicated Policy: Food may be brought to a resident by the family members, the resident's responsible party, or friends (visitors) if the food is compatible with the Attending Physician's diet order. Procedure: (B) Food from outside sources should be stored in a sealable container with the resident's name and date it was bought to the facility. The P&P did not indicate a procedure for safe storage of food and where to store the foods.
During an interview with Dietary Supervisor (DS) on 8/6/2024 at 10:19 a.m., the DS stated they have a food from home policy for the resident's visitor who brought food for the residents and nursing staff implemented it. The DS stated they did not have a refrigerator in the resident's room, nursing station and in the kitchen designated as resident's refrigerator. The DS stated family and visitors were only allowed to bring pastries or ice cream and residents had to eat it right away.
During an interview with Licensed Vocational Nurse 1 (LVN 1) on 12:51 a.m. at the [NAME] Station, LVN 1 stated resident's family and visitors were allowed to bring food from the outside and they must sign a paper for bringing food from the outside. LVN 1 stated, they were not allowed to keep resident's leftover food as they did not have any refrigerator in the nursing stations or inside the resident's room. LVN 1 stated they were not allowed to store frozen prepared food items from the resident's visitors because they prepare foods for the residents every day in the facility's kitchen. LVN 1 stated they could only keep food at room temperature for two (2) hours but was not sure if that was the exact time, because it would not be fresh anymore. LVN 1 stated the potential outcome for the residents would be upset stomach, nausea, vomiting and diarrhea if the food was not refrigerated. LVN 1 stated it would not be good for resident's health. LVN 1 stated she told the families that they could not bring food from the outside beyond one meal. LVN 1 stated she educated families regarding the reason why they could not store food from the outside beyond one (1) meal unless it was cookies.
During an interview with Licensed Vocational Nurse 2 (LVN 2) at 8/6/2024 at 1:12 p.m. at [NAME] one station, LVN 2 stated resident's visitors could always bring food from the outside however, residents could not save the food or later consumption and must eat it right away because the food would spoil without refrigeration. LVN 2 stated they did not have refrigerators in the resident's room and nursing unit. LVN 2 stated food like cookies were stored in the resident's drawers and they labeled it with name and date. LVN 2 stated they educated residents to bring enough food they could consume right away and if there were other foods brought in, they tell the visitors that they could not bring the food in. LVN 2 stated she would maybe take the food in the kitchen and keep it there or ask the supervisors if she could do that. LVN 2 stated residents could get mad as a potential outcome for not allowing them to bring food for later consumption.
During an interview with Director of Nursing on 8/6/2024 at 2:07 p.m., the DON stated they do not have refrigerators in resident's room and nursing stations for resident's food storage and resident's family were aware that they could only bring food for one time use only. The DON stated they store crackers and cookies from visitors in the resident's drawer but denied other perishable foods and discarded them as they could not store them. The DON stated it was the resident's right to bring food from the outside, but they were never allowed to store it for safety reasons. The DON stated as a potential outcome, residents would not be able to eat and could upset the residents if they were not allowed to store food from the outside.
During an interview with the Administrator (ADM) on 8/6/2024 at 2:28 p.m., the ADM stated residents were allowed to bring food from the outside and any perishable items needed to be consumed within two hours. The ADM stated they could only eat the food for the day they brought the food in, and it needed to be discarded if not consumed as there were no refrigerators in the resident's room and nurse's station. The ADM stated there were refrigerators in her office and nursing office that they could use if resident's visitor brought food from the outside. The ADM stated there was no significant potential outcome from not storing food from the outside for more than one day consumption.
During an interview with the ADM on 8/6/2024 at 2:40 p.m., the ADM stated the food storage guidelines for food brought by visitors fell off when they updated the policy on 6/6/2024 and the original policy dated 5/1/2024 indicated storage guidelines for food brought from the outside.
A review of P&P titled Food Brought in by Visitors dated 5/1/2024 indicated VI. Perishable food requiring refrigeration will be discarded two (2) hours at bedside, and if refrigerated, it will be labeled, dated, and discarded after 48 hours.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to:
a. Ensure one (1) food item in the walk-in refrigerator and three (3) food items in the reach-in refrigerator had a label.
b. Ensure the bulk condiment container lid had no chips and scratches.
c. Ensure four (4) dented cans were not stored with non-dented cans.
d. Ensure one storage rack was not six (6) inches ([in.] unit of measurement) above the floor.
e. Ensure [NAME] 1 was not wearing two gold bracelets while scooping food and Dietary Aide 1 (DA 1) was not wearing a watch while scooping soup during lunch trayline.
f. Ensure Yogurts were at 58.5 degrees Fahrenheit ([°F], degree of temperature), 57.2°F and 58.2°F.
g. Ensure eight resident's trays had no cracks and chips.
h. Ensure the Staff checked and monitored the temperature when testing solution for sanitizer.
i. Ensure Staff properly cooled the buckwheat.
These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 239 of 239 medically compromised residents who received food and ice from the kitchen.
Findings:
a. During an initial kitchen tour observation on 8/5/2024 at 8:18 a.m. in the walk-in refrigerator, a pan of food had no name.
During a concurrent observation of the reach in refrigerator and interview with Dietary Supervisor (DS) on 8/5/2024 at 8:37 a.m. DS stated there were 3 pans of meat that had no name and there was no product name printed on the food itself however, everyone in the kitchen knows what the product was. DS stated the three pans of meat was ground beef and regular beef. DS stated staff forgot to label them. DS stated their process of labeling and dating included labeling it with the name of the product, the date when the food was pulled from the freezer and the used by date. DS stated it was important to label the food with name to identify what kind of meat, food and what kind of products were in the refrigerators. DS sated the residents could possibly receive wrong food items causing the residents to have diarrhea, and not catering their dislikes as a potential outcome.
A review of facility's Policies and Procedures (P&P) titled Food Storage dated 1/29/2024 indicated II. Frozen Meat/Poultry and Food Guidelines. (i). label and date all food items.
A review of Food Code 2017 indicated 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.
b. During an initial kitchen tour observation of the dry storage area on 8/5/2024 at 9:02 a.m. the bulk container lids for bulgar 1, bulgar 2, sugar, pasta, rice, scalloped potatoes, Calrose, lentil, green lentils, and flour had chips and scratches.
During a concurrent observation of the bulk containers and interview with DS and Administrator (ADM) on 8/5/2024 at 9:17 a.m., DS stated the bulk containers had scratches and physical contaminants could go to the food. DS stated bacteria could grow in these scratches because the container would be hard to clean. ADM sated the containers were not filled up to touch, but it would be a concern for physical contaminants. DS stated the potential outcome would be cross-contamination.
c. During an initial kitchen tour observation of the dry storage area on 8/5/2024 at 9:09 a.m. one (1) dented can was stored in the non-dented cans section.
During a concurrent observation of the dry storage area and interview with DS on 8/5/2024 at 9:18 a.m., DS stated there was a designated area for dented cans so as not to consume it. DS stated dented cans were not good for consumption as the food inside would be spoil. DS stated the expectation was to separate dented cans from non-dented cans to avoid using them. DS stated there were total of four (4) dented cans stored with the undented cans. Residents could get sick if they consumed food from dented cans as a potential outcome.
A review of facility's P&P titled Receiving Food and Supplies dated 1/29/2024 indicated V. Do not accept and return to the supplier, any items that are: B. Dented, rusted, damaged cans.
A review of facility's P&P titled Food Storage dated 1/29/2024 canned fruits and vegetable storage guidelines C. Dented or bulging cans should be placed in separate storage area and returned for credit.
A review of Food Code 2017 indicated 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.
d. During a concurrent observation of storage rack in the dry storage area used to store paper supplies and interview with DS and ADM on 8/5/2024 at 9:10 a.m. one storage rack was not more than six (6) inches above floor. DS stated the expectation for all the dry storage racks would be 6 inches or more. DS stated it was important to have the racks or shelves to be more than 6 inches above he floors for the rodents not to get into the food or paper supplies and for infection control. ADM stated the rack was used for paper supply storage that's why it was not more than 6 inches high from the floor. DS stated all the racks or shelves in the dry storage should be above 6 inches from the floors.
A review of the facility's P&P titled Food Storage dated 1/29/2024 indicated Dry Storage Guidelines H.) Shelving should be mounted at least 6 inches from the floor, preferably on castors for ease of cleaning, and 18 inches from the ceiling.
A review of Food Code 2017 indicated 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (3) at least 15 cm (6 inches) above the floor.
e. During an observation of [NAME] 1 on 8/5/2024 at 11:06 a.m., [NAME] 1 was wearing two gold bracelets while cooking and stirring soup.
During an observation of trayline on 8/5/2024 at 11:44 a.m., [NAME] 1 was wearing gold bracelets while dishing out hot food and DA 1 was wearing a watch while dishing out soup.
During a concurrent observation of the trayline and interview with DS on 8/5/2024 at 11:52 a.m. DS stated [NAME] 1 was wearing gold bracelets while dishing out food in trayline and it was not allowed due to physical hazard and infection control. DS stated they only allowed their employees to wear a plain wedding band and watch.
During an interview with [NAME] 1 on 8/5/2024 at 11:57 a.m. [NAME] 1 sated she did not usually wear bracelets and she just forgot to remove it. [NAME] 1 stated she was aware of the importance for not wearing jewelries during food preparation and it was for infection control.
A review of facility's P&P titled Personal Hygiene dated 1/29/2024 indicated Objective: Participants will learn what guidelines for personal hygiene are needed to promote a safe and sanitary Food and Nutrition Services department. Jewelry is limited to wedding band and post earrings.
A review of Food Code 2022 indicated 2-303.11 Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.
f. During an observation of the yogurt on resident's tray inside the cart waiting outside the kitchen hallway on 8/5/2024 at 11:35 a.m., yogurt 1 was at 58.5°F, and yogurt 2 was at 57.2°F.
During a concurrent observation of the yogurt and interview with DS on 8/5/2024 at 11:37 a.m., DS stated staff started placing the cold items including the yogurt on the resident's tray around 11:10-11:20 a.m. DS stated the yogurt in one of the trays was 58.1°F when she tempted it using the facility thermometer. DS stated it was not okay as it should be at 41°F or below to avoid the danger zone ([temperature between 41°F and 135°F], temperatures where bacteria grow rapidly) where bacteria could grow. DS stated she would change all the yogurts on the trays because it would no longer be good to serve to the residents as they could get sick and have diarrhea.
A review of facility's P&P titled Food Temperatures - Danger Zone dated 1/29/2024 indicated Purpose: To ensure the safety and well-being of residents by maintaining at safe temperatures and preventing the growth of harmful bacteria in compliance with Title 22 regulations of the California Code of Regulations. Danger zone: The temperature range between 41°F (5°C) and 135°F (57°C) where bacteria can grow rapidly. Perishable foods: Food that require time and temperature control for safety, including meats, dairy products, cooked vegetables, and certain prepared foods. Policy: (1) Temperature Control: All perishable must be kept out of the danger zone. Cold food must be maintained at or below 40°F (5°C), and hot food must be maintained at or above 140°F (57°C).
A review of facility's P&P titled Food Temperatures dated 1/29/2024, indicated III. Acceptable Serving Temperatures: Milk, juice <41°F. V. If temperatures are not at acceptable levels and cannot be corrected in time for meal service, and appropriate menu substitution should be implemented. B. Cold food may be put in a freezer 30 minutes to 45 minutes prior to meal service to obtain serving temperature. (i.) Bring only one tray at a time out of the trayline. Place on ice. Ice down all cold foods on trayline.
A review of Food Code 2017, indicated 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5°C (41°F) or less.
g. During a concurrent observation of the resident's trays and interview with DS on 8/5/2024 at 12:36 p.m. eight (8) resident's trays had chip and cracks. DS stated they needed to change the trays with crack and chips as bacteria could grow in it. DS stated potential outcome would be cross-contamination.
A review of facility's P&P titled Discarding of Chipped/Cracked Dishes and Single Service Items dated 1/29/2024 indicated Policy: The dietary staff will maintain a sanitary environment in the dietary department by discarding compromised service ware and single service items. Procedure: I. The dietary staff will discard chipped or cracked dish or glass ware.
A review of Food Code 2017 indicated 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections.
h. During a demonstration of checking sink and surface cleaner sanitizer concentration by [NAME] 2 and interview with [NAME] 2 on 8/6/2024 at 9:56 a.m. [NAME] 2 did not check the sanitizer solution when checking the concentration. [NAME] 2 stated she did not check and record the temperature of the solution prior to checking the premix sanitizer solution by the two-compartment sink.
During concurrent interview with DS and review of sink and surface cleaner manufacturer's guidelines on 8/6/2024 at 10:16 a.m. the sink and surface sanitizer indicated Sanitation range testing - 1. Testing solution should be at or above room temperature: 65°F (18.3°C). DS stated she tested the water temperature for testing solution for sanitizer however, she was not recording it anywhere. DS stated the staff were also not recording the temperature of the solution prior to testing the sanitizer. DS stated they did not follow manufacturer's guidelines for the sanitizer, and it was important to follow the manufacturer's guidelines of the sanitizer to ensure the strength of the sanitizing solution for it to sanitize the dishes for infection control. DS stated she had to include the temperature check in the form.
A review of facility's log titled Food and Nutrition: Sanitizer Test Strips Log dated May 2024 and August 2024, indicated there was no solution temperature recorded when testing the sanitizer concentration.
A review of the facility's chemical manufacturer's guidelines titled Sink and Surface Cleaner Sanitizer not dated, indicated Sink and Surface Test Strips. Measurement can be taken at any temperature above 65°F.
A review of the facility's P&P dated Cleaning and Sanitation Solution dated 1/29/2024 indicated Policy: The dietary department is responsible for following the manufacturer's guidelines for cleaning and sanitation solution concentration and use, as well as proper use of buckets. II. Red buckets will be used for sanitizer solution. A. Test concentration range of sanitizer solution prior to use and adhere to minimum water temperature.
i. During concurrent interview with DS and review of cooling log in 8/6/2024 at 1:30 p.m. DS stated the buckwheat was made from scratch on 8/4/2024 and was cooled following the cooling process. DS stated the process of cooling were as followed:
After cooking the food, temperature is recorded on the cooling log.
Temperature of the food needed to go down in the refrigerator at 70°F in two (2) hours. If it did not go down to 70°F, the food needed to be thrown away or reheated to 165°F.
Overall cooling process was 6 hours. Four (4) hours to go down from 70°F to 40°F.
DS stated the weekend cook did not record the initial time and temperature of the buckwheat as it was not reflected in the cooling log. DS stated it was important to monitor time and temperature when cooling of foods to prevent foodborne illnesses and temperature abuse. DS stated diarrhea and foodborne illnesses were the potential outcome for the residents.
A review of facility's P&P titled Food Temperatures - Danger Zone dated 1/29/2024 indicated 6. Cool hot foods from 135°F (57°F) to 70°F (21°C) within 2 hours, and from 70°F (21°C) to 41°F (5°C) or below within an additional 4 hours. 8. Monitoring and Record-keeping. Record temperatures during receiving, storage, cooking, holding, cooling, and reheating in designated logs. Procedure: 7. Monitoring and Documentation: Conduct temperature checks at each critical point: receiving, storage, preparation, cooking, holding, cooling, and reheating. Maintain accurate and up-to-date logs for review during inspections.
A review of Food Code 2017 indicated 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C (135°F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54°C (130°F) or above.
A review of Food Code 2017 indicated 3-501.14 Cooked time/temperature for safety shall be cooled (1) Within 2 hours from 57°F (135°F) to 21 °C (70°F); and (2) Within a total of 6 hours from 57°F (135°F) to 5°C (41°F) or less.

Based on observation, interview, and record review the facility failed to:
1.Label one Latanoprost (a medication used to treat glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle for Resident 122, with an open date in accordance with facility requirements and manufacturer's requirements in one of four inspected medication carts (Medication Cart North Middle East.)
2. Dedicate a refrigerator for medication storage only for one of six inspected medication refrigerators (Medication Refrigerator in ADMIN office hallway.)
3. Remove and discard 7 unopened expired Afluria (an influenza [also known as flu] vaccine [a substance that provides immunity to an infectious disease] used to provide protection against the flu vaccine for the 2023 -2024 flu season) vials, one opened expired Afluria vial, 4 unopened expired Procrit (a medication used to treat anemia [having low red blood cells) vials, and 15 expired COVID-19 prefilled (already loaded with the medication) syringes from facility stock use, in accordance with manufacturer's requirements in one of six inspected medication refrigerators (Medication Refrigerator in Administrator [ADMIN] office.)
4. Remove and discard 3 unopened expired Procrit vials for Resident 335 and 336 from use, in accordance with manufacturer's requirements in one of six inspected medication refrigerators (Medication Refrigerator in Administrator [ADMIN] office.)
These deficient practices increased the risk that Residents 122, 335, 336 and all other residents in the facility could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications such as worsening glaucoma, anemia, and infections potentially requiring hospitalization.
During an observation on 8/5/2024 at 11:26 PM, in Medication Cart North Middle East, in the presence of Licensed Vocational Nurse (LVN) 7, the following medication was found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, expired and not discarded, or stored and labeled contrary to facility policies:
1. One open Latanoprost eye drop bottle for Resident 122 was found stored at room temperature and not labeled with a date on which storage at room temperature began.
According to the manufacturer's product storage and labeling, opened Latanoprost bottles may be stored at room temperature up to 77 degrees Fahrenheit and used or discarded within 6 weeks of opening/use.
During a concurrent interview with LVN 7, LVN 7 stated that the Latanoprost eye drop bottle was not labeled with a date when use or storage at room temperature began and should not be used for Resident 122. LVN 7 stated that eye drop medications were usually good for 28 days after opening the bottle. LVN 7 stated LVN 7 was unable to identify the expiration date without knowing the date when use began, and considering pharmacy filled the medication on 6/20/2024 the bottle was considered expired. LVN 7 stated that using expired eye drop medication will not be effective in treating Resident 122's glaucoma and potentially cause eye infections since the dropper of the bottle was no longer sterile beyond the 28-day expiration date. LVN 7 stated the Latanoprost bottle for Resident 122 needed to be immediately removed from the medication cart and replaced with a new one from pharmacy.
During an observation, on 8/6/2024 at 11:55 AM, in the presence of Nurse Consultant (NC) and Director of Nursing (DON), in the Medication Refrigerator located in the ADMIN office hallway, the refrigerator was stored with different food items.
During a concurrent interview in the presence of NC and DON, the DON stated the medication refrigerator was currently being used for staff food storage, even though staff have a dedicated food refrigerator in staff break room, and that during influenza season was used for storing influenza vaccines only. The DON stated that DON understands the risk associated with mixing medications and food together in error.
During an observation, on 8/6/2024 at 12 PM, in the presence of ADMIN, NC and DON, in the Medication Refrigerator located in the ADMIN's office, the following medications were found expired and not discarded and stored contrary to facility policies:
1. Seven (7) unopened vials of Afluria 2023-2024 formula vaccines for facility stock were found stored in the refrigerator.
According to the manufacturer expiration dating, the Afluria vials should be stored in the refrigerator and discarded by 6/30/2024.
2. One (1) opened vial of Afluria 2023-2024 formula vaccine for facility stock was found stored in the refrigerator with and labeled with a date indicating that use of the vial began on 11/15/2023.
According to the manufacturer storage and labeling once the Afluria multi-use vial was opened to discard within 28 days.
3. Fifteen (15) unopened prefilled syringes of COVID-19 vaccine for facility stock were found stored in the refrigerator.
According to the manufacturer expiration dating, the Afluria vials should be stored in the refrigerator and discarded by 7/1/2024.
4. Four (4) unopened vials of Procrit for facility stock were found stored in the refrigerator.
According to the manufacturer expiration dating, the Procrit vials should be stored in the refrigerator and discarded by 1/2024.
5. Two (2) unopened vials of Procrit for Resident 335 were found stored in the refrigerator.
According to the manufacturer expiration dating, the Procrit vials should be stored in the refrigerator and discarded by 12/2023.
6. One (1) unopened vial of Procrit for Resident 336 was found stored in the refrigerator.
According to the manufacturer expiration dating, the Procrit vials should be stored in the refrigerator and discarded by 1/2024.
During a concurrent interview in the presence of NC and DON, the DON stated the above medications in the ADMIN office refrigerator were expired and needed to be removed from the refrigerator and discarded to prevent accidental use. The DON stated administering expired vaccines and medications to residents in the facility will not provide protection from the flu, COVID-19 and not help treat anemia. The DON stated several licensed staff failed to remove expired medications from the refrigerator which can potentially lead to the accidental use of expired medications and harm residents.
During an interview on 8/8/2024 at 10:55 AM, in the presence of Administrator (ADMIN), the Director of Nursing (DON) stated that the facility failed to label the Latanoprost eye drop bottle for Resident 122 with a date indicating when use began. DON stated that opened multi-use (used more than once) medications, such as eye drops, should be labeled with a date when use began to know when they should be disposed of, otherwise these medications are considered expired and should be removed from the medication cart. The DON stated this failure can potentially lead to the administration of expired Latanoprost to Resident 122, which will not be effective in treating the resident's Glaucoma and causing eye infections due to the compromised sterility of the medication.
Review of the facility's policy and procedures (P&P), titled Procedures for All Medications, dated 1/29/2024, the P&P indicated To administer medications in a safe and effective manner.
E. Check expiation date on package/container. When opening a multi-dose container, place the date on the container.
Review of facility's guide, titled Medication Storage, dated 5/3/2023, the guide indicated the following:
Xalatan (Latanoprost) stored at room temperature opened has an expiration date of 42 days.
Review of the facility's P&P, titled Storage of Medications, dated 1/29/2024, the P&P indicated: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.
K. Medications requiring refrigeration or temperature between 36 to 46 Fahrenheit are kept in a refrigerator .
L. Refrigerated medications are kept in closed and labeled container, with internal and external medications separated and separate from fruit juices, applesauce, and other foods in administering medications. Other foods such as employee lunches and activity department refreshments are not stored in this refrigerator.
M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.
Review of the facility's P&P, titled Discontinued Medications, dated 1/29/2024, the P&P indicated: When medications are expired, .the medications are marked as discontinued or stored in a separate location and later destroyed or donated .
A. If a medication expires, .the discontinued drug container shall be marked or otherwise identified or shall be stored in a separate location designated solely for this purpose.
B. Medications are removed from the medication cart or storage area prior to expiration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 211's admission Record, the admission record indicated the facility admitted the resident on 8/22/2022, with diagnoses that included type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (a type of kidney disease caused by diabetes) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks).
During a review of Resident 211's History and Physical (H&P), dated 8/11/2023, indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 211's Order Summary Report, indicated an order for:
-7/17/2024 Novolin N FlexPen Subcutaneous Suspension Pen-injector 100 unit (the amount of insulin required to reduce the blood glucose)/milliliters (ml, a unit of volume) (Insulin NPH Human [Isophane]). Inject 4 unit subcutaneously in the morning related to type 2 diabetes mellitus with diabetic chronic kidney disease.
-6/14/2024 Novolog Injection Solution 100 unit/ml (Insulin Aspart). Inject as per sliding scale (varies the dose of insulin based on blood glucose level): if 150-200=2 unit; 201-250=4 unit; 251-300=6 unit; 301-350=8 unit; 351-400=10 unit, subcutaneously before meals related to type 2 diabetes mellitus with diabetic chronic kidney disease. Call MD if fingerstick (a procedure in which a finger is pricked with a lancet to obtain a small quantity of capillary blood for testing) blood sugar (BS) is above 400 or below.
During a review of Medication Administration Record of insulin for 6/2024 to 7/2024 indicated Novolog insulin was administered on as follows on the following dates:
6/22/2024 at 7 am on (20) the left and above the level of umbilicus (navel).
6/22/2024 at 11:30 am on (20) the left and above the level of umbilicus.
7/7/2024 at 7 am on (21) right and below level of umbilicus.
7/7/2024 at 11:30 am on (21) right and below level of umbilicus.
7/10/2024 at 7 am on (22) left and below level of umbilicus.
7/10/2024 at 11:30 am on (22) left and below level of umbilicus.
7/19/2024 at 11:30 am on (19) to right and above umbilicus.
7/20/2024 at 7 am on (19) to right and above umbilicus.
7/22/2024 at 11:30 am on (21) right and below level of umbilicus.
7/22/2024 at 5 pm on (21) right and below level of umbilicus.
7/24/2024 at 5 pm on (12) left upper arm.
7/25/2024 at 7 am on (12) left upper arm.
7/29/2024 at 7 am on (21) right and below level of umbilicus.
7/29/2024 at 11:30 am (21) right and below level of umbilicus.
During a concurrent interview and record review on 8/8/2024, at 12:04 p.m., with Registered Nurse 1 (RN 1), Resident 211's Order Summary Report and the Medication Administration Record for 6/2024 to 7/2024 was reviewed. RN 1 stated there was an order for Novolin insulin for the resident and the MAR from 6/2024 to 7/2024 indicated there were multiple instances where the insulin administration sites were not rotated by the licensed nurses. RN 1 stated the failure of the licensed nurse to rotate insulin administration sites could cause skin irritations such as abscess, necrosis, and lipodystrophy. RN 1 stated not rotating insulin administration sites was considered a medication error.
During an interview on 8/9/2024, at 5:03 p.m., with the Director of Nursing (DON), the DON stated it was common knowledge for licensed nurses to rotate insulin administration sites to prevent tenderness, discomfort, and lipodystrophy to the sites that was frequently administered with insulin. The DON stated not rotating insulin administration sites was considered a medication error.
During a review of the facility's recent policy and procedure titled, Medication- Errors, last reviewed on 1/29/2024, the policy indicated to ensure the prompt reporting of errors in the administration of medications and treatments to residents. Definition- The preparation or administration of medications or biologicals which is not in accordance with:
A. The prescriber's order.
B. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological.
C. Accepted professional standards and principles which apply to professionals providing services.
i. Accepted professional standards and principles include the various practice regulations in the state, and currently commonly accepted health standards established by national organizations, boards, and councils.
During a review of the facility provided undated, Novolog Manufacturer's Recommendation for Novolog (insulin aspart) injection 100 U/ml is an insulin analog indicated to improve glycemic control in adults and pediatric patients with diabetes mellitus, indicated repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis have been reported to result in hyperglycemia; and a sudden change in the injection site (to an unaffected area) has been reported to result in hypoglycemia. Advise patients who have repeatedly injected into areas of lipodystrophy or localized cutaneous amyloidosis to change the injection site to unaffected areas and closely monitor for hypoglycemia.
Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two (2) out of 2 sampled residents (Residents 43, and 211) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.
These deficient practices had the potential to result in adverse effects (unwanted, unintended result) and complications of same site subcutaneous administration such as insulin induced lipodystrophy (This complication occurs because of repeated injections at the same site. An abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).
Cross Reference F658
Findings:
a. During a review of Resident 43's admission Record, the admission record indicated the facility admitted Resident 43 on 3/17/2021 and readmitted on [DATE] with diagnoses that included congestive heart failure (CHF - a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply), type two diabetes mellitus (DM 2 - a long term condition that causes the level of sugar [glucose] in the blood to become too high), and aphasia (a language disorder that makes it hard for a person to read, write, and say what you mean to say).
During a review of Resident 43's Order Summary Report indicated the following physician's order dated 6/13/2024:
-Insulin lispro-aabc injection solution 100 unit per milliliter (unit/ml - a unit of measurement). Inject as per sliding scale: if 150-200 = 2 unit; 201-250 = 4 unit; 251-300 = 6 unit; 301-350 = 8 unit; 351-400 = 10 unit, SQ before meals related to DM 2. Call physician if fingerstick blood sugar is above 400 or below 70.
During a review of Resident 43's History and Physical (H&P) dated 6/14/2024, the H & P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 211's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/8/2024, indicated the resident had rarely to never had the ability to make self-understood and sometimes understand others. The MDS indicated the resident had highly impaired vision and was on a high-risk drug class hypoglycemic (occurs when the level of glucose in the blood drops below normal) medication insulin.
During a review of Resident 43's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/1/2024 indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating, partial to moderate assistance with walking, was dependent with toileting, bathing, and lower body dressing and required substantial to maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 43 received insulin.
During a review of Resident 43's Medication Administration Record (MAR) from 6/2024 to 7/2024, indicated insulin lispro injection solution was administered as follows on the following dates:
06/23/24 11:30 subcutaneously Right Upper Arm (RUA)
06/23/24 17:00 subcutaneously - RUA
06/25/24 11:30 subcutaneously Left Upper Arm (LUA)
06/25/24 17:00 subcutaneously - LUA
06/27/24 17:00 subcutaneously - Left Deltoid (LD)
06/28/24 07:00 subcutaneously - LD
06/30/24 07:00 subcutaneously - RUA
06/30/24 11:30 subcutaneously - RUA
07/02/24 11:30 subcutaneously - RUA
07/02/24 17:00 subcutaneously - RUA
07/03/24 11:30 subcutaneously - LUA
07/03/24 17:00 subcutaneously - LUA
07/10/24 11:30 subcutaneously - LUA
07/10/24 17:00 subcutaneously - LUA
07/13/24 11:30 subcutaneously - RUA
07/13/24 17:00 subcutaneously - RUA
07/19/24 17:00 subcutaneously - RUA
07/20/24 17:00 subcutaneously - RUA
07/20/24 11:30 subcutaneously - LUA
07/20/24 17:00 subcutaneously - LUA
07/23/24 11:30 subcutaneously - RUA
07/23/24 17:00 subcutaneously - RUA
07/24/24 17:00 subcutaneously - RUA
07/28/24 11:30 subcutaneously - LUA
07/28/24 17:00 subcutaneously - LUA
07/29/24 07:00 subcutaneously - Right & Above Umbilicus
07/29/24 11:30 subcutaneously - Right & Above Umbilicus
07/30/24 11:30 subcutaneously - Right & Below Level of Umbilicus
07/30/24 17:00 subcutaneously - Right & Below Level of Umbilicus
During a concurrent interview and record review on 8/8/24 at 12:04 p.m., Resident 43's MAR for 6/2024 and 7/2024 was reviewed with Registered Nurse 1 (RN 1). RN 1 verified the insulin administration sites were not rotated by the licensed nurses. RN 1 stated the insulin administration sites should have been rotated as the residents could develop irritation on the site, possibly abscess, and lipodystrophy. RN 1 stated it was a standard of practice and considers not rotating insulin administration site as a medication error.
During a review of the facility's policy and procedure titled, Medication- Errors, last reviewed on 1/29/2024, indicated a medication error is the preparation or administration of medications or biologicals which is not in accordance with:
-The prescriber's order.
-Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; and/or
-Accepted professional standards and principles which apply to professionals providing services.
-Accepted professional standards and principles include the various practice regulations in the state, and currently commonly accepted health standards established by national organizations, boards, and councils.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 79) drug regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure by failing to
provide a detailed clinical rationale for continuing Trazadone (a psychotropic medication used for depression [also referred to as antidepressant] and insomnia [inability to sleep]) as originally prescribed on 6/18/2023 for Resident 79.
These deficient practices had the potential to place Resident 79 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic medications, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status.
Cross refernec to F756
Findings:
During a review of Resident 79's admission Record (a document containing demographic and diagnostic information,) dated 8/7/2024, the admission Record indicated Resident 79 was originally admitted to the facility on [DATE] with a diagnosis including depression (a health condition that causes constant feeling of sadness and loss of interest in activities that one would normally enjoy, and often associated with insomnia [inability to sleep]).
During a review of Resident 79's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 5/29/2024, indicated Resident 79 did not have symptoms of little interest or pleasure in doing things, felling down, depressed, or hopeless. The MDS indicated Resident 79 was not marked for having trouble falling or staying asleep. Resident 79's MDS indicated Resident 79 received antidepressant medication on a routine basis.
During a review of Resident 79's Order Summary Report, dated 8/8/2024, the report indicated Resident 79 was prescribed Trazadone (a psychotropic [any medication capable of affecting the mind, emotions, and behavior] medication used for depression and insomnia) 75 milligram ([mg] - a unit of measure of mass) tablet to give by mouth at bedtime for depression manifested by constant health complaints and insomnia, starting 6/18/2023.
During a review of the Medication Regimen Review (MRR) note by the Consultant Pharmacist (CP) for Resident 79 on 8/7/2024, titled Note to Attending Physician/Prescriber and dated 7/4/2024, the note stated This resident continues on Trazadone 75 mg qhs (at bedtime) from 6/18/2023. The Federal nursing regulations require that a gradual dose reduction ([GDR] - lowering dose, frequency or discontinuing medication]) be attempted in two separate quarters (with at least one month between attempts) within the first year in which a resident receives psychopharmacological medication. Please assess if clinically appropriate at this time to consider a GDR. If dose to continue, please include documentation describing a dose reduction as clinically not indicated in your progress notes or on this form. Thank you. The document did not contain a response from a physician and was not signed or dated by a physician.
During a review of Resident 79's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record,) for July 2024, the MAR indicated Resident 79 had no episodes of insomnia documented between 7/1/2024 and 7/31/2024.
During a review of Resident 79's Psychiatry Progress Note, dated 7/29/2024, the note indicated that staff reports resident having infrequent behaviors but are stable on current dose of Trazadone. The note indicated to continue Trazadone 75 mg qhs, its clinically contraindicated (not recommended) to lower or discontinue medication at this time.
During an interview and concurrent record review of Resident 79's clinical record, MDS, MRR, MAR, Psychiatric notes on 8/7/2024 at 3:10 PM, with Director of Nursing (DON,) the DON stated that Resident 79 did not have documented behaviors of insomnia for July 2024. The DON stated based on Resident 79 not exhibiting behaviors of insomnia for July 2024, there should have been an attempt for a GDR and/or documentation in the psychiatry note, dated 7/29/24, indicating a clinical rationale for continuing the Trazadone at the originally prescribed dose or what clinical contraindications presented for not considering a GDR at that time. The DON stated the DON was unable to find a clinical rationale to continue the Trazodone 75 mg qhs. The DON stated it was important to properly assess the absence of behaviors and consider GDR to ensure Resident 79 was receiving treatment that was optimal for Resident 79's condition and to maintain their highest level of well-being. The DON stated as a result, Resident 79 was placed at risk of continuing unnecessary psychotropic medications that could result in adverse consequences and side effects, negatively impacting the resident's well-being. The DON stated the facility and physician failed to document a clinical rationale for continuing the Trazadone as originally prescribed for depression manifested by insomnia on 6/18/2023, for Resident 79.
During a review of the facility's Policy and Procedures (P&P,) titled Behavioral - Management, dated 11/1/2017, the P&P indicated: To ensure that Facility Staff performs an appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions before and after the resident begins taking psychotherapeutic medications.
E. Ensuring pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated.
During a review of the facility's P&P titled Psychotherapeutic Drug Management, dated 5/17/2024, the P&P indicated the following:
Purpose
II. To help promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being,
III. To ensure the resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed condition(s).
V. To ensure clinically significant adverse consequences are minimized.
Policy
II. The Facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits.
III. Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation.
Procedure
I. K. The Attending Physician/LHP will respond to any irregularities reported by the pharmacist .by reviewing the irregularities and documenting in the resident's medical record that the irregularity has been reviewed, and what, if any, action has been taken to address it.
A. If no action has been taken, the Attending Physician/LHP must document his/her rationale.
IX. A. Goals of GDR are to achieve the lowest effective dose; to discontinue the mediations that are no longer benefit the resident; and to minimize exposure to increased risk of adverse consequences.
B. GDR is indicated when the resident's clinical condition has improved or stabilized or the underlying causes of symptoms have resolved
X. A. During the first year of receiving an antipsychotic or other psychopharmacological medication, at least one attempt at GDR or dose tapering is attempted.
B. A second attempt, in a subsequent quarter the same year (12-month period) unless the first attempt demonstrated that GDR or tapering was clinically contraindicated.
C. After the first year, GDR or tapering should be attempted once a year.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Consultant Pharmacist's (CP) recommendation for July 2024's Medication Regimen Review (MRR) (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) note was reviewed, addressed or carried out as per facility policy and procedure for one of five sampled residents (Resident 79).
The deficient practice had the potential to result in the increased risk of receiving medication that was not optimal for Resident 79's medical condition, that would not maintain the resident's highest level of physical, mental and psychosocial well-being and/or increase the risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) from the medication therapy.
Cross reference to F758
Findings:
During a review of Resident 79's admission Record (a document containing demographic and diagnostic information,) dated 8/7/2024, the admission Record indicated Resident 79 was originally admitted to the facility on [DATE], with a diagnosis including depression (a health condition that causes constant feeling of sadness and loss of interest in activities that one would normally enjoy, and often associated with insomnia [inability to sleep]).
During a review of Resident 79's Order Summary Report, dated 8/8/2024, the report indicated Resident 79 was prescribed Trazadone (a psychotropic [any medication capable of affecting the mind, emotions, and behavior] medication used for depression and insomnia) 75 milligram ([mg] - a unit of measure of mass) tablet by mouth at bedtime for depression manifested by constant health complaints and insomnia, starting 6/18/2023.
During a review of Resident 79's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record,) for July 2024, the MAR indicated Resident 79 had no episodes of insomnia documented between 7/1/2024 and 7/31/2024.
During a review of the MRR note by the CP for Resident 79 on 8/7/2024, titled Note to Attending Physician/Prescriber and dated 7/4/2024, the note stated This resident continues on Trazadone 75mg qhs (at bedtime) from 6/18/2023. The Federal nursing regulations require that a gradual dose reduction (GDR) be attempted in two separate quarters (with at least one month between attempts) within the first year in which a resident receives psychopharmacological medication. Please assess if clinically appropriate at this time to consider a GDR. If dose to continue, please include documentation describing a dose reduction as clinically not indicated in your progress notes or on this form. Thank you. The document did not contain a response from a physician and was not signed or dated by a physician.
During an interview on 8/7/2024 at 3:10 PM, with the DON, the DON stated per facility policy the MRR irregularity notes by the CP needed to be reviewed and documented within 30 days of the written report. The DON stated it was important to review the irregularities timely to ensure residents were receiving treatment that was optimal for their condition and to maintain their highest level of well-being. The DON stated the facility and physician failed to timely review and address the CP MRR note written on 7/4/2024 for the Trazadone 75 mg qhs identified irregularity and failed to document a clinical rationale for continuing the Trazadone as originally prescribed for depression manifested by insomnia on 6/18/2023, for Resident 79.
A Review of the facility policy and procedure (P&P) titled Drug Regimen Review, dated 11/1/2017, the policy indicated that The intent is that the facility maintains the resident's highest practicable level of physical, mental and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing (DON).
The policy further indicates the pharmacist will review each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications.
The pharmacist will report any irregularities to the attending physician and the facility's medical director and DON, and these reports must be acted upon.
Procedure
II. The pharmacist performing the DRR will review the resident's medical record to appropriately monitor the medication regimen and verify the medication each resident is taking is clinically indicated.
III. B. The consulting Pharmacist will report any irregularities such as unnecessary drugs (which include but are not limited to excessive dosage, excessive duration, inadequate monitoring, inadequate indications for use or adverse consequences of use) to the Facility's Medical Director, DON, and the Attending Physician.
i. Irregularities must be addressed in a separate, written report. The report will include the resident's name, the relevant drug, and the irregularity the pharmacist identified.
IV. The Attending physician will respond to any irregularities reported by the pharmacist by reviewing the irregularities and documenting in the resident's medical record that the irregularity has been reviewed, and what, if any, action has been taken to address it.
A. If not action has been taken, the attending physician must document his/her rationale.
B. Documentation by the Attending Physician must occur within 30 days of issuance of the pharmacist's report, unless the irregularity is an emergent issue requiring immediate action.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 227's admission Record indicated the facility admitted the resident to the facility on [DATE], with diagnoses including glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called optic nerve) and dysphagia (difficulty swallowing).
During a review of Resident 227's Care Plan titled, Family Education related to resident's safe feeding/eating precautions, initiated on 5/16/2024, indicated to instruct visitors that either feeding or resident eating with visitor should be under close supervision of staff.
During a review of Resident 227's H&P, dated 5/22/2024, indicated the resident had the capacity to understand and make decisions.
During a review of Resident 227's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision and had intact cognition (gaining of knowledge and understanding).
During a review of Resident 227's Order Summary Report, the report did not indicate a physician's order for Areds 2.
During a review of Resident 227's Interdisciplinary Team (IDT - a group of people from different disciplines or fields of knowledge who work together to address a common problem or goal), dated 6/26/2024, indicated the resident was alert and oriented times three (alert and oriented to person, place, and time). Knows his vitamins and supplements, wanted to keep his medications at the bedside.
During an observation on 8/6/2024, at 8:45 a.m., while inside Resident 227's room, Resident 227 was taking one tablet from a medication bottle labeled Areds 2.
During a concurrent interview and record review on 8/6/2024, at 8:47 a.m., with LVN 3, Resident 227's Order Summary Report and Medication Administration Record (MAR - a record of mediations administered to residents) were reviewed. LVN 3 stated there was no order for the resident to self-administer medications and that it was okay to keep the medications at the bedside on the Order Summary Report. LVN 3 also stated there was no order for the medication Areds 2. LVN 3 stated she does not know how the bottle of Areds 2 was left at the resident's bedside. LVN 3 stated it must be the family member that gave the medication Areds 2 to the resident.
During a concurrent interview and record review on 8/6/2024, at 9:05 a.m., with the Minimum Data Set Coordinator (MDSC), the Order Summary Report, Assessment for Self-Administration of Medication, and IDTs done for the resident was reviewed. The MDSC stated there was no order for Areds 2 and that it was okay to self-Administer medications on the Order Summary Report. The MDSC also stated there was no Medication Self-Administration Assessment done on admission for the resident. The MDSC confirmed there was a desire from the resident to keep supplements and vitamins at the bedside of the resident during an Interdisciplinary done on 6/26/2024, and they failed to assess the resident for self-administration of medications. The MDSC stated it was important to assess the resident for their ability to self-administer their medications to honor the resident's rights. The MDSC stated after assessing the resident for their ability to self-administer medication they should get an order from the physician for the resident to self-administer medication to ensure safe use.
During an interview on 8/9/2024, at 4:52 p.m., with the DON, the DON stated a self-administration medication assessment should be done on admission. The DON stated they should honor the resident's right to self-administer medications. The DON stated the resident was a researcher and was alert and oriented very much capable of taking his own medications. The DON stated the failure of the staff to do an assessment for medication self-administration for the resident deprived the resident of his right to self-determination and the failure of the staff to ensure there was an order for the medication Areds 2 had predisposed the resident to taking unnecessary medications and the adverse effect of the medication that can cause harm to the resident.
During a review of the facility's recent P&P titled, Physician Orders, last reviewed on 1/29/2024, indicated the purpose of the policy was to ensure all physician orders are complete and accurate. Medication orders will include the following:
A. Name of the medication;
B. Dosage;
C. Frequency; and
D. Duration of order
E. The route and the condition/diagnosis for which the medication is ordered, if applicable.
Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline.
During a review of the facility's recent P&P titled, Medication- Self Administration, last reviewed on 1/29/2024, indicated Residents who request to perform medication self-administration will be assessed for capacity. During the admission process, residents will be asked if they wish to self-administer medications. Those residents who wish to self-administer medications will be assessed during the admission process to ensure they have the necessary knowledge and skill(s) to safely self-administer medications.
A. Additional assessments will be completed at least quarterly based on OBRA timeframes.
If the resident is assessed as clinically appropriate for medication self-administration, by the IDT, the Licensed Nurse obtains a physician's order for self-administration of selected medications.
A. The resident's record should contain documentation that demonstrates that he/she was part of the IDT process in determining whether self-administration is safe and appropriate.
The IDT develops and implements a care plan for medication self-administration. The care plan will identify:
i. Where the medications are stored;
ii. Education for resident/family regarding medication self-administration process; specific medication information and safe, effective use of medications;
a. Obtaining medication;
b. Administering medication according to physician order;
iii. How Licensed Nurses will validate that medications are taken as ordered by the attending physician; and;
iv. How non-compliance and/or refusal to take medications will be managed.
3. During an observation on 8/5/2024 at 11:26 AM, with LVN 7, of Medication Cart North Middle East, there was a discrepancy in the count between the Controlled Drug Record accountability log and the amount of medication remaining in the medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following residents:
a. One dose of clonazepam (a CM used for anxiety) 0.25 milligram ([mg] - a unit of measure of mass) tablet was missing from the medication bubble pack compared to the count indicated on the Controlled Drug Record accountability log for Resident 25. The Controlled Drug Record accountability log for clonazepam indicated the medication bubble pack should have contained a total of 11 clonazepam 0.25 mg tablets, after the last administration of clonazepam 0.25 mg tablet documented/signed-off on 8/4/2024 at 9 AM, however the medication bottle contained 10 clonazepam 0.25 mg tablets and contained no other documentation of subsequent administrations.
b. One dose of diphenoxylate with atropine (a combination CM used for functional diarrhea [where 75% of stools are mushy and watery) 2.5/0.025 mg tablet was missing from the medication bubble pack compared to the count indicated on the Controlled Drug Record accountability log for Resident 30. The Controlled Drug Record accountability log for diphenoxylate with atropine indicated the medication bubble pack should have contained a total of 10 diphenoxylate with atropine 2.5/0.025 mg tablets, after the last administration of diphenoxylate with atropine 2.5/0.025 mg tablet documented/signed-off on 8/1/2024 at 9 AM, however the medication bottle contained nine (9) diphenoxylate with atropine 2.5/0.025 mg tablets and contained no other documentation of subsequent administrations.
During a concurrent interview, LVN 7 stated LVN 7 administered clonazepam 0.25 mg tablet to Resident 25 and diphenoxylate with atropine 2.5/0.025 mg tablet to Resident 30 that morning at 9 AM and forgot to sign the Controlled Drug Record accountability logs. LVN 7 stated LVN 7 failed to follow the facility's policy of signing each CM dose on the Controlled Drug Record accountability log after preparing the dose for the resident. LVN 7 stated LVN 7 understood it was important to sign each dose once administered to ensure accountability, prevention of CM diversion, and accidental exposures of harmful substances to residents. LVN 7 stated if documentation was not accurate then it can lead to medication error if overdosed (administering more than the prescribed dose) leading to stoppage of breathing, hospitalization and possibly death for Resident 25 and 30.
During a record review on 8/6/2024 at 12:04 PM, with the DON, in the presence of the Nurse Consultant (NC), four (4) Controlled Drug Record accountability logs for CM's and 9 Drug Destruction Logs for discontinued medications awaiting final disposition did not contain verifying signatures.
During a concurrent interview, in the presence of the NC, the DON stated the DON was unable to locate the verifying signatures of LVNs and Registered Nurse (RN)/DON on the 4 Controlled Drug Record accountability logs and was unable to locate the verifying signatures of LVNs on the 9 Drug Destruction Logs. The DON stated the DON failed to sign the Controlled Drug Record logs upon receipt of the CM's and the LVN's failed to sign upon handing the CMs to the DON. The DON stated the DON counts the CMs with the LVN's upon receipt of the accountability logs, however there was no consistent process to sign the logs. The DON stated there was also no consistent process of the LVN's signing the Drug Destruction Logs. The DON stated the DON needed to immediately implement a process for including verifying signatures of the LVN's and RN/DON on the Controlled Drug Record and Drug Destruction Logs forms. The DON stated the DON understood the importance of CM accountability to ensure each CM dose was accounted for until disposed. The DON stated it was also important to verify and sign these logs to prevent medication diversions and accidental exposure of harmful substances to residents.
During an interview on 8/8/2024 at 10:55 AM, in the presence of the ADMIN, the DON stated LVN 7 failed to follow facility the policy for documenting the preparation of CM immediately on the Controlled Drug Record accountability log for Resident 25 and 30. The DON stated not documenting the Controlled Drug Record timely can lead to accountability failures, CM diversion, inaccurate clinical records, and accidental use of harmful substances for residents.
During a review of Resident 25's admission Record (a document containing demographic and diagnostic information,) dated 5/21/2024, the admission Record indicated Resident 25 was originally admitted to the facility on [DATE] with a diagnosis including anxiety.
During a review of Resident 25's Order Summary Report, dated 8/1/2024, the report indicated Resident 25 was prescribed clonazepam 0.25 mg to give by mouth twice a day as needed for anxiety manifested by agitation/irritability (yelling/screaming for no apparent reason) and constant pacing in the hallways with repetitive questions where do I go, what do I do, starting 6/6/2024.
During a review of Resident 25' s MAR, for August 2024, the MAR indicated Resident 25 was prescribed clonazepam 0.25 mg twice a day Pro Re Nata ([PRN] - as needed) and was administered a dose on 8/8/2024 at 9 AM.
During a review of Resident 30's admission Record, dated 2/15/2024, the admission Record indicated Resident 30 was originally admitted to the facility on [DATE] with a diagnosis including functional diarrhea.
During a review of Resident 30's Order Summary Report, dated 8/1/2024, the report indicated Resident 30 was prescribed diphenoxylate with atropine 2.5/0.025 mg to give by mouth three times a day for functional diarrhea, starting 11/4/2022.
During a review of Resident 30's MAR for August 2024, the MAR indicated Resident 30 was prescribed diphenoxylate with atropine 2.5/0.025 mg for functional diarrhea three times a day, at 9 AM, 1 PM and 5 PM.
During a review of the P&P titled, Controlled Medications, dated 1/29/2024, the P&P indicated that Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.
A. The Director of Nursing and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications.
C. When a controlled mediation is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR:
a. Date and time of administration
b .Amount administered
c. Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply.
D. When a dose of a CM is removed from the container for administration but refused by the resident or not given for any reason .It must be destroyed according to facility policy in the presence of 2 licensed nurses and the disposal documented on the accountability record .The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules.
During a review of the P&P titled, Controlled Medication Storage, dated 1/29/2024, the P&P indicated that At each shift change, a physical inventory of all CM, including the emergency supply is conducted by 2 licensed nurses and is documented on the CM accountability record.
During a review of the P&P titled, Controlled Medication Disposal, dated 1/29/2024, the P&P indicated that When a dose of a CM is removed from the container for administration but refused by the resident or not given for any reason .It must be destroyed according to facility policy in the presence of two licensed nurses and the disposal documented on the accountability record .The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules and doses of CS wasted for any reason.
During a review of the P&P titled, Medication Destruction, dated 1/29/2024, the P&P indicated that:
C. Non-controlled medication destruction occurs in the presence of two licensed nurses.
D. The nurse(s) and/or pharmacist witnessing the destruction ensure that the following information is entered on the medication disposition form.
6) Signature of witnesses.
Based on observation, interview, and record review, the facility failed to accurately and safely provide or obtain pharmaceutical services, including the provision of routine medications, for two of two sampled residents reviewed during a general observation and investigated under residents' rights (Resident 177 and Resident 227) by failing to:
1. Obtain a physician's order for Resident 177's bottle of saline spray (a mixture of salt and water that is sprayed into the nose) present on the resident's bedside table.
2. Obtain a physician's order for the use of Areds 2 (supplement for age-related macular degeneration [an eye disease that can blur the central vision]) observed at the bed side taken by Resident 227 on 8/6/2024.
These deficient practices had the potential to result in residents taking medications not authorized for administration by the physician, result in unsafe access of medications by residents, staff, and visitors, and can lead to adverse reactions (an undesired effect of a drug or other type of treatment) due to accidental ingestion of unnecessary medication.
Additionally, based on interview and record review, the facility failed to:
3. Account for two doses of Controlled Medications (also known as Controlled Drug and Controlled Substance [CM, CD, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 25 and 30 in one of four inspected medication carts (Medication Cart North Middle East.)
4. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Controlled Drug Record accountability logs for four of four sampled records.
5. Include the verifying signatures of two LVN's on the Drug Destruction Log for nine of nine sampled records.
As a result, these failures resulted in a lack of control and accountability of discontinued medications and CM awaiting final disposition (process of returning and/or destroying unused medications).
These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use), which had the potential to result in the risk that Resident 25 and 30 could have delayed medication treatment and continuity of care due to lack of availability of the CM, and had the potential to result in accidental exposure to harmful medications to all residents, possibly leading to physical and psychosocial harm.
Cross-reference F554, F656, and F689.
Findings:
1. During a review of Resident 177's admission Record, the admission record indicated Resident 177 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than the normal), hyponatremia (a condition that occurs when the level of sodium in the blood is too low), and allergic rhinitis (also known as seasonal allergies, a response causing itchy, watery eyes, sneezing, and other similar symptoms).
During a review Resident 177's History and Physical (H&P), dated 7/2/2023, the H&P indicated Resident 177 had fluctuating capacity to understand and make decisions.
During a review of Resident 177's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/26/2024, the MDS indicated Resident 177 was able to understand and make decisions, required setup assistance with eating, required touching assistance or supervision with walking up to 150 feet (a unit of measure for length), and required moderate assistance to total dependence on facility staff for surface-to-surface transfers, hygiene, bathing or showering, and dressing.
During a review of Resident 177's Order Summary Report, the order summary report did not indicate an order for saline solution nasal spray.
During a concurrent observation and interview with Resident 177, on 8/5/2024, at 10:26 a.m., inside Resident 177's room, Resident 177's bedside table contained saline spray bottle. Resident 177 further stated she uses the saline spray as needed to help her breathe.
During a concurrent interview and record review with LVN 1, on 8/8/2024, at 9:35 a.m., Resident 177's Order Summary Report was reviewed and LVN 1 confirmed Resident 177 did not have an order saline spray. LVN 1 stated without physician orders, the facility cannot administer medications. LVN 1 further stated for any diagnosis and condition, the physician should be aware in order to prescribe medications.
During an interview with Resident 177, on 8/8/2024, at 10:15 a.m., Resident 177 stated when she was admitted to the general acute care hospital (GACH), her physician ordered a saline spray for her. Resident 177 further stated when she returned to the facility from the GACH, she brought the saline spray with her to the facility.
During an interview with the DON, on 8/9/2024, at 8:55 a.m., the DON stated any medications the resident takes, there should be a physician's order. The DON further stated without a physician's order the facility would not be able to give resident's their medication and would not be able to provide care for the residents.
During a review of the facility's policy and procedure (P&P) titled, Medication - Errors, last reviewed on 1/29/2024, the P&P indicated a medication error may be administration or omission of medication which is not currently prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from neglect (the failure to provide healthcare services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of seven residents (Resident 1), who had impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), at high risk for falls, and was diagnosed with parkinsonism (brain conditions that cause slowed movements, stiffness and tremors), by failing to:
1. Provide Resident 1 with the required two-person staff assistance for the use of a mechanical lift (a device used to assist with transfers of individuals who require support for mobility) in weighing Resident 1 on 6/1/2024 at around 11 a.m.
2. Ensure Certified Nursing Assistant 1 (CNA 1) did not leave Resident 1 unattended. On 6/1/2024 at around 11 a.m., CNA 1, by herself, brought a mechanical lift inside Resident 1's room to weigh Resident 1. After CNA 1 placed the sling lift (a fabric device used on lift machines to carry patients in a hammock-type position) underneath Resident 1, CNA 1 left Resident 1 unattended to get another staff to assist in weighing Resident 1 using the mechanical lift.
3. Ensure CNA 1 followed Resident 1's care plan (a summary of a person's health condition and current treatment interventions associated with care needs) on Parkinson's disease (a brain disorder causing uncontrolled movements including shaking or difficulty with balance and coordination), initiated on 7/12/2021, regarding Resident 1's risk for injuries from tremors (condition that includes shaking or trembling movements in one or more parts of the body) and involuntary (not done intentionally) muscle movements, indicating the goal of Resident 1's safety with interventions including observing environment for safety measures and to keep it free from hazards (any source of potential damage, harm or adverse health effects). When CNA 1 brought the mechanical lift at Resident 1's bedside on 6/1/2024 at around 11 a.m., it (mechanical lift) posed as a hazard to Resident 1 when CNA 1 left Resident 1 unattended.
4. Ensure Resident 1 had a physician's order for the use of the mechanical lift to weigh Resident 1 in accordance with the current facility-provided policy and procedure titled, Total Mechanical Lift, revised on 8/1/2014, indicating, The resident will have a physician's order for the use of a mechanical lift.
As a result, on 6/1/2024 at around 11 a.m., Resident 1 sustained a fall resulting in Resident 1's face landing on the base of the mechanical lift device. Resident 1 sustained a skin tear with bleeding on her forehead and bleeding from the left eye and nose. The facility transferred Resident 1 to a General Acute Care Hospital (GACH) for further evaluation where Resident 1 was identified with multiple facial fractures (bone breakage) and facial laceration (skin tear), and ultimately passing away on the afternoon of 6/1/2024 (time not determined) in the GACH due to the extent of injuries related to the fall.
On 6/13/2024 at 2:35 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Director of Nursing (DON), and the Risk Management Registered Nurse (RM 1) due to the facility's failure to ensure Resident 1 was free from neglect under 42 CFR § 483.12 Freedom from Abuse, Neglect, and Exploitation.
On 6/14/2024 at 4:03 p.m., the ADM submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified and confirmed the facility's implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM, DON, and RM [ROOM NUMBER] on 6/14/2024 at 4:50 p.m.
The acceptable IJ Removal Plan included the following summarized actions:
1) On 6/1/2024 the resident (Resident 1) affected by the deficient practice was immediately transferred to the GACH for treatment. Resident 1 passed away at the GACH.
2) On 6/1/2024, CNA 1 who was involved in the incident was immediately suspended pending investigation. On 6/7/2024, the employee was terminated upon the completion of the investigation.
3) On 6/1/2024, the facility's Registered Nurse (RN) Supervisors immediately initiated facility rounds to ensure no other residents were affected by the deficient practices.
4) On 6/3/2024, the interdisciplinary team (IDT - comprises of professionals from various disciplines who work in collaboration to address a patient with multiple needs) conducted a root cause analysis (the process of discovering the root causes of problems to identify appropriate solutions) of the incident and identified the potentially affected populations: those with Parkinson's disease and parkinsonism as well as those requiring the use of a mechanical lift. No other residents were found to be affected.
5. On 6/3/2024 Information Systems Nurse conducted a diagnosis search to identify all residents with diagnosis of Parkinson's Disease or parkinsonism. 17 residents were identified in-house. The list was provided to Care Planner Nurses, who then conducted a chart audit of residents' care plans to ensure that the care plans were comprehensive, individualized, measurable, realistic, and goal oriented. No additional residents were identified as being affected by the deficient practice.
6. On 6/03/2024, the Director of Staff Development (DSD) initiated in-services (training) for all nursing staff pertaining to: safety, use of mechanical lift device (during weighing and transfers), resident environment by keeping free it of hazards (not leaving any equipment in residents' rooms unattended), ensuring presence of two or more (2+) staff when utilizing lifting machines, and following residents' care plans regarding safety.
7. On 6/03/2024, RN Supervisors and Risk Management Nurse conducted rounds (to go around and see the residents) throughout the shift (the time assigned for work) to ensure that all residents who required the use of lift machines were transferred appropriately and safely according to facility's policy and procedures.
8. On 6/5/2024 at 1:42 p.m., the ADM informed all nursing staff (CNAs, Restorative Nursing Assistants [RNAs], and Licensed Nurses) via Carefeed (a communication platform that interfaces with facility's electronic medical software as well as payroll software) that two persons must be present when utilizing a mechanical lift.
9. On 6/13/2024, RN Supervisors on the shift initiated additional in-services for all CNAs and licensed vocational nurses (LVNs) pertaining to safety, use of mechanical lift (during weighing and transfers), and keeping the environment free of hazards (by not leaving any equipment in the residents' rooms unattended), ensuring presence of 2+ staff when utilizing lifting machines, following residents' care plans regarding safety, and ensuring that all residents who utilize mechanical lifts have physician orders for its use (licensed nurses only).
10. On 6/13/2024, the Regional Mentor (a licensed Occupational Therapist) provided additional training to all nursing staff on all shifts to ensure additional reinforcement of procedures, safety protocols, with one-on-one (person-to-person contact) return demonstrations to verify acknowledgment and demonstrate learning. On 6/14/2024, the Regional Mentor initiated training for all nursing and rehab staff utilizing a mechanical lift and a mannequin for hands-on demonstrations and return demonstrations to be completed by every employee in attendance.
11. On 6/13/2024, the Minimum Data Set (MDS) Nurses reviewed all 30 residents' charts (medical records) who required the use of mechanical lifts to ensure presence of physician orders for use of mechanical lifts. No additional residents were identified to be affected by the deficient practice.
12. Effective 6/14/2024, an in-service was provided by an outside entity to all current nursing and rehabilitation staff (staff who assist individuals with a disability and/or illness that is continuing for a long time to attain and maintain maximum function) with mandatory (required) return demonstrations (a teaching strategy that involves the learner demonstrating their understanding or mastery of a skill or concept by performing it themselves) for all those present on the use of mechanical lift and safe transfers. Any nursing staff not on duty will receive training upon returning to work.
13. On 6/14/2024, the CNA, RNA, Licensed Nursing, and rehabilitation team skills checklists were updated to include return demonstrations of transfer skills utilizing mechanical lifts.
14. Updated skills checklists were included in the newly hired packets for all nursing staff and rehabilitation department to ensure proper training and return demonstrations of transfer techniques and use of lift machines is correct prior to staff working with residents. Any staff not on duty will receive training upon return to work.
15. All newly admitted and readmitted residents will be assessed by RN Supervisors upon admission/readmission for dependence on use of mechanical lift for transfers.
16. On 6/13/2024, the DON posted a memo notifying all staff that effective immediately, weighing (monthly and/or weekly) will be done on Mondays during morning shift only, in the presence of Risk Management Nurse, DSD, or RN Supervisors.
17. Effective 6/13/2024 MDS nurses will communicate with the DON, RN Supervisors and PIQI (Performance Improvement, Quality Improvement) Nurses regarding residents who suddenly require the use of a mechanical lift. The DON, RN Supervisors, and/or PIQI Nurses will then obtain an order from the physician for resident transfers with the use of mechanical lift. Resident teaching will be provided to resident and/or responsible party with updated care plan.
18. Effective 6/14/2024, the Administrator, DON, Director of Rehab, Information Systems Nurses, and MDS nurses will discuss the residents who are newly admitted /readmitted and those with any changes of condition who may require mechanical lifting machine for transfers as a part of the daily Stand-Up meeting (short meeting to discuss progress and identify blockers) that takes places Mondays through Fridays. Any changes over the weekend will be discussed on the following business day.
19. The DON and/or designee (during the weekends) will review the Shift Monitoring and Reporting Tool daily to gather data on RN Supervisors' visual audits of staff transfer practices on all shifts to monitor adherence and maintain/sustain compliance. Any identified concerns will be reported to the ADM for resolution as warranted.
20. The PIQI Nurses and/or RN Supervisors (on the weekends) will review the Shift Monitoring and Reporting Tool for compliance and report the findings to the ADM and DON. The ADM and DON will then present findings to the PIQI Committee monthly for the first 3 months and quarterly for at least 8 quarters, until substantial compliance of 100 percent (% - one part in every hundred) is achieved.
Cross Reference with F689.
Findings:
A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 7/9/2021 with diagnoses including parkinsonism, Alzheimer's disease (a brain disorder affecting memory and thinking skills that worsens over time), dementia (loss of thinking or remembering affecting daily life), and age-related osteoporosis (loss of bone mass with increasing risk for bone breakage).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/14/2024, indicated that Resident 1's cognitive skills (ability to think and process information) for daily decision-making tasks were severely impaired. The MDS indicated Resident 1 was dependent (helper does ALL the effort and resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) for eating, oral hygiene (cleaning teeth), toileting hygiene, shower or bathing, upper and lower body dressing, putting on or removing footwear, and personal hygiene needs (combing hair and washing or drying face or hands).
A review of Resident 1's record titled, Progress Notes, dated 6/1/2024 at 12:10 p.m., indicated that Resident 1's assigned CNA (CNA 1) was about to weigh Resident 1 with a lift machine (mechanical lift, a lift device with a weighing scale designed to lift and transfer patients from a bed to a wheelchair or vice versa). CNA 1 then left Resident 1 unattended to ask for assistance from another staff member (unidentified). CNA 1 was then quoted as stating, I was almost at the door when I heard a loud sound. I turned my back, opened the curtain and I saw my resident (Resident 1) on the floor on the legs of the lifting machine. The record indicated CNA 1 noted blood around Resident 1's head.
A review of Resident 1's record titled, Physician's Order Sheet, dated 6/1/2024 at 12 p.m., indicated the order to Transfer the resident to hospital via 911 (a phone number to contact the emergency services) for further treatment and evaluation status post (after) fall.
A Review of Resident 1's GACH Emergency Department (ED) records, dated 6/1/2024 at 7:09 p.m., indicated Resident 1 was noted with a V-shaped laceration (a deep cut or tear on the skin) across the forehead extending to glabella (area of skin between the eyebrows and above the nose) and nasal bridge (the bony part of the nose), a laceration to the right infraorbital (below the right eye) region, and bilateral periorbital ecchymosis (discoloration to the left and right surrounding eye area due to trauma). Per ED records, a Computed Tomography scan (CT scan - medical imaging used to obtain detailed internal images of the body) was done on 6/1/2024 at 12:47 p.m. revealing Resident 1 to have a Type lll Odontoid Fracture (bone breakage located in the neck area of the spine) and multiple maxillofacial (affecting the mouth, face, and jaw) bone fractures resulting in Resident 1 passing away in the ED in the afternoon (time not determined).
On 6/6/2024 at 1:45 p.m., during an interview, CNA 4 stated she had been assigned with Resident 1 in the past, and that Resident 1 was not alert and was fully dependent on staff for care. CNA 4 stated that Resident 1 needed a lift machine for transferring from the bed to the wheelchair, or from the wheelchair back to the bed. CNA 4 stated, For use of a lift machine, it is always with two staff because it's dangerous if done by self. CNA 4 stated, If it is just one person, it's dangerous because the sling (mechanical lift sling, a flexible strap or belt used in the form of a loop to support or raise a weight) moves, or the resident can move. CNA 4 stated, having only one staff cannot hold the lift machine and keep the resident steady on the sling all at the same time.
On 6/6/2024 at 2:47 p.m., during an interview, LVN 1 stated that on 6/1/2024 at approximately between 11 a.m. to 11:20 a.m., LVN 1 was called to Resident 1's room with Resident 1 found on the floor with blood coming out from Resident 1's forehead. LVN 1 stated CNA 1's explanation was CNA 1 placed the mechanical lift sling underneath Resident 1, then CNA 1 left to call for assistance, and that was when Resident 1 rolled off the bed hitting Resident 1's head against the metal legs of the mechanical lift machine.
On 6/6/2024 at 3:22 p.m., during an interview, Registered Nurse 1 (RN 1) stated (on 6/1/2024 at around 11 a.m.) RN 1 rushing to Resident 1's room and saw Resident 1 on the floor with the nursing staff (unidentified) attempting to stop the bleeding from Resident 1's head. RN 1 asked what CNA 1 should have done differently for Resident 1's safety, RN 1 stated, I would not have left the resident (Resident 1) alone.
On 6/7/2024 at 11:26 a.m. during a phone interview, CNA 1 stated on 6/1/2024, at around 11 a.m., CNA 1 went to Resident 1's room to weigh Resident 1. CNA 1 stated she used the mechanical lift machine. CNA 1 stated the rules for using a lift machine is with two staff members. CNA 1 described the procedure as, I put the sling under the resident (while in bed), the sling is what carries the resident. I turned around towards the door, then I heard a loud noise and saw the resident face down on the leg of the lift machine. CNA 1 stated, From the start of this, I would have walked in with the second person already from the beginning so they can assist with the care needed for the resident (Resident 1). CNA 1 was asked if there was a floor mat beside the bed, CNA 1 stated, There was no floor mat where the patient (Resident 1) had landed.
On 6/7/2024 at 3:05 p.m., during a concurrent interview and a review of Resident 1's care plans for fall and functional abilities, RN 4 stated Resident 1's fall risk score was 16. RN 4 stated a score of 10 and above represented high risk for falls. Resident 1's Fall Risk Care Plan initiated on 3/3/2024 indicated the care plan interventions included placing a floor mat next to resident's bed to prevent the resident from injuries. RN 4 stated a floor mat allowed the resident (in general) to fall on the cushion. RN 4 stated, Having a fall is not desirable, but it is better to land on a soft surface than a hard surface. Resident 1's care plan titled, Functional Abilities of Everyday Activities, initiated on 3/3/2024, indicated the intervention was to have two or more persons physical assist for all activities as needed. RN 4 stated the care plan indicated when transferred Resident 1 in and out of bed or wheelchair daily, staff needed to provide two or more persons physical assist when using mechanical lift.
On 6/13/2024 at 11:56 a.m., during a phone interview, CNA 1 stated two staff (in general) are needed to use the lift machine. CNA 1 stated one staff needed to stand next to the lift machine and the other staff needed to attend to the resident. CNA 1 stated, I should not have left the resident (Resident 1) alone and should not have left the machine with the resident.
On 6/14/2024 at 12:04 p.m., during a concurrent interview and record review of Resident 1's physician orders for 6/2024, and Resident 1's Progress Notes, dated 6/1/2024, RN 4 stated that Resident 1 did not have a Physician's Order for use of a mechanical lift device RN 4 stated, I would not have left the resident (Resident 1) alone RN 4 stated I would not leave the lift machine unattended because we always make sure the residents' environment needs to be free from hazards. RN 4 stated this lifting machine for this case was a hazard because it is made of metal. RN 4 stated, because CNA 1 left Resident 1 alone, and because the mechanical lift was left unattended at Resident 1's bedside, Resident 1 ended up having a fall with a sustained injury. A concurrent record review of Resident 1's Progress notes, dated 6/1/2024 at 12:10 p.m., indicated that Resident 1 had a skin tear on the forehead, and was bleeding from the left eye and nose.
On 6/14/2024 at 1:05 p.m., during an interview, LVN 5 stated CNA 1 left Resident 1 alone with the lift machine (mechanical lift) in the room, and CNA 1 was supposed to keep Resident 1 safe. LVN 3 stated, The machine should not be there, and it should have been the floormat as per care plan. LVN 3 stated CNA 1 could lower the bed, replace the floormat, and remove the machine. LVN 3 stated, Because this was not done, the resident fell off the bed. LVN 3 stated Resident 1 sustained a skin tear on the forehead, and bleeding from the left eye and nose.
A review of the current facility-provided policy and procedure titled, Total Mechanical Lift, revised on 8/1/2014, indicated, The resident will have a physician's order for the use of a mechanical lift.
A review of the current facility-provided policy and procedure titled, Resident Rooms and Environment, with last revised date of 11/1/2017, indicated, Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk.
A review of the current facility-provided policy and procedure titled, Care Planning, with last revised date of 10/24/2022, indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The policy indicated, The resident has the right to receive the services and/or items included in the plan of care.
A review of the current facility-provided policy and procedure titled, Safety of Residents, with last revised date of 5/1/2023, indicated the purpose, To provide a safe environment for residents and Facility staff.
A review of the current facility-provided policy and procedure titled, Fall Management Program, with last revised date of 2/29/2024, indicated, It is the policy of this facility to provide the highest quality of care in the safest environment for the residents residing in the facility.
A review of the current facility-provided policy and procedure titled, Abuse Prevention and Prohibition Program, with last revised dated 8/1/2023, indicated, 1. Each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property (illegal use of another person's property of funds). The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of property. 2. The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff The policy also defines neglect as Leaving someone unattended who needs supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of seven residents (Resident 1), who was with impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was high risk for falls, and was diagnosed with parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), was free from accidents, by failing to:
1. Provide Resident 1 with the required two-person staff assistance for the use of a mechanical lift (a device used to assist with transfers of individuals who require support for mobility) in weighing Resident 1 on 6/1/2024 at around 11 a.m.
2. Ensure Certified Nursing Assistant 1 (CNA 1) did not leave Resident 1 unattended. On 6/1/2024 at around 11 a.m., CNA 1, by herself, brought a mechanical lift inside Resident 1's room to weigh Resident 1. After CNA 1 placed the sling lift (a fabric device used on lift machines to carry patients in a hammock-type position) underneath Resident 1, CNA 1 left Resident 1 unattended to get another staff to assist in weighing Resident 1 using the mechanical lift.
3. Ensure CNA 1 followed Resident 1's care plan (a summary of a person's health condition and current treatment interventions associated with care needs) on Parkinson's disease (a brain disorder causing uncontrolled movements including shaking or difficulty with balance and coordination), initiated on 7/12/2021, regarding Resident 1's risk for injuries from tremors (condition that includes shaking or trembling movements in one or more parts of the body) and involuntary (not done intentionally) muscle movements, indicating the goal of Resident 1's safety with interventions including observing environment for safety measures and to keep it free from hazards (any source of potential damage, harm or adverse health effects). When CNA 1 brought the mechanical lift at Resident 1's bedside on 6/1/2024 at around 11 a.m., it (mechanical lift) posed as a hazard to Resident 1 when CNA 1 left Resident 1 unattended.
4. Ensure Resident 1 had a physician's order for the use of the mechanical lift to weigh Resident 1 in accordance with the current facility-provided policy and procedure titled, Total Mechanical Lift, revised on 8/1/2014, indicating, The resident will have a physician's order for the use of a mechanical lift.
As a result, on 6/1/2024 at around 11 a.m., Resident 1 sustained a fall resulting in Resident 1's face landing on the base of the mechanical lift device. Resident 1 sustained a skin tear with bleeding on her forehead and bleeding from the left eye and nose. The facility transferred Resident 1 to a General Acute Care Hospital (GACH) for further evaluation where Resident 1 was identified with multiple facial fractures (bone breakage) and facial laceration (skin tear), and ultimately passing away on the afternoon of 6/1/2024 (time not determined) in the GACH due to the extent of injuries related to the fall.
On 6/13/2024 at 2:35 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Director of Nursing (DON), and the Risk Management Registered Nurse (RM 1) due to the facility's failure to ensure Resident 1 was free from accidents under 42 CFR § §483.25 (d) (1) (2) Accidents.
On 6/14/2024 at 4:03 p.m., the ADM submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified and confirmed the facility's implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the in the presence of the ADM, DON, and RM [ROOM NUMBER] on 6/14/2024 at 4:50 p.m.
The acceptable IJ Removal Plan included the following summarized actions:
1) On 6/1/2024 the resident (Resident 1) affected by the deficient practice was immediately transferred to the GACH for treatment. Resident 1 passed away at the GACH.
2) On 6/1/2024, CNA 1 who was involved in the incident was immediately suspended pending investigation. On 6/7/2024, the employee was terminated upon the completion of the investigation.
3) On 6/1/2024, the facility's Registered Nurse (RN) Supervisors immediately initiated facility rounds to ensure no other residents were affected by the deficient practice.
4) On 6/3/2024, the interdisciplinary team (IDT - comprises of professionals from various disciplines who work in collaboration to address a patient with multiple needs) conducted a root cause analysis (the process of discovering the root causes of problems to identify appropriate solutions) of the incident and identified the potentially affected populations: those with Parkinson's disease and parkinsonism as well as those requiring the use of a mechanical lift. No other residents were found to be affected.
5. On 6/3/2024 Information Systems Nurse conducted a diagnosis search to identify all residents with diagnosis of Parkinson's Disease or parkinsonism. 17 residents were identified in-house. The list was provided to Care Planner Nurses, who then conducted a chart audit of residents' care plans to ensure that the care plans are comprehensive, individualized, measurable, realistic, and goal oriented. No additional residents were identified as being affected by the deficient practice.
6. On 6/03/2024, the Director of Staff Development (DSD) initiated in-services (training) for all nursing staff pertaining to: safety, use of mechanical lift device (during weighing and transfers), resident environment by keeping free it of hazards (not leaving any equipment in residents' rooms unattended), ensuring presence of two or more (2+) staff when utilizing lifting machines, and following residents' care plans regarding safety.
7. On 6/03/2024, RN Supervisors and Risk Management Nurse conducted rounds (to go around and see the residents) throughout the shift (the time assigned for work) to ensure that all residents who required the use of lift machines were transferred appropriately and safely according to facility's policy and procedures.
8. On 6/5/2024 at 1:42 p.m., the ADM informed all nursing staff (CNAs, Restorative Nursing Assistants [RNAs], and Licensed Nurses) via Carefeed (a communication platform that interfaces with facility's electronic medical software as well as payroll software) that two persons must be present when utilizing a mechanical lift.
9. On 6/13/2024, RN Supervisors on the shift initiated additional in-services for all CNAs and licensed vocational nurses (LVNs) pertaining to safety, use of mechanical lift (during weighing and transfers), and keeping the environment free of hazards (by not leaving any equipment in the residents' rooms unattended), ensuring presence of 2+ staff when utilizing lifting machines, following residents' care plans regarding safety, and ensuring that all residents who utilize mechanical lifts have physician orders for its use (licensed nurses only).
10. On 6/13/2024, the Regional Mentor (a licensed Occupational Therapist) provided additional training to all nursing staff on all shifts to ensure additional reinforcement of procedures, safety protocols, with one-on-one (person-to-person contact) return demonstrations to verify acknowledgment and demonstrate learning. On 6/14/2024, the Regional Mentor initiated training for all nursing and rehab staff utilizing a mechanical lift and a mannequin for hands-on demonstrations and return demonstrations to be completed by every employee in attendance.
11. On 6/13/2024, the Minimum Data Set (MDS) Nurses reviewed all 30 residents' charts (medical records) who required the use of mechanical lifts to ensure presence of physician orders for use of mechanical lifts. No additional residents were identified to be affected by the deficient practice.
12. Effective 6/14/2024, an in-service was provided by an outside entity to all current nursing and rehabilitation staff (staff who assist individuals with a disability and/or illness that is continuing for a long time to attain and maintain maximum function) with mandatory (required) return demonstrations (a teaching strategy that involves the learner demonstrating their understanding or mastery of a skill or concept by performing it themselves) for all those present on the use of mechanical lift and safe transfers. Any nursing staff not on duty will receive training upon returning to work.
13. On 6/14/2024, the CNA, RNA, Licensed Nursing, and rehabilitation team skills checklists were updated to include return demonstrations of transfer skills utilizing mechanical lifts.
14. Updated skills checklists were included in the newly hired packets for all nursing staff and rehabilitation department to ensure proper training and return demonstrations of transfer techniques and use of lift machines is correct prior to staff working with residents. Any staff not on duty will receive training upon return to work.
15. All newly admitted and readmitted residents will be assessed by RN Supervisors upon admission/readmission for dependence on use of mechanical lift for transfers.
16. On 6/13/2024, the DON posted a memo notifying all staff that effective immediately, weighing (monthly and/or weekly) will be done on Mondays during morning shift only, in the presence of Risk Management Nurse, DSD, or RN Supervisors.
17. Effective 6/13/2024 MDS nurses will communicate with the DON, RN Supervisors and PIQI (Performance Improvement, Quality Improvement) Nurses regarding residents who suddenly require the use of a mechanical lift. The DON, RN Supervisors, and/or PIQI Nurses will then obtain an order from the physician for resident transfers with the use of mechanical lift. Resident teaching will be provided to resident and/or responsible party with updated care plan.
18. Effective 6/14/2024, the Administrator, DON, Director of Rehab, Information Systems Nurses, and MDS nurses will discuss the residents who are newly admitted /readmitted and those with any changes of condition who may require mechanical lifting machine for transfers as a part of the daily Stand-Up meeting (short meeting to discuss progress and identify blockers) that takes places Mondays through Fridays. Any changes over the weekend will be discussed on the following business day.
19. The DON and/or designee (during the weekends) will review the Shift Monitoring and Reporting Tool daily to gather data on RN Supervisors' visual audits of staff transfer practices on all shifts to monitor adherence and maintain/sustain compliance. Any identified concerns will be reported to the ADM for resolution as warranted.
20. The PIQI Nurses and/or RN Supervisors (on the weekends) will review the Shift Monitoring and Reporting Tool for compliance and report the findings to the ADM and DON. The ADM and DON will then present findings to the PIQI Committee monthly for the first 3 months and quarterly for at least 8 quarters, until substantial compliance of 100 percent (% - one part in every hundred) is achieved.
Cross Reference with F600.
Findings:
A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 7/9/2021 with diagnoses including parkinsonism, Alzheimer's disease (a brain disorder affecting memory and thinking skills that worsens over time), dementia (loss of thinking or remembering affecting daily life), and age-related osteoporosis (loss of bone mass with increasing risk for bone breakage).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/14/2024, indicated that Resident 1's cognitive skills (ability to think and process information) for daily decision-making tasks were severely impaired. The MDS indicated Resident 1 was dependent (helper does ALL the effort and resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) for eating, oral hygiene (cleaning teeth), toileting hygiene, shower or bathing, upper and lower body dressing, putting on or removing footwear, and personal hygiene needs (combing hair and washing or drying face or hands).
A review of Resident 1's record titled, Progress Notes, dated 6/1/2024 at 12:10 p.m., indicated that Resident 1's assigned CNA (CNA 1) was about to weigh Resident 1 with a lift machine (mechanical lift, a lift device with a weighing scale designed to lift and transfer patients from a bed to a wheelchair or vice versa). CNA 1 then left Resident 1 unattended to ask for assistance from another staff member (unidentified). CNA 1 was then quoted as stating, I was almost at the door when I heard a loud sound. I turned my back, opened the curtain and I saw my resident (Resident 1) on the floor on the legs of the lifting machine. The record indicated CNA 1 noted blood around Resident 1's head.
A review of Resident 1's record titled, Physician's Order Sheet, dated 6/1/2024 at 12 p.m., indicated the order to Transfer the resident to hospital via 911 (a phone number to contact the emergency services) for further treatment and evaluation status post (after) fall.
A Review of Resident 1's GACH Emergency Department (ED) records, dated 6/1/2024 at 7:09 p.m., indicated Resident 1 was noted with a V-shaped laceration (a deep cut or tear on the skin) across the forehead extending to glabella (area of skin between the eyebrows and above the nose) and nasal bridge (the bony part of the nose), a laceration to the right infraorbital (below the right eye) region, and bilateral periorbital ecchymosis (discoloration to the left and right surrounding eye area due to trauma). Per ED records, a Computed Tomography scan (CT scan - medical imaging used to obtain detailed internal images of the body) was done on 6/1/2024 at 12:47 p.m. revealing Resident 1 to have a Type lll Odontoid Fracture (bone breakage located in the neck area of the spine) and multiple maxillofacial (affecting the mouth, face, and jaw) bone fractures resulting in Resident 1 passing away in the ED in the afternoon (time not determined).
On 6/6/2024 at 1:45 p.m., during an interview, CNA 4 stated she had been assigned with Resident 1 in the past, and that Resident 1 was not alert and was fully dependent on staff for care. CNA 4 stated that Resident 1 needed a lift machine for transferring from the bed to the wheelchair, or from the wheelchair back to the bed. CNA 4 stated, For use of a lift machine, it is always with two staff because it's dangerous if done by self. CNA 4 stated, If it is just one person, it's dangerous because the sling (mechanical lift sling, a flexible strap or belt used in the form of a loop to support or raise a weight) moves, or the resident can move. CNA 4 stated, having only one staff cannot hold the lift machine and keep the resident steady on the sling all at the same time.
On 6/6/2024 at 2:47 p.m., during an interview, LVN 1 stated that on 6/1/2024 at approximately between 11 a.m. to 11:20 a.m., LVN 1 was called to Resident 1's room with Resident 1 found on the floor with blood coming out from Resident 1's forehead. LVN 1 stated CNA 1's explanation was CNA 1 placed the mechanical lift sling underneath Resident 1, then CNA 1 left to call for assistance, and that was when Resident 1 rolled off the bed hitting Resident 1's head against the metal legs of the mechanical lift machine.
On 6/6/2024 at 3:22 p.m., during an interview, Registered Nurse 1 (RN 1) stated (on 6/1/2024 at around 11 a.m.) RN 1 rushing to Resident 1's room and saw Resident 1 on the floor with the nursing staff (unidentified) attempting to stop the bleeding from Resident 1's head. RN 1 asked what CNA 1 should have done differently for Resident 1's safety, RN 1 stated, I would not have left the resident (Resident 1) alone.
On 6/7/2024 at 11:26 a.m. during a phone interview, CNA 1 stated on 6/1/2024, at around 11 a.m., CNA 1 went to Resident 1's room to weigh Resident 1. CNA 1 stated she used the mechanical lift machine. CNA 1 stated the rules for using a lift machine is with two staff members. CNA 1 described the procedure as, I put the sling under the resident (while in bed), the sling is what carries the resident. I turned around towards the door, then I heard a loud noise and saw the resident face down on the leg of the lift machine. CNA 1 stated, From the start of this, I would have walked in with the second person already from the beginning so they can assist with the care needed for the resident (Resident 1). CNA 1 was asked if there was a floor mat beside the bed, CNA 1 stated, There was no floor mat where the patient (Resident 1) had landed.
On 6/7/2024 at 3:05 p.m., during a concurrent interview and a review of Resident 1's care plans for fall and functional abilities, RN 4 stated Resident 1's fall risk score was 16. RN 4 stated a score of 10 and above represented high risk for falls. Resident 1's Fall Risk Care Plan initiated on 3/3/2024 indicated the care plan interventions included placing a floor mat next to resident's bed to prevent the resident from injuries. RN 4 stated a floor mat allowed the resident (in general) to fall on the cushion. RN 4 stated, Having a fall is not desirable, but it is better to land on a soft surface than a hard surface. Resident 1's care plan titled, Functional Abilities of Everyday Activities, initiated on 3/3/2024, indicated the intervention was to have two or more persons physical assist for all activities as needed. RN 4 stated the care plan indicated when transferred Resident 1 in and out of bed or wheelchair daily, staff needed to provide two or more persons physical assist when using mechanical lift.
On 6/13/2024 at 11:56 a.m., during a phone interview, CNA 1 stated two staff (in general) are needed to use the lift machine. CNA 1 stated one staff needed to stand next to the lift machine and the other staff needed to attend to the resident. CNA 1 stated, I should not have left the resident (Resident 1) alone and should not have left the machine with the resident.
On 6/14/2024 at 12:04 p.m., during a concurrent interview and record review of Resident 1's physician orders for 6/2024, and Resident 1's Progress Notes, dated 6/1/2024, RN 4 stated that Resident 1 did not have a Physician's Order for use of a mechanical lift device RN 4 stated, I would not have left the resident (Resident 1) alone RN 4 stated I would not leave the lift machine unattended because we always make sure the residents' environment needs to be free from hazards. RN 4 stated this lifting machine for this case was a hazard because it is made of metal. RN 4 stated, because CNA 1 left Resident 1 alone, and because the mechanical lift was left unattended at Resident 1's bedside, Resident 1 ended up having a fall with a sustained injury. A concurrent record review of Resident 1's Progress notes, dated 6/1/2024 at 12:10 p.m., indicated that Resident 1 had a skin tear on the forehead, and was bleeding from the left eye and nose.
On 6/14/2024 at 1:05 p.m., during an interview, LVN 5 stated CNA 1 left Resident 1 alone with the lift machine (mechanical lift) in the room, and CNA 1 was supposed to keep Resident 1 safe. LVN 3 stated, The machine should not be there, and it should have been the floormat as per care plan. LVN 3 stated CNA 1 could lower the bed, replace the floormat, and remove the machine. LVN 3 stated, Because this was not done, the resident fell off the bed. LVN 3 stated Resident 1 sustained a skin tear on the forehead, and bleeding from the left eye and nose.
A review of the current facility-provided policy and procedure titled, Total Mechanical Lift, revised on 8/1/2014, indicated, The resident will have a physician's order for the use of a mechanical lift.
A review of the current facility-provided policy and procedure titled, Resident Rooms and Environment, with last revised date of 11/1/2017, indicated, Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. This shall include ensuring that residents can receive care and services safely and that the physical layout of the Facility maximizes resident independence and does not pose a safety risk.
A review of the current facility-provided policy and procedure titled, Care Planning, with last revised date of 10/24/2022, indicated, To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The policy indicated, The resident has the right to receive the services and/or items included in the plan of care.
A review of the current facility-provided policy and procedure titled, Safety of Residents, with last revised date of 5/1/2023, indicated the purpose, To provide a safe environment for residents and Facility staff.
A review of the current facility-provided policy and procedure titled, Fall Management Program, with last revised date of 2/29/2024, indicated, It is the policy of this facility to provide the highest quality of care in the safest environment for the residents residing in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of six sampled residents (Resident 3 and Resident 4) were included in the list of residents assisted by a Restorative Nursing Assistant (RNA) during dinner on 6/23/2024.
This deficient practice had the potential to result in Resident 3 and Resident 4 ' s not being assisted during meal and had a potential to negatively impact the residents ' physical, mental, and psychosocial well-being.
Findings:
A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 8/3/2018 with diagnoses that included atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls), Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
A review of Resident 3 ' s History and Physical, dated 8/8/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 3 ' s Care Plan on RNA program, initiated on 5/16/2024, indicated the resident was on therapeutic RNA dining program for breakfast, lunch, and dinner. The Care Plan intervention included to assist Resident 3 to eat meal while minimizing distraction.
A review of Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/19/2024, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was moderately impaired. The Functional Limitation in Range of Motion (ROM - extent of movement of a joint) section indicated Resident 3 had impairment on both sides of the upper extremity (shoulder, elbow, wrist, and hand) and both sides of the lower extremity (hip, knee, ankle, and foot). The MDS indicated Resident 3 required maximal assistance (helper lifts or holds trunk or limbs and provided more than half the effort) on eating.
A review of Resident 3 ' s Restorative Care Weekly Summary Therapeutic Dining section, dated 6/1/2024, 6/15/2024, and 6/22/2024, indicated the resident was able to consume 50 percent (%) to 74% of food.
A review of Resident 3 ' s Nutrition - Amount Eaten, dated 6/23/2024, indicated the resident consumed 26% to 50% of food.
A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 3/22/2023 with diagnoses that included atherosclerotic heart disease, Alzheimer ' s disease, and dementia.
A review of Resident 4 ' s Care Plan on RNA program, initiated on 5/16/2024, indicated the resident was on therapeutic RNA dining program for breakfast, lunch, and dinner.
A review of Resident 4 ' s MDS dated [DATE], indicated resident ' s skills for daily decision making was severely impaired. The Functional Limitation in Range of Motion section indicated Resident 4 had impairment on both sides of the upper and lower extremities. The MDS indicated Resident 4 was dependent on facility staff on eating.
A review of Resident 4 ' s Restorative Care Weekly Summary Therapeutic Dining section, dated 6/5/2024, 6/12/2024, and 6/19/2024, indicated the resident was able to consume 75% to 100% of food.
A review of Resident 4 ' s Nutrition - Amount Eaten, dated 6/23/2024, indicated the resident consumed 51% to 75% of food.
On 6/24/2024 at 1:47 p.m., during a concurrent interview and record review, the Residents in Therapeutic RNA Dining Program was reviewed with Activity Team Leader 1 (ATL 1) and indicated there were 16 residents in the program. The Nursing Staffing Assignment and Sign-in Sheet for Resident in Therapeutic RNA Dining Program, dated 6/23/2024, was reviewed with ATL 1 and indicated that Resident 3 and Resident 4 were not on the list of residents assisted on eating during dinner. ATL 1 stated that the RNA should write the room number of the resident they assisted on eating dinner on the Nursing Staffing Assignment. ATL 1 stated that Resident 3 and Resident 4 was either not assigned to an RNA for dinner on 6/23/2024 or the RNA forgot to write the residents ' room numbers. ATL 1 stated that residents that were not on the list had the potential to not be assisted on eating.
On 6/24/2024 at 2:48 p.m., during an interview, the Director of Nursing (DON) stated that the Registered Nurse (RN) Supervisor on weekends was in charge to make sure all the residents on the RNA dining program list were assisted on eating dinner and documented on the Nursing Staffing Assignment sheet.
A review of the current facility-provided policy and procedure titled, Restorative Dining Program, dated 1/29/2024, indicated the purpose is to provide the opportunity for residents to attain their highest level of independence in feeding, improve appropriate mealtime behavior, self-image, and socialization skills. The Procedure section of the policy indicated the program size was determined by the amount of assistance required with a goal of four to six residents for each RNA is desired. The policy indicated that staff member should sit while assisting or feeding the residents and to report any changes in the resident to the charge nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for five of ten sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 10) by failing to ensure staff documented in the physician ' s order sheet, the time the physician ' s orders were received.
This deficient practice resulted in incomplete medical information entered in the residents' medical record.
Findings:
a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/1/2022 with diagnoses that included dysphagia (swallowing difficulties) oropharyngeal (the middle part of the throat, behind the mouth) phase, Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks), and Parkinsonism (a motor syndrome that manifests as rigidity, tremors, and bradykinesia [slowness of movement and progressive hesitation or halts as movements are continued]).
A review of Resident 1 ' s Physician Order Sheet indicated telephone orders dated 5/17/2023, 6/1/2023, 12/5/2023, 1/27/2024, 3/9/2024, with no documented time the orders were received.
A review of Resident 1 ' s Initial History and Physical, dated 6/29/2023, indicated the resident does not have the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/21/2024, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.
On 5/14/2024 at 11:48 a.m., during a concurrent interview and record review, Resident 1 ' s Physician Order Sheets were reviewed with the Director of Nursing (DON). The DON stated that date and time must be indicated on all telephone orders. The DON stated Resident 1 ' s Physician Orders did not indicate the time the telephone orders were received. The DON stated that the facility failed to record and document the time the telephone orders had been received according to the facility ' s policy and procedures.
During a concurrent interview and record review on 5/15/2024 at 12:27 p.m., with the DON, facility ' s policy and procedure titled, Telephone Orders for Medication dated 8/1/2014 and reviewed on 1/29/2024 was reviewed. The DON stated their policy indicated Receiving a telephone order, the receiver documents the order immediately on the prescriber order form including date and time order is received.
b. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/28/2020 with diagnoses that included hemiplegia (paralysis that affects only one side of your body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dysphagia (swallowing difficulties) following cerebral infarction, and Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks).
A review of Resident 2 ' s MDS, dated [DATE], indicated the resident ' s cognition was severely impaired.
A review of Resident 2 ' s Initial History and Physical, dated 4/27/2024, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 2 ' s Physician Order Sheet indicated telephone orders dated 4/26/2024, 4/27/2024, and 5/3/2024, with no documented time the orders were received.
On 5/14/2024 at 11:48 a.m., during a concurrent interview and record review, Resident 2 ' s Physician Order Sheets were reviewed with the Director of Nursing (DON). The DON stated that date and time must be indicated on all telephone orders. The DON stated Resident 2 ' s Physician Orders did not indicate the time the telephone orders were received. The DON stated that the facility failed to record and document the time the telephone orders had been received according to the facility ' s policy and procedures.
During a concurrent interview and record review on 5/15/2024 at 12:27 p.m., with the DON, facility ' s policy and procedure titled, Telephone Orders for Medication dated 8/1/2014 and reviewed on 1/29/2024 was reviewed. The DON stated their policy indicated Receiving a telephone order, the receiver documents the order immediately on the prescriber order form including date and time order is received.
c. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 4/8/2024 with diagnoses that included Alzheimer ' s disease, dysphagia, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
A review of Resident 3 ' s Initial History and Physical, dated 4/8/2024, indicated the resident does not have the capacity to understand and make decisions.
A review of Resident 3 ' s MDS, dated [DATE], indicated resident ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 3 required moderate assistance (helper lifts or holds or supports trunk or limbs and provides less than half the effort) on eating. The Swallowing and Nutritional Status section of the MDS indicated Resident 3 required a mechanically altered diet and therapeutic diet on admission and while a resident in the facility.
A review of Resident 3 ' s Physician Order Sheet indicated telephone orders dated 4/9/2024 to 4/11/2024, 4/19/2024, 5/1/2024 to 5/3/2024, 5/6/2024, and 5/8/2024, with no documented time the orders were received.
On 5/14/2024 at 11:48 a.m., during a concurrent interview and record review, Resident 3 ' s Physician Order Sheets were reviewed with the Director of Nursing (DON). The DON stated that date and time must be indicated on all telephone orders. The DON stated Resident 3 ' s Physician Orders did not indicate the time the telephone orders were received. The DON stated that the facility failed to record and document the time the telephone orders had been received according to the facility ' s policy and procedures.
During a concurrent interview and record review on 5/15/2024 at 12:27 p.m., with the DON, facility ' s policy and procedure titled, Telephone Orders for Medication dated 8/1/2014 and reviewed on 1/29/2024 was reviewed. The DON stated their policy indicated Receiving a telephone order, the receiver documents the order immediately on the prescriber order form including date and time order is received.
d. A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 5/31/2023 with diagnoses that included Alzheimer ' s disease, dysphagia, and dementia.
A review of Resident 4 ' s Initial History and Physical, dated 5/31/2023, indicated the resident does not have the capacity to understand and make decisions.
A review of Resident 4 ' s MDS, dated [DATE], indicated resident ' s cognitive skills for daily decisions were moderately impaired.
A review of Resident 4 ' s Physician Order Sheet indicated telephone orders dated 4/16/2024, 4/25/2024, 4/29/2024, and 5/3/2024, with no documented time the orders were received.
On 5/14/2024 at 11:48 a.m., during a concurrent interview and record review, Resident 4 ' s Physician Order Sheets were reviewed with the Director of Nursing (DON). The DON stated that date and time must be indicated on all telephone orders. The DON stated Resident 3 ' s Physician Orders did not indicate the time the telephone orders were received. The DON stated that the facility failed to record and document the time the telephone orders had been received according to the facility ' s policy and procedures.
During a concurrent interview and record review on 5/15/2024 at 12:27 p.m., with the DON, facility ' s policy and procedure titled, Telephone Orders for Medication dated 8/1/2014 and reviewed on 1/29/2024 was reviewed. The DON stated their policy indicated Receiving a telephone order, the receiver documents the order immediately on the prescriber order form including date and time order is received.
e. A review of Resident 10 ' s admission Record indicated the facility admitted the resident on 1/18/2021 with diagnoses that included fracture (bone breaks) of unspecified (unconfirmed) part of the neck of the right femur (thigh bone), pneumonia (lung infection) due to Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) and Alzheimer ' s disease.
A review of Resident 10 ' s History and Physical dated 11/30/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 10 ' s Physician Order Sheet indicated a telephone order dated 8/31/2023, with no documented time the order was received.
During a concurrent interview and record review on 5/14/2024 at 4:10 p.m., with Licensed Vocational Nurse 5 (LVN 5), Resident 10 ' s Physician Order Sheet dated 8/31/2023 was reviewed. The Physician Order Sheet dated 8/31/2023 indicated no time of when telephone order was received. LVN 5 stated telephone orders should be documented with time it was received to indicate time physician called and gave the telephone order.
During an interview on 5/14/2024 at 4:41 p.m., the DON stated nurses did not document in the physician order sheet, time they received the telephone order. The DON stated nurses should document the time, telephone order was received.
During a concurrent interview and record review on 5/15/2024 at 12:27 p.m., with the DON, facility ' s policy and procedure titled, Telephone Orders for Medication dated 8/1/2014 and reviewed on 1/29/2024 was reviewed. The DON stated their policy indicated Receiving a telephone order, the receiver documents the order immediately on the prescriber order form including date and time order is received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plan (contains relevant information about a resident ' s health conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation) with measurable objectives and interventions addressing the training on aspiration precautions (precautions followed to prevent aspiration [food or liquid goes into the airway instead of the stomach]) to the family members of three of ten sampled residents (Resident 1, Resident 2, and Resident 3) with dysphagia (swallowing difficulties).
These deficient practices had the potential for failure to deliver the necessary care and services and placed Residents 2 and 3 at risk for aspiration which had the potential to cause serious harm and death. The facility staff allowed Family Member 1 (FM 1) to assist Resident 1 in eating dinner without the presence of a facility staff to monitor the resident.
Findings:
a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/1/2022 with diagnoses that included dysphagia oropharyngeal (the middle part of the throat, behind the mouth) phase, Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks), and Parkinsonism (a motor syndrome that manifests as rigidity, tremors, and bradykinesia [slowness of movement and progressive hesitation or halts as movements are continued]).
A review of Resident 1 ' s Care Plan on dysphagia, initiated on 2/2/2024, indicated the resident was at risk for choking and aspiration. The Care Plan indicated that on 12/9/2022 Resident 1 required assistance in eating. On 12/15/2022, the Care Plan indicated Resident 1 was on Restorative Nursing Assistant (RNA) dining program. Resident 1 ' s Care Plan goal indicated the resident will tolerate food texture/fluid consistency as evidenced by no choking/aspiration. The Care Plan interventions included to set up tray and assist Resident 1 during meal and snack times daily as needed; RNA to provide therapeutic dining program for breakfast and lunch; observe for tolerance of food texture/fluid consistency and notify the medical doctor of any difficulties; and to follow safe swallow precautions. There were no interventions on teaching Resident 1 ' s family members on aspiration precautions and giving eating assistance to Resident 1.
A review of Resident 1 ' s Speech Therapy (ST-a health professional who diagnoses and treats communication and swallowing problems) Plan of Care on dysphagia, dated 5/17/2023, indicated the resident ' s problems were impaired swallowing, impaired chewing skills, reduced ability to follow safe swallow precautions, and on modified texture/consistency diet. The care plan goal indicated safe and efficient swallow on least restrictive diet, to maintain nutritional or oral (mouth) gratification needs without risk of aspiration. The care plan approaches indicated training in safe swallow strategies and caregiver training. The care plan did not indicate the specific caregiver who was given the training.
A review of Resident 1 ' s Physician ' s Order Sheet, dated 5/17/2023, indicated to downgrade to fortified (foods to which extra nutrients have been added), no added salt (NAS), puree textures, and mildly thickened liquids. The physician order indicated to follow safe swallow precautions.
A review of Resident 1 ' s Initial History and Physical, dated 6/29/2023, indicated the resident does not have the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/21/2024, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on eating. The MDS also indicated Resident 1 required a mechanically altered diet (required change in texture of food or liquids such as pureed food and thickened liquids) and therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) while a resident in the facility.
A review of Resident 1 ' s Weekly Summary, dated 3/8/2024, indicated the resident ' s hearing and vision was impaired. It indicated that Resident 1 had unclear speech, did not have the ability to understand others, and make self understood. The Weekly Summary indicated Resident 1 was totally dependent on eating (the ability to use suitable utensils to bring food and / or liquid to the mouth and swallow food and /or liquid once the meal is placed before the resident).
A review of Resident 1 ' s Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 3/9/2024, indicated that at 5:45 p.m. Life Enrichment Coordinator 1 (LEC 1 – activity coordinator) informed LVN 1 that Resident 1 was not feeling good. The RN/LVN notes indicated that LVN 1 observed Resident 1 to be unresponsive, with eyes and mouth open, and no visible food in the resident ' s mouth. The notes indicated that Resident 1 appeared to be choking on food provided by Resident 1 ' s daughter. The RN/LVN Notes did not indicate that FM 1 was instructed on aspiration precautions when assisting Resident 1 with meals.
A review of Resident 1 ' s Physician ' s Order Sheet, dated 3/9/2024, indicated to transfer Resident 1 to GACH 1.
On 5/7/2024 at 3:13 p.m., during a concurrent interview and record review, RN 1 stated Resident 1 ' s family members usually visited Resident 1 around dinner time and assisted the resident in eating. RN 1 stated that on 3/9/2024 at 5 p.m., Resident 1 was in the north dining room seated on a high back wheelchair. RN 1 stated that a facility staff (name not given) transferred Resident 1 and FM 1 to the north dining room patio. RN 1 stated that Resident 1 was on puree diet because Resident 1 had Parkinson ' s disease (a movement disorder affecting movement including tremors, slowness of movements and trouble walking) and had weakening of the throat muscles and dysphagia. RN 1 stated that family members assisting residents with eating were verbally reminded on admission and before assisting the resident, about the aspiration precautions. RN 1 was not able to provide documented evidence that Resident 1 ' s family members were provided with training on aspiration precautions.
On 5/7/2024 at 4:23 p.m., during an interview, using Language Interpreter 1 ([NAME] 1), Life Enrichment Coordinator 1 (LEC 1) stated Resident 1 was in the north dining room seated on a high back wheelchair. LEC 1 stated that at around 5:15 p.m., FM 1 visited Resident 1 in the north dining room. LEC 1 stated that FM 1 wanted to assist Resident 1 in eating and had asked LEC 2 if Resident 1 could go to the north dining room patio. LEC 1 stated that a CNA (name not given) took Resident 1 ' s food tray outside to the patio with Resident 1 and FM 1. LEC 1 stated that there were no facility staff in the north dining room patio with Resident 1 and FM 1. LEC 1 stated that she could not see Resident 1 from the north dining room because Resident 1 was on a high back wheelchair with the resident ' s back turned towards the dining room. LEC 1 stated that Resident 1 was on RNA program and the CNAs assist the resident with eating. LEC 1 stated that this was not the first time Resident 1 ' s family members assisted Resident 1 to eat.
On 5/8/2024 at 12:10 p.m., during a concurrent interview and record review, Resident 1 ' s Speech Language Pathologist (SLP) Discharge summary, dated [DATE], was reviewed with the SLP and it indicated Resident 1 was on puree diet and was able to tolerate soft bread and cheese for oral gratification. The Training section indicated Resident 1 and caregivers were instructed on safe swallow techniques with 100 % carryover demonstrated by caregivers. The SLP defined caregivers as everybody that took care of Resident 1 including the family if they were involved. The SLP stated that Resident 1 ' s SLP Discharge Summary did not indicate the specific caregivers that demonstrated 100 % understanding. The SLP stated that Resident 1 was 100 % total dependence on a person to assist the resident on eating.
On 5/8/2024 at 1:18 p.m., during an interview, using [NAME] 2, LEC 2 stated FM 1 requested to stay at the north dining room patio to assist Resident 1 in eating. LEC 2 stated that she opened the door for FM 1. LEC 2 stated she was not sure who brought Resident 1 ' s tray to the north dining room patio. LEC 2 stated that there were no facility staff members in the patio while FM 1 was assisting Resident 1 with eating. LEC 2 stated that since she started working at the facility six months ago, she did not observe family members getting trained on how to assist residents with aspiration precautions in eating.
On 5/9/2024 at 9:29 a.m., during a concurrent interview and record review, Resident 1 ' s Care Plan on therapeutic RNA dining program, dated 12/15/2022, was reviewed with RNA Team Leader (RNA TL). Resident 1 ' s Care Plan indicated the RNA dining program was for breakfast and lunch to promote dietary intake and decrease distraction at mealtime. The RNA TL stated that she created the RNA care plans for the residents on the RNA program and updated the RNA care plans every three months based on the MDS assessment or on the residents ' change of condition. Resident 1 ' s Care Plan goal on the therapeutic dining program had a target date of 8/24/2023. The RNA TL stated that Resident 1 was on the continuous RNA dining program. The RNA TL stated that Resident 1 ' s care plan was not updated after the target date. The RNA TL stated that she should ensure Resident 1 ' s RNA dining program care plan was updated. The TL stated that care plans that were not updated had the potential for resident ' s care to not be good. The RNA TL stated that she did not know if the resident ' s family were allowed to assist residents on the RNA dining program.
On 5/9/2024 at 2:15 p.m., during a concurrent interview and record review, the DON stated that Resident 1 ' s family members were given teachings on aspiration precautions during interdisciplinary team (IDT-a group of health care professionals with various area of expertise who work together toward the goals of the resident) meetings. Resident 1 ' s Interdisciplinary Care Conference Review form was reviewed with the DON, dated 6/16/2022, 9/13/2022, 12/6/2022, 2/28/2023, 5/23/2023, 8/15/2023, 11/07/2023, and 1/30/2024, indicated that Resident 1 ' s family members participated through telephone call on one of eight interdisciplinary care conferences. The document did not indicate that Resident 1 ' s family members were provided instructions on aspiration precautions on all eight interdisciplinary care conferences. Resident 1 ' s RN/LVN Notes were also reviewed with the DON, and she was not able to provide documented evidence that Resident 1 ' s family members received specific instructions on assisting the resident while eating.
On 5/14/2024 at 10:31 a.m., during a concurrent interview and record review, the policies titled Education of Residents and Aspiration Precautions were reviewed with the ADM. The ADM stated family education does not need to be specific. ADM was asked to read the facility-provided policy and procedure titled, Education of Residents, dated 1/29/2024. The ADM stated that the policy indicated documentation is performed by the responsible discipline and will include a description of the education provided to the resident/family/responsible party. The policy titled, Aspiration Precautions, dated 1/29/2024, was reviewed with the ADM. The ADM stated that the policy indicated that residents identified for aspiration, exhibiting signs of impaired swallowing, or displaying symptoms of potential aspiration will have aspiration precautions implemented. Aspiration precautions included assistance with feeding and supervision as indicated in the resident ' s plan of care. Resident 1 ' s care plan on therapeutic diet was reviewed with the ADM. The ADM stated the care plan intervention included to set up tray and assist resident daily. The ADM was asked to elaborate on the word daily. The ADM stated that daily meant all meals and snack times. The ADM was asked to elaborate the word assist. The ADM stated that assist meant putting the tray in front of the resident, opening the food, setting the food up, or handing the tray to someone.
A review of the facility ' s policy and procedure titled, Care Planning, dated 1/29/2024, indicated the purpose to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs.
b. On 5/9/2024 at 11:45 a.m., during a concurrent observation and interview, observed Resident 2 and FM 3 on the first table at the south dining room patio. Resident 2 was sitting on a high back wheelchair with the back of the wheelchair facing the south dining room. FM 3 stated that facility staff informed them that residents and family members assisting residents in eating cannot stay in the dining room. FM 3 stated that during rainy days they did not have a choice but to stay in the resident ' s room. FM 3 stated that it would be nice to stay in the dining room with comfortable seating. FM 3 stated that Resident 2 ' s diet was chopped diet because of the denture problems of the resident. FM 3 stated that Resident 2 had no swallowing problems. FM3 stated that the RNA informed them to assist Resident 2 in eating slowly and the resident was required to be seated upright. FM 3 stated that the facility staff meet with them when Resident 2 had diet change or was losing weight. FM 3 stated that the facility staff did not teach them on how to assist Resident 2 in eating.
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/28/2020 with diagnoses that included hemiplegia (paralysis that affects only one side of your body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dysphagia (swallowing difficulties) following cerebral infarction, and Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks).
A review of Resident 2 ' s Care Plan on therapeutic easy to chew diet, initiated on 9/16/2022, indicated the resident was at risk for choking and aspiration. The Care Plan Goal indicated Resident 2 will tolerate food texture as evidenced by no choking and aspiration. The Care Plan Interventions included to assist Resident 2 during all meals and snack times, RNA to provide therapeutic dining program for breakfast and lunch, follow safe swallow precautions as ordered, and to observe for tolerance of food and liquid and notify physician (MD) of any difficulties. The Care Plan interventions did not indicate teaching Resident 2 ' s family members on aspiration precautions and eating assistance.
A review of Resident 2 ' s Care Plan on RNA Therapeutic Dining Program, dated 7/27/2023, indicated the resident was on RNA therapeutic dining program for breakfast and lunch. The Care Plan Interventions included to notify charge nurse of any difficulty and/or intake less than 50 percent. The Care Plan interventions did not indicate teaching Resident 2 ' s family members on aspiration precautions and eating assistance.
A review of Resident 2 ' s MDS, dated [DATE], indicated the resident ' s cognition was severely impaired. The MDS indicated that Resident 2 had impairment on both sides of the upper extremities (shoulder, elbow, wrist, and hand) and both sides of the lower extremities (hip, knee, ankle, and foot). Resident 2 required the use of a wheelchair and was dependent (resident does none of the effort to complete the activity) on eating. The MDS indicated Resident 2 required a mechanically altered diet and therapeutic diet.
A review of Resident 2 ' s untimed Physician Order Sheet, dated 4/26/2024, indicated ST plan of care to address dysphagia for oral (mouth) motor strengthening, safe swallow precautions and strategies, diet texture modifications, oral care, and patient/family/staff education.
A review of Resident 2 ' s SLP Evaluation and Plan of Treatment, dated 4/26/2024, indicated a treatment diagnosis of dysphagia, oropharyngeal phase. The Assessment Summary section indicated that Resident 2 had decreased swallow function, prolonged oro-pharyngeal stage (swallowing problems occurring in the mouth and / or the throat), and delayed swallow initiation. The Risk Factors section indicated Resident 2 was at risk for aspiration, dehydration, malnutrition, muscle atrophy (the thinning or loss of muscle tissue), and weight loss.
A review of Resident 2 ' s ST Therapy Progress Report, dated 5/2/2024, indicated Resident 2 required a continued skill services from the SLP for the resident ' s remaining impairments that included delayed pharyngeal swallow (the reflex initiated by the touch receptors in the pharynx as a bolus of food is pushed to the back of the mouth by the tongue), reduced pharyngeal contraction, reduced tongue base retraction (the base of the tongue retracts, pushing the bolus of food against the pharyngeal wall), and reduced laryngeal elevation (a known important protective mechanism during swallowing). There was no documented evidence from 4/26/2024 to 5/8/2024 on specific caregivers that were provided education on Resident 2 ' s safe swallow precautions and strategies.
A review of Resident 2 ' s Initial History and Physical, dated 4/27/2024, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 2 ' s Interdisciplinary Care Conference Review, dated 5/1/2024, indicated the assessment type was quarterly and there was no revision on Resident 2 ' s care plan. The Summary of Conference Discussion section did not indicate the facility teachings provided to family members on safe swallow precautions and strategies.
On 5/14/2024 at 10:31 a.m., during a concurrent interview and record review, the policy titled Education of Residents was reviewed with the Administrator (ADM). The ADM stated the family education does not need to be specific. ADM was asked to read the facility-provided policy and procedures titled Education of Residents, dated 1/29/2024. The ADM stated that the policy indicated documentation is performed by the responsible discipline and will include a description of the education provided to the resident/family/responsible party. The policy titled Aspiration Precautions, dated 1/29/2024, was reviewed with the ADM. The ADM stated that the policy indicated that residents identified for aspiration, exhibiting signs of impaired swallowing, or displaying symptoms of potential aspiration will have aspiration precautions implemented. Aspiration precautions included assistance with feeding and supervision as indicated in the resident ' s plan of care. Resident 1 ' s care plan on therapeutic diet was reviewed with the ADM. The ADM stated the care plan intervention included to set up tray and assist resident daily. The ADM was asked to elaborate on the word daily. The ADM stated that daily meant all meals and snack times. The ADM was asked to elaborate the word assist. The ADM stated that assist meant putting the tray in front of the resident, opening the food, setting the food up, or handing the tray to someone.
A review of the facility ' s policy and procedure titled, Care Planning, dated 1/29/2024, indicated the purpose to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs.
c. On 5/9/2024 at 12:04 p.m., during a concurrent observation and interview, Observed Resident 3 and FM 4 at the far end table in the south dining room patio. Resident 3 was sitting on a regular wheelchair with the back of the wheelchair facing the south dining room. FM 4 was observed putting a spoon with pureed consistency food into Resident 3 ' s mouth. FM 4 stated that facility staff informed him to stay in the patio or in Resident 3 ' s room while eating. FM 4 stated he was not given the reason for staying in the patio during meals. FM 4 stated that another family member visits Resident 3 more often and FM 4 was only there to accompany the resident for a dental appointment after lunch. FM 4 stated that the facility staff did not inform FM 4 on aspiration precautions when assisting Resident 3 on eating.
A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 4/8/2024 with diagnoses that included Alzheimer ' s disease, dysphagia, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
A review of Resident 3 ' s Initial History and Physical, dated 4/8/2024, indicated the resident does not have the capacity to understand and make decisions.
A review of Resident 3 ' s SLP Evaluation and Plan of Treatment, dated 4/9/2024, indicated a treatment diagnosis of dysphagia, oropharyngeal phase. The Assessment Summary section indicated that Resident 3 had delayed pharyngeal, reduced pharyngeal contraction, reduced tongue base retraction, and reduced laryngeal elevation. The Risk Factors section indicated Resident 3 was at risk for aspiration, dehydration, malnutrition, muscle atrophy, and weight loss.
A review of Resident 3 ' s MDS, dated [DATE], indicated resident ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 3 required moderate assistance (helper lifts or holds or supports trunk or limbs and provides less than half the effort) on eating. The Swallowing and Nutritional Status section of the MDS indicated Resident 3 required a mechanically altered diet and therapeutic diet on admission and while a resident in the facility.
A review of Resident 3 ' s untimed Physician Order Sheet, dated 4/19/2024, indicated ST diet downgraded to No Added Salt (NAS) puree texture and regular consistency liquids, and follow safe swallow precautions.
A review of Resident 3 ' s Care Plan on Therapeutic NAS Puree diet, initiated on 4/24/2024, indicated Resident 3 required assistance in eating and was at risk for choking and aspiration. The Care Plan interventions included set up tray, prompt, and assist resident with meals daily as needed, follow safe swallow precautions as ordered, and monitor for tolerance of food and liquid texture and notify MD of difficulties. On 4/30/2024, an added focus indicated Resident 3 was on RNA dining program. The intervention added was RNA to provide therapeutic dining program for breakfast and lunch. The Care Plan interventions did not indicate teaching Resident 2 ' s family members on aspiration precautions and eating assistance.
A review of Resident 3 ' s ST Therapy Progress Report, dated 4/29/2024, indicated Resident 3 required a continued skill services from the SLP for the resident ' s remaining impairments that included decreased oral motor movement, decreased oral motor coordination and control, delayed pharyngeal swallow, reduced pharyngeal contraction, reduced tongue base retraction. There was no documented evidence from 4/23/2024 to 4/29/2024 on specific caregivers that were provided education on Resident 3 ' s safe swallow precautions.
A review of Resident 3 ' s Care Plan on RNA program, initiated on 4/30/2024, indicated Resident 3 was on therapeutic RNA dining program for breakfast and lunch. The Care Plan Interventions included notify charge nurse of any difficulty with assisting on eating and /or dietary intake of less than 50 percent. The Care Plan interventions did not indicate teaching Resident 3 ' s family members on aspiration precautions and eating assistance.
A review of Resident 3 ' s Interdisciplinary Care Conference Review, dated 5/1/2024, indicated the assessment type was initial assessment. The Summary of Conference Discussion section indicated that Resident 3 was on therapeutic RNA dining program for breakfast and lunch. There was no documentation that indicated the facility teachings were provided to Resident 3 ' s family members on safe swallow precautions.
A review of Resident 3 ' s untimed Physician Order Sheet, dated 5/2/2024, indicated discharge ST services to CNA care, follow safe swallow precautions, and continue with current diet.
On 5/14/2024 at 10:31 a.m., during a concurrent interview and record review, the policy titled Education of Residents was reviewed with the Administrator (ADM). The ADM stated the family education does not need to be specific. ADM was asked to read the facility-provided policy and procedures titled Education of Residents, dated 1/29/2024. The ADM stated that the policy indicated documentation is performed by the responsible discipline and will include a description of the education provided to the resident/family/responsible party. The policy titled Aspiration Precautions, dated 1/29/2024, was reviewed with the ADM. The ADM stated that the policy indicated that residents identified for aspiration, exhibiting signs of impaired swallowing, or displaying symptoms of potential aspiration will have aspiration precautions implemented. Aspiration precautions included assistance with feeding and supervision as indicated in the resident ' s plan of care. Resident 1 ' s care plan on therapeutic diet was reviewed with the ADM. The ADM stated the care plan intervention included to set up tray and assist resident daily. The ADM was asked to elaborate on the word daily. The ADM stated that daily meant all meals and snack times. The ADM was asked to elaborate the word assist. The ADM stated that assist meant putting the tray in front of the resident, opening the food, setting the food up, or handing the tray to someone.
A review of the facility ' s policy and procedure titled, Care Planning, dated 1/29/2024, indicated the purpose to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs.

Based on observation, interview, and record review, the facility failed to ensure that a resident with urinary indwelling catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services that included to anchor (secure) the urinary catheter tubing to resident ' s thigh for one of three sampled residents (Resident 8).
This deficient practice had the potential to result in urinary catheter dislodgement (forcefully pulled out of a secure position) causing urethral (the tube through which urine leaves the body) tearing that may result in pain and bleeding.
Findings:
A review of Resident 8 ' s admission Record indicated the facility initially admitted the resident on 3/23/2022 and recently readmitted the resident on 5/12/2024 with diagnoses that included encephalopathy (damage or disease that affects the brain that can lead to an altered mental state, leaving you confused and not acting like you usually do), chronic obstructive pulmonary disease (COPD-a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), unspecified( unconfirmed) neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems) and unspecified obstructive and reflex uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional).
A review of Resident 8 ' s History and Physical, dated 5/14/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 8 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 4/18/2024, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 8 was dependent to staff for toileting and personal hygiene. The MDS indicated Resident 8 was always incontinent (unable to control) of bowel functions and had a urinary indwelling catheter.
A review of Resident 8 ' s Physician Order Sheet, dated 5/12/2024, indicated an order for Foley catheter (one of many types of urinary catheters) care, 16 French (sized by a universal system that measures the diameter of the tube, larger sizes will be a higher number and smaller sizes will be a lower number) every shift due to obstructive uropathy.
During a concurrent observation and interview, on 5/14/2024 at 4:07 p.m., with Certified Nursing Assistant 6 (CNA 6) inside Resident 8 ' s room, observed Resident 8 lying in bed with white sheet covering from waist down to toes, and an indwelling catheter tubing hanging on the left side of the bed, facing the door. Observed CNA 6 lifted the white sheet and noted a stat lock (strap free device which locks the catheter in place, stabilizes the catheter and eliminates any chance of sudden pull) on Resident 8 ' s right upper thigh while the indwelling catheter tubing is on the left side of the bed. CNA 6 stated the indwelling catheter tubing was not anchored and can be accidentally pulled out if not secured.
During an interview, on 5/15/2024 at 8:30 a.m., the Director of Nursing (DON) stated urinary indwelling catheter needs to be anchored and secured to prevent dislodgement.
During a concurrent interview and record review, on 5/15/2024 at 12:27 p.m., with the DON, facility ' s policy and procedure (P&P) titled, Care of Catheter, dated 9/1/2014 and approved on 1/29/2024 was reviewed. The DON stated urinary catheter should be attached to the leg with a strap to prevent urethral tearing. The P&P indicated Procedure:
D. Remove leg strap and inspect the area for signs and symptoms of adhesive burns, redness, tenderness, blisters, or open skin areas.
H. Reattach the catheter to the leg strap. Ensure that the catheter is properly anchored to prevent urethral tearing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide safe eating practices for four of ten sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) who were on aspiration precaution (precautions followed to prevent aspiration [food or liquid goes into the airway instead of the stomach]) by:
1. Failing to ensure Family Member 1 (FM 1) was provided education and training before being allowed to assist with Resident 1 ' s meals.
2. Failing to monitor and supervise Resident 1 while FM 1 was assisting Resident 1 with dinner on 3/9/2024.
3. Failing to provide Resident 1 with a Restorative Nursing Assistant (RNA) to assist Resident 1 in eating during dinner on 3/9/2024.
4. Failing to ensure Resident 1 ' s care plan on Therapeutic Diet (a meal plan that controls the intake of certain foods or nutrients) Secondary to Hypertension and Dysphagia (swallowing difficulties): At Risk for Choking/Aspiration . was specific to Resident 1 ' s needs.
On 3/9/2024 at 5:30 p.m., facility staff allowed FM 1 to assist Resident 1 in eating dinner at the north dining room patio without the presence of a facility staff to monitor Resident 1. On 3/9/2024 at 5:45 p.m., FM 1 observed Resident 1 was unresponsive. Licensed Vocational Nurse 1 (LVN 1) found Resident 1 pulseless and was not breathing. A facility staff member (name not given) called the paramedics (health professionals certified to perform advanced life support procedures) through 911 (a phone number to contact the emergency services).
As a result, the paramedics brought Resident 1 to General Acute Care Hospital 1 (GACH 1) on 3/9/2024 at 5:45 p.m. On 3/13/2024 at 2:36 p.m., Resident 1 passed away at GACH 1 with death diagnoses including aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs instead of being swallowed), cardiac arrest (occurs when the heart stops beating suddenly), anoxic brain injury (caused by a complete lack of oxygen to the brain which results in the death of brain cells after approximately four minutes of oxygen deprivation), and acute respiratory failure with hypoxemia (occurs when a person did not have enough oxygen in the blood).
5. Failing to ensure the family members of Residents 2, 3, and 4, who were on aspiration precautions, were provided education and training before being allowed to assist with Residents 2, 3, and 4 ' s meals. This deficient practice had the potential for Residents 2, 3, and 4 to have aspiration incidents.
On 5/14/2024 at 1:27 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure under 42 CFR § 483.25 Quality of care.
On 5/15/2024 at 6:04 p.m., the ADM and DON submitted an IJ Removal Plan (a detailed plan to address the IJ findings). While onsite at the facility, the SSA verified and confirmed the facility ' s implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA accepted the IJ Removal Plan and removed the IJ situation in the presence of the ADM and DON on 5/15/2024, at 7:04 p.m.
The acceptable IJ Removal Plan included the following summarized actions:
1. On 5/14/2024, the DON and ADM identified all residents with a care plan for aspiration precautions and choking, and diagnosis of dysphagia through a diagnosis search in the Electronic Health Record (EHR - Point Click Care [PCC]). All residents currently residing at the facility (census 249) had a potential to be affected by the same deficient practice.
2. On 5/14/2024, licensed nurses reviewed all the residents ' dietary cards on the dinner trays for accuracy and completeness.
3. On 5/14/2024, Registered Nurse (RN) supervisors on the evening shift completed full body assessments on all residents to ensure that no residents were affected by the deficient practice. No further individuals were identified.
4. On 5/14/2024, the DON, the ADM, and RN Supervisors provided 1:1 education on safe feeding techniques and supervision to all families present in the dining rooms, patios, and resident rooms during meals.
5. On 5/14/2024, all families present at dinnertime were provided with Feeding Guidelines and instructed by RN Supervisors to move to the dining rooms during feeding for close observation and supervision.
6. On 5/15/2024, the ADM composed a letter and the facility ' s business office mailed the letter to the residents ' responsible parties addressing the importance of following policies and procedures for safe eating techniques during visitation and checking in with Charge Nurse (CN) on duty before providing and/or assisting residents with any food. The letter addressed the importance of all family members who were involved in assisting the residents on eating, received proper training on safe eating and swallowing techniques and completeness of tray. The letter addressed the importance of following the residents ' prescribed diets, not giving the residents food that were outside of their diet plan, the importance of not force-feeding residents, and providing residents with right to decline food. A Visitor Education on Feeding Precautions was attached to the letter that the facility sent out to families listing the facility protocols that included only food within the resident ' s diet (nutrition and texture) were permitted, the licensed nurse must approve all food given to a resident, residents must be positioned at a 90-degree angle while eating, and residents must be allotted sufficient time to chew and swallow food. The facility protocol indicated visitors must wash their hands prior to handling food, visitors shall not assist other residents except for whom they were visiting, visitors must remain under staff supervision while assisting the resident in eating, recommended locations are dining rooms, visitors shall not force feed, and visitors must be sitting down at eye level with the resident while assisting the resident in eating.
7. On 5/14/2024, the ADM modified the Visitor Education on Feeding Precautions form to include resident ' s name, visitor ' s name, relationship, date, and visitor ' s signature. The form included a section for questions and licensed nurses ' signature as evidence of provided training.
8. On 5/14/2024 and 5/15/2024, the Adm and the DON provided the receptionists and RN supervisors blank copies of the Visitor Education on Feeding Precautions acknowledgment form. Receptionists and RN supervisors were provided education on the new system of providing the form to all visitors. On 5/14/2024, the ADM and the DON provided instructions to licensed nurses and receptionists to provide the forms to all visitors as evidence of education on the new policy, upon visiting a resident in the facility.
9. On 5/15/2024, the ADM provided the facility ' s business office a copy of the family letter and Visitor Education on Feeding Precautions form to be included in the new admission packet for all future residents.
10. On 05/15/2024 at 11:14 a.m., the ADM texted all residents ' contacts listed in PCC about the new policies and procedures pertaining to assisting residents in eating.
11. The ADM and the DON created a binder for the Visitor Education on Feeding Precautions acknowledgment forms with alphabetical listing of all residents in the facility. The binder was located at the reception desk.
12. On 5/15/2024, The ADM updated the policy and procedures on Visitor Rules (RR-14 Form A, section Visitor Protocols) to reflect the new forms and procedures.
13. On 5/14/2024, the DON and the facility ' s care planning team developed a new Care Plan for all residents pertaining to family education related to residents ' safe eating precautions.
14. The DSD posted the Visitor Education on Feeding Precautions in the facility lobby, dining rooms, and on patio doors.
15. RN Supervisors on duty monitored visitors for compliance with new feeding protocols during facility rounds, particularly during mealtimes, and document on the Shift Monitoring & Reporting Tool every shift. Any noncompliance will be documented in the pink licensed notes in the resident ' s chart. Responsible parties will be notified if the noncompliance with feeding is observed from a visitor.
16. On 5/15/2024, the Food & Nutritional Supervisor updated all residents ' tray cards for breakfast, lunch, and dinner to list the items that must be present on the resident ' s meal tray and ensure completeness of the meal tray.
17. On 5/14/20204 and 5/15/2024, the ADM, the DON, and the DSD in-serviced all receptionists, licensed nurses, and certified nursing assistants (CNAs) in the morning and evening shifts, on the new visitor protocols and guidelines. RN supervisor on duty or the DSD will train the facility staff that were absent from training upon returning to work. 73% of nursing staff (146 of approximately 200) were in-serviced from 5/14/24 to 5/15/2024.
18. On 5/15/2024, the DON and the DSD in-serviced all licensed nurses, CNAs, and RNAs on the new system of updated tray cards/tickets, on aspiration precautions, visitor education, and visitor supervision while assisting residents with eating.
19. On 5/15/2024, the ADM, the DON, and the DSD updated the RNA schedule to have RNA feeding program during dinner time.
20. Performance Improvement Quality Improvement (PIQI) nurses will monitor Family Education Care Plan quarterly to ensure presence, completion, accuracy, and implementation.
21. PIQI nurses will report quarterly to the PIQI Committee the results of PIQI findings pertaining to residents ' care plan.
Findings:
a. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/1/2022 with diagnoses that included dysphagia oropharyngeal (the middle part of the throat, behind the mouth) phase, Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks), and Parkinsonism (a motor syndrome that manifests as rigidity, tremors, and bradykinesia [slowness of movement and progressive hesitation or halts as movements are continued]).
A review of Resident 1 ' s Care Plan on dysphagia, initiated on 2/2/2024, indicated the resident was at risk for choking and aspiration. The Care Plan indicated that on 12/9/2022 Resident 1 required assistance in eating. On 12/15/2022, the Care Plan indicated Resident 1 was on RNA dining program. Resident 1 ' s Care Plan Goal indicated the resident will tolerate food texture/fluid consistency as evidenced by no choking/aspiration. The Care Plan interventions indicated to set up tray and assist Resident 1 during meal and snack times daily as needed and RNA to provide therapeutic dining program for breakfast and lunch. Resident 1 ' s Care Plan interventions also included to observe for tolerance of food texture/fluid consistency, notify the medical doctor of any difficulties, and to follow safe swallow precautions. There were no interventions on teaching Resident 1 ' s family members on aspiration precautions and giving eating assistance to Resident 1.
A review of Resident 1 ' s Speech Therapy (ST-a health professional who diagnoses and treats communication and swallowing problems) Plan of Care on dysphagia, dated 5/17/2023, indicated the resident ' s problems were impaired swallowing, impaired chewing skills, reduced ability to follow safe swallow precautions, and on modified texture/consistency diet. The care plan goal indicated safe and efficient swallow on least restrictive diet, to maintain nutritional or oral (mouth) gratification needs without risk of aspiration. The care plan approaches indicated training in safe swallow strategies and caregiver training. The care plan did not indicate the specific caregiver that was given the training.
A review of Resident 1 ' s Physician ' s Order Sheet, dated 5/17/2023, indicated to downgrade to fortified, no added salt (NAS), puree textures (a food that had been blended, mixed, or processed into a smooth and uniform texture), and mildly thickened liquids. The physician order indicated to follow safe swallow precautions.
A review of Resident 1 ' s Initial History and Physical, dated 6/29/2023, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/21/2024, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on eating. The Swallowing and Nutritional Status section of the MDS indicated Resident 1 required a mechanically altered diet (required change in texture of food or liquids such as pureed food and thickened liquids) and therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) while a resident in the facility.
A review of Resident 1 ' s Certified Nursing Assistant (CNA) documentation on the resident ' s nutrition, dated 3/2024, indicated Resident 1 was dependent (resident does none of the effort to complete the activity) on staff on eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident).
A review of Resident 1 ' s Weekly Summary, dated 3/8/2024, indicated the resident ' s hearing and vision was impaired. It indicated that Resident 1 had unclear speech, did not have the ability to understand others, and make self understood. The Functional Status section indicated Resident 1 was totally dependent on staff on eating.
A review of Resident 1 ' s meal ticket, dated 3/9/2024, indicated the resident had fortified NAS, puree, nectar thickener, and mildly thick (MT2) consistency for dinner. The meal ticket indicated Resident 1 ' s preference was magic cup (dietary supplement) and may have soft bread and cheese. The meal ticket did not indicate Resident 1 ' s allergies and dislikes.
A review of Resident 1 ' s Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 3/9/2024, indicated that at 5:45 p.m. Life Enrichment Coordinator 1 (LEC 1 - activity coordinator) informed LVN 1 that Resident 1 was not feeling good. The RN/LVN notes indicated that LVN 1 observed Resident 1 to be unresponsive, with eyes and mouth open, and no visible food in the resident ' s mouth. The notes indicated that Resident 1 appeared to be choking on food provided by Resident 1 ' s daughter. It indicated that Heimlich maneuver (the manual application of sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the trachea) was initiated by LVN 1 and was unsuccessful. The RN/LVN notes indicated that 911 was called. LVN 1 performed Cardio-Pulmonary Resuscitation (CPR), gave oxygen at three liters per minute (unit of measurement) through nasal cannula (a device that delivers extra oxygen through a tube and into the nose), and suctioned Resident 1. It indicated that at 5:50 p.m., the paramedics arrived and took over Resident 1 ' s resuscitation. Resident 1 was transferred to GACH 1 at 6:20 p.m., unresponsive and had a heart rate of 111 beats per minute (normal resting heart rate for adults ranges from 60 to 100 beats per minute). The RN/LVN Notes did not indicate that FM 1 was instructed on aspiration precautions when assisting Resident 1 with meals.
A review of Resident 1 ' s Physician ' s Order Sheet, dated 3/9/2024, indicated to transfer Resident 1 to GACH 1.
A review of Resident 1 ' s Los Angeles Fire Department (LAFD) paramedics report, dated 3/9/2024, indicated that the paramedics were notified at 5:50 p.m. on 3/9/2024. The paramedics report indicated that Resident 1 was unresponsive, apnea (no airflow or stopped breathing), pale, and sluggish pupils (the black opening in the middle of the colored part of the eye). The Arrest Details section indicated that LAFD personnel initiated the CPR. Resident 1 ' s heart rate started after two doses of epinephrine (the primary medication administered during CPR to reverse cardiac arrest) 0.01 milligrams (mg - unit of measurement). Resident 1 was transferred to GACH 1.
A review of Resident 1 ' s GACH 1 Emergency Department (ED) Provider Note, dated 3/9/2024, indicated the resident arrived at the ED unresponsive, pale, pupils dilated and fixed, course breath sounds received bagged (a medical devise placed over the nose and mouth of a patient in respiratory distress) breaths, and presence of emesis (vomitus) around the lips, face, and in the oropharynx (the area from the soft palate to the base of the tongue). The ED Notes indicated Resident 1 ' s diagnoses of respiratory failure and cardiac arrest.
A review of Resident 1 ' s GACH 1 History and Physical, dated 3/10/2024, indicated the resident ' s active problems included aspiration pneumonia, acute hypoxemic respiratory failure secondary to aspiration pneumonia, cardiac arrest with likely anoxic brain injury (caused by a complete lack of oxygen not the brain that results in the death of brain cells after approximately four minutes of oxygen deprivation), and seizures (sudden uncontrolled bursts of electrical activity in the brain) secondary to likely anoxic brain injury.
A review of Resident 1 ' s GACH 1 Death Summary, dated 3/13/2024, indicated that 3/13/2024 at 2:38 p.m. was Resident 1 ' s date and time of death. The Death Summary indicated diagnoses that included cardiac arrest, anoxic brain injury, aspiration pneumonia, acute respiratory failure with hypoxemia (a low level of oxygen in the blood).
On 5/7/2024 at 3:13 p.m., during a concurrent interview and record review, RN 1 stated Resident 1 ' s family members usually visited Resident 1 around dinner time and assisted the resident in eating. RN 1 stated that on 3/9/2024 at 5 p.m., Resident 1 was in the north dining room seated on a high back wheelchair. RN 1 stated that a facility staff (name not given) transferred Resident 1 and FM 1 to the north dining room patio. RN 1 stated that Resident 1 was on puree diet because Resident 1 had Parkinson ' s disease (a movement disorder affecting movement including tremors, slowness of movements and trouble walking) and had weakening of the throat muscles and dysphagia. RN 1 stated that family members assisting residents with eating were verbally reminded on admission and before assisting the resident, about the aspiration precautions. RN 1 was not able to provide documented evidence that Resident 1 ' s family members were provided with training on aspiration precautions. RN 1 stated that LVN 1 screamed for help, and she followed LVN 1 to the north dining room patio. RN 1 stated that she saw LVN 1 was performing Heimlich maneuver on Resident 1. RN 1 stated that she checked for Resident 1 ' s pulse and breathing but the resident was pulseless, not breathing, pale, and with eyes open. RN 1 stated that there were no facility staff outside at the north dining room patio with Resident 1 and FM 1. RN 1 stated that Resident 1 and FM 1 were seated on the first table near the north dining room patio door. RN 1 stated that it took around one minute and 30 seconds to go to the north dining room patio from the north nurse station, perform Heimlich maneuver and assessment on Resident 1, wheel Resident 1 back to the room, and transfer Resident 1 from the wheelchair to the resident ' s bed.
On 5/7/2024 at 4:23 p.m., during an interview, using Language Interpreter 1 ([NAME] 1), Life Enrichment Coordinator 1 (LEC 1) stated Resident 1 was in the north dining room seated on a high back wheelchair. LEC 1 stated that at around 5:15 p.m., FM 1 visited Resident 1 in the north dining room. LEC 1 stated that FM 1 wanted to assist Resident 1 in eating and had asked LEC 2 if Resident 1 could go to the north dining room patio. LEC 1 stated that a CNA (name not given) took Resident 1 ' s food tray outside to the patio with Resident 1 and FM 1. LEC 1 stated that there were no facility staff in the north dining room patio with Resident 1 and FM 1. LEC 1 stated that she could not see Resident 1 from the north dining room because Resident 1 was on a high back wheelchair with the resident ' s back turned towards the dining room. LEC 1 stated that Resident 1 was on RNA program (a facility-implemented program that focuses on achieving and maintaining the residents ' optimal physical, mental, and psychosocial functioning) and the CNAs assist the resident with eating. LEC 1 stated that this was not the first time Resident 1 ' s family members assisted Resident 1 to eat. LEC 1 stated that around 5:40 p.m., FM 1 came in the dining room and stated that Resident 1 was not breathing well. LEC 1 stated she went to the north dining room patio and saw Resident 1 was weak, the resident ' s eyes were open, and the resident was not breathing well. LEC 1 stated that she went inside to ask LVN 1 for help. LEC 1 stated that she went back inside to assist other residents and did not know what happened to Resident 1.
On 5/7/2024 at 5:35 p.m., during a concurrent observation and interview, LEC 1 demonstrated Resident 1 and FM 1 ' s position at the north dining room patio. LEC 1 stated that Resident 1 and FM 1 were at the far end of the north dining room patio. LEC 1 demonstrated Resident 1 and FM 1 ' s position and stated that the resident was sitting on a high back wheelchair with the resident ' s back turned towards the dining room. LEC 1 demonstrated that FM 1 was seated at Resident 1 ' s right side facing the resident.
On 5/8/2024 at 9:59 a.m., during a telephone interview, LVN 1 stated that at around 5 p.m., FM 1 went to the north dining room. LVN 1 stated that at 5:45 p.m., LEC 1 informed him that Resident 1 was not feeling good. LVN 1 stated he did not know where Resident 1 was so LEC 1 pointed to the north dining room patio. LVN 1 stated that Resident 1 ' s mouth and eyes were open, the resident had no reflexes on the arms, and the resident did not have a pulse. LVN 1 stated that Resident 1 was sitting on a high back wheelchair with the resident ' s back turned towards the north dining room. LVN 1 stated that he did a mouth sweep and there was no food inside Resident 1 ' s mouth. LVN 1 stated that he did a Heimlich maneuver three times on Resident 1 and there was no food that came out of the resident ' s mouth. LVN 1 stated that it took less than one minute from the time LEC 1 reported Resident 1 ' s condition to the time CPR was started inside the resident ' s room. LVN 1 stated that CNAs were assisting residents in eating dinner. LVN 1 stated that LVNs and CNAs supervise family members assisting residents in eating. LVN 1 stated that a facility staff member should be supervising family members assisting residents in eating at the patio. LVN 1 stated that residents should be facing the dining room for more supervision.
On 5/8/2024 at 12:10 p.m., during a concurrent interview and record review, Resident 1 ' s Speech Language Pathologist (SLP) Discharge summary, dated [DATE], was reviewed with the SLP, indicated Resident 1 had a treatment diagnosis of dysphagia, oropharyngeal phase. The SLP stated that Resident 1 was on puree diet and was able to tolerate soft bread and cheese for oral gratification. SLP stated that Resident 1 had difficulty tolerating mechanical soft regular diet and had difficulty on swallowing. The SLP stated that Resident 1 was discharged from speech therapy to Restorative Nursing Assistant (RNA) program. The Functional Outcomes section of the SLP Discharge Summary indicated that Resident 1 ' s swallowing ability was moderate. The Training section indicated Resident 1, and caregivers were instructed on safe swallow techniques with 100 % carryover demonstrated by caregivers. The SLP defined caregivers as everybody that took care of Resident 1 including the family if they were involved. The SLP stated that Resident 1 ' s SLP Discharge Summary did not indicate the specific caregivers that demonstrated 100 % understanding. The SLP stated that Resident 1 was 100 % total dependence on a person to assist the resident on eating.
On 5/8/2024 at 1:18 p.m., during an interview, using [NAME] 2, LEC 2 stated FM 1 requested to stay at the north dining room patio to assist Resident 1 in eating. LEC 2 stated that she opened the door for FM 1. LEC 2 stated she was not sure who brought Resident 1 ' s tray to the north dining room patio. LEC 2 stated that there were no facility staff members in the patio while FM 1 was assisting Resident 1 with eating. LEC 2 stated that since she started working at the facility six months ago, she did not observe family members getting trained on how to assist residents with aspiration precautions in eating.
On 5/9/2024 at 9:29 a.m., during a concurrent interview and record review, Resident 1 ' s Care Plan on therapeutic RNA dining program, dated 12/15/2022, was reviewed with RNA Team Leader (RNA TL). Resident 1 ' s Care Plan indicated the RNA dining program was for breakfast and lunch to promote dietary intake and decrease distraction at mealtime. The RNA TL stated that she created the RNA care plans for the residents on the RNA program and updated the RNA care plans every three months based on the MDS assessment or on the residents ' change of condition. Resident 1 ' s Care Plan goal on the therapeutic dining program had a target date of 8/24/2023. The RNA TL stated that Resident 1 was on the continuous RNA dining program. The RNA TL stated that Resident 1 ' s care plan was not updated after the target date. The RNA TL stated that she should ensure Resident 1 ' s RNA dining program care plan was updated. The TL stated that care plans that were not updated had the potential for resident ' s care to not be good. The RNA TL stated that the RNA dining program was for breakfast and lunch only. The RNA TL stated that the RNAs assist the residents in eating and the family waits until the resident had finished eating. The RNA TL stated that RNAs were scheduled from 6:30 a.m. to 3 p.m. to assist residents during breakfast and lunch. RNA TL stated that CNAs assist the residents on eating dinner. The RNA TL stated that she did not know if the resident ' s family were allowed to assist residents on the RNA dining program.
On 5/9/2024 at 11:28 a.m., during a concurrent observation and interview, maintenance staff (MS) measured the distance from the right far end patio table located at the north dining room patio to Resident 1 ' s bedside where the facility staff performed CPR on the resident. MS stated that the total distance was 188 feet (ft - unit of measurement).
On 5/9/2024 at 2:15 p.m., during a concurrent interview and record review, the DON stated that Resident 1 ' s family members were given teachings on aspiration precautions during interdisciplinary team (IDT-a group of health care professionals with various area of expertise who work together toward the goals of the resident) meetings. Resident 1 ' s Interdisciplinary Care Conference Review form was reviewed with the DON, dated 6/16/2022, 9/13/2022, 12/6/2022, 2/28/2023, 5/23/2023, 8/15/2023, 11/07/2023, and 1/30/2024, indicated that Resident 1 ' s family members participated through telephone call on one of eight interdisciplinary care conferences. The document did not indicate that Resident 1 ' s family members were provided instructions on aspiration precautions on all eight interdisciplinary care conferences. Resident 1 ' s RN/LVN Notes were also reviewed with the DON, and she was not able to provide documented evidence that Resident 1 ' s family members received specific instructions on assisting the resident while eating.
On 5/10/2024 at 1:25 p.m., during a telephone interview, FM 1 stated that around 5:30 p.m. on 3/9/2024, FM 1 saw Resident 1 sitting in a wheelchair inside the north dining room. FM 1 stated that LEC 1 handed Resident 1 ' s dinner tray to FM 1 and told FM 1 to assist Resident 1 on eating the dinner at the north dining room patio. FM 1 stated that Resident 1 had a puree food on the dinner tray. FM 1 went in the dining room twice to get water. FM 1 gave Resident 1 two plastic spoons of mashed potatoes, but the resident spat out the second spoon of mashed potatoes. FM 1 placed Resident 1 ' s dinner tray on the side. FM 1 stated that upon turning back towards Resident 1, FM 1 saw the resident ' s eyes was looking up and the resident was not responding. FM 1 stated there were no facility staff in the north dining room patio while FM 1 was assisting Resident 1 with the dinner. FM 1 stated that the facility staff did not teach FM 1 about Resident 1 ' s aspiration precautions.
On 5/13/2024 at 8:25 a.m., during a concurrent observation and interview, observed a large orange water container on a cart with transparent plastic cups on the side. The water container was located on the far-left corner of the north dining room coming from the patio door. LEC 3 stated that the facility staff provided water with thickener to residents on aspiration precautions based on the posted list of residents who are on thickener.
On 5/13/2024 at 10:40 a.m., during a concurrent interview and record review, the Director for Staff Development (DSD) stated that she used the same checklist competency for RNAs and CNAs. The DSD stated that both RNAs and CNAs were trained to assist residents on eating.
On 5/13/2024 at 11:19 a.m., during a follow up interview, the DSD stated residents that required eating assistance, losing weight, and residents requiring extra time to eat were assigned to the RNA dining program for breakfast and lunch. The DSD stated that the RNAs were required to have a special training and a certificate.
On 5/13/2024 at 3:50 p.m., during a follow up telephone interview, FM 1 stated Resident 1 ' s tray did not have water in it. FM 1 went inside the north dining room and took a cup of water from the orange water container. FM 1 stated that facility staff were present in the north dining room when FM 1 went inside and got Resident 1 a cup of water. FM 1 stated that facility staff saw her getting water from the orange water container. The facility staff did not ask FM 1 who the water was for and did not offer help. FM 1 stated that Resident 1 ' s tray included a pre-packed orange juice which FM 1 gave the resident. Resident 1 finished drinking the orange juice without using a straw. FM 1 stated that facility staff did not provide FM 1 training on assisting Resident 1 on eating.
On 5/14/2024 at 10:31 a.m., during a concurrent interview and record review, the policies titled Education of Residents and Aspiration Precautions were reviewed with the ADM. The ADM stated family education does not need to be specific. ADM was asked to read the facility-provided policy and procedure titled, Education of Residents, dated 1/29/2024. The ADM stated that the policy indicated documentation is performed by the responsible discipline and will include a description of the education provided to the resident/family/responsible party. The policy titled, Aspiration Precautions, dated 1/29/2024, was reviewed with the ADM. The ADM stated that the policy indicated that residents identified for aspiration, exhibiting signs of impaired swallowing, or displaying symptoms of potential aspiration will have aspiration precautions implemented. Aspiration precautions included assistance with feeding and supervision as indicated in the resident ' s plan of care. Resident 1 ' s care plan on therapeutic diet was reviewed with the ADM. The ADM stated the care plan intervention included to set up tray and assist resident daily. The ADM was asked to elaborate on the word daily. The ADM stated that daily meant all meals and snack times. The ADM was asked to elaborate the word assist. The ADM stated that assist meant putting the tray in front of[TRUNCATED]

Based on interview and record review, the facility failed to ensure the resident was free from any significant medication error for one of three sampled residents (Resident 1). There was no documented evidence that Licensed Vocational Nurse 1 (LVN 1) and LVN 2 administered metoprolol tartrate (medication used to treat high blood pressure) on 4/14/2024 and 4/15/2024 at 8 p.m., as per physician ' s order, to Resident 1.
This deficient practice had the potential to result in uncontrolled elevated blood pressure.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/27/2024 with diagnoses that included Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks), unspecified (unconfirmed) atrial fibrillation (irregular heartbeat), and essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition).
A review of Resident 1 ' s Care Plan on at risk for episode of hypertension (high blood pressure) or hypotension (low blood pressure), dated 2/27/2024, indicated an intervention to monitor blood pressure and pulse and administer metoprolol tartrate by mouth as ordered.
A review of Resident 1 ' s History and Physical (H&P), dated 2/28/2024, indicated the resident had fluctuating capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/5/2024, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.
A review of Resident 1 ' s Physician Order, dated 4/12/2024, indicated an order for metoprolol tartrate 50 milligram (mg - unit of measurement), one tablet by mouth three times a day, hold for systolic blood pressure (sbp - pressure in the arteries when the heart beats) less than 100 or hear rate less 60.
During an interview and record review on 4/18/2024 at 9:39 a.m., with Registered Nurse 1 (RN 1), Resident 1 ' s Medication Administration Record (MAR), dated 4/2024, and RN Progress Notes, dated 4/14/2024 and 4/15/2024, were reviewed. The MAR indicated on 4/14/2024 and 4/15/2024 at 8 p.m., metoprolol was left blank. RN 1 stated medication was not given if not signed. RN 1 stated Progress Note, dated 4/14/2024 and 4/15/2024, did not indicate if metoprolol tartrate was given.
During an interview on 4/18/2024 at 10:57 a.m., the Director of Nursing (DON) stated nurses should sign the MAR if medication was administered.
During an interview on 4/18/2024 at 11:32 am., Licensed Vocational Nurse 1 (LVN 1) stated there was no documented evidence that metoprolol tartrate was administered on 4/15/2024 at 8 p.m.
During an interview on 4/18/2024 at 1:26 p.m., LVN 2 stated there was no documented evidence that metoprolol tartrate was administered on 4/14/2024 at 8 p.m.
A review of the facility ' s policy and procedure titled, Medication-Administration, dated 7/1/2016 and reviewed on 1/29/2024, indicated, Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner The licensed nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the MAR.

Based on interview and record review, the facility failed to ensure one of five sampled resident (Resident 2) was free of any significant medication error when Licensed Vocational Nurse failed to administer metoprolol tartrate (medication that works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure [the pressure of blood pushing against the walls of your arteries]) to Resident 2 as prescribed for four out of four days.
This deficient practice had the potential for Resident 2 ' s blood pressure to be elevated.
Findings:
A review of Resident 2 admission Record indicated the facility admitted the resident on 12/16/2023 with diagnosis including atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time), atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), hypertensive heart disease (when the pressure in your blood vessels is too high [140/90 mmHg or higher]), and chronic diastolic (congestive) heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen).
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/18/2024, indicated Resident 2 had the ability to be understood and be understood. The MDS indicated Resident 2 required moderate assistance with oral hygiene, toileting hygiene, showering, upper and lower body dressing, and putting on and taking off footwear.
A review of the Physician ' s Orders for Resident 2, dated 12/16/2023, indicated metoprolol tartrate tablet 25 milligrams (mg- a unit of measurement) give 1 tablet by mouth two times a day related to hypertensive heart disease with food or snack. Hold if systolic blood pressure (SBP-pressure in your arteries when your heart beats) is less than 110 or heart rate is less than 60.
A review of Resident 2 ' s Medication Administration Record (MAR- is a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) for 4/2024 indicated:
- metoprolol tartrate 25 mg give 1 tablet by mouth two times a day and hold if SBP is less than 110 or heart rate is less than 60. Medication was not given for the 7 p.m. dose on 4/1/2024 through 4/4/2024
- monitor temperature, respiratory symptoms, and vital signs every shift. The blood pressure and heart rate for evening shift on:
-4/1/2024: B/P: 126/52, HR: 79
-4/2/2024: B/P: 122/61, HR:73
-4/3/2024: B/P: 126/67, HR: 70
-4/4/2024: B/P: 126/70, HR: 75
During a concurrent record review and interview on 4/9/2024 at 3:57 p.m., the Risk Manager (RM) stated MAR indicates metoprolol tartrate is prescribed two time a day and will have to verify with the nurse but from MAR it appears the medication was not given from 4/1/2024 to 4/4/2024.
During an interview on 4/9/2024 at 4:12 p.m., Licensed Vocational Nurse 3 (LVN 3) stated she worked on 4/2/2024 and 4/3/2024 from 3 p.m. to 11 p.m. LVN 3 stated does recall administering metoprolol tartrate to Resident 2, checked Resident 2 vital and they were within range and administered the medication. LVN 3 stated the MAR for Resident 2 indicates the medication was not given. LVN 3 stated reasoning for documenting medication is to ensure the medication was in fact given. LVN 3 stated if the medication is not documented can be a risk that we missed the medication, and if not given the blood pressure can increase. LVN 3 stated if not documented unable to verify the medication was given.
During an interview on 4/9/2024 at 4:24 p.m., RM stated for all medication administration the documentation should be as soon as the administration is done, if the documentation is not done the administration did not happen. The RM stated the risk for not documenting can be for a medication error, also for Resident 2 it was a blood pressure medication and not getting the medication can increase Resident 2 ' s blood pressure.
A review of the facility ' s policies and procedures titled, Medication- Administration, last revised on 7/2016, indicated medication will be administered by a Licensed Nurse per the order of an Attending Physician or independent practitioner. The License Nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dignity when on 4/8/2024 the Restorative Nursing Assistant 2 (RNA 2) failed to assist a resident with their meals at eye-level for one out of five sampled residents (Resident 5).
This deficient practice had the potential to affect Resident 5's self-worth.
Findings:
A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 3/28/2020 and was readmitted on [DATE] with diagnoses that included hemiplegia (paralysis that affects only one side of your body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), dysphagia (swallowing difficulties), dementia (the loss of cognitive functioning — thinking, remembering, and reasoning — to such an extent that it interferes with a person's daily life and activities), and Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks).
A review of the Physician ' s Orders, dated 9/7/2022, indicated fortified diet easy to chew texture, regular consistency.
A review of Resident 5 ' s Care Plan developed on 5/25/2023 for Resident 5's therapeutic fortified easy to chew diet secondary to possible weight loss and dysphagia, included in the intervention to assist resident during all meals and snack times, encourage resident to consume at least 85% of meals daily, RNA to provide therapeutic dining program for breakfast and lunch and to follow safe swallow precaution as ordered.
A review of Resident 5 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 1/31/2024, indicated Resident 5 was able to sometimes understand and was sometimes understood. The MDS indicated Resident 5 was dependent on eating, oral hygiene, showering, upper and lower body dressing, and personal hygiene. The MDS further indicate Resident 5 requires mechanically altered diet, change in texture of food or liquids (e.g., pureed food, thickened liquids).
During a concurrent observation and interview on 4/8/2024 at 9:44 a.m. in Resident 5 ' s room observed RNA 2 standing over Resident 5, Resident 5 is sitting up in wheelchair with bedside table in front of Resident 5, a chair is observed in Resident 5 ' s room. RNA 2 stated she just started feeding Resident 5 gave her a banana and an egg. RNA 2 then proceed to pull the chair in Resident 5 room next to Resident 5 and RNA 2 sat next to Resident 5. RNA 2 stated she should be sitting at eye level with Resident 5 this provided respect and dignity to the resident. RNA 2 stated that there is a need to be eye level to ensure resident is done with food, ensure that the resident is not pocketing any food, and is not risk for choking.
During an interview on 4/9/2024 at 4:24 p.m Risk Management (RM) stated staff should not be standing over resident when they assist them with their meals. The RM stated issue with dignity when staff stand over resident need to respect resident dignity. The RM stated there are issues with not having a visualization of the resident ' s mouth because there is a need to see if resident is pocketing food to avoid any aspiration.
A review of the facility ' s Policy and Procedures titled, Resident Rights, last revised on 5/2023, indicated, the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident ' s individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 1, Resident 2, and Resident 3) received the necessary care to prevent falls. The facility failed to:
1. Ensure Resident 1 was monitored for behaviors of restlessness and constant episodes of standing up from the wheelchair.
As a result, on 1/16/2024 at 11 a.m., Resident 1 fell out of the wheelchair hitting the floor, left shoulder first. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where the resident was diagnosed with left shoulder traumatic fracture (broken bone). Resident 1 required a left shoulder arthroplasty (a surgical procedures that removes damaged areas of the bone and replace them with parts made of metal and plastic).
2. Ensure Resident 2 was monitored for impulsive behaviors, restlessness, and episodes of trying to get out of bed.
As a result, on 1/22/2024 at 4:15 a.m. and 1/23/2024 at 5:10 a.m., Resident 2 was found on the floor in the resident ' s room. Resident 2 was transferred to General Acute Care Hospital 2 (GACH 2) where the resident was diagnosed with intertrochanteric fracture (broken hip bone) of the left hip. Resident 2 required a left hip intramedullary nail fixation (a surgical procedure in which a metal rod inserted into the medullary cavity [central cavity of a bone shaft] of a bone and across the fracture to provide a solid support for the fractured bone).
3. Ensure Resident 3 was monitored for non-compliance behavior, [NAME] back posture, and constant episodes of trying to get out of bed.
As a result, on 1/25/2024 at 11:20 p.m., Resident 3 was found on the floor in the resident ' s room. Resident 2 was transferred to General Acute Care Hospital 2 (GACH 2) where the resident sustained multiple facial and spinal fractures.
Cross reference to F656.
Findings:
1. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/13/2023 with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills), dementia (the loss of cognitive [thinking, remembering, and reasoning] function to such an extent that it interferes with the person ' s daily life and activities), and age-related osteoporosis (occurs when the bone naturally lose density and their ability to regrow or remodel which makes the bones more fragile than they should be).
A review of Resident 1 ' s Care Plan for fall risk, initiated on 2/24/2023, indicated the resident was at risk for falls because of impaired vision and unsteady balance during transition and walking, only able to stabilize balance with staff assistance. The care plan had an added problem on 8/11/2023 indicating Resident 1 was only able to stabilize balance with staff assistance when moving from seated to standing position, walking, turning around and facing the opposite direction while walking, and moving on and off the toilet. The care plan intervention included to assess Resident 1 ' s balance for steadiness during transition and provide assistance to stabilize balance as needed.
A review of Resident 1 ' s History and Physical, dated 4/28/2023, indicated that the resident did not have the capacity to understand and make decisions.
A review of Resident 1 ' s Care Plan on functional abilities of everyday activities, initiated on 11/3/2023, indicated the resident required assistance on transfers (sit to stand, to and from chair or wheelchair to bed). The care plan interventions included to assist Resident 1 to stand up and get in and out of bed and chair or wheelchair daily as needed.
A review of Resident 1 ' s Weekly Summary, dated 1/2/2024 and 1/9/2024, indicated that the resident had functional limitation (limitation that interfered with daily functions or placed a resident at risk of injury) in range of motion (how far a person can move or stretch a part of the body such as a joint or a muscle) on elbows, hips, and ankles. Resident 1 required assistance on transfer, ambulation (walking), and use of wheelchair.
A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 1/14/2024, indicated the resident had cognitive impairment (conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on sit to stand and chair to chair transfers. Resident 1 had functional limitation in range of motion for both sides of the upper extremity (shoulder, elbow, wrist, and hand) and for both sides of the lower extremity (hip, knee, ankle, and foot). Resident 1 used a walker and wheelchair as mobility devices. The MDS Skin Condition section indicated Resident 1 had a diabetic foot ulcer (an open sore or wound that occurs to people with diabetes [a serious condition where the blood sugar level was too high] and commonly located on the bottom of the foot).
A review of Resident 1 ' s Fall Risk Assessment, dated 1/16/2024, indicated the resident had a total of 18 (highest score not indicated). A total score above 10 represented high risk for falls.
A review of Resident 1 ' s Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 1/16/2024 timed at 11 a.m., signed by RN 1, indicated Life Enrichment Coordinator 1 (LEC 1) saw Resident 1 in the dining room, trying to get up and out of the wheelchair, tripped over the wheelchair ' s footrest, and fell on the floor hitting the left side of the body. RN 1 documented that Resident 1 had a left heel diabetic ulcer RN 1 documented that Resident 1 was not able to move the left upper extremity and complained of pain on the left arm. Resident 1 was given ice pack and Tylenol 650 milligrams (mg – unit of measurement) for pain. RN 1 documented that attending physician 1 (MD 1) was notified and gave an order to transfer Resident 1 to GACH 1.
A review of Resident 1 ' s Physician Order Sheet, dated 1/16/2024, indicated to transfer the resident to GACH 1 status post (s/p - after) fall and probable fracture of left arm.
A review of Resident 1 ' s GACH 1 emergency room (ER) Template, dated 1/16/2024 at 1:30 p.m., indicated Resident 1 had left shoulder and left knee tenderness (pain or discomfort when an affected area is touched) with palpation (a method of feeling with the fingers or hands during a physical examination).
A review of Resident 1 ' s GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the left shoulder report, dated 1/16/2024 at 3:20 p.m., indicated the resident sustained a comminuted moderately displaced fracture (occurs when the bone snaps into two or more pieces and moves so that the two ends are not lined up straight) of the humeral head (large rounded part of the humerus [upper arm]) and surgical neck (the bony constriction at the end of a bone) of the humerus.
A review of Resident 1 ' s GACH 1 Discharge Summary Note, dated 1/24/2024, indicated the discharge diagnoses included s/p fall with traumatic fracture of the left shoulder and s/p left shoulder arthroplasty.
On 2/5/2024 at 9:49 a.m., during an interview, LEC 1 stated that Resident 1 had been observed standing up and then sits back again while in the dining room. LEC 1 stated Resident 1 was forgetful. LEC 1 stated that she saw Resident 1 stand up, stepped sideways to the left, and tried to get out of the wheelchair but fell on the floor hitting the resident ' s left shoulder.
On 2/5/2024 at 10:24 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 required maximum assistance on body movement and activities of daily living.
On 2/5/2024 at 1:15 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was a high fall risk because the resident had the behavior of wanting to get up from the wheelchair unassisted. LVN 1 stated that Resident 1 was forgetful and confused.
On 2/5/2024 at 3:59 p.m., during a concurrent interview and record review, Resident 1 ' s medical records were reviewed with the Director of Rehabilitation (DOR). Resident 1 ' s Physical Therapy (PT) Discharge summary, dated [DATE], indicated the Resident 1 ' s long term goal required supervised assistance to complete a sit-to-stand movement and transfers. The PT Discharge Summary indicated Resident 1 required a standby assistance (SBA) to safely ambulate (walk) on level surfaces using a two-wheeled walker with supervised assistance for proper positioning with use of activity pacing and with ability to right self to achieve or maintain balance. The DOR stated that SBA meant the facility staff was required to be beside Resident 1, ready to hold the resident if needed and provide verbal or tactile (touch) cues. The DOR stated that Resident 1 needed SBA with activities of daily living (ADL) and gait. The DOR stated that Resident 1 ' s discharge status indicated the resident was at risk for falls.
On 2/6/2024 at 4:25 p.m., during a concurrent interview and record review, Resident 1 ' s medical records were reviewed with the Director of Nursing (DON). Resident 1 ' s Care Plan on risk for falls indicated that the resident required assistance to stabilize balance as needed. The DON stated that Resident 1 had periods of confusion and required assistance with ADLs. The DON stated that the facility did not exhaust all the efforts or interventions at the same time so they will have interventions if another incident occurs. The DON stated that the facility would do better in creating and implementing Resident 1 ' s care plan interventions.
2. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 5/9/2023 with diagnoses including dementia (the loss of cognitive [thinking, remembering, and reasoning] function to such an extent that it interferes with the person ' s daily life and activities), and age-related osteoporosis (occurs when the bone naturally lose density and their ability to regrow or remodel which makes the bones more fragile than they should be), and anxiety disorder (a persistent and excessive worry that interferes with daily activities).
A review of Resident 2 ' s History and Physical, dated 5/22/2023, indicated that the resident did not have the capacity to understand and make decisions.
A review of Resident 2 ' s Care Plan for fall risk, initiated on 5/22/2023, indicated the resident was at risk for falls because of impaired vision and unsteady balance during transition and only able to stabilize balance with staff assistance. The Care Plan indicated that Resident 2 had impairment of the upper extremities (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot) on both sides, muscle weakness, abnormalities of gait (a manner of walking or moving on foot) and mobility and had history of falls. The Care Plan had an added problem on 5/21/2023 indicating Resident 2 was observed on the floor next to the resident ' s bed. The interventions, initiated on 5/22/2023, included to instruct and assist Resident 2 to sit at the edge of bed, dangle feet, count from one to 20 before transferring to prevent dizziness or fall and to place Resident 2 in the falling star program to alert staff of the resident ' s high risk for falls. The Care Plan had an added problem on 8/6/2023 indicating Resident 2 was observed on the floor in the dining room. The Care Plan had an added problem on 1/22/2024 and 1/23/2024 indicating Resident 2 was observed on the floor next to the resident ' s bed. The interventions, initiated on 1/22/2024, included Resident 2 may have a floor mat (a protective pad made from high density foam to prevent injuries in the event a person falling to the floor) next to bed to prevent injuries.
A review of Resident 2 ' s Care Plan on functional abilities of everyday activities, initiated on 11/8/2023, indicated the resident required assistance on bed mobility (rolling, sitting to lying, and lying to sitting) and transfers (sit to stand, to and from chair or wheelchair to bed). The Care Plan interventions included to assist Resident 2 with sit to lying, lying to sitting position changes, to roll side to side, and to stand up and get in and out of bed and chair or wheelchair daily as needed.
A review of Resident 2 ' s Fall Risk Assessment, dated 1/15/2024, indicated the resident had a total of 24. A total score above 10 represented high risk for falls.
A review of Resident 2 ' s Weekly Summary, dated 1/20/2024, indicated that the resident had functional limitation (limitation that interfered with daily functions or placed a resident at risk of injury) in range of motion (how far a person can move or stretch a part of the body such as a joint or a muscle) on elbows, hips, and ankles. Resident 2 required assistance on Activities of Daily Living (ADL) such as bed mobility, transfers, and ambulation (walking).
A review of Resident 2 ' s MDS, dated [DATE], indicated the resident had cognitive impairment (conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 2 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on rolling left to right, lying to sitting on side of bed, sit to stand, and chair to chair transfers. Resident 2 had functional limitation in range of motion for both sides of the upper and lower extremities. Resident 2 used a wheelchair as mobility device.
A review of Resident 2 ' s Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 1/22/2024 timed at 4:15 a.m., signed by RN 2, indicated that Certified Nursing Assistant 1 (CNA 1) saw Resident 2 sitting on the floor next to the resident ' s bed. Attending Physician 2 (MD 2) was notified and gave an order to transfer Resident 2 to GACH 2.
A review of Resident 2 ' s Physician Order Sheet, dated 1/22/2024, indicated an order to transfer the resident to GACH 2 status post (s/p - after) fall and right hip pain.
A review of Resident 2 ' s GACH 2 Imaging section of the Emergency Department Reports, dated 1/22/2024, indicated an imaging procedure was done on the resident ' s right hip and right knee. Resident 2 ' s imaging results indicated there were no fractures on the right hip and right knee.
A review of Resident 2 ' s RN / LVN Progress Notes, dated 1/23/2024 timed at 5:10 a.m., signed by RN 3, indicated that Resident 2 was observed on the floor next to the resident ' s bed, yelling and verbalizing pain on the left leg. Resident 2 refused pain medication. Resident 2 was not able to stand up even with facility staff assistance. MD 2 was notified and gave an order for x-ray (imaging that creates different shades of black and white pictures of the inside of the body) and to transfer Resident 2 to GACH 2.
A review of Resident 2 ' s Physician Order Sheet, dated 1/23/2024, indicated an order for x-ray of the left femur (thigh bone) and left tibia and fibula (two long bones in the lower leg) and to transfer the resident to GACH 2 status post (s/p - after) fall.
A review of Resident 2 ' s GACH 2 Emergency Department (ED) Reports, dated 1/23/2024 at 9:16 a.m., indicated that the resident was brought in by ambulance for the complaint of multiple falls. The History of Present Illness section indicated that Resident 2 complained of left hip pain. The ED report indicated that the nursing facility ' s Director of Nursing (DON) reported to the GACH 2 ' s staff that Resident 2 was a very agitated individual who required a one-on-one sitter (a staff that were immediately at hand to help prevent a fall or redirect a patient from engaging in a harmful act) and was found on the floor after a fall from the resident ' s bed.
A review of Resident 2 ' s GACH 2 General Diagnostic report, dated 1/23/2024 at 2:30 p.m., indicated the resident sustained a left femoral intertrochanteric fracture.
A review of Resident 2 ' s GACH 2 Surgery and Procedure Reports, dated 1/24/2024 at 8:28 p.m., indicated the resident had a left hip intramedullary nail fixation.
A review of Resident 2 ' s GACH 2 Discharge Summaries Notes, dated 1/28/2024 at 4:40 p.m., indicated the resident was discharged to the skilled nursing facility with a final diagnoses including intertrochanteric fracture of the left hip s/p left hip intramedullary nail fixation performed on 1/24/2024.
On 2/5/2024 at 2:50 p.m., during a concurrent interview and record review, Resident 2 ' s medical records were reviewed with RN 4. RN 4 stated that Resident 2 was able to stand up but could not ambulate. RN 4 stated that Resident 2 was confused, a high fall risk, and not able to make needs known. RN 4 stated that Resident 2 did not have a floor mat before the fall on 1/22/2024.
On 2/5/2024 at 3:59 p.m., during a concurrent interview and record review, Resident 2 ' s medical records were reviewed with the Director of Rehabilitation (DOR). Resident 2 ' s Physical Therapy (PT) Discharge summary, dated [DATE], indicated the resident required moderate assistance on bed mobility, transfers, and activities of daily living (ADL). The DOR stated that Resident 2 ' s discharge status indicated the resident was at risk for falls.
On 2/6/2024 at 3:38 p.m., during a telephone interview, Certified Nursing Assistant 1 (CNA 1) stated that Resident 2 was confused, impulsive, and trying to stand up without assistance. CNA 1 stated that Resident 2 was able to stand up with staff assistance but was unsteady and wobbly. CNA 1 Stated that he found Resident 2 on the floor beside the resident ' s bed. CNA 1 stated that Resident 2 was grimacing and was holding the left leg.
On 2/6/2024 at 4:25 p.m., during a concurrent interview and record review, Resident 2 ' s medical records were reviewed with the DON. Resident 2 ' s Care Plan on risk for falls indicated that the resident required assistance to stabilize balance as needed. The DON stated that Resident 2 required assistance with ADLs. The DON stated that Resident 2 was not impulsive but was confused. The DON stated that the facility did not exhaust all the efforts or interventions at the same time so that they will have interventions if another incident occurs. The DON stated that the facility would do better in creating and implementing the resident ' s care plan interventions.
3. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 2/2/2021 with diagnoses including dementia (the loss of cognitive [thinking, remembering, and reasoning] function to such an extent that it interferes with the person ' s daily life and activities), and age-related osteoporosis (occurs when the bone naturally lose density and their ability to regrow or remodel which makes the bones more fragile than they should be), and benign prostatic hyperplasia (enlarged prostate [a part of the male reproductive system]).
A review of Resident 3 ' s Care Plan for fall risk, initiated on 2/15/2021, indicated the resident was at risk for falls because of impairment of the upper extremities (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot) on both sides and a history of lumbar 3 (part of the spine) wedge compression fracture (occurs when the front of the spinal bone collapsed). The Care Plan had an added problem, dated 5/22/2023 and 7/17/2023, indicated that Resident 3 was observed sitting on the floor in the restroom. The Care Plan indicated that on 1/25/2024, Resident 3 was observed face down on the floor next to the resident ' s bed. The interventions included to assess Resident 3 ' s balance for steadiness during transitions and walking and provide assistance to stabilize balance as needed. The Care Plan did not indicate interventions for Resident 3 ' s fall on 7/17/2023.
A review of Resident 3 ' s History and Physical, dated 2/28/2023, indicated that the resident had fluctuating capacity to understand and make decisions.
A review of Resident 3 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 11/27/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. Resident 3 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on rolling left to right, sit to lying, lying to sitting on side of bed, sit to stand, and chair to chair transfers. Resident 3 had functional limitation in range of motion for both sides of the upper (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot). Resident 3 used a walker and wheelchair as mobility device.
A review of Resident 3 ' s Fall Risk Assessment, dated 11/28/2023, indicated the resident had a total of 25. A total score above 10 represented high risk for falls.
A review of Resident 3 ' s Care Plan on functional abilities of everyday activities, initiated on 12/11/2023, indicated the resident required assistance on bed mobility (rolling, sitting to lying, and lying to sitting) and transfers (sit to stand, to and from chair or wheelchair to bed). Resident 3 required supervision in walking and taking turns with assistive device such as walker. The Care Plan interventions included to assist Resident 3 with rolling left and right with proper body alignment and perform lying to sitting position changes with two or more person physical assistance as needed. The intervention indicated to assist Resident 3 to get in and out of bed and chair daily as needed.
A review of Resident 3 ' s Weekly Summary, dated 1/19/2024, indicated that the resident had functional limitation (limitation that interfered with daily functions or placed a resident at risk of injury) in range of motion (how far a person can move or stretch a part of the body such as a joint or a muscle) on ankles, hips, and knees. Resident 3 required assistance on Activities of Daily Living (ADL) such as bed mobility, transfers, and ambulation (walking).
A review of Resident 3 ' s Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 1/25/2024 timed at 11:20 p.m., indicated that Resident 3 was observed face down on the floor, next to the resident ' s bed. The progress notes indicated that Resident 3 sustained a skin laceration (skin wound) on the nose bridge and a right periorbital (around the eyes) swelling and bruising. Resident 3 complained of headache after the fall and was given pain medication and required ice pack on the nose bridge. The progress notes indicated that Attending Physician 3 (MD 3) was notified and gave an order to transfer Resident 3 to GACH 3.
A review of Resident 3 ' s Physician Order Sheet, dated 1/25/2024, indicated an order to transfer the resident to GACH 3 status post (s/p - after) fall.
A review of Resident 3 ' s GACH 3 Internal Medicine Progress Note, dated 1/28/2024, indicated that the resident was admitted on [DATE] after a facility reported unwitnessed ground-level fall. The progress note indicated Resident 3 was a poor historian and did not remember what happened. The progress note indicated that Resident 3 ' s computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the head indicated the resident sustained a right maxillary sinus (a hollow space in the bones around the nose) fracture and a right orbital wall (boney cavity that contains the eyeball) fracture. Resident 3 ' s magnetic resonance imaging (MRI, a procedure that uses magnets and radio waves to make detailed pictures of the person ' s organs, muscles, soft tissues, and structures) of the cervical spine (neck region of the spinal column or backbone) indicated the resident sustained a fifth and sixth cervical fracture.
On 2/5/2024 at 11:55 a.m., during an observation, Resident 3 was observed walking on the hallway using the front wheeled walker. Resident 3 had a [NAME] back and looking down posture while walking.
On 2/5/2024 at 2:03 p.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated that Resident 3 walked slow and bent forward, using a walker. CNA 2 demonstrated Resident 3 ' s posture while walking and observed CNA 2 walk hunch backed and looking down on the floor.
On 2/5/2024 at 2:50 p.m., during a concurrent interview and record review, Resident 3 ' s medical records were reviewed with RN 4 and indicated that the resident was at risk for falls because of the resident ' s history of falls and non-compliance on calling for help. RN 4 stated that Resident 3 did not have a floor mat (a protective pad made from high density foam to prevent injuries in the event a person falling to the floor) before the fall.
On 2/6/2024 at 3:09 p.m., during a telephone interview, CNA 3 stated that she heard someone calling for help and found Resident 3 lying face down on the floor, beside the resident ' s bed. CNA 3 stated she observed Resident 3 ' s face with blood. CNA 3 stated that she could not remember if Resident 3 had a floor mat.
On/2/6/2024 at 4:05 p.m., during a telephone interview, LVN 1 stated CNA 3 informed her that Resident 3 was on the floor. LVN 1 stated she found the resident lying on the floor beside the resident ' s bed with a laceration between the eyebrows and blood on the floor. LVN 1 stated that Resident 3 ' s blanket was wrapped around the resident ' s body. LVN 1 stated that Resident 3 walks using a walker and had a hunch back posture. LVN 1 stated that Resident 3 had a high risk for falls and was non-compliant with asking for assistance in ambulating.
On 2/6/2024 at 4:25 p.m., during a concurrent interview and record review, Resident 3 ' s medical records were reviewed with the Director of Nursing (DON). Resident 3 ' s Care Plan on risk for falls indicated that the resident required assistance to stabilize balance as needed. The DON stated that Resident 3 required assistance with ADLs and did not have non-compliance behavior. The DON stated that the facility did not exhaust all the efforts or interventions at the same time so they will have interventions if another incident occurs. The DON stated that the facility would do better in creating and implementing the resident ' s care plan interventions.
A review of the facility ' s policy and procedures titled, Fall Risk Assessment, dated 1/29/2024, indicated the purpose that the facility will ensure that the resident ' s environment remains as free of accident hazards as possible, and that each resident receives adequate supervision and assistance to prevent accidents.
A review of the facility ' s policy and procedures titled, Fall Management Program, dated 1/29/2024, indicated the purpose of the policy was to prevent resident falls and minimize complications associated with falls through development of a fall management program. Nursing staff will develop a plan of care specific to the resident ' s needs with interventions to reduce the risk of falls. It also indicated that one of the universal fall prevention measures for all residents was to reassess mobility status and encourage use of assistive devices as appropriate.
A review of the facility ' s policy and procedure titled, Care Planning, dated 1/29/2024, indicated the purpose of the policy was to ensure a comprehensive person-centered care plan was developed for each resident based on their individual assessed needs. Each resident ' s comprehensive care plan would describe services that were to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for three of three sampled residents (Resident 1, Resident 2, and Resident 3). The facility failed to develop and implement individualized care plan interventions addressing:
1. Resident 1 ' s restlessness and constant episodes of standing up from the wheelchair as stated by Life Enrichment Coordinator 1 (LEC 1) and Licensed Vocational Nurse 1 (LVN 1).
As a result, on 1/16/2024 at 11 a.m., Resident 1 fell out of the wheelchair hitting the floor left shoulder first. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where the resident was diagnosed with left shoulder traumatic fracture (broken bone). Resident 1 required a left shoulder arthroplasty (a surgical procedures that removes damaged areas of the bone and replace them with parts made of metal and plastic).
2. Resident 2 ' s impulsive behaviors, restlessness, and episodes of trying to get out of bed as stated by Certified Nursing Assistant 1 (CNA 1).
As a result, on 1/22/2024 at 4:15 a.m. and 1/23/2024 at 5:10 a.m., Resident 2 was found on the floor in the resident ' s room. Resident 2 was transferred to General Acute Care Hospital 2 (GACH 2) where the resident was diagnosed with intertrochanteric fracture (broken hip bone) of the left hip. Resident 2 required a left hip intramedullary nail fixation (a surgical procedure in which a metal rod inserted into the medullary cavity [central cavity of a bone shaft] of a bone and across the fracture in order to provide a solid support for the fractured bone).
3. Resident 3 ' s non-compliance with instructions and hunch backed posture as stated by CNA 2.
As a result, on 1/25/2024 at 11:20 p.m., Resident 3 was found on the floor in the resident ' s room. Resident 2 was transferred to General Acute Care Hospital 2 (GACH 2) where the resident sustained multiple facial and spinal fractures.
Cross reference to F689.
Findings:
1. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/13/2023 with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills), dementia (the loss of cognitive [thinking, remembering, and reasoning] function to such an extent that it interferes with the person ' s daily life and activities), and age-related osteoporosis (occurs when the bone naturally lose density and their ability to regrow or remodel which makes the bones more fragile than they should be).
A review of Resident 1 ' s Care Plan for fall risk, initiated on 2/24/2023, indicated the resident was at risk for falls because of impaired vision and unsteady balance during transition and walking, only able to stabilize balance with staff assistance. The care plan had an added problem on 8/11/2023 indicating Resident 1 was only able to stabilize balance with staff assistance when moving from seated to standing position, walking, turning around and facing the opposite direction while walking, and moving on and off the toilet. The care plan intervention included to assess Resident 1 ' s balance for steadiness during transition and provide assistance to stabilize balance as needed.
A review of Resident 1 ' s History and Physical, dated 4/28/2023, indicated that the resident did not have the capacity to understand and make decisions.
A review of Resident 1 ' s Care Plan on functional abilities of everyday activities, initiated on 11/3/2023, indicated the resident required assistance on transfers (sit to stand, to and from chair or wheelchair to bed). The care plan interventions included to assist Resident 1 to stand up and get in and out of bed and chair or wheelchair daily as needed.
A review of Resident 1 ' s Weekly Summary, dated 1/2/2024 and 1/9/2024, indicated that the resident had functional limitation (limitation that interfered with daily functions or placed a resident at risk of injury) in range of motion (how far a person can move or stretch a part of the body such as a joint or a muscle) on elbows, hips, and ankles. Resident 1 required assistance on transfer, ambulation (walking), and use of wheelchair.
A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 1/14/2024, indicated the resident had cognitive impairment (conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on sit to stand and chair to chair transfers. Resident 1 had functional limitation in range of motion for both sides of the upper extremity (shoulder, elbow, wrist, and hand) and for both sides of the lower extremity (hip, knee, ankle, and foot). Resident 1 used a walker and wheelchair as mobility devices. The MDS Skin Condition section indicated Resident 1 had a diabetic foot ulcer (an open sore or wound that occurs to people with diabetes [a serious condition where the blood sugar level was too high] and commonly located on the bottom of the foot).
A review of Resident 1 ' s Fall Risk Assessment, dated 1/16/2024, indicated the resident had a total of 18 (highest score not indicated). A total score above 10 represented high risk for falls.
A review of Resident 1 ' s Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 1/16/2024 timed at 11 a.m., signed by RN 1, indicated Life Enrichment Coordinator 1 (LEC 1) saw Resident 1 in the dining room, trying to get up and out of the wheelchair, tripped over the wheelchair ' s footrest, and fell on the floor hitting the left side of the body. RN 1 documented that Resident 1 had a left heel diabetic ulcer RN 1 documented that Resident 1 was not able to move the left upper extremity and complained of pain on the left arm. Resident 1 was given ice pack and Tylenol 650 milligrams (mg – unit of measurement) for pain. RN 1 documented that attending physician 1 (MD 1) was notified and gave an order to transfer Resident 1 to GACH 1.
A review of Resident 1 ' s Physician Order Sheet, dated 1/16/2024, indicated to transfer the resident to GACH 1 status post (s/p - after) fall and probable fracture of left arm.
A review of Resident 1 ' s GACH 1 emergency room (ER) Template, dated 1/16/2024 at 1:30 p.m., indicated Resident 1 had left shoulder and left knee tenderness (pain or discomfort when an affected area is touched) with palpation (a method of feeling with the fingers or hands during a physical examination).
A review of Resident 1 ' s GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the left shoulder report, dated 1/16/2024 at 3:20 p.m., indicated the resident sustained a comminuted moderately displaced fracture (occurs when the bone snaps into two or more pieces and moves so that the two ends are not lined up straight) of the humeral head (large rounded part of the humerus [upper arm]) and surgical neck (the bony constriction at the end of a bone) of the humerus.
A review of Resident 1 ' s GACH 1 Discharge Summary Note, dated 1/24/2024, indicated the discharge diagnoses included s/p fall with traumatic fracture of the left shoulder and s/p left shoulder arthroplasty.
On 2/5/2024 at 9:49 a.m., during an interview, LEC 1 stated that Resident 1 had been observed standing up and then sits back again while in the dining room. LEC 1 stated Resident 1 was forgetful. LEC 1 stated that she saw Resident 1 stand up, stepped sideways to the left, and tried to get out of the wheelchair but fell on the floor hitting the resident ' s left shoulder.
On 2/5/2024 at 10:24 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 required maximum assistance on body movement and activities of daily living.
On 2/5/2024 at 1:15 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 was a high fall risk because the resident had the behavior of wanting to get up from the wheelchair unassisted. LVN 1 stated that Resident 1 was forgetful and confused.
On 2/5/2024 at 3:59 p.m., during a concurrent interview and record review, Resident 1 ' s medical records were reviewed with the Director of Rehabilitation (DOR). Resident 1 ' s Physical Therapy (PT) Discharge summary, dated [DATE], indicated the Resident 1 ' s long term goal required supervised assistance to complete a sit-to-stand movement and transfers. The PT Discharge Summary indicated Resident 1 required a standby assistance (SBA) to safely ambulate (walk) on level surfaces using a two-wheeled walker with supervised assistance for proper positioning with use of activity pacing and with ability to right self to achieve or maintain balance. The DOR stated that SBA meant the facility staff was required to be beside Resident 1, ready to hold the resident if needed and provide verbal or tactile (touch) cues. The DOR stated that Resident 1 needed SBA with activities of daily living (ADL) and gait. The DOR stated that Resident 1 ' s discharge status indicated the resident was at risk for falls.
On 2/6/2024 at 4:25 p.m., during a concurrent interview and record review, Resident 1 ' s medical records were reviewed with the Director of Nursing (DON). Resident 1 ' s Care Plan on risk for falls indicated that the resident required assistance to stabilize balance as needed. The DON stated that Resident 1 had periods of confusion and required assistance with ADLs. The DON stated that the facility did not exhaust all the efforts or interventions at the same time so they will have interventions if another incident occurs. The DON stated that the facility would do better in creating and implementing Resident 1 ' s care plan interventions.
2. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 5/9/2023 with diagnoses including dementia (the loss of cognitive [thinking, remembering, and reasoning] function to such an extent that it interferes with the person ' s daily life and activities), and age-related osteoporosis (occurs when the bone naturally lose density and their ability to regrow or remodel which makes the bones more fragile than they should be), and anxiety disorder (a persistent and excessive worry that interferes with daily activities).
A review of Resident 2 ' s History and Physical, dated 5/22/2023, indicated that the resident did not have the capacity to understand and make decisions.
A review of Resident 2 ' s Care Plan for fall risk, initiated on 5/22/2023, indicated the resident was at risk for falls because of impaired vision and unsteady balance during transition and only able to stabilize balance with staff assistance. The Care Plan indicated that Resident 2 had impairment of the upper extremities (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot) on both sides, muscle weakness, abnormalities of gait (a manner of walking or moving on foot) and mobility and had history of falls. The Care Plan had an added problem on 5/21/2023 indicating Resident 2 was observed on the floor next to the resident ' s bed. The interventions, initiated on 5/22/2023, included to instruct and assist Resident 2 to sit at the edge of bed, dangle feet, count from one to 20 before transferring to prevent dizziness or fall and to place Resident 2 in the falling star program to alert staff of the resident ' s high risk for falls. The Care Plan had an added problem on 8/6/2023 indicating Resident 2 was observed on the floor in the dining room. The Care Plan had an added problem on 1/22/2024 and 1/23/2024 indicating Resident 2 was observed on the floor next to the resident ' s bed. The interventions, initiated on 1/22/2024, included Resident 2 may have a floor mat (a protective pad made from high density foam to prevent injuries in the event a person falling to the floor) next to bed to prevent injuries.
A review of Resident 2 ' s Care Plan on functional abilities of everyday activities, initiated on 11/8/2023, indicated the resident required assistance on bed mobility (rolling, sitting to lying, and lying to sitting) and transfers (sit to stand, to and from chair or wheelchair to bed). The Care Plan interventions included to assist Resident 2 with sit to lying, lying to sitting position changes, to roll side to side, and to stand up and get in and out of bed and chair or wheelchair daily as needed.
A review of Resident 2 ' s Fall Risk Assessment, dated 1/15/2024, indicated the resident had a total of 24. A total score above 10 represented high risk for falls.
A review of Resident 2 ' s Weekly Summary, dated 1/20/2024, indicated that the resident had functional limitation (limitation that interfered with daily functions or placed a resident at risk of injury) in range of motion (how far a person can move or stretch a part of the body such as a joint or a muscle) on elbows, hips, and ankles. Resident 2 required assistance on Activities of Daily Living (ADL) such as bed mobility, transfers, and ambulation (walking).
A review of Resident 2 ' s MDS, dated [DATE], indicated the resident had cognitive impairment (conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 2 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on rolling left to right, lying to sitting on side of bed, sit to stand, and chair to chair transfers. Resident 2 had functional limitation in range of motion for both sides of the upper and lower extremities. Resident 2 used a wheelchair as mobility device.
A review of Resident 2 ' s Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 1/22/2024 timed at 4:15 a.m., signed by RN 2, indicated that Certified Nursing Assistant 1 (CNA 1) saw Resident 2 sitting on the floor next to the resident ' s bed. Attending Physician 2 (MD 2) was notified and gave an order to transfer Resident 2 to GACH 2.
A review of Resident 2 ' s Physician Order Sheet, dated 1/22/2024, indicated an order to transfer the resident to GACH 2 status post (s/p - after) fall and right hip pain.
A review of Resident 2 ' s GACH 2 Imaging section of the Emergency Department Reports, dated 1/22/2024, indicated an imaging procedure was done on the resident ' s right hip and right knee. Resident 2 ' s imaging results indicated there were no fractures on the right hip and right knee.
A review of Resident 2 ' s RN / LVN Progress Notes, dated 1/23/2024 timed at 5:10 a.m., signed by RN 3, indicated that Resident 2 was observed on the floor next to the resident ' s bed, yelling and verbalizing pain on the left leg. Resident 2 refused pain medication. Resident 2 was not able to stand up even with facility staff assistance. MD 2 was notified and gave an order for x-ray (imaging that creates different shades of black and white pictures of the inside of the body) and to transfer Resident 2 to GACH 2.
A review of Resident 2 ' s Physician Order Sheet, dated 1/23/2024, indicated an order for x-ray of the left femur (thigh bone) and left tibia and fibula (two long bones in the lower leg) and to transfer the resident to GACH 2 status post (s/p - after) fall.
A review of Resident 2 ' s GACH 2 Emergency Department (ED) Reports, dated 1/23/2024 at 9:16 a.m., indicated that the resident was brought in by ambulance for the complaint of multiple falls. The History of Present Illness section indicated that Resident 2 complained of left hip pain. The ED report indicated that the nursing facility ' s Director of Nursing (DON) reported to the GACH 2 ' s staff that Resident 2 was a very agitated individual who required a one-on-one sitter (a staff that were immediately at hand to help prevent a fall or redirect a patient from engaging in a harmful act) and was found on the floor after a fall from the resident ' s bed.
A review of Resident 2 ' s GACH 2 General Diagnostic report, dated 1/23/2024 at 2:30 p.m., indicated the resident sustained a left femoral intertrochanteric fracture.
A review of Resident 2 ' s GACH 2 Surgery and Procedure Reports, dated 1/24/2024 at 8:28 p.m., indicated the resident had a left hip intramedullary nail fixation.
A review of Resident 2 ' s GACH 2 Discharge Summaries Notes, dated 1/28/2024 at 4:40 p.m., indicated the resident was discharged to the skilled nursing facility with a final diagnoses including intertrochanteric fracture of the left hip s/p left hip intramedullary nail fixation performed on 1/24/2024.
On 2/5/2024 at 2:50 p.m., during a concurrent interview and record review, Resident 2 ' s medical records were reviewed with RN 4. RN 4 stated that Resident 2 was able to stand up but could not ambulate. RN 4 stated that Resident 2 was confused, a high fall risk, and not able to make needs known. RN 4 stated that Resident 2 did not have a floor mat before the fall on 1/22/2024.
On 2/5/2024 at 3:59 p.m., during a concurrent interview and record review, Resident 2 ' s medical records were reviewed with the Director of Rehabilitation (DOR). Resident 2 ' s Physical Therapy (PT) Discharge summary, dated [DATE], indicated the resident required moderate assistance on bed mobility, transfers, and activities of daily living (ADL). The DOR stated that Resident 2 ' s discharge status indicated the resident was at risk for falls.
On 2/6/2024 at 3:38 p.m., during a telephone interview, Certified Nursing Assistant 1 (CNA 1) stated that Resident 2 was confused, impulsive, and trying to stand up without assistance. CNA 1 stated that Resident 2 was able to stand up with staff assistance but was unsteady and wobbly. CNA 1 Stated that he found Resident 2 on the floor beside the resident ' s bed. CNA 1 stated that Resident 2 was grimacing and was holding the left leg.
On 2/6/2024 at 4:25 p.m., during a concurrent interview and record review, Resident 2 ' s medical records were reviewed with the DON. Resident 2 ' s Care Plan on risk for falls indicated that the resident required assistance to stabilize balance as needed. The DON stated that Resident 2 required assistance with ADLs. The DON stated that Resident 2 was not impulsive but was confused. The DON stated that the facility did not exhaust all the efforts or interventions at the same time so that they will have interventions if another incident occurs. The DON stated that the facility would do better in creating and implementing the resident ' s care plan interventions.
3. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 2/2/2021 with diagnoses including dementia (the loss of cognitive [thinking, remembering, and reasoning] function to such an extent that it interferes with the person ' s daily life and activities), and age-related osteoporosis (occurs when the bone naturally lose density and their ability to regrow or remodel which makes the bones more fragile than they should be), and benign prostatic hyperplasia (enlarged prostate [a part of the male reproductive system]).
A review of Resident 3 ' s Care Plan for fall risk, initiated on 2/15/2021, indicated the resident was at risk for falls because of impairment of the upper extremities (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot) on both sides and a history of lumbar 3 (part of the spine) wedge compression fracture (occurs when the front of the spinal bone collapsed). The Care Plan had an added problem, dated 5/22/2023 and 7/17/2023, indicated that Resident 3 was observed sitting on the floor in the restroom. The Care Plan indicated that on 1/25/2024, Resident 3 was observed face down on the floor next to the resident ' s bed. The interventions included to assess Resident 3 ' s balance for steadiness during transitions and walking and provide assistance to stabilize balance as needed. The Care Plan did not indicate interventions for Resident 3 ' s fall on 7/17/2023.
A review of Resident 3 ' s History and Physical, dated 2/28/2023, indicated that the resident had fluctuating capacity to understand and make decisions.
A review of Resident 3 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 11/27/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. Resident 3 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on rolling left to right, sit to lying, lying to sitting on side of bed, sit to stand, and chair to chair transfers. Resident 3 had functional limitation in range of motion for both sides of the upper (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot). Resident 3 used a walker and wheelchair as mobility device.
A review of Resident 3 ' s Fall Risk Assessment, dated 11/28/2023, indicated the resident had a total of 25. A total score above 10 represented high risk for falls.
A review of Resident 3 ' s Care Plan on functional abilities of everyday activities, initiated on 12/11/2023, indicated the resident required assistance on bed mobility (rolling, sitting to lying, and lying to sitting) and transfers (sit to stand, to and from chair or wheelchair to bed). Resident 3 required supervision in walking and taking turns with assistive device such as walker. The Care Plan interventions included to assist Resident 3 with rolling left and right with proper body alignment and perform lying to sitting position changes with two or more person physical assistance as needed. The intervention indicated to assist Resident 3 to get in and out of bed and chair daily as needed.
A review of Resident 3 ' s Weekly Summary, dated 1/19/2024, indicated that the resident had functional limitation (limitation that interfered with daily functions or placed a resident at risk of injury) in range of motion (how far a person can move or stretch a part of the body such as a joint or a muscle) on ankles, hips, and knees. Resident 3 required assistance on Activities of Daily Living (ADL) such as bed mobility, transfers, and ambulation (walking).
A review of Resident 3 ' s Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated 1/25/2024 timed at 11:20 p.m., indicated that Resident 3 was observed face down on the floor, next to the resident ' s bed. The progress notes indicated that Resident 3 sustained a skin laceration (skin wound) on the nose bridge and a right periorbital (around the eyes) swelling and bruising. Resident 3 complained of headache after the fall and was given pain medication and required ice pack on the nose bridge. The progress notes indicated that Attending Physician 3 (MD 3) was notified and gave an order to transfer Resident 3 to GACH 3.
A review of Resident 3 ' s Physician Order Sheet, dated 1/25/2024, indicated an order to transfer the resident to GACH 3 status post (s/p - after) fall.
A review of Resident 3 ' s GACH 3 Internal Medicine Progress Note, dated 1/28/2024, indicated that the resident was admitted on [DATE] after a facility reported unwitnessed ground-level fall. The progress note indicated Resident 3 was a poor historian and did not remember what happened. The progress note indicated that Resident 3 ' s computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the head indicated the resident sustained a right maxillary sinus (a hollow space in the bones around the nose) fracture and a right orbital wall (boney cavity that contains the eyeball) fracture. Resident 3 ' s magnetic resonance imaging (MRI, a procedure that uses magnets and radio waves to make detailed pictures of the person ' s organs, muscles, soft tissues, and structures) of the cervical spine (neck region of the spinal column or backbone) indicated the resident sustained a fifth and sixth cervical fracture.
On 2/5/2024 at 11:55 a.m., during an observation, Resident 3 was observed walking on the hallway using the front wheeled walker. Resident 3 had a [NAME] back and looking down posture while walking.
On 2/5/2024 at 2:03 p.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated that Resident 3 walked slow and bent forward, using a walker. CNA 2 demonstrated Resident 3 ' s posture while walking and observed CNA 2 walk hunch backed and looking down on the floor.
On 2/5/2024 at 2:50 p.m., during a concurrent interview and record review, Resident 3 ' s medical records were reviewed with RN 4 and indicated that the resident was at risk for falls because of the resident ' s history of falls and non-compliance on calling for help. RN 4 stated that Resident 3 did not have a floor mat (a protective pad made from high density foam to prevent injuries in the event a person falling to the floor) before the fall.
On 2/6/2024 at 3:09 p.m., during a telephone interview, CNA 3 stated that she heard someone calling for help and found Resident 3 lying face down on the floor, beside the resident ' s bed. CNA 3 stated she observed Resident 3 ' s face with blood. CNA 3 stated that she could not remember if Resident 3 had a floor mat.
On/2/6/2024 at 4:05 p.m., during a telephone interview, LVN 1 stated CNA 3 informed her that Resident 3 was on the floor. LVN 1 stated she found the resident lying on the floor beside the resident ' s bed with a laceration between the eyebrows and blood on the floor. LVN 1 stated that Resident 3 ' s blanket was wrapped around the resident ' s body. LVN 1 stated that Resident 3 walks using a walker and had a hunch back posture. LVN 1 stated that Resident 3 had a high risk for falls and was non-compliant with asking for assistance in ambulating.
On 2/6/2024 at 4:25 p.m., during a concurrent interview and record review, Resident 3 ' s medical records were reviewed with the Director of Nursing (DON). Resident 3 ' s Care Plan on risk for falls indicated that the resident required assistance to stabilize balance as needed. The DON stated that Resident 3 required assistance with ADLs and did not have non-compliance behavior. The DON stated that the facility did not exhaust all the efforts or interventions at the same time so they will have interventions if another incident occurs. The DON stated that the facility would do better in creating and implementing the resident ' s care plan interventions.
A review of the facility ' s policy and procedures titled, Fall Management Program, dated 1/29/2024, indicated the purpose of the policy was to prevent resident falls and minimize complications associated with falls through development of a fall management program. Nursing staff will develop a plan of care specific to the resident ' s needs with interventions to reduce the risk of falls. It also indicated that one of the universal fall prevention measures for all residents was to reassess mobility status and encourage use of assistive devices as appropriate.
A review of the facility ' s policy and procedure titled, Care Planning, dated 1/29/2024, indicated the purpose of the policy was to ensure a comprehensive person-centered care plan was developed for each resident based on their individual assessed needs. Each resident ' s comprehensive care plan would describe services that were to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the licensed nursing staff failed to communicate to the primary doctor and the diagnostic imaging center (describes a variety of non-invasive methods of looking inside the body to help determine the causes of an injury or an illness, and to confirm a diagnosis) the presence of a cardiac pacemaker (a device used to control an irregular heart rhythm) on a resident undergoing a magnetic resonance imaging (MRI, a non-invasive imaging technology that produces three dimensional detailed anatomical images) of the left wrist without contrast (chemical substances used in MRI scans) to one of three sampled residents (Resident 1).
The deficient practice had the potential for the pacemaker of Resident 1 to malfunction once exposed to the magnetic field of the MRI imaging machine that poses a threat to Resident 1 ' s well-being.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 8/9/2023, with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm), presence of cardiac pacemaker, and atherosclerotic heart disease (thickening or hardening of the arteries [blood vessels]).
A review of Resident 1 ' s History and Physical (H&P), dated 4/3/2023, indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/17/2023, indicated Resident 1 had the ability to make self-understood and understand others. The MDS indicated Resident 1 had a pacemaker.
A review of Resident 1 ' s Care Plan, initiated on 8/18/2021, indicated Resident 1 had a care plan for atrial fibrillation with pacemaker, with an intervention to keep resident away from running microwaves and to educate and instruct resident if cell phone was used that the resident was at risk for malfunctioning of pacemaker.
A review of Resident 1 ' s Physician ' s Order Sheet, dated 6/14/2023, indicated a telephone order for MRI of left wrist (outpatient) without contrast with Medical Doctor (MD) taken by Registered Nurse Supervisor (RN Sup).
A review of Resident 1's Progress Notes, dated 6/20/2023, indicated Resident 1 left at 2:15 p.m. to radiology appointment. The Progress Notes indicated Resident 1 returned at 5:30 p.m. from radiology appointment.
A review of Resident 1 ' s Progress Notes, dated 6/21/2023, indicated unable to do MRI because patient had pacemaker, MD, and Family Member 1 (FM 1) notified. Pacemaker non-compatible with MRI documented by RN Sup.
A review of Resident 1 ' s Progress Notes, dated 6/21/2023, indicated discussed the failure to do MRI on resident with MD who recommended computed axial tomography (CAT, combines a series of x-ray images taken from different angles of the body scan) of left wrist instead and FM 1 notified documented by the Director of Nursing (DON).
During an interview on 9/22/2023, at 9:33 a.m., Licensed Vocational Nurse 2 (LVN 2) stated when they send residents with pacemaker for tests like MRI, they prepare a packet that includes the doctor ' s order, history, medication administration record (MAR), face sheet (a document that gives a patient ' s information at a quick glance), recent laboratory results, code status (describes the type of resuscitation procedures the healthcare team to conduct if the heart stopped beating), and pacemaker documentation. LVN 2 also stated they have a list of pacemaker residents, if the family is taking the resident to the test, they give the packet to the family member and they call the diagnostic imaging center to make them aware of the resident having a pacemaker. If the ambulance transport is used, she gives the packet and report to them, and they also call the diagnostic imaging center. LVN 2 added they place them on nurses notes and document who they gave report to.
During an interview on 9/22/2023, at 11:58 a.m., with the DON, RN Sup stated she cannot recall telling the doctor about the pacemaker and calling the diagnostic imaging center to give report regarding the resident having a pacemaker. The DON stated the licensed nurse should have told the doctor about the pacemaker of the resident and called for report to the diagnostic imaging to make sure that they were aware that the resident had a pacemaker.
During an interview on 9/22/2023, at 1:25 p.m., the Director of Staff Development (DSD) stated every time they send residents with pacemakers to MRI, they should give report to the receiving diagnostic imaging center because the resident has a metallic gadget on the body and the MRI has magnetic field that could interfere with the pacemaker.
During an interview on 9/22/2023, at 3:01 p.m., Medical Doctor (MD) stated he communicated with the diagnostic imaging center that the resident had a pacemaker, and he does not know why they did not do the MRI.
During an interview on 9/22/2023, at 3:22 p.m., the Practice Manager (PM) of the diagnostic imaging center stated there was no record of the name of the doctor endorsing Resident 1. The PM stated there was no documentation also why the MRI was not done. The PM stated that there could be a lot of factors why an MRI was not done, one of them could be that the resident had a pacemaker. The PM added if the doctor insists on having MRI on a resident with a pacemaker, the doctor will send the information ahead of time, it will involve a lot of investigation. The PM further stated what was on the documentation of Resident 1 was physician verbally approved to change the MRI to CAT scan with left wrist. The PM concluded that if the resident was sent with a pacemaker and the doctor okayed it, they still must call the company and ask for the pacemaker card, the screening form filled out and they had to reschedule.
During an interview on 9/22/2023, at 3:50 p.m., Family Member 1 (FM 1) stated she went to the diagnostic imaging center, the manager was not aware that the Resident 1 had a pacemaker. FM 1 stated she filled out the screening form for the father. FM 1 stated the diagnostic imaging manager told her that they cannot do the MRI due to the pacemaker on his father. FM 1 stated the manager told her that the MRI machine can cause interference to the father ' s pacemaker that could place the father in danger.
A review of the facility ' s recent policy and procedure titled, Pacemaker Management, last reviewed on 1/23/2023, indicated staff will not use any electrical appliances (e.g., electric razors) that come in contact with the resident ' s skin. The resident will be advised to avoid microwave ovens, diathermy (a therapeutic treatment that uses electric currents (radio and sound waves) to generate heat in layers of your skin below the surface)or heavy electrical appliances that may cause electrical malfunction. In case the resident requires medical procedures, staff will communicate to primary physician the make and model of pacemaker prior to receiving orders (MRI, CT Scan, X-ray, etc.).
A review of the facility ' s recent policy and procedure titled, Transfer and Discharge, last reviewed on 1/23/2023, indicated should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, the Facility will:
1. Notify the resident ' s Attending Physician;
2. Notify the receiving facility that the transfer is being made;
3. Prepare the resident for transfer;
4. Prepare a transfer form to send with the resident;
5. Notify the resident ' s representative; and
6. Assist in obtaining transportation.
To facilitate a smooth transition of care, the Facility will provide a copy of the following information to the receiving entity, as applicable:
1. Contact information for the practitioner responsible for the care of the resident;
2. Resident representative information, including contact information;
3. Advance Directive information;
4. Special instructions or precautions for ongoing care, as appropriate;
5. Comprehensive care plan goals; and
6. Other necessary information, including a copy of the resident ' s Discharge Summary, as applicable.
Based on interview and record review, the licensed nursing staff failed to communicate to the primary doctor and the diagnostic imaging center (describes a variety of non-invasive methods of looking inside the body to help determine the causes of an injury or an illness, and to confirm a diagnosis) the presence of a cardiac pacemaker (a device used to control an irregular heart rhythm) on a resident undergoing a magnetic resonance imaging (MRI, a non-invasive imaging technology that produces three dimensional detailed anatomical images) of the left wrist without contrast (chemical substances used in MRI scans) to one of three sampled residents (Resident 1).
The deficient practice had the potential for the pacemaker of Resident 1 to malfunction once exposed to the magnetic field of the MRI imaging machine that poses a threat to Resident 1's well-being.
Findings:
A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 8/9/2023, with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm), presence of cardiac pacemaker, and atherosclerotic heart disease (thickening or hardening of the arteries [blood vessels]).
A review of Resident 1's History and Physical (H&P), dated 4/3/2023, indicated Resident 1 had the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/17/2023, indicated Resident 1 had the ability to make self-understood and understand others. The MDS indicated Resident 1 had a pacemaker.
A review of Resident 1's Care Plan, initiated on 8/18/2021, indicated Resident 1 had a care plan for atrial fibrillation with pacemaker, with an intervention to keep resident away from running microwaves and to educate and instruct resident if cell phone was used that the resident was at risk for malfunctioning of pacemaker.
A review of Resident 1's Physician's Order Sheet, dated 6/14/2023, indicated a telephone order for MRI of left wrist (outpatient) without contrast with Medical Doctor (MD) taken by Registered Nurse Supervisor (RN Sup).
A review of Resident 1's Progress Notes, dated 6/20/2023, indicated Resident 1 left at 2:15 p.m. to radiology appointment. The Progress Notes indicated Resident 1 returned at 5:30 p.m. from radiology appointment.
A review of Resident 1's Progress Notes, dated 6/21/2023, indicated unable to do MRI because patient had pacemaker, MD, and Family Member 1 (FM 1) notified. Pacemaker non-compatible with MRI documented by RN Sup.
A review of Resident 1's Progress Notes, dated 6/21/2023, indicated discussed the failure to do MRI on resident with MD who recommended computed axial tomography (CAT, combines a series of x-ray images taken from different angles of the body scan) of left wrist instead and FM 1 notified documented by the Director of Nursing (DON).
During an interview on 9/22/2023, at 9:33 a.m., Licensed Vocational Nurse 2 (LVN 2) stated when they send residents with pacemaker for tests like MRI, they prepare a packet that includes the doctor's order, history, medication administration record (MAR), face sheet (a document that gives a patient's information at a quick glance), recent laboratory results, code status (describes the type of resuscitation procedures the healthcare team to conduct if the heart stopped beating), and pacemaker documentation. LVN 2 also stated they have a list of pacemaker residents, if the family is taking the resident to the test, they give the packet to the family member and they call the diagnostic imaging center to make them aware of the resident having a pacemaker. If the ambulance transport is used, she gives the packet and report to them, and they also call the diagnostic imaging center. LVN 2 added they place them on nurses notes and document who they gave report to.
During an interview on 9/22/2023, at 11:58 a.m., with the DON, RN Sup stated she cannot recall telling the doctor about the pacemaker and calling the diagnostic imaging center to give report regarding the resident having a pacemaker. The DON stated the licensed nurse should have told the doctor about the pacemaker of the resident and called for report to the diagnostic imaging to make sure that they were aware that the resident had a pacemaker.
During an interview on 9/22/2023, at 1:25 p.m., the Director of Staff Development (DSD) stated every time they send residents with pacemakers to MRI, they should give report to the receiving diagnostic imaging center because the resident has a metallic gadget on the body and the MRI has magnetic field that could interfere with the pacemaker.
During an interview on 9/22/2023, at 3:01 p.m., Medical Doctor (MD) stated he communicated with the diagnostic imaging center that the resident had a pacemaker, and he does not know why they did not do the MRI.
During an interview on 9/22/2023, at 3:22 p.m., the Practice Manager (PM) of the diagnostic imaging center stated there was no record of the name of the doctor endorsing Resident 1. The PM stated there was no documentation also why the MRI was not done. The PM stated that there could be a lot of factors why an MRI was not done, one of them could be that the resident had a pacemaker. The PM added if the doctor insists on having MRI on a resident with a pacemaker, the doctor will send the information ahead of time, it will involve a lot of investigation. The PM further stated what was on the documentation of Resident 1 was physician verbally approved to change the MRI to CAT scan with left wrist. The PM concluded that if the resident was sent with a pacemaker and the doctor okayed it, they still must call the company and ask for the pacemaker card, the screening form filled out and they had to reschedule.
During an interview on 9/22/2023, at 3:50 p.m., Family Member 1 (FM 1) stated she went to the diagnostic imaging center, the manager was not aware that the Resident 1 had a pacemaker. FM 1 stated she filled out the screening form for the father. FM 1 stated the diagnostic imaging manager told her that they cannot do the MRI due to the pacemaker on his father. FM 1 stated the manager told her that the MRI machine can cause interference to the father's pacemaker that could place the father in danger.
A review of the facility's recent policy and procedure titled, Pacemaker Management, last reviewed on 1/23/2023, indicated staff will not use any electrical appliances (e.g., electric razors) that come in contact with the resident's skin. The resident will be advised to avoid microwave ovens, diathermy (a therapeutic treatment that uses electric currents (radio and sound waves) to generate heat in layers of your skin below the surface)or heavy electrical appliances that may cause electrical malfunction. In case the resident requires medical procedures, staff will communicate to primary physician the make and model of pacemaker prior to receiving orders (MRI, CT Scan, X-ray, etc.).
A review of the facility's recent policy and procedure titled, Transfer and Discharge, last reviewed on 1/23/2023, indicated should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, the Facility will:
1. Notify the resident's Attending Physician;
2. Notify the receiving facility that the transfer is being made;
3. Prepare the resident for transfer;
4. Prepare a transfer form to send with the resident;
5. Notify the resident's representative; and
6. Assist in obtaining transportation.
To facilitate a smooth transition of care, the Facility will provide a copy of the following information to the receiving entity, as applicable:
1. Contact information for the practitioner responsible for the care of the resident;
2. Resident representative information, including contact information;
3. Advance Directive information;
4. Special instructions or precautions for ongoing care, as appropriate;
5. Comprehensive care plan goals; and
6. Other necessary information, including a copy of the resident's Discharge Summary, as applicable.

Based on interview and record review, the facility failed to implement infection control practices for one of three sampled resident (Resident 1) by:
1. Failing to conduct an immediate search for any exposed residents and staff who had contact with Resident 1 who was confirmed positive for scabies (an infestation of mites [tiny insects] characterized by small, red bumps and intense itching. This highly contagious infection often spreads from person to person during close contact) on 3/30/2022.
2. Failing to create a contact identification list as per facility's policy and procedure.
These deficient practices had the likelihood to spread scabies infestation to other residents and staff.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 8/9/2021 with the diagnoses that included atrial fibrillation (irregular heartbeat), atherosclerotic heart disease (thickening or hardening of arteries [A vessel that carries oxygen-rich blood to the body] without angina pectoris (chest pain), Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and pruritus (severe itching).
A review of Resident 1 ' s History and Physical, dated 8/10/2021, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/7/2022, indicated Resident 1 ' s cognition (mental action or process of acquiring knowledge and understanding) skills for daily decision were moderately impaired. The MDS indicated Resident 1 needed extensive one person assistance for dressing, toilet use and personal hygiene.
A review of Resident 1 ' s Visit Note (VN) dated on 3/30/2022, which was provided by DD's clinic, indicated the resident went to see a Dermatologist Doctor (DD- medical doctor who specializes in treating the skin, hair, and nails). The VN indicated Resident 1 was seen for a complaint of red and itchy rash on the right leg and trunk (includes the shoulders, chest, lower abdomen, back and buttocks). The VN indicated a skin scrape (scooping out) was done from the left anterior (front) distal (away) thigh, placed on a glass side and an examination of the slide showed scabies. The VN indicated resident and family member was notified. The VN indicated scabies is an infestation of mites that is very contagious and household contacts should be treated.
A review of Resident 1 ' s Physician Order, dated 3/30/2022, indicated the following orders.
1. Ivermectin (medication used to treat parasite) three milligrams (mg-unit of measure) tablet. Take four tablets now by mouth and then in three days.
2. Permethrin (medication used to treat scabies [an infestation of tiny insects characterized by small, red bumps and intense itching. This highly contagious infection often spreads from person to person during close contact]) five percent (%) cream. Apply from chin to toes overnight, wash off in the morning and repeat in seven days.
3. Initiate scabies protocol in regard to clothing and beddings.
A review of Resident 1 ' s Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) Progress Note (PN), dated 3/30/2022, indicated between 7 a.m. to 3 p.m., Resident 1 visited doctors ' office and with diagnosis of scabies. The PN indicated family was aware of Resident 1 ' s condition.
A review of Resident 1 ' s Care Plan, dated 3/30/2022, indicated a diagnosis of scabies.
During an interview on 7/12/2023 at 10:11 a.m., RN 1 stated Resident 1 went to DD on 3/30/2022 and came back with orders of Ivermectin, Permethrin and to initiate scabies protocol. RN 1 stated she called the DD ' s clinic and spoke to a nurse who informed her that it was scabies under the microscope (instrument used for viewing very small objects). RN 1 stated she requested a copy of the Visit Note from the DD's clinic but were never provided and she reported to the Director of Nursing (DON). RN 1 stated scabies is contagious and can spread to other resident and staff.
During an interview on 7/12/2023 at 1:28 p.m., the ADM stated she was not informed that Resident 1 had scabies on 3/30/2022.
During an interview on 7/12/2023 at 2:35 p.m., DD stated she did scrape test on 3/30/2022, look under microscope and confirmed Resident 1 was positive for scabies. DD stated she informed the resident, the family member, and the representative from Skilled Nursing Facility 1 (SNF 1). DD stated scabies is contagious and can easily spread to other resident in contact with him.
During an interview on 7/12/2023 at 3:13 p.m., Primary Medical Doctor (PMD) stated the facility did not provide a test result that Resident 1 tested positive for scabies. PMD stated he did not speak to DD after 3/30/2022 visit.
During an interview on 7/12/2023 at 3:22 p.m., the DON stated if they had received the confirmed diagnosis of scabies from DD on 3/30/2022, they could have created a line list to record all staff and resident who had close contact with Resident 1 and monitor them for any signs and symptoms of scabies.
During an interview on 7/13/2023 at 10:40 a.m., LVN 1 stated when Resident 1 returned from his DD visit on 3/30/2022, the resident informed her that he had scabies. LVN 1 stated she saw the orders for Ivermectin, Permethrin and to initiate scabies protocol so she reported to RN 1.
During a concurrent interview and record review on 7/13/2023 at 12:54 p.m., the policy and procedure (PnP) titled, Communicable Diseases-Outbreak, dated 12/1/2021, was reviewed with RN 2. The PnP indicated An outbreak of communicable disease within the facility are promptly identified and appropriately treated and reported. An outbreak of most communicable diseases is defined as one of the following: A. One case of an infection that is highly communicable. Contact between the infected individuals are assessed as appropriate to determine if any actions need to be taken. RN 2 stated facility should have created a contact identification list and check residents and staff ' s skin for any signs of scabies for tracking purposes and according to their policy.
A review of facility ' s PnP titled, Scabies, dated 8/1/2014 and reviewed on 1/23/2023, indicated, The facility works to prevent the spread of scabies by strictly adhering to the standards set out by the Centers for Disease Control and Prevention (CDC- A U.S. federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability) and State of California Department of Public Health (CDPH-is the state department responsible for public health in California). The PnP indicated the Infection Control Coordinator will follow the guidance provided in the following publications to prevent and minimize the outbreak of scabies. B. Prevention and Control of Scabies in California Long-Term Care Facilities.
A review of facility ' s PnP titled, Prevention and Control of Scabies in California Long-Term Care Facilities, dated 3/2008 and reviewed on 1/23/2023, indicated, When scabies is suspected, an immediate search for additional cases should be initiated. As soon as a possible case of scabies is identified, the infection control practitioner should develop a contact identification list. This list should identify every resident, health care worker, visitor and volunteer who may have had a direct, physical contact with the case within the previous month.
A review of County of Los Angeles Public Health on Acute Communicable Disease Control Program for Scabies Prevention and Control Guidelines for Healthcare Settings dated 7/2019, indicated Summary of Action Steps:
1. Evaluate patients/ residents on affected units and immediately placed patients/residents with suspected scabies in contact precaution.
2. Immediately remove from work any Healthcare Worker (HCW) with signs and symptoms of scabies and refer to employee health or other healthcare consultants or clinician experienced in the diagnosis of scabies.
7. Prepare a line listing of symptomatic patient/residents and HCW with a separate line list of their contacts. Evaluate contact for scabies.

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) by:
1. Failing to document Primary Medical Doctor (PMD) were notified when Resident 1 came back from Dermatologist Doctor (DD-medical doctor who specializes in treating the skin, hair, and nails) visit with diagnosis of scabies (an infestation of mites [tiny insects] characterized by small, red bumps and intense itching. This highly contagious infection often spreads from person to person during close contact) on 3/30/2022.
2. Failing to obtain a copy of the notes of the DD visit on 3/30/2022 that indicated Resident 1 had confirmed scabies.
This deficient practice had the potential to result in inaccurate documentation and delay in care.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 8/9/2021 with the diagnoses that included atrial fibrillation (irregular heartbeat), atherosclerotic heart disease (thickening or hardening of arteries [A vessel that carries oxygen-rich blood to the body] without angina pectoris (chest pain), Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and pruritus (severe itching).
A review of Resident 1 ' s History and Physical, dated 8/10/2021, indicated the resident had the capacity to understand and make decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/7/2022, indicated Resident 1 ' s cognition (mental action or process of acquiring knowledge and understanding) skills for daily decision were moderately impaired. The MDS indicated Resident 1 needed extensive one person assistance for dressing, toilet use and personal hygiene.
A review of Resident 1 ' s DD Visit Note (VN), dated on 3/30/2022, which was provided by DD's clinic, indicated the resident went to see a DD. The VN indicated Resident 1 was seen for a complaint of red and itchy rash on the right leg and trunk (includes the shoulders, chest, lower abdomen, back and buttocks). The VN indicated a skin scrape (scooping out) was done from the left anterior (front) distal (away) thigh, placed on a glass side and an examination of the slide showed scabies. The VN indicated resident and family member was notified. The VN indicated scabies is an infestation of mites that is very contagious and household contacts should be treated.
A review of Resident 1 ' s Physician Order, dated 3/30/2022, indicated the following orders.
1. Ivermectin (medication used to treat parasite) three milligrams (mg-unit of measure) tablet. Take four tablets now by mouth and then in three days.
2. Permethrin (medication used to treat scabies) five percent (%) cream. Apply from chin to toes overnight, wash off in the morning and repeat in seven days.
3. Initiate scabies protocol in regard to clothing and beddings.
A review of Resident 1 ' s Registered Nurse (RN)/ Licensed Vocational Nurse (LVN) Progress Note (PN), dated 3/30/2022, indicated between 7 a.m. to 3 p.m., resident visited doctors ' office and with diagnosis of scabies. The PN indicated family was aware of Resident 1 ' s condition. The PN did not indicate Resident 1's Primary Medical Doctor (PMD) was notified.
A review of Resident 1 ' s Care Plan, dated 3/30/2022, indicated a diagnosis of scabies.
A review of Resident 1 ' s Laboratory results indicated no scabies exam test result dated 3/30/2022 in resident ' s medical record.
During an interview on 7/12/2023 at 9:39 a.m., the Director of Nursing (DON) stated they do not have the official laboratory test result for scabies exam, and they do not have a copy of Dermatologist Doctor ' s (DD- medical doctor who specializes in treating the skin, hair, and nails) visit note on 3/30/2022 and DD ' s clinic did not provide it.
During an interview on 7/12/2023 at 10:11 a.m., RN 1 stated Resident 1 went to DD on 3/30/2022 and came back with orders of Ivermectin, Permethrin and to initiate scabies protocol. RN 1 stated she called the DD ' s clinic and spoke to a nurse who informed her that it was scabies under the microscope (instrument used for viewing very small objects). RN 1 stated she requested a copy of the Visit Note from DD clinic but were never provided and she reported to the Director of Nursing (DON). RN 1 stated scabies is contagious and can spread to other resident and staff.
During an interview on 7/12/2023 at 1:54 p.m., Medical Records Staff (MRS) stated they do not have the 3/30/2022 notes of the DD ' s visit on Resident 1 ' s medical record.
During an interview on 7/12/2023 at 2:35 p.m., DD stated she did scrape test, look under microscope and confirmed Resident 1 was positive for scabies. DD stated she informed the resident, the family member, and the representative from Skilled Nursing Facility 1 (SNF 1). DD stated scabies is contagious and can easily spread to other resident in contact with him.
During an interview on 7/12/2023 at 3:13 p.m., Primary Medical Doctor (PMD) stated the facility did not provide a test result that Resident 1 tested positive for scabies. PMD stated he did not speak to DD after the 3/30/2022 visit.
During an interview on 7/12/2023 at 3:22 p.m., the DON stated if they had received the confirmed diagnosis of scabies from DD on 3/30/2022, they could have created a line list to record all staff and resident who had close contact with Resident 1 and monitor them for any signs and symptoms of scabies.
During an interview on 7/13/2023 at 10:40 a.m., LVN 1 stated when Resident 1 returned from his DD visit on 3/30/2022, the resident informed her that he had scabies. LVN 1 stated she saw the orders for Ivermectin, Permethrin and to initiate scabies protocol so she reported to RN 1.
During an interview on 7/13/2023 at 11:05 a.m., RN 1 stated she did not document that she called the DD clinic twice on 3/30/2022 to obtain a copy of Resident 1 ' s Visit Note. RN 1 stated she also did not document that she notified the PMD and the DON. RN 1 stated documentation is important to show what they did for the resident and for accurate medical record.
A review of facility ' s policy and procedure (PnP) titled, Change of Condition Notification, dated 1/1/2017 and reviewed 1/23/2023, indicated, The facility will promptly inform the resident, consult with the resident ' s PMD, and notify the residents legal representative when the resident endures a significant change in condition caused by: C. a significant change in treatment. The Licensed Nurse will notify the residents PMD when there is: F. A need to alter a treatment significantly based on lab results. The licensed nurse will document the following: ii. The time PMD was contacted, the method he was contacted, the response time, whether orders were received.
A review of facility ' s PnP titled, Documentation-Nursing, dated 1/1/2016 and reviewed on 1/23/2023, indicated, Nursing documentation will be concise, clear, pertinent, and accurate. Nursing Documentation D. Any communications with family, durable power of attorney (DPOA-a document that authorizes a person you choose to manage your financial affairs if you become unable to manage them yourself) or doctor are to be noted in nurses ' notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received services with reasonable accommodation of the resident needs for two of four sampled residents (Residents 3 and 4). Residents 3 and 4, who were at risk for falls, did not have their call light (an alerting device for residents to call for assistance) within the residents ' reach.
This deficient practice had the potential for not meeting the residents needs for assistance.
Findings:
a. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 8/8/2018 with diagnoses including atherosclerotic heart disease (a condition that develops when sticky substance called plaque builds up inside the arteries), Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills), and osteoporosis (a condition that causes bones to become fragile and break easily).
A review of Resident 3 ' s Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 1/10/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) wase moderately impaired Resident 3 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene.
A review of Resident 3 ' s Fall Risk Assessment, dated 3/25/2023, indicated the resident had a total score of 16. A score above 10 represented high risk for falls.
A review of Resident 3 ' s Care Plan, revised on 8/21/2018 for the resident ' s fall risk, included in the interventions keeping the call light easily available to address the resident ' s needs.
On 3/29/2023 at 4:01 p.m., during an observation of Resident 3 lying in bed facing the right side. The call light cord and button were under two pillows, at the left side, behind Resident 1 ' s head. An interview with Resident 3 was attempted but the resident did not respond. During a concurrent interview with Licensed Vocational Nurse 4 (LVN 4), present in the room, she traced the call light cord from the wall to the bed and located the call light button under Resident 3 ' s pillows. LVN 4 stated the call light was not visible and not within the resident ' s reach. LVN 4 further stated the staff and family would not be able to use the call light when needed.
On 4/4/2023 at 8:38 a.m., during an observation of Resident 3 lying in bed, the call light cord coiled and attached to the wedge pillow (used to elevate the upper or lower body to relieve pressure on sensitive areas) located on the head part of the bed. Restorative Nursing Assistant 1 (RNA 1) present in the room, stated the call light was not within the resident ' s reach. RNA 1 stated all residents whether they could use or not the call light, should have the call light within reach.
b. A review of Resident 4 ' s admission Record indicated the facility admitted the resident on 6/21/2022 with diagnoses including Parkinson ' s disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and atherosclerotic heart disease (a common condition that develops when sticky substance called plaque builds up inside the arteries).
A review of Resident 4 ' s MDS, dated [DATE], indicated the resident cognitive skills were moderately impaired. Resident 4 required extensive assistance with bed mobility, transfer, locomotion on unit (how resident moves between locations in her room and adjacent corridor on same floor), dressing, toilet use and personal hygiene.
A review of Resident 4 ' s Fall Risk Assessment, dated 2/7/2023, indicated the resident had a total score of 24. A score above 10 represented high risk for falls.
A review of Resident 4 ' s Care Plan, revised on 3/10/2023, indicated the resident was at risk for falls and the intervention included keeping Resident 4 ' s call light within easy reach and answer it promptly.
On 4/4/2023 at 8:42 a.m., during an observation of Resident 4 lying in bed, the call light was hanging at the head part of the bed and not within the resident ' s reach. R An interview with Resident 3 was attempted but the resident did not respond. During a concurrent interview with Registered Nurse 1 (RN 1) present at the time of the observation, she stated that Resident 4 ' s call light was not within the resident ' s reach.
On 4/4/2023 at 9:33 a.m., during an interview, the Director of Staff Development (DSD) stated the call lights should be clipped near the resident and within the resident ' s reach even if the resident were cognitively impaired.
During an interview on 4/4/2023 at 10:16 a.m. with the Director of Nursing (DON), the DON stated the call light should be within the resident ' s reach even if the residents were not alert. The DON further stated that residents would not be able to call if the call light were not within reach and residents could potentially fall and have an accident trying to reach call lights that are away from them.
A review of the facility ' s policy and procedure titled, Communication-Call System, dated 1/23/2023, indicated the purpose to provide a mechanism for residents to promptly communicate with nursing staff from their beds and toileting/bathing facilities. It also indicated that call cords will be placed within the resident ' s reach in the resident ' s room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly notify the attending physician (MD 1) a change of condition after a fall incident that required physician intervention of one of four sampled residents (Resident 1). On [DATE] at 3:30 p.m., Resident 1 fell from the wheelchair hitting the floor face first and the licensed nurses working that afternoon during the 3 p.m. to 11 p.m. (Registered Nurse 3 [RN 3] and Licensed Vocational Nurse 3 [LVN 3] did not notify MD 1 of Resident 1 ' s facial swelling and bruising. RN 4 and LVN 7 working the 11 p.m. to 7 a.m. did not notify MD 1 of Resident 1 ' s facial swelling and bruising. RN 2, who took over Resident 1 ' s care at 7 a.m. on [DATE], did not notify MD 1 of Resident 1 ' s facial injuries (swelling and large bruising).
This deficient practice resulted in delayed medical interventions for Resident 1.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident, a [AGE] year-old female, on [DATE] with diagnoses including atherosclerotic heart disease (a condition that develops when sticky substance called plaque builds up inside the arteries) and Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated the resident had cognitive impairment (conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 1 sometimes understood and made herself understood. Resident 1 was unable to walk and was dependent on staff with locomotion on unit (how resident moves between location in her room and adjacent corridor on same floor), locomotion off unit (how resident moves to and returns from off-unit locations. Resident 1 used a wheelchair as mobility device.
A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] and timed at 3:30 p.m. signed by LVN 3, indicated Certified Nursing Assistant 2 (CNA 2) reported to LVN 3 when wheeling Resident 1 in the dining room, the resident fell from the wheelchair hitting the right side of the face. LVN 3 note did not document monitoring Resident 1 ' s facial condition and did not call MD 1 during the shift about the resident ' s face swelling and discoloration. RN 3 did not document monitoring Resident 1 ' s for facial injuries and did not call MD 1 during her shift about Resident 1 ' s facial swelling and bruising for MD 1 determine the course of treatment. RN 3 did not document calling MD 1 with updates about Resident 1 ' s significant facial injuries.
A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] for the 11 p.m. to 7 a.m. shift, signed by LVN 7, did not include calling MD 1 about Resident 1 ' s facial injuries.
A review of the staff schedule and assignments indicated RN 4 was the supervisor during the 11 p.m. to 7 a.m. ([DATE]) working with LVN 7. There was no documentation RN 4 called MD 1 to report Resident 1 ' s visible injuries on the face.
A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] and timed at 7:45 a.m., by LVN 2, indicated the resident was non-responsive to verbal and tactile stimuli (to voice and touch) and did not open her eyes. LVN 2 documented she would notify the (RN) supervisor. LVN 2 did not describe Resident 1 ' s facial condition.
A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] and timed at 8:00 a.m., by RN 2, indicated Resident 1 was non-responsive to sternal rub (pain to breastbone) and did not open her eyes. RN 2 called MD 1 and received order to transfer the resident to General Acute Care Hospital 1 (GACH 1) via 911 (telephone number to call for immediate emergency medical services [EMS or paramedic healthcare professional trained to give emergency medical care to people who are injured or ill]. Paramedics took Resident 1 to GACH 1 at 9:15 a.m.
A review of Resident 1 ' s paramedics Patient Care Report, dated [DATE] at the scene at 8:59 a.m., indicated Resident 1 was unresponsive and had a large hematoma (it happens when an injury causes blood to collect and pool under the skin) to the right eye.
A review of Resident 1 ' s GACH 1 Emergency Department (ED) Trauma Record, dated [DATE] and timed at 9:26 a.m., indicated the resident had right periorbital (around the eye) ecchymosis (discoloration of the skin due to the rupture of the blood vessels below the surface of the skin) and hematoma.
A review of Resident 1 ' s GACH 1 ED Physician ' s Note, dated [DATE], indicated the resident had raccoon eyes (dark purple or blue bruises under the eyes), contusion (a bruise), and right periorbital erythema (reddening of the skin).
A review of Resident 1 ' s GACH 1 Death Summary indicated Resident 1 died on [DATE] at 4:22 a.m.
On [DATE] at 4:40 p.m., during an interview with RN 2 and concurrent review of Resident 1 ' s RN/LVN Progress Notes dated [DATE], RN 2 stated on [DATE] she observed Resident 1 ' s right side of the face was very swollen with reddish to blue discoloration. RN 2 stated she did not document the assessment but she informed LVN 2 to monitor Resident 1 closely.
On [DATE] at 2:32 p.m. during an interview with MD 1, who was also the facility ' s medical director, she stated the RN supervisor (RN 3) reported Resident 1 ' s fall ([DATE] at 3:30 p.m.) and no changes in the resident ' s mental condition and no obvious changes from the resident ' s baseline. RN 3 did not inform her (MD 1) about the swollen face and discoloration. MD 1 stated she did not receive any notification of Resident 1 ' s change of condition until the resident became unresponsive on [DATE], and she ordered emergent transfer to GACH 1. MD 1 stated if she knew about Resident 1 ' s facial swelling and bruising, she would have ordered facial/head X-rays (a type of radiation called electromagnetic waves that create pictures of the inside of the body) to rule out facial bone fractures (broken bones on the face).
A review of the facility ' s policy and procedure titled, Change of Condition Notification, dated [DATE], indicated the purpose of the policy was to ensure residents, family, legal representatives, and physicians are informed of the changes in the resident ' s condition in a timely manner. It indicated the licensed nurse should notify the resident ' s attending physician when there is a significant change in the resident ' s physical, mental or psychosocial status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of four sampled residents (Resident 1). The facility failed to develop and implement individualized care plan interventions addressing:
1. Resident 1 ' s abnormal posture identified by the Physical Therapist (PT).
2. Resident 1 ' s non-compliance with instructions, restlessness, constantly leaning forward as described by Licensed Vocational 2 (LVN 2).
3. Resident 1 ' s repetitive movement of rocking back and forth as indicated by Registered Nurse 2 (RN 2).
4. Resident 1 ' s impulsiveness as stated by Certified Nursing Assistant 2 (CNA 2).
5. Discontinuation of Resident 1 ' s Risperdal (antipsychotic medication [to treat psychosis which is a mental illness characterized by a disconnection from reality]) given for the resident ' s constant attempts to get out of bed and wheelchair. There were no non-pharmacological (non-medication) behavioral interventions as recommended by the psychiatrist and monitoring Resident 1 ' s behavior after Risperdal was discontinued.
As a result, on [DATE] at 3:30 p.m., Resident 1 fell forward from the wheelchair hitting the floor face first resulting in right facial fractures (broken bones) and brain bleed. Resident 1 died on [DATE] at 4:22 a.m. at General Acute Care Hospital 1 (GACH 1).
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident, on [DATE] with diagnoses including atherosclerotic heart disease (a condition that develops when sticky substance called plaque builds up inside the arteries) and Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills).
A review of Resident 1 ' s Care Plan developed on [DATE] for the resident ' s fall risk, had an added problem on [DATE] of Resident 1 ' s abnormal posture but did not describe what the abnormal posture was that increased her fall risk. The care plan was not revised explain what the abnormal posture and to develop interventions related to Resident 1 ' s abnormal posture.
A review of the Physician ' s Order for Resident 1, dated [DATE], indicated to administer to Resident 1 the medication Risperdal 0.25 milligrams (mg) by mouth every evening for constant attempts to get out of bed and wheelchair.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated the resident had cognitive impairment (conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 1 was unable to walk and was dependent on staff with locomotion on unit (how resident moves between location in her room and adjacent corridor on same floor), locomotion off unit (how resident moves to and returns from off-unit locations. Resident 1 used a wheelchair as mobility device. The MDS Mood section indicated Resident 1 was moving or speaking so slowly that other people have noticed or the opposite, being so fidgety or restless that she has been moving around a lot more than usual. This symptom was present in the past 12-14 days nearly every day. Resident 1 was receiving daily antipsychotic medication daily.
A review of Resident 1 ' s Fall Risk Assessment, dated [DATE], indicated the resident had a total score of 15. A total score above 10 represented high risk for falls.
A review of Resident 1 ' s Care Plan, dated [DATE] and revised on [DATE], indicated the resident was at risk for falls because of the abnormal posture but did not explain what the abnormal posture consisted of. The goal was minimizing potential for falls/injury.
The care plan did not indicate specific and individualized intervention for Resident 1 ' s abnormal posture.
A review of Resident 1 ' s Psychiatric Progress Notes, dated [DATE], indicated Resident 1 ' s behaviors were stable, had less episodes of trying to get out of bed and wheelchair. Will discontinue the Risperdal and provide non-pharmacological interventions.
A review of Resident 1 ' s licensed nursing notes, medication and treatment administration records, and care plans, from [DATE] to [DATE], indicated no documentation Resident 1 was monitored for presence of the behaviors of restlessness and attempts to get out of bed and wheelchair and what non-pharmacological behavioral interventions nursing staff had to implement or had implemented.
A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] timed at 3:30 p.m., signed by LVN 3, indicated CNA 2 wheeled Resident 1 to the dining room, when the resident suddenly moved forward, falling onto the floor hitting her face first.
A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] timed at 7:45 a.m., by LVN 2, indicated the resident was non-responsive to verbal and tactile stimuli (to voice and touch) and did not open her eyes. LVN 2 documented she would notify the (RN) supervisor. LVN 2 documented Resident 1 did not sustain injuries and the attending physician (MD 1) was notified.
A review of Resident 1 ' s RN/LVN Progress Notes, dated [DATE] at 8 a.m., by RN 2, indicated the resident was not responding to sternal rub (application of painful stimuli with the knuckles of a closed fist to the center chest of a patient who was not alert and does not respond to verbal stimuli), paramedics were called, and Resident 1 was transferred to GACH 1 on [DATE] at 9:15 a.m.
A review of Resident 1 ' s paramedics Patient Care Report, dated [DATE], at the scene at 8:59 a.m., indicated Resident 1 was unresponsive and had a large hematoma (it happens when an injury causes blood to collect and pool under the skin) to the right eye.
A review of Resident 1 ' s GACH 1 Emergency Department (ED) Trauma Emergency Department Record, dated [DATE] at 9:26 a.m., indicated Resident 1 had right periorbital ecchymosis (discoloration of the skin around the eyes due to the rupture of the blood vessels below the surface of the skin) and hematoma.
A review of Resident 1 ' s GACH 1 ED Physician Note, dated [DATE] at 9:48 a.m., indicated the resident had raccoon eyes (dark purple or blue bruises under the eyes), contusion (a bruise), and right periorbital erythema (inflammation of the eyelids).
A review of Resident 1 ' s GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the head report, dated [DATE] at 9:51 a.m., indicated the resident sustained extensive intracranial hemorrhage (bleeding between the brain tissue and skull) with leftward midline shift (occurs when something pushes the natural centerline of the brain to the left) and right facial fractures (broken bones in the face).
A review of Resident 1 ' s GACH 1 Geriatric (a medical specialty focused on providing care for the unique health needs of older adults) Service Physician Note, dated [DATE], timed at 2:28 p.m., indicated CT of the head showed right facial fractures and extensive intracranial hemorrhage with severe mass effect (local pressure). Resident 1 was DNR (Do not Resuscitate or not try to revive) and DNI (do not intubate), neurosurgery (surgery of the nervous system) not indicated and was allowed to rest comfortably.
A review of Resident 1 ' s GACH 1 Death Summary indicated Resident 1 died on [DATE], at 4:22 a.m. with the diagnosis of traumatic cerebral compression (an injury in which something increases the amount of pressure pushing on the brain, which can damage brain tissue) / compression of brain.
During an interview on [DATE] at 3:21 p.m., LVN 2 stated that Resident 1 was confused, non-compliant with instructions, high risk for falls, restless, constantly leaning forward, and not able to follow directions.
During an interview on [DATE] at 4:40 p.m., RN 2 stated Resident 1 had been observed to have a repetitive movement of rocking back and forth. RN 2 stated that Resident 1 ' s behavior had been ongoing for months. RN 2 could not explain why the behaviors were not monitored.
During an interview on [DATE] at 5:16 p.m., CNA 2 stated Resident 1 was confused and impulsive.
On [DATE] at 8:50 a.m., during an interview with the Director of Rehabilitation (DOR) and a concurrent review of Resident 1 ' s PT Evaluation and Plan of Treatment conducted on [DATE], the DOR was not able to provide documentation on the specific abnormal posture identified. The DOR stated the definition of abnormal posture was the inability of the person to hold a posture in normal alignment. Resident 1 ' s PT Discharge summary, dated [DATE], indicated Resident 1 ' s short-term and long-term goal was to increase dynamic sitting balance (spontaneously righting self when needed to facilitate upright posture and reduce the risk for falls) from poor to fair. Resident 1 ' s baseline and discharge dynamic sitting balance was poor plus (+). The DOR stated poor + indicated Resident 1 was very high risk for fall if the resident shifted weight. There were no recommendations to use supporting devices while sitting to improve posture and safety.
During an interview on [DATE] at 10:52 a.m., the Director of Nursing (DON) stated an individualized care plan should have been created to address Resident 1 ' s identified special needs. The DON stated there was no care plan created for the rocking behavior and restlessness. The DON stated PT should have made recommendations such as a custom-made wheelchair to address Resident 1 ' s abnormal posture and restlessness. The DON further stated Resident 1 ' s care plan did not include safety interventions related to abnormal posture and restlessness.
A review of the facility ' s policy and procedure titled, Care Planning, dated [DATE], indicated the purpose of the policy was to ensure a comprehensive person-centered care plan was developed for each resident based on their individual assessed needs. Each resident ' s comprehensive care plan would describe services that were to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being.
A review of the facility ' s policy and procedures titled, Fall Management Program, dated [DATE], indicated the purpose of the policy was to prevent resident falls and minimize complications associated with falls through development of a fall management program. Nursing staff will develop a plan of care specific to the resident ' s needs with interventions to reduce the risk of falls. It also indicated that one of the universal fall prevention measures for all residents was to reassess mobility status and encourage use of assistive devices as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services provided meet accepted professional standards of clinical nursing practice for one of four sampled residents (Resident 1). On [DATE] at 3:30 p.m., Resident 1 fell from the wheelchair hitting the floor face first and the licensed nurses working that afternoon during the 3 p.m. to 11 p.m. (Registered Nurse 3 [RN 3] and Licensed Vocational Nurse 3 [LVN 3] did not monitor the status of Resident 1 ' s facial injuries and did not document it. RN 4 and LVN 7 working the 11 p.m. to 7 a.m. did not monitor the status of Resident 1 ' s facial injuries and did not document it. RN 2, who took over Resident 1 ' s care at 7 a.m. on [DATE], d did not monitor the status of Resident 1 ' s facial injuries and did not document it.
This deficient practice resulted in delayed medical interventions for Resident 1.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident, a [AGE] year-old female, on [DATE] with diagnoses including atherosclerotic heart disease (a condition that develops when sticky substance called plaque builds up inside the arteries) and Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills).
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated the resident had cognitive impairment (conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 1 sometimes understood and made herself understood. Resident 1 was unable to walk and was dependent on staff with locomotion on unit (how resident moves between location in her room and adjacent corridor on same floor), locomotion off unit (how resident moves to and returns from off-unit locations. Resident 1 used a wheelchair as mobility device.
A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] and timed at 3:30 p.m. signed by LVN 3, indicated Certified Nursing Assistant 2 (CNA 2) reported to LVN 3 when wheeling Resident 1 in the dining room, the resident fell from the wheelchair hitting the right side of the face. LVN 3 note did not document monitoring Resident 1 ' s facial condition and did not call MD 1 during the shift about the resident ' s face swelling and discoloration. RN 3 did not document assessing Resident 1 ' s facial injuries (swelling and bruising). RN 3 did not document Resident 1 ' s significant facial injuries.
A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] for the 11 p.m. to 7 a.m. shift, signed by LVN 7, did not include document Resident 1 ' s facial injuries.
A review of the staff schedule and assignments indicated RN 4 was the supervisor during the 11 p.m. to 7 a.m. ([DATE]) working with LVN 7. There was no documentation RN 4 documented assessing Resident 1 ' s visible injuries on the face.
A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] and timed at 7:45 a.m., by LVN 2, indicated the resident was non-responsive to verbal and tactile stimuli (to voice and touch) and did not open her eyes. LVN 2 documented she would notify the (RN) supervisor. LVN 2 did not describe Resident 1 ' s facial condition.
A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] and timed at 8:00 a.m., by RN 2, indicated Resident 1 was non-responsive to sternal rub (pain to breastbone) and did not open her eyes. RN 2 called MD 1 and received order to transfer the resident to General Acute Care Hospital 1 (GACH 1) via 911 (telephone number to call for immediate emergency medical services [EMS or paramedic healthcare professional trained to give emergency medical care to people who are injured or ill]. Paramedics took Resident 1 to GACH 1 at 9:15 a.m. RN 2 did not document assessing Resident 1 ' s facial injuries.
A review of Resident 1 ' s paramedics Patient Care Report, dated [DATE] at the scene at 8:59 a.m., indicated Resident 1 was unresponsive and had a large hematoma (it happens when an injury causes blood to collect and pool under the skin) to the right eye.
A review of Resident 1 ' s GACH 1 Emergency Department (ED) Trauma Record, dated [DATE] and timed at 9:26 a.m., indicated the resident had right periorbital (around the eye) ecchymosis (discoloration of the skin due to the rupture of the blood vessels below the surface of the skin) and hematoma.
A review of Resident 1 ' s GACH 1 ED Physician ' s Note, dated [DATE], indicated the resident had raccoon eyes (dark purple or blue bruises under the eyes), contusion (a bruise), and right periorbital erythema (reddening of the skin).
A review of Resident 1 ' s GACH 1 Death Summary indicated Resident 1 died on [DATE] at 4:22 a.m.
During a concurrent interview and record review on [DATE] at 4:40 p.m. with RN 2, RN 2 stated that on [DATE], observed Resident 1 ' s right side of the face was very swollen with reddish to blue discoloration. RN 2 stated that assessments were not documented but she informed LVN 2 to monitor Resident 1 closely. RN 2 stated that documentation of assessments should be in real time (as it happens).
On [DATE] at 2:32 p.m. during an interview with MD 1, who was also the facility ' s medical director, she stated the RN supervisor (RN 3) reported Resident 1 ' s fall ([DATE] at 3:30 p.m.) and no changes in the resident ' s mental condition and no obvious changes from the resident ' s baseline. RN 3 did not inform her (MD 1) about the swollen face and discoloration. MD 1 stated she did not receive any notification of Resident 1 ' s change of condition until the resident became unresponsive on [DATE], and she ordered emergent transfer to GACH 1. MD 1 stated if she knew about Resident 1 ' s facial swelling and bruising, she would have ordered facial/head X-rays (a type of radiation called electromagnetic waves that create pictures of the inside of the body) to rule out facial bone fractures (broken bones on the face).
During an interview on [DATE] at 4:48 p.m. with the Director of Nursing (DON), the DON stated that assessments should be documented immediately.
A review of the facility ' s policy and procedure titled Change of Condition Notification, dated [DATE], indicated the purpose to ensure residents, family, legal representatives, and physicians are informed of the changes in the resident ' s condition in a timely manner. It indicated the licensed nurse should document the date, time, and pertinent details of the incident, and the subsequent assessment in the nursing notes. It also indicated that licensed nurse should document the time the attending physician was contacted, the method by which the attending physician was contacted, the response time, and whether orders were received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents receive the necessary care based on the assessed individual needs to prevent accidents and minimize injuries for one of four sampled residents (Residents 1). The facility failed to ensure:
1. Resident 1 was provided postural support while sitting in the wheelchair due to abnormal posture.
2. Resident 1 was monitored for behaviors of restlessness and constant episodes of trying to get out of bed and wheelchair after the antipsychotic medication Risperdal (to treat psychosis, a mental illness characterized by a disconnection from reality) was discontinued on [DATE].
3. Resident 1 was provided with non-pharmacological (non-medication) interventions after Risperdal was discontinued on [DATE] if having episodes of trying to get out of bed and wheelchair, restlessness, rocking back and forth, and impulsive behaviors.
As a result, on [DATE] at 3:30 p.m., Resident 1 fell out of the wheelchair hitting the floor face first. Resident 1 remained in the facility and on [DATE] at 8 a.m. she was unresponsive (not reacting or responding to an action: pain, touch, or verbal commands).
Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with facial bone fractures (broken bones) and extensive intracranial hemorrhage (bleeding between the brain tissue and skull) with leftward midline shift (occurs when something pushes the natural centerline of the brain to the left). Resident 1subsequently died on [DATE] at 4:22 a.m.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses including atherosclerotic heart disease (a condition that develops when sticky substance called plaque builds up inside the arteries) and Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills).
A review of Resident 1 ' s Care Plan developed on [DATE] for the resident ' s fall risk, had an added problem on [DATE] of Resident 1 ' s abnormal posture (did not explain what the abnormal posture consisted of) that increased her fall risk. The care plan did not include specific interventions for the abnormal posture.
A review of Resident 1 ' s Care Plan for Fall Risk, dated [DATE], revised on [DATE], indicated the resident was at risk for falls because of the abnormal posture but did not describe what the abnormal posture was. The goal was minimizing potential for falls/injury. The care plan did not include specific and individualized intervention for Resident 1 ' s abnormal posture.
A review of the Physician ' s Order for Resident 1, dated [DATE], indicated to administer to Resident 1 the medication Risperdal 0.25 milligrams (mg) by mouth every evening for constant attempts to get out of bed and wheelchair.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated the resident had cognitive impairment (conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident 1 was unable to walk and was dependent on staff with locomotion on unit (how resident moves between location in her room and adjacent corridor on same floor), locomotion off unit (how resident moves to and returns from off-unit locations). Resident 1 used a wheelchair as mobility device. The MDS Mood section indicated Resident 1 was moving or speaking so slowly that other people have noticed or the opposite, being so fidgety or restless that she has been moving around a lot more than usual. This symptom was present in the past 12-14 days nearly every day. Resident 1 was receiving antipsychotic medication daily.
A review of Resident 1 ' s Fall Risk Assessment, dated [DATE], indicated the resident had a total score of 15. A total score above 10 represented high risk for falls.
A review of Resident 1 ' s Psychiatric (relating to mental illness or its treatment) Progress Notes, dated [DATE], indicated Resident 1 ' s behaviors were stable, had less episodes of trying to get out of bed and wheelchair. Will discontinue the Risperdal and provide non-pharmacological interventions.
A review of Resident 1 ' s licensed nurses progress notes, medication and treatment administration records, and care plans, from [DATE] to [DATE], indicated there was no documentation Resident 1 was monitored for presence of the behaviors of restlessness and attempts to get out of bed and wheelchair and what non-pharmacological behavioral interventions nursing staff had to implement or had implemented.
A review of Resident 1 ' s Registered Nurse (RN) / Licensed Vocational Nurse (LVN) Progress Notes, dated [DATE] timed at 3:30 p.m., signed by LVN 3, indicated Certified Nursing Assistant 2 (CNA 2) was wheeling Resident 1 inside the dining room, the resident suddenly moved forward, falling onto the floor hitting her face first. LVN 2 documented Resident 1 did not sustain injuries and the attending physician (MD 1) was notified.
A review of Resident 1 ' s RN / LVN Progress Notes, dated [DATE] timed at 7:45 a.m., by LVN 2, indicated the resident was non-responsive to verbal and tactile stimuli (to voice and touch) and did not open her eyes. LVN 2 documented she would notify the (RN) supervisor. There was no documentation about the condition of Resident 1 ' s face (if swelling, pain, redness, or bruising).
A review of Resident 1 ' s RN/LVN Progress Notes, dated [DATE] at 8 a.m., by RN 2, indicated the resident was not responding to sternal rub (application of painful stimuli with the knuckles of a closed fist to the center chest of a patient who was not alert and does not respond to verbal stimuli), paramedics were called, and Resident 1 was transferred to GACH 1 on [DATE] at 9:15 a.m.
A review of Resident 1 ' s paramedics Patient Care Report, dated [DATE] at the scene at 8:59 a.m., indicated Resident 1 was unresponsive and had a large hematoma (it happens when an injury causes blood to collect and pool under the skin) to the right eye.
A review of Resident 1 ' s GACH 1 Emergency Department (ED) Trauma Emergency Department Record, dated [DATE] at 9:26 a.m., indicated Resident 1 had right periorbital ecchymosis (discoloration of the skin around the eyes due to the rupture of the blood vessels below the surface of the skin) and hematoma.
A review of Resident 1 ' s GACH 1 ED Physician Note, dated [DATE] at 9:48 a.m., indicated the resident had raccoon eyes (dark purple or blue bruises under the eyes), contusion (a bruise), and right periorbital erythema (inflammation of the eyelids).
A review of Resident 1 ' s GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the head report, dated [DATE] at 9:51 a.m., indicated the resident sustained extensive intracranial hemorrhage (bleeding between the brain tissue and skull) with leftward midline shift (occurs when something pushes the natural centerline of the brain to the left) and right facial fractures.
A review of Resident 1 ' s GACH 1 Geriatric (a medical specialty focused on providing care for the unique health needs of older adults) Service Physician Note, dated [DATE], timed at 2:28 p.m., indicated CT of the head showed right facial fractures and extensive intracranial hemorrhage with severe mass effect (local pressure). Resident 1 was DNR (Do not Resuscitate or not try to revive) and DNI (do not intubate) and neurosurgery (surgery of the nervous system) was not indicated, and Resident 1 was allowed to rest comfortably.
A review of Resident 1 ' s GACH 1 Death Summary indicated Resident 1 died on [DATE], at 4:22 a.m. with the diagnosis of traumatic cerebral compression (an injury in which something increases the amount of pressure pushing on the brain, which can damage brain tissue) / compression of brain.
A review of the facility ' s Investigation report indicated Resident 1 ' s fall incident ([DATE]) occurred in a crowded (with residents) dining room. The investigation did not address the crowded space may have triggered the resident to try to get out of the wheelchair and the lack of monitoring the behavior of trying to get out of bed and wheelchair.
During an interview on [DATE] at 3:21 p.m., LVN 2 stated that Resident 1 was confused, non-compliant with instructions, high risk for falls, restless, constantly leaning forward, and not able to follow directions.
During an interview on [DATE] at 4:40 p.m. with RN 2 stated Resident 1 had been observed to have a repetitive movement of rocking back and forth. RN 2 stated that Resident 1 ' s behavior had been ongoing for months. RN 2 could not explain why the behaviors were not monitored.
During an interview on [DATE] at 5:16 p.m., CNA 2 stated Resident 1 was confused and impulsive.
On [DATE] at 8:50 a.m., during an interview with the Director of Rehabilitation (DOR) and a concurrent review of Resident 1 ' s Physical Therapy (PT) Evaluation and Plan of Treatment conducted on [DATE], the DOR was not able to provide documentation on the specific abnormal posture identified. The DOR defined abnormal posture as the inability to hold a posture in normal alignment. Resident 1 ' s PT Discharge summary dated [DATE], indicated Resident 1 ' s short-term and long-term goal was to increase dynamic sitting balance (spontaneously righting self when needed to facilitate upright posture and reduce the risk for falls) from poor to fair. Resident 1 ' s baseline and discharge dynamic sitting balance was poor plus (+). The DOR stated poor + indicated Resident 1 was very high risk for fall if the resident shifted weight. The DOR stated that care givers were educated on positioning techniques but there were no recommendations to use supporting device while sitting to improve posture and safety.
During an interview on [DATE] at 10:52 a.m., the Director of Nursing (DON) stated an individualized care plan should have been created to address Resident 1 ' s identified special needs. The DON stated there was no care plan created for the rocking behavior and restlessness. The DON stated PT should have made recommendations to address Resident 1 ' s abnormal posture and restlessness to prevent falls and injuries. The DON further stated Resident 1 ' s care plan did not include safety interventions related to abnormal posture and restlessness to prevent accidents. The DON stated that after the Risperdal was discontinued there were no monitoring and no non-pharmacological behavioral interventions were done for Resident 1 from [DATE] to [DATE].
A review of the facility ' s policy and procedures titled, Fall Management Program, dated [DATE], indicated the purpose of the policy was to prevent resident falls and minimize complications associated with falls through development of a fall management program. Nursing staff will develop a plan of care specific to the resident ' s needs with interventions to reduce the risk of falls. It also indicated that one of the universal fall prevention measures for all residents was to reassess mobility status and encourage use of assistive devices as appropriate.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of Coronavirus disease 2019 (COVID-19, a viral infection, highly contagious and easily transmitted from person-to-person, causing respiratory symptoms and even death) during a recent COVID outbreak dated 3/9/2023 and having current positive residents. On 3/29/2023 at 5:28 p.m., Certified Nursing Assistant 3 (CNA 3) walked in the hallway in the residents ' living area without a mask and entered Resident 3 ' s room without using a mask.
This deficient practice placed residents and staff at risk for exposure and contracting COVID-19.
Findings:
On 3/17/2023 at 8:25 a.m., upon entrance to the facility, it was observed a signage at the front entrance door indicated COVID-19 exposure date on 3/9/2023.
On 3/17/2023 at 8:30 a.m., during an interview, the Director of Nursing (DON) stated there were six COVID-19 positive residents and a total of 13 COVID-19 positive employees and nine had already returned to work.
During an observation on 3/29/2023 at 5:28 p.m., CNA 3 was walking in the North Unit hallway without wearing a mask. CNA 3 started talking to CNA 2 while walking the hallway. CNA 3 proceeded to enter Resident 3 ' s room without a mask on.
On 3/29/2023 at 7:08 p.m., during an interview, CNA 3 stated she was aware she needed to wear a mask upon entering the facility while in the residents ' living areas. CNA 3 could not explain why she was not wearing a mask.
On 3/30/2023 at 12:53 p.m., during an interview, the Infection Preventionist Nurse (IPN) stated all staff must always wear a mask while inside the facility except in the staff lounge, patio, or restroom.
A review of the facility ' s policy and procedure titled, Infection Prevention and Control Program, dated 1/23/2023, indicated the purpose of the policy was to ensure the facility establishes and maintains an infection control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements.
A review of the facility ' s policy and procedure titled, Personal Protective Equipment, dated 1/23/2023, indicated the staff may use certified N95 filtering facepiece respirators to prevent the risk of exposure to infectious respiratory illnesses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 171's admission Record indicated the resident was admitted on [DATE] with diagnoses that included dementia (a loss of mental ability severe enough to interfere with normal activities of daily living) and dysphagia (difficulty swallowing).
A review of Resident 171's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 09/05/2021, indicated the resident required extensive assistance with eating and required physical assistance from nursing staff.
During an observation, on 10/20/2021, at 8:54 a.m., observed at Resident 171's bedside a medication cup with medication mixed in with apple sauce.
During a concurrent observation and interview, on 10/20/2021 at 8:59 a.m., Licensed Vocational Nurse 1 (LVN 1) confirmed the medication at bedside mixed in with apple sauce. LVN 1 stated she left Resident 171's medication at bedside because she had to check on another resident and may have been there for about 5-10 minutes. LVN 1 stated she was not supposed to leave medication at bedside for residents' safety.
During an interview, on 10/22/2021, at 12:08 p.m., the Director of Staff Development (DSD) stated medications should not be left at the bedside for safety, for another resident may take it, and for safe medication administration practice.
A review of the facility's policy and procedures, titled Medication - Administration, reviewed and approved on 01/25/2021, indicated that the purpose of this policy is to provide practice standards for safe administration of medications for residents in the facility. The policy procedure indicated medications will not be left at the bedside and do not allow for distractions during the process.
c. A review of Resident 66's admission Record indicated the facility admitted the resident on 06/12/2019, with diagnoses that included paroxysmal atrial fibrillation (irregular, often rapid heart rate), heart failure (congestive heart failure [CHF] - chronic, progressive condition which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), unspecified convulsions (seizure - episode in which you experience rigidity and uncontrolled muscle spasms along with altered consciousness), gastrostomy status (gastrostomy tube, often called G-Tube - a surgically placed device used to give direct access to stomach for supplemental feeding, hydration, or medications).
A review of Resident 66's History and Physical (H&P), dated 06/17/2021, indicated the resident does not have the capacity to understand and make decisions.
A review of Resident 66's Physician's Orders indicated to administer:
1.
Levetiracetam (medication used to treat seizures) 100 milligrams/1milliliter (mg/ml - unit of measurement) give 500 mg, administer 5 ml via G-Tube (GT) twice a day for convulsions.
2.
Clopidogrel (medication used to prevent heart attack or stroke) 75 mg 1 tablet vis GT daily for atrial fibrillation
3.
Furosemide (medication used to reduce extra fluid in the body [edema] caused by conditions such as heart failure) 20 mg via GT daily for CHF.
A review of Resident 66's Medication Administration Record (MAR), dated 10/01/2021 to 10/31/2021, indicated scheduled time of 9 a.m. for the following medications:
1.
Levetiracetam 100 mg/1ml (500 mg) administer 5ml via GT twice a day for convulsions
2.
Clopidogrel 75 mg 1 tablet vis GT daily for atrial fibrillation
3.
Furosemide 20 mg via GT daily for CHF
During an observation, on 10/21/2021, at 9:31 a.m., observed Licensed Vocational Nurse (LVN 3) preparing Resident 66's morning medications. LVN 3 placed medications, levetiracetam, clopidogrel, and furosemide, on top of medication cart 1 (Med Cart 1), located in hallway outside of Resident 66's room. LVN 3 stated Resident 66 did not have water at the bedside, to administer with medications. LVN 3 left medications on top of Med Cart 1 and walked around a drawn curtain to get water and lost sight of medications on top of Med Cart 1.
During an interview, on 10/21/2021 at 10:25 a.m., LVN 3 stated she should not have lost sight of Resident 66's medications. LVN 3 stated the risk of leaving medications unattended is resident safety and further stated a resident could have walked by and taken the medications.
During an interview, on 09/22/2021, at 02:04 p.m., with Director of Staff Development (DSD), the DSD stated LVN 3 should have prepared water at bedside before administering medications and further stated LVN 3 should not have crossed over the curtain to get water. The DSD stated it is important for safety not to turn back on medications and further stated a resident can be harmed if a medication is not taken by the right resident.
A review of the facility's policy and procedures, titled Medication - Administration, reviewed 01/25/2021, dated 07/01/2016, indicated the policy's purpose to provide practice standards for safe administration of medications for residents in the facility. The policy and procedure indicated to assemble the necessary equipment .approach medication preparation task in a calm manner and do not allow for distractions during the process.
Based on observation, interview, record review, the facility failed to ensure the residents' safety for three of three sampled residents (Resident 65, Resident 66 and Resident 171) by:
1.
Failing to ensure LVN 4 disposed a lancet (small devices that provides a way to take blood samples) used on Resident 65 in a designated sharps container (a container that can be filled with used medical needles and all categories of sharps waste, before being disposed of safely) rather than a trash can.
2.
Failing to ensure facility staff did not leave medications for Resident 66 and Resident 171 unattended.
These deficient practices had the potential to result in injury and/or harm to residents and/or staff through needle prick (an accidental puncture of the skin with an unsterilized needle) and through the ingestion of unattended medications.
Findings:
a. A review of Resident 65's admission records indicated that the resident was admitted to the facility on [DATE] with diagnosis including type 2 diabetes mellitus (a chronic condition that affects the way the body processes sugar) with diabetic nephropathy (a type of nerve damage that can occur if you have diabetes), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), and long term use of insulin (medication used to control sugar levels in the blood).
A review of Resident 65's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 08/03/2021, indicated Resident 65 rarely/never understands others and is unable to make self-understood. The MDS further indicated that Resident 65 was totally dependent with physical assistance with bed mobility, transfers, and toilet use.
On 10/21/2021 at 11:52 a.m., during a medication pass observation with Licensed Vocational Nurse 4 (LVN 4), observed LVN 4 performing a glucose check (using a lancet to pierce the skin of a resident to obtain a blood sample in order to determine the level of sugar in the blood) on Resident 65. LVN 4 was then observed disposing the lancet inside a trash bin.
On 10/21/2021 at 11:54 a.m., during an interview with LVN 4, LVN 4 stated and confirmed that he disposed of the lancet used on Resident 65 in the trash bin. LVN 4 stated that sharp items with needles should be placed in a secured designed sharps container for safety.
On 10/22/2021 at 10:23 a.m., during an interview with the Director of Nursing (DON), DON stated that all needles and sharps should be disposed of in a sharp's container.
A review of the facility's policy titled Sharps Disposal, revised on 8/1/2014 indicated that nursing staff is to discard contaminated sharps into designated containers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility failed to ensure that Licensed Vocational Nurse 4 did not first sign the Medication Administration Record (MAR-flowsheet that indicates medications given to a resident) prior to administering insulin (medication used to decrease levels of sugar in the blood) for one of three sampled residents (Resident 65).
This deficient practice placed Resident 65 at risk for unsafe patient care. It can lead to a lack in continuity of care, the inability to evaluate the appropriateness of the care delivered
Findings:
A review of Resident 65's admission records indicated that the resident was admitted to the facility on [DATE] with diagnosis including type 2 diabetes mellitus (a chronic condition that affects the way the body processes sugar) with diabetic nephropathy (a type of nerve damage that can occur if you have diabetes), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), and long term use of insulin (medication used to control sugar levels in the blood).
A review of Resident 65's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 08/03/2021, indicated Resident 65 rarely/never understands others and is unable to make self-understood. The MDS further indicated that Resident 65 was totally dependent with physical assistance with bed mobility, transfers, and toilet use.
A review of Resident 65's physician's order dated 4/18/2021, indicated an order for Novolog (fast acting insulin) to be given subcutaneously (injected under the skin) before meals. The order further indicated that for blood sugar levels of 181 to 230 milligrams per deciliter (mg/dL- a unit of measure), licensed nurses are to give a total of six (6) units (u- unit of measurement) of insulin.
During a medication pass observation for Resident 65 on 10/21/2021 at 11:52 a.m., LVN 4 was observed performing a glucose check (a test to check the level of sugar in a resident's blood) on Resident 65.
During an observation and concurrent interview on 10/21/2021 at 11:55 a.m., LVN 4 stated that Resident 65 required six (6) units of Novolog insulin as per the physician's orders for a blood sugar level of 229 (normal range of blood sugar is less than 140 mg/dL).LVN 4 was then observed drawing up (collecting a medication in a syringe) six units of insulin. LVN 4 then signed Resident 65's MAR indicating she had given the medication to the resident. LVN 4 was asked if procedure was to sign that a medication was given prior to actually giving the medication. LVN 4 stated that she should have signed Resident 65's MAR after she had given the medication. LVN 4 states it is important to sign only after giving a medication to a resident to help prevent medication errors.
On 10/22/2021 at 10:23 a.m., during an interview with the Director of Nursing (DON), DON stated that licensed nurses should sign a resident's MAR after providing the resident with their prescribed medication.
A review of facility policy and procedure titled Medication Pass undated, indicated that staff should administer medication by pour (preparing the medication), pass (administering medication) and then chart (documenting medication as given).

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). A total of three medication errors were observed out of 25 total opportunities, medication error rate 12%, affecting one out of three sampled residents (Resident 66).
This deficient practice of administering medications contrary to accepted professional standards had the potential to negatively affect the health and well-being of Resident 66.
Findings:
A review of Resident 66's admission Record indicated the facility admitted the resident on 06/12/2019, with diagnoses that included paroxysmal atrial fibrillation (irregular, often rapid heart rate), heart failure (congestive heart failure [CHF] - chronic, progressive condition which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), unspecified convulsions (seizure - episode in which you experience rigidity and uncontrolled muscle spasms along with altered consciousness), gastrostomy status (gastrostomy tube, often called G-Tube - a surgically placed device used to give direct access to stomach for supplemental feeding, hydration, or medications).
A review of Resident 66's History and Physical (H&P), dated 06/17/2021, indicated the resident does not have the capacity to understand and make decisions.
A review of Resident 66's Physician's Orders indicated to administer:
1.
Levetiracetam (medication used to treat seizures) 100 milligrams/1milliliter (mg/ml - unit of measurement) give 500 mg, administer 5 ml via G-Tube (GT) twice a day for convulsions.
2.
Clopidogrel (medication used to prevent heart attack or stroke) 75 mg 1 tablet vis GT daily for atrial fibrillation
3.
Furosemide (medication used to reduce extra fluid in the body [edema] caused by conditions such as heart failure) 20 mg via GT daily for CHF.
A review of Resident 66's Medication Administration Record (MAR), dated 10/01/2021 to 10/31/2021, the MAR indicated scheduled time of 9 a.m. for the following medications:
1.
Levetiracetam 100 mg/1ml (500 mg) administer 5ml via GT twice a day for convulsions
2.
Clopidogrel 75 mg 1 tablet vis GT daily for atrial fibrillation
3.
Furosemide 20 mg via GT daily for CHF
During an observation on 10/21/2021 at 10:18 a.m., observed Licensed Vocational Nurse (LVN 3) administering Resident 66's morning medications, levetiracetam, clopidogrel, and furosemide.
During a concurrent interview and record review, on 10/21/2021 at 10:25 a.m., of Resident 66's Medication Administration Record (MAR) for 10/2021, LVN 3 stated the following medications scheduled for 9 a.m. were not administered on time:
1.
Levetiracetam 100 mg/ 1ml (500 mg) administer 5ml via GT twice a day for convulsions.
2.
Clopidogrel 75 mg 1 tablet vis GT daily for atrial fibrillation
3.
Furosemide 20 mg via GT daily for CHF
LVN 3 stated she should have given medications on time and further stated she could have prepared earlier to give medications on time.
During an interview, on 09/22/2021, at 02:04 p.m., with the Director of Staff Development (DSD), the DSD stated it was important to gather the necessary equipment prior to medication administration to make sure you are not missing anything and it saves time. The DSD further stated it also allows administering medications in a timely manner.
A review of the facility's policy and procedures, titled Medication - Administration, reviewed 1/25/2021, dated 07/01/2016, indicated the policy's purpose indicates to provide practice standards for safe administration of medications for residents in the facility. The policy indicates medications may be administered one hour before or after the scheduled medication administration time. The policy procedure indicates to assemble the necessary equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1.
Administer 4 doses of Advair (fluticasone-salmeterol, a purple circular inhaler device that administers medication to a resident to aide in breathing) between the dates, 10/16/2021 and 10/21/2021, to one of two sampled residents (Resident 19) investigated on breathing treatment medications.
2.
Administer 14 doses of albuterol (an inhaled medication used to treat breathing problems) between the dates 10/16/2021 and 10/21/2021, to one of two sampled residents (Resident 192) investigated on breathing treatment medications.
The deficient practice of failing to administer medications in accordance with physician's orders increased the risk that Resident 19 and 192 could have experienced serious health complications such as respiratory arrest (the inability to breathe).
Findings:
a. A review of Resident 19's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs).
A review of Resident 19's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/03/2021, indicated the resident Resident 19 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) in daily decision making and needed one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, dressing, and toilet use.
A review of Resident 19's Physician's Orders, dated 04/10/2021, indicated an order for fluticasone-salmeterol aerosol powder breath activated (also known as Advair Diskus) 250-50 microgram (mcg - unit of measurement)/dose, one puff by mouth (orally) two times a day related to COPD.
A review of Resident 19's Medication Administration Record (MAR) for 10/2021, indicated the resident received the oral medication, Advair Diskus from 10/16/2021 at 9 a.m. until 10/20/2021 at 9 a.m., for a total of 10 doses.
A review of the Pharmacy 1 delivery receipts, indicated a 60-dose supply of Advair Diskus was delivered to the facility on [DATE] at 2:06 a.m.
During an observation of Station One [NAME] Medication Cart interior contents, record review, and concurrent interview with Registered Nurse 1 (RN 1) on 10/21/2021, at 9 a.m. 9:00 a.m., observed an Advair Diskus medication box with a 10/16/2021 open date and indicated there were 60 doses. Inside the medication box was the Advair Diskus inhaler with a counter number, 54. The counter number upon opening is 60 and each time a dose is administered, the counter will count down by 1. According to Resident 19's 10/2021 MAR, there should be ten doses administered. The counter should indicate the number, 50. RN 1 was unable to explain the four missing doses. RN 1 stated Resident 1 always took the medication on the mornings she worked. RN 1 stated Resident 19 self-administers the Advair Diskus.
During an interview with RN 1 and Licensed Vocational Nurse 5 (LVN 5) on 10/21/2021 at 3:30 p.m., LVN 5 stated Resident 19 administers the Advair Diskus herself in his presence. LVN 5 stated the other licensed nurses who administer the Advair Diskus may not have checked to make sure the counter decreased in number after medication administration. RN 1 stated she checks to make sure the counter decreased but other licensed nurses may have not checked the counter to ensure Resident 19 received a dose of the medication.
During an interview with the Director of Nurses (DON) on 10/21/2021 at 4:30 p.m., the DON stated licensed nursing staff may not have checked the Advair Diskus counter decreased in number when administering the medication. The DON stated it is important for the counter decrease to ensure a dose was correctly administered.
A review of the facility-provided Advair Diskus Production Information, dated 2000, indicated to administer medication by sliding the lever away from the mouthpiece as far as it will go until it clicks. The production information indicated, at that point, the number on the counter will count down by 1.
b. A review of the admission Record indicated Resident 192 was admitted to the facility on [DATE], with diagnoses that included heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood with symptoms such as fatigue and shortness of breath).
A review of Resident 192's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 07/31/2021, indicated the resident was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) for daily decision making and needed one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, dressing, and toilet use.
A review of Resident 192's Physician's Orders, dated 10/15/2021, indicated an order for albuterol (an inhaled medication to treat breathing problems) 2.5 milligrams/3 milliliters (mg/ml - unit of measurement) via nebulizer (a device to give an inhaled medication) every six hours for one week for congestion and cough.
A review of Resident 192's Medication Administration Record (MAR) for 10/2021, indicated the resident received the albuterol medication from 10/16/2021 at 6 a.m. until 10/21/2021 at 6 a.m., for a total of 21 doses.
A review of the Pharmacy 1 delivery receipts indicated a 75 quantity of albuterol were delivered to the facility on [DATE] at 01:59 a.m., 75 was derived from 25 albuterol vials with 3 mL in each vial for a total of 75.
During a medication cart observation, a record review, and a concurrent interview with Licensed Vocational Nurse 2 (LVN 2) on 10/21/2021, at 10:14 a.m., observed Medication Cart West, Station 2 interior contents. Observed Resident 192's albuterol sulfate box with 17 albuterol plastic vials inside a pouch in the box. LVN 2 stated the albuterol box, contained 25 of 3 mL plastic vials, when first opened before the 6 a.m. dose on 10/16/2021. A review of Resident 192's 10/2021 MAR indicated a total of 21 doses of albuterol were signed as given from 10/16/2021 at 6 a.m. until 10/21/2021 at 6 a.m. There should be four plastic albuterol vials left, but there were 17 albuterol vial doses left in the albuterol box. LVN 2 was unable to explain the discrepancy. LVN 2 stated Resident 192 never refused any doses on the days she worked.
During an observation and interview with Resident 192 in the presence of LVN 2, on 10/21/2021 at 12:45 p.m., Resident 192 refused to take the albuterol breathing treatment. When asked if licensed staff give her all her medications each time, she stated she does not remember if they give them or not.
During an interview with Licensed Vocational Nurse 6 (LVN 6) on 10/21/2021 at 3:45 p.m., she stated she documented she administered the albuterol to Resident 192 on 10/16/2021 at 6 p.m., 10/18/2021 at 6 p.m., and 10/19/2021 at 6 p.m. LVN 6 stated Resident 192 refused to take the medication on 10/18/2021 and 10/19/2021 but forgot to document the resident refused the medication. LVN 6 stated when a resident refuses a medication, she initials the date/time space and circles them on the MAR and documents the medication name and reason for refusal on the back of the form. LVN 6 stated she should have documented Resident 192's refusal. LVN 6 stated she did not notify Resident 192's physician of the resident's refusal.
During a record review and concurrent interview with Registered Nurse 2 (RN 2) on 10/21/2021, at 3:50 p.m., RN 2 presented the emergency kit (E Kit, a box containing medications that can be given immediately if needed) sign-out log to confirm Resident 192's albuterol was not ever taken from there.
During an interview with the Director of Nurses (DON) on 10/21/2021 at 4:30 p.m., the DON stated she was unable to explain why there were 17 doses in Resident 192's albuterol medication box when there should be only four left.
During a phone interview with the Pharmacy 1's Pharmacist (Pharm 1) on 10/22/2021 at 9:33 a.m. in the presence of RN 2, Pharm 1 stated there was one box of 25 count of 3 mL plastic vials sent to the facility on [DATE] at 01:59 a.m. Pharm 1 stated the quantity 75 is the total of 25 count x 3 ml. Pharm 1 stated there were only that many doses sent because the manufacturer seals these vials in a light proof pouch and no more doses can be added to a box of 25 plastic albuterol vials.
During an interview with Registered Nurse 1 (RN 1) on 10/22/2021 at 9:45 a.m., she stated she could not explain why there were 17 albuterol doses left in the pouch when there should be four doses left.
A review of the facility's policy and procedure titled, Medication - Administration, reviewed 01/25/2021, indicated if a resident is refusing to take medication, the licensed nurse who is passing the medications will initial and draw a circle around his/her initials in the designated area on the MAR. Documentation will be entered on the back of the MAR stating the reason for the refusal.

Based on observations, interviews, and record reviews, the facility failed to ensure that the daily medication room thermometer readings were monitored and recorded in a room temperature log in the Central Supply Office to assure a safe temperature range for medication storage for one of one storage room for over the counter (OTC) floor stock medications at the facility.
This deficient practice had the potential for harm to residents due to the potential loss of strength of the drugs, and the potential for the residents to receive ineffective drug dosages.
Findings
During an observation of the facility's Central Supply office on 10/21/2021, at 11:15 a.m., observed that there was no room thermometer or temperature monitoring log. Observed on the shelves were numerous over the counter oral medications (medications that do not require a doctor's prescription for purchase) such as pain relievers, dietary supplements (medications that add nutrients to a diet) and allergy medications (medications that prevent abnormal reactions of the immune system when exposed to a substance).
During an interview on 10/21/2021, at 11:20 a.m. with the Central Supply Coordinator (CSC), CSC stated he does not take daily temperature checks of the medication storage room. CSC stated he was not instructed that daily temperature monitoring was needed for medication storage room. CSC further stated that the facility does not keep a log to record the temperatures inside the medication storage room.
During an interview on 10/21/2021, at 11:30 a.m., the Administrator (ADM) stated and confirmed that facility staff were not checking the Central Supply Office daily room temperatures.
A review of the facility's policy and procedure, titled, Medication Storage in the Facility, reviewed 01/25/2021, indicated medications requiring storage at room temperature are kept at temperatures ranging from 59 degrees Fahrenheit (F-unit of measure) to 86 degrees Fahrenheit.

Based on observation, interview, and record review, the kitchen staff failed to ensure the proper storage, preparation, and distribution of food was done under sanitary conditions for 236 of 237 residents by:
1.
Failing to ensure two packages of frozen alfredo sauce were labeled with the date received by the facility.
2.
Failing to ensure one package of sliced bread was labeled with the date received by the facility.
3.
Failing to ensure one bag of frozen pastry dough was labeled with an expiration date.
4.
Failing to discard one large bag of expired carrots stored in the kitchen refrigerator and readily accessible for use in preparing meals.
These deficient practices had the potential to result in foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) of residents causing symptoms of nausea, vomiting, stomach cramps, and diarrhea.
Findings:
a. During an initial kitchen tour observation, on 10/19/2021, at 8:15 a.m., with the Head [NAME] (HCK), there were two packages of frozen alfredo sauce in Freezer 1 without a date sticker label indicating the date the food item was received by the facility.
During an interview on 10/19/2021, at 8:15 a.m., with the HCK, the HCK stated she placed the alfredo sauce packages in the freezer and forgot to label them with the date the facility received them. The HCK stated food items are labeled with that date to ensure the first items placed in the freezer are the first items out (to be used in meals). The HCK confirmed it was against the facility's policy to have undated alfredo sauce in Freezer 1.
During an interview, on 10/21/2021 at 8:25 a.m., with the Dietary Supervisor (DS), she stated the frozen alfredo sauce should have been labeled with the date (received) and it was an oversight. She stated the policy is to label every food item that arrives at the facility.
During an interview, on 10/22/2021, at 8:53 a.m., with the Administrator (ADM), she stated the facility policy is that food is labeled with the date the facility received it. ADM confirmed the frozen alfredo sauce should have been labeled with the received date per the facility policy.
A review of the facility's revised policy and procedures titled, Food Storage, revised date 01/25/2021, indicated the purpose is to establish guidelines for storing, thawing, and preparing food. The policy and procedures indicated food items will be stored, thawed, and prepared in accordance with good sanitary practice.
b. During a concurrent observation and interview, on 10/19/2021, at 8:30 a.m., with the Dietary Supervisor (DS), observed one loaf of sliced bread in the Dry Goods storage room without a date sticker label indicating the date the food item was received by the facility. The DS confirmed the sliced bread did not have a date sticker label and stated all bread should have a sticker indicating when it arrived at the facility.
During an interview, on 10/22/2021, at 8:53 a.m., with the Administrator (ADM), she stated the facility policy is that food is labeled with the date the facility received it.
A review of the facility's revised policy and procedures titled, Food Storage, revised date 01/25/2021, indicated the purpose is to establish guidelines for storing, thawing, and preparing food. The policy and procedures indicated food items will be stored, thawed, and prepared in accordance with good sanitary practice. The policy and procedures indicated products are to be labeled and dated and stock is to be rotated.
c. During an initial kitchen tour observation, on 10/19/2021, at 8:35 a.m., with the Dietary Supervisor (DS), observed frozen pastry dough squares being stored in a large bag, not the original box, in Freezer 2. The pastry dough bag was labeled with the open date, there was no use by or expiration date.
During a concurrent observation and interview, on 10/19/2021, at 8:37 a.m., with the DS, the DS stated the facility had limited storage and staff removed the pastry dough squares from the original boxes and placed them in the large bag in Freezer 2. The DS stated the pastry dough was frozen and did not need an expiration date label. The DS stated the Ice Cream Freezer contained more boxes of pastry dough.
Observed seven boxes labeled Pastry Dough Squares in the Ice Cream Freezer. The seven boxes were labeled with a stamp indicating a pull by date of 08/10/2022. The DS confirmed the pull by date was the expiration date of the pastry dough squares.
During an interview, on 10/22/2021, at 8:53 a.m., with the Administrator (ADM), she stated the facility policy is food items that are removed from the original packaging will be labeled with the expiration date. ADM stated all food has an expiration date and should be labeled accordingly. ADM confirmed the frozen pastry dough should have been labeled with the pull by date per the facility policy.
A review of the facility's undated Refrigerated Storage Guidelines, indicated the recommended maximum storage period for pie shells, baked or unbaked, was three months.
A review of the facility's revised policy and procedures titled, Food Storage, revised date 01/25/2021, indicated the purpose is to establish guidelines for storing, thawing, and preparing food. The policy and procedures indicated food items would be stored, thawed, and prepared in accordance with good sanitary practice.
d. During an initial kitchen tour observation, on 10/19/2021, at 8:20 a.m., with the Head [NAME] (HCK), observed a large bag of carrots with two yellow stickers dated 8/25/2021 in the refrigerator.
During an interview, on 10/19/2021, at 8:22 a.m., with the HCK, she stated carrots should not be kept in the facility for almost two months.
During a concurrent observation and interview, on 10/19/2021, at 8:24 a.m., with the DS, she stated the bag of carrots should be used within one month per the food storage guidelines. The carrots were observed with some browning at the ends near the stems. The DS stated the bag of carrots would be thrown out.
During a concurrent review of the facility's Food Storage Guidelines and an interview, on 10/22/2021, at 8:25 a.m., with the DS, she stated the Food Storage Guidelines indicated root vegetables can be stored in the refrigerator for two weeks. The DS stated she threw out the expired bag of carrots.
During an interview, on 10/22/2021, at 8:53 a.m., with the Administrator (ADM), she stated the bag of carrots should not have been in the refrigerator if it was dated 08/25/2021. ADM confirmed the food storage guideline for root vegetables is to discard them after two weeks.
A review of the facility's undated Refrigerated Storage Guidelines, indicated the recommended maximum storage period for root vegetables is two weeks.
A review of the facility's revised policy and procedures titled, Food Storage, revised date 01/25/2021, indicated the purpose is to establish guidelines for storing, thawing, and preparing food. The policy and procedures indicated food items will be stored, thawed, and prepared in accordance with good sanitary practice. The policy and procedures indicated fresh vegetables should be checked and sorted for ripeness and fresh vegetables should be ordered frequently to ensure freshness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During an observation on 10/20/2021 at 1:20 p.m., observed four to six staff members drank coffee and ate cookies in nursing station [NAME] 1. An electric coffee maker, four to six full cups of coffee, and a package of cookies were located on the nursing station's computer and charting work surface area. Two to four staff members removed the cups of coffee and the package of cookies and quickly walked away.
During an interview, on 10/20/2021, at 1:22 p.m., with Certified Nursing Assistant 5 (CNA 5), she stated she and her coworkers were drinking Armenian coffee and eating cookies in the nursing station. CNA 5 stated it was against the facility policy to eat in the nursing station and she apologized. CNA 5 stated staff should only eat in the staff lounge.
During a concurrent observation and interview, on 10/20/2021, at 1:28 p.m., with Restorative Nursing Assistant 1 (RNA 1), she was observed sitting in nursing station [NAME] 1 while charting with full cups of coffee located to her left on the work surface area. RNA 1 stated it's important to not drink and share coffee because of infection control. She stated there is a break room to eat in.
During an interview, on 10/22/2021, at 11:12 a.m., with the Administrator (ADM), she stated staff should never have coffee or food in the nursing station. ADM stated she was made aware of the incident and staff was given an inservice training regarding the matter. ADM stated the staff knew it was wrong.
During an interview, on 10/22/2021, at 11:23 a.m., with the Director of Staff Development (DSD), she stated it is important that staff does not drink coffee or eat at the nursing station because it's not allowed, and it's an infection control issue. \
A review of the facility's revised policy and procedure titled, Infection Prevention and Control Program, dated 10/01/2021, indicated the policy is to ensure the facility maintains an Infection Control Program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. The policy and procedures indicated that employees are prohibited from eating and drinking in areas where there is a reasonable likelihood of occupational exposure. Occupational exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.
c. A review of the admission Record indicated Resident 65 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) with diabetic nephropathy (is a type of nerve damage that can occur if you have diabetes), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia in other disease classified elsewhere without behavioral disturbances (a group of thinking and social symptoms that interferes with daily functioning), and long term use of insulin (hormone that lowers the level of glucose [sugar] in the blood).
A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 08/03/2021, indicated Resident 65 rarely/never understands others or can make self-understood. The MDS indicated Resident 65 was totally dependent with physical assistance with bed mobility, transfer, and toilet use.
On 10/21/2021, at 11:52 a.m., during medication administration observation with Licensed Vocational Nurse 4 (LVN 4), observed LVN 4 performing glucose check (fingerstick - using a lancet to pierce the skin of a resident to obtain a blood sample in order to determine the level of sugar in the blood) on Resident 65. Observed LVN 4 dispose of the used items gloves, strip, alcohol swab, and lancet in a cup into the trash can on the medication cart.
On 10/21/2021, at 11:54 a.m., during an interview, LVN 4 stated she placed the used lancet in the trash can. LVN 4 further stated the used lancets usually go in sharps container (a container that can be filled with used medical needles and all categories of sharps waste, before being disposed of safely), but Resident 65's used lancet was in a cup in a trash can covered with her gloves.
On 10/22/2021, at 10:23 a.m., during an interview with the Director of Nursing (DON), she stated that all needles and sharps need to be placed in a sharps container, and if the needle is not visible and is inside the cup, the DON stated that she thinks it's okay to be in trash.
A review of facility's policy and procedures titled, Sharps Disposal, revised on 08/01/2014 indicated:
I. Nursing staff using sharps discard them as soon as feasible into designated containers.
II. Contaminated sharps are discarded into containers that are:
A.
Closable
B.
Puncture resistant.
C.
Leakproof on side and bottom;
D.
Labeled with words Sharps Waste or with the international biohazard symbol and the word Biohazard
E.
Impermeable and capable of maintaining impermeability through final waste disposal.
Based on observation, interview, and record review, the facility failed to implement infection control policy and procedure for two of two residents (Resident 41 and 65) and for 237 of 237 residents residing in the facility by:
1. Failing to ensure the Certified Nursing Assistant 6 (CNA 6) performed hand hygiene before moving from a contaminated body site to a clean body site, followed facility's peri-care procedure, and wore eye protection during perineal care for Resident 41.
2. Failing to ensure that four to six facility staff members were not observed drinking coffee and eating cookies in [NAME] 1 Nursing Station.
3. Failing to dispose Resident 65's used lancet (small devices that provide a way to take blood samples) in the designated sharps container (a container that can be filled with used medical needles and all categories of sharps waste, before being disposed of safely) instead of the trash can.
These deficient practices had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) and spread of infection.
Findings:
a. A review of Resident 41's admission Record indicated the resident was admitted on [DATE] with diagnoses including chronic kidney disease (gradual loss of kidney function-to remove wastes and excess water from the body) and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living).
A review of Resident 41's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/05/2021, indicated the resident required total dependence to nursing facility staff with toileting and bathing.
A review of Resident 41's care plan titled, Incontinent of Bowel and Bladder, indicated the resident with goals of being clean every shift and included interventions such as keeping the resident clean and dry.
During an observation and interview, on 10/21/2021, at 9:08 a.m., Certified Nursing Assistant 6 (CNA 6) was not wearing any eye protection. CNA 6 stated she was assisting the primary CNA for Resident 41's morning care. CNA 6 stated she was going to change Resident 41's pads.
During a peri-care observation for Resident 41 while resident was in bed, on 10/21/2021, at 9:13 a.m., CNA 6 performed hand hygiene and put on gloves. CNA 6 removed resident's pads and used one wet wash cloth and sprayed rinse-free clean and fresh solution on the washcloth and wiped resident's pubic area using two strokes of same side of wash cloth. CNA 6 did not separate each side of the resident's pubic area and did not use a clean area of the washcloth for each stroke. CNA 6 used the same washcloth with clean side to clean buttocks and peri-anal area. CNA 6 then dried Resident 41's pubic area and peri-anal area using a towel. CNA 6, while using the same gloves, applied vitamin A&D (skin protectant) and placed new pads under Resident 41. CNA 6 removed her gloves and put on Resident 41's socks.
During an interview, on 10/21/2021 at 9:30 a.m., CNA 6 confirmed she had finished providing morning care to Resident 41.
During an interview on 10/21/2021 at 1:54 p.m., CNA 6 stated she washes her hands before and after care. CNA 6 stated, for Resident 41, she washed before and after care. CNA 6 confirmed she did not wash or perform hand hygiene after removing gloves and after cleaning resident's pubic area and peri-anal area. CNA 6 stated she then removed her gloves and put on resident's clothes and after she finished then she washed her hands. CNA 6 stated she washed the resident's pubic area from front to bottom and peri-anal area using same wash cloth but different cloth. CNA 6 stated she wiped the front with two strokes and the back with the other clean side of the washcloth. CNA 6 confirmed she did not wear her googles because it kept falling off and does not stay put on her head. CNA 6 stated she knew she was supposed to have her googles on but did not wear it when providing care to Resident 41.
During an interview, on 10/22/2021, at 11:15 a.m., the Director of Staff Development (DSD) stated she provides hand hygiene in-services (training) to facility staff and oversees CNAs. DSD stated it is important to perform hand hygiene to prevent infection from spreading in the facility. DSD stated clean hands, saves lives. DSD stated facility staff are expected to perform hand hygiene before and after they come to work, before putting on and after removing off gloves, and anytime they go from dirty to clean area when providing peri-care to residents.
During an interview on 10/22/2021 at 11:19 a.m., DSD stated for peri-care, staff should use one clean side of the washcloth per site, and from front to the back to prevent skin irritation, skin infection, and urinary tract infections (UTI - infection that affects part of the urinary tract-kidneys, ureters, urinary bladder and the urethra).
During an interview, on 10/22/2021, at 11:20 a.m., DSD stated facility staff are expected to wear eye protection while providing resident care for the resident and staff protection and part of infection control prevention.
A review of the facility's policy and procedures titled, Personal Protective Equipment, reviewed and approved on 01/25/2021, indicated that it is the facility's policy to ensure the availability of personal protective equipment. The policy and procedures indicated hands are washed before and after the removing of gloves and protective eyewear (googles and/or face shields) must be worn when anticipating splashes of blood or body fluids to the eyes.
A review of the facility's policy and procedure titled, Hand Hygiene, reviewed and approved on 01/25/2021, indicated that the purpose of this policy is to ensure that all individuals use appropriate hand hygiene while at the facility. The facility staff must perform hand hygiene procedures in the following circumstances. A. Wash hands with soap and water in between glove changes.
A review of the facility's policy and procedure titled, Perineal Care, reviewed and approved on 01/25/2021, indicated that the purpose of this policy is to maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown and perineal care is provided as part of a resident's hygienic program. The procedure included:
VI. Wash the pubic area. For female residents:
i. Separate the labia. Wash with soapy washcloth, moving from front to back, on each side of the labia and in the center over the urethra and vaginal opening, using a clean area of the washcloth for each stroke.
ii. Rinse area, moving from front to back, using clean area of the washcloth for each stroke.
iii. Dry area moving from front to back, using a blotting motion with towel.
VII. Turn resident to side.
VIII. Wash, rinse and dry buttocks and [NAME]-anal area without contaminating perineal area.
IX. Remove wet linen.
X. Place dry linens or briefs or both underneath resident.
XII. Remove gloves. Wash hands or use alcohol-based hand sanitizer.
XIII. Put on clean gloves.
XIV. Clean and return all equipment to its proper place.
XV. Place soiled linen in proper container.
XVI. Remove gloves.
XVII. Wash hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality by staff standing over the resident while assisting during a meal for two of three sampled residents (Resident 171 and Resident 220).
This deficient practice had the potential to affect the residents' self-worth and self-esteem.
Findings:
a. A review of Resident 171's admission Record (face sheet) indicated the resident was admitted on [DATE] with diagnoses that included dementia (a loss of mental ability severe enough to interfere with normal activities of daily living) and dysphagia (difficulty swallowing).
A review of Resident 171's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 09/05/2021, indicated the resident had severely impaired cognitive skills (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for decision making. The MDS also indicated Resident 171 required extensive assistance with eating and required physical assistance from nursing staff.
A review of Resident 171's Physician's Order datedd 10/09/2021, indicated no added salt (NAS) and consistent carbohydrate (CCHO) diet, easy to chew texture, and regular consistency liquids.
A review of Resident 171's care plan titled, Therapeutic Diet, initiated date 01/05/2021, indicated resident with goals of tolerating texture consistency as evidenced by no choking or aspiration. The care plan indicated Resident 171's interventions of setting up tray and assisting resident during meals daily as needed.
During an observation inside Resident 171's room, on 10/19/2021, at 9:14 a.m., observed Resident 171 in bed with head of bed up and Certified Nursing Assistant 1 (CNA 1) who stood over the resident while assisting the resident with breakfast.
During an observation inside Resident 171's room, on 10/19/2021, at 12:29 p.m., observed Resident 171 in bed with head of bed up and CNA 1 who stood over the resident while assisting the resident with lunch.
During a concurrent observation and interview, on 10/19/2021, at 12:32 p.m., CNA 1 confirmed Resident 171 ate 45% of lunch meal.
During an interview, on 10/19/2021, at 12:40 p.m., CNA 1 confirmed she does not use a chair while feeding Resident 171 because she cannot reach the resident while sitting down. CNA 1 stated she should be sitting down but she does not.
During an interview, on 10/22/2021, at 11:20 a.m., the Director of Staff Development (DSD) stated for eating, facility staff are expected to wash hands before eating and have them sitting across the resident at eye level to see the resident's swallowing reflex and make conversation enjoyable.
A review of the facility's updated policy and procedure titled, Restorative Dining Program, revised date 01/25/2021, indicated the program is to provide the opportunity for residents to attain their highest level of independence in feeding, improve appropriate mealtime behavior, self-image, and socialization skills. The policy indicated staff members should sit while assisting or feeding a resident.
A review of the facility's updated policy and procedure titled, Privacy and Dignity, revised date 01/25/2021, indicated staff assists the resident in maintaining self-esteem and self-worth. The policy indicated the facility promotes independence and dignity in dining.
b. A review of Resident 220's admission Record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses of, but not limited to, vascular dementia (long term and often gradual decrease in the ability to think, remember, and make decisions), dysphagia (difficulty swallowing) following cerebral infarction (damage to brain tissue that occurs due to a loss of oxygen), and generalized muscle weakness.
A review of Resident 220's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 09/29/2021, indicated the resident had the ability to make self understood and sometimes had the ability to understand others. The MDS indicated the resident needed extensive assistance with bed mobility, transfer, dressing, toilet use, and eating. The MDS also indicated the resident had a poor appetite.
A review of Resident 220's care plan addressing, Therapeutic RNA Dining Program for breakfast and lunch, initiated 07/07/2021, indicated the Restorative Nursing Assistant program (RNA, a program that focuses on residents achieving and maintaining optimal physical, mental, and psychosocial functioning) was to promote dietary intake and decrease distraction at mealtime.
During an interview on 10/19/2021 at 10:15 a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 220 was on a feeding program and was not able to feed herself.
During a meal observation on 10/20/21 at 08:48 a.m., observed Resident 220 sitting in a wheelchair in her room while Certified Nursing Assistant 2 (CNA 2) stood over the resident during the entirety of assisting the resident with her breakfast.
During an interview on 10/20/2021 at 09:15 a.m. with CNA 2, she stated she stood over Resident 220 while feeding her and the facility policy is to sit. CNA 2 stated she should have sat with the resident because it's important that the resident is able to make eye contact and feel comfortable (while eating).
During an interview on 10/20/2021 at 01:16 p.m. with LVN 2, she stated it's never appropriate to stand and feed a resident. She stated it's the facility policy to sit with residents that are on the RNA dining program.
During an interview on 10/21/2021 at 10:53 a.m. with the Director of Nursing (DON), the DON stated CNAs and RNAs should always sit while feeding residents. The DON stated she oversees the RNA program, and it's the policy to sit with residents.
During an interview on 10/22/2021 at 11:23 a.m., with the Director of Staff Development (DSD), she stated it is important to have staff sit at eye level (while assisting with feeding) to watch the resident's swallow reflex and to make it pleasurable and have conversation at eye level.
A review of the facility's updated policy and procedure titled, Restorative Nursing Program Guidelines, revised 01/25/2021, indicated nursing assistants/aides are trained in the techniques that promote resident involvement in the activity.
A review of the facility's updated policy and procedure titled, Restorative Dining Program, revised date 01/25/2021, indicated the program is to provide the opportunity for residents to attain their highest level of independence in feeding, improve appropriate mealtime behavior, self-image, and socialization skills. The policy indicated staff members should sit while assisting or feeding a resident.
A review of the facility's updated policy and procedure titled, Privacy and Dignity, revised date 01/25/2021, indicated staff assists the resident in maintaining self-esteem and self-worth. The policy indicated the facility promotes independence and dignity in dining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 19), did not self-administer (take medications without supervision from a licensed nurse) their medications unless the interdisciplinary team ([IDT]- a team of individuals from multiple medical disciplines tasked with providing a clinical plan of care for a resident) determined it was clinically safe, and appropriate to do so.
This deficient practice increased the risk of Resident 19 omitting medications or taking them incorrectly which could negatively impact health and well-being.
Findings:
A review of Resident 19's admission record indicated Resident 19 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs).
A review of Resident 19's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/03/2021, indicated Resident 19 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) in daily decision making and needed one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, dressing, and toilet use.
A review of Resident 19's Physician's Orders, dated 04/10/2021, indicated an order for Fluticasone-Salmeterol Aerosol Powder (combination of two medicines that decrease inflammation and help to open up the airways of your lungs) Breath Activated (handheld device that delivers a dose of medicine as a mist when you inhale )250-50 microgram per dose (mcg/dose), one puff orally two times a day related to COPD.
A review of Resident 19's Medication Administration Record (MAR-flowsheet that indicates medications given to a resident) for October 2021, indicated Resident 19 received the medication Fluticasone-Salmeterol Aerosol Powder twice a day from 10/01/2021 until 10/21/2021.
During an interview with Licensed Vocational Nurse 5 (LVN 5) on 10/21/2021, at 3:30 p.m., LVN 5 stated Resident 19 self-administers Fluticasone-Salmeterol Aerosol Powder herself.
During an interview with Registered Nurse 1 (RN 1) on 10/21/2021, at 3:30 p.m., RN 1 stated Resident 19 self-administers the Fluticasone-Salmeterol Aerosol Powder.
During an interview and concurrent record review with Registered Nurse 2 (RN 2) on 10/22/21, at 3:25 p.m., Resident 19's medical record was reviewed. Noted was an IDT entry and physician order for the self-administration of Fluticasone-Salmeterol Aerosol Powder by Resident 19 dated 10/22/2021. RN 2 stated that facility staff should have obtained a physician order and conducted an IDT meeting to address the self-administration of Fluticasone-Salmeterol Aerosol Powder for Resident 19 prior to allowing the resident to self-administer the medication.
A review of the facility's policy and procedure titled, Medication - Self Administration, dated 01/25/2021, indicated a resident who request to perform medication self-administration will be assessed for capability. The policy indicated if a resident is assessed as clinically appropriate for medication self-administration by the IDT, the licensed nurse obtains a physician's order for self-administration of selected medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of the admission Records indicates Resident 95 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning), history of falling, unspecified abnormalities of gait and mobility, other encephalopathy (a broad term for any brain disease that alters brain function or structure), sequelae (abnormal condition resulting from a previous disease) of cerebral infarction (about one-third of stroke survivors experience depression, anxiety or apathy, which are the most common neuropsychiatric sequelae of stroke), and major depressive disorder (a persistent feeling of sadness and loss of interest).
A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 08/09/2021, indicated Resident 95 was able to understand others and make herself understood. The MDS also indicated Resident 95 required extensive physical assistance with bed mobility and transfer, and physical assistance with toilet use. The MDS indicated Resident 95 was frequently incontinent of bladder.
A review of the care plan initiated on 05/16/2017, indicated At risk for fall secondary to unsteady balance during transitions and walking has impairment of upper and lower extremities on both sides/muscles weakness/difficulty in walking/history of falling, and care plan initiated on 05/24/2018, indicated ambulation with assistance due to unsteady gait and balance, indicated Resident 95 intervention as keep call light easily available and answer promptly.
A review of the Fall Risk Assessment, dated 08/10/2021, indicated Resident 95 was at high risk for falls.
During an observation and interview, on 10/19/2021, at 08:46 a.m., observed Resident 95 sitting up in wheelchair with call light not within reach. Observed the resident's call on bed out of reach from Resident 95. Asked Resident 95 if she had a call light button, the resident shrugged her shoulders and stated, I don't know.
During an interview, on 10/19/2021, at 8:51 a.m., Certified Nursing Assistant 4 (CNA 4) stated they (staff) forgot to give the call light to Resident 95. Observed CNA 4 walkd into the room and gave Resident 95 the call light button. CNA 4 stated Resident 95 could fall if she was trying to get up.
On October 22, 2021 at 10:29 a.m., during an interview, the Director of Nursing (DON) stated every resident should have a call light within reach, and that staff is aware to give call light to all residents.
A review of the facilities policy titled Communication-Call System, revised on 01/01/2016, indicated that the facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities.
A review of the facilities policy titled Fall Management Program, revised on 03/01/2015, indicated the following are suggested measures that can be used in the prevention of falls. This list is not all-inclusive:
A.
Environmental
ii. Position call bell, urinal if applicable, and bedside [NAME] within reach.
D. Education
i. Educate resident in the use of the call light system and to ask assistance.
Educate in other specific safety measure as indicated.
Based on observation, interview, and record review, the nursing staff failed to ensure the call light button was within reach of the residents while they were sitting in the wheelchair next to the bed for two of two sampled residents (Resident 184 and Resident 95) at high risk for falls.
This deficient practice had the potential to result in residents not being able to summon health care workers for assistance as needed that may include urgent care.
Findings:
a. A review of the admission Record indicated Resident 184 was admitted on [DATE], with diagnoses including, but not limited to, Parkinson's disease (a progressive disorder of the brain that affects movement), rheumatoid arthritis (a disease that causes joint inflammation, stiffness, loss of function, and pain), Alzheimer's disease (a progressive form of dementia [decline in mental ability severe enough to interfere with daily functioning/life] that causes memory loss and cognitive decline), and generalized weakness.
A review of Resident 184's Initial History and Physical dated 07/21/2021, indicated Resident 184 had fluctuating capacity to understand and make decisions.
A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 09/06/2021, indicated Resident 184 had the ability to make self understood and understand others. The MDS indicated Resident 184 required extensive assistance with bed mobility, transfer, dressing, and toilet use. The MDS indicated Resident 184 required total dependence with locomotion on and off the unit.
A review of the care plan addressing Risk for fall secondary to unsteady balance during transitions and walking/only able to stabilize balance with staff assistance, initiated on 07/15/2019 and most recently re-evaluated on 09/13/2021, indicated Resident 184 should have the call light within easy reach. The care plan indicated Resident 184 had impairment of upper and lower extremities.
A review of the care plan addressing Needs assistance in proficiencies/activities of daily living, initiated on 07/15/2019 and most recently re-evaluated on 09/13/2021, indicated Resident 184 should have the call light easily accessible.
A review of the Fall Risk assessment dated [DATE], indicated Resident 184 was at high risk of fall due to intermittent confusion, poor vision, balance problems while walking and standing, and diagnoses with predisposing conditions.
During a concurrent observation and interview on 10/19/2021 at 10:35 a.m., with Resident 184 and translated by Licensed Vocational Nurse 2 (LVN 2), observed Resident 184 sitting in the wheelchair next to the resident's bed. The call light device was clipped to the bed's pillow five feet away. Resident 184 stated she could not reach the call light device.
During an interview on 10/19/2021 at 10:38 a.m., with LVN 2, she stated the call light should not have been that far away from Resident 184. LVN 2 moved the call within reach of the resident. LVN 2 stated the call light should be within reach so the resident can call for help. LVN 2 confirmed it was against the facility's policy to have the call light device not within reach of Resident 184.
During an interview on 10/22/2021 at 8:41 a.m., with the Director of Nursing (DON), she stated the facility's policy is the call light device should be within reach of the residents.
A review of the facility's revised policy and procedures titled, Communication - Call System, dated 01/01/2016, indicated it is the facility's policy to provide a mechanism for resident's to promptly communicate with nursing staff. The call cords will be placed within the resident's reach in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, Licensed Vocational Nurse 6 (LVN 6) failed to notify the resident's physician about a medication refusal for one of two sampled residents (Resident 192) investigated addressing prescribed breathing treatments. Resident 192 refused to take albuterol sulfate (an inhaled medication used to treat breathing problems) on two separate occasions with LVN 6, who did not notify Resident 192's physician of the refusal.
This had the potential for Resident 192 to have a decline in health and increased breathing problems.
Findings:
A review of Resident 192's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood with symptoms such as shortness of breath).
A review of Resident 192's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 07/31/2021, indicated the resident was moderately impaired in cognition (mental action or process of acquiring knowledge and understanding) for daily decision making and needed one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with transfer, dressing, and toilet use.
A review of Resident 192's Physician's Orders, dated 10/15/2021, indicated an order for albuterol (an inhaled medication to treat breathing problems) 2.5 milligrams (mg - unit of measurement)/3 milliliter (ml - unit of measurement) via nebulizer (a device to give an inhaled medication) every six hours for one week for congestion and cough.
A review of Resident 192's Medication Administration Record (MAR) for 10/2021, indicated the resident received the albuterol medication from 10/16/2021 at 6 a.m. until 10/21/2021 at 6 a.m., for a total of 21 doses.
During an observation and interview with Resident 192 in the presence of Licensed Vocational Nurse 2 (LVN 2) on 10/21/2021 at 12:45 p.m., the resident refused to take the albuterol breathing treatment. When asked if licensed nursing staff give her all her medications each time, she stated she does not remember if they gave them or not.
During an interview with Licensed Vocational Nurse 6 (LVN 6) on 10/21/2021 at 3:45 p.m., she stated Resident 192 refused to take the albuterol medication on 10/18/2021 and 10/19/2021 but she forgot to document that the residen refused the medication. LVN 6 stated when a resident refuses a medication, she initials the date/time space, circles them on the MAR, and documents the medication name and reason for refusal on the back of the form. LVN 6 stated she should have documented Resident 192's refusal. LVN 6 stated she did not notify Resident 192's physician of the resident's refusal to take the albuterol.
A review of the facility's policy and procedure titled, Medication - Administration, reviewed 01/25/2021, indicated if a resident is refusing to take medication, the licensed nurse will re-approach the resident and attempt to give the medications, at a later time, but if the resident continues to refuse after one hour, the refused medications will be destroyed. The policy indicated the licensed nurse will notify the attending physician and document in the medical record. The policy indicated if the resident repeatedly refuses the medication, the licensed nurse will contact the physician to discuss alternative measures for medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and care screening tool) accurately reflected Resident 246's discharge status, for one out of three residents (Resident 246) investigated for closed record review.
This deficient practice had the potential to inaccurately reflect Resident 246's care assessment and care planning.
Findings:
A review of the Face Sheet (admission record), indicated Resident 246 was admitted to the facility, on 09/28/2021, with diagnoses that included heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), paroxysmal atrial fibrillation (irregular, often rapid heart rate), and chronic kidney disease (the stages of kidney disease are based on how well the kidneys can filter waste and extra fluid out of the blood).
A review of the History and Physical Examination, dated 09/28/2021, indicated Resident 246 had fluctuating capacity to make decisions.
A review of the MDS, dated [DATE], indicated Resident 246 was discharged to an acute hospital.
A review of the Physician Order Summary, dated 10/04/2021, indicated Resident 246 was discharged home against medical advice (AMA-when a resident leaves against the advice of their doctor).
A review of the Discharge Summary Report, dated 10/04/2021, indicated Resident 246 was discharged to home AMA.
During a concurrent interview and record review, on 10/20/2021 at 04:21 p.m., the Minimum Data Set Nurse (MDSN) verified that Section A, subsection discharge status of the MDS, was coded incorrectly as discharged to hospital. MDSN further stated it should have been coded as discharged to community because resident was discharged home. The MDSN stated the importance of documenting correctly to ensure accuracy.
During a concurrent interview and record review, on 10/21/2021, at 01:35 p.m., the Director of Nursing (DON) confirmed the MDS was coded incorrectly as discharged to hospital and stated it should have been coded correctly as discharged to community.
A review of the facility's policy, titled Resident Assessment Instrument (RAI) process, reviewed 01/25/2021, dated 10/01/2019, indicated the facility will utilize the RAI process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the RAI manual.