Alameda Care Center

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) who had an episode of hematuria (presence of blood in the urine) accurately.This failure had the potential for confusion and may delay in the delivery of necessary care and services to Resident 1. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/15/2026, with diagnoses that included unspecified (unconfirmed) encephalopathy (a change in how your brain functions), unspecified dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).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 1/15/2026, 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 1/20/2026, 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 always incontinent (unable to control) of bowel and bladder functions.During a review of Resident 1's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 2/13/2026, the COC indicated on 2/13/2026, at 3 a.m. and at 6:30 a.m. Certified Nursing Assistant 1 (CNA 1) reported to Licensed Vocational Nurse 1 (LVN 1) that Resident 1 had diaper with blood-tinged (a small amount of blood) urine.During a review of Resident 1's Order Listing Report, dated 2/13/2026, the Order Listing Report indicated the following orders:-Urinalysis (urine test) with culture and sensitivity (test detects bacteria or yeast in the urine and determines the most effective antibiotic for treatment).-May do straight catheterization (a thin, flexible, single-use tube inserted temporarily through the urethra to drain urine and removed immediately after) for urine collection, if unable to obtain clean catch (a technique for collecting a sterile, midstream urine specimen).During a review of Resident 1's Care Plan, dated 2/13/2026, about episodes of hematuria, the Care Plan indicated the following interventions:Monitor indwelling catheter (a hollow tube that is inserted into your bladder to drain urine) and change catheter or bag as ordered.Foley catheter (a specific, common type of indwelling catheter) cares every shift or as ordered.Maintain proper alignment of foley catheter to promote proper drainage.During an interview on 3/10/2026, at 11:10 a.m., with LVN 2, LVN 2 stated on 2/13/2026, she (LVN 2) assisted Registered Nurse 1 (RN 1) in obtaining urine sample for urinalysis, culture and sensitivity to Resident 1's using straight catheterization. LVN 2 stated Resident 1 had no indwelling catheter.During a concurrent interview and record review on 3/10/2026, at 12:18 p.m., with the Director of Nursing (DON), Resident 1's Care Plan, dated 2/13/2026, about hematuria was reviewed. The DON stated Resident 1's Care Plan should have been individualized to reflect use of straight catheter instead of indwelling catheter. The DON stated indwelling catheter is a continuous use of catheter. The DON stated the care plan was not accurate because Resident 1 never had an indwelling catheter. The DON stated a care plan should be individualized to be consistent and accurate in providing care specific to Resident 1.During a concurrent interview and record review on 3/10/2026, at 12:45 p.m., with the DON, facility's policy and procedure (P&P) titled, The Resident Care Plan, undated and last reviewed on 1/14/2026, the P&P indicated, To provide an individualized nursing care plan and to promote continuity of resident care.Record the following: 1. Procedures directly ordered by the physician; 2. Procedures associated with specific resident teaching; 3. Care necessitated by the resident's individual needs. The DON stated Resident 1's Care plan should be individualized for Resident 1's needs.

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to:1. Ensure Licensed Vocational Nurse 1 (LVN 1) document accurately the time Family Member 1 (FM 1) was notified of Resident 1's change of condition on 2/13/2026.2. Ensure Registered Nurse 1 (RN 1) and LVN 2 document obtaining of urine sample through straight catheterization (a medical procedure, also known as intermittent or in-and-out catheterization, where a flexible tube is inserted through the urethra into the bladder to drain urine, then immediately removed) of Resident 1.3. Ensure nurses document notification of the physician of Resident 1's laboratory test result on 2/17/2026 and 2/20/2026.These failures had the potential to result in confusion in care and the 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 1/15/2026, with diagnoses that included unspecified (unconfirmed) encephalopathy (a change in how your brain functions), unspecified dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).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 1/15/2026, 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 1/20/2026, 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 always incontinent (unable to control) of bowel and bladder functions.During a review of Resident 1's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 2/13/2026, the COC indicated on 2/13/2026, at 3 a.m. Certified Nursing Assistant 1 (CNA 1) reported to LVN 1 that Resident 1 had diaper with blood-tinged (a small amount of blood) urine. LVN 1 noted Resident 1 with hematuria (bloody urine) but had no pain and no burning sensation. The COC indicated on 2/13/2026, at 6:30 a.m., CNA 1 reported to LVN 1 the second episode of blood-tinged urine in Resident 1's diaper. The COC indicated notification to FM 1 on 2/13/2026, at 12 midnight.During a concurrent interview, and record review on 3/10/2026, at 12:18 p.m., with the Director of Nursing (DON), Resident 1's COC, dated 2/13/2026, was reviewed. The DON stated LVN 1 documented notification of FM 1 on 2/13/2026, at 12 midnight but the blood-tinged urine did not happen until 2/13/2026, at 3 a.m. and 6:30 a.m. The DON stated 12 midnight was not the accurate time. The DON stated LVN 1 should have documented accurately the time she (LVN 1) called FM 1.b. During a review of Resident 1's Order Listing Report, dated 2/13/2026, the Order Listing Report indicated the following orders:- Urinalysis (urine test) with culture and sensitivity (test detects bacteria or yeast in the urine and determines the most effective antibiotic for treatment).- May do straight catheterization for urine collection, if unable to obtain clean catch (a technique for collecting a sterile, midstream urine specimen).During a concurrent interview, and record review on 3/6/2026, at 1:48 p.m., with RN 2, Resident 1's Physician Order, dated 2/13/2026, were reviewed. RN 2 stated the physician ordered urinalysis, culture and sensitivity to Resident 1's using straight catheterization for urine collection.During an interview on 3/10/2026, at 10:37 a.m., with RN 1, RN 1 stated on 2/13/2026, she (RN 1) with the help of LVN 2, had straight-catheterized Resident 1 and obtained urine sample for urinalysis, culture and sensitivity but there was an issue with the labelling so on 2/14/2026, LVN 2 had to straight-catheterized Resident 1 again with RN 2.During an interview on 3/10/2026, at 11:10 a.m., with LVN 2, LVN 2 stated on 2/13/2026, she (LVN 2) assisted RN 1 to straight-catheterized Resident 1 in obtaining urine sample for urinalysis, culture and sensitivity. LVN 2 stated she (LVN 2) did not document the straight catheterization of Resident 1 on 2/13/2026. LVN 2 stated RN 1 should have documented since she (RN 1) was the one who performed the procedure on 2/13/2026. LVN 2 stated she (LVN 2) placed the urine sample in a specimen cup but was informed on 2/14/2026, that it should have been in a tube. LVN 2 stated on 2/14/2026, she (LVN 2) had straight-catheterized Resident 1 again. LVN 2 stated she (LVN2) did not document that she (LVN 2) performed the straight catheterization to Resident 1 on 2/14/2026. LVN 2 stated she (LVN 2) should have documented in Resident 1's medical record because it happened and it was an invasive procedure (a medical action that enters the body by cutting, puncturing the skin, or inserting instruments [example given, catheters, scopes {thin, flexible or rigid tubes equipped with cameras and lights, used by specialists to visualize, diagnose, and treat internal organs and body cavities without major surgery}] through natural orifices [opening]) so documentation of how the Resident 1 tolerated the procedure is important and for completeness of Resident 1's medical record.During an interview on 3/10/2026 at 12:18 p.m., with the DON, the DON stated RN 1 and LVN 2 should have documented nursing procedures like straight catheterization and how well Resident 1 tolerated (how well a resident's body accepts a certain treatment or medication) the procedure. The DON stated the facility failed to document two invasive procedures in Resident 1's medical record.c. During a review of Laboratory Results Report, dated 2/17/2026, the Laboratory Results Report for urinalysis indicated on 2/17/2026, at 4:39 a.m., the laboratory received the urine specimen. The Laboratory Results Report indicated on 2/17/2026, at 7:37 p.m., the laboratory reported the urinalysis result to the facility and on 2/20/2026, at 5:45 p.m., the laboratory reported the urine culture result to the facility.During a concurrent interview, and record review on 3/10/2026, at 8:51 a.m. with RN 1, Resident 1's Laboratory Results Report, dated 2/17/2026, and Progress Notes, dated 2/17/2026 and 2/20/2026, were reviewed. The Laboratory Results Report indicated the urinalysis result reported to the facility on 2/17/2026, at 7:37 p.m. and the urine culture result reported to the facility on 2/20/2026 at 5:45 p.m. RN 1 stated there was no documentation in Resident 1's medical record that the physician was notified on 2/17/2026, of the urinalysis result and on 2/20/2026, of the urine culture result. RN 1 stated she (RN 1) worked on both days on 2/17/2026, and 2/20/2026, but only until 3 p.m. RN 1 stated after 3 p.m. the assigned LVNs in Station 1 or in Station 2 should have received the fax (the telephonic transmission of scanned printed material normally to a telephone number connected to a printer or other output device) of any laboratory results and send a copy thru electronic message (text) to the physician on 2/17/2026, and on 2/20/2026. RN 1 stated Resident 1's urinalysis and culture result may have indicated signs of urine infection. RN 1 stated the nurses should have documented that physician was notified of the urinalysis and urine culture test result on 2/17/2026, and 2/20/2026.During an interview on 3/10/2026, at 11:58 a.m. with the DON, the DON stated there was no documented evidence in Resident 1's medical record that the nurses have notified the physician on 2/17/2026, and 2/20/2026, of the urinalysis and urine culture test result. The DON stated it is important to document notification of the physician of the laboratory test result for the continuity and communication of care and to obtain physician order like medication such as antibiotics (medication used to treat infection) appropriate for the laboratory test result. The DON stated failing to document means physician notification was not done. The DON stated the facility's policy for charting was not followed and Resident 1's medical record was not complete and accurate.During a review of facility's policy and procedure (P&P), titled, Charting and Documentation, dated 7/2017, and last reviewed on 1/14/2026, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial (the interrelation of social factors and individual thought and behavior) condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (IDT- a coordinated group of experts from several different fields who work together) regarding the resident's condition and response to care.2. The following information is to be documented in the resident medical record: . c. Treatments or services performed;3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/ treatment; d. how the residents tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting.

Based on interview and record review, the facility failed to notify the physician promptly (acting immediately, without delay, or exactly at a scheduled time) for one of three sampled residents (Resident 1) by:1. Failing to notify the physician promptly when Resident 1 had a change of condition with blood-tinged (a small amount of blood) urine on 2/13/2026, at 3 a.m.2. Failing to notify the physician promptly when the facility received Resident 1's urinalysis (urine test) result on 2/17/2026.These failures had the potential for a delay in the delivery of necessary care and services and had the potential for increased risk of infection to Resident 1.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/15/2026, with diagnoses that included unspecified (unconfirmed) encephalopathy (a change in how your brain functions), unspecified dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).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 1/15/2026, 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 1/20/2026, 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 always incontinent (unable to control) of bowel and bladder functions.During a review of Resident 1's Change of Condition (COC- a document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 2/13/2026, the COC indicated on 2/13/2026, at 3 a.m. Certified Nursing Assistant 1 (CNA 1) reported to Licensed Vocational Nurse 1 (LVN 1) that Resident 1 had diaper with blood-tinged urine. LVN 1 noted Resident 1 with hematuria (bloody urine) but had no pain and no burning sensation. The COC indicated on 2/13/2026, at 6:30 a.m., CNA 1 reported to LVN 1 the second episode of blood-tinged urine in Resident 1's diaper. The COC indicated Registered Nurse 1 (RN 1) notified the physician at 7:13 a.m.During a concurrent interview and record review on 3/6/2026, at 1:48 p.m., with RN 2, Resident 1's COC, dated 2/13/2026, was reviewed. RN 2 stated LVN 1 should have informed the physician right away on the first sign of hematuria on 2/13/2026, at 3 a.m. RN 2 stated Resident 1's condition can worsen because of delay in physician notification.During an interview on 3/6/2026, at 2:34 p.m., with LVN 2, LVN 2 stated physician should be notified immediately if there was a blood-tinged urine. LVN 2 stated that delay in physician notification can delay care and worsen Resident 1's hematuria and could lead to urinary tract infection (UTI- an infection in the bladder/urinary tract).During an interview on 3/10/2026, at 8:51 a.m. with RN 1, RN 1 stated her (RN 1) work starts from 7 a.m. to 3 p.m. RN 1 stated on 2/13/2026, she (RN 1) was informed by LVN 1 that Resident 1 had hematuria at 3 a.m. and again at 6:30 a.m. and the physician was not yet notified so as soon as she (RN 1) came she (RN 1) notified the physician. RN 1 stated LVN 1 should have notified the physician on the first sign of blood-tinged urine on 2/13/2026 at 3 a.m. RN 1 stated delay in physician notification can result to infection and possible sepsis (a life-threatening blood infection).During an interview on 3/10/2026, at 12:18 p.m. with the Director of Nursing (DON), the DON stated LVN 1 should have notified the physician on 2/13/2026, at 3 a.m., on the first sign of hematuria despite no complaints of pain. The DON stated that timely notification of physician is important to inform the physician and obtain an order for laboratory test (a medical procedure analyzing samples of blood, urine, or tissue to gather data on a patient's health). The DON stated there was a delay in Resident 1's physician notification that could worsen Resident 1's hematuria.b. During a review of Resident 1's Order Listing Report, dated 2/13/2026, the Order Listing Report indicated an order for urinalysis with culture and sensitivity (test detects bacteria or yeast in the urine and determines the most effective antibiotic for treatment).During a concurrent interview and record review on 3/10/2026, at 8:51 a.m. with RN 1, Resident 1's Laboratory Results Report, dated 2/17/2026, and Progress Notes, dated 2/17/2026, were reviewed. The Laboratory Results Report indicated the urinalysis result reported to the facility on 2/17/2026, at 7:37 p.m. RN 1 stated there was documentation in Resident 1's medical record that the physician was notified on 2/17/2026, of the urinalysis result. RN 1 stated she (RN 1) worked that day on 2/17/2026, but only until 3 p.m. RN 1 stated after 3 p.m. the assigned LVNs in Station 1 or in Station 2 should have received the fax (the telephonic transmission of scanned printed material normally to a telephone number connected to a printer or other output device) of any laboratory results and send a copy thru electronic message (text) to the physician on 2/17/2026. RN 1 stated Resident 1's urinalysis result may have indicated signs of infection, and the physician should have been notified right away.During a concurrent interview and record review on 3/10/2026, at 11:58 a.m. with the DON, the text messages from the facility phone, dated 2/17/2026, and 2/18/2026, were reviewed. The facility phone indicated a text of a picture of Resident 1's urinalysis result sent to the physician on 2/18/2026, at 3:37 p.m. The DON stated the facility phone did not indicate notification to the physician on 2/17/2026.During an interview on 3/10/2026, at 12:18 p.m. with the DON, the DON stated the LVNs should have notified the physician of the urinalysis result on 2/17/2026. The DON stated physicians should be notified of laboratory test results to proceed with appropriate plan of care to address the problem, obtain a new set of laboratory test or obtain new medication like antibiotic (medication used to treat infection) to fight the infection. The DON stated delay in physician notification can cause further complication (something that makes a situation more difficult) and lead to Resident 1's infection.During a review of facility's policy and procedure (P&P), titled, Change in Condition, dated 1/24/2017, and last reviewed on 1/14/2026, the P&P indicated, A change in condition is a sudden or marked difference in resident's.4. Output (example given low urine output, hematuria.).5. Laboratory or radiology reports.A. All changes of condition in a resident shall be handled promptly.C. Upon a Change in Condition for any reason, nursing staff members are to take the following actions: Physician shall be called promptly.-If for some reason physician cannot be reached, alternative physician shall be contacted.- If alternate cannot be reached, Medical Director is to be contacted.- All contacts or attempts to contact shall be documented and include the correct time of the activity.- If no physician is available, arrangements are to be made for physician services that may include transfer to emergency room for appropriate care.

**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 three of five sampled residents (Residents 1, 6, and 7), by failing to:1. Ensure treatment for rashes was provided to Resident 1 as per physician order. Resident 1's Treatment Administration Record (TAR) was blank on 1/16/2026, 1/20/2026, and 1/27/2027.2. Obtain a physician order for Resident 6's treatment for rashes from 11/1/2025 to 11/13/2025.3. Ensure Dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders) was notified as per physician order on 5/17/2025. Resident 6 was never seen by a Dermatologist for eight months after a physician order.4. Ensure Dermatologist was notified as per physician order. Resident 7 had physician order for Dermatologist consultation on 12/25/2025 and was not seen until 1/26/2026. These failures had the potential for Residents 1, 6, and 7's delay in Dermatologist treatment and could potentially lead to worsening of residents' rashes. Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/28/2025, and readmitted on [DATE], with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior)-bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and chronic viral hepatitis B (a long-term [lifelong] infection of the liver caused by the hepatitis B virus (HBV) that lasts for more than six months. It means the immune system could not clear the virus, allowing it to remain in the blood and liver, potentially causing silent damage, scarring or liver cancer over time).During a review of Resident 1's Skin Reassessment, dated 1/15/2026, the Skin Reassessment indicated Treatment Nurse 2 (TN 2) documented Resident 1 had rashes to chest and abdomen.During a review of Resident 1's Order Summary Report, dated 1/15/2026, the Order Summary Report indicated an order to clean chest and abdominal rash with normal saline (salt in water solution), pat dry, apply hydrocortisone (medication used to treat inflammation, itching and swelling) cream one percent (%-one part in every hundred) on affected area and leave open to air daily on day and evening shift for four weeks.During a review of Resident 1's Treatment Administration Record (TAR), dated 1/2026, the TAR indicated blank on the following dates and times:1. 1/16/2026, at day and evening shift,2. 1/20/2026, at day shift3. 1/27/2026, at day shift.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool,) dated 2/2/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During a concurrent interview and record review on 2/17/2026, at 9:03 a.m., with TN 1, Resident 1's Order Summary Report, dated 1/15/2026, and TAR, dated 1/2026, were reviewed. TN 1 stated Resident 1's TAR was left blank on 1/16/2026, 1/20/2026, and 1/27/2026.During an interview on 2/18/2026, at 10:15 a.m., with the Registered Nurse Supervisor (RNS), the RNS stated blank TAR means rashes treatment was not signed and treatment was not provided to Resident 1.During an interview on 2/18/2026, at 10:57 a.m., with the Minimum Data Set nurse (MDSN), the MDSN stated blank TAR means treatment was not provided to Resident 1. The MDSN stated Resident 1's rashes can worsen since treatment for rashes was not provided.During a concurrent interview, and record review on 2/19/2026, at 11:08 a.m., with the MDSN, facility's policy and procedure (P&P), titled, Administering Medications, dated 3/2023, and last reviewed on 1/14/2026, the P&P indicated, Medications are administered in accordance with prescriber's orders, including any required time frame.20. The individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones.21. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:a. the date and time the medication was administered;b. the dosage;c. the route of administration;d. the injection site (if applicable);e. any adverse or undesired result;f. any results achieved and when those results were observed; andg. the signature and title of the person administering the drug.b. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 12/4/2024, with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), unspecified dementia and unspecified dermatitis (a common, non-contagious inflammation of the skin characterized by itching, redness, rashes, and dryness).During a review of Resident 6's Physician Order, dated 10/2/2025, the Physician Order indicated to clean generalized rashes to bilateral upper extremities (BUE), bilateral lower extremities (BLE) and chest with normal saline, pat dry, apply clotrimazole (medication used to treat skin infections)-betamethasone (medication used to reduce itching, redness, swelling, and inflammation from skin conditions) external cream 1 %-0.05 % to affected areas and leave open to air daily on day and evening shift for unspecified dermatitis for four weeks.During a review of Resident 6's Skilled Nursing Facility (SNF) Wound Care notes, dated 10/28/2025, the Wound Care notes indicated the Nurse Practitioner (NP) for wound care assessed Resident 6 with generalized unspecified dermatitis and documented plan to cleanse with normal saline and apply clotrimazole 1% and betamethasone 0.05% cream twice daily.During a review of Resident 6's Treatment Administration Record (TAR), dated 11/2025, the TAR indicated no treatment was provided to Resident 6 from 11/1/2025, to 11/13/2025.During a review of Resident 6's SNF Wound Care notes, dated 11/11/2025, the Wound Care notes indicated the NP assessed Resident 6 with generalized unspecified dermatitis and documented plan to cleanse with normal saline and apply clotrimazole 1% and betamethasone 0.05% cream twice daily.During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decisions were severely impaired.During a concurrent interview and record review on 2/17/2026, at 8:53 a.m., with TN 1, Resident 6's TAR, and Physician Order, dated 11/2025 were reviewed. TN 1 stated Resident 6 still had rashes on BUE, BLE and chest on 11/1/2025 until 11/13/2025. TN 1 stated on 10/29/2025, TN 1 documented in Skin Rash Report that Resident 6 had rashes to BUE, BLE and chest with treatment was clotrimazole and betamethasone. TN 1 stated no documented physician order for Resident 6's rashes and no treatment was provided to Resident 6 from 11/1/2025 to 11/13/2025. TN 1 stated the treatment order was not renewed. TN 1 stated it the responsibility of the TNs to call the physician to obtain order to renew the treatment order. TN 1 stated if there was no documented treatment, Resident 6's rashes were not treated from 11/1/2025 to 11/13/2025. TN 1 stated Resident 6 rashes can worsen and spread if no treatment was provided.During an interview on 2/18/2026, at 10:06 a.m., with the RNS, the RNS stated if there was no physician order on 11/1/2025 for Resident 6 rashes, it means no treatment was provided to Resident 6. The RNS stated Resident 6's rashes could worsen if treatment was not provided for 13 days.During an interview on 2/18/2026, at 10:57 a.m., with the MDSN, Resident 6 rashes can worsen since no treatment was documented for 13 days. The MDSN stated TNs should have called the physician to renew the order for Resident 6's treatment for rashes.During a concurrent interview, and record review on 2/20/2026, at 2:59 p.m., with the RNS, facility's P&P, titled, Administering Medications, dated 3/2023, and last reviewed on 1/14/2026, the P&P indicated, Medications are administered in a safe, timely manner and as prescribed. The RNS stated Resident 6 should have received the treatment for rashes since it was documented that he (Resident 6) still had rashes. The RNS stated treatment for Resident 6 should not have stopped. The RNS stated because treatment was not provided to Resident 6 for 13 days, Resident 6's rashes can worsen and cause Resident 6 discomfort from itching.During a review of facility's P&P titled, Non-Pressure Sore Management, undated and last reviewed on 1/14/2026, the P&P indicated, Notification of physician and orders for non-pressure sore treatment.During a review of facility's P&P, titled, Alteration in Skin Integrity, undated and last reviewed on 1/14/2026, the P&P indicated, Residents with alteration in skin integrity will be assessed, orders for treatment will be obtained and care plans will be developed. Procedure:1. Skin alteration will be assessed by licensed staff to include: a. Distribution of skin alteration (measurement of affected skin areas). b. Description of actual affected area(s), including degree of skin alteration. c. Symptoms, if any, manifested by resident, including degree of itching, mild, moderate, severe.2. Physician will be notified and appropriate orders obtained.c. During a review of Resident 6's Order Summary Report, dated 5/17/2025, the Order Summary Report indicated an order for Dermatology consultation and follow up treatment as indicated.During a review of Resident 6's SNF Wound Care notes, from 2/25/2025 to 12/25/2025, the SNF Wound Care notes indicated the NP documented the following:2/25/2025, 3/4/2025, 3/11/2025, 3/18/2025, 4/1/2025, 4/15/2025, and 5/1/2025 - Resident 6 had generalized fungal dermatitis (a widespread skin infection characterized by itchy, red, scaly, and sometimes blistering rashes caused by fungi)6/17/2025, 7/15/2025, and 8/19/2025 -Resident 6 had generalized unspecified dermatitis, other (widespread skin inflammation of unknown origin, often appearing as extensive rash, redness, itching, and scaling [the visible shedding, peeling, or flaking of the skin's outer layer]).9/2/2025, 9/16/2025, 9/30/2025, 10/14/2025, 10/28/2025, 11/11/2025, 11/25/2025, 12/9/2025, and 12/25/2025 - Resident 6 had generalized unspecified dermatitis.During a concurrent interview and record review on 2/13/2026, at 3:21 p.m., with the Infection Preventionist (IP), Resident 6's Transfer Form, dated 1/16/2026, was reviewed. The Transfer Form indicated Resident 6 was transferred to General Acute Care Hospital 1 (GACH 1) on 1/16/2026, due to altered mental status (AMS- a non-specific, often acute change in brain function, resulting in confusion, decreased alertness, disorientation) and abnormal vital signs (measurements falling outside established healthy ranges for adults, typically indicating physiological distress). The IP stated Resident 6 was transferred to GACH 1 with body rashes.During an interview on 2/17/2026, at 8:53 a.m., TN 1 stated Resident 6 was never seen by the Dermatologist only by the NP who was a wound care specialist.During an interview on 2/17/2026, at 9:03 a.m., TN 1 stated the Dermatologist came and visited the facility on 1/26/2026, and Resident 6 was already transferred out to GACH 1 on 1/16/2026.During a concurrent interview and record review on 2/18/2026, at 9:53 a.m., with the IP, Resident 6's Oder Summary Report, dated 5/17/2025, was reviewed. The IP stated Resident 6 had order for dermatology consultation since 5/17/2025.During an interview on 2/18/2026, at 10:06 a.m., with the RNS, the RNS stated the Dermatologist did not come and did not assess Resident 6 rashes from 5/17/2025, (date of physician order) to 1/16/2026, (day of transfer to GACH 1), for almost eight months. The RNS stated the NP is not a Dermatologist but a wound care specialist. The RNS stated Resident 6 rashes can worsen if not seen by the Dermatologist for eight months. The RNS stated if the Dermatologist was notified of Resident 6 ongoing rashes, the Dermatologist could have ordered skin scraping (a common, minimally invasive diagnostic procedure where a technician uses a dull scalpel blade to collect surface skin cells, debris, or parasites for microscopic examination) and treatment for rashes before Resident 6 was transferred to GACH 1 and preventing Resident 6 from testing positive in GACH 1 for scabies (a skin infestation resulting in intense itching and a pimple-like rash, especially at night) which can possibly result to spread of scabies amongst staff and resident. The RNS stated if Resident 6 was seen earlier by the Dermatologist scabies outbreak (a sudden, unexpected increase in cases of a specific disease within a particular, often localized, geographic area or population, exceeding what is normally expected) could have been prevented.During an interview on 2/19/2026, at 12:34 p.m., with the NP, the NP stated he (NP) did brought up to the Director of Nursing (DON) the scabies test and treatment before the 12/25/2025, but he (NP) was informed not to order the scabies test and treatment since the holiday was coming up and the facility might have a potential scabies outbreak and affect the staffing. The NP stated the facility informed him (NP) not to make aggressive treatment for scabies. The NP stated the facility intervened with him (NP) by preventing him (NP) ordering scabies tests and treatment for scabies. The NP stated he (NP) was notified on 1/2026, that the Department was in the facility for scabies outbreak. The NP stated before 1/2026, the facility had no Dermatologist for two years.During a review of facility's P&P, titled, Wound Care, dated 3/2023, and last reviewed on 1/14/21026, the P&P indicated, The purpose of this procedure is to provide guideline for the care of wounds to promote healing. Preparation:1. Verify that there is a physician's order for this procedure.During a review of facility's submitted document titled, Acute Communicable Disease Control Program- Scabies Prevention and Control Guidelines for Healthcare Setting (the Guideline), dated 7/2019 was reviewed. The Guideline indicated, Access to and use as needed of the diagnostic skills of a clinician and or other healthcare consultant experienced in recognizing scabies to evaluate difficult or unusual; cases or response to treatment.Confirm the presence of scabies by microscopic identification of the mite or its products (skin scraping) in one or more symptomatic patients/residents or healthcare worker.d. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 1/27/2023, with diagnoses that included unspecified cerebral infarction (a type of ischemic stroke caused by a blocked blood vessel, leading to brain tissue death [necrosis] due to oxygen deprivation), unspecified dementia and unspecified pneumonia (an infection/inflammation in the lungs).During a review of Resident 7's Order Summary Report, dated 12/25/2025, the Order Summary Report indicated Dermatology Consult and follow-up treatment as indicated.During a review of Resident 7's Skin Reassessment, dated 12/26/2025, the Skin Reassessment indicated Resident 7 had rashes to BUE, BLE, chest and back.During a review of Resident 7's Care Plan, dated 1/5/2026, about rash, the Care Plan indicated an intervention to notify Dermatologist of non-response. During a review of Resident 7'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 1/8/2026, the H&P indicated Resident 7 did not have the capacity to understand and make decisions.During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decisions were intact.During a concurrent interview, and record review on 2/13/2026, at 3:21 p.m., with the IP, Resident 7's Skin Rash Report, dated 1/9/2026, and 1/24/2026, were reviewed. The Skin Rash report indicated Resident 7 had rashes to BUE, BLE and back.During a review of Resident 7's TAR, dated 1/2026, the TAR indicated Resident 7 received triamcinolone (medication used to reduce inflammation, itching, and redness in skin conditions) twice a day for dermatitis from 1/1/2026 to 1/31/2026.During an interview on 2/17/2026, at 9:03 a.m., with TN 1, TN 1 stated Resident 7 was Resident 6's roommate (tested positive for scabies in GACH 1 on 1/22/2206). TN 1 stated Resident 7 had rashes since 12/26/2025. TN 1 stated Resident 7 was not seen by the Dermatologist until 1/26/2026, when the Dermatologist came to the facility to assess and evaluate nine residents with rashes and after Resident 6 tested positive for scabies.During an interview on 2/18/2026, at 10:15 a.m., with the RNS, the RNS stated the facility should have followed the physician order for dermatologist consultation. The RNS stated a delay of Dermatologist notification for one month can worsen Resident 7's rashes.During a concurrent interview, and record review on 2/19/2026 at 8:41 a.m., with TN 1, Resident 7's SNF Wound Care notes were reviewed. TN 1 stated there were no Wound Care notes after 12/25/2025, when the physician ordered the Dermatologist consultation. TN 1 stated Resident 7 was last seen by the NP on 12/9/2025, for right lower leg cellulitis (a skin infection that causes swelling and redness) and not for rashes. TN 1 stated the NP should have been notified on 12/25/2025, upon readmission with rashes and the Dermatologist should have been notified as per physician order. TN 1 stated Resident 7 was seen by the Dermatologist one month after the physician order. TN 1 stated Resident 7 's rashes can worsen since he (Resident 7) was not seen by the NP and the Dermatologist timely.During an interview on 2/19/2026, at 10:36 a.m., with TN 1, TN 1 stated Registered Nurse (RNs) obtains Dermatologist consultation order. TN 1 stated Dermatologist are informed thru fax (a way to transmit a paper document, image, or text from one location to another instantly) or thru phone of the consultation. TN 1 stated she (TN 1) did not call the Dermatologist because the facility does not have a Dermatologist until 1/26/2026.During a concurrent interview, and record review on 2/20/2026, at 2:59 p.m., with the RNS, facility's P&P, titled, Non-Pressure Sore Management, undated and last reviewed on 1/14/2026, the P&P indicated, Notification of physician and orders for non-pressure sore treatment.During a concurrent interview and record review on 2/20/2026, at 3:13 p.m., with the RNS, facility's P&P, titled, Change in Condition, dated 1/24/2027, and last reviewed on 1/14/2026, the P&P indicated, To ensure proper assessment and follow-through for any resident with a change of condition. A change in condition is a sudden or marked difference in residents: .11. Bruises, lacerations, blisters, rashes or skin tears. Upon a change in condition for any reason, nursing staff members are to take the following actions: Physician shall be called promptly. The RNS stated that when Resident 7 had rashes on 12/26/2026, a change of condition should have been created, and physician order should have been followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement infection control measures for six of fifteen sampled residents (Residents 1, 2, 3, 4, 5, and 6) after a scabies (a highly contagious [an illness or condition that can be easily spread from one person to another] skin infestation [the state of being invaded or overrun by pests or parasites] caused by the microscopic [too small to be seen by the naked eye] mite [relatives of spiders and ticks found in nearly all habitats] Sarcoptes scabiei [the human itch mite], which burrows [make a hole or tunnel], into the skin to lay eggs causing intense itching especially at night and a pimple-like rash) outbreak (occurs when there is a sudden, unexpected increase in the number of people getting sick with a specific illness in a particular place) was identified in the facility on 1/27/2026, by failing to:1. Ensure Resident 1's Skin Rash Report was completed weekly following Resident 1's readmission on [DATE].2. Notify the Wound Care Physician (WCP) that Resident 1 was readmitted on [DATE], with skin rashes.3. Ensure Treatment Nurse (TN) 1 and TN 2 informed the Dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders), who was present in the facility on 1/26/2026, of Resident 1's rashes and informed of an order for a dermatology consultation.4. Document the notification received on 2/9/2026, from General Acute Care Hospital 2 (GACH 2) that Resident 1 tested positive for scabies. 5. Report the scabies outbreak to the State Survey Agency (SSA) on 2/9/2026, upon notification of the second confirmed case of scabies involving Resident 1.6. Perform and document daily skin assessments for four residents (Resident 2, 3, 4, and 5) exposed to Resident 1.7. Provide training and education to ensure TN 1 and TN 2 were competent (having the necessary skills, knowledge, and ability to perform a task or role effectively) in performing skin scrapings (procedure used to collect surface or deep skin cells usually with a scalpel [sharp, small, straight-bladed knife] blade and mineral oil to identify mites, parasites, or fungal infections under a microscope [an instrument that is used to magnify small objects]).8. Ensure Certified Nursing Assistant 1 (CNA) 1, who developed lower back rashes on 1/28/2026, was assessed for scabies via skin scraping.9. Develop a line list (a table that contains key information about each case in an outbreak), identifying CNA 1's resident contacts for the six weeks prior to the onset of symptoms (beginning 12/17/2025) through 1/28/2026, when CNA 1 developed rashes on her lower back.10. Follow its facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence) /Skin Breakdown, last reviewed on 1/14/2026, that indicated, Inspect skin condition weekly for any new skin breakdown and changes in skin conditions such as skin tears, bruising, pressure injuries, skin rash.11. Follow its P&P titled, Alteration in Skin Integrity, last reviewed on 1/14/2026, that indicated Weekly skin progress reports will be completed using the non-pressure skin form.12. Follow its P&P titled, Non-Pressure Sore Management, last reviewed on 1/14/2026, that indicated Wound Physician notification for physician, indicating non pressure sore.13. Follow its P&P titled, Reporting Communicable (one that is spread from one person to another) Disease, last reviewed on 1/14/2026, that indicated, the Infection Preventionist (IP) is responsible for notifying the local, district, or state health department of confirmed cases of state-specific reportable disease.14. Follow the facility provided document titled, Acute Communicable Disease Control Program on Scabies Prevention and Control Guidelines for Healthcare Settings, dated 7/2019, that indicated, the following: a. Report healthcare-associated scabies outbreak (two or more cases) to Los Angeles County (LAC)-Department of Public Health. b. Confirm the presence of scabies by microscopic identification of mite or its products in one or more symptomatic resident or employee. c. Prepare a line listing of symptomatic healthcare workers from six weeks before the onset of symptoms until current date and symptoms in household or other close contact. d. Outbreak reported to LAC Health Facilities Inspection Division (HFID) or California Department of Public health Licensing and Certification local office. e. Resident line list completed. f. Daily skin assessment/ documented on all exposed residents.These failures had the likelihood for the residents with scabies, that is not detected by the facility, to continue to transmit and spread scabies to other residents, staff, and visitors. Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/28/2025, and readmitted on [DATE], with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior)-bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and chronic viral hepatitis B (a long-term [lifelong] infection of the liver caused by the hepatitis B virus (HBV) that lasts for more than six months. It means the immune system could not clear the virus, allowing it to remain in the blood and liver, potentially causing silent damage, scarring or liver cancer over time). During a review of Resident 1's Skin Reassessment, dated 1/15/2026, the Skin Reassessment indicated TN 2 documented Resident 1 had rashes to the chest and abdomen.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 2/2/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During a concurrent interview and record review on 2/19/2026, at 8:41 a.m., with TN 1, Resident 1's Skin Reassessment, dated 1/15/2026, Skin Rash Reports, and Treatment Administration Record (TAR), dated 1/2026, and 2/2026, were reviewed. TN 1 stated the facility readmitted Resident 1 on 1/15/2026, and the Skin Reassessment, dated 1/15/2026, indicated TN 2 documented Resident 1 had rashes to chest and abdomen and TN 2 notified the Primary Physician (PP). TN 1 stated there were no weekly Skin Rash Report after 1/15/2026, until Resident 1 was transferred to GACH 2 on 2/6/2026. TN 1 stated the TAR, dated 1/2026, and 2/2026, indicated administration of hydrocortisone (medication used to treat inflammation, itching and swelling) twice a day to Resident 1 for rashes to chest and abdomen from 1/15/2026, to 2/6/2026. TN 1 stated weekly skin rash report should have been documented in Resident 1's medical record to keep track of the progress of the rashes and to find out if treatment was effective. TN 1 stated the weekly Skin Rash Report was not started on 1/15/2026. TN 1 stated as a TN she (TN 1) should have made sure it was done and documented weekly. TN 1 stated as TN they failed to perform and document skin rash report on 1/22/2026, 1/29/2026 and 2/5/2026. TN 1 stated they check residents' skin weekly every Thursday and rash report should have been documented.During an interview on 2/19/2026, at 10:36 a.m., with TN 1, TN 1 stated TN 2 did Resident 1's Skin Reassessment on 1/15/2026, and TN 2 should have opened the Skin Rash Report and documented. TN 1 stated Skin Rash Report was not done and not documented in Resident 1's medical record for three weeks.During a concurrent interview, and record review on 2/19/2026, at 11:08 a.m., with the Minimum Data Set Nurse (MDSN), facility's policy and procedure (P&P), titled, Prevention of Pressure Injuries/Skin Breakdown, dated 1/2026, was reviewed. The P&P indicated, Inspect skin condition weekly for any new skin breakdown and changes in skin condition such as skin tear, bruising, pressure injuries, skin rash. Non pressure wound will be documented in the non-pressure wound report and skin rash report, which will be updated weekly until skin problem is resolved or resident discharged from the facility. The MDSN stated there were no documented weekly skin rash report in Resident 1's medical record after the readmission on [DATE]. The MDSN stated the P&P was not followed. The MDSN stated TNs should do a weekly skin rash report assessment and documentation. The MDS stated if weekly skin rash report was not done and not documented, staff might miss some interventions and can worsen Resident 1's rashes.During a concurrent interview, and record review on 2/20/2026, at 2:59 p.m., with the RNS, facility's P&P, titled, Body Checks, undated and last reviewed on 1/14/2026, the P&P indicated, To help reduce skin impairment in geriatric (specialized medicine, care, and conditions associated with older age, focusing on complex health needs, often involving multiple chronic illnesses, rather than just chronological age) residents, residents lose sensitivity in their skin and may not feel discomfort until it's too late, and a condition has become severe. It is important to inspect these residents during daily care and also on a weekly basis. The RNS stated the facility's policy was not followed. The RNS stated Resident 1's rashes can worsen if skin rashes are not assessed weekly.During an interview on 2/21/2026, at 9:10 a.m., with TN 2, TN 2 stated Resident 1's skin rash report should have been assessed and documented weekly. TN 2 stated without weekly skin rash report there will be no documentation of the progress of rashes if worsening or getting better. TN 2 stated Resident 1's rashes can worsen if not checked weekly. During a review of facility's P&P, titled, Alteration in Skin Integrity, undated and last reviewed on 1/14/2026, the P&P indicated, Weekly skin progress will be completed using the non-pressure skin form.b. During a review of Resident 1's Order Summary Report, dated 1/15/2026, the Order Summary Report indicated an order for chest and abdominal rash to be cleanse with normal saline (salt in water solution), pat dry, apply hydrocortisone cream, one percent (%-one part in every hundred) on affected area and leave open to air every day and evening shift.During a concurrent interview and record review on 2/17/2026, at 9:03 a.m., with TN 1, Resident 1's Skilled Nursing Facility (SNF) Wound Care notes were reviewed. TN 1 stated there were no documented SNF Wound Care notes from the WCP or the Nurse Practitioner (NP) after 1/15/2026 readmission. TN 1 stated if there was no documentation it means Resident 1 was not seen by the WCP or the NP.During a concurrent interview, and record review on 2/19/2026, at 8:41 a.m., with TN 1, Resident 1's Skin Reassessment, and Progress Notes, dated 1/15/2026, were reviewed. The Skin Reassessment indicated TN 2 documented the NP will reassess and change order if needed. TN 1 stated there was no documentation that the NP was informed of Resident 1's rashes on readmission on [DATE]. TN 1 stated if not documented it was not done. TN 1 stated if the NP was not informed, he (NP) will not be aware of the Resident 1's rashes and will not see the resident. TN 1 stated Resident 1's rashes could worsen if the NP was not informed.During an interview on 2/19/2026, at 9:31 a.m., with the IP, the IP stated TNs should inform the NP who was the wound care provider that oversees skin and wound care that Resident 1 was readmitted on [DATE], with rashes. The IP stated if the NP was not informed appropriate treatment could not be provided to treat Resident 1's rashes. The IP stated Resident 1's rashes can worsen.During an interview on 2/19/2026, at 11:08 a.m., with the MDSN, the MDSN stated TNs should have informed the NP and document the notification. The MDSN stated if not documented, the NP was not informed and if the NP was not informed, right treatment for rashes could not be provided to Resident 1.During an interview on 2/19/2026, at 12:34 p.m., with the NP, the NP stated he (NP) was not informed of Resident 1's rashes. The NP stated if he (NP) was informed he (NP) would have seen Resident 1 and left a documentation. The NP stated if Resident 1 was not seen, correct diagnosis and treatment would not be provided to treat the rashes. The NP stated evaluation could not be done if the treatment was effective for Resident 1's rashes.During an interview on 2/19/2026, at 2:06 p.m., with RN 1, RN 1 stated wound care provider which is the NP should have been notified of Resident 1's rashes. RN 1 stated if the NP was not notified Resident 1's rashes could potentially exacerbate (to make a disease, condition, or its symptoms worse, more severe, or more intense).During a concurrent interview, and record review on 2/20/2026, at 2:59 p.m., with the RNS, facility's P&P, titled, Non-Pressure Sore management, undated and last reviewed on 1/14/2026, the P&P indicated, Procedure: . 3. Notification of physician and orders for on-pressure sore treatment. 7. Wound Physician Notification for Physician, indicating Non-Pressure Sore. The RNS stated the WCP or the NP should have been notified of Resident 1's rashes on readmission on [DATE]. The RNS stated there is a potential spread of scabies if the physician was not notified. The RNS stated Resident 1 was not evaluated for scabies while the facility had scabies outbreak.During an interview on 2/21/2026, at 9:10 a.m., with TN 2, TN 2 stated he (TN 2) had called Resident 1's Primary Physician (PP) of Resident 1's readmission with rashes on 1/15/2026 but was not sure if he (TN 2) had called and notified the WCP or the NP. TN 2 stated he (TN 2) did not document if he (TN 2) had called the NP. TN 2 stated if it was not documented, the NP was not notified of rashes on 1/15/2026. TN 2 stated if the WCP or the NP was not notified Resident 1's rashes can worsen.c. During a review of Resident 1's Order Summary Report, dated 1/15/2026, the Order Summary Report indicated an order for Dermatology Consult and follow up treatment as indicated.During a review of Resident 1's Care Plan Report, dated 1/15/2026, on alteration in skin integrity-rashes, the Care Plan Report indicated an intervention for Dermatologist consult as per physician order.During an interview on 2/19/2026, at 11:41 a.m., with the IP, the IP stated TNs should have informed the Dermatologist who was here on 1/26/2026, of Resident 1's rashes so Dermatologist could assess and order skin scraping for early detection of scabies if necessary and obtain an order for Elimite cream to prevent spread of scabies. The IP stated if Resident 1 was seen by the Dermatologist on 1/26/2026, she (Resident 1) would have been tested for scabies and received Elimite and will have less chance of testing positive in GACH 2. The IP stated because it was not detected early, Resident 1 could have spread scabies among staff, residents and staff in GACH 2.During an interview on 2/19/2026, at 2:41 p.m., with the Dermatologist, the Dermatologist stated when he (Dermatologist) came to the facility on 1/26/2026, he (Dermatologist) was provided with a list of residents with rashes and he (Dermatologist) went around and ordered skin scraping and elimite cream. The Dermatologist stated he (Dermatologist) cannot remember if he (Dermatologist) had evaluated Resident 1's rashes. The Dermatologist stated if Resident 1 was evaluated on 1/26/2026, and was provided with Elimite cream there will be less chance of her (Resident 1) testing positive for scabies, resulting in less chance of spreading scabies.During a concurrent interview, and record review on 2/19/2026, at 4:08 p.m., with the ADM, residents Dermatologist Progress Notes, dated 1/26/2026, were reviewed. The Dermatologist Progress Notes, indicated the Dermatologist seen, evaluated, ordered skin scraping and Elimite application to nine residents (Residents 3, 7, 8, 9, 10, 11, 13, 14, and 15). The ADM stated the Dermatologist only saw nine residents. The ADM stated TN 1 should have notified the Dermatologist of all residents with rashes including Resident 1. The ADM stated she (ADM) had expected the Dermatologist to have assessed and evaluated all residents on 1/26/2026. During an interview on 2/20/2026, at 8:36 a.m., with the IP, the IP stated the Dermatologist returned and evaluated resident on 2/2/2026. The IP stated it was TNs second chance to inform the Dermatologist of Resident 1's rashes but still was not done.During an interview on 2/20/2026, at 11:42 p.m., with the Medical Director (MD), the MD stated he (MD) was not informed of Resident 1's rashes while the facility was on scabies outbreak. The MD stated if he (MD) was informed he (MD) would have ordered skin scraping to check for the presence of scabies and order Elimite cream for Resident 1.During a review of facility's P&P, titled, Scabies: Prevention and Control, undated and last reviewed on 1/14/2026, the P&P indicated, Nurses and other healthcare workers will be trained to recognize and report any patient, themselves or other healthcare worker with signs and symptoms compatible with scabies infestation.During a review of facility's P&P, titled, Change of Condition, undated and last reviewed on 1/14/2026, the P&P indicated, A change in condition is a sudden marked difference in residents. 11. Bruises, lacerations, blisters, rashes or skin tears. Upon a change in condition for any reason, nursing staff members are to take the following actions. 1. physicians shall be called promptly: If for some reason physician cannot be reached, alternative physician. shall be contacted. If alternate cannot be reached, Medical Director is to be contacted. All contacts or attempt to contact shall be documented and include the correct time of the activity.d. During an interview on 2/17/2026, at 10:01 a.m., with the Marketer, the Marketer stated GACH 2 called him (Marketer) on his (Marketer) personal phone to notify him (Marketer) that Resident 1 was positive for scabies. The Marketer stated he (Marketer) did not remember the date he (Marketer) was notified. The Marketer stated he (Marketer) did not document in Resident 1's electronic medical record because he (Marketer) does not have access to the electronic medical record. The Marketer stated he (Marketer) reported to the ADM. During a concurrent interview and record review on 2/17/2026 at 10:08 a.m., with the ADM, Resident 1's Progress Notes, dated 2/9/2026, were reviewed. The ADM stated on 2/9/2026, the Marketer notified her (ADM) that Resident 1 tested positive for scabies in GACH 2. The ADM stated she (ADM) reported to the IP and IP should have documented it in Resident 1's medical record.During a concurrent interview, and record review on 2/19/2026, at 11:08 a.m., with the MDSN, facility's policy and procedure (P&P), titled, Charting and Documentation, dated 7/2017, and last reviewed on 1/14/2026, the P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The MDSN stated there should be a documentation that the facility was notified of Resident 1 testing positive for scabies in GACH 2. The MDSN stated the policy was not followed. The MDSN stated Resident 1's medical record was not complete.e. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 12/4/2024, with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), unspecified dementia and unspecified dermatitis (a common, non-contagious inflammation of the skin characterized by itching, redness, rashes, and dryness).During a review of Resident 6's Minimum Data Set (MDS-a resident assessment tool) dated 12/3/2025, the MDS indicated Resident 6's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During a review of Resident 6's Change of Condition (COC) Assessment Form, dated 1/16/2026, the COC indicated Resident 6 was transferred to GACH 1 on 1/16/2026, due to altered mental status (illnesses, disorders and injuries affect brain function) and abnormal vital signs (measurements falling outside established healthy ranges for adults).During a review of Resident 6's Scabies Examination, dated 1/18/2026, the Scabies Examination resulted in presence of scabies tested in GACH 1.During an interview on 2/13/2026, at 3:21 p.m., with the IP, the IP stated Resident 6 tested positive for scabies in GACH 1 and the facility was informed on 1/22/2026. The IP stated the facility then had a second case of positive scabies when Resident 1, who was transferred to GACH 2 on 2/6/2026, tested positive in GACH 2 and the facility was informed on 2/9/2026. The IP stated 12 residents who developed rashes were skin scraped for scabies in the facility since Resident 6 tested positive and one staff (CNA 1) had developed lower back rashes on 1/28/2026, and was treated with Elimite cream.During an interview on 2/17/2026, at 10:01 a.m., with the Marketer, the Marketer stated GACH 2 called him (Marketer) on his (Marketer) personal phone to notify him (Marketer) that Resident 1 was positive for scabies. The Marketer stated he (Marketer) did not remember the date he (Marketer) was notified. The Marketer stated he (Marketer) reported to the ADM.During an interview on 2/17/2026, at 10:08 a.m., with the ADM, the ADM stated on 2/9/2026, she (ADM) was notified by the Marketer that Resident 1's tested positive for scabies in GACH 2. The ADM stated she (ADM) did not report to SSA because they were already on scabies outbreak and she (ADM) already reported the first case of scabies on 1/23/2026 when Resident 1 tested positive for scabies in GACH 1.During an interview on 2/18/2026, at 10:15 a.m., with RNS 1, RNS 1 stated positive cases of scabies should be reported to SSA.During an interview on 2/19/2026, at 11:41 a.m., with the IP, the IP stated scabies outbreak is when there are two cases of scabies and should have been reported to SSA as soon as possible within 24 hours.During an interview on 2/19/2026, at 12:31 p.m., with the IP, the IP stated the facility was on scabies outbreak since 1/27/2026.During a concurrent interview, and record review on 2/19/2026, at 12:56 p.m., with the ADM, facility's policy and procedure (P&P) titled, Unusual Occurrences, undated and last reviewed on 1/14/2026, the P&P indicated, The facility is to report unusual occurrences to the local health department within 24 hours of each occurrence. The examples listed below are not intended to be an all-inclusive list of unusual occurrences. This list is not to replace sound, professional judgment.2. An epidemic (a widespread occurrence of an infectious disease in a community at a particular time) outbreak of any disease, prevalence of communicable disease or infestation by parasites or vectors. The ADM stated Resident 6's scabies were reported to SSA and Public Health on 1/23/2026, under unusual occurrence. The ADM stated the facility was notified by Public Health that one case of scabies should not be reported as outbreak.During a concurrent interview, and record review on 2/19/2026, at 1:19 p.m., with the ADM, facility's policy and procedure (P&P) titled, Scabies: Prevention and Control, undated and last reviewed on 1/14/2026, the P&P indicated, Immediate action when the threshold for scabies outbreak has been reached will include: Reporting to local Public Health Nurse and Licensing and Certification (SSA) when two or more suspected cases of scabies are treated with Elimite five % within a 14-day period, regardless of whether confirmed cases are identified. The ADM stated she (ADM) did not report the second case of scabies because her (ADM) QANC did not advise her (ADM) to report. The ADM stated the P&P indicated to report scabies if there were two confirmed, two alleged or two or more clinically suspected. The ADM stated she (ADM) should have reported that the facility had a second confirmed case of scabies under scabies outbreak to Public Health and SSA as per the facility's P&P. The ADM stated the P&P was not followed.During an interview on 2/20/2026, at 8:36 am with the IP, the IP stated scabies outbreak should be reported to SSA for further investigation.During an interview on 2/20/2026, at 2:59 p.m., with RNS 1, facility's submitted guidelines titled, Acute Communicable Disease Control Program-Scabies Prevention and Control Guidelines for Healthcare Settings, dated 7/2019, was reviewed. The Guideline indicated, Outbreak definition: Two (2) or more clinically suspect or confirmed cases of scabies identified in patients/residents, healthcare workers, volunteers and/or visitors during a six (6) week time period.Report healthcare-associated scabies outbreaks (two or more cases) to LAC Department of Public Health. RNS 1 stated scabies outbreak should have been reported to SSA to prevent the spread of scabies among staff and residents and to get help on how to control the spread.During an interview on 2/21/2026, at 3:31 p.m. with the ADM, the ADM stated she (ADM) should have reported the second case when Resident 1 tested positive for scabies to SSA to prevent delay in investigation. The ADM stated delay in investigation can potentially cause spread of scabies among staff and residents.During a review of facility's P&P titled, Reporting Communicable Disease, dated 4/2023, and last reviewed on 1/14/2026, the P&P indicated, the Infection Preventionist is responsible for notifying the local, district, or state health department of confirmed cases of state-specific reportable disease.f. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/15/2026, with diagnoses that included unspecified encephalopathy (a broad term for any disease or dysfunction of the brain, causing altered mental state, confusion, memory loss, and personality changes), unspecified dementia and generalized muscle weakness.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 1/15/2026, 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.During a review of Resident 2's Care Plan, dated 2/9/2026, about contact isolation (are steps that healthcare facility visitors and staff need to follow before going into a patient's room) precaution for suspicious rashes, the Care Plan indicated an intervention to observe contact isolation.During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 7/17/2025, with diagnoses that included unspecified dementia, unspecified dermatitis and history of falling.During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decisions were severely impaired.During a review of Resident 3's Dermatology Progress Notes, dated 1/26/2026, the Dermatology Progress Notes indicated the Dermatologists ordered Elimite, skin scraping, oral (by mouth) and topical (applied directly to a specific, local surface area of the body most commonly the skin) steroids (medications used to reduce inflammation, swelling, and allergic reactions throughout the body).During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 10/14/2021, with diagnoses that included unspecified dementia, history of falling and unspecified schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 4's H&P, dated 1/17/2025, the H&P indicated Resident 4 did not have the capacity to understand and make decisions.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive for daily decisions were severely impaired.During a review of Resident 4's TAR, dated 2/2026, the TAR indicated Resident 4 received Elimite cream on 2/11/2026, at 11:16 p.m.During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 3/1/2022, with diagnoses that included unspecified dementia, unspecified encephalopathy and unspecified cataract (a common, age-related clouding of the eye's natural lens that causes blurry, faded vision, glare, and difficulty seeing at night).During a review of Resident 5's H&P, dated 5/1/2025, 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 was intact.During a review of Resident 5's TAR, dated 2/2026, the TAR indicated Resident 5 received Elimite cream on 2/12/2026 at 4:09 a.m.During a concurrent interview and record review on 2/19/2026, at 2:06 p.m., with RN 1, facility's submitted guidelines titled, Acute Communicable Disease Control Program-Scabies Prevention and Control Guidelines for Healthcare Settings, dated 7/2019, was reviewed. The Guideline included an Appendix B-Scabies Outbreak Management Checklist that indicated daily skin assessment documented on all exposed residents. RN 1 stated daily skin assessment should be done and documented in resident's medical record.During an interview on 2/20/2026, at 8:36 a.m., with the IP, the IP stated Resident 1 had contact with Residents 2, 3, 4, and 5 before Resident 1 tested positive for scabies in GACH 2. The IP stated Resident 2 was Resident 1's roommate and Residents 3, 4, and 5 were exposed to Resident 1 while seated on the dining during mealtimes. The IP stated there were no documented daily skin assessments on four residents (Resident 2, 3, 4, and 5) who were exposed to Resident 1. The IP stated if there were no daily skin assessment the facility would not know if the four residents (Resident 2, 3, 4, and 5) had developed rashes that could potentially delay treatment and could potentially spread scabies.During a concurrent interview, and record review on 2/20/2026, at 2:59 p.m., with the RNS, facility's policy and procedure (P&P) titled, Scabies Identification, Treatment and Environmental Cleaning dated 8/2016, and last reviewed on 1/14/2026, the P&P indicated, A resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If symptoms are not present, daily assessments should be made until the case has been resolved. The RNS stated according to the P&P, daily skin assessment should have been done until the case was resolved. The RNS stated Resident 1's roommate was Resident 2. The RNS stated if daily skin assessment was not done to check for the presence of rashes, possible spread of scabies can occur.g. During an interview on 2/20/2026, at 8:36 a.m., with the Director of Staff Development (DSD)/IP, the DSD stated there was no inservice, education or training provided to TN 1 and TN 2 on skin scraping. The DSD stated TN 1 and TN 2 were not checked for skin scraping competency. The DSD stated TN 1 and TN 2 should have been taught by the NP of the Dermatologist. The DSD stated if TN 1 and TN 2 were not competent in skin scraping, the procedure would not be done correctly and might affect the result of the skin scraping.During an interview on 2/20/2026 at 2:59 p.m., with the RNS, the RNS stated no training was provided to the staff before skin scraping on 1/26/2026. The RNS stated training should have been done and competency should have been evaluated before 1/26/2026, when skin scraping was done to residents. The RNS stated the importance of providing training and competency for skin scraping was for accurate specimen collection. The RNS stated if staff were not trained, an inaccurate result could possibly happen causing a potential spread of scabies.During an interview on 2/2

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1), by:1. Failing to accurately document number of pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) in Resident 1's medical record.2. Failing to accurately document medication administration. Licensed Vocational Nurse 1 (LVN 1) documented administration of Mirtazapine (medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]), Potassium (medication used to prevent and treat low blood potassium), Depakote (medication used to treat manic [elevated or high energy] episodes associated with bipolar disorder [mood swings that range from the lows of depression to elevated periods of emotional highs]) on 1/16/2026, and LVN 2 documented administration of Depakote on 1/15/2026, at 12 noon when Resident 1 was in General Acute Care Hospital (GACH) from 1/14/2026, to 1/19/2026.These failures had the potential to cause confusion in Resident 1's care and the medical records containing inaccurate documentation.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/18/2025, with diagnoses that included metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body), stage four pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) in the sacral area (tailbone) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities).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 7/19/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's admission Reassessment, dated 7/19/2025, the admission Reassessment indicated Resident 1 had left heel pressure ulcer and sacrococcyx (sacro-end of spine, coccyx-tailbone) pressure ulcer.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 7/23/2025, 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 on staff for toileting, showering, dressing, and personal hygiene. The MDS indicated Resident 1 was always incontinent (unable to control) of bowel and bladder functions. The MDS indicated Resident 1 had two unstageable (a severe, full thickness wound where the base is completely covered by dead tissue, making it impossible to see how deep the damage goes) pressure injury present upon admission.During a review of Resident 1's Skin Issues, dated 12/11/2025, the Skin Issues indicated Resident 1 had one stage three (full-thickness loss of skin. Dead and black tissue may be visible) sacrococcyx pressure ulcer.During a review of Resident 1's Skin Issues, dated 1/6/2026, the Skin issues indicated Resident 1 had four stage three pressure ulcers and one stage four (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) pressure ulcer.During a concurrent interview, and record review on 2/3/26, at 10:30 a.m., with the Treatment Nurse (TN), Resident 1's Skin Issues, dated 1/6/2026, were reviewed. The TN stated the Skin Issues dated 1/6/2026, were not accurate. The TN stated Resident 1 had only one stage four pressure ulcer in the sacrococcyx. The TN stated inaccurate documentation could cause confusion of care and made Resident 1's medical record inaccurate.During a concurrent interview, and record review on 2/3/2026, at 10:54 a.m., with Registered Nurse 1 (RN 1), Resident 1's Skin Issues, dated 1/6/2026, was reviewed. RN 1 stated the TN was the one who documented inaccurately the number of pressure ulcers on 1/6/2026. RN 1 stated the TN should document accurately and completely. RN 1 stated inaccurate documentation can create confusion in care and can create gap in communication.During a concurrent interview, and record review on 2/3/2026, at12:29 p.m., with the Registered Nurse Supervisor (RNS), facility's policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, and last reviewed on 1/14/2026, the P&P indicated, The following information is to be documented in the resident medical record: a. Objective observations; . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The RNS stated it is the facility's policy to document accurately to prevent confusion in care.b. During a review of Resident 1's Order Summary Report, dated 7/18/2025, the Order Summary Report indicated the following orders:1. Depakote oral tablet delayed release, give 375 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount) by mouth three times a day for mood disorder manifested by extreme mood swings causing stress such as increased irritability and yelling.2. Mirtazapine oral tablet 15 mg, give one tablet by mouth at bedtime for mood disorder manifested by self-isolation by pulling bedsheet overhead.3. Potassium chloride extended release 10 milliequivalent (meq-unit of chemical measure), give one tablet by mouth daily for hypokalemia (low blood potassium level), take with food and full glass of water.During a review of Resident 1's Resident Transfer Record, dated 1/14/2026, the Resident Transfer Record indicated Resident 1 was transferred to GACH for generalized weakness and pocketing of food.During a review of Resident 1's Progress Notes, dated 1/19/2026, timed at 10:01 p.m., the Progress Notes indicated Resident 1 returned to facility on 1/19/2026, at 7:20 p.m., from GACH.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 1/2026, the MAR indicated the following:1. LVN 2 administered Depakote on 1/15/2026, at 12 noon.2. LVN 1 administered mirtazapine on 1/16/2026, at 8 p.m.3. LVN 1 administered potassium on 1/16/2026, at 5 p.m.4. LVN 1 administered Depakote on 1/16/2026, at 4 p.m.During a concurrent interview, and record review on 2/3/2026, at 9:28 a.m., with the Minimum Data Set Nurse (MDSN), Resident 1's MAR, dated 1/2026, was reviewed. The MDSN stated Resident 1 was in GACH from 1/14/2026, to 1/19/2026. The MDSN stated check mark in MAR indicated medication administered. The MDSN stated the documentation was incorrect because Resident 1 was in GACH. The MDSN stated the nurses are supposed to sign the MAR after medication administration. The MDSN stated LVN 1 and LVN 2 should verify that Resident 1 was in the facility before medication administration documentation.During an interview on 2/3/2026, at 10:54 a.m., with Registered Nurse 1 (RN 1), RN 1 stated nurses should verify the residents' name and date of birth and make sure residents are actively in the facility. RN 1 stated inaccurate documentation can cause confusion in care.During an interview on 2/3/2026, at 12:29 p.m., with the Registered Nurse Supervisor (RNS), RNS stated the nurse should verify residents' identity, check the electronic MAR for correct medication, correct resident, correct time and correct documentation. RNS stated nurses should also check documentation after medication administration. RNS stated inaccurate documentation can cause confusion in care. During a review of facility's policy and procedure (P&P), titled, Charting and Documentation, dated 7/2017, and last reviewed on 1/14/2026, the P&P indicated, The following information is to be documented in the resident medical record: .b. Medications administered;During a review of facility's P&P, titled, Administering Medications, dated 3/2023, and last reviewed on 1/14/2026, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed.9. The individual administering medications verify the resident's identity before giving the resident his/her medication. Methods of identifying the residents include: a. checking identification band; b. checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel.20. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.21. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site (the act of administering a liquid-like medicine into the body using a needle); e. any adverse (harmful, unintended, and unexpected reactions to medications or treatments that occur at normal doses) or undesired result; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug.

Based on interview and record review, the facility failed to report an allegation of employee to resident abuse within two hours to the State Survey Agency (SSA- the agency that inspects long-term care facilities for the purposes of survey and certification), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the law enforcement agency (LLE) as per its policy on abuse for one of three sampled residents (Resident 2).This failure had the potential to place Resident 2 at further risk of abuse.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/12/2025, with diagnoses that included unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and generalized weakness.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 9/13/2025, 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 12/15/2025, the MDS indicated Resident 2 had the ability to sometimes understand others and make self-understood. The MDS indicated Resident 2 required supervision from staff with toileting and showering.During a review of Resident 2's Progress Notes, dated 1/6/2026, the Progress Notes indicated on 1/6/2026, Resident 2 had exhibited verbal and physical restlessness and anger outburst (a sudden, intense, and often disproportionate burst of rage, yelling, or aggression) before shower. The Progress Note indicated Resident 2 calmed down and agreed to the shower but in the middle of the shower, Resident 2 became physically aggressive, yelled and spit at Certified Nursing Assistant 1 (CNA 1).During an interview on 2/2/2026, at 11:06 a.m., with CNA 2, CNA 2 stated on 1/6/2026, CNA 1 showered Resident 2 and CNA 2 together with Student 1 showered Resident 3 in the shower room, when Resident 2 got agitated. CNA 2 stated after the shower, Student 1 reported to her (CNA 2) that CNA 1 slapped Resident 2 in the face. CNA 2 stated she (CNA 2) instructed Student 1 to report it and Student 1 stated that she (student) had already reported it. CNA 2 stated she (CNA 2) should have reported it directly to the Administrator (ADM). CNA 2 stated she (CNA 2) did not report to the ADM because the ADM already called for CNA 1.During an interview on 2/2/2026, at 11:22 a.m., with the Director of Staff Development (DSD), the DSD stated on 1/6/2026, CNA 1 reported that during Resident 2's shower, Resident 2 became combative (being eager or ready to fight), agitated (to feel very worried, upset, or nervous, showing this state through restlessness, irritability) and spit at CNA 1 inside the shower room. The DSD stated CNA 1 reported that she (CNA 1) tried to cover herself by blocking Resident 2's spit with CNA 1's two hands.During a concurrent interview, and record review on 2/3/2026, at 12:21 p.m., with the ADM, facility's policy and procedure (P&P), titled, Abuse and Mistreatment of Residents, undated but last reviewed on 1/14/2026, the P&P indicated, Reporting: Facility shall ensure reporting of all alleged and substantiated (something is proven true) violations to the state agency and all other agencies as required, and take all necessary corrective action based on the results of the investigation. A mandated reporter is any person who has assumed full or intermittent responsibility for care or custody of an elder or dependent adult, whether or not that caretaker receives compensation. This includes administrators, supervisors, and any staff of a public or private facility that provides care or services for elder or dependent adults, or any elder or dependent adult care custodian, health practitioner, or employee of a county adult protective services agency or a local law enforcement agency. It is the facility's policy for any mandated reporter working in a facility to report abuse to their supervisor as well as the California Department of Public Health (CDPH/SSA). When an incident has been determined to have satisfied the definition of an abuse:a) Facility Administrator shall be responsible for reporting of all alleged and substantiated violations to the state agency and all other agencies as required.b) Facility shall report the incident by notifying the CDPH within two hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident. This letter shall be maintained in a separate file and made available to the CDPH upon request. The ADM stated allegations of abuse should be reported within two hours to SSA, Ombudsman and police. The ADM stated CNA 2 did not report the allegation on 1/6/2026. The ADM stated yesterday 2/2/2026, she (ADM) spoke to CNA 2 and CNA 2 reported that on 1/6/2026, Student 1 mentioned that CNA 1 slapped Resident 2. The ADM stated CNA 2 should have reported to her (ADM) immediately on 1/6/2026. The ADM stated not reporting allegations of abuse could cause Resident 2's psychological (related to the mental and emotional state of a person) distress and could potentially cause further abuse.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of three sampled residents (Residents 1 and 2) by:1. Failing to develop a care plan for Resident 2's behavior of spitting.2. Failing to develop a care plan on Resident 1's use of wedge pillow (a firm, triangle-shaped foam cushion used to prop up parts of the body at an angle while sleeping, resting, or sitting in bed).3. Failing to develop a care plan for Resident 1's refusal of repositioning.These failures had the potential for delays in the delivery of necessary care and services to Resident 1. Findings:a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/12/2025, with diagnoses that included unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and generalized weakness.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 9/13/2025, 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 12/15/2025, the MDS indicated Resident 2 had the ability to sometimes understand others and make self-understood. The MDS indicated Resident 2 required supervision from staff with toileting and showering.During a review of Resident 2's Progress Notes, dated 1/6/2026, the Progress Notes indicated on 1/6/2026, Resident 2 had exhibited verbal and physical restlessness and anger outburst (a sudden, intense, and often disproportionate burst of rage, yelling, or aggression) before shower. The Progress Notes indicated Resident 2 calmed down and agreed to the shower but in the middle of the shower, Resident 2 became physically aggressive, yelled and spit at Certified Nursing Assistant 1 (CNA 1).During an interview on 2/2/2026 at 11:22 a.m., with the Director of Staff Development (DSD), the DSD stated on 1/6/2026, CNA 1 reported that Resident 2 had spit on her (CNA 1).During an interview on 2/2/2026, at 11:52 a.m., with the Administrator (ADM), the ADM stated on 1/6/2026, CNA 1 reported that Resident 2 yelled and spit at her (CNA 1).During a concurrent interview, and record review on 2/2/2026, at 12:28 p.m., with Minimum Data Set Nurse (MDSN), Resident 1's Care Plans were reviewed. The MDSN stated Resident 1 had a behavior of spitting and kicking. The MDSN stated there was no care plan on Resident 1's behavior of spitting.During an interview on 2/2/2026, at 12:57 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated Resident 2 had a behavior of kicking, but spitting was something new.During an interview on 2/3/2026, at 10:54 a.m., with Registered Nurse 1 (RN 1), RN 1 stated care plan should have been developed for new behavior to provide utmost level of care and make sure Resident 2 received the care she (Resident 2) needed and to manage her (Resident 2)'s behavior.During a review of facility's policy and procedure (P&P), titled, Behavioral Assessment, Intervention and Monitoring, dated 3/2019, and last reviewed on 1/14/2026, the P&P indicated, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial (the interrelation of social factors and individual thought and behavior) well-being in accordance with the comprehensive assessment and plan of care. 2. As part of the comprehensive assessment, staff will evaluate, based on input from the residents, family and caregivers, review of medical record, and general observations: a. the resident's usual patterns of cognition, mood and behavior; b. the resident's usual method of communicating things like pain, hunger, thirst, and other physical discomforts; c. the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration and other triggers; and d. the resident's previous patterns of coping with stress, anxiety, and depression. 4. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. 7. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities.b. During an observation on 2/2/2026, at 9:39 a.m., inside Resident 1's room, observed a wedge pillow on Resident 1's left side.During a concurrent interview, and record review on 2/2/2026, at 9:47 am, with the Treatment Nurse (TN), Resident 1's Care Plans were reviewed. The TN stated Resident 1 had a wedge pillow used to keep Resident 1's sacral (tailbone) area off the bed to prevent worsening of the pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence). The TN stated there was no care plan for Resident 1's use of wedge pillow.During a concurrent interview and record review on 2/2/2026, at 10:50 a.m., with RN 1, Resident 1's Care Plans were reviewed. RN 1 stated there was no care plan Resident 1's use of wedge pillow.During a concurrent interview, and record review on 2/2/2026, at 12:28 p.m., with Minimum Data Set Nurse (MDSN), Resident 1's Care Plans were reviewed. MDSN stated there was no care plan for Resident 1's use of wedge pillow. The MDSN stated there should be a care plan on the use of wedge pillows. The MDSN stated care plan provides nurses with a guide on how to take care of the resident.During an interview on 2/3/2026, at 10:54 a.m., with RN 1, RN 1 stated care plan should have been developed on the use of wedge pillow. RN 1 stated care plans guide the nurses on what intervention to provide to prevent pressure ulcers.During an interview on 2/3/2026, at 12:29 p.m., with the Registered Nurse Supervisor (RNS), the RNS stated interventions provided to Resident 1 to address the current problem which is pressure ulcer should have a care plan. The RNS stated without a care plan, nurses would not be able to evaluate if intervention is effective and could possibly cause worsening of Resident 1's pressure ulcer.During a review of facility's P&P, titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 4/2018, and last reviewed on 1/14/2026, the P&P indicated, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement (the medical process of cleaning a wound by removing dead, damaged, or infected tissue) approaches, dressings and application of topical (a medication, cream, or treatment that is applied directly to a specific, localized part of the body) agents.During a review of facility's P&P, titled, Prevention of Pressure Injuries, dated 4/2020, and last 1/14/2026, the P&P indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device.c. During an interview on 2/2/2026, at 9:47 a.m., with the TN, the TN stated Resident 1 was noncompliant with repositioning.During a concurrent interview and record review on 2/2/2026, at 12:28 p.m., with the MDSN, Resident 1's Care Plan was reviewed. The MDSN stated there was no care plan developed for Resident 1s' refusal to be repositioned. The MDSN stated care plan helps minimize further decline or prevent worsening of pressure ulcers. The MDSN stated that without the care plan for refusal to be repositioned, Resident 1's wound can worsen.During an interview on 2/2/2026, at 1:13 p.m. with LVN 4, LVN 4 stated Resident 1 refused to be repositioned. LVN 4 stated CNAs had reported Resident 1's refusal and she (LVN 4) would talk to Resident 1 and Resident 1 would still refuse. LVN 4 stated she (LVN 4) did not develop a care plan for Resident 1's refusal to be repositioned. LVN 4 stated RNs develop the care plan. LVN 4 stated she (LVN 4) did not report Resident 1's noncompliance to the RN. LVN 4 stated care plan should have been developed. LVN 4 stated that without the care plan for resident 1's refusal for repositioning, Resident 1's wound could worsen.During an interview on 2/3/2026, at 12:29 p.m., with the RNS, the RNS stated care plan should have been developed to address Resident 1's refusal for repositioning to make sure resident rights for refusal are followed to prevent worsening of Resident 1's pressure ulcer.During a review of facility's policy and procedure (P&P), titled, Wound Care, dated 3/2023, and last reviewed on 1/14/2026, the P&P indicated, Review the resident's care plan to assess for any special needs of the resident.a. For example, the residents may have pro re nata (PRN-as needed) orders for pain medication to be administered prior to would care.Documentation:The following information should be recorded in the resident's medical record: .8. Any problems complaints made by the resident related to the procedure.9. If the resident refused the treatment and the reason(s) why.During a review of facility's policy and procedure (P&P), titled, Comprehensive Person-Centered Care Plans, dated 3/2022, and last reviewed on 1/14/2026, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (I) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . e. reflects currently recognized standards of practice for problem areas and conditions.10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on observation, interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 1), by:1. Failing to provide wound care treatments as per physician order on 8/3/2025, 11/25/2025, 12/24/2025, 1/20/2026 and 1/27/2026.2. Failing to perform head to toe skin assessment before Resident 1's transfer to General Acute Care Hospital (GACH) on 1/14/2026.3. Failing to obtain a physician order for the use of wedge pillow (a firm, triangle-shaped foam cushion used to prop up parts of the body at an angle while sleeping, resting, or sitting in bed).These failures had the potential for the development and worsening of Resident 1's pressure ulcers.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/18/2025, with diagnoses that included metabolic encephalopathy (when the brain has trouble working because of a chemical, or metabolic, problem in the body), stage four pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) in the sacral area (tailbone) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities).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 7/19/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 1's admission Reassessment, dated 7/19/2025, the admission Reassessment indicated Resident 1 had left heel pressure ulcer and sacrococcyx (sacro-end of spine, coccyx-tailbone) pressure ulcer.During a review of Resident 1's Physician Order, dated 7/19/25, the Physician Order indicated the following:1. For left heel deep tissue injury (DTI- a serious form of pressure injury where soft tissue is damaged underneath intact skin) - cleanse with normal saline (salt in water), pat dry, paint with betadine (used to treat and prevent skin infections) and cover with foam dressing daily for wound care management for four weeks.2. For sacrococcyx DTI- cleanse with normal saline, pat dry, apply zinc oxide (a medicated cream, ointment or paste that treats or prevents skin irritation like cuts, burns or diaper rash) to affected area and cover with foam dressing daily for wound care management for four weeks.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 7/23/2025, 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 on staff for toileting, showering, dressing, and personal hygiene. The MDS indicated Resident 1 was always incontinent (unable to control) of bowel and bladder functions. The MDS indicated Resident 1 had two unstageable (a severe, full thickness wound where the base is completely covered by dead tissue, making it impossible to see how deep the damage goes) pressure ulcer present upon admission.During a review of Resident 1's Skin Issues, dated 12/11/2025, the Skin Issues indicated Resident 1 had one stage three (full-thickness loss of skin. Dead and black tissue may be visible) sacrococcyx pressure ulcer.During a review of Resident 1's Skin Issues, dated 1/6/2026, the Skin Issues indicated Resident 1 had four stage three pressure ulcers and one stage four (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) pressure ulcer.During a review of Resident 1's Treatment Administration Record (TAR), dated 8/2025, the TAR indicated on 8/3/2025, the treatment for left heel and sacrococcyx DTI was left blank.During a review of Resident 1's Physician Order, dated 11/11/25, the Physician Order indicated for sacrococcyx stage 3 pressure ulcer to be cleanse with quarter strength Dankins solution (bleach solution used as an antiseptic to clean, disinfect, and treat infected wounds), pat dry., apply Santyl ointment (medicine used to clean, heal, and remove dead tissue from serious wounds) 250 units per gram to wound bed and zinc oxide to peri-wound (around the wound), apply calcium alginate (a natural, gel-like material that is primarily used in advanced wound care to manage heavily draining wounds) over wound bed and cover with dry dressing every day for wound care treatment for four weeks.During a review of Resident 1's TAR, dated 11/2025, the TAR indicated on 11/25/2025, the treatment for sacrococcyx stage three pressure ulcer was left blank.During a review of Resident 1's Physician Order, dated 12/17/25, the Physician Order indicated for sacrococcyx stage three pressure injury- cleanse with normal saline, pat dry, apply Santyl external ointment 250 unit per gram to wound bed and zinc oxide to peri wound, apply calcium alginate over wound bed and cover with super absorbent dressing daily for wound care for four week.During a review of Resident 1's TAR, dated 12/2025, the TAR indicated on 12/24/2025, the treatment for sacrococcyx stage three pressure ulcer was left blank.During a review of Resident 1's Physician Order, dated 1/20/2026, the Physician Order indicated for sacrococcyx stage four pressure injury- cleanse with normal saline, pat dry, apply zinc oxide paste to peri wound, Santyl external ointment 250 unit per gram to wound bed, apply calcium alginate over wound bed and cover with dry dressing daily for wound care management for four weeks.During a review of Resident 1's TAR, dated 1/2026, the TAR on 1/2026 was reviewed. The TAR indicated on 1/20/2026 and 1/27/2026, the treatment for sacrococcyx stage four pressure ulcers was left blank.During a concurrent interview, and record review on 2/3/2026, at 9:28 a.m., with the Minimum Data Set Nurse (MDSN), Resident 1's TAR, from 8/2025, to 1/2026, were reviewed. The MDSN stated TAR were blank on 8/3/2025, 11/11/2025, 12/24/2025, 1/20/2026 and 1/27/2026. The MDSN stated blank TAR means the Treatment Nurse (TN) did not sign the TAR. The MDSN stated if TAR is not signed treatment was not done. The MDSN stated if treatment was not done, pressure ulcer could get worse.During an interview on 2/3/2026, at 10:19 a.m., with the Administrator (ADM), the ADM stated the facility had issues with wound treatments.During an interview on 2/3/2026, at 10:54 a.m., with Registered Nurse 1 (RN 1), RN 1 stated if treatment not provided Resident 1's pressure ulcer could worsen.During a concurrent interview, and record review on 2/3/2026, at 12:29 p.m., with the Registered Nurse Supervisor (RNS), facility's policy and procedure (P&P) titled, Wound Care dated 3/2023, and last reviewed on 1/14/2026, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.1. Verify that there is a physician's order for this procedure.Documentation:The following information should be recorded in the resident's medical record1. The type of wound care given.2. The date and time of the wound care was given.3. The position in which the resident was placed.4. The name and title of the individual performing the wound care. The RNS stated if TAR was left blank means treatment not done and could result in worsening of Resident 1's pressure ulcer. The RNS stated pressure ulcer treatment should be done as per physician order. The RNS stated the facility's policy indicated to verify wound treatment order and document date and time wound care was given. The RNS stated if treatment is not done, the TN need to document reason why, if Resident 1 refused or if the TN was busy to endorse to other staff for wound care treatment.b. During a review of Resident 1's Interact Assessment Form (COC), dated 1/14/2026, the COC indicated Resident 1 had generalized weakness and pocketing of food with overall decline in activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Discharge Summary Report, dated 1/14/2026, the Discharge Summary Report indicated Resident 1 was transferred to GACH on 1/14/2026, at 12:52 p.m.During a review of Resident 1's Resident Transfer Record, dated 1/14/2026, the Resident Transfer Record indicated Resident 1 was transferred with sacrococcyx stage three pressure ulcer.During an interview on 2/2/2026, at 10:50 a.m., with RN 1, RN 1 stated if the facility had to transfer a resident whether planned or unplanned a complete head to toe skin assessment is done and documented in the Resident Transfer Record form and reported to the accepting GACH.During an interview on 2/3/2026, at 12:47 p.m., with RN 2, RN 2 stated on 1/14/2026, the Director of Nursing (DON) instructed her (RN 2) to complete the Discharge Summary Report and Resident Transfer Record, dated 1/14/2026. RN 2 stated the DON was the one who completed the COC and should be the one to do the head-to-toe skin assessment prior to transfer to GACH. RN 2 stated when she (RN 2) completed the Resident Transfer Record, she (RN 2) just looked at the sacral area and did not perform a head to toe skin assessment therefore she (RN 2) was not sure if the resident had rashes (any noticeable change in the color, texture, or feel of your skin that makes it look irritated, inflamed, or swollen) anywhere on her body. RN 2 stated RNS are also responsible for head-to-toe skin assessment prior to transfer.During a concurrent interview, and record review on 2/3/2026, at 1:18 p.m., with the RNS, facility's P&P, titled, Transfer/Discharge, undated and last review on 1/14/2026, the P&P indicated, Purpose:1. To ensure that there is continuity of care when a transfer is necessary.2. To prevent transfer trauma.3. To ensure proper information is sent with the resident.7. Complete a body check when possible and document findings. the RNS stated RNs are responsible for the complete head to toe skin assessment before Resident 1's transfer to GACH. The RNS stated that without complete head-to-toe skin assessment, the facility would not know if Resident 1 had rashes and nothing will be documented in Resident 1's medical record. The RNS stated the facility's policy before transferring residents was to perform a complete body assessment when possible and document in resident medical record.During a review of facility's P&P, titled, Prevention of Pressure Injuries, dated 4/2020, and last 1/14/2026, the P&P indicated, Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge.c. During an observation on 2/2/2026, at 9:39 a.m., inside Resident 1's room, observed a wedge pillow on Resident 1's left side.During an interview on 2/2/2026, at 9:47 am, with the TN, the TN stated Resident 1 had a wedge pillow used to keep Resident 1's sacral area off the bed to prevent worsening of the pressure ulcer.During a concurrent interview, and record review on 2/2/2026, at 10:50 a.m., with RN 1, Resident 1's Physician Orders were reviewed. RN 1 stated there was no physician order for the use of the wedge pillow.During an interview on 2/2/2026, at 1:42 p.m., with the TN, the TN stated the facility needs a physician order before wedge pillow can be used by Resident 1. The TN stated the DON or the RNS should have obtained an order.During an interview on 2/3/2026, at 10:54 a.m., with RN 1, RN 1 stated physician order should have been obtained for Resident 1's use of wedge pillow.During a review of facility's P&P, titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 4/2018, and last reviewed on 1/14/2026, the P&P indicated, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement (the medical process of cleaning a wound by removing dead, damaged, or infected tissue) approaches, dressings and application of topical (a medication, cream, or treatment that is applied directly to a specific, localized part of the body) agents.During a review of facility's P&P, titled, Prevention of Pressure Injuries, dated 4/2020, and last 1/14/2026, the P&P indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical records of four of six sampled residents (Resident 1, Resident 2, Resident 5, and Resident 6) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:1. Ensure TxN 1 documented the level of care provided to Resident 1 while the resident was in the facility when TxN 1 documented the level of care she provided to Resident 1 on 1/17/2026 but Resident 1 was discharged to the General Acute care Hospital (GACH) 1 on 1/16/2026.2. Ensure licensed nurses documented Resident 2's skin condition accurately when the resident was readmitted in the facility on 12/25/2025.3. Ensure Treatment Nurse (TxN) 1 accurately and timely documented Resident 2, Resident 5, and Resident 6's skin scraping procedures. Resident 2, 5, and 6's Treatment Administration Records (TARs) were signed two days after the procedures were done. 4. Ensure the licensed nurse that performed the skin scraping procedure signed the TAR. TxN 2 signed Residents 2, 5, and 6's TARs for the skin scraping procedure (a procedure done to collect skin cells to diagnose skin conditions) performed by TxN 1.These deficient practices resulted in incomplete and inaccurate information on Residents 1, 2, 5, and 6'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 12/17/2024 and readmitted on [DATE] with diagnoses including dermatitis (conditions that cause inflammation of the skin), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and Parkinson's disease (a slow-progressing brain disorder that affects movement, causing shaking, stiffness, slow movement, and balance issues). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/3/2025, 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 Physician Orders, dated 1/9/2026, the Physician Orders indicated a treatment order to apply clotrimazole-betamethasone external cream (a medication, applied on the skin, used to treat inflamed fungal skin infections) 1 - 0.05 percent (% - unit of measurement) to affected areas every day and evening shift for unspecified dermatitis (an itchy, inflamed skin rash that had not been given a specific diagnosis). During an interview on 1/28/2026 at 2:03 p.m. and concurrent record review of Resident 1's Change of Condition (COC) Interact Assessment Form, dated 1/16/2026, reviewed with TxN 1, TxN 1 stated Resident 1 was transferred to GACH 1 on 1/16/2026. TxN 1 stated Resident 1's Treatment Administration Record (TAR), dated 1/1/2026 to 1/31/2026, indicated her initials on 1/17/2026. TxN 1 stated she forgot to change the resident's chart code to hospitalized . TxN 1 stated the documentation was not accurate and had the potential for confusion amongst the care team. During an interview on 1/28/2026 at 3:55 p.m. with the Director of Nursing (DON), the DON stated Resident 1's TAR should indicate the resident was in the hospital. The DON stated TxN 1's documentation was not accurate. The DON stated that inaccurate documentation had the potential for inaccurate treatment and provision of care to Resident 1. The DON stated the facility failed to follow the process of timely and accurate documentation. During a review of the facility's policy and procedure (PnP) titled, Charting and Documentation, last reviewed on 1/14/2026, the PnP indicated all services provided to the resident. shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (a collaborative group of professionals who work together to provide comprehensive patient-centered care) regarding the resident's condition and response to care. The PnP indicated the following information is to be documented in the resident medical records.c. treatments or services performed. The PnP indicated documentation in the medical record will be objective, complete, and accurate. The PnP indicated documentation of procedures and treatments will include care-specific details, including.the date and time the procedure/treatment was provided.the name and title of the individual(s) who provided the care. During a review of Resident 2's admission Record (undated), the admission Record indicated the facility admitted the resident on 1/27/2023 with diagnoses including cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), muscle weakness, and essential hypertension (high blood pressure that is not due to another medical condition). 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. During a review of Resident 2's Physician Orders, dated 1/26/2026, the Physician Orders indicated to perform skin scrape STAT (immediately without delay) for unspecified dermatitis. During a review of Resident 2's TAR, dated 1/1/2026 to 1/31/2026, printed on 1/27/2026 at 4:43 p.m., the TAR indicated the skin scrape STAT for 1/26/2026 did not have a licensed nurse initial and time. During an interview on 1/28/2026 at 1:26 p.m. and concurrent record review of Resident 2's TAR, dated 1/1/2026 to 1/31/2026, printed on 1/28/2026 at 8:56 a.m., reviewed with TxN 2, TxN 2 stated on 1/26/2026, he was observing TxN 1 perform the skin scraping procedure on Resident 2 as he (TxN 2) had not done a skin scarping procedure before. TxN 2 stated he signed Resident 2's TAR on 1/28/2026, two days after TxN 1 performed the procedure on the resident. TxN 2 stated he does not remember what time the skin scraping procedure was done. TxN 2 stated he guessed the time the skin scarping procedure was done on Resident 2. TxN 2 stated it took 30 minutes to 45 minutes to complete the skin scraping procedure on one resident. TxN 2 stated he documented the time of the skin scarping procedures of nine residents at zero to 15 minutes per resident. TxN 2 stated inaccurate documentation of the time a procedure was done had the potential for confusion amongst the healthcare team. During an interview on 1/28/2026 at 2:03 p.m. with TxN 1, TxN 1 stated TxN 2 observed her perform the skin scraping procedure. TxN 1 stated she did not document the skin scraping procedure in Resident 2's TAR. TxN 1 stated the documentation on Resident 2's TAR was not timely and was not accurate. During an interview on 1/28/2026 at 3:55 p.m. and concurrent record review of Resident 2's Clinical Admission, dated 12/25/2025, reviewed with the Director of Nursing (DON), the Clinical admission indicated Resident 2's skin was warm, dry, normal skin color, and normal turgor. Resident 2's Clinical admission indicated there was no skin issues. The DON stated Resident 2's Skin Reassessment, dated 12/26/2025, indicated the resident had rashes on bilateral lower extremities (BLE - both legs from hip to toes), bilateral upper extremities (BUE - both arms from shoulder down to the fingertips), chest, and back. The DON stated on 1/26/2026, TxN 1 performed a skin scraping procedure on Resident 2. The DON stated TxN 2 documented Resident 2's skin scraping procedure on 1/28/2026, two days after the skin scraping procedure was completed. TxN 2 was not the licensed nurse that performed the skin scraping procedure on Resident 2. The DON stated the documentation was not accurate. The DON stated it had the potential to cause inaccurate provision of care for Resident 2. The DON stated the facility failed to accurately document Resident 2's identified skin issues. The DON stated the facility failed to follow the process of timely documenting the treatment done on residents. During a review of the facility's policy and procedure (PnP) titled, Charting and Documentation, last reviewed on 1/14/2026, the PnP indicated all services provided to the resident. shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (a collaborative group of professionals who work together to provide comprehensive patient-centered care) regarding the resident's condition and response to care. The PnP indicated the following information is to be documented in the resident medical records.c. treatments or services performed. The PnP indicated documentation in the medical record will be objective, complete, and accurate. The PnP indicated documentation of procedures and treatments will include care-specific details, including.the date and time the procedure/treatment was provided.the name and title of the individual(s) who provided the care. During a review of the facility's PnP titled, Scabies Identification, Treatment and environmental Cleaning, last reviewed on 1/14/2026, the PnP indicated the purpose was .to treat residents infected with and sensitized to sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. The Documentation section of the PnP indicated: the following information should be recorded in the resident's medical record: 1. The date and time that care was given, 2. The name and title of the individual (s) who assisted with the care. During a review of Resident 5's admission Record (undated), the admission Record indicated the facility admitted the resident on 7/17/2025 with diagnoses including unspecified dementia (a significant cognitive decline but the specific type had not been identified), essential hypertension, and age-related osteoporosis (a condition where bones become thin, weak, and brittle due to aging). During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making was severely impaired. During a review of Resident 5's Physician Orders, dated 1/26/2026, the Physician Orders indicated to perform skin scrape STAT for unspecified dermatitis. During a review of Resident 5's TAR, dated 1/1/2026 to 1/31/2026, printed on 1/27/2026 at 4:39 p.m., the TAR indicated the skin scrape STAT for 1/26/2026 did not have a licensed nurse initial and time. During an interview on 1/28/2026 at 1:26 p.m. and concurrent record review of Resident 5's TAR, dated 1/1/2026 to 1/31/2026, printed on 1/28/2026 at 9:01 a.m., reviewed with TxN 2, TxN 2 stated on 1/26/2026, he was observing TxN 1 perform the skin scraping procedure on Resident 5 as he (TxN 2) had not done a skin scarping procedure before. TxN 2 stated he signed Resident 5's TAR on 1/28/2026, two days after TxN 1 performed the procedure on the resident. TxN 2 stated he does not remember what time the skin scraping procedure was done. TxN 2 stated he guessed the time the skin scarping procedure was done on Resident 5. TxN 2 stated it took 30 minutes to 45 minutes to complete the skin scraping procedure on one resident. TxN 2 stated he documented 7:16 p.m. on both Resident 5 and Resident 6's TAR for the skin scarping procedure. TxN 2 stated inaccurate documentation of the time a procedure was done had the potential for confusion amongst the healthcare team. During an interview on 1/28/2026 at 2:03 p.m. with TxN 1, TxN 1 stated TxN 2 observed her perform the skin scraping procedure. TxN 1 stated she did not document the skin scraping procedure in Resident 5's TAR. TxN 1 stated the documentation on Resident 5's TAR was not timely and was not accurate. During an interview on 1/28/2026 at 3:55 p.m. and concurrent record review of Resident 5's TAR, dated 1/1/2026 to 1/31/2026, reviewed with the DON, the DON stated on 1/26/2026, TxN 1 performed a skin scraping procedure on Resident 5. The DON stated Resident 5's TAR indicated TxN 2 documented the resident's skin scraping procedure on 1/28/2026 two days after the skin scraping procedure was completed. TxN 2 was not the licensed nurse that performed the skin scraping procedure on Resident 5. The DON stated the documentation was not accurate. The DON stated inaccurate documentation had the potential to cause inaccurate provision of care for Resident 5. The DON stated the facility failed to timely and accurately document Resident 5's skin scraping procedure. The DON stated the facility failed to follow the process of timely documenting the treatment done on residents. During a review of the facility's policy and procedure (PnP) titled, Charting and Documentation, last reviewed on 1/14/2026, the PnP indicated all services provided to the resident. shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (a collaborative group of professionals who work together to provide comprehensive patient-centered care) regarding the resident's condition and response to care. The PnP indicated the following information is to be documented in the resident medical records.c. treatments or services performed. The PnP indicated documentation in the medical record will be objective, complete, and accurate. The PnP indicated documentation of procedures and treatments will include care-specific details, including.the date and time the procedure/treatment was provided.the name and title of the individual(s) who provided the care. During a review of the facility's PnP titled, Scabies Identification, Treatment and environmental Cleaning, last reviewed on 1/14/2026, the PnP indicated the purpose was .to treat residents infected with and sensitized to sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. The Documentation section of the PnP indicated: the following information should be recorded in the resident's medical record: 1. The date and time that care was given, 2. The name and title of the individual (s) who assisted with the care. During a review of Resident 6's admission Record (undated), the admission Record indicated the facility admitted the resident on 4/28/2017 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by chemical imbalance in the body), unspecified dementia, and essential hypertension. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making was severely impaired. During a review of Resident 6's Physician Orders, dated 1/26/2026, the Physician Orders indicated to perform skin scrape STAT for unspecified dermatitis. During a review of Resident 6's TAR, dated 1/1/2026 to 1/31/2026, printed on 1/27/2026 at 4:38 p.m., the TAR indicated the skin scrape STAT for 1/26/2026 did not have a licensed nurse initial and time. During an interview on 1/28/2026 at 1:26 p.m. and concurrent record review of Resident 6's TAR, dated 1/1/2026 to 1/31/2026, printed on 1/28/2026 at 9:02 a.m., reviewed with TxN 2, TxN 2 stated on 1/26/2026, he was observing TxN 1 perform the skin scraping procedure on Resident 6 as he (TxN 2) had not done a skin scraping procedure before. TxN 2 stated he signed Resident 6's TAR on 1/28/2026, two days after TxN 1 performed the procedure on the resident. TxN 2 stated he does not remember what time the skin scraping procedure was done. TxN 2 stated he guessed the time the skin scraping procedure was done on Resident 6. TxN 2 stated it took 30 minutes to 45 minutes to complete the skin scraping procedure on one resident. TxN 2 stated he documented 7:16 p.m. on both Resident 5 and Resident 6's TAR for the skin scraping procedure. TxN 2 stated inaccurate documentation of the time a procedure was done had the potential for confusion amongst the healthcare team. During an interview on 1/28/2026 at 2:03 p.m. with TxN 1, TxN 1 stated TxN 2 observed her perform the skin scraping procedure. TxN 1 stated she did not document the skin scraping procedure in Resident 6's TAR. TxN 1 stated the documentation on Resident 6's TAR was not timely and was not accurate. During an interview on 1/28/2026 at 3:55 p.m. and concurrent record review of Resident 6's TAR, dated 1/1/2026 to 1/31/2026, reviewed with the DON, the DON stated on 1/26/2026, TxN 1 performed a skin scraping procedure on Resident 6. The DON stated Resident 6's TAR indicated TxN 2 documented the resident's skin scraping procedure on 1/28/2026 two days after the skin scraping procedure was completed. TxN 2 was not the licensed nurse that performed the skin scraping procedure on Resident 6. The DON stated the documentation was not accurate. The DON stated inaccurate documentation had the potential to cause inaccurate provision of care for Resident 6. The DON stated the facility failed to timely and accurately document Resident 6's skin scraping procedure. The DON stated the facility failed to follow the process of timely documenting the treatment done on residents. During a review of the facility's policy and procedure (PnP) titled, Charting and Documentation, last reviewed on 1/14/2026, the PnP indicated all services provided to the resident. shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (a collaborative group of professionals who work together to provide comprehensive patient-centered care) regarding the resident's condition and response to care. The PnP indicated the following information is to be documented in the resident medical records.c. treatments or services performed. The PnP indicated documentation in the medical record will be objective, complete, and accurate. The PnP indicated documentation of procedures and treatments will include care-specific details, including.the date and time the procedure/treatment was provided.the name and title of the individual(s) who provided the care. During a review of the facility's PnP titled, Scabies Identification, Treatment and environmental Cleaning, last reviewed on 1/14/2026, the PnP indicated the purpose was .to treat residents infected with and sensitized to sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. The Documentation section of the PnP indicated: the following information should be recorded in the resident's medical record: 1. The date and time that care was given, 2. The name and title of the individual (s) who assisted with the care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice by failing to:1.Ensure two of four sampled residents (Resident 1 and Resident 2), who presented with skin rashes and itching, was tested to rule out scabies (a contagious skin infestation by a microscopic mite, sarcoptes scabiei).2. Ensure Resident 2 (Resident 1's roommate), was tested for scabies before the scabies treatment was administered.3. Ensure three of seven sampled facility staff (Treatment Nurse [TxN] 1, Licensed Vocational Nurse [LVN] 2, and Certified Nursing Assistant [CNA] 1), who provided care to Resident 1, were informed about Resident 1's positive scabies result. 4. Ensure one of three sampled residents (Resident 4), who was exposed to Resident 1 was assessed for scabies. These deficient practices had the potential for undetected and untreated scabies which could negatively impact the residents, visitors, and facility staff's health and safety.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 12/17/2024 and readmitted on [DATE] with diagnoses including dermatitis (conditions that cause inflammation of the skin), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and Parkinson's disease (a slow-progressing brain disorder that affects movement, causing shaking, stiffness, slow movement, and balance issues). During a review of Resident 1's admission Reassessment, dated 5/18/2025, the admission Reassessment indicated the resident was sent out with. rashes on the chest, bilateral lower extremities (BLE - both legs from hip to toes), and bilateral upper extremities (BUE - both arms from shoulder down to the fingertips). The admission Reassessment indicated Resident 1 returned to the facility on 5/17/2025 with rashes that spread to the resident's back and abdomen. During a review of Resident 1's Care Plan on skin integrity impairment, revised on 6/19/2025, the Care Plan indicated the resident had skin rash. The Care Plan indicated interventions including administer treatment as ordered, notify dermatologist of non-response. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/3/2025, 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 Change of Condition (COC) Interact Assessment Form, dated 1/16/2026, the COC Interact Assessment Form indicated Resident 1 was transferred to the General Acute Care Hospital (GACH) 1 for altered mental status and abnormal vital signs (reflect essential body functions, including the heartbeat rate, breathing rate, temperature, and blood pressure). The background section of the COC Interact Assessment Form indicated Resident 1 had body rash. During a review of the facility-provided Scabies Examination, dated 1/18/2026, the Scabies Examination indicated Resident 1 had a skin tissue specimen collected. The Scabies Examination result indicated Resident 1 was positive for scabies. During an interview on 1/26/2026 at 11:20 a.m. and concurrent record review of the facility-provided Scabies Case Contact Line List Form, dated 1/26/2026, reviewed with the Director of Staff Development (DSD), the Scabies Case Contact Line List Form indicated the names of Resident 1, Resident 2, and Resident 3 (roommates). The DSD stated she could not access the Infection Preventionist Nurse's (IPN) Scabies Case Contact Line List Form. The DSD created a new Scabies Case Contact Line List Form. The Scabies Case Contact Line List Form indicated three resident names (Residents 1, 2, and 3 were roommates). There was no documented evidence of assessments done on other residents exposed to Resident 1 except for Resident 1's roommates. During an interview on 1/26/2026 at 11:25 a.m. with TxN 1, TxN 1 stated she was assigned to provide care to Resident 1. TxN 1 stated the facility did not inform her that Resident 1 tested positive for scabies until she returned to work on 1/25/2026, three days after the facility was made aware of Resident 1's positive scabies result. During an interview on 1/26/2026 at 12:12 p.m. with CNA 1, CNA 1 stated she was assigned to provide care to Resident 1. CNA 1 stated she witnessed Resident 1 scratching all over the resident's body. CNA 1 stated she reported Resident 1's rashes to the TxN. CNA 1 stated the TxN informed her that Resident 1's rashes were treated with medications. CNA 1 stated the facility did not inform her that Resident 1 tested positive for scabies until she returned to work on 1/24/2026, two days after the facility was made aware of Resident 1's positive scabies result. During an interview on 1/26/2026 at 1:41 p.m. with the MDS Nurse (MDSN), the MDSN stated Resident 1 shared the same table with two residents in the activity room. During an interview on 1/26/2026 at 2:52 p.m. with Nurse Practitioner (NP) 1, NP 1 stated he got push backs from the facility management which consisted of the Administrator (ADM), the Director of Nursing (DON), and the Infection Preventionist Nurse (IPN). NP 1 stated the DON gave the most push back on ordering skin scraping (a procedure done to collect skin cells to diagnose skin conditions) for some residents. NP 1 stated the facility management informed him that skin scraping on residents may result in positive scabies results which may put the facility on scabies outbreak and be fined. NP 1 stated he raised the scabies concerns to the facility management but was informed that a scabies outbreak may lead to less nursing staff taking care of the other residents. NP 1 stated the facility did not have a dermatologist (a medical doctor who specializes in diagnosing, treating, and preventing diseases and condition affecting the skin, hair, and nails). NP 1 stated he was not informed about Resident 1's positive scabies result. During an interview on 1/27/2026 at 11:06 a.m. and concurrent record review of Resident 1's Skin Rash Report, reviewed with LVN 2, LVN 2 stated she provided care to Resident 1. LVN 2 stated the Skin Rash Report indicated on 10/29/2025, 11/26/2025, and 12/10/2025, Resident 1 complained of itchiness. LVN 2 stated skin scraping should have been done on Resident 1 after the resident was observed and reported itching. LVN 2 stated there was no documented evidence that a skin scraping was done on Resident 1. LVN 2 stated there was no documented evidence a dermatologist was consulted for Resident 1's rashes. LVN 2 stated skin scraping confirms the presence of scabies and the type of scabies. LVN 2 stated the facility did not inform her that Resident 1 tested positive for scabies. LVN 2 stated she received a group text message from the facility on 1/26/2026, four days after the facility was made aware of Resident 1's positive scabies result. LVN 2 stated that unidentified scabies had the potential to spread to other residents, staff, family members, and visitors. During a follow up interview on 1/27/2026 at 3:27 p.m. with the DSD, the DSD stated on 1/26/2026, the residents that were seated beside Resident 1 in the dining room were added to the Scabies Case Contact Line List Form. The DSD stated she did not know if the facility staff that took care of Resident 1 before he was tested positive for scabies were notified. The DSD stated a skin scraping test identifies the presence and type of scabies on the resident. The DSD stated the two types of scabies had different treatments and isolation duration. The DSD stated untreated scabies had the potential to spread and infect other residents, visitors, family members, and staff. During an interview on 1/28/2026 at 3:55 p.m. with the DON, the DON stated the facility corporate determined that Physician (MD) 1's group would handle skin and wound assessments and treatments in the facility. The DON stated meetings were held with NP 1 and the facility had discussed resident skin scraping. The DON stated NP 1 informed the DON there was no need for resident skin scraping to be done on any resident with rashes. The DON stated the facility did not have a dermatologist for two years. The DON stated that she and the ADM decided to bring the dermatology services back in the facility after Resident 1 tested positive for scabies. The DON stated the facility waited for the dermatologist, who was an expert in skin rashes, to determine the residents that needed skin scraping. The DON stated the residents exposed to Resident 1 in the dining room were not assessed for scabies. The DON stated the facility failed to consider timely skin scraping tests on residents. The DON stated the facility failed to perform assessments on the residents exposed to Resident 1 which may cause contamination of other residents and facility staff. During a review of the facility's policy and procedure (PnP) titled, Scabies Identification, Treatment and environmental Cleaning, last reviewed on 1/14/2026, the PnP indicated the purpose was .to treat residents infected with and sensitized to sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. The PnP indicated secondary bacterial skin infections may result from untreated scabies. The PnP indicated the common locations of scabies included .b. around the waist; c. between fingers and palm of hand; d. on the inner thigh, groin, buttocks; e. anterior surfaces of the wrists and elbows; g. upper back of nursing home residents. The PnP indicated diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. The PnP indicated a resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If signs and symptoms are not present, daily assessments should be made until the case has resolved. During a review of the facility-provided Acute Communicable Disease Control (ACDC) Program titled, Scabies Prevention and Control Guidelines For Healthcare Settings, dated 7/2019, the ACDC Program indicated .evaluate patients/residents on affected units and immediately place patients/residents with suspected scabies in contact precautions.prepare a line listing of symptomatic patients/residents and healthcare workers (HCW) with a separate line list of their contacts. Evaluate contacts for scabies.provide prophylactic scabicide to all contacts of symptomatic cases. should all be accomplished within the same 24-hour period to prevent reinfestation of treated or prophylaxed individuals. The Scabies Prevention and Control Program section indicated . healthcare workers who are trained to be suspicious of scabies in themselves or their patients/residents if unexplained rash or pruritus occurs and to report such occurrences to their supervisors. access to and use as needed of the diagnostic skills of a clinician and /or other healthcare consultant experienced in recognizing scabies to evaluate difficult or unusual cases or response to treatment. The Management of Symptomatic Cases section indicated None-the-less, it is recommended that efforts be made to confirm the diagnosis of scabies by skin scraping in at least one symptomatic individual. The Symptomatic Patients/Residents section indicated immediately place any patient/resident with suspected scabies infestation on contact precautions. for patients/residents with typical scabies, maintain contact precautions until treatment is completed. For patients/residents with atypical or crusted scabies, contact precautions should be maintained until treatment is completed and the signs any symptoms of infestation have abated. During a review of Resident 2's admission Record (undated), the admission Record indicated the facility admitted the resident on 1/27/2023 and readmitted on [DATE] with diagnoses including cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), muscle weakness, and essential hypertension (high blood pressure that is not due to another medical condition). During a review of Resident 2's Physician Orders, dated 12/25/2025, the Physician Orders indicated dermatology consult and follow up treatment as indicated. During a review of Resident 2's Clinical Admission, dated 12/25/2025, the Clinical admission indicated the resident had no skin issues. During a review of Resident 2's Skin Reassessment, dated 12/26/2025, the Skin Reassessment indicated the resident had rashes on BUE, BLE, chest and back. The Skin Reassessment indicated Resident 2 did not complain of itchiness. 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. During a review of Resident 2's Care Plan on skin integrity impairment, revised on 1/5/2026, the Care Plan indicated the resident had skin rash. The Care Plan indicated interventions including administer treatment as ordered, notify dermatologist of non-response. During a review of Resident 2's Physician Orders, dated 1/22/2026, the Physician Orders indicated permethrin external cream (medication used to treat scabies) five precent (% - unit of measurement) to be applied one time from the head to the toes for prophylaxis for possible exposure to rashes. During a review of Resident 2's Physician Orders, dated 1/22/2026, the Physician Orders indicated to place the resident on contact isolation precaution every shift, for one day for prophylaxis and possible exposure to rashes. During a review of Resident 2's Medication Administration Record (MAR), dated 1/1/2026 to 1/31/2026, the MAR indicated on 1/22/2026 at 8:45 p.m., Resident 2 received the permethrin external cream 5%. During a review of Resident 2's Skin Rash Report, dated 1/24/2026 and 1/26/2026, the Skin Rash Report indicated the resident complained of itching. During a review of Resident 2's Physician Orders, dated 1/26/2026, the Physician Orders indicated to perform skin scrape STAT (immediately without delay) for unspecified dermatitis. During a review of Resident 2's Treatment Administration Record (TAR), dated 1/1/2026 to 1/31/2026, the TAR indicated on 1/26/2026 at 6:15 p.m., a skin scrape was performed on Resident 2. During an observation on 1/26/2026 at 2:35 p.m. observed Resident 2's room with an enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) signage on the wall. CNA 1 was observed inside Resident 2's room, not wearing personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), touching Resident 2's curtain and other items in the resident's room. During a concurrent observation and interview on 1/26/2026 at 2:40 p.m. with Resident 2, Resident 2 stated he had the rashes for a long time. Resident 2 stated the rashes was itchy all the time. Resident 2 was observed with small scattered red rashes on the top of both hands, in between the fingers, wrist, inner aspect of the lower and upper arms, and axillary area of both upper extremities. Resident 2 was observed with small red rashes on both shoulders and upper back. Resident 2 was observed with scabbed rashes on the upper right chest and abdomen. Resident 2 was observed with red and brown rashes on the lower abdomen, pubis, both inner thighs, inguinal area, lower back, and around the waist. Resident 2's black pants was observed with white dry skin flakes around the waist area. Resident 2 demonstrated how he scratches his body using his fingertips and palms, rubbing on both arms, abdomen, lower back and inner thigh areas. TxN 1 stated she this was the first time she saw Resident 2's rashes on the webs of the fingers. TxN 1 stated resident 2 received the permethrin cream treatment on 1/22/2026. TxN 1 stated the treatment nurses perform the skin scraping in the facility. TxN stated she observed and did a skin scraping procedure once in her nursing career. TxN 1 stated skin scraping was not ordered for Resident 2 During an interview on 1/27/2026 at 11:06 a.m. and concurrent record review of Resident 2's medical records, reviewed with LVN 2, LVN 2 stated there was no documented evidence that a dermatologist assessed Resident 2. LVN 2 stated there was no documented evidence that Resident 2 had skin scraping done. LVN 2 stated she took care of Resident 2 for four months. LVN 2 stated she saw Resident 2's hands, neck and face. LVN 2 stated she had not assisted in changing Resident 2's disposable briefs and had not seen the resident's back and legs. During an interview on 1/27/2026 at 3:27 p.m. with the DSD, the DSD stated Resident 2 and Resident 1 were roommates. The DSD stated Resident 2 had generalized rashes and was exposed to Resident 1. The DSD stated Resident 2's skin scraping was done after the resident received the permethrin cream treatment. The DSD stated a skin scraping test identifies the presence and type of scabies on the resident. The DSD stated the two types of scabies had different treatments and isolation duration. The DSD stated untreated scabies had the potential to spread and infect other residents, visitors, family members, and staff. During an interview on 1/28/2026 at 3:55 p.m. with the DON, the DON stated the facility corporates determined that Physician (MD) 1's group would handle skin and wound assessments and treatments in the facility. The DON stated meetings were held with NP 1 and the facility had discussed resident skin scraping. The DON stated NP 1 informed the DON there was no need for resident skin scraping to be done on any resident with rashes. The DON stated the facility did not have a dermatologist for two years. The DON stated that she and the ADM decided to bring the dermatology services back in the facility after Resident 1 tested positive for scabies. The DON stated the facility waited for the dermatologist, who was an expert in skin rashes, to determine the residents that needed skin scraping. The DON stated the facility failed to consider timely skin scraping tests on Resident 2. During a review of the facility's policy and procedure (PnP) titled, Scabies Identification, Treatment and environmental Cleaning, last reviewed on 1/14/2026, the PnP indicated the purpose was .to treat residents infected with and sensitized to sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. The PnP indicated secondary bacterial skin infections may result from untreated scabies. The PnP indicated the common locations of scabies included .b. around the waist; c. between fingers and palm of hand; d. on the inner thigh, groin, buttocks; e. anterior surfaces of the wrists and elbows; g. upper back of nursing home residents. The PnP indicated diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. The PnP indicated a resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If signs and symptoms are not present, daily assessments should be made until the case has resolved. During a review of the facility-provided Acute Communicable Disease Control (ACDC) Program titled, Scabies Prevention and Control Guidelines For Healthcare Settings, dated 7/2019, the ACDC Program indicated .evaluate patients/residents on affected units and immediately place patients/residents with suspected scabies in contact precautions.prepare a line listing of symptomatic patients/residents and healthcare workers (HCW) with a separate line list of their contacts. Evaluate contacts for scabies.provide prophylactic scabicide to all contacts of symptomatic cases. should all be accomplished within the same 24-hour period to prevent reinfestation of treated or prophylaxed individuals. The Management of Symptomatic Cases section indicated None-the-less, it is recommended that efforts be made to confirm the diagnosis of scabies by skin scraping in at least one symptomatic individual. The Symptomatic Patients/Residents section indicated immediately place any patient/resident with suspected scabies infestation on contact precautions. for patients/residents with typical scabies, maintain contact precautions until treatment is completed. For patients/residents with atypical or crusted scabies, contact precautions should be maintained until treatment is completed and the signs any symptoms of infestation have abated. During a review of Resident 4's admission Record (undated), the admission Record indicated the facility admitted the resident on 1/27/2020 and readmitted on [DATE] with diagnoses including Alzheimer's disease a progressive brain disorder that slowly destroys memory, thinking skills, and eventually making it hard to carry out simple daily tasks), muscle weakness, and essential hypertension. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making was severely impaired. During an interview on 1/26/2026 at 11:20 a.m. and concurrent record review of the facility-provided Scabies Case Contact Line List Form, dated 1/26/2026, reviewed with the Director of Staff Development (DSD), the Scabies Case Contact Line List Form indicated the names of Resident 1, Resident 2, and Resident 3 (roommates). The DSD stated she could not access the Infection Preventionist Nurse's (IPN) Scabies Case Contact Line List Form. The DSD created a new Scabies Case Contact Line List Form. The Scabies Case Contact Line List Form indicated three resident names (Residents 1, 2, and 3 were roommates). There was no documented evidence of assessments done on other residents exposed to Resident 1 except for Resident 1's roommates. During a follow up interview on 1/27/2026 at 3:27 p.m. with the DSD, the DSD stated Resident 1 and Resident 2 goes to the dining room for meals and activities. The DSD stated Resident 1 and Resident 2's seatmates in the dining room were added on the Scabies Case Contact Line List Form on 1/26/2026, four days after the facility was made aware of Resident 1's positive scabies result. During an interview on 1/28/2026 at 3:55 p.m. with the DON, the DON stated residents exposed to a resident positive for scabies should be identified, assessed, and placed on contact isolation until the treatment had been completed. The DON stated residents exposed to Resident 1 and Resident 2 in the dining room were not assessed after Resident 1 tested positive for scabies. The DON stated the facility failed to perform assessments on the residents exposed to Resident 1 and Resident 2 which may cause contamination of other residents and facility staff. During a review of the facility's policy and procedure (PnP) titled, Scabies Identification, Treatment and environmental Cleaning, last reviewed on 1/14/2026, the PnP indicated the purpose was .to treat residents infected with and sensitized to sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. The PnP indicated secondary bacterial skin infections may result from untreated scabies. The PnP indicated the common locations of scabies included .b. around the waist; c. between fingers and palm of hand; d. on the inner thigh, groin, buttocks; e. anterior surfaces of the wrists and elbows; g. upper back of nursing home residents. The PnP indicated diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. The PnP indicated a resident sharing a room with someone infected with scabies should be examined carefully for scabies. If signs and symptoms are present, the resident should be treated in accordance with these procedures. If signs and symptoms are not present, daily assessments should be made until the case has resolved. During a review of the facility-provided Acute Communicable Disease Control (ACDC) Program titled, Scabies Prevention and Control Guidelines For Healthcare Settings, dated 7/2019, the ACDC Program indicated .evaluate patients/residents on affected units and immediately place patients/residents with suspected scabies in contact precautions.prepare a line listing of symptomatic patients/residents and healthcare workers (HCW) with a separate line list of their contacts. Evaluate contacts for scabies.provide prophylactic scabicide to all contacts of symptomatic cases. should all be accomplished within the same 24-hour period to prevent reinfestation of treated or prophylaxed individuals. The Management of Symptomatic Cases section indicated None-the-less, it is recommended that efforts be made to confirm the diagnosis of scabies by skin scraping in at least one symptomatic individual. The Symptomatic Patients/Residents section indicated immediately place any patient/resident with suspected scabies infestation on contact precautions. for patients/residents with typical scabies, maintain contact precautions until treatment is completed. For patients/residents with atypical or crusted scabies, contact precautions should be maintained until treatment is completed and the signs any symptoms of infestation have abated.

Based on interview and record review, the facility failed to ensure three of three sampled facility staff (Treatment Nurse [TxN] 1, TxN 2, and Infection Preventionist Nurse [IPN]) were competent to provide nursing services to the residents by failing to ensure competency skill assessments that included skin scraping (a procedure done to collect skin cells to diagnose skin conditions) were completed upon hire and annually. This deficient practice had the potential to negatively impact the residents' safety and prevent the residents from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.Findings: During a review of TxN 1's employee file indicated the hire date of 11/13/2024 and her most recent competency skills assessment was completed on 1/14/2025. There was no documented competency skills assessment done that included skin scraping procedures. During a review of TxN 2's employee file indicated the hire date of 2/11/2025 and his most recent competency skills assessment was completed on 2/12/2025. There was no documented competency skills assessment done that included skin scraping procedures. During a review of IPN's employee file indicated the hire date of 6/12/2024 and her most recent competency skills assessment was completed on 10/13/2025. There was no documented competency skills assessment done that included skin scraping procedures. During an interview on 1/27/2026 at 3:27 p.m. and concurrent record review of the facility's employee files, reviewed with the Director of Staff Development (DSD), the DSD stated TxN 1, TxN 2, and the IPN's skill competency assessment did not include skin scraping procedures. The DSD stated if skin scraping competency assessment was not done, the facility will not know if the licensed nurses did the skin scraping procedure correctly. The DSD stated the facility failed to ensure the facility staff were competent on performing skin scraping procedure. During an interview on 1/28/2026 at 3:55 p.m. with the Director of Nursing (DON), the DON stated there were no skin scraping competency assessments done on the licensed nurses. The DON stated the facility started the hands-on skin scraping competency assessments with the licensed nurses. The DON stated that without skin scraping competency assessments, the skin scraping procedure had the potential not to be done properly and may negatively affect the accuracy of the results. The DON stated the facility failed to train the licensed nurses on performing the skin scraping procedure. During a review of the facility-provided Acute Communicable Disease Control (ACDC) Program titled, Scabies Prevention and Control Guidelines For Healthcare Settings, dated 7/2019, the ACDC Program indicated .evaluate patients/residents on affected units and immediately place patients/residents with suspected scabies in contact precautions.prepare a line listing of symptomatic patients/residents and healthcare workers (HCW) with a separate line list of their contacts. Evaluate contacts for scabies. The Scabies Prevention and Control Program section indicated . healthcare workers who are trained to be suspicious of scabies in themselves or their patients/residents if unexplained rash or pruritus occurs and to report such occurrences to their supervisors. access to and use as needed of the diagnostic skills of a clinician and /or other healthcare consultant experienced in recognizing scabies to evaluate difficult or unusual cases or response to treatment. During a review of the facility's policy and procedure (PnP) titled, Competency Assessment, last reviewed on 1/14/2026, the PnP indicated . each employee must demonstrate competency requirement related to skills, technique, and training necessary to providing nursing and related care and services for all residents in accordance with resident care plans. Competency will be completed by the employee prior to an assignment.

Based on interview and record review, the facility failed to ensure interventions to prevent falls were in place for one of four sampled residents (Resident 1) when Resident 1 had a fall on 11/6/2025, by failing to: 1. Ensure interventions were developed through a care plan after Resident 1's fall on 11/6/2025. 2. Update Resident 1's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling).3. Ensure monitoring was provided after Resident 1's fall. These deficient practices had the potential to place Resident 1 at risk for more falls in the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/12/2025 with diagnoses 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 difficulty in walking. During a review of Resident 1's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling), dated 9/12/2025, the Fall Risk Evaluation indicated Resident 1's fall risk score was 16 (a total score of 10 or greater, the resident should be considered at high risk for potential falls).During a review of Resident 1's Physician History and Physical (H&P- a process used by doctors to understand resident's health combining medical history and physical examination), dated 9/13/2025, 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 9/17/2025, the MDS indicated Resident 1 sometimes understood and was sometimes understood. The MDS indicated Resident 1 was dependent (helper does all the effort) 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 Electronic Medical Record (EMR- digital collection of medical information about a person that is stored on a computer) on 11/13/2025 at 10:27 a.m., the EMR indicated Resident 1 did not have a Fall Risk Evaluation dated 11/6/2025. During an interview on 11/13/2025 at 12:08 p.m. with Activity Assistant (AA 1), AA 1 stated on 11/6/2025 at 3 p.m. in the dining room she (AA 1) heard a commotion and saw Resident 1's wheelchair moving slowly without Resident 1 on it. AA 1 stated Resident 1's wheelchair was moving on its own and Resident 1 was sitting on the floor in the entrance of the dining room closest to Resident 1's room. AA 1 stated she was not aware of how Resident 1 ended up on the floor. During an interview on 11/13/2025 at 12:47 p.m. with AA 2, AA 2 stated on 11/6/2025 at 3 p.m. AA 2 was in the dining room by the entrance closest to Room A. AA 2 stated she (AA 2) was facing the opposite entrance near Resident 1's room (Room B) and Resident 1 was by the entrance near Resident 1's room. AA 2 stated she (AA 2) saw Certified Nursing Assistant (CNA) 1 brought Resident 1 into the dining room. AA 2 stated Resident 1 got up and turned quickly on her own and fell on Resident 1's left side. During an interview on 11/13/2025 at 3:03 p.m. with CNA 1, CNA 1 stated on 11/6/2025 at 3 p.m. she (CNA 1) was already about to leave the facility and saw Resident 1 going into a room that was not hers (Resident 1). CNA 1 stated she (CNA 1) took Resident 1 into the dining room. CNA 1 stated she (CNA 1) left Resident 1 at the entrance of the dining room and did not take Resident 1 all the way to the dining room table. CNA 1 stated she (CNA 1) then clocked out and on her (CNA 1) way out CNA 1 saw Resident 1. During an interview on 11/13/2025 at 3:40 p.m. with the Director of Staff Development (DSD), the DSD stated Resident 1 had a fall in the dining room. The DSD stated CNA 1 was going to clock out and saw Resident 1 in the hallway and placed Resident 1 in the dining room to join any activities. The DSD stated CNA 1 left Resident 1 in the dining room by doorway then CNA 1 clocked out and while clocking out and passed by dining room saw Resident 1 on the floor. During a concurrent interview and record review on 11/13/2025 at 4:38 p.m., Resident 1's EMR was reviewed with the Director of Nursing (DON). The DON stated on 11/6/2025 at 3 p.m. she (DON) was leaving her office which is located across the dining room when she (DON) saw Resident 1 on the floor on her right side in a fetal position. During a concurrent interview and record review on 11/13/2025 at 4:38 p.m., Resident 1's EMR was reviewed with the Director of Nursing (DON). The DON stated on 11/6/2025 at 3 p.m. she (DON) was leaving her office which is located across the dining room when she (DON) saw Resident 1 on the floor on her right side in a fetal position. The DON stated when a fall occurs, staff should create a COC. The DON stated the COC for Resident 1's fall was created only today (11/13/2025). The DON reviewed COC Assessment Form, dated 11/6/2025, and the DON stated it indicated it was created on 11/13/2025 at 10:56 a.m. The DON stated Resident 1's COC should have been done on the same day or it can be an hour later but should be done during the shift and care plan and the rest of the forms can be done the following day. The DON was not able to provide documented evidence the MD and the RR were notified on 11/6/2025. The DON stated not documenting the COC can result to not providing the appropriate interventions and/or not following the plan of care. The DON stated monitoring should be specific to the COC. The DON stated there was no 72 hours monitoring for the fall. The DON stated COC monitoring should be per shift for 72 hours after a new COC and since this was not documented it did not occur. The DON stated the care plans were also not done until today (11/13/2025). During a review of the facility's policy and procedure (P&P) titled, Incident and Accidents, last reviewed on 1/29/2025, the P&P indicated charge nurse initiating the report will be responsible for the completeness and accuracy of the information contained in the report. 11. Nursing assessment and documentation of incident onb. Nurses notes to include:i. complete body checkii. documentation of resident's activities prior to incidentiii. MD notifiediv. MD orders carried outv. Family notified12. Nursing assessment and documentation of incident on:c. care plan entryd. investigation of incident/falle. documentation of conclusion and steps taken to prevent recurrence completed within five (5) days f. in-service as related to incident g. Post Fall Assessment completed. During a review of the facility's P&P titled, The Resident Care Plan, last reviewed on 1/29/2025, the P&P indicated to provide an individualized nursing care plan and to promote continuity of resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of an employee-to-resident physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) to the State Survey Agency (SSA), the ombudsman (advocates for residents of nursing homes), and local law enforcement for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Abuse & Mistreatment of Residents, when on 11/6/2025 at 3 p.m. Activities Assistant (AA) 1 alleged Certified Nursing Assistant (CNA) 1 pushed Resident 1.This deficient practice increased Resident 1's risk for further abuse, which could have led to additional unreported incidents and failure to protect other residents from potential harm. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/12/2025 with diagnoses 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 difficulty in walking. During a review of Resident 1's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling), dated 9/12/2025, the Fall Risk Evaluation indicated Resident 1's fall risk score was 16 (a total score of 10 or greater, the resident should be considered at high risk for potential falls). During a review of Resident 1's Physician History and Physical (H&P- a process used by doctors to understand a resident's health by combining medical history and physical examination), dated 9/13/2025, 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 9/17/2025, the MDS indicated Resident 1 sometimes understood and was sometimes understood. The MDS indicated Resident 1 was dependent (helper does all the effort) 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 Change in Condition (COC- when there is a sudden change in a resident's condition) assessment dated [DATE] at 4:27 p.m., the COC Assessment indicated Resident 1 had a fall from the wheelchair at around 3 p.m., after CNA 1 brought Resident 1, in a wheelchair, to the big dining room and placed Resident 1 by the area near the TV. The COC Assessment indicated CNA 1 quickly went to clock out and when CNA 1 returned she saw Resident 1 on the floor. The COC Assessment indicated that within two to three seconds after CNA 1 placed Resident 1 in the dining room, Resident 1 quickly stood up from the wheelchair and landed on her (Resident 1) right side without hitting her (Resident 1) head. During an interview on 11/13/2025 at 12:08 p.m. with AA 1, AA 1 stated on 11/6/2025 at around 3 p.m. she (AA 1) was in the dining room and heard a commotion then observed Resident 1's wheelchair moving slowly without Resident 1 on it. AA 1 stated Resident 1's wheelchair was moving on its own and Resident 1 was found sitting on the floor in the entrance of the dining room closest to Resident 1's room. AA 1 stated she was not aware of how Resident 1 ended up on the floor.During an interview on 11/13/2025 at 3:03 p.m. with CNA 1, CNA 1 stated on 11/6/2025 at 3 p.m. she (CNA 1) was already leaving and saw Resident 1 going into a room that was not hers (Resident 1). CNA 1 stated she (CNA 1) took Resident 1 into the dining room. CNA 1 stated she (CNA 1) left Resident 1 in the entrance of the dining room and did not take Resident 1 all the way to the dining room table. CNA 1 stated she (CNA 1) then clocked out and on her (CNA 1) way out CNA 1 saw Resident 1 on the floor. CNA 1 stated she (CNA 1) then went home. CNA 1 stated she heard from other staff that AA 1 was going around telling everyone that CNA 1 pushed Resident 1 and that was why Resident 1 fell on the floor. CNA 1 stated she (CNA 1) did not push Resident 1 but was told on 11/7/2025 by the Administrator (Adm) that she (CNA 1) was suspended pending investigation because the facility thought it was an alleged abuse. CNA 1 stated she informed the facility that AA 1 was going around telling everyone that she (CNA 1) pushed Resident 1. CNA 1 stated on 11/12/2025 she (CNA 1) was terminated and was told this is what is best. During an interview on 11/13/2025 at 3:40 p.m. with the Director of Staff Development (DSD), the DSD stated CNA 1 was suspended by the Adm because CNA 1 placed Resident 1 into the dining room and left Resident 1 in the dining room by the doorway. DSD stated CNA 1 then clocked out and when passing by the dining room saw Resident 1 on the floor. The DSD stated the Adm informed CNA 1 she would be suspended pending investigation because staff were saying CNA 1 had basically pushed Resident 1 into the dining room causing Resident 1 to fall. The DSD stated because it was alleged that Resident 1 was pushed that was why Adm wanted to investigate the allegation of pushing and see what the staff meant by that. The DSD stated AA 1 was the one alleging CNA 1 pushed Resident 1 into the dining room. The DSD stated pushing, if intentional and aggressive would be considered abuse. During an interview on 11/13/2025 at 4:22 p.m. with the Adm, the Adm stated the CCTV footage for 11/6/2025 was reviewed but Adm did not keep the footage because the footage gets erased automatically after five days. The Adm stated on 11/6/2025 at 3 p.m. the footage showed CNA 1 bringing Resident 1 inside the dining room and pushed Resident 1 who was in the wheelchair. The Adm stated CNA 1 was observed leaving to clock out and Resident 1 then stood up and fell. The Adm stated AA 1 said CNA 1 pushed Resident 1. The Adm stated she (Adm) spoke to AA 1 and asked why AA 1 was gossiping saying CNA 1 pushed Resident 1 if AA 1 did not see how Resident 1 fell. The Adm stated AA 1 said she (AA 1) did not see Resident 1 fall. The Adm stated because AA 1 said CNA 1 pushed Resident 1, CNA 1 was suspended. The Adm stated the allegation from AA 1 that Resident 1 was a pushed is a form of abuse. The Adm stated she (Adm) did not report the alleged abuse because Resident 1 had no injuries. During an interview on 11/13/2025 at 4:45 p.m. with the Adm, the Adm stated she did not keep the video footage because she did not think it was anything like abuse. The Adm stated the word push came up but not sure when we were aware of the word push was being used, AA 1 was heard saying that Resident 1 was pushed, and Adm stated maybe a day or two after was told to her (Adm) that Resident 1 was pushed and no one reported it. The Adm stated this was more of a hearsay. The Adm stated when hearing the word push there is a concern for abuse. The Adm stated any abuse allegations must be reported within 2 hours. The Adm stated this allegation was not reported. The Adm stated it was not reported because no one reported it to us (Adm) directly and it was just a hearsay. During a review of the facility's P&P titled, Abuse & Mistreatment of Residents, last reviewed on 1/29/2025, the P&P indicated facility shall ensure reporting of all alleged and substantiated violation to the state agency and all other agencies as required, and take all necessary corrective action based on the results of the investigation. Knowledge of an incident that reasonable appears to be a physical abuse or reasonably suspects abuse, shall be reported the known or suspected instance of abuse by telephone immediately or as soon as practically possible, and by written report sent within two (2) working days, to the local Ombudsmen and the local law enforcement agency shall report any case of known or suspected abuse to the State Department of Health Services. During a review of the Facility P&P titled, Close-Circuit TV's, last reviewed on 1/29/2025, the P&P indicated videotape will be kept for five (5) days and then destroyed unless the video content is needed for legal or other purposes.

Based on interview and record review the facility failed to inform the Medical Doctor (MD) and the Resident Representative (RR) for one of four sampled resident (Resident 1) when on 11/6/2025 at 3 p.m. Resident 1 had a fall. 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 9/12/2025 with diagnoses 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 difficulty in walking. During a review of Resident 1's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling), dated 9/12/2025, the Fall Risk Evaluation indicated Resident 1's fall risk score was 16 (a total score of 10 or greater, the resident should be considered at high risk for potential falls). During a review of Resident 1's Physician History and Physical (H&P- a process used by doctors to understand a resident's health by combining medical history and physical examination), dated 9/13/2025, 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 9/17/2025, the MDS indicated Resident 1 sometimes understood and was sometimes understood. The MDS indicated Resident 1 was dependent (helper does all the effort) 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 Electronic Medical Record (EMR- digital collection of medical information about a person that is stored on a computer) as of 11/13/2025 at 10:27 a.m., the EMR indicated Resident 1 did not have a Change in Condition (COC- when there is a sudden change in a resident's condition) Assessment for 11/6/2025, and no Fall Risk Evaluation dated 11/6/2025. During an interview on 11/13/2025 at 12:08 p.m. with Activity Assistant (AA 1), AA 1 stated on 11/6/2025 at 3p.m. in the dining room AA 1 stated she heard a commotion and saw Resident 1's wheelchair moving slowly without Resident 1 on it. AA 1 stated Resident 1's wheelchair was moving on its own and Resident 1 was sitting on the floor in the entrance of the dining room closest to Resident 1's room. AA 1 stated not aware of how Resident 1 ended up on the floor. During an interview on 11/13/2025 at 12:47 p.m. with AA 2, AA 2 stated on 11/6/2025 at 3 p.m. AA 2 was in the dining room by the entrance closest to Room A and AA 2 was facing the opposite entrance near Resident 1's room (Room B) and Resident 1 was by the entrance near Resident 1's room. AA 2 stated she (AA 2) saw when Certified Nursing Assistant (CNA) 1 brought Resident 1 into the dining room, Resident 1 then got up and turned quickly on her own and fell on Resident 1's left side. During an interview on 11/13/2025 at 3:03 p.m. with CNA 1, CNA 1 stated on 11/6/2025 at 3 p.m. she (CNA 1) was already leaving and saw Resident 1 going into a room that was not hers (Resident 1) then CNA 1 took Resident 1 into the dining room. CNA 1 stated she (CNA 1) left Resident 1 in the entrance of the dining room and did not take Resident 1 all the way to the dining room table. CNA 1 stated she (CNA 1) then clocked out and on her (CNA 1) way out CNA 1 saw Resident 1.During an interview on 11/13/2025 at 3:40 p.m. with the Director of Staff Development (DSD), the DSD stated Resident 1 had a fall in the dining room. The DSD stated CNA 1 was going to clock out and saw Resident 1 in the hallway and placed Resident 1 into the dining room for activities and left Resident 1 in the dining room by doorway then CNA 1 clocked out and while clocking out and passed by dining room saw Resident 1 on the floor. During a concurrent interview and record review on 11/13/2025 at 4:38 p.m., Resident 1's EMR was reviewed with the Director of Nursing (DON). The DON stated on 11/6/2025 at 3 p.m. she (DON) was leaving her office which is located across the dining room when she (DON) saw Resident 1 on the floor on her right side in a fetal position. The DON stated when a fall occurs, staff should create a COC. The DON stated the COC for Resident 1's fall was created only today (11/13/2025). The DON reviewed COC Assessment Form, dated 11/6/2025, and the DON stated it indicated it was created on 11/13/2025 at 10:56 a.m. The DON stated Resident 1's COC should have been done on the same day or it can be an hour later but should be done during the shift and care plan and the rest of the forms can be done the following day. The DON was not able to provide documented evidence the MD and the RR were notified on 11/6/2025. The DON stated not documenting the COC can result to not providing the appropriate interventions and/or not following the plan of care. The DON stated monitoring should be specific to the COC. The DON stated there was no 72 hours monitoring for the fall. The DON stated COC monitoring should be per shift for 72 hours after a new COC and since this was not documented it did not occur. The DON stated the care plans were also not done until today (11/13/2025). During a review of the facility's Policy and Procedures (P&P) title, Change of Condition, last review date of 1/29/2025, the P&P indicated a change of condition is a sudden or marked difference in resident. All changes of condition in a resident shall be handled promptly. E. Documentation of change in condition shall be performed by the Licensed Nurse accordingly:1. Documentation for at least 72 hours, or longer if condition change warrants.2. Using appropriate form for daily charting.3. Documentation vital sign each shift.4. Care plan evident.8. COC/SBAR will be completed as indicated. During a review of the Facility P&P titled, Incident and Accidents, last review date of 1/29/2025, the P&P indicated charge nurse initiating the report will be responsible for the completeness and accuracy of the information contained in the report. 11. Nursing assessment and documentation of incident onb. Nurses notes to include:i. complete body checkii. documentation of resident's activities prior to incidentiii. MD notifiediv. MD orders carried outv. Family notified12. Nursing assessment and documentation of incident on:c. care plan entryd. investigation of incident/falle. documentation of conclusion and steps taken to prevent recurrence completed within five (5) days f. in-service as related to incident g. Post Fall Assessment completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the electrical and patient care equipment in safe operating condition for five of five sampled residents (Residents 19, 64, 44, 57, and 34) reviewed under environmental task by failing to ensure:1. Resident 19's fall mat/floor mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have peeling covers.2. Residents 64, 44, 57, and 34's bed remote control did not have frayed/exposed wires. The deficient practices had the potential for residents to sustain accidents such as electrical shock and falls.Findings:
1. During a review of Resident 19’s admission Record, the admission Record indicated the facility admitted the resident on 5/4/2022, and readmitted the resident on 8/26/2022, with diagnoses including age-related osteoporosis (is a condition where this natural bone thinning becomes severe, making bones weak and brittle, and much more likely to break, often from a minor fall or even a cough or sneeze), history of falling, and presence of right artificial hip joint (also known as a hip prosthesis, is a replacement for a damaged hip joint that helps restore movement and reduce pain).
During a review of Resident 19’s History and Physical (H&P), dated 1/17/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 19’s Minimum Data Set (MDS, a resident assessment tool), dated 4/18/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a pronounced decline in thinking abilities that significantly impacts daily life, often preventing independent living). 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 19’s Order Summary Report, dated 8/26/2022, the Order Summary Report indicated an order for low bed (bed frame or mattress set that is closer to the floor compared to standard bed frames) with bilateral floor mat to decrease potential injury. (Informed consent obtained from resident/responsible party after explanation of risks and benefits, and verified with MD). Every shift.
During a review of Resident 19’s Fall Risk Assessment, dated 4/18/2025, the Fall Risk Assessment indicated the resident was high risk for falls.
During a review of Resident 19’s Care Plan (CP) Record regarding the resident having impaired visual functioning, last revised on 2/3/2025, the CP indicated an intervention to provide for a safe environment, free of hazards.
During a concurrent observation and interview on 6/30/2025, at 10:43 a.m., with Licensed Vocational Nurse (LVN) 1, inside Resident 19’s room, observed Resident 19’s fall mat at the left side of the resident’s bed with peeling covers. LVN 1 stated the fall mat at the left side of the bed should be replaced as the covering is peeling off already compromising the integrity of the fall mat to prevent injurious falls, and it is not promoting a homelike environment to the resident.
During an interview on 7/2/2025, at 1:51 p.m., with the Director of Nursing (DON), the DON stated the fall mat of Resident 19 should not have a peeling cover at it can compromise the fall mat’s ability to decrease the impact of the fall and injury. The DON also stated having a peeling fall mat at the resident’s room does not promote a homelike environment.
During a review of the facility's recent policy and procedure (P&P) titled Homelike Environment, last reviewed on 1/29/2025, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.
During a review of the facility's recent P&P titled Maintenance Service, last reviewed on 1/29/2025, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment.
1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
During a review of the facility's recent P&P titled Fall and Fall Risk, Managing, last reviewed on 1/29/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to prevent the resident from falling and to try to minimize complications from falling.
1. Environment al factors that contribute to the risk of falls include:
d. obstacles in the footpath.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/29/2025, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.
1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:
a. Bed safety;
g. Electrical safety.
2. During a review of Resident 64’s admission Record, the admission Record indicated the facility admitted the resident on 1/29/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), hallucinations (a false perception of objects or events involving your senses: sight, sound, smell, touch and taste), 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 64’s H&P, dated 1/17/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 64’s MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a noticeable decline in thinking skills that affects daily life).
During a review of Resident 64’s Fall Risk Assessment, dated 4/29/2025, the Fall Risk Assessment indicated the resident was high risk for falls.
During a review of Resident 64’s CP Report regarding the resident being at high risk for falls/injury, last revised on 5/4/2025, the CP indicated an intervention to provide resident with safe and clutter-free environment.
During a concurrent observation and interview on 6/30/2025, at 11:02 a.m., with LVN 1, inside Resident 64’s room, observed Resident 64’s bed remote control cord with frayed/exposed wires. LVN 1 stated there should be no exposed/frayed wires on the resident’s bed to prevent accidental electrocution of the resident. LVN 1 stated all staff were responsible in ensuring the resident’s environment is safe, and all potential hazards should be reported immediately to the maintenance department for replacement of defective hospital equipment.
During an interview on 7/2/2025, at 1:51 p.m., with the DON, the DON stated the facility failed to ensure there were no defective equipment in the facility. The DON stated Resident 64 should not have a bed remote control with frayed/exposed wires as it can cause electrocution on the resident. The DON stated all staff should check for defective equipment inside the resident’s room and report it immediately to the departments responsible.
During a review of the facility's recent P&P titled Homelike Environment, last reviewed on 1/29/2025, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.
During a review of the facility's recent P&P titled Maintenance Service, last reviewed on 1/29/2025, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment.
1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
During a review of the facility's recent P&P titled Fall and Fall Risk, Managing, last reviewed on 1/29/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to prevent the resident from falling and to try to minimize complications from falling.
1. Environment al factors that contribute to the risk of falls include:
d. obstacles in the footpath.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/29/2025, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.
1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:
a. Bed safety;
g. Electrical safety.
3. During a review of Resident 44’s admission Record, the admission Record indicated the facility admitted the resident on 8/21/2020, with diagnoses including dementia, Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), and psychosis.
During a review of Resident 44’s H&P, dated 10/15/2024, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 44’s MDS, dated [DATE], the MDS indicated the residents sometimes had the ability to make self-understood and understand others and had impaired cognition.
During a review of Resident 44’s Fall Risk Evaluation, dated 5/13/2025, the Fall Risk Evaluation indicated the resident was not at risk for falls.
During a review of Resident 44’s CP Report regarding the resident being at risk for falls/injury, last revised on 5/27/2025, the CP indicated an intervention to provide a safe and clutter-free environment.
During a concurrent observation and interview on 6/30/2025, at 10:20 a.m., with Certified Nursing Assistant (CNA) 5, inside Resident 44’s room, observed Resident 44’s bed remote control cord with exposed/frayed wires. CNA 5 stated there should be no exposed/frayed wires on the resident’s call light cord to prevent accidental electrocution of the resident. CNA 5 stated all staff were responsible for checking the safety of environment of the resident.
During an interview on 7/2/2025, at 1:51 p.m., with the DON, the DON stated the facility failed to ensure there were no defective equipment in the facility. The DON stated Resident 44 should not have a bed remote control with frayed/exposed wires as it can cause electrocution on the resident. The DON stated all staff should check for defective equipment inside the resident’s room and report it immediately to the departments responsible.
During a review of the facility's recent P&P titled Homelike Environment, last reviewed on 1/29/2025, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.
During a review of the facility's recent P&P titled Maintenance Service, last reviewed on 1/29/2025, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment.
1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
During a review of the facility's recent P&P titled Fall and Fall Risk, Managing, last reviewed on 1/29/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to prevent the resident from falling and to try to minimize complications from falling.
1. Environment al factors that contribute to the risk of falls include:
d. obstacles in the footpath.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/29/2025, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
4. During a review of Resident 57’s admission Record, the admission Record indicated the facility admitted Resident 57 on 10/1/2021, with diagnoses including dementia (a progressive state of decline in mental abilities), mood disorder (mental health condition causing persistent and intense sadness, elation and/or anger), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).
During a review of Resident 57’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 2/19/2025, the H&P indicated Resident 57 did not have the capacity to understand and make decisions.
During a review of Resident 57’s Minimum Data Set (MDS, a resident assessment tool), dated 5/19/2025, the MDS indicated Resident 57 was sometimes able to understand others and make her needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 57 required partial/moderate assistance with bed mobility and toilet transfers; total assistance from staff with eating, toileting, and bathing; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During an observation on 6/30/2025 at 8:44 a.m. inside Resident 57’s room, observed Resident 57 sitting up on the wheelchair. Resident 57’s bed control was placed on top of the bed and observed the base of the bed control with the wires exposed.
During a concurrent observation and interview on 6/30/2025 at 2:30 p.m., inside Resident 57’s room with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident 57’s bed control had frayed or exposed wires at the base. CNA 7 stated if staff observed any equipment in the resident room is in disrepair, the maintenance department should be notified as soon as possible to have the bed control replaced. CNA 6 stated the maintenance department should have been notified by the staff to change Resident 57’s bed control as soon as possible as the exposed wires placed the resident at risk for electrocution which may lead to injury.
During an interview on 7/2/2025, at 11:54 a.m., with the Director of Nursing (DON), the DON stated there should be no frayed/exposed wires on all the resident’s bed controller to prevent accidents such as electrical shock on the residents. The DON stated that the staff during their resident rounds should identify hazards that can cause harm to residents. The DON stated upon observation of the frayed/exposed wires the staff should have reported the incident to the maintenance department for immediate replacement.
During a review of the facility's recent policy and procedure (P&P) titled Maintenance Service, last reviewed on 1/29/2025, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment. The P&P further indicated maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/29/2025, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. The P&P further indicated:
-Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
-Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.
-Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:
g. Electrical safety.
5. During a review of Resident 59’s admission Record, the admission Record indicated the facility originally admitted Resident 59 on 3/1/2022 and readmitted in the facility on 4/30/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), difficulty in walking, and generalized weakness.
During a review of Resident 59’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 5/1/2025, the H&P indicated Resident 59 did not have the capacity to understand and make decisions.
During a review of Resident 59’s Minimum Data Set (MDS, a resident assessment tool), dated 6/2/2025, the MDS indicated Resident 59 was able to understand others and make her needs known and had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 59 required set up or clean-up assistance with eating, substantial/maximal assistance with tub/shower transfers, and partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During an observation on 6/30/2025 at 11:51 a.m. inside Resident 59’s room, Resident 59 observed lying in bed asleep with the bed control placed on top of the bed. Observed the base of the bed control with the wires frayed or exposed.
During a concurrent observation and interview on 6/30/2025 at 12:11 p.m., inside Resident 34’s room with Certified Nursing Assistant (CNA) 9, CNA 9 stated Resident 59’s bed control had frayed or exposed wires at the base. CNA 9 stated she did not realize that Resident 59’s bed control had frayed or exposed wires. CNA 9 stated if staff observed any equipment in the resident room is in disrepair, the maintenance department should be notified as soon as possible to have the bed control replaced. CNA 9 stated the maintenance department should have been notified by the staff to change Resident 59’s bed control as soon as possible as the exposed wires placed the resident at risk for electrocution which may lead to injury.
During an interview on 7/2/2025, at 11:54 a.m., with the Director of Nursing (DON), the DON stated there should be no frayed/exposed wires on all the resident’s bed controller to prevent accidents such as electrical shock on the residents. The DON stated that the staff during their resident rounds should identify hazards that can cause harm to residents. The DON stated upon observation of the frayed/exposed wires the staff should have reported the incident to the maintenance department for immediate replacement.
During a review of the facility's recent policy and procedure (P&P) titled Maintenance Service, last reviewed on 1/29/2025, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment. The P&P further indicated maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/29/2025, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. The P&P further indicated:
-Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
-Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.
-Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:
g. Electrical safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement 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) for two of three sampled residents (Residents 60 and 78) by:1. Failing to monitor Resident 60 for the adverse effect (undesired or harmful effects) of Augmentin (medication used to treat infection) on the following dates and times:a. 7 a.m. to 3 p.m. on 6/6/2025, 6/7/2025, 6/9/2025, and 6/12/2025.b. 3 p.m., to 11 p.m. on 6/11/2025, and 6/12/2025.c. 11 p.m. to 7 a.m. on 6/5/2025, 6/6/2025, 6/7/2025, 6/8/2025, 6/10/2025, 6/11/2025. and 6/12/2025.2. Failing to monitor Resident 78 for the adverse effect of Cephalexin (medication used to treat infection) on 6/17/2025. at 3 p.m. - 11 p.m., and 11 p.m. - 7 a.m., and 6/18/2025, at 7 a.m. - 3 p.m., and 3 p.m.- 11 p.m.These failures had the potential to increase antibiotic resistance (inability to respond to a drug) from unnecessary or inappropriate antibiotic use.Findings: a. During a review of Resident 60's admission Record, the admission Record indicated the facility admitted Resident 60 on 6/5/2025, with diagnoses that included cerebral infarction (a condition where blood flow to the brain is blocked, leading to brain tissue damage or death due to oxygen deprivation), unspecified (unconfirmed ) dementia (a progressive state of decline in mental abilities) and urinary tract infection (UTI-an infection in the bladder/urinary tract). During a review of Resident 60'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 60 did not have the capacity to understand and make decisions. During a review of Resident 60's Minimum Data Set (MDS-a resident assessment tool), dated 6/11/2025, the MDS indicated Resident 60's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 60 was dependent on staff for 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 60 was always incontinent (unable to control) bowel and bladder functions. During a review of Resident 60's Physician Order, dated 6/5/2025, the Physician Order indicated an order for the resident to receive Augmentin oral tablet 500-125 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth two times a day for UTI, for four days. During a review of Resident 60'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 60 received Augmentin from 6/6/2025, to 6/9/2025. During a concurrent interview, and record review on 7/1/2025, at 8:02 a.m., with the Infection Preventionist (IP), Resident 60's Progress Notes, and Licensed Nurses Notes, dated 6/5/2025 to 6/12/2025 were reviewed. The IP stated Resident 60 was admitted on [DATE] at 3:28 p.m., and Augmentin was started at 4 p.m. The IP stated residents on antibiotic like Augmentin are monitored for the adverse effects every shift (every eight hours) and monitoring are documented in the Progress Notes. The IP stated antibiotic adverse effects are monitored while Resident 60 were on antibiotic from 6/5/2025 to 6/9/2025 (last dose of antibiotic) and until three days after (6/12/2025) the dose was completed. The IP stated Resident 60's Progress Notes from 6/5/2025 to 6/12/2025 did not have any documentation that monitoring for adverse effect of Augmentin was done for Resident 60. The IP stated the facility failed to monitor Resident 60 every shift for the adverse effect of Augmentin. The IP stated the Licensed Nurses Notes had missing documentation on monitoring for Augmentin adverse effect on the following dates and times:a. 7 a.m. to 3 p.m. on 6/6/2025, 6/7/2025, 6/9/2025, and 6/12/2025.b. 3 p.m., to 11 p.m. on 6/11/2025, and 6/12/2025.c. 11 p.m. to 7 a.m. on 6/5/2025, 6/6/2025, 6/7/2025, 6/8/2025, 6/10/2025, 6/11/2025. and 6/12/2025. b. During a review of Resident 78's admission Record, the admission Record indicated the facility admitted Resident 78 on 5/7/2024 with diagnoses that included unspecified encephalopathy, unspecified dementia and UTI. During a review of Resident 78's H&P, dated 7/1/2025, the H&P indicated Resident 78 did not have the capacity to understand and make decisions. During a review of Resident 78's MDS, dated [DATE], the MDS indicated Resident 78's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 78 needed maximum assistance from staff for eating, dressing and transferring. The MDS indicated Resident 78 was always incontinent for bowel and bladder functions. During a review of Resident 78's Physician Order, dated 6/13/2025, the Physician Order indicated Cephalexin oral capsule 500mg, give one capsule by mouth every 12 hours for UTI until 6/16/2025. During a review of Resident 78's MAR dated 6/2025, the MAR indicated Resident 78 received Cephalexin from 6/13/2025 to 6/16/2025. During a concurrent interview and record review on 7/1/2025 at 8:02 a.m., with the IP, Resident 78's Licensed Nurses Notes dated 6/13/2025 to 6/19/2025 were reviewed. The IP stated there was no monitoring for the adverse effect documented for Resident 78 for use of Cephalexin on 6/17/2025, at 3 p.m. - 11 p.m., and 11 p.m. - 7 a.m., and 6/18/2025, at 7 a.m. - 3 p.m., and 3 p.m.- 11 p.m. During a concurrent interview and record review on 7/2/2025 at 1:46 p.m., with the Director of Nursing (DON), facility's policy and procedure (P&P), titled, Antimicrobial Stewardship Program undated and last reviewed on 1/29/2025, the P&P indicated, It is the policy of the facility to implement an Antimicrobial Stewardship Program that will focus on a coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of optimal antimicrobial drug regimen including dosing, duration of therapy and route of administration. The team will be responsible for the following: -review and monitor antibiotic usage patterns on a regular basis. The DON stated antibiotic monitoring for adverse effects should be every shift and documented in the Progress Notes. The DON stated the facility failed to monitor potential side effects or adverse effect and if not monitored, nurses would not be able to recognize adverse effects of antibiotic and possible delays the physician notification causing delay in care. The DON stated monitoring for antibiotic adverse effects is basic nursing care.

Based on observation, interview and record review, the facility failed to implement infection control practices for one of three sampled staff (Laundry Staff 1 [LS 1]) reviewed for Infection Control by failing to ensure laundry area was kept clean and sanitary. On 7/1/2025 personal belongings (two bags, one sweater, one cellphone and one pair of sunglasses) were noted inside the clean laundry room.This failure had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminant from one surface to another) and spread infections and illnesses to residents, and staff.Findings: During a concurrent observation, and interview on 7/1/2025, at 7:30 a.m., with the Housekeeping Manager (HSKM), inside the clean laundry room. Observed one black bag, one white printed bag and one black sweater hanging by the door and observed one cellphone and a pair of sunglasses under the air-conditioning unit just beside the table with the folded clean linens. The HSKM stated the personal belongings belong to LS 1. During an interview on 7/1/2025, at 8:02 a.m., with the Infection Preventionist (IP), the IP stated personal belongings are not allowed inside the clean laundry room. The IP stated the laundry room where washed linens and clothes is a clean area, and personal belongings are dirty and should not be in the clean laundry area. The IP stated LS 1 should have placed her (LS 1) personal belongings in the staff breakroom to prevent the spread of infection. During an interview on 7/1/2025, at 9:28 a.m., with LS 1 and translated by Licensed Vocational Nurse 1 (LVN 1), LS 1 stated the two bags, sweater, cellphone and sunglasses all belongs to her (LS 1). During an interview on 7/1/2025, at 10:07 a.m., with the HSKM and translated by LVN 1, the HSKM stated laundry staff were provided with a locker inside the janitor room where they can place their personal belongings. The HSKM stated personal belongings are not allowed in the clean laundry room for infection control. During a concurrent interview, and record review on 7/2/2025, at 1:46 p.m., with the Director of Nursing (DON), facility's policy and procedure (P&P), titled, Soiled Laundry and Bedding, dated 9/2022, and last reviewed on 1/29/2025, the P&P indicated, Employee personal belongings should not be left in a designated area. Should not be stored or left in laundry area/room. The DON stated the facility failed to keep laundry area clean and free from potential infection related to placing of personal belongings. The DON stated the facility needs to provide a small cabinet or built in storage for the contracted (individuals hired by a company for a specific project or period, rather than as permanent employees) laundry staff for their personal belongings. The DON stated LS 1's belongings should not be left in the laundry room. The DON stated the possibility of cross contamination may occur and might result in the spread of infection. During a review of facility's P&P, titled, Departmental (Environmental Services) dated 4/2023, and last reviewed on 1/29/2025, the P&P indicated, Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to:1. Develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one (1) of two (2) sampled residents (Resident 22) reviewed for dignity care area by failing to develop and implement a care plan on the resident's disrobing behavior.2. Ensure to have person-centered care by failing to implement the care plan for one (1) of five (5) residents (Resident 32) reviewed for unnecessary medications (any drug in excess) by failing to implement monitoring for adverse effects (also known as adverse consequences - unwanted, uncomfortable, or dangerous effects that a drug may have) with the use of carbidopa-levodopa (a medication used for Parkinson Disease [a condition that affects movement causing tremors, stiffness, and difficulty with balance and coordination]) for Resident 32, starting 2/3/2025.These deficient practices had a potential for delays in the delivery of necessary care and services that promotes maintenance or enhancement of Resident 22's quality of life, recognizing the resident's individuality; and had the potential to cause Resident 32 to receive suboptimal (less than the highest standard or quality) care leading to the use of unnecessary medications causing potential adverse effects and negatively impacting their physical, mental, and psychosocial well-being. Cross-reference F756 and F757.Findings:
During a review of Resident 22’s admission Record (a document containing demographic and diagnostic information,) the admission Record indicated the facility admitted the resident on 12/11/2024, with diagnoses including mood disorder (a mental health condition characterized by significant disturbances in a person's emotional state, leading to prolonged periods of extreme happiness, sadness, or both), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions).
During a review of Resident 22’s History and Physical (H&P), dated 12/1/2024, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 22’s Minimum Data Set (MDS, a resident assessment tool), dated 6/9/2025, the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had severely impaired cognition (a pronounced decline in thinking abilities that significantly impacts daily life, often preventing independent living). The MDS indicated the resident was dependent on lower body dressing while needing partial to moderate assistance on upper body dressing.
During a review of Resident 32’s admission Record, dated 7/1/2025, the record indicated Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including Parkinson Disease.
During a review of Resident 32’s Care Plan, dated 2/3/2025, the Care Plan indicated: “CARBIDOPA. Resident is at risk for adverse effects from … CARBIDOPA. Monitor for potential risk/effects and alert MD when indicated.”
During a review of Resident 32’s Medication Administration Record (MAR - a record of medications administered to residents), for June 2025, the MAR indicated Resident 32 was prescribed:
· carbidopa-levodopa extended release ([ER] – a formulation of medication designed to deliver a drug slowly over a specific period, rather than all at once, allowing the medication to have a longer effect in the body, providing more consistent drug levels as compared to immediate release tablets) 50-200 milligram (mg – a unit of measure of mass) tablet to give one (1) tablet by mouth midnight for Parkinson Disease.
· carbidopa-levodopa 25-100 mg tablet to give one (1) tablet by mouth four (4) times a day for Parkinson Disease, at 8 a.m., 12 p.m., 4 p.m. and 8 p.m.
The MAR did not contain documentation for monitoring for adverse effects with the use of carbidopa.
During a concurrent observation and interview on 6/30/2025, at 11:08 a.m., with Licensed Vocational Nurse (LVN) 1, inside Resident 22’s room, observed resident without a shirt on, upper body exposed and the curtain was not drawn. LVN 1 stated the resident tends to remove her clothing and she will help the resident put back her clothes on.
During an interview on 6/30/2025, at 11:16 a.m., with Registered Nurse (RN) 2, RN 2 stated she was not aware of Resident 22 removing her clothes. RN 2 stated if she knew the resident was disrobing or removing her clothes, she would have assessed the resident and created a care plan on the disrobing behavior of the resident.
During an interview on 6/30/2025, at 11:18 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 22 had been removing her clothes every time she was changed for two weeks now and he reported the resident’s behavior to his charge nurse. CNA 3 stated he cannot remember anymore who he spoke to but he is sure he had communicated the issue to a licensed staff. CNA 3 stated to his knowledge every time they have a resident that undresses themselves and were confused, the licensed staff created a care plan on the disrobing behavior of the resident to promote resident respect and dignity.
During a concurrent record review and interview on 7/1/2025 at 2:15 p.m., with Registered Nurse (RN) 2, RN 2 reviewed Resident 32’s physician orders, June 2025 MAR and Care Plan dated 2/3/2025. RN 2 stated the Care Plan indicated Resident 32 was at risk of adverse effects, such as dyskinesia (uncontrolled, involuntary movements) from the use of carbidopa, and to monitor for potential risk/effects and inform the physician. RN 2 stated monitoring for adverse effects would be documented on the MAR, and that RN 2 was unable to locate documentation for monitoring for adverse effects related to use of carbidopa for Resident 32 for June 2025. The RN 2 stated monitoring for dyskinesia with carbidopa use was important to ensure Resident 32 did not have additional tremors (shaking, movement) that was unnoticed, which may harm the resident further. RN 2 stated the facility failed to ensure to have person-centered care by failing to implement the Care Plan dated 2/3/2025 to accurately reflect the needs of Resident 32; and ensure maintaining the highest level of functionality and quality of life by adequately monitoring the adverse effects related to the use of carbidopa to prevent unnecessary medication use.
During a concurrent record review and interview on 7/2/2025 at 11:58 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 32’s June 2025 MAR and Care Plan dated 2/3/2025. The DON stated the Care Plan indicated Resident 32 was at risk of adverse effects from the use of carbidopa, and to monitor for potential risk/effects and inform the physician. The DON stated the monitoring for adverse effects would be documented on the MAR, and that the DON was unable to locate monitoring for the adverse effects with the use of carbidopa between 6/1/2025 and 6/30/2025 for Resident 32. The DON stated monitoring for adverse effects with the use of carbidopa was important to ensure Resident 32 did not have adverse effects that were unnoticed, which would cause the resident more harm than benefit with the use of carbidopa. The DON stated the facility failed to monitor for adverse effects with the use of carbidopa for Resident 32 by failing to implement the Care Plan dated 2/3/2025 placing the resident at risk of not maintaining their highest level of functionality and quality of life and increasing the risk of adverse effects such as additive tremors.
During a phone interview on 7/2/2025 at 1:13 p.m., with the Pharmacy Consultant (PC,) the PC stated Resident 32 should be monitored for adverse effects of carbidopa-levodopa such as dyskinesia. The PC stated not having monitoring for side effects with use of carbidopa-levodopa will lead to the use of unnecessary medications harming Resident 32 by having adverse effects go unnoticed resulting in more harm than benefit to the resident.
During an interview on 7/2/2025, at 1:51 p.m., with the DON, the DON stated the facility failed to formulate a care plan and discuss with the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients) members the resident’s behavior of disrobing. The DON stated the licensed staff should have created and implemented a care plan on the resident’s disrobing to ensure they identify the approaches applicable to the resident’s behavior and communicate the issues to all healthcare team to promote dignity and respect on a demented (acting in a confused, irrational, or insane manner) resident.
During a review of the facility's recent policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, last reviewed on 1/29/2025, the P&P indicated a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.
2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.
7. The comprehensive, person-centered care plan:
b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being…
e. reflects currently recognized standards of practice for problem areas and conditions.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards:1. For one of one sampled resident (Resident 35) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use 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.2. For one of five sampled residents (Resident 25) reviewed for unnecessary medications by failing to rotate sq insulin administration sites.The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site sq 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:
a. During a review of Resident 35’s admission Record, the admission Record indicated the facility originally admitted the resident on 5/24/2023 and readmitted in the facility on 10/21/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), type two diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), and long-term use of insulin.
During a review of Resident 35’s History and Physical (H&P), dated 10/23/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 35’s Minimum Data Set (MDS - a resident assessment tool), dated 5/19/2025, the MDS indicated Resident 35 was not able to understand others and make his needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 35 required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 35 received insulin.
During a review of Resident 35’s care plan (CP) on risk for hypoglycemia (low level of sugar in the blood) and hyperglycemia (high level of sugar in the blood) related to DM 2, the CP indicated to administer medication as ordered as one of the interventions to prevent unrecognized signs and symptoms of hypoglycemia or hyperglycemia.
During a review of Resident 35’s Order Summary Report, the Order Summary Report indicated the following physician’s order:
- 4/23/2025 and discontinued on 4/23/2025: Lantus solostar (a long-acting insulin) sq solution pen-injector 100 unit per milliliter (unit/ml – a unit of measurement) inject 10 units subcutaneously at bedtime for DM 2 hold for blood sugar (BS) less than (< - a unit of measurement) 110. May give orange juice (OJ) for BS < 60. Rotate site.
- 4/23/2025: Basaglar kwikpen (insulin glargine – a long-acting insulin) sq solution pen-injector 100 unit/ml inject 10 units subcutaneously at bedtime for DM 2 hold for BS <110. May OJ for BS < 60. Rotate site.
- 4/8/2025 and discontinued on 4/23/2025: Humalog kwikpen (a short acting insulin) sq solution pen-injector 100 unit/ml (insulin lispro) inject as per sliding scale (the increasing administration of the pre meal insulin dose based on the blood sugar level before the meal): if 0=150: 0 units. Call physician (MD) if BS <60; 151-200 = 1 unit; 201-250 = two units; 251-300 = three units; 301-350 = four units; 351-400 = five units; 401 plus = six units.
Call MD if BS continue to read above 400 subcutaneously three times a day for DM 2 to give 15 minutes before meal.
- 4/23/2025: Novolog flexpen (a short acting insulin) sq solution pen injector (insulin aspart) inject as per sliding scale: if 0=150: 0 units. Call physician (MD) if BS <60; 151-200 = one unit; 201-250 = two units; 251-300 = three units; 301-350 = four units; 351-400 = five units; 401 plus = six units.
Call MD if BS continue to read above 400 subcutaneously three times a day for DM 2 to give 15 minutes before meal.
During a concurrent interview and record review on 7/2/2025 at 10:50 a.m. with the MDS Coordinator (MDSC), Resident 35’s Order Summary Report, CP, and sq administration sites for Basaglar, Lantus, insulin aspart, and insulin lispro from 4/1/2025 to 6/30/2025 were reviewed. The MDSC stated Resident 35 received insulin, had a physician’s order for Basaglar that was changed to Lantus, and insulin lispro that was changed to insulin aspart, and were administered as follows:
- Basaglar kwikpen (insulin glargine) sq solution:
4/04/25 7:34 p.m. subcutaneously Abdomen – left lower quadrant (LLQ)
4/05/25 7:51 p.m. subcutaneously Abdomen - LLQ
4/08/25 8:47 p.m. subcutaneously Abdomen – right lower quadrant (RLQ)
4/09/25 8:04 p.m. subcutaneously Abdomen - RLQ
4/16/25 7:15 p.m. subcutaneously Abdomen – left upper quadrant (LUQ)
04/17/25 8:39 p.m. subcutaneously Abdomen – LUQ
- Humalog kwikpen (insulin lispro) sq solution:
4/08/25 7:15 p.m. subcutaneously arm - right
4/09/25 8:04 p.m. subcutaneously arm – right
- Novolog flexpen sq solution:
5/18/25 12:00 p.m. subcutaneously Arm - left
5/18/25 5:57 p.m. subcutaneously Arm - left
5/20/25 11:15 a.m. subcutaneously Arm - left
5/20/25 5:30 p.m. subcutaneously Arm – left
The MDSC stated that the administration sites for insulin should be rotated per standards of practice, manufacturer’s guidelines, and per physician’s order to prevent hardening or lumps in the skin. LVN 3 stated the location of administration sites for Resident 35’s Basaglar, Humalog (insulin lispro), and Novolog (insulin aspart) were not rotated. The MDSC stated there was a physician’s order to rotate administration sites. The MDSC stated Resident 47’s administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident’s skin which can affect the absorption of the insulin.
During an interview on 7/2/2025 at 10:55 a.m. with Registered Nurse (RN) 4, RN 4 stated that nurses are supposed to rotate the insulin administration sites as indicated in the physician’s order, manufacturer’s guideline, and according to professional standards of practice. RN 4 stated Resident 35’s insulin administration sites should have been rotated as it placed the resident at risk for development of lipodystrophy which may affect the absorption of the insulin and lead to hyperglycemia.
b. During a review of Resident 25’s admission Record, the admission Record indicated the facility admitted the resident on 5/5/2025, with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a systemic illness or condition that disrupts normal metabolic processes), DM 2 with diabetic neuropathy (nerve damage caused by diabetes), and long-term use of insulin.
During a review of Resident 25’s H&P, dated 5/6/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 25’s MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a noticeable decline in thinking skills that affects daily life). The MDS indicated the resident was on a high-risk drug class hypoglycemic (medicines to control diabetes).
During a review of Resident 25’s Order Summary Report, dated 6/21/2025, the Order Summary Report indicated orders for Insulin Aspart Flexpen Subcutaneous Solution Pen- Injector 100 unit/ml (Insulin Aspart). Inject eight units subcutaneously before meals for diabetes. Hold administration of insulin for blood sugar (BS) less than (<) 110 [rotate site] and Lantus SoloStar Subcutaneous Solution Pen-Injector 100 unit/ml (Insulin Glargine). Inject 35 units subcutaneously one time a day for DM 2. Hold administration of insulin for BS < 110 [rotate sites].
During a review of Resident 25’s CP Report regarding the resident being at risk for hypoglycemia and hyperglycemia related to DM 2, last revised on 5/18/2025, the CP indicated an intervention to administer medications as ordered.
During a review of Resident 25’s Location of Administration Report of Insulin for 5/2025 through 6/2025, indicated:
-Lantus Solo Star Subcutaneous Solution Pen-injector 100 unit/ml was administered on
5/6/2025 at 9:19 a.m. on the Abdomen- LLQ
5/7/2025 at 8:19 a.m. on the Abdomen-LLQ
5/21/2025 at 7:45 a.m. on the Deltoid-right
5/22/2025 at 7:34 a.m. on the Deltoid-right
-Insulin Aspart FlexPen Subcutaneous Solution Pen-injector 100 unit/ml on
5/14/2025 at 5:22 p.m. on the Arm-left
5/15/2025 at 8 a.m. on the Arm-left
6/23/2025 at 5:23 p.m. on the Abdomen-LLQ
6/24/2025 at 6:52 a.m. on the Abdomen-LLQ
During a concurrent interview and record review on 7/1/2025 at 3:20 p.m. with RN 3, Resident 25’s Medical Diagnosis, Order Summary Report, Location of Administration of Insulin, for 5/2025 through 6/2025, and Care Plan were reviewed. RN 3 stated there were multiple instances where the licensed nurses did not rotate the insulin administration sites for Resident 25. RN 3 stated the licensed staff should rotate insulin administration sites to prevent lipodystrophy that can affect the absorption of insulin if injected on the sites of lipodystrophy.
During an interview on 7/2/2025 at 1:51 p.m. with the Director of Nursing (DON), the DON stated the licensed staff should have rotated the sites of insulin administration on Resident 25. The DON stated the sites of administration should be rotated to prevent discomfort, irritation, and lipodystrophy of the frequented sites of administration of insulin. The DON stated the staff should check the electronic healthcare record of the last site of administration of the insulin prior to administering them to prevent repetition of sites of administration. The DON stated that not rotating insulin administration sites on Resident 25 can lead to malabsorption (difficulty in the digestion or absorption of medication) of the insulin that can cause hypo (low) or hyperglycemia on the resident.
During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 1/29/2025, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P further indicated:
- Re-check that the amount of insulin drawn into the syringe matches the amount of insulin ordered.
- Insulin may be injected into the sq tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel.
- Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility-provided manufacturer’s guideline for Basaglar (insulin glargine) injection solution, undated, the manufacturer’s guideline indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
During a review of the facility-provided manufacturer’s guideline for injection insulin aspart injection, for sq or intravenous use, undated, the manufacturer’s guideline indicated to rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine), with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate injection sites to reduce 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 ensure one (1) of five (5) sampled residents (Resident 25) was free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures by failing to ensure:1. Resident 25 had specific, measurable target behaviors monitored related to the use of valproic acid (a psychotropic medication used for bipolar disorder [mental health conditions characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function]) to ensure resident's drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring).This deficient practice had the potential to place Resident 25 at risk for significant adverse consequence (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the residents' mental, physical condition, functional, and psychosocial status.Cross-reference F756 Findings:During a review of Resident 25's admission Record (a document containing demographic and diagnostic information,) dated 7/1/2025, indicated Resident 25 was admitted to the facility on [DATE] with a diagnosis including bipolar disorder. During a review of Resident 25's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 5/10/2025, indicated Resident 25 was moderately impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. MDS indicated Resident 25 had no mood, and no behavioral symptoms. During a review of Resident 25's Medication Administration Record (MAR - a record of medications administered to residents), for June 2025, the MAR indicated Resident 25 was prescribed the following: Valproic acid 250 milligram (mg - a unit of measure of mass) to give one (1) capsule by mouth once a day for bipolar disorder manifested by extreme irritability that affects activities of daily living (ADL)s, at 8 a.m. Valproic acid 250 mg to give one (1) capsule by mouth at bedtime for bipolar disorder manifested by extreme irritability that affects ADLs, at 8 p.m.During the same review, the MAR indicated the following: Monitor episodes of bipolar disorder manifested by extreme irritability as evidence of aggressive behavior towards staff that affects ADLs and tally by hashmarks for (valproic acid) use every shift, starting 5/22/2025.The MAR indicated monitoring was documented for three (3) times a day, with two (2) behaviors documented during the day on 6/20/2025, and no behaviors for the remainder of the shifts and days. During a concurrent record review and interview on 7/1/2025 at 2:25 p.m., with Registered Nurse (RN) 2, RN 2 reviewed Resident 25's MAR for June 2025. RN 2 stated Resident 25's valproic acid order prescribed for bipolar disorder manifested by extreme irritability as evidence of aggressive behavior towards staff that affects ADLs, does not have a specific type of irritability or aggressive behavior identified. RN 2 stated there are many different types of irritability and aggressive behavior, such as yelling, hitting, screaming. RN 2 stated psychotropic 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 2 stated that without specific targeted behaviors of irritability and aggression different licensed nurses can interpret and document for different behaviors resulting in the physician making an inaccurate assessment of Resident 25's medication therapy leading to the use of unnecessary medication causing adverse consequences and harming the resident. During an interview and concurrent record review on 7/2/2025 at 11:58 a.m., with the Director of Nursing (DON,) the DON reviewed Resident 25's June MAR. The DON stated the valproic acid order for Resident 25 does not include a specific irritability and aggressive behavior to monitor. The DON stated without specific targeted behavior monitoring, assessments and evaluations for the use of valproic acid 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 25. During a phone interview on 7/2/2025 at 1:13 p.m., with the Pharmacy Consultant (PC,) the PC stated the PC reviewed and completed Resident 25's medication regimen review (MRR) for May and June 2025 and failed to identify the lack of specific behavior monitoring for irritability and aggression with the use of valproic acid in the monthly written reports to the facility. The PC stated not having specific behavior monitoring will lead to inaccurate monitoring and an inability to measure the effectiveness of psychotropic medications, potentially causing unnecessary use and more harm than benefit to Resident 25. During a review of the facility's Policy and Procedures (P&P,) titled Behavioral Health Services, last reviewed 1/29/2025, the P&P indicated: The Facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Review of the facility's P&P titled Policy for Unnecessary Medication, last reviewed 1/29/2025, the P&P indicated: Facility will follow state and federal regulation to ensure that all residents will be free from unnecessary psychotropic medication and unnecessary drugs.Licensed nurse will review resident's drug regimen based on the following criteria:3. Adequate indication4. Adequate monitoringFacility will conduct pharmacy CQI regularly to ensure compliance. Review of the facility's P&P titled Psychotherapeutic Medications, last reviewed 1/29/2025, the P&P indicated: Evaluate the resident's response to psychotropic medication therapy to determine that the medications are appropriate andresident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.The licensed nurse will assess resident to ensure:D. Specific behavior being monitored every shift.M. The pharmacist will complete monthly drug regimen review and give recommendations as indicated and the facility will follow up with the recommendations. Review of the facility's P&P titled Psychotherapeutic Medications, last reviewed 1/29/2025, the P&P indicated:1. The use of psychotherapeutic medications shall be kept to a minimum in this facility. These medications are to be used only for specific behaviors by a resident.2. A specific diagnosis, and a specific behavior or thought process justifying the need for psychotherapeutic mediations are to be identified in the resident's health record.3. Data shall be collected on all episodes of this specific behavior for the physician to use in evaluating the effectiveness of the medication. During a review of facility P&P titled Medication Regimen Review (Monthly Report), last reviewed 1/29/2025, the P&P indicated The consultant pharmacist performs a comprehensive MRR at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.B. The consultant pharmacist reviews the MRR of each resident at least monthly either on site or remotely.D. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the DON, and/or prescriber as appropriate.

Based an observation, interview, and record review, the facility failed to ensure that two of eight residents (Residents 21 and 79) 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) 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 an interview conducted during the Resident Council Meeting on 7/1/2025 at 10:30 a.m., Residents 21 and Resident 79 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. The residents stated they would like to know the facility's latest survey inspection results and the corrections that the facility put into place. During a concurrent observation and interview on 7/1/2025 at 11:30 a.m. with the Activity Director (AD), in the dining room, the survey result binder was under the cabinet in the corner of the dining room. The AD stated the facility had two survey binders, one in the front lobby of the facility for visitors and family members and another one in the dining room. The AD stated the residents were informed that if they (residents) want to see the survey results that they (residents) could always ask the staff. The AD grabbed the survey binder from under the cabinet and verified the label on the binder was too small to be read by the residents. The AD stated the survey binder must be easily accessible to all residents without having to ask the staff. During an interview on 7/1/2025 at 2:15 p.m. with the Administrator (ADM), the ADM stated the survey result binder's label was too small for residents to read. During a concurrent interview and record review on 7/2/2025 at 1:46 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Examination of Survey Results, dated 2001 and last reviewed on 1/29/2025, the P&P was reviewed and indicated, A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisit reports, along with state approved plans of corrections of noted deficiencies, is maintained in a three ring binder located in the area frequented by most residents, such as the main lobby or resident activity room. The DON stated the facility failed to let the resident access the survey result binder. The DON stated the survey result was for public access and should be readily accessible to residents and visitors. The DON stated the survey binder results help the family decide if they (family) want to keep their family in the facility or transfer them out. During a review of facility's P&P titled Resident Rights, dated 2/2021 and last reviewed on 1/29/2025, the P&P indicated Employee shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: .w. examine survey results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor the resident's right to be informed in advance by the physician or other practitioner or professional, of the risks and benefits of proposed care, treatment and treatment alternative or option for two of two sampled residents (Residents 25 and 1) reviewed for informed consents (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure:1. Resident 25's Zyprexa (treatment for mental health conditions such as schizophrenia and bipolar I disorder) had the correct dosage on the consent form.2. Resident 1's Depakote (it helps manage manic or mixed episodes [periods of high energy, irritability, or both] in adults with bipolar disorder) indicated the dosage on the consent form. This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications (substances that, when taken in or administered into one's system, affect mental processes, e.g. perception, consciousness, cognition or mood and emotions).Findings: 1. During a review of Resident 25's admission Record, the admission Record indicated the facility admitted the resident on 5/5/2025, with diagnoses including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive state of decline in mental abilities), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 25's History and Physical (H&P), dated 5/6/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 25's Minimum Data Set (MDS, a resident assessment tool), dated 5/10/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a noticeable decline in thinking skills that affects daily life). The MDS indicated the resident was on a high-risk drug class antipsychotic (medications used to treat psychosis, a mental state where a person's thoughts and perceptions are significantly distorted). During a review of Resident 25's Order Summary Report, dated 6/11/2025, the Order Summary Report indicated an order for Zyprexa oral tablet 5 milligrams (mg, a unit of weight) (Olanzapine). Give 1 tablet by mouth every 12 hours for schizoaffective disorder, bipolar (a mental health condition that causes extreme mood swings) type monitor behavior (m/b) paranoia (the irrational and persistent feeling that people are 'out to get you' or that you are the subject of persistent, intrusive attention by others), delusional (having false or unrealistic beliefs), responding to internal stimuli as evidence of talking to self, affecting activities of daily living. During a review of Resident 25's Care Plan (CP) Report regarding the resident's use of Zyprexa and having episodes of schizoaffective disorder, bipolar type, last revised on 6/23/2025, the CP indicated an intervention to explain all procedures and involve the family in care if possible/available and encourage resident to discuss interest/concerns. During a review of Resident 25's Informed Consent, dated 5/5/2025, the Informed Consent indicated a consent for Zyprexa 1 mg 1 tablet every (q) 12 hours (hrs.). During a concurrent interview and record review on 7/1/2025, at 9:10 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 reviewed Resident 25's Medical Diagnosis, Order Summary Report, Informed Consent, and Care Plan. LVN 3 stated the Zyprexa dosage written on the Informed Consent was wrong. LVN 3 stated instead of Zyprexa 5 mg per physician's order, the Informed Consent indicated 1 mg. LVN 3 stated it was important to indicate the correct dosage on the form as it might affect the decision of the resident or representative to accept or decline the proposed treatment. During a concurrent interview and record review on 7/1/2025, at 3:36 p.m., with Registered Nurse (RN) 3, RN 3 reviewed Resident 25's Medical Diagnosis, Order Summary Report, and Informed Consent. RN 3 stated the dosage on the use of Zyprexa Informed Consent was wrong, it should be 5mg per physician's order. RN 3 stated it was important to ensure the correct dosage on the Informed Consent is indicated as it could potentially affect the decision of the resident to accept or decline the proposed medication treatment. During a concurrent interview and record review on 7/2/2025, at 1:51 p.m., with the Director of Nursing (DON), the DON reviewed Resident 25's Informed Consent. The DON stated the dosage indicated on the Zyprexa Informed Consent was wrong, it should be 5mg. The DON stated it was important to indicate the correct dosage on the informed consent to ensure the resident or representative was accurately informed of the physician's proposed treatment to honor the resident's right to informed consent. During a review of the facility's recent policy and procedure (P&P) titled Policy: Informed Consent, last reviewed on 1/29/2025, the P&P indicated to ensure that residents and/or their representatives are fully informed of the benefits, risks, frequency/duration, and alternatives before initiating the administration of psychotherapeutic drugs or physical restraints.Procedure:2. Prior to obtaining Informed Consent, the attending physician and/or prescriber must provide the residents or their representatives with information on the following topics, including but are not limited to:-Treatment Details: Nature and procedures involved in the proposed treatment, including the probable frequency and duration.4. Informed consent may be obtained through the following means:-In person-By phone-Via fax-By email. 2. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 12/30/2020, and readmitted the resident on 4/2/2025, with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mood disorder (a mental health condition characterized by significant disturbances in a person's emotional state, leading to prolonged periods of extreme happiness, sadness, or both). During a review of Resident 1's H&P, dated 4/3/2025, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 1's MDS, dated [DATE], the MDS indicated the resident usually make self-understood and understand others and had sever cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident was on a high-risk drug class antipsychotic (medications used to treat psychosis, a mental state where a person's thoughts and perceptions are significantly distorted). During a review of Resident 1's Order Summary Report, dated 4/2/2025, the Order Summary Report indicated an order for Depakote Sprinkles oral capsule delayed release sprinkle 125 mg (Divalproex Sodium). Give 2 capsules by mouth three times a day for mood disorder m/b anger outburst leading to combativeness. During a review of Resident 1's CP Report regarding resident having episodes of mood disorder, last revised on 4/11/2025, the CP indicated an intervention to explain all procedures and involve the family in care if possible/available and encourage resident to discuss interest/concerns. During a review of Resident 1's Informed Consent, dated 4/2/205, the Informed Consent did not indicate the dosage of Depakote. During a concurrent interview and record review on 7/1/2025, at 3:24 p.m., with RN 3, RN 3 reviewed Resident 1's Medical Diagnosis, Order Summary Report, and Informed Consent. RN 3 stated the Informed Consent did not indicate the dosage of Depakote. RN 3 stated it was important to ensure the dosage on the Informed Consent is indicated as it could potentially affect the decision of the resident to accept or decline the proposed medication treatment. During a concurrent interview and record review on 7/2/2025, at 1:51 p.m., with the DON, the DON reviewed Resident 1's Informed Consent. The DON stated the dosage should be indicated on the Informed Consent. The DON stated it was important to indicate the dosage on the informed consent to ensure the resident or representative was accurately informed of the physician's proposed treatment to honor the resident's right to informed consent. During a review of the facility's recent P&P titled Policy: Informed Consent, last reviewed on 1/29/2025, the P&P indicated to ensure that residents and/or their representatives are fully informed of the benefits, risks, frequency/duration, and alternatives before initiating the administration of psychotherapeutic drugs or physical restraints.Procedure:2. Prior to obtaining Informed Consent, the attending physician and/or prescriber must provide the residents or their representatives with information on the following topics, including but are not limited to:-Treatment Details: Nature and procedures involved in the proposed treatment, including the probable frequency and duration.4. Informed consent may be obtained through the following means:-In person-By phone-Via fax-By email.

Based on observation, interview, and record review, the facility failed to honor the resident's right to a dignified existence for one of two sampled residents (Resident 22), reviewed for dignity care area by failing to prevent a confused resident from undressing and removing her top clothing and was vulnerable for visitors and staff's view when passing by the resident's bed. This deficient practice had the potential to cause emotional distress and affect their self-esteem and cause a loss of dignity and decline in psychosocial wellbeing. Findings: During a review of Resident 22's admission Record, the admission Record indicated the facility admitted the resident on 12/11/2024, with diagnoses including mood disorder (a mental health condition characterized by significant disturbances in a person's emotional state, leading to prolonged periods of extreme happiness, sadness, or both), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions). During a review of Resident 22's History and Physical (H&P), dated 12/1/2024, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 22's Minimum Data Set (MDS, a resident assessment tool), dated 6/9/2025, the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had severely impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident was dependent on lower body dressing while needing partial to moderate assistance on upper body dressing. During a concurrent observation and interview on 6/30/2025, at 11:08 a.m., with Licensed Vocational Nurse (LVN) 1, inside Resident 22's room, observed resident without a shirt on, upper body exposed and the curtain was not drawn. LVN 1 stated the resident tends to remove her clothing and she will help the resident put back her clothes on. During an interview on 6/30/2025, at 11:16 a.m., with Registered Nurse (RN) 2, RN 2 stated she was not aware of Resident 22 removing her clothes. RN 2 stated if she knew the resident was disrobing or removing her clothes, she would have assessed the resident and created a care plan on the disrobing behavior of the resident. During an interview on 6/30/2025, at 11:18 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 22 had been removing her clothes every time she was changed for two weeks now and he reported the resident's behavior to his charge nurse. CNA 3 stated he cannot remember anymore who he spoke to but he is sure he had communicated the issue to a licensed staff. CNA 3 stated to his knowledge every time they have a resident that undresses themselves and were confused, the licensed staff created a care plan on the disrobing behavior of the resident to promote resident respect and dignity. During an interview on 7/1/2025, at 2:47 p.m., with LVN 1, LVN 1 stated Resident 22 removing her upper clothing and leaving the curtains open is a dignity issue for the resident. LVN 1 stated putting herself in the shoes of the resident, she does not want anybody to see her topless even if she has impaired cognition, she would love her dignity to be promoted and respected by making sure she was distracted from the disrobing behavior and drawing the curtains to protect her dignity. LVN 1 stated every time they have a resident that disrobes and confused, they communicate them to all the healthcare team and monitor the resident for disrobing and making sure the curtains was drawn to provide privacy. LVN 1 stated the RN supervisors creates a care plan to standardize the care provided to the resident to promote dignity and respect to resident. During an interview on 7/2/2025, at 1:51 p.m., with the Director of Nursing (DON), the DON stated the facility failed to promote dignity to resident by failing to timely identify the behavior, distract the resident from disrobing by providing activities, and formulate a care plan and discuss with the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients) members the resident's behavior of disrobing. The DON stated the licensed staff should have created and implemented a care plan on the resident's disrobing to ensure they identify the approaches applicable to the resident's behavior and communicate the issues to all healthcare team to promote dignity and respect on a demented (acting in a confused, irrational, or insane manner) resident. The DON stated the failure of the staff to identify the disrobing behavior placed the resident at risk for violation of their right to dignified existence. The DON stated that even if the resident had dementia (a progressive state of decline in mental abilities), they needed to be treated with dignity and respect as anybody else. During a review of the facility's recent policy and procedure (P&P) titled Dignity, last reviewed on 1/29/2025, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.e. encouraged to dress in clothing that they prefer.11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. During a review of the facilities recent P&P titled Policy for Dementia Care, last reviewed on 1/29/2025, the P&P indicated facility will develop and implement person-centered care plans with useful interventions include and support the dementia care needs, identified in the comprehensive assessment. Facility will monitor resident condition on a daily basis; evaluate staff performance and conduct resident council meeting regularly to ensure all staff will have the appropriate competencies and skill sets to provide dementia care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (also called pressure ulcer, localized damage to the skin and/or underlying tissue usually over a bony prominence) for two of two sampled residents (Resident 6 and 10) investigated under pressure injury by:1. Failing to ensure Resident 6's bilateral heel protectors (protective cushions or coverings for the heels) were applied on the resident as ordered by the physician.2. Failing to ensure Resident 10's low air loss mattress (LALM - a mattress that helps prevent and treat pressure injuries by circulating air and relieving pressure on the body) was set according to resident's weight or comfort.These deficient practices had the potential for the development and worsening of pressure injuries to residents.
Findings:
a. During a review of Resident 6’s admission Record, the admission Record indicated the facility originally admitted Resident 6 on 8/23/2019 and readmitted in the facility on 5/5/2023, with diagnoses including pressure ulcer stage three (full-thickness loss of skin, dead and black tissue may be visible) of sacral (a large, triangular bone at the bottom of the spine) region, contracture (tightness in the tissues around a joint that limits its ability to move freely) of both elbows and both knees, and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).
During a review of Resident 6’s History and Physical (H&P - a medical examination that involves a doctor taking a resident’s medical history, performing a physical exam, and documenting their findings), dated 5/192025, the H&P indicated Resident 6 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 5/14/2025, the MDS indicated Resident 6 was not able to understand others and make his needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 6 required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 6 had stage three pressure injury.
During a review of Resident 6’s Order Summary Report, dated 5/31/2024, the Order Summary Report indicated a physician’s order to apply heel protectors to both feet when in bed and when out of bed in wheelchair for skin breakdown prevention management every shift.
During a review of Resident 6’s care plan (CP) on skin integrity impairment, initiated on 10/29/2024 and last revised on 5/29/2025, the CP indicated to apply pressure relieving devices as appropriate and/or as one of the interventions to resolve stage three pressure injury on the sacral region without complications.
During a review of Resident 6’s Braden Scale (a tool designed to assess a resident’s risk of developing pressure injuries), dated 5/14/2025, the Braden Scale indicated Resident 6 was a high risk for developing pressure injuries.
During an observation on 6/30/2025 at 2:30 p.m. inside Resident 6’s room, Resident 6 laid in bed with eyes open but does not respond verbally. Resident 6 did not have heel protectors on both feet.
During a concurrent observation and interview on 7/1/2025 at 2:20 p.m. inside Resident 6’s room with Certified Nursing Assistant (CNA) 6, CNA 6 stated Resident 6 did not have heel protectors on both feet. CNA 6 stated she was familiar with Resident 6 and had never used the heel protectors on the resident. CNA 6 stated she was not aware if the resident had an order to apply heel protectors. CNA 6 stated she placed a pillow in between Resident 6’s legs as one of the interventions to prevent pressure injury but had not applied the heel protectors. CNA 6 stated the heel protectors should have been applied on Resident 6 if there was a physician’s order to prevent skin breakdown as the resident was a very high risk for pressure ulcers.
During a concurrent observation and interview on 7/1/2025 at 2:31 p.m. inside Resident 6’s room with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 6 did not have heel protectors on both feet. LVN 4 stated any pressure relieving devices such as heel protectors and LALM are part of the Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and he is responsible for ensuring that the heel protectors are in place and the LALM setting was in the correct setting according to physician’s orders. LVN 4 stated Resident 6’s bilateral heel protectors should have been applied as ordered by the physician as it placed Resident 6 at risk for development or worsening of pressure injuries considering the resident’s condition such as fragile skin, contracture of both upper and lower extremities, and not eating well.
During an interview on 7/2/2025 at 11:45 a.m. with Registered Nurse (RN) 4, RN 4 stated Resident 6 had a physician’s order to apply heel protectors on both feet when in bed and when out of bed in wheelchair for skin breakdown prevention and management as Resident 6 was a high risk for pressure ulcers due to the resident’s condition such as fragile skin, contracture of both upper and lower extremities, and not eating well. RN 4 stated the licensed nurse or CNA assigned to Resident 6 should have ensured that the heel protector was applied on Resident 6 as ordered by the physician.
b. During a review of Resident 10’s admission Record, the admission Record indicated the facility originally admitted Resident 10 on 11/2/2020 and readmitted in the facility on 12/22/2020, with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).
During a review of Resident 10’s H&P, dated 12/22/2023, the H&P indicated Resident 10 did not have the capacity to understand and make decisions.
During a review of Resident 10’s MDS, dated [DATE], the MDS indicated Resident 10 was not able to understand others and make his needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 10 required total assistance from staff with all ADLs.
During a review of Resident 10’s Order Summary Report, the Order Summary Report indicated the following physician’s orders:
- 6/25/2025: Right gluteus (a group of three muscles commonly known as the buttocks) stage four pressure injury (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). Cleanse with normal saline (NS - a saltwater solution), pat dry, apply santyl (an ointment used to help clean wounds and promote healing) and pack with alginate (a type of wound dressing which absorbs fluid resulting in gels the wound moist and minimize bacterial infections), cover with border gauze dressing every day shift for wound care management for four weeks.
- 3/7/2025: LALM: Setting is based on resident's current weight, adjust as indicated and it should be on alternating mode pressure setting; some are on automatic alternating setting.
During a review of Resident 10’s CP on risk for developing pressure sore, and other types of skin breakdown, initiated on 11/15/2020 and last revised on 3/17/2025, the CP indicated LALM with settings based on the resident’s current weight as one of the interventions to minimize the risk of skin breakdown or pressure sore daily.
During a review of Resident 10’s Weights and Vitals Summary, dated 6/4/2025, the Weights and Vitals Summary indicated that Resident 10’s current weight was 114 pounds (lbs. – a unit of measurement).
During a review of Resident 10’s Braden Scale, dated 5/30/2025, the Braden Scale indicated Resident 10 was a moderate risk for developing pressure injuries.
During an observation on 6/30/2025 at 10:47 a.m. inside Resident 10’s room, observed Resident 10’s LALM with the setting at 160 lbs. The LALM indicated increments of 40 lbs. for each setting starting at 80 lbs.
During a concurrent observation, interview, and record review on 6/30/2025 at 11 a.m. with the Infection Preventionist (IP) inside Resident 10’s room, the IP stated Resident 10’s LALM was set at 160 lbs. and the resident’s current weight, dated 6/4/2025, was 114 lbs. The IP stated the setting of the LALM was in increments of 40 lbs. starting at 80 lbs. then followed by 120 lbs., 160 lbs., 200 lbs., up to maximum of 400 lbs. The IP stated Resident 10 did not look like 160 lbs. The IP stated if Resident 10’s current weight was 114 lbs., the LALM should have been set to 120 lbs. as it was closest setting according to the resident’s weight. The IP stated 160 lbs. might be firm for Resident 10 and it placed the resident at risk for worsening of the pressure injury considering the resident’s frail condition and fragile skin.
During an interview on 7/2/2025 at 2:58 p.m. with the Director of Nursing (DON), the DON stated LALM should be set according to the resident’s current weight and licensed nurses are supposed to ensure that the setting was correct. The DON stated she was made aware that Resident 10’s LALM was set at 160 lbs. instead of 120 lbs. which was the closest setting according to Resident 10’s current weight of 114 lbs. The DON stated Resident 10’s LALM should have been set to 120 lbs. The DON stated if the setting was placed on a firmer setting, it had the potential for further skin breakdown, affect the healing process, and/or worsening of the current pressure injury.
During a review of the facility’s policy and procedure (P&P) titled, “Prevention of Pressure Injuries,” last reviewed on 1/29/2025, the P&P indicated to review the resident’s CP and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The P&P further indicated to select the appropriate support surfaces based on the resident’s risk factors, in accordance with current clinical practice.
During a review of the facility’s P&P titled, “Support Surface Guidelines,” last reviewed on 1/29/2025, the P&P indicated to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The P&P further indicated:
- General Guidelines:
1. Redistributing support surfaces are to promote comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction.
- Interventions/Care Strategies:
6. Monitor for pressure ulcer risk factors and provide interventions as needed.
During a review of the facility provided operations manual for LALM 1, the operations manual indicated:
- The LALM 1 system is intended to reduce the incidence of pressure ulcers while optimizing patient comfort.
- Users can adjust the air mattress to the desired firmness according to a patient’s weight or the suggestion from a healthcare professional. The operations manual indicated to press the up/down buttons on the panel to adjust the weight or pressure level to the patient’s specific requirements.

**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 seven of seven sampled Residents (Residents 24, 12, 45, 10, 34, 57, and 59) reviewed for accidents by failing to ensure:1. Residents 24, 12, 45, 10, and 34's fall mattress/floor mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have any furniture or medical equipment on top of them.2. Residents 57's and 59's bed controller (device used to change the height and angle of the bed) cord did not have visible wires. (Cross Reference F908)These deficient practices increased the risk of accidents such as falls with injuries and electric shock on residents.Findings:
1. During a review of Resident 24’s admission Record, the admission Record indicated the facility admitted the resident on 4/28/2017, and readmitted the resident on 2/27/2022, with diagnoses including Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of right and left elbow, and contracture of left knee.
During a review of Resident 24’s History and Physical (H&P), dated 10/15/2024, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 24’s Minimum Data Set (MDS, a resident assessment tool), dated 4/7/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a significant decline in a person's ability to think, learn, remember, and make decisions). 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 24’s Order Summary Report, dated 10/7/2022, the Order Summary Report indicated an order for low bed (a bed frame that sits closer to the ground than a standard bed) with bilateral floor mat to decrease potential injury. (Informed consent obtained from resident/responsible party after explanation of risks and benefits, and verified with MD). Every shift.
During a review of Resident 24’s Fall Risk Assessment, dated 4/7/2025, the Fall Risk Assessment indicated the resident was high risk for falls.
During a review of Resident 24’s Care Plan (CP) Report regarding the resident being at risk for falls/injury, last revised on 10/26/2024, the CP indicated an intervention of low bed with bilateral floor mats as ordered and to provide resident with a safe and clutter-free environment.
During a concurrent observation and interview on 6/30/2025, at 9:48 a.m., with the Director of Staff Development (DSD), inside Resident 24’s room, observed Resident 24 with bilateral fall mat and the left fall mat had a chair on top of them. The DSD stated there should be no chair on top of the left side of the resident’s fall mat because when the resident rolls down on the fall mat, the resident will hit the hard surfaces of the chair instead of the mat defeating its purpose to lessen the injury of the resident when they fall.
During an interview on 7/1/2025, at 2:52 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated there should be no objects on top of the fall mat of Resident 24 because leaving a heavy object on top of the fall mat will create a permanent dent on the fall mat decreasing its capacity to lessen the fall impact. LVN 1 stated if the resident falls down on a fall mat with an object on top of them, the resident can sustain a bruise, skin tear, or even fracture (a break or crack in a bone).
During an interview on 7/2/2025, at 1:51 p.m., with the Director of Nursing (DON), the DON stated there should be no furniture or medical equipment on top of Resident 24’s fall mat. The DON stated placing a furniture or medical equipment on top of the fall mat can cause injury to the resident when the resident rolls down from the bed, instead of landing on the soft surface of the mat, the resident will land on the hard surfaces of the object on top of them causing injuries such as skin tear, laceration (a skin wound), bumps, hematoma (a collection of blood outside of a blood vessel caused by a broken blood vessel), and even fracture.
During a review of the facility's recent policy and procedure (P&P) titled Maintenance Service, last reviewed on 1/29/2025, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment.
1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
During a review of the facility's recent P&P titled Fall and Fall Risk, Managing, last reviewed on 1/29/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to prevent the resident from falling and to try to minimize complications from falling.
1. Environment al factors that contribute to the risk of falls include:
d. obstacles in the footpath.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/29/2025, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.
1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:
a. Bed safety;
g. Electrical safety.
During a review of the facility-provided Instructions on the use of Fall Mat (FM) 1, undated, indicated when moving equipment such as lifts and wheelchairs across the mat, always make sure wheel locks are not engaged, as locked wheels may damage the surface. Sharp objects may cause damage to the mat. Never leave heavy objects on mat surface for extended periods, as indentations and damage may occur.
2. During a review of Resident 12’s admission Record, the admission Record indicated the facility admitted the resident on 6/25/2018, and readmitted the resident on 1/6/2025, with diagnoses including Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and contracture of the right and left knees.
During a review of Resident 12’s H&P, dated 1/10/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 12’s MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition. The MDS indicated the resident was dependent to needing setup assistance on mobility and ADLs.
During a review of Resident 12’s Order Summary Report, dated 1/6/2025, the Order Summary Report indicated an order for low bed with bilateral floor mat to decrease potential injury. (Informed consent obtained from resident/responsible party after explanation of risks and benefits, and verified with MD). Every shift.
During a review of Resident 12’s Fall Risk Evaluation, dated 5/29/2025, the Fall Risk Evaluation indicated the resident was not high risk for falls.
During a review of Resident 12’s CP Report regarding the resident being at risk for falls/injury, last revised on 6/5/2025, the CP indicated an intervention of low bed with bilateral floor mats as ordered and to provide resident with a safe and clutter-free environment.
During a concurrent observation and interview on 7/1/2025, at 9:38 a.m., with LVN 1, inside Resident 12’s room, observed Resident 12’s right fall mat had the wheel of the bed on top of them. LVN 1 stated there should be no objects on top of the fall mat of Resident 12 because leaving a heavy object on top of the fall mat will create a permanent dent on the fall mat decreasing its capacity to lessen the fall impact. LVN 1 stated if the resident falls down on a fall mat with an object on top of them, the resident can sustain a bruise, skin tear, or even fracture.
During an interview on 7/2/2025, at 1:51 p.m., with the DON, the DON stated there should be no furniture or medical equipment on top of Resident 24’s fall mat. The DON stated placing a furniture or medical equipment on top of the fall mat can cause injury to the resident when the resident rolls down from the bed, instead of landing on the soft surface of the mat, the resident will land on the hard surfaces of the object on top of them causing injuries such as skin tear, laceration, bumps, hematoma, and even fracture.
During a review of the facility's recent P&P titled Maintenance Service, last reviewed on 1/29/2025, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment.
1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
During a review of the facility's recent P&P titled Fall and Fall Risk, Managing, last reviewed on 1/29/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to prevent the resident from falling and to try to minimize complications from falling.
1. Environment al factors that contribute to the risk of falls include:
d. obstacles in the footpath.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/29/2025, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.
1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:
a. Bed safety;
g. Electrical safety.
During a review of the facility-provided Instructions on the use of FM 1, undated, indicated when moving equipment such as lifts and wheelchairs across the mat, always make sure wheel locks are not engaged, as locked wheels may damage the surface. Sharp objects may cause damage to the mat. Never leave heavy objects on mat surface for extended periods, as indentations and damage may occur.
3. During a review of Resident 45’s admission Record, the admission Record indicated the facility admitted the resident on 6/20/2019, and readmitted the resident on 4/2/2024, with diagnoses including age-related osteoporosis (happens as you get older and your bones lose their ability to regrow and reform themselves), history of falling, and history of traumatic fracture (occurs when significant or extreme force is applied to a bone).
During a review of Resident 45’s H&P, dated 5/19/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.
During review of Resident 45’s MDS, dated [DATE], the MDS indicated the resident usually makes self-understood and understand others and had impaired cognition. The MDS indicated the resident required partial to supervision assistance on mobility and ADLs.
During a review of Resident 45’s Order Summary Report, dated 4/3/2024, the Order Summary Report indicated an order for low bed with bilateral floor mat to decrease potential injury. (Informed consent obtained from resident/responsible party after explanation of risks and benefits, and verified with MD). Every shift.
During a review of Resident 45’s Fall Risk Assessment, dated 4/3/2025, the Fall Risk Assessment indicated the resident was high risk for falls.
During a review of Resident 45’s CP Report regarding the resident being high risk for falls/injury, last revised on 10/14/2024, the CP indicated an intervention of low bed with bilateral floor mat to decrease potential injury and provide resident with a safe and clutter-free environment.
During a concurrent observation and interview on 6/30/2025, at 11:01 a.m., with Certified Nursing Assistant (CNA) 4, inside Resident 45’s room, observed Resident 45’s fall mat at the right side of the bed had a side table on top of them. CNA 4 stated there should be no objects on top of the fall mat of Resident 45 because leaving a heavy object on top of the fall mat will create a permanent dent on the fall mat decreasing its capacity to lessen the fall impact. CNA 4 stated if the resident falls down on a fall mat with an object on top of them, the resident can sustain a bruise, skin tear, or even fracture.
During an interview on 7/2/2025, at 1:51 p.m., with the DON, the DON stated there should be no furniture or medical equipment on top of Resident 45’s fall mat. The DON stated placing a furniture or medical equipment on top of the fall mat can cause injury to the resident when the resident rolls down from the bed, instead of landing on the soft surface of the mat, the resident will land on the hard surfaces of the object on top of them causing injuries such as skin tear, laceration, bumps, hematoma, and even fracture.
During a review of the facility's recent P&P titled Maintenance Service, last reviewed on 1/29/2025, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment.
1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
During a review of the facility's recent P&P titled Fall and Fall Risk, Managing, last reviewed on 1/29/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to prevent the resident from falling and to try to minimize complications from falling.
1. Environment al factors that contribute to the risk of falls include:
d. obstacles in the footpath.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/29/2025, the P&P indicated our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.
1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:
a. Bed safety;
g. Electrical safety.
During a review of the facility-provided Instructions on the use of FM 1, undated, indicated when moving equipment such as lifts and wheelchairs across the mat, always make sure wheel locks are not engaged, as locked wheels may damage the surface. Sharp objects may cause damage to the mat. Never leave heavy objects on mat surface for extended periods, as indentations and damage may occur.
4. During a review of Resident 10’s admission Record, the admission Record indicated the facility originally admitted Resident 10 on 11/2/2020 and readmitted in the facility on 12/22/2020, with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), and history of falling.
During a review of Resident 10’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 12/20/2024, the H&P did not indicate Resident 10’s capacity to understand and make decisions.
During a review of Resident 10’s Minimum Data Set (MDS, a resident assessment tool), dated 5/30/2025, the MDS indicated Resident 10 was not able to understand others and make her needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 10 required 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 10’s Order Summary Report, the Order Summary Report indicated a physician’s order dated 6/23/2023 for low bed with bilateral floor mat.
During a review of Resident 10’s fall risk evaluations dated 12/3/2024, 3/1/2025, and 5/30/2025, the fall risk evaluations indicated Resident 10 was at risk for falls.
During a review of Resident 10’s care plan (CP) on risk for falls initiated on 6/30/2023 and last revised on 6/9/2025, the CP indicated to provide the resident with a safe and clutter-free environment to reduce Resident 10’s risk of falls and/or injury through appropriate interventions.
During a concurrent observation and interview on 6/30/2025 at 11:23 a.m. inside Resident 10’s room with Certified Nursing Assistant (CNA) 8, CNA 8 stated the wheel of Resident 10’s bed was placed on top of the resident’s right floor mat. CNA 8 stated there should be no furniture or heavy objects on top of the floor mats as the residents as it can affect the integrity of the floor mat and not provide protection for the residents in case of a fall and get injured. CNA 8 stated the wheel of Resident 10’s bed should not have been placed on top of the floor mat as the bed is heavy and can affect the integrity of the floor mat and not protect Resident 10 from getting injured in case of a fall.
During an interview on 7/2/2025 at 2:21 p.m. with the Director of Nursing (DON), the DON stated it is not appropriate to have furniture or equipment on top of the fall mats because the heavy object can affect the integrity of the floor mat and unable to provide protection to the resident in case of a fall. The DON stated when the resident rolls down from the bed and the floor mat had damage and indentations, the floor mat is not able to protect the resident and can cause skin tear, laceration (a tear or cut in the skin and underlying tissues), bump, (a collection of blood outside of a blood vessel caused by a broken blood vessel), or fracture (a broken bone).
During a review of the facility's recent policy and procedure (P&P) titled Fall and Fall Risk, Managing, last reviewed on 1/29/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to prevent the resident from falling and to try to minimize complications from falling.
- Environmental factors that contribute to the risk of falls include:
d. obstacles in the footpath.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/29/2025, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. The P&P further indicated:
- Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
- Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes.
- Due to complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:
a. Bed safety
During a review of the facility-provided instructions on the use of Fall Mat (FM) 1, undated, the instructions indicated:
- When moving equipment such as lifts and wheelchairs across the mat, always make sure wheel locks are not engaged, as locked wheels may damage the surface.
- Sharp objects may cause damage to the mat.
- Never leave heavy objects on the mat surface for extended periods, as indentations and damage may occur.
5. During a review of Resident 34’s admission Record, the admission Record indicated the facility originally admitted Resident 34 on 9/29/2022 and readmitted in the facility on 6/19/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), contracture of both knees, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).
During a review of Resident 34’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 6/19/2025, the H&P did not indicate Resident 34’s capacity to understand and make decisions.
During a review of Resident 34s Minimum Data Set (MDS, a resident assessment tool), dated 3/28/2025, the MDS indicated Resident 34 was not able to understand others and make his needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 34 required 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 34’s Order Summary Report, the Order Summary Report indicated a physician’s order dated 6/19/2024 for low bed with bilateral floor mat.
During a review of Resident 34’s fall risk evaluations dated 10/2/2024, 12/31/2024, and 3/28/2025, the fall risk evaluations indicated Resident 34 was at risk for falls.
During a review of Resident 34’s care plan (CP) on risk for falls initiated on 10/7/2022 and last revised on 10/14/2024, the CP indicated to provide resident with a safe and clutter-free environment and low bed with bilateral floor mat as a few of the interventions to reduce Resident 34’s risk of falls and injury.
During a concurrent observation and interview on 6/30/2025 at 10:44 a.m. inside Resident 34’s room with Certified Nursing Assistant (CNA) 8, CNA 8 stated the wheel of Resident 34’s bed was placed on top of the resident’s right floor mat. CNA 8 stated there should be no furniture or heavy objects on top of the floor mats as the residents as it can affect the integrity of the floor mat and not provide protection for the residents in case of a fall and get injured. CNA 8 stated the wheel of Resident 34’s bed should not have been placed on top of the floor mat as the bed is heavy and can affect the integrity of the floor mat and not protect Resident 34 from getting injured in case of a fall.
During an interview on 7/2/2025 at 2:21 p.m. with the Director of Nursing (DON), the DON stated it is not appropriate to have furniture or equipment on top of the fall mats because the heavy object can affect the integrity of the floor mat and unable to provide protection to the resident in case of a fall. The DON stated when the resident rolls down from the bed and the floor mat had damage and indentations, the floor mat is not able to protect the resident and can cause skin tear, laceration (a tear or cut in the skin and underlying tissues), bump, (a collection of blood outside of a blood vessel caused by a broken blood vessel), or fracture (a broken bone).
During a review of the facility's recent policy and procedure (P&P) titled Fall and Fall Risk, Managing, last reviewed on 1/29/2025, the P&P indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to prevent the resident from falling and to try to minimize complications from falling.
- Environmental factors that contribute to the risk of falls include:
d. obstacles in the footpath.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/29/2025, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. The P&P further indicated:
- Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
- Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes.
- Due to complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:
a. Bed safety
During a review of the facility-provided instructions on the use of Fall Mat (FM) 1, undated, the instructions indicated:
- When moving equipment such as lifts and wheelchairs across the mat, always make sure wheel locks are not engaged, as locked wheels may damage the surface.
- Sharp objects may cause damage to the mat.
- Never leave heavy objects on the mat surface for extended periods, as indentations and damage may occur.
6. During a review of Resident 57’s admission Record, the admission Record indicated the facility admitted Resident 57 on 10/1/2021, with diagnoses including dementia (a progressive state of decline in mental abilities), mood disorder (mental health condition causing persistent and intense sadness, elation and/or anger), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).
During a review of Resident 57’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 2/19/2025, the H&P indicated Resident 57 did not have the capacity to understand and make decisions.
During a review of Resident 57’s Minimum Data Set (MDS, a resident assessment tool), dated 5/19/2025, the MDS indicated Resident 57 was sometimes able to understand others and make her needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 57 required partial/moderate assistance with bed mobility and toilet transfers; total assistance from staff with eating, toileting, and bathing; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During an observation on 6/30/2025 at 8:44 a.m. inside Resident 57’s room, observed Resident 57 sitting up on the wheelchair. Resident 57’s bed control was placed on top of the bed and observed the base of the bed control with the wires exposed.
During a concurrent observation and interview on 6/30/2025 at 2:30 p.m., inside Resident 57’s room with Certified Nursing Assistant (CNA) 7, CNA 7 stated Resident 57’s bed control had frayed or exposed wires at the base. CNA 7 stated if staff observed any equipment in the resident room is in disrepair, the maintenance department should be notified as soon as possible to have the bed control replaced. CNA 6 stated the maintenance department should have been notified by the staff to change Resident 57’s bed control as soon as possible as the exposed wires placed the resident at risk for electrocution which may lead to injury.
During an interview on 7/2/2025, at 11:54 a.m., with the Director of Nursing (DON), the DON stated there should be no frayed/exposed wires on all the resident’s bed controller to prevent accidents such as electrical shock on the residents. The DON stated that the staff during their resident rounds should identify hazards that can cause harm to residents. The DON stated upon observation of the frayed/exposed wires the staff should have reported the incident to the maintenance department for immediate replacement.
During a review of the facility's recent policy and procedure (P&P) titled Maintenance Service, last reviewed on 1/29/2025, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment. The P&P further indicated maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.
During a review of the facility's recent P&P titled Safety and Supervision of Residents, last reviewed on 1/29/2025, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. The P&P further indicated:
- Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
- Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.
- Due to their complexity and scope, certain resident risk facto

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure physician visited one of three sampled residents (Resident 29) by:1. Failing to ensure the Attending Physician (AP) made an initial face-to-face visit within 30 days for the first 90 days following Resident 29's admission.2. Failing to ensure Resident 29 was seen the Psychiatrist Doctor (Psych MD- a medical doctor specializing in mental health, who can diagnose and treat mental, emotional and behavioral disorders) as per physician order.These failures had the potential to result in an undetected decline in medical, health or psychosocial condition and could lead to a delay in necessary care, treatment and services.Findings:
During a review of Resident 29’s admission Record, the admission Record indicated the facility initially admitted Resident 29 on 9/18/2024, and readmitted on [DATE], with diagnoses including cerebral ischemia (a condition where the brain doesn't receive enough blood flow, leading to a lack of oxygen and nutrients, unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and unspecified insomnia (trouble falling asleep or staying asleep)cerebral ischemia.
During a review of Resident 29’s Initial Psychiatric Evaluation, dated 10/5/2024, the Initial Psychiatric Evaluation was done and signed by the Psychiatrist Nurse Practitioner 1 (Psych NP 1- refers to a registered nurse who has completed advanced education and training).
During a review of Resident 29’s Order Summary Report dated 11/4/2024, the Order Summary Report indicated an order for Psychiatrist consultation with treatment and follow up as indicated.
During a review of Resident 29’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 11/6/2024, the H&P indicated Resident 29 did not have the capacity to understand and make decisions.
During a review of Resident 29’s Minimum Data Set (MDS-a resident assessment tool), dated 5/2/2025, the MDS indicated Resident 29’s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.
During a concurrent interview, and record review on 7/2/2025, at 4:05 p.m., with Registered Nurse 3 (RN 3), Resident 29’s admission Record, and Progress Notes, from 12/17/2024, to 6/17/2025, were reviewed. RN 3 stated Resident 29 was admitted to the facility on [DATE] and was seen by Psychiatrist NP 2 on the following dates: 12/17/2024, 1/16/2025, 2/14/2025, 4/11/2025, 5/16/2025 and 6/17/2025.
During an interview on 7/2/2025, at 4:20 p.m., with RN 3, RN 3 stated there was no documentation in Resident 29’s medical record that the AP and the Psych MD came and visited Resident 29 in the facility. RN 3 stated only the NPs of the AP and the Psych MD’s visited Resident 29.
During a concurrent interview, and record review on 7/2/2025, at 4:27 p.m., with the Director of Nursing (DON), Resident 29’s History and Physical (H&P), Progress Notes, and policy and procedure (P&P) titled, “Physician Visits” dated 4/2013, and last reviewed on 1/29/2025. The P&P indicated, “The attending physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. After the first ninety (90) days, if the attending physician determines that a resident need not be seen by him/her every thirty (30) days, an alternate schedule of visits may be established, but not to exceed every sixty (60) days. A physician assistant or nurse practitioner may make alternate visits after the initial ninety (90) days following admission, unless restricted by law or regulations.” The DON stated there were no H&P and Progress Notes from the AP in Resident 29’s medical record. The DON stated the AP attends monthly visits in the facility but does not see a specific resident. The DON stated the initial Psych MD visit was from NP 1 and should have been from the Psych MD. The DON stated, she (DON) and the Medical Record Director (MRD) should attempt to call the AP and Psych MD to come and visit their residents. The DON stated the facility failed to follow AP and Psych MD required visitation. The DON stated facility may not be able to identify Resident 29 medical issues and could result in delays in care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) for two of eight sampled residents (Residents 60, and 32) and for one of one inspected medication room (Medication Room Station 1) by:1. Failing to ensure Medication Disposition Log (a record that documents the handling and disposal of medications, ensuring compliance with regulations and maintaining accountability. It details the type of medication, the quantity, the reason for disposal, and the individuals involved in the process) was completed. Resident 60's one extra Augmentin (medication that treats infection) tablet was not logged in the Medication Disposition Log and bubble pack (medications are pre-sorted and sealed into individual compartments) was missing.2. Failing to administer carbidopa-levodopa (a medication used for Parkinson Disease [a condition that affects movement causing tremors, stiffness, and difficulty with balance and coordination]) on time to Resident 32.3. Failing to reconcile (the process of comparing transactions and activity to supporting documentation) one medication emergency kit (eKIT) containing Controlled Medications ([CM] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Drugs or Controlled Substances [CS]) on 6/2025.These failures resulted to medication errors and had the potential to cause Resident 32 to experience adverse effects (unwanted, uncomfortable effects from a medication) such as dyskinesia (uncontrolled, involuntary movements) and negatively impact their health and well-being, and 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), and placing the residents at risk of exposure to harmful medications, leading to physical and psychosocial harm, and hospitalization.Findings:
a. During a review of Resident 60’s admission Record, the admission Record indicated the facility admitted Resident 60 on 6/5/2025, with diagnoses that included cerebral infarction (a condition where blood flow to the brain is blocked, leading to brain tissue damage or death due to oxygen deprivation), unspecified (unconfirmed ) dementia (a progressive state of decline in mental abilities) and urinary tract infection (UTI - an infection in the bladder/urinary tract).
During a review of Resident 60’s Physician Order, dated 6/5/2025, the Physician Order indicated Augmentin oral tablet 500-125 milligram (mg - metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth two times a day for UTI, for four days.
During a review of the facility’s Pharmacy Delivery, dated 6/5/2025, the Pharmacy Delivery indicated on 6/5/2025, at 10:05 p.m., Licensed Vocational Nurse (LVN) 2 signed and received eight tablets of amoxicillin/clavulanate (Augmentin) 500 -125 mg.
During a review of Resident 60’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 60 received Augmentin from 6/6/2025, to 6/9/2025 for a total of seven doses.
During a review of Resident 60’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 60 did not have the capacity to understand and make decisions.
During a review of Resident 60’s Minimum Data Set (MDS - a resident assessment tool), dated 6/11/2025, the MDS indicated Resident 60’s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 60 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).
During a concurrent observation and interview on 7/2/2025 at 7:42 a.m. with the Infection Preventionist (IP), the facility’s Pharmacy Delivery Receipt, dated 6/5/2025, and Resident 60’s MAR, dated 6/2025, were reviewed. The IP stated the facility received eight tablets of amoxicillin/clavulanate (Augmentin) 500-125mg on 6/5/2025 at 10:05 p.m. The IP stated Resident 60 received only seven tablets of Augmentin from the eight tablets delivered.
During a concurrent interview and record reviewed on 7/2/2025 at 8:57 a.m. with the Director of Nursing (DON), Medication Disposition Log, dated 6/2025, was reviewed. The DON stated the remaining one tablet of Augmentin was not listed in the Medication Disposition Log for Resident 60.
During a concurrent observation and interview on 7/2/2025 at 9:12 a.m. with the DON, there were two boxes of discontinued medications inside the DON’s office. The DON stated the two boxes of discontinued medications were not yet logged in the Medication Disposition binder. The DON looked into every single medication bubble pack and no bubble pack for Resident 60’s Augmentin was found. The DON stated she (DON) might have discarded the Augmentin and did not log in the Medication Disposition binder. The DON stated before discarding medication it should be logged in the Medication Disposition.
During a concurrent interview and record review on 7/2/2025 at 1:46 p.m. with the DON, the facility’s policy and procedure (P&P) titled, “Disposal of Medications and Medication-Related Supplies, dated 1/2013 and last reviewed on 1/29/2025, was reviewed and the P&P indicated, “Discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed….
C. non-controlled medication (medication that doesn’t have a high potential for abuse and dependence) 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.
1) Date of destruction
2) Resident's name
3) Name and strength of medication
4) Prescription number
5) Amount of medication destroyed
6) Signatures of witnesses….
E. Medication is destroyed within 90 days from the date the medication is discontinued.
F. The medication disposition form is kept on file in the facility for 3 years.”
The DON stated the facility failed to find and explain the missing one tablet of Augmentin. The DON stated the process for medication disposal after the medication was discontinued, was for the nurses to complete and sign the Medication Disposition log indicating the date, time, name and dose of medication and number of tablets left and leave the medication in the locked medication room or in the locked DONs office and DON collects the medication three to four times a week. The DON stated one tablet, even half a tablet should have been disposed properly.
b. During a review of Resident 32’s admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including Parkinson Disease.
During a review of Resident 32’s MAR, dated 6/2025, the MAR indicated Resident 32 was prescribed with:
• carbidopa-levodopa extended release ([ER] – a formulation of medication designed to deliver a drug slowly over a specific period, rather than all at once, allowing the medication to have a longer effect in the body, providing more consistent drug levels as compared to immediate release tablets) 50-200 mg tablet to give one tablet by mouth at midnight for Parkinson Disease.
• carbidopa-levodopa 25-100 mg tablet to give one tablet by mouth four times a day for Parkinson Disease, at 8 a.m., 12 p.m., 4 p.m. and 8 p.m.
During a review of Resident 32’s MAR, dated 6/2025, the MAR indicated the carbidopa-levodopa ER 50-200 mg tablet was scheduled and administered at 6:30 a.m. between 6/1/2025, and 6/30/2025.
During a concurrent interview and record review on 7/1/2025 at 2:15 p.m. with Registered Nurse (RN) 2, Resident 32’s physician orders and MAR, dated 6/2025, were reviewed. RN 2 stated Resident 32’s physician ordered carbidopa-levodopa ER 50-200 mg tablet to give at midnight. RN 2 stated Resident 32’s carbidopa-levodopa ER 50-200 mg dose was scheduled and administered at 6:30 a.m. between 6/1/2025 and 6/30/2025, not according to the physician orders. RN 2 stated this was considered a medication error. RN 2 stated Resident 32 was at risk of increased side effects such as dyskinesia from administering carbidopa-levodopa ER 50-200 mg tablet at 6:30 a.m. since the resident also was administered carbidopa-levodopa 25-100 mg immediate release tablets, at 8 a.m., 12 p.m., 4 p.m. and 8 p.m.
During a concurrent record review and interview on 7/2/2025 at 11:58 p.m. with the DON, Resident 32’s MAR, dated 6/2025, was reviewed. The DON stated Resident 32’s physician order indicated to administer carbidopa-levodopa ER 50-200 mg tablet at midnight and MAR indicated Resident 32 was administered carbidopa-levodopa ER 50-200 mg tablet at 6:30 a.m. between 6/1/2025 and 6/30/2025. The DON stated the facility failed to administer carbidopa-levodopa ER 50-200 mg according to Resident 32’s physician order placing Resident 32 at risk of harm from additive side effects of receiving carbidopa-levodopa ER 50-200 mg tablet too close to the next dose of carbidopa-levodopa immediate release 25-100 mg tablet at 8 a.m.
c. During a concurrent observation and interview on 6/30/2025 at 1 p.m. with LVN 5 in Medication room [ROOM NUMBER], there was one medication eKIT stored in the refrigerator labeled “REF270” containing CMs without an accountability log for the reconciliation of CM inventory at every shift change for 6/2025. LVN 5 stated that all CMs, including medication eKITs containing CMs should be reconciled at every shift. LVN 5 stated that the one eKIT labeled “REF270” containing CMs in Medication Room Station 1 refrigerator was not reconciled at every shift on 6/2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion and accidental exposure of harmful substances to residents.
During an interview on 7/2/2025 at 11:58 p.m. with the DON, the DON 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 stated one eKIT labeled “REF270” containing CMs in Medication Room Station 1 was not reconciled at each shift change for 6/2025. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKITs at each shift change in Medication Room Station 1.
During a review of the facility’s P&P titled, “Medication Administration-General Guidelines,” last reviewed 1/29/2025, the P&P indicated that “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.
Administration…
2. Medications are administered in accordance with written orders of the attending physician.”
During a review of the facility’s P&P titled, “Administering Medications,” last reviewed 1/29/2025, the P&P indicated that “Medications are administered in a safe and timely manner, and as prescribed….
3. Medications are administered in accordance with prescriber orders, including any required time frame….
10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.”
During a review of the facility’s P&P titled, “Adverse consequences and Medication Errors,” last reviewed 1/29/2025, the P&P indicated:
4. “A ‘Medication error’ is defined as the preparation or administration of drugs or biologicals which is not in accordance with the prescriber’s order, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.
5. Examples of medications error include:
l. wrong time.”
During a review of the facility’s P&P titled, “Controlled Medication Storage,” last reviewed 1/29/2025, 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 in collaboration 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 log.
I. The director of nursing in conjunction with the consultant pharmacist or designee routinely monitors CM storage, records, and expiration dates during the medication storage inspection.”
During a review of the facility’s P&P titled, “Controlled Substances,” last reviewed 1/29/2025, the P&P indicated: “This facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of CMs.
6. CSs are reconciled upon receipt, administration, disposition, and at the end of each shift.
10. CMs are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Pharmacy Consultant (PC) failed to identify and report any irregularities in the monthly drug/medication regimen review (MRR) to the attending physician and director of nursing (DON) for one (1) of five (5) sampled residents (Resident 25) reviewed for unnecessary medication (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use by failing to ensure:1. Resident 25 had monitoring for specific, measurable target behaviors related to the use of valproic acid (a psychotropic medication [any medication capable of affecting the mind, emotions, and behavior] used for bipolar disorder [mental health conditions characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function,]) starting 5/22/2025. 2. Resident 32 had monitoring for medication adverse effects (undesired, unwanted, uncomfortable, or dangerous effects that a drug may have) with the use of carbidopa-levodopa (a medication used for Parkinson Disease [a condition that affects movement causing tremors, stiffness, and difficulty with balance and coordination]) These deficient practices had the potential to cause significant adverse effects from the use of medications not adequately monitored, which could result in impairment or decline in Residents 25's and 32's mental, physical condition, functional, and psychosocial status. Cross-reference F605, F656, F757Findings:
During a review of Resident 25’s admission Record (a document containing demographic and diagnostic information,) dated 7/1/2025, indicated Resident 25 was admitted to the facility on [DATE] with a diagnosis including bipolar disorder.
During a review of Resident 25’s Minimum Data Set (MDS – a comprehensive resident assessment tool), dated 5/10/2025, indicated Resident 25 was moderately impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. MDS indicated Resident 25 had no mood, and no behavioral symptoms.
During a review of Resident 25’s Medication Administration Record (MAR - a record of medications administered to residents), for June 2025, the MAR indicated Resident 25 was prescribed the following:
· Valproic acid 250 milligram (mg – a unit of measure of mass) to give one (1) capsule by mouth once a day for bipolar disorder manifested by extreme irritability that affects activities of daily living (ADL)s, at 8 a.m.
· Valproic acid 250 mg to give one (1) capsule by mouth at bedtime for bipolar disorder manifested by extreme irritability that affects ADLs, at 8 p.m.
During the same review, the MAR indicated the following:
· Monitor episodes of bipolar disorder manifested by extreme irritability as evidence of aggressive behavior towards staff that affects ADLs and tally by hashmarks for (valproic acid) use every shift, starting 5/22/2025.
During a review of the May and June 2025 MRR, the May and June 2025 MRR’s did not indicate irregularities identified and reported to the attending physician and DON for Resident 25 by the PC.
During a review of Resident 32’s admission Record dated 7/1/2025, indicated Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including Parkinson Disease.
During a review of Resident 32’s Care Plan, dated 2/3/2025, the Care Plan indicated: “CARBIDOPA. Resident is at risk for adverse effects from … CARBIDOPA. Monitor for potential risk/effects and alert MD when indicated.”
During a review of Resident 32’s MAR for June 2025, the MAR indicated Resident 32 was prescribed:
· carbidopa-levodopa extended release ([ER] – a formulation of medication designed to deliver a drug slowly over a specific period, rather than all at once, allowing the medication to have a longer effect in the body, providing more consistent drug levels as compared to immediate release tablets) 50-200 milligram (mg – a unit of measure of mass) tablet to give one (1) tablet by mouth midnight for Parkinson Disease.
· carbidopa-levodopa 25-100 mg tablet to give one (1) tablet by mouth four (4) times a day for Parkinson Disease, at 8 a.m., 12 p.m., 4 p.m. and 8 p.m.
The MAR did not contain documentation for monitoring for adverse effects with the use of carbidopa.
During a review of the April, May and June 2025 MRR, the MRR’s did not indicate irregularities identified and reported to the attending physician and DON for Resident 32 by the PC.
During a phone interview on 7/2/2025 at 1:13 p.m., with the PC, the PC stated the PC reviewed and completed Resident 25’s MRR for May and June 2025 and failed to identify the lack of specific behavior monitoring for irritability and aggression with the use of valproic acid in the monthly written reports to the facility. The PC stated not having specific behavior monitoring will lead to inaccurate monitoring and an inability to measure the effectiveness of psychotropic medications, potentially causing unnecessary use and more harm than benefit to Resident 25.
During the same interview, the PC stated Resident 32 should be monitored for adverse effects of carbidopa-levodopa such as dyskinesia (uncontrolled, involuntary movements.) The PC stated not having monitoring for side effects with use of carbidopa-levodopa will lead to the use of unnecessary medications harming Resident 32 by having adverse effects go unnoticed resulting in more harm than benefit to the resident. The PC stated the PC reviewed and completed Resident 32’s MRR’s and failed to identify the lack of monitoring for adverse effects with the use of carbidopa in the monthly written reports to the facility.
During a review of facility P&P titled “Medication Regimen Review (Monthly Report),” last reviewed 1/29/2025, the P&P indicated “The consultant pharmacist performs a comprehensive MRR at least monthly. The MRR includes evaluating the resident’s response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.
B. The consultant pharmacist reviews the MRR of each resident at least monthly either on site or remotely.
D. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the DON, and/or prescriber as appropriate.”
During a review of the facility’s P&P titled “Psychotherapeutic Medications,” last reviewed 1/29/2025, the P&P indicated: “Evaluate the resident’s response to psychotropic medication therapy to determine that the medications are appropriate and resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.
M. The pharmacist will complete monthly drug regimen review and give recommendations as indicated and the facility will follow up with the recommendations.”
During a review of facility Policy and Procedures (P&P,) titled “Policy for Unnecessary Medication,” last reviewed 1/29/2025, the P&P indicated: Facility will follow the state and federal regulation to ensure that all residents will be free from … unnecessary drugs.
Licensed nurse will review residents’ drug regimen based on the following criteria:
4. Adequate monitoring
Facility will include the pharmacist in the QA meeting to discuss the drug regimen review and update the plan if needed.
Facility will conduct pharmacy CQI regularly to ensure compliance.”
During a review of the facility’s P&P, titled “Adverse consequences and Medication Errors,” last reviewed 1/29/2025, the P&P indicated:
1. “Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported.
2. An ‘adverse consequence’ is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual’s mental or physical condition or functional or psychosocial status. An adverse consequence may include:
a. Adverse drug/medication reaction
b. Side effect
4. The staff and practitioner shall strive to minimize adverse consequences by:
a. Following relevant clinical guidelines and manufacturer’s specifications for use, dose, administration, duration, and monitoring of the medication.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs (any drug in excess) for one (1) of five (5) sampled residents (Resident 32) for unnecessary medication review by failing to:1. Monitor for adverse effects (also known as adverse consequences - unwanted, uncomfortable, or dangerous effects that a drug may have) with the use of carbidopa-levodopa (a medication used for Parkinson Disease [a condition that affects movement causing tremors, stiffness, and difficulty with balance and coordination]) for Resident 32, between 6/1/2025 and 6/30/2025. This deficient practice had the potential to cause Resident 32 to receive suboptimal (less than the highest standard or quality) care leading to the use of unnecessary medications causing potential adverse effects and negatively impacting their physical, mental, and psychosocial well-being. Cross-reference F656 and F756Findings:
During a review of Resident 32’s admission Record (a document containing demographic and diagnostic information,) dated 7/1/2025, indicated Resident 32 was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including Parkinson Disease.
During a review of Resident 32’s Care Plan, dated 2/3/2025, the Care Plan indicated: “CARBIDOPA. Resident is at risk for adverse effects from … CARBIDOPA. Monitor for potential risk/effects and alert MD when indicated.”
During a review of Resident 32’s Medication Administration Record (MAR - a record of medications administered to residents), for June 2025, the MAR indicated Resident 32 was prescribed:
· carbidopa-levodopa extended release ([ER] – a formulation of medication designed to deliver a drug slowly over a specific period, rather than all at once, allowing the medication to have a longer effect in the body, providing more consistent drug levels as compared to immediate release tablets) 50-200 milligram (mg – a unit of measure of mass) tablet to give one (1) tablet by mouth midnight for Parkinson Disease.
· carbidopa-levodopa 25-100 mg tablet to give one (1) tablet by mouth four (4) times a day for Parkinson Disease, at 8 a.m., 12 p.m., 4 p.m. and 8 p.m.
The MAR did not contain documentation for monitoring for adverse effects with the use of carbidopa.
During a concurrent record review and interview on 7/1/2025 at 2:15 p.m., with Registered Nurse (RN) 2, RN 2 reviewed Resident 32’s physician orders, June 2025 MAR and Care Plan dated 2/3/2025. RN 2 stated the Care Plan indicated Resident 32 was at risk of adverse effects, such as dyskinesia (uncontrolled, involuntary movements) from the use of carbidopa, and to monitor for potential risk/effects and inform the physician. RN 2 stated monitoring for adverse effects would be documented on the MAR, and that RN 2 was unable to locate documentation for monitoring for adverse effects related to use of carbidopa for Resident 32 for June 2025. The RN 2 stated monitoring for dyskinesia with carbidopa use was important to ensure Resident 32 did not have additional tremors (shaking, movement) that was unnoticed, which may harm the resident further. RN 2 stated the facility failed to ensure to have person-centered care by failing to implement the Care Plan dated 2/3/2025 to accurately reflect the needs of Resident 32; and ensure maintaining the highest level of functionality and quality of life by adequately monitoring the adverse effects related to the use of carbidopa to prevent unnecessary medication use.
During a concurrent record review and interview on 7/2/2025 at 11:58 p.m., with the Director of Nursing (DON,) the DON reviewed Resident 32’s June 2025 MAR and Care Plan dated 2/3/2025. The DON stated the Care Plan indicated Resident 32 was at risk of adverse effects from the use of carbidopa, and to monitor for potential risk/effects and inform the physician. The DON stated the monitoring for adverse effects would be documented on the MAR, and that the DON was unable to locate monitoring for the adverse effects with the use of carbidopa between 6/1/2025 and 6/30/2025 for Resident 32. The DON stated monitoring for adverse effects with the use of carbidopa was important to ensure Resident 32 did not have adverse effects that were unnoticed, which would cause the resident more harm than benefit with the use of carbidopa. The DON stated the facility failed to monitor for adverse effects with the use of carbidopa for Resident 32 by failing to implement the Care Plan dated 2/3/2025 placing the resident at risk of not maintaining their highest level of functionality and quality of life and increasing the risk of adverse effects such as additive tremors.
During a phone interview on 7/2/2025 at 1:13 p.m., with the Pharmacy Consultant (PC,) the PC stated Resident 32 should be monitored for adverse effects of carbidopa-levodopa such as dyskinesia. The PC stated not having monitoring for side effects with use of carbidopa-levodopa will lead to the use of unnecessary medications harming Resident 32 by having adverse effects go unnoticed resulting in more harm than benefit to the resident.
During a review of facility Policy and Procedures (P&P,) titled “Policy for Unnecessary Medication,” last reviewed 1/29/2025, the P&P indicated: Facility will follow the state and federal regulation to ensure that all residents will be free from … unnecessary drugs.
Licensed nurse will review residents’ drug regimen based on the following criteria:
4. Adequate monitoring
Facility will include the pharmacist in the QA meeting to discuss the drug regimen review and update the plan if needed.
Facility will conduct pharmacy CQI regularly to ensure compliance.”
During a review of the facility’s P&P, titled “Adverse consequences and Medication Errors,” last reviewed 1/29/2025, the P&P indicated:
1. “Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported.
2. An ‘adverse consequence’ is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual’s mental or physical condition or functional or psychosocial status. An adverse consequence may include:
a. Adverse drug/medication reaction
b. Side effect
4. The staff and practitioner shall strive to minimize adverse consequences by:
a. Following relevant clinical guidelines and manufacturer’s specifications for use, dose, administration, duration, and monitoring of the medication.”

**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 (5) percent (%). Four (4) medication errors out of 26 total opportunities contributed to an overall medication error rate of 15.38% affecting one (1) of 15 residents observed for medication administration (Resident 81.) The medication errors were as follows:1. Resident 81 received famotidine (a medication used for peptic ulcer disease [PUD - painful sores in the stomach] prophylaxis [prevention,]) hydrochlorothiazide (a medication used for high blood pressure,) losartan (a medication used for high blood pressure,) and buspirone (a medication used for anxiety) at a different time than ordered by Resident 81's physician.These failures had the potential for Residents 81 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have,) and health complications such as stomach pain, uncontrolled blood pressure and anxiety, resulting in Resident 81's health and well-being to be negatively impacted.Findings:
During an observation on 6/30/2025 at 09:49 a.m., in Medication Cart Station 2, Licensed Vocational Nurse (LVN) 2 was observed administering famotidine 20 milligram ([mg] – a unit of measure of mass) tablet, buspirone 5 mg tablet, hydrochlorothiazide 12.5 mg tablet and losartan 50 mg tablet orally to Resident 81. Resident 81 was observed swallowing the tablets whole with glass of juice followed by a glass of water.
During an interview on 6/30/2025 at 12:08 p.m., with LVN 2, LVN 2 stated that LVN 2 administered famotidine 20 mg, buspirone 5 mg, hydrochlorothiazide 12.5 mg and losartan 50 mg tablets orally that day (6/30/2025) at 9:49 a.m. to Resident 81. LVN 2 acknowledged the physician’s order specified to administer famotidine at 7:30 a.m. and buspirone, hydrochlorothiazide and losartan at 8 a.m. LVN 2 stated, per facility policy, there was a 60-minute window before and after the scheduled time for medication administration and LVN 2 administered the famotidine, buspirone, hydrochlorothiazide and losartan outside that timeframe. LVN 2 stated that LVN 2 failed to follow 5 rights of medication administration and failed to administer famotidine, buspirone, hydrochlorothiazide and losartan to Resident 81 at the correct time of administration. LVN 2 stated these were considered medication errors.
During an interview on 7/2/2025 at 1:13 p.m., with the Director of Nursing (DON), the DON stated that LVN 2 failed to administer famotidine, buspirone, hydrochlorothiazide and losartan to Resident 81, at the time scheduled by Resident 81’s physician. The DON stated per facility policy, medications should be administered within a 60-minute window from the time scheduled. The DON stated LVN 2 failed to follow facility medication administration guidelines and 5 rights of medication administration to ensure physician medication orders were administered at the right times to Resident 81. The DON stated these were considered medication errors. The DON stated that it was very important to administer medications as ordered by the physician, since medications are ordered specific to treat a condition and by deviating from that schedule will not help treat the resident’s condition and possibly worsen it.
During a review of Resident 81’s admission Record (a document containing demographic and diagnostic information,) dated 6/30/2025 the admission Record indicated Resident 81 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including anxiety, hypertension (high blood pressure) and gastro-esophageal reflux disease (a condition where stomach acid frequently flows back causing irritation and discomfort.)
During a review of Resident 81’s Order Summary Report (a report listing the physician order for the resident,) dated 6/30/2025, the report indicated Resident 81 was prescribed:
1. buspirone 5 mg one (1) tablet orally three (3) times a day for anxiety, starting 4/18/2025.
2. famotidine 20 mg one (1) tablet orally with meals for PUD prophylaxis, starting 4/10/2025.
3. hydrochlorothiazide 12.5 mg one (1) tablet orally in the morning for hypertension, starting 4/11/2025.
4. Losartan 50 mg one (1) tablet orally in the morning for hypertension, starting 4/11/2025.
During a review of Resident 81’s ([MAR] - a document of the medications administered to a resident that is part of the resident’s permanent medical record], for June 2025, the MAR indicated Resident 81 was prescribed:
1. buspirone 5 mg one (1) tablet orally three (3) times a day for anxiety, at 8 a.m., 12 p.m. and 4 p.m.
2. famotidine 20 mg one (1) tablet orally with meals for PUD prophylaxis, at 7:30 a.m., 12 p.m. and 5:30 p.m.
3. hydrochlorothiazide 12.5 mg one (1) tablet orally in the morning for hypertension, at 8 a.m.
4. Losartan 50 mg one (1) tablet orally in the morning for hypertension, at 8 a.m.
During a review of the facility’s Policy and Procedures (P&P) titled “Medication Administration-General Guidelines,” last reviewed 1/29/2025, the P&P indicated that “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, 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.
10.Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before or after meals, which are administered based on mealtimes.”
During a review of the facility’s P&P titled “Administering Medications,” last reviewed 1/29/2025, the P&P indicated that “Medications are administered in a safe and timely manner, and as prescribed.
4. Medications are administered in accordance with prescriber orders, including any required time frame.
7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
8. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
During a review of the facility’s P&P, titled “Adverse consequences and Medication Errors,” last reviewed 1/29/2025, the P&P indicated:
5. “A ‘Medication error’ is defined as the preparation or administration of drugs or biologicals which is not in accordance with the prescriber’s order, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.
6. Examples of medications error include:
l. wrong time.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards):1. For one of one sampled resident (Resident 35) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.2. For one of five sampled residents (Resident 25) 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 F658Findings:
a. During a review of Resident 35’s admission Record, the admission Record indicated the facility originally admitted the resident on 5/24/2023 and readmitted in the facility on 10/21/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), type two diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), and long-term use of insulin.
During a review of Resident 35’s History and Physical (H&P), dated 10/23/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 35’s Minimum Data Set (MDS - a resident assessment tool), dated 5/19/2025, the MDS indicated Resident 35 was not able to understand others and make his needs known and had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 35 required total assistance from staff with all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 35 received insulin.
During a review of Resident 35’s care plan (CP) on risk for hypoglycemia (low level of sugar in the blood) and hyperglycemia (high level of sugar in the blood) related to DM 2, the CP indicated to administer medication as ordered as one of the interventions to prevent unrecognized signs and symptoms of hypoglycemia or hyperglycemia.
During a review of Resident 35’s Order Summary Report, the Order Summary Report indicated the following physician’s order:
- 4/23/2025 and discontinued on 4/23/2025: Lantus solostar (a long-acting insulin) subcutaneous solution pen-injector 100 unit per milliliter (unit/ml – a unit of measurement) inject 10 units subcutaneously at bedtime for DM 2 hold for blood sugar (BS) less than (< - a unit of measurement) 110. May give orange juice (OJ) for BS < 60. Rotate site.
- 4/23/2025: Basaglar kwikpen (insulin glargine – a long-acting insulin) subcutaneous solution pen-injector 100 unit/ml inject 10 units subcutaneously at bedtime for DM 2 hold for BS <110. May OJ for BS < 60. Rotate site.
- 4/8/2025 and discontinued on 4/23/2025: Humalog kwikpen (a short acting insulin) subcutaneous solution pen-injector 100 unit/ml (insulin lispro) inject as per sliding scale (the increasing administration of the pre meal insulin dose based on the blood sugar level before the meal): if 0=150: 0 units. Call physician (MD) if BS <60; 151-200 = one unit; 201-250 = two units; 251-300 = three units; 301-350 = four units; 351-400 = five units; 401 plus = six units.
Call MD if BS continue to read above 400 subcutaneously three times a day for DM 2 to give 15 minutes before meal.
- 4/23/2025: Novolog flexpen (a short acting insulin) subcutaneous solution pen injector (insulin aspart) inject as per sliding scale: if 0=150: 0 units. Call physician (MD) if BS <60; 151-200 = one unit; 201-250 = two units; 251-300 = three units; 301-350 = four units; 351-400 = five units; 401 plus = six units.
Call MD if BS continue to read above 400 subcutaneously three times a day for DM 2 to give 15 minutes before meal.
During a concurrent interview and record review on 7/2/2025 at 10:50 a.m., with the MDS Coordinator (MDSC), Resident 35’s Order Summary Report, CP, and subcutaneous administration sites for Basaglar, Lantus, insulin aspart, and insulin lispro, from 4/1/2025 to 6/30/2025, was reviewed. The MDSC stated Resident 35 received insulin, had a physician’s order for Basaglar that was changed to Lantus, and insulin lispro that was changed to insulin aspart, and were administered as follows:
- Basaglar kwikpen (insulin glargine) subcutaneous solution:
4/04/25 7:34 p.m. subcutaneously Abdomen – left lower quadrant (LLQ)
4/05/25 7:51 p.m. subcutaneously Abdomen - LLQ
4/08/25 8:47 p.m. subcutaneously Abdomen – right lower quadrant (RLQ)
4/09/25 8:04 p.m. subcutaneously Abdomen - RLQ
4/16/25 7:15 p.m. subcutaneously Abdomen – left upper quadrant (LUQ)
04/17/25 8:39 p.m. subcutaneously Abdomen – LUQ
- Humalog kwikpen (insulin lispro) subcutaneous solution:
4/08/25 7:15 p.m. subcutaneously arm - right
4/09/25 8:04 p.m. subcutaneously arm – right
- Novolog flexpen subcutaneous solution:
5/18/25 12:00 p.m. subcutaneously Arm - left
5/18/25 5:57 p.m. subcutaneously Arm - left
5/20/25 11:15 a.m. subcutaneously Arm - left
5/20/25 5:30 p.m. subcutaneously Arm – left
The MDSC stated that the administration sites for insulin should be rotated per standards of practice, manufacturer’s guidelines, and per physician’s order to prevent hardening or lumps in the skin. LVN 3 stated the location of administration sites for Resident 35’s Basaglar, Humalog (insulin lispro), and Novolog (insulin aspart) were not rotated. The MDSC stated there was a physician’s order to rotate administration sites. The MDSC stated Resident 47’s administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident’s skin which can affect the absorption of the insulin.
During an interview on 7/2/2025 at 10:55 a.m. with Registered Nurse (RN) 4, RN 4 stated that nurses are supposed to rotate the insulin administration sites as indicated in the physician’s order, manufacturer’s guideline, and according to professional standards of practice. RN 4 stated Resident 35’s insulin administration sites should have been rotated as it placed the resident at risk for development of lipodystrophy which may affect the absorption of the insulin and lead to hyperglycemia.
b. During a review of Resident 25’s admission Record, the admission Record indicated the facility admitted the resident on 5/5/2025, with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a systemic illness or condition that disrupts normal metabolic processes), DM 2 with diabetic neuropathy (nerve damage caused by diabetes), and long-term use of insulin.
During a review of Resident 25’s History and Physical (H&P), dated 5/6/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 25’s MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had moderate cognitive impairment (a noticeable decline in thinking skills that affects daily life). The MDS indicated the resident was on a high-risk drug class hypoglycemic (medicines to control diabetes).
During a review of Resident 25’s Order Summary Report, dated 6/21/2025, the Order Summary Report indicated orders for Insulin Aspart Flexpen Subcutaneous Solution Pen- Injector 100 unit/ml (Insulin Aspart). Inject eight units subcutaneously before meals for diabetes. Hold administration of insulin for blood sugar (BS) < 110 [rotate site] and Lantus SoloStar Subcutaneous Solution Pen-Injector 100 unit/ml (Insulin Glargine). Inject 35 units subcutaneously one time a day for DM 2. Hold administration of insulin for BS < 110 [rotate sites].
During a review of Resident 25’s Care Plan (CP) Report regarding the resident being at risk for hypoglycemia (a condition in which your blood sugar [glucose] level is lower than the standard range) and hyperglycemia (high blood glucose) related to DM 2, last revised on 5/18/2025, the CP indicated an intervention to administer medications as ordered.
During a review of Resident 25’s Location of Administration Report of Insulin for 5/2025 through 6/2025, indicated:
-Lantus Solo Star Subcutaneous Solution Pen-injector 100 unit/ml was administered on
5/6/2025 at 9:19 a.m. on the Abdomen - LLQ
5/7/2025 at 8:19 a.m. on the Abdomen - LLQ
5/21/2025 at 7:45 a.m. on the Deltoid - right
5/22/2025 at 7:34 a.m. on the Deltoid - right
-Insulin Aspart FlexPen Subcutaneous Solution Pen-injector 100 unit/ml on
5/14/2025 at 5:22 p.m. on the Arm - left
5/15/2025 at 8 a.m. on the Arm - left
6/23/2025 at 5:23 p.m. on the Abdomen - LLQ
6/24/2025 at 6:52 a.m. on the Abdomen - LLQ
During a concurrent interview and record review on 7/1/2025 at 3:20 p.m. with Registered Nurse (RN) 3 Resident 25’s Medical Diagnosis, Order Summary Report, Location of Administration of Insulin, for 5/2025 through 6/2025, and Care Plan were reviewed. RN 3 stated there were multiple instances where the licensed nurses did not rotate the insulin administration sites on Resident 25. RN 3 stated the licensed staff should rotate insulin administration sites to prevent lipodystrophy that can affect the absorption of insulin if injected on the sites of lipodystrophy.
During an interview on 7/2/2025 at 1:51 p.m. with the Director of Nursing (DON), the DON stated the licensed staff should have rotated the sites of insulin administration on Resident 25. The DON stated the sites of administration should be rotated to prevent discomfort, irritation, and lipodystrophy of the frequented sites of administration of insulin. The DON stated the staff should check the electronic healthcare record of the last site of administration of the insulin prior to administering them to prevent repetition of sites of administration. The DON stated that not rotating insulin administration sites on Resident 25 can lead to malabsorption (difficulty in the digestion or absorption of medication) of the insulin that can cause hypo (low) or hyperglycemia on the resident.
During a review of the facility's recent policy and procedure (P&P) titled Insulin Administration, last reviewed on 1/29/2025, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P further indicated:
- Re-check that the amount of insulin drawn into the syringe matches the amount of insulin ordered.
- Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel.
- Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility-provided manufacturer’s guideline for Basaglar (insulin glargine) injection solution, undated, the manufacturer’s guideline indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
During a review of the facility-provided manufacturer’s guideline for injection insulin aspart injection, for subcutaneous or intravenous use, undated, the manufacturer’s guideline indicated to rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine), with initial U.S. approval in 2000, the Highlights of Prescribing Information indicated to rotate injection sites to reduce 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 label:1. one (1) budesonide (a medication used to treat and prevent shortness of breath) inhalation solution foil pouch (package made of foil protecting the inhalation solution from light and degradation) for Resident 55 at room temperature in accordance with the manufacturer's requirements in one (1) of one (1) inspected medication carts (Medication Cart Station 1.)2. one (1) budesonide and formoterol (a combination medication used to treat Chronic Obstructive Pulmonary Disease [COPD]- a disease that blocks air flow and makes breathing difficult]) inhalation aerosol (form of medication that is inhaled) for Resident 57 with an open date, in accordance with facility requirements and manufacturer's requirements in one (1) of one (1) inspected medication carts (Medication Cart Station 1.)These deficient practices increased the risk that Residents 55 and 57 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death.Findings:
During an observation, on [DATE] at 12:45 p.m., in Medication Cart Station 1, with Licensed Vocational Nurse (LVN) 5, the following medication were 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, or stored and labeled contrary to facility policies:
1. one (1) open budesonide inhalation solution foil (aluminum) pouch (envelope) for Resident 55, was found stored at room temperature and not labeled with a date indicating when the foil pouch was opened. Three (3) inhalation solutions were observed stored in the open foil pouch.
According to the manufacturer’s product storage and labeling, opened foil pouch of budesonide inhalation solutions should always be stored in the foil pouch at room temperature between 68 and 77 degrees Fahrenheit and used or discarded within two (2) weeks of opening the foil pouch.
2. One (1) open and used budesonide and formoterol inhalation aerosol for Resident 57 was found stored at room temperature and not labeled with a date on which aerosol inhaler was opened and removed from the foil pouch.
According to the manufacturer’s product storage and labeling, budesonide and formoterol inhalation aerosol inhaler should be stored at room temperature between 68 to 77 degrees Fahrenheit and once the foil pouch was removed to be used or discarded within 3 months.
During a concurrent interview, LVN 5 stated the budesonide inhalation solution foil pouch for Resident 55 in the Medication Cart Station 1 was opened and not labeled with a date indicating when the foil pouch was opened, and three (3) inhalations remained stored in the foil pouch. LVN 5 stated per facility policy multi-dose (containing more than one dose) products such as inhalation solutions should be labeled with the date when first opened to know when they expire, and according to manufacturer guidelines the inhalation solutions once opened from the foil pouch needed to discard within two (2) weeks. LVN 5 stated it was unknown when the three (3) budesonide inhalation solutions would expire and if used beyond the two (2) weeks were considered expired and lost potency (effectiveness), potentially leading to the administration of ineffective medication to Resident 55 causing harm by not treating the asthma (a condition that makes breathing difficult) leading to difficulty in breathing, requiring immediate treatment and potential hospitalization. LVN 5 stated three (3) budesonide inhalation solutions for Resident 55 should be discarded from Medication Cart Station 1.
During a concurrent interview, LVN 5 stated the budesonide with formoterol inhaler for Resident 57 in Medication Cart Station 1 was opened, used and not labeled with a date indicating when the inhaler was removed from the foil pouch. LVN 5 stated per facility policy multi-dose products such as inhalation solutions should be labeled with the date when first opened to know when they expire, and according to manufacturer guidelines for budesonide with formoterol inhaler once opened from the foil pouch or overwrap (additional layer of packaging that covers the product,) needed to be discarded within three (3) months. LVN 5 stated it was unknown when the inhaler was opened and when it would expire and if used in error beyond three (3) months was considered expired and lost potency, potentially leading to the administration of ineffective medication to Resident 57 causing harm by not treating the wheezing associated with COPD leading to difficulty in breathing, exacerbating the COPD requiring potential hospitalization.
During an interview, on [DATE] at 11:458 p.m., with the Director of Nursing (DON,) the DON stated that breathing inhalation solutions stored in foil pouches should be labeled with a date when opened and removed from the pouch to know when the beyond use date was (a date identifying an expiration date after opening a multi-dose product,) otherwise unable to determine the expiration date. The DON stated budesonide inhalation solutions expire within two (2) weeks of opening the pouch, and budesonide with formoterol inhalers expire within three (3) months opening and storing outside the foil pouch. The DON stated that expired inhalation treatments have lost effectiveness and when administered in error will not treat the asthma or COPD further causing respiratory (related to breathing) distress and stoppage of breathing for Resident 55 and 57 requiring immediate treatment and hospitalization.
During a review of the facility’s Policy and Procedures (P&P,) titled “Administering Medications,” last reviewed [DATE], the P&P indicated that “Medications are administered in a safe and timely manner, and as prescribed.
12.The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.”
During a review of the facility’s P&P, titled “Procedure for all Medications,” last reviewed [DATE], the P&P indicated: “To administer medications in a safe and effective manner.
E. Check expiration date on package/container. When opening a multi-dose container, place the date on the container.”
During a review of manufacturer's guide “Instructions for Use” for budesonide with formoterol inhalation aerosol, dated [DATE], the guide indicated “Throw away budesonide with formoterol inhalation aerosol when the counter shows zero (“0”) or 3 months after you take your budesonide with formoterol inhalation aerosol inhaler out of its foil pouch, whichever comes first.”
Review of facility’s P&P, titled “Guide for Special Handling of Medications,” last revised [DATE], the P&P listed the following:
“Symbicort (brand name for budesonide with formoterol) – Product should be used within 3 months after opening overwrap.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the facility's menu and nutritional adequacy by failing to ensure residents with No Added Salt (NAS, leaves out all salt in preparing and cooking foods) diet were not provided with an extra packet of salt on their meal tray. The deficient practice had the potential for residents to consume more than allowable sodium intake that can affect their medical condition.Findings:
During a review of Resident 79’s admission Record, the admission Record indicated the facility admitted the resident on 6/21/2024, and readmitted the resident on 3/25/2025, with diagnoses including chest pain, essential hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition), and cardiomegaly (an enlarged heart).
During a review of Resident 79’s History and Physical (H&P), dated 3/27/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 79’s Minimum Data Set (MDS, a resident assessment tool), dated 6/16/2025, 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 was on a therapeutic diet (usually a modification of a regular diet).
During a review of Resident 79’s Order Summary Report, dated 3/25/2025, the Order Summary Report indicated an order for NAS (No Added Salt) diet. Regular texture, thin consistency.
During a review of Resident 21’s admission Record, the admission Record indicated the facility admitted the resident on 12/27/2024, with diagnoses including obesity, essential hypertension, and atherosclerosis of aorta (the buildup of fats, cholesterol and other substances in and on the artery walls).
During a review of Resident 21’s H&P, dated 12/29/2024, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 21’s MDS, dated [DATE], the MDS indicated the resident had intact cognition and was on a therapeutic diet.
During a review of Resident 21’s Order Summary Report, dated 6/14/2025, the Order Summary Report indicated an order for consistent or controlled carbohydrate diet (CCHO, eating the same amount of carbohydrates every day that helps keep the blood sugar, or glucose levels stable), NAS diet. Mechanical soft texture. Thin consistency, 4 ounces (oz., a unit of weight) cranberry juice at breakfast, replace dessert with fruit for (X) 6 months, replace whole milk with nonfat milk X 6 months.
During the Resident Council Meeting on 7/1/2025, at 10:30 a.m., Resident 79 and Resident 21 stated they had been getting extra packets of salt on their meal tray.
During an observation on 7/1/2025, at 12:10 p.m., observed the food trays of the following residents with a packet of salt and pepper added on their trays:
1. During a review of Resident 55’s admission Record, the admission Record indicated the facility admitted the resident on 10/21/2024, and readmitted the resident on 5/21/2025, with diagnosis of essential hypertension.
During a review of Resident 55’s H&P, dated 5/22/2025, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 55’s MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident was on a therapeutic diet.
During a review of Resident 55’s Order Summary Report, dated 5/22/2025, the Order Summary Report indicated an order for NAS diet. Mechanical soft texture, thin consistency, no milk.
2. During a review of Resident 46’s admission Record, the admission Record indicated the facility admitted the resident on 8/26/2019, and readmitted the resident on 7/29/2022, with diagnoses including moderate protein-calorie malnutrition (s a state where the body doesn't get enough protein and calories (energy) to function properly. It can range from mild to severe, with different impacts on the body) and tremor.
During a review of Resident 46’s H&P, dated 8/13/2024, the H&P indicated the resident does not have the capacity to make decisions.
During a review of Resident 46’s MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had impaired cognition. The MDS indicated the resident was on a therapeutic diet.
During a review of Resident 46’s Order Summary Report, dated 12/202/2024, the Order Summary Report indicated an order for NAS. Regular texture, thin consistency, 4 oz. yogurt with breakfast + 4 oz. of cranberry juice with meals.
3. During a review of Resident 10’s admission Record, the admission Record indicated the facility admitted the resident on 11/2/2020, and readmitted the resident on 12/22/2020, with diagnoses including essential hypertension, peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), and atherosclerotic heart disease (a condition where plaque, a buildup of cholesterol and other substances, narrows and hardens the arteries, making it harder for blood to flow to the heart).
During a review of Resident 10’s MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition. The MDS indicated the resident was on a therapeutic diet.
During a review of Resident 10’s Order Summary Report, dated 6/27/2025, the Order Summary Report indicated an order for CCHO NAS diet. Puree texture. Thin consistency, large portion, 4 oz. cranberry juice for breakfast.
4. During a review of Resident 68’s admission Record, the admission Record indicated the facility admitted the resident on 11/19/2024, with diagnoses including essential hypertension and heart failure (the heart is unable to pump blood around the body properly).
During a review of Resident 68’s H&P, dated 11/20/2024, the H&P indicated the resident does not have the capacity to make decisions.
During a review of Resident 68’s MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had impaired cognition. The MDS indicated the resident was on a therapeutic diet.
During a review of Resident 68’s Order Summary Report, dated 11/19/2024, the Order Summary Report indicated an order for NAS diet. Regular texture, thin consistency, large portions, double protein (per daughter’s request).
During an observation and interview on 7/1/2025, at 12:14 p.m., with the Dietary Service Supervisor (DSS), while doing Tray Line observation, observed kitchen staff adding extra packets of salt and pepper on all trays of the residents. The DSS stated the kitchen staff added extra packets of salt and pepper on all the trays. The DSS stated the kitchen staff should have checked the tray ticket of the resident was on a NAS diet. The DSS stated Residents 55, 46, 10, and 68 should have no extra packet of salt on their tray. The DSS stated residents with NAS diet are supposed to have no extra packet of salt on their tray as it could affect their medical condition. The DSS stated continued provision of salt packets to residents on NAS diet could result in increased blood pressure of the residents.
During an interview on 7/2/2025, at 1:51 p.m. with the Director of Nursing (DON), the DON stated the facility failed to check the accuracy of the diet orders in the resident’s trays. The DON stated the kitchen staff should have checked residents on NAS diet and not provided an extra packet of salt on the trays. The DON stated the failure of the kitchen staff had the potential for residents to have uncontrolled blood pressure and edema (swelling caused by excess fluid trapped in your body's tissues).
During a review of the facility provided “Summer Menu Recipe,” undated, the menu indicated No Added Salt (NAS); regular diet with no salt packet and 2-gram sodium (2 gm Na, often recommended by healthcare providers to help manage conditions such as high blood pressure, heart disease, kidney disease, and fluid retention)- may have small/reg portions only.
During a review of the facility's recent policy and procedure (P&P) titled Menu, last reviewed on 1/29/2025, the P&P indicated the menus will be prepared as written using standardized recipes. The Dietary Services Supervisor and cooks are trained and responsible for the preparation and service of therapeutic diets prescribed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure:1. A container of thickener on the coffee tray was dated.2. A creamer with use by date of 8/15/2025 and a can of open fruit cocktail covered with saran wrap was labeled with an open date.3. A water pitcher with water and thickener (a substance which can increase the viscosity of a liquid without substantially changing its other properties) was labeled with the date it was poured on the pitcher.4. A pitcher with punch dated 6/27/25 and a can of opened sliced jalapenos dated 6/25/25 were discarded.5. A block of ham, a pan of packaged chicken. and bologna in the kitchen refrigerator was dated with the received date.6. A box of popsicle and fruit bars were labeled with an open date.7. A container of strawberry pudding and two 2 cups of uncovered milk, with an open date.8. 1 cup of uncovered fruit punch, with the date poured.9. A pitcher of fruit punch dated 6/20/2025, a pitcher of water with thickener dated 6/20/2025, a can of opened Nacho sliced jalapenos w/ received date of 6/25/25, and a pitcher of water with thickener dated 6/27/2025 were all discarded. These deficient practices had the potential for food-borne illnesses on residents.Findings: During a kitchen tour on 6/30/2025, at 8:05 a.m., with [NAME] 1 (CK 1), inside the Kitchen, observed the following:1. Coffee Cart-Thickener container on the coffee tray with no date.-a creamer with use by date of 8/15/25, with no open date.-a water pitcher with water and thickener with no date.- a pitcher with juice punch, dated 6/27/25.2. Kitchen Refrigerator- a block of ham on the kitchen refrigerator with no date.-a pack of bologna undated.- a box of popsicles, with no open date.-a box of fruit bar, with no open date.3. Walk-in Refrigerator- a container of strawberry pudding, no date.- 2 cups of uncovered milk, undated.- 1 cup of uncovered fruit punch, undated.- a pitcher of fruit punch dated 6/20/2025.- a pitcher of water with thickener dated 6/20/2025.- a pitcher of water with thickener dated 6/27/2025.- a can of opened Nacho sliced jalapenos w/ received date of 6/25/25 and no open date.- a can of open fruit cocktail covered with saran wrap w/ no open date.- a pan of packaged chicken with no received date. During a concurrent observation and interview on 6/30/2025, at 8:10 am, with [NAME] (CK) 1, CK 1 stated the thickener container should have been dated on when it was poured on the container, the coffee creamer should have been labeled with an open date, the pitcher of water with thickener should have been dated on when it was poured, and the pitcher of fruit punch dated 6/27/25 should have been discarded to ensure the food is safe to consume by the residents. During a concurrent observation and interview on 6/30/2025, at 8:15 a.m., with CK 1, CK 1 stated the block of ham should have been dated with the received date, the pack of bologna should have been dated with the received date, and the popsicles and fruit bar should have been labeled with open date to ensure the food is safe to use. During a concurrent observation and interview on 6/30/2025, at 8:30 a.m., with Dietary Assistant (DA) 1, inside the kitchen, DA 1 stated the food products should be labeled with the date they were received and open date to ensure the food is safe for consumption, the water pitchers and juices should be dated daily, and the outdated pitchers with water and thickener and fruit punch should have been discarded to ensure the residents will not consume them to prevent gastrointestinal (GI, refers to the stomach and intestines, or more broadly, the digestive system) issues. The packs of chicken on a pan should have been dated with a received date. During an interview on 7/1/2025, at 3:43 p.m., with the Dietary Service Supervisor (DSS), the DSS stated food products should be labeled with the date they were received and open date to ensure the food is safe for consumption. The DSS stated the water pitchers and juices should be dated daily, and the outdated pitchers with water and thickener and fruit punch should have been discarded to ensure the residents will not consume them to prevent GI issues, and the packs of chicken on a pan should have been dated with received date. The DSS stated they should have dated and discarded the food products after 3 days opened. The food products should not be left inside the can, they should be transferred to a plastic sealed container and dated to prevent food-borne illnesses. During an interview on 7/2/2025, at 1:51 p.m., with the Director of Nursing (DON), the DON stated the kitchen staff should follow their procedure for proper handling, storage, dating and labeling, and disposing of food. The DON stated the failure of the staff to properly handle, store, date and label, and dispose of food had the potential for food contamination, medical issues relating to stomach such as diarrhea and vomiting. During a review of the facility's recent policy and procedure (P&P) titled Refrigerator/Freezer Storage, last reviewed on 1/29/2025, the P&P indicated dietary staff will check and record temperatures of all refrigerators and freezers to ensure the equipment is within appropriate temperature for food storage and handling.6. Leftover food or unused portions of packaged foods should be covered, dated and labeled to ensure they will be used first.8. All meat and perishable food, e.g. milkshakes, pies, etc. placed in the refrigerator for thawing must be labeled and re-dated with the date the item was transferred to the refrigerator.11. All items should be properly covered, dated and labeled. Food items should have the following appropriate dates:Delivery date- upon receiptOpen date- opened containers of PHFThaw date- any frozen items12. Frozen food taken from original packaging should be labeled and dated. Food that has freezer burns should be discarded.13. Leftovers will be covered, dated, labeled and discarded within 72 hours. During a review of the facility's recent P&P titled Storage of Canned and Dry Goods, last reviewed on 1/29/2025, the P&P indicated food, and supplies will be stored properly and in a safe manner. New stock must be placed behind the old stock so the oldest items will be used first. Products should be dated to ensure FIFO- First-in-First-out. All food will be dated according to- month, day, and year. Remove food from packaging boxes upon delivery to minimize pests. Loose items like cookies, crackers, sugar packets, etc. should be placed in containers or bins. Bins will be dated, labeled, and covered.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly. This deficient practice had the potential to attract pests that can bring diseases to all the residents in the facility. Findings: During an observation on 6/30/2025, at 6:46 a.m., observed the facility's blue trash bin's lid was not totally shut due to overfilled trash and the box/cardboard bin was left open with no lid. Pictures taken for reference. During an observation on 7/1/2025, at 7:01 a.m., observed the facility's blue trash bin's lid was not totally shut due to overfilled trash and the box/cardboard bin was left open with no lid. Pictures taken for reference. During an interview and record review on 7/1/2025, at 3:40 p.m., with the Dietary Service Supervisor (DSS), the DSS reviewed the pictures taken on the facility's trash bins. The DSS stated the blue trash bin was not closed shut, and the bin for cardboard boxes were overflowing and not shut closed. The DSS stated the trash bins should be shut closed to prevent attracting rodents to the trash and spreading diseases in the facility. During an interview and record review on 7/2/2025, at 1:51 p.m., with the Director of Nursing (DON), the DON reviewed the pictures taken on the facility's trash bins. The DON stated the facility failed to follow their policy and procedure on garbage disposal to ensure it is covered to avoid flies, rats, and for pest control. The DON stated the pests can go inside the facility and can cause medical issues, diseases and infestation. During a review of the facility's recent policy and procedure (P&P) titled, Waste Control and Disposal, last reviewed on 1/29/2025, the P&P indicated all waste will be disposed of daily and as needed throughout the day. 2. Trash bins should be covered at all times. 6. Outside garbage bin should be kept closed at all times and surrounding areas must be kept clean. 8. All cardboard boxes will be broken down and disposed of timely. During a review of the facility's recent P&P titled, Pest Control, last reviewed on 1/29/2025, the P&P indicated our facility shall maintain an effective pest control program. Garbage and trash are not permitted to accumulate and removed from the facility daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a complete and accurate medical records in accordance with accepted professional standards for three of eight sampled residents (Residents 22, 32, and 60) reviewed for informed consents (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) and infection control by:1. Failing to document the method used for verification that the physician discussed the risk and benefits of the proposed treatment to Resident 22 and resident representative.2. Failing to ensure Resident 32's informed consent form was completed and accurate prior to signing and acknowledging the form.3. Failing to ensure Augmentin (medication used to treat infection) was documented as administered on 6/5/2025, at 4 p.m. in Resident 60's medical record.These failures had the potential for failing to ensure the residents or representative consented to the proposed treatment and their right to informed consent was honored and respected for Residents 22 and 32. This had the potential to result in confusion in the care and services rendered to Resident 60 and resulted in inaccurate information entered in Resident 60's medical record.Findings:
a. During a review of Resident 22’s admission Record, the admission Record indicated the facility admitted the resident on 12/11/2024, with diagnoses including depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), 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 22’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 12/17/2024, the H&P indicated the resident does not have the capacity to understand and make decisions.
During a review of Resident 22’s Minimum Data Set (MDS, a resident assessment tool), dated 6/9/2025, the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions).
During a review of Resident 22’s Order Summary Report, dated 4/11/2025, the Order Summary Report indicated an order for Divalproex Sodium (medication used to stabilize mood) oral capsule delayed release sprinkle 125 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount). Give two capsules by mouth at bedtime for mood disorder (a mental health condition characterized by significant disturbances in a person's emotional state, leading to prolonged periods of extreme happiness, sadness, or both) (2 caps= 250 mg) monitor behavior (m/b) uncontrollable anger outbursts interfering with daily living activities.
During a review of Resident 22’s Informed Consent, for Divalproex Sodium, dated 4/11/2025, the Informed Consent did not indicate how the information was provided to the resident and/or representative.
During a review of Resident 22’s Care Plan (CP) Report, regarding the resident having episodes of mood disorder, last revised on 12/26/2024, the CP indicated an intervention to explain all procedures and involve the family in care if possible/available and encourage to discuss interests/concerns.
During a concurrent interview, and record review on 7/1/2025, at 9:10 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 reviewed Resident 22’s Medical Diagnosis, Order Summary Report, Informed Consent, and Care Plan. LVN 3 stated the Informed Consent was missing information on how the consent was verified by the licensed nurse. LVN 3 stated the options on how the verification was done was left blank. LVN 3 stated it was important to ensure the mode of verification was filled out to ensure the informed consent was discussed with the resident or resident representative.
During a concurrent interview, and record review on 7/1/2025, at 3:31 p.m., with Registered Nurse (RN) 3, RN 3 reviewed Resident 22’s Informed Consent. RN 3 stated the Informed Consent was incomplete, it did not indicate how the consent was verified. RN 3 stated the licensed nurses should check the Informed Consent for accuracy and completeness prior to affixing their signatures. RN 3 stated the failure of the staff to ensure the completeness and accuracy of the Informed Consent predisposes the residents to violation of their right to informed consent.
During an interview, and record review on 7/2/2025, at 1:51 p.m., with the Director of Nursing (DON), the DON reviewed Resident 22’s Informed Consent. The DON stated the consent was not complete because the information on how the consent was verified was not documented. The DON stated the licensed nurse verifying the consent should inspect the consent for its accuracy and completeness prior to affixing their signatures. The DON stated the failure of the staff to ensure the accuracy and completeness of the consent predisposes the resident to violation of the right to informed consent.
During a review of the facility's recent policy and procedure (P&P) titled Policy: Informed Consent, last reviewed on 1/29/2025, the P&P indicated to ensure that residents and/or their representatives are fully informed of the benefits, risks, frequency/duration, and alternatives before initiating the administration of psychotherapeutic drugs or physical restraints.
Procedure:…
2. Prior to obtaining Informed Consent, the attending physician and/or prescriber must provide the residents or their representatives with information on the following topics, including but are not limited to:
-Treatment Details: Nature and procedures involved in the proposed treatment, including the probable frequency and duration….
4. Informed consent may be obtained through the following means:
-In person
-By phone
-Via fax
-By email.
During a review of the facility's recent P&P titled Charting and Documentation, last reviewed on 1/29/2025, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care….
2. The following information is to be documented in the resident medical record:
e. Events, incidents or accidents involving the resident.
3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate….
7. Documentation of procedures and treatments will include care-specific details, including:
a. the date and time the procedure/treatment was provided.
b. During a review of Resident 32’s admission Record, the admission Record indicated the facility admitted the resident on 10/25/2024, and readmitted the resident on 1/23/2025, with diagnoses including depression (a mood disorder characterized by persistent feelings of sadness and loss of interest in activities that were once enjoyable), dementia, and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness).
During a review of Resident 32’s H&P, dated 10/25/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions.
During a review of Resident 32’s MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others and had moderate cognitive impairment (a noticeable decline in thinking skills that affects daily life). The MDS indicated the resident was on a high-risk drug class antidepressant (prescription medications that help treat depression).
During a review of Resident 32’s Order Summary Report, dated 1/23/2025, the Order Summary Report indicated an order for Oxcarbazepine (medication used to calm overactive nerves in the brain) oral tablet 150 mg. Give one tablet by mouth two times a day for mood disorder m/b anger outburst during care that interferes with activities of daily living; ADD: wear gloves when administering.
During a review of Resident 32’s Informed Consent for Oxcarbazepine, dated 1/23/2025, the Informed Consent did not indicate the date the consent was signed by the physician and how the informed consent was verified by the licensed nurse.
During a review of Resident 32’s CP Report, regarding the resident having episodes of mood disorder, last revised on 11/4/2024, the CP indicated an intervention to explain all procedures and involve the family in care if possible/available and encourage to discuss interests/concerns.
During a concurrent interview, and record review on 7/1/2025, at 9:10 a.m., with LVN 3, LVN 3 reviewed Resident 32’s Medical Diagnosis, Order Summary Report, Informed Consent, and Care Plan. LVN 3 stated the Informed Consent had missing information. The date beside the physician’s signature was left blank and the options on how the verification was done were left blank. LVN 3 stated it was important to ensure the signature of the physician is dated to ensure the currency of the informed consent and mode of verification was filled out to ensure the informed consent was discussed with the resident or resident representative.
During a concurrent interview, and record review on 7/1/2025, at 3:31 p.m., with RN 3, RN 3 reviewed Resident 32’s Informed Consent. RN 3 stated the Informed Consent was incomplete, it did not have the date the signature of the physician was affixed, and it did not indicate how the consent was verified. RN 3 stated the licensed nurses should check the Informed Consent for accuracy and completeness prior to affixing their signatures. RN 3 stated the failure of the staff to ensure the completeness and accuracy of the Informed Consent predisposes the residents to violation of their right to informed consent.
During an interview and record review on 7/2/2025, at 1:51 p.m., with the DON, the DON reviewed Resident 32’s Informed Consent. The DON stated the consent was not complete because the signature of the physician was not dated and the information on how the consent was verified was not documented. The DON stated the licensed nurse verifying the consent should inspect the consent for its accuracy and completeness prior to affixing their signatures. The DON stated the failure of the staff to ensure the accuracy and completeness of the consent predisposes the resident to violation of the right to informed consent.
During a review of the facility's recent P&P titled Policy: Informed Consent, last reviewed on 1/29/2025, the P&P indicated to ensure that residents and/or their representatives are fully informed of the benefits, risks, frequency/duration, and alternatives before initiating the administration of psychotherapeutic drugs or physical restraints.
Procedure: …
2. Prior to obtaining Informed Consent, the attending physician and/or prescriber must provide the residents or their representatives with information on the following topics, including but are not limited to:
-Treatment Details: Nature and procedures involved in the proposed treatment, including the probable frequency and duration….
4. Informed consent may be obtained through the following means:
-In person
-By phone
-Via fax
-By email.
During a review of the facility's recent P&P titled Charting and Documentation, last reviewed on 1/29/2025, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care….
2. The following information is to be documented in the resident medical record:
e. Events, incidents or accidents involving the resident.
3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate….
7. Documentation of procedures and treatments will include care-specific details, including:
a. the date and time the procedure/treatment was provided.
c. During a review of Resident 60’s admission Record, the admission Record indicated the facility admitted Resident 60 on 6/5/2025, with diagnoses that included cerebral infarction (a condition where blood flow to the brain is blocked, leading to brain tissue damage or death due to oxygen deprivation), unspecified (unconfirmed ) dementia and urinary tract infection (UTI-an infection in the bladder/urinary tract).
During a review of Resident 60’s H&P, dated 6/6/2025, the H&P indicated Resident 60 did not have the capacity to understand and make decisions.
During a review of Resident 60’s MDS, dated [DATE], the MDS indicated Resident 60’s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 60 was dependent on staff for 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 60 was on antibiotic (medication used to treat infection).
During a review of Resident 60’s Physician Order, dated 6/5/2025, the Physician Order indicated Augmentin oral tablet 500-125 mg, give one tablet by mouth two times a day for UTI, for four days.
During a review of Resident 60’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 60 did not received Augmentin on 6/5/2025 at 4 p.m.
During a review of facility’s Oral Emergency Drug Supply (Emergency Kit- typically contain a limited supply of commonly used medications and other necessary items to address immediate needs and prevent harm to residents due to delayed access to medications) indicated the facility had four tablets of Augmentin 500-125 mg available.
During a review of facility’s Emergency Kit Pharmacy Log dated 6/5/2025, the Emergency Kit Pharmacy Log indicated LVN 2 opened the Emergency Kit and removed one tablet of Augmentin 500-125 mg and administered to Resident 60 on 6/5/2025 at 4:15 p.m.
During a concurrent interview, and record review on 7/1/2025, at 8:02 a.m., with the Infection Preventionist (IP), Resident 60’s Progress Notes, and Licensed Nurses Notes, dated 6/5/2025 were reviewed. The IP stated the facility admitted Resident 60 on 6/5/2025, at 3:28 p.m. The IP stated Resident 60’s Progress Notes, dated 6/5/2025, timed at 4 p.m., indicated LVN 2 waited for pharmacy to deliver Augmentin.
During a concurrent interview, and record review on 7/2/2025, at 7:42 a.m., with the IP, facility’s Oral Emergency Drug Supply, and the Emergency Kit Pharmacy Log, dated 6/5/2025 were reviewed. The IP stated the facility had a supply of four tablets of Augmentin in the Emergency Kit and the Emergency Kit Pharmacy Log dated 6/5/2025, indicated LVN 2 opened the emergency kit and administered Augmentin to Resident 60 on 6/5/2026, at 4:15 p.m. The IP stated LVN 2 should have documented in Resident 60’s MAR on 6/5/2025, at 4:15 p.m., that Augmentin was administered to Resident 60. The IP stated Resident 60’s medical record had inaccurate documentation. The IP stated the facility did not know if Resident 60 received the Augmentin or not. The IP stated the importance of accurate documentation was to complete the antibiotic dose and to know if the antibiotic was effective for Resident 60’s UTI.
During a concurrent interview, and record review on 7/2/2025, at 1:46 p.m., with the DON, facility’s P&P, titled “Charting and Documentation”, dated 7/2017, and last reviewed on 1/29/2025, the P&P indicated, “The following information is to be documented in the resident medical record…. b. Medications administered. Documentation in the medical record will be objective, complete and accurate. The DON stated the facility failed to properly document the medication given to Resident 60. The DON stated once medication was administered the nurses need to document accurately in residents MAR so nurses could show medication was given timely as ordered by the physician. The DON stated Resident 60 might have a missed dose if medication was not documented as administered. The DON stated the facility’s P&P indicated to document right after medication administration.
During a review of facility’s P&P titled, “Administering Medications”, dated 4/2019, and last reviewed on 1/29/2025, the P&P indicated, “Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident medical record;
a. the date and time the medication was administered
b. the dosage;
c. the route of administration;
d. the injection (the act of administering a liquid, especially a drug, into a person's body using a needle and a syringe) site;
e. any complaints or symptoms for which the drug was administered;
f. any results achieved and when those results were observed; and
g. the signature and title of the person administering the drug.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet the required room size of 80 square feet (sq feet - a unit of measurement) per resident in multiple resident bedrooms for 19 of 34 rooms (Rooms 1, 2, 4, 5, 6, 8, 10, 12, 14, 16, 17, 18, 19, 20, 21, 22, 23, 25, and 34). This deficient practice had the potential to result in inadequate useable living space for all the residents, negatively impacting the residents' privacy, and inadequate working space for the caregivers.Findings: During a review of the facility provided document titled, Re: Variance for 483.90 (e) (1)(ii) - Physical Environment, dated 6/30/2025, the request for room variance indicated:1. Each room has easy accessibility to the bathroom and shower rooms.2. There is sufficient room between the beds and the foot of the beds to allow wheelchair residents freedom of movement getting in and out of their wheelchairs.The Request for room variance indicated the following rooms did not meet the 80 square feet (sq ft - a unit of measurement) per resident requirement and the waiver request was for the following rooms: room [ROOM NUMBER]: three beds, 238 sq ft room [ROOM NUMBER]: three beds, 228 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 213 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 195 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 212 sq ft room [ROOM NUMBER]: three beds, 209 sq ft room [ROOM NUMBER]: three beds, 217 sq ftThe minimum square footage for a 3-bed resident room should be 240 sq ft. During the initial tour conducted on 6/30/2025 and multiple observations conducted throughout the recertification survey, the observations indicated the square footage of the rooms requested for waiver did not interfere with the care and services provided by the staff. The residents observed had enough space to move about freely inside the rooms and there was enough space for residents' bed, dresser, and resident care equipment. During a concurrent observation and interview on 7/2/2025 at 10:36 a.m. inside room [ROOM NUMBER] with Certified Nursing Assistant (CNA) 6, observed CNA 6 providing care to Resident 10 without any issues and able to move around freely. CNA 6 stated there was no issue or concern related to space in residents' rooms and staff were able to provide resident care with no issues. CNA 6 stated staff were able to move resident wheelchairs or any resident care equipment in the room without any issues. During a general observation of rooms [ROOM NUMBERS] on 6/30/2025 and 7/2/2025, the residents had ample space to move freely inside the rooms. There was sufficient space to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There was also sufficient space for beds, side tables and resident care equipment. During a concurrent interview and record review with the Administrator (Adm), on 7/2/2025 at 3:40 p.m., reviewed the facility provided document titled, , Re: Variance for 483.90 (e) (1)(ii) - Physical Environment, dated 6/30/2025, with the Adm. The Adm confirmed Rooms 1, 2, 4, 5, 6, 8, 10, 12, 14, 16, 17, 18, 19, 20, 21, 22, 23, 25, and 34 had a square footage of less than 80 square feet per resident. The Adm stated the residents have not brought up any concerns related to space in the room. The Adm stated the staff can provide nursing care for the residents without issues. The Adm further stated if a resident brings up concerns regarding the space in the room, the facility could make a room change to accommodate the residents. During a review of the facility's policy and procedure (P&P) titled, Bedrooms, last reviewed 1/20/2025, the P&P indicated residents will be provided with clean, comfortable, and safe bedrooms that meet federal and state requirements. The P&P further indicated bedrooms must measure at least 80 sq ft of space per resident.

Based on interview and record review, the facility failed to respect the rights and dignity for one of three sampled residents, Resident 1. During lunch, a facility staff was witnessed yelling at Resident 1. This deficient practice prevents the facility ' s residents who are dependent on staff from maintaining and/or enhancing their mental health and social interactions.
Findings:
A review of Resident 1 ' s admission Record indicated an admission date of 2/8/2023 with the following diagnoses of unspecified dementia (a decline in memory, thinking, and language skills), schizoaffective disorder bipolar type (encountering hallucinations and delusions alongside mood changes of extreme highs and lows), and other specified persistent mood disorders.
A review of Resident 1 ' s Minimum Data Set (MDS- a resident screening tool) dated 5/9/2025 indicated Resident 1 was severely impaired with thought process and judgement.
During an interview on 6/11/2025 at 2:08 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 5/25/2025, approximately during lunch time as 12 p.m. to 1 p.m., lunch trays are being served, Resident 1 started getting aggressive towards Certified Nursing Assistant 2 (CNA 2). CNA 1 indicated witnessing Resident 1 throw a spoon towards CNA 2, and CNA 2 throwing the spoon back towards the direction of Resident 1. CNA 1 indicated never hearing CNA 2 curse back at Resident 1. CNA 1 stated, The only thing I noticed was the CNA (CNA 2) raising her voice back at the resident. CNA 1 also stated, The CNA (CNA 2) failed to provide a dignified existence to the resident (Resident 1) when she raised her voice back at the resident and when she threw the spoon back towards the resident.
A record review of the facility provided Policy and Procedure titled Dignity with the last revised date of 2/2021 indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The policy also indicated the following;
1. Residents are treated with dignity and respect at all times.
2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident ' s facility stay.
3. Individual needs and preferences of the resident are identified through assessment process.
4. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility.
13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example:
a. addressing the underlying motives or root causes for behavior; and
b. not challenging or contradicting the resident ' s beliefs or statements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a call light device (also known as a call bell or nurse call button, is a device typically found near a patient's bed or within reach. consists of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the room) was within reach for two of three sampled residents (Resident 2 and 3).
This failure had the potential to result in a delay in care and not receiving assistance timely.
Findings:
During a review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 2/2/2017 with diagnoses that included unspecified (unconfirmed) Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities), essential hypertension (HTN-high blood pressure) and cognitive communication deficit (difficulty communicating due to a disruption in cognitive processes like attention, memory, and reasoning, rather than a primary language or speech problem).
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 4/15/2023, 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 12/1/2024, the MDS indicated Resident 2 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was severely impaired. The MDS indicated Resident 2 needed moderate assistance from staff for toileting, dressing and personal hygiene.
During a review of Resident 2 ' s Care Plan about self-care deficit (when someone has trouble performing daily tasks related to health and well-being), created on 5/29/2018 and last revised on 3/10/2025, the Care Plan indicated an intervention that call light will be within reach and attend needs promptly.
During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 9/8/2021 with diagnoses that included chronic obstructive pulmonary disease (COPD-chronic lung disease causing difficulty in breathing), muscle weakness and Alzheimer ' s Disease.
During a review of Resident 3 ' s H&P, dated 1/28/2025, 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 decisions was severely impaired. The MDS indicated Resident 3 was dependent to staff for toileting, showering and transferring.
During a review of Resident 3 ' s Care Plan about self-care deficit, created on 9/8/2021 and last revised on 2/5/2025, the Care Plan indicated an intervention that call light will be within reach and attend needs promptly.
During an observation on 3/11/2025 at 8:54 a.m., inside Resident 2 ' s room, observed Resident 2 ' s call light on the floor by the right side of the bed above Resident 2 ' s head.
During an observation on 3/11/2025 at 8:55 a.m., in Resident 3 ' s bedside, observed Resident 3 ' s call light on the floor by the right side of the bed tangled with Resident 4 ' s call light.
During an observation on 3/11/2025 at 8:59 a.m., outside of Resident 3 ' s room, observed Certified Nursing Assistant 1 (CNA 1) went inside Resident 3 ' s room and came out with Resident 3 ' s food tray.
During a concurrent observation and interview on 3/11/2025 at 9:01 a.m., with Restorative Nursing Assistant 1 (RNA 1), at Resident 3 ' s bedside, Resident 3 ' s call light was on the floor. RNA 1 stated Resident 3 and Resident 4 ' s call light were tangled with each other and was on the floor. RNA 1 stated Resident 4 was outside the room and Resident 3 ' s call light was not within Resident 3 ' s reach.
During an interview on 3/11/2025 at 9:02 a.m., CNA 1 stated she (CNA 1) went inside Resident 3 ' s room and picked up Resident 3 ' s the food tray. CNA 1 stated she (CNA 1) did not notice that the call light was on the floor. CNA 1 stated she (CNA 1) should have looked around the bed and made sure call light was within Resident 3 ' s reach.
During an interview on 3/11/2025 at 10:41 a.m., the Director of Nursing (DON) stated facility failed to ensure call light was within Resident 2 and Resident 3 ' s reach. The DON stated staff should make sure call light was within reach of each residents. The DON stated call light was a device to help residents call for assistance if residents need something. The DON stated if call light are not within reach, resident cannot call for assistance and residents needs would possibly be delayed.
During a concurrent interview and record review on 3/11/2025 at 10:51 a.m., with the DON, the facility ' s policy and procedure (P&P) titled, Call System, Residents, dated 9/2022 and last reviewed on 1/29/2025, was reviewed. The P&P indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Each resident is provided with a means to call staff directly for assistance from his or her bed, from toileting or bathing facilities and from the floor. The DON stated the facility's policy was to have the call light within resident reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services for two of three sampled residents (Resident 1 and Resident 2) when:
1. Resident 1 had a skin rash and itchiness on bilateral (both) upper and lower extremities (refers to the hands and feet, or parts of the body farthest from the center, like the arms and legs). Medical Doctor (MD) 1 was not informed of the change of Resident 1's skin condition.
This deficient practice placed Resident 1 at risk for more skin irritation and delay in provision of care.
2. The facility failed to effectively manage Resident 2's discomfort by not identifying the cause of Resident 2's skin itchiness. Resident 2 stated the itchiness keeps her awake at night because she cannot sleep at night.
This deficient practice had the potential for Resident 2 to experience unnecessary discomfort.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), angina pectoris (type of chest pain caused by reduced blood flow to the heart), and dysphagia (difficulty in swallowing).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/6/2025, the MDS indicated the resident was severely impaired with his cognitive ((mental action or process of acquiring knowledge and understanding) skills for daily decision-making and required supervision from staff with activities of daily living (ADLs).
During a review of Resident 1's SBAR (Situation, Background, Assessment and Recommendation - a communication and assessment tool), dated 1/14/2025, the SBAR indicated Resident 1 had rashes unspecified but no indication of itching. The SBAR further indicated to keep Resident 1's skin clean and dry and to provide skin care maintenance per physician.
During an observation on 3/3/2025, at 9:15 a.m., Resident 1 was observed lying and moaning in bed while itching her both arms and moving back and forth rubbing her skin against the sheet/mattress in bed. Resident 1's skin rashes were observed as raised, some are open, and red in color.
During an interview at 11:55 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, LVN 1 stated that she has been doing skin treatment for Resident 1 and that this was the first time she is noticing the raised rashes on Resident 1 skin. LVN 1 was asked if she had reported the change of condition to the Physician, she stated she had not but will be calling MD 1 to inform him of the change in resident's skin condition.
During a review of Resident 1's Nursing-Daily Medicare Notes/Change of Condition, dated 3/3/2025 at 9:33 a.m., the notes documented by Licensed Vocational Nurse (LVN) 1 indicated Resident 1's vital signs were within normal range and was showing no sign and symptoms of distress or discomfort. The nursing note did not mention physician and family notification.
During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/16/2023 with diagnoses that included Alzheimer's disease (is a progressive brain disorder that gradually destroys memory, thinking skills, and the ability to perform everyday tasks), metabolic encephalopathy (is a change in how your brain works due to an underlying condition), and unspecified dermatitis (skin inflammation or irritation of an unknown or unspecified origin).
During a review of Resident 2's MDS, dated [DATE], indicated the resident's cognition was severely impaired.
During an observation on 3/3/2025 at 9:45 a.m., Resident 2 was observed sitting at the edge of the bed scratching her neck, chest area, and back. Resident 2 was asked how long she had skin itchiness, she stated it has been weeks. Resident 2 stated the itchiness is so bad at night that it keeps her awake without sleep. Resident 2 stated the facility staff applied some cream, but it does not help.
During an interview on 3/3/2025, at 10:26 a.m., Registered Nurse (RN) 1 stated there was no documented evidence indicating Resident 1 and Resident 2's physician was notified due to change of skin condition. RN 1 stated the licensed nurses should have notified the physician immediately after they noticed the change of condition.
During and interview on 3/3/2025 at 10:45 a.m., LVN 1 stated she did not call MD 1 to report the changes of condition for both Resident 1 and Resident 2
During an interview on 3/3/2025 at 11 a.m., the Director of Nursing (DON) stated the policy is to report to the physician any change in a resident's condition. The DON was unable to explain as to why the licensed nurses did not call the physician once they noticed the changes of skin condition in Residents 1 and 2.
During a telephone interview on 3/3/2025 at 4:03 p.m., MD 1 stated he has not been informed of any resident's change of skin condition and that he is planing to stop by at the facility tomorrow to look at all residents with itching and will order skin scraping to rule out scabies (a contagious skin condition caused by tiny mites that burrow under the skin, leading to intense itching and rash).
A review of the facility-provided policy and procedure titled, Changes in Resident Condition initiated on January 29,2025 indicated all upon changes in condition for any reason nursing staff members are to During a review of the facility-provided policy and procedure titled, Change of Condition, reviewed 1/29/2025, indicated, Content: A. ALL CHANGES OF CONDITION IN A RESIDENT SHALL BE HANDLED PROMPTLY C. Upon a Change in Condition for any reason, nursing staff members are to take the following actions. Physician shall be called promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to notify Medical Doctor (MD) 1 when two of three sampled residents (Resident 1 and Resident 2) had a change of skin condition and itchiness.
This deficient practice had the potential to result in delayed medical intervention to Residents 1 and 2.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), angina pectoris (type of chest pain caused by reduced blood flow to the heart), and dysphagia (difficulty in swallowing).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/6/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.
During a review of Resident 1's SBAR (Situation, Background, Assessment and Recommendation - a communication and assessment tool), dated 1/14/2025, the SBAR indicated Resident 1 had rashes unspecified but no indication of itching. The SBAR further indicated to keep Resident 1's skin clean and dry and to provide skin care maintenance per physician.
During an observation on 3/3/2025, at 9 a.m., Resident 1 was observed lying and moaning in bed while itching her both arms and moving back and forth rubbing her skin against the sheet/mattress in bed. Resident 1's skin rashes were observed as raised, some are open, and red in color.
During a review of Resident 1's Nursing-Daily Medicare Notes/Change of Condition, dated 3/3/2025 at 9:33 a.m., the notes documented by Licensed Vocational Nurse (LVN) 1 indicated Resident 1's vital signs were within normal range and was showing no sign and symptoms of distress or discomfort. The nursing note did not mention physician and family notification.
During concurrent interview on 3/3/2025, 2025, at 10 a.m., the MDS coordinator (MDS 1) stated she could not find any documented evidence indicating Resident 1's physician was notified of the itchiness and redness of the skin. MDS 1 stated the licensed nurses should have notified Resident 1's physician.
During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 12/16/2023 with diagnoses that included Alzheimer's disease (is a progressive brain disorder that gradually destroys memory, thinking skills, and the ability to perform everyday tasks), metabolic encephalopathy (is a change in how your brain works due to an underlying condition), and unspecified dermatitis (skin inflammation or irritation of an unknown or unspecified origin).
During a review of Resident 2's MDS, dated [DATE], indicated the resident's cognition was severely impaired.
During an observation on 3/3/2025 at 9:45 a.m., Resident 2 was observed sitting at the edge of the bed scratching her neck, chest area, and back. Resident 2 was asked how long she had skin itchiness, she stated it has been weeks. Resident 2 stated the itchiness is so bad at night that it keeps her awake without sleep. Resident 2 stated the facility staff applied some cream, but it does not help.
During and interview on 3/3/2025 at 10:45 a.m., LVN 1 stated she did not call the physician to report the changes of condition for both Resident 1 and Resident 2
During an interview on 3/3/2025 at 11 a.m., the Director of Nursing (DON) stated the policy is to report to the physician any change in a resident's condition. The DON was unable to explain as to why the licensed nurses did not call the physicians once they noticed the change of skin condition in Residents 1 and 2.
During a telephone interview on 3/3/2025 at 4:03 p.m., MD 1 stated he has not been informed of any residents' changes of condition and that he is planing to stop by at the facility tomorrow to look at all residents with itching and will order skin scraping to rule out scabies (a contagious skin condition caused by tiny mites that burrow under the skin, leading to intense itching and rash).
During a review of the facility-provided policy and procedure titled, Change of Condition, reviewed 1/29/2025, indicated, Content: A. ALL CHANGES OF CONDITION IN A RESIDENT SHALL BE HANDLED PROMPTLY C. Upon a Change in Condition for any reason, nursing staff members are to take the following actions. Physician shall be called promptly.

Based on interview and record review, the facility failed to implement and maintain an infection control program by failing to ensure the Nursing Station 1 and Nursing Station 2 high touch areas (surfaces that are frequently touched by healthcare providers and clients such as computers, telephones, and work surfaces) were routinely disinfected during an invasive group A streptococcus (IGAS, a severe and sometimes life-threatening infection in which the bacteria have invaded parts of the body where bacteria are not usually found, such as the blood, deep muscle and fat tissue) outbreak (OB, the occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area or season).
This deficient practice had the potential to spread microorganisms, including IGAS, to facility residents, visitors, and staff.
Findings:
During a review of the Nursing Station 1 (NS 1) and Nursing Station 2 (NS 2) Disinfection Logs for High Touch Areas for 9/2024, the logs indicated in order to prevent an outbreak, it is critical that staff thoroughly clean and disinfect all high contact areas such as, but not limited to; hand rails, door knobs, light switches, sink knobs, hand soap and sanitizer dispenser handles, hand towels, dispenser handles, telephones, counter tops, employee clock, etc.
During an interview on 9/25/2024 at 8:16 a.m. with the Director of Staff Development (DSD), the DSD stated there was an IGAS OB in the facility. The DSD stated the Public Health Nurse provided guidance to the facility to stop the OB. The DSD stated IGAS is spread by contact (spread of infection by direct or indirect contact) and droplet (spread of infection by droplet of body secretions through the air) transmission. The DSD stated NS 1 and NS 2 high touch areas are disinfected using disinfectant wipes. The DSD stated the nursing stations are disinfected by the licensed nurses (LN) on every 3 p.m. to 11 p.m. shift and every 11 p.m. to 7 a.m. shift and nurses document in the Disinfection Logs.
During a concurrent interview and record review on 9/25/2024 at 9:15 a.m., the Infection Preventionist (IP) reviewed the NS 1 Disinfection Logs for High Touch Areas for 9/2024. The IP stated hydrogen peroxide (an antiseptic agent) wipes are used in the nursing stations to disinfect the high touch areas every two hours. The IP stated the Disinfection Log was specifically created to control the OB and to ensure the LNs were disinfecting during the time the housekeeping staff were not in the facility. The IP stated the log is used to document the date, shift, and initials of the LN that disinfected the nursing station. The IP reviewed the Disinfection Logs for NS 1 and noted the following:
-On 9/13/2024 for the 11 p.m. to 7 a.m. shift, there were no LN initials.
-On 9/14/2024 for the 11 p.m. to 7 a.m. shift, there were no LN initials.
-On 9/15/2024 for the 11 p.m. to 7 a.m. shift, there were no LN initials.
-On 9/16/2024 for the 11 p.m. to 7 a.m. shift, there were no LN initials.
-On 9/18/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
-On 9/19/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
-On 9/20/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
-On 9/21/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
-On 9/22/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
-On 9/23/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
-On 9/24/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
During a concurrent interview and record review on 9/25/2024 at 9:30 a.m., the IP reviewed the NS 2 Disinfection Log for High Touch Areas for 9/2024 and noted the following:
-On 9/18/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
-On 9/19/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
-On 9/20/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
-On 9/21/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
-On 9/22/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
-On 9/23/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
-On 9/24/2024 for the 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shifts, there were no LN initials.
The IP further stated she did not know why the LNs stopped completing the logs, but it was important to complete them.
During a concurrent interview and record review on 9/25/2024 at 12 p.m., the IP reviewed the facility policy and procedures regarding infection control and communicable diseases. The IP stated the importance of documenting in the Disinfection Logs was to ensure that the staff that worked on a particular shift disinfected the nursing station to prevent to the transmission of diseases. The IP stated the log confirms that it was done. The IP stated if it is not documented then it was not done. The IP stated when the nursing stations are not disinfected then germs can be transmitted from staff to residents making them ill and prolonging the facility IGAS OB.
During an interview on 9/25/2024 at 12:40 p.m., the Director of Nursing (DON) stated she was made aware the Disinfection Logs were not completed by the LNs. The DON stated the importance of LNs completing the logs is to show that they are doing the disinfecting, especially during the hours when the facility housekeeping staff is not there.
A review of the facility provided Group A Streptococcal Infections form, undated, indicated Group A streptococci are bacteria commonly found in the throat and on the skin. These bacteria can cause life threatening skin rashes or other infections. These bacteria are spread by direct contact with nose and throat secretions of someone who has an active infection.
A review of the facility policy and procedure titled, Outbreak of Communicable Diseases, last reviewed 1/10/2024, indicated outbreaks of communicable diseases within the facility are promptly identified and managed. All staff follow standard precautions (a set of basic infection prevention practices intended to prevent transmission of infectious diseases from one person to another) at all times.
A review of the facility policy and procedure titled, Infection control, last reviewed 1/10/2024, indicated the facility has established and will maintain 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.
A review of the facility policy and procedure titled, Cleaning and Disinfection of Environmental Surfaces, last reviewed 1/10/2024, indicated the environmental surfaces will be cleaned and disinfected according to current Center of Disease and Control recommendations for disinfection of healthcare facilities. Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions. Devices that are used by staff but not in direct contact with residents (e.g. computer keyboards, etc) shall be cleaned and disinfected regularly (according to facility schedule) by the environmental services staff and as needed by nursing staff.

Based on interview and record review, the facility failed to ensure a STAT (immediate or urgent) X-ray (a medical procedure that creates pictures of the structures of the inside of the body) was implemented timely for one of three sampled residents (Resident 1).
This deficient practice resulted to a delay in obtaining results and delay in the necessary medical care impacting Resident 1.
Findings:
During a review of Resident 1's admission Record, it indicated the facility admitted the resident on 3/21/2018, with diagnoses including Alzheimer's Disease (a brain disorder that gradually destroys memory and thinking skills) and dementia (the loss of cognitive [ relating to the brain's mental processes, such as thinking, learning, and remembering] functioning - thinking, remembering, and reasoning).
During a review of Resident 1's History & Physical (H&P), dated 11/12/2022, it indicated the resident had displaced left proximal humerus fracture (a break in the upper arm bone, or humerus, near the shoulder joint) with mild angulation.
During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/23/2024, it indicated that resident had severe cognitive (thought process) impairment.
During a review of Resident 1's Order Summary Report, dated 9/10/2024, it indicated an order for STAT x-ray of left humerus.
During a concurrent interview and record review on 9/23/2024, at 10 a.m., with the Director of Nursing (DON), Resident 1's progress notes were reviewed. The DON stated the STAT X-ray ordered after Resident 1 had a fall on 9/10/2024 at 10:30 p.m. was not done. The DON assessed Resident 1 on 9/11/2024 at 9:30 a.m., in Resident 1's room and observed that Resident 1 was lying in bed, guarding her left arm and Resident 1 stated it hurts. The DON stated Resident 1's left arm was swelling and with increased limitation with movements. The DON stated physician was notified who ordered to transfer Resident 1 to general acute hospital for further evaluation instead of waiting for the portable x-ray.
During a telephone interview with Registered Nurse 1 (RN 1) on 9/23/2024, at 12:35 p.m., RN 1 stated she received an order on 9/10/2024 11 p.m. for STAT X-ray. RN 1 further stated that STAT X-ray means it must be done within four to six hour window.
During an interview with License Vocational Nurse 2 (LVN 2) on 9/24/2024, at 6:52 a.m., LVN 2 stated STAT X-ray order must be done within four to six hours and should call the radiology provider to follow up. LVN 2 stated not able to follow up because LVN 2 was busy.
During an interview on 9/24/2024, at 10:57 a.m., with RN 2, RN 2 stated that STAT X-ray was not done for Resident 1.
During a concurrent interview and record review on 9/24/2024, at 11:00 a.m., with RN 2, Resident 1's progress notes were reviewed and indicated that at 9/11/2024 at 3:20 p.m., Resident 1 was transferred to general acute hospital for further evaluation. RN 2 stated STAT X-ray must be done within four to six hours to know the results right away and to provide the appropriate intervention to Resident 1. RN 2 further stated there was a delay of care.
During a concurrent interview and record review on 9/24/2024, at 11:10 a.m., with RN 2, Resident 1's left humerus x-ray report from the general acute care hospital records, dated 9/11/2024, 2:54 p.m., were reviewed indicating Resident 1 had acute displaced and angulated midshaft humeral fracture.
During a concurrent interview and record review on 9/24/2024, at 11:20 a.m., with RN 2, the facility's radiology provider contract was reviewed. RN 2 stated the contract indicated to make every effort to complete STAT X-ray exams within four hours.
During concurrent interview and record review on 9/24/2024, at 11:25 a.m., with RN 2, the facility's policy and procedure titled, Request for Diagnostic Services, undated, was reviewed. The policy and procedure indicated that orders for diagnostic services will be promptly carried out as instructed by the physician's order. RN 2 further stated that in Resident 1's case, the physician order was not followed because stat orders must be done within four to six hours and x-ray was not done until 9/11/2024 2:54 p.m.
During a review of the facility's policy and procedure titled, Request for Diagnostic Services, undated, it indicated that orders for diagnostic services will be promptly carried out as instructed by physician's order. Also indicate Emergency requests must be labeled stat to assure that prompt action is taken.
During a review of the facility contract with Trident Care title, Client and Imaging Provider Respective Responsibilities, indicated to make every effort to complete STAT X-ray exams within 4 hours.

Based on observation, interview, and record review the facility failed to have a 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 beyond one (1) mealtime.
This deficient practice had the potential to cause a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 78 of 78 facility residents.
Findings:
During a review of the facility's Policies and Procedures (P&P) titled Food from Outside Sources dated 1/10/2024, the P&P indicated Policy: Food from outside sources is discouraged due to concerns with food safety and infection control and maintaining control of therapeutic diet orders. Procedure:
1. While it is preferred that families and/or friends do not bring foods or beverages into the facility, it is within resident's rights to allow the resident to eat outside food, especially if an individual is eating poorly. If outside food is brought in, the facility is not liable for any food safety and infection control concerns.
2. If a resident, family member, or friend wants to bring the resident an outside food or beverage, the resident, family member, or friend should talk with the charge nurse and or Dietary Services Supervisor and or food service manager to determine if the outside food or beverage is within the resident's prescribed diet.
3. The charge nurse must be notified if any outside food or beverage is brought in. It is recommended that only enough food/beverage be brought for the visit/meal with the resident. The staff will discard any leftovers.
During concurrent interview with the Registered Dietitian (RD) and facility document review of the food from the outside sources policy on 7/24/2024 at 8:55 a.m., the RD stated they tell the residents that they could bring food from the outside though it was not recommended for them due to food safety. The RD stated they label, date, and put the food from the outside in the resident's refrigerator. The RD stated they only keep the food for 72 hours and discard the rest of the food. The RD stated the residents might not comply with the policy if food that were not expired were thrown away and it could cause them to get upset. The RD stated the policy did not indicate safe food storage guidelines.
During concurrent interview with the Director of Nursing (DON) and facility food from the outside sources policy review on 7/24/2024 at 9:10 a.m., the DON stated their policy regarding food from home were as follows:
1. Staff checked what was type of food families/friends are bringing in the facility.
2. They encourage the family to bring food just enough for the day. However, it was important to have food from home because the residents miss their home cooked foods.
The DON stated the food from outside sources policy was very general, had no guidance for food storage and needed to be revised as it indicated staff will discard any leftovers. The DON stated she learned from dietary that they could only keep food from outside for 72 hours and the rest would be discarded. The DON stated family and residents would find the foods and could cause emotional change in behavior and weight loss as a potential outcome.
During a review of facility's P&P titled Resident's Refrigerator/Freezer Storage dated 1/10/2024, the P&P indicated 5. Leftover food or unused portions of packaged foods should be discarded. No food will be stored beyond 72 hours from received.

Based on observation, interview and record review, the facility failed to post daily staffing information that included the total number of Registered Nurses (RN), Licensed Vocational Nurses (LVNs), Certified Nursing Assistants (CNAs) and their actual hours worked for three of three sampled dates (7/21/2024, 7/22/2024, and 7/23/2024) during a review of sufficient and competent staff facility task.
This deficient practice resulted in residents, visitors, and facility staff not knowing how many staff were available to provide care to the residents.
Findings:
During a concurrent observation and interview on 7/23/2024 at 2:25 p.m., with the Director of Staff Development (DSD), reviewed the daily staffing posting for 7/23/2024. The DSD stated the wall next to Station 1 is the only place where they post the nurse staffing information. The DSD stated the posting did not show how many staff were working for the day, but it showed the projected hours and the actual hours.
The DSD stated the nursing staffing information posted dated 7/23/2024, should have been updated to reflect the number of direct patient care of RNs, LVNs, and CNAs so the staff, residents and visitors would be aware how many licensed and unlicensed staff were working. The DSD stated she is responsible for posting the nurse staffing data at the beginning of the shift.
During an interview on 7/23/2024 at 2:52 p.m., with the Administrator (Adm), the Adm stated the facility was not aware that the nursing staffing posting should include the number of licensed and unlicensed staff working and the number of hours. The Adm stated the posting should indicate the number of RNs, LVNs, and CNAs working for the day and the actual hours worked per regulation to ensure that all visitors and staff would be aware how many staff are working.
During a review of the facility's policy and procedure titled, Post Nursing Staffing information, last reviewed 1/10/2024 indicated, the facility will post nurse staffing information in a prominent place to ensure that the nurse staffing information is accessible to all residents and visitors on a daily basis. The policy indicated the posted nurse staffing information will include:
Facility name
Current date
Resident census
Total number of staff and actual hours worked per shift for
-
Registered Nurses
-
Licensed Nurses
-
Certified Nurse Aides

Based on observation, interview and record review, the facility failed to provide individualized care approaches to meet the emotional and psychosocial needs of residents with mental disorder diagnosis for one of three sampled residents (Resident 70) residents investigated during review of behavioral-emotional care area by failing to address Resident 70's behavior of disrobing.
This deficient practice had the potential to prevent Resident 70 from receiving appropriate treatment, approaches, and the ability to attain the highest practicable mental and psychosocial well-being.
Cross reference F550 and F656
Findings:
During a review of Resident 70's admission Record, it indicated the facility admitted Resident 70 on 9/8/2023 with diagnoses including, but not limited to, dementia (loss of memory, language, and other thinking abilities that interfere with daily life and gets worse over time), Alzheimer's Disease (a common type of dementia), major depressive disorder (a persistent feeling of sadness and loss of interest), and anxiety disorder (excessive worry and feelings of fear and uneasiness).
During a review of Resident 70's History and Physical (H&P), dated 11/8/2023, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 70's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/13/2024, the MDS indicated Resident 70 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect the everyday life) and needed maximum assistance with upper body dressing, lower body dressing, toileting, hygiene, and bathing.
During an observation on 7/23/2024 at 11:10 a.m., outside of Resident 70's room, Resident 70 could be viewed from the hallway disrobed from the waist up; the privacy curtain was partially drawn. Upon entering Resident 70's room, Resident 70 was up in her wheelchair with her shirt off, breast exposed while other residents were passing by the room. Resident 70 yelled out nonsensically (not making sense) when interview was attempted.
During a concurrent observation and interview on 7/23/2024, at 11:15 a.m., inside Resident 70's room, with Restorative Nursing Assistant (RNA) 1, RNA 1 assisted Resident 70 back into her shirt and confirmed that Resident 70 had the behavior of disrobing in the past. RNA 1 further explained the behaviors are to be reported to the charge nurse. RNA 1 further stated he will report the behavior to the charge nurse.
During an interview and record review on 7/23/2024, at 12:30 p.m., with the Director of Medical Records (DMR), reviewed the Clinical Chart of Resident 70. The DMR stated there were no care plans or interventions addressing Resident 70's behavior of disrobing.
During an interview on 7/25/24 at 8:30 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated she cared for Resident 70 approximately 4 times in the last month and Resident 70 disrobed once or twice. CNA 7 stated she reported to the charge nurse each time the resident had the behavior of disrobing but does not remember which date or charge nurse she reported it to. CAN 7 further explained she was unaware of specific approaches to assist Resident 70 when she disrobes.
During a concurrent interview and record review on 7/25/24 at 9:15am with the Director of Staff Development (DSD), reviewed the MAR and care plan of Resident 70. The DSD stated on 7/23/2024 she was covering as the charge nurse for the first shift (7:00 a.m.- 3:30 p.m.) in station two (the station that covers the area of Resident 70) and did not remember if the behavior of disrobing was reported to her that day. The DSD stated she remembers Resident 70 disrobing her shirt since she was admitted to the facility and any new identified behaviors are to be reported to the supervising registered nurse. The DSD further stated the behaviors are tallied in the MAR, but disrobing is not listed as a behavior to monitor in the MAR nor was there a care plan or interventions to address the behavior of disrobing.
During a concurrent interview and record review on 7/25/2024 at 9:55 a.m. with Registered Nurse (RN) 2, reviewed the MAR, care plan and notes of Resident 70. RN 2 stated the disrobing behavior was not reported to her and if the behavior is not in the MAR, it is not care planned. RN 2 confirmed disrobing is not mentioned in any notes, care plans or the MAR in Resident 70's chart. RN 2 further stated the resident could miss out on measurable goals and approaches that staff could use during care without the care plan.
During a review of the facility's policy and procedure (P&P) titled, Policy: The Resident Care Plan, last reviewed 1/10/2024, the P&P indicated the resident care plan shall be implemented for each resident on admission and developed throughout the assessment process. The P&P further indicated, the care plan should include measurable goals and approaches to meet the goals.
During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed 1/10/2024, indicated residents have the right to be informed of, and participate in, his or her care planning and treatment.

Based on interview and record review, the facility failed to ensure control and accountability of Controlled Substance (CS- medications which have a potential for abuse and may also lead to physical or psychological dependence, also known an Controlled Medication [Drug]) awaiting final disposition (process of returning and/or destroying unused medications) when the facility's Antibiotic or Controlled Drug Record accountability logs did not include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with the Licensed Vocational Nurse (LVN) for seven of seven sampled logs.
This deficient practice increased the opportunity for CS diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and accidental exposure of residents to harmful medications, potentially negatively impacting their health and wellbeing.
Findings:
During a review of Antibiotic or Controlled Drug Record accountability logs on 7/24/2024 at 1:13 PM, with the DON, 7 Antibiotic or Controlled Drug Record accountability logs indicated the CSs awaiting final disposition did not contain any verifying signatures.
During a concurrent interview on 7/24/2024 at 1:13 p.m., with the DON, the DON stated she was unable to locate the verifying signatures of LVNs and the RN/DON on the seven accountability logs. The DON stated the DON failed to sign the seven Antibiotic or Controlled Drug Record accountability logs upon receipt of the CS's. The DON stated the DON counts the CSs with the LVNs upon receipt of the accountability logs, however there was no consistent process of signing the logs. The DON stated the DON needed to immediately implement a process for including verifying signatures on the accountability logs to ensure each CS dose was accounted for until disposed. The DON stated it was also important to verify and sign the logs to prevent diversions and accidental exposure of harmful substances to residents.
During a review of the facility's policy and procedures (P&P) titled, Controlled Medications, dated April 2008, 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 DON and the consultant pharmacist (CP) in collaboration maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications.
A review of the facility's P&P titled, Controlled Medication Disposal, dated April 2008, 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 DON, in collaboration with the CP, is responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications.
B. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses, and the disposal documented on the accountability record/book on the line representing that dose. 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.
Review of the facility's P&P titled, Controlled Substances, dated March 2023, the P&P indicated that The facility complies with all laws, regulations, and other requirements related to administration, handling, storage, disposal, and documentation of controlled medications.
9b. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet.

Based on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) recommendation for June 2024 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 carried out as per facility policy and procedure for one of four sampled residents (Resident 70).
The deficient practice increased the risk of receiving medication that was not optimal for Resident 70'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 70's admission Record (a document containing demographic and diagnostic information,) dated 7/26/2024, the admission Record indicated the facility originally admitted Resident 70 on 9/8/2023 and re-admitted the resident on 11/7/2023 with a diagnosis of anxiety.
During a review of Resident 70's Order Summary Report, dated 7/26/2024, the report indicated Resident 70 was prescribed Ativan (a medication used for anxiety) 0.5 milligram ([mg] - a unit of measure of mass) tablet to give 1 tablet by mouth twice a day for anxiety manifested by constant movement/rolling out of bed to exhaustion, starting 2/21/2024.
During a review of the MRR note for Resident 70 by the CP on 7/25/2024 at 2:43 PM, titled Note to Attending Physician/Prescriber and dated 6/13/2024, stated Resident has been taking Ativan 0.5 mg BID (abbreviated for twice a day), since 2/2024. Please consider a dose reduction if appropriate. If therapy is to continue, please document risk versus benefit assessment. The document did not contain a response from a physician and was not signed or dated by a physician.
During a review of Resident 70's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record,) on 7/25/2024 at 2:48 PM, the MAR indicated Resident 70 was prescribed Ativan 0.5 mg to give 1 tablet by mouth twice a day for anxiety manifested by constant movement/rolling out of bed to exhaustion, since 2/21/2024.
During an interview on 07/26/24 at 9:35 AM, with the Director of Nursing (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 6/13/2024 for the Ativan 0.5 mg BID identified irregularity and failed to document a rationale for continuing the Ativan order for anxiety manifested by constant movement/rolling out of bed to exhaustion, for Resident 70.
Review of facility policy and procedure (P&P) titled Medication Regimen Review (Monthly Report), dated July 2024, the policy indicated The consultant pharmacist performs a comprehensive MRR at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.
C. Recommendations are acted upon and documented by the facility staff and or the prescriber.
1) If irregularities are found the DON and/or designated licensed nurse will follow up with the prescriber within 30 working days of receipt of the MRR report.
3) The prescriber, the DON or the designated licensed nurse will document the rational if the recommendation is declined.
Review of the facility's P&P titled Policy for Unnecessary Medication, dated July 2024, the P&P indicated: Facility will follow state and federal regulation to ensure that all residents will be free from unnecessary psychotropic medication and unnecessary drugs.
Licensed nurse will review resident's drug regimen based on the following criteria:
1.
Excessive dose
2.
Excessive duration
3.
Adequate indication
Licensed nurse will communicate with the primary physician and adjusting the medication dosage, duration, frequency and/or discontinue the medication if indicated.
Licensed nurse will communicate with the primary physician regarding the pharmacist recommendation on a monthly basis to ensure all residents' medications are appropriate.

**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 70) 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 identify specific, measurable target behaviors related to the use of Ativan (a psychotropic medication used to treat anxiety) for Resident 70.
These deficient practices had the potential to place Resident 70 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 reference to F756
Findings:
During a review of Resident 70's admission Record (a document containing demographic and diagnostic information,) dated 7/26/2024, the admission Record indicated Resident 70 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis anxiety.
During a review of Resident 70's Order Summary Report, dated 7/26/2024, the report indicated Resident 70 was prescribed Ativan 0.5 milligram ([mg] - a unit of measure of mass) tablet to give 1 tablet by mouth twice a day for anxiety manifested by constant movement/rolling out of bed to exhaustion, starting 2/21/2024.
During a review of Resident 70's Minimum Data Set (MDS - a comprehensive resident assessment tool), dated 5/13/2024, the MDS indicated Resident 70 did not have potential indicators of psychosis, no hallucinations (perceptual experiences in the absence of real external sensory stimuli), and no delusions (misconceptions or beliefs that are firmly held, contrary to reality). Resident 70's MDS indicated there were no physical, verbal, or other behavioral symptoms exhibited or directed toward others, including no pacing, wandering, or disrobing. Resident 70's MDS indicated Resident 70 received antianxiety medication on a routine basis.
During a review of the Medication Regimen Review (MRR) note for Resident 70 by the Consultant Pharmacist (CP) on 7/25/2024 at 2:43 PM, titled Note to Attending Physician/Prescriber and dated 6/13/2024, stated Resident has been taking Ativan 0.5 mg BID (abbreviated for twice a day), since 2/2024. Please consider a dose reduction if appropriate. If therapy is to continue, please document risk versus benefit assessment. The document did not contain a response from a physician and was not signed or dated by a physician.
During a review of Resident 70's Medication Administration Record ([MAR] - a record of mediations administered to residents) between 5/1/2024 through 7/26/2024, on 7/25/2024 at 2:48 PM, the MAR indicated Resident 70 had zero documented episodes for anxiety manifested by constant movement/rolling out of bed to exhaustion for 85 out of 87 days. The MAR also indicated Resident 70 continued to be prescribed Ativan 0.5 mg 1 tablet by mouth twice a day for anxiety manifested by constant movement/rolling out of bed to exhaustion, since 2/21/2024.
During a review of Resident 70's Psychiatric FU Note on 7/25/2024 at 3 PM, dated 5/4/2024, the note indicated Last seen in February 2024. Ativan started for agitation and verbally aggressive as Thyroid Stimulating Hormone ([TSH] - hormone that control how the body uses energy) was elevated (depicted by arrow up symbol) which may contribute. The note indicated to continue current medications, behavior not well controlled, and no dose reduction indicated.
During a review of Resident 70's Psychiatric FU Note on 7/25/2024 at 3:05 PM, dated 7/4/2024, the note indicated Patient remains restless and anxious. The note indicated to continue current medications, behavior not well controlled, and no dose reduction indicated.
During a review of progress note by Registered Nurse (RN) 2, dated 7/25/2024 at 6:36 PM, the note indicated Nurse Practitioner (NP,) . made aware of pharmacy recommendation to reduce Ativan 0.5 mg PO (by mouth) BID but NP stated no Gradual Dose Reduction (GDR) d/t (due to) worsening symptoms.
During a concurrent record review of Resident 70's clinical record, MAR, MRR, MDS and an interview on 7/26/2024 at 9:35 AM, with the Director of Nursing (DON,) the DON stated after identifying that the facility failed to review and document the MRR note by the CP written on 6/13/2024, the DON contacted the NP on 7/25/2024 and the NP made an addendum (addition) to the Psychiatric FU Note originally dated 7/4/2024 that Resident 70 was disrobing per staff report on 7/25/24 and no GDR indicated. The DON stated that Resident 70 did not have documented behaviors of anxiety manifested by constant movement/rolling out of bed to exhaustion since May 2024. The DON stated the DON was unable to find a clinical rationale to continue the Ativan 0.5 mg BID indicated for constant movement/rolling out of bed to exhaustion, as those behaviors have resolved. The DON stated there was no new Ativan order prescribed for the specific targeted behavior of disrobing therefore that behavior was not monitored. The DON stated the decision for not completing a GDR of the Ativan for Resident 70 was based on a behavior of disrobing for which the Ativan order was not indicated for. The DON stated continuing Ativan 0.5 mg BID for disrobing behavior that was different than constant movement/rolling out of bed to exhaustion originally indicated for, was inappropriate for Resident 70. The DON stated without specific targeted behavior monitoring, assessments, and evaluations for medication orders such as lowering the dose or discontinuing the medication will be inaccurate leading to unnecessary use of medications which may result in adverse consequences for the residents.
During an interview on 7/26/2024 at 11:23 PM, with Licensed Vocational Nurse (3), LVN 3 stated LVN 3 takes care of Resident 70 four times a week and was very familiar with the resident. LVN 3 stated Ativan 0.5 mg BID was prescribed for anxiety manifested by constant movement/rolling out of bed to exhaustion since 2/21/2024 for Resident 70. LVN 3 stated that Resident 70 was not exhibiting anxiety manifested by constant movement/rolling out of bed to exhaustion since May 2024. LVN 3 stated that according to psychiatric note addendum on 7/25/2024 no GDR was indicated for Ativan 0.5 mg BID due Resident 70 disrobing. LVN 3 stated that there was no Ativan prescribed for disrobing, and as a result disrobing behaviors were not being monitored for Resident 70. LVN 3 stated if there was a new behavior concern of disrobing then a medication for that specific behavior should be prescribed to ensure behaviors and medication effectiveness were being monitored for Resident 70. LVN 3 stated that medications should have indications for specific target behaviors to ensure specific behavior monitoring, evaluation of medication effectiveness for that behavior, and to prevent adverse consequences by continuing use of unnecessary medications for resolved behaviors.
Review of the facility's Policy and Procedures (P&P,) titled Behavioral Health Services, dated May 2023, the P&P indicated: The Facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.
Review of the facility's P&P titled Policy for Unnecessary Medication, dated July 2024, the P&P indicated: Facility will follow state and federal regulation to ensure that all residents will be free from unnecessary psychotropic medication and unnecessary drugs.
Licensed nurse will review resident's drug regimen based on the following criteria:
1. Excessive dose
2. Excessive duration
3. Adequate indication
Licensed nurse will communicate with the primary physician and adjusting the medication dosage, duration, frequency and/or discontinue the medication if indicated.
Licensed nurse will communicate with the primary physician regarding the pharmacist recommendation on a monthly basis to ensure all residents' medications are appropriate.
Review of the facility's P&P titled Psychotherapeutic Medications, dated July 2024, the P&P indicated to Evaluate the resident's response to psychotropic medication therapy to determine that the medications are appropriate, and resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy.
The licensed nurse will assess resident to ensure:
D. Actual behavior with goals and approaches on care plan
K. Attempt Gradual Dose Reduction unless clinically contraindicated, at least twice in first year and yearly thereafter.
L. System I pace to document explanation of repeated behavior on MAR with notification of physician and reevaluation for intervention.
M. The pharmacist will complete monthly drug regimen review and give recommendations as indicated and the facility will follow up with the recommendations.

**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 (%). Two medication errors out of twenty-five (25) total opportunities contributed to an overall medication error rate of eight % affecting one of seven residents observed for medication administration (Resident 14.) The medication errors were as follows:
1. Resident 14 did not receive a dose of Tylenol (a medication used for pain) as ordered by Resident 14's physician, and
2. Resident 14 received Keflex (a medication used to treat an infection) in a form that was not ordered by Resident 14's physician.
These failures had the potential to result in Resident 14 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 14's health and well-being to be negatively impacted.
Findings:
During an observation on 7/23/2024 at 12:15 PM, in Medication Cart Station 1, Licensed Vocational Nurse (LVN) 1 was observed opening Keflex 500 milligram ([mg]-a unit of measure of mass) capsule and pouring the contents into a small plastic cup (a process similar to when crushing [pressing the medication very hard so that the shape is destroyed and forms a soft powder] medications) containing applesauce for Resident 14.
During an observation on 7/23/2024 at 12:22 PM with LVN 1, Resident 14 was observed swallowing spoonsful of the applesauce containing the contents of the Keflex 500 mg capsule followed by a glass of juice.
During an interview on 7/23/2024 at 3:11 PM, with Registered Nurse (RN) 1, RN 1 stated that Resident 14's clinical chart did not contain physician orders instructing to open Keflex capsules and mix with applesauce. RN 1 stated if there was no order indicating to do so then it should not have been done.
During an observation on 7/24/2024 at 9:13 AM, in Medication Cart Station 1, in the presence of RN1, LVN 2 was observed administering one (1) tablet of Tylenol 500 mg to Resident 14. Resident 14 was observed swallowing the tablet whole with a glass of juice.
During an interview on 7/24/2024 at 11:27 PM, with RN 1 and LVN 2, LVN 2 stated that LVN 2 administered one (1) tablet of Tylenol 500 mg to Resident 14 during the morning medication administration on 7/24/2024 at 9:13 AM. LVN 2 acknowledged the physician's order specified to give two (2) tablets (1000 mg). LVN 2 stated LVN 2 failed to administer two (2) tablets as ordered by the physician and underdosed (gave an insufficient amount) Resident 14. LVN 2 stated there was a risk Resident 14 would not see the therapeutic (expected response from a treatment) effect of the Tylenol and continue to be in pain. RN 1 and LVN 2 stated an additional tablet of Tylenol 500 mg will be administered immediately to Resident 14.
During an interview on 7/24/2024 at 12:43 PM, with the Director of Nursing (DON,), the DON stated that Resident 14 did not have a physician order stating to open the Keflex 500 mg capsule and mix with applesauce for administration. The DON stated that certain medications should not be opened or crushed as they can cause adverse effects such as stomach irritation. The DON stated that Resident 14 had an order of Tylenol 1000 mg for Osteoarthritis pain, and not receiving the prescribed amount can lead to uncontrolled pain for the resident. The DON stated that LVN 1 and LVN 2 failed to follow the 5 rights of medication administration to ensure physician orders were followed and the right doses and forms of medications were administered to Resident 14. The DON stated these were considered medication errors.
During an interview on 7/26/2024 at 11:11 AM, with LVN 1, LVN 1 stated that LVN 1 administered opened Keflex 500 mg capsule mixed with applesauce on 7/23/2024 at 12:22 PM to Resident 14, and that there was no physician order instructing LVN 1 to do so. LVN 1 stated this is considered a medication error. LVN 1 stated not all medications could be opened (similar to not all medications can be crushed) and if the wrong medication was opened it may not have the desired effect and could cause adverse effects to the resident. LVN 1 stated LVN 1 failed to follow the facility's medication administration policy and failed to follow physician orders.
During a review of Resident 14's admission Record (a document containing demographic and diagnostic information,) dated 7/23/2024, the admission Record indicated Resident 14 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including osteoarthritis (breakdown of bone causing pain and stiffness,) and dermatophytosis (infection of the skin and nails.)
During a review of Resident 14's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], dated 7/23/2024, the MAR indicated Resident 14 was prescribed the following:
1) Tylenol 500 mg tablet to give 2 tablets by mouth two times a day at 8 AM and 4 PM for pain management related to osteoarthritis, starting 5/20/2024. The order indicated the medication should be given as two tablets for a dose of 1000 mg twice a day.
2) Keflex 500 mg capsule to give 1 capsule by mouth three times a day at 8 AM, 12 PM, 4 PM for right second finger infection for 7 days, starting 7/17/2024. The physician order did not specify to open the Keflex capsule and mix the contents with applesauce.
During a review of Resident 14's clinical record, the record contained no documentation that Resident 14 should be given one (1) Tylenol 500 mg tablet and no documentation to mix the contents of Keflex 500 mg capsule with applesauce.
During a review of the facility's policy and procedures (P&P), titled Medication Administration - General Guidelines, dated October 2017, the P&P indicated that Medications are administered as prescribed .
A. Preparation
3) Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label.
B. Administration
2) Medications are administered in accordance with written orders of the attending physician.
During a review of the facility's P&P, titled Procedures for all Medications, dated April 2008, the P&P indicated: To administer medications in a safe and effective manner.
F. Read medication label before administering.
During a review of the facility's P&P, titled Med Pass, [undated], the P&P indicated:
I.A.2. The 5 Rights
Make sure that meds are administered according to:
b. Right medications
c. Right dose
III.A. Med errors
A med error is a violation in the 5 rights, or in medication regulations; or in approved medication policy or current standard of practice.
C.Survey deficiencies
A survey deficiency is a combination of significant and insignificant med errors that amount to 5% or [NAME] of the total opportunities for error.
VIII.G. Crushed Meds
Meds may be crushed and mixed with applesauce or pudding, per physician order .
During a review of the facility's P&P, titled Crushing Medications, dated March 2023, the P&P indicated that Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for three of ten sampled residents (Resident 10, 38, and 76) by:
1. Failing to ensure nurses were rotating (a method to ensure repeated injections are not administered in the same area) the insulin (a medication that regulates sugar in the blood) injection sites for Resident 10 during review of insulin care area.
2. Administering insulin to Resident 38 when the blood sugar (BS - the amount of sugar measured in the blood stream) was below the physician ordered parameters (a set of limits determining if a medication can be given) during review of insulin care area.
3. Failing to ensure Treatment Nurse 1 (TN 1) administered the first dose of Keflex (an antibiotic [medication that fights infections caused by bacteria delivered directly into the bloodstream]) immediately or within four hours of receiving a verbal order from the Wound Care Consultant (WCC) for Resident 76 with an active skin infection reviewed during the Infection Control task.
This deficient practice had the potential to result in bruising, pain, and/or lipohypertrophy (lump or accumulation of fatty tissue under skin) to Resident 10, placed Resident 38 at risk for hypoglycemia (a condition when the blood sugar is dangerously low), and had the potential to jeopardize the therapeutic effectiveness of the antibiotic resulting in further complications of Resident 76's infection.
Cross refence to F658 and F880.
Findings:
1. During a review of Resident 10's admission Record, it indicated the facility admitted the resident on 3/10/2023, with diagnoses including, but not limited to, type 2 diabetes mellitus (DM - a disease that occurs when the glucose, also called blood sugar, is too high) with unspecified complications, and long-term use of insulin.
During a review of Resident 10's History and Physical (H&P), dated 3/4/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/13/2024, the MDS indicated the resident had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect the everyday life) and required moderate assistance with eating, oral hygiene, and upper body dressing.
During a review of Resident 10's Order Summary Report, printed on 7/25/2025, the report indicated Resident 10 had an order increase on 7/4/2024 for Lantus (long-acting insulin) SoloStar Subcutaneous (SQ - into the fatty layer under the skin) Solution Pen-injector (a device used to administer medication into the body through a needle) 100 unit per milliliters (unit/ml, a unit of fluid volume) from 12 to 14 units: inject 14 unit SQ at bedtime (HS). Hold if BS is less than 110. May give orange juice for BS less than 60. Rotate site.
During a review of Resident 10's Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis) for 5/2024-7/2024, indicated Lantus SoloStar SQ Solution Pen-injector; inject 14 units SQ at HS was administered on:
5/7/2024 at 8:00 p.m. on the left lower quadrant
5/8/2024 at 8:00 p.m. on the left lower quadrant
5/12/2024 at 8:00 p.m. on the abdomen
5/13/2024 at 8:00 p.m. on the abdomen
5/14/2024 at 8:00 p.m. on the abdomen
5/17/2024 at 8:00 p.m. on the right lower quadrant
5/18/2024 at 8:00 p.m. on the right lower quadrant
5/24/2024 at 8:00 p.m. on the left lower quadrant
5/25/2024 at 8:00 p.m. on the left lower quadrant
6/2/2024 at 8:00 p.m. on the abdomen
6/3/2024 at 8:00 p.m. on the abdomen
6/8/2024 at 8:00 p.m. on the abdomen
6/9/2024 at 8:00 p.m. on the abdomen
6/10/2024 at 8:00 p.m. on the abdomen
6/11/2024 at 8:00 p.m. on the abdomen
6/19/2024 at 8:00 p.m. on the left lower quadrant
6/20/2024 at 8:00 p.m. on the left lower quadrant
7/3/2024 at 8:00 p.m. on the left arm
7/4/2024 at 8:00 p.m. on the left arm
7/5/2024 at 8:00 p.m. on the left lower quadrant
7/6/2024 at 8:00 p.m. on the left lower quadrant
7/12/2024 at 8:00 p.m. on the left lower quadrant
7/13/2024 at 8:00 p.m. on the left lower quadrant
7/18/2024 at 8:00 p.m. on the left lower quadrant
7/19/2024 at 8:00 p.m. on the left lower quadrant
7/21/2024 at 8:00 p.m. on the left arm
7/22/2024 at 8:00 p.m. on the left arm
During a concurrent interview and record review on 7/24/2024, at 3:00 p.m., with Registered Nurse (RN) 3, reviewed the Order Summary Report and the MAR of Resident 10 with RN 3. RN 3 stated there were multiple instances where the injection sites of the insulin were not rotated from 5/2024 to 7/2024. RN 3 stated the sites of insulin administration should be rotated to prevent bruising, hardening of the skin injection sites, and lipodystrophy (abnormal distribution of fat). RN 3 also stated the failure to follow the physician's order to rotate the insulin administration site is considered a medication error.
During a review of the facility's Policy and Procedure (P&P) titled, Medication Error, last reviewed on 1/10/2024, the P&P indicated the facility will follow the medication administration P&P to avoid any medication errors including wrong route of administration.
During a review of the facility's P&P titled, Insulin Administration, last reviewed on 1/10/2024, the P&P indicated to select an injection site.
a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior and lateral areas of the thighs and abdomen. Avoid the are approximately 2 inches around the navel.
b. Injection sites should be rotated, preferably within the same general area.
During a review of the facility provided FDA Label for Lantus SoloStar, undated, it indicated to rotate injection sites within the same area you choose each time form one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis (skin with lumps). Do not use the same spot for injection.
2. During a review of Resident 38's admission Record, it indicated the facility admitted the resident on 2/20/2019, with diagnoses including, but not limited to, type 2 diabetes mellitus without complications.
During a review of Resident 38's H&P, dated 2/13/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 38's MDS, dated [DATE], the MDS indicated the resident was severely cognitively impaired. The MDS indicated Resident 38 is dependent on eating, toileting, showers, dressing, personal hygiene, and mobility.
During a review of Resident 38's Order Summary Report, printed on 7/25/2024, the Order Summary Report indicated an order for Basaglar (long-acting insulin) KwikPen Solution Pen-Injector 100 u/ml.: inject 4 units SQ one time a day. Rotate site; hold for BS less than 90.
During a review of Resident 38's Care Plan (CP) focused on hypoglycemia related to DM, revised on 1/28/2024, the CP indicated to administer the medications as ordered.
During a review of Resident 38's MAR for 4/2024 to 7/2024, the MAR indicated:
Basaglar KwikPen Solution Pen-Injector 100 u/ml.: inject 4 units SQ one time a day. Rotate site; hold for BS less than 90, was administered on:
a. 4/1/2024 at 8:00 a.m. on the right arm with a BS of 89.
b. 7/2/2024 at 8:00 a.m. on the right lower quadrant with a BS of 80.
During a concurrent interview and record review on 7/24/2024, at 2:30 p.m. with Licensed Vocational Nurse (LVN) 3, reviewed the Order Summary Report and the MAR of Resident 38 with LVN 3. LVN 3 stated, she gave the resident insulin with BS below 90, when it should have been held to prevent the BS from going down even lower.
During an interview on 7/25/2024, at 6:25 p.m., with the Director of Nursing (DON), the DON stated the orders must be double checked; the parameters the physician ordered must always be followed to prevent hypoglycemia. The DON further stated not following the physician ordered parameters during administration of insulin constitutes a medication error.
During a review of the facility's P&P titled, Medication Error, last reviewed on 1/10/2024, indicated the facility will follow the medication administration P&P to avoid any medication errors including failure to follow parameters for specific medications.
During a review of the facility's P&P titled, Insulin Administration, last reviewed on 1/10/2024, the P&P indicated to check the order for the amount of insulin and the blood sugar parameter per physician order.
3. During a review of Resident 76's admission Record, it indicated the facility admitted the resident on 4/4/2023 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (a condition in which the force of the blood against the artery walls is too high), and malignant neoplasm (commonly referred to as cancer, term for a disease in which abnormal cells divide without control and can invade nearby tissues) of the skin.
During a review of Resident 76's MDS 6/10/2024, the MDS indicated the resident was sometimes able to understand others and was sometimes able to make himself understood. The MDS further indicated the resident requires substantial/maximal assistance from staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility.
During a review of Resident 76's CP titled, (Resident 76) has unspecified dermatitis. Location: generalized body rash (bilateral upper extremities, chest, back) ., initiated 6/13/2024, the CP indicated goals to promote healing without complications and will show no signs and development of infection. The CP indicated to monitor for signs and symptoms of infection (redness, presence of drainage, odor, pain), to report change in resident's kin condition to physician and resident's family, and to provide treatment as ordered.
During a review of Resident 76's Skilled Nursing Facility Wound Care Consultant notes, dated 7/24/2024, the Wound Care Consultant Notes indicated Resident 76 had an infected wound with scant serous drainage. The notes indicated to start the resident on Keflex 500 mg, four times a day for seven days.
During a review of Resident 76's physician orders, the orders indicated the following orders:
-Keflex oral capsule 500 milligrams (mg, a unit of measurement), give one capsule by mouth one time only for bacterial folliculitis (the hair follicle becomes infected/inflamed and forms a pustule), first dose from the emergency kit (e-kit, emergency drug supplies), dated 7/24/2024.
-Monitor for symptoms and signs of Group A Streptococcus (IGAS, a severe and sometimes life threatening infection in which the bacteria have invaded parts of the body where bacteria are not usually found, such as the blood, deep muscle and fat tissue): cough; sore throat; fever; skin infection - tenderness or pain, heat, swelling, serous drainage at affected site and document yes/no, (if yes, indicate in the nurse's note and call physician), every shift until 8/17/2024, dated 7/17/2024.
During a review of Resident 76's MAR, the MAR indicated the following:
-On 7/24/2024 at 3:15 p.m., TN 1 documented the administration of Keflex Oral Capsule 500 mg capsule.
During an observation on 7/23/2024 at 11:40 a.m., observed Resident 76 sitting in a wheelchair in the hallway outside the resident's room. Observed the resident with multiple open wounds on the left arm and a clear dry crusted substance on the left wrist.
During an observation and interview on 7/24/2024 at 11 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she was caring for Resident 76. LVN 3 assessed Resident 76 and stated the resident had open wounds with discharge that she was not aware of. LVN 3 called TN 1. LVN 3 stated TN 1 stated the resident was seen by the wound care consultant that morning and would be started on antibiotics for an infection.
During an interview on 7/24/2024 at 1:32 p.m., TN 1 stated the facility currently has an Outbreak (OB, the occurrence of disease cases in excess of normal expectancy) of IGAS. TN 1 stated Resident 76's left wrist was crustier today when she made rounds with the WCC at 6:30 a.m. and the WCC verbally ordered antibiotics for a skin infection on Resident 76's left wrist. TN 1 stated she was not given a start date for the antibiotics, so she was going to enter the verbal order to give the first dose on 7/25/2024, the next day. TN 1 then stated antibiotics should be given immediately or within two hours of an order. TN 1 stated the antibiotics should have been given by 8:30 a.m. TN 1 stated it was now 1:45 p.m. and the antibiotics had not been administered to Resident 76. TN 1 stated when antibiotics are delayed a wound can worsen.
During an interview on 7/24/2024 at 2:09 p.m., with the Infection Preventionist (IP), the IP stated the facility currently has an OB for IGAS. The IP stated the guidance given to the facility by the Department of Public Health was to monitor all residents for signs and symptoms of IGAS including open wounds with signs of infection. The IP stated a resident identified with an open wound with signs of infection should be tested to confirm or rule out as IGAS, the primary physician should be notified, and treatment should be started. The IP stated TN 1 did not notify her there are any newly identified residents with open wounds that have signs and symptoms of infection. The IP stated TN 1 should have notified her in the morning regarding Resident 76's wound and started the antibiotic treatment because the facility has an OB. The IP stated when the WCC gave a verbal order for antibiotics, the antibiotics should have been started within four hours because the resident has an infection, they want to stop the infection from worsening, and to prevent the OB from spreading to other residents.
During an interview and record review on 7/25/2024 at 5 p.m., with the DON reviewed the facility policies regarding antibiotic medication administration and antibiotic stewardship. The DON stated for a new order of antibiotics, the first dose should be given within four hours of receiving the order. The DON stated TN 1 should have asked someone for help when she was making rounds with the WCC and was given a verbal order to start Resident 76 on antibiotics. The DON stated the facility policies do not specifically indicate antibiotics must be started within four hours, but it is a standard of practice. The DON stated the antibiotic was available in the facility e-kit and should have been given to Resident 76 as soon as possible and not the following day. The DON stated it was a medication error to delay the initial dose of antibiotics.
During a review of the facility P&P titled, Physician Orders and Telephone Orders, last reviewed 1/10/2024, the P&P indicated all orders must be specific and complete with all necessary details to carry out the prescribed order without any questions. Methods of obtaining orders may be verbal. All orders must indicate the date and time received and must be noted by the professional staff taking the order.
During a review of the facility P&P titled, Organizational Aspects, last reviewed 1/10/2024, the P&P indicated the pharmacy provides routine and timely pharmacy services seven days a week and emergency pharmacy service 24 hours per day, seven days a week. Medications which should be promptly available, such as anti-infectives are available within four hours.
During a review of the facility P&P titled, Medication Ordering and Receiving from Pharmacy, last reviewed 1/10/2024, the P&P indicated medications and related products are received from the dispensing pharmacy on a timely basis. Stat and emergency medications, the initial dose is obtained from the emergency kit and administered immediately.
During a review of the facility P&P titled, Medication Orders, last reviewed 1/10/2024, the P&P indicated medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Each medication is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The nurse on duty at the time the order is received enters it on the physician order sheet/telephone sheet. If the order is from a prescriber other than the attending physician, the order is verified with the current attending physician. Emergency/STAT medicine order is scheduled to be given within the legally specified time.
During a review of the facility P&P titled, Antibiotic Stewardship - Orders for Antibiotics, last reviewed 1/10/2024, the P&P indicated antibiotics will be prescribed and administered to residents under the guidance of the facilities antibiotic stewardship program in conjunction with the facilities general policy for medication utilization and prescribing. If an antibiotic is indicated, providers will provide complete antibiotic orders. Before a nurse removes an antibiotic from the emergency supply of medication, he or she will report the use to the infection preventionist.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when the broccoli was mushy, overcooked and did not have a garlic flavor.
This deficient practice placed 21 of 78 facility residents on regular consistency texture (texture with no restriction) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.
Findings:
A review of the facility's summer menu spreadsheets (a list containing types and amount of foods of what each diet type would receive) dated 7/23/2024, indicated regular texture diet included the following food items on the tray:
-Roast Turkey 3 ounces (oz, unit of measurement)
-Gravy 1 oz
-Bread stuffing 2.7 oz
-Broccoli with garlic ½ cup (c, household measurement)
-Wheat roll 1 piece
-Glazed apple square 1 pc, except for the following diets: consistent carbohydrate diet (CCHO, diet that had the same amount of carbohydrates per meal).
During a trayline (an area where food was assembled) observation on 7/23/2024 at 12:20 p.m., the broccoli in the steam table looked overcooked and mushy.
During a test tray conducted with the Dietary Supervisor (DS) and Registered Dietitian (RD) on 7/23/2024 at 12:51 p.m. for regular diet (diet with no restrictions), broccoli was mushy, overcooked and no garlic flavor. DS stated the broccoli was mushy, overcooked, soft and it was served to everybody including soft diet textures. The DS stated the broccoli had no garlic flavor after tasting it. RD stated overcooked vegetables could lose its nutrients and flavor and as a potential outcome, residents would not get the proper nutrients they were supposed to get.
During a review of the facility's diet manual titled Regular diet dated 2020, it indicated The regular diet is designed to meet the nutritional needs of residents who do not need dietary modification or restrictions.
A review of the facility's recipe titled Recipe: Broccoli with Garlic dated week 4, Tuesday, 2024 indicated the recipe contained the following ingredients:
-Broccoli, fresh 12 pounds (lbs., unit of measurement) or frozen 15 lbs.
-Margarine, melted 1 1/8 c.
-Garlic powder 1 ½ - 3 tablespoon (tbsp, household measurement).
During a review of the facility's policies and procedures (P&P) titled Food Preparation dated 1/10/2024, the P&P indicated POLICY. Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value. Procedure: (1) All food will be prepared by methods that preserve nutritive value, flavor, and appearance and will be attractively served at the proper temperature and in a form that meet the individual needs of the resident. (6) Prepare foods as close as possible to serving time in order to preserve the nutritive value, freshness, and to prevent overcooking.

Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when:
1. Resident (Resident 33) on vegan (a diet containing plant and plant products only), lactose free diet (diet that consist of food with no lactose, a type of sugar in milk, found in milk, cheese and dairy products) received grilled cheese and bread stuffing containing eggs, poultry seasoning, low sodium chicken stock and lactose on her lunch tray.
2. Fifteen (15) of 78 residents on puree diet (food with smooth, pudding like consistency) had parsley flakes on top of puree foods as garnish.
These deficient practices had the potential to cause weight loss and frustrations (Resident 33), coughing, choking (to keep from breathing the normal way) and death for residents on puree diets.
Findings:
1. During a review of Resident 33's admission Record, it indicated the facility admitted the resident on 2/23/2020 with diagnoses including unspecified dementia (a form of mild or mixed dementia characterized with a mild cognitive impairment), iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells) and chronic kidney disease stage 3 (a reduced in kidney function associated loss of kidney function overtime).
During a review of Resident 33's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/30/2024, the MDS indicated Resident 33 had severe cognitive impairment (unable to reason and make their own decision) and able to eat with set-up or clean-up assistance.
During a review of Resident 33's diet order by physician, dated 6/17/2024, the physician order indicated Mechanical soft diet (foods that are soft and chopped), vegetarian diet, nectar/mildly thick (a fluid which flows off a spoon but slower than thin liquids) Additional directions: vegetarian diet, inner lip plate for all meals.
During a review of Resident 33's care plan (CP) initiated 5/30/2024, the CP indicated Resident is at risk for alteration in nutritional status and interventions included mechanically altered diet, lactose free milk. Adhere to food preferences. Resident requests grilled cheese sandwich.
During concurrent trayline observation (an area where resident's foods were assembled) and interview with Registered Dietitian (RD) and DS on 7/23/2024 at 12:40 p.m., Resident 33's meal ticket indicated a diet of order of mechanical soft, regular diet, fluids-nectar mildly thick. Adaptive Equipment: lip late. Notes: VEGAN, lactose free. Resident 33's tray contained grilled cheese, bread stuffing, broccoli, nectar thickened milk, juice, and water. The RD stated the tray was wrong because Resident 33 was not supposed to get grilled cheese due to resident was on vegan diet per diet ticket. The DS stated Resident 33 requested grilled cheese all the time and the diet needed to be changed to a vegetarian diet. The DS stated the meal ticket needed to reflect vegetarian diet instead of Vegan diet, however, she was not sure and needed to double check. The DS stated vegan diet should not receive dairy, milk, and cheese. The DS stated the resident was on a lactose free diet hence cheese should not be served on to the resident. The DS stated the potential outcome of not updating resident's diet ticket would be residents might not eat and could cause weight loss, frustrations, and complaints.
During a review of the facility's recipe titled Bread Dressing dated week 4, Tuesday 2024, the recipe indicated ingredients included poultry seasoning and low sodium chicken stock.
During a review of the facility's diet manual titled Vegetarian and Vegan Diet dated 2020, the diet manual indicated There are four general categories of adequate vegetarian diets: (1) Vegans use vegetables, salads, legumes, tofu, fruits, whole grains, nuts, and seeds. Excluded all animal products. (2) Lacto-ovo-vegetarians use the above plus dairy products (milk, butter, cheese, yogurt, and eggs (3) lacto-vegetarians use dairy items but not eggs.
During a review of the facility's diet manual titled Lactose Restricted Diet dated 2020, the diet manual indicated Description: This diet provides a restricted intake of lactose in the dietetic management of patients exhibiting lactose intolerance. Words that may indicate lactose in food: milk, lactose, margarine, butter, milk solids, curds, sweet cream, whey, cheese flavors and sour cream. Read labels carefully. Food to be avoided included cheese.
During a review of facility's policies and procedure (P&P) titled Resident Food Preferences revised 1/10/2024, the P&P indicated Procedure: Dietary Service Supervisor (DSS) will meet with resident or representative to go over food preferences, allergies, likes and dislikes upon admission and as needed. The DSS will update meal ticket according to resident food preferences, diet order and nourishments.
During a review of facility's P&P titled Menu, dated 1/10/2024, the P&P indicated (7) Individual resident trays will have a meal ticket which identifies the residents name, room number, diet order. Also sated on the card:
-Portion size.
-Food preferences
-Beverage preferences
-Allergies
-Nourishment order if applicable
Meal tickets are periodically checked by the Dietary Services Supervisor and/or Consultant Dietitian for accuracy.
2. During a review of the facility's summer menu spreadsheets (a list containing types and amount of foods of what each diet type would receive) dated 7/23/2024, the menu spreadsheets indicated puree diet included the following food items on the tray:
-Puree Roast Turkey ½ cup (c, household measurement)
-Gravy 1 oz (if needed)
-Puree Bread stuffing 2.7 ounces with gravy (oz, a unit of measurement)
-Puree Broccoli with garlic 2.7 oz
-Puree Wheat roll 2.7 oz
-Puree Glazed apple square 2.7 oz, except for the following diets: consistent carbohydrate diet (CCHO, diet that had the same amount of carbohydrates per meal).
During a trayline observation on 7/23/2024 at 12:20 p.m., staff used parsley flakes for puree diet garnishing.
During a test tray for puree diet tray conducted with the DS and the RD on 7/23/2024 at 12:51 p.m., the puree turkey, puree stuffing had parsley flakes garnish. The RD stated there was a lot of parsley flakes as a garnish that would produce lumps that would have a potential outcome of aspiration-to-aspiration risk residents. The RD stated puree diets were allowed to use parsley flakes per the facility policy.
During a review of the facility's diet manual titled Regular Pureed Diet dated 2020, the diet manual indicated Description: The Pureed Diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are normally in soft and smooth state such as pudding, ice cream, applesauce, mashed potatoes, etc. Food allowed included: raw vegetable- pureed, cooked vegetables-pureed.
During a review of facility's P&P titled Food Preparation dated 1/10/2024, the P&P indicated Foods will be cut, chopped, ground, or pureed to meet individual needs of the resident.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:
a.
Walk-in refrigerator shelves were chipped and cracked.
b.
Freezer one (1) and two (2) bottom shelves had dried up pink liquid, and dust buildup.
c.
One (1) dented can was stored with non-dented cans.
d.
Knife container had dust and sticky residue.
e.
One scoop had sticky and dirt debris was stored with the clean scoops.
f.
Scoop handles storage was not in one direction.
g.
Clean storage area for pots and pans had dust, crumbs, food residues and dried up food.
h.
Mixer had dirt and food buildup.
i.
Food carts used for lunch service had dried up milk spill and tape residues.
j.
Resident's food from home in the resident's refrigerator had no label and no received date.
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 78 of 78 medically compromised residents who received food and ice from the kitchen.
Findings:
a. During an initial kitchen tour observation on 7/23/2024 at 8:13 a.m. in the walk-in refrigerator, shelves was chipped and cracked.
During a concurrent observation of the walk-in refrigerator shelves and interview with Dietary Supervisor (DS) on 7/23/2024 at 8:41 a.m., the DS stated it was not okay that the paint of the shelves were coming off. The DS stated it did not look good and bacteria could live there and grow because it's a place to store food. DS stated the shelves surface should be smooth to prevent cross-contamination.
During a review of facility's Policies and Procedures (P&P) titled Sanitizing Equipment and Surfaces dated 1/10/2024, the P&P indicated (6) Dietary staff should ensure that all the equipment, shelves, utensils, and surface area are clean and in good condition.
During a review of Food Code 2017 , the P&P 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.
b. During an initial kitchen tour observation of the reach-in freezer one (1) on 7/23/2024 at 8:22 a.m., the bottom shelves had dried up pink liquid and dirt debris.
During an initial kitchen tour observation of the reach-in freezer two (2) on 7/23/2024 at 8:25 a.m., the bottom shelves had dirt and tape debris.
During a concurrent observation of the reach-in freezer 1 and 2 and interview with DS on 7/23/2024 at 8:36 a.m., DS stated the freezers had dirt and it was not supposed to be there. DS stated they cleaned the refrigerator daily when its dirty and deep clean it every Wednesdays. DS stated the spills, dust build up, sticker and label residues were not acceptable as it could attract germs. DS stated residents could get sick with diarrhea, vomiting, upset stomach and food poisoning as potential outcome.
During a review of facility's P&P titled Sanitation and Infection Control dated 1/10/2024 indicated Food service employees will follow infection control policies to ensure the department operates under sanitary condition at all times.
During a review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) NonFood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris.
c. During a concurrent observation of the dry storage area and interview with the DS on 7/23/2024 at 8:49 a.m., the DS stated there was one dented can along with undented cans. The DS stated there was a separate area for dented cans because they could not sure the dented cans as it was dangerous due to metal inside the can that could cause botulism (a serious illness caused by toxin that attacks the body's nerves). The DS stated when the can metal part was broken it would start to create or grow bacteria. The DS stated residents could die from it if they eat the food from dented cans as a potential outcome. The DS stated it was important to separate dented cans from non-dented cans to avoid using the product accidentally. The DS stated they needed to return cans that were dented even if it only had a little dent.
During a review of facility's P&P titled Storage of Canned and Dry Goods dated 1/10/2024, the P&P indicated 10. Canned items should be inspected for damage such as dented, leaking or bulging cans. These items will be stored separately in the designated area-DENTED CANS for return to the vendor or disposed of properly.
During a review of Food Code 2017, it 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 the knife container and interview with the DS on 7/23/2024 at 10:38 a.m., the DS stated the knife container had a sticky and dirt residue. DS stated staff cleaned the knife container every Wednesday and it was important to maintain the cleanliness for infection control.
e. During a concurrent observation of the scoop drawer and interview with the Registered Dietitian (RD) on 7/23/2024 at 10:49 a.m., a scoop with purple handle had sticky residue. RD stated the scoop had grease build up and it was stored along with the clean ones that could contaminate the rest. The RD stated it needed to be cleaned to prevent cross-contamination.
During a review of Food Code 2017, it indicated 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306.
f. During a concurrent observation of the scoop drawer and interview with the RD and the DS on 7/23/2024 at 10:49 a.m., the scoops used for trayline were stored in a cabinet with the handles in different direction. The RD stated the scoop storage as not organized but the storage was sanitary. The RD stated they follow the Retail Food Code but needed to check why the practice of storing the scoop handle in different direction was not a good practice.
During a review of Food Code 2017, it indicated 4-904.11 Kitchenware and Tableware (A) Single-service and Single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food-and lip-contact surfaces is prevented.
g. During a concurrent observation of the clean pots and pans storage area by the trayline and interview with the RD and the DS on 7/23/2024 at 11:04 a.m., the clean area had dust, crumbs, and other food debris. The RD stated there were crumbs in the pots and pans storage and needed to be cleaned to prevent cross-contamination. DS stated they would clean it today.
h. During a concurrent observation of the mixer and interview with the RD and the DS on 7/23/2024 at 11:08 a.m., the RD stated the mixer had dried up dirt. The DS stated they did not use the mixer always however it needed to be cleaned after each use. The DS sated they also needed to cover the mixer when not in sue as there was dust and dried up food residue. The DS stated it was important to clean the mixer as dirt could get into the food and residents could get sick when they ate the food.
During a review of Food Code 2017, it indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. 4-701.10 Food Contact Surfaces and Utensils shall be sanitized. 4-702.11 Before use After cleaning. Utensils and Food-Contact Surfaces of Equipment shall be sanitized before use after cleaning.
i. During concurrent observation of the food carts and interview with DS on 7/23/2024 at 11:18 a.m., the food carts had white dirt spill and tape residues. DS stated four (4) of 4 carts had dried up milk spill and needed to be cleaned to prevent cross-contamination. DS stated residents could get sick if the carts were not cleaned after each meal.
During a review of facility's P&P titled Cleaning Schedule dated 1/10/2024, the P&P indicated All areas and equipment should be cleaned daily. The assigned dietary personnel will deep clean the area equipment assigned for them that day using the dietary cleaning schedule. Daily cleaning schedule weekly checklist: refrigerators, freezers, tray carts and mixer.
j. During concurrent observation of the resident's refrigerator and interview with the Director of Nursing (DON) and the RD on 7/24/2024 at 9:10 a.m., a bottle of yogurt had no name and received date. The DON sated this was clearly their mistake that there was no name and label on the yogurt. The DS stated it was important to label food from the outside so that they would know who it belongs to and ensure diet correctness and meal restrictions of the residents. The DON stated they label outside food with name, received date and three (3) days self-life. The DS stated they follow labeling and dating policies from dietary. The RD stated it was important to label outside food to ensure correctness of diet texture and allergies of the residents. The RD stated allergic reactions and chocking as a potential outcome of not labeling outside food.
During a review of facility's P&P titled Resident's Refrigerator/Freezer Storage dated 1/10/2024, the P&P indicated (6) All items should be properly covered, dated, and labeled. Food items should have appropriate dates: delivery date-when received; open date-opened containers of PHF.
During a review of Food Code 2017, it 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.

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, plastic utensils, other dirt debris and liquid drippings from the garbage bin.
This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 78 of 78 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 7/24/2024 at 8:20 a.m., the bottom of the blue dumpster had soiled plastic spoon and fork, trash, and liquid drippings from dumpster. The DS stated the trash surroundings was not clean.
During a concurrent observation of the trash area and interview with the Maintenance Supervisor (MS) on 7/24/2024 at 8:22 a.m., the MS stated he was the one cleaning the trash area and brought the blower last Saturday to blow away the leaves. The MS stated they do not use water pressure to clean. The MS stated it was important to maintain the cleanliness of the trash's surroundings to prevent the spread of infection. The MS stated he did not know if the garbage area was clean or not clean.
During a concurrent observation of the trash area and interview with the Housekeeping Supervisor (HKS) on 7/24/2024 at 8:30 a.m., the HKS stated he cleaned the trash surroundings this morning but did not get to the bottom of the trash bin. The HKS stated the trash area had trash and liquid drippings. HKS stated they needed to keep the trash surroundings clean for the prevention of spread of infection.
During a record review of the facility's policies and procedures (P&P) titled Waste Control and Disposal dated 1/10/2024, the P&P indicated (6) Outside garbage bin should be kept closed at all times and surrounding area must be kept clean.
During a review of Food Code 2017, it indicated, 5-501.15 Outside receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.
During a review of Food Code 2017, it indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.

Based on interview and record review, the facility failed to provide appropriate hospice services (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) to one of three sampled residents (Resident 68) receiving hospice care by failing to officially designate the facility's staff member responsible for coordinating hospice services in the facility's policy and ensure the facility's licensed staff were aware of the facility's designated coordinator for hospice care.
These failures that the potential to prevent Resident 68 from receiving well-coordinated and comprehensive hospice services.
Cross reference to F580.
Findings:
During a review of the facility's policy and procedure (P&P) titled, Hospice Program, revised 7/2017, the P&P did not indicate the name and title of the staff to coordinate care provided to the resident by the facility staff and hospice staff.
During an interview on 7/25/2024 at 8:25 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 did not know who the facility's hospice coordinator was. LVN 3 stated the licensed nurses directly coordinated care with the hospice nurse and physician.
During an interview on 7/25/2024 at 9:11 a.m. with the Administrator (ADM), the ADM stated the Director of Nursing (DON) or the Registered Nurse (RN) supervisor coordinated care with the hospice.
During an interview on 7/25/2024 at 11:02 a.m. with the Treatment Nurse (TN 1), TN 1 did not know who the facility's hospice coordinator was.
During an interview on 7/25/2024 at 1:00 p.m. with Registered Nurse 2 (RN 2), RN 2 stated the DON communicated information from the hospice to the nursing staff.
During an interview on 7/25/2024 at 2:09 p.m. with the Director of Staff Development (DSD), the DSD did not know who the facility's hospice coordinator was.
During an interview on 7/25/2024 at 2:26 p.m. with the DON, the DON stated the Social Services Designee (SSD) and the DON are the facility's hospice coordinators. The DON stated the SSD is the facility's main hospice coordinator and the DON fills in when SSD is not available. The DON stated the SSD involved the interdisciplinary team (group of healthcare professionals working together to treat a person) and ensured the resident was appropriate for hospice.
During an interview on 7/26/2024 at 7:59 a.m. with the Minimum Data Set ([MDS] a comprehensive assessment and care planning tool) Nurse (MDSN), the MDSN did not know who the facility's coordinator was.
During an interview on 7/26/2024 at 11:30 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the hospice nurse came to the facility but did not know who the facility's hospice coordinator was.
During a concurrent interview and record review on 7/26/2024 at 12:12 p.m. with the ADM, the facility's P&P titled, Hospice Program, was reviewed. The ADM stated the facility's hospice coordinator was SSD with the DON and the ADM as back-up coordinators. The ADM stated the staff knew to communicate with SSD for any hospice related issues. The ADM reviewed the facility's P&P and stated the policy had blank lines that did not indicate the name and title of the staff to coordinate care provided to the resident by the facility staff and hospice staff. The ADM stated there could be gaps in communication and provision of care if the facility's staff did not know who the facility's hospice coordinator was.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 2's admission Record, it indicated the facility admitted the resident on 9/29/2022 and readmitted the resident on 1/25/2023 with diagnoses including dementia, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dermatitis (inflammation of the skin with dry skin, redness, and itchiness), and dermatophytosis (also known as ringworm, a fungal infection of the skin that may affect the skin, hair, and nails).
During a review of Resident 2s History and Physical (H&P) dated 2/20/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 2s MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance from staff with mobility; substantial/maximal assistance with tub/shower transfers; and supervision or touching assistance 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 2s care plan (CP), the CP indicated:
-Group A Streptococcus Infection, Resident is at risk for sore throat, cough, fever more than 99.6, skin infection; tenderness or pain, heat, swelling, serous drainage at affected site related to exposure initiated 7/12/2024 indicated to utilize appropriate PPE if indicated as one of the interventions.
During an observation on 7/23/2024 at 11:18 a.m. outside Resident 2's room by the door, observed a sign for EBP with instructions on the type of PPE to use during high contact activities with the resident. Observed inside the resident's room CNA 4 without a gown on while applying cream on Resident 2's skin.
During an interview on 7/23/2024 at 11:27 a.m. with CNA 4, CNA 4 stated the sign by the door indicated Resident 2 was placed on EBP and he should be wearing a gown while providing care to the resident as the facility currently has an outbreak for IGAS. CNA 4 stated not wearing a gown can spread the infection among residents and staff.
During an interview on 7/25/2024 at 9:53 a.m., with the IP, the IP stated that all residents were placed on EBP following an outbreak of IGAS in the facility and staff were in-serviced multiple times on hand hygiene, proper donning (put on) and donning (take off) of PPEs, types of isolations, and EBP. The IP stated staff should wear an isolation gown and gloves after proper hand hygiene during direct patient care or high contact activities for residents on EBP. The IP stated CNA 4 was present during the in-services and CNA 4 should have donned an isolation gown while applying a cream to Resident 2 to prevent spread of infection among other residents and staff.
During an interview on 7/26/2024 at 11:31 p.m., with the DON, the DON stated that all residents were placed on EBP due to exposure to IGAS infection. The DON stated CNA 4 should have donned an isolation prior to application of cream to Resident 2's skin. The DON stated all staff should wear an isolation gown and gloves after hand hygiene during close or direct patient care to prevent spread of infection among other residents and staff.
During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, last reviewed 1/10/2024, the P&P indicated EBP are utilized to prevent the spread of multi-drug resistant organisms (MDROs). The policy indicated:
1. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.
o
Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room).
Based on observation, interview, and record review the facility failed to implement and maintain an infection control program for two of six sampled residents (Resident 76 and Resident 2) reviewed under the Infection Control task by failing to:
1. Ensure Licensed Vocational Nurse 3 (LVN 3) monitored, identified, and reported Resident 76's open wounds (a break in the skin) with signs and symptoms (s/s) of invasive group A streptococcus (IGAS - a severe and sometimes life-threatening infection that is spread from person to person through respiratory droplets or touching other surfaces contaminated with bacteria that may invade parts of the body where bacteria are not usually found) on the left wrist.
2. Ensure Treatment Nurse 1 (TN 1) identified and reported Resident 76's open wounds with s/s of IGAS on the left wrist.
3. Ensure Resident 76's open wound was immediately tested for IGAS and the resident was placed in contact /droplet isolation (used to help prevent the spread of infectious agents that spread by direct or indirect contact with a resident or a resident's environment) for suspected IGAS or colonization of IGAS.
4. Ensure TN 1 administered the first dose of Keflex (an antibiotic [medication that fights infections caused by bacteria delivered directly into the bloodstream]) immediately or within four hours of receiving a verbal order from the Wound Care Consultant (WCC) for a resident with an active skin infection.
5. Ensure Certified Nursing Assistant 4 (CNA 4) wore a gown while providing care to Resident 2 who was placed on enhanced barrier precautions (EBP - a type of precaution that involves utilizing gown and gloves during high contact activities for residents with known infection or at risk for acquiring infections).
These deficient practices had the potential to spread microorganisms including IGAS to facility residents, visitors, and staff.
Cross reference to F580 and F760.
Findings:
a. During a review of Resident 76's admission Record, it indicated the facility admitted the resident on 4/4/2023 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), hypertension (a condition in which the force of the blood against the artery walls is too high), and malignant neoplasm (commonly referred to as cancer [term for a disease in which abnormal cells divide without control and can invade nearby tissues]) of the skin.
During a review of Resident 76's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/10/2024, the MDS indicated the resident was sometimes able to understand others and was sometimes able to make himself understood. The MDS further indicated the resident requires substantial/maximal assistance from staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility.
During a review of Resident 76's Care Plan (CP) titled, (Resident 76) has unspecified dermatitis. Location: generalized body rash (bilateral upper extremities, chest, back) ., initiated 6/13/2024, the CP indicated goals to promote healing without complications and will show no signs and development of infection. The CP indicated to monitor for signs and symptoms of infection (redness, presence of drainage, odor, pain), to report change in resident's kin condition to physician and resident's family, and to provide treatment as ordered.
During a review of Resident 76's physician orders, the physician orders indicated the following orders:
-Monitor for symptoms and signs of IGAS: cough; sore throat; fever; skin infection (tenderness or pain, heat, swelling, serous drainage [a clear to yellow fluid that leaks out of a wound and may be a sign of infection] at affected site) and document yes/no, (if yes, indicate in the nurse's note and call physician), every shift until 8/17/2024, dated 7/17/2024.
-Keflex oral capsule 500 milligrams (mg, a unit of measurement), give one capsule by mouth one time only for bacterial folliculitis (the hair follicle becomes infected/inflamed and forms a pustule), first dose from the emergency kit (e-kit, emergency drug supplies), dated 7/24/2024.
During an observation and interview on 7/23/2024 at 9:58 a.m., observed Resident 76 in a wheelchair (WC) outside the resident's room. Observed the resident with multiple open skin wounds on the left upper extremity and a clear dried substance crusted on the left dorsal wrist. Certified Nursing Assistant 9 (CNA 9) stated the resident had multiple open wounds on the left arm and he did not know when it started.
a.1. During a review of Resident 76's Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis), the MAR indicated on 7/23/2024 for the evening shift (3 p.m. to 7 p.m.), LVN 3 documented the resident did not have any signs or symptoms of IGAS.
During an observation, interview, and record review on 7/24/2024 at 11 a.m., with LVN 3 reviewed Resident 76's progress notes for July 2024. LVN 3 stated she was caring for Resident 76 on 7/23/2024 and 7/24/2024 and was not aware of any issues on the resident's skin. Observed LVN 3 assess Resident 76's left wrist while the resident sat in the WC in the hallway. LVN 3 stated the resident had open wounds with discharge on the L wrist that she was not aware of. LVN 3 stated she would do skin assessment daily of the resident, but on 7/23/2024 and 7/24/2024 she only scanned the resident while administering his medications. LVN 3 stated she relies on the CNAs to report any skin changes. LVN 3 reviewed the resident progress notes and stated there was no documentation that the resident had a change of condition (COC, decline in a resident's status) on the skin of the left wrist. LVN 3 called TN 1. LVN 3 stated TN 1 stated the resident was seen by the wound care consultant that morning and would be started on antibiotics for an infection.
During an interview on 7/24/2024 at 11:30 a.m., CNA 9 stated Resident 76 had an issue on his left wrist that was progressively getting worse. CNA 9 stated he did not know for how long the resident had the issue, but the charge nurses were aware.
During an interview on 7/24/2024 at 2:09 p.m., with the Infection Preventionist (IP), the IP stated the facility currently has an outbreak (OB, the occurrence of disease cases in excess of normal expectancy) for IGAS. The IP stated the guidance given to the facility by the Department of Public Health was to monitor all residents for signs and symptoms of IGAS including open wounds with signs of infection. The IP stated a resident identified with an open wound with signs of infection should immediately be placed in contact/droplet isolation, the wound should be tested to confirm or rule out IGAS, the primary physician should be notified, and treatment should be started.
During an interview and record review on 7/24/2024 at 5:26 p.m., with the IP reviewed Resident 76's Medication Administration Record (MAR) for 7/2024. The IP stated on 7/23/2024 evening shift LVN 3 documented that she monitored Resident 76 for s/s of IGAS and there were no s/s of skin infection present. The IP stated monitoring a resident's skin includes removing the clothing and completing a head-to-toe skin assessment. The IP stated when LVN 3 did not do a thorough skin assessment on Resident 76, LVN 3 did not identify the new skin issue and it resulted in a delay of the necessary care and treatment for the resident.
During an interview on 7/24/2024 at 8:25 a.m., with LVN 3, LVN 3 stated she did not remove Resident 76's sleeves or clothing to monitor the resident's skin. LVN 3 stated if she would have done a thorough skin assessment on 7/23/2024, she would have identified the change of condition. LVN 3 stated because she did not do a skin assessment and it resulted in a delay in care to the resident and a delay in placing the resident in isolation. LVN 3 stated things should have been done with more urgency.
During an interview on 7/25/2025 at 9:42 a.m., the IP stated anything new on a resident is a change of condition and should be reported. The IP stated LVN 3 did not follow the facility policy for monitoring for, identifying, and reporting a change of condition.
During a review of the facility policy and procedure (P&P) titled, Outbreak of Communicable Diseases, last reviewed 1/10/2024, the P&P indicated outbreaks of communicable diseases within the facility are promptly identified and managed. The infection preventionist and director of nursing are responsible for monitoring ill residents and staff and initiating transmission-based precautions as appropriate. The nursing staff are responsible for notifying the director of nursing services of newly symptomatic residents, providing infection surveillance data in a timely manner.
a.2. During an observation and interview on 7/24/2024 at 11 a.m., Licensed Vocational Nurse 3 (LVN 3) stated she was caring for Resident 76. Observed LVN 3 assessed Resident 76 sitting in a WC in the hallway and stated the resident had open wounds with discharge that she was not aware of. LVN 3 called TN 1. LVN 3 stated TN 1 stated the resident was seen by the WCC that morning and would be started on antibiotics for an infection.
During an interview on 7/24/2024 at 1:32 p.m., TN 1 stated she provides daily skin treatments to Resident 76's generalized body rash that includes the bilateral upper extremities (both arms). TN 1 stated the facility currently has an OB of IGAS and the public health nurse thinks resident rashes may be related to the OB. TN 1 stated she noticed on 7/23/2024 that Resident 76's left wrist was irritated and moist. TN 1 stated she did not report to anyone that on 7/23/2024 the resident's wrist was irritated and moist. TN 1 stated Resident 76's left wrist was crustier today when she made rounds with the WCC at 6:30 a.m. and the WCC verbally ordered antibiotics for an infection of Resident 76's left wrist wound. TN 1 stated she was not given a start date for the antibiotics, so she was going to enter the verbal order to give the first dose on 7/25/2024, the next day. TN 1 then stated antibiotics should be given immediately or within two hours of an order. TN 1 stated the antibiotics should have been given by 8:30 a.m. TN 1 stated it was now 1:45 p.m. and the antibiotics had not been administered to Resident 76. TN 1 stated when antibiotics are delayed a wound can get worse.
TN 1 further stated any residents with open wounds that have signs and symptoms of infection are considered possibly contagious and should be placed in contact/droplet isolation. TN 1 stated Resident 76 was not placed in contact/droplet isolation.
TN 1 stated the facility is currently swabbing all open wounds to test for IGAS, but resident 76 was not swabbed.
TN 1 stated she did not notify the IP or Director of Nursing (DON) that Resident 76 had an open skin wound with an infection, place the resident on contact/droplet isolation, or swab the resident's open wound because she was very busy that morning.
During a review of Resident 76's Skilled Nursing Facility Wound Care Consultant notes, dated 7/24/2024, the notes indicated Resident 76 had an infected wound with scant serous drainage. The notes indicated to start the resident on Keflex 500 mg, four times a day for seven days.
During an interview on 7/24/2024 at 2:09 p.m., with the IP, the IP stated the facility currently has an OB of IGAS. The IP stated the guidance given to the facility by the Department of Public Health was to monitor all residents for signs and symptoms of IGAS including open wounds with signs of infection. The IP stated a resident identified with an open wound with signs of infection should immediately be placed in contact/droplet isolation, the wound should be tested to confirm or rule out IGAS, the primary physician should be notified, and treatment should be started. The IP stated TN 1 did not notify her there were any newly identified residents with open wounds that had signs and symptoms of infection. The IP stated TN 1 should have notified her in the morning regarding Resident 76's wound so she could have assessed the wound, placed the resident in isolation, swabbed the wound for IGAS, and started the antibiotic treatment because the facility has an OB. The IP stated they want to prevent the OB from spreading to other residents.
During a review of Resident 76's Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis), the MAR indicated the following:
-On 7/24/2024 at 3:15 p.m., TN 1 documented the administration of Keflex 500 mg capsule.
During an interview on 7/24/2024 at 3:17 p.m., with the IP, the IP stated she just assessed Resident 76's left wrist and there is an open wound with serous drainage. The IP stated TN 1 should have identified Resident 76's change of condition on 7/23/2024 and again on 7/24/2024 when TN 1 was with the WCC. The IP stated TN 1 should have notified the IP immediately because there is an OB. The IP stated she spoke with TN 1 and TN 1 stated she did not notify the IP because she was overwhelmed.
During an interview on 7/25/2025 at 9:42 a.m., with the IP, the IP stated anything new on a resident is a change of condition and should be reported. The IP stated TN 1 did not follow the facility policy for monitoring for, identifying, and reporting a change of condition.
During an interview and record review on 7/25/2024 at 5 p.m., with the DON, reviewed the facility policies regarding antibiotic medication administration. The DON stated for a new order of antibiotics, the first dose should be given within four hours of receiving the order. The DON stated TN 1 should have asked someone for help when she was making rounds with the WCC and was given a verbal order to start Resident 76 on antibiotics. The DON stated the facility policies do not specifically indicate antibiotics must be started within four hours, but it is a standard of practice.
During a review of the facility policy and procedure (P&P) titled, Outbreak of Communicable Diseases, last reviewed 1/10/2024, the P&P indicated outbreaks of communicable diseases within the facility are promptly identified and managed. The infection preventionist and director of nursing are responsible for monitoring ill residents and staff and initiating transmission-based precautions as appropriate. The nursing staff are responsible for notifying the director of nursing services of newly symptomatic residents and providing infection surveillance data in a timely manner.
During a review of the facility provided Group A Streptococcal (GAS) Infections form, undated, the form indicated Group A streptococci are bacteria commonly found in the throat and on the skin. Usually, these bacteria cause strep throat but can cause life threatening skin rashes or other infections. These bacteria are spread by direct contact with nose and throat secretions of someone who has an active infection. The risk of spread is greatest when an individual is ill, such as when people have strep throat or an infected wound.
During a review of the facility provided Centers for Disease Control and Prevention, Decision Tool for investigating Group A Streptococcus Infections in Long-Term Care Facilities (LTCF), undated, it indicated one invasive case of GAS should prompt an epidemiological investigation by the LTCF infection control personnel. Identify additional symptomatic cases by surveying all residents for symptoms of GAS infection. Culture throat or skin lesions of residents as clinically indicated. Residents with suspected or confirmed GAS infection or colonization should be placed on appropriate Transmission-Based Precautions pending culture results: wound- residents with GAS cultured from a wound should remain on contact and droplet precautions until 24 hours after the initiation of effective antibiotic therapy and any wound drainage stops or can be contained by a dressing.
During a review of the facility policy and procedure titled, Infection control 'Isolation Precautions', last reviewed 1/10/2024, the P&P indicated it is the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions.
During a review of the facility policy and procedure titled, Organizational Aspects, last reviewed 1/10/2024, indicated the pharmacy provides routine and timely pharmacy services seven days a week and emergency pharmacy service 24 hours per day, seven days a week. Medications which should be promptly available, such as anti-infectives are available within four hours.
During a review of the facility policy and procedure titled, Medication Ordering and Receiving from Pharmacy, last reviewed 1/10/2024, indicated medications and related products are received from the dispensing pharmacy on a timely basis. Stat and emergency medications, the initial dose is obtained from the emergency kit and administered immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition for one of one sampled resident (Resident 46) investigated during a random observation when Resident 46's bed controller (device used to change the height and angle of the bed) cable was observed with exposed wires.
This deficient practice had the potential to place Resident 46 at risk for injury.
Findings:
During a review of Resident 46's admission Record, it indicated the facility admitted the resident on 8/26/2019 and readmitted on [DATE] with diagnoses including 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), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood, and history of falling.
During a review of Resident 46's History and Physical (H&P) dated 3/15/2024, the HP indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/16/2024, the MDS indicated the resident had severe cognition (mental action or process of acquiring knowledge and understanding) and required 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 an observation on 7/23/2024 at 10:17 a.m., inside Resident 46's room, Resident 46 was observed in the wheelchair with the bed controller placed on top of the resident's bed and within reach. Observed the base of the bed controller cable with the white, red, green, and yellow wires exposed.
During a concurrent observation and interview on 7/23/2024 at 10:17 a.m. inside Resident 46's room, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the base of resident's bed controller had exposed wires and further stated it is not safe for the resident to have exposed wires within their reach as it placed the resident at risk for injury from being electrocuted. CNA 1 stated she will notify the Maintenance Supervisor (MS) to change the bed controller.
During an interview on 7/26/2024 at 10:49 a.m., with the Director of Nursing (DON), the DON stated the maintenance department makes rounds every month to check for any malfunctioning equipment in the building. The DON stated the staff are supposed to report any equipment issues to the MS such as a bed control with exposed wires. The DON stated a bed control with exposed wires placed the resident's safety at risk.
During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, last reviewed 1/10/2024, the P&P indicated the following:
-
Maintenance service shall be provided to all areas of the building, grounds, and equipment.
-
The maintenance department is responsible for maintaining the buildings grounds, and equipment in a safe and operable manner at all times.
-
Maintaining the building in good repair and free from hazards
-
Maintaining the heat/cooling system, plumbing fixtures, wiring, etc. in good working order.

Based on observation, interview, and record review, the facility failed ensure resident rooms meet the requirement of 80 square feet (sq feet - a unit of measurement) per resident in multiple resident bedrooms (Rooms 1, 2, 3, 4, 5, 6, 8, 10, 12, 14, 16, 17, 18, 19, 20, 21, 22, 23, 25, and 34).
This deficient practice had the potential to result in inadequate usable living space and privacy for the residents and working space for the health caregivers.
Findings:
During a review of the Request for Room Size Waiver letter dated 7/23/2024 submitted by the Administrator, the letter indicated 19 rooms did not meet the 80 square feet requirement per federal regulation. The letter indicated the resident beds are in accordance with the special needs of the residents and will not adversely affect resident's health and safety and do not impede the ability of the residents in the room to obtain their highest practicable well-being.
The following rooms provided less than 80 square; feet per resident:
,
Rooms # Beds Floor Area Sq. Ft.
1 3 238
2 3 232
4 3 212
5 3 212
6 3 212
8 3 212
10 3 213
12 3 212
14 3 212
16 3 212
17 3 212
18 3 212
19 3 212
20 3 212
21 3 212
22 3 212
23 3 212
23 3 212
34 3 212
The minimum square footage for a 3-bed resident room should be 240 sq ft.
During a review of the Resident Council meeting minutes dated 5/21/2024, 6/18/2024, 7/9/2024, and 7/22/2024, the meeting minutes did not indicate there were no concerns brought up by the residents regarding the size of the rooms.
During a concurrent observation and interview with Resident 40 on 7/24/2024 at 6:26 p.m. inside the resident's room, observed Resident 40 moving freely inside the room. Resident 40 stated she can move freely in the room, and she had ample space for her personal belongings.
During interviews with staff on 7/24/2024 and 7/25/2024, there were no concerns regarding the size of the aforementioned rooms.
During a general observation of the mentioned resident rooms on 7/23/2024 to 7/25/2024, the residents had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There were also sufficient space for beds, side tables and resident care equipment.
The facility submitted a written request for continued waiver dated 7/23/2024.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when one (1) fly (a type of insect) was observed flying in the kitchen and landing on surfaces and yellow cake.
This deficient practice had a potential to result in 78 of 78 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.
Findings:
During a concurrent observation of the kitchen and interview with the Registered Dietitian (RD) and the Dietary Supervisor (DS) on 7/23/2024 at 10:53 a.m., an insect landed on the can opener. The RD stated the insect was a fly. The DS stated the fly could be coming from the breakroom or office when staff opened the door. The DS stated they did not want the fly on the food because it could transmit germs and residents could get sick and an infection.
During concurrent observation in the trayline (area where food was assembled) area and interview with the RD and the DS on 7/23/2024 at 12:34 p.m., a fly landed on a baked good placed on top of the trayline area. The DS stated the food on top of the trayline area was a yellow cake. The RD stated they would not use the yellow cake and would throw it away instead.
During a review of facility's Policy and Procedure (P&P), titled, Pest Control Policy, dated 1/10/2024, the P&P indicated, The facility shall maintain an effective pest control program. (1) This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

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 for two of two sampled residents (Residents 55 and 70) investigated under the dignity care area by:
1. Failing to ensure Certified Nursing Assistant 11 (CNA 11) was at eye level with Resident 55 while providing feeding assistance for Resident 55.
2. Failing to ensure Resident 70 did not disrobe (removing clothing) within public view.
These deficient practices had the potential to result in a decrease in the residents' psychosocial well-being and loss of dignity.
Findings:
1. During a review of Resident 55's admission Record, it indicated the facility admitted the resident on 8/29/2020 with diagnoses including 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 difficulty in walking.
During a review of Resident 55's History and Physical (H&P) dated 3/15/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 55's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/7/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision/touching assistance with mobility, and upper body dressing; total assistance from staff with eating; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 46's care plan titled, Resident has self-care deficits: need assistance with ADLs, initiated 8/29/2020 last revised 6/26/2024, the care plan indicated the resident required dependent assistance with eating. The care plan indicated the following interventions but not limited to:
-
Assist with ADLs as needed.
-
Maintain resident's privacy and respect their rights.
During an observation on 7/24/2024 at 8:30 a.m., observed Resident 55 in the wheelchair and CNA 11 standing over the resident and not within eye level while assisting the resident with eating.
During an interview on 7/24/2024 at 8:35 a.m., with CNA 11, CNA 11 stated that she should be sitting on a chair and at eye level while assisting Resident 55 with eating. CNA 11 stated it was important to sit and interact with the resident while assisting with eating for respect, maintain their dignity, and safety to ensure they can chew the food properly to prevent choking incident.
During an interview on 7/26/2024 at 11:15 a.m., the Director of Nursing (DON), the DON stated when assisting resident with eating, the best practice is for staff to sit at eye level with the resident to maintain respect and dignity.
During a review of the facility's policy and procedure titled, Dignity, last reviewed 1/10/2024, it indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.
During a review of the facility's policy and procedure titled, Resident Rights, last reviewed 1/10/2024, it indicated employees shall treat all residents with kindness, respect, and dignity. The policy indicated:
-
Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:
A dignified existence.
Be treated with respect, kindness, and dignity.
2. During a review of Resident 70's admission Record, it indicated the facility admitted Resident 70 on 9/8/2023 with diagnoses including, but not limited to, dementia (loss of memory, language, and other thinking abilities that interfere with daily life and gets worse over time), Alzheimer's Disease (a common type of dementia), major depressive disorder (a persistent feeling of sadness and loss of interest), and anxiety disorder (excessive worry and feelings of fear and uneasiness).
During a review of Resident 70's History and Physical (H&P), dated 11/8/2023, it indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 70's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/13/2024, the MDS indicated Resident 70 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect the everyday life) and needed maximum assistance with upper body dressing, lower body dressing, toileting, hygiene, and bathing.
During a review of Resident 70's Care Plan on 7/23/2024, a plan of care with interventions (action to help or change a situation) for the behavior of disrobing was not found.
During an observation on 7/23/2024 at 11:10 a.m., outside of Resident 70's room, Resident 70 could be viewed from the hallway disrobed from the waist up; the privacy curtain was partially drawn. Upon entering Resident 70's room, Resident 70 was up in her wheelchair with her shirt off, exposing her breasts while other residents were passing by the room. Resident 70 yelled out nonsensically (not making sense) when interview was attempted.
During a concurrent observation and interview on 7/23/2024, at 11:15 a.m., inside Resident 70's room, with Restorative Nursing Assistant (RNA) 1, RNA 1 assisted Resident 70 back into her shirt and stated that Resident 70 had the behavior of disrobing in the past. RNA 1 further explained the behaviors are to be reported to the charge nurse. When asked about privacy, RNA 1 confirmed the curtain was not completely closed and pulled the curtain over to provide privacy. RNA 1 further stated he will report the behavior to the charge nurse.
During an interview on 7/25/24 at 8:30 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated she cared for Resident 70 approximately 4 times in the last month and Resident 70 disrobed once or twice. CNA 7 further stated she reported to the charge nurse each time the resident had the behavior of disrobing but does not remember which date or charge nurse she reported it to.
During a concurrent interview and record review on 7/25/24 at 9:15 a.m., with the Director of Staff Development (DSD), reviewed the MAR and care plan of Resident 70. The DSD stated on 7/23/2024 she was covering as the charge nurse for the first shift (7:00 a.m.- 3:30 p.m.) in station two (the station that covers the area of Resident 70) and did not remember if the behavior of disrobing was reported to her that day. The DSD stated she remembers Resident 70 disrobing her shirt since she was admitted to the facility and any new identified behaviors are to be reported to the supervising registered nurse. The DSD further stated the behaviors are tallied in the MAR, but disrobing was not listed as a behavior to monitor in the MAR. The DSD continued by stating the behavior could affect Resident 70's dignity and privacy because anyone walking by can see her undressed.
During a concurrent interview and record review on 7/25/2024 at 9:55 a.m. with Registered Nurse (RN 2), reviewed the MAR, care plan and notes of Resident 70. RN 2 stated the disrobing behavior was not reported to her and if the behavior was not in the MAR, it was not care planned. RN 2 confirmed disrobing was not mentioned in any notes, care plans or the MAR in Resident 70's chart. RN 2 further stated there are a lot of males in the facility and it can affect resident 70's dignity as well as privacy.
During a review of the facility's policy and procedure (P&P) titled, Dignity, last reviewed 1/10/2024, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. The P&P further indicated staff shall promote, maintain, and protect resident privacy, including bodily privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a review of Resident 35's admission Record, it indicated the facility admitted the resident on 5/24/2023 with diagnoses including vascular dementia (a general term describing problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to the brain), hemiplegia (refers to total paralysis on one side of the body) and hemiparesis (refers to weakness or inability to move on one side of the body) following cerebral infarction (also known as stroke, a condition that refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, and altered mental status.
During a review of Resident 35's H&P dated 6/10/2024, the H&P it indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 35's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition and required 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 35's Fall Risk Assessments dated 5/31/2024, 5/29/2024, 2/27/2024, and 11/27/2023, the assessments indicated the resident was a high risk for falls.
During a review of Resident 35's care plans, the following care plans indicated:
a.
Resident 35 has self-care deficits dependent assistance with all ADLS, initiated 6/4/2023, with target date 8/27/2024, indicated the following interventions but not limited to:
o
Assist with ADLs as needed.
o
Provide a safe environment.
o
Call light within reach and attend needs promptly.
b.
Resident 35 is at risk foals/injury related to poor safety awareness/judgment, and dementia initiated 5/24/2023, last revised 3/8/2024, with target date of 8/27/2024, indicated the following interventions but not limited to:
o
Keep call light within easy reach and encourage resident to use it to get assistance.
o
Keep frequently used personal items within easy reach.
During a concurrent observation and interview on 7/23/2024 at 9:44 a.m. with CNA 2 inside Resident 35's room, observed the resident in the wheelchair parked on the right side of the bed approximately four floor tiles away. Observed the call light on top of the bed. CNA 2 verified Resident 35's call light was placed on top of the bed and was not within resident's reach. CNA 2 the call should be within reach so the resident can call for assistance when needed. CNA 2 stated Resident 3 can fall if assistance was not provided timely.
During a concurrent interview and review of on 7/26/2024 at 11:27 a.m., with the DON, the DON stated all call lights should be within resident reach for safety and prompt assistance with their needs. The DON stated staff would be unable to assist the residents with their needs if the call light was not within reach and may result in an accident.
During a review of the facility's policy and procedure titled, Call lights, last reviewed 1/10/2024, indicated a purpose to assure residents receive prompt assistance. The policy indicated:
o
All staff shall know how to place a call light for a resident and how to use the call light system.
o
Ensuring that the call light is within the resident's reach when in his/her room or when on the toilet.
o
Monitoring the lights and making sure that the lights are answered promptly, regardless of who is assigned to each resident.
2. During a review of Resident 52's admission Record, it indicated the facility admitted the resident on 5/12/2023 and readmitted the resident on 7/15/2024 with diagnoses that included intervertebral disc degeneration (the breakdown of the cushion between the bones of the spine) lumbar region (lower back), muscle weakness, history of falling, psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
During a review of Resident 52's MDS dated [DATE], the MDS indicated the resident was sometimes able to understand others and was sometimes able to make himself understood. The MDS further indicated the resident was dependent on staff for toileting, dressing, and mobility.
During a review of Resident 52's H&P, dated 7/15/2024, it indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 52's CP titled, (Resident 52) has self-care deficits, initiated 5/12/2023, the CP indicated a goal to minimize the risk of decline. The CP further indicated to provide a safe environment and place the call light within reach and attend to needs promptly.
During a review of Resident 52's CP titled, (Resident 52) has cognitive and communication deficit . initiated 5/12/2023, the CP indicated to keep the call light within reach.
During a review of Resident 52's CP titled, Actual Fall .factors: severe to no regards to his safety awareness due to advanced dementia, impaired cognition, confused and disoriented, initiated 6/4/2023, the CP indicated to attach the call to the bed within access of resident.
During an observation on 7/23/2024 at 9:25 a.m., Resident 52 was lying in bed with the call light clipped to the sheet of the bed on the left upper corner of the mattress. Observed the call light dangling behind the bed and out of reach of the resident while unattended by staff.
During an observation and interview on 7/23/2024 at 9:37 a.m., CNA 8 entered Resident 82's room and stated the call light was clipped to the mattress at the top left corner of the resident's bed. Observed CNA 8 move the call light and clipped it to the pillow. CNA 8 stated she moved the call light because it was not withing reach of the resident. CNA 8 stated it was important to have the call light within reach of the resident.
During an interview on 7/25/2024 at 1:19 p.m., with Registered Nurse 2 (RN 2), RN 2 stated every single resident in the facility should have the call light within reach because residents have fluctuating capabilities and at some point, they may use it. RN 2 stated the call light should always be within reach of the resident while in bed or in the wheelchair in the resident's room. RN 2 stated when the call light is not within reach, the resident could potentially try to get up unassisted and the resident could fall resulting in injuries like a brain bleed, a broken hip, or a broken arm.
During an interview on 7/25/2024 at 2:31 p.m., with the DON, the DON stated the facility policy indicates call lights should be within reach of all the facility residents.
A review of the facility policy and procedure titled, Call Lights, last reviewed 1/10/2024, indicated the purpose of the policy was to assure residents receive prompt assistance. Nursing and care duties include ensuring the call light is within the resident's reach when in his/her room.
3. During a review of Resident 31's admission Record, it indicated the facility admitted the resident on 6/23/2021 and readmitted the resident on 2/4/2022 with diagnoses that included psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), mood disturbance (mental health condition marked by disruptions in emotions), anxiety (feeling of worry, nervousness, or restlessness [uneasiness]), muscle weakness, history of falling, and syncope(a loss of consciousness for a short period of time) and collapse.
During a review of Resident 31's MDS dated [DATE], the MDS indicated the resident was sometimes able to understand others and was sometimes able to make herself understood. The MDS further indicated the resident required partial/moderate assistance from staff for oral hygiene, toileting, showering, dressing, and transferring from sit to stand.
During a review of Resident 31's H&P, dated 6/13/2024, it indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 31's CP titled, (Resident 31) is at risk for falls/injury . initiated 7/1/2023, the CP indicated to keep the call light within easy reach and encourage the resident to use it to get assistance.
During a review of Resident 31's CP titled, Actual Fall . status post fall from bed to floor pad . initiated 3/23/2024, the CP indicated to attach the call light to bed within access of resident.
During an observation on 7/23/2024 at 9:48 a.m., observed Resident 31 sitting in a wheelchair facing the window at the foot of the resident's bed. Observed the call light clipped to the sheet at the head of the right side of the bed while the resident was unattended by staff.
During an observation and interview on 7/23/2024 at 9:55 a.m., CNA 8 entered Resident 31's room and stated the resident was not able to move herself in the wheelchair. CNA 8 stated the call light did not reach the resident while sitting in the wheelchair and the call light was not within reach of the resident. CNA 8 stated the call light only needed to be within reach of the resident when the resident was in bed.
During an interview on 7/25/2024 at 1:19 p.m., with RN 2, RN 2 stated every single resident in the facility should have the call light within reach because residents have fluctuating capabilities and at some point, they may use it. RN 2 stated the call light should always be within reach of the resident while in bed or in the wheelchair in the resident's room. RN 2 stated there is an extension that may be added to the call light in order to ensure the resident has access while in the wheelchair. RN 2 stated when the call light is not within reach, the resident could potentially try to get up unassisted and the resident could fall resulting in injuries like a brain bleed, a broken hip, or a broken arm.
During an interview on 7/25/2024 at 2:31 p.m., with the DON, the DON stated the facility policy indicates call lights should be within reach of all the facility residents.
A review of the facility policy and procedure titled, Call Lights, last reviewed 1/10/2024, it indicated the purpose of the policy was to assure residents receive prompt assistance. Nursing and care duties include ensuring the call light is within the resident's reach when in his/her room.
4. During a review of Resident 57's admission Record, it indicated the facility admitted the resident on 9/4/2020 with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), unspecified dementia, and primary generalized osteoarthritis (condition that causes the joints to become very painful and stiff).
During a review of Resident 57's MDS dated [DATE], the MDS indicated the resident was sometimes able to understand others and was sometimes able to make herself understood. The MDS further indicated the resident was dependent on assistance from staff for toileting, showering, dressing, and transferring to the toilet or tub/shower.
During an observation on 7/23/2024 at 9:48 a.m., observed Resident 57 sitting in a wheelchair on the left side of the resident's bed. Observed the call light clipped to the upper right side of the resident's bed while unattended by staff.
During an observation and interview on 7/23/2023 at 9:55 a.m., with Resident 57 and CNA 8, CNA 8 stated the call light did not reach the resident while sitting in the wheelchair and the call light was not within reach of the resident. Resident 57 stated she did not have a call light.
During an interview on 7/25/2024 at 1:19 p.m., with RN 2, RN 2 stated every single resident in the facility should have the call light within reach because residents have fluctuating capabilities and at some point, they may use it. RN 2 stated the call light should always be within reach of the resident while in bed or in the wheelchair in the resident's room. RN 2 stated when the call light is not within reach, the resident could potentially try to get up unassisted and the resident could fall resulting in injuries like a brain bleed, a broken hip, or a broken arm.
During an interview and record review on 7/25/2024 at 2:31 p.m., with the DON, the DON stated the facility policy indicates call lights should be within reach of all the facility residents.
A review of the facility policy and procedure (P&P) titled, Call Lights, last reviewed 1/10/2024, the P&P indicated the purpose of the policy was to assure residents receive prompt assistance. Nursing and care duties include ensuring the call light is within the resident's reach when in his/her room.
Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences to five out of twelve residents (Resident 25, 52, 61, 7, and 135) investigated during review of environment facility task by failing to ensure:
1. The call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was available for Resident 25.
2. The call light was within reach for Resident 52, 31, 57, and 35.
These deficient practices had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being.
Findings:
1. During a review of Resident 25's admission Record, it indicated the facility admitted the resident on 4/28/2017, with diagnoses including but not limited to dementia (loss of memory, language, and other thinking abilities that interfere with daily life and gets worse over time), Alzheimer's Disease (a common type of dementia), adult failure to thrive (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and anxiety disorder (excessive worry and feelings of fear and uneasiness).
During a review of Resident 25's History and Physical (H&P), dated 10/7/2023, it indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 25's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/19/2024, the MDS the resident had severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect the everyday life) and was dependent on staff for toileting, eating, dressing, showering, and personal hygiene.
During a review of Resident 25's Care Plan (CP) titled, (Resident 25) has self-care deficits, initiated 4/3/2018 and revised on 6/4/2024, the CP indicated a goal to minimize the risk of decline. The CP further indicated to provide a safe environment and place the call light within reach and attend to needs promptly.
During a review of Resident 25's CP titled, (Resident 25) has cognitive and communication deficit . initiated 4/3/2018 and revised on 6/4/2024, the CP indicated to keep the call light within reach.
During a review of Resident 25's CP titled, Actual Fall .factors: severe to no regards to his safety awareness due to advanced dementia, impaired cognition, confused and disoriented, initiated 4/3/2018 and revised on 5/6/2024, the CP indicated to provide resident with a safe environment, and to keep call light within easy reach and encourage resident to use it to get assistance.
During a concurrent observation and interview on 7/23/2024 at 9:40 a.m. in Resident 25's room, Certified Nursing Assistance (CNA) 6 entered the room and confirmed Resident 25 did not have a call light available for use. CNA 6 stated having a call light available and within reach of the resident prevent accidents.
During an interview on 7/25/2024 at 6:25 p.m., the Director of Nursing (DON), the DON stated without a call light, it can cause a delay of care and the facility policy indicates call lights should be within reach of all the facility residents.
During a review of the facility policy and procedure titled, Call Lights, last reviewed 1/10/2024, it indicated the purpose of the policy was to assure residents receive prompt assistance. Nursing and care duties include ensuring the call light is within the resident's reach when in his/her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documented evidence that advance directives (AD, written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed with the residents and that the facility maintained a current copy of the resident's AD in the clinical record for three of four sampled residents (Resident 21, 52, and 57) reviewed under the Advance Directives care area.
These deficient practices violated the resident's rights and/or representative's right to be fully informed of the option to formulate an AD and had the potential to cause conflict with a resident's wishes regarding health care.
Findings:
a. During a review of Resident 21's admission Record, it indicated the facility admitted the resident on 5/4/2022 and readmitted the resident on 8/26/2022 with diagnoses that included Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks) unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood).
During a review of Resident 21's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/14/2024, the MDS indicated the resident was sometimes able to understand others and was sometimes able to make herself understood. The MDS further indicated the resident required substantial/maximal assistance from staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility.
During a review of Resident 21's Care Plan (CP) titled, Advance Directive initiated ., initiated 5/4/2022, the CP indicated to respect the resident and family's wishes.
During a review of Resident 21's Advance Directive Acknowledgment form (document provided by the facility that indicates whether a resident has an advance directive, would like information regarding creation of an advance directive, or refusal to create an advance directive), dated 5/4/2023, the form indicated the resident was not capable of making preferred intensity of care decisions. The form indicated Resident 21 had executed an Advance Directive.
During an interview and record review on 7/24/2024 at 11:08 a.m., with Licensed Vocational Nurse 3 (LVN 3), reviewed Resident 21's Advance Directive Acknowledgment form, dated 5/4/2023. LVN 3 stated the form indicated the resident had an AD, but the AD was not located in the resident's chart. LVN 3 stated the AD should be in the chart, but it was not there.
During an interview and record review on 7/25/2024 at 11:07 a.m. with the Director of Staff Development (DSD), the DSD reviewed Resident 21's Advance Directive Acknowledgment form, dated 5/4/2023. The DSD stated the resident's representative completed the form and indicated the resident had an AD, but there was no AD in the resident's chart.
During an interview on 7/25/2024 at 1 p.m., with Registered Nurse 2 (RN 2), RN 2 stated the AD is the resident's wishes for what they and their family want for their care including if the resident does not want to transfer to a hospital or wants to be do not resuscitate (DNR, do not perform life sustaining procedures). RN 2 stated the AD should be in the resident's chart.
During an interview and record review on 7/25/2024 at 2:31 p.m., with the Director of Nursing (DON), the DON reviewed the facility policy regarding ADs. The DON stated she was made aware that Resident 68's AD was not in the resident's chart, and they are following up with the family. The DON stated the AD should be kept in the resident's chart. The DON stated staff should have followed up to ensure the resident's AD was in the chart, but it is not there. The DON stated the importance of having the AD was to know the resident's wishes for care and if it is not available there is a potential the resident's wishes will not be followed. The DON stated the facility policy was not followed.
A review of the facility policy and procedure (P&P) titled, Advance Directives, last reviewed 1/10/2024, indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance Directive is written instructions, such as a living will or durable power of attorney for health care, recognized by state law, relating to the provisions of health care when the individual is incapacitated. Prior to admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident or representative indicates that he or she does not have an AD, the facility staff will offer assistance in establishing an AD. The resident or representative is given the option to accept or decline assistance. Nursing staff will document in the medical record the offer to assist and the decision to accept or decline. Information about whether the resident has executed an AD is displayed prominently in the medical record in a section of the record that is retrievable by any staff. If the resident has executed an AD, or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. The resident's wishes are communicated to the resident's direct care staff and physician by placing the AD documents in a prominent, accessible location in the medical record.
A review of the facility policy and procedure titled, Resident Rights, last reviewed 1/10/2024, indicated federal and state law guarantee certain basic rights to all residents of the facility. These rights include the resident's right to self-determination.
b. During a review of Resident 52's admission Record, it indicated the facility admitted the resident on 5/12/2023 and readmitted the resident on 7/15/2024 with diagnoses that included psychosis (severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality) and unspecified dementia.
During a review of Resident 52's MDS dated [DATE], it indicated the resident was sometimes able to understand others and was sometimes able to make himself understood. The MDS further indicated the resident was dependent on staff for toileting, dressing, and mobility.
During a review of Resident 52's History and Physical (H&P), dated 7/15/2024, it indicated the resident did not have the capacity to understand and make decisions. The H&P further indicated an Advance Directive was executed for the resident.
During a review of Resident 57's Advance Directive Acknowledgment form, dated 3/20/2024, it indicated the resident was not capable of making preferred intensity of care decisions. The form indicated Resident 21 had executed an Advance Directive.
During a review of Resident 52's Care Plan (CP) titled, Advance Directive initiated ., initiated 5/12/2023, the CP indicated to respect the resident and family's wishes.
During an interview and record review on 7/25/2024 at 11:07 a.m. with the DSD, the DSD reviewed Resident 21's Advance Directive Acknowledgment form, dated 3/20/2024. The DSD stated the resident's representative completed the form and indicated the resident had an AD, but there was no AD in the resident's chart.
During an interview on 7/25/2024 at 1 p.m., with RN 2, RN 2 stated the AD is the resident's wishes for what they and their family want for their care including if the resident does not want to transfer to a hospital or wants to be DNR. RN 2 stated the AD should be in the resident's chart.
During an interview and record review on 7/25/2024 at 2:31 p.m., with the DON, reviewed the facility policy regarding ADs. The DON stated she was made aware that Resident 52's AD was not in the resident's chart, and they are following up with the family. The DON stated the AD should be kept in the resident's chart. The DON stated staff should have followed up to ensure the resident's AD was in the chart, but it is not there. The DON stated the importance of having the AD was to know the resident's wishes for care and if it is not available there is a potential the resident's wishes will not be followed. The DON stated the facility policy was not followed.
A review of the facility policy and procedure (P&P) titled, Advance Directives, last reviewed 1/10/2024, the P&P indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance Directive is written instructions, such as a living will or durable power of attorney for health care, recognized by state law, relating to the provisions of health care when the individual is incapacitated. Prior to admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident or representative indicates that he or she does not have an AD, the facility staff will offer assistance in establishing an AD. The resident or representative is given the option to accept or decline assistance. Nursing staff will document in the medical record the offer to assist and the decision to accept or decline. Information about whether the resident has executed an AD is displayed prominently in the medical record in a section of the record that is retrievable by any staff. If the resident has executed an AD, or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. The resident's wishes are communicated to the resident's direct care staff and physician by placing the AD documents in a prominent, accessible location in the medical record.
A review of the facility policy and procedure (P&P) titled, Resident Rights, last reviewed 1/10/2024, the P&P indicated federal and state law guarantee certain basic rights to all residents of the facility. These rights include the resident's right to self-determination.
c. During a review of Resident 57's admission Record, it indicated the facility admitted the resident on 9/4/2020 with diagnoses that included Alzheimer's disease, and unspecified dementia.
During a review of Resident 57's MDS dated [DATE], the MDS indicated the resident was sometimes able to understand others and was sometimes able to make herself understood. The MDS further indicated the resident was dependent on assistance from staff for toileting, showering, dressing, and transferring to the toilet or tub/shower.
During a review of Resident 57's H&P, dated 10/17/2024, it indicated the resident did not have the capacity to understand and make decisions. The H&P indicated the resident had an AD.
During a review of Resident 57's CP titled, Advance Directive initiated ., initiated 9/14/2020, the CP indicated to respect the resident and family's wishes.
During a review of Resident 57's Advance Directive Acknowledgment form, dated 5/10/2021, it indicated the resident was not capable of making preferred intensity of care decisions. The form indicated a blank space on the line for the physician's signature, did not indicate a resident representative was informed of their rights to formulate an Advanced Directive, and did not indicate if the resident had executed and AD.
During an interview and record review on 7/25/2024 at 11:07 a.m. with the DSD, the DSD reviewed Resident 57's Advance Directive Acknowledgment form, dated 5/10/2023. The DSD stated the resident was not capable of making decisions and the representative did not complete the form. The DSD stated there was no documentation to indicate the resident's representative was informed of their right to formulate an AD and the form was not signed by the physician.
During an interview on 7/25/2024 at 1 p.m., with RN 2, RN 2 stated the AD is the resident's wishes for what they and their family want for their care including if the resident does not want to transfer to a hospital or wants to be DNR. RN 2 stated the social services department gets in touch with the residents family at admission and discusses the AD and the AD Acknowledgement form is completed.
During an interview and record review on 7/25/2024 at 2:31 p.m., with the DON, reviewed the facility policy regarding ADs. The DON stated she was made aware that Resident 57's AD Acknowledgment form was not completed, and they are following up with the family. The DON stated the AD acknowledgement form indicates that the family was made aware of their right to formulate an AD and without the form they do not know if the family wishes to formulate and AD or not. The DON stated the facility policy was not followed.
A review of the facility policy and procedure titled, Advance Directives, last reviewed 1/10/2024, indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance Directive is written instructions, such as a living will or durable power of attorney for health care, recognized by state law, relating to the provisions of health care when the individual is incapacitated. Prior to admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident or representative indicates that he or she does not have an AD, the facility staff will offer assistance in establishing an AD. The resident or representative is given the option to accept or decline assistance. Nursing staff will document in the medical record the offer to assist and the decision to accept or decline. Information about whether the resident has executed an AD is displayed prominently in the medical record in a section of the record that is retrievable by any staff. If the resident has executed an AD, or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. The resident's wishes are communicated to the resident's direct care staff and physician by placing the AD documents in a prominent, accessible location in the medical record.
A review of the facility policy and procedure (P&P) titled, Resident Rights, last reviewed 1/10/2024, the P&P indicated federal and state law guarantee certain basic rights to all residents of the facility. These rights include the resident's right to self-determination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 five residents with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns (Resident 68) and one of six sampled residents reviewed under the Infection Control task (Resident 76) by failing to:
1. Report Resident 68's refusal to participate in ROM exercises, especially to the right arm.
2. Report Resident 68's new onset pain and increased swelling in the right arm on 6/20/2024 to the primary physician and responsible party in accordance with Resident 68's care plan and the facility's policy.
These failures had the potential for Resident 68 to have an undetected injury in the right arm.
(Cross reference to F689 and F849.)
3. Ensure Licensed Vocational Nurse 3 (LVN 3) monitored, identified, and reported to the physician and the Infection Preventionist (IP) Resident 76's open wounds (a break in the skin) with signs and symptoms (s/s) of invasive group A streptococcus (IGAS - a severe and sometimes life-threatening infection that is spread from person to person through respiratory droplets or touching other surfaces contaminated with bacteria that may invade parts of the body where bacteria are not usually found) on the left wrist.
4. Ensure Treatment Nurse 1 (TN 1) identified and reported Resident 76's open wounds with s/s of IGAS on the left wrist.
These deficient practices had the potential to result in worsening of Resident 76's wound including necrotizing fasciitis (a life-threatening soft tissue infection) and in the spread of IGAS to facility residents, visitors, and staff.
Findings:
a. During a review of Resident 68's admission Record, the facility admitted Resident 68 on 6/30/2022 and readmitted on [DATE] with diagnoses including dementia (decline in mental ability severe enough to interfere with daily life), type 2 diabetes mellitus (high blood sugar), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning), Vitamin D deficiency (not enough Vitamin D needed for strong bones and teeth), and contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to the right hand, both elbows, and both knees. The admission Record indicated Resident 68 was admitted to palliative care (specialized medical care that focuses on providing patients relief from pain and other symptoms of a serious illness) on 2/26/2024 with diagnosis of cerebral atherosclerosis (blood vessels in the brain have become blocked by fatty substances).
During a review of Resident 68's care plan for spontaneous (sudden), pathological (caused by disease), stress (tiny breaks in bone) fracture (break in bone), initiated on 6/30/2022 and revised on 3/20/2024, the care plan interventions included to observe Resident 68 for sudden pain, swelling, and guarded movement (cautious with resistance, protecting against pain) of the extremity (arm or leg), handle gently and carefully during care, encourage mild exercises as tolerated and within joint limitation, and to notify the physician, responsible party, and the Hospice (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) Registered Nurse (Hospice RN) of changes in condition.
During a review of Resident 68's physician orders, dated 4/24/2023, the physician orders indicated for the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) to provide passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) to both arms, five times per week as tolerated. A review of another Resident 68's physician orders, dated 12/8/2023, indicated for the RNA to apply both elbow extension splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) and a right-hand roll (material placed in the hand to prevent the fingers from bending into the palm) for one to two hours per day, five times per week. A review of another Resident 68's physician orders, dated 2/13/2024, indicated for the RNA to provide PROM to both legs and apply a right knee extension splint for up to five hours, five times per week.
During a review of Resident 68's physician orders, dated 3/7/2024, the physician orders indicated to give two tablets of acetaminophen (pain medication) 325 milligrams ([mg] unit of weight) by mouth two times per day for pain management. A review of another physician order, dated 3/7/2024, indicated to give 0.25 mg of Morphine Sulfate (pain medication for moderate to severe pain) to Resident 68 by mouth every two hours as needed for moderate to severe pain.
During a review of Resident 68's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 6/10/2024, the MDS indicated Resident 68 was severely impaired for daily decision making, had ROM limitations in both arms and legs, and 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, upper and lower body dressing, rolling to both sides in bed, and chair/bed-to-chair transfers.
During a review of Resident 68's Documentation Survey Report (record of nursing assistant tasks) for RNA in 6/2024, the Documentation Survey Report indicated Resident 68 refused RNA for PROM to both arms and legs, application of the right knee extension splint, and application of both arm extension splint and the right-hand roll on 6/10/2024, 6/18/2024, 6/19/2024, 6/20/2024, 6/25/2024, 6/26/2024, and 6/27/2024.
During a review of Resident 68's Restorative Nursing (RNA) Weekly Summary - Range of Motion (ROM), dated 6/15/2024, 6/22/2024, and 6/29/2024, the RNA Weekly Summary - ROM indicated Resident 68 refused RNA for ROM and nursing (unknown) was notified.
During a review of Resident 68's RNA Weekly Summary - Splint Care, dated 6/15/2024, 6/22/2024, and 6/29/2024, the RNA Weekly Summary - Splint Care indicated Resident 68 refused to wear the right-hand roll, right elbow extension splint, and the right knee splint and nursing (unknown) was notified.
During a review of the RNA Monthly Meeting notes, dated 6/28/2024, the RNA Monthly Meeting notes indicated Resident 68 refused participating in RNA, had pain, and held the arm (unspecified) not wanting the RNA to move the arm.
During a review of Resident 68's Documentation Survey Report (record of nursing assistant tasks) for RNA in 7/2024, the Documentation Survey Report indicated Resident 68 refused RNA for PROM to both arms and legs, application of the right knee extension splint, and application of both arm extension splint and the right-hand roll on 7/9/2024, 7/10/2024, 7/11/2024, 7/16/2024 7/17/2024, and 7/18/2024. The Documentation Survey Report for RNA was blank for 7/7/2024, 7/8/2024, 7/14/2024, 7/15/2024, 7/21/2024 and 7/22/2024.
During a review of Resident 68's Restorative Nursing (RNA) Weekly Summary - ROM, dated 7/6/2024, 7/13/2024, and 7/20/2024, the RNA Weekly Summary - ROM indicated Resident 68 refused RNA for ROM and nursing (unknown) was notified.
During a review of Resident 68's RNA Weekly Summary - Splint Care, dated 7/6/2024, 7/13/2024, and 7/20/2024 the RNA Weekly Summary - Splint Care indicated Resident 68 refused to wear the right-hand roll, right elbow extension splint, and the right knee splint and nursing (unknown) was notified.
During a review of Resident 68's Hospice Skilled Nursing Visit Note, dated 7/15/2024 written by Hospice RN 1, the Hospice Skilled Nursing Visit Note indicated the facility's License Vocation Nurse (LVN) 1 notified Hospice RN 1 regarding Resident 68's right arm swelling and increased pain especially with movement. The Hospice Skilled Nursing Visit Note indicated Hospice RN 1 observed Resident 68s right arm which had whole arm swelling and pain with movement when gentle ROM was attempted. The Hospice Skilled Nursing Visit Note indicated Hospice RN 1 called Resident 68's Responsible Party (RP 1) to discuss observations during the visit, including worsening pain with movement in the right arm that prevents ROM, elevation of the arm, and adjustment to Resident 68's pain medication.
During a review of Resident 68's physician orders, dated 7/15/2024, the physician orders indicated to discontinue Resident 68's two tablets of acetaminophen 325 mg by mouth two times per day. The physician order, dated 7/15/2024, indicated for Resident 68 to start taking one tablet of Norco (medication used to treatment moderate to severe pain) which included 5 mg of hydrocodone (pain medication used to treatment moderate to severe pain) and 325 mg of acetaminophen (Norco 5/325 mg), two times per day routinely, for pain management.
During a concurrent observation and interview on 7/23/2024 at 3:30 p.m. with Certified Nursing Assistant (CNA) 8 in the bedroom, Resident 68 was sitting up in a reclining wheelchair. Resident 68 was using the left arm to hold onto the right arm. CNA 8 stated Resident 68 had pain and swelling in the right elbow but had not fallen or had any injury. CNA 8 attempted to lift Resident 68's right arm but Resident 68 immediately used the left arm to grab and guard the right arm, had a facial wince (gesture in the face of pain), and had tears in the left eye. CNA 8 stated Resident 68 appeared to be in 10 out of 10 pain (pain scale from zero [0], indicating no pain, to 10, indicating the worst pain possible) in the right arm because Resident 68's eye was tearing up. CNA 8 stated Resident 68 complained of right elbow pain for one to two weeks.
During an interview on 7/24/2024 at 7:47 a.m. with Restorative Nursing Aide (RNA) 3, RNA 3 stated the nurse (unknown) was giving Resident 68 pain medication prior to the RNA session this morning. RNA 3 stated Resident 68 was seen yesterday evening (7/23/2024) for RNA. RNA 3 stated Resident 68 did not tolerate the exercises to the right arm yesterday and did not apply the right arm splints due to Resident 68's right elbow pain and swelling. RNA 3 stated Resident 68 used the left arm to guard and hold onto the right arm. RNA 3 stated Resident 68 did not want anyone to touch her right arm due to the pain for the past month. RNA 3 stated Resident 68's right arm pain was reported to the Director of Rehabilitation (DOR) and the Director of Staff Development (DSD) during the monthly RNA Meeting.
During an observation on 7/24/2024 at 8:24 a.m. with RNA 3 in the bedroom, Resident 68 was lying in bed with swelling throughout the right arm compared to the left arm. RNA 3 stood on the left side of the bed and performed exercises to Resident 68's left shoulder, elbow, and hand. RNA 3 stood on the right side of the bed, lifted the right arm at the shoulder joint, and attempted to extend the elbow. Resident 68 immediately held onto the right arm using the left hand and flexed (bent) the body as a pain response. RNA 3 stated Resident 68 was in pain.
During an interview on 7/24/2024 at 9:15 a.m. with CNA 8, CNA 8 stated LVN 1 and the DSD were aware of Resident 68's right arm pain and Resident 68 was receiving pain medication.
During a concurrent interview and record review on 7/24/2024 at 10:25 a.m. with the DSD, the RNA Monthly Meeting notes, dated 6/28/2024, were reviewed. The DSD stated the RNA reported Resident 68 had pain and refused RNA. The DSD stated she saw Resident 68 the next day and observed Resident 68 had swelling in the right arm and pulled the right arm away due pain when the DSD attempted to move the right arm. The DSD stated Resident 68 did not have any previous reports of pain in the right arm.
During a concurrent interview and record review on 7/24/2024 at 10:42 a.m. with the DSD, Resident 68's Progress Notes, dated 6/1/2024 to 7/24/2024, and Change of Condition (COC) Assessment Forms were reviewed. The DSD stated the primary physician should be notified if a resident (in general) was in pain and refusing RNA sessions since it was a change of condition. The DSD reviewed Resident 68's Progress Notes and stated there was no documentation Resident 68's physician (MD 1) or the Hospice RN 1 was notified of Resident 68's change of condition, including right arm pain and refusing RNA. The DSD reviewed Resident 68's COC Assessment Forms and stated a COC Assessment Form was not completed for Resident 68's refusal to participate in RNA and increased pain to the right arm.
During a concurrent interview and record review on 7/24/2024 at 11:38 a.m. with the Director of Nursing (DON), Resident 68's Progress Notes, dated 6/1/2024 to 7/24/2024, and Change of Condition (COC) Assessment Forms were reviewed. The DON stated the facility provided all treatments to residents on hospice, including Resident 68. The DON stated the process when a resident (in general) refused RNA included the RNA informing the licensed nurse, who would gather more information and assess the resident. The DON stated Resident 68's refusal to participate in RNA and right arm pain was a change of condition that should have been reported to MD 1. The DON stated Resident 68's arm contractures increased Resident 68's risk for injury. The DON stated Resident 68 could be experiencing right elbow pain due to the contracture or could have an injury. The DON reviewed Resident 68's Progress Notes, dated 6/1/2024 to 7/24/2024, and the COC Assessment Forms. The DON stated Resident 68's clinical record did not include a COC Assessment Form and the Progress Notes did not indicate Resident 68 had right arm pain and refused RNA. The DON stated the licensed nurses should have completed documentation indicating Resident 68's right arm pain, refusal to participate in RNA, and a COC Form Assessment, which would have included notification to MD 1. The DON stated Resident 68's change of condition should have been monitored and addressed as a team, including the physician, nursing, and the hospice team.
During a telephone interview on 7/25/2024 at 8:11 a.m. with Resident 68's Responsible Party (RP 1), RP 1 stated Hospice RN 1 usually called RP 1 regarding Resident 68's care. RP 1 stated the facility did not inform RP 1 that Resident 68 had right arm pain and refused exercises. RP 1 stated Hospice RN 1 contacted RP 1 about Resident 68's right arm swelling and changing medications but was not informed Resident 68 had right arm pain and refused exercises. RP 1 felt uncomfortable that the facility did not contact RP 1 directly and wanted to know the cause of Resident 68's right arm pain.
During an interview on 7/25/2024 at 12:04 p.m. with Hospice RN 1, the Hospice physician (Hospice MD 1), and the DON, the Hospice RN 1 stated LVN 1 reported Resident 68 had more swelling, stiffness, and pain in right arm on 7/15/2024. Hospice RN 1 stated Resident 68 did have with more body stiffness and pain during the assessment on 7/15/2024. Hospice RN 1 stated Hospice RN 1 called RP 1 about the recommendation to adjust Resident 68's pain medication to Norco 5/325 mg, which Hospice MD 1 prescribed. Hospice MD 1 stated Resident 68's new onset pain and swelling could be associated with injury but would not recommend any tests since Resident 68 was on hospice care.
During an interview on 7/25/2024 at 1:00 p.m. with the DON, the DON reviewed the facility's policy and procedure (P&P), titled Change of Condition. The DON stated the facility did not follow the P&P since the facility did not contact MD 1 and RP 1.
During a concurrent interview and record review on 7/25/2024 at 5:29 p.m. with the DON, the DON reviewed Resident 68's Documentation Survey Report for 6/2024 and 7/2024. The DON stated the licensed nurse should have completed Resident 68's COC Assessment Form on 6/20/2024, which was Resident 68's fourth RNA refusal. The DON stated Resident 68's COC Assessment would have included communication to the DON, the hospice team, MD 1, and RP 1. The DON stated the DON knew about Resident 68's increased pain, inability to tolerate exercises with RNA, and increase in pain medication to Norco 5/325 mg on 7/15/2024 but did not further investigate the reason for Resident 68's need for increased pain medication. The DON stated the facility did not contact RP 1 because Hospice RN 1 called RP 1 on the facility's behalf.
During a concurrent interview and record review on 7/26/2024 at 11:30 a.m. with LVN 1, Resident 68's MAR for 6/2024 and Progress Notes, dated 6/1/2024 to 7/24/2024, were reviewed. LVN 1 stated either the CNA (unknown) or the Hospice CNA (unknown) informed LVN 1 that Resident 68 had pain the right arm which was new for Resident 68. LVN 1 stated Resident 68 moaned and grimaced with movement to the right arm on 6/21/2024 and administered Morphine. LVN 1 reviewed Resident 68's Progress Notes and stated LVN 1 contacted Resident 68's hospice when the Morphine was administered and should have documented the communication with the hospice team in Resident 68's Progress Note. LVN 1 stated Resident 68 did not have any pain if lying in bed but did have pain when moving Resident 68's right arm. LVN 1 stated the change of condition documentation, which included notifying the RN to further assess the resident, informing the resident's primary physician, and contacting the responsible party, was not completed for Resident 68's right arm pain and swelling because Resident 68 was on hospice. LVN 1 stated the facility educated LVN 1 to communicate with the hospice team if Resident 68 had any changes in condition. LVN 1 stated a COC Assessment Form should have been completed for Resident 68's right arm pain and swelling, which should have been monitored for 72 hours. LVN 1 stated she did not know Resident 68 refused RNA sessions.
During a concurrent interview and record review on 7/26/2024 at 12:01 p.m. with LVN 1 and RNA 3, Resident 68's RNA Weekly Summary - ROM and Splint Care, dated 6/15/2024, 6/22/2024, and 6/29/2024, were reviewed. RNA 3 reviewed Resident 68's RNA Weekly Summaries, which indicated RNA 3 informed the licensed nurse. RNA 3 stated LVN 1 was not informed about Resident 68's refusal to participate in ROM and application of splints and did not remember which licensed nurse was informed.
During a review of the facility's undated P&P titled, Change of Condition, the P&P indicated the facility ensured proper assessment and follow-through for any resident with a change in condition. The P&P indicated all changes of condition in a resident shall be handled promptly, which included prompt notification of the resident's physician, completion of the nursing report, daily assessment of the resident, and documentation of the change of condition.
b. During a review of Resident 76's admission Record, it indicated the facility admitted the resident on 4/4/2023 with diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities), hypertension (a condition in which the force of the blood against the artery walls is too high), and malignant neoplasm (commonly referred to as cancer [term for a diseases in which abnormal cells divide without control and can invade nearby tissues]) of skin.
During a review of Resident 76's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/10/2024, the MDS indicated the resident was sometimes able to understand others and was sometimes able to make himself understood. The MDS further indicated the resident requires substantial/maximal assistance from staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility.
During a review of Resident 76's Care Plan (CP) titled, (Resident 76) has unspecified dermatitis. Location: generalized body rash (bilateral upper extremities, chest, back) ., initiated 6/13/2024, the CP indicated goals to promote healing without complications and will show no signs and development of infection. The CP indicated to monitor for signs and symptoms of infection (redness, presence of drainage, odor, pain), to report change in resident's kin condition to physician and resident's family, and to provide treatment as ordered.
A review of Resident 76's physician orders indicated the following orders:
-Monitor for symptoms and signs of IGAS: cough; sore throat; fever; skin infection (tenderness or pain, heat, swelling, serous drainage [a clear to yellow fluid that leaks out of a wound and may be a sign of infection] at affected site) and document yes/no, (if yes, indicate in the nurse's note and call physician), every shift until 8/17/2024, dated 7/17/2024.
During an observation and interview on 7/23/2024 at 9:58 a.m., with Certified Nursing Assistant 9 (CNA 9) observed Resident 76 in a wheelchair (WC) outside the resident's room. Observed the resident with multiple open skin wounds on the left upper extremity and a clear dried substance crusted on the left dorsal wrist. CNA 9 stated the resident had multiple open wounds on the left arm and he did not know when it started.
b.1. During a review of Resident 76's Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis), the MAR indicated on 7/23/2024 for the evening shift (3 p.m. to 7 p.m.), LVN 3 documented the resident did not have any signs or symptoms of IGAS.
During an observation, interview, and record review on 7/24/2024 at 11 a.m., with LVN 3, reviewed Resident 76's progress notes for July 2024. LVN 3 stated she was caring for Resident 76 on 7/23/2024 and 7/24/2024 and was not aware of any issues on the resident's skin. Observed LVN 3 assess Resident 76's left wrist while the resident sat in the WC in the hallway. LVN 3 stated the resident had open wounds with discharge on the L wrist that she was not aware of. LVN 3 stated she should do a skin assessment daily of the resident, but on 7/23/2024 and 7/24/2024 she only scanned the resident while administering his medications. LVN 3 stated she relies on the CNAs to report any skin changes. LVN 3 reviewed the resident progress notes and stated there was no documentation that the resident had a change of condition (COC, decline in a resident's status) on the skin of the left wrist.
During an interview on 7/24/2024 at 11:30 a.m., with CNA 9, CNA 9 stated Resident 76 had an issue on his left wrist that was progressively getting worse. CNA 9 stated he did not know for how long the resident had the issue, but the charge nurses were aware.
During an interview on 7/24/2024 at 2:09 p.m., with the Infection Preventionist (IP), the IP stated the facility currently has an Outbreak (OB, the occurrence of disease cases in excess of normal expectancy) for IGAS. The IP stated the guidance given to the facility by the Department of Public Health was to monitor all residents for signs and symptoms of IGAS including open wounds with signs of infection. The IP stated a resident identified with an open wound with signs of infection should immediately be placed in contact/droplet isolation (used to help prevent the spread of infectious agents that spread by direct or indirect contact with a resident or a resident's environment), the wound should be tested to confirm or rule out IGAS, the primary physician should be notified, and treatment should be started.
During an interview and record review on 7/24/2024 at 5:26 p.m., with the IP, reviewed Resident 76's Medication Administration Record (MAR) for 7/2024. The IP stated on 7/23/2024 evening shift LVN 3 documented that she monitored Resident 76 for s/s of IGAS and there were no s/s of skin infection present. The IP stated monitoring a resident's skin includes removing the clothing and completing a head-to-toe skin assessment. The IP stated when LVN 3 did not do a thorough skin assessment on Resident 76, LVN 3 did not identify the new skin issue and it resulted in a delay of the necessary care and treatment for the resident.
During an interview on 7/24/2024 at 8:25 a.m., LVN 3 stated she did not remove Resident 76's sleeves or clothing to monitor the resident's skin. LVN 3 stated if she would have done a thorough skin assessment on 7/23/2024, she would have identified a change of condition. LVN 3 stated because she did not do a skin assessment, it resulted in a delay in care to the resident and a delay in placing the resident in isolation. LVN 3 stated things should have been done with more urgency.
During an interview on 7/25/2025 at 9:42 a.m., with the IP, the IP stated anything new on a resident is a change of condition and should be reported. The IP stated LVN 3 did not follow the facility policy for monitoring for, identifying, and reporting a change of condition.
During a review of the facility policy and procedure (P&P) titled, Change of Condition, last reviewed 1/10/2024, the (P&P) indicated the purpose of the policy was to ensure proper assessment and follow through for any resident with a change of condition. A change of condition is a sudden or marked difference in resident's drainage from a wound (anything abnormal), open or red areas, rashes, or skin conditions (swelling or discoloration). All changes of condition in a resident shall be handled promptly. The physician shall be called promptly. Documentation of change in condition shall be performed by the licensed nurse accordingly and a change of condition will be completed as indicated.
[NAME] a review of the facility policy and procedure (P&P) titled, Charting and Documentation, last reviewed 1/10/2024, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation of procedures and treatments will include care-specific details, including the date and time the procedure/treatment was provided, the assessment data and/or any unusual findings obtained during the procedure/treatment, whether the resident refused the procedure/treatment, and the notification of family, physician or other staff if indicated.
b.2.During an interview on 7/24/2024 at 1:32 p.m., with TN 1, TN 1 stated she provides daily skin treatments to Resident 76's generalized body rash that includes the bilateral upper extremities (both arms). TN 1 stated the facility currently has an OB of IGAS and the public health nurse thinks the resident's rashes may be related to the OB. TN 1 stated she noticed on 7/23/2024 that Resident 76's left wrist was irritated and moist. TN 1 stated she did not report to anyone that the resident's wrist was irritated and moist. TN 1 stated Resident 76's left wrist was crustier today when she made rounds with the Wound Care Consultant (WCC) at 6:30 a.m. and the WCC verbally ordered antibiotics for an infection of Resident 76's left wrist wound. TN 1 stated any residents with open wounds that have signs and symptoms of infection are considered possibly contagious and should be placed in contact/droplet isolation. TN 1 stated she did not notify the IP or DON that Resident 76 had an open skin wound with an infection because she was very busy.
During a review of Resident 76's Skilled Nursing Facility Wound Care Consultant notes, dated 7/24/2024, it indicated Resident 76 had an infected wound with scant serous drainage. The notes indicated to start the resident on Keflex (a medication that treats infections) 500 milligrams (mg-unit of measurement), four times a day for seven days.
During an interview on 7/24/2024 at 2:09 p.m., with the IP, the IP stated the facility currently has an OB of IGAS. The IP stated the guidance given to the facility by the Department of Public Health was to monitor all residents for signs and symptoms of IGAS including open wounds with signs of infection. The IP stated a resident identified with an open wound with signs of infection should immediately be placed in contact/droplet isolation, the wound should be tested to confirm or rule out IGAS, the primary physician should be notified, and treatment should be started. The IP stated TN 1 did not notify her there were any newly identified residents with open wounds that had signs and symptoms of infection. The IP stated TN 1 should have notified her in the morning regarding Resident 76's wound so she could have assessed the wound, placed the resident in isolation, swabbed the wound for IGAS, and started the antibiotic treatment because the facility has an OB. The IP stated they want to prevent the OB from spreading to other residents.
During an interview on 7/24/2024 at 3:17 p.m., with the IP, the IP stated she just assessed Resident 76's left wrist and there is an open wound with serous drainage. The IP stated TN 1 should have identified Resident 76's change of condition on 7/23/2024 and again on 7/24/2024 when TN 1 was with the WCC. The IP stated TN 1 should have notified the IP immediately because there is an OB. The IP stated she spoke with TN 1 and TN 1 stated she did not notify the IP because she was overwhelmed.
During an interview on 7/25/2025 at 9:42 a.m., with the IP, the IP stated anything new on a resident is a change of condition and should be reported. The IP stated TN 1 did not follow the facility policy for monitoring for, identifying, and reporting a change of condition.
During a review of the facility policy and procedure titled, Change of Condition, last reviewed 1/10/2024, the P&P indicated the purpose of the policy was to ensure proper assessment and follow through for any resident with a change of condition. A change of condition is a sudden or marked difference in resident's drainage from a wound (anything abnormal), open or red areas, rashes, or skin conditions (swelling or discoloration). All changes of condition in a resident shall be handled promptly. The physician shall be called promptly. Documentation of change in condition shall be performed by the licensed nurse accordingly and a change of condition will be completed as indicated.
During a review of the facility policy and procedure titled, Charting and Documentation, last reviewed 1/10/2024, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation of procedures and treatments will include care-specific details, including the date and time the procedure/treatment was provided, the assessment data and/or any unusual findings obtained during the procedure/treatment, whether the resident refused the procedure/treatment, and the notification of family, physician or other staff if indicated.
During a review of the facility policy and procedure titled, Outbreak of Communicable Diseases, last reviewed 1/10/2024, the P&P indicated outbreaks of communicable diseases within the facility are promptly identified and managed. The infection preventionist and director of nursing are responsible for monitoring ill residents and staff and initiating transmission-based precautions as appropriate. The nursing staff are responsible for notifying the director of nursing services of newly symptomatic residents and providing infection surveillance data in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one out of one sampled resident (Resident 46) investigated during a random observation by:
1. Failing to obtain an appropriate physician order for the use of bed pad alarm (a pressure-sensitive pad placed under the mattress or seat cushion that trigger an alarm or warning light when they detect a change in pressure).
2. Failing to assess Resident 46 quarterly for continued use of the bed pad alarm per facility policy and procedure.
These deficient practices Resident 46 at risk for unnecessary prolonged use of restraints, restriction from freedom of movement which can lead to a decline in functioning.
Findings:
During a review of Resident 46's admission Record, the facility admitted the resident on 8/26/2019 and readmitted on [DATE] with diagnoses including 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), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood, and history of falling.
During a review of Resident 46's History and Physical (H&P) dated 3/15/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/16/2024, the MDS indicated the resident had severe cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 46 used a bed alarm.
During a review of Resident 46's Order Summary Report, it indicated the following physician's order dated 7/29/2022:
- Non-Restraint. Apply pad alarm in bed as nursing intervention to alert staff for unassisted transfer and attempting to walk. Nursing staff to check proper placement and function every shift.
During a review of Resident 46's care plan (CP), the CP indicated the following:
1. Risk for falls or injury related but not limited to dementia, generalized weakness, history of falls, and impaired cognition initiated on 7/4/2023 and a goal to reduce falls and injury daily with a target date 8/14/2024. The care plan indicated to apply bed pad alarm to alert staff for unassisted transfer and attempting to walk ad nursing staff to check proper placement and function every shift as one of the interventions.
2. Falling Star program: At risk for falls related to balance deficit, bladder/bowel dysfunction, cognitive impairment, history of falls, etc. initiated on 7/23/2024 and a goal to reduce risk for fall and /or injury thru appropriate interventions daily with a target date 8/14/2024, indicated bed pad alarm as one of the interventions.
During a review of Resident 46's Fall Risk Assessments dated 5/16/2024, 2/12/2024, and 11/16/2023, it indicated the resident is a high risk for falls.
During a review of resident 46's Restraint - Physical (Quarterly/Annual Evaluation), it indicated the facility reassessed the resident for continued use of the bed pad alarm on 2/12/2024, 11/30/2023, and 8/31/2023. There was no documented evidence Resident 46 was reassessed on 5/2024.
During a concurrent observation and interview on 7/25/2024 at 10:34 a.m. with Registered Nurse 2 (RN 2) and Certified Nursing Assistant 3 (CNA 3) inside Resident 46's room, observed Resident 46 constantly moving in bed from left to right. RN 2 stated the bed pad alarm will trigger a sound when it detected a change in pressure when Resident 46 was moving from side to side. RN 2 stated the bed pad alarm was a nursing intervention and not considered a restraint.
During a concurrent interview and record review on 7/26/2024 at 12:20 p.m., reviewed Resident 46's physician's order for bed alarm, informed consent, care plans, and restraint assessments with the Director of Nursing (DON). The DON stated the bed pad alarm was a nursing intervention to help prevent Resident 46 from rolling out of bed by accident and sustain injury. The DON stated the bed pad alarm is not considered a restraint by the facility as indicated in the physician's order. However, the DON stated the bed pad alarm is a restraint as it restricts the resident's movements because when the resident moves, the alarm will sound. The DON stated the physician's order should have indicated the bed pad alarm as a restraint. The DON verified there was no documented evidence of a restraint assessment/reassessment on 5/2024. The DON stated restraint assessments are supposed to be completed quarterly, annually, and as needed to evaluate necessity for continued use of the bed pad alarm.
During a review of the facility's policy and procedure titled, Physical Restraints, last reviewed 1/10/2024, indicated physical restraint assessment and use shall be managed accordingly. The policy indicated the following:
1. The licensed nurse shall be responsible for obtaining an order form the attending physician, which is to include:
- Specific type of restraint.
- Purpose of the restraint.
- Time and place of application.
- Approaches to prevent decreased functioning when applicable.
- Informed consent obtained from resident or from surrogate decision-maker.
During a review of the facility's policy and procedure titled, Use of Restraints, last reviewed 1/10/2024, indicated retrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive method of restraints, or total restraint elimination.

Based on interview and record review the facility failed to implement policies and procedures (P&P) related to screening (sometimes called background check - a process a person or company uses to verify that an individual is who they claim to be and do not possess a criminal record) procedures by failing to conduct a background check screening prior to employment of one of seven staff members (Restorative Nursing Assistant 1, [RNA 1] ) investigated under the sufficient and competent nurse staffing facility task.
This failure placed the residents at risk for abuse, neglect, and exploitation, and misappropriation of resident property for approximately nine months.
Findings:
During a concurrent interview and record review on 7/25/2024 at 3:30 p.m. with the Director of Staff Development (DSD), reviewed Restorative Nursing Aides (RNA - Certified Nursing Assistants [CNA] with specialized training to help residents regain their physical function and quality of life after illness or injury) 1's employee file. The DSD stated RNA 1 was hired on 4/9/2019 and did not have a background check screening until 1/15/2022. The background check came back with a criminal record of driving with a suspended license, misdemeanor. The DSD further stated she was unsure why the background check was completed late, and the delay put the residents at risk.
During an interview on 7/25/2024 at 6:40 p.m. with the Director Of Nursing (DON), the DON stated background checks must be completed prior to employment to ensure the safety of the residents and staff. The DON further stated RNA 1 should not have started working until the background check was completed and that facility's policy was not followed.
During a review of the facility's policy and procedure (P&P) titled, Hiring Process, last reviewed 1/10/2024, the P&P indicated prior to hiring of any employee, facility shall ensure provisions covering employment screening for potential history of abuse, neglect, or mistreatment of residents.
During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last reviewed 1/10/2024, the P&P indicated employee background checks must be conducted to prevent abuse, neglect, exploitation and misappropriation of residents.

Based on interview and record review the facility failed to develop and implement a person-centered care plan with measurable objectives and timeframes to one out of three sampled residents (Resident 70) investigated during review of behavioral/emotional care area by failing to develop a care plan that addressed the resident's behavior of disrobing (the act of removing clothing).
The deficient practice had violated Resident 70's right to maintain their highest practicable psychosocial well-being.
Cross reference to F550.
Findings:
During a review of Resident 70's admission Record, it indicated the facility admitted Resident 70 on 9/8/2023 with diagnoses including, but not limited to, dementia (loss of memory, language, and other thinking abilities that interfere with daily life and gets worse over time), Alzheimer's Disease (a common type of dementia), major depressive disorder (a persistent feeling of sadness and loss of interest), and anxiety disorder (excessive worry and feelings of fear and uneasiness).
During a review of Resident 70's History and Physical (H&P), dated 11/8/2023, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 70's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/13/2024, the MDS indicated Resident 70 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect the everyday life) and needed maximum assistance with upper body dressing, lower body dressing, toileting, hygiene, and bathing.
During an observation on 7/23/2024 at 11:10 a.m., outside of Resident 70's room, Resident 70 could be viewed from the hallway disrobed from the waist up; the privacy curtain was partially drawn. Upon entering Resident 70's room, Resident 70 was up in her wheelchair with her shirt off, exposing her breasts while other residents were passing by the room. Resident 70 yelled out nonsensically (not making sense) when interview was attempted.
During a concurrent observation and interview on 7/23/2024, at 11:15 a.m., inside Resident 70's room, with Restorative Nursing Assistant (RNA) 1, RNA 1 assisted Resident 70 back into her shirt and confirmed that Resident 70 had the behavior of disrobing in the past. RNA 1 further explained the behaviors are to be reported to the charge nurse. When asked about privacy, RNA 1 confirmed the curtain was not completely closed and pulled the curtain over to provide privacy. RNA 1 further stated he will report the behavior to the charge nurse.
During an interview and record review on 7/23/2024, at 12:30 p.m., with the Director of Medical Records (DMR), reviewed the Clinical Chart of Resident 70. The DMR stated there were no care plan or notes for the behavior of disrobing for Resident 70.
During an interview on 7/25/24 at 8:30 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated she cared for Resident 70 approximately 4 times in the last month and Resident 70 disrobed once or twice. CNA 7 further stated she reported to the charge nurse each time the resident had the behavior of disrobing but does not remember which date or charge nurse she reported it to.
During a concurrent interview and record review on 7/25/24 at 9:15 am with the Director of Staff Development (DSD), reviewed the MAR and care plan of Resident 70. The DSD stated on 7/23/2024 she was covering as the charge nurse for the first shift (7:00 a.m.- 3:30 p.m.) in station two (the station that covers the area of Resident 70) and did not remember if the behavior of disrobing was reported to her that day. The DSD stated she remembers Resident 70 disrobing her shirt since she was admitted to the facility and any new identified behaviors are to be reported to the supervising registered nurse. The DSD further stated the behaviors are tallied in the MAR, but disrobing is not listed as a behavior to monitor in the MAR nor was there a care plan to address the behavior of disrobing.
During a concurrent interview and record review on 7/25/2024 at 9:55 a.m. with Registered Nurse (RN) 2, reviewed the MAR, care plan and notes of Resident 70. RN 2 stated the disrobing behavior was not reported to her and if the behavior is not in the MAR, it is not care planned. RN 2 confirmed disrobing is not mentioned in any notes, care plans or the MAR in Resident 70's chart. RN 2 further stated the resident could miss out on measurable goals and approaches that staff could use during care without the care plan.
During a review of the facility's policy and procedure (P&P) titled, Policy: The Resident Care Plan, last reviewed 1/10/2024, the P&P indicated the resident care plan shall be implemented for each resident on admission and developed throughout the assessment process. It further indicated, although the care area assessment (CAAs) triggers most problem areas, all other problems not identified in the CAAs must also be included in the care plan.
During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed 1/10/2024, the P&P indicated residents have the right to be informed of, and participate in, his or her care planning and treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in accordance with professional standards of quality by:
1. Failing to ensure the nurses were rotating (a method to ensure repeated injections are not administered in the same area) the insulin (a medication that regulates sugar in the blood) injection sites for one of two sampled residents, (Resident 10) investigated during review of insulin care area.
2. Administering insulin when the blood sugar (BS - the amount of sugar measured in the blood stream) was below the physician ordered parameters (a set of limits determining if a medication can be given) for one of two sampled residents (Resident 38) investigated during review of insulin care area.
These deficient practices had the potential to result in bruising, pain, and/or lipohypertrophy (lump or accumulation of fatty tissue under skin) to Resident 10 and placed Resident 38 at risk for hypoglycemia (a condition when the blood sugar is dangerously low).
Cross-reference to F760.
Findings:
1. During a review of Resident 10's Face Sheet (admission record), the Face Sheet indicated the facility admitted the resident on 3/10/2023, with diagnoses including, but not limited to, type 2 diabetes mellitus (DM - a disease that occurs when the glucose, also called blood sugar, is too high) with unspecified complications, and long-term use of insulin.
During a review of Resident 10's History and Physical (H&P), dated 3/4/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 10's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/13/2024, the MDS indicated the resident had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect the everyday life) and required moderate assistance with eating, oral hygiene, and upper body dressing.
During a review of Resident 10's Order Summary Report, printed on 7/25/2025, it indicated Resident 10 had an order increase on 7/4/2024 for Lantus (long-acting insulin) SoloStar Subcutaneous (SQ - into the fatty layer under the skin) Solution Pen-injector (a device used to administer medication into the body through a needle) 100 unit per milliliters (unit/ml, a unit of fluid volume) from 12 units to 14 units: inject 14 unit SQ at bedtime (HS). Hold if BS is less than 110. May give orange juice for BS less than 60. Rotate site.
During a review of Resident 10's Medication Administration Record (MAR) for 5/2024-7/2024, indicated Lantus SoloStar SQ Solution Pen-injector; inject 14 units SQ at HS was administered on:
5/7/2024 at 8:00 p.m. on the left lower quadrant
5/8/2024 at 8:00 p.m. on the left lower quadrant
5/12/2024 at 8:00 p.m. on the abdomen
5/13/2024 at 8:00 p.m. on the abdomen
5/14/2024 at 8:00 p.m. on the abdomen
5/17/2024 at 8:00 p.m. on the right lower quadrant
5/18/2024 at 8:00 p.m. on the right lower quadrant
5/24/2024 at 8:00 p.m. on the left lower quadrant
5/25/2024 at 8:00 p.m. on the left lower quadrant
6/2/2024 at 8:00 p.m. on the abdomen
6/3/2024 at 8:00 p.m. on the abdomen
6/8/2024 at 8:00 p.m. on the abdomen
6/9/2024 at 8:00 p.m. on the abdomen
6/10/2024 at 8:00 p.m. on the abdomen
6/11/2024 at 8:00 p.m. on the abdomen
6/19/2024 at 8:00 p.m. on the left lower quadrant
6/20/2024 at 8:00 p.m. on the left lower quadrant
7/3/2024 at 8:00 p.m. on the left arm
7/4/2024 at 8:00 p.m. on the left arm
7/5/2024 at 8:00 p.m. on the left lower quadrant
7/6/2024 at 8:00 p.m. on the left lower quadrant
7/12/2024 at 8:00 p.m. on the left lower quadrant
7/13/2024 at 8:00 p.m. on the left lower quadrant
7/18/2024 at 8:00 p.m. on the left lower quadrant
7/19/2024 at 8:00 p.m. on the left lower quadrant
7/21/2024 at 8:00 p.m. on the left arm
7/22/2024 at 8:00 p.m. on the left arm
During a concurrent interview and record review on 7/24/2024, at 3:00 p.m., with Registered Nurse (RN) 3, reviewed the Order Summary Report and the MAR of Resident 10 with RN 3. RN 3 stated there were multiple instances where the injection sites of the insulin were not rotated from 5/2024 to 7/2024. RN 3 stated the sites of insulin administration should be rotated to prevent bruising, hardening of the skin injection sites, and lipodystrophy (abnormal distribution of fat).
During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 1/10/2024, the P&P indicated to select an injection site.
a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior and lateral areas of the thighs and abdomen. Avoid the are approximately 2 inches around the navel.
b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility provided FDA Label for Lantus SoloStar, undated, it indicated to rotate injection sites within the same area you choose each time form one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis (skin with lumps). Do not use the same spot for injection.
2. During a review of Resident 38's Face Sheet, the Face Sheet indicated the facility admitted the resident on 2/20/2019, with diagnoses including, but not limited to, type 2 diabetes mellitus without complications.
During a review of Resident 38's H&P, dated 2/13/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 38's MDS, dated [DATE], the MDS indicated the resident was severely cognitively impaired. The MDS indicated Resident 38 is dependent on eating, toileting, showers, dressing, personal hygiene, and mobility.
During a review of Resident 38's Order Summary Report, printed on 7/25/2024, the Order Summary Report indicated an order for Basaglar (long-acting insulin) KwikPen Solution Pen-Injector 100 u/ml.: inject 4 units SQ one time a day. Rotate site; hold for BS less than 90.
During a review of Resident 38's Care Plan (CP) focused on hypoglycemia related to DM, revised on 1/28/2024, the CP indicated to administer the medications as ordered.
During a review of Resident 38's MAR for 4/2024 to 7/2024, the MAR indicated:
a. Basaglar KwikPen Solution Pen-Injector 100 u/ml.: inject 4 units SQ one time a day. Rotate site; hold for BS less than 90, was administered on:
4/1/2024 at 8:00 a.m. on the right arm with a BS of 89.
7/2/2024 at 8:00 a.m. on the right lower quadrant with a BS of 80.
During a concurrent interview and record review on 7/24/2024, at 2:30 p.m. with Licensed Vocational Nurse (LVN) 3, reviewed the Order Summary Report and the MAR of Resident 38 with LVN 3. LVN 3 stated, she gave the resident insulin with BS below 90, when it should have been held to prevent the BS from going down even lower.
During an interview on 7/25/2024, at 6:25 p.m., with the Director of Nursing (DON), the DON stated the orders must be double checked; the parameters the physician ordered must always be followed to prevent hypoglycemia.
During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 1/10/2024, the P&P indicated to check the order for the amount of insulin and the blood sugar parameter per physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs for one of one sampled resident (Resident 2) investigated during a random observation by:
1. Failing to ensure Certified Nursing Assistant 4 (CNA 4) did not apply the hydrocortisone (a type of medicine used for treating dermatitis [inflammation of the skin with dry skin, redness, and itchiness] and other skin conditions that cause itching) 1 percent (% - a unit of measurement) cream on the resident's abdomen, bilateral lower extremities (BLE), and bilateral breast folds.
This deficient practice placed the resident at risk for adverse reactions due to CNA 4's application of the medication without physician's orders and not within the scope of CNA 4's practice.
2. Failing to ensure there was a physician's order prior to administering hydrocortisone 1% cream.
These deficient practices placed Resident 2 at risk for developing adverse reactions from the topical medication such as skin irritation due to application of the medication without physician's orders.
Findings:
During a review of Resident 2's admission Record, it indicated the facility admitted the resident on 9/29/2022 and readmitted on [DATE] with diagnoses including 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), dermatitis (inflammation of the skin with dry skin, redness, and itchiness), and dermatophytosis (also known as ringworm, a fungal infection of the skin that may affect the skin, hair, and nails).
During a review of Resident 2's History and Physical (H&P) dated 2/20/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/5/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance from staff with mobility; substantial/maximal assistance with tub/shower transfers; and supervision or touching assistance 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 2's Order Summary Report, there was no documented evidence of an active physician's order for hydrocortisone 1% cream. The Order Summary Report indicated the following physician's order:
7/9/2024: BLE rash - Cleanse with Normal saline (NS - a mixture of salt and water that can be used to rinse the sinuses, clean wounds, flush the eyes and more), pat dry, apply nystatin external cream (a type of medicine used to treat skin infections caused by fungus or yeast) 1000000 units per gram (unit/gm - a unit of measurement) to affected area, and leave open to air every day shift for fungal dermatitis for four (4) weeks.
6/26/2024: Bilateral breast fold rash - Cleanse with NS, pat dry, apply nystatin external cream 1000000 unit/gm to affected area, and leave open to air every day shift for fungal dermatitis for four (4) weeks.
6/26/2024: Abdomen rash - Cleanse with Cleanse with NS, pat dry, apply nystatin external cream 1000000 unit/gm to affected area, and leave open to air every day shift for fungal dermatitis for four (4) weeks.
During a review of Resident 2's care plan (CP), the CP indicated alteration in skin integrity actual presence of rashes - fungal dermatitis on the following sites:
-BLE initiated on 3/13/2024 last revised 7/8/2024 target date 8/17/2024.
-Abdomen initiated on 3/27/2024 last revised 7/8/2024 target date 7/25/2024.
-Bilateral breast fold initiated on 6/26/2026 2024 last revised 7/8/2024 target date 7/25/2024.
The care plan indicated the following interventions but not limited to keep skin clean and dry provide skin care maintenance per MD order, provide treatment per MD order, provide ongoing assessment of treatment effectiveness and report to MD if ineffective.
During a review of Resident 2's Treatment Administration Record (TAR - a report detailing the treatment, such as a drug, to a patient by a healthcare professional at a facility) for 5/2024, 6/2024, and 7/2024, there was no documented evidence Resident 2 received hydrocortisone 1% cream for rashes.
During an observation on 7/23/2024 at 11:18 a.m. inside Resident 2's room, observed CNA 4 explaining to the resident regarding application of the hydrocortisone cream as requested by the resident.
During an interview on 7/23/2024 at 11:27 a.m., with CNA 4, CNA 4 stated he applied the hydrocortisone cream as requested by the resident on both lower legs, abdomen, and bilateral breast folds. CNA 4 stated a nurse left the cream at the bedside (unable to tell which nurse). CNA 4 stated the hydrocortisone cream is a medication.
During an interview on 7/23/2024 at 11:34 a.m., with Treatment Nurse 1 (TN 1), TN 1 stated CNAs are not supposed to apply the hydrocortisone cream on the resident because it is a medication prescribed by the physician and applying the medication to the resident was not within the scope of the CNAs' practice. TN 1 stated the resident had an order for hydrocortisone cream as needed.
During a concurrent interview and record review on 7/25/2024 at 3:15 p.m., reviewed Resident 2's physician's order with TN 1. TN 1 stated there was no active physician's order for the application of hydrocortisone cream on Resident 2's rashes. TN 1 verified the current treatment order for Resident 2 was nystatin cream for the abdomen, BLE, and bilateral breast folds daily. TN 1 stated the hydrocortisone cream should not have been applied to Resident 2 as there was no physician's order and the resident can develop adverse reactions.
During an interview on 7/26/2024 at 11:17 a.m., with the Director of Nursing (DON), the DON stated CNAs are not supposed to apply the hydrocortisone cream. The DON stated it is a medication prescribed by the physician and CNAs are not authorized to administer prescribed medications. The DON stated the hydrocortisone cream should not have been applied to Resident 2 as it was administering a medication without a physician's order. The DON stated if the resident had a previous order for hydrocortisone cream, the physician should have been called and obtain an order to continue the medication.
During a review of the facility's Job Description for CNA dated 1/27/2022, it indicated the essential duties and responsibilities include the following but not limited to:
Observe resident's skin and documentations and report skin conditions.
Responsible for skin management that includes drying of skin and application of lotions, ointments, etc. ad indicated.
During a review of the facility's policy and procedure (P&P) titled, Physician Orders and Telephone Orders, last reviewed 1/10/2024, the P&P indicated physician orders shall be obtained prior to the initiation of any medication or treatment from a person lawfully authorized to prescribe for and treat human illness.

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/PU, injuries to the skin and underlying tissue resulting from prolonged pressure) by failing to set the Low Air Loss Mattress (LALM, a mattress designed to prevent and treat PIs) in accordance with manufacturer's instructions for one randomly sampled resident (Resident 68) observed during the screening process.
This deficient practice had the potential for the worsening of or development of PIs.
Findings:
During a review of Resident 68's admission Record, it indicated the facility admitted the resident on 6/30/2022 and readmitted the resident on 1/13/2023 with diagnoses that included encounter for palliative care (hospice, a type of medical care for residents who are in the last stages of life), unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), pressure ulcer of sacral region (at the bottom of the spine lying between the lumbar spine [L5] and the coccyx [tailbone]) stage two (the skin breaks open, wears away, or forms a wound which is usually tender and painful), and pressure induced deep tissue damage (purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure) of right heel.
During a review of Resident 68's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/10/2024, the MDS indicated the resident was rarely/never able to understand others and was rarely/never able to make herself understood. The MDS further indicated the resident was dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and mobility.
During a review of Resident 68's physician orders, it indicated an order for a low airloss mattress; setting is based on the resident's current weight, adjust as indicated, for skin maintenance, dated 7/31/2023.
During a review of Resident 68's Current Vital Sign form, dated 7/5/2024, it indicated the residents current weight was 77 pounds (lbs, a unit of measurement).
During a review of Resident 68's Care Plan (CP) titled, Risk for developing pressure sore, and other types of skin breakdown related to: aging process, diabetes mellites (a chronic condition that affects the way the body processes blood sugar [glucose]), fragile skin, dermatophytosis (superficial skin, hair, and nail infections), pressure ulcer sacral region, pressure-induced deep tissue damage of right heel, initiated 6/30/2022, the CP indicated a goal to minimize the risk of skin breakdown/pressure sore. The CP indicated a low air loss mattress for wound care and management.
During an observation and interview on 7/23/2024 at 9:15 a.m., observed the door to Resident 68's room closed. Upon entering Resident 68's room observed the resident lying in bed on a LALM. Certified Nursing Assistant 8 (CNA 8) entered the resident's room and stated Resident 68's LALM pump was labeled Setting Weight: 100. CNA 8 stated the LALM pump was set to about 225 lbs. CNA 8 stated she did not set the LALM to 225 lbs. because she does not change the weight settings. Observed CNA 8 change the LALM pump setting to 100 lbs.
During an observation, interview, and record review on 7/25/2024 at 11:37 a.m., with TN 1, reviewed Resident 68's Current Vital Sign form, dated 7/5/2024 and TN 1 stated Resident 68 weighed 77 lbs. TN 1 stated she sets and monitors the LALM settings for facility residents. TN 1 entered Resident 68's room and stated TN 1 labeled Resident 68's LALM pump to be set to 100 lbs., the closest setting to the resident's actual weight per the guidance provided by the company that provides the LALM.
TN 1 stated Resident 68 needs a LALM because the resident had skin issues in the past and it is used for prevention. TN 1 stated the LALM has chambers that even out the weight of the resident and prevent pressure in one area of the body. TN 1 stated when the LALM is set to a weight that is too high it becomes firmer and could cause too much pressure with the potential for the development of a pressure ulcer.
During an interview and record review on 7/25/2024 at 1 p.m., with Registered Nurse 2 (RN 2) reviewed Resident 68's Current Vital Sign form, dated 7/5/2024. RN 2 stated the LALM mattress is set according to the resident's weight and if the resident's weight is 77 lbs., then the LALM pump should be set to 100 lbs. RN 2 stated it was important to set the correct weight because the LALM is used for bedridden residents to prevent pressure ulcers. RN 2 stated when Resident 68's LALM was set to over 200 lbs. the LALM was incorrectly set.
During a review of the facility provided LALM 1 Operation Manual, undated, it indicated the LALM 1 is designed for prevention, treatment, and management of pressure ulcers. Users can adjust air mattress to desired firmness according to the patient's weight or the suggestion from a health care professional.
During a review of the facility policy and procedure (P&P) titled, Pressure-Reducing Mattress, last reviewed 1/10/2024, the P& indicated the objective of the policy was to provide the mattress that will prevent and/or minimize pressure on the skin and to provide comfort if resident prefers.
During a review of the facility policy and procedure titled, Prevention of Pressure Injuries, last reviewed 1/10/2024, the P&P indicated the purpose of the policy was to ensure that all residents will receive the proper care based on their assessment to reduce the risks for pressure injuries. Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice.
During a review of the facility policy and procedure titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, last viewed 1/10/2024, the P&P indicated the facility will assist with wound risk assessment to identify factors to ensure that all residents will receive necessary treatment and services to prevent skin breakdown and promote wound healing. The facility will implement measures for skin maintenance that may include providing a special device if needed. The pressure relieving device may include a LALM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to four of five sampled residents (Resident 52, 68, 21, and 69) 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. Ensure Resident 52's left (L) thumb spica wrist brace (a device to decrease movement and provide support and comfort through immobilization after an injury) was applied per physician orders.
2. Monitor the placement of Resident 52's left thumb spica wrist brace.
3. Notify Resident 52's physician regarding Resident 52's refusal to wear the left thumb spica wrist brace at all times.
4. Provide Resident 68 with ambulation (the act of walking) using a front-wheeled walker (FWW, an assistive device with two front wheels used for stability when walking), five times per week, in accordance with the physician orders, dated 11/25/2022, from 11/2022 to 12/2022.
5. Ensure Resident 68's Joint Mobility Screening (brief assessment of a resident's range of motion in both arms and both legs) - Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) and Joint Mobility Screening - Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function), dated 1/16/2023 and 1/19/2024, corresponded with the joint assessments included in the facility's policy titled, Joint Mobility Assessment.
6. Monitor Resident 68's ROM in each joint of both arms and legs during the quarterly Joint Mobility Screen, dated 4/19/2023 and 7/19/2023, in accordance with the facility's policy titled, Joint Mobility Assessment.
7. Provide Resident 68 with passive range of motion (PROM, movement of joint through the ROM with no effort from the person) to both legs, five times per week, in accordance with the physician orders, dated 3/14/2023, for the months of 5/2023, 11/2023, ad 1/2024.
8. Provide Resident 68 with PROM to both arms and the application of a right resting hand splint (material secured with straps that extends from the fingers to the forearm to properly position the fingers and wrist) and right elbow splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for one to two hours per day, five times per week, in accordance with the physician orders, dated 4/24/2023, during the months of 5/2023, 11/2023, and 1/2024.
9. Provide Resident 21 with PROM to both legs, five times per week, in accordance with the physician orders, dated 6/30/2023, during the months of 7/2023, 11/2023, 1/2024, and 3/2024.
10. Provide Resident 69 with ambulation, three times per week, in accordance with the physician orders, dated 8/1/2023, during the months of 11/2023, 1/2024, 3/2024, and 4/2024.
These failures had the potential for Resident 67, 21, 52, and 69 to develop ROM and mobility limitations, including development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness), decline in ambulation, and increased risk for injury.
Findings:
a. During a review of Resident 52's admission Record, it indicated the facility admitted the resident on 5/12/2023 and readmitted the resident on 7/15/2024 with diagnoses that included intervertebral disc degeneration (the breakdown of the cushion between the bones of the spine) lumbar region (lower back), muscle weakness, history of falling, psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) and unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).
During a review of Resident 52's Minimum Data Set (MDS - an assessment and care screening tool) dated 6/6/2024, the MDS indicated the resident was sometimes able to understand others and was sometimes able to make himself understood. The MDS further indicated the resident was dependent on staff for toileting, dressing, and mobility.
During a review of Resident 52's History and Physical (H&P), dated 7/15/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 52's physician orders, it indicated an order to apply L spica wrist brace at all times, status post fall, until further clarification, dated 7/16/2024.
During a review of Resident 52's CP titled, Occupational Therapist plan of care . initiated 7/16/2024, the CP indicated to apply the left thumb spica wrist brace at all times.
During a review of Resident 52's CP titled, Impaired balance, transfer, ambulation, bed mobility initiated 7/16/2024, the CP indicated to apply the left thumb spica wrist brace at all times until further clarification, status post fall.
During an observation on 7/23/2024 at 9:25 a.m., Resident 52 lay in bed. Observed the resident did not have a L thumb spica wrist brace applied.
During an observation and interview on 7/23/2024 at 2:45 p.m., Certified Nursing Assistant 8 (CNA 8) stood next to Resident 52 sitting in a wheelchair in the hallway. CNA 8 stated Resident 52 did not have a brace on his L wrist. CNA 8 stated Resident 52 had not had a brace applied all day and she had not previously seen the resident wearing a brace on his wrist.
During an observation, interview, and record review on 7/23/2024 at 2:56 p.m., Licensed Vocational Nurse 4 (LVN 4) reviewed Resident 52's physician orders and progress notes for July 2024. LVN 4 stated the resident had a fall on 6/25/2024 and should wear the L wrist spica brace at all times. LVN 4 stated Resident 52's brace was in the nurse's station. Observed a blue brace on the desk in Nursing Station 1. LVN 4 stated the brace should be on the resident to make sure the wrist properly heals and to prevent pain. LVN 4 stated Resident 52 was noncompliant and often removed the wrist brace. LVN 4 stated when Resident 52 removes the wrist brace, staff should redirect the resident and reapply it. LVN 4 stated if the resident repeatedly refused the wrist brace, then the physician should be notified. LVN 4 stated there was no documentation by nursing staff that the resident removed the brace or that the physician was notified.
During a concurrent interview and record review on 7/25/2024 at 11:56 a.m., with the Director of Rehabilitation (DOR), the DOR stated Resident 52 had a fall and needed to wear the L wrist brace until the resident was able to be seen by a hand specialist. The DOR stated the brace was a precaution to prevent further injury for a sprain in the ligament (injury to flexible bands of tissue that hold bones together). The DOR stated the physician's order for the splint would not be discontinued until the resident saw the hand specialist.
During an interview on 7/25/2024 at 12:38 p.m. with Registered Nurse 2 (RN 2) reviewed Resident 52's physician orders and progress notes for July 2024. RN 2 stated on 7/23/2024 the resident had an order to wear the L spica wrist brace at all times. RN 2 stated if the resident was removing the brace the physician should have been notified and the order could have been clarified. RN 2 stated there was no documented evidence by nursing that the resident was noncompliant with the brace or that the physician was notified the resident was refusing the brace. RN 2 stated repetitive resident refusals warrants the need to make changes in the resident's plan of care.
During an interview and record review on 7/25/2024 at 1:45 p.m., with the DOR, reviewed Resident 52's Occupational Therapy Treatment Encounter Notes, dated 7/16/2023 and stated it was documented that the resident refused the brace on multiple attempts and that nursing staff was notified. The DOR stated the Director of Nursing (DON) was aware the resident had repetitive behavior of refusing the brace. The DOR stated when the DON was notified the resident was refusing the brace, the expectation was that the DON would speak with the resident's physician.
During a review of Resident 52's Occupational Therapy Treatment Encounter Notes, dated 7/16/2023, the notes indicated the resident was noncompliant to application of L thumb spica wrist brace and nursing was aware.
During a review of Resident 52's Occupational Therapy Treatment Encounter Notes, dated 7/16/2023, the notes indicated the resident refused to apply the L hand brace despite multiple attempts and brace was given to the certified nursing assistant.
During an interview on 7/25/2024 at 2:31 p.m., with the DON, the DON stated she was aware that Resident 52 had an order to wear the L spica wrist brace at all times. The DON stated there was a concern that there was no documented monitoring for the application of the brace, but there should have been. The DON stated the order was entered into the computer wrong and there was no task for monitoring. The DON stated the importance of monitoring the brace was to know if the resident had it on and to at least attempt to reapply it when it was found to not be on the resident. The DON stated when the resident repeatedly refused the treatment, the DON or the licensed nurses should have clarified the order with the physician to indicate the brace is worn as tolerated, but they did not. The DON stated the importance of monitoring for the placement of the brace, ensuring the resident was wearing the brace per the physician's order, and notifying the physician of the resident's refusal of the treatment was to promote healing and prevent further complications.
During a review of the facility policy and procedure (P&P) titled, Assistive Devices and Equipment, last reviewed 1/10/2024, the P&P indicated the facility maintains and supervises the use of assistance devices and equipment for residents. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include, but are not limited to, mobility devices (splints, hand rolls, etc.).
During a review of the facility policy and procedure titled, Physician Orders and Telephone Orders, last reviewed 1/10/2024, the P&P indicated physician's orders shall be obtained prior to the initiation of any treatment from a person lawfully authorized for treating human illness. All orders must be specific and complete with all necessary details to carry out the prescribed orders without any questions.
b. During a review of Resident 68's admission Record, the facility admitted Resident 68 on 6/30/2022 and readmitted on [DATE] with diagnoses including dementia (decline in mental ability severe enough to interfere with daily life), type 2 diabetes mellitus (high blood sugar), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning), Vitamin D deficiency (not enough Vitamin D needed for strong bones and teeth), and contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to the right hand, both elbows, and both knees. The admission Record indicated Resident 68 was admitted to palliative care (specialized medical care that focuses on providing patients relief from pain and other symptoms of a serious illness) on 2/26/2024 with diagnosis of cerebral atherosclerosis (blood vessels in the brain have become blocked by fatty substances).
During a review of Resident 68's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 6/10/2024, the MDS indicated Resident 68 was severely impaired for daily decision making, had ROM limitations 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, upper and lower body dressing, rolling to both sides in bed, and chair/bed-to-chair transfers.
1. During a review of Resident 68's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 68 safely ambulated 100 feet using a FWW. Resident 68's PT Discharge Summary indicated a recommendation for a RNA program for ambulation.
During a review of Resident 68's physician orders, dated 11/25/2022, the physician orders indicated for the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) to provide ambulation with FWW for 100 feet (unit of measure) or as tolerated.
During a review of Resident 68's Documentation Survey Report (record of nursing assistant tasks) for RNA in 11/2022, the Documentation Survey Report was blank on 11/28/2022, 11/29/2022, and 11/30/2022.
During a review of Resident 68's Documentation Survey Report for RNA in 12/2022, the Documentation Survey Report was blank on 12/7/2022, 12/8/2022, 12/9/2022, 12/12/2022, 12/13/2022, 12/16/2022, 12/19/2022, 12/20/2022 12/21/2022, 12/22/2022, 12/23/2022, 12/26/2022, 12/27/2022, 12/28/2022, 12/29/2022, and 12/30/2022.
During an interview on 7/23/2024 at 8:52 a.m. with the Director of Rehabilitation (DOR), the DOR stated the purpose of RNA (in general) was to maintain a resident's level of mobility achieved during therapy and to prevent decline.
During an interview on 7/23/2024 at 12:15 p.m. with Resident 68's family member (FM 1), FM 1 stated Resident 68 used to walk upon admission to the facility but did not walk anymore.
During a concurrent observation and interview on 7/23/2024 at 3:30 p.m. with Certified Nursing Assistant 8 (CNA 8) in the bedroom, Resident 68 was sitting up in a reclining wheelchair. Resident 68 did not have any active movement in the right arm but moved the left arm. CNA 8 sated Resident 68 used to walk without any assistive device upon admission to the facility but had a decline in ability to walk.
During an interview on 7/26/2024 at 8:32 a.m. with the Director of Staff Development (DSD), the DSD stated a blank box in the Documentation Survey Report for RNA indicated the treatment was not completed.
During a concurrent interview and record review on 7/26/2024 at 9:56 a.m. with the DSD, Resident 68's Documentation Survey Report for RNA in 11/2022 and 12/2022 were reviewed. The DSD stated the Documentation Survey Report for 11/2022 indicated RNA was not provided to Resident 68 at the end of the month. The DSD stated the Documentation Survey Report for 12/2022 indicated RNA was not provided to Resident 68 for most of the month. The DSD stated Resident 68 could potentially decline in the ability to walk without the provision of RNA services.
During a review of the facility's undated policy and procedure (P&P) titled, Restorative Nursing Program, the P&P indicated the RNA program maintained the resident's functional ability and reduce further decline. The P&P also indicated the RNA would walk with resident requiring ambulation as prescribed by the physician.
2. During a review of Resident 68's Joint Mobility Screening - OT, dated 1/16/2023 and 1/19/2024, the Joint Mobility Screening - OT indicated assessments of Resident 68's PROM in each shoulder, elbow, wrist, and hand. Each joint included an assessment of full ROM, minimal loss (less than [<] 25 percent [%] ROM loss), moderate loss (26 to 50% ROM loss), severe loss (more than [>] 50% loss), and not applicable (N/A).
During a review of Resident 68's Joint Mobility Screening - PT, dated 1/16/2023 and 1/19/2024, the Joint Mobility Screening - PT indicated assessments of Resident 68's PROM in each hip, knee, and ankle. Each joint included an assessment of full ROM, minimal loss, moderate loss, severe loss, and N/A.
During a review of the facility's P&P titled, Joint Mobility Assessment, the P&P indicated PT and OT will assess each joint for ROM and document finding on the Joint Mobility Assessment annually. The P&P indicated limitations in joint mobility will be defined as within normal limits (WNL, full range of motion without limitation), minimal loss, moderate loss, moderate/severe loss (decrease in joint mobility of 50% to 75%, 25% to 50% available range), and severe loss.
During a concurrent interview and record review on 7/25/2024 at 2:46 p.m. with the DOR, Resident 68's Joint Mobility Screening - OT and PT, dated 1/16/2023 and 1/19/2024, and the facility's P&P titled, Joint Mobility Assessment, were reviewed. The DOR stated PT and OT performed Joint Mobility Screenings annually. The DOR stated the joint mobility limitation categories included in Resident 68's Joint Mobility Screenings were different from the joint mobility limitation categories included in the facility's P&P. The DOR stated Resident 68's Joint Mobility Screenings did not include an assessment category for moderate/severe loss.
3. During a review of Resident 68's Joint Mobility Screen - Quarterly, dated 4/19/2023, the Joint Mobility Screen - Quarterly indicated Resident 68 maintained the assessed mobility (unspecified) and tolerated the RNA program for PROM to both arms, five times per week. The Joint Mobility Screen did not include an assessment of the ROM of each major joint in both arms and legs.
During a review of Resident 68's Joint Mobility Screen - Quarterly, dated 7/19/2023, the Joint Mobility Screen - Quarterly did not include an assessment of the ROM of each major joint in both arms and legs.
During a review of the facility's undated P&P titled, Joint Mobility Assessment, the P&P indicated the facility determined a resident's ROM for all major joints to increase, maintain, or prevent decline in joint mobility. The P&P indicated all residents will be assessed for joint mobility limitations upon admission and at minimum every three months.
During an interview on 7/25/2024 at 2:46 p.m. with the MDS Assistant (MDSA), Resident 68's Joint Mobility Screen - Quarterly, dated 4/19/2023 and 7/19/2023, and the facility's P&P titled, Joint Mobility Assessment, were reviewed. The MDSA stated she performed the quarterly Joint Mobility Screen. The MDSA stated the purpose of quarterly screens was to ensure the resident (in general) did not decline in ROM. The MDSA reviewed Resident 68's quarterly Joint Mobility Screens and stated they did not include Resident 68's joint mobility in each major joint. The MDSA stated the quarterly Joint Mobility Screens did not follow the facility's P&P to assess each major joint to prevent ROM loss.
4. During a review of Resident 68's physician orders, dated 3/14/2023, the physician orders indicated for the RNA to provide PROM to both legs. Another physician order, dated 4/24/2023, indicated for the RNA to provide resident 68 with PROM to both arms and apply a right resting hand splint and right elbow extension splint for one to two hours per day, five times per week.
During a review of Resident 68's Documentation Survey Report for RNA in 5/2023, the Documentation Survey Report indicated not applicable NA for RNA treatment on 5/1/2023, 5/4/2023, 5/5/2023, 5/6/2023, 5/7/2023, 5/10/2023, 5/11/2023, 5/12/2023, 5/13/2023, 5/17/2023, and 5/19/2023.
During a review of Resident 68's Documentation Survey Report for RNA in 11/2023, the Documentation Survey Report was blank for RNA treatment on 11/3/2023, 11/10/2023, 11/16/2023, 11/17/2023, 11/24/2023, 11/27/2023, 11/28/2023, and 11/30/2023.
During a review of Resident 68's Documentation Survey Report for RNA in 1/2024, the Documentation Survey Report was blank for RNA treatment on 1/2/2024, 1/3/2024 1/7/2024, 1/9/2024, 1/11/2024, 1/14/2024, 1/15/2024, 1/16/2024, and 1/18/2024.
During an interview on 7/26/2024 at 8:32 a.m. with the DSD, the DSD stated a blank box in the Documentation Survey Report for RNA indicated the treatment was not completed.
During an concurrent interview and record review on 7/26/2024 at 9:56 a.m. with the DSD, Resident 68's Documentation Survey Reports for RNA were reviewed, including 5/2023, 11/2023, and 1/2024. The DSD stated Resident 68's Documentation Survey Report for RNA indicated N/A in 5/2023 because a Certified Nursing Assistant (CNA) entered documentation for the RNA, which disabled the RNA from documenting the treatment session. The DSD stated the Documentation Survey Report for 5/2023, 11/2023, and 12/2023 did not indicate RNA provided treatment to Resident 68 in accordance with the physician orders. The DSD stated Resident 68 had the potential to decline in mobility without the provision of RNA treatment.
During a review of the facility's undated P&P titled, Restorative Nursing Program, the P&P indicated the RNA program maintained the resident's functional ability and reduce further decline.
c. During a review of Resident 21's admission Record, the facility admitted Resident 21 on 5/4/2022 and readmitted on [DATE] with diagnoses including Alzheimer's disease (generalized brain deterioration that leads to progressive decline in mental ability severe enough to interfere with daily life), history of falling, fracture (break in bone) of the right femur (hip bone), and presence of a right artificial (made or produced by human being rather than naturally occurring) hip joint.
During a review of Resident 21's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge summary, dated [DATE], the PT Discharge Summary indicated a recommendation for Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) to perform passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to both legs.
During a review of Resident 21's physician orders, dated 6/5/2023, the physician orders indicated for the RNA to provide PROM to both legs as tolerate, five times per week.
During a review of Resident 21's Documentation Survey Report (record of nursing assistant tasks) for RNA in 7/2023, the Documentation Survey Report was blank on 7/2/2023, 7/6/2023, 7/7/2023, 7/10/2023, 7/14/2023, 7/17/2023, 7/24/2023, 7/25/2023, 7/26/2023, and 7/31/2023.
During a review of Resident 21's Documentation Survey for RNA in 11/2023, the Documentation Survey Report was blank on 11/6/2023, 11/13/2023, 11/20/2023, 11/22/2023, 11/24/2023, 11/27/2023, 11/28/2023, 11/29/2023, and 11/30/2023.
During a review of Resident 21's Documentation Survey Report for RNA in 1/2024, the Documentation Survey Report was blank on 1/17/24, 1/18/2024, 1/19/2024, and 1/20/2024.
During a review of Resident 21's Documentation Survey Report for RNA in 3/2024, the Documentation Survey Report was blank on 3/13/2024, 3/14/2024, 3/15/2024, 3/19/2024, 3/20/2024, 3/21/2024, 3/22/2024, 3/23/2024, 3/28/2024, and 3/30/2024.
During a review of Resident 21's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 6/14/2024, the MDS indicated Resident 21 had severely impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 21 had ROM impairments in both arms and one leg and required substantial/maximal assistance (helper does more than half the effort) for oral hygiene, toileting, showering/bathing, dressing, rolling in bed to either side, sit to stand transfers, and chair/bed-to-chair transfers.
During an interview on 7/23/2024 at 8:52 a.m. with the Director of Rehabilitation (DOR), the DOR stated the purpose of RNA (in general) was to maintain a resident's level of mobility achieved during therapy and to prevent decline.
During an observation on 7/23/2024 at 9:38 a.m., Resident 21 was sleeping while seated in a wheelchair.
During an observation on 7/23/2024 at 9:44 a.m., Resident 21 woke up but was non-verbal. Resident 21 moved both arms and legs.
During a concurrent interview and record review on 7/26/2024 at 8:32 a.m. with the Director of Staff Development (DSD), Resident 21's Documentation Survey Reports were reviewed, including 11/2023, 1/2024, and 3/2024. The DSD stated a blank box in the Documentation Survey Report for RNA indicated the treatment was not completed. The DSD stated Resident 21 was not seen for PROM to both legs, five times per week, in accordance with the physician orders during the months of 7/2023, 11/2023, 1/2024, and 3/2024. The DSD stated Resident 21 had the potential to decline in mobility without the provision of RNA treatment.
During a review of the facility's undated policy and procedure(P&P) titled, Restorative Nursing Program, the P&P indicated the RNA program maintained the resident's functional ability and reduce further decline.
d. During a review of Resident 69's admission Record, the facility admitted Resident 69 on 2/13/2023 with diagnoses including dementia (decline in mental ability severe enough to interfere with daily life), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning), osteoporosis (medical condition in which the bones become brittle and fragile from loss of tissue), and repeated falls.
During a review of the Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 69 walked 125 feet without an assistive device with minimal assistance (physical steadying assistance or requires less than 25 percent (%) physical assistance to perform the task). The PT Discharge Summary indicate to a recommendation for Resident 69 to ambulate with Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) using handheld assistance ([HHA] handheld physical assistance of another person).
During a review of Resident 69's physician orders, dated 5/10/2023, the physician orders indicated for the RNA to provide ambulation (the act of walking) as tolerated using a front-wheeled walker (FWW, an assistive device with two front wheels used for stability when walking), three times per week. Resident 69's physician orders, revised on 8/1/2023, indicated for the RNA to provide ambulation with HHA, three times per week.
During a review of Resident 69's Documentation Survey Report (record of nursing assistant tasks) for RNA in 11/2023, the Documentation Survey Report was blank on 11/2/2023, 11/22/2023, 11/24/2023, 11/30/2023.
During a review of Resident 69's Documentation Survey Report for RNA in 1/2024, the Documentation Survey Report was blank on 1/9/2024, 1/16/2024, 1/17/2024, and 1/18/2024.
During a review of Resident 69's Documentation Survey Report for RNA in 3/2024, the Documentation Survey Report was blank on 3/13/2024, 3/14/2024, 3/19/2024, 3/20/2024, 3/21/2024, and 3/28/2024.
During a review of Resident 69's Documentation Survey Report for RNA in 4/2024, the Documentation Survey Report was blank on 4/14/2024, 4/23/2024, 4/24/2024, and 4/25/2024.
During an interview on 7/23/2024 at 8:52 a.m. with the Director of Rehabilitation (DOR), the DOR stated the purpose of RNA (in general) was to maintain a resident's level of mobility achieved during therapy and to prevent decline.
During an observation on 7/25/2024 at 9:17 a.m. with Restorative Nursing Aide 3 (RNA 3) in the hallway, Resident 69 was awake and sitting up in a wheelchair. RNA 3 placed a gait belt (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) around Resident 69's waist. RNA 3 held onto Resident 69's hands to assist Resident 69 with transferring from sit to stand. Resident 69 walked down the facility's hallways with RNA 3's HHA.
During an interview on 7/26/2024 at 8:32 a.m. with the Director of Staff Development (DSD), the DSD stated a blank box in the Documentation Survey Report for RNA indicated the treatment was not completed.
During a concurrent interview and record review on 7/26/2024 at 9:27 a.m. with the DSD, Resident 69's Documentation Survey Reports for RNA were reviewed, including 11/2023, 1/2024, 3/2024, and 4/2024. The DSD stated Resident 69 was not seen for ambulation, three times per week, in accordance with Resident 69's physician orders. The DSD stated Resident 69 had the potential to decline in mobility without the provision of RNA treatment.
During a review of the facility's undated policy and procedure(P&P) titled, Restorative Nursing Program, the P&P indicated the RNA program maintained the resident's functional ability and reduce further decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. During a review of Resident 68's admission Record, the facility admitted Resident 68 on 6/30/2022 and readmitted the resident on 1/13/2023 with diagnoses including dementia (decline in mental ability severe enough to interfere with daily life), type 2 diabetes mellitus (high blood sugar), major depressive disorder (depression, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning), Vitamin D deficiency (not enough Vitamin D needed for strong bones and teeth), and contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to the right hand, both elbows, and both knees. The admission Record indicated Resident 68 was admitted to palliative care (specialized medical care that focuses on providing patients relief from pain and other symptoms of a serious illness) on 2/26/2024 with diagnosis of cerebral atherosclerosis (blood vessels in the brain have become blocked by fatty substances).
During a review of Resident 68's care plan for spontaneous (sudden), pathological (caused by disease), stress (tiny breaks in bone) fracture (break in bone), initiated on 6/30/2022 and revised on 3/20/2024, the care plan interventions included to observe Resident 68 for sudden pain, swelling, and guarded movement (cautious with resistance, protecting against pain) of the extremity (arm or leg), handle gently and carefully during care, encourage mild exercises as tolerated and within joint limitation, and to notify the physician, responsible party, and the Hospice (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) Registered Nurse (Hospice RN) of changes in condition.
During a review of Resident 68's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 6/10/2024, the MDS indicated Resident 68 was severely impaired for daily decision making, had ROM limitations in both arms and legs, and 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, upper and lower body dressing, rolling to both sides in bed, and chair/bed-to-chair transfers.
During a concurrent observation and interview on 7/23/2024 at 3:30 p.m. with Certified Nursing Assistant (CNA) 8 in the bedroom, Resident 68 was sitting up in a reclining wheelchair. Resident 68 was using the left arm to hold onto the right arm. CNA 8 stated Resident 68 had pain and swelling in the right elbow but had not fallen or had any injury. CNA 8 attempted to lift Resident 68's right arm but Resident 68 immediately used the left arm to grab and guard the right arm, had a facial wince (gesture in the face of pain), and had tears in the left eye. CNA 8 stated Resident 68 appeared to be in 10 out of 10 pain (pain scale from zero [0], indicating no pain, to 10, indicating the worst pain possible) in the right arm because Resident 68's eye was tearing up. CNA 8 stated Resident 68 complained of right elbow pain for one to two weeks.
During an interview on 7/24/2024 at 7:47 a.m. with Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility)) 3 (RNA 3), RNA 3 stated the nurse (unknown) was giving Resident 68 pain medication prior to the RNA session this morning. RNA 3 stated Resident 68 was seen yesterday evening (7/23/2024) for RNA. RNA 3 stated Resident 68 did not tolerate the exercises to the right arm yesterday and did not apply the right arm splints due to Resident 68's right elbow pain and swelling. RNA 3 stated Resident 68 used the left arm to guard and hold onto the right arm. RNA 3 stated Resident 68 did not want anyone touching her right arm due to the pain for the past month.
During an observation on 7/24/2024 at 8:24 a.m. with RNA 3 in the bedroom, Resident 68 was lying in bed with swelling throughout the right arm compared to the left arm. RNA 3 stood on the left side of the bed and performed exercises to Resident 68's left shoulder, elbow, and hand. RNA 3 stood on the right side of the bed, lifted the right arm at the shoulder joint, and attempted to extend the elbow. Resident 68 immediately held onto the right arm using the left hand and flexed (bent) the body as a pain response. RNA 3 stated Resident 68 was in pain. RNA 3 called CNA 8 to assist with transferring Resident 68 from the bed to the wheelchair.
During a concurrent observation and interview on 7/24/2024 at 8:48 a.m., Resident 68 was already seated in the reclining wheelchair. RNA 3 described and demonstrated how RNA 3 and CNA 8 transferred Resident 68 from the bed to the wheelchair. RNA 3 stated the reclining wheelchair was positioned directly next to the bed. RNA 3 stated both RNA 3 and CNA 8 stood on the left side of Resident 68's bed. RNA 3 stated CNA 8 held onto Resident 68's trunk while RNA 3 lowered both legs to sit Resident 68 at the edge of the bed. RNA 3 stated Resident 68 sat at the edge of the bed while RNA 3 stood on Resident 68's right side and CNA 8 stood on Resident 68's left side. RNA 3 stated she cradled Resident 68's upper body by placing one arm underneath Resident 68's right axilla (armpit) and the RNA 3's other arm held onto the right leg. CNA 8 stated she similarly cradled Resident 68's upper body by placing one arm underneath Resident 68's left axilla and CNA 8's other arm held onto the left leg. RNA 3 stated both RNA 3 and CNA 8 physically lifted Resident 68 from the edge of the bed and into the reclining wheelchair.
During an interview on 7/24/2024 at 11:38 a.m. with the Director of Nursing (DON), the DON stated Resident 68's contractures increased Resident 68's risk for injury.
During a concurrent interview and record review on 7/24/2024 at 12:25 p.m. with the DON, Resident 68's MDS was reviewed. The DON stated Resident 68 was dependent for all activities of daily living ([ADLs] tasks related to personal care including bathing, dressing, hygiene, eating, and mobility) including bed/chair-to-bed transfers. The DON stated Resident 68 should be transferred with two persons - one person carrying the resident's upper body and the second person carrying the lower body.
During an interview on 7/25/2024 at 5:29 p.m. with the DON, the DON stated the facility usually used two persons to physically transfer each resident to different surfaces and did not routinely use a mechanical lift. The DON stated physically transferring Resident 68, who already had right arm swelling and pain, could potentially increase Resident 68's pain and risk for injury.
During a review of the facility's undated policy and procedure (P&P) titled, Accident/Incident Prevention, the P&P indicated the facility strived to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, identify each resident at risk for accidents/incidents, and provide care plans with procedures to prevent accidents.
Based on observation, interview, and record review the facility failed to provide an environment free from accidents and hazards, ensure residents received adequate supervision, and implement interventions to prevent accidents for five out of five sampled residents (Residents 2, 22, 46, 62, and 68) investigated under the Accidents care area by:
1. Failing to ensure two tubes of hydrocortisone (a type of medicine used for treating dermatitis [inflammation of the skin with dry skin, redness, and itchiness] and other skin conditions that cause itching) 1 percent (% - a unit of measurement) cream were not left unattended and easily accessible on top of Resident 2's overbed table.
This deficient practice placed other residents at risk for obtaining topical medication without staff knowledge resulting in accidental ingestion causing harm to residents.
2. Failing to ensure Residents 22, 46, and 62's wheelchair were not placed on top of floor mat while the residents were up on the wheelchair.
This deficient practice had the potential to result in the wheelchair becoming unstable on a soft surface resulting in resident injury.
3. Failing to ensure Resident 46's bed pad alarm (a pressure-sensitive pad placed under the mattress or seat cushion that trigger an alarm or warning light when they detect a change in pressure) was functioning properly.
This deficient practice had the potential to result in Resident 46 exiting the bed without staff knowledge and sustaining injuries from falls.
4. Failing to ensure one of five sampled residents (Resident 68) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) was transferred from the bed to the wheelchair in a manner to reduce the risk of injury to Resident 68, including the right arm which had pain and swelling.
This failure placed Resident 68 at increased risk for physical injury.
Cross reference to F580.
Findings:
a. During a review of Resident 2's admission Record, it indicated the facility admitted the resident on 9/29/2022 and readmitted the resident on 1/25/2023 with diagnoses including 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), dermatitis (inflammation of the skin with dry skin, redness, and itchiness), and dermatophytosis (also known as ringworm, a fungal infection of the skin that may affect the skin, hair, and nails).
During a review of Resident 2's History and Physical (H&P) dated 2/20/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/5/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance from staff with mobility; substantial/maximal assistance with tub/shower transfers; and supervision or touching assistance 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 2's Order Summary Report, there was no documented evidence of an active physician's order for hydrocortisone 1% cream.
During an observation on 7/23/2024 at 11:18 a.m. inside Resident 2's room, observed CNA 4 explaining to the resident regarding application of the hydrocortisone cream as requested by the resident.
During an interview on 7/23/2024 at 11:27 a.m., with CNA 4, CNA 4 stated he applied the hydrocortisone cream as requested by the resident on both lower legs, abdomen, and bilateral breast folds. CNA 4 stated a nurse left the cream at the bedside (unable to tell which nurse). CNA 4 stated the hydrocortisone cream is a medication.
During a concurrent observation and interview on 7/23/2024 at 11:34 a.m., with Treatment Nurse 1 (TN 1), TN 1 stated there was a tube half empty tube of hydrocortisone cream on top of resident's overbed table. TN 1 there should be no medication left at the resident's bedside at all times as they are prescribed medications for certain conditions and other residents can easily access the medication by accident and may result in injury.
During an interview on 7/26/2024 at 11:17 a.m., with the Director of Nursing (DON), the DON stated the hydrocortisone cream should not have been left at the bedside as it placed other residents at risk of easy access to the medication and may result in injury.
During a review of the facility's policy and procedure titled, Med Pass, last reviewed 1/10/2024, indicated do not leave medications at the bedside for resident unless ordered by physician.
b. During a review of Resident 22's admission Record, it indicated the facility admitted the resident on 2/2/2017 and readmitted on [DATE] with diagnoses including 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 generalized muscle weakness.
During a review of Resident 22's History and Physical (H&P) dated 4/15/2023, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/2/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating and mobility; 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).
During a review of Resident 22's Order Summary Report, it indicated:
-5/22/2024: [Non-RESTRAINT] Low bed with bilateral floor mat to decrease potential injury (Informed consent obtained from
During a review of Resident 22's Fall Risk assessment dated [DATE], it indicated the resident was a high risk for falls.
During a review of Resident 22's care plan (CP), the CP indicated the following:
1. Resident is on low bed with bilateral floor mat to prevent or reduce incident of injury or fall as well as for comfort of getting in and out of bed initiated 5/23/2024 last revised 6/16/2026 target date 8/31/2024 indicated to attempt to use less restrictive devices on an ongoing basis.
2. Resident 22 has self-car deficits needs assistance with ADLs; supervision touching assistance with transfers and ambulation in room and corridor initiated 5/29/2018 last revised 6/16/2024 target date 8/31/2024 indicated to provide a safe environment as one of the interventions.
During a concurrent observation and interview on 7/23/2024 at 9:32 a.m., inside Resident 22's room, observed resident in the wheelchair and the wheelchair was on top of the floor mat. Certified Nursing Assistant 3 (CNA 3) stated the wheelchair is not supposed to be left on top of the floor mat while a resident is sitting on it. CNA 3 stated the resident 's wheelchair can get caught on the floor mat and the resident may fall from the wheelchair when the resident tries to move.
During an interview on 7/26/2024 at 12:20 p.m., with the Director of Nursing (DON), the DON stated the wheelchair should not be left on top of the floor mat while the resident is sitting on it as it can get unstable and can cause accident and/or injury.
During a review of the facility provided instruction manual, undated, on Medical Equipment 2 (ME 2), it indicated the following:
-Never leave heavy objects on mat surface for extended periods, as indentations and damage may occur.
-Failure to comply with instructions, warnings, and cautions may result in serious injury to the patient.
-Keep sharp objects away from mat or damage may occur.
c. During a review of Resident 46's admission Record, it indicated the facility admitted the resident on 8/26/2019 and readmitted the resident on 7/29/2022 with diagnoses including 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), schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood, and history of falling.
During a review of Resident 46's History and Physical (H&P) dated 3/15/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 46's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/16/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated the resident was using a bed alarm.
During a review of Resident 46's Order Summary Report, it indicated the following physician's order:
-7/29/2022: [NON-RESTRAINT] Apply pad alarm in bed as nursing intervention to alert staff for unassisted transfer and attempting to walk. Nursing staff to check proper placement and function every shift.
-8/10/2023: [Non-RESTRAINT] Low bed with bilateral floor mat to decrease potential injury (Informed consent obtained from resident/responsible party after explanation of risks and benefits and verified with MD) every shift.
During a review of Resident 46's care plan (CP), the CP indicated the following:
1. Risk for falls or injury related but not limited to dementia, generalized weakness, history of falls, and impaired cognition initiated on 7/4/2023 and a goal to reduce falls and injury daily with a target date 8/14/2024. The care plan indicated the following interventions:
- Apply bed pad alarm to alert staff for unassisted transfer and attempting to walk ad nursing staff to check proper placement and function every shift.
- Low bed with bilateral pads.
- provide resident with a safe and clutter- free environment.
2. Falling Star program: At risk for falls related to balance deficit, bladder/bowel dysfunction, cognitive impairment, history of falls, etc. initiated on 7/23/2024 and a goal to reduce risk for fall and /or injury thru appropriate interventions daily with a target date 8/14/2024. The care plan indicated the following interventions:
- Low bed with bilateral pads in place
- Quarterly review of the fall risk assessment.
- Bed pad alarm
During a review of Resident 46's Fall Risk Assessments dated 5/16/2024, 2/12/2024, and 11/16/2023, it indicated the resident is a high risk for falls.
During a concurrent observation and interview on 7/23/2024 at 10:17 a.m., inside Resident 46's room, observed resident in the wheelchair and with wheelchair was on top of the floor mat. Certified Nursing Assistant 1 (CNA 1) stated the wheelchair is not supposed to be left on top of the floor mat while the resident is sitting on it. CNA 1 stated the resident wheelchair can get caught on the floor mat and the resident may fall from the wheelchair when the resident tries to move.
During a concurrent observation and interview on 7/25/2024 at 10:34 a.m. with Registered Nurse 2 (RN 2) and Certified Nursing Assistant 3 (CNA 3) inside Resident 46's room, observed Resident 46 constantly moving in bed from left to right. Observed Resident 46's bed alarm box hanging on the headboard with the cord connected to the pad alarm underneath the resident's sheets. RN 2 and CNA 3 turned resident towards the left side and the bed alarm did not trigger an alarm. RN 2 and CNA 3 verified the bed pad alarm did not function when the resident was turned to the side. CNA 3 stated she checks the alarm functionality by pressing on the sensor pad then release and the alarm will sound. RN 2 stated the box will emit beeping sounds and a flashing red light when the battery is low. RN 2 stated there was no flashing red light and beeping sound from the bed alarm box. RN 2 tested alarm functionality by pressing her hand and knee and release pressure on the sensor pad but the alarm did not sound. RN 2 stated the bed pad alarm should be in working order to alert staff because Resident 46 is at risk for rolling out of the bed accidentally and sustaining injury due to constant moving from left to right while in bed.
During an interview on 7/26/2024 at 12:20 p.m., the Director of Nursing (DON), the DON stated bed pad alarm functionality should be checked every shift every shift. The DON stated monitoring of functionality is documented in the Medication Administration Record (MAR). The DON stated the bed pad alarm should be functioning well as the resident can accidentally roll out of the bed and sustain an injury. The DON stated the wheelchair should not be left on top of the floor mat while the resident is sitting on it as the wheelchair can get unstable and may cause accident and/or injury.
During a review of the facility provided instruction manual, undated, on Medical Equipment 1 (ME 1) indicated the following:
-It is the responsibility of the caregiver to ensure that the product is properly installed, tested, and functioning correctly before each use.
-Low Battery indicator on the front of the alarm will flash or light up when the battery is low and needs to be replaced. Replace battery immediately if indicator flashes or lights.
-Bench test monitor and sensor pad prior to use. Use the hand to apply pressure to the sensor pad. The monitor will automatically sense the pressure and provide an audible beep when activated. Remove the pressure and the alarm will sound.
During a review of the facility provided instruction manual, undated, on Medical Equipment 2 (ME 2) indicated the following:
-Never leave heavy objects on mat surface for extended periods, as indentations and damage may occur.
-Failure to comply with instructions, warnings, and cautions may result in serious injury to the patient.
-Keep sharp objects away from mat or damage may occur.
During a review of the facility's policy and procedure titled, Accident/Incident Prevention, last reviewed 1/10/2024, indicated the facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control. The policy indicated:
-The facility will repair equipment to prevent defective equipment such as wheelchairs, geri-chairs with loose nuts/bolts, etc.
-Identify and eliminate electrical appliances with frayed wires, lock up cleaning supplies not in use, and identify wet floors.
d. During a review of Resident 62's admission Record, it indicated the facility admitted the resident on 2/2/2017 and readmitted the resident on 2/27/2018 with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), mood disorder (a mental health condition that primarily affects emotional state experiencing long periods of extreme happiness, extreme sadness, or both), and dermatophytosis (also known as ringworm, a fungal infection of the skin that may affect the skin, hair, and nails).
During a review of Resident 62's History and Physical (H&P), dated 2/3/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 62's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/11/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with toileting; partial/moderate assistance with mobility and ambulation; dependent with eating and showers; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During a review of Resident 62's Order Summary Report, it indicated:
-10/20/2023: [Non-RESTRAINT] Low bed with bilateral floor mat to decrease potential injury (Informed consent obtained from resident/responsible party after explanation of risks and benefits and verified with MD) every shift.
During a review of Resident 62's Fall Risk assessment dated [DATE], 4/11/2024, and 1/11/2024, the assessments indicated the resident was a high risk for falls.
During a review of Resident 62's care plan (CP), the CP indicated the following:
1. Resident is on low bed with bilateral floor mat to prevent or reduce incident of injury or fall as well as for comfort of getting in and out of bed initiated 1/22/2023 last revised 10/23/2023 target date 10/10/2024 indicated for the prevention/management of safety/injury from potential falls and attempt to use less restrictive devices on an ongoing basis as a few of the interventions.
2. Resident 62 has self-car deficits needs assistance with ADLs; partial to maximal assistance with bed mobility, supervision to substantial assistance with transfers and partial to moderate assistance with ambulation in room and corridor initiated 10/1/2021 last revised 6/16/2024 target date 8/31/2024 indicated to provide a safe environment as one of the interventions.
3.Resident 62 is at risk for falls/injury related to dementia and abnormalities of gait/mobility initiated 7/1/2023 last revised 10/23/2023 target date 10/10/2024 indicated to provide resident with a safe and clutter free environment and keep frequently used personal items within easy reach.
During a concurrent observation and interview on 7/23/2024 at 10:17 a.m., inside Resident 62's room, observed the resident in the wheelchair and the wheelchair was on top of the floor mat. Certified Nursing Assistant 3 (CNA 3) stated the wheelchair is not supposed to be left on top of the floor mat while a resident is sitting on it. CNA 3 stated the resident 's wheelchair can get caught on the floor mat and the resident may fall from the wheelchair when the resident tries to move.
During a concurrent observation and interview on 7/23/2024 at 10:18 a.m., inside resident 62's room, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated wheelchairs with residents sitting on it should not be left on top of the floor mat as the floor mat can get unstable and could result into accidents or injury.
During an interview on 7/26/2024 at 12:20 p.m., with the Director of Nursing (DON), the DON stated the wheelchair should not be left on top of the floor mat while the resident is sitting on it as the wheelchair can get unstable and cause accident and/or injury.
During a review of the facility provided instruction manual, undated, on Medical Equipment 2 (ME 2), it indicated the following:
-Never leave heavy objects on mat surface for extended periods, as indentations and damage may occur.
-Failure to comply with instructions, warnings, and cautions may result in serious injury to the patient.
-Keep sharp objects away from mat or damage may occur.
During a review of the facility's policy and procedure (P&P) titled, Accident/Incident Prevention, last reviewed 1/10/2024, thr P&P indicated the facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control. The policy indicated:
-The facility will repair equipment to prevent defective equipment such as wheelchairs, geri-chairs with loose nuts/bolts, etc.
-Identify and eliminate electrical appliances with frayed wires, lock up cleaning supplies not in use, and identify wet floors.

Based on interview and record review, the facility failed to complete a performance evaluation (PE - a formal and productive procedure to measure an employee's work and results based on their job responsibilities) every twelve months for three Restorative Nursing Aides (RNA - Certified Nursing Assistants [CNA] with specialized training to help residents regain their physical function and quality of life after illness or injury) reviewed under the sufficient and competent nurse staffing task.
This deficient practice prevented the identified RNA's from receiving individualized training and education based on the outcome of their PE that could impact resident safety and satisfaction.
Findings:
During a review of the facility's RNA job description, last reviewed on 1/10/2024, it indicated the RNA performs restorative nursing approaches on residents to assist the resident in reaching their maximum potential mobility. The RNA duties and responsibilities included range of motion, daily and weekly documentation for residents in the program, assistance with walking and transfers, activities of daily living (ADL - basic tasks that must be accomplished every day for an individual to thrive), placement of restorative devices and equipment such as wheelchairs and walkers, positioning, and restorative feeding program (individualized assistance to residents during mealtimes).
During a concurrent interview and record review on 7/25/2024 at 3:30 p.m. with the Director of Staff Development (DSD), reviewed RNA 1, 2, and 3's employee files:
1. RNA 1 was hired on 4/9/2019 and did not have a PE for 2019, 2022 and 2023. The DSD stated she was responsible for conducting the PE on all RNAs and CNAs and she does not know why the PE's were not done.
2. RNA 2 was hired on 4/18/2022 and did not have a PE for 2022 and 2023. The DSD stated, she must have overlooked it, when asked why the PEs were not completed.
3. RNA 3 was hired on 7/4/2015 and did not have a PE for 2015, 2016, 2017, 2019, 2022, and 2023. The DSD stated that she must have overlooked it and did not get a chance to complete them.
The DSD stated it is important to complete a PE every 12 months to ensure staff knows how to complete their job functions as well as provide the best care for the residents.
During an interview on 7/25/2024 at 6:40 p.m. with the Director Of Nursing (DON), the DON stated PEs must be completed annually to reevaluate staff; if they are still performing the same, as this can possibly lead to mistakes, errors, and failure to provide the correct care.
During a review of the facility's policy and procedure (P&P) titled, Employee Evaluation Policy, last reviewed 1/10/2024, the P&P indicated employees are evaluated annually and as needed based on performance. Employees who need immediate improvement may be evaluated more frequently.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Invasive Group A Streptococcal disease (iGAS - occurs when GAS bacteria get into parts of the body where these bacteria were not usually found and cause severe infection) for one of five sampled residents (Resident 5) by failing to:
a. Ensure facility staff's personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was worn inside the facility. Housekeeping 1's (HKP 1) face mask was not covering the nose while talking to Resident 5. Resident 5 was not wearing a face mask. Kitchen [NAME] (KC) was not wearing a face mask while inside the facility kitchen.
b. Ensure the facility staff performed hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before and after touching the used face mask.
These deficient practices placed the residents and staff at risk for exposure and contracting iGAS.
Findings:
A review of Resident 5's admission Record indicated the facility admitted the resident on 1/25/2023 with diagnoses including unspecified dementia (a confusion or mild cognitive impairment cannot be clearly diagnosed as a specific type of dementia), major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy), and primary osteoarthritis (condition that causes the joints to become very painful and stiff) of the left ankle and foot.
A review of Resident 5's History and Physical, dated 11/29/2021, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 5's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 5/3/2024, indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired.
On 7/12/2024 at 11:34 a.m., during a concurrent observation and interview, observed HKP 1 pulled her face mask down exposing HKP 1's nose. Resident 5 was talking to HKP 1 in the hallway without a face mask covering both nose and mouth. HKP 1 did not perform hand hygiene after she touched her mask and adjusted it up to cover the nose then touched the housekeeper cart. HKP 1 stated touching her mask and not performing hand hygiene had the potential to contaminate and spread infection to other residents and staff.
On 7/12/2024 at 12:02 p.m., during a concurrent observation and interview, Kitchen [NAME] (KC) was observed without a face mask inside the facility kitchen. Kitchen Aide 1 (KA 1) was observed inside the facility kitchen with face mask pulled down exposing KA 1's nose. Observed KA 1 touched her face mask and adjusted it to cover her nose. KA 1 did not perform hand hygiene after touching her face mask. KA 1 stated that her face mask was below the nose after she bent over to check the food tray.
On 7/12/2024 at 12:06 p.m., during an interview, KC stated he did not have his face mask on before the surveyor went inside the kitchen. KC stated that not wearing a face mask had the potential to contaminate the food and spread infection to all the residents.
On 7/12/2024 at 12:43 p.m., during an interview, the Infection Preventionist Nurse (IPN) stated face mask were supposed to be worn above the nose and below the chin covering both the nose and mouth. The IPN stated that the outside of the face mask was considered dirty and contaminated, The IPN stated hand hygiene should be done before and after touching the face mask. The IPN further stated infection could potentially spread to other residents and staff. The IPN stated the facility failed to ensure face masks were worn properly and infection control protocol were followed.
A review of the facility's policy and procedure titled, Infection Control, dated 1/10/2024, indicated the facility had established and will maintain an infection control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.
A review of the facility's policy and procedure titled, Personal Protective Equipment - Using face Masks, dated 1/10/2024, indicated the objective to prevent transmission of infectious agents through the air, to protect the wearer from inhaling droplets, and to prevent transmission of some infections that are spread by direct contact with mucous membrane. The policy indicated to be sure that face mask covers the nose and mouth while performing treatment or services for the patient. The policy indicated to avoid unnecessary handling of the mask and to wash hands.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 2) was provided privacy while talking on the phone. On 3/12/2024, observed Resident 2 talking on the phone while standing outside of Station 2.
This deficient practice violated Resident 2's right to have a private conversation.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/1/2024 with diagnoses that included unspecified (unconfirmed) Alzheimer ' s disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Alzheimer's disease involves parts of the brain that control thought, memory, and language), dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy), and history of fall.
A review of Resident 2 ' s History and Physical, dated 3/1/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 2 ' s Care Plan on at risk for self-care, developed on 3/1/2024, indicated an intervention to maintain residents ' privacy and respect their rights.
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/12/2024, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.
During an observation on 3/12/2024 at 8:40 a.m., observed Resident 2 standing by Station 1 requesting to make a phone call.
During an observation on 3/12/2024 at 8:44 a.m., observed Registered Nurse 1 (RN 1) sat on the right side of Station 1 and made a phone call and then put down the phone. Observed RN 1 going to the left side of Station 1 and attempted to pick up a call on the other phone but was not successful. RN 1 was observed talking and telling Resident 2 to walk with RN 1 to Station 2 to make a phone call.
During an observation on 3/12/2024 at 9 a.m., observed Resident 2 standing outside of Station 2 talking and crying on the phone. Observed RN 1 and LVN 1 inside Station 2 and Resident 3 and Resident 4 were seated in the wheelchair by the hallway close to Station 2.
During a concurrent observation and interview on 3/12/2024 at 9:03 a.m., with Licensed Vocational Nurse 1 (LVN 1) at Station 2, Resident 2 observed talking on the phone. LVN 1 stated Resident 2 was on the phone talking to Family Member 1 (FM 1). LVN 1 stated Resident 2 did not have any privacy while talking on the phone.
During an interview on 3/12/2024 at 9:12 a.m., LVN 1 stated residents usually makes a phone call in the nurse ' s station. LVN 1 stated Resident 2 should be provided with privacy when on the phone.
During an interview on 3/12/2024 at 10:17 a.m., RN 1 stated Resident 2 informed her that she missed and wanted to talk to FM 1. RN 1 stated they provide phone call privacy whenever resident requests it and Resident 2 did not request to have a private phone call. RN 1 stated she did not offer making a private conversation and that was something she needs to improve. RN 1 stated she could have used the facility's cellphone that was provided for the RN ' s and have the call inside the activity room.
During an interview n 3/12/2024 at 11:10 a.m. the Director of Nursing (DON) stated, staff should provide privacy during a resident ' s phone call.
A review of facility ' s policy and procedure titled, Resident Rights dated 2/2021 and reviewed by Quality Assurance Committee on 1/10/2024 indicated, Federal and state laws guarantee certain basic rights to all residents if this facility. These rights include the resident rights to:
t. privacy and confidentiality.
ac. Communicate in person and by main, email and telephone with privacy.
A review of facility ' s policy and procedure titled, Resident Use of Telephones dated 5/2017 and reviewed by Quality Assurance Committee on 1/10/2024 indicated, Designated telephones are available to residents to make and receive private telephone calls. The telephones at the nursing stations should ordinarily reserve for staff use unless no other alternative is available. Telephone will be in the areas that offer privacy and accommodate the hearing impaired, and wheelchair bound residents.

Based on observation, interview and record review, the facility failed to report allegation of family to resident abuse no later than two hours after the allegation was made, to the State Survey Agency (responsible for surveying/licensing the facility) for one of four sampled residents (Resident 2).
This deficient practice placed Resident 2 at risk for further abuse.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/1/2024 with diagnoses that included unspecified (unconfirmed) Alzheimer ' s disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Alzheimer's disease involves parts of the brain that control thought, memory, and language), dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy) and history of fall.
A review of Resident 2 ' s History and Physical, dated 3/1/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 2 ' s Care Plan on cognitive and communication deficit, developed on 3/1/2024, indicated an intervention to acknowledge and support verbal, non-verbal expressions.
A review of Resident 2 ' s Care Plan on abuse, developed on 3/1/2024, indicated an intervention that resident and or appointed representative has been informed and will be updated as needed throughout the year regarding the facility policies and procedure for identifying and reporting any forms of abuse.
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/12/2024, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.
During an observation on 3/12/2024 at 8:44 a.m., observed Resident 2 standing outside of Station 1 talking to Registered Nurse 1 (RN 1). Observed Resident 2 asking RN 1 if she was abused and RN 1 replied not to say abuse and instead offered to call Resident 2 ' s Family Member 1 (FM 1).
During an interview on 10:17 a.m., RN 1 stated, Resident 2 reported that FM 1 was abusing her, stole her identity and placed her in the facility. RN 1 stated she cannot remember the exact date when Resident 2 reported the allegation of abuse about FM 1. RN 1 stated today Resident 2 mentioned that she was abused again because she was placed inside the facility. RN 1 stated she had reported the allegation of abuse to the Administrator (ADM) when the ADM came in the facility.
During an interview on 3/12/2024 at 11:01 p.m., the ADM stated RN 1 reported Resident 2 ' allegation of abuse against FM 1 at 10 a.m. The ADM stated she had not reported it yet to State Survey Agency, Ombudsman (advocates for residents of nursing homes, assisted living facilities, board and care homes, and similar adult care homes) and had not yet called the law enforcement. ADM stated RN 1 should have reported the allegation of abuse right away so they can make a timely report within two hours after the allegation was made.
A review of facility ' s policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating dated 9/2022 and reviewed by Quality Assurance Committee on 1/10/2024, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) thoroughly investigated by facility management. Reporting allegation to the Administrator and authorities.
1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately o the administrator and to other officials according to state law.
2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies.
a. The state licensing/certification agency responsible for surveying/licensing the facility.
b. The local or state ombudsman.
d. Adult protective services (where state law provides jurisdiction in long term care)
e. law enforcement officials.
3. Immediately is defined as:
a. within two hours of an allegation involving abuse or result ins serious bodily injury.

Based on observation, interview, and record review, the facility failed to follow its abuse policy by failing to report an allegation of family to resident abuse no later than two hours after the allegation was made, to the State Survey Agency (responsible for surveying/licensing the facility) for one of four sampled residents (Resident 2).
This deficient practice placed Resident 2 at risk for further abuse.
Findings:
A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/1/2024 with diagnoses that included unspecified (unconfirmed) Alzheimer ' s disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Alzheimer's disease involves parts of the brain that control thought, memory, and language), dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy) and history of fall.
A review of Resident 2 ' s History and Physical, dated 3/1/2024, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 2 ' s Care Plan on cognitive and communication deficit, developed on 3/1/2024, indicated an intervention to acknowledge and support verbal, non-verbal expressions.
A review of Resident 2 ' s Care Plan on abuse, developed on 3/1/2024, indicated an intervention that resident and or appointed representative has been informed and will be updated as needed throughout the year regarding the facility policies and procedure for identifying and reporting any forms of abuse.
A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/12/2024, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired.
During an observation on 3/12/2024 at 8:44 a.m., observed Resident 2 standing outside of Station 1 talking to Registered Nurse 1 (RN 1). Observed Resident 2 asking RN 1 if she was abused and RN 1 replied not to say abuse and instead offered to call Resident 2 ' s Family Member 1 (FM 1).
During an interview on 10:17 a.m., RN 1 stated, Resident 2 reported that FM 1 was abusing her, stole her identity and placed her in the facility. RN 1 stated she cannot remember the exact date when Resident 2 reported the allegation of abuse about FM 1. RN 1 stated today Resident 2 mentioned that she was abused again because she was placed inside the facility. RN 1 stated she had reported the allegation of abuse to the Administrator (ADM) when the ADM came in the facility.
During an interview on 3/12/2024 at 11:01 p.m., the ADM stated RN 1 reported Resident 2 ' allegation of abuse against FM 1 at 10 a.m. The ADM stated she had not reported it yet to State Survey Agency, Ombudsman (advocates for residents of nursing homes, assisted living facilities, board and care homes, and similar adult care homes) and had not yet called the law enforcement. ADM stated RN 1 should have reported the allegation of abuse right away so they can make a timely report within two hours after the allegation was made.
A review of facility ' s policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating dated 9/2022 and reviewed by Quality Assurance Committee on 1/10/2024, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) thoroughly investigated by facility management. Reporting allegation to the Administrator and authorities
1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately o the administrator and to other officials according to state law.
2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies.
a. The state licensing/certification agency responsible for surveying/licensing the facility.
b. The local or state ombudsman.
d. Adult protective services (where state law provides jurisdiction in long term care)
e. law enforcement officials.
3. Immediately is defined as:
a. within two hours of an allegation involving abuse or result ins serious bodily injury.

Based on interview and record review, the facility failed to follow its facility ' s policy and procedure on fall and accidents and failed to provide necessary care and services to ensure the safety of one of four sampled resident (Resident 1) when Certified Nursing Assistant 1 (CNA 1) witnessed Resident 1 slide down to the floor unassisted on 3/6/2024 by:
1. Failing to update the fall care plan after the fall.
2. Failing to complete a Rehab Post Fall Assessment.
3. Failing to complete a Post Fall Risk Assessment.
3. Failing to conduct an interdisciplinary team (IDT- a coordinated group of experts from several different fields who work together) meeting.
These deficient practices had the potential to place Resident 1 at risk for injury from falls.
Findings:
A review of Resident 1 ' s admission Record, indicated the facility admitted the resident on 9/8/2023, with diagnoses that included unspecified (unconfirmed) dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Alzheimer ' s disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment. Alzheimer's disease involves parts of the brain that control thought, memory, and language), other seizures (uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body) 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 History and Physical, dated 11/8/2023, 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 2/12/2024, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.
A review of Resident 1 ' s Change of Condition (COC), dated 3/6/2024, indicated at 12:15 p.m., Certified Nursing Assistant 1 (CNA 1) attempted to feed resident, but resident became anxious and combative. The COC indicated resident continuous to exhibit aggressive behavior and was resistance to care and pushed CNA 1 and Licensed Vocational Nurse 2 (LVN 2). The COC indicated at 12:45 p.m., resident bumps her head on the overbed table causing swelling and discoloration on the right lateral (side) forehead. The COC indicated Registered Nurse 1 (RN 1) attempted to apply ice pack, but resident refused.
During an interview on 3/12/2024 at 10:17 a.m., RN 1 stated on 3/6/2024 at lunch time, CNA 1 called and when she responded in Resident 1 ' s room she saw the resident seated in the wheelchair and trying to slide down. RN 1 stated CNA 1, the Infection Preventionist (IP) was inside the room.
During a concurrent interview and record review on 3/12/2024 at 11:50 a.m., with the Medical Records Director (MRD), Resident 1 ' s Fall Risk Assessments, Rehabilitation Post Fall Risk Assessments, Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together) notes and fall care plan on or after 3/6/2024 was reviewed. The MRD stated the latest fall risk assessment was dated 2/12/24 that indicated resident was a high risk for fall. The MRD stated there were no fall risk assessment, no rehab fall risk assessment, no IDT, and no update in fall care plan after the fall on 3/6/2024.
During an interview on 3/12/204 at 12:03 p.m., the Director of Rehabilitation (DOR) stated there was no reported fall incident for Resident 1. The DOR stated if there was a fall incident, nurses would report to them so they can do a rehab post fall risk assessment.
During an interview on 3/12/2024 at 12:11 p.m., the IP stated on 3/6/2024 at lunch time, she was in the dining room when CNA 2 called her to check on Resident 1. The IP stated when she came inside Resident 1 ' s room, she saw the resident sitting on the floor mat with a right forehead bump. The IP stated CNA 1 was in the room who reported to her that resident was aggressive and bump her head on the table. The IP stated she and CNA 1 assisted the resident back to the wheelchair and that ' s when RN 1 came, and Resident 1 was trying to slide again on the floor.
During an interview on 3/12/2024 at 12:21 p.m., CNA 1 stated on 3/6/2024 around 12 noon he brought the lunch tray to Resident 1 who was inside her room seating on a wheelchair, but resident was aggressive, so he left to feed the other residents in the dining room. CNA 1 stated after 15 minutes he came back to Resident 1 ' s room with resident seating in the wheelchair with the overbed table in front of her with lunch tray. CNA 1 stated resident was still aggressive and while he was standing in front of the overbed table, Resident 1 grabbed CNA 1 ' s hand, pushed CNA 1 away and swung Resident 1 ' s hands at CNA 1. CNA 1 stated he did not want to aggravate so he steps back and that ' s when Resident 1 hit her head on the overbed table. CNA 1 stated he then witnessed Resident 1 sliding down on the floor. CNA 1 stated he called for assistance when resident was already on the floor. CNA 1 stated she was not sure if sliding down to the floor was a fall. CNA 1 stated Resident 1 slid down on her own. CNA 1 stated he did not assist her sliding down.
During an interview on 3/12/2024 at 12:30 p.m., the Director of Staff Development (DSD) stated CNA 1 should have reported the fall if resident slid down on the floor. The DSD stated if he had reported they would complete a change in condition form, assess residents for fall risk, conduct an IDT meeting and rehabilitation assessment would be done.
During an interview on 3/12/2024 at 12:43 p.m., the Administrator (ADM) stated she was notified that CNA 1 placed Resident 1 down on the floor after Resident 1 hit her head on the table. The ADM stated their intervention all focuses on Resident 1 ' s head hitting the table. The ADM stated the nurses assess her, but they did not document.
During an interview on 3/12/2024 at 3:07 p.m., the Director of Nursing (DON) stated they did not conclude the incident as fall based on the report, they received from CNA 1. The DON stated if it was not an assisted fall then it is considered a fall. The DON stated they did not reassess Resident 1 for fall risk; they did not update the care plan for fall because it was not reported to them.
A review of facility ' s policy and procedure titled, Initial Fall Risk Assessment undated and reviewed by Quality Assurance Committee on 1/10/2024 indicated, The plan of care will be reviewed by the IDT quarterly and as needed for update of the resident ' s current needs.
A review of facility ' s policy and procedure titled, Rehabilitation-Fall Assessment/Risk Assessment undated and reviewed by Quality Assurance Committee on 1/10/2024 indicated, When a fall occurs, the Therapist will re-screen residents using the fall assessment form. An investigation and IDT meeting should address all resident safety issues and a care plan developed to prevent recurrence.
A review of facility ' s policy and procedure titled, Incidents/Accidents undated and reviewed by Quality Assurance Committee on 1/10/2024 indicated, It is the policy of this facility to investigate incidents/accidents and report as indicated:
1. Incidents/Accidents will be reported to the charge nurses and documented on the accident/incident report as soon it occurs.
3. The charge nurses or supervisor will initiate an investigation report if needed. The supervisor will interview residents, staff or visitors and document conversations and events related to the incident.
12. Nursing assessment and documentation of incident on
c. care plan entry
g. post fall assessment completed.

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) by failing to document administration of enalapril maleate (medication used to treat high blood pressure) accurately and per physician order.
This deficient practice had the potential to result in inadequate management of Resident 1 ' s high blood pressure and the medical records containing inaccurate documentation can result in the delay of delivery of care.
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/21/2022 with diagnoses that included periprosthetic fracture (a broken bone that occurs around the implants of a total hip replacement) around the internal prosthetic (implant- is an artificial device that replaces a missing body part) right hip joint, history of fall, unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and essential hypertension (high blood pressure that doesn't have a known cause).
A review of Resident 1 ' s History and Physical, dated 11/1/2023, indicated the resident did not have the capacity to understand and made decisions.
A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/25/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.
A review of Resident 1 ' s Care Plan on at risk for cardiac distress related to hypertension, dated 9/22/2022, indicated an intervention to give medications as ordered.
During a concurrent interview and record review on 1/10/2024 at 10:20 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 1 ' s Physician Order, dated 10/31/2023, and Medication Administration Record (MAR- record of medications received by the resident), dated 11/2023, was reviewed. The Physician Order, dated 10/31/2023, indicated an order for enalapril maleate (medication used to treat high blood pressure) tablet five milligram (mg-unit of measure), give one tablet by mouth one time a day for essential hypertension, hold for systolic blood pressure (SBP - pressure in the arteries when the heart beats) less than 110. The MAR dated 11/1/2023 indicated Resident 1 ' s blood pressure was 105/73 and enalapril maleate had a check mark sign at 8 a.m. LVN 1 stated check mark sign indicated the medication was given. LVN 1 stated she did not give the medication and documented it in error. LVN 1 stated she should have documented medication was held in the MAR.
During an interview on 1/10/2024 at 11:10 a.m., Registered Nurse 1 (RN 1) stated LVN 1 should have documented that medication was held as per physician order. RN 1 stated giving blood pressure medication to a low blood pressure may cause hypotension (uncontrolled low blood pressure), and resident will be high risk for incidence of fall.
During an interview on 1/10/2024 at 11:58 a.m., the Director of Nursing (DON) stated LVN 1 should have documented that medication was held per physician ' s order.
A review of facility ' s policy and procedure titled, Administering Medications, dated 3/2023, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame.
19. If drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and document the reason.

Based on observation, interview, and record review the facility failed to implement infection control practices for one out of nine sampled residents (Resident 6) by failing to ensure:
1. The suction canister (a temporary storage container for secretions or fluids removed from the body) and Yankauer suction tip (an oral suctioning tool used in medical procedures)of Resident 6 was dated and labeled with the name of the resident.
2. The Yankauer suction tip (an oral suctioning tool used in medical procedures) of Resident 6 was not touching the floor.
These deficient practices had to potential for pathogens (an organism causing disease to the host) to grow in the canisters and tubing that could cause residents to get sick.
Findings:
A review of Resident 6 ' s admission Record indicated the facility admitted Resident 6 on 10/28/2022 and the facility readmitted Resident 6 on 5/23/2023, with diagnoses including chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), allergic rhinitis (inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mold, or flakes of skin from certain animals), and personal history of urinary tract infection (common infections that happen when bacteria, often from the skin or rectum, enters the urethra [duct that transmits urine from the bladder to the exterior of the body during urination], and infect the urinary tract).
A review of Resident 6 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/29/2023, indicated Resident 6 sometimes had the ability to make self-understood and understand others.
During a concurrent observation and interview on 9/19/2023, at 9:52 a.m., observed with Certified Nursing Assistant 2 (CNA 2) Resident 6 ' s suction canister was not labeled with the date of when the canister was last changed. Observed with CNA 2 the Yankauer suction tip of Resident 6 was not labeled with the date of when it was last changed and touching the floor. CNA 2 stated she does not know if the canister and the Yankauer suction tip needed to be dated. CNA 2 stated that the Yankauer suction tip should not be touching the floor to prevent infection.
During an interview on 9/19/2023 at 10:45 a.m., Licensed Vocational Nurse 1 (LVN 1) stated the suction canister and the Yankauer suction tip tubing should be dated to in order to know when to replace them. LVN 1 stated the suction canister and the Yankauer can cause infection if used over a long period of time.
During an interview on 9/19/2023 at 11:34 a.m., the Director of Nursing (DON) stated the suction canister should be dated and should be changed every 3 to 7 days for infection control purposes.
During an interview on 9/19/2023 at 12:51 p.m., the Infection Preventionist (IP) stated the suction canister must be dated and labeled with patient name and changed after each use for infection control. The IP added stated the Yankauer suction tip must be dated and labeled with the resident's name and discarded after each use.
A review of the facility ' s recent policy and procedure titled Suctioning, last reviewed on 8/18/2023, indicated suction catheters are to be changed daily and after each use. Suction bottles are to be emptied and washed at the end of each shift, or as recommended when using suction collecting gel materials.

Based on observation, interview, and record review, the facility failed to ensure the residents 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) for one of three residents (Resident 2) by failing to set the low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) to appropriate setting per manufacturer's recommendation.
This deficient practice placed Resident 2 at risk for the development and worsening of pressure ulcers.
Findings:
A review of Resident 2's admission Record indicate the facility admitted the resident on 8/15/2022 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interfered with doing everyday activities), pressure ulcer (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) on the sacral region (bottom of the spine). and essential hypertension (abnormally high blood pressure that was not the result of a medical condition).
A review of Resident 2's History and Physical, dated 8/16/2022, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 2's Minimum Date Set (MDS – a standardized assessment and care screening tool), dated 5/19/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required extensive assistance (resident involved in activity, staff provide weight-bearing support) on transfer, walk in room and corridor (how the resident walks between locations in the room and in the corridor on unit), and bathing. Resident 2 required limited assistance (resident highly involved in activity and staff provide guided maneuvering of limbs or other non-weight-bearing assistance) on dressing, toilet use, and personal hygiene. The skin conditions section indicated Resident 2 was at risk of developing PU. The MDS skin and ulcer/injury treatment section indicated Resident 2 required a pressure reducing device for bed.
A review of Resident 2's Physician Orders, dated 6/23/2023, indicated stage two pressure injury to be cleansed with normal saline (NS, a mixture of salt and water used for cleaning wounds), pat dry, apply hydrogel (a gel in which the liquid constituent was water), and cover with dry dressing every day for 30 days.
A review of Resident 2's Skin Assessment Report, dated 7/11/2023, indicated the resident had a stage 2 (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) PU. The therapeutic measures section indicated Resident 2 required alternating positive pressure mattress, LALM, turning /repositioning.
A review of Resident 2's Physician Orders, dated 7/14/2023, indicated low air-loss mattress for wound care and management every shift.
During a concurrent observation, interview, and record review on 7/17/2023 at 10:13 a.m., observed Resident 2's MDT24A20 LALM machine setting at 240 pounds (lbs - unit of weight measurement), on normal pressure, and on static setting (all air cells in the mattress were equally inflated). Licensed Vocational Nurse 1 (LVN 1) confirmed Resident 2's LALM settings. LVN 1 stated that the LALM setting were based on the resident's weight and checked daily. LVN 1 reviewed Resident 2's weight on the electronic health record (EHR) and it indicated that the resident's current weight, dated 7/5/2023, was 109 lbs. LVN 1 stated that Resident 2's LALM machine should be set at a lower weight setting.
During a concurrent interview and record review on 7/17/2023 at 2:01 p.m., the Director of Nursing (DON) stated that the LALM machine was from Resident 2's hospice company and the facility were made aware of the functions of the machine. The DON reviewed the manufacturer's operating manual and stated that it indicated the use of alternate pressure mode (alternating air cells are partially deflated and inflated) to avoid prolonged pressure on any single point beneath the resident. It also indicated the use to prevent pressure ulcers. DON stated that Resident 2's LALM setting should be on alternate pressure mode and based on the resident's weight.
A review of the facility's policy and procedure titled, Pressure -Reducing Mattresses, dated 4/28/2023, indicated the objective to provide mattresses that will prevent and/or minimize pressure on the skin. The policy did not indicate the setting operations of the LALM machine.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality for one of four sampled residents (Resident 2) by failing to ensure the privacy curtain was drawn while Licensed Vocational Nurse 1 (LVN 1) and Certified Nursing Assistant 1 (CNA 1) were changing the resident's wound dressing (a type of bandage used to cover a wound).
This deficient practice violated Resident 2's right for privacy and had the potential to affect the resident's self-esteem, self-worth, and psychosocial well-being.
Findings:
A review of Resident 2's admission Record indicate the facility admitted the resident on 8/15/2022 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interfered with doing everyday activities), pressure ulcer (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) on the sacral region (bottom of the spine). and essential hypertension (abnormally high blood pressure that was not the result of a medical condition).
A review of Resident 2's History and Physical, dated 8/16/2022, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 2's Minimum Date Set (MDS – a standardized assessment and care screening tool), dated 5/19/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required extensive assistance (resident involved in activity, staff provide weight-bearing support) on transfer, walk in room and corridor (how the resident walks between locations in the room and in the corridor on unit), and bathing. Resident 2 required limited assistance (resident highly involved in activity and staff provide guided maneuvering of limbs or other non-weight-bearing assistance) on dressing, toilet use, and personal hygiene. The skin conditions section indicated Resident 2 was at risk of developing PU.
A review of Resident 2's Physician Orders, dated 6/23/2023, indicated stage two pressure injury to be cleansed with normal saline (NS, a mixture of salt and water used for cleaning wounds), pat dry, apply hydrogel (a gel in which the liquid constituent was water), and cover with dry dressing every day for 30 days.
During an observation on 7/17/2023 at 10:13 a.m., observed LVN 1 and CNA 1 changing Resident 2's wound dressing with the privacy curtain covering half of the resident's bed. The privacy curtain between Resident 2 and Resident 3 was not drawn, exposing Resident 2. Resident 2 observed with pants pulled down to mid-thigh level and incontinent brief open, exposing the resident's buttocks.
On 7/17/2023 at 1:12 p.m., during an interview, CNA 1 stated she should have fully drawn the privacy curtain while providing care to Resident 2 for privacy and resident's dignity.
On 7/17/2023 at 2:01 p.m., during an interview, the Director of Nursing (DON) stated that privacy curtains must be drawn fully, covering the resident, while facility staff provided resident care. The DON further stated that facility staff failed to provide privacy for Resident 2.
A review of the facility's policy and procedure titled, Resident Rights, dated 4/28/2023, indicated the resident has the right to personal privacy and confidentiality of personal and clinical records. The policy indicated personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups.
A review of the facility's policy and procedure titled Dignity, dated 4/28/2023, indicated that each resident should be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The policy indicated staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and treatment procedures.

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan and failed to review and revise the care plan based on the needs of the resident for one of six sampled residents (Resident 4). Resident 4, who was at risk of falls, had behavior problems, had poor safety awareness, had a hunchback (kyphotic posture, a spinal disorder in which an excessive curve of the spine results in an abnormal rounding of the upper back), was receiving physical therapy (PT, the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise), and had an open wound on the right foot requiring the use of a special shoe. The care plan was not reviewed and revised to include the assistance needed, the interventions related to the use of the special shoe, and the hunchback posture affecting the balance.
As a result, nursing staff did not meet Resident 4's needs to provide the necessary care and services and did not ensure the resident did not walk unassisted and unsupervised.
Findings:
On 6/1/2023 at 10:10 a.m., during an observation and interview, Resident 4 was sitting in a wheelchair, had a hunchback, and was wearing a right shoulder sling (used to both support the weight of the arm and limits arm movement) on the right arm. Resident 4 was wearing a black special shoe (called post-surgical shoe, post-op shoe or hard sole shoe, is a medical shoe used to protect the foot and toes after an injury or a surgery) on the right foot. Resident 4 was wearing a non-skid sock on the left foot. Resident 4 stated she had a sling because she fell but could not remember the details. Resident 4 refused to answer other questions.
A review of Resident 4's admission Record indicated the facility initially admitted the resident on 11/2/2020 and readmitted the resident on 12/22/2020. Resident 4's diagnoses included type 2 diabetes mellitus (a disease that occurs when the blood sugar levels were too high) with diabetic foot ulcers on the right foot, muscle weakness, and osteoarthritis (occurs when the cartilage that cushions the ends of the bones or joints gradually deteriorates).
A review of Resident 4's Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 5/2/2023, indicated the resident had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 4 required limited assistance (staff provided guided maneuvering of limbs) with one-person physical assist with walking in room (how resident walks between locations in the room) and walking in corridor (how resident walks in corridor on unit). Resident 4's balance during transition and walking were not steady (only able to stabilize with staff assistance). Resident 4 used a wheelchair as mobility device.
A review of Resident 4's Care Plan for risk for fracture, initiated on 11/2/2020 and revised on 11/17/2021, indicated the goal of reducing the risk of injury. The interventions included assisting with all transfers and ambulation as needed. The type of assistance was not included.
A review of Resident 4's Care Plan addressing secured unit placement, initiated on 11/2/2020 and last revised on 11/17/2021, indicated the resident was at risk for purposeless wandering (a common behavior in dementia [decline in mental ability severe enough to interfere with daily functioning/life] causing people to become lost or confused about their location) and potential for self-injury. The goals indicated were for the resident to have safe wandering and directed activities with no self-injury. The interventions included managing behavioral and psychological symptoms of dementia (BPSD).
A review of Resident 4's Care plan on elopement (when a resident who is cognitively, physically, or mentally impaired wanders away, walks away, runs away, escapes, or otherwise leaves a caregiving facility or environment unsupervised) risk, initiated on 11/10/2022 and last revised on 11/24/2022, included interventions of monitoring the resident at frequent intervals and re-directing the resident to alternatives like activities, watching television, calling family contact, offering magazine, and providing one on one (1:1) supervision (one staff to be with the resident at all times) if indicated to redirect behavior on interim basis (temporarily).
A review of Resident 4's Interdisciplinary Wound Management Care Plan forms dated 4/27/2023, indicated the wound on the right mid-foot metatarsal (the ball of the foot) had reopened.
A review of the Physician's Orders for Resident 4, dated 4/27/2023, indicated to apply the post-op shoe on the right lower extremity during functional mobility (while standing and walking).
A review of Resident 4's Fall Risk Assessment, dated 5/2/2023 at 2:02 p.m., indicated the resident had a total score of 20. A total score above 18 represented high risk for falls. The level of consciousness/mental status section indicated Resident 4 had intermittent confusion, poor safety awareness, and noncompliance. The gait (manner of walking) and balance section indicated that Resident 4 had unsteady gait (when a person is having trouble with their balance or the way they walk) and poor sitting or standing balance.
A review of Resident 4's Interdisciplinary Team (IDT, a group of healthcare professionals from different disciplines who participate in the care of the resident) meeting notes, dated 5/2/2023, indicated an IDT meeting was conducted due to Resident 4's re-opening of the right foot diabetic ulcer. The IDT meeting note indicated Resident was typically pacing (walking or moving repeatedly, often back and forth) around, even wandering around, was fully ambulatory, wearing proper footwear with non-skid socks but sometimes preferred only the non-skid socks.
A review of Resident 4's Care Plan developed for the resident's self-care deficit and needing assistance with activities of daily living (ADLs, including walking, transfers, toilet use, bathing, dressing, and personal hygiene), initiated on 11/2/2020 and last revised on 5/13/2023, had a goal for the resident to be clean and dry daily and another goal to minimize decline. The care plan interventions included to assist with ADLs and provide a safe environment. The type of the assistance was not addressed. The use of the post-op shoe ordered on 4/27/2023 was not addressed.
A review of Resident 4's Care Plan on Falling Star Program (program that includes interventions for residents identified as fall risk), initiated on 11/2/2020 and last revised on 5/13/2023, indicated the resident was at risk for falls secondary to balance deficit, cognitive impairment, poor safety awareness, difficulty in walking, and muscle weakness. The goal was to reduce Resident 4's risk of falls through appropriate interventions. The interventions included to respect the resident's wishes for independence and dignity, to conduct frequent visual monitoring, and to place the resident close to the activity designee station for close observation. The use of the post-op shoe ordered on 4/27/2023 was not addressed as an increased risk for falls due to the thick sole. The resident's need for CGA and HHA was not included.
A review of Resident 4's Licensed Nurse Record from 5/21/2023 to 5/24/2023, indicated the resident required extensive assistance with one-person assist with gait and ambulation.
A review of Resident 4's Physical Therapy (PT) Treatment Encounter Notes, dated 5/22/2023, 5/23/2023, and 5/24/2023, indicated the resident required contact guard assistance (CGA, the contact is made to help steady the body and help with balance) and hand-held assistance (HHA) while walking on level surfaces. The PT notes did not address the post-op shoe Resident 1 was using that due to the thick sole would cause imbalance during standing and walking.
On 6/1/2023 at 10:36 a.m., during an interview, CNA 2 stated Resident 4 walks while looking down on the floor. CNA 2 stated Resident 4 was standing at the hallway across the kitchen door, with no wheelchair, and falling forward tilting towards the right side. CNA 2 stated he was not able to reach Resident 4 to prevent the fall because of the distance between them. CNA 2 stated there was no other staff in the hallway at the time of Resident 4's fall. CNA 2 could not remember what footwear Resident 4 had at the time of the fall.
On 6/1/2023 at 11:02 a.m., during an interview, Registered Nurse 2 (RN 2) stated Resident 4 walks slowly looking down on the floor. RN 2 demonstrated Resident 4's posture (hunchback) during ambulation. RN2 could not remember what footwear Resident 4 had at the time of the fall.
On 6/1/2023 at 12:03 p.m. during an interview, CNA 3 stated Resident 4 could walk but needed assistance. CNA 3 stated Resident 4 stated that before the fall, Resident 4 was wearing the post-op shoe on the right foot and was sitting on the wheelchair in front of the Nursing Station 2. CNA 3 stated Resident 4 constantly attempts to get out of the wheelchair. CNA 3 stated the resident was not safe walking with the post-op shoe because of the uneven footing from the sole thickness of the post-op shoe.
On 6/1/2023 at 1:13 p.m., during a concurrent interview and record review, RN 3 stated Resident 4 was stable in ambulating before the right foot ulcer reopened. RN 3 stated Resident 4 walked wearing the post-op shoes during the MDS assessment. RN 3 defined limited assistance as resident's ability to perform 75% of the task with minimal staff assistance. Resident 4's MDS functional status section was reviewed with RN 3 and confirmed the resident was not steady and needed staff to be beside the resident while ambulating. RN 3 further stated Resident 4's use of the post-op shoes should have been evaluated as a fall risk and should have been included in the care plan.
On 6/1/2023 at 1:58 p.m., during a concurrent interview and record review, the Director of Rehab (DOR) stated Resident 4 had unsteady gait and needed close supervision for redirecting. The DOR stated Resident 4 had a right diabetic foot wound and had been walking up to 125 feet with the post-op shoes during PT sessions. The DOR stated Resident 4 could walk more than 125 feet but required frequent rest periods. The DOR defined Resident 4's kyphotic (hunchback) posture as rounded spinal curvature which changed the resident's center of balance. The DOR stated a kyphotic posture was a contributing factor for Resident 4's unsteady gait. The DOR confirmed not addressing in the PT notes Resident 4's hunchback and the use of the post-op shoes as fall risk. The DOR confirmed Resident 4 required CGA and HHA during ambulation. The DOR acknowledged the care plans were not reviewed and revised to address the resident's need for CGA and HHA, the need of increased awareness as the special post-op shoe, and the hunchback affected the resident's balance.
On 6/1/2023 at 2:32 p.m., during a concurrent interview and record review, RN 2 confirmed Resident 4's MDS indicated the resident required limited assistance with one-person assist and had unsteady gait. RN 2 stated Resident 4 should be closely supervised while walking.
On 6/5/2023 at 10:15 a.m., during an interview, the Director of Nursing (DON) verified the care plans did not include the post-op shoe, the hunchback, and the need of CGA and HHA.
A review of the facility's policy and procedure titled. The Resident Care Plan, dated 2/10/2023, indicated the objective to provide an individualized nursing care plan and to promote continuity of resident care. The policy indicated the nursing section of the care plan must indicate long and short-term goals with plans for restorative and rehabilitative nursing care. It also indicated the nursing care plan acts as a communication instrument between nurses and other discipline.
A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, dated 2/10/2023, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy also indicated the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

Based on observation, interview and record review, the facility failed to prevent a fall and injury for one of six sampled residents (Resident 4), who was identified as a high fall risk, with unsteady standing and walking balance, and poor safety awareness. The facility failed to:
1. Provide Resident 4 with contact guard assistance (CGA, the contact is made to help steady the body and help with balance) and hand-held assistance (HHA) while walking, as assessed by the physical therapist (PT, a health professional trained to evaluate and treat people who have conditions or injuries that limit their ability to move and do physical activities).
2. Identify the fall risk posed by Resident 4's use of the post-op shoe (also called post-surgical shoe, or hard sole shoe - a medical shoe used to protect the foot and toes when there is an injury, a wound, or after surgery) to the right foot for wound management ordered on 4/27/2023.
3. Identify and make recommendations to address Resident 4's posture due to a hunchback (abnormal rounding of the upper back) that affected the resident's balance and caused the resident to look down while walking.
4. Review and revise Resident 4's care plan interventions that were person-centered and were individualized based on the resident's risks, physical, and mental condition.
5. Implement the facility's policies and procedure on Accident/Incident Prevention; Falls and Fall Risk, Managing; The Resident Care Plan; Falling Star Program; and Promoting Safety, Reducing Falls.
As a result, on 5/25/2023 at 9:45 a.m., Resident 4 fell onto the floor while walking unassisted in the hallway and sustained a right shoulder fracture (broken bone).
Findings:
On 6/1/2023 at 10:10 a.m., during an observation and interview, noted Resident 4 with a hunchback and observed the resident sitting on a wheelchair in the activity room. Resident 4 was wearing a right shoulder sling (used to both support the weight of the arm and limits arm movement). Resident 4 stated she had a sling because of a fall but she did not remember the details and she did not answer further questions. The resident also had a black post-op shoe with a thick sole on the right foot and had a non-slip non-skid sock (improves the grip to help preventing slip and fall) on the left foot.
A review of Resident 4's admission Record indicated the facility initially admitted the resident on 11/2/2020 and readmitted the resident on 12/22/2020. Resident 4's diagnoses included type 2 diabetes mellitus (a disease that occurs when the blood sugar levels were too high) with diabetic foot ulcers (open sores or wounds of patients with diabetes) on the right foot, muscle weakness, and osteoarthritis (occurs when the cartilage that cushions the ends of the bones or joints gradually deteriorates).
A review of Resident 4's Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 5/2/2023, indicated the resident had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 4 required limited assistance (staff provided guided maneuvering of limbs) with one-person physical assist with walking in room (how resident walks between locations in the room) and walking in corridor (how resident walks in corridor on unit). Resident 4's balance during transition and walking were not steady (only able to stabilize with staff assistance). Resident 4 used a wheelchair as mobility device.
A review of Resident 4's Care Plan developed for the resident's self-care deficit and needing assistance with activities of daily living (ADLs, including walking, transfers, toilet use, bathing, dressing, and personal hygiene), initiated on 11/2/2020 and last revised on 5/13/2023, had a goal for the resident to be clean and dry daily and another goal to minimize decline. The care plan interventions included to assist with ADLs and provide a safe environment.
A review of Resident 4's Care Plan on risk for fracture, initiated on 11/2/2020 and revised on 11/17/2021, indicated the goal of reducing the risk of injury. The interventions included assisting the resident with all transfers and ambulation as needed.
A review of Resident 4's Care Plan on Falling Star Program (program that includes interventions for residents identified as fall risk), initiated on 11/2/2020 and last revised on 5/13/2023, indicated the resident was at risk for falls secondary to balance deficit, cognitive impairment, poor safety awareness, difficulty in walking, and muscle weakness. The goal was to reduce Resident 4's risk of falls through appropriate interventions. The interventions included to respect the resident's wishes for independence & dignity, to conduct frequent visual monitoring, and to place the resident close to the activity designee station for close observation.
A review of Resident 4's Care Plan addressing secured unit placement, initiated on 11/2/2020 and last revised on 11/17/2021, indicated the resident was at risk for purposeless wandering (a common behavior in dementia [decline in mental ability severe enough to interfere with daily functioning/life] causing people to become lost or confused about their location) and potential for self-injury. The goals indicated were for the resident to have safe wandering and directed activities with no self-injury. The interventions included managing behavioral and psychological symptoms of dementia (BPSD).
A review of Resident 4's Care plan on elopement (when a resident who is cognitively, physically, or mentally impaired wanders away, walks away, runs away, escapes, or otherwise leaves a caregiving facility or environment unsupervised) risk, initiated on 11/10/2022 and last revised on 11/24/2022, included interventions of monitoring the resident at frequent intervals and re-directing the resident to alternatives like activities, watching television, calling family contact, offering magazine, and providing one on one (1:1) supervision (one staff to be with the resident at all times) if indicated to redirect behavior on interim basis (temporarily).
A review of Resident 4's Interdisciplinary Wound Management Care Plan forms dated 4/27/2023, indicated the wound on the right mid-foot metatarsal (the ball of the foot) had reopened.
A review of Resident 4's Physician's Orders, dated 4/27/2023, indicated to apply the post-op shoe on the right lower extremity during functional mobility (while standing and walking).
A review of Resident 4's Fall Risk Assessment, dated 5/2/2023, indicated the resident had a total score of 20. A total score above 18 represented high risk for falls. The level of consciousness/mental status section indicated Resident 4 had intermittent confusion, poor safety awareness, and noncompliance. The gait (manner of walking) and balance section indicated Resident 4 had unsteady gait (when a person is having trouble with their balance or the way they walk) with poor sitting or standing balance.
A review of Resident 4's Interdisciplinary Team (IDT, a group of healthcare professionals from different disciplines who participate in the care of the resident) notes, dated 5/2/2023, indicated an IDT meeting was conducted due to Resident 4's re-opening of the right foot diabetic ulcer. The IDT meeting note indicated Resident was typically pacing (walking or moving repeatedly, often back and forth) around, even wandering around, was fully ambulatory, wearing proper footwear with non-skid socks but sometimes preferred only the non-skid socks.
A review of Resident 4's Licensed Nurse Record from 5/21/2023 to 5/24/2023, indicated the resident required extensive assistance with one-person assist with gait and ambulation.
A review of Resident 4's Physical Therapy (PT) Treatment Encounter Notes, dated 5/22/2023, 5/23/2023, and 5/24/2023, indicated the resident required CGA and HHA with walking on level surfaces. The PT notes did not address the post-op shoe Resident 1 was using that the thick sole would cause imbalance during standing and walking.
A review of Resident 4's Change of Condition (COC) Assessment Form, dated 5/25/2023, indicated that at 9:15 a.m., the resident was seen multiple times walking in the hallways. At 9:45 a.m., Certified Nursing Assistant 2 (CNA 2) saw the resident lying on the floor across the kitchen hallway. Upon checking Resident 4's right arm, the resident had facial grimace and complained of pain on the right shoulder. At 10:10 a.m., the physician was notified and ordered x-rays (a procedure that creates pictures of the inside of the body in different shades of black and white). At 2:34 p.m. the x-rays result showed acute fracture of the right shoulder. At 3:22 p.m., the physician ordered transfer to General Acute Care Hospital 1 (GACH 1).
A review of Resident 4's IDT Narrative Notes, dated 5/25/2023 at 5:51 p.m., indicated the resident had confusion, disorientation, poor safety awareness, and impulsiveness. Resident 4 was ambulatory and required physical assist with ADLs. The IDT narrative notes indicated Resident 4's fall was not prevented because of the distance between the witness and the resident.
A review of Resident 4's GACH 1 right shoulder x-ray report, dated 5/25/2023 timed at 7:46 p.m., indicated the resident sustained a mildly comminuted fracture (the breaking of a bone into several small pieces) and impacted fracture (happens when a bone is compressed causing parts of the bone to crumble) of the right proximal (at the shoulder level) humerus (the long bone of the upper arm). Resident 4 was sent back to the facility the same day with the sling and with instructions to have follow-up appointment with orthopedic surgery (the branch of surgery concerned with conditions involving the musculoskeletal [muscles and bones] system) in the next three months.
On 6/1/2023 at 10:36 a.m., during an interview, CNA 2 stated Resident 4 walks while looking down on the floor. CNA 2 stated Resident 4 was standing at the hallway across the kitchen door, with no wheelchair, and falling forward tilting towards the right side. CNA 2 stated he was not able to reach Resident 4 to prevent the fall because of the distance between them. CNA 2 stated there was no other staff in the hallway at the time of Resident 4's fall. CNA 2 could not remember what footwear Resident 4 was wearing at the time of the fall.
On 6/1/2023 at 11:02 a.m., during an interview, Registered Nurse 2 (RN 2) stated Resident 4 walks slowly looking down on the floor. RN 2 demonstrated Resident 4's posture (hunchback) during ambulation. RN 2 could not remember what footwear Resident 4 had at the time of the fall.
On 6/1/2023 at 12:03 p.m. during an interview, CNA 3 stated Resident 4 could walk but needed assistance. CNA 3 stated Resident 4 stated that before the fall, Resident 4 was wearing the post-op shoe on the right foot and was sitting on the wheelchair in front of Nursing Station 2. CNA 3 stated Resident 4 constantly attempts to get out of the wheelchair. CNA 3 stated the resident was not safe walking with the post-op shoe because of the uneven footing from the sole thickness of the post-op shoe.
On 6/1/2023 at 1:13 p.m., during a concurrent interview and record review, RN 3 stated Resident 4 was stable in ambulating before the right foot ulcer reopened. RN 3 stated Resident 4 walked wearing the post-op shoe during the MDS assessment. RN 3 defined limited assistance as resident's ability to perform 75% of the task with minimal staff assistance. Resident 4's MDS functional status section was reviewed with RN 3 and confirmed the resident was not steady and needed staff to be beside the resident while ambulating. RN 3 further stated Resident 4's use of the post-op shoes should have been evaluated as a fall risk and should have been included in the care plan.
On 6/1/2023 at 1:58 p.m., during a concurrent interview and record review, the Director of Rehab (DOR) stated Resident 4 had unsteady gait and needed close supervision for redirecting. The DOR stated Resident 4 had a right diabetic foot wound and had been walking up to 125 feet with the post-op shoes during PT sessions. The DOR stated Resident 4 could walk more than 125 feet but required frequent rest periods. The DOR defined Resident 4's kyphotic (hunchback) posture as rounded spinal curvature (abnormal alignment of the backbone) which changed the resident's center of balance. The DOR stated a kyphotic posture was a contributing factor for Resident 4's unsteady gait. The DOR confirmed not addressing in the PT notes Resident 4's hunchback and the use of the post-op shoes as fall risk. The DOR stated Resident 4 required CGA and HHA during ambulation.
On 6/1/2023 at 2:32 p.m., during a concurrent interview and record review, RN 2 stated Resident 4's MDS indicated the resident required limited assistance with one-person assist and the resident had unsteady gait. RN 2 stated Resident 4 should be closely supervised while walking.
On 6/5/2023 at 10:15 a.m., during an interview, the Director of Nursing (DON) stated prior to the fall (on 5/25/2023) staff observed Resident 4 walking around the nursing stations, in the hallways two to three times at resident's normal pace. The DON stated there was no CGA provided to Resident 4 while walking in the hallways. The DON stated at the time of Resident 4's fall, there was no staff in the hallway except CNA 2 who was passing by at the end (opposite side) of the hallway.
A review of the facility's policy and procedure titled, Accident/Incident Prevention, dated 2/10/2023, indicated the facility strives to prevent accidents by providing an environment that is free from accident hazards as well as identification of each resident at risk for accident/incidents and the provision of adequate care plans with procedures to prevent accidents. The policy also indicated to provide an environment that is free of accident hazards, that facility will provide care planning with implementation plans.
A review of the facility's policy and procedure titled, Promoting Safety, Reducing Falls, dated 2/10/2023, indicated caregivers should regularly inspect the condition of a resident's feet to make sure that there were no deformities or open areas that might affect gait.
A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, revised 2/10/2023, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The policy also indicated the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.
A review of the facility's policy and procedures titled, Falling Star Program, revised on 2/10/2023, indicated residents identified at risk for falls would participate in the Falling Star Program. The procedures included placing an identifying colorful star in personal resident areas such as the head of the bed, name plate on the entrance to the room, bathroom door, and wheelchair. Recommendations to ensure a successful program would be to include the following: .evaluation for appropriate useful interventions for fall reduction.
A review of the facility's policy and procedures titled, Super Star Program – for Severely High-Risk Residents at Risk for Falls & Injuries, revised on 2/10/2023, indicated this special program was for residents who have a score of 8 or above on the Fall Risk Assessment and any of the following: 1. Noncompliant, 2. Very confused, .4. History of falls . The procedures included: 1. Discuss safety of room and replace furniture with plastic items or re-arrange furniture to provide a safe environment, .7. Non-skid footwear, .8. Location of room close to nursing station for closer observation

Based on observation, interview, and record review, the facility failed to provide informed consent (permission granted in the knowledge of possible health risks) by the physician before administering an antipsychotic (mind altering medication to treat mental health conditions) medication from the resident's responsible party (RP), for two of 41 sampled residents (Residents 44 and 67).
This deficient practice had the potential to affect the residents' right to make decisions on medication therapy.
Findings:
A review of the admission Record indicated Resident 44 was admitted to the facility, on 10/19/2021, with diagnoses including dementia (chronic brain disorder marked by memory disorders, personality changes, and impaired reasoning), and depression (feelings of sadness).
A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/23/2021, indicated Resident 44 was severely impaired in cognition (process of acquiring knowledge and understanding through thought, experience, and the senses) in skills required for daily decision making. The MDS indicated Resident 44 sometimes understood others. The MDS indicated Resident 44 required one-person extensive assistance (resident involved in activity, staff provide weight bearing support) for bed mobility, transfer, dressing, and personal hygiene.
A review of the physician orders indicated Resident 44 was to receive risperidone (antipsychotic medication) 0.25 milligrams (mg., a unit of measure) by mouth two times a day related to schizoaffective disorder (mental disorder), depressive type with agitation manifested by the inability to cope with daily living activities causing anger outbursts, dated 10/19/2021.
During an interview, on 12/30/2021 at 12:32 p.m., RP 1 stated she had not spoken to Resident 44's primary care physician or psychiatrist regarding the medications.
During an interview, on 12/30/2021 at 1:23 p.m., Licensed Vocational Nurse (LVN 3) stated the RN supervisor would call the RP to get the consent for psychotropic medications. LVN 3 stated she had been trained to assist the Registered Nurse (RN) to call the RP but had not performed that duty since being hired by the facility.
During a phone interview, on 12/30/21 at 2:15 p.m., Resident 44's Psychiatrist (Psych MD) stated she had not spoken to Resident 44 or Resident 67's RP on the phone about the psychotropic medications. The Psych MD stated the licensed nurses would speak to RP to obtain consent.
During a concurrent interview and record review, on 12/30/2021 at 3 p.m., the Director of Nursing (DON) confirmed RN supervisor called Resident 44's RP 1 for verbal consent to give risperidone to Resident 44 after Resident 74's physician had ordered the risperidone on 10/19/2021.
During an interview with RN 1 on 12/30/21 at 3:30 p.m., she stated the RNs would call the family and inform them of the psychotropic meds not the doctor.
b. A review of the admission Record indicated Resident 67 was admitted to the facility, on 8/11/2021, with a diagnosis of dementia, depression, and schizoaffective disorder.
A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/17/2021, indicated Resident 67 was moderately impaired in cognition in skills required for daily decision making. The MDS indicated Resident 67 required total dependence (full staff performance every time during an entire seven day period) for bed mobility, transfer, and dressing.
A review of the physician's orders indicated the following:
1.
Resident 67 was to receive Depakote Sprinkles Capsule 250 mg by mouth three times a day related to persistent mood affective disorder, manifested by uncontrollable extreme mood swings causing combativeness interfering with daily living activities, dated 12/20/2021.
2.
Resident 67 was to receive Seroquel 25 mg tablet by mouth two times a day related to schizoaffective disorder, depressive type, manifested by auditory hallucinations (hearing things not there) interfering with activities of daily living causing anger outbursts, dated 12/20/2021.
During a concurrent interview and record review, on 12/30/2021 at 3 p.m., the DON confirmed the RN supervisor called Resident 67's RP 2 for verbal consent to give Seroquel and Depakote Sprinkles capsule after Resident 67's physician had ordered those medications on 10/20/2021.
During an interview with Resident 67's RP 2, on 12/28/2021 at 12:10 p.m., she stated she had not spoken to the doctor but the nurses had told her about the resident's antipsychotic medications.
During an interview, on 1/03/2022 at 1:30 p.m., Resident 67's Physician (MD 2) stated he had not spoken RP 2 for Resident 67 regarding getting consent for the psychotropic meds.
A review of the facility's policy titled, Psychotherapeutic Medications, reviewed 1/15/2021, indicated informed consent will be obtained from physician prior to administering psychotherapeutic drugs.

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse 3 (LVN 3) accurately documented on the medication administration record (MAR) for seven (Residents 18, 26, 46, 52, 64, 69 and 84) of seven sample residents.
This deficient practice had the potential not to receive accurate information in the medical records with blank entries for medications that were administered.
Findings:
a A review of admission Record indicated Resident 18 was admitted to the facility, on 3/25/2021, with diagnoses that included diabetes mellitus (high blood sugar) and hypertension (high blood pressure).
A review of Resident 18's MAR, for the month of 12/2021, indicated blank entries on 12/25/2021, for Lisinopril (blood pressure medication) at 8 a.m., Humalog solution (medication to lower blood sugar) at 11:45 a.m., and Humalog solution at 11:30 a.m.
b. A review of the admission Record indicated Resident 26 was admitted to the facility, on 12/30/2020, with diagnoses that included dementia (chronic brain disorder marked by memory disorders, personality changes, and impaired reasoning), stroke, chronic pain syndrome (pain lasting longer than six months) and hypertension.
A review of the MAR, for the month of 12/2021 indicated on 12/25/2021 there were blank spaces at 8 a.m. for aspirin (blood thinner medication) tablet 81 mg, docusate sodium (stool softener medication) 100 mg, multi-vitamin tablet, nifedipine extended release tablet (blood pressure medication) 60 mg, zyprexa (mood altering medication) tablet 1.25 mg, calcium carbonate (supplement) tablet 600 mg, gabapentin (anti-seizure medication) capsule 100 mg, galantamine hydrobromide (medication for dementia) tablet 12 mg, memantine (medication to slow dementia progression) tablet 10 mg, and Tylenol (medication for mild pain) tablet 650 mg.
c. A review of the admission Record indicated Resident 46 was admitted to the facility, on 11/07/2006, with diagnoses that included schizophrenia (brain disorder).
A review of Resident 46's MAR for the month of 12/2021, indicated on 12/25/2021 there were blank spaces at 8 a.m. for multi-vitamin with minerals one tablet, vitamin C 500 mg. tablet, and vitamin D3 tablet 25 mcg (micrograms - unit of measure).
d. A review of the admission Record indicated Resident 52 was admitted to the facility, on 02/14/2020, with diagnoses that included schizophrenia.
A review of Resident 52's MAR for the month of 12/2021 indicated on 12/25/2021 there were blank spaces at 8 a.m. for docusate sodium 100 mg., multivitamin with minerals one tablet, and vitamin D3 25 mcg.
e. A review of the admission Record indicated Resident 64 was admitted to the facility, on 11/02/2020, with a diagnosis of hypertension.
A review of Resident 64's MAR for the month of 12/2021 indicated on 12/25/2021 there were blank spaces for the amlodipine (blood pressure medication) 10 mg to be given at 8:00 a.m.
f. A review of the admission Record indicated Resident 69 was admitted to the facility, on 8/10/2020, with diagnoses that included schizoaffective disorder, depressive type (a combination of symptoms of schizophrenia [a mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions, and withdrawal from reality]).
A review of Resident 69's MAR for the month of 12/2021 indicated on 12/25/2021 there were blank spaces for depakote sprinkles capsule (mind altering medication) 250 mg. to be given at 12:00 p.m., docusate sodium 100 mg at 8:00 a.m., haloperidol (mind altering medication) 1 mg at 12:00 p.m., and multi-vitamin with minerals 1 tablet at 8:00 a.m.
g. A review of the admission Record indicated Resident 84 was admitted to the facility, on 3/02/2021, with diagnoses that included vitamin B-12 deficiency (low B-12 levels which are needed for red blood production), anxiety (feelings of uneasiness), seizures, Alzheimer's disease (disease causing loss of cognitive function), and hypertension.
A review of Resident 84's MAR for the month of 12/2021 indicated on 12/25/2021 there were blank spaces for docusate sodium 100 mg at 8 a.m., lorazepam (mind altering medication) 0.5 mg at 8 a.m., multi-vitamin at 8 a.m., vitamin deficiency system B12 kit at 8 a.m., keppra (seizure medication) 750 mg. tablet at 8 a.m., memantine 10 mg. tablet at 8 a.m., cranberry capsule 425 mg at 8 a.m. and 12 p.m., and diltiazem 30 mg. tablet at 2 p.m.
During a concurrent interview and record review, on 01/03/2022, the Director of Nursing (DON) stated the nurse administered the medications but did not document they were given for Residents 18, 26, 46, 52, 64, 69, and 84 for the month of 12/2021 on the MAR.
During an interview, on 1/03/2022 at 3:21 p.m., LVN 3 stated she gave the medications for Resident 18, 26, 46,52, 64, 69, and 84. LVN 3 stated she clicked yes to having given the meds on the computer but forgot to hit the save button. LVN stated she should have correctly documented the medications as administered to decrease medication errors.
A review of the facility's policy titled, Medication Pass, reviewed 1/15/2021, indicated before going to the next resident, and after current resident takes medications, the medication given is to be signed as being given on the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three Certified Nurse Assistants (CNA 1, 2, and 3) were not standing while assisting residents with feeding, for three out of nine sample residents (Residents 68, 48, and 80) investigated for dining observation.
This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem.
Findings:
a. A review of the admission Record indicated Resident 68 was admitted to the facility, on 09/09/2020 and was readmitted on [DATE], with diagnoses that included sepsis (body's extreme response to an infection) unspecified organism, other idiopathic peripheral autonomic neuropathy (nerves that control involuntary bodily functions are damaged), and unspecified dementia (group of conditions that affect memory, thinking and behavior) with behavioral disturbance.
A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/16/2021, indicated Resident 68 had severely impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance with eating, personal hygiene, and toilet use.
During a concurrent observation and interview, on 12/28/2021, at 12:48 p.m., with CNA 1, Resident 68 was observed in his wheelchair in hallway. CNA 1 was observed standing while feeding the resident. CNA 1 stated she was standing and should be sitting down when feeding the resident.
b. A review of the admission Record indicated Resident 48 was admitted to the facility, on 04/28/0217 and readmitted on [DATE], with diagnoses that included encephalopathy (damage or disease that affects the brain) unspecified, cerebrovascular disease (group of conditions that affect blood flow and blood vessels in the brain), and senile (caused by old age) degeneration (decline or deterioration) of brain not elsewhere classified.
A review of the MDS, dated [DATE], indicated Resident 48 had severely impaired cognition and was totally dependent on staff for bed mobility, eating, toilet use, and personal hygiene.
During a concurrent observation and interview, on 12/28/2021, at 1:01 p.m., with CNA 2, Resident 48 was sitting up in bed in her room. CNA 2 was observed standing while feeding the resident. CNA 2 stated she was standing and should have been sitting down when feeding the resident.
c. A review of the admission Record indicated Resident 80 was admitted to the facility, on 08/26/2019, with diagnoses that included unspecified dementia with behavioral disturbance, Alzheimer's disease (type of dementia that affects memory, thinking and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning) recurrent unspecified.
A review of the MDS, dated [DATE], indicated Resident 80 had severely impaired cognition and was totally dependent on staff for locomotion on and off the unit, dressing, and eating. The MDS indicated Resident 80 required extensive assistance with transfers, walk in room, walk in corridor, dressing, toilet use, and personal hygiene.
During a concurrent observation and interview, on 12/28/2021, at 1:07 p.m., with CNA 3, Resident 80 was observed in her wheelchair in room being assisted by CNA 3. CNA 3 was observed standing while feeding the resident. CNA 3 stated she was standing and should have been sitting down when feeding the resident.
During an interview, on 12/30/2021, at 5 p.m., the DON stated CNAs should be at eye level with residents when feeding them to maintain their dignity.
A review of the facility's policy titled, Policy: Feeding Residents, reviewed and approved on 01/16/2021, indicated to ensure proper and safe feeding of residents .staff should be sitting down within eye level of resident.

**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 (%). A total three medication errors were observed out of a total of 25 opportunities affecting one out of four residents (Resident 34) observed for medication administration resulting in an overall medication error rate of 12 %.
The deficient practice of administering medications contrary to physician's orders, manufacturer's specifications, or accepted professional standards increased the risk that Resident 34's health and well-being may be negatively affected.
Findings:
On 12/29/2021 at 08:32 a.m., observed Licensed Vocational Nurse 1 (LVN 1) administering the following medications to Resident 34:
1. Ferrous Gluconate 240 milligram (mg., a unit of measure) tablet.
2. Vitamin B-12 500 micrograms (mcg., a unit of measure) tablet.
3. Vitamin D 25 mcg. tablet.
On 12/29/2021 at 10 a.m., during a record review, reviewed Resident 34's admission Record indicated Resident 34 was admitted to the facility on [DATE] with diagnoses that included vitamin B12 deficiency anemia (a condition in which your body does not have enough healthy red blood cells, due to a lack of vitamin B12 [ helps make red blood cells, energy, and tissues, and keeps nerve cells healthy]) and vitamin D deficiency (a lack of vitamin D in the body which is needed to keep bones healthy).
A review of Resident 34's Minimum Data Set (MDS- an assessment and care screening tool) dated 10/14/2021 indicated the resident sometimes understands others and is understood sometimes. The MDS indicated Resident 34 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 34 required supervision with bed mobility, dressing, eating, and walking.
A review of Resident 34's Physician's Orders, indicated the following:
1.
Vitamin B12 tablet extended release, give 2500 mcg. by mouth one time a day related to vitamin B12 deficiency anemia, dated 8/17/2021.
2.
Vitamin D3 tablet, give 125 mcg. by mouth one time a day related to vitamin D deficiency, dated 4/20/2021.
3.
Ferrous Sulfate tablet, give 325 mg. by mouth one time a day for anemia, dated 11/17/2021.
On 12/29/2021 at 10:16 a.m., during an interview, LVN 1 stated he should have given Resident 34 ferrous sulfate 325 mg. tablet and not the ferrous gluconate 240 mg. tablet. LVN 1 stated he should have given five of B12 tablets instead of one so that Resident 34 would receive the correct dose of vitamin B12. LVN 1 stated he should have given five tablets of vitamin D3 tablets and not the one tablet that he gave during the medication pass.
During an interview with the Director of Nursing (DON) on 12/29/2021 at 12 p.m., she stated LVN 1 should have given the correct dosages for vitamin B12 and vitamin D3 to Resident 34 during the medication pass on 12/29/2021.
During a concurrent record review and interview with the DON on 12/29/2021 at 2:43 p.m., reviewed a bottle of ferrous gluconate 240 mg. which indicated the tablet contained twenty-seven mg. of iron and reviewed a ferrous sulfate 325 mg. bottle which indicated the tablet contained 65 mg. of iron. The DON stated Resident 34 should have received the ordered ferrous sulfate 325 mg. tablet since the ferrous gluconate did not contain the same amount of iron that the ferrous sulfate contained.
A review of the facility's policy and procedures entitled Medication Administration, reviewed 1/15/2021, indicated licensed nurses are to follow the '5 Rights' which ensures that medications are administered according to the right medication ordered and the right dose ordered.

Based on observation, interview and record review, the facility failed to meet the required room size of 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident bedrooms for the 19 out of 34 resident rooms (Rooms 1, 2, 4, 5, 6, 8, 10, 12, 14, 16, 17, 18, 19, 20, 21, 22, 23, 25, and 34).
This deficient practice had the potential to result in inadequate useable living space for all the residents and working space for the health caregivers.
Findings:
The Request for Room Size Waiver letter dated 12/29/2021, submitted by the Administrator for the 19 rooms was reviewed. The letter indicated the rooms did not meet the 80 square feet requirement per federal regulation. The letter indicated the resident beds are in accordance with the special needs of the residents and will not adversely affect resident's health and safety and do not impede the ability of the residents in the room to obtain their highest practicable well being.
The following rooms provided less than 80 square feet per resident:
Rooms # Beds Floor Area Sq. Ft. Sq. Ft/Resident
1
3
238
79
2
3
232
77
4
3
212
70.66
5 3
212
70.66
6
3
212 70.66
8
3
212
70.66
10
3
213
71
12
3
212
70.66
14
3
212
70.66
16
3
212
70.66
17
3
212
70.66
18
3
212
70.66
19
3
212
70.66
20
3
212
70.66
21
3
212
70.66
22
3
212
70.66
23
3
212
70.66
23
3
212
70.66
34
3
212
70.66
The minimum square footage for a 3-bed room should be 240 sq. ft.
During the Resident Council meeting on 12/29/2021 at 10:30 a.m., no concerns were brought up by the residents regarding the size of the rooms.
During interviews with staff on 12/29/2021 there were no concerns regarding the size of the aforementioned rooms.
During the general observation of the residents' rooms on 12/28/2021 to 01/03/2021, the residents had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There were also sufficient space for beds, side tables and resident care equipment.
The facility submitted a written request for continued waiver.