Every finding on record at Alamitos West Health & Rehabilitation

Based on observation, interview, closed medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were provided for one of nine sampled residents (Resident 1). * The facility failed to ensure Resident 1's cefepime hydrochloride (antibiotic) medication was administered on 7/11/26 at 1000 hours as ordered by the physician. This failure posed the risk for negative health outcomes for Resident 1.Findings: Review of the facility's P&P titled Medication Administration revised 2/2022 showed it is the policy of this facility that medications shall be administered as prescribed by the attending physician. Under the Procedures section showed unless otherwise specified by the resident's attending physician, routine medications should be administered as scheduled. The nurse administering the medication must record such information on the resident's MAR before administering the next resident's medication. The nurse administering the medications must initial the resident's MAR/EMAR, on the appropriate line and date for that specific day. Closed medical record review for Resident 1 was initiated on 7/30/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 7/13/26, showed Resident 1 had no capacity to understand and make decisions. Review of Resident 1's Order Summary Report dated 7/8/26, showed a physician's order dated 7/8/26, for cefepime hydrochloride (antibiotic) intravenous solution reconstituted 2 grams, and use 2 grams intravenously two times a day for LLE wound infection until 7/18/26 at 2159 hours. Review of Resident 1's IV MAR failed to show documented evidence the cefepime hydrochloride medication was administered to Resident 1 on 7/11/26 at 1000 hours. On 8/4/26 at 1337 hours, an interview and concurrent closed medical record review was conducted with RN 2. RN 2 verified there was no documentation the cefepime hydrochloride medication was administered to Resident 1 on 7/11/26 at 1000 hours. RN 2 stated the licensed nurse should have notified Resident 1's physician if it was a missed dose. RN 2 further stated the licensed nurse should have made sure the medication was administered and documented. On 8/4/26 at 1358 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated she did not see any documentation Resident 1's cefepime hydrochloride medication was given on 7/11/26 at 1000 hours. The DON stated Resident 1's physician, the resident, and the family should have been notified by the licensed nurse of why the cefepime hydrochloride medication was not given.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of five sampled residents (Resident 1) attained and maintained their highest practicable physical well-being. * The facility failed to ensure the sleep study results were obtained and followed up for Resident 1. This failure had the potential to cause a delay in providing care to Resident 1, which would cause negative impact to the resident's well-being.Findings: Review of the facility's P&P titled Change in Condition revised 4/2025 showed the following:- if, at any time, it is recognized by any one of the members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following but not limited to changes in medical condition including but not limited to low or high blood sugar, hypoglycemic episodes, or fever of unknown origin;- the nurse will perform and document an assessment of the resident and identify needs for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions;- the nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report; and- there will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgement and shall contact the physician based on the urgency of the situation. The resident and the resident representative will be notified of the change of condition and any changes in the resident's medical or nursing care. Review of the facility's P&P titled Diagnostic Test Results Notification revised 1/2022 showed the following:- notification of test results will be documented in the resident's clinical record; and- results of lab, radiology, and diagnostic services shall be made part of the resident's medical record Medical record review for Resident 1 was initiated on 7/22/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 10/18/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's Brief Interview for Mental Status (BIMS) score was 13, indicating intact cognition. On 7/22/26 at 1637 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 1. RN 1 verified the physician's order dated 5/14/26, for nocturnal desaturation study. RN 1 verified Resident 1's medical record failed to show the nocturnal desaturation study or sleep study results and documentation of the follow up from the facility. On 7/22/26 at 1707 hours, an interview was conducted with the DON. The DON verified Resident 1 had completed the sleep study on 6/6/26, in the facility and night owl device used for the sleep study was returned to Hospital A on 6/8/26. In addition, the DON verified the sleep study results were not followed up by any licensed nurses since 6/8/26. On 7/23/26 at 1118 hours, a concurrent interview was conducted with the DON and IP. The IP stated she called Hospital A today to follow up on Resident 1's sleep study and was able to obtain the results. Resident 1's home sleep report conclusion and treatment plan dated 6/2026 was reviewed with the DON and IP. The results showed Moderate Obstructive Sleep Apnea (a common sleep disorder characterized by loud snoring, daytime fatigue, and repeated breathing pauses caused by throat muscles relaxing and blocking the airway during sleep), and treatment options of Continuous Positive Airway Pressure (a medical device that uses mild air pressure to keep your breathing airways open while you sleep, and it is mainly used to treat sleep apnea) or Bi-level Positive Airway Pressure (a non-invasive medical device that helps people breathe by providing two alternating pressure levels: higher pressure when you inhale and lower pressure when you exhale). The DON stated Resident 1's moderate obstructive sleep apnea is a new diagnosis and considered a change in condition. In addition, the DON stated the delay in obtaining the results and recommendations could negatively impact Resident 1's condition and plan of care. Furthermore, the DON stated all the licensed nurses must follow up with the results of the diagnostic tests and procedures, including sleep study, then report the results to the physician and resident's responsible party. On 7/23/26 at 1715 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 1) was informed of the risks and benefits of proposed care, treatment, and treatment alternatives or options, and the choice to choose an alternative option in advance. * The facility failed to ensure Resident 1 and Family Member 1 were informed of the physician's order for psychiatry consult, as well as providing alternative options for treatment. These failures had the potential for Resident 1 and Family Member 1 to not to be informed of the psychiatry consultation and prevent the resident and resident's representative from participating in choosing the resident's treatment decisions.Findings: Review of the facility's P&P titled Change in Condition revised 4/2025 showed the following:- the resident/resident representative will be notified of the change of condition and any changes in the resident's medical or nursing care. Review of the facility's P&P titled Physician order revised 5/2021 showed transcribing, and notification, included:- all orders for medications, treatments, and diagnostic services shall be in writing or electronically written under electronic health record (EHR); and- all new orders are to be documented in the nursing notes. Resident and resident representative are to be notified of all new orders and documented. Medical record review for Resident 1 was initiated on 7/22/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 10/18/25, showed Resident 1 had the capacity to understand and make decisions. Family Member 1 had the power of attorney for decision making in Resident 1's care. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's Brief Interview for Mental Status (BIMS) score was 13, indicating intact cognition. On 7/22/26 at 1508 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 2. Resident 1's physician's order was reviewed with LVN 2 and verified the psychiatry consult was ordered on 6/30/26. In addition, the SBAR dated 6/30/26, was reviewed with LVN 2 which showed LVN 1 notified the physician and Resident 1 at the same time at 1115 hours. LVN 2 stated it was impossible to notify the physician and Resident 1 at the exact same time; must take at least five minutes or more to provide report to the physician, obtain orders, then go to Resident 1's room to notify him. Furthermore, LVN 2 stated she must notify Resident 1 and Family Member 1 for everything, regarding Resident 1. On 7/22/26 at 1641 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 1. Resident 1's SBAR dated 6/30/26, was reviewed with LVN 1. LVN 1 verified notifying Resident 1's physician and receiving a physician's order for psychiatry consult; however, LVN 1 did not notify Resident 1 and Family Member 1 of the new order for the psychiatry consult. On 7/22/26 at 1707 hours, an interview was conducted with the DON. The DON stated the licensed nurses must notify the resident and resident's representative for any physician's orders, results, and/or change of condition. In addition, the DON stated all licensed nurses must notify Resident 1 and Family Member 1 for all the physician's orders, results, and/or change of condition. On 7/23/26 at 1715 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure necessary dental services was coordinated for one of six sampled residents (Resident 2). * The facility failed to ensure a follow up dental appointment was scheduled for Resident 2 as per resident's request and per the facility's dental progress notes. This failure had the potential for the resident to not receive the necessary dental care. Findings: Review of the facility's P&P titled Dental Services revised 4/2025 showed it is the policy of this facility to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier. The facility will provide or obtain from an outside resource, routine, and emergency dental services for each resident. The facility will assist the resident as necessary or requested to make appointments for dental services or arrange for transportation to and from dental services locations. Review of the facility's P&P titled Resident Appointment and Transportation revised 8/2023 showed it is the policy of the facility to assist residents in arranging appointments and transportation to and/or from when necessary. The facility social services and/or designee will assist residents or responsible representatives in scheduling for appointments including, but not limited to diagnostic procedures outside the facility. Medical record review for Resident 2 was initiated on 6/4/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 10/28/25, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's Dental Progress Note dated 3/5/26, showed dental consult was due to Resident 2's report of pain on tooth #5 (the upper right first premolar). The note showed Resident 2 was informed of possible retreatment and/or new crown. Resident 2 refused the test. Further review of the dental progress notes showed will arrange appointment with outside dentist to save the tooth. On 6/4/26 at 1303 hours, an interview was conducted with Resident 2. Resident 2 stated although she had seen the facility dentist, she still wanted to see her primary dentist for dental work which the facility dentist could not do. Resident 2 stated she has been waiting for an appointment for four to five months. On 6/10/26 at 0941 hours, an interview and concurrent medical record review for Resident 2 was conducted with the SSD. The SSD verified the Dental Progress Notes showed Resident 2 refused test and will arrange appointment with outside dentist to save the tooth. The SSD stated the nursing staff and social services should follow up on the dental progress notes to ensure any recommendations made by the dentist were followed up and appointments were scheduled. On 6/10/26 at 1330 hours, a follow-up interview was conducted with Resident 2. Resident 2 stated she did not have dental pain; however, stated she had sensitivity. Resident 2 further stated she wanted to be seen by her primary dentist for a second opinion on recommendations made by the facility dentist. On 6/10/26 at 1655 hours, an interview with the Administrator, DON, and MDS Resource was conducted. The Administrator, DON, and MDS Resource were made aware and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary physician services was provided for one of six sampled residents (Resident 1). * The facility failed to ensure the cardiologist recommendations for Resident 1's diagnostic tests were signed by the physician for the staff to ensure the appointments were scheduled in a timely manner. This failure had the potential for the resident to not receive the necessary services in a timely manner. Findings: Review of the facility's P&P titled Physician Services revised 2/2022 showed physician services shall mean those services provided by physicians responsible for the care of individual residents in the facility. All persons admitted or accepted for care by the facility must be under the care of a physician selected by the resident, the resident's authorized representative, or the medical director. The physician services include, but are not limited to:B. A medical evaluation of the resident and review of orders for care and treatment;E. Written or signed orders for diet, care, diagnostic tests and treatment of residents by others. Review of the facility's P&P titled Resident Appointment and Transportation revised 8/2023 showed it is the policy of the facility to assist the residents in arranging appointments and transportation to and/or from when necessary. The facility social services and/or designee will assist residents or responsible representatives in scheduling appointments including, but not limited to diagnostic procedures outside the facility. Medical record review for Resident 1 was initiated on 6/4/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE].Review of Resident 1's H&P examination dated 10/18/25, showed Resident 1 had the capacity to understand and make decisions.Review of Resident 1's Nursing Progress Note dated 5/14/26 at 0834 hours, showed the nocturnal desaturation study with the diagnosis of sleep apnea, and Lexiscan MIBI stress test with the diagnosis of chest pain were ordered by Resident 1's cardiologist. The note further showed the orders were noted and carried out. Review of Resident 1's Order Summary Report for June 2026 showed the following physician's orders: - dated 5/14/26, nocturnal desaturation study (measures the blood oxygen levels and heart rate while asleep) for diagnosis of sleep apnea; - dated 5/14/26, Lexiscan MIBI stress test for diagnosis of chest pain; and - dated 5/26/26, echocardiogram for diagnosis of abnormal EKG and chest pain.Further review of Resident 1's medical records failed to show the scheduled appointments or results for the ordered tests. On 6/10/26 at 0820 hours, an interview and concurrent record review for Resident 1 was conducted with RN 1. RN 1 verified Resident 1 had a cardiologist appointment on 5/11/26, and returned with new orders. RN 1 stated the facility contacted Resident 1's cardiologist office to verify the orders for a Lexiscan MIBI stress test, nocturnal desaturation study, and the echocardiogram. RN 1 stated for the facility to schedule the appointments, Resident 1's attending physician at the facility needed to sign off on the orders and approve of the cardiologist's recommendations. RN 1 further stated multiple attempts to contact Resident 1's physician and the physician's office were made and the cardiologist orders were faxed to the physician's office for physician's approval. RN 1 verified Resident 1's orders were not signed until 5/26/26, by another attending physician. RN 1 stated this could cause a delay in care. On 6/10/26 at 1531 hours, an interview and medical record review for Resident 1 was conducted with the Medical Office Staff from Resident 1's physician's office. The Medical Office Staff stated the office received the orders for the Lexiscan stress test, nocturnal desaturation study, and echocardiogram on 5/14/26, and the signed physician's orders were faxed back to the facility on 5/20/26. When the fax number was verified with Medical Office Staff, the signed orders were faxed to the wrong fax number. The Medical Office Staff verified it was not accurately faxed to the facility. On 6/10/26 at 1655 hours, an interview with the Administrator, DON, and MDS Resource was conducted. The Administrator, DON, and MDS Resource was made aware and acknowledged the above findings.

Based on interview, facility document review, and facility P&P review, the facility failed to implement their P&P for pre-employment investigations for one of three sampled employees (CNA 1) prior to working with the elderly or vulnerable individuals. * The facility failed to conduct a background check for CNA 1 prior to the date of hire. This failure had the potential to put the residents at risk for elder abuse.Findings: Review of the facility's P&P titled Pre-Employment Investigations California - SNF revised 1/2022 showed reasonable and prudent pre-employment investigations, including reference checks, applicable licensing and certification verifications, criminal background checks and other necessary or desirable pre-employment checks are conducted on applicants for employment. The purpose showed to ensure that all applicants for employment have all credentials, experience and skills appropriate to the position applied for and to verify that the applicant has not been convicted of an offense or any other negative government finding that would preclude employment by a provider to federal or state health care programs or working with elderly or vulnerable individuals or as a vehicle driver. Employment may not commence unless the Accurate Background Check disposition is Pass. The P&P further showed if the applicant completed a paper Disclosure and Authorization form, it should be uploaded to the applicant's record in the Accurate system at the time the package is requested and the originals maintained in the applicant's confidential personnel file. The Accurate Background Check consists of state (county) and federal criminal records checks, a Healthcare Sanctions and Exclusions check, and a national Sex Offender Record Search. Review of CNA 1's employee file showed CNA 1's date of hire was 4/16/26. Review of CNA 1's Disclosure Regarding Background Investigation dated 4/15/26, showed CNA 1 signed and agreed for an Accurate Background check to be conducted. Further review of CNA 1's employee file failed to show documented evidence an Accurate Background check was conducted prior to the start of employment as per facility's P&P. On 6/5/26 at 0904 hours, an interview and concurrent employee file review of CNA 1 was conducted with the DON. The DON verified CNA 1 signed and agreed for a background check on 4/15/26; however, there was no documented evidence of the background check results in CNA 1's employee file. On 6/5/26 at 1150 hours, an interview and concurrent employee file review of CNA 1 was conducted with the HR. The HR verified CNA 1's employee file did not have a background check prior to date of hire and that a background check was done on 6/5/26. The HR stated background checks were conducted before an employee was hired and were done to ensure the employees working with the residents do not have prior criminal charges. The HR stated the background check for CNA 1 was missed. On 6/5/26 at 1700 hours, an interview with the Administrator was conducted with the DON present. The Administrator stated the background checks should be done before the date of hire. On 6/10/26 at 1655 hours, an interview with the Administrator, DON, and MDS Resource was conducted. The Administrator, DON, and MDS Resource was made aware and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's responsible party or Power of Attorney (POA) was informed of a change on the resident's condition for one of six sampled residents (Resident 1). * The facility failed to notify Resident 1's POA of the change in condition on 6/4/26. This failure had the potential for Resident 1's responsible party uninformed of the resident's status.Findings: Review of the facility's P&P titled Change of Condition (COC) Reporting dated 5/2019 showed the responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. All attempt to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response. Medical record review for Resident 1 was initiated on 6/4/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 10/18/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Advance Health Care Directive dated 2/11/26, showed You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. The explanation showed the Part 1 of the form was a power of attorney for health care. Part 1 lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. Unless the form you sign limits the authority of your agent, your agent may make all health care decision for you. Further review of Resident 1's Advance Health Care Directive - Part 1 - Power of Attorney for Health Care showed Family Member 1 was the designated agent to make the resident health care decisions. Moreover, the form showed Family Member 1 was authorized to make health care decisions effective immediately. Review of Resident 1's eINTERACT Change in Condition Evaluation - V 5.1 dated 6/4/26, showed Resident 1 alleged CNA 1 of not assisting with care and closing the door on him. Further review of the COC evaluation failed to show documented evidence if Resident 1's POA was notified of the COC. On 6/9/26 at 1600 hours, a telephone interview was conducted with the IP. The IP verified she documented Resident 1's COC on 6/4/26. The IP stated she did not notify Family Member 1 of the resident's COC. The IP further stated the residents' responsible parties should have been notified to ensure they were aware of the residents' conditions. On 6/9/26 at 1614 hours, an interview and concurrent medical record review of Resident 1 was conducted with the ADON. The ADON verified Resident 1's COC dated 6/4/26, failed to show Resident 1's POA was notified of the change in the resident's condition. The ADON verified Resident 1's power of attorney for health care decisions showed Family Member 1 was the designated agent and should have been notified of any changes in the resident's condition. On 6/10/26 at 1655 hours, an interview with the Administrator, DON, and MDS Resource was conducted. The Administrator, DON, and MDS Resource was made aware and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to report an abuse allegation to CDPH, L&C Program for one of four residents (Resident 1) reviewed for abuse. * The facility failed to ensure SOC 341 was submitted and the alleged abuse was reported to CDPH, L&C Program, Ombudsman, and law enforcement on the day the alleged abuse was reported to the facility staff. This failure had the potential for the abuse allegation going unreported and uninvestigated.Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against revised 4/1/25, showed it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. Under the Reporting/Response section showed all allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations. Medical record review for Resident 1 was initiated on 5/15/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. On 5/11/26, CDPH, L&C Program received a complaint which showed complainant claimed on 4/23/26, CNA 3 (1500 to 2300 shift) told Resident 1 that if the resident pressed the call light or called out for help, that they would not come and that no one else would come. Same CNA gave Resident 1 the middle finger after the resident asked the nurse to wash hands before feeding three weeks before. However, the review of facility record for Resident 1 did not show SOC 341 was submitted on 4/23/26 to CDPH, L&C Program. Review of Resident 1's Nursing Progress Notes dated 4/23/26, showed Resident 1's son called the nurse and complained CNA 3 was assigned to his father who flipped a middle finger at his father before, and now the staffing coordinator still assigned CNA 3 to his father. Review of Resident 1's MDS assessment dated [DATE], showed the resident was cognitively intact. On 5/15/26 at 1555 hours, an observation and concurrent interview was conducted with Resident 1. Resident 1 was lying in bed and watching TV. Resident 1 stated CNA 3 showed me like this while showing a middle finger. Resident 1 stated he asked CNA 3 to wash her hands but he thought she did not want to help him. When Resident 1 was asked when the alleged abuse happened, Resident 1 stated he did not remember. On 5/19/26 at 1115 hours, an interview was conducted with the SSD. The SSD stated the IP told her on 4/24/26, about the alleged abuse of Resident 1 and LVN 3 told the alleged abuse to the IP. The SSD verified the facility staff did not submit SOC 341. The SSD stated Resident 1 did not want to report the incident as an abuse. The SSD stated the documentation would be on grievance interview and follow-up. On 5/19/26 at 1525 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 1 verbalized CNA 3 gave him a middle finger. When LVN 3 was asked when the alleged abuse happened, LVN 3 stated she was not sure but she thought it was in April. LVN 3 stated she reported the alleged abuse right away to the DSD and IP. On 5/21/26 at 1320 hours, an interview was conducted with the DON. The DON acknowledged the facility staff did not report the alleged abuse to CDPH, Ombudsman, and law enforcement on 4/23/26. The DON stated the IDT team should investigate, gather all the information, and conclude if the alleged abuse happened. The DON stated the IDT team did not submit SOC 341 because the incident did not happen on the day it was reported. The DON stated the IDT team completed a grievance report on 4/24/26.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections for two of four sampled residents (Residents 2 and 3). * The facility failed to ensure LVN 1 wore a gown when providing catheter care to Resident 2. In addition, the facility failed to ensure Resident 2 was placed on EBP related to the use of the indwelling urinary catheter. Furthermore, the facility failed to ensure an EBP signage was posted on the resident's door, and an orange dot was placed by the resident's name by the door. * The facility failed to ensure Resident 3's indwelling urinary catheter drainage tubing was not touching the floor. In addition, the facility failed to ensure Resident 3 was placed on EBP related to the use of the indwelling urinary catheter, and an orange dot was placed by the resident's name by the door. These failures had the potential for cross-contamination and spread of infectious organisms in the facility.Findings: 1. Review of the CMS QSO-24-08-NH dated 3/20/24, for Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of MDROs, showed MDRO transmission is common in long-term care facilities such as nursing homes, contributing to substantial resident morbidity and mortality and increased healthcare costs. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. EBP refers to an infection control intervention designed to reduce transmission of MDROs that employ targeted gown and glove use during high-contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. According to CDC's Implementation of PPE use in Nursing Homes to Prevent Spread of MDROs, under the Implementation Section, showed when implementing EBP, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE such as gown and gloves. Review of the facility's P&P titled IPCP Standard and Transmission-Based Precautions revised 4/2025 under EBP section, showed the examples of high-contact resident care activities requiring gown and gloves use for EBP included device care or use of indwelling urinary catheter. On 4/30/26 at 0915 hours, an isolation cart containing gowns and gloves was observed by Room A. There were no signages posted outside Room A. Resident 2 was observed in bed with an indwelling urinary catheter. Medical record review for Resident 2 was initiated on 4/30/26. Resident 2 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 2's Plan of Care showed a care plan problem dated 4/22/26, to address Resident 2's indwelling catheter. The interventions/tasks included using EBP. Review of Resident 2's Order Summary Report showed the following physician's orders dated 4/27/26, for Foley catheter size 14 Fr with 10 ml normal saline, to drainage every shift. Review of Resident 2's medical record did not show a physician's order for EBP and any documented evidence to show Resident 2 was placed on EBP related to the indwelling urinary catheter. On 4/30/26 at 1005 hours, an observation for Resident 2 and concurrent interview was conducted with CNA 2. When asked about Resident 2's indwelling urinary catheter and catheter care, CNA 2 verified Resident 2 had an indwelling urinary catheter and CNA 2 stated the CNAs were responsible for providing the catheter care to the residents with an indwelling urinary catheter; however, she has not provided hygiene care to the resident yet. On 4/30/26 at 1036 hours, a follow-up observation for Resident 2 and concurrent interview was conducted with CNA 2. An EBP signage was posted outside Room A, and an orange dot was placed by Resident 2's name. CNA 2 who was wearing a gown and gloves was observed providing care to Resident 2, and CNA 2 stated a catheter care will be provided by the treatment nurse. On 4/30/26 at 1038 hours, an observation for Resident 2 and concurrent interview and medical record review was conducted with LVN 1. LVN 1 verified an EBP signage was posted outside Room A, and an orange dot was placed by Resident 2's name. LVN 1 stated maybe the QIC/IP have placed the EBP signage and the orange dot. The EBP signage alerted the providers and staff to wear gloves and a gown for high-contact resident care activities such as catheter care. When asked about the orange dot by Resident 2's name, LVN 1 stated the orange dot was placed by the resident's name to indicate the resident was on EBP. On 4/30/26 at 1047 hours, a catheter care observation for Resident 2 and concurrent interview was conducted with LVN 1. LVN 1 was observed only wearing gloves and not donning a gown when performing the catheter care to Resident 2. LVN 1 verified the above findings. 2. On 4/30/26 at 0921 and 1000 hours, Resident 3 was observed in bed with an indwelling urinary catheter attached to a urinary drainage bag. The indwelling urinary catheter tubing was observed on the floor. On 4/30/26 at 1014 hours, an observation for Resident 3 and concurrent interview was conducted with CNA 1. CNA 1 verified Resident 3's indwelling urinary catheter tubing was touching the floor. When asked about Resident 3's catheter care, CNA 1 stated the treatment nurses were in charge of performing catheter care to residents with the indwelling urinary catheter. Medical record review for Resident 3 was initiated on 4/30/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report showed the following physician's order dated 4/2/26:- For Foley catheter size 16 Fr with 10 ml for neurogenic bladder, and foley catheter care every shift;- To change foley catheter including drainage bag if leaking, dislodged, non-patency or prior to urine specimen collection (if insertion date is more than two weeks) as needed for Foley catheter management; and- May flush the Foley catheter with 60 ml normal saline if clogged or non-patency as needed for Foley catheter management. To call the physician if not resolved. Review of Resident 3's Plan of Care showed a care plan problem dated 4/22/26, to address Resident 2's indwelling urinary catheter. The interventions/tasks included to use EBP. Review of Resident 3's medical record did not show a physician's order for EBP, and any documented evidence to show Resident 2 was placed on EBP related to the indwelling urinary catheter. On 4/30/26 at 1134 hours, an observation for Residents 2 and 3 and concurrent interview and medical record review was conducted with the QIC/IP. The QIC/IP stated EBP should be in place for the residents with medical devices such as indwelling urinary catheter. When asked about EBP for Resident 2, the QIC/IP verified she posted the EBP signage and the orange dot by the resident's name on the door just this morning. When QIC/IP reviewed Resident 2's medical record, the QIC/IP also verified the physician's order to place Resident 2 on EBP was just entered this morning. When asked about the EBP signage, the QIC/IP stated to alert the provider and staff that when a resident was on EBP, the staff should wear gloves and a gown when providing the high-contact care activities such as indwelling urinary catheter care. When asked about the orange dot placed by the resident's name on the door, the QIC/IP stated it was the facility's procedure to indicate the residents on EBP. The QIC/IP verified there was no orange dot placed on Resident 3's name by the door. When QIC/IP reviewed Resident 3's medical record, the QIC/IP also verified the physician's order to place Resident 3 on EBP. On 4/30/26 at 1452 hours, an interview was conducted with the Administrator and QIC/IP. The Administrator and QIC/IP were informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the discharge planning process was thoroughly completed for one of three sampled residents (Resident 1). * The facility failed to notify the Ombudsman 30 days prior to the facility-initiated discharge date for Resident 1. * The facility failed to develop a care plan for Resident 1's discharge. These failures had the potential for the residents to have an inappropriate discharge.Findings: Review of the facility's P&P titled Admission, Transfer and Discharge revised 4/2025 showed the following: 1. The Facility shall permit each resident to remain in the Facility, and not transfer or discharge the resident from the Facility unless:a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility;b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the Facility;c. The safety of individuals in the Facility is endangered due to the clinical or behavioral status of the resident;d. The health of individuals in the Facility would otherwise be endangered;e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the Facility. N. payment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. F. a resident who becomes eligible for Medicaid after admission, the Facility may charge a resident only allowable charges under Medicaid; [NAME]. The Facility ceases to operate. 2. Prior to transfer or discharge, the Facility shall notify the resident and the resident's representative of the transfer or discharge and the reason for the transfer or discharge in writing in a language and manner they understand.a. The facility shall send a copy of the notice to the State Long-Term Care Ombudsman.b. The notice shall be made at least 30 days before the resident is transferred or discharged or as soon as practicable before transfer or discharge when:The safety or health of individuals in the facility would be endangered;The resident's health improves to allow a more immediate transfer or discharge;An immediate transfer or discharge is required by the resident's urgent need; orA resident has not resided in the facility for 30 days.c. The notice shall include the following:The reason for transfer or discharge;The effective date of transfer or discharge;The location to which the resident is transferred or discharged ;A statement of the resident's appeal rights, including the name, address (mailing and email), and entity which receives the requests;Information on how to obtain an appeal form and assistance in completing and submitting the hearing request;Name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;Provide the agency name, address (mailing and email) for residents with special needs (e.g., agency for protection/advocacy for individuals with intellectual and developmental disabilities or agency for protection/advocacy for individuals with mental disorders or related disabilities).d. If the information in the notice changes prior to the transfer or discharge, the facility shall update the notice once the information becomes available. 3. If the resident (and/or their representative) exercises their right to appeal a transfer or discharge notice, the Facility shall not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the Facility. The Facility shall document the danger that failure to transfer, or discharge would pose. If the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the Facility, the resident's physician shall document the following in the resident's medical record:a. The basis of the transfer;b. The specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving Facility to meet the need(s). Medical record review for Resident 1 was initiated on 3/12/26. Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis of Parkinson's disease and contractures to the right and left ankles. Review of Resident 1's Order Summary Report showed a physician order dated 1/30/26, okay to go to a board and care if okay with the family and resident, may go with PT evaluation, and HH. a. Review of Resident 1's Notice of Proposed Transfer/discharge date d 2/2/26, showed the following:- date this notice was provided to the resident: 2/2/26;- date resident representative notified of transfer/discharge in writing: 2/2/26;- date of notice of proposed transfer/discharge mailed to Long Term Care Ombudsman: 2/2/26; and-date of transfer/discharge: [DATE] Further review of the document showed the reason for discharge was because Resident 1's health improved sufficiently so services of the facility were no longer required. Notice was given as soon as practicable. Review of Resident 1's medical record failed to show documented evidence the Ombudsman was notified of the resident's discharge. On 3/19/26 at 1520 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified the notice of transfer/discharge should have been provided to the Ombudsman 30 days in advance. b. Review of Resident 1's care plans failed to show a care plan was developed for a discharge plan. On 3/19/26 at 1513 hours an interview and concurrent medical record review for Resident was conducted with the DON. The DON verified the discharge plan care plan was not developed for Resident 1.

Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure adequate supervision was provided for one of four sampled residents (Resident 1). * Resident 1 was left unattended outside the facility while waiting for the transportation to take the resident to the doctor's appointment. This failure had the potential to place Resident 1 at risk for accidents and serious injuries.Findings: On 1/9/26, the CDPH L&C Program received a complaint alleging on 1/7/26, Resident 1 was left unattended outside the facility while waiting for the transportation to pick him up for a doctor's appointment. Medical record review for Resident 1 was initiated on 1/26/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 10/18/25, showed Resident 1 had the capacity to make decisions. On 1/27/26 at 1222 hours, an interview was conducted with CNA 4. CNA 4 was asked about Resident 1 being left unattended while waiting for the transportation for a doctor's appointment. CNA 4 stated on 1/7/26, after Resident 1's lunch, she was with Resident 1 outside the facility while waiting for his family to come to pick him up for the doctor's appointment. CNA 4 stated Resident 1 kept telling her to leave him. CNA 4 stated she left to give him space, but she was inside the door. CNA 4 stated she should have stayed with Resident 1. On 1/27/26 at 1400 hours, an interview was conducted with the DON. The DON stated CNA 4 should have stayed with Resident 1 until the family came to pick up the resident.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of two sampled residents (Resident 1). * The facility failed to ensure Resident 1's physician's orders for carbidopa-levodopa (medication to treat Parkinson's disease) was clarified with the physician, when there were two duplicate orders with different dates. This failure had the potential for the resident's care needs not being met as the medical information was inaccurate.Findings: Review of the facility's P&P titled Medication Administration - Nursing Clinical revised February 2012 showed only licensed medical and nursing personnel or other lawfully authorized staff member may prepare, administer, and record medications. All the current drugs and dosage schedules must be recorded on the resident's medication administration record (MAR). The nurse administering the medication must initial the resident's MAR on the appropriate line and date. Medical record review for Resident 1 was initiated on 1/26/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed a physician's order dated 1/14/26, for carbidopa-levodopa oral tablet 25-100 mg, give two tablets by mouth a day for Parkinson's. Review of Resident 1's MAR for January 2026 showed there were two physician's orders dated 11/25/25 and 1/14/26, for carbidopa-levodopa oral tablet 25-100 mg give two tablets by mouth a day for Parkinson's scheduled to be administered at 0900 hours. On 1/27/26 at 1200 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 1. LVN 1 stated she administered carbidopa-levodopa oral tablet 25-100 mg two tablets at 0900 hours. LVN 1 verified there were two duplicate orders with different dates, and further stated she should have clarified the orders with Resident 1's physician. On 2/3/26 at 1204 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (Residents 13 and 41) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 13's orthostatic (a sudden drop in blood pressure when standing up, causing symptoms like dizziness, lightheadedness, and fainting) blood pressure was accurately monitored as ordered by the physician for the use of the risperidone (antipsychotic) medication. * The facility failed to ensure Resident 41's orthostatic blood pressure was accurately monitored as ordered by the physician for the use of the Seroquel (antipsychotic) medication; in addition, the facility failed to ensure the accurate monitoring of Resident 41's behavior was done for the use of the Seroquel medication. These failures had the potential for adverse effects from the psychotropic medications use and the potential for not providing the correct data to the prescriber to adjust the dosage of psychotropic medications.Findings: Review of the facility's P&P titled Chemical Restraints and Psychotropic Medication Management revised 4/2024 showed psychotropic medications shall not be administered for the purpose of discipline or convenience. Based on a comprehensive assessment, the facility will ensure that residents who use psychotropic drugs receive gradual does reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. The IDT will review to ensure:a. The psychotropic medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record;b. Not in excessive dosage;c. Behavior is not related to delirium or other reversible conditions;d. Monitoring for adverse consequences and effectiveness of medications are in place;e. PRN medications are within guidelines;f. Informed consent was obtained prior to medication use;g. Review of plan of care shows individualized, person-centered care approaches to manage behavior with non-pharmacological interventions.New physician's orders for psychotropic medications will be communicated to the Social Services department for review with the IDT and appropriate care planning will be done to ensure updated information in the resident's psychosocial care plan. 1. Medical record review for Resident 13 was initiated on 9/23/25. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's H&P examination dated 6/16/25, showed Resident 13 had no capacity to understand and make decisions. Review of Resident 13's MDS assessment dated [DATE], showed Resident 13 had moderately impaired cognition. Review of Resident 13's Order Summary Report dated 9/24/25, showed the following physician's orders:- dated 6/18/25, to administer risperidone (antipsychotic medication) 0.25 mg one tablet by mouth two times a day for psychosis (a mental state where a person loses contact with reality, characterized by symptoms like hallucinations (seeing or hearing things that aren't there) and delusions (false, fixed beliefs)) manifested by suspicious of her roommate harming her, - dated 7/7/25, for the use of the antipsychotic medication, to obtain Resident 13's orthostatic blood pressure in the sitting position, every Sunday during the day shift,- dated 7/7/25, to obtain Resident 13's orthostatic blood pressure in the standing position, every Sunday during the day shift, and- dated 7/7/25, to obtain Resident 13's orthostatic blood pressure in the lying position, every Sunday during the day shift. Review of Resident 13's MAR for August and September 2025 showed the following documented orthostatic BP readings:- on 8/10/25, the BP reading was documented as 132/78 mmHg for the sitting, lying, and standing position.- on 9/14/25, the BP reading was documented as 128/74 mmHg for the sitting and standing position.- on 9/21/25, the BP reading was documented as 115/80 mmHg for the sitting, lying, and standing position. On 9/24/25 at 1527 hours, an interview and concurrent medical record review for Resident 13 was conducted with RN 1. RN 1 stated for the residents on the antipsychotic medications were monitored for orthostatic hypotension by obtaining the resident's BP in the lying, sitting, and standing (if applicable) positions and comparing the BP readings. RN 1 reviewed Resident 13's medical record and verified the above findings. 2. Medical record review for Resident 41 was initiated on 9/23/25. Resident 41 was admitted to the facility on [DATE]. Review of Resident 41's H&P examination dated 8/20/25, showed Resident 41 had fluctuating capacity to understand and make decisions. Review of Resident 41's MDS assessment dated [DATE], showed Resident 41 had severely impaired cognition. Review of Resident 13's Orders Summary Report dated 9/25/25, showed the following physician's orders:- dated 8/18/25, for the use of the Seroquel (antipsychotic) medication, to monitor the episodes of antipsychotic behavior manifested by sudden anger outburst, every shift. To document the non-pharmacological interventions using the following codes: 1= Redirect with activities of interest, 2= Reduce of remove possible stressors, 3= Model appropriate interactions, 4= Remind and set boundaries, 5= Offer support, 6= Remove resident from environment, or 7= Return to room, - dated 9/2/25, to administer Seroquel 12.5 mg one tablet by mouth two times a day for psychosis (a mental state where a person loses contact with reality, characterized by symptoms like hallucinations (seeing or hearing things that aren't there) and delusions (false, fixed beliefs)) manifested by visual hallucinations,- dated 9/5/25, for the use of the psychotropic medication, to obtain Resident 41's orthostatic blood pressure in the lying position, every Sunday during the day shift, - dated 9/5/25, for the use of the psychotropic medication, to obtain Resident 41's orthostatic blood pressure in the sitting position, every Sunday during the day shift, and- dated 9/5/25, for the use of the psychotropic medication, to obtain Resident 41's orthostatic blood pressure in the standing position, every Sunday during the day shift. a. Review of Resident 41's MAR for September 2025 showed the following documented orthostatic BP readings:- on 9/2/25, the BP reading was documented as 121/61 mmHg for the lying and standing positions.- on 9/7/25, the BP reading was documented as 117/70 mmHg for the lying, sitting, and standing positions.- on 9/14/25, the BP reading was documented as 120/72 mmHg for the lying and sitting positions.- on 9/21/25, the BP reading was documented as 110/71 mmHg for the lying position, and NA (not applicable) was documented for the sitting and standing positions. b. Review of Resident 41's MAR for September 2025 showed the licensed nurses were monitoring Resident 41 for the episodes of sudden anger outbursts, every shift from 9/1 to 9/25/25. The MAR showed the licensed nurses' documentation of the nonpharmacologic interventions implemented and it's effectiveness for Resident 41's episodes of sudden anger outbursts, however the number of episodes observed were documented as 0 zero. For example:- on 9/1/25, zero episode was documented during the day and night shifts; however, the licensed nurses documented 2- Reduce or remove possible stressors, for the nonpharmacological interventions attempted.- on 9/2/25, zero episode was documented during the day, night, and NOC shifts; however, the licensed nurses documented 5-offer support, for the nonpharmacological interventions attempted. Further review of the MAR for September 2025 failed to show any monitoring of Resident 41 for the episodes of visual hallucinations, for the use of the Seroquel medication. On 9/26/25 at 0949 hours, an interview and concurrent medical record review for Resident 41 was conducted with RN 1. RN 1 stated for the residents taking the antipsychotic medications, the residents would be monitored every shift by the licensed nurses for the manifested behaviors and the potential side effects related to the use of the antipsychotic medication. RN 1 stated if the monitored behaviors were observed, the licensed nurses should implement the nonpharmacological interventions and document the number of episodes observed during the shift, the non-pharmacological interventions implemented and the effectiveness of the interventions. RN 1 reviewed Resident 41's medical record and verified the above findings. On 11/19/25 at 1015 hours, an interview was conducted with the DON. The DON stated for the residents prescribed with psychotropic medications, the residents were monitored for the potential side effects such as orthostatic hypotension. The DON stated the monitoring for the orthostatic hypotension was done once every week, and the residents' BP readings were obtained when they were in the lying, sitting, and standing positions. The DON stated the BP readings obtained for the different positions should not be the same and should not be marked N/A. The DON stated the monitoring of the specific behaviors related to the use of the psychotropic medications were also done every shift by the licensed nurses. The DON stated if the monitored behavior was observed, the licensed nurses were expected to document the number of episodes during the shift and the non-pharmacological interventions implemented and its effectiveness in the MAR. On 11/19/25 at 1430 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for two of 27 final sampled residents (Residents 29 and 141). * The facility failed to ensure the right arm sling was applied as ordered by the physician for Resident 29. * The facility failed to ensure Resident 141's physician was notified timely of the UA (urine analysis) results and the resident's signs and symptoms of UTI (urinary tract infection). These failures had the potential for not providing the necessary care and services to the residents to meet their needs and delay in treatment. Findings: Review of the facility's P&P titled Sling, Arm revised 11/2007 showed it is the policy of this facility to: 1. Elevate ad support the arm. 2. Reduce edema. 3. Relieve stress on the shoulder or elbow. 4. Immobilize a strained or sprained muscle. 5. Immobilize a fracture. 6. Facilitate return circulation from the extremities. Medical record review for Resident 29 was initiated on 9/23/25. Resident 29 was admitted to the facility on [DATE], with the diagnosis of fracture of unspecified part of the right clavicle. Review of Resident 29's H&P examination dated 9/2/25, showed Resident 29 was hospitalized due to a mechanical fall resulting in a right clavicular fracture. Further review of the H&P showed Resident 29 had no capacity to make decisions. Review of Resident 29's Plan of Care showed a care plan problem dated 9/2/25, addressing Residents 29's ADL self-care performance deficit. The interventions included non-weight bearing to the right upper extremity and to apply the right arm sling at all times, may be removed during shower and ADL care. Review of Resident 29's Order Summary Report dated 9/25/25, showed a physician's order dated 9/2/25, for Resident 29 to wear the right arm sling at all times; may remove the sling during shower and ADL care and for non-weight bearing to the right upper extremity, every shift. On 9/23/25 at 1235 hours, an observation for Resident 29 was conducted. Resident 29 was observed lying on bed while CNA 2 was observed repositioning Resident 29 in the bed. Resident 29 was not observed wearing a sling on the right arm. On 9/24/25 at 1055 and 1553 hours, Resident 29 was observed lying in bed. Resident 29 was not observed wearing a right arm sling. On 9/25/25 at 0732 and 1210 hours, Resident 29 was observed lying in bed. A staff was not observed in the room providing care to Resident 29 and the resident was not observed wearing a sling on the right arm. On 9/25/25 at 1450 hours, an interview and concurrent observation for Resident 29 was conducted with CNA 3. When asked about Resident 29's use of the sling, CNA 3 stated she was not informed Resident 29 needed to wear a sling. CNA 3 stated Resident 29 had not been wearing a sling during CNA 3's shift that day, during the 0700 to 1500 shift. CNA 3 further stated there was a sling in Resident 29's restroom, however CNA 3 stated she was not informed the sling was for Resident 29. A concurrent observation was conducted of Resident 29 with CNA 3. Resident 29 was observed lying on the bed, and CNA 3 verified Resident 29 was not wearing a sling on her right arm. On 9/25/25 at 1457 hours, an interview and concurrent observation and record review for Resident 29 was conducted with LVN 3. LVN 3 stated Resident 29 had a cervical fracture on the right side. LVN 3 reviewed Resident 29's medical record and stated there was a physician's order for Resident 29 to wear a sling on the right arm. A concurrent observation of Resident 29 was conducted with LVN 3. LVN 3 verified Resident 29 was not wearing a sling on the right arm. LVN 3 stated Resident 29 should be wearing a sling at all times except for showers. LVN 3 further stated Resident 29 had received a shower today, however the CNA did not ask LVN 3 to assist to apply the sling. On 11/18/25 at 1015 hours, an interview was conducted with the DON. The DON stated for the residents with a physician's order to wear the sling, the sling should be applied as per the physician's order. The DON further stated the licensed nurses were responsible for checking the residents to ensure the slings were worn as ordered. On 11/19/25 at 1430 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 2. Review of the facility's P&P titled Physician Order, Transcribing and Notification revised 5/2021 showed laboratory orders are transferred to the laboratory request and physician's order sheet. The laboratory services is notified of the diagnostic procedure ordered. All laboratory orders will be verified, and physician will be notified of results of the laboratory work up. On 9/23/25 at 0933 hours, during the initial tour of the facility, Resident 141 was observed awake in her room. Resident 141 stated she had UTI and the facility had not done anything about her UTI. Resident 141 stated it burned when she urinated, and her urine smelled bad. Resident 141 stated she had a urine sample test done last week and had been begging the facility to find out the results. Resident 141 further stated her son asked the facility staff yesterday and he was told the facility was still waiting for the physician to call about the results. Medical record review for Resident 141 was initiated on 9/23/25. Resident 141 was admitted to the facility on [DATE]. Review of Resident 141's H&P examination dated 7/13/25, showed Resident 141 had the capacity to understand and make decisions. Review of Resident 141's SBAR Communication Form dated 9/11/25 at 1230 hours, showed Resident 141 verbalized she had dysuria, increased in urination, and burning sensation when voiding. Physician 1 was notified and recommended to test the resident's urine for UA with culture and sensitivity. Review of Resident 141's Laboratory Results Report showed: - collected on 9/12/25 at 1350 hours, and reported on 9/13/25 at 1821 hours, Resident 141's urinalysis with culture reflex resulted with multiple organisms present in the urine with possible contamination; and - collected on 9/18/25 at 1300 hours, and reported on 9/20/25 at 1101 hours, Resident 141's urinalysis with culture reflex resulted with positive Escherichia coli (E. coli). Review of Resident 141's Progress Notes showed the following: - dated 9/16/25 at 1644 hours, Physician 1 was reinformed regarding Resident 141's urinalysis with culture and sensitivity laboratory result which showed multiple organisms present in the urine and possible contamination, awaiting response from Physician 1. The note also showed Resident 141 was still complaining of burning sensations and dysuria and increased in frequency urination; and - dated 9/18/25 at 1209 hours, Physician 1 saw Resident 1 in the facility, saw the result of the urine test which was done on 9/12/25, and ordered to recollect urine for UA with culture and sensitivity test. Physician 1 also ordered to change Resident 141's cranberry supplement to twice daily. - dated 9/25/25 at 1406 hours, Physician 2 was informed of the result of the UA with culture and sensitivity test but no response; - dated 9/25/25 at 1459 hours, Physician 2 was reinformed of the result of the UA with culture and sensitivity test but no response; - dated 9/26/25 at 1512 hours, Resident 141 was still verbalizing bladder discomfort and frequency/urgency in urination. Physician 2 was informed and awaiting for response. Further review of Resident 141's medical record did not show documented evidence the physician was notified of the result of the urinalysis with culture reflex reported to the facility on 9/20/25. In addition, the medical record failed to show documented evidence of continued monitoring/assessment for Resident 141 by the licensed nurses when the resident had a change of condition related to signs and symptoms of the UTI. On 9/26/25 at 1404 hours, an interview and concurrent medical record review for Resident 141 was conducted with LVN 6. LVN 6 stated she was familiar with Resident 141. LVN 6 stated Resident 141 had complained of issues with urination like burning sensation and feeling of increased urgency to urinate. LVN 6 stated Resident 141 had these issues since 9/11/25. LVN 6 stated the charge nurse was responsible to follow up with the physician regarding the laboratory results. LVN stated if there was no response, they would endorse to the next shift's charge nurse and would call the following day. LVN 6 stated if three days had passed and the physician still had not responded, they would ask for help from the DON. LVN 6 further stated they would contact the Medical Director if the physician did not respond for five days. LVN 6 verified no one informed Resident 141's physician after the laboratory reported to the facility the result of the urine test on 9/20/25. On 9/26/25 at 1430 hours, an interview and concurrent medical record review for Resident 141 was conducted with the IP. The IP stated Resident 141 did not have any current documented signs and symptoms of infection. The IP stated she was not aware Resident 141 had any signs and symptoms of urinary infection. The IP stated Resident 141's last change of condition was on 9/11/25, and the urinary test showed it was contaminated at that time. The IP stated she was not aware of Resident 141's contaminated urinary result until 9/18/25 and Physician 1 ordered to recollect urine sample to repeat the UA with culture and sensitivity test. The IP stated there was no change or report to her afterwards that Resident 141 still had dysuria. The IP stated for the result on 9/12/25, the nurse reviewed the results on 9/12/25 at 0830 hours. The IP stated the nurse who had reviewed the results was responsible for notifying the physician. The IP acknowledged the physician was not attempted to be notified until 9/15/25. The IP stated they should have followed up with the physician as soon as possible and notified the physician as soon as they got the laboratory result. The IP stated each nurse on every shift should follow up. The IP stated another urine sample was sent out in the laboratory on 9/18/25. The IP stated the results came back on 9/22/25, and the results were reviewed by an RN. The IP verified there was no documented evidence the physician was notified on 9/22/25, of the result of the urine test and it was only not until 9/25/25, when the nurses attempted to notify the physician. The IP verified she was not monitoring Resident 141 and the resident was not on her infection surveillance record. The IP stated the follow up to the physician regarding the result of the urine test ordered was a delay of care. The IP further stated the nurses should attempt to notify the resident's attending physician three times of the laboratory results or any changes in the resident's condition, and if there was no response then the medical director should be notified. On 11/19/25 at 1530 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure ulcers (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for three of six final sampled residents (Residents 8, 9, and 29) reviewed for pressure ulcers. * The facility failed to ensure the wound treatment was administered as per the physician's order for Resident 8. * The facility failed to conduct the Weekly Skin Evaluations and IDT Skin Review for Resident 9's coccyx to right buttock wound, as per the facility's P&P and care plan. * The facility failed to ensure the LAL mattress setting was appropriate for Resident 29's weight. These failures posed the potential risks for complications and delayed wound healing for Residents 8, 9, and 29. Findings: Review of the facility's P&P titled Skin and Wound Monitoring and Management revised 4/2025 showed it is the policy of this facility that a resident having pressure injury(s) receives the necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. For the ongoing skin and wound assessments, a licensed nurse would assess/evaluate a resident's skin at least weekly. Areas of breakdown, excoriation, or discoloration, or other unusual findings (either initially identified at the time of admission or as new findings) must be documented in the nursing notes or on the appropriate weekly assessment form (Skin Pressure Ulcer Weekly, Skin Ulcer Non-Pressure Weekly, or Skin Evaluation-PRN/Weekly). A licensed nurse would assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. This assessment evaluation should include but not limited to: 1) Measuring the skin injury, 2) Staging the skin injury (when the cause is pressure), 3) Describing the nature of the injury (e.g. pressure, stasis, surgical incision), 4) Describing the location of the skin altercation, 5) Describing the characteristics of the skin alteration, 6) Describing the progress with healing, and any barriers to healing which may exists, and 7) Identifying any possible complications or signs/symptoms consistent with the possibility of infection. Once an area of an alteration in skin integrity has been identified, assessed, and documented, the nursing staff shall administer the treatment to each affected area as per the physician's order. Treatments per the physician's order should be documented in the resident's clinical record at the time they are administered. Further review of the facility's P&P showed in order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, the nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows, etc.). If the clinical assessment/evaluation for the Pressure Ulcer, Non-pressure Ulcer, and PRN/Weekly Skin Assessment/Evaluation indicated a change in condition or decline in the wound, the assessing/evaluating nurse would notify the physician and create a narrative note documenting the notification. Under the section Monitoring showed monitoring would be conducted weekly via the Skin Weekly Committee. The facility would prepare and maintain Skin Committee Review Notes and recommendations in the resident's clinical record. Review of the manual titled Supra Air Low Air Loss Alternating Pressure Mattress and Pump (undated) under the section Operating Instructions, showed Step 6- to determine the resident's weight and set the control knob to that weight on the control unit. 1. Medial record review for Resident 9 was initiated on 9/23/25. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's H&P examination dated 10/20/25, showed Resident 9 had the capacity to understand and make decisions. Review of Resident 9's Order Summary Report showed the following physician's orders: - dated 9/16/25, to re-evaluate the coccyx (a small triangular bone at the base of the spinal column in humans) extending to the right buttock pressure injury every day shift, for one day. - dated 9/17/25, to re-evaluate the coccyx extending to the right buttock open area, every day shift, for one day. - dated 9/17/25, for the coccyx extending to the right buttock open area, to cleanse with normal saline, pat dry, apply Calmoseptine cream (topical ointment used to protect and heal skin irritations by creating a moisture barrier and providing a soothing effect), cover with foam dressing every day for 14 days, then re-evaluate. Review of Resident 9's Progress Note dated 11/19/25, showed a nursing entry on 9/16/25 at 0741 hours. The licensed nurse documented the CNA informed the licensed nurse of Resident 9's open skin to the buttock. The resident was assessed and noted with a small open skin to the coccyx extending to the right buttock, approximately 0.3 mm in size. The resident stated she was getting changed yesterday and the CNA kind of accidentally put pressure while cleaning. The treatment was initiated per the facility protocol and Resident 9's physician was informed of the new change of condition and approved of the wound treatment. Review of Resident 9's LN- Skin Evaluation-PRN/Weekly dated 9/16/25, showed the licensed nurse's documentation of Resident 9's 0.3 mm by 0.3 mm pressure injury to the coccyx extending the right buttock. Review of Resident 9's Post-Event IDT Review dated 9/16/25, showed the documentation Resident 9 had a skin alteration on a fragile body area during care. The resident sustained a superficial 0.3 mm size open skin to the coccyx area. The interventions showed caregiver education was provided to ensure post incontinent care, and treatment as ordered. Review of Resident 9's Plan of Care showed a care plan problem dated 9/16/25, addressing Resident 9's open area sustained during care to the lower back area. The interventions included administering the treatments as ordered, to monitor for effectiveness, and to assess/record/monitor the wound healing; to measure the length, width, and depth where possible, to assess ad document the status of the wound perimeter, wound bed, and healing progress. To report improvements and declines to the physician. Review of Resident 9's TAR for September 2025 showed the documentation of the treatment order for the coccyx extending to the right buttock open area, to cleanse with normal saline, pat dry, apply Calmoseptine cream, and cover with foam. Review of Resident 9's TAR for October 2025 failed to show the documented evidence the above dressing every day for 14 days, then re-evaluate, was administered from 9/17 to 9/30/25. wound care was provided to Resident 9 from 10/1 to 10/7/25 (up to the time when Resident 9 was transferred to the acute care hospital). Further review of Resident 9's medical record failed to show the documentation Resident 9's coccyx extending to the right buttocks wound was monitored and evaluated weekly as per the P&P and care plan, re-evaluated after 14 days of treatment as per the physician's orders, and failed to show the documentation the IDT Skin Review was conducted weekly for Resident 9. On 11/19/25 at 0936 hours, an interview and concurrent medical record review for Resident 9 was conducted with LVN 2. LVN 2 stated upon notification of a new skin impairment, the licensed nurse or treatment nurse would assess the resident's wound, initiate a change of condition, complete the initial skin assessment, and notify the physician for the treatment orders. When asked about classification of the wound and differentiating between pressure and non-pressure wounds, LVN 2 stated if the wound was over a bony prominence, like the coccyx area, then that wound would be classified as a pressure injury. LVN 2 stated for the pressure and non-pressure wounds, the treatment nurse was responsible for assessing and evaluating the wounds weekly to monitor the wound status, to determine if the treatment was effective, or if the wound was deteriorating or getting better. LVN 2 stated following the weekly skin assessments, IDT Skin Review would be conducted weekly to discuss the residents with skin problems. LVN 2 reviewed Resident 9's medical record and verified the above findings. On 11/19/25 at 1015 hours, an interview and concurrent medical record review for Resident 9 was conducted with the DON. The DON stated when a new skin impairment was reported, the licensed nurse was responsible for assessing the resident and completing the initial LN- Skin Evaluation- PRN. The DON stated following the assessment, a weekly skin assessment should be conducted to monitor the wound and the effectiveness of the treatment. The DON stated an IDT Skin Review would be conducted weekly to discuss the resident's skin impairment. The DON stated if the location of the wound was over a bony prominence, the wound should be classified as a pressure injury. The DON reviewed Resident 9's medical record and verified the above findings. The DON stated there should have been the weekly skin assessment/evaluation to monitor the status of the wound and if the wound resolved, then there should have been some documentation in the resident's medical record. 2. On 9/23/25 at 1000 hours, during the initial tour of the facility, Resident 29 was observed lying in bed. The Low Air Loss (LAL) mattress device was observed on and the weight setting was set at 125 pounds. Medical record review for Resident 29 was initiated on 9/23/25. Resident 29 was admitted to the facility on [DATE]. Review of Resident 29's MDS assessment dated [DATE], showed Resident 29 had severely impaired cognition, was at risk for developing pressure ulcers/injuries, and required partial/moderate assistance (where the helper does less than half the effort) for rolling left and right, and substantial/maximal assistance (where the helper does more than half the effort) for sit to lying, and lying to sitting on the side of the bed for bed mobility. Review of Resident 29's Order Summary Report for September 2025 showed a physician's order dated 9/17/25, for the LAL mattress for skin maintenance and wound care. Review of Resident 29's Plan of Care showed a care plan problem initiated on 9/3/25, addressing Resident 29's potential for pressure injury development. The interventions included the LAL mattress for wound care and skin maintenance. Review of Resident 29's Weights and Vitals Summary dated 9/25/25, showed on 9/14/25, Resident 29 weighed 80 pounds; and on 9/21/25, Resident 29 weighed 81 pounds. On 9/24/25 at 1000, 1055, and 1553 hours, Resident 29 was observed lying on her back on the LAL mattress. The LAL mattress unit was observed turned on and set at 125 pounds. The staff was not observed in Resident 29's room providing care to the resident. On 9/24/25 at 1603 hours, an interview and concurrent observation and medical record review for Resident 29 was conducted with LVN 2. LVN 2 stated Resident 29 could assist with turning in bed but was at risk for developing pressure injuries. LVN 2 stated Resident 29 had a LAL mattress for pressure relief and the setting should be set based on Resident 29's current weight. LVN 2 stated the LAL mattress settings were checked every morning by the treatment nurses to ensure the settings were correct for each resident. LVN 2 reviewed Resident 29's medical record and stated Resident 29's most recent weight was obtained on 9/21/25, and she weighed 81 pounds. An observation was conducted at Resident 29's bedside and LVN 2 verified the LAL mattress setting was set at 125 pounds. LVN 2 stated the LAL mattress weight setting should be set at Resident 29's current weight. On 11/19/25 at 1015 hours, an interview was conducted with the DON. The DON stated for the residents on the LAL mattress, the LAL mattress setting should be set based on the resident's current weight or their comfort level. The DON stated if the LAL setting was not set per the resident's weight and there could be the potential risk of the resident developing pressure injuries. The DON stated if the LAL mattress setting was set per the resident's comfort level and not their weight, then there should be a care plan to address the weight setting discrepancy on the LAL mattress unit. On 11/19/25 at 1430 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 3. On 9/23/25 at 1120 hours, during the initial tour of the facility, Resident 8 was observed awake and sitting in the wheelchair inside the room. Resident 8 stated she had a wound on her bottom and was being treated by the nurse. Medical record review for Resident 8 was initiated on 9/30/25. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 8/14/25, showed Resident 8 had the capacity to understand and make decisions. Review of Resident 8's Order Summary Report showed a physician's order dated 9/22/25, to cleanse left ischium (a thick, irregularly shaped bone in the pelvis that serves multiple functions. It is also known as a sit bone) pressure injury with NS, pat dry, apply Medihoney (wound treatment that creates a moist healing environment, cleanses wounds, and helps remove dead tissue), apply alginate (used for the management of moderate to heavily exuding wounds to promote healing by maintaining a moist environment) dressing, and cover with dry dressing every day shift for 30 days. Review of Resident 8's Wound assessment dated [DATE] at 1916 hours, showed a surgical debridement of the left buttock wound was performed by the wound physician. The wound physician documented on the plan interventions for the left buttock pressure injury to treat with collagen powder, Medihoney, and cover with dry dressing. The record showed due to Resident 8's medical comorbities, wound healing prolonged and difficult despite optimal nursing care in place. On 9/30/25 at 1515 hours, an interview and concurrent medical record review for Resident 8 was conducted with LVN 2. LVN 2 stated the wound consultant/physician came to the facility every Thursday of the week. LVN 2 verified Resident 8 had a pressure injury in the left buttock since 9/20/25. LVN 2 stated the current treatment he was providing Resident 8 was Medihoney with alginate dressing. LVN 2 stated he assisted the wound physician and the physician would tell the treatment nurses the new treatment orders on the same day and it would also be recorded in the physician's wound assessment note. LVN 2 stated the wound physician would tell him about changes to the wound treatment orders. LVN 2 stated the wound physician reclassified the wound in Resident 8's left buttock and there was a new order for Medihoney and collagen powder on 9/25/25. LVN 2 verified he did not update the treatment orders per the wound physician's orders. LVN 2 further stated he was aware of the new treatment orders for Resident 8's left buttock wound since 9/25/25. On 11/19/25 at 1530 hours, an interview was conducted with the Administrator, DON, and Nursing Consultant. The Administrator, DON, and Nursing Consultant were informed and acknowledged the above findings for Resident 8.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 3) reviewed for falls were provided the necessary services after a fall. * The facility failed to ensure Resident 3's fall risk evaluation was completed after Resident 3 had a fall on 8/9/25, and failed to ensure Resident 3's Fall Risk Evaluations were completed accurately. These failures had the potential risk of inaccurate fall risk score and the failure to implement the appropriate fall risk interventions for Resident 3. Findings: Review of the facility's P&P titled Fall Management System revised 4/2025 showed it was the policy of the facility to provide each resident with the appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurred. On admission, the Fall Risk Evaluation would be completed to determine the resident's risk for sustaining a fall. When a resident sustained a fall, a physical assessment would be completed by a licensed nurse, with the results documented in the medical record. The Fall Risk Evaluation would be completed post fall incident. Medical record review for Resident 3 was initiated on 9/23/25. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's H&P examination dated 6/26/25, showed Resident 3 had no capacity to make decisions and the diagnosis of dysphagia (difficulty or pain when swallowing) as a late effect of a cerebrovascular accident (a stroke that occurs when blood flow to the brain is interrupted, either by a blockage or a ruptured blood vessel, causing brain cells to die). Review of Resident 3's MDS assessment dated [DATE], showed Resident 3 had severely impaired cognitive skills for daily decision making. Review of Resident 3's Plan of Care showed a care plan problem dated 7/26/25, addressing Resident 3's risk for falls. The care plan showed Resident 3 was found on the floor on 7/21, 8/9, 9/1, 9/10, and 9/14/25. Review of Resident 3's Fall Risk Evaluations showed the following licensed nurses' documentation: - dated 7/25/25, Resident 3 had no falls in the past three months (however, Resident 3 had a fall on 7/21/25), - dated 9/10/25, Resident 3 had one to two falls in the past three months and had no predisposing diseases or conditions (however, Resident 3 had more than two falls in the last three months and had the diagnosis of a cerebrovascular accident), - dated 9/14/25, Resident 3 had one to two falls in the past three months (however, Resident 3 had more than two falls in the last three months). Further review of Resident 3's medical records failed to show a Fall Risk Evaluation was completed for Resident 3's fall on 8/9/25. On 9/30/25 at 1526 hours, an interview and concurrent medical record review for Resident 3 was conducted with the ADON. The ADON stated upon admission to the facility, a Fall Risk Assessment was completed to identify the residents that were at risk for falls. The ADON stated the fall risk interventions were implemented based on the resident's fall risk scores, therefore the assessment should be accurate. The ADON further stated after the resident sustained a fall at the facility, the fall risk reevaluation should be completed. The ADON reviewed Resident 3's medical record and verified the above findings. On 11/19/25 at 1015 hours, an interview was conducted with the DON. The DON stated after a resident had a fall at the facility, the licensed nurse should complete the Fall Risk Evaluation. The DON stated the Fall Risk Reevaluation should be accurate because the fall interventions for the residents were implemented based on the resident's fall risk scores. On 11/19/25 at 1430 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to one of one final sampled resident (Resident 4) reviewed for dialysis. * The facility failed to ensure Resident 4's dialysis communication forms were accurately completed. * The facility failed to ensure Resident 4 had a clamp scissors (a device for dialysis residents that control bleeding or secure tubing) available in the emergency kit at bedside. * The facility failed to ensure Resident 4's 1000 ml fluid restriction in a 24-hour period was maintained. These failures had the potential of not identifying possible negative outcomes related to the dialysis treatment for the resident.Findings: Review of the facility's P&P titled Dialysis (Renal), Pre- and Post-Care revised 1/2022 showed the care of the resident receiving dialysis services will reflect ongoing communication, coordination and collaboration between the nursing home and dialysis staff. Staff will immediately contact and communicate with the attending physician and/or practitioner, resident/resident representative, and designated dialysis staff such as the nephrologist (a medical doctor who specializes in diagnosing and treating kidney disease) or registered nurse regarding any significant changes in the resident's status related to clinical complications or emergent situations that may impact the dialysis portion of the care plan. The P&P further showed documentation related to pre- and post-dialysis care will be placed in the clinical record and include: - Resident assessments, interventions, and any provided education. - Assessment of renal dialysis access site, to include presence or absence and quality of a bruit (the sound of blood flowing through an artery) and thrill (a vibration felt by blood flowing through the fistula) for residents with an arteriovenous fistula (the connection the artery and vein for dialysis access). - Communication between facility and dialysis staff or medical provider. 1. Medical record review for Resident 4 was initiated on 9/23/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 9/3/25, showed Resident 4 had the capacity to understand and make decisions. a. Review of Resident 4's Order Summary Report for September 2025 showed the following physician's orders:- dated 8/30/25, for hemodialysis (a medical procedure that uses a machine to filter and clean a person's blood when their kidneys have failed) days on Monday, Wednesday, and Fridays. - dated 9/17/25, to access dialysis site left chest permacath (a long-term, tunneled central venous catheter used for hemodialysis, inserted into a large vein, typically in the neck, and threaded to the right side of the heart) every 30 minutes for four hours post dialysis treatment. Assess for s/s (signs and symptoms) of bleeding, infections, or any issues. Document in the nurses notes if any issues are present and notify MD (Doctor of Medicine). Review of Resident 4's Nurses Dialysis Communication Record under the section for Pre-Dialysis showed the following:- No documentation of the number of lumen (the cavity or channel within a hollow, tubular organ or vessel, such as a blood vessel or the intestine) on 9/19, 9/22, and 9/24/25. Review of Resident 4's Dialysis Communication Record under the section for Dialysis Center showed the following:- Access site marked to the right upper chest.- No documentation of the number of lumen on 9/19, 9/22, and 9/24/25. Review of Resident 4's Dialysis Communication Record under the section for Post-Dialysis showed the following:- A documentation to show the resident has a bruit and thrill on 9/17/25.- No documentation of the number of lumen on 9/17/25.- No documentation of the access site on 9/24/25. - No documentation of redness, swelling, pain, drainage, or bleeding on 9/24/25. On 9/26/25 at 0922 hours, an interview and concurrent medical record review for Resident 4 was conducted with the ADON. The ADON verified the above findings. The ADON stated the dialysis communication forms were completed for pre-dialysis, at dialysis, and post-dialysis. The ADON further stated the charge nurse assigned to the resident were to complete the form prior to the dialysis, upon return, and also follow up with the dialysis center if information on the dialysis communication forms were incomplete or inaccurate. b. Review of Resident 4's Order Summary Report for September 2025 showed the following physician's orders:- dated 8/30/25, for hemodialysis days on Monday, Wednesday, and Fridays. - dated 9/17/25, to access dialysis site left chest Permacath every 30 minutes for four hours post dialysis treatment. Assess for signs and symptoms of bleeding, infections, or any issues. Document in the nurses notes if any issues are present and notify the MD. On 9/26/25 at 0922 hours, an observation and concurrent interview for Resident 4 was conducted with the ADON in Resident 4's room. The ADON verified the emergency dialysis kit at Resident 4's bedside did not have the clamp scissors available in the emergency dialysis kit. The ADON verified the emergency dialysis kit had a tourniquet (a device for stopping the flow of blood through a vein or artery, typically by compressing a limb with a cord or tight bandage), gauze, sterile gloves, and tape. The ADON stated clamp scissors should be at the resident's bedside to be used for bleeding. c. Review of Resident 4's Order Summary Report for September 2025 showed the following physician's orders:- dated 8/30/25, for hemodialysis days on Monday, Wednesday, and Fridays. - dated 8/30/25, for 1000 ml per day fluid restriction. Review of Resident 4's medical record titled Fluid Intake dated 10/21 to 11/19/25, showed Resident 4 received over 1000 ml fluid restriction in a day on the following:- dated 10/21/25, 1600 ml;- dated 10/22, 10/25, and 11/6/25, 1200 ml;- dated 11/4/25, 1320 ml; and- dated 11/5/25, 1440 ml. On 11/19/25 at 1008 hours, an interview and concurrent medical record review for Resident 4 was conducted with the IP. The IP verified Resident 4 received over 1000 ml of fluids on multiple dates noted above. The IP also verified Resident 4 was on hemodialysis and had a physician's order for fluid restriction of 1000 ml per day. The IP stated the 1000 ml fluid restriction should be maintained to ensure Resident 4 did not go into fluid overload. On 11/19/25 at 1510 hours, an interview was conducted with the Administrator, DON, Nurse Consultant, and Certified Dietary Manager. The Administrator, DON, Nurse Consultant, and Certified Dietary Manager acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for two of 27 final sampled residents (Residents 29 and 85) and one nonsampled resident (Resident 18) to meet the needs of each resident. * The facility failed to verify with the physician the medication route for Resident 18's medication ordered. * The facility failed to ensure the metoprolol (medication to treat high blood pressure) was administered as ordered by the physician for Resident 29. * The facility failed to ensure the amlodipine (medication to treat high blood pressure) was administered as ordered by the physician for Resident 85. These failures posed the risk for negative health outcomes to the residents.Findings: Review of the facility's P&P titled Medication Administration revised 2/2022 showed it is the policy of this facility that medications shall be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a drug order seems to be unrelated to the resident's current diagnosis or condition, the nurse should contact the physician. 1. On 9/25/25 at 0847 hours, medication administration observation for Resident 18 was conducted with LVN 6. LVN 6 was observed administering the multiple vitamins-minerals one tablet via GT (Gastrostomy tube, a tube inserted through the belly that brings nutrition directly to the stomach) to Resident 18. Medical record review for Resident 18 was initiated on 9/25/25. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's H&P examination dated 4/24/25, showed Resident 18 had fluctuating capacity to understand and make decisions. Review of Resident 18's Order Summary Report showed a physician's order dated 8/18/25, to administer multiple vitamins-minerals one tablet by mouth one time a day for supplement. On 9/25/25 at 1430 hours, an interview and concurrent medical record review for Resident 18 was conducted with LVN 6. LVN 6 stated Resident 18 was currently NPO (nothing by mouth) because of dysphagia (difficulty or pain when swallowing). LVN 6 stated Resident 18 was not able to take any medications or food by mouth. LVN 6 further stated all the medications for Resident 18 had been given via GT. LVN 6 verified the multiple vitamins-minerals tablet was administered via GT during medication administration observation conducted earlier. LVN 6 verified the route for medication was incorrect for the multiple vitamins-minerals. LVN 6 stated the charge nurse was responsible in clarifying the order with the physician as well as informing the physician if the medication order was not appropriate for the condition of the resident. On 11/19/25 at 1530 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 2. Medical record review for Resident 29 was initiated on 9/23/25. Resident 29 was admitted to the facility on [DATE]. Review of Resident 29's MDS assessment dated [DATE], showed Resident 29 had severely impaired cognition and had the diagnosis of hypertension (high blood pressure). Review of Resident 29's Plan of Care showed a care plan problem dated 9/2/25, addressing Resident 29's altered cardiovascular status related to hypertension. The interventions included to administer the medications as ordered. Review of Resident 29's Order Summary Report for September 2025 showed a physician's order dated 9/2/25, to administer metoprolol (high blood pressure medication) 25 mg one tablet two times a day for hypertension; to hold the medication if the systolic blood pressure (SBP) was below 100 mmHg or the heart rate was below 60 beats per minute. Review of Resident 29's MAR for September 2025 showed the following licensed nurses' documentation for the administration of the metoprolol 25 mg one tablet two times a day, to hold if the SBP was less than 100 mmHg or the heart rate was less than 60 beats per minute: - on 9/3/25 at 1700 hours, the licensed nurse documented the BP was 108/69 mmHg and the heart rate was 93 beats per minute. The licensed nurse documented 12, - on 9/6/25 at 1700 hours, the licensed nurse documented the BP was 108/79 mmHg and the heart rate was 86 beats per minute. The licensed nurse documented 12, - on 9/12/25 at 0900 hours, the licensed nurse documented the BP was 108/76 mmHg and the heart rate was 78 beats per minute. The licensed nurse documented 12, - on 9/17/25 at 0900 hours, the licensed nurse documented the BP was 105/68 mmHg and the heart rate was 75 beats per minute. The licensed nurse documented 12, and - on 9/24/25 at 1700 hours, the licensed nurse documented the BP was 102/55 mmHg and the heart rate was 68 beats per minute. The licensed nurse documented 12. Further review of the MAR for September 2025 under Chart Codes showed 12= the BP below the set parameters. On 9/25/25 at 1152 hours, an interview and concurrent medical record review for Resident 29 was conducted with LVN 3. LVN 3 stated for the administration of the blood pressure medications, the resident's BP reading and heart rate were obtained and the medication administered to the resident if the BP reading and heart rate were within the ordered parameters. LVN 3 stated if the BP reading or heart rate were not within the ordered parameters, the BP medication would be held and documented in the MAR. LVN 3 reviewed Resident 29's medical record and verified the above findings. LVN 3 stated the blood pressure medications should have been administered to Resident 29 for the above dates and times. 3. Medical record review for Resident 85 was initiated on 9/23/25. Resident 85 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 85's MDS assessment dated [DATE], showed Resident 85 had severely impaired cognition. Review of Resident 85's Order Summary Report dated 9/29/25, showed a physician's order dated 9/1/25, to administer amlodipine (medication to treat high blood pressure) 2.5 mg one tablet by mouth two times a day for hypertension (high blood pressure); to hold if the blood pressure was less than 135 mmHg, per Resident 85's family member's request for concern of low BP. Review of Resident 85's MAR for September and October 2025 showed documentation the amlodipine medication 2.5 mg one tablet two times a day was administered to Resident 85 when the BP reading was outside of the ordered parameters: - on 9/13/25 at 0900 hours, the BP was 131/67 mmHg, - on 9/20/25 at 0900 hours, the BP was 131/89 mmHg, - on 10/11/25 at 0900 hours, the BP was 123/74 mmHg, - on 10/12/25 at 0900 hours, the BP was 130/70 mmHg, - on 10/13/25 at 09000 hours, the BP was 128/74 mmHg, - on 10/19/25 at 0900 hours, the BP was 106/64 mmHg, - on 10/20/25 at 0900 hours, the BP was 134/70 mmHg, - on 10/22/25 at 0900 hours, the BP was 126/78 mmHg, - on 10/25/25 at 0900 hours, the BP was 134/74 mmHg, - on 10/26/25 at 0900 hours, the BP was 128/74 mmHg, and - on 10/27/25 at 0900 hours, the BP was 127/74 mmHg. On 11/18/25 at 1357 hours, an interview and concurrent medical record review for Resident 85 was conducted with LVN 1. LVN 1 stated for the administration of the blood pressure medications, the licensed nurse should check the resident's BP prior to the administration of the BP medication. LVN 1 stated if the BP reading was within the ordered parameters, then the BP medication would be administered. LVN 1 further stated, if the BP reading was not within the ordered parameters, then the medication would be held. LVN 1 stated after the administration of the medication, the licensed nurses documented in the MAR and a check mark would show the medication was administered. LVN 1 reviewed Resident 85's medical record and verified the above findings. On 11/19/25 at 1015 hours, an interview was conducted with the DON. The DON stated the licensed nurses were responsible for the preparation and administration of the resident's medications as per the physician's orders. On 11/19/25 at 1430 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and P&P review, the facility failed to ensure the pharmacy recommendations for one of five final sampled residents (Resident 11) reviewed for unnecessary medications were followed through. * The facility failed to ensure Resident 11's physician was notified of the pharmacy recommendations to notify the physician of the resident's risk for bleeding on allopurinol (medication to lower excess uric acid levels in the blood) and aspirin (medication to treat pain, fever, and inflammation). This failure had the potential to cause negative outcomes for Resident 11. Findings: Review of the facility's P&P titled Medication (Drug) Regimen Review (MRR) revised 4/2025 showed the drug regimen of each resident will be reviewed at least once a month by a licensed pharmacist. The MRR is 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. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The report will be sent to the attending physician, the facility's medical director, and the DON to be acted upon. The P&P further showed communication and physician response will be documented in the clinical record, along with any new orders or changes to medication regimen. Medical record review for Resident 11 was initiated on 9/23/25. Resident 11 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 11 was discharged from the facility on 9/30/25. Review of Resident 11's Order Summary Report for showed a physician's orders dated 5/5/25, for allopurinol 100 mg to give two tablets by mouth one time a day for gout (a type of arthritis that causes severe join pain) and for aspirin EC (enteric coated) 81 mg give one tablet by mouth one time a day for CVA PPX (cerebrovascular accident prophylaxis). Further review of Resident 11's Order Summary Report for September 2025 failed to show documented evidence for monitoring of bleeding and bruising. Review of Resident 11's H&P examination dated 5/7/25, showed Resident 11 had no capacity to understand and make decisions. Review of Resident 11's facility document titled Consultant Pharmacist's MRR dated 8/21/25, showed Resident 11 had very low platelets (tiny, disc-shaped blood cells essential for blood clotting to stop bleeding) while on medications aspirin and allopurinol. Please ensure MD is aware of this level. Thrombocytopenia (medical condition characterized by low platelet count) side effects: Fever, chills, lightheadedness, N/V (nausea/vomiting). Please caution for bleeding and bruising as well. On 9/30/25 at 1345 hours, an interview and concurrent medical record review for Resident 11 was conducted with RN 1. RN 1 verified the above findings. RN 1 verified Resident 11's orders for the allopurinol and aspirin were still active orders. RN 1 stated she reviewed the pharmacy recommendations on 8/21/25, for Resident 11; however, she stated she did not document the resident's primary physician or hospice physician were notified of the pharmacy's recommendation. RN 1 also stated she should have received orders from the MD to monitor for bleeding and bruising as per Consultant Pharmacist's MRR recommendations. On 11/19/25 at 1510 hours, an interview was conducted with the Administrator, DON, Nurse Consultant, and Certified Dietary Manager. The Administrator, DON, Nurse Consultant, and Certified Dietary Manager acknowledged findings.

Based on observation, interviews, medical record review, and facility P&P review, the facility failed to ensure the residents' needs were accommodated in a timely manner for four of 27 final sampled residents (Residents 8, 14, 141, and 146) and one nonsampled resident (Resident 37). * The facility failed to ensure the call lights were promptly answered for Residents 8, 14, 37, 141, and 146 when the residents called for assistance from the staff. This failure placed the residents at risk for not receiving the assistance from staff to meet their needs and potentially compromise their safety and dignity.Findings: Review of the facility's P&P titled Call Light/Bell revised 5/2023 showed the facility staff should answer the light/bell within a reasonable time and respond to the resident's request. If the item is not available or you are unable to assist, explain to the resident and notify the-charge nurse for further instructions. 1. Medical record review for Resident 146 was initiated on 9/23/25. Resident 146 was admitted to the facility on [DATE]. Review of Resident 146's care plan dated 9/21/25, showed Resident 146 had bowel and bladder incontinence related to generalized weakness. The intervention included incontinent: Check as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. On 9/23/25 at 1000 hours, an observation and concurrent interview was conducted with Resident 146. Resident 146 was observed lying in bed, awake, alert, and verbally responsive. Resident 146 stated she had a bowel movement and had been waiting approximately 20 minutes for a diaper change. Resident 146 mentioned a staff member entered the room and turned off the call light, but she did not know who the staff member was. Resident 146 was watching the clock to track how long she had been waiting and expressed feeling upset about the delay. Resident 146 also stated at times she has waited more than 45 minutes to receive assistance for diaper changes or other needs. Resident 146 turned the call light on again. On 09/23/25 at 1015 hours, an interview was conducted with LVN 4. LVN 4 stated CNA 5 who was assigned to the patient, was still busy assisting another resident with a shower. The CNA also reported having a headache and requested a break. LVN 4 stated they would look for another staff member to help. On 09/23/2025 at 1025 hours, CNA 5 went to the room of Resident 146 and provided assistance to Resident 146. On 9/23/2025 at 1300 hours, Resident 146 stated that she had been waiting for almost 40 minutes for assistance with a diaper change. On 9/23/2025 at 1440 hours, an interview was conducted with CNA 5. CNA 5 stated that she was busy and had to give a shower to another resident. One resident's shower might take 30 to 45 minutes, including dressing and bathing. CNA 5 stated after she finished showering the other resident, she returned to assist Resident 146 with a diaper change. Resident 146 required assistance with a diaper change. 2. On 9/23/25 at 0933 hours, during the initial tour of the facility, Resident 8 was observed awake in her room. Resident 8 stated she had to wait for more than an hour for the call light to be answered whenever she called for repositioning or to fix the bed sheets. Resident 8 further stated she knew how long she waited because she pressed the call light at the same time as her roommates, Residents 14 and 37. Medical record review for Resident 8 was initiated on 9/23/25. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 8/14/25, showed Resident 8 had the capacity to understand and make decisions. Review of Resident 8's MDS assessment dated [DATE], showed Resident 8 was dependent from the staff for ADL care and mobility. On 9/26/25 at 1345 hours, an observation and concurrent interview was conducted with Resident 8. Resident 8 was observed awake and sitting in the wheelchair. Resident 8 stated the facility staff put her on the wrong incontinence pad, the bed was placed wrong, and the sheet was sliding down. Resident 8 stated she pressed the call light because she wanted to be readjusted since she had a wound on her buttock. Resident 8 stated her bed moved because she had a LAL (Low Air Loss-mattress designed to prevent and treat pressure injuries) mattress, she got over the pad, and the sheet was already down to her feet. Resident 8 stated she felt terrible because the facility staff took at least an hour and a half to answer the call light. Resident 8 further stated she called at the same time as her roommate and that was how she knew how long before the facility staff answered their call lights. 3. On 9/26/25 at 1345 hours, an observation and concurrent interview was conducted with Resident 14. Resident 14 was observed awake in her room. Resident 14 stated last night, she and her roommates, Residents 8 and 37, hit the call light button at the same time but no one was coming so they started yelling one at a time. Resident 14 stated she needed her pain medication at 1900 hours. Resident 14 stated she knew it was 1900 hours because she was watching TV, and all her roommates also pressed the call light button at the same time as hers. Resident 14 stated she felt like she was not worth any attention and angry about the call light waiting time. Resident 14 further stated the facility staff told them they had a lot of residents. Medical record review for Resident 14 was initiated on 9/23/25. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's H&P examination dated 9/18/25, showed Resident 14 was alert and oriented times four (person, place, time, and situation). Review of Resident 14's MDS assessment dated [DATE], showed Resident 14 needed substantial/maximal assistance from the staff with ADL care and mobility. 4. On 9/26/25 at 1345 hours, an observation and concurrent interview was conducted with Resident 37. Resident 37 was observed awake in her room. Resident 37 stated last night she waited for over an hour for the call light to be answered at 1900 hours. Resident 37 stated she even called the front desk. Resident 37 stated she was looking at the clock in her room for the time. Resident 37 further stated she did not feel good about waiting so long. Medical record review for Resident 37 was initiated on 9/23/25. Resident 37 was admitted to the facility on [DATE]. Review of Resident 37's H&P examination dated 9/16/25, showed Resident 37 had the capacity to make medical decisions. Review of Resident 37's MDS assessment dated [DATE], showed Resident 37 needed substantial/maximal assistance from the staff with ADL care and mobility. 5. On 9/23/25 at 0933 hours, during the initial tour of the facility, Resident 141 was observed awake in her room. Resident 141 stated she used the call light and the last time was over the weekend, on Saturday night when she asked to be changed at 2230 hours. Resident 141 stated she did not get changed until the following morning at 0600 hours. Resident 141 stated she used the clock to check the time. Resident 141 stated she started crying because she felt nasty, useless, and not worth anything. Resident 141 further stated she had complained about the call light not being answered right away all the time to the facility staff. Medical record review for Resident 141 was initiated on 9/23/25. Resident 141 was admitted to the facility on [DATE]. Review of Resident 141's H&P examination dated 7/13/25, showed Resident 141 had the capacity to understand and make medical decisions. Review of Resident 141's MDS assessment dated [DATE], showed Resident 141 needed partial/moderate assistance from the staff with ADL care and substantial/maximal assistance with mobility. On 11/19/25 at 1530 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure one of two sampled residents (Resident 1) remained free from accident hazards. * The CNA improperly positioned Resident 1 on the side of the bed with a low air loss mattress (LALM, a mattress used for prevention or treatment of skin breakdown) while independently providing incontinence care to Resident 1. Resident 1 subsequently fell off the LALM onto the floor and sustained a cervical fracture (a bone is broken in the neck of the spine). * Resident 1's Fall Risk care plan showed an intervention for the implementation of bilateral floor mats. When Resident 1 fell off the LALM onto the floor and sustained a cervical fracture, the bilateral floor mats were not in place. * Before the fall in which Resident 1 sustained a cervical fracture, Resident 1 had a prior fall at the facility from the bed with the LALM. As a result of the facility's fall investigation for Resident 1's initial fall, the facility identified the use of a LALM as a risk for falls for Resident 1 and subsequently discontinued the LALM. When the facility reconstituted a LALM for use by Resident 1, the facility failed to implement the measures/interventions to reduce Resident 1's risk for another fall from the bed with the LALM. After the facility reinstituted the bed with the LALM, Resident 1 sustained another fall, at which time she suffered a cervical fracture. * After Resident 1's initial fall at the facility from the bed with the LALM, the facility conducted a Post Fall Evaluation which showed the nursing intervention (to be implemented in Resident 1's care plan) to provide Resident 1 with two-staff assistance. Review of Resident 1's care plans failed to show any revisions were made for the nursing interventions to provide two-staff assistance. These failures resulted in Resident 1's fall in which Resident 1 sustained a cervical fracture. Findings: Review of the facility's P&P titled Resident Centered Fall Prevention Plan revised 10/24/19, showed a fall risk screening is completed for all residents to identify current or future fall risk. An individualized fall prevention program is implemented for each resident to ensure the safest environment possible. After review of the fall risk evaluation is completed the care plan is developed as appropriate. Review of the facility's P&P titled Post Fall Assessment revised 10/24/20, showed all residents will be assessed immediately who fall, to identify causative factors that may be related to the fall. Upon this assessment, actions will be taken to decrease the potential for future falls. Review of the facility's P&P titled Comprehensive Care Plans revised 10/28/20, showed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. Medical record review for Resident 1 was initiated on 5/25/21. Resident 1 was admitted to the facility on [DATE]. On 6/15/21 at 1149 hours, a telephone interview and concurrent facility document review was conducted with the DON. Review of the facility's Occurrence Report dated 4/23/19, showed on 4/23/19, Resident 1 fell from her bed with the LALM onto the floor. Resident 1 was observed sitting on a floor mat with her back leaning on the bed. Resident 1 was unable to state how the fall had occurred due to impaired cognition associated with her diagnosis of dementia. The DON stated Resident 1 had a behavioral history of sitting on the edge of the LALM and sliding onto the floor, as the LALM cover sheet fabric was slippery. The facility's Occurrence Report dated 4/23/19, showed after Resident 1's fall from the bed with the LALM, the facility recommended to discontinue the LALM due to the slippery cover sheets. The DON verified Resident 1's LALM was discontinued after Resident 1 fell from her LALM bed on 4/23/19. Review of Resident 1's Post Fall Evaluation dated 4/24/19, showed the nursing interventions in Resident 1's care plan included two-staff assistance. Review of Resident 1's plan of care showed a care plan problem initiated 12/6/16, addressing the resident's self-care deficits. The interventions included one to two person total assist with bed mobility, with the effective date of 12/30/16. Review of Resident 1's plan of care failed to show any revisions were made on 4/24/19, after the post fall evaluation was conducted for the nursing interventions to show two-staff assistance. The DON verified the findings. The DON was then asked if the need for two-staff assistance (as specified in Post Fall Evaluation dated 4/24/19) referred to the level of staff assistance required for Resident 1 for bed mobility. The DON stated she was uncertain as no revisions were made to Resident 1's care plan for bed mobility after Resident 1 fell on [DATE]. Review of the physician's order dated 1/8/21, showed the facility reinstituted a bed with a LALM for Resident 1's skin management. Review of Resident 1's plan of care failed to show the interventions to reduce Resident 1's identified fall risks associated with the use of a LALM. On 6/9/21 at 1101 hours, a telephone interview and concurrent medical record review was conducted with the DON. The DON verified a LALM was reinstituted for Resident 1 on 1/8/21. The DON was asked if Resident 1 was at risk for falls from a LALM due to Resident 1 had previously fell from a LALM on 4/26/19. The DON stated Resident 1 was at risk for another fall from a LALM due to Resident 1's prior fall from a LALM on 4/26/19, and Resident 1's past behavior of sliding off the LALM onto the floor. The DON was asked what interventions were implemented by the facility when Resident 1's LALM was reinstituted on 1/8/21, in order to reduce Resident 1's identified fall risk associated with the use of LALM. The DON stated the interventions would include ensuring Resident 1 to be positioned in the center of the LALM when one staff member was providing care to Resident 1. The DON stated positioning Resident 1's body weight on the side of the LALM (versus the center) could cause the mattress to collapse resulting in Resident 1 falling onto the floor, or result in Resident 1 slipping off the mattress onto the floor. The DON stated an additional intervention was to ensure the facility staff first pulled Resident 1 toward the staff before turning Resident 1 onto her side to ensure Resident 1 once turned was positioned in the center of the bed rather than on the side of the bed. The DON stated when Resident 1's LALM was reinstituted on 1/8/21, the interventions the DON described to reduce the risk of another fall from a LALM would be documented on Resident 1's care plans. The DON reviewed Resident 1's care plans from 1/8/21 (date LALM reinstituted) through 5/14/21, (date of Resident 1's fall from LALM, with fracture) and verified Resident 1's care plans failed to show the interventions the DON described were implemented. The DON was asked if these interventions had been implemented by CNA 1, Resident 1's fall on 5/14/21, could have been avoided, to which she replied yes. Review of Resident 1's plan of care showed a care plan problem dated 12/6/16, addressing Resident 1's risk for falls as evidenced by dementia, muscle weakness, and poor safety awareness. The interventions included to apply the bilateral floor mats, effective 2/3/19. Review of Resident 1's MDS dated [DATE], showed Resident 1 had severely impaired cognition and required extensive two-person physical assistance with bed mobility. Review of Resident 1's Physical Therapy Treatment Encounter Notes dated 4/30/21, showed after approximately 10 minutes of sitting on edge of bed, Resident 1 started sliding and due to the LALM, Resident 1 was high risk for sliding off the bed. Review of Resident 1's Physical Therapy Progress Report dated 5/10/21, showed the precautions included risk for falls. Resident 1 was assessed to have the following impairments: decreased functional capacity, deficits in judgement, decreased static balance, strength impairments, safety awareness deficits, and body awareness deficits. Review of Resident 1's Physical Therapy Treatment Encounter Notes dated 5/14/21, showed Resident 1 was totally dependent on staff for bed mobility without attempts to initiate. Review of Resident 1's Psychotherapy Note dated 3/5/21, showed Resident 1 had a diagnosis of dementia with severe cognitive decline. Review of Resident 1's Fall Risk evaluation dated 3/12/21, showed Resident 1's risk factors for falls included impaired mobility, poor vision, impaired cognition, and diminished safety awareness. The Fall Risk evaluation showed if Resident 1 had at least one fall risk factor, to ensure a fall care plan was in place. Review of the LALM User Manual (undated) for Resident 1's LALM showed the following warning: when using therapy mattress system, always ensure that the resident is positioned properly within the confines of the bed. The resident's head should be positioned in the center of the top section of the therapy mattress. Review of Resident 1's Clinical Notes completed by LVN 1 dated 5/14/21 at 1627 hours, showed Resident 1 fell from her bed with a LALM onto the floor on 5/14/21. Resident 1 was observed on the floor and sustained a laceration to her forehead, which measured 2.5 cm (length) x 0.5 cm (width). Resident 1's physician was notified of the fall and Resident 1 was then transferred to Acute Care Hospital 1 for further evaluation. Review of Resident 1's medical record from Acute Care Hospital 1 showed a CT scan of Resident 1's Cervical Spine was performed on 5/14/21. The results of the CT scan showed Resident 1 sustained an acute type II odontoid fracture (cervical spine fracture). On 5/25/21 at 1053 hours, an observation was conducted of Resident 1. Resident 1 was observed lying in her bed with a cervical collar immobilization device placed around her neck. Resident 1 was also observed with a bandage on her forehead. Resident 1 was nonverbal. On 5/25/21 at 1331 hours, an interview was conducted with CNA 2. CNA 2 stated he witnessed Resident 1 lying on the floor after having fallen out of bed on 5/14/21. CNA 2 stated on 5/14/21, CNA 2 heard CNA 1 calling for assistance after Resident 1 had fallen out of bed onto the floor. CNA 2 stated he observed Resident 1 with a cut and bump on her forehead. CNA 2 stated there were no floor mats in place at the time of Resident 1's fall. On 5/25/21 at 1351 hours, an interview was conducted with LVN 1. LVN 1 was assigned to care for Resident 1 on 5/14/21, during the time Resident 1 fell from her bed with a LALM. LVN 1 was asked to describe the circumstances regarding Resident 1's fall. LVN 1 stated she heard CNA 1 call for help, at which time LVN 1 entered Resident 1's room and saw Resident 1 lying face up on the floor. LVN 1 stated she observed Resident 1 bleeding from a laceration on her forehead. LVN 1 stated Resident 1 fell from the bed while CNA 1 was independently providing care to Resident 1. LVN 1 stated CNA 1 was changing Resident 1's adult brief and Resident 1 fell out of bed onto the floor. LVN 1 stated there were no floor mats (as per Resident 1's active care plans) in place adjacent to Resident 1's bed at the time of the fall. LVN 1 stated Resident 1's fall on 5/14/21, was the first time Resident 1 sustained a fall at the facility, and the floor mats were implemented after Resident 1's fall on 5/14/21. On 5/25/21 at 1418 hours, a follow-up interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 1's active care plan problem titled Fall Risk effective on 12/6/16, showed Resident 1 was at risk for falls (as evidenced by muscle weakness, dementia, and poor safety awareness). Resident 1's Fall Risk care plan showed an intervention for bilateral floor mats, effective as of 2/3/19. LVN 1 verified the findings and stated Resident 1 should have had the floor mats in place at the time of her fall on 5/14/21. On 5/25/21 at 1645 hours, an interview was conducted with CNA 3. CNA 3 was asked to describe the technique she utilized to turn Resident 1 on her LALM bed when providing care to Resident 1 independently. CNA 3 stated first she would ensure Resident 1 was lying on her back, then pulled Resident 1 toward her before turning Resident 1 onto her side, to ensure Resident 1 was positioned in the center of the bed once turned onto her side. CNA 3 stated once turned, if Resident 1 was improperly positioned on the side of the LALM, Resident 1's weight would cause the LALM to shift, potentially resulting in Resident 1 slipping off the mattress and falling onto the floor. On 5/27/21 at 1226 hours, an interview and concurrent facility document review was conducted with RN 1. RN 1 verified she conducted the facility's investigation of Resident 1's fall from her bed with a LALM on 5/14/21. RN 1 documented her investigative findings on the facility's Occurrence Report dated 5/19/21. RN 1 stated she conducted an interview with CNA 1 to determine causal and contributing factors regarding Resident 1's fall. CNA 1 stated the following to RN 1: on 5/14/21, CNA 1 was changing Resident 1's disposable brief and soiled draw sheet. CNA 1 had raised Resident 1's bed waist high to protect CNA 1's back. Resident 1 was turned onto her right side and when CNA 1 was about to tuck in a clean draw sheet, Resident 1 slid off the bed onto the floor. Resident 1 was positioned on a LALM which had a slippery cover sheet, CNA 1 attempted to stop Resident 1 from rolling off the bed; however, due to Resident 1's weight and Resident 1 being positioned on the edge of the LALM, CNA 1 was unable to prevent Resident 1 from rolling off the bed. Resident 1 sustained a left forehead laceration and acute type II odontoid fracture. RN 1 stated CNA 1 verified no fall mats were in place at the time of Resident 1's fall. Review of the facility's Verification of Investigation dated 5/19/21, showed the causal and contributing factors to Resident 1's fall on 5/14/21, included Resident 1's slippery LALM and Resident 1 being positioned on the edge of the bed by CNA 1, which caused Resident 1 to roll off the bed onto the floor. RN 1 stated CNA 1's technique contributed to Resident 1's fall on 5/14/21. RN 1 stated CNA 1 was re-educated by the facility to ensure Resident 1 was first pulled closer to (CNA 1) when being turned in bed, in order to prevent Resident 1's weight being placed at the edge of the LALM. On 6/9/21 at 1101 hours, a telephone interview and concurrent facility document review was conducted with the DON. Review of the Facility's Verification of Investigation dated 5/19/21, showed the following causal/contributing factors: Resident 1 had a slippery LALM and the weight of Resident 1 was placed at the edge of the bed, that caused Resident 1 to roll off the bed onto the floor. The DON verified the Facility's Verification of Investigation findings dated 5/19/21. The DON was asked her belief as to the cause of Resident 1's fall on 5/14/21. The DON stated CNA 1 demonstrated poor technique when CNA 1 turned Resident 1. The DON stated CNA 1 was not a full-time staff member and was contracted by the facility as needed. The DON was asked if CNA 1 received education from the facility on how to properly position the residents on a LALM, or received education regarding Resident 1's risk for falls from a LALM, to which the DON replied, no not specifically. The DON was asked if Resident 1's fall on 5/14/21, could have been avoided had Resident 1 been properly positioned in the center of the LALM, rather than on the side of the LALM, to which the DON replied yes. The DON was asked if Resident 1's fall mats had been in place (as per Resident 1's fall risk care plan, 2/3/19) at the time of Resident 1's fall on 5/14/21, could the fall mats have mitigated the risk of Resident 1 sustaining a cervical fracture. The DON stated had the falls mats been in place, they could have mitigated the risk of injury to Resident 1.

Based on interview and clinical record review, the facility failed to ensure one of three sampled residents (Resident 1) was allowed to refuse treatment. Resident 1 stated she was forced to have a medicated skin cream applied to her entire body. When the resident tried to object, the CNA performing the treatment ignored the resident and continued with the procedure. Resident 1 was frightened and angry by what happened and felt she had no choice but to comply with the procedure. Findings: A telephone interview with Resident 1's family member was initiated on 7/13/11 at 0830 hours. The family member stated a CNA at the facility tried to apply a cream to the resident's entire body about a week ago. Resident 1 has serious skin allergies and tried to stop CNA 1, but the CNA continued and tried to hold the resident down. Resident 1 told the CNA she had the right to refuse treatment, but the CNA ignored her protests and did not stop the procedure. The family member stated Resident 1 was very scared by the incident. After the CNA finished applying the cream to the resident's entire body, the CNA "stormed out of the room." Clinical record review for Resident 1 was initiated on 7/14/11. Review of the MDS dated [DATE], showed Resident 1's BIMS (brief interview for mental status) score was 14 (a score denoting good cognition and memory). An interview with Resident 1 was initiated on 7/14/11 at 1015 hours. Resident 1 stated she had severe skin allergies and was concerned when CNA 1 wanted to apply a medicated cream. Resident 1 stated CNA 1 made her stand up against the wall and began forcefully applying the medicated cream to her entire body. The resident said the CNA was standing very close to her and she was trapped by the CNA. Resident 1 asked the CNA to stop the treatment, but the CNA continued without speaking to her. Resident 1 stated she told the CNA she had the right to refuse treatment, but the CNA ignored her and continued. The CNA acted as though she could not understand English. Resident 1 stated she was scared and didn't like it. The resident said the CNA was much stronger than she was and she had no other options but to comply with the treatment. An interview with MSW 1 was initiated on 7/14/11 at 1100 hours. The MSW was asked about the incident. MSW 1 stated she and LVN 1 were informed what happened to Resident 1 after the incident and went to talk to the resident. MSW 1 stated she was trying to calm the resident and apologized for what happened. MSW 1 was asked if she thought the CNA should have stopped the treatment to Resident 1. She stated, yes. MSW 1 was asked if she informed anyone at the facility about the incident. She stated she told LVN 1. An interview with LVN 1 was initiated on 7/14/11 at 1105 hours. LVN 1 stated on 6/30/11, Resident 1 was given a treatment with a medicated cream over her entire body. After the treatment, both she and MSW 1 visited Resident 1 when hearing how upset the resident was. LVN 1 confirmed that Resident 1 stated the CNA was forceful and the resident told her to stop the treatment. LVN 1 was asked if she made a report to the DON or Executive Director about the incident. She stated, no. An interview with CNA 1 was initiated on 7/18/11 at 1445 hours. CNA 1 stated she applied the cream to Resident 1 a few weeks ago. She stated the resident was concerned about her applying the cream to her face, so the CNA did not apply the cream to the resident's face. The CNA stated, after that, the resident did not object to the treatment. CNA 1 stated, while she was applying the cream to the resident, the resident was seated in the wheelchair, but had to stand up so the cream could be applied to the resident's back. CNA 1 stated she did not know there was a problem with the cream application until the next day when the charge nurse spoke to her about the issue. She stated, the day after that, LVN 1 also talked to her about the issue. CNA 1 stated, if the resident would have asked her to stop, she would have complied.

Based on interview and clinical record review, the facility failed to provide sufficient fluid intake to maintain adequate hydration for Resident 1. Resident 1 had a history of [REDACTED]. The facility failed to continuously assessed and evaluate Resident 1's hydration status, develop a resident specific plan of care to ensure the resident consumed adequate fluid intake as assessed by the RD to maintain hydration and failed to initiate the facility's P&P on intake and output (I&O) to ensure the resident met the daily fluid intake needs. Twenty one days after readmission, Resident 1 was readmitted to the acute care hospital due to altered mental status, septic shock with hypovolemia (a decrease in blood volume which may be caused by dehydration), [MEDICAL CONDITION] (elevated sodium) and acute [MEDICAL CONDITION] (rapid loss of kidney function associated with dehydration). Findings: Closed clinical record review for Resident 1 was initiated on 6/28/11. The resident's clinical record showed an admitted to the facility of 6/18/08, and a transfer date to the acute hospital care on 5/21/11. The facility's discharge summary sheet from 6/11/08 to 5/21/11, showed admitting and discharge [DIAGNOSES REDACTED]. Review of the acute hospital admission history and physical dated 5/21/11, showed Resident 1's evaluation in the ER revealed elevated WBCs in the urine, elevated sodium and potasium, and a negative CT scan of the brain. The history and physical showed a chief complaint of altered mental status, dehydration and [MEDICAL CONDITION]. Resident 1 was readmitted to the facility on [DATE]. The laboratory results upon discharge from the acute hospital on [DATE], showed sodium 144 mmol/L (normal 137-145); Chloride 111 mmol/L (normal 98-111); BUN 8 mg/dL (normal 7-17); Creatinine 0.90 mg/dL (normal 0.52-1.04); Calcium 8.2 mg/dL (normal 8.4-10.2); and WBC 7.9 K/mcL (normal 3.8-10.8). On 6/16/11, the resident was readmitted to the acute hospital for acute septic shock from acute urinary tract infection, acute severe dehydration, and [MEDICAL CONDITION]. According to the U.S. National Library of Medicine and the National Institute of Health website: www.nlm.nih.gov/medlineplus/ency/article/ 2.htm <http://www.nlm.nih.gov/medlineplus/ency/article/ 2.htm>, dehydration can be caused by losing too much fluid, not drinking enough fluid, or both. The elderly and those with illnesses are also at higher risk. Blood tests which may be elevated with dehydration include blood urea nitrogen (BUN, used to check the amount of urea nitrogen in the blood) and Creatinine (Cr). Prevention of dehydration includes drinking plenty of fluids every day. To prevent dehydration, carefully monitor someone who is ill, especially an infant, child or older adult. Review of the MDSs for Resident 1 dated 3/22/11 and 5/3/11, identified the resident with cognitive impairment, requiring extensive to total assistance with ADLs. The MDSs identified the resident required one person's physical assistance with feeding. Review of the physician's admission orders [REDACTED]. The physician's order dated 5/26/11, showed an order for [REDACTED]. Review of the comprehensive care plan problems developed from 5/26/11 to 6/9/11, identified Resident 1 is at risk for aspiration (fluids/food going into the lungs) due to dysphagia (difficulty swallowing), at risk of weight loss, pain, low hematocrit and hemoglobin (indicators of [MEDICAL CONDITION]), fall, skin breakdown, has alteration in ADLs, impaired cognition, potential for bleeding, and continence in bowel and bladder. The approaches to address these care plan problems included to provide the diet as ordered, offer fluids as preferred, provide supplements and nourishments, fluids per physician's order, and encourage intake. There was no physician's order for the resident's fluid intake. There was no documentation showing how the resident is encourage for fluid intake. There was no documentation showing a plan of care was developed for the resident to address their hydration needs and urosepsis. Review of the facility's P&P titled Intake and Output (I&O) showed, upon identification the resident is at risk for dehydration based on their medical condition, Intake and Output will be initiated. The P&P showed residents presenting with dehydration signs and symptoms may be started on I&O as a nursing measure. On 6/28/11 at 1428 hours, an interview with CNA 2 was conducted. The CNA stated, since readmission of Resident 1 to the facility on [DATE], the resident required assistance in feeding. The CNA stated she had to hold the cup for the resident to drink fluids. The CNA stated the resident was totally dependent in feeding. When asked how much fluid the resident consumed daily, the CNA was not able to specify. Review of the CNA ADL Flow Sheet from 6/1/11 to 6/16/11, showed Resident 1 had a decrease in food intake from 90% to 5% or nothing. The flowsheet showed the resident had been refusing the substitutes offered. On 6/28/11 at 1527 hours, an interview with LVN 2 was conducted. The LVN stated Resident 1's hydration was addressed in the the plan of care with the approach of liquids per physician's order and to encourage fluid. The LVN was not able to find the goal set to address Resident 1's hydration, the amount of fluid intake for the resident, the provision of assistance in hydration and other interventions to address the resident's hydration needs. The LVN stated, when the resident's oral intake is low, substitutes will be provided. When asked about the intervention provided when the resident refused the substitutes, the LVN was not able to verbalize. The LVN was not able to show documentation of continuous monitoring of the resident's hydration status. On 6/28/11 at 1535 hours, an interview with RN 1 was conducted. The RN stated I&O should be initiated automatically by the admitting nurse once a resident is identified at risk for dehydration or with [DIAGNOSES REDACTED]. LVN 2, who was present, stated the I&O was not done. Review of the Nutritional Assessment Form dated 6/1/11, completed by the RD showed the estimated needs for daily fluid intake of Resident 1 was from 1,425 ml to 1,710 ml per day. There was no documented evidence the recommended fluid intake by the RD was in the resident's plan of care to ensure the resident received adequate hydration. Review of the Nutritional Progress Notes dated 6/14/11, completed by the RD, showed Resident 1 had 10% to 30% oral intake. The notes showed the RD was informed of Resident 1's spitting out food and liquids, and refusing meals. The RD notes showed the resident's poor oral intake was due to disease process, advanced age, and weight loss is expected. There was no documentation showing the RD had addressed the resident's hydration. On 7/1/11 at 0837 hours, the RD stated Resident 1 had poor oral intake. The RD stated she relied on nursing to alert her of a resident's change of condition. The RD stated she did not address the fluid intake since Resident 1 is at risk for aspiration. The RD acknowledged she should have addressed the hydration of Resident 1. Further review of the clinical record showed on 6/16/11 at 1100 hours, the physician's order showed to transfer Resident 1 to the acute care hospital via 911 secondary to unresponsiveness and decrease in oxygen saturation (the amount of oxygen circulating in the blood). The resident was in the facility for 21 days since readmission from the acute hospital on [DATE]. Review of the acute hospital Physician Documentation dated 6/16/11, showed Resident 1 was admitted with altered mental status and decrease in respirations. The vital signs obtained in the acute hospital showed a blood pressure of 75/46, and a heart rate of 111 beats per minute. The Merck Manual fourteenth edition (reference designed to meet the needs of general practitioners in the medical field), showed common signs and symptoms associated with hypovolemic shock include lethargy (sluggish), confusion, and somnolence (sleepiness). The manual showed additional signs and symptoms include rapid and weak heart rate and low or unobtainable blood pressure. The manual showed the mortality rate in elderly patients remains extremely high. Review of Resident 1's laboratory test results in theER on [DATE], showed Resident 1's BUN was 79; Creatinine was 6.10; Sodium 169 mmol/L; and Chlorine was 130 mmol/L. In addition the WBC was 22.2 K/mcL. The resident was administered an IV a [MEDICATION NAME] of normal saline 2,000 ml; [MEDICATION NAME] IV push; multiple IV antibiotics ([MEDICATION NAME], and [MEDICATION NAME]); and [MEDICATION NAME] ([MEDICATION NAME] used for treatment of [REDACTED]. The ER physician diagnosed Resident 1 with septic shock, urinary tract infection, hypovolemia with acute [MEDICAL CONDITION] due to prerenal azotemia (abnormally high level of nitrogen waste in the blood due to dehydration), and [MEDICAL CONDITION]. After multiple aggressive IV hydration, triple IV antibiotics and [MEDICATION NAME] drip, Resident 1 was admitted to the Intensive Care Unit.

Based on interview and clinical record review, the facility failed to adequately supervise two of three residents (Residents 2 and 3) to prevent accidents and elopement. Resident 2 has a history of multiple falls. Resident 2 had been identified to have cognitive impairment, requiring supervision. Resident 2 was not being supervised when she removed her self release seat belt and her personal alarm while sitting in a wheelchair. She stood up and fell , sustaining a hip fracture. In addition Resident 2, identified as a high risk for elopement, was inadequately supervised and was found on the sidewalk outside of the facility. The staff was not inserviced on the proper use of a specialized wheelchair for Resident 3, resulting in a fall. Findings: 1a. Clinical record review for Resident 2 was initiated on 12/29/10. Resident 2 was admitted to the facility on [DATE]. An MDS dated [DATE], showed Resident 2 has short and long term memory impairment with moderate cognitive impairment, requiring cues and supervision. Review of Resident 2's Fall RAP Summary dated 4/19/10, showed the resident has a history of having multiple falls in the past 31-180 days. Resident 2's interventions include a low bed, floor mats, and a personal alarm in bed and the chair. Review of Resident 2's MDS dated [DATE], showed the resident had four falls since admission to the facility: two with no injuries, one with minor injuries and one with a major injury. Review of Resident 2's Fall Assessments showed on 4/19/10, a score of 16, on 7/20/10, a score of 18, on 10/14/10, a score of 18 and on 12/3/10, a score of 23 (a score of 10 or above indicates a risk of falling). Review of Resident 2's Interdisciplinary Team Progress Notes showed, on 6/19/10 at 1900 hours, the resident got up from the wheelchair, lost her balance and fell . Review of the Post Fall assessment dated [DATE], showed to continue the use of a personal alarm and a low bed. Review of an Interdisciplinary Team Progress Note dated 7/21/10, showed Resident 2's alarm sounded. Staff noted the resident lying face down on the floor; sustained a right eye laceration measuring 3 cm by 2.5 cm, a right elbow skin tear measuring 0.3 cm by 0.3 cm, and complained of left wrist pain. She was evaluated in the emergency room and was diagnosed with [REDACTED]. Review of the Post Fall Assessment Form (undated) showed Resident 2's fall occurred on 7/20/10. The documentation showed, on 7/20/10 at 1645 hours, the personal alarm sounded, the resident stood up and fell . She sustained a deep laceration above her right eye, right elbow skin tear and a fractured left wrist. The recommendation was to move the resident to a room closer to the nurses' station, use a personal alarm, a bed alarm and a self release seat belt in the wheelchair. Review of the Interdisciplinary Team Progress Note dated 8/24/10, showed, on 8/20/10 at 1530 hours, the resident was observed on the floor; part of her body on the floor mat. Review of the Post Fall Assessment (undated) showed Resident 2's fall occurred on 8/20/10 at 1530 hours. The interdisciplinary team's recommendation was for a low bed, bilateral floor mats and a sensor alarm in bed. Review of the care plan showed a short term care plan problem dated 8/20/10, to address an actual fall. The interventions include the use of a low bed with floor pads, a sensor pad alarm, and "frequent visual checks." A revised care plan problem dated 9/11/10, addressed Resident 2's risk for fall or injury related to standing up unassisted. The approach plan included a low bed with soft mats for safety, personal alarm in bed and in the wheelchair, self release wheelchair belt (an update dated 7/21/10), invite/assist for daily activities of her choice, check at least every "2 hours" to ensure safety, anticipate all needs and a bed sensor pad alarm in bed (an update dated 8/27/10). Review of the Interdisciplinary Team Progress Note dated 12/6/10, showed on 12/3/10 at 1230 hours, Resident 2's personal alarm sounded from her room. The resident was observed sitting on the wheelchair footrests. Documentation also showed Resident 2 stated she released her self release seat belt in the wheelchair and slid down. The resident sustained [REDACTED]. Review of the Post Fall assessment dated [DATE], showed the recommendation to use a chair alarm and a nonskid pad in the wheelchair. Review of the care plan showed the care plan problem to address the risk for falls was updated on 12/3/10, to show the resident was able to release the self release seat belt. There was no revision to address the resident's need for supervision in light of the fact, she could remove the self release seat belt in the wheelchair. Review of Resident 2's Licensed Personnel Progress Notes dated 12/23/10 at 1700 hours, showed a staff member heard Resident 2 groaning and noticed her lying on the floor on her right side in the hallway. Her self release belt and personal alarm remained attached to the wheelchair. Resident 2 complained of left hip pain, an x-ray was obtained, showing she sustained a fractured left hip. Review of a Witness Report from CNA 3 dated 12/23/10 showed the CNA had assisted Resident 2 to the bathroom at 1600 hours. After she was finished, she transferred the resident back to the Wheelchair and applied her self release seat belt and wheeled the resident to the Station 4 TV room entrance and applied the brakes. Review of the Witness Report dated 12/23/10, showed LVN 2 documented on 12/23/10 at 1700 hours, she was in the Station 4 nurses' station when she heard Resident 2 groaning. LVN 2 looked up and saw Resident 2 lying on the floor on her right side in the hallway in front of room 421. During an interview on 12/29/10 at 1350 hours, the DON stated, if a resident is identified as being a high risk for falls, the resident should have a low bed, floor mats, sensor alarms, lap buddy or pummel cushion. She stated, if the resident continued to fall, and the interventions were ineffective, then the resident should have a non-release seat belt or a 1:1 sitter. The DON stated Resident 2 did not have a non-release seat belt or a 1:1 sitter. On 1/21/11 at 1415 hours, LVN 2 was interviewed by telephone. LVN 2 stated she remembered on 12/23/10, when Resident 2 fell , she (LVN 2) was in the middle of the nurses' station working on paperwork. She stated there were a lot of people in the station. She headed towards the fax machine, heard groaning, looked over another nurse's shoulder and saw Resident 2 on the floor. When asked if Resident 2 had her seat belt on, LVN 2 stated she couldn't remember. When asked if the resident's personal alarm sounded, LVN 2 stated she probably would have documented if the alarm was off. Review of a type written Interdisciplinary Team Note dated 12/24/10, showed a conclusion that the resident removed the self release wheelchair belt and disconnected her personal alarm, stood up, walked a few steps and lost her balance. b. Review of the facility's P&P titled "Elopement Risk Assessment" dated 4/10, showed all residents will be assessed for elopement, and forms completed upon admission and quarterly. A resident found at risk for elopement would have a care plan developed. Review of Resident 2's Interdisciplinary Team Progress Notes dated 12/3/10, showed on 11/29/10 at 1230 hours, an unidentified man passing by the facility's front door saw Resident 2 wheeling herself toward the street (the front door to the facility is on a major, heavily traveled city street). The man entered the facility and notified the staff of Resident 2 being unsupervised outside the facility. Review of Resident 2's Witness Report dated 11/29/10, showed an unidentified stranger had entered the facility, stopped at the receptionist's desk and notified the staff a resident was outside of the facility. The DSD went outside and observed Resident 2 wheeling herself down the sidewalk, along side the busy street. Review of Resident 2's Elopement Risk Evaluation dated 7/13/10, showed she wanders, seeking family, and has a history of leaving the facility without supervision or informing the staff. No care plan problem to address her risk of elopement was available in Resident 2's active clinical record. Later, a care plan problem dated 7/22/09, to address the resident's risk of elopement related to being observed sitting outside in front of the facility was found in Resident 2's thinned record. During an interview on 12/29/10 at 1135 hours, RN 2 stated Resident 2 was able to make her needs known. She stated she was unaware of Resident 2's locomotion off of the unit. During an interview on 12/29/10 at 1140 hours, the DSD stated on 11/29/10 at 1230 hours, she was talking on the phone at the receptionist area, with her back turned toward the entrance door. She stated she overheard a stranger telling the receptionist that a resident was outside the entrance door, near the sidewalk. The DSD stated she had previously seen Resident 2 self-propelling her wheelchair around the facility, but was unaware she had left the facility. She stated if a resident is at risk to wander, the facility would place a resident on a 1:1 status (one staff member to one resident) or arrange for a transfer to an appropriate setting. The DSD stated an inservice titled "Resident Orientation and Elopement" was given on 11/15/10 (14 days prior) and another inservice is scheduled for today. 2. Clinical record review for Resident 3 was initiated on 12/29/10. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Interdisciplinary Progress note dated 6/15/10, showed Resident 3 was found lying on the floor, on her left side after her wheelchair tipped over. An intervention recommended a high back wheelchair with anti-tippers, elevated leg rests and the use of a lap tray for safety. Review of Resident 3's Licensed Personnel Progress Notes dated 12/6/10 at 1000 hours, showed to do a trial release of the lap tray with the new Tilt n Space wheelchair (reclining wheelchair). On 12/14/10 at 1000 hours, a physician's orders [REDACTED]. On 12/18/10 at 1550 hours, Resident 3 fell out of the wheelchair. Review of Resident 3's Incident/Accident Report dated 12/18/10 at 1550 hours, showed Resident 3 was sitting in the Tilt n Space wheelchair, tried to stand up and fell forward. The wheelchair tipped over and the resident landed on her knees, and her head hit the floor. Review of Resident 3's Post Fall Evaluation dated 12/20/10, showed a recommendation to place the resident in a tilt position when unsupervised in the Tilt n Space wheelchair. During an interview on 12/29/10 at 1435 hours, RN 3 stated Resident 3 is alert and sometimes follows commands. She stated the resident can move all her extremities and can propel herself short distances in a wheelchair. RN 3 stated on 12/18/10, Resident 3 was sitting in her Tilt n Space wheelchair in the Television Room on Station 4. She stated Resident 3 leaned forward, and the wheelchair tipped over. Resident 3 landed on her knees and her head hit the floor. RN 3 stated the wheelchair was not in a tilt position. During an interview on 12/29/10 at 1510 hours, the Director of Rehabilitation stated Resident 3 has a history of falling asleep in her wheelchair and leans forward. She stated a lap tray was used to prevent her from falling out of her wheelchair. The Director of Rehabilitation stated a Tilt n Space wheelchair was ordered for Resident 3 on 11/19/10, and delivered on 12/6/10, to discontinue the use of the lap tray. She stated on 12/18/10, if Resident 3's Tilt n Space wheelchair had been tilted backwards, her feet would not have been able to touch the ground and the fall would have been preventable. When the Director of Rehabilitation was asked if the staff had been trained on the use of the Tilt n Space wheelchair for Resident 3, she stated, "yes." In addition, she stated the facility has four residents using the Tilt n Space wheelchairs. During an interview on 12/29/10 at 1530 hours, CNA 1 stated Resident 3 is able to move by herself in bed. When CNA 1 was asked if she had ever been inserviced to use Resident 3's new Tilt n Space wheelchair, she stated, "no." In addition, she stated two residents on Station 4 have a Tilt n Space wheelchair. During an interview on 12/29/10 at 1540 hours, CNA 2 stated Resident 3 was alert and oriented at times. He stated Resident 3 is able to turn herself in bed. When CNA 2 was asked if he had ever been inserviced to use Resident 3's new Tilt n Space wheelchair, he stated, "no." During an interview on 12/29/10 at 1550 hours, the DON stated if Resident 3's Tilt n Space wheelchair would have been properly positioned, her fall would have been preventable.