Every finding on record at Alexandria Care Center

Based on interview and record review, the facility failed to ensure Resident 1's discharge record was complete and accurately reflected Resident 1's clinical condition and care needs at the time of transfer to a boarding care facility.This deficient practice had the potential to result in the receiving facility being inadequately informed of the resident's needs, placing the resident at risk for inappropriate care, unmet needs, avoidable outcomes, and an unsafe transition.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including heart failure (a heart disorder which causes the heart not to pump the blood efficiently, sometimes resulting in leg swelling) and type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/3/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required supervision or touching assistance (helper provides cues or touching/contact guard assistance as resident completes the activity) for activities of daily living (ADLs - the basic, routine self-care tasks such as bathing, dressing, and toileting a person performs daily) such as toilet hygiene, oral hygiene, upper body dressing, and personal hygiene.During a review of Resident 1's History and Physical Examination (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 5/14/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Physician Progress Notes (PPN) dated, 8/8/2025, the PPN indicated Resident 1 had a diagnosis of dementia (a general term for a loss of memory, language, problem solving, and other thinking abilities that are severe enough to interfere with daily life) with psychosis (a mental health state characterized by a loss of contact with reality, during which a person's thoughts and perceptions are severely disrupted).During a review of Resident 1's medical record, titled Psychiatry Progress Note, dated 9/25/2025, the Psychiatry Progress Note indicated that Resident 1 had diagnosis of unspecified psychosis, insomnia (a common sleep disorder characterized by persistent difficulty falling asleep), and dementia.During a review of Resident 1's Discharge Summary (DS), dated 5/29/2026, the DS indicated Resident 1's health has improved sufficiently and no longer need the service provided by the facility. The DS indicated diagnosis during stay cerebral infarction (occurs when a blocked or narrowed blood vessel cut off blood flow to the brain), aphasia (a language disorder caused by damage to the brain) following cerebral infarction, heart failure, and type 2 diabetes. The discharge summary did not include a diagnosis of dementia with psychosis.During an interview with social services director (SSD) on 7/1/2026 at 2:15 p.m., the SSD stated that she (SSD) sent an electronic mail to the boarding care personnel on 5/11/2026 at 3:18 p.m. The SSD stated that she (SSD) included a copy of Resident 1's face sheet (a document that provides a quick overview of resident's details, medical history, and current health status), medication review, and history and physical (a comprehensive medical evaluation). The SSD stated the diagnosis of dementia with psychosis was not recorded in any of the documents she (SSD) sent to boarding care. The SSD stated that she (SSD) was not aware that Resident 1 had a diagnosis of dementia with psychosis. The SSD stated that there was miscommunication between the Medical Doctors and the facility staff. The SSD stated that not providing the boarding care facility with the complete medical record including all the diagnosis can result in inappropriate care and treatment of the resident.During an interview with the Director of Nurses (DON) on 7/1/2026 at 3:15 p.m., the DON stated the boarding care received Resident 1's Medication Administration Record which included a diagnosis of psychosis. The DON stated that the facility failed to update the diagnoses of dementia in the discharge summary (a final, comprehensive document prepared when a resident leaves the facility) and their minimum date set tool. The DON stated the discharge summary needed to include the diagnosis of dementia for accuracy. The DON stated this failure had the potential for ineffective care and treatment of resident while in the boarding care facility.During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised on July 2017, the P&P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on interview and record review, the facility failed to ensure physician - ordered treatment was transcribed to the Treatment Administration Record (TAR) and implemented for one of three sampled residents (Resident 1).This deficient practice had the potential to delay necessary treatment and compromise Resident 1's skin integrity.Findings:During a review of Resident 1's undated admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes (the body's inability to process sugar), history of falling, hypertension (elevated blood pressure), and neurocognitive disorder (a decrease in mental function).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/30/2026, the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was severely impaired. The MDS indicated Resident 1 required moderate assistance with oral hygiene, bathing, and dressing.During a review of Resident 1's Order Summary Report (OSR) for the active orders as of 6/16/2026, the OSR indicated an order to cleanse with Normal Saline (NS - a sterile salt water) the skin irritation (a localized, non-allergic inflammatory response that occurs when the skin's protective outer barrier is damaged) on chin, pat dry, apply triple antibiotic ointment (a topical medication used to prevent infections in minor skin wounds) and leave open to air for 14 days with an order date of 6/5/2026.During an interview with Licensed Vocational Nurse (LVN 1) on 6/16/2026 at 2:15 p.m., LVN 1 stated, CNA 1 reported to her (LVN1) that CNA 1 was shaving Resident 1's face and noted a small abrasion (a surface wound caused by skin rubbing) on Resident 1's chin. LVN 1 stated she notified the Medical Doctor and received an order to apply triple antibiotic ointment to the chin for 14 days. LVN 1 stated she provided the treatment to Resident 1 after receiving the order; however, the order was not carried out in the Treatment Administration Record (TAR - a formal medical log used by healthcare workers to track the treatments given to a resident). LVN 1 stated the order needed to be carried out as ordered by the physician.During a concurrent interview and record review with the Director of Nurses (DON) on 6/16/2026 at 3:10 p.m., the DON stated she did not see the treatment order in Resident 1's TAR and the LVN 1 must not have carried out the order completely. The DON stated it is important to fully carry out physician orders, so residents receive the proper medical treatment.During a review of the facility's policy and procedure (P&P) titled, Medication and Treatment Orders. dated July 2016, the P&P indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. The P&P indicated verbal orders must be recorded immediately in the Resident's chart by the person receiving the order and must include prescriber's last name, credentials, date and time of the order.

Based on interview and record review, the facility failed to update the care plan titled, Resident is at risk for elopement related to: Resident expresses desire to leave the facility prematurely (not medically ready for discharge), Cognitive loss/dementia quarterly for one of two sampled residents (Resident 1). This failure had the potential to result in a lack of continuity of care based on Resident 1's condition and in staff being unaware of Resident 1's elopement risk interventions, which could compromise Resident 1's safety. Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including heart failure (a heart disorder which causes the heart not to pump the blood efficiently, sometimes resulting in leg swelling) and type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/03/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required supervision or touching assistance (helper provides cues or touching/contact guard assistance as residents completes the activity) for activities of daily living (ADLs - the basic, routine self-care tasks such as bathing, dressing, and toileting a person performs daily).During a review of Resident 1's History and Physical Examination (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 5/14/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Elopement Evaluation, dated 5/14/2025 and timed 1:08 p.m., the Elopement Evaluation indicated, Resident 1 was not at risk for elopement.During a review of Resident 1's Care Plan Report (CP), initiated on 9/6/2025, the Focus indicated Resident is at risk for elopement related to: Resident expresses desire to leave the facility prematurely (not medically ready for discharge), Cognitive loss/dementia. The care plan indicated intervention to monitor the nature and circumstances of attempted elopement during specific activities, involvement of others with resident/patient, pattern and adjust care delivery.During a review of Resident 1's Progress Notes, dated 9/6/2025 and timed 3:51 p.m., the progress note indicated, Patient has been reporting to different CNAs that he's been planning to leave the facility any day now, which he (Resident 1) expressed for the whole week. Wife is concerned and requested to have patient get wander guard instead of being placed in station 4, called the doctor and explained the situation, received an order, noted and carried out.During a review of Resident 1's Progress Notes, dated 9/7/2025 and timed 5:13 p.m., the Progress Note indicated, Family requested to transfer the resident to more secure unit which is located in station 4 due to behavioral concern; resident looking for exit doors and being aggressive towards staff this morning with COC. MD made aware and gave an order to transfer the resident to station 4 for safety. During an interview on 6/4/2026 at 10:39 a.m. with Certified Nurse (CNA) 1, CNA 1 stated that Resident 1 frequently attempted to leave the facility to return home. CNA 1 stated the staff transferred Resident 1 from station 1 to station 4 because Resident 1 attempted to leave the facility on multiple occasions. CNA 1 stated Resident 1 was forgetful and would try to leave the facility at least once a week.During a concurrent interview and record review on 6/4/2026 at 1:02 p.m. with Registered Nurse (RN) 1, Resident 1's care plan report titled, Resident is at risk for elopement related to: Resident expresses desire to leave the facility prematurely (not medically ready for discharge), Cognitive loss/dementia, was reviewed. RN 1 stated that the facility should have revised Resident 1's care plan to evaluate whether the resident's goals had been met. RN 1 stated that the interdisciplinary team (IDT) is responsible for updating and revising Resident 1 care plan after each meeting. RN 1 stated the care plan should be revised quarterly and if there is a change in condition. During a review of the facility's policy and procedures (P&P) titled, Care Planning-Interdisciplinary Team, dated 8/25/202, indicated, Assessment of residents are ongoing, and care plans are reviewed and revised as information about the resident and the resident's condition change. The Interdisciplinary Team (IDT) is responsible for evaluation and updating of care plans at least quarterly.

Based on interview and record review, the facility failed to ensure accurate medical records for one of two sampled residents (Resident 1), when the facility failed to ensure the Minimal Data Set (MDS) nurse accurately documented diagnoses of unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), insomnia (trouble falling asleep or staying asleep), and dementia (a progressive state of decline in mental abilities) in section I of Resident 1's Minimum Data Set (MDS - a resident assessment tool). This failure had the potential to result in inaccurate representation of Resident 1's condition and lack of documentation in the medical record.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including heart failure (a heart disorder which causes the heart not to pump the blood efficiently, sometimes resulting in leg swelling) and type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/3/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required supervision or touching assistance (helper provides cues or touching/contact guard assistance as residents completes the activity) for activities of daily living (ADLs - the basic, routine self-care tasks such as bathing, dressing, and toileting a person performs daily).During a review of Resident 1's History and Physical Examination (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 5/14/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's medical record, titled Psychiatry Progress Note, dated 9/25/2025, the Psychiatry Progress Note indicated that Resident 1 had diagnosis of unspecified psychosis, insomnia, and dementia.During a concurrent interview and record review on 6/4/2026 at 1:55 p.m. with MDS nurse, Resident 1's medical record titled, Psychiatry Progress notes, dated 9/25/2025, and MDS section I, dated 4/3/2026, were reviewed. The MDS nurse stated that the facility failed to capture the diagnosis of psychosis and insomnia in Resident 1's MDS section I. The MDS nurse stated that she (MDS Nurse) was not sure why Resident 1's diagnosis of psychosis and insomnia were not captured. The MDS nurse stated that medical records and MDS nurse are responsible for capturing Resident 1's active diagnosis. The MDS nurse stated that Resident 1 does not have dementia and that is why the diagnosis of dementia was not captured for Resident 1.During a concurrent interview and record review on 6/4/2026 at 3:07 p.m. with the Director of Nursing (DON), Resident 1's medical record titled, Psychiatry Progress notes, dated 9/25/2025 was reviewed. The DON stated that nursing staff that received the new diagnosis from Psychiatry for Resident 1, should have informed the MDS nurse. DON stated that Resident 1's diagnosis of insomnia, dementia, and psychosis should have been captured by the MDS nurse. DON stated that Resident 1 was being treated for psychosis and insomnia by the psychiatry doctor. DON stated that the Interdisciplinary team (IDT) should have also captured Resident 1's new diagnosis since they review all active medications quarterly.During a review of the facility's policy and procedure (P&P) titled, MDS completion and Submission Timeframes, revised on10/2023, the P&P indicated that The assessment coordinator or designee is responsible for ensuring resident assessment are submitted .in accordance with current federal and state guidelines.During a review of the facility's undated P&P, titled, Charting and documentation, the P&P indicated:All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shell be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.Documentation in the medical record will be objective, complete, and accurate.

Based on observation, interview, and record review, the facility failed to properly dispose of garbage when: a. The trash can was not completely closed when not in use in the kitchen. b. The dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that specially designed garbage truck lifts) contained dried brown residue on its exterior and the surrounding floors had visible trash and debris. These failures had potential to attract birds, flies, insects, pests (animal or microorganism that has a negative effect on humans) and possibly spread infection to 164 of 164 facility residents. Findings: a. During an observation on 5/18/2026 at 11:50 a.m., of the grey garbage can near the trayline (an area where foods were assembled from the steamtable to resident's plate) and dishwashing machine, observed the garbage can was not completely covered and it was not in use. During an interview on 5/18/2026 at 12:48 p.m., with the Dietary Supervisor (DS), the DS stated that the garbage lid should be on top and completely closed to prevent the smell of the garbage attracting flies. The DS stated the garbage can was not completely closed and it was not acceptable due to infection control concerns. b. During a concurrent observation and interview on 5/19/2026 at 10:43 a.m., of the dumpster located outside the facility with the DS, observed the dumpster surroundings had liters of paper, and wraps of condiments. Observed the body of the dumpster contained dry brownish spills. The DS stated it was not okay to have trash and spills on the dumpster because it could attract pests and it needed to be cleaned for infection control During an interview on 5/19/2026 at 10:58 a.m., with the Environmental Service Supervisor (EVSS), the EVSS stated they only sweep the dumpster area two times a day, particularly one time in the morning and one time in the afternoon. The EVSS stated the maintenance department oversees the power washing of the area. The EVSS stated there should not be any trash around the dumpster as it attracts flies and for infection control. During a review of the facility's policies and procedures (P&P) titled Environment, dated 1/4/2026, the P&P indicated, 6. All trash will be contained in covered, leak-proof containers that prevent cross contamination. 7. All trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for four of five sampled residents (Residents 15, 155,10, and 147) reviewed for physical restraints by failing to ensure: 1. Resident 15 did not have bilateral (both right and left side) foam wedge cushions (firm, triangular-shaped foam cushion used to elevate parts of the body) tucked under the fitted sheet while the resident lay in bed. 2. Resident 15's physical restraint assessment (a safety check performed by healthcare staff to determine if, how, and why a patient's freedom of movement should be temporarily limited) for the bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was completed prior to use. This deficient practice had the potential to result in the restriction of the resident's freedom of movement, a decline in physical functioning, and mobility. 3. Resident 155's physical restraint assessment was completed prior to use. This deficient practice had the potential to result in the restriction of the resident's freedom of movement, a decline in physical functioning, and mobility. 4. Resident 147`s Bed placed against the wall had a restraint assessment, a physician's order, and an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered). 5. Resident 10`s use of wheelchair lap tray (a padded bar or tray that sits across a user's lap) had a restraint assessment (a routine medical and safety check performed on a patient who is physically or chemically restrained) and the physician's order to release the restraint every two hours was followed. These deficient practices had the potential to result in the restriction of the resident's freedom of movement, a decline in physical functioning, and mobility. Findings: a. During a review of Resident 15's admission Record (AR- the front page of the chart that contains a summary of basic information about the resident), the AR indicated that the facility admitted the resident on 4/13/2023 with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) , major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized muscle weakness. During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool), dated 2/9/2026, the MDS indicated the resident sometimes makes self-understood and sometimes has the ability to understand others. The MDS indicated that the resident was totally dependent on staff for oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene and moving from lying to sitting position and transfers. The MDS indicated the resident required substantial / maximal assistance from staff for rolling left to right. The MDS further indicated the resident used a bed alarm daily. During a review of Resident 15's Order Summary Report, the Order Summary Report indicated a physician order for a bed alarm while in bed, check for placement and function every shift, dated 7/2/2025. During a review of Resident 15's Care Plan (CP) titled Resident is at risk for falls: cognitive loss, lack of safety awareness, muscle weakness, . 4/25/2025 status post fall, 6/2/2025 status post fall, dated 5/8/2026, the CP indicated the resident with goals of having no falls with injury and interventions that included bed alarm while in bed. During a review of Resident 15's CP titled At risk for impaired bed mobility (moving within bed, getting in and out of bed)., dated 11/29/2025, the CP indicated the resident with goals of maintaining or improving independence in bed mobility. During an observation on 5/18/2026 at 3:40 p.m. inside Resident 15's room, observed Resident 15 lying in bed and attempting to roll over onto her left side, observed the resident extended her arm out towards a doll on the floor. Observed a bed pad alarm flashing green and foam wedge cushions were placed under the fitted sheets on both sides of the resident at the hip area. During a concurrent observation and interview on 5/18/2026 at 3:45 p.m. with Certified Nursing Assistant (CNA) 5, inside Resident 15's room, observed CNA 5 entered the room and observed the resident. CNA 5 stated Resident 15 had a bed pad alarm. Observed CNA 5 then exited the room and the bilateral foam wedge cushions remained under the fitted sheets. During an observation on 5/18/2026 at 3:47 p.m., inside Resident 15's room, observed Licensed Vocational Nurse (LVN) 8 entered the room and handed the resident the doll. Observed LVN 8 then exited the room and the bilateral foam wedge cushions remained under the fitted sheets. During a concurrent observation and interview on 5/18/2026 at 3:58 p.m. with the Infection Preventionist (IP), inside Resident 15's room, observed the IP entered the room and stated the resident had a pad alarm and there were bilateral foam cushions tucked under the fitted sheet. The IP stated the resident should not have the foam cushions tucked under the sheet. Observed the IP removed the bilateral foam cushions from under the fitted sheet. During a follow-up interview on 5/18/2026 at 4 p.m. with the IP, outside of Resident 15's room, the IP stated a foam wedge cushion may be used as a resident positioning tool on top of the fitted sheet if the resident is able to remove it themself. The IP stated when bilateral foam wedge cushions are tucked under the fitted sheet the resident cannot remove them, they restrict the resident's mobility, and the wedge cushions are considered a restraint. The IP stated CNA 5 and LVN 8 should have identified and removed the wedges, but they did not, potentially result in the resident attempting to climb over the wedges leading to a fall with injuries. During a concurrent interview and record review on 5/20/2026 at 11:17 a.m. with the Assistant Director of Nursing (ADON), Resident 15's Physical Restraint Assessments and physician orders were reviewed. The ADON stated foam wedge cushions are used for resident positioning and should not be used to prevent falls. The ADON stated when bilateral foam wedges are placed under the fitted sheets it prevents the resident from moving and is considered a restraint. The ADON stated Resident 15 was at risk for injuries from falls, did not have a physician's order or consent for the use of the foam wedge cushions, and should not have had bilateral foam cushions placed under the fitted sheets. During an interview on 5/21/2026 at 1:48 p.m. with CNA 4, CNA 4 stated on 5/18/2026, she (CNA 4) placed the bilateral wedge cushions under the fitted sheets of Resident 15 to prevent the resident from falling. CNA 4 stated she was not the only staff member to place bilateral foam wedge cushions under the sheets to prevent Resident 15 from falling. During a concurrent interview and record review on 5/22/2026 at 1:45 p.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedure (P&P) regarding restraints. The DON stated a foam wedge cushion may be used for resident positioning on top of the sheets so the resident can move. The DON stated when the cushions were placed bilaterally under Resident 15's fitted sheets to prevent falls it was considered a restraint and the facility P&P was not followed potentially resulting in psychosocial affects when the resident feels like they can't move or physical affects like contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion, caused by immobility). During a review of the facility's P&P titled, Use of Restraints, last reviewed and approved on 1/14/2026, the P&P indicated that Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary to, and the ongoing re-evaluation for the need for restraints will be documented. Policy and Implementation. 1. 'Physical Restraints' are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that the resident's physical condition., and this restricts his/her typical ability to change position or place, that device is considered a restraint. .19. Documentation regarding the use of restraints shall include: a. Full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode b. A description of the resident's medical symptoms (i.e., an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints; c. How the restraint use benefits the resident by addressing the medical symptom, d. The type of the physical restraint used; e. The length of effectiveness of the restraint time; and f. Observation, range of motion and repositioning flow sheets. b. During a concurrent interview and record review on 5/20/2026 at 11:17 a.m. with the ADON, Resident 15's Physical Restraint Assessments, Informed Consent for bed pad alarm, and physician orders were reviewed. The ADON stated the bed alarm sounds to alert staff that the resident is attempting to get out of the bed. The ADON stated the pad alarm may also stop the resident from getting up when it alarms potentially resulting in a limitation in the resident's freedom of movement and causing them to stay in place and not move. The ADON stated the use of a resident bed pad alarm requires informed consent. The ADON stated Resident 15 uses a bed alarm to prevent falls and the informed consent form indicated the pad alarm is a restraint. The ADON stated all restraints require a physical restraint assessment prior to use to assess the device use and any potential adverse effects. The ADON stated there was no documented evidence of a physical restraint assessment prior to the use of the bed pad alarm for Resident 15 but there should have been. During an interview on 5/20/2026 at 1:30 p.m. with the ADON, the ADON stated when the physical restraint assessment for the use of bed pad alarm is not completed, the resident could exhibit adverse effects such as decline in ADLs and/or mobility. During an interview on 5/20/2026 at 3:41 p.m. with the DON, the DON stated the bed pad alarm is considered a restraint. The DON stated before the application of the bed pad alarm there has to be a physical restraint assessment, consent, care plan, and a physician order. The DON stated they use the form physical restraint assessment for bed pad alarm. The DON stated the purpose of the physical restraint assessment is to assess the effectiveness and outcome of the restraint that was applied on that assessment. The DON stated Resident 15 should have had a physical restraint assessment for the use of the bed pad alarm but did not. The DON stated the facility P&P was not followed. During a review of the facility's P&P titled, Tab Alarms, Bed Alarms, Wanderguard System, last reviewed and approved on 1/14/2026, the P&P indicated, Tab alarms or bed alarms may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident's care plan that the resident is at risk for falls. For each resident to reach his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience. Procedure. 1. Nursing Assessment of each resident must be done on admission and change in status to evaluate if he/she is at risk for falls or elopement. 2. A plan of care must be formulated with eh Interdisciplinary Team. to determine the need for tab or bed alarms. 6. After applying the tab alarm or bed alarms in place, a safety check to make sure they are in proper working condition must be done before leaving the resident. c. During a review of Resident 155's AR, the AR indicated that the facility admitted the resident on 4/1/2018 with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and generalized muscle weakness. During a review of Resident 155's History and Physical (H&P), dated 4/2/2026, the H&P indicated that the resident did not have the capacity to understand and make decisions. During a review of Resident 155's MDS, dated [DATE], the MDS indicated the resident sometimes makes self-understood and sometimes had the ability to understand others. The MDS indicated the resident had severely impaired cognitive skills for decision making. The MDS indicated that the resident was totally dependent on staff with activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) including oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene and with mobility. During a review of Resident 155's physician order, dated 4/7/2026, the physician order indicated Bed alarm while in bed (check for placement and function) every shift. During a review of Resident 155's Care Plan (CP) titled Resident is at risk for falls/injury, dated 3/28/2026, the CP indicated the resident with goals of having no falls with injury and included interventions bed alarm while in bed. During a concurrent observation and interview on 5/18/2026 at 3:25 p.m. with Restorative Nurse Assistant (RNA) 1, inside Resident 155's room, Resident 155 was observed lying in bed with bed pad alarm underneath. RNA 1 stated CNA1 placed Resident 155 back to bed around 1 p.m. RNA 1 stated when Resident 155 goes back to bed they place the bed pad alarm. RNA 1 stated she (RNA 1) does not see any blinking light on the pad alarm device. RNA 1 stated she (RNA 1) will get LVN 1. During a concurrent observation and interview on 5/18/2026 at 3:30 p.m. with RNA 1 and LVN 1, inside Resident 155's room, LVN 1 stated the pad alarm device was not powered on, it was turned off. Observed LVN 1 turned the switch to on and the green light flashed. LVN 1 stated it was not turned on so it was working. LVN 1 stated Resident 155 has the pad alarm while in bed to alert the staff that she (Resident 155) is trying to get out of bed. LVN 1 stated when the device is not turned on Resident 155 could get out of bed unassisted and risk further falls. During a concurrent interview and record review on 5/20/2026 at 1:30 p.m. with the ADON, Resident 155's Physical Restraint Assessments were reviewed. The ADON stated that the physical restraint assessment for the use of bed pad alarm was not done and it should have been assessed so they know the plan and goal. The ADON stated monitor any adverse reaction regarding its use and if it limits the resident's mobility and ADLs due to the use of the bed pad alarm. The ADON stated it should have been completed for the initial assessment and then reassessed according to their policy and if there's a change in condition. The ADON stated when the physical restraint assessment for the use of bed pad alarm is not completed the resident could exhibit adverse effects such as decline in ADLs and/or mobility and they were not able to monitor it. During an interview on 5/20/2026 at 3:41 p.m. with the DON, the DON stated before the application of the bed pad alarm there has to be a physical restraint assessment, consent, care plan, and a physician order. The DON stated they use the form physical restraint assessment for bed pad alarm. The DON stated the purpose of the physical restraint assessment is to assess the effectiveness and outcome of the restraint that was applied on that assessment. During a review of the facility's P&P titled, Tab Alarms, Bed Alarms, Wanderguard System, last reviewed and approved on 1/14/2026, the P&P indicated that Tab alarms or bed alarms may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident's care plan that the resident is at risk for falls. Procedure 1. Nursing Assessment of each resident must be done on admission and change in status to evaluate if he/she is at risk for falls or elopement. 6. After applying the tab alarm or bed alarms in place, a safety check to make sure they are in proper working condition must be done before leaving the resident. During a review of the facility's P&P titled, Use of Restraints, last reviewed and approved on 1/14/2026, the P&P indicated that Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary to, and the ongoing re-evaluation for the need for restraints will be documented. Policy and Implementation 1. 'Physical Restraints' are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that the resident's physical condition., and this restricts his/her typical ability to change position or place, that device is considered a restraint. 19. Documentation regarding the use of restraints shall include: a. Full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode b. A description of the resident's medical symptoms (i.e., an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints; c. How the restraint use benefits the resident by addressing the medical symptom, d. The type of the physical restraint used; e. The length of effectiveness of the restraint time; and f. Observation, range of motion and repositioning flow sheets. d. During a review of Resident 147's AR, the AR indicated that the facility originally admitted Resident 147 on 6/10/2017, and readmitted on [DATE], with diagnoses including metabolic encephalopathy (a temporary brain malfunction caused by chemical imbalances in the body rather than a direct head injury), generalized muscle weakness, polyp of colon (a small, abnormal clump of cells that grows on the inside lining of your large intestine). During a review of Resident 147's H&P dated 10/31/2024, the H&P indicated that Resident 147 did not have the capacity to understand and make decisions. During a review of Resident 147's MDS dated [DATE], the MDS indicated Resident 147 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral and toileting hygiene, lower body dressing and putting on/taking off footwear. The MDS indicated that the resident was independent to staff with roll left and right (The ability to roll from lying on back to left and right side, and return to lying on back on the bed), sit to lying (The ability to move from silting on side of bed to lying flat on the bed), lying to sitting on side of bed (The ability to move from lying on the back to sitting on the side of the bed and with no back support). The MDS indicated Resident 147 was not using any physical restraints. During an observation on 5/18/2026 at 12:10 p.m. in Resident 147's room, observed Resident 147's bed was positioned against the wall on the left side. During a concurrent observation and interview on 5/18/2026 at 12:22 p.m. with Registered Nurse (RN) 3 inside Resident 147's room, RN 3 stated that Resident 147's bed was positioned against the wall on the left side, which limits the resident's ability to move freely and access that side of the bed. RN 3 stated that this positioning may be considered a form of restraint. RN 3 stated that this could also be resident's preference. RN 3 interviewed Resident 147 if the bed positioned against the wall was the resident's preference. Resident 147 stated that this was not his preference. Resident 147 was uncertain why the bed was positioned against the wall. RN 3 stated placing the bed against the wall on one side posed a risk for injury, physical and psychological harm to the resident. During a concurrent interview and record review on 5/20/2026 at 1:48 p.m. with RN 7, RN 7 stated that positioning a resident's bed against the wall may be considered a form of restraint, as it would limit resident's ability to move freely to the left side of the bed. RN 7 further stated that when a restraint is in use, there must be a physician's order, an informed consent, a restraint assessment and an individualized care plan (CP) addressing the use of the restraint. RN 7 reviewed Resident 147's electronic and paper medical records. RN 7 stated there were no physician's order, informed consent, restraint assessment and no documentation of Resident 147 requesting his bed to be placed against the wall. RN 7 stated failure to obtain these required elements had the potential to result in the use of an unauthorized restraint, placing the resident at risk for restricted movement, injury and decreased mobility. e. During a review of Resident 10's AR, the AR indicated that the facility originally admitted Resident 10 on 5/31/2023, and readmitted on [DATE], with diagnoses including type two Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), history of falling, right eye blindness. During a review of Resident 10's H&P dated 2/12/2025, the H&P indicated that Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 was dependent (helper does all of the effort) to staff with toileting hygiene, lower body dressing, putting on/taking off footwear, and required substantial/maximal assistance (helper does more than half the effort) with shower, upper body dressing, personal hygiene, sit to lying, lying to sitting on side of bed, chair/bed-to chair transfer (The ability to transfer to and from a bed to a chair (or wheelchair). The MDS indicated Resident 10 was using trunk restraint daily. During a review of Resident 10's Order Summary Report (OSR), dated 2/15/2026, the OSR indicated may use lap tray when up on wheelchair per family request for postural support. Check and remove every two hours for positioning every day and evening shift. During an observation on 5/20/2026 at 9:40 a.m. in Resident 10's room, observed Resident 10's wheelchair had lap tray resting on the wheelchair next to the resident's bed. During a concurrent observation and interview on 5/20/2026 at 9:42 a.m. with CNA 7 inside Resident 10's room, CNA 7 stated that the wheelchair with lap tray, placed by the resident's bed, belonged to Resident 10. CNA 7 stated that lap tray was installed and used every time Resident 10 was up on wheelchair. CNA 7 stated the lap tray was used to help the resident to rest her hands on them. During a concurrent interview and record review on 5/20/2026 at 9:45 a.m. with RN 7, RN 7 stated that Resident 10's lap tray was for the resident's postural support, to prevent Resident 10 from slouching on wheelchair. RN stated that Resident 10 used lap tray every time she (Resident 10) was up on the chair. RN 7 stated that the resident was unable to remove the lap tray on her own. RN 7 stated that if the resident cannot remove the lap tray on her own, the lap tray would be considered a restraint. RN 7 reviewed Resident 10's CP addressing lap tray. The CP indicated that Resident 10 exhibited anxiety, restlessness of wanting to get up from wheelchair and/or bed. The intervention for the problem indicated that lap tray may be used when up on wheelchair per family request for postural support, check and remove lap tray every two hours for positioning. RN 7 stated that lap tray used to prevent the resident from getting up would be considered a restraint. RN 7 reviewed Resident 10's electronic and paper medical records, stated there was no documentation indicating restraint assessment and lap tray removal every two hours as indicated in Physician's order. RN 7 added that missed restraint assessment and lap tray removal every two hours as ordered by the physician could potentially lead to Resident 10 being exposed to an unassessed and unmonitored restraint, increasing the risk for impaired mobility, skin breakdown, decreased circulation, and injury. During an interview on 5/22/2026 at 2:35 p.m. with the DON, the DON stated that placing resident's bed against the wall may constitute a restraint, unless requested by the resident. Placing resident's bed against the wall required documented informed consent from the resident and/or responsible party, physician's order and completion of a comprehensive restraint assessment. Failure to secure informed consent, obtain physician's order, conduct restraint assessment, could place the resident at risk for restricted mobility, potential injury, psychosocial harm and violation of resident rights. The DON stated that not having a lap tray restraint assessment and not following a physician's order to release the restraint every two hours could lead to increased risk of physical harm, decreased circulation, skin breakdown, loss of mobility, and violation of resident's rights. During a review of facility's P&P titled Resident Rights, dated 1/14/2026, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the residents' symptoms. During a review of the facility's P&P titled, Use of Restraints, dated 1/14/2026, indicated Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Policy Interpretation and Implementation 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition ., and this restricts his/her typical ability to change position or place, that device is considered a restraint. 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove. 5. e. Restrained residents must be repositioned at least every two (2) hours on all shifts. 14. Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use.

Based on interview, and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of care to two of five sampled residents (Residents 13 and 14) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Findings: 1. During a review of Resident 14's admission Records (AR - the front page of the chart that contains a summary of basic information about the resident), the AR indicated that the facility originally admitted Resident 14 on 6/6/2024, and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), type two Diabetes Mellitus (DM2-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet). During a review of Resident 14's Minimum Data Set (MDS - a resident assessment tool) dated 3/12/2026, the MDS indicated that the resident had intact cognitive (thinking or mental processing) skills for daily decision making. The MDS indicated that Resident 14 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (a type of medicine used to lower high blood sugar levels, primarily in people with Type 2 diabetes). During a review of Resident 14's Order Summary Report (OSR), the OSR indicated an order for: 5/2/2026 Insulin Aspart injection solution (a fast-acting, man-made version of human insulin) 100 units per milliliter (unit/ml, measures how concentrated insulin is, showing how many tiny doses of insulin are packed into a one mL vial) inject as per sliding scale (a pre-set chart used to determine rapid or short-acting insulin dosage based on blood sugar levels measured just before meals or at bedtime): if blood sugar (BS) 0 - 70 and the resident conscious give 4 ounces (oz) of juice, if unconscious give Glucagon 1 milligram (mg - measures the unit of measurement for mass/weight) intramuscularly (IM - a shot of medicine given deep into a muscle) and notify the physician; 140 - 199 = 1 Unit; 200 - 249 = 2 Units; 250 - 299 = 3 Units; 300 - 349 = 4 Units; 350 - 499 = 5 Units; more than (>) 400 = call the physician, subcutaneously (SQ) before meals and at bedtime for DM control. During a review of Resident 14's Location of Administration Report (LAR) for insulin for 5/2026, the LAR indicated insulin was subcutaneously administered on: Insulin Aspart Injection Solution 100 unit/ml 5/16/2026 at 9:24 p.m. on the Right Arm (RA) 5/17/2026 at 4:54 p.m. on the RA 5/18/2026 at 12:09 p.m. on the RA 5/19/2026 at 4:30 p.m. on the RA During a concurrent interview and record review on 5/20/2026 at 10:48 a.m. with Registered Nurse (RN) 7, RN 7 reviewed Resident 14's OSR, LAR and Care Plan (CP). RN 7 stated there was an order for Insulin Aspart for Resident 14. RN 7 stated that there was no documented care plan regarding insulin use. RN 7 further stated there were multiple instances that the licensed staff did not rotate the insulin administration sites for Resident 14. RN 7 stated it was important to rotate the insulin administration sites to prevent bruising, trauma and lipodystrophy on residents. RN 7 added administering insulin on sites of lipodystrophy will have an effect on its absorption causing hypo (low)/hyperglycemia (high blood sugar) on residents. 2. During a review of Resident 13's AR, the AR indicated that the facility originally admitted Resident 13 on 12/24/2021, and readmitted on [DATE], with diagnoses including type II DM, pleural effusion (an abnormal buildup of excess fluid in the pleural space), generalized muscle weakness. During a review of Resident 13's MDS, dated [DATE], the MDS indicated that the resident had intact cognitive (thinking or mental processing) skills for daily decision making. The MDS indicated that Resident 13 was dependent (helper does all of the effort) to staff with toileting hygiene, shower, lower body dressing and putting on/takin off footwear. During a review of Resident 13's OSR, the OSR indicated an order for: 4/23/2026 Humalog (insulin Lispro - fast-acting man-made version of human insulin used to control blood sugar spikes right around mealtime) Injection Solution 100 unit/ml. Inject 6 Units SQ before meals for DM. 4/23/2026 Insulin Aspart Injection Solution 100 unit/ml. inject as per sliding: if BS less than (<) 70 and the resident conscious = 4 oz of juice or Glucogel (a concentrated, fast-acting sugar gel primarily used by people with diabetes to quickly treat dangerously low blood sugar), if unconscious = Glucagon 1 mg intramuscularly (IM - a shot of medicine given deep into a muscle) and notify the physician; 70 - 139 = 0 Unit; 140 - 199 = 1 Unit; 200 - 249 = 4 Units; 250 - 299 = 7 Units; 300 - 349 = 10 Units; 350 - 399 = 12 Units; if BS > 400 = 14 Units and call the physician, SQ before meals and at bedtime for DM. 4/23/2026 Lantus SQ Solution (Insulin Glargine) - long-acting man-made version of human insulin) 100 unit/ml. Inject 75 Units SQ in the evening for DM. During a review of Resident 13's Care Plan (CP) Report, the CP indicated the resident had a diagnosis of diabetes: insulin dependent. The CP interventions did not indicate intervention to rotate injections sites regularly. During a review of Resident 13's LAR for Insulin for 5/2026, the LAR indicated insulin was administered SW on: Humalog Injection Solution 100 unit/ml 5/2/2026 at 4:55 p.m. on the Abdomen - Right Upper Quadrant (RUQ) 5/3/2026 at 10:44 a.m. on the Abdomen - Left Lower Quadrant (LLQ) 5/3/2026 at 4:11 p.m. on the Abdomen - LLQ 5/8/2026 at 4:28 p.m. on the Abdomen - LLQ 8/18/2026 at 4:49 p.m. on the Right Arm (RA) Insulin Aspart Injection Solution 100 unit/ml 5/2/2026 at 9:02 p.m. on the Abdomen - RUQ 5/8/2026 at 4:28 p.m. on the Abdomen - LLQ 5/8/2026 at 8:25 p.m. on the Abdomen - LLQ 5/10/2026 at 3:49 p.m. on the Abdomen - LLQ 5/18/2026 at 4:51 p.m. on the RA Lantus SQ Solution 100 unit/ml 5/10/2026 at 4:34 p.m. on the Abdomen - LLQ During a concurrent interview and record review on 5/22/2026 at 9:22 a.m. with MDS Director (MDSD), the MDSD reviewed Resident 13's OSR, LAR and CP. The MDSD stated that there were three orders for insulin for Resident 13. The MDSD stated there were multiple instances that the licensed staff did not rotate the insulin administration sites for Resident 13. The MDSD stated CP addressing insulin use did not indicate rotating insulin injection sites regularly. The MDSD stated that licensed nurses must assess and rotate insulin administration sites prior to administration to ensure insulin is not repeatedly administered to the same location. The MDSD stated that the regular rotation of injection sites was essential to prevent complications such as bruising, lipodystrophy and muscle tissue damage. The MDSD further stated that not rotating sites may lead to decreased insulin absorption and reduced efficacy, which can result in poor blood glucose control. The MDSD added that CP interventions must reflect rotation of insulin injection sites. The MDSD stated the staff did not follow facility's Policies and Procedures (P&P), titled Insulin Administration Purpose and the Manufacturer's Specifications for Aspart, Humalog and Lispro. During an interview on 5/22/2026 at 2:40 p.m. with the Director of Nursing (DON), the DON stated Resident 13's and 14's insulin administration sites should be rotated to prevent lipodystrophy, muscle dystrophy, and abscesses. The DON stated that injecting insulin on the same site can cause poor absorption leading to less insulin efficacy and hyperglycemia. The DON stated the staff did not follow their policy and procedure (P&P) titled Insulin Administration and the Manufacturer's Specifications for Aspart, Humalog and Lispro. During a review of the facility's P&P titled Insulin Administration Purpose, last reviewed on 1/14/2026, the P&P indicated, Preparation. The nursing staff have access to specific instructions (from the manufacturer, if appropriate) on all forms of insulin delivery systems prior to their use. Steps in the Procedure (Insulin Injections via Syringe) . 20. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm) . During a review of the facility-provided Product Monograph (PM - a highly detailed, scientific instruction manual for a medication) for the use of Humalog injection SQ with initial U.S. (United States) approval date 10/8/1996, the PM indicated, Subcutaneous administration, preferably by the patient, should be in the upper arms, thighs, buttocks or abdomen. Injection sites should be rotated so that the same site is not used more than approximately once a month, in order to reduce the risk of lipodystrophy and localized cutaneous amyloidosis (skin condition where misfolded proteins build up in the top layers of your skin). During a review of the facility-provided Highlights of Prescribing Information (HPI) on the use of Lantus for SQ injection with initial U.S. approval: 2000, the HPI indicated, Change (rotate) your injection sites within area you choose with each dose. Do not use the exact spot for each injection. During a review of the facility-provided HPI on the use of Insulin Aspart Injection for SQ use with initial U.S. approval: 2000, the HPI indicated Change (rotate) your injection sites within the area you choose with each dose to reduce your risk of getting lipodystrophy and localized cutaneous amyloidosis (skin with lumps) at the injection site.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards and adequate supervision to prevent accidents for three of six sampled residents (Residents 140, 110, and 155) reviewed under the Accidents care area by failing to: 1. Ensure medications were not left at the bedside readily available for resident self- administration for Residents 140, 110, and 23. These deficient practices had the potential to result in resident harm from omission of medications, overdose of medications, and residents ingesting medications not intended for their use. 2. Ensure Resident 155's bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was turned on when it was in use. This deficient practice had the potential to result in Resident 155 sustaining an injury from a fall.3. Ensure Resident 9's right floor mat did not have a chair on top of it.This deficient practice had the potential to result in resident injury from falls when the floor mat was damaged. Findings: a. During a review of Resident 140's admission Record (AR), the AR indicated that the facility admitted the resident on 5/9/2022 with diagnoses including hypertension (HTN-high blood pressure), hyperlipidemia (HLD - high cholesterol [a waxy substance that can build up in the blood resulting in stroke or heart issues]), chronic kidney disease (CKD a condition in which the kidneys are damaged and cannot filter blood as well as they should), and age related nuclear cataract (excessive amount of yellowing and light scattering affecting the center of the lens). During a review of Resident 140's Minimum Data Set (MDS- a resident assessment tool), dated 5/7/2026, the MDS indicated the resident had the ability to make himself understood and had the ability to understand others. The MDS indicated the resident required partial / moderate assistance from staff with activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) including shower/bathe self, lower body dressing, and putting on/taking off footwear. During a review of Resident 140's History and Physical (H&P), dated 5/14/2026, the H&P indicated the resident had fluctuating capacity (an individual experiences changes in their mental state, which can affect their decision-making abilities). During a review of Resident 140's Order Summary Report, the Order Summary Report indicated the following physician orders: - Benazepril HCI (medication to treat HTN) tablet 10 milligrams (mg, a unit of measurement), give one (1) tablet by mouth two times a day for HTN, hold (do not give) for systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart]) less than (<) 100 millimeters of mercury (mmHg – measurement of pressure), dated 12/2/2024. - Fish Oil (supplement to treat HDL) oral capsule 1000 mg, give 1 capsule by mouth one time a day for Supplement, dated 4/4/2024.- Aspirin (medication that helps prevent blood clots [clumping of blood]) tablet chewable, 81 mg, give 1 tablet by mouth one time a day for cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) prophylaxis (prevention), dated 05/09/2022. During a concurrent observation and interview on 5/18/2026 at 9:50 a.m. with Resident 140, Resident 140 was observed lying in bed while no staff was present in the room. On the floor next to the resident's bed were two tablets and two clear capsules. Resident 140 stated the nurse left his medications during breakfast and they fell on the floor while he was eating. Resident 140 stated he thought he took some of the medications, but he was not sure. During an observation on 5/18/2026 at 9:58 a.m., Certified Nursing Assistant (CNA) 6 entered Resident 140's room and stood directly over the two tablets and two capsules on the floor while speaking with the resident. CNA 6 exited the room and the two tablets and two capsules remained on the floor. During a concurrent observation, interview, and record review on 5/18/2026 at 10:05 a.m., at Resident 140's room, with Licensed Vocational Nurse (LVN) 7, reviewed Resident 140's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident. LVN 7 stated the facility protocol for medication administration is the licensed nurse (LN) should watch the resident take the medication. LVN 7 stated medications should not be left at bedside for self-administration. LVN 7 stated if the resident does not take the medication, then the LN nurse should take the medications out of the room, place them in the medication cart, return to administer the medications when the resident is ready, and then document in the MAR after the medications are administered. LVN 7 stated earlier in the morning, she left Resident 140's medications at bedside for the resident to self-administer. LVN 7 stated she did not watch Resident 140 administer the medications because she was called away to attend to another resident. LVN 7 stated she should not have left the medications at bedside for the resident to self-administer, but she did. LVN 7 then entered Resident 140's room and stood directly over the two tablets and two capsules on the floor. Observed LVN 7 exited Resident 140's room and the medications remained on the floor. LVN 7 then re-entered Resident 140's room upon the request of the surveyor and stated there was a benazepril tablet, an aspirin tablet, and two fish oil capsules on the floor. LVN 7 stated she did not follow the facility medication administration protocol. LVN 7 stated it was not safe to leave resident medications unattended at bedside because the resident may not take the medications or another resident could take the medications. LVN 7 stated leaving medications at bedside causes a resident safety issue. During an interview on 5/18/2026 at 10:35 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the medication administration process is to supervise the resident while they take the medications to ensure the medications are administered. The ADON stated residents have the right to self-administer medication after a medication self-administration assessment is completed and it is determined that the resident is safely able to do so. The ADON stated Resident 140 did not have a self-administration assessment completed and it was not safe for the resident to self-administer medications. The ADON stated even if a resident is able to self-administer medications, medications should never be left at bedside because other residents could take the medication. The ADON stated LVN 7 did not follow the facility protocol. During a concurrent interview and record review on 5/22/2026 at 1:45 p.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedure (P&P) regarding medication administration and medication self-administration. The DON stated LVN 7 did not follow the facility protocol for medication administration when she left medications at bedside for resident self-administration. The DON stated leaving medications at bedside could potentially affect other confused residents who could accidentally ingest the medication resulting in unstable vital signs (clinical measurements used to assess the body's most basic functions) leading to adverse reactions. The DON stated the facility did not have an accident prevention P&P, but medications are not left at bedside to prevent accidents from occurring. The DON stated the facility P&Ps were not followed. During a review of the facility's P&P titled, Self-Administration of Medications, last reviewed and approved on 1/14/2026, the P&P indicated that Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. 8.Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge or return to the family or responsible party. During a review of the facility's P&P titled, Bedside Medication Storage in the Facility, last reviewed and approved on 1/14/2026, the P&P indicated that Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. c. For residents who self-administer medications, the following conditions are met for bedside storage to occur: 1) The manner of storage prevents access by other residents. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. b. During a review of Resident 110's AR, the AR indicated that the facility admitted the resident on 3/27/2026 with diagnoses including liver (organ that removes toxins from the body's blood supply) cell carcinoma (cancer), cirrhosis of liver (permanent scarring that damages the liver), and cognitive communication deficit (difficulty with communication). During a review of Resident 110's MDS, dated [DATE], the MDS indicated the resident had the ability to make himself understood and had the ability to understand others. The MDS indicated the resident required partial to moderate assistance from staff with ADLs including showering and bathing self, toileting hygiene, lower body dressing, and mobility. During a review of Resident 110's Medication Self-Administration Evaluation form, dated 3/28/2026, the Medication Self-Administration Evaluation form indicated the resident was unable to demonstrate secure storage of medication kept in the room and self-administration of medication was not recommended. During a review of Resident 110's Order Summary Report, the Order Summary Report indicated a physician's order for lactulose (a laxative medication used to treat complications of cirrhosis) oral solution 20 grams (gm, a unit of measurement) 30 milliliters (mL, a unit of measurement), give 30 mL by mouth two times a day for liver cirrhosis related to liver cell carcinoma, dated 4/22/2026. During an interview on 5/18/2026 at 10:35 a.m. with the ADON, the ADON stated the medication administration process is to supervise the resident while they take the medications to ensure the medications are administered. The ADON stated residents have the right to self-administer medication after a medication self-administration assessment is completed and it is determined that the resident is safely able to do so. The ADON stated even if a resident is able to self-administer medications, medications should never be left at bedside because other residents could take the medication. During a concurrent observation and interview on 5/18/2026 at 10:40 a.m. with Resident 110, Resident 110 was observed lying in bed with a clear plastic cup containing approximately 20 mL of yellow tinted liquid on the bedside rolling table. Resident 110 stated the cup contained medication to help soothe his stomach. Resident 110 stated the nurse leaves the medication so he can take it whenever he wants to. Resident 110 stated he would drink the medication when he felt like it. During a concurrent observation and interview on 5/18/2026 at 10:45 a.m., with CNA 8, CNA 8 entered Resident 110's room. CNA 8 confirmed the clear cup contained liquid and she believed it was Mylanta (medication to treat stomach upset). CNA 8 was observed exiting the room and the medication remained at the bedside. During a concurrent observation and interview on 5/18/2026 at 10:50 a.m., with LVN 7, outside Resident 110's room, LVN 7 stated she gave Resident 110 a cup with 30 mL of lactulose and then closed the resident's curtain and left the room. LVN 7 stated she did not observe Resident 110 take the 30 mL of lactulose. LVN 7 stated she should have ensured the resident administered the 30 mL of lactulose, but she did not. LVN 7 stated residents should be supervised during medication administration to ensure medications are fully administered and not left at bedside for self-administration. During an interview on 5/20/2026 at 9:39 a.m. with the ADON, the ADON stated LVN 7 did not follow the facility protocol for medication administration when she left Resident 110's lactulose at bedside for self-administration. The ADON stated when medications are left at bedside the resident may not administer the medication resulting in increased confusion or other confused residents may take the medication resulting in adverse effects in the resident. During a concurrent interview and record review on 5/22/2026 at 1:45 p.m. with the DON, the DON reviewed the facility P&P regarding medication administration and medication self-administration. The DON stated LVN 7 did not follow the facility protocol for medication administration when she left medications at bedside for resident self-administration. The DON stated when LVN 7 left lactulose at Resident 110's bedside it could potentially result in the resident not taking the medication leading to irregularities in liver function resulting in increased confusion. The DON stated leaving medications at bedside could potentially affect other confused residents who could accidentally ingest the medication leading to adverse reactions. The DON stated the facility did not have an accident prevention P&P, but medications are not left at bedside to prevent accidents from occurring. The DON stated the facility P&Ps were not followed. During a review of the facility's P&P titled, Self-Administration of Medications, last reviewed and approved on 1/14/2026, the P&P indicated that Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. 8.Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge or return to the family or responsible party. During a review of the facility's P&P titled, Bedside Medication Storage in the Facility, last reviewed and approved on 1/14/2026, the P&P indicated that Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. c. For residents who self-administer medications, the following conditions are met for bedside storage to occur:. 1) The manner of storage prevents access by other residents. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. c. During a review of Resident 155's AR, the AR indicated that the facility admitted the resident on 4/1/2018 with diagnoses including dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and generalized muscle weakness. During a review of Resident 155's H&P, dated 4/2/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 155's MDS, dated [DATE], the MDS indicated the resident sometimes makes self-understood and sometimes has the ability to understand others. The MDS indicated the resident has severely impaired cognitive skills for decision making. The MDS indicated that the resident was totally dependent on staff with ADLs including oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene and with mobility. During a review of Resident 155's physician order, dated 4/7/2026, the physician order indicated Bed alarm while in bed (check for placement and function) every shift. During a review of Resident 155's CP titled Resident is at risk for falls/injury, dated 3/28/2026, the CP indicated the resident goal is to have no falls with injury and included interventions to use a bed alarm while in bed. During a concurrent observation and interview on 5/18/2026 at 3:25 p.m. with Restorative Nurse Assistant (RNA) 1, inside Resident 155's room, Resident 155 was observed lying in bed with bed pad alarm underneath. RNA 1 stated CNA 1 placed Resident 155 back to bed around 1 p.m. RNA 1 stated when Resident 155 goes back to bed they place the bed pad alarm. RNA 1 stated she does not see any blinking light on the pad alarm device. RNA 1 stated she will get LVN 1. During a concurrent observation and interview on 5/18/2026 at 3:30 p.m. with RNA 1 and LVN 1, inside Resident 155's room, LVN 1 stated the pad alarm device was not powered on, it was turned off. LVN 1 turned the switch to on and the green light flashed. LVN 1 stated it was not turned on so it was working. LVN 1 stated Resident 155 has the pad alarm while in bed to alert the staff that she is trying to get out of bed. LVN 1 stated when the device is not turned on Resident 155 could get out of bed unassisted and risk further falls. During an interview on 5/20/2026 at 1:45 p.m. with the ADON, the ADON stated whoever placed the bed pad alarm should check its function and placement to make sure they are working and must be done before leaving the resident. The ADON stated if placement is not the checked the resident could be leaning out then it won't alarm. The ADON stated checking for the function includes checking the battery, the connection and powered on because the resident could manipulate it and it was turned off. The ADON stated when bed pad alarm is not turned on then its effectiveness for fall precaution would not be followed. The ADON stated the staff would not be alerted the resident is trying to get out of bed and the resident could have another fall and sustain an injury. During a review of the undated Pad Alarm Attendant (PAA) 1 manufacturer specifications, the manufacturer specifications indicated that the on/off switch – can disable all functionality to preserve battery life. In-use light – notifies you at a glance that the unit is properly operating. Versatile – alarm can be used with bed and chair pads . During a review of the facility's P&P titled, Tab Alarms, Bed Alarms, Wander guard System, last reviewed and approved on 1/14/2026, the P&P indicated that Tab alarms or bed alarms may be used on a resident who is deemed unsafe through the nursing assessment and documented on the resident's care plan that the resident is at risk for falls. Procedure. 6. After applying the tab alarm or bed alarms in place, a safety check to make sure they are in proper working condition must be done before leaving the resident. d. During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted the resident on 5/4/2026, with diagnoses including presence of left artificial hip joint (a surgically implanted, artificial metal or ceramic joint on left side that replaced the natural hip), muscle weakness and other reduced mobility and need for assistance with personal care. During a review of Resident 23's Minimum Data Set (MDS – a resident assessment tool), dated 5/19/2026, the MDS did not indicate any assessment for mental status. The MDS indicated an incomplete assessment of functional abilities. During a review of History and Physical (H&P) dated 5/4/2026, the H&P indicated that [Resident] remains mildly confused and required moderate to maximum assistance with transferring and ambulation. During a review of Resident 23's Care Plan, initiated on 5/5/2026, the Care Plan indicated a focus that patient shown decline on her bed mobility, transfer, and gait. The Care Plan also included a focus indicating that the resident exhibits or is at risk for alterations in comfort related to Surgical post-op with interventions including, to evaluate pain characteristics, quality, severity, location, etc., advise resident to request pain medication before pain becomes severe, and medicate resident, as ordered for pain and monitor for effectiveness and side effects, report to physician as indicated. During an initial observation on 5/18/2026 at 10:03 a.m. with Resident 23 inside resident's room, a Diclofenac Sodium Topical Gel, 1% (NSAID), a topical gel used for pain relief, was observed placed at the table to the right side of the resident's bed. Resident 23 stated that the topical gel has been there for days. Resident 23 stated that she has been applying the gel by herself to her right knee and leg. During a concurrent observation and interview on 5/18/2026 at 10:04 a.m. with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated Resident 23 can make self-understood and can understand others. LVN 5 stated that the medication should not have been in resident's possession and should refrain from applying it by herself, given she has a prescribed ointment. LVN 5 stated that unsupervised use of the medication could result in overdosing and could potentially lead to drug interaction. During a concurrent interview and record review on 5/20/2026 at 9:35 a.m. with Registered Nurse 1 (RN 1), RN 1 stated that before a resident can self-administer any uncontrolled medications, there must be a self-administering assessment and physician's order for a resident to self-administer medications. RN 1 stated that Resident 23 did not have an assessment and order for self-administration of medication. RN 1 stated that nurses do not have control over how much was applied and could lead to overdosing. RN 1 further stated that residents can potentially have an adverse side effect like rash. During an interview on 5/22/2026 at 1:42 p.m. with the Director of Nursing (DON), the DON stated that medications should not be left at bedside especially if the resident does not have an order to self-administer medication. The DON stated that residents can have accidental ingestion which could potentially lead to complications and adverse reactions. During a review of the facility's Policy and Procedure (P&P) titled, Self-Administration of Medications, last reviewed and approved on 1/14/2026, the P&P indicated that Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents.8.Any medications found at bedside that are not authorized for self-administration are turned over to the nurse in charge or return to the family or responsibly party. e. During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted the resident on 4/10/2026, with diagnoses including left femur fracture (broken left thighbone), muscle weakness, dependence of supplemental oxygen (lungs cannot put enough oxygen from the normal air on their own).During a review of Resident 9's Care Plan, initiated on 4/10/2026, the Care Plan indicated a focus that the resident is at risk for falls/injury, impaired mobility, on antihypertensive medications, needs assist with transfers and bed mobility. The Care Plan indicated an intervention including low beds with bilateral floor mats and maintaining a clutter-free environment in the resident's room and consistent furniture arrangement. During a review of Resident 9's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had an intact cognition (means that a person's mental abilities – such as thinking, memory attention, and language – are working well and have not had experienced significant decline or impairment). The MDS indicated that the resident needs supervision or touching assistance with eating, and substantial/maximal assistance on toileting and other personal hygiene, and dependence on transfers and ambulation. During an observation on 5/18/2026 at 10:09 a.m., the floor mat to the right-side of Resident 9 was observed to have a black colored chair on top of the mat and had a plastic cup of water over the chair. During a concurrent observation and interview on 5/18/2026 at 10:10 a.m. with LVN 5, LVN 5 stated that floor mat is to protect residents from getting injured in a fall. LVN 5 stated that a chair was positioned on top of the floor mat, which should not have occurred. LVN 5 stated that if there is an object on top of the floor mat, the resident could hit the chair and possibly sustain an injury instead of landing safely in the floor mat. During an interview on 5/20/2026 at 9:52 a.m. with RN 1, RN 1 stated that placing an object on top of the floor mat is unacceptable. RN 1 stated that the whole point of placing a floor mat next to the resident's bed is for safety reasons. RN 1 further stated that residents could possibly fall and hit the chair that could lead to skin tears or fractures. During an interview on 5/22/2026 at 1:42 p.m. with the Director of Nursing (DON), the DON stated that the purpose of floor mat is to prevent injury to residents during a fall. The DON stated that floor mats should be free from any objects for safety reasons. The DON stated that residents could possibly get hit by the object and cause to injure than landing on the floor mat safely. During a review of facility's Policy and Procedure (P&P) titled, Fall Management with effective date on 5/26/2021 indicated that Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. 2.Develop individualized plan of care, for example: including devices such as floor mats, bed to low position, alarm.

Based on observation, interview and record review, the facility failed to ensure resident care was provided to residents consistent with professional standards of practice for three (3) of six sampled residents (Resident 9, 61, and 135) reviewed for respiratory care by failing to:1. Ensure that Resident 9's oxygen (O2) nasal cannula (NC - a simple, two-pronged device that delivers extra oxygen to the nose) tubing was not touching the floor.2. Ensure the oxygen concentrator (a medical device that pulls in regular room air, filters out the nitrogen, and delivers purified oxygen for you to breathe) humidifier (a refillable plastic bottle that infuses the normal flow of oxygen with water droplets) was labeled with a date, and the oxygen was running at the rate ordered by the physician for Resident 61.3. Ensure the oxygen humidifier for Resident 155 was not empty and labeled with a date and ensured that the oxygen was running at the rate ordered by the physician.These deficient practices had the potential to result in inadequate oxygen delivery, leading to hypoxia (low levels of oxygen in body tissues) or oxygen toxicity (damage to the lungs that happens from breathing in too much oxygen), airway dryness and increased risk of respiratory infection.Findings: 1. During a review of Resident 9's admission Record (AR), the AR indicated the facility admitted the resident on 4/10/2026, with diagnoses including left femur fracture (broken left thighbone), muscle weakness, dependence of supplemental oxygen (Supplemental oxygen helps increase oxygen levels in the blood and reduce symptoms such as fatigue and shortness of breath). During a review of Resident 9's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (means that a person's mental abilities – such as thinking, memory attention, and language – are working well and have not had experienced significant decline or impairment). The MDS indicated that the resident needs supervision or touching assistance with eating, and substantial/maximal assistance with toileting and other personal hygiene, and dependence with transfers and ambulation. During a review of Resident 9's Care Plan, initiated on 4/18/2026, the Care Plan indicated that the resident exhibits or is at risk for respiratory complications related to other, with a goal indicating resident will have no signs/symptoms of respiratory distress x 30 days, and interventions indicating O2 as ordered via nasal cannula. During an initial observation on 5/18/2026 at 10:08 a.m. while inside Resident 9's room, Resident 9's oxygen tubing was not connected to resident 9's nose, and the nasal cannula tube was touching the bed, and the rest of the tubing was found touching the floor. During an observation and interview on 5/18/2026 at 10:09 a.m. with Licensed Vocational Nurse 5 (LVN 5), while inside Resident 9's room, LVN 5 stated that the oxygen tubing must not touch the floor and this does not comply with infection control protocols. LVN 5 stated that improper handling of oxygen tubing may increase the risk of respiratory infection complications due to potential infections among residents. During an interview on 5/19/2026 at 9:40 a.m. with Registered Nurse 1 (RN 1), RN 1 stated that oxygen tubing should not touch the floor, and the rest of the oxygen tubing must be placed inside a bag. RN 1 stated that oxygen tubing touching the floor poses an infection control issue, as it could possibly affect respiratory function if being used or reapplied. During an interview on 5/22/2026 at 1:42 p.m. with the Director of Nursing (DON), the DON stated that oxygen tubing that comes into contact with the floor is an infection control concern and increases the risk of respiratory complications for residents. The DON also stated that it is a safety concern as the tubing can get caught in another object and cause injury to residents. During a review of the facility's Policy and Procedure (P&P), titled Oxygen Administration reviewed and updated on 1/14/2026 the policy indicated in the General Guidelines 1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head. During a review of the facility's P&P, titled Changing of Nasal Cannula/Oxygen Tubing reviewed and updated on 1/14/2026, the policy indicated in the General Guidelines a. It is the policy of this facility to change nasal cannula and oxygen tubing weekly and as needed, if the nasal cannula is visibly soiled or damaged. b. Setup bags are dated and placed with each nasal cannula to prevent the nasal cannula from touching the floor when not being used. 2. During a review of Resident 135's admission Records (AR - the front page of the chart that contains a summary of basic information about the resident), the AR indicated that the facility admitted Resident 135 on 5/4/2026, with diagnoses including pneumonia (an infection/inflammation in the lungs), atrial fibrillation (AFib - an irregular, often rapid heart rhythm), acute systolic congestive heart failure (when the heart is suddenly too weak to squeeze blood out efficiently). During a review of Resident 135's History and Physical (H&P - a document with a patient's medical history and physical examination done by a physician) dated 5/7/2026, the H&P indicated that Resident 135 had the capacity to understand and make decisions. During a review of Resident 135's Minimum Data Set (MDS - a resident assessment tool) dated 5/10/2026, the MDS indicated that Resident 135 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower, lower body dressing and putting on and taking off footwear. During an observation on 5/18/2026 at 12:22 p.m. while in Resident 135's room, Resident 135 was receiving oxygen therapy via a nasal cannula (N/C – a flexible plastic tube delivering extra oxygen through two small prongs inserted into the nostrils) at 4 liters per minute (LPM - a measuring unit of liquid or gas flowing through a device in one minute) rate. The oxygen concentrator humidifier was empty and did not have a label with the date it was provided to the resident. During a concurrent observation and interview on 5/18/2026 at 12:27 p.m. with Registered Nurse (RN) 3 while in Resident 135's room, RN 3 stated that the oxygen concentrator humidifier was empty and was not labeled with the date it was provided to the resident. RN 3 stated that oxygen was flowing at 4 LPM via N/C. RN 3 stated that oxygen concentrator humidifier bottle was empty. RN 3 stated that empty humidifier placed Resident 135 at risk for airway dryness and scratched. RN 3 stated not labeling the humidifier with the date it was provided could potentially lead to respiratory infection and harm to the resident. During a concurrent interview and record review on 8/18/2026 at 12:35 p.m. with RN 3, RN 3 reviewed Resident 135's Order Summary Report (OSR). RN 3 stated that OSR dated 5/6/2026 indicated an order to infuse oxygen at 3 LPM via N/C continuously every shift related to acute systolic congestive heart failure. RN 3 stated that the OSR dated 5/6/2026 indicated to change the oxygen tubing weekly and label each component with the date and initials. RN 3 further stated that the physician's orders were not followed. RN 3 added that administering oxygen at 4 LPM placed Resident 135 at the potential risk for oxygen toxicity. 3. During a review of Resident 61's AR, the AR indicated that the facility originally admitted Resident 61 on 10/29/2020, then readmitted Resident 61 on 5/5/2026, with diagnoses including urinary tract infection (UTI - an infection in the bladder/urinary tract), acute respiratory failure (a life-threatening emergency where your lungs suddenly stop working properly) with hypoxia, cerebral palsy (a group of lifelong conditions that affect movement, posture, and muscle control). During a review of Resident 61's MDS dated [DATE], the MDS indicated that Resident 61 had moderately impaired (poor decisions, required cues/supervision) cognitive skills (mental abilities that enable us to think, learn, remember, and solve problems). The MDS indicated Resident 61 was dependent (helper does all of the effort) in all Activities of Daily Living (ADL - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 8/18/2026 at 12:49 p.m. while in Resident 61's room, Resident 61 was receiving oxygen therapy via N/C at 3 LPM. The oxygen concentrator humidifier did not have a label with the date it was provided to the resident. During a concurrent observation and interview on 8/18/2026 at 12:55 p.m. with RN 3 while in Resident 61's room, RN 3 stated that the oxygen concentrator humidifier was not labeled with the date it was provided to the resident. RN 3 stated that the oxygen was flowing at 3 LPM via N/C. RN 3 stated that the oxygen concentrator humidifiers must be labeled with a date it was provided to the resident. RN 3 stated not labeling the humidifier with the date it was provided could potentially lead to respiratory infection and harm to the resident. During a concurrent interview and record review on 8/18/2026 at 12:57 p.m. with RN 3, RN 3 reviewed Resident 61's OSR. RN 3 stated that the OSR dated 5/5/2026 indicated an order to infuse oxygen at 2 LPM via N/C continuously to maintain oxygen saturation levels (a measure of how much oxygen your red blood cells are carrying compared to their maximum capacity) 92% and above every shift. RN 3 stated that OSR dated 5/10/2026, indicated to change the oxygen tubing weekly, label each component with the date and initials. RN 3 stated that the Physician's orders were not followed. RN 3 added that administering oxygen at 3 LPM placed Resident 61 at a potential risk for oxygen toxicity. During an interview on 5/22/2026 at 2:32 p.m. with the Director of Nursing (DON), the DON stated that oxygen tubbing and humidifier bottles must be labeled with the date initiated to ensure timely replacement and reduce risk of respiratory infections. The DON stated that without proper labeling staff were unable to determine when the equipment was last changed, which had the potential to promote bacterial growth and placed residents at risk for respiratory infections. The DON stated that the purpose of humidification was to provide moisture during oxygen administration to prevent mucosal dryness. The DON added failure to maintain a filled humidifier placed the resident at risk for nasal dryness, irritation, mucosal breakdown and potential injury to the nasal passages. The DON stated that administering oxygen at a higher than ordered rate had the potential to result in respiratory discomfort and may contribute to tissue damage. During a review of facility's Policies and Procedures (P&P) titled Stationary Oxygen Concentrators, dated 1/14/2026, the P&P indicated, Oxygen delivery devices and humidifiers should be changed weekly. Make sure the flow is set at the prescribed amount.

Based on observation, interview and record review, the facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for one of five sampled residents (Resident 4) reviewed for Unnecessary Medications by failing to ensure the Licensed Nurse (LN) administered as needed (PRN) oxycodone with acetaminophen (an opioid, also called a narcotic - powerful pain-reducing medication) per the physician's order and based on the assessed numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine). This deficient practice had the potential to result in side effects from unnecessary administration of narcotics including constipation, and mismanagement of resident pain resulting in limited resident participation in activities of daily living (ADLs -activities such as bathing, dressing and toileting a person performs daily), general activities, and mobility. Findings: During a review of Resident 4's admission Record (AR), the AR indicated the facility originally admitted the resident on 6/2/2017 and most recently admitted the resident on 1/22/2026 with diagnoses that included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily living), and spina bifida (a condition that occurs when the spine and spinal cord don't form properly). During a review of Resident 4's Minimum Data Set (MDS - resident assessment tool), dated 2/25/2026, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident was dependent on staff for toileting and showering, required substantial / maximal assistance with lower body dressing and personal hygiene, and required partial / moderate assistance with moving from sitting to lying. During a review of Resident 4's Order Summary Report (OSR), the OSR indicated the following orders: - Document pain level for treatments before, during, and after treatment, administer PRN medication if pain is present, every day shift, dated 1/23/2026. - Acetaminophen oral tablet 325 milligrams (mg - a unit of measurement), give two tablets by mouth every six hours as needed for pain, dated 1/30/2026. - Oxycodone with acetaminophen 5-325 mg, give one tablet by mouth every six hours as needed for severe pain (pain scale eight [8] to 10), dated 2/9/2026. During a review of Resident 4's Care Plan (CP) titled, Resident exhibits or is at risk for alterations in comfort related to acute pain, chronic pain, neurogenic pain (nerve pain)., initiated on 1/10/2025, the CP indicated a goal that the resident would achieve acceptable level of pain control with interventions that included to evaluate pain characteristics, medicate resident as ordered, and report to physician as indicated. During a concurrent interview and record review on 5/20/2026 at 8:04 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 4's physician orders and Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) were reviewed. The MDSC stated Resident 4 received acetaminophen as needed for pain and oxycodone with acetaminophen as needed for severe pain 8 to 10. The MDSC stated there were no pain parameters indicated for acetaminophen or any pain level below 8. The MDSC reviewed Resident 4's MAR and noted oxycodone with acetaminophen for pain level 8 to 10 was not administered per physician's orders on the following dates and times: - On 5/3/2026 at 1:44 p.m. for a pain level of six (6). - On 5/7/2026 at 11:20 a.m. for a pain level of 6. - On 5/10/2026 at 7:30 a.m. for a pain level of 6. - On 5/15/2026 at 7:30 a.m. for a pain level of seven (7). The MDSC further stated the licensed nurse should have clarified the pain medication orders to include as needed pain scale parameters for pain levels below 8 prior to administration, but they did not. During an interview on 5/20/2026 at 9:33 a.m. with Resident 4, inside Resident 4's room, the resident stated he received oxycodone with acetaminophen for pain and does not take any other pain medications. Resident 4 stated oxycodone with acetaminophen was not always affective. During a concurrent interview and record review on 5/20/2026 at 10:55 a.m. with Registered Nurse (RN) 5, Resident 4's physician orders and MAR were reviewed. RN 5 stated she was caring for Resident 4 and the resident had occasional pain and was able to verbalize the numeric pain scale. RN 5 stated Resident 4 received oxycodone with acetaminophen as needed for pain 8-10. RN 5 reviewed Resident 4's MAR and noted that she administered oxycodone and acetaminophen for a pain level below 8 on the following dates and times: - On 5/3/2026 at 1:44 p.m. for a pain level of 6. - On 5/7/2026 at 11:20 a.m. for a pain level of 6. - On 5/10/2026 at 7:30 a.m. for a pain level of 6. - On 5/15/2026 at 7:30 a.m. for a pain level of 7. RN 5 then stated she misread the physician's order for PRN oxycodone with acetaminophen. RN 5 stated the writing on the order was small and she thought it said to administer for a pain level of 6 to 10. RN 5 stated it was important to avoid overuse of narcotics because of the risk for side effects. RN 5 stated she did not administer oxycodone with acetaminophen per the physician's orders potentially resulting in over sedation of the resident. During a concurrent interview and record review on 5/20/2026 at 12:07 p.m. with the Assistant Director of Nursing (ADON), Resident 4's physician orders and MAR were reviewed. The ADON stated it was important to administer PRN pain medication per the physician's orders. The ADON stated Resident 4 was not administered oxycodone with acetaminophen per the physicians' orders potentially resulting in poor pain management with overuse of opiates leading to the medication being less effective over time and other adverse effects like constipation, opiate overdose, or changes in level of consciousness. During a concurrent interview and record review on 5/22/2026 at 1:45 p.m. with the Director of Nursing (DON), the facility's policy and procedures (P&P) regarding pain medication was reviewed. The DON stated RN 5 should have followed the physician's order for the administration of PRN oxycodone with acetaminophen because the controlled medication has a risk of side effects and should only be administered when needed based on the resident's pain scale. The DON stated when oxycodone with acetaminophen was administered for a lower pain level there was the potential to result in unnecessary side effects like lethargy and sleepiness. The DON stated the facility P&P was not followed. During a review of the facility P&P titled, Administering Pain Medication, last reviewed and approved on 1/14/2026, the P&P indicated that The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. General Guidelines. 1. The pain management program is based on a facility-wide commitment [NAME] appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary process that includes the following: a. identifying signs and symptoms of and assessing existing pain; .6. When opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose. a. Any resident who uses opioids for long-term management of chronic pain is at risk for opioid overdose. Equipment and Supplies. 1. Standardized pain assessment tools, as indicated per facility protocol. Steps in the Procedure. Administer pain medications as ordered.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 14) who was receiving dialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatment, received services consistent with professional standards of practice, by failing to ensure: 1. Licensed Nurses (LNs) followed the physician's order for a 1200 cc (cubic centimeter - unit of measurement used for liquids, (1cc equivalent to 1 ml (milliliter) - metric unit of measurement used for liquids) a day fluid restriction (limiting the total amount of liquids you consume each day) and monitored Resident 14's fluid intake. 2. LNs obtained a physician's order to monitor Resident 14's intake and output (I&O - the measurement of all the fluids that go into a person's body and all the fluids that leave it). 3. The facility developed and implemented a comprehensive, resident centered Care Plan (CP) addressing the 1200 cc a day fluid restriction. 4. LNs notified the physician of Resident 14's noncompliance with the prescribed fluid restriction. 5. The facility developed and implemented comprehensive, resident centered CP addressing Resident 14's noncompliance with fluid restrictions. These deficient practices had the potential to result in fluid overload (body holding too much water and salt) in resident on dialysis, leading to shortness of breath, swelling and fluid buildup in the lungs, increased strain on the heart, elevated blood pressure. It could also result in dehydration (body losing more fluids than it takes in) leading to electrolyte imbalance (too much or too little of essential minerals (like sodium, potassium, and calcium) in your body), hypotension (low blood pressure), confusion and weakness. Findings: During a review of Resident 14's admission Records (AR - the front page of the chart that contains a summary of basic information about the resident), the AR indicated that the facility originally admitted Resident 14 on 6/6/2024, and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), type two Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet). During a review of Resident 14's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2026, the MDS indicated that the resident had intact cognitive (thinking or mental processing) skills for daily decision making. The MDS indicated that Resident 14 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (a type of medicine used to lower high blood sugar levels, primarily in people with Type two diabetes). During a review of Resident 14's Order Summary Report (OSR), the OSR indicated an order for fluid restriction of 1200 cc; Dietary = 720 cc, Nursing: 180 cc, 7 - 3 shift (work schedule) = 180 cc, 11 - 7 shift = 120 cc, every shift. The OSR review indicated no physician order to monitor Resident 14's I&O. During a review of resident 14's Medication Administration Report (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 5/2026, the MAR indicated no documentation of Resident 14's consumed fluid amount. During a review of Resident 14's CP Report, CR indicated no documentation of a CP addressing the resident`s 1200 cc a day fluid restriction. During a concurrent observation and interview on 5/21/2026 at 10:55 a.m. with Certified Nurse Assistant (CNA) 4 inside Resident 14's room, observed a water pitcher containing 250 ml clear liquid, one 2/3 full bottle of Gatorade (flavored sugar water with added salts) drink on Resident 14's bedside table, and one bottle of unopened soda drink on Resident 14's nightstand. CNA 4 stated she (CNA 4) provided the resident with a pitcher of water with measurement markings, filled to 800 ml at the beginning of her shift (around 7 a.m.). CNA 4 stated that Resident 14 received additional fluids throughout the day, including a cup of coffee with breakfast, a cup of water or juice during lunch, water when taking medications, and one to two cups of juice in between meals. CNA 4 stated Resident 14's visitors [NAME] Gatorade and a bottle of soda. CNA 4 added that she (CNA 4) repeatedly instructed the resident not to consume outside fluids due to Resident 14's dialysis status and ordered fluid restriction, however, the resident remained noncompliant. CNA 4 stated that she (CNA 4) was not instructed to document the amount of fluids consumed by the resident and that she (CNA 4) was not aware of any designated place to record that information. CNA 4 further stated she (CNA 4) only documents completion of the task by checking it off in the MAR, without recording the actual intake amount. CNA added that she (CNA 4) would not report the resident's fluid intake to a LN. During a concurrent interview and record review on 5/21/2026 at 11:05 a.m. with Registered Nurse (RN) 4, RN 4 stated when a resident placed on a fluid restriction, there should be a physician's order for an I&O, and CP addressing fluid restriction. RN 4 stated CNA's must be instructed to monitor resident's I&O, and report to CNs. RN 4 reviewed Resident 14's OSR, MAR for 5/2026 and CP. RN 4 stated there was an order for 1200 cc a day fluid restriction. RN 4 stated that MAR for 5/2026 indicated task completion for 1200 cc a day fluid restriction monitoring every shift and did not indicate the amount that Resident 14 had consumed. RN 4 reported CP addressing 12oo cc fluid restriction was not comprehensive and did not indicate resident centered interventions on how to meet the resident's needs. RN 4 further stated if Resident 14 was noncompliant with a fluid restriction, the staff needed to provide education to the resident on the importance of adhering to the restrictions. RN 4 stated that the physician must be notified of the noncompliance, and the noncompliance must be addressed in the CP. RN 4 reviewed Resident 14's Progress Notes (PN), and CP report. RN 4 stated there was not documentation of physician notification of Resident 14's noncompliance with 1200 cc fluid restriction. RN 4 further stated that there was no care plan developed addressing Resident 14's noncompliance with fluid restriction. RN 4 stated that residents on dialysis and on fluid restriction who were not properly monitored could experience complications such as fluid overload, shortness of breath, hypertension, dehydration and weakness. RN 4 added that failure to notify the physician of noncompliance and to update the care plan may prevent the interdisciplinary team (a group of experts from different fields who work closely together to solve a complex problem or care for a person's specific needs) from identifying patterns and implementing appropriate interventions. During an interview on 5/22/2026 at 2:40 p.m. with the Director of Nursing (DON), the DON stated that for a resident on a fluid restriction, failure to monitor fluid intake may result in fluid overload or dehydration, as well as complications such as edema, shortness of breath. The DON stated that comprehensive, resident centered care plan must be developed and implemented, including individualized intervention and monitoring requirement for the resident. The DON stated Resident 14's noncompliance with fluid restriction should have been communicated with the physician, and care planned. Not notifying the physician and not updating the CP can lead to failure to recognize and respond to changes in the resident's condition, resulting in unaddressed fluid overload or dehydration, delayed interventions, shortness of breath, low blood pressure and worsening of the resident's health condition. During a review of the facility's Policies and Procedures (P&P) titled Dialysis Care, last updated on 1/14/2026, the P&P indicated, .Ill. PROCEDURE. 2. Care Plan a. The Interdisciplinary Team (IDT) will ensure that the resident's Care Plan includes documentation of the resident's renal condition and necessary precautions (e.g., shunt site, weights, dietary and fluid restrictions, no B/P on affected side, lab draws, IV, injection on arm with shunt, observe for signs and symptoms of infection, etc.). i. The resident's Care Plan will be updated as needed. b. If the resident does not comply with his or her Care Plan, the Facility will document this non-compliance with following Care Plan and make the necessary adjustments, including providing additional education to the resident. Dialysis Care. b. Fluid Restrictions i. Dialysis residents are given fluid based on the fluid restriction as ordered by the physician. The Nursing Staff will notify the attending physician about resident's noncompliance to the fluid restriction. During a review of the facility's P&P, titled Encouraging and Restricting Fluids, last updated on 1/14/2026, the P&P indicated, Restricting Fluids: 1. Remove the resident's water pitcher and cup from the room. Store in designated area. If the resident refuses to have the water pitcher removed, notify the supervisor and in turn, the physician. 6. Record the amount of fluid consumed on the intake side of the intake and output record. Record fluid intake in mls. Documentation. 6. The amount (in mls) of fluids consumed by the resident during the shift. 8. If the resident refused the treatment, the reason(s) why and the intervention taken.

Based on observation, interview, and record review the facility failed to safely use bed rails (metal or plastic bars or guards attached to the sides of a bed to act as a barrier or support) for four of four sampled residents (Resident 14, 77, 82 and 108) by failing to ensure: 1. Resident 14's half (1/2) bed rails (a 1/2 (half-length) bed rail is a safety barrier that covers only the top portion of a bed, typically near the user's torso) had an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) and complete bed rail assessment on its use. 2. Resident 77's 1/2 bed rails had a physician's order, informed consent and a comprehensive, person-centered care plan for its use. 3. Resident 82's 1/2 bed rails had a physician's order, informed consent, bed rail assessment and comprehensive, person-centered care plan for its use. 4. Resident 108's 1/2 bed rails had a physician's order, complete bed rail assessment and comprehensive, person-centered care plan for its use. These deficient practices placed the residents at risk for potential accidents such as a body part being caught between the rails, falls if a resident attempts to climb over, around, between, or through the rails. Findings: 1. During a review of Resident 14's admission Records (AR - the front page of the chart that contains a summary of basic information about the resident), the AR indicated that the facility originally admitted Resident 14 on 6/6/2024, and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD - irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), type two Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet). During a review of Resident 14's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2026 had intact cognitive (thinking or mental processing) skills for daily decision making. The MDS indicated that Resident 14 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. During an observation on 5/18/2026 at 10:13 a.m. inside Resident 14's room, observed Resident 14 lying in bed with bilateral 1/2 bed rails elevated. During a review of Resident 14's Order Summary Report (OSR), the OSR indicated an order for bed rails as an enabler for turning and positioning, dated 5/2/2025. During a review of Resident 14's Bed Rail Evaluation (BRE) dated 5/2/2026, the BRE indicated that the resident/resident representative was not informed about the medical needs that would be addressed by the use of side rails, educated about the benefits and potential side effects from the use of bed rails, and informed of alternatives attempted that failed to meet the resident's needs. During a review of Resident 14's Care Plan (CP) Report titled At risk for impaired bed mobility, the CP indicated an intervention to obtain informed consent from resident/resident representative for use of positioning to assist with moving within the bed, getting in and out of bed. During a concurrent observation and interview on 5/22/2026 at 12:48 p.m. with MDS Director (MDSD) inside Resident 14's room, observed Resident 14's bilateral 1/2 bed rails elevated. The MDSD stated the resident used the bed rails for repositioning and mobility. During a concurrent interview and record review on 5/22/2026 at 1:00 p.m. with MDSD, the MDSD reviewed Resident 14's electronic and paper medical records. The MDSD stated there was no documentation of bed rail informed consent. The MDSD reviewed BRE and stated the BRE was incomplete, because the BRE indicated resident/resident representative was not informed about the medical needs that would be addressed by the use of side rails, educated about the benefits and potential side effects from the use of bed rails, and informed of alternatives attempted that failed to meet the resident's needs. 2. During a review of Resident 77's AR, the AR indicated that the facility officially admitted the resident on 3/5/2019, and readmitted on [DATE], with diagnoses including catheter-associated urinary tract infection (CAUTI - an infection in the bladder/urinary tract caused by urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) use), stage 4 chronic kidney disease (CKD - kidneys are damaged and cannot filter blood the way they should), and DM. During a review of Resident 77's History and Physical (H&P), dated 11/25/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 77's MDS, dated [DATE], the MDS indicated Resident 77 had intact cognitive skills. The MDS indicated the resident required substantial/maximal assistance with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. During an observation on 5/18/2026 at 10:29 a.m. in Resident 77's room, observed Resident 77 lying in bed with bilateral 1/2 bed rails elevated. During a review of Resident 77's OSR, the OSR indicated no documentation of physician's order for bed rail use. During a review of Resident 77's Care Plan (CP) Report, the CP indicated no documentation of care plan for bed rail use. During a concurrent observation and interview on 5/22/2026 at 12:51 p.m. with MDSD inside Resident 77's room, observed Resident 77's bilateral 1/2 bed rails elevated. The MDSD stated the resident used the bed rails for repositioning and mobility. During a concurrent interview and record review on 5/22/2026 at 1:00 p.m. with MDSD, the MDSD reviewed Resident 77's electronic and paper medical records. The MDSD stated there were no physician's order, bed rail informed consent, and CP documented for Resident 77's bed rail use. 3. During a review of Resident 82's AR, the AR indicated that the facility officially admitted the resident on 3/10/2023, and readmitted on [DATE], with diagnoses including DM, hypertension (high blood pressure), hypothyroidism (when your thyroid gland doesn't produce enough essential hormones). During a review of Resident 82's H&P, dated 12/20/2024, the H&P indicated Resident 82 had the capacity to understand and make decisions. During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82 had moderately impaired cognitive skills (can manage basic self-care, need help with more complex tasks like managing money, taking medications correctly, or following multi-step directions). The MDS indicated Resident 82 was dependent (helper does all of the effort) on shoer and putting on/taking off footwear, required partial/moderate (helper does less than half the effort) with oral and personal hygiene and upper body dressing. During an observation on 5/18/2026 at 10:30 a.m. inside Resident 82's room, observed Resident 82 lying in bed with bilateral 1/2 bed rails elevated. During a review of Resident 82's OSR, the OSR indicated no documentation of physician's order for bed rail use. During a review of Resident 82's Care Plan (CP) Report, the CP indicated no documentation of care plan for bed rail use. During a concurrent observation and interview on 5/22/2026 at 12:53 p.m. with MDSD inside Resident 82's room, observed Resident 82's bilateral 1/2 bed rails elevated. The MDSD stated the resident used the bed rails for repositioning and mobility. During a concurrent interview and record review on 5/22/2026 at 1:00 p.m. with MDSD, the MDSD reviewed Resident 82's electronic and paper medical records. The MDSD stated there were no physician's order, BRE, bed rail informed consent, and CP documented for Resident 82's bed rail use. 4. During a review of Resident 108's AR, the AR indicated that the facility officially admitted the resident on 11/22/2024, and readmitted on [DATE], with diagnoses including DM, depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities you normally enjoy), dysphagia (difficulty swallowing). During a review of Resident 108's H&P, dated 11/19/2025, the H&P indicated Resident 108 had fluctuating (changing) capacity to understand and make decisions. During a review of Resident 108's MDS, dated [DATE], the MDS indicated Resident 108 had moderately impaired cognitive skills. The MDS indicated Resident 108 required substantial/maximal assistance with toileting and personal hygiene, shower, lower body dressing, putting on/taking off footwear. During an observation on 5/18/2026 at 10:13 a.m. in Resident 108's room, observed Resident 108 lying in bed with bilateral 1/2 bed rails elevated. During a review of Resident 108's OSR, the OSR indicated no documentation of physician's order for bed rail use. During a review of Resident 108's Care Plan (CP) Report, the CP indicated no documentation of care plan for bed rail use. During a concurrent observation and interview on 5/22/2026 at 12:29 p.m. with MDSD in Resident 108's room, observed Resident 108's bilateral 1/2 bed rails elevated. The MDSD stated the resident used the bed rails for repositioning and mobility. During a concurrent interview and record review on 5/22/2026 at 1: 10 p.m. with MDSD, the MDSD reviewed Resident 108's electronic and paper medical records. The MDSD stated there were no physician's order and CP documented for Resident 108's bed rail use. The MDSD reviewed Resident 1089's BRE, dated 11/18/2025, and stated the BRE was incomplete, because the BRE indicated resident/resident representative was not informed about the medical needs that would be addressed by the use of side rails, educated about the benefits and potential side effects from the use of bed rails, and informed of alternatives attempted that failed to meet the resident's needs. During a subsequent interview on 5/22/2026 at 1:20 p.m. with the MDSD, the MDSD stated that bed rails were considered a form of restraint and require a physician's order, informed consent, bed rail assessment and a comprehensive, person-centered care plan. The MDSD stated if the physician's order was not in place, the use of bed rails would be unauthorized and could place the resident at risk for improper use. The MDSD further stated that if a care plan is not developed, staff may not have clear guidance on the proper use of bed rails. The MDSD added if the bed rail assessment was not completed, potential hazards such as entrapment, suffocation, or falls may not be identified. The MDSD stated if informed consent was not obtained, the resident/responsible party may not be aware of the risks, benefits, and alternatives of bed rail use. The MDSD added that lack of consent documentation may indicate resident's rights were not respected, the residents have the right to accept or decline the use of bed rails. During an interview on 5/22/2026 at 2:40 p.m. with the Director of Nursing (DON), the DON stated bed rails were considered a restraint, and required having physician's order, informed consent, bed rail assessment and a care plan. The DON stated the absence of any of these required elements can result in increased potential for resident harm, including injury, entrapment, falls, and violation of resident rights. During a review of facility's Policies and Procedures (P&P), titled Siderails, last reviewed on 1/14/2026, the P&P indicated, PROCEDURE Physical Restraint is defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical' device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. III. The Licensed Nurse will complete the Bedrail Evaluation UDA and develop a Care Plan reflecting that evaluation. a. The IDT will discuss the risks involved wit side rails with the resident and/or the resident's surrogate decision maker and caregivers and describe alternatives that may be safer and feasible (e.g., a lower bed, trapeze, transfer pole). b. Prior to placing a side rail on the bed informed consent will be obtained when side rail meets the definition of a physical restraint even when it is also be an enabler.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) by failing to:1.Ensure Licensed Vocational Nurse (LVN) 7 administered benazepril (medication to treat high blood pressure), aspirin (medication that helps prevent blood clots [clumping of blood]), fish oil (supplement to treat high cholesterol), and refresh tears eyes drops (medication to treat dry eyes) per the physician's orders on 5/18/2026. during the routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely) for one of six sampled residents (Resident 140) reviewed for Accidents. 2.Ensure LVN 7 did not document the administration of benazepril, aspirin, and fish oil prior to leaving the medication for self-administration for one of six sampled residents (Resident 140) reviewed for Accidents. 3.Ensure LVN 7 did not document the administration of refresh tears eye drops prior to administering the medication for one of six sampled residents (Resident 140) reviewed for Accidents.4.Ensure LVN 7 administered refresh tears eye drops per the facility policy and procedure (P&P), from one hour before to one hour after the scheduled administration time for one of six sampled residents (Resident 140) reviewed for Accidents. These deficient practices resulted in inaccurate MAR documentation and had the potential to result in increased blood pressure, cholesterol levels, and a risk for cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) for Resident 140.5.Account for two doses of controlled substances (CS- medications which have potential for abuse and may lead to physical or psychological dependence) for Resident 72 in one of four inspected medication carts (Medication Cart Station 3) reviewed for Medication Storage and Labeling tasks. These deficient practices increased the opportunity for CS diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel or distribution or use) and increased the risk that Resident 72's could have delayed medication treatment and continuity of care.Cross-reference F760 and F842.Findings: a. During a review of Resident 140's admission Record (AR), the AR indicated that the facility admitted the resident on 5/9/2022 with diagnoses including hypertension (HTN-high blood pressure), hyperlipidemia (HLD - high cholesterol [a waxy substance that can build up in the blood resulting in stroke or heart issues]), chronic kidney disease (CKD a condition in which the kidneys are damaged and cannot filter blood as well as they should), and age related nuclear cataract (excessive amount of yellowing and light scattering affecting the center of the lens). During a review of Resident 140's Minimum Data Set (MDS- a resident assessment tool), dated 5/7/2026, the MDS indicated the resident had the ability to make himself understood and had the ability to understand others. The MDS indicated the resident required partial to moderate assistance from staff with activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) including showering and bathing self, lower body dressing, and putting on and taking off footwear. During a review of Resident 140's History and Physical (H&P), dated 5/14/2026, the H&P indicated the resident had fluctuating capacity (an individual experiences changes in their mental state, which can affect their decision-making abilities). During a review of Resident 140's Order Summary Report, the Order Summary Report indicated the following physician orders: -Benazepril HCI tablet 10 milligrams (mg, a unit of measurement), give one (1) tablet by mouth two times a day for HTN, hold (do not give) for systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart]) less than (<) 100 millimeters of mercury (mmHg – measurement of pressure), dated 12/2/2024. -Fish Oil oral capsule 1000 mg, give 1 capsule by mouth one time a day for Supplement, dated 4/4/2024.-Aspirin tablet chewable, 81 mg, give 1 tablet by mouth one time a day for cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) prophylaxis (prevention), dated 05/09/2022.-Refresh Tears Solution 0.5 % (carboxymethylcellulose Sodium, eye drop medication to treat dry eyes) Instill 1 drop in both eyes three times a day for dry eyes, dated 5/9/2022. During a concurrent observation and interview on 5/18/2026 at 9:50 a.m. with Resident 140, Resident 140 was observed lying in bed while no staff was observed in the room. On the floor next to the resident's bed there were two tablets and two clear capsules. Resident 140 stated the nurse left his medications during breakfast and they fell on the floor while he was eating. Resident 140 stated he thought he took some of the medications, but he was not sure. During a concurrent observation, interview, and record review on 5/18/2026 at 10:05 a.m., while at Resident 140's room, with LVN 7, Resident 140's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) were reviewed. LVN 7 stated the facility protocol for medication administration is that the licensed nurse (LN) should watch the resident take the medication and then document the administration after the medications are taken. LVN 7 stated medications should not be left at bedside for self-administration. LVN 7 stated if the resident does not take the medication, then the LN nurse should take the medications out of the room, place them in the medication cart, return to administer the medications when the resident is ready, and then document in the MAR after the medications are administered. LVN 7 stated earlier in the morning, she left Resident 140's medications at the bedside for the resident to self-administer. LVN 7 stated she did not watch Resident 140 administer the medications because she was called away to attend to another resident. LVN 7 stated she should not have left the medications at the bedside for the resident to self-administer, but she did. LVN 7 then stated she documented Resident 140's medications as administered in the MAR when the medications were left at bedside. LVN 7 stated she should not have documented Resident 140's medications prior to administration, but she did. LVN 7 then stated she did not yet administer Resident 140's refresh eye drops, but she had also documented the eye drops as administered in the MAR prior to administration. LVN 7 stated the eye drops should have been administered before 10 a.m., but they were not. LVN 7 then entered Resident 140's room and stood directly over the two tablets and two capsules on the floor and administered the refresh tears eye drops to Resident 140. LVN 7 exited Resident 140's room and the medications remained on the floor. LVN 7 then re-entered Resident 140's room upon the request of the surveyor and stated there was a benazepril tablet, an aspirin tablet, and two fish oil capsules on the floor. LVN 7 stated she did not follow the facility medication administration protocol. LVN 7 stated it was not safe to leave resident medications unattended at bedside because the resident may not take the medications. During a concurrent observation and interview on 5/18/2027 at 10:15 a.m., while in the hallway at the medication cart, the Assistant Director of Nursing (ADON) and LVN 7 compared Resident 140's medication bubble packs (a package that contains multiple sealed compartments with medication) with the medication found on the resident's floor. The ADON stated the medications were confirmed to be benazepril, aspirin, and fish oil. During an interview on 5/18/2026 at 10:35 a.m., with the ADON, the ADONstated the medication administration process is that the LN supervises the resident while they take the medications to ensure the medications are administered and then the LN documents in the MAR. The ADON stated documentation is to be done in the MAR after medications are administered to make sure the MAR reflects accurately what medications were taken and when. The ADON stated Resident 140 was not safe to self-administer medications. The ADON stated LVN 7 did not follow the facility protocol. During a follow-up concurrent interview and record review on 5/19/2026 at 2:22 p.m., with LVN 7, LVN 7 reviewed Resident 140's MAR and stated on 5/18/2026 she did not administer Resident 140's benazepril, aspirin, or fish oil because she could not determine if the medications found on the floor were the medications she left at bedside. LVN 7 stated she did not want to give additional doses of the medication if she was not sure. LVN 7 stated when Resident 140 did not receive the benazepril there was the potential that the resident's blood pressure would go up, without the aspirin there was the potential the resident could have a blood clot, and without the fish oil capsule there was the potential for an increase in the resident's cholesterol. During a follow-up concurrent interview and record review on 5/20/2026 at 9:39 a.m. with the ADON, the ADON reviewed Resident 140's MAR and stated there was no way to know if Resident 140 received benazepril, aspirin, or fish oil per the physician's orders on 5/19/2026 and it was considered a medication error. The ADON stated on 5/19/2026 LVN 7 documented benazepril, aspirin, and fish oil as administered, but they do not know if they were administered. The ADON stated LVN 7 should not have documented in the MAR prior to giving the medications, but she did. The ADON stated LVN 7 did not follow the facility process for documenting the administration of medication. The ADON further stated the facility process entails that medications are administered one hour before or one hour after the scheduled administration time at 9 a.m. The ADON stated Resident 140's refresh eye drops should have been administered before 10 a.m., but they were not. The ADON stated it was a medication error when the refresh eye drops were administered late. During a concurrent interview and record review on 5/22/2026 at 1:45 p.m. with the Director of Nursing (DON), | administration when she left medications at the bedside for Resident 140 to self-administer. The DON stated it was a medication error when LVN 7 did not know if Resident 140 received benazepril, aspirin, and fish oil. The DON stated the medication error could potentially result in the resident developing issues from the missed medications like unregulated cholesterol, risk for blood clots, and high blood pressure. The DON then stated it was important to ensure medications are administered at the correct time so there is an adequate amount of time between doses. The DON stated it was a documentation and medication error when LVN 7 documented Resident 140's eye drops as administered at 9:36 a.m. on 5/18/2026, but LVN 7 did not administer the eye drops until after 10 a.m. The DON stated the eye drops were administered over one hour after the administration time and considered late. The DON further stated it was important to ensure the MAR reflected the actual time of medication administration so that the staff would know when the last dose of medication was administered and to be able to monitor any side effects. The DON stated the facility P&Ps were not followed when LVN 7 documented Resident 140's medications as administered prior to giving, and LVN 7 was not able to determine if Resident 140's medications were administered, the eye drops were administered late, and the MAR did not accurately reflect the time of the eye drops administration. During a review of the facility's P&P titled, Administering Medications, last reviewed and approved on 1/14/2026, the P&P indicated that Medications are administered in a safe and timely manner, and as prescribed. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. If a drug is withheld, refused, or given at a time other than the scheduled, document refusal. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: The date and time the medication was administered. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. During a review of the facility's P&P titled, Medication Errors, last reviewed and approved on 1/14/2026, the P&P indicated that The Facility will work to keep medication error rates five percent or lower. Medication Error means the administration of medication:. At the wrong time. An omission in the documentation in the Medication administration Record may or may not constitute a medication error. During a review of the facility's P&P titled, Charting and Documentation, last reviewed and approved on 1/14/2026, the P&P indicated that All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The following information is to be documented in the resident medical record: Medications administered. Documentation in the medical record will be . complete, and accurate. During a review of the facility's P&P titled, Documentation of Medication Administration, last reviewed and approved on 1/14/2026, the P&P indicated that A medication administration record is used to document all medications administered. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR). Administration of medications is documented immediately after it is given. b. During a review of Resident 72's AR, the AR indicated that the facility originally admitted the resident on 3/17/2025 and readmitted on [DATE] with diagnosis including urinary tract infection (UTI- an infection in the bladder/urinary tract), type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic pain. During a review of Resident 72's MDS, dated [DATE], the MDS indicated that the resident makes self-understood and has the ability to understand others. The MDS indicated that the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). The MDS indicated that the resident was taking opioids (sometimes called narcotics, are medications prescribed by doctors to treat persistent or severe pain). During a review of Resident 72's physician order, the physician order indicated the following: -Dated 3/25/2026, Lyrica (a CS used for nerve pain) oral capsule 50 milligrams (mg – a unit of measurement) (pregabalin) give one (1) capsule by mouth every eight (8) hours for nerve pain. -Dated 5/2/2026, Methadone hydrochloride (a CS used for severe chronic pain) oral tablet 10 mg, give two tablets by mouth one time a day for pain management hold if respiratory rate less than 12 or with excess sedation. During a concurrent observation and interview on 5/20/2026 at 11:38 a.m., with LVN 3, at Medication Cart Station 2 T2, there was a discrepancy in the count between the Antibiotic or Controlled Drug Record (also known as Controlled Medication or CS or Controlled Drug Record or Controlled Drug Administration Record) and the amount of medication remaining in the medication bubble pack for Resident 72: One dose of pregabalin capsule and one dose of a methadone tablet were missing from the medication bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record forms. The Antibiotic or Controlled Drug Record form for pregabalin indicated the medication bubble pack should have contained a total of 38 pregabalin 50 mg capsules, after the last administration of pregabalin 50 mg documented/signed off on 5/19/2026 at 10 p.m., however the medication bubble pack contained 37 pregabalin 50 mg capsules and contained no other documentation of subsequent administrations. The Antibiotic or Controlled Drug Record form for methadone indicated the medication bubble pack should have contained a total of seven (7) methadone 10 mg tablets, after the last administration of methadone documented/signed off on 5/20/2026 at 6 a.m., however the medication bubble pack contained six (6) methadone 10 mg tablets and contained no other documentation of subsequent administrations. LVN 3 stated he did not sign Resident 72's methadone 10 mg tablet this morning when he administered it at 9 a.m. LVN 3 stated the Antibiotic or Controlled Drug Record should have reflected 6 methadone 10 mg tablets, but he forgot to sign it this morning. LVN 3 stated he should have signed the Antibiotic or Controlled Drug Record right after administration and signing the Medication Administration Record. LVN 3 stated the pregabalin should have a total of 37 pregabalin 50 mg capsules, but it was not signed this morning. LVN 3 stated the count should be correct because these are controlled medications they want to make sure that the medication was administered to the resident and that he did not take it himself. During an interview on 5/20/2026 at 1:33 p.m., with the ADON, the ADON stated they signed off the Medication Administration Record and the Antibiotic or Controlled Drug Record before moving on to the next resident. The ADON stated that when the Antibiotic or Controlled Drug Record is not signed right away there is a tendency the licensed nurse will forget it and the count would not be correct. The ADON stated the Controlled Drug Record count, and the medication bubble pack should match. The ADON stated that when the Antibiotic or Controlled Drug Record and the medication bubble pack count are not correct there is potential for loss and diversion and the resident not receiving the medication. During a review of the facility's P&P titled, Controlled Substances, last reviewed and approved on 1/14/2026, the P&P indicated that The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-IV of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Dispensing and Reconciling Controlled Substances. 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately in one of two medication rooms (Med Room Station 1) and one of four medication carts (Med Cart Station 3) observed during the Medication Storage and Labeling task by failing to: 1. Label the house supply of tuberculin purified protein derivative (PPD) (Aplisol - an injectable solution used in the skin test to detect tuberculosis [TB - a bacterial infection that primarily affects the lungs] infections) with an open date in accordance with manufacturer's requirements in Med Room Station 1. 2. Ensure the removal and disposal of Resident 112's hydrocodone-acetaminophen (used to treat moderate to severe pain) bubble pack (a medication packaging system that contains individual doses of medication per bubble) slot #28 with broken seal and was covered with tape in Med Cart Station 3. 3. Ensure the removal of expired medication, Resident 29's morphine, in Med Cart Station 3. These deficient practices had the potential to result in residents receiving medication that had become ineffective or toxic due to improper storage or labeling. Findings: a. During a concurrent observation and interview on 5/20/2026 at 11:23 a.m. with Licensed Vocational Nurse (LVN) 5, in Med Room Station 1, LVN 5 stated inside the medication refrigerator one tuberculin PPD vial was opened and used with no open date. LVN 5 stated it should have an open date because it's only good for 30 days. LVN 5 stated she will inform the Infection Preventionist and call the pharmacy to reorder. The tuberculin PPD box indicated fill date 4/3/2026 and instructions Once entered, vial should be discarded after 30 days. During an interview on 5/20/2026 at 1:36 p.m. with the Assistant Director of Nursing (ADON), the ADON stated the tuberculin PPD vial is a multi-dose vial and should have an open date of when it was first used because it's only good for certain number of days, 30 days once opened. The ADON stated the tuberculin PPD vial could be expired already, and the effectiveness would not be accurate. The ADON stated that when the tuberculin PPD is administered especially residents of advanced age could experience side effects such as rashes or itchiness. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, last reviewed and approved on 1/14/2026, the P&P indicated that the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Medication Labeling. 5. Multi-dose vials that have been opened or accessed (e.g., needle puncture) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 6. Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date. b. During a review of Resident 112's Administration Record (AR), the AR indicated that the facility originally admitted the resident on 6/17/2022 and readmitted on [DATE] with diagnoses including fall, contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left knee, right ankle, and left ankle, and asthma (a chronic [long-term] lung disease that can cause breathing problems). During a review of Resident 112's physician order, dated 5/4/2026, the physician order indicated hydrocodone-acetaminophen tablet 5-325 mg, give one (1) tablet by mouth every six (6) hours as needed for moderate to severe pain (4-10) not to exceed three (3) grams (g - a unit of measurement) of acetaminophen in 24 hours. Hold if respiratory rate less than 12 or with excess sedation. During a concurrent observation and interview on 5/20/2026 at 11:46 a.m. with LVN 2, in Medication Cart Station 3, LVN 2 stated Resident 112's hydrocodone-acetaminophen 5-325 mg bubble pack slot #28 with a broken seal and covered with tape. LVN 2 stated he does not know who put the tape over it and he did not notice it before. LVN 2 stated he will inform the supervisor to surrender and destroy 1 hydrocodone-acetaminophen 5-325 mg tablet in the bubble pack. LVN 2 stated it should not have been placed back inside and should not have been covered with tape. During an interview on 5/20/2026 at 1:40 p.m. with the ADON, the ADON stated once the medication is removed from the bubble pack and for whatever reason was not used or administered to the resident then it has to be surrendered to the Director of Nursing for destruction. The ADON stated that when the medication tablet is placed back in the bubble pack it could compromise the counting and the medication has already been contaminated. The ADON stated the medication could have fallen on the floor or left out. The ADON stated that when this medication is administered to the resident they could experience adverse reaction such as vomiting from contaminated medication. During a review of the facility's P&P titled, Controlled Substances, last reviewed and approved on 1/14/2026, the P&P indicated The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-IV of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Dispensing and Reconciling Controlled Substances. 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies tot eh director of nursing services. 6. Unless otherwise instructed by the director of nursing services, when a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given) the medication is destroyed and may not be returned to the container. c. During a review of Resident 29's AR, the AR indicated that the facility admitted the resident on 12/3/2024 with diagnosis including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), hypertension (HTN- high blood pressure), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 29's physician order, indicated the following: - dated 12/3/2024, the physician order indicated morphine sulfate oral solution 10 mg/ five (5) milliliters (ml - a unit of measurement) give 0.5 ml by mouth every two hours as needed for severe pain give by sublingual (under the tongue). - dated 4/17/2026, the physician order indicated morphine sulfate oral solution 10 mg/5 ml, give 0.5 ml sublingually every two hours as needed for severe pain (8-10) hold if respiratory rate less than 12 or excess sedation. During a concurrent observation and interview on 5/20/2026 at 11:50 a.m. with LVN 2, in Medication Cart Station 3, LVN 2 observed and stated Resident 29's morphine has a use by date of 12/3/2025. LVN 2 stated it should have been removed from the medication cart and disposed of when it expired on 12/3/2025. LVN 2 stated there is potential this medication could have been administered to Resident 29. During an interview on 5/20/2026 at 2:09 p.m. with the ADON, the ADON stated that expired medications should be removed from the medication cart on the same day when the medication expired. The ADON stated that when expired meds are not removed from the medication cart the licensed nurse could potentially administer expired medication to the resident. The ADON stated the licensed would not know if the medication is effective or not and if the resident is still having worsening pain or a change in condition or because the medication was ineffective. During a record review of the facility's P&P titled, Discarding and Destroying Medications, last reviewed and approved on 1/14/2026, the P&P indicated that Medications that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances. 5. Schedule II, III, and IV (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications. c. Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident.

Based on observation, interview, and record review, the facility failed to follow the menu to meet the nutritional needs of 68 to 164 residents, when staff did not provide the three (3) ounce (oz, unit of measurement) portion size of pork roast indicated on the menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) and served 1.5 oz portion instead. This failure had the potential to result in a decrease in food flavor, a decrease in food and nutrient intake that could result in unplanned weight loss. Findings: During a review of the facility's menu spreadsheet titled Spring 2026, dated 5/18/2026, the spreadsheet indicated residents on a regular texture diet would include the following foods on the tray: Pork Roast 3 oz During an observation on 5/18/2026 at 11:53 a.m. of the food preparation, the roast pork was not uniform in size, some were bigger while some were smaller.During an interview on 5/18/2026 at 12:25 p.m. with [NAME] 1, [NAME] 1 stated he cut the pork roast from scratch as they were not individually pre-portioned. [NAME] 1 stated he did not weigh the pork roast so he would not know how heavy each portion size was. During a concurrent observation and interview on 5/18/2026 at 12:27 p.m. of the DS weighing random portions of pork roast using the facility food scale with the DS, the DS stated the portion size of the pork roast and the facility scales read: 1st portion: 2.52 oz 2nd portion: 3.7 oz 3rd portion: 3.93 ozThe DS stated [NAME] 1 needed to weigh the pork roast, to ensure it was the right cut and portion. The DS stated they need to follow the spreadsheet to make sure residents are receiving the right nutrition that they are required to receive. The DS stated the residents would not be receiving the right nutrition and it would result in weight loss due to the lesser portions of pork roast, and residents could be at risk of not following their diets, would get sick and cause high blood pressure for those getting more portions of pork roast than the spreadsheet indicated. During a review of the facility's policies and procedures (P&P) titled, Menus, dated 1/14/2026, the P&P indicated, Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guideline. Procedure: Menu cycles will be developed and tailored to meet the needs and requirements of the facility. Menu cycles will include standardized recipes. Menu cycles will include nutritional analysis to ensure all the client (adolescent, adult, geriatric) nutritional needs are met in accordance with the most recent edition of the Food and Nutrition Board, Institute of Medicine, National Academies, and the Dietary Guidelines for Americans 2020-2025 edition. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal.During a review of the facility's standardized recipe titled, Pork Roast/Gravy, dated 1/14/2026, the recipe indicated, Suggested portion: 3 oz.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature and flavor when hot foods were not served hot and pork roast, and seasoned black beans were not seasoned well and tasted bland. These failures had the potential to result in 157 of 164 facility residents including Resident 149, Resident 34, Resident 50, and Resident 163 to be at risk of unplanned weight loss, a consequence of poor food intake and receiving food from the kitchen.Findings: a). During a review of Resident 149's admission Record (AR), the AR indicated the facility initially admitted Resident 149 on 3/16/2017 with diagnosis including, but not limited to gastrointestinal reflux disease (GERD, stomach acid or contents frequently flow back in to the esophagus [the tube connecting the mouth and stomach]) without esophagitis (swelling or irritation of the tissues lining the esophagus), anxiety disorder (excessive fear or worry about a specific situation), and anemia (a condition in which the body does not have enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). During a review of Resident 149's Minimum Data Sheet (MDS- a federally mandated resident assessment tool) dated 3/5/2026, the MDS indicated Resident 149 understood others and made self-understood. The MDS indicated Resident 149 required set-up and clean-up assistance (helper sets up or cleans up; residents complete the activity. Helper assists only prior to or following the activity) when eating. During a review of Resident 149's Order Recap Report, dated 4/15/2026, the report indicated Resident 149 was ordered a regular diet, regular texture with thin liquid consistency (diet with no restriction).During an interview on 5/18/2026 at 11:00 a.m. with Resident 149, Resident 149 stated the food products are substandard and gross. Resident 149 further stated the food is not good.b). During a review of Resident 34's AR, the AR indicated the facility admitted Resident 34 on 12/2/2025 with diagnosis including, but not limited to dysphagia, oropharyngeal phase (difficulty swallowing), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities) and malignant neoplasm of the prostate (term for cancerous tumor located just below the bladder and surrounds the top portion of the tube that drains urine from the bladder).During a review of Resident 34's MDS dated [DATE], the MDS indicated Resident 34 understood others and makes self-understood. The MDS indicated Resident 34 required set-up and clean up assistance (helper provides verbal cues and/or touching/steadying and/or contract guard assistance as resident completes the activity. Assistance may be provided throughout the activity or intermittently) when eating. During a review of Resident 34's Order Summary Report, dated 12/18/2025, the report indicated Resident 34 was ordered Cardiac (diet avoiding foods high in fat, cholesterol, and salt), bite size texture (soft, tender and moist with no thin liquid leaking or dripping from the food), thin consistency.During an interview on 5/18/2026 at 11:28 a.m., with Resident 34, Resident 34 stated the food does not taste good.c). During a review of Resident 50's AR, the AR indicated the facility admitted Resident 50 on 4/1/2026 with diagnosis including, but not limited to dysphagia oropharyngeal phase, hyperlipidemia (high levels of fat and cholesterol in the blood) and unspecified protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body function).During a review of Resident 50's MDS dated [DATE], the MDS indicated Resident 50 understood others and make self-understood. The MDS indicated Resident 50 needed setup and clean-up assistance when eating. During a review of Resident 50's Order Summary Report, dated 5/14/2026, the report indicated Resident 50 was ordered a cardiac diet, easy to chew (diet consisting of food that is soft, tender and need less chewing), thin consistency diet. During an interview on 5/18/2026 at 12:56 p.m. with Resident 50, Resident 50 stated the food does not taste good.e). During a review of Resident 163's AR, the AR indicated the facility admitted Resident 163 on 5/1/2026 with diagnosis including, but not limited to GERD, essential hypertension (HTN, increased blood pressure), type 2 diabetes mellitus (a chronic condition in which the body does not make enough insulin [natural hormone produced by the pancreas] or cannot use it properly resulting in increased blood sugar levels.During a review of Resident 163's Order Summary, dated 5/1/2026, the report indicated Resident 163 was ordered carbohydrate controlled (limiting amount of carbohydrates rich food in the diet), no added salt (NAS, no salt packet on the trays), regular texture, and thin consistency diet.During a review of Resident 163's MDS dated [DATE], the MDS indicated Resident 163 understood others and makes self-understood. The MDS indicated Resident 163 required supervision or touching assistance when eating. During an interview on 5/18/2026 at 4:00 p.m. with Resident 163, Resident 163 stated meals are very bland, with no seasoning and no flavor.During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Spring 2026 dated 5/18/2026, the spreadsheet indicated residents on a regular texture diet would include the following foods on the tray: Pork Roast 3 ounces (oz, a unit of measurement). Seasoned black beans 1/2 cup (c, a household measurement). Smothered cabbage 1/2 c. Cornbread/margarine 1 each. Beverage 8 oz.During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 5/18/2026 at 2:04 p.m. of the regular diet, the Dietary Supervisor (DS) took the temperature of the following food using the facility thermometer. The DS stated the thermometer read the following temperature: Pork roast with gravy 104 degrees Fahrenheit ( F, a degree of temperature) Seasoned black beans 90 F Smothered cabbage 111 FDuring a review of the facility's cook spreadsheet titled, Spring Menus, dated 5/18/2026, the spreadsheet indicated residents on a puree diet/International Dysphagia Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 would include the following foods on the tray: Pureed roast pork with gravy 1/2 c. Pureed seas black beans 1/2 c. Pureed smothered cabbage 1/4 c. Pureed corn bread with margarine 1/3c / 1 piece. Apple sauce 1/2 c. Beverage 8 oz. During a concurrent test tray observation and interview on 5/18/2026 at 2:05 p.m. of the puree diet, the DS took the temperature of the following foods using the facility thermometer. The DS stated the thermometer read the following temperature: Pureed pork roast 114 F. Pureed seasoned black beans 97 F. Pureed smothered cabbage 105 F.During an interview on 5/18/2026 at 2:07 p.m. with the DS, the DS stated the seasoned black beans needed to be more seasoned and pork roast was bland. The DS further stated that the food temperature could be a little hotter. The DS stated that residents would not eat the food and were not getting the full flavor of the meal and palatable temperatures. The DS stated residents could have a potentially poor food intake and weight loss if they don't eat the food.During a review of the facility's policies and procedures (P&P) titled Food: Quality and Palatability, dated 1/14/2026, the P&P indicated, Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive and served in a manner, form, and texture to meet resident's needs. Definitions: Food attractiveness refers to the appearance of the food when served to the residents. Food palatability refers to the taste and flavor of the food. Proper (safe and appetizing) temperature-food should be at the appropriate temperature as determined by the type of food to ensure residents' satisfaction and minimize the risk of scalding and burns. 1.The dining services director and cook(s) are responsible for the food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 2.The cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate. (2) [NAME] use proper cooking techniques to ensure color and flavor retention.During a review of the facility's P&P titled, Menus, dated 1/14/2026, the P&P indicated, Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guideline. Procedure: Menu cycles will include standardized recipes. During a review of the facility's recipe titled, Pork Roast dated 1/14/2026, the recipe indicated, ingredient: pork roast, black pepper, salt, garlic gloves.During a review of the facility's recipe titled, Seasoned Black Beans, dated 1/14/2026, the recipe indicated, ingredient: ground cumin, coriander, oregano, marjoram, dry black beans, onions, garlic gloves, jalapeno pepper, bay leaf, tomato puree, salt and black pepper.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed corn bread was too sticky and did not fall from the spoon during the spoon tilt test (a method used to determine the stickiness of the food and ability of food to hold together) and the puree smothered cabbage did not hold its shape and it was flat on the plate causing it to touch the other food items. These failures had the potential to result in difficulty swallowing and difficulty in eating, and a decrease in food and nutrient intake to 33 of 33 residents on a puree diet (foods that are soft, pudding like consistency and hold its shape), resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).Findings: During a review of the facility's cook spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Spring Menus, dated 5/18/2026, the spreadsheet indicated residents on a puree diet/International Dysphagia Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 would include the following foods on the tray: Pureed roast pork with gravy 1/2 cup (c, a household measurement). Pureed seas black beans 1/2 c. Pureed smothered cabbage 1/4 c. Pureed corn bread with margarine 1/3 c/ 1 piece. Apple sauce 1/2 c. Beverage 8 oz. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 4/20/2026 at 2:36 p.m. of the puree tray with the Dietary Supervisor (DS), the DS stated the puree smothered cabbage did not hold its shape and it was flat on the plate causing it to touch the other food items. The DS further stated that the puree corn bread took time to fall off the spoon and it was after putting pressure while titling that it fell off from the spoon during the spoon tilt test. The DS stated the puree corn bread was sticky. The DS stated it would be hard for residents to swallow if the puree food is sticky and could cause choking as a potential outcome. The DS stated that puree food that is flat and does not hold its shape could also cause residents to choke as a potential outcome. During an interview on 5/19/2026 at 11:19 a.m., with the Registered Dietitian (RD), the DS stated she was not sure if the pureed food was checked on the trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates) but it is important to perform the spoon tilt test as food gets thickened over time and it gets too sticky resulting in residents having a harder time trying to swallow the food. The RD stated there would be a risk of difficulty swallowing and food not going down smoothly as a potential outcome. The RD further stated puree foods that are flat on the plate would not be presentable and not pleasant to look at and residents would not want to eat the food.During a review of the facility's policies and procedures titled Diet Manual, dated 1/14/2026, the P&P indicated, An approved diet manual will be used for menu planning for regular and therapeutic diet plans. 4. The dining services director and Registered Dietitian/Nutritionist (RDN), or other clinically qualified nutrition professionals, will ensure that the Diet Manual serves as a guide for ordering diets, and that the menus served will be consistent with the Diet Manual.During a review of the facility's diet manual, titled Dysphagia Texture, Puree IDDSI Level 4, dated 1/14/2026, the diet manual indicated, A diet used in the dietary management of dysphagia with the food texture should be prepared lump-free, not firm or sticky and holds it shape on a plate. The diet requires no biting or chewing. Any liquids must not separate from the food, and the food can fall off a spoon intact. The food is more easily swallowed and prevents aspiration. 3. Puree foods do not require chewing. They should have a pudding-like consistency without lumps (i.e. sour cream or mayonnaise thickness/moistness). All foods are appropriate if the consistency is pureed smooth without fibrous particles. Gravy or sauce may be added for lubrication or flavor enhancement. Should not be sticky. All prepared pureed recipes should be tested prior to service to ensure the texture meets the IDDSI guidelines. They should pass the fork drip test and spoon tilt test. It is recommended to use water in the preparation of puree recipes as utilizing water would not alter nutritional composition. However, broth, milk, or juice may also be used.During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with a spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and fork drip test.

Based on observations, interviews and record reviews, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 5/18/2026.This deficient practice had the potential to result in hunger and frustration for 157 to 164 residents, including Resident 163.Findings: During a review of Resident 163's admission Record (AR), the AR indicated the facility admitted Resident 163 on 5/1/2026 with diagnosis including, but not limited to gastrointestinal reflux disease (GERD, stomach acid or contents frequently flow back in to the esophagus [the tube connecting the mouth and stomach]) without esophagitis (swelling or irritation of the tissues lining the esophagus), essential hypertension (HTN, increased blood pressure), type 2 diabetes mellitus (a chronic condition where body does not make enough insulin [natural hormone produced by the pancreas] or cannot use it properly resulting to increase of blood sugar levels.During a review of Resident 163's Order Summary, dated 5/1/2026, the report indicated Resident 163 was ordered a carbohydrate controlled (limiting amount of carbohydrates rich food in the diet), no added salt (NAS, no salt packet on the trays), regular texture, and thin consistency diet.During a review of Resident 163's Minimum Data Sheet (MDS- a federally mandated resident assessment tool) dated 5/8/2026, the MDS indicated Resident 163 understood others and make self-understood. The MDS indicated Resident 163 needed supervision or touching assistance (helper provides verbal cues and or touching/steadying and/or contract guard assistance as resident completes the activity. Assistance may be provided throughout the activity or intermittently) when eating. During an interview on 5/18/2026 at 4:00 p.m., with Resident 163, Resident 163 stated the food is often up to two (2) hours late. Resident 163 stated there are no meals that are later than the others, but lunch was late today.During a review of the facility document titled, Resident Council Minutes, dated 2/12/2026, the minutes indicated, sometimes the food cart comes out late.During an observation on 5/18/2026 at 11:53 a.m. kitchen staff were observed taking temperatures of the food on the steamtable (kitchen appliance that keeps food warm at a safe temperature for serving). During an interview on 5/18/2026 at 12:32 a.m. with the Dietary Supervisor (DS), the DS stated lunch is at 12 noon and they finish trayline (an area where foods were assembled from the steamtable to resident's plates) service, around 1:00 p.m. to 1:15 p.m.During an observation of the last meal cart on 5/18/2026 at 1:55 p.m., the meal cart arrived at Station 3.During an observation of the last meal cart in Station 3 on 5/18/2026 at 2:03 p.m., the nursing staff passed the last meal tray to residents in Station 3.During an interview on 5/19/2026 at 10:04 a.m., with the DS, the DS stated the lunch meal schedule was at 12:00 p.m. but they were behind yesterday because everybody was nervous and they needed to double check the texture of the food. The DS stated there were some days that residents complain of late meal service. The DS stated the dietary staff were not focused on meal planning and worrying about the meal preparation for dinner causing delays for lunch. The DS stated food could get cold, residents would have no appetite, and they could be upset as a potential outcome of late meals. During a review of the facility's policies and procedures titled, Mealtimes, dated 1/14/2026, the P&P indicated, lunch meal was at 12:00 p.m. to 1:15 p.m.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen and storage areas were not free from dirt and debris. a. Walk-in refrigerator racks had white dirt residue, black dirt and dry food particles. b. Walk-in refrigerator floor contained dry lettuce, trash and tape debris. c. Dry storage floor had cream of wheat particles. 2. Kitchen storage surfaces were not of cleanable surfaces a. Two (2) metal racks in the walk-in freezer had amber discoloration and rust. b. Four (4) of 4 racks had paint coming off in the dry storage area. c. Sixty-six (66) of 66 residents' trays had cracks, chips, and scratches. d. Three (3) drying racks were rusted with amber discoloration. 3. Mislabeled foods in the dry storage room area indicated expired foods. 4. There was no thermometer in the dry storage area. 5. One (1) dented (a metal container with a depression or hollow made by pressure or impact) can was stored with non-dented cans. 6. Observed cross-contamination in the kitchen a. Soiled towel was near the chopped cabbage during food preparation. b. Kitchen staff used the same chopping board and knife while chopping chicken tenders and bread. 7. [NAME] 2 and Dietary Aide 1 (DA 1) were wearing dangling earrings, bracelets and watches and [NAME] 2 was wearing nail polish during food preparation. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 157 of 164 medically compromised residents who received food and ice from the kitchen. Findings: 1.a. During an observation on 5/18/2026 at 8:31 a.m., of the walk-in refrigerator, observed the shelves had dry white dirt residue. During an interview on 5/18/2026 at 8:47 a.m., with the Dietary Supervisor (DS), the DS stated the racks contained foods residue, dry juice spills and dirt and there would be a risk of physical cross-contamination. The DS stated residents could get sick of salmonella, Escherichia coli (E. Coli, a type of bacteria that normally lives in the intestines of healthy humans and animals) and other food poisoning or food borne illness because of cross-contamination. During a review of the facility's policies and procedures (P&P) titled, Equipment, dated 1/14/2026, the P&P indicated, All food service equipment will be clean, sanitary, and in proper working order. 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris. During a review of the facility's P&P titled, Refrigerator and Freezers, dated 1/14/2026, the P&P indicated, Refrigerator and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary. b. During an observation on 5/18/2026 at 8:31 a.m., of the walk-in refrigerator, observed vegetables, tape and box debris on the floor. During an interview on 5/18/202026 at/ 8:47 a.m. with the DS, the DS stated the staff clean the walk-in refrigerator right after each meal and deep clean every Sunday. The DS stated the floor was just cleaned and mopped a few minutes ago. The DS stated there was tape debris, dried lettuce and paper trash on the floor. The DS further stated the floor needed to be cleaned and make sure there are no stains and spills to prevent pests in the kitchen. During a review of the facility's P&P titled, Environment, dated 1/14/2026, the P&P indicated, All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. c. During a concurrent observation and interview on 5/18/2026 at 9:27 a.m., of the dry storage area floor with the DS, observed white particles on the floor. The DS stated it was cream of wheat debris, and it was important to have debris-free food floors to prevent pest in the storage area. The DS stated pests could spread viruses and infection to the residents as a potential outcome. During a review of the facility's P&P titled, Environment, dated 1/14/2026, the P&P indicated, The Dining Service Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lightning, and ventilation. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At any time when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 2.a. During an observation on 5/18/2026 at 8:38 a.m., of the walk-in freezer, observed the racks used for food storage had rust and amber discoloration. During an interview on 5/18/2026 at 9:00 a.m. with the DS, the DS stated the racks have rust that could cause cross-contamination. The DS stated residents could get sick of foodborne illness as a potential outcome. During a review of the facility's P&P titled, Refrigerators and Freezers, dated 1/14/2026, the P&P indicated, Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. b. During a concurrent observation and interview on 5/18/2026 at 9:03 a.m., of the racks in the dry storage area with the DS, observed the racks had cracks and rust. The DS stated the four (4) metal shelves' paint was peeling off. The DS stated food storage that has crack or chipped paint would not be a cleanable surface resulting in bacterial growth and cross contamination. c. During an observation on 5/18/2026 at 11:25 a.m. of the residents' trays, observed 66 of 66 residents' trays had cracks, chips and scratches. During an interview on 5/18/2026 at 12:08 p.m. with the DS, the DS stated residents' trays are cracked and chipped and they could not clean it resulting in bacterial growth. The DS stated residents could get foodborne illnesses as potential outcome of cross contamination of food from the cracked and chipped trays. d. During a concurrent observation and interview on 5/18/2026 at 12:51 p.m., of the dishwashing area with the DS, observed three (3) drying racks were rusted. The DS stated all three racks were rusted and it was not okay because of cross contamination. During a review of the facility's P&P titled, Storage Areas, Maintenance, dated 1/14/2026, the P&P indicated, All storage area must be kept free from accumulation of trash, rubbish, oily rags, paper, etc., at all times. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. 3. During a concurrent observation and interview on 5/18/2026 at 9:16 a.m., of the food inside the dry storage area with the DS, observed the following foods with label of: - Cheerios used by date 5/19/2026 - [NAME] Krispies used by date 5/19/2026 - [NAME] powder used by date 5/15/2026 The DS stated the dietary aide mislabeled the food and it was important to properly label the food so the staff would know the expiration date of the food, it's not spoiled and how long the food has been in storage. The DS stated if the residents were given spoiled food, it could result in food borne illnesses. During a review of the facility's P&P titled, Receiving, dated 1/14/2026, the P&P indicated, 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. During a review of the facility's P&P titled, Food Storage: Dry Goods, dated 1/14/2026, the P&P indicated, 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety. 4. During a concurrent observation and interview on 5/18/2026 at 9:03 a.m., of the dry storage area with the DS, there was no thermometer inside the dry storage area. The DS stated they do not have a thermometer and do not monitor temperature in the dry storge area. During an interview on 5/18/2026 at 9:20 a.m. with the DS, the DS stated it was important to monitor the temperature in the dry storage area because if it's too hot or too cold the food could spoil. The DS stated acceptable temperature range for the dry storage area is 75-80 degrees Fahrenheit ( F, a scale of temperature). The DS stated residents could get foodborne illness from consuming spoiled food as a potential outcome. The DS stated there was no particular reason why they do not monitor temperature in the dry storage area. During a review of the facility's P&P titled, Food Receiving and Storage, dated 1/14/2026, the P&P indicated, Non-refrigerated foods, disposable and napkins are stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 5. During a concurrent observation and interview on 5/18/2027 at 9:22 a.m., of the dry storage area by the hallway, observed one (1) dented can stored with non-dented cans. The DS stated the dented cans are separated in the office because the food from the dented cans could be spoiled. The DS stated that when can is dented, air could go in and bacteria could develop. The DS stated consuming food from dented cans is not good because residents could get sick of foodborne illness. During a review of the facility's P&P titled, Receiving, dated 1/14/2026, the P&P indicated, Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. 4. All canned foods will be appropriately inspected for dents, rust and bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 6.a. During an observation on 5/18/2026 at 11:29 a.m., of the food preparation, observed [NAME] 1 chopping cabbage and lettuce leaves and there was a soiled towel hanging near the sink where he was preparing the vegetables. During an interview on 5/18/2026 at 12:10 p.m., with the DS, the DS stated the staff should put the soiled towels in the plastic bag and it is not acceptable to have the soiled towel hanging around the cabbage in the preparation sink because of cross contamination. During a review of the facility's P&P titled Food Preparation and Service, dated 1/14/2026, the facility indicated, Cross contamination can occur when harmful substances, i.e., chemical or disease- causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. b. During a concurrent observation and interview on 5/18/2026 at 12:39 p.m. of the trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates) with the DS, observed Dietary Aide 1 (DA 1) sliced the bread into halves using soiled white chopping board and soiled knife used to cut chicken fingers in the countertop near the stove. The DS stated DA 1 should not use the same chopping board and knife used for chicken fingers because of cross-contamination. The DS stated if there was one resident allergic to chicken and ate the bread, residents could potentially have allergic reactions. During a review of the facility's P&P titled, Food Preparation and Service, dated 1/14/2026, the P&P indicated, Food preparation staff adhere to proper hand hygiene and sanitary practices to prevent the spread of foodborne illness. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. 7. During an observation on 5/18/2026 at 11:34 a.m., of the hamburger preparation in the preparation area, observed [NAME] 2 wearing two (2) dangling earrings, a watch, a bracelet and nail polish during food preparation. During an observation on 5/18/2026 at 11:46 a.m., of the food preparation, observed Dietary Aide 1 (DA 1) wearing a watch during food preparation. During an interview on 5/18/2026 at 12:13 a.m., with the DS, the DS stated kitchen staff are not allowed to wear jewelry and dangling earrings because it could fall into the food and contaminate it. The DS stated [NAME] 2 was wearing dangling earrings. The DS stated the only jewelry the kitchen staff could wear is a plain wedding band. During an interview on 5/18/2026 at 12:16 p.m., with the DS, the DS stated kitchen staff cannot wear nail polish because it could get chipped and could fall to the food causing cross-contamination. During a review of the facility's P&P titled, Staff Attire, dated 1/14/2026, the P&P indicated, All employees wear approved attire for the performance of their duties. 5. Hand jewelry will be limited to a plain band. Arm jewelry and dangling jewelry is not permitted. 6. Fingernails will be kept clean, trimmed, filed and maintained. 7. Use of nail polish, acrylic and gel nails are permitted unless wearing intact gloves, in good repair, when handling food. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical bracelets.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two (2) of five sampled residents (Resident 83 and 141) reviewed for medication administration task by failing to:1. Ensure that the Psychotropic Medication Administration Disclosure had the physician's signature, and date when the resident signed the consent. 2. Ensure that Licensed Vocational Nurse (LVN) 7 and Registered Nurse (RN) 5 accurately documented Resident 141's administered medications as ordered on 5/16/2026 and 5/19/2026. These deficient practices had the potential to result in incomplete, inaccurate, and delayed records that could lead to miscommunication between healthcare providers and resident harm.Findings: 1. During a review of Resident 83's admission Record (AR), the AR indicated that the facility admitted the resident on 4/17/2026 with diagnoses including cerebral infarction (also known as ischemic stroke occurs when the blood supply to part of the brain is blocked or reduced), depression (a serious mood disorder that causes persistent sadness, loss of interest in activities), and muscle weakness. During a review of Resident 83's General Acute Care Hospital (GACH) History and Physical (H&P), dated 3/28/2026, the H&P indicated that the resident had the capacity to understand and make decisions. During a review of Resident 83's Minimum Data Set (MDS – a resident assessment tool), dated 4/23/2026, the MDS indicated that the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally, and are not impaired). The MDS indicated that the resident required partial to moderate assistance with eating and personal hygiene, substantial to maximal assistance with toileting hygiene, and bathing as well as with transferring and ambulating. During a review of Resident 83's physician order dated 4/28/2026, the physician order indicated to administer trazadone HCI (for insomnia or depression) oral tablet 50 mg (Trazadone HCI) 0.5 tablet by mouth at bedtime for depression manifested by (m/b) sleeplessness as evidenced by (AEB) less than six hours of sleep at night and Venlafaxine HCI ER (commonly sold as Effexor, used to treat depression) oral capsule extended release 24 hour 75 mg, give 1 capsule by mouth one time a day for depression m/b episodes of refusing to socializing/attending activities. During an interview on 5/21/2026 at 9:50 a.m. with Resident 83 while inside the resident's room, Resident 83 stated that she was familiar with the medications that she was taking. Resident 83 stated that when she came to the facility, she learned that additional medications were ordered for her. Resident 83 stated that she does not recall what those were and that no one had explained to her what type of medication she was taking. Resident 83 stated that she does not recall signing any papers regarding psychotropic medications and further stated that she may have signed a document considering that she was bombarded with many information and could not recall signing any document and further stated that she had never spoken to any physician regarding psychotropic medication since admission. During an interview and record review on 5/21/2026 at 10:06 a.m. with Registered Nurse 2 (RN 2), RN 2 stated that Resident 83 has an order for psychotropic medications and was ordered to start on 4/18/2026. RN 2 stated that before giving any psychotropic medications, a consent must be obtained from the resident. RN 2 stated that obtaining consent from the resident is the responsibility of the charge nurse or RN Supervisor RN 2 stated that the physician is required to personally examine the resident and provide an explanation for the proposed treatment and ensure follow-up occurs within 72 hours. RN 2 further stated that Resident 83 was not properly consented because the documentation was incomplete and no progress note showing that the physician explained to the resident the reasons for taking psychotropic medications. RN 2 stated that consent is important to ensure that the patient is aware and involved in the care as it is their right to know what kind of treatment they are receiving to avoid a medication error. During an interview on 5/22/2026 at 1:42 p.m. with the Director of Nursing (DON), the DON stated that psychotropic medications are high risk medications and residents must have continuous monitoring. The DON stated that the Psychotropic Medication Administration Disclosure form must be completed within 72 hours. The DON stated that prior to residents signing the consent form, the physician should communicate with the resident regarding the purpose of the treatment and its potential side effects. The DON further added that the policy and procedure for charting and documentation was not being followed. During a review of the facility's undated Policy and Procedure (P&P), titled Charting and Documentation dated 1/14/2026, the P&P indicated that All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 1.Documentation in the medical record must be electronic, manual or a combination. 2.The following information is to be documented in the resident medical record:b. medications administered. 3.Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.7.Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided. b. The name and title of the individual(s) who provided the care.f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting. During a review of the facility's P&P titled Informed Consent for Psychotropic Drugs reviewed and updated on 1/14/2026, the P&P indicated under Responsibilities: Prescribing Practitioner (e.g., Physician, nurse Practitioner, Physician Assistant within Scope) included: obtaining informed consent for all psychotropic medications prior to initiation or dose increase, discuss material information with the resident/representative in a language they understand, provide written information if available (e.g., FDA medication guides or side effects summaries), document the discussion, resident/representative's understanding, and consent/refusal in the medical record ( .). 2. During a review of Resident 141's admission Record (AR), the AR indicated that the facility originally admitted Resident 141 on 11/12/2023 and readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), anxiety disorder (an abnormal condition characterized by persistent and excessive worries that interfere with daily activities), and asthma (a chronic [long-term] lung disease that can cause breathing problems). During a review of Resident 141's Minimum Data Set (MDS- a resident assessment tool), dated 5/17/2026, the MDS indicated the resident makes self-understood and has the ability to understand others. The MDS indicated that the resident was cognitively intact (a person's thinking, learning, and memory abilities are functioning normally and are not impaired). During a review of Resident 141's physician orders, the physician orders indicated the following: - Carbidopa-Levodopa (Sinemet- used to treat symptoms of Parkinson's disease) extended release (ER) oral tablet 25-100 milligrams (mg – a unit of measurement), give one (1) tablet by mouth five times a day for Parkinson's Disease, dated 8/22/2025. - Carbidopa-Levodopa oral tablet 25-100 mg, Give 0.5 tablet by mouth five times a day for Parkinson's Disease, give medication with Sinemet ER, dated 8/22/2025. - Docusate Sodium (DSS - stool softener) oral capsule 100 mg, give 1 capsule by mouth two times a day for bowel management, hold if with loose stool, dated 8/22/2025. - Entacapone (used in combination with Sinemet) tablet 200 mg, give 1 tablet by mouth five times a day for Parkinson's Disease give at the same time as Sinemet, dated 8/22/2025. - Entresto oral tablet 49-51 mg, give 1 tablet by mouth two times a day for congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), dated 8/22/2025. - Escitalopram oxalate (antidepressant) oral tablet 10 mg, give 1 tablet by mouth one time a day every other day for depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities) manifested by verbalization of having low mood due to current condition and physical limitations brought about his diagnosis of Parkinson's disease, dated 5/12/2026. - Gabapentin oral capsule 400 mg, give 1 capsule by mouth three times a day for neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), dated 5/9/2026 - Lorazepam oral tablet 1 mg, give 1 tablet by mouth every 12 hours for anxiety manifested by overconcern with health, dated 3/13/2026 - Omega 3 oral capsule 1000 mg, give 2 capsules by mouth one time a day for supplement, dated 8/22/2025. - Tizanidine hydrochloride oral tablet, give 1 mg by mouth two times a day for muscle relaxant, dated 5/1/2026. During a concurrent interview and record review on 5/20/2026 at 1:49 p.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 141's Medication Administration Record (MAR) for the month of 5/2026, the ADON stated LVN 7 was the charge nurse for Resident 141 on 5/19/2026 on the 7 a.m. to 3 p.m. shift. The ADON stated medications were not signed off for two doses of carbidopa-levodopa 25-100 mg 1 tablet, two doses of carbidopa levodopa 25-100 mg 0.5 mg tablet, DSS 100 mg 1 tablet, entacapone 200 mg 1 tablet, Entresto 49-51 mg 1 tablet, escitalopram 10 mg 1 tablet, gabapentin 400 mg 1 tablet, lorazepam 1 mg 1 tablet, omega 3 1000 mg 2 capsules, and tizanidine 1 mg 1 tablet. The ADON stated RN 5 was the charge nurse on 5/16/2026 and had not signed off for entacapone 200 mg 1 tablet. During an interview on 5/20/2026 at 1:56 p.m. with the ADON, the ADON stated that the medication administration documentation/signed off is done right after administering the medication. The ADON stated that when the licensed nurses do not document the medication they administer there would be no way of knowing if it was given or not. The ADON stated for medications used to treat Parkinson's disease symptoms when not taken the resident's could have increase in tremors, for gabapentin the resident could experience increase or unrelieved nerve pain and for DSS the resident is at increased risk for constipation. The ADON stated the checkmark on the MAR meant that the medication was given. The ADON stated that the standard of practice is to document once done, if it's not documented then it was not done. During a review of the facility's policy and procedure (P&P) titled, Documentation of Medication Administration, last reviewed and approved on 1/14/2026, the P&P indicated that a medication administration record is used to document all medications administered. Policy Interpretation and Implementation 1. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication is documented immediately after it is given.

Based on interview and record review, the facility failed to ensure adequate supervision to prevent fall and injuries for one of three sampled residents, (Resident 1), who was assessed as at risk of elopement (a patient who leaves the healthcare facility unnoticed and doing so may present an imminent threat to the patient's health or safety because the patient has been deemed too ill or impaired to make a reasoned decision to leave), had wandering behavior (aimless, slow, or pointless movements, meandering, or repetitive locomotion that exposes the individual to harm; it is frequently incongruent with boundaries, limits, or/and obstacles). Resident 1 was transported three times a week, unaccompanied (not escorted by a responsible adult) in a contracted transportation service (TC 1) to an outside [CONDITION(S)] center (DC, a center to perform treatment of kidney failure). As a result, on 9/4/2021 at 12:50 p.m., TC 1's driver (Driver 1), unaware of Resident 1's diagnoses and behaviors, dropped off the resident outside DC and left. Resident wandered away and fell , paramedics (or emergency medical services [EMS] are health professionals certified to perform advanced life support procedures who respond to 911 calls and treat and transport people in health crisis) picked him up and transferred Resident 1 to General Acute Care Hospital 1 (GACH 1) where he was diagnosed with a right shoulder fracture (broken bone). Resident 1 was discharged to the facility on [DATE] with an arm sling (a device that helps immobilize the shoulder and elbow) with coaptation splint (a short splint or plastic bandage designed to immobilize a fracture). Resident 1 experienced a decline in function after readmission from GACH 1 Cross reference F840 Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident, on 5/18/2019 to the Dementia Unit (a secure unit [doors need a specific code to open] of the facility for resident with exit-seeking behavior and at risk for elopement). Resident 1's diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), end stage renal disease ([CONDITION(S)], total loss of kidney function) and dependence on renal hemodialysis (a procedure to remove fluid and waste products from the blood and to correct electrolyte imbalances with a [CONDITION(S)] machine [an artificial kidney] or a dialyzer. To get the blood into the dialyzer, the doctor needs to make an access, or entrance, into the blood vessels), and hypertension (high blood pressure). A review of Resident 1's Care Plan, developed on 4/18/2020, for the resident's risk of decreased ability to perform activities of daily living (ADLs, such as toilet use, bathing, grooming, personal hygiene, and dressing), included in the interventions monitoring of decline in ADL function and providing cueing for safety and sequencing to maximize current level of functioning. A review of Resident 1's Care Plan, developed on 4/18/2020, for the resident's fall risk due to cognitive loss and lack of safety awareness related to Alzheimer's disease and hypertension, included in the interventions providing verbal cues for safety and sequencing when needed and assessing resident for changes in medical, pain and mental status. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/26/2021, indicated the resident had a severely impaired cognition (the person has a very hard time remembering things, making decisions, concentrating, or learning. Severe levels of impairment can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently). Resident 1 was independent with bed mobility, transfers, walking in the room, dressing, and eating. Resident 1 required supervision with walking in the corridor, toilet use, and personal hygiene. A review of Resident 1's Physician's Orders, dated 5/28/2020, indicated for the resident to have [CONDITION(S)] treatment at DC three times a week on Tuesdays, Thursdays, and Saturdays and transportation to pick up Resident 1 each [CONDITION(S)] day between 12:15 p.m. and 12:45 p.m. A review of Resident 1's Change in Condition Evaluation, dated 11/21/2020, indicated Resident 1 had an actual incident of leaving the facility unattended. During this incident, the Police Department was contacted and helped look for the resident. Resident 1 was found and accompanied by the police back to the facility. A review of Resident 1's Care Plan, developed on 11/21/2020, for the resident's risk of elopement due to cognitive loss and impulsive behavior related to his Alzheimer's disease, included in the interventions monitoring the resident's location with visual checks at least every hour and as needed. A review of Resident 1's Elopement Evaluation form, dated 7/5/2021, indicated Resident 1 had a history of wandering and was at a significant risk of getting to a potentially dangerous place such as stairs or outside of the facility. A review of Resident 1's Care Plan, developed on 8/30/2021, indicated Resident 1 had a decline in cognitive function or impaired thought process related to Alzheimer's disease. The interventions included providing consistent, trusted caregiver, and structured daily routine, when possible. A review of Resident 1's Progress Notes, dated 9/4/2021, indicated Resident 1 was in stable condition and was picked up by Driver 1 at 12:20 p.m. to go to [CONDITION(S)] treatment. Resident 1 was ambulatory (walking)with steady gait. A review of Resident 1's Progress Notes, dated 9/4/2021, indicated at 1:35 p.m., DC staff called to inform Resident 1 did not arrive to his [CONDITION(S)] appointment. The MDS Nurse called TC 1 and found out Driver 1 was new and got lost but was already on his way to DC. At 2:59 p.m., paramedics called to inform Resident 1 was wandering in downtown, had fallen, and was taken to GACH 1 for evaluation. A review of Resident 1's GACH 1's History and Physical exam, with an admitted [DATE], indicated Resident 1 arrived with right arm pain. A review of Resident 1's GACH 1's Diagnostic Radiology Consultation Report, dated 9/4/2021, indicated x-rays (type of [CONDITION(S)] called electromagnetic waves. X-ray imaging creates pictures of the inside of the body) of the right shoulder and humerus (long bone of the arm) showed an acute comminuted fracture (a break of the bone into more than two fragments) through the surgical neck of the right humerus (the neck lies just below the head of the humerus, it is called the surgical neck because this is the location of many fractures that require surgery). A review of Resident 1's GACH 1's Discharge Summary, dated 9/8/2021, indicated Resident 1 received orthopedic (relating to the branch of medicine dealing with the correction of deformities of bones or muscles) consultation and was placed in a coaptation splint. A review of Resident 1's Admission Record indicated the facility readmitted the resident on 9/8/2021 with a new diagnosis of comminuted fracture of the right humerus. A review of Resident 1's Nursing Admission Assessment, dated 9/9/2021, indicated Resident 1came with bruising and swelling of the right arm and face. A review of Resident 1's Admission Skin Check Assessment, dated 9/9/2021, indicated Resident 1 came from GACH 1 with multiple abrasions and discoloration on his back and right arm swelling with a removal cast / immobilizer. A review of Resident 1's MDS dated [DATE] indicated the resident's physical condition had deteriorated after readmission. After re-admission, Resident 1 needed limited assistance with walking in the room and eating and required extensive assistance with bed mobility, transfers, walking in the corridor, dressing, toilet use, and personal hygiene. On 9/15/2021 at 12:01 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on 9/4/2021 she was in charge of the resident. LVN 1 stated Certified Nursing Assistant 2 (CNA 2) accompanied Resident 1 to the facility's lobby to meet Driver 1. LVN 1 stated she did not know if CNA 2 informed Driver 1 of the safety precautions needed with Resident 1 due to his wandering and elopement behaviors. On 9/15/2021 at 12:47 p.m., during an interview, CNA 2 stated on 9/4/2021, she took the resident to the lobby to meet with Driver 1 and did not inform him of safety precautions needed with Resident 1. On 9/15/2021 at 2:13 p.m., during an interview, Registered Nurse 1 (RN 1) stated on 9/4/2021, she called TC 1 after paramedics informed them Resident 1 was found wandering in the street of downtown. RN 1 stated she was informed Driver 1 was new to the company. RN 1 stated the expectation was for drivers to drop off the resident inside DC and leave him with a [CONDITION(S)] staff. On 9/15/2021 at 2:30 p.m., during an interview, Director of Nursing (DON) confirmed Resident 1 was an elopement risk and was at fall risk. On 9/15/2021 at 3:08 p.m., during an interview, Administrator (ADM) stated TC 1 did not follow a door-to-door transportation (transportation of a person from the door of the initial location through the door of the end location). ADM stated Driver 1 should have accompanied Resident 1 into DC. On 10/14/2021 at 10:39 a.m., during a telephone interview, Dispatch Manager (DM) at TC 1 stated the facility did not communicate to Driver 1 Resident 1's elopement and wandering risks and Driver 1 did not know he needed to escort Resident 1 into DC. On 10/20/2021 at 12 p.m., during a telephone interview, Driver 1 stated he dropped off Resident 1 in front of DC and did not escort the resident into the building because he did not know Resident 1 was confused or was at risk of going elsewhere. On 10/21/2021 at 1:07 p.m., during a telephone interview with ADM and concurrent review of a document titled, Business Associate Agreement between the facility and TC 1, dated 5/18/2019, did not include a door-to-door transportation agreement. The ADM reviewed the document and stated, door-to-door transportation was an expected service from TC 1 when providing private transportation. A review of the facility's policy and procedures titled, Dementia: Care of Patient, revised on 6/1/2021, indicated practice standards included monitoring residents for elopement risk and safety to self and/or others. Communicate care plan changes to patient, family, patient representative, and staff. A review of the facility's policy and procedures titled, Elopement of Patient, revised on 2/28/2021, indicated residents determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. A review of the facility's policy and procedures titled, Falls Management, revised on 6/1/2021, indicated residents determine to be at risk will receive appropriate interventions to reduce risk and minimize injury. The policy further indicated that it is the facility's practice standard to communicate patient's fall risk status to caregivers. A review of the facility's policy and procedures titled, [CONDITION(S)]: Hemodialysis (HD) Provided by a Certified [CONDITION(S)] Facility, revised on 11/1/2019, indicated, The facility's staff must assist the patient in making arrangements for safe transportation to and from the [CONDITION(S)] facility. A review of the facility's document titled, Nursing Home [CONDITION(S)] Transfer Agreement, signed on 2/18/2010, between the facility and DC, indicated Facility shall have the responsibility for arranging suitable transportation of the designated resident to and from center, including the selection of the mode of transportation, qualified personnel to accompany the designated resident and transportation equipment usually associated with this type of transfer including the use of appropriate life support measures in accordance with the applicable federal and state laws and regulations. Facility shall be responsible for ensuring that the designated resident is medically stable to undergo such transportation, shall be responsible for the designated resident during transfer to and from center, including medical and non-medical emergencies, and shall be responsible for all costs of transportation associated with the transfer of the designated resident to and from center and facility. Facility shall be responsible for, and shall provide the necessary personnel for, assisting the designated resident in entering into and exiting from center. A review of the facility's document titled, Business Associate Agreement between the facility and the transportation company, dated 5/18/2019, did not include a door-to-door transportation agreement.

Based on interview and record review, the facility failed to follow contract agreements between the facility and Transportation Company 1 (TC 1) and the facility and [CONDITION(S)] Center (DC - an outside treatment center, for residents who require [CONDITION(S)]- a procedure for removal of accumulated waste from the blood) to ensure the safety of one of three sampled residents (Resident 1). On 9/4/2021 at 12:20 p.m., TC 1's driver (Driver 1) picked up Resident 1, who was confused, at risk of elopement (a patient who leaves a health facility when doing so may present an imminent threat to the patient's health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave), to transport him to DC. The facility did not send an escort with Resident 1 as the contract agreements did not indicate TC 1 and DC were responsible for the resident's safety. Driver1, dropped off Resident 1 outside the DC and wandered off. As a result, Resident 1 fell and sustained an avoidable broken right shoulder and hospitalization . Cross reference F689 Finding: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted the resident, on 5/18/2019 to the Dementia Unit (a secure unit [doors need a specific code to open] of the facility for resident with exit-seeking behavior and at risk for elopement). Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . To get the blood into the dialyzer, the doctor needs to make an access, or entrance, into the blood vessels), and hypertension (high blood pressure). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/26/2021, indicated the resident had severely impaired cognition (the person has a very hard time remembering things, making decisions, concentrating, or learning. Severe levels of impairment can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently). Resident 1 was independent with bed mobility, transfers, walking in the room, dressing, and eating. Resident 1 required supervision with walking in the corridor, toilet use, and personal hygiene. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's Progress Notes, dated 9/4/2021, indicated Resident 1 was in stable condition and was picked up by Driver 1 at 12:20 p.m. to go to [CONDITION(S)] treatment. Resident 1 was ambulatory (walk unassisted) with steady gait. A review of Resident 1's Progress Notes, dated 9/4/2021, indicated at 1:35 p.m., DC staff called to inform Resident 1 did not arrive to his [CONDITION(S)] appointment. The MDS Nurse called TC 1 and found out Driver 1 was new and got lost but was already on his way to DC. At 2:59 p.m., paramedics (or emergency medical services [EMS] are health professionals certified to perform advanced life support procedures who respond to 911 calls and treat and transport people in health crisis) called to inform Resident 1 was wandering in downtown, had fallen, and was taken to General Acute Care Hospital 1 (GACH 1) for evaluation. A review of Resident 1's GACH 1's Diagnostic Radiology Consultation Report, dated 9/4/2021, indicated x-rays (type of [CONDITION(S)] called electromagnetic waves. X-ray imaging creates pictures of the inside of the body) of the right shoulder and humerus (long bone of the arm) showed an acute comminuted fracture (a break of the bone into more than two fragments) through the surgical neck of the right humerus (the neck lies just below the head of the humerus, it is called the surgical neck because this is the location of many fractures that require surgery). On 9/15/2021 at 12:01 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated on 9/4/2021 she was in charge of the resident. LVN 1 stated Certified Nursing Assistant 2 (CNA 2) accompanied Resident 1 to the facility's lobby to meet Driver 1. LVN 1 stated she did not know if CNA 2 informed Driver 1 of the safety precautions needed with Resident 1 due to his wandering and elopement behaviors. On 9/15/2021 at 12:47 p.m., during an interview, CNA 2 stated on 9/4/2021, she took the resident to the lobby to meet with Driver 1 and did not inform him of safety precautions needed with Resident 1. On 9/15/2021 at 2:13 p.m., during an interview, Registered Nurse 1 (RN 1) stated on 9/4/2021, she called TC 1 after paramedics informed them Resident 1 was found wandering in the street of downtown. RN 1 stated she was informed Driver 1 was new to the company. RN 1 stated the expectation was for drivers to drop off the resident inside DC and leave him with a [CONDITION(S)] staff. On 9/15/2021 at 3:08 p.m., during an interview, Administrator (ADM) stated TC 1 did not follow a door-to-door transportation (transportation of a person from the door of the initial location through the door of the end location). ADM stated Driver 1 should have accompanied Resident 1 into DC. On 10/14/2021 at 10:39 a.m., during a telephone interview, Dispatch Manager (DM) at TC 1 stated the facility did not communicate to Driver 1 Resident 1's elopement and wandering risks and Driver 1 did not know he needed to escort Resident 1 into DC. On 10/20/2021 at 12 p.m., during a telephone interview, Driver 1 stated he dropped off Resident 1 in front of DC and did not escort the resident into the building because he did not know Resident 1 was confused or was at risk of going elsewhere. On 10/21/2021 at 1:07 p.m., during a telephone interview with ADM and concurrent review of a document titled, Business Associate Agreement between the facility and TC 1, dated 5/18/2019, did not include a door-to-door transportation agreement. The ADM verified and stated, door-to-door transportation agreement was not included in the agreement. The ADM further stated door-to-door was an expected service from TC 1 when providing private transportation. A review of the facility's document titled, Nursing Home [CONDITION(S)] Transfer Agreement, signed on 2/18/2010, between the facility and DC, indicated Facility shall have the responsibility for arranging suitable transportation of the designated resident to and from center, including the selection of the mode of transportation, qualified personnel to accompany the designated resident and transportation equipment usually associated with this type of transfer including the use of appropriate life support measures in accordance with the applicable federal and state laws and regulations. Facility shall be responsible for ensuring that the designated resident is medically stable to undergo such transportation, shall be responsible for the designated resident during transfer to and from center, including medical and non-medical emergencies, and shall be responsible for all costs of transportation associated with the transfer of the designated resident to and from center and facility. Facility shall be responsible for, and shall provide the necessary personnel for, assisting the designated resident in entering into and exiting from center.

Based on observation, interview, and record review, the facility failed to ensure three of 50 sampled residents (Residents 119, 103 and 139) were free of neglect (failure to provide goods and services to residents that are necessary to avoid physical harm, pain, mental anguish (mental suffering), or emotional distress) and rough handling by: 1. Failing to provide wound dressing changes on an as needed basis and as requested by Resident 119 for 25 days (from (MONTH) 10, (YEAR) to (MONTH) 5, (YEAR)), when the wound dressing was saturated with drainage, to prevent irritation to the surrounding skin and provide comfort to the resident. 2. Failing to provide [MEDICAL CONDITION] (an opening into the large intestine, through the abdomen) care timely when requested by Resident 119. 3. Failing to implement the facility's policy and procedure on Abuse Prohibition by not conducting thorough investigation of allegations of neglect made by Resident 119, regarding provision of care for the resident's wound dressings and providing [MEDICAL CONDITION] care. 4. Failing to report allegations of neglect in provision of care made by Resident 119 to the Abuse Prevention Coordinator timely. 5. Failing to implement the facility's policy and procedure on Grievance/Concern, by not addressing, not investigating, not taking corrective actions, and not resolving grievances voiced by Resident 119. 6. Failing to ensure Social Service Director (SSD 1) would promote and protect Resident 119's psychological well-being and right to be free from neglect in provision of necessary care. 7. Failing to ensure the nursing staff would attend to Residents 119, 103, and 139's needs (changing/emptying [MEDICAL CONDITION] bag-a container placed on the abdomen over a the [MEDICAL CONDITION] site for discharge of bowel movements, changing incontinence brief, assistance to go to the restroom, toileting needs, incontinence care) timely and would not turn off the call light without addressing the residents' needs. 8. Failing to ensure Resident 119 was free from rough handling during care and during wound treatment and failing to ensure Residents 103, and 139 would be free from rough handling. 9. Failing to ensure Resident 103 would be assisted to the restroom when requested to prevent the resident from soiling his incontinence brief. As a result, Resident 119 felt sad, neglected, and was subjected to mental anguish and distress as evidenced by crying, resident's verbalization of wanting to leave the facility due to unmet necessary wound care and [MEDICAL CONDITION] care. These deficient practices also placed Resident 119 at risk for unnecessary skin irritation and can lead to further discomfort. These deficient practices also resulted in Resident 103 experiencing preventable incontinence episodes, which could lead to embarrassment, and Residents 119, 103, and 109 experiencing rough handling, which could result in physical injuries and affect the psychosocial well-being of the residents. These deficient practices also had the potential to affect 157 residents currently in the facility. Findings: a. A review of the admission record indicated Resident 119 was originally admitted to the facility on (MONTH) 28, (YEAR), and readmitted on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED].-a classification of the particular stage reached by a progressive disease, due to coverage of wound bed by dead or non-viable-not capable of healing, tissue). A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated (MONTH) 4, (YEAR), indicated Resident 119 had intact cognition and required limited one person physical assistance with bed mobility (movement while in bed), transfer (movement from one surface to another including bed to chair), toilet use and personal hygiene. The MDS indicated Resident 119 had an ostomy (an artificial opening in an organ of the body) and two unstageable pressure ulcers measuring 8 centimeters (cm) length by 5 cm width. A review of the History and Physical (H&P-information about a resident's medical past and examination findings) report completed on (MONTH) 6, (YEAR), indicated Resident 119 was alert and oriented. Resident 119 was admitted with [DIAGNOSES REDACTED]. The physical examination section indicated right buttock metastatic ulcer (indurated- a localized hardening of soft tissue of the body that becomes firm/hard). A review of Resident 119's care plan initiated on (MONTH) 28, (YEAR), and revised on (MONTH) 4, (YEAR), indicated the resident had altered skin breakdown related to recent surgery, limited mobility, right inferior (lower in place or position) pressure injury unstageable, right superior (a higher place or position) pressure injury unstageable, and under scrotal area pressure injury unstageable. The care plan goal indicated the wound will remain free from signs and symptoms of infection for 14 days and the resident's wound will heal as evidenced by decrease in size, absence of [DIAGNOSES REDACTED] (abnormal redness of the skin) and drainage, and presence of granulation (a grainy surface as part of the healing process) for 14 days. The care plan interventions included: 1. Apply barrier cream with each cleansing 2. Evaluate wound area daily including surrounding tissue and presence or absence of drainage/infection and/or new wound pain and report to physician as indicated 3. Monitor for effectiveness and/or side effects of medication (used to treat pressure injury) 4. Monitor for verbal and nonverbal signs of pain related to wound or wound treatment 5. Obtain dietitian consult as needed/ordered 6. Provide pericare (rectal, urinary and genital area) and /incontinence (any accidental or involuntary loss of urine from the bladder or bowel movement) as needed. A review of the care plan initiated on (MONTH) 10, (YEAR), indicated Resident 119 was incontinent of bowel (any accidental or involuntary loss of bowel movements)and was unable to physically participate in a retraining program due to [MEDICAL CONDITION] status. The care plan goal indicated Resident 119 will have incontinence care met by staff to maintain dignity and comfort and to prevent incontinence related complication. The care plan interventions included: apply moisture barrier to perianal (around the rectum) and perineal (urinary and genital area) as indicated, assist with perineal care as needed, complete an incontinence assessment at intervals according to policy and procedure, monitor for skin redness/irritation and report as indicated, provide privacy and comfort, and use absorbent product as needed. The care plan did not address necessary care specific to Resident 119's [MEDICAL CONDITION] care. A review of the Grievance/Concern Form indicated Resident 119 filed a grievance on (MONTH) 10, (YEAR), indicating that his wound dressing was not being changed during the second (3 p.m. to 11 p.m.) and third (11 p.m. to 7 a.m.) shifts. The investigation section indicated that the charge nurse was interviewed and that the charge nurse stated Resident 119's dressing was changed. The Resolution of Grievance/Concern section indicated that Resident 119 was informed that the charge nurse changed the dressing and that according to the charge nurse, the resident forgot. Resident 119's Grievance/Concern Form dated (MONTH) 10, (YEAR), did not include information as per the facility's policy and procedure for completion as follows: 1. The date the alleged incident occurred 2. The name of the alleged nursing staff involved. 3. Documentation of a thorough investigation; 4. How Resident 119's grievance was resolved; 5. Action plan to prevent further occurrence; 6. Protection of Resident 119 during the investigation; 7. Monitoring of Resident 119's feelings about the incidents; and 8. Corrective actions that were taken. A review of Resident 119's physician orders [REDACTED]. 1. Right inferior buttock pressure injury (wound), right superior buttock pressure injury, and under scrotal area pressure injury: cleanse with wound cleanser, pat dry, apply Santyl ointment (a remedy used to help the healing of skin ulcers), cover with dry dressing every day shift for 14 days and as needed every day shift for 14 days, dated (MONTH) 15, (YEAR) with end date of (MONTH) 29, (YEAR). 2. Right inferior buttock pressure injury (wound), right superior buttock pressure injury, and under scrotal area pressure injury: cleanse with wound cleanser, pat dry, apply Santyl ointment, cover with dry dressing every day shift for 14 days and as needed every day shift for 14 days, dated (MONTH) 29, (YEAR). 3. Monitor wound sites (right inferior buttock, right superior buttock, under scrotal area) daily for status of surrounding tissue and wound pain. Monitor for status of dressing (s), if applicable additional documentation in the nursing notes if needed, every shift. A review of the Resident 119's Treatment Administration Record (TAR) from (MONTH) 28, (YEAR) to (MONTH) 5, (YEAR), did not indicate that the nursing staff provided wound care/dressing changes as needed. A review of Resident 119's Wound Evaluation and Management Summary dated (MONTH) 2, (YEAR), indicated the resident was oriented to person, place, time, and situation. The focused wound exam section indicated the following: 1. Burn Wound ([MEDICAL CONDITION] burn, a skin condition from treatment of [REDACTED]. many different surfaces): 30 percent (%), Granulation tissue: 70 %, wound progress: deteriorated. 2. Unstageable Deep Tissue Injury (DTI-a pressure-related injury to subcutaneous tissues under intact skin), wound size: 5 cm length by 3 cm width by 0.5 cm depth, surface area: 15.00 square centimeter, exudates: Moderate serous, slough (including biofilm): 20 %, Granulation tissue (healing surface of a wound): 80 %, wound progress: No change. On (MONTH) 2, (YEAR) at 11:31 a.m., during an observation, Resident 119 was lying in bed, awake, alert, and oriented to person, place, time, and situation. During a concurrent interview, Resident 119 stated that he felt like he was being neglected, like the nursing staff were ignoring him (the resident was crying, wiping his tears, sometimes pausing before continuing talking). Resident 119 stated that the nursing staff did not change his incontinence brief, wound dressing, [MEDICAL CONDITION] bag timely, and did not empty his [MEDICAL CONDITION] bag. Resident 119 stated that he was tired of asking the nursing staff to perform those tasks, because it made him feel like a child. Resident 119 stated that he sometimes emptied his [MEDICAL CONDITION] bag because some nursing staff did not want to empty it. Resident 119 stated that the nursing staff (assigned after 3 p.m.) did not want to change his wound dressing and that he notified (on an unspecified date) the social worker and the social worker helper, who stated they will look into it and take care of the concern. Resident 119 stated that he notified Licensed Vocational Nurse 7 (LVN 7), who told the resident to insist that the nursing staff assigned after 3 p.m. change his wound dressing in the evening. Resident 119 stated that sometimes, the wound dressing would be saturated with drainage and that he would remove the cushion- spongy part of the dressing and change the incontinence brief (soiled by drainage). Resident 119 stated that when the wound dressing would become saturated with drainage, the drainage would go on the surrounding skin and irritate the skin; the resident would have to get a small towel and wipe the skin frequently until the morning shift. Even the incontinence brief would be wet from the wound drainage. Resident 119 stated that the call light response during the night was worse because the nursing staff would sometimes respond and acknowledge his needs and sometimes would answer the call light and tell him that they will notify his assigned nurse, but no one would show up. Resident 119 stated that LVN 8 was one of the nurses that did not want to change his wound dressing. When asked how not having his needs met made him feel, Resident 119 responded that it made him feel really sad because he had been residing in the facility for almost two months (admitted in (MONTH) (YEAR)), and since talking to the LVN 7 and the social workers about the situation (not having his wound dressing changed during the evening), things had not gotten any better. On (MONTH) 2, (YEAR) at 12:19 p.m., during an interview, LVN 7 stated that Resident 119 reported to him twice, the first or 2 week of the resident's admission (last week of (MONTH) (YEAR) or first week of (MONTH) (YEAR)), that his wound dressing was saturated with drainage and that the nurses during the evening/night shifts did not change his the dressing. LVN 7 stated that he notified the charge nurse (could not remember the name of the charge nurse) of Resident 119's complaint when the resident reported the concerns. LVN 7 stated that prior to changing Resident 119's wound dressing in the morning, the wound dressing would be saturated with drainage, which would lead the incontinence brief to be soiled as well. LVN 7 stated that Resident 119 emptied his [MEDICAL CONDITION] bag because the resident knew how to care for his [MEDICAL CONDITION] and preferred to care for it on his own. On (MONTH) 2, (YEAR) at 2:55 p.m., during an interview, the Social Service Director (SSD) stated that the facility's procedure was to complete a grievance form whenever a resident filed a grievance (verbal or written). The grievance form would be given to the Social Service Department, which would assign the grievance to the appropriate discipline for resolution. On (MONTH) 3, (YEAR) at 7:15 a.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated that last week (could not remember the specific date), Resident 119 verbalized to her that the nursing staff did not change his wound dressing in the afternoon. CNA 2 stated that she notified LVN 6, who went to the resident's room and changed the resident's wound dressing. CNA 2 stated that Resident 119 had not verbalized he was depressed or sad, but CNA 2 could tell on the resident's face that he was sad (could not give specific details). On (MONTH) 3, (YEAR) at 8:17 a.m., during an interview, LVN 6 stated that Resident 119 reported to her that his wound dressing was not being changed, which prompted LVN 6 to complete the grievance form on (MONTH) 10, (YEAR). LVN 6 stated that Resident 119's wound had a lot of drainage. LVN 6 stated that LVN 7 had not reported to her that Resident 119 had complained in the past that his wound dressing was not being changed. On (MONTH) 3, (YEAR) at 8:57 a.m., during an interview, the Quality Assurance Nurse (QA Nurse) stated she was responsible for investigating the grievance filed by Resident 119 on (MONTH) 10, (YEAR). The QA Nurse stated that she interviewed LVN 5 and LVN 9, who stated that Resident 119 was able to verbalize when his wound dressing needed to be changed. The QA Nurse stated that LVN 9 stated Resident 119's wound dressing was changed on (MONTH) 9, (YEAR), during the 3 p.m. to 11 p.m. shift and that the resident probably forgot his dressing was changed. The QA nurse stated that she informed Resident 119 that LVN 9 changed his dressing. The QA Nurse stated that during the investigation, Resident 119's clinical record indicated that the wound dressing had been changed on (MONTH) 9, (YEAR), during the 3 p.m. to 11 p.m. shift. However at 9:24 p.m., during a follow-up interview, the QA Nurse stated she was unable to provide documented evidence the licensed nursing staff provided wound care/wound dressing change to Resident 119's wound areas (right inferior and superior buttock, under scrotal area) on (MONTH) 9, (YEAR), in (MONTH) (YEAR), and/or (MONTH) (YEAR), during the 3 p.m. to 11 p.m. and/or 11 p.m. to 7 a.m. shift. On (MONTH) 4, (YEAR) at 9:28 a.m., during an interview, LVN 7 stated that he did not document Resident 119's concern (wound dressing not being changed as verbalized by the resident the first week after admission) because the charge nurses are responsible for documenting any concerns. LVN 7 stated that he notified the charge nurse and the social service department on an unspecified date. On (MONTH) 4, (YEAR) at 10:37 a.m., during an observation, Resident 119 was lying in bed and LVN 6 was at the bedside administering (giving) medications. During a concurrent interview, Resident 119 stated that sometimes, he would change his [MEDICAL CONDITION] bag and that when he asked some nurses to perform that task, they did not want to do it. Resident 119 stated that he did not receive any education/training from the facility staff of how to care for the [MEDICAL CONDITION]. After Resident 119's statement, LVN 6, who was present during the interview, stated that it was the first time she was made aware that Resident 119, sometimes performed his own [MEDICAL CONDITION] care. On (MONTH) 4, (YEAR) at 12:07 p.m., during an interview, LVN 7 stated that Resident 119 told him (about the second week after admission-September 5 to12, (YEAR)), that he changed his own [MEDICAL CONDITION] bag. LVN 7 stated that he did not notify anyone and did not document, because he assumed the nurses knew Resident 119 was changing his own [MEDICAL CONDITION] bag and performing [MEDICAL CONDITION] care. LVN 7 reviewed Resident 119's care plan for bowel incontinence and stated that it did not address how to care for the resident's [MEDICAL CONDITION]. On (MONTH) 5, (YEAR) at 8:45 a.m., during wound care observation, LVN 7 removed the right buttock dressing, which was saturated with serous sanguineous (containing both blood and the liquid part of blood) drainage. The wound was hard and there was a strong, foul odor coming from the wound. The periwound (the skin surrounding an injury) was macerated (occurs when skin is in contact with moisture for too long, often associated with improper wound care) with a grayish color and the wound had yellowish and granulated (healthy) tissues. LVN 7 measured the right buttock wound and stated that the dimensions were 12 cm length by 12 cm width. LVN 7 cleansed the wound with a cleansing solution (spray), patted dry, applied Santyl, and covered the wound with a dry dressing. LVN 7 performed the same wound care treatment to Resident 119's under the scrotal wound area. Resident 119's [MEDICAL CONDITION] bag was full` and was leaking. On (MONTH) 5, (YEAR) at 9 a.m., during an interview in the presence of the Administrator of the facility, Resident 119 stated that he asked LVN 10 to change his wound dressing four times yesterday (on (MONTH) 4, (YEAR)) in the evening, but LVN 10 kept saying she was busy and would be back. Resident 119 stated that LVN 10 sent LVN 5 to perform his dressing change, but he (the resident) refused, because LVN 5 does not use the proper technique (uses a towel and water from the restroom, instead of gauze and cleaning solution) to change the dressing. Resident 119 stated that the towel was rough on his wound. Resident 119 stated LVN 10 did not want to empty and/or change his [MEDICAL CONDITION] bag. Resident 119 stated that he would change his incontinence brief because of the drainage from the wound soiled the brief and would change and/or empty his [MEDICAL CONDITION] bag, because some people did not want to do it. Resident 119 stated the first week he was admitted into the facility (August 28, (YEAR) to (MONTH) 4, (YEAR)), he told LVN 7, that the nursing staff was not changing his wound dressing during the night. The resident stated that he told one of his CNAs, and spoke with the Social Service Director (SSD) and Social Service Designee 1 (SSD 1) about his concern about 10 days ago (September 25, (YEAR)), but things did not get better. When asked if he had told the SSD and SSD 1 how he felt, Resident 119 responded, no because the social service staff never asked him how he was feeling. The resident became tearful during the interview at times and wiped his tears stating that he felt neglected, sad, and wanted to be out of here, meaning out of the facility. Resident 119 stated he did not know why the nurses were behaving like they did not care about the job and that he was having a hard time as a resident in the facility. Resident 119 stated that some staff were rough during care: one time, a staff member (tall male with curly hair) came into the room, did not even turn on the light, removed the sheet, kept turning him from side to side rolling him like a burrito, and did not say I am sorry. Resident 119 stated he did not ask that staff to change him anymore because he treats people bad, is rough. On (MONTH) 5, (YEAR) at 9:20 a.m., during an interview in the presence of the Administrator of the facility, the SSD stated she received Resident 119's grievance on (MONTH) 10, (YEAR), and communicated the grievance to the QA Nurse. The SSD stated she returned to the resident and notified him that the QA Nurse would address his concern, but did not follow-up to ensure Resident 119's concerns were addressed. When presented with the Grievance Form completed on (MONTH) 10, (YEAR), the Administrator stated that the investigation did not address the resident's concern and that no other interviews were conducted regarding the concerns. On (MONTH) 5, (YEAR) at 11:11 a.m., during a Quality Assurance interview regarding Resident 119, in the presence of the QA Nurse, the Administrator, who was also the Abuse Prevention Coordinator, stated that the grievance was indicative of neglect (a type of abuse) and that he was not notified of the resident's concern. In addition, the QA Nurse stated that she did not notify the Abuse Prevention Coordinator of the resident's concerns. On (MONTH) 5, (YEAR) at 4:11 p.m., during an interview, LVN 8 stated Resident 119 was carrying himself a bit more different (more understanding) when initially admitted , but now the resident was more lethargic, sad, weak, and on the bluer side. LVN 8 stated that Resident 119 would usually request to have his wound dressing changed around 9 p.m. or 10 p.m. before going to sleep. LVN 8 stated she provided wound treatment when requested, but was unable to provide documented evidence she provided dressing changes to Resident 119's wound (right buttock and under scrotal area) in (MONTH) (YEAR), and/or (MONTH) (YEAR), during the 3 p.m. to 11 p.m. shift. On (MONTH) 9, (YEAR) at 9:15 a.m., during a phone interview, the Wound Care Physician Consultant (WCMD) stated that Resident 119's wound had a lot of drainage. The WCMD stated that Resident 119's wound was not expected to get better and that the drainage was not detrimental to the wound, but was more of a comfort concern because the drainage could be irritating to the surrounding skin. The WCMD stated that the physician order [REDACTED]. There was no documented evidence in (MONTH) (YEAR), and/or the (MONTH) (YEAR), physician orders [REDACTED]. A review of the facility's revised policy dated (MONTH) 1, (YEAR), titled Abuse Prohibition indicated the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. The facility will implement an abuse prohibition program through the following: 1. Screening of potential hires; 2. Training of employees (both new employees and ongoing training for all employees); 3. Prevention of occurrence 4. Identification of possible incidents or allegation which need investigation; 5. Investigation of incidents and allegations; 6. Protection of patients during investigations; and 7. Reporting of incidents, investigations, and center response to the results of their investigations. Neglect is defined as the failure of the center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Center Executive Director (CED) or designee will perform the following: 1. Enter allegation into the Risk Management System 2. Report allegations involving neglect, exploitation, or mistreatment (including injuries of unknown source) and misappropriation of resident property within 24 hours if the event does not result in serious bodily injury 3. Notify local law enforcement, Licensing Boards and Registries, and other agencies as required 4. Provide subsequent reports to the Department as often as necessary to inform the Department of significant changes in the status of affected individuals or changes in material facts originally reported. 5. Initiate an investigation within 24 hours of an allegation of abuse that focuses on: whether abuse or neglect occurred and to what extent, clinical examination for signs of injuries, if indicated, causative factors, and intervention to prevent further injury. 6. The investigation will be thoroughly documented. Ensure that documentation of witnessed interviews is included. 7. The center will protect patients from further harm during an investigation 8. Assign a representative from Social Services or a designee to monitor the patient's feeling concerning the incident, as well as the patient involvement in the investigation. 9. The CED or designee will take all necessary corrective action depending on the result of the investigation. A review of the facility's revised policy and procedure dated (MONTH) 1, (YEAR), titled, Grievance/Concern, indicated all residents and/or representatives may voice grievances/concerns and recommendations for changes. Center leadership will investigate, document, and follow up on all formal concerns and grievances registered by any resident or resident representative. Social Service Personnel will serve as patient advocates in the grievance/concern process. When the formal grievance/concern is logged, the Center Executive Director (CED) and appropriate department manager will be notified. Immediate action will be taken to prevent further potential violations of any resident right while the alleged violation is being investigated. For reports of abuse, follow the state-specific abuse policy for management of the incident and documentation requirements. The department manager will contact the person filling the grievance to acknowledge receipt, investigate the grievance, take corrective actions as needed, engage the support of the Ombudsman, if warranted, and notify the person filing the grievance of resolution within 72 hours by providing a copy of Grievance/Concern Form to the resident/resident representative. Review grievances/concerns at the Quality Improvement Committee meeting to identify trends. A review of the facility's revised policy dated (MONTH) 1, (YEAR), titled Person-Centered Care Plan indicated a comprehensive, individualized care plan will be developed within seven days after completion of the comprehensive assessment for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs that are identified in the comprehensive assessments. The interdisciplinary, in conjunction with the resident and/or resident representative, as appropriate, will establish the expected goals and outcome of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. A review of the facility's Job Description for Director of Social Services 1 revised on (MONTH) 9, 2012, indicated under the section of Advocacy, that the Director of Social Services 1: 1. Works with Social Service staff, interdisciplinary team, and administration to promote and protect resident rights and the psychological well-being of all patients/residents. Prevents and addresses patient/resident abuse as mandated by law and professional licensure. 2. Works with patients/residents, families, significant others and staff to provide support and information for taking a more proactive role in self-advocacy to improve the quality of life/care for individual patients/residents. 3. Respond to issues identifies by patients/residents and families to determine satisfaction with services. b. A review of the admission record indicated Resident 103 was admitted to the facility on (MONTH) 3, (YEAR), with [DIAGNOSES REDACTED]. A review of the History and Physical report completed on (MONTH) 6, (YEAR), indicated Resident 103 was awake and alert. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated (MONTH) 10, (YEAR), indicated Resident 103 had intact cognition and required extensive/total physical assistance with bed mobility, transfer, toilet use, personal hygiene, and bathing. On (MONTH) 2, (YEAR) at 12:45 p.m., during an observation, Resident 103 was sitting in his wheelchair, awake, alert, and oriented to person, place, and time. During a concurrent interview, Resident 103 stated that he had requested to go to the restroom about an hour ago, but no one assisted him and he had soiled himself. During the same interview at 12:50 p.m., Resident 103 stated that a lot of facility staff did not stop to listen to his concerns or questions; some nursing staff would walk away when he would try to ask them a question. Resident 103 stated that about a couple of months ago around 5:30 a.m., a lady nurse (did not know the name) rough handled him during care, pulled his arm, was pushing him around really hard, and pushing him back and forth. Resident 103 stated that he did notify the head nurse (did not remember the head nurse's name). Resident 103 stated that there was another instance when one CNA was providing incontinence care, was pushing him hard and told him that he was good for nothing. Resident 103 also stated that a couple of month ago, he requested a urinal from a CNA, and the CNA told him there was no more urinals and that he did not need it because he was using a diaper. The resident stated that he notified the charge nurse. When asked how he felt about his concerns, resident stated that he felt sad and depressed. c. A review of the admission record indicated Resident 139 was admitted into the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED].), and [MEDICAL CONDITION] (lower-than-normal number of red blood cells or hemoglobin in the blood). A review of the History and Physical Report completed on (MONTH) 8, (YEAR), indicated Resident 139 had the capacity to understand and make medical decisions. A review of Resident 139's Certificate of Terminal Illness dated (MONTH) 5, (YEAR), indicated the resident was terminally ill and had a life expectancy of less than six months. Resident 139 was awake, alert, and oriented to person, place, and time. A review of the Minimum Data Set (a c

Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) received care, consistent with professional standards of practice, to promote healing of a Stage II pressure ulcer (injury to the skin and underlying tissues resulting from prolonged pressure) and prevent the development of two new pressure ulcers. As a result, Resident 1' pressure ulcer to the tailbone area worsened to the point of requiring surgical intervention and Resident 1 developed pressure ulcers to the right and left buttocks. Findings: On 3/21/18, at 11 a.m., an unannounced visit was made to the facility to investigate a complaint about Resident 1' quality of care. A review of the facility's actual census indicated Resident 1 no longer resided in the facility and was discharged on [DATE] to General Acute Care Hospital 1 (GACH 1) and did not return to the facility. According to the Admission Record, Resident 1 was initially admitted on [DATE] with the [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the Progress Notes dated 7/5/17, timed at 6 p.m., indicated an admission of Resident 1 for rehabilitation. The Braden Scale (used for predicting pressure sore risk) score was 16 (meaning the mild risk to develop pressure sores). Resident 1 had a surgical incision (cut) on the left hip (from the hip surgery). A review of the Progress Notes dated 7/5/17, timed at 10 p.m., indicated Resident 1 had Sacro-coccyx (tailbone area) Stage II pressure sore measuring 3.5 centimeters (cm) in length, 1.5 cm in width, 0.2 cm in depth. A review of the Care Plan developed on 7/6/17, for Resident 1's skin breakdown on the sacro-coccyx, included in the interventions provide wound treatment as ordered, skin checks per policy, weekly skin assessment by the licensed nurse to include measurements and description of the wound status. A review of physician's orders [REDACTED]. as needed for 30 days. A review of the Progress Notes dated 7/7/17 indicated Resident 1 was alert with confusion, did not speak English and refused breakfast and lunch. Resident 1's family would bring traditional food (Resident 1's culture) to entice Resident 1 to eat more. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 7/12/17, indicated Resident 1 could sometimes understand and be understood, required extensive assistance and one-person physical assist with bed mobility, transfers, toilet use, eating, and personal hygiene, and weighed 140 pounds. A review of the Nutritional assessment dated [DATE], indicated Resident 1 had poor intake and risk for weight changes/abnormal hydration related to dementia. Resident 1's intake was not meeting the nutritional needs. The Registered Dietitian (RD) recommended multivitamins with minerals for wound healing, add Peroneal® (medical food developed for the dietary management of wounds and conditions requiring supplemental protein) 30 milliliters (ml) for wound healing, house supplement daily with breakfast, and document the percentage consumed. Food preferences (ice cream, scrambled egg, cream soup, soy milk, and coffee with cream) were updated, the family verbalized Resident 1's choice to not having a feeding tube. The staff would continue to encourage meal and fluid intake based on Resident 1's tolerance. A review of the Care plan developed on 7/17/17 for Resident 1's nutritional risk related to weight loss and poor intake, included in the interventions encouraging food and fluid consumption, honoring food preferences, weighing as ordered and alert the RD and Physician if any significant weight loss or gain. The approaches did not include the use of pressure relieving devices (mattress and cushions). A review of the Skin Integrity Reports dated 7/13/17 and 7/19/17, indicated Resident 1 pressure sore size and status did not change since admission, 7/5/17. A review of the Weight Summary indicated on 7/19/17, Resident 1's weight was 121 pounds, a weight loss of 19 pounds in two weeks. A review of the Progress Notes dated 7/19/17, at 12:43 p.m., indicated the nurse informed the Physician about Resident 1's weight loss, who recommended tube feeding and calorie count of food consumed for two days. A review of the Progress Notes dated 7/22 and 7/23/17, indicated Resident 1 was encouraged to eat, was noted not eating the facility's food and only small amounts of the food the family provided. The calorie count documentation was incomplete. A review of a physician's orders [REDACTED]. A review of the nursing notes indicated no evidence Resident 1's surgical infection was infected; there was no documentation of sign or symptoms of infection to the surgical wound. A review of the Progress Notes dated 7/25/17, at 7:02 p.m., indicated that a Certified Nursing Assistant (CNA) informed the licensed nurse that Resident 1 had right and left buttocks skin breakdown. The licensed nurse indicated the sacro-coccyx pressure sore was a deep tissue injury (DTI) measuring 5 cm in length by 4 cm in width. The left buttocks had Stage II pressure sore measuring 5 cm in length by 4 cm in width and a right buttocks Stage II measuring 5.5 cm in length by 5.5 cm in width and a right upper buttock Stage I (reddened area with no broken skin) measuring 3 cm by 6 cm. Resident 1 had pain on the three pressure sores. A review of the Care Plan for skin breakdown on the right and left buttocks dated 7/25/17, indicated to continue with the 7/6/17, plan for skin breakdown of the sacro-coccyx. On 7/26/17, the Care Plan for the sacro-coccyx pressure sore was updated with interventions including multivitamins with minerals and ProHeal® as ordered, turn and reposition every two hours as needed. According to the Treatment Administration Record for 7/2017, Resident 1 refused the treatment on 7/9, 7/12, 7/15, 7/18, 7/21 and 7/23/17. There was no documentation on how many attempts staff made on the days Resident 1 refused treatment and if the nurses sought help from the family to get Resident 1's cooperation. A review of the Progress Notes indicated on 7/26/17, Resident 1's weight was noted to be 108.9 pounds. The family decided to have Resident 1 get a tube feeding and intravenous (IV) fluids for hydration. The nurses transferred Resident 1 to GACH 1 on the same day, 7/26/17 at 7 p.m. A review of GACH 1 Consultation Note dated 7/29/17, indicated Resident 1 presented with a pre-sacral area measuring 6 cm by 4 cm Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia (thin sheath of fibrous tissue enclosing a muscle or other organ), muscle, tendon, ligament, cartilage or bone) pressure ulcer. The ulcer had necrotic (dead) tissue which required surgical debridement (removal of death tissue) in the operating room under sedation and local anesthesia. Resident 1's Discharge Summary date 8/8/17, indicated final discharge [DIAGNOSES REDACTED]. On 5/2/18, at 11 a.m., during an interview, the Director of Nursing (DON) stated Resident 1 had poor dietary intake and did not like the facility's food. The DON was unable to explain why the licensed nurses did not promptly identify the deterioration of the sacro-coccyx pressure sore and the development of a right and left new pressure ulcers. On 6/8/18, at 1:48 p.m., during an interview, Resident 1's Family Member 1 (FM 1) stated the staff would not assist Resident 1 to eat or drink, and they would not turn and frequently reposition as requested by the family. Resident 1 was not provided an air mattress (pressure relieving device) despite the family's request. A review of the facility's policy titled, Skin Integrity Management revised on 11/28/16, indicated the purpose of the policy was to provide safe and effective care to prevent the occurrence of pressure ulcers. Manage treatment, and promote healing of all wounds; identify skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information; determine the need for support surface for bed and chair; review care plan weekly and revise as indicated; and document daily monitoring of ulcer site, with or without dressing. A review of the facility's policy for Nutrition/Hydration Management revised on 3/15/16, indicated the purpose of the policy was to provide safe and effective care to manage nutrition and hydration needs. Develop an interdisciplinary plan of care for enhancing oral intake and promoting adequate nutrition and hydration. Include interventions for residents with functional difficulties which may affect the ability to eat or drink independently, observe oral consumption of meals, supplements, and snacks and complete the meal data collection sheet when ordered or indicated, and revise care plan as needed. Document percentage of food/fluid Intake on Meal Monitor Data Collection Sheet when ordered or recommended; and administer supplements.

Based on interview and record review the facility failed to ensure a resident who is fed by enteral means (delivery of nutrients through a feeding tube directly into the stomachs) receives appropriate treatment and services to prevent complications for one of two residents (Resident 1), including: 1. Failure to ensure Resident 1's naso-gastric tube (NGT - flexible tubing inserted through the nose into the stomach to provide nutrition and medications) was maintained and checked for proper placement when the different pumps tried were not working and showed error which suggested the problem were not the multiple pumps but rather the NGT. 2. Failure to implement the Care Plan for Resident 1 having an NGT by not properly checking patency and placement of the NGT. 3. Failure to implement the facility's Enteral Management policy by not preventing Resident 1 from complications including aspiration pneumonia (an inflammation (usually due to an infection) of the lungs and [MEDICATION NAME] tubes that occurs after you inhale foreign matter) and vomiting. Ensure enteral feedings provided by syringe bolus (a type of feeding method using a syringe to deliver formula through your feeding tube) was used for select situations and stable residents who do not have a history of previous aspiration pneumonia and are able to protect their airways or provide their own care. 4. Failure to implement the facility's Enteral Nutrition Reference by not verifying Resident 1's NGT proper tube placement with x-ray when proper placement was questioned and monitor Resident 1 for clinical signs of misplaced tube - [MEDICAL CONDITION] congestion (an excessive accumulation of fluid in the lungs) dyspnea (difficulty breathing). As a result, on 1/16/18, Resident 1 required transfer to General Acute Care hospital 1 (GACH 1) where x-rays showed the tip of the NGT was not in the stomach but 15 centimeters (cm) above on the esophagus (a muscular tube that carries food and liquids from the mouth to the stomach) and was diagnosed with [REDACTED]. Findings: On 2/20/18, an unannounced visit was made to the facility to investigate a complaint regarding Quality of Care. A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Nursing Admission assessment dated [DATE], indicated Resident 1 was alert, had impaired cognition (reasoning), was unable to communicate, required total care and was dependent on an NGT. The lungs were assessed with [REDACTED]. A review of the physician's orders [REDACTED].® 1.2 calories at 50 milliliters (ml) per hour (50 ml/hr.) for 20 hours using an enteral feeding pump. Flush the NGT with 150 ml of water every four hours. Check tube placement prior to administration. Another physician's orders [REDACTED]. Resident 1 was also on antibiotic for pneumonia administered through the NGT. A review of the Care Plan initiated on 1/11/18 developed for Resident 1 having an NGT included in the goals for Resident 1 not to display signs of aspiration or complications from the NGT. The interventions included, once the pump issue is resolved, the Registered Dietitian (RD) recommended to initiate continues feeding at 50 ml per hour for 20 hours. Check patency and placement of tube daily and before administering feeding. A review of the nursing Progress Notes dated 1/12/18, timed at 12 p.m., indicated the NGT was in place. A review of the nursing Progress Notes dated 1/13/18, timed at 9 a.m., indicated Resident 1 was receiving continuous NGT feeding. At 3:54 p.m., the Physician was called and made aware the NGT pump was malfunctioning. The Physician ordered [MEDICATION NAME]® 1.5 bolus feeding (type of feeding method using a syringe to deliver formula through the feeding tube) one can (237 ml) three times daily (9 a.m., 1 p.m., and 9 p.m.) until the pump malfunction was resolved. At 5 p.m. the NGT was checked for placement and air was heard upon auscultation (listening to the internal sounds of the body, usually using a stethoscope) of the stomach. At 5 p.m., Resident 1 was receiving oxygen Resident 1 was suctioned once with a small amount of phlegm (mucous secretions). At 10:36 p.m., the NGT was working fine. A review of the nursing Progress Notes dated 1/14/18, timed at 9 a.m., indicated Resident 1 was suctioned twice with a small amount of phlegm noted and with a relative at bedside. At 2 p.m., [MEDICATION NAME]® 1.5 was given. A review of the nursing Progress Notes dated 1/15/18, at 12:13 a.m., Resident 1 was noted with restlessness, Resident 1's son requested to give Resident 1 Tylenol®. At 6:27 p.m., the bolus feeding was given. A review of the nursing Progress Note dated 1/16/18, at 9:07 a.m., a change of condition on Resident 1 was noted. Resident 1 vomited. The Physician was notified and ordered medication for vomiting. At 10:18 a.m., the resident vomited twice. At 12:30 p.m., Resident had elevated temperature 102 degrees Fahrenheit (normal range from 97°F to 99°F) with no signs of respiratory distress. The family members were at bedside. The Physician was notified and ordered to transfer Resident 1 to GACH 1. At 2:20 p.m., Resident 1 was transported to GACH 1. A review GACH 1 clinical record indicated a chest x-ray report dated 1/16/18 done at 4:43 p.m., indicated the tip of the NGT was not in Resident 1's stomach but in the esophagus about 15 centimeters from the stomach. The impression was the NGT needed to be advanced at least 15 cm further into the stomach. A review of the KUB (x-ray of kidney, ureter and bladder) dated 1/17/18 done at 12:38 a.m. indicated the NGT was advanced and the NGT was in the fundus (upper part) of the stomach. A review of the Consultation Report dated 1/17/18, at 10:05 a.m., indicated the residents was in respiratory distress with coarse bilateral breath sounds with wheezing and crackles. The chest x-ray showed [MEDICAL CONDITION] (lung) infiltrates (a substance denser than air, which lingers in the lungs). The History and Physical exam indicated Resident 1's chief complaint was fever, cough and shortness of breath. The family stated the NGT may have been pulled out and requested further evaluation. The chest x-ray and history pointed toward possible aspiration pneumonia. On 5/4/18, at 3:25 p.m., during interview, the Director of Nursing (DON) stated the facility always had extra stock of feeding tube pumps or they could obtain one from the supplier or from another facility. On 5/4/18, at 3:35 p.m., during interview, Registered Nurse 1 (RN 1) stated if an NGT is pulled out, the physician is called for order to reinsert the NGT. To check placement of the NGT, the nurse is to listen with a stethoscope for gurgling from the air injected into the tube with a syringe. Also, an x-ray could confirm placement. If the feeding pump malfunctions it must be replaced or call the physician to get an order for [REDACTED].>On 5/4/18, at 3:45 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she was caring for Resident 1 on 1/13/18 during the 3 pm to 11 pm shift. She stated after 5 ml of feeding, the feeding pump alarmed and stopped. LVN 1 stated she checked for placement by listening for bowel sounds injecting air in the NGT and listening with the stethoscope. LVN 1 then changed and tried several other feeding pumps, but all the pumps stopped and read error as the first pump. Each pump continued beeping reading error. LVN 1 called the Physician and reported the malfunctioning feeding pump. The physician ordered bolus feedings and did not order x-ray to check the NGT placement. During an interview on 5/4/18, at 4:07 p.m., LVN 2 stated she remembered having problems with Resident 1's feeding pump and Resident 1 gurgling from his mouth requiring suctioning. Resident 1's family members at bedside often requested Resident 1 to be suctioned and they would assist in the suctioning. LVN 2 further stated she checked placement of the NGT with air injected in the tube, then listening with the stethoscope. During an interview on 5/4/18, at 4:19 p.m., the Director of Nursing (DON) stated there was no chest x-ray for NGT placement due to no report the NGT was pulled out. On 5/7/18, at 2:35 p.m., during an interview the Nurse Practitioner (NP) stated there was no complaint of the NGT placement mentioned and a KUB (x-ray of kidney, ureter and bladder) which assess the gastrointestinal organs or chest x-ray would have been ideal to check for the NGT placement. A review of the facility's Enteral Management policy effective date 10/01/12, indicated based on the comprehensive assessment, the center must ensure that a patient fed by enteral means receives appropriate treatment and services to restore, if possible, prevent complications of enteral feedings including but not limited to aspiration pneumonia, vomiting, dehydration and metabolic abnormalities. Enteral feedings may be provided by syringe bolus when ordered by physician. This method of feeding is for select situations for stable patients who do not have a history of previous aspiration pneumonia or gastric-[MEDICAL CONDITION] reflux, who have normal gastric function, and are able to protect their airways or provide their own care. A review of the facility's policy on Enteral Nutrition Reference dated 1/2013, indicated interventions for potential problems and preventive actions which included verifying proper tube placement: Beside verification techniques: x-ray for tube placement verification any time proper placement is questioned. Monitor resident for clinical signs of misplaced tube - [MEDICAL CONDITION] congestion, dyspnea (difficulty breathing), tachypnea (increased respiratory rate), [MEDICAL CONDITION](increased heart rate) and abdominal distention/tenderness/hardness. Auscultation: Inject 10-20 ml of air using a 30 ml syringe, while listening for a whooshing or gurgling sound in the upper left quadrant of the abdomen.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures to ensure residents were free from abuse and neglect for two of 26 sampled Residents (Residents 14 and 17) and 12 of 22 Randomly Selected Residents (RSR 29, 31, 32, 34, 36, 37, 38, 39, 45, 47, and 49), including: 1. Failure to implement the facility's policy and procedure on Abuse Prevention Manual - Training, by not providing training on abuse prevention twice a year and as needed to Licensed Vocational Nurse 3 (LVN 3). 2. Failure to implement the facility's administrative policy and procedure on Temporary Agency Background Checks, by not verifying LVN 1, who was employed through a temporary staffing agency, had a complete criminal background check. 3. Failure to ensure CNA 2, who had an allegation of verbally abusing Resident 49, had an employee's file available for review of credentials, competency, training, and background check. 4. Failure to implement the facility's policy and procedure on Abuse Prevention Manual - Investigation, Corrective Actions and Administrative Action, by not conducting thorough investigations of allegations of abuse made by residents or their families. 5. Failure to implement the facility's policy and procedure on Abuse Prevention Manual - Protection, by not removing from the care of residents, staff who were accused of abuse to residents. 6. Failure to implement the facility's policy and procedure on Abuse Prevention Manual - Reporting, by not reporting to the Department (State Agency) an allegation of staff abuse involving RSR 29, 35, 47 and 49. 7. Failure to implement the facility's policy and procedure on Grievance/Concern, by not addressing, not investigating, not taking corrective actions, and not resolving grievances voiced by residents and/or their families. As a result, residents felt angry, humiliated, neglected, and were subjected to mental anguish and had the potential to affect 168 of 168 residents currently residing in the facility. On [DATE], at 11:40 a.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a resident) was called in the presence of the facility Administrator, Director of Nursing (DON) and the Resource Nurse. The facility submitted an acceptable Plan of Action (POA) on [DATE], at 5:35 p.m., which was validated through observation, interview, and record review, to verify compliance. The acceptable POA included: 1. On [DATE], the Administrator, Director of Staff Development (DSD), and the Clinical Quality Specialist began educating the staff members on policies and Procedures on Abuse prohibition with emphasis on post-abuse training for each alleged occurrence of abuse and/or neglect. 2. On [DATE], the social service staff interviewed Resident 14, Resident 17, RSR 31, RSR 47, and RSR 49 and provided psychosocial support to ensure the residents felt safe, secure, and their needs were met in a timely manner. 3. On [DATE] and 6, 2017, the department head/manager staff interviewed 86 residents, who were able to communicate, to inquire about concerns related to call lights response, incontinence care, and customer service. 4. Starting [DATE], the department heads/managers and the nursing staff would assess the residents who were unable to communicate their needs for signs and symptoms of distress, fear, pain, and sudden changes in behavior related to inflicted abuse. 5. The Administrator, social service staff and the DON proceeded with a thorough investigation including necessary interventions as indicated in the facility's Abuse Prevention Policy and reported the allegation of neglect for Resident 14, Resident 17, RSR 31, RSR 47, and RSR 49, to the Department, the Ombudsman, and the local law enforcement. 6. A log was created for temporary health employees/registry agency which will contain all the necessary requirement for employment (evidence of credentials, training, background check, etc.) which shall be kept for three years. 7. The facility will maintain current, complete, and accurate personnel records for all employed, including agency (registry) as per Federal Regulations and Title 22, Section . 8. The Regional Vice President of Operations provided re-education to the Administrator, the DON, and Human Resource staff regarding Abuse Prohibition Process and Hiring Process to assure employees have the necessary background checks, abuse prohibition training, licenses and certificates verification and their personnel files are readily available upon request. The IJ was removed on [DATE], at 5:51 p.m. after the survey team validated the above immediate plan of action. Findings: a. On [DATE] at 10:10 a.m., during an observation, Resident 17 was sitting at the edge of the bed, awake, alert, and oriented to person, place and time. Upon interview, Resident 17 stated the nursing staff was rude and not nice. The Certified Nursing Assistants (CNAs) would respond to the call light and state, What do you want? Also, Licensed Vocational Nurse 1 (LVN 1) would tell Resident 17 she was very busy and would take 45 minutes to take care of his requests. Resident 17 stated that when she pressed the call light to request her soiled incontinence brief to be changed, staff would respond that she would not be changed because it was almost time for lunch. Resident 17 stated it made her upset seeing CNAs standing in the hallway, chatting or on their cellphones instead of attending to her needs. While the resident was expressing her concerns, she started crying. Resident 17 stated she requested assistance one evening during night shift (11 p.m. to 7 a.m. shift) and CNA 1 responded, What do you want? I have 25 rooms and its 5 a.m. On [DATE] at 4 p.m., during a follow-up interview, Resident 17 stated she notified the staff (did not specify the name) regarding the nursing staff's attitude/behavior, but nothing was done about it, which made her angry. According to the Admission Record, Resident 17 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated [DATE], indicated Resident 17 had no memory problems and was able to make decisions. Resident 17 required extensive assistance with one-person physical assist with transfer, dressing, toilet use, and personal hygiene, and was incontinent of bowel and bladder functions. The MDS also indicated Resident 17 was feeling down, depressed or hopeless (seven to 11 days), had trouble falling or staying asleep (seven to 11 days in the past 14 days), and had poor appetite (two to six days in the past 14 days). b. On [DATE] at 8:13 a.m., during an observation in the presence of Registered Nurse 2 (RN 2), Resident 14 was lying in bed, awake, alert and oriented to person and place. During a concurrent interview, Resident 14 stated it usually took the nursing staff 15 minutes to one hour to answer call lights. Resident 14 stated the nursing staff was not nice and when she called for assistance, they would respond, What do you want? in a mean manner. Resident 14 stated the attitude of the nursing staff made her feel angry because when she called them, it was to request staff assistance and not, To bother people. On [DATE] at 12:35 p.m., during a follow-up interview, Resident 14 stated the nursing staff treated her as she was stupid and would say she was a, Difficult patient. In addition, staff would sometimes raise their voice at her and rough handle her while providing incontinent care. Resident 14 stated night shift staff was mean. According to the Admission Record, Resident 14 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated Resident 14 sometimes understood and made herself understood, and required extensive assistance with one-person physical assist with transfer, dressing, toilet use, and personal hygiene. On [DATE] at 1:45 p.m., during a follow-up interview, Resident 14 stated she did not notify administrative staff of her concerns regarding the attitude of the staff. c. On [DATE] at 9:29 a.m., during an observation, RSR 31 was sitting at the edge of the bed, awake, alert, and oriented to person, place, and time. Upon interview, in the presence of RN 2, RSR 31 stated the nursing staff was rude, and had a nasty attitude. RSR 31 stated LVN 1, a former employee, was rude to him. RSR 31 also stated that when he pressed the call light to request assistance, the nursing staff would stroll by his room and not answer the call light to attend to his needs. According to the Admission Record, RSR 31 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated RSR 31 had no memory problems, was able to make decisions, required extensive assistance with one-person physical assist with dressing and toilet use. The MDS indicated RSR 31 was feeling down, depressed or hopeless (two to six days in the past 14 days), had trouble falling or staying asleep (two to six days in the past 14 days), and feeling tired or having little energy (two to six days in the past 14 days). On [DATE] at 11 a.m., during a review of employees' file with the DSD and concurrent interview, she was unable to provide LVN 1's employee file and explained LVN 1 was hired through a registry and they were trying to contact the registry to request LVN 1's file. On [DATE] at 10:55 a.m., during an interview, the Administrator, who was also the abuse prevention coordinator, stated LVN 1's employee file was not available and that it will be available on [DATE] from the registry. The Administrator stated she was unable to provide documented evidence the facility had verified the nursing staff provided by the contracted registry had verified previous employment history, criminal background, and licenses. d. On [DATE] at 8:20 a.m., during an interview, Family Member 1 stated nursing staff was rude to RSR 49. FM 1 stated during one of her visits in [DATE], RSR 49 was crying saying she did not want to reside in the facility because the nursing staff was mean to her. FM 1 stated RSR 49 told her that a day prior to her visit, RSR requested assistance to go to the bathroom for bowel movement and CNA 2 told the resident to pass the bowel movement in her incontinence brief. After RSR 49 had done so, CNA 2 called RSR 49, Nasty lady while cleaning her. According to the Admission Record, RSR 49 was originally admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated RSR 49 required extensive assistance with one-person physical assist with transfer, dressing, toilet use, and personal hygiene. A review of the Grievance Form indicated FM 1 filed a grievance on [DATE] regarding RSR 49 not liking CNA 2 because of resident to CNA incompatibility. The corrective action indicated CNA 2 would no longer be assigned to RSR 49. On [DATE] at 7:20 a.m., during an interview, Social Services Designee 3 (SSD 3) stated when she received the grievance from FM 1 on [DATE], she felt it was an allegation of abuse. SSD 3 stated she interviewed CNA 2 regarding the allegation, but did not interview other residents assigned to CNA 2, to inquire about her behavior, attitude, and/or work ethics. On [DATE] at 9:20 a.m., during an interview, the Administrator stated she would re-open the investigation. The ADM also stated if FM 1 had reported that CNA 2 called RSR 49 a, Nasty lady, then the abuse allegation should have been reported to the Department. On [DATE] at 11 a.m., during a review of employees' file with the DSD and concurrent interview, DSD stated she was unable to provide CNA 2's employee file at the time and was trying to locate it. e. On [DATE] at 7:50 a.m., during an observation, RSR 32 was lying in bed, awake, alert, and oriented to person, place, and time. During a concurrent interview, RSR 32 stated the nursing staff had been rude to him in the past. According to the Admission Record, RSR 32 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of a Grievance form indicated RSR 32's representative (FM 3) filed a grievance on [DATE]. FM 3 reported RN 4 was rude and unprofessional on the phone. On [DATE] at 12:15 p.m., during an interview, SSD 1 stated the administrative staff did not interview other residents assigned to CNA 9 and RN 4 to inquire about CNA 9's attitude. A review of the MDS dated [DATE], indicated RSR 32 had no memory problem and was able to make decisions. RSR 32 required extensive assistance with one-person physical assist with transfer, dressing, toilet use, and personal hygiene. A review of a Grievance Form indicated the RSR 32 filed a grievance on [DATE]. RSR 32 reported that on [DATE], he pressed the call light at 6:30 p.m. to have his incontinence brief changed and CNA 9 did not answer the call light until 8:30 p.m. The corrective action was to provide an in-service regarding answering call lights in a timely manner to all CNAs and charge nurses. On [DATE], the facility was unable to provide documented evidence an in-service was provided to all CNAs and charge nurses as indicated in the corrective action. f. According to the Admission Record, RSR 47 was originally admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of a Grievance form indicated RSR 47's family member (FM 2) filed a grievance on [DATE]. FM 2 reported that on [DATE], LVN 4 had poor bedside manners when she requested RSR 47's blood pressure to be taken and to give RSR 47 pain medication. LVN 4 told FM 2, I will get to that room when I get to that area, or go away, or I will get there when I get there. FM 2 also reported she approached LVN 3 to request RSR 47's blood pressure to be taken. LVN 3 responded, No, I am busy. Go to the charge nurse. LVN 3 was short tempered and did not listen to FM 2's concerns. The assigned CNA did not offer to provide incontinence care to RSR 47 during the 7 a.m. to 3 p.m. shift. LVN 10 did not assess RSR 47's pain to determine which pain medication to administer. The recommended corrective action was to add frequent check to the CNA's plan of care and the three employees involved in the grievance would no longer return to work at the facility. On [DATE] at 7:20 a.m., during an interview, the DON stated the grievance received on [DATE] indicated neglect from LVN 3 and LVN 4. The DON stated she did not interview other residents assigned to LVN 3, 4, and 10 to inquire about their treatment to the residents and families; did not provide in-service education regarding elder abuse prevention to the nursing staff after the incident occurred; the facility did not conduct a detailed investigation in regards to the alleged occurrence of neglect/abuse; and the abuse allegations were not reported to the Department. On [DATE] at 9:20 a.m., during an interview, the Administrator stated she would re-open the investigation. On [DATE] at 12:53 p.m., during an interview, FM 2 stated the nursing staff had been neglecting RSR 47 by ignoring her medical status and her pain. FM 2 stated on [DATE], RSR 47 was agitated because of pain. FM 2 told LVN 4 to provide pain medication to RSR 47, but LVN 4 did not show up for two hours (from 4 p.m. to 6 p.m.). When FM 2 approached another nursing staff (LVN 3) requesting pain medication, LVN 3 responded he was busy and got mad. FM 2 stated that the CNAs working during the night shift would, Disappear and did not attend to RSR 47's needs. FM 2 stated that during her visits at the facility, she had witnessed nursing staff calling residents derogatory (disrespectful) names, such as, Pig or ignoring the residents' calls for assistance. On [DATE] at 11 a.m., a review of LVN 3's employee file was reviewed in the presence of the DSD. LVN 3's license had expired on [DATE]. The DSD stated LVN 3 licensed was checked, but was not placed in the employee's file. The employee file did not contain evidence of abuse prevention training and the DSD was unable to provide documentation on training education on elder abuse prevention training within the past year. g. According to the Admission Record, RSR 45 was originally admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated RSR 45 required total assistance with dressing and personal hygiene. On [DATE] at 9:05 a.m., during an observation, RSR 45 was sitting in her wheelchair, awake, alert and oriented to person. The pad call light was located behind the resident's wheelchair (not within reach). There was a note posted on the wall by RSR 45's bed indicating to place the call light on the chest, not on the nightstand. On [DATE] at 11:30 a.m., during an interview, RSR 45's responsible party (RP 1) stated CNAs had been, Mean and nasty to the resident. RP 1 stated that about three weeks ago, a CNA threw RSR 45's call light under the bed after the resident pressed the call light to request assistance during night shift (11 p.m. to 7 a.m.). RP 1 stated she placed the sign on the wall because she noticed the nurses were placing the call light on the night stand because, They did not want to be bothered. On [DATE] at 11:50 a.m., during an interview in the presence of RP 1, RSR 45 stated the CNAs were sometimes mean and rough handled her during incontinence care. RSR 45 stated the way the CNAs talked to her was mean. RSR 45 stated that she did not want to give out any names. h. According to the Admission Record, RSR 35 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Grievance form received on [DATE], indicated RSR 35 reported he was disappointed with the provision of care, in particular call lights response and the lack of follow up. RSR 35 reported that on [DATE] during night shift (11 p.m. to 7 a.m.), the nursing staff responded to his call light, but made him wait too long for a bed pan, which then, was too late. On [DATE] between 4 p.m. to 4:37 p.m., during an interview while reviewing the Grievance forms, the Administrator stated the grievance required further investigation and confirmed the investigation did not address RSR 35's grievance. i. According to the Admission Record, RSR 29 was originally admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of a Grievance form received on [DATE] indicated RSR 29 reported CNA 9 got him out of bed at 12 noon on that day, and did not turn him so he could watch television as he could not turn on his own. On [DATE] between 4 p.m. to 4:37 p.m., during an interview while reviewing the grievance forms, the Administrator stated the grievance forms did not indicate administrative staff interviewed other residents assigned to CNA 9 to inquire about her treatment to them. j. According to the Admission Record, RSR 36 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Grievance form indicated RSR 36's family member (FM 4) complained during the interdisciplinary team (IDT) meeting on [DATE], that on [DATE] (a Saturday) at around 1:45 p.m., RSR 36 was soiled with bowel movement and the pitcher of water was out of reach and on the same spot they left it on Tuesday (after four days). FM 4 stated when RSR 36 was given water, he drank it all as if he was not given water regularly. The administrative staff interviewed CNA 3 as part of the investigation for the alleged occurrence. A review of CNA 3's employee file on [DATE] at 11 a.m. in the presence of the DSD, disclosed CNA 3's certification expired on [DATE]. k. According to the Admission Record, RSR 37 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the grievance received on [DATE] indicated RSR 37's family member (FM 5) reported that on [DATE] at around 4:00 p.m. to 4:30 p.m., RSR 37 had diarrhea (watery stool), pressed the call light and a nursing staff just turned off the light without even checking what RSR 37 wanted. The grievance form did not indicate administrative staff interviewed other residents or staff in regards to the alleged incident. l. According to the Admission Record, RSR 38 was originally admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the grievance received on [DATE] indicated RSR 38's family member (FM 6) reported concerns the night shift (11 p.m. to 7 a.m.) did not turn and reposition RSR 38 and resulted on RSR 38 developing wounds on her backside. The grievance form did not contain an investigation. m. According to the Admission Record, RSR 39 was originally admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the grievance received on [DATE] indicated RSR 39's family member (FM 7) reported the CNA working between the 11 p.m. to 7 a.m. shift, did not check on RSR 39 because she visited RSR 39 at 7 a.m., and RSR 39 was soiled with bowel movement all the way up to RSR 39's back. The grievance form did not contain an investigation. A review of the facility's revised policy and procedure dated [DATE], titled, Abuse Prevention Manual, indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family member(s) or legal guardian, friend(s), or other individuals. The Center will take proactive measures to prevent the occurrence of abuse to any resident. The policy indicated that the purpose is to ensure the resident's rights are protected by providing a method for the prevention, reporting and investigation of any type of alleged resident abuse. Procedures: Screening: All potential employees will have reference verification with current and/or past employment. All CNAs will be properly screened for criminal background and approved by the Department of Health Services, through use of their CNA Abuse Registry and Certification Program. Any CNA who has been previously employed out of the state of California will also be subject criminal background screens through state registry. Licenses will be verified for all employees who hold licenses. Training: All employees will receive orientation and ongoing training on abuse prevention and reporting. All employees/caregivers will be oriented to their role in abuse prevention as mandated reporters and that abuse will not be tolerated in this Center. Bi-annual and as necessary in-service training will be provided for review of Center's policy on abuse prevention and mandated reporting. Identification: Staff will report complaints and observations of suspected alleged violations and injuries of unknown origin so that investigations can be conducted to rule out abuse; as well as file all requirements of DOJ's mandated reporter. Occurrences, patterns and trends will be assessed by administrative staff, licensed staff, and interdisciplinary team to determine the corrective action based on the results of the investigation. Results will be reported to Administrator and Quality Assurance and Assessment Committee for further direction and actions plan if necessary. Protection: If a resident incident is reported, discovered or suspected, where the health, welfare of safety of the resident(s) is involved, the Center will take steps to provide a safe environment for the resident(s) as indicated by the situation: if the suspected perpetrator is an employee, then immediately remove the employed from the care of vicinity of the resident. Suspend the employee during the investigation. Where the circumstances of the alleged violation warrants, the Director of Nursing of Services or designee shall initiate a physical and mental assessment of the resident and document the findings. Factual information only shall be documented, not assumptions. The Director of Nursing Services or designee shall notify the attending physician regarding the alleged violation, assessment findings and document in the medical record. Investigation: The assigned staff will be informed of the nature of the incident and continue the investigation process. The investigation shall include interviews of employees, resident(s), family, visitors who may have knowledge of the alleged incident. Factual information only will be documented, not assumptions or speculations. The investigation and report shall include, at a minimum name of witnesses and their statement of the incident, when applicable, information from any other individuals involved, recommendations for corrective action if applicable, outcome of investigation, and follow-up resolution of further action if necessary. Evidence of investigation of alleged violations shall be maintained as required by state and federal laws. The Facility Investigation Report shall be completed after the investigation is complete and provided to survey agencies when requested or required by state or federal law. This form shall be maintained in the Administrator's office as part of the confidential file for QAA review. It is NOT part of the medical record. Reporting: It is this facilities policy that any known or suspected abuse will be reported by completing an Incident and Injury Report. The Administrator shall report all alleged or suspected violations to the appropriate state agencies immediately or within 24 hours (California H&S Code 1418.19a) and Vice-President of Operations. Administrator or designee shall investigate all suspected or alleged abuse and report incident to the local ombudsman or the local law enforcement agency by telephone immediately or as soon as practically possible, and by written report (S(NAME) 341) sent within two working days. Corrective Action: The facility shall make reasonable efforts to determine the cause of the alleged violation and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. The Director of Nursing Services or designee, shall initiate a care plan where appropriate to reflect the resident's condition and measure taken to prevent reoccurrence. Any facility staff member found to be neglecting any resident will be suspended during the investigation and could ultimately be terminated depending upon the outcome of the investigation and the Administrator's conclusion regarding the situation. Any employee suspected of alleged abuse will be suspended during the investigation and ultimately terminated if investigation confirms willful abuse. It the investigation confirms the alleged incident as suspected abuse, appropriate steps shall be taken immediately to prevent reoccurrence of the incident. The Center will notify the appropriate licensing agency if incident involves a licensed employee or to the State Nursing Assistant Registry Board, if the incident involves a CNA. Documentation in the medical record shall be made where necessary for continuity of care for the resident. Administrative Action: The Administrator of designee shall initiate an investigation immediately, which may include interviews of the involved resident(s), and other parties (employees, visitors, and other residents, volunteers, family members, etc.) who have knowledge of the alleged incident. These statements should be in writing and signed by the person making the statement. A summary of any incidents shall be submitted to the Quality Assurance and Assessment (QAA) Committee for trending and continued problem solving. The QAA members will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. The Administrator of designee will verify that mandated in-services are presented on a timely basis. If incident involves a facility staff member, verify that the employee involved attended that appropriate in-service. A review of the facility's revised policy and procedure dated [DATE] and titled, HR206 Temporary Agency Background Checks: Criminal and Driving, indicated Genesis Healthcare will only use temporary staffing agencies that complete criminal background checks on their staff. Background checks must include: verification of credentials, licenses, certificates, or other documents required for the position, criminal background check, driving record check, substance abuse screening, abuse registry check, Health and Human Services Office of Inspector General and General Services Administration check, and employee health screening. Before a Genesis Healthcare location is permitted to use an external temporary staffing agency, the agency must provide confirmation that they are in compliance with this policy pursuant to the terms of their contract. A review of the facility's revised policy and procedure dated February 13, 2017 and titled, Grievance/Concern, indicated when the formal grievance/concern is logged, the Center Executive Director (CED) and appropriate department manager will be notified. Immediate action will be taken to prevent further potential violations of any resident right while the alleged violation is being investigated. For reports of abuse, follow the state-specific abuse policy for management of the incident and documentation requirements. The department manager will contact the person filling the grievance to acknowledge receipt, investigate the grievance, take corrective actions as needed, engage the support of the Ombudsman, if warranted, and notify the person filing the grievance of resolution within 72 hours by providing a copy of Grievance/Concern Form to the resident/resident representative. Review grievances/concerns at the Quality Improvement Committee meeting to identify trends.

Based on observation, review of facility documents, pest control technician and facility staff interviews, the facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards for food safety when the facility failed to: 1. Suppress cockroach population by maintaining a pest control service in the kitchen. 2. Follow pest technician recommendations on the control of the cockroaches including patching holes and cracks that allowed the entry of cockroaches into the kitchen. 3. Maintain floor drains, a source of water for the cockroaches. 4. Maintain the kitchen in a sanitary manner. Cockroaches are nocturnal insects. They prefer to live and feed in the dark, a cockroach seen during the day is a possible sign of infestation. Cockroaches tend to prefer dark, moist places to hide and breed and can be found behind refrigerators, sinks and stoves, as well as under floor drains and inside of motors and major appliances. The bodies of dead cockroaches can also be found throughout the house. (www.orkin.com) According to the booklet titled Effective Management of Cockroach Infestations by the County of Los Angeles Vector Management Program, the German cockroach is the most common of the cockroach species. This species reproduces more rapidly than the other common pest cockroaches. German cockroaches are believed to be capable of transmitting disease causing organisms such as Staphylococcus spp., Streptococcus spp., [MEDICAL CONDITION] virus, and coliform bacteria. They also have been implicated in the spread of [MEDICATION NAME] and dysentery. They prefer food preparation areas, kitchens, and bathrooms because they favor warm, humid areas that are close to food and water. In severe infestations they may spread to other parts of the structure. Generally, for every cockroach seen in the daytime there are many more concealed in dark, protected locations. The facility's blocked kitchen sewage drains and wet floor provided the moisture that was needed to keep cockroaches thriving. The dirty kitchen environment including cracks in the walls and floors provided both food and safe places to harbor and the warm kitchen conditions was the final condition necessary to encourage the cockroaches to thrive. The German cockroach was the kind of cockroach found in the facility's kitchen and food storage area. . These deficient practices had the potential to affect all 168 residents in the facility when the immediate jeopardy situation was declared. Nursing home residents risk serious complications from food poisoning as a result of their compromised health status. Symptoms of food borne illness include diarrhea, vomiting, headaches, fever, confusion, loss of appetite, abdominal cramping and pain. When those conditions persist they can lead to dehydration and may require hospitalization and in some cases death. Immediate Jeopardy was declared on 10/03/17 at 5:05 pm. The Administrator and Director of Nursing were informed of the Immediate Jeopardy situation. The saliva, droppings and decomposing bodies of cockroaches contain proteins known to trigger allergies [REDACTED]. Cockroaches are also capable of mechanically transmitting disease causing organisms such as Staphylococcus spp., Streptococcus spp., [MEDICAL CONDITION] virus, and coliform bacteria, salmonella, E. coli that can cause food poisoning. Nursing home residents risk serious complications from food poisoning as a result of their compromised health status. Symptoms of food borne illness include diarrhea, vomiting, headaches, fever, confusion, loss of appetite, abdominal cramping and pain. When those conditions persist they can lead to dehydration and may require hospitalization and in some cases death. An acceptable plan of action was provided by the facility Administrator on 10/03/17 at 8:15 pm. The plan of action included clearing the floor drains by hydro-jetting the drain lines and deep cleaning after the hydro jetting. Hydro jetting is a method used by professional plumbing contractors to clean clogged or slow sewage lines. A blast of water at high pressure is sent into the drain lines that will usually remove blockages and build up. Also included in the plan of action was the pest control company performing several treatments to exterminate the cockroaches. The kitchen floor and other surfaces were deep cleaned to remove build-up of grease, grime and other debris. Also included in the plan of action was the kitchen will be closed from food preparation and service. The pest control treatments will be conducted later that night (on October 3, 2017). The facility also planned to use the emergency / disaster food supply for the residents' meals. The use of the disaster food was to ensure that possible contaminated food was not used in the preparation of meals. The emergency food was stored in a separate room that did not indicate evidence of the presence of cockroaches After the facility's plan of action was implemented by clearing the kitchen floor drains, deep cleaning the kitchen after the hydro jetting, the pest control company performing several treatments to exterminate the cockroaches, completing kitchen floor and other kitchen surfaces deep cleaning to remove build-up of grease, grime and other debris, and closing the kitchen from food preparation and service and using the facility's planned use of the emergency / disaster food supply for the residents' meals, the Immediate Jeopardy was abated on 10/5/17 at 4:20 pm. Findings: During the tour of the kitchen on 10/03/17 at 8:10 am, the floor of the dry storage room was soiled with food debris and sticky material. There were open bags of tortillas, muffins and a partially opened bag of chocolate pudding mix was observed on the shelves in the dry storage room. Two live cockroaches were also observed crawling across the floor during the concurrent observation in the dry storage room. Two Dietary Service Supervisors (DSS and DSS 2) were present during the observation. The floor of the dry storage room was dirty with a build up of dark colored dirt and grime. There was a thick build up of dark colored oily substance around the stove and cooking area. On October 3, 2017 at 8:15 am, the DSS stated in a concurrent interview and observation of the kitchen, the Pest Control Company Technician (PCT) had come to perform services the week before, and the night before the observations (of 10/03/17 at 8:10 am). In addition, there was a sewage back-up of two floor drains in the kitchen. On October 3, 2017 at 12:29 pm, a big drain under the dish washing machine, measuring about 12 inches by 8 inches, was observed with an accumulation of black colored, malodorous liquid in the drain. An examination of the drain contents showed black colored sediments. At 12:48 pm on October 3, 2017, water with a strong, rotten odor was observed flowing freely out of one of the kitchen floor drains, leaving a puddle surrounding the drain. The floor in the area of the kitchen drain remained wet, and the sewage (waste water conveyed in sewers) was tracked throughout the kitchen. There were wet shoe prints throughout the kitchen. On October 3, 2017 at 1:55 pm in an interview, the Assistant Supervisor (AS), stated whenever the hand washing sink and dish washing machine are used at the same time, the kitchen drains back up. Dietary Aide 2, who was one of the many food service staff present, stated the water flowing out of the floor drain, when hand washing is being done, happened in the past two to four months and happened also the day before (on October 2, 2017). Diet Aide 3 stated the kitchen drain back up happened last night and today. On October 3, 2017 at 3:30 pm, while hand washing, in kitchen hand washing sink, located at the entrance to the kitchen, water was observed flowing out of the floor drain onto the kitchen floor. The Maintenance Supervisor (MS) who was present, stated the drain pipes were old, but did snake the pipe every three to 4 months and jet (hydro) every six months to keep the drain lines flowing (open). The MS stated the food service staff inform him of the kitchen sewer drain line back up, once a month. A review of a receipt by a plumbing company dated 03/02/2017 showed the kitchen floor drains were backed up. The plumbing company had to snake all floor drains and perform hydrojet on all lines. The plumbing services rendered on March 2, 2017, provided a 2 - month warranty. In addition, there was a recommendation to repipe (remove and replace with new pipes) drain lines. There was no documented evidence provided to the survey team, by the facility to indicate recommendations to repipe drain lines, or other services were performed to resolve the ongoing floor drain sewage back up. On October 3, 2017 starting at 4:05 pm there were four additional live cockroaches observed crawling underneath the food preparation kitchen sink. Inspection of the kitchen, revealed holes in the walls behind the dish washing machine, a hole approximately 3 inch by 3 inch behind the door in the dry storage room, numerous floor tile cracks, tiles and coving separated from the walls in several areas throughout the kitchen. One dead cockroach was observed on the ladder in the dry storage room. There was a large gaping hole on the wall adjacent to the elevator door that was about 30 inches long and 2 inches wide. A live cockroach was observed crawling on the coving next to the elevator. At 4:15 pm on October 3, 2017, the plumber from the same company who had performed services on March 2, 2017, was observed in the kitchen. In a concurrent interview the MS stated the work on the floor drains had been completed and the floor drains were flowing well. A review of the receipt provided, confirmed observations that had been made by the survey team. The plumbing company found two drains were backing up on the same branch line . Found there was a usual build up in pipe. The receipt also indicated last time we performed jet 3/2/17. The MS stated in the concurrent interview and observation at 4:16 pm, the drains had not been re-piped and the facility had plans to do so in the near future. The facility had a bid out for the repairs. In an interview conducted on October 3, 2017 at 4:30 pm, food and nutrition staff 1 (FNS 1), stated the presence of cockroaches in the kitchen have been observed for several months and had been reported to the previous food service supervisor. A review of the binder containing receipts of pest control services performed from June 12, 2017 through October 1, 2017, showed the kitchen had not been included in the areas treated prior to September 20, 2017. The pest control report titled Customer Service Report showed from June 12, 2017, the pest control services were only performed for the exterior of the facility building, only for large fly, rodents and cockroaches in the dumpster/ garbage area and basement interior. This service report indicated there was a 1/4 inch gap or greater at the exit door in the basement area next to the laundry. The report recommended replacing the door sweep to reduce the number of pests entering the area. The kitchen is located in the basement. The pest control report dated 7/9/2017 indicated under the subheading structural concerns that could cause pest problems, the kitchen interior floor tiles or baseboards loose missing. The report noted please repair to eliminate potential pest harborage / breeding site. The report dated 9/20/2017, indicated cockroaches noted during service, activity noted in cook line area. The report indicated the presence of a hole/gap behind the dish washing machine. The facility regional food and nutrition manager (RFNM) stated in an interview at 4:35 pm on October 3, 2017, the kitchen is part of the areas the pest control company were contracted to treat. The RFNM stated he would ask the maintenance supervisor for information to verify the kitchen was part of the facility's pest control program. At 5:05 pm on October 3, 2017, the Administrator (ADM) and the Director of Nursing (DON) were informed of the Immediate Jeopardy situation. During the meeting, the ADM stated the kitchen had been deep cleaned the day before (on October 2, 2017), causing the cockroaches to come out. The Administrator stated the kitchen will be closed, no kitchen food preparation and service will be done and the pest control treatment will be done later that night (on October 3, 2017). The facility's plan included to use the emergency / disaster food supply for residents' meals. On October 4, 2017 at 11:05 am after the kitchen had been serviced by the pest control company (on October 3, 2017), the kitchen was inspected for the presence of cockroaches. There was one live cockroach observed in the dry storage room. A wet tile which was lifted with ease off the floor, in the dry storage room, revealed the presence of about six dead cockroaches underneath the tile. The location of the wet tile was on the floor next to the wall that separated the dry storage room from the kitchen, across from the dish washing area. The presence of moisture on the floor in the dry storage room, indicated an amount of water leaked from the dishwashing area of the kitchen, sufficient enough to move into the dry storage area underneath the wall. On October 4, 2017 at 11:55 am, in the Dining Room, meal service was set up, served and distributed, in one corner of the Main Dining Room. On observation, the area lacked hand washing facilities. When two employees were asked where they wash their hands, they stated they washed their hands in the kitchen (in the basement). The staff after asked about handwashing went to wash their hands down the hallway at the nurse's station before meal service. The food from the emergency menu had been prepared (heated) at the sister facility. The food was transported to the facility in an employee's car, of an unknown sanitary condition. On October 4, 2017 starting at 6:52 pm, one live cockroach was observed in the kitchen food preparation area underneath the sink, on the back wall, around a mesh and plaster covering. Another cockroach was observed behind the freezer crawling into one of the floor drains. Another live cockroach was observed on the wall adjacent to the food preparation sink. The cockroach was crawling around one of the pipes. A live baby cockroach was also found a few minutes later, underneath the sink near the mesh and plaster area, in the same vicinity as was observed with the first cockroach at 6:52 pm. In a telephone interview with the pest control technician on October 4, 2017 at 7:22 pm, the PCT stated he had only recently restarted performing pest control services to the facility's kitchen, because of a change in the kitchen management. PCT stated he had not been granted access to the kitchen by the previous supervisor, and in September of 2017, the new kitchen Assistant Manager ensured he had access to the kitchen to be able to perform services. The PCT stated he had not seen any live cockroaches in the kitchen when he sprayed the night before (on October 3, 2017). PCT explained he treated around the desk area of the dry storage room, the electrical panel, and the cook line (cooking area). When the PCT was notified of the areas observed with cockroaches, PCT stated fumigation of the whole kitchen, instead of treatment of [REDACTED]. At 8:00 pm on October 4, 2017, the facility presented a different proposal as to change in the meals being prepared from the emergency menu to the regular menu and meal service from the dining room to the staff lounge with access to a handwashing sink and a bigger space for better meal distribution. The plan included meal preparation and transportation from another facility a mile away owned by the same licensee. The facility rented a truck used solely for food transportation. On October 5, 2017 at 8:25 am, there were also approximately twenty dead cockroaches in the water on the floor, underneath the dish washing machine, in the kitchen. No other cockroaches were observed during subsequent checks to the kitchen on October 5, 2017 at 3:30 pm. All the wall and floor cracks had been repaired and sealed. No food preparation was taking place in the kitchen, all floor tiles in the dry storage room were removed with plans to replace them, the whole kitchen was deep cleaned including walls. All food items in the dry storage room had been discarded. Immediate Jeopardy was lifted on October 5, 2017 at 4:20 pm. On October 6, 2017 at 8:30 am two small live cockroaches were observed in the dry storage room. Deep cleaning of the kitchen equipment and kitchen hood were observed. The facility's kitchen remained closed until October 7, 2017.

Based on observation, review of facility documents, pest control technician and facility staff interviews, the facility failed to ensure there was an effective pest control program to prevent the infestation of roaches in the kitchen when the facility failed to: 1. Suppress cockroach population by maintaining a pest control service in the kitchen. 2. Follow pest technician recommendations on the control of the roaches including patching holes and cracks that allowed the entry of roaches into the kitchen. 3. Maintain floor drains, a source of water for the roaches. 4. Maintain the kitchen in a sanitary manner. For roaches to thrive, they need three components: water (moisture), food and temperature. The facility's blocked kitchen sewage drains and wet floor provided the moisture that was needed to keep them thriving. The dirty kitchen environment including cracks in the walls and floors provided both food and safe places to harbor and the warm kitchen conditions was the final conditions encouraging the roaches to thrive. The saliva, droppings and decomposing bodies of roaches contain proteins known to trigger allergies [REDACTED]. Roaches are also capable of mechanically transmitting disease causing organisms such as Staphylococcus spp., Streptococcus spp., [MEDICAL CONDITION] virus, and coliform bacteria, salmonella, E. coli that can cause food poisoning. These deficient practices had the potential to affect all 168 residents in the facility when the immediate jeopardy situation was declared. Nursing home residents risk serious complications from food poisoning as a result of their compromised health status. Symptoms of food borne illness include diarrhea, vomiting, headaches, fever, confusion, loss of appetite, abdominal cramping and pain. When those conditions persist they can lead to dehydration and may require hospitalization and in some cases death. Immediate Jeopardy was declared on 10/03/17 at 5:05 pm. The Administrator and Director of Nursing were informed of the immediate jeopardy. An acceptable plan of action was provided by the facility Administrator on 10/03/17 at 8:15 pm. The plan of action included clearing the floor drains by hydro-jetting the drain lines and deep cleaning after the hydro jetting. Hydro jetting is a method used by professional plumbing contractors to clean clogged or slow sewage lines. A blast of water at high pressure is sent into the drain lines that will usually remove blockages and build up. Also included in the plan of action was the pest control company performing treatments to exterminate the roaches. The kitchen floor and other surfaces were deep cleaned to remove build -up of grease and other debris. Also included in the plan of action was that the kitchen will be closed from food preparation and service. The pest control treatments will be conducted later that night. The facility planned to use the emergency / disaster food supply for the residents' meals. The use of the disaster food was to ensure that possible contaminated food was not used in the preparation of meals. The emergency food was stored in a separate room that did not indicate evidence of the presence of cockroaches. The Immediate Jeopardy was abated on 10/5/17 at 4:20 pm. Findings: During the tour of the kitchen on 10/03/17 at 8:10 am, the floor of the dry storage room was soiled with food debris and sticky material. There were open bags of tortilla, muffins and a partially opened bag of chocolate pudding mix observed on the shelves in the dry storage room. Two live roaches were also observed crawling across the floor during the concurrent observation in the dry storage room. Two Dietary Services Supervisor (DSS and DSS 2) were present during the observation. On October 3, 2017 at 8:15 am, the DSS stated in the concurrent interview and observation the Pest Control Company technician (PCT) had come to perform services the week before and the night before the observations (of 10/03/17 at 8:10 am) were made. In addition, there was a sewage back-up of two floor drains in the kitchen. On October 3, 2017 at 12:29 pm a big drain under the dish washing machine, measuring about 12 inches by 8 inches, was observed with an accumulation of black colored, malodorous liquid in the drain. An examination of the drain showed black colored sediments. At 12:48 pm on October 3, 2017, water with a strong rotten odor was observed flowing freely out of one of the floor drains leaving a puddle surrounding the drain. The floor in the area of the kitchen drain remained wet and the sewage (waste water conveyed in sewers) was tracked throughout the kitchen. There were wet shoe prints throughout the kitchen. On October 3, 2017 at 1:55 pm, in an interview the Assistant Supervisor (AS), stated whenever the hand washing sink and dish washing machine are used at the same time, the kitchen drains back up. Dietary Aide 2, who was one of the many food service staff present, stated the water flowing out of the floor drain, as the hand washing is being done, happened in the past two to four months and happened also the day before (on October 2, 2017). Diet Aide 3 stated the drain back up happened last night and today. On October 3, 2017 at 3:30 pm, while hand washing, in kitchen hand washing sink, located at the entrance to the kitchen, water was observed flowing out of the floor drain onto the kitchen floor. The Maintenance Supervisor (MS) who was present, stated the drain pipes were old but did snake the pipe every three to 4 months and jet (hydro) every six months to keep the lines flowing. MS stated the food service staff inform him of kitchen sewer drain line back ups once a month. A review of a receipt by a plumbing company dated 03/02/2017 showed the kitchen floor drains were backed up. The plumbing company had to snake all floor drains and perform hydrojet on all lines. The plumbing services rendered on March 2, 2017, provided a 2 - month warranty. In addition, there was a recommendation to repipe (change and replace with new pipes) drain lines. There was no documented evidence provided to the survey team, by the facility to indicate recommendations to repipe drain lines, or other services were performed to resolve the ongoing floor drain sewage back up. On October 3, 2017 starting at 4:05 pm there were four additional live roaches observed crawling underneath the food preparation kitchen sink. Inspection of the kitchen, revealed holes in the walls behind the dish washing machine, a hole approximately 3 inch by 3 inch behind the door in the dry storage room, numerous floor tile cracks, tiles and coving separated from the walls in several areas throughout the kitchen. One dead cockroach was observed on the ladder in the dry storage room. There was a large gaping hole on the wall adjacent to the elevator door that was about 30 inches long and 2 inches wide. A live cockroach was observed crawling on the coving next to the elevator. At 4:15 pm on October 3, 2017, the plumber from the same company who had performed services on March 2, 2017, was observed in the kitchen. In a concurrent interview the MS stated the work on the floor drains had been completed and the floor drains were flowing well. A review of the receipt provided confirmed observations that had been made by the survey team. The plumbing company found two drains were backing up on the same branch line . Found there was a usual build up in pipe. The receipt also indicated last time we performed jet 3/2/17. The MS stated in the concurrent interview and observation at 4:16 pm, the drains had not been re-piped and the facility had plans to do so in the near future and had a bid out for the repairs. In an interview conducted on October 3, 2017 at 4:30 pm, food and nutrition staff 1 (FNS 1), stated the presence of roaches in the kitchen have been observed for several months and had been reported to the previous food service supervisor. A review of the binder containing receipts of pest control services performed from June 12, 2017 through October 1, 2017, showed the kitchen had not been included in the areas treated prior to September 20, 2017. The pest control report titled Customer Service Report showed from June 12, 2017, the pest control services were only performed for the exterior of the facility building only for large fly, rodents and cockroaches in the dumpster/ garbage area and basement interior. This service report indicated there was a 1/4 inch gap or greater at the exit door in the basement area next to the laundry and recommended replacing the door sweep to reduce the number of pests entering the area. The kitchen is located in the basement. The reported dated 7/9/2017 indicated under the subheading structural concerns that could cause pest problems, kitchen interior floor tiles or baseboards loose missing. The report further noted please repair to eliminate potential pest harborage / breeding site. Another report dated 9/20/2017, indicated cockroaches noted during service, activity noted in cook line area. The report also indicated the presence of a hole/gap behind the dish washing machine. The facility regional food and nutrition manager (RFNM) stated in an interview at 4:35 pm on October 3, 2017, the kitchen is part of the areas the pest control company were contracted to treat. The RFNM stated he would ask the maintenance supervisor for information to verify the kitchen was part of the facility's pest control program. No additional information was provided during the survey to show the kitchen was treated by the pest control company prior to June 2017. At 5:05 pm on October 3, 2017, the administrator (ADM) and the Director of Nursing (DON) were informed of the immediate jeopardy situation. During the meeting, the ADM stated the kitchen had been deep cleaned the day before causing the roaches to come out (on October 2, 2017). At 5:05 pm on October 3, 2017, the Administrator stated the kitchen will be closed, no kitchen food preparation and service will be done and the pest control treatment will be done later that night (on October 3, 2017). The facility's plan included to use the emergency / disaster food supply for residents' meals. On October 4, 2017 at 11:05 am after the kitchen had been serviced by the pest control company (on October 3, 2017), the kitchen was inspected for the presence of roaches. There was one live cockroach observed in the dry storage room. A wet tile which was lifted with ease off the floor, in the dry storage room revealed the presence of about six dead roaches underneath the tile. The location of the wet tile was on the floor next to the wall that separated the dry storage room from the kitchen, across from the dish washing area. The presence of moisture on the floor in the dry storage room, indicated an amount of water leaked from the dishwashing area of the kitchen, sufficient enough to move into the dry storage area underneath the wall. On October 4, 2017 at 11:55 am, in the Dining Room, meal service was set up, served and distributed, in one corner of the main dining room. On observation, the area lacked hand washing facilities. When two employees were asked where they wash their hands, they stated they washed their hands in the kitchen (in the basement). The staff after asked about handwashing went to wash their hands down the hallway at the nurse's station before meal service. The food from the emergency menu had been prepared (heated) at the sister facility. On October 4, 2017 starting at 6:52 pm, one live cockroach was observed in the kitchen food preparation area underneath the sink, on the back wall, around a mesh and plaster covering. Another cockroach was observed behind the freezer crawling into one of the floor drains. Another live cockroach was observed on the wall adjacent to the food preparation sink. The cockroach was crawling around one of the pipes. A live baby cockroach was also found a few minutes later underneath the sink near the mesh and plaster area, in the same vicinity as was observed with the first cockroach at 6:52 pm. A review of the contract between the pest control company and the facility indicated a contract had been in place since November 21, 2014. In a telephone interview with the pest control technician on October 4, 2017 at 7:22 pm, PCT stated he had only recently restarted performing pest control services to the kitchen, because of a change in the kitchen management. PCT stated he had not been granted access to the kitchen by the previous supervisor, and in September of 2017, the new kitchen Assistant Manager ensured he had access to the kitchen to be able to perform services. PCT stated he had not seen any live roaches in the kitchen when he sprayed the night before (on October 3, 2017). PCT explained he treated around the desk area of the dry storage room, the electrical panel, and the cook line (cooking area). When the PCT was notified of the areas observed with roaches, PCT stated fumigation of the whole kitchen, instead of treatment of [REDACTED]. On October 5, 2017 at 8:25 am, there were also approximately twenty dead roaches in the water on the floor, underneath the dish washing machine. No other roaches were observed during subsequent checks to the kitchen on October 5, 2017 at 3:30 pm. All the wall and floor cracks had been repaired and sealed. No food preparation was taking place in the kitchen, all floor tiles in the dry storage room were removed with plans to replace them, the whole kitchen was deep cleaned including walls. All food items in the dry storage room had been discarded. Immediate Jeopardy was lifted on October 5, 2017 at 4:20 pm. On October 6, 2017 at 8:30 am two small live roaches were observed in the dry storage room. Deep cleaning of the kitchen equipments and kitchen hood were observed. The facility's kitchen remained closed until October 7, 2017.

Based on observation, interview, and record review, the facility failed to prevent the development of pressure sores (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction, also referred to as pressure ulcers) and failed to promote healing of pressure sores for one of 26 sampled residents (Resident 10) by failing to: 1. Provide Resident 10 with a low air loss mattress (LAL a mattress which provides alternating pressure to aid in the management of pressures sores) as ordered by the physician on June 26, 2017 to promote healing and prevent re-occurrences. The facility failed to obtain a physician's orders [REDACTED]. The facility provided Resident 10 with a LAL on September 18, 2017 when Resident 10 was identified with nine pressure injuries. 2. Notify the Registered Dietitian (RD) of Resident 10's development of pressure sores on June 26, 2017 to ensure recommendations were implemented to aid in wound healing. 3. Promptly notify the supervising nurse regarding the development of a newly identified Stage 2 pressure sore (outer layer of the skin and part of the underlying layer of skin is damaged or lost) to Resident 10's right hip. As a result of these failures, Resident 10: 1. Developed a left hip deep tissue pressure injury (DTI, intact or non intact skin with localized area of persistent non blanchable deep red, maroon, purple discoloration) on June 26, 2017, 2. Developed a sacro-coccyx (tailbone area) DTI on June 27, 2017, 3. Had a left hip Stage 3 pressure injury (full thickness tissue loss, subcutaneous (under the skin) fat may be visible but bone, tendon or muscle are not exposed) develop into an unstageable pressure injury (stage of pressure ulcer is unclear due to inability to clearly see the wound, which may be covered by a thick layer of other tissue and pus), and 4. Developed a right lateral (outer) hip Stage 2 pressure injury on October 10, 2017. Findings: During an initial tour observation of the facility on October 3, 2017 at 8:06 a.m. with Registered Nurse 5 (RN 5), Resident 10 was sleeping in bed. Resident 10 was lying on a low air mattress (LAL a pressure relieving mattress to prevent and release pressure). On closer observation of Resident 10's LAL on 10/3/17 at 8:15 a.m., the LAL mattress power box indicated that the mattress had a power fail. RN 5 called Treatment Nurse 1 to attend to the low air loss mattress's power failure. In an interview on October 3, 2017 at 8:15 a.m., Treatment Nurse 1 stated the LAL was important to relieve pressure points for Resident 10's multiple pressure sores. During an observation on October 10, 2017 at 10:45 a.m., Treatment Nurse 1 performed treatment to Resident 10's pressure sores with the assistance of Certified Nursing Assistant 11 (CNA 11). Resident 10 had wound dressings to the right foot, left outer knee, and left inner knee. After removing the disposable incontinent pad, Treatment Nurse 1 and CNA 11 turned Resident 10 towards the right side in preparation for cleaning a sore to a sacro coccyx (tailbone area) Stage 2 pressure sore. There were two additional dressings to Resident 10's left hip and buttock, which appeared soiled. After cleaning and dressing the sacro coccyx Stage 2 pressure sore, Treatment Nurse 1 and CNA 11 turned Resident 10 towards the left side in preparation for cleaning a sore to the right buttock. Once Resident 10 was turned towards the left side, Resident 10 had an open area to the right hip. Treatment Nurse 1 stated the open area was a new Stage 2 pressure sore to the right lateral hip, which was not present the day before. CNA 11 stated noticing the open sore on the right lateral hip in the morning when providing care to Resident 10 but did not report it to Treatment Nurse 1 or the supervising nurse. A review of the Admission Record indicated Resident 10 was initially admitted to the facility on [DATE] with the most recent re admission on September 16, 2017. Resident 10's [DIAGNOSES REDACTED]. A review of the Admission Skin Assessment form dated March 3, 2017 indicated Resident 10 had discoloration to both forearms with no other skin problems. Resident 10 weighed 136.8 pounds and was 61 inches tall. A review of Resident 10's Minimum Data Set (MDS standardized assessment and care planning tool) dated June 16, 2017 indicated the resident's cognition (memory and thinking skills) was severely impaired and required extensive assistance for bed mobility and transfers. The MDS indicated the resident was assessed as being at risk for skin breakdown and had no pressure ulcers. A review of Resident 10's MDS dated [DATE] indicated Resident 10 weighed 112 pounds and had multiple pressure ulcers, including one Stage 2, two Stage 3, one unstageable and four unstageable DTIs. A review of the care plan dated March 3, 2017, indicated Resident 10 was at risk for skin breakdown as evidenced by thin fragile skin. The interventions included evaluating skin risk factors, monitoring skin for signs/symptoms of skin breakdown, and Norton/Braden assessments per policy. The care plan did not include specific interventions to prevent the development of pressure sores and the frequency to monitor Resident 10 for signs and symptoms of skin breakdown. A review of the Nursing Progress Notes dated June 7, 2017 indicated Resident 10 required transfer to a General Acute Care Hospital (GACH) due to low oxygen saturation (amount of oxygen in the blood) and lethargy. Resident 10 was transferred back to the skilled nursing facility on June 14, 2017 with no skin breakdown. A review of a Change in Condition Evaluation dated June 26, 2017, indicated Resident 10's left lateral (outer) hip developed a DTI, measuring six centimeters (cm) by 5.5 cm. A review of the facility's policy revised on November 28, 2016, titled NSG236 Skin Integrity Management, indicated the purpose of the policy was to provide safe and effective care to prevent the occurrence of pressure ulcers, management treatment, and promote healing of all wounds. The policy indicated to notify the dietitian as indicated but did not specify when the dietitian should be notified. During an interview on October 10, 2017, at 3:35 p.m., Registered Dietitian (RD) stated the RD should be notified if a resident developed a pressure ulcer in order to determine if the existing nutritional support was appropriate for the resident and to recalculate the estimated needs for calories, proteins, and fluids. In RD's review of Resident 10's clinical record, RD evaluated Resident 10 on June 21, 2017. RD stated that nursing did not notify the RD regarding Resident 10's pressure ulcer development on June 26, 2017. RD stated that a re-evaluation did not occur for Resident 10 until July 27, 2017. A review of a physician's orders [REDACTED]. In a review of the Nursing Progress Notes dated June 26, 2017 at 10:19 p.m., Licensed Vocational Nurse (LVN 12) indicated Resident 10 was not lying on a LAL mattress. On June 28, 2017 at 12:13 a.m., LVN 12 indicated in the Nursing Progress Notes that Resident 10 was still not lying on a LAL mattress. During an interview on October 11, 2017 at 6:30 p.m., LVN 12 reviewed the Nursing Progress Notes and confirmed that Resident 10 was not on a LAL mattress from June 26 to June 28, 2017. During an interview on October 12, 2017 at 9:37 a.m., Treatment Nurse 1 stated that the Maintenance Supervisor (MS) was verbally notified when a resident needed a LAL mattress. Treatment Nurse 1 stated that all LAL mattresses were distributed to other residents on June 26, 2017. MS contacted a rental company to obtain a LAL mattress for Resident 10. A review of a Change in Condition Evaluation dated June 27, 2017, indicated Resident 10 developed a DTI injury to the sacro coccyx area. The DTI's the size and description was not indicated. During an interview on October 12, 2017 at 9:37 a.m., Treatment Nurse 1 stated Resident 10 received a LAL mattress during the day shift on June 28, 2017 since the Treatment Administration Record (TAR) for June 2017 indicated the LAL mattress was monitored for functioning. During an interview on October 12, 2017 at 9:37 a.m., the Director of Staff Development (DSD) stated the LAL mattress should have been provided to Resident 10 on June 26, 2017 when Resident 10's left lateral hip DTI was identified. A review of the Nursing Progress Notes on July 2, 2017 indicated Resident 10 was transferred to a General Acute Care Hospital (GACH) and was re admitted to the skilled nursing facility on July 7, 2017. A review of the Admission Skin Assessment form dated July 8, 2017 indicated Resident 10 had pressure sores, including: 1. Right heel DTI, 2. Left heel DTI, 3. Left hip Stage 2 pressure injury, and 4. Sacro-coccyx Stage 2 pressure injury. In a review of Resident 10's clinical record, there was no indication in the TAR, Nursing Progress Notes, and care plan that Resident 10 was provided with a LAL mattress to promote healing of the pressure sores after readmitted on [DATE]. A review of the Nursing Progress Notes dated July 9, 2017 indicated Resident 10 was transferred to a GACH and was re admitted to the skilled nursing facility on July 20, 2017. A review of the Nursing Progress Note dated July 21, 2017 indicated Resident 10 had multiple pressure sores, including: 1. Right lateral (outer) heel DTI, 2. Left trochanter (bony prominence of the hip bone - site 1) Stage 3 pressure sore, 3. Left trochanter (site 2) Stage 2 pressure sore, and 4. Sacro-coccyx Stage 4 pressure sore (full thickness skin and tissue loss with exposed or directly noticeable fascia (thin fibrous tissue enclosing a muscle or organ), muscle, tendon, ligament, cartilage, or bone in the ulcer). A review of the physician's orders [REDACTED]. During an interview on October 12, 2017 at 11:36 a.m., the DSD confirmed there was no documentation in the TAR, physician's orders [REDACTED]. A review of a Change in Condition Evaluation dated September 5, 2017 indicated Resident 10's left hip (site 1) Stage 3 pressure sore developed into an unstageable pressure injury. A review of Treatment Nurse 1's Nursing Progress Note dated September 5, 2017 confirmed Resident 10's left hip (site 1) Stage 3 transitioned to an unstageable pressure injury with 80% black eschar (dead tissues) and 10% slough (dead subcutaneous tissue). A review of Resident 10's September 2017 TAR indicated monitoring for proper functioning and set up of a LAL mattress for wound management began on September 6, 2017. Resident 10's September 2017 TAR indicated that monitoring for both heel protectors also began on September 6, 2017. A review of the Nursing Progress Notes on September 9, 2017 indicated Resident 10 transferred to a GACH for elevated blood sugar. Resident 10 was re admitted to the skilled nursing facility on September 16, 2017. A review of Treatment Nurse 2's Nursing Progress Note dated September 16, 2017, indicated Resident 10 had multiple pressure areas, including: 1. Right lateral heel Stage 3 pressure injury, 2. Right middle foot DTI, 3. Left greater trochanter unstageable pressure injury, 4. Left inferior (lower) greater trochanter open blister, 5. Left inner knee Stage 3 pressure injury, and 6. Sacro-coccyx Stage 2 pressure injury. A review of Treatment Nurse 1's Nursing Progress Note dated September 18, 2017 indicated Resident 10 developed three additional injuries, including a right lateral malleolus (outer ankle) DTI, right lateral foot DTI, and left lateral knee DTI. Resident 10 had nine pressure injuries. A review of Resident 10's physician's orders [REDACTED]. A review of Resident 10's TAR included monitoring the functioning of the LAL mattress beginning September 18, 2017. The facility used the Pressure Injury /Ulcer Prevention Guideline revised on 2005 as a resource. The guideline indicated to evaluate for presence of specific risk factors and develop plan of care to address the following risk factors: Impaired/decreased mobility or function, bed mobility problem, and cognitive impairment. The Pressure Injury/Ulcers Prevention Guidelines indicate daily observation of the skin would be performed daily.

Based on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 10) and one of randomly selected residents (RSR 45) did not develop a decline in range of motion. The facility failed to: 1. Provide Resident 10 with Restorative Nursing Assistant (RNA - nursing assistant program that help residents maintain any progress made after therapy intervention to maintain their function) services for passive range of motion (PROM - amount of motion at a given joint when moved by another person) to both arms after Occupational Therapy (OT) services discharged the resident on 3/24/17. Resident 10 did not receive RNA services for PROM to both arms until 9/22/17. 2. Follow the facility's guidebook on Restorative Nursing Care Delivery Process, which indicated therapists would educate RNAs to ensure adequate training, return demonstration, and problem solving prior to discharge from skilled therapy. RNA 2 and RNA 3 did not receive training prior to Resident 10's discharge from OT services. 3. Develop a plan of care for Resident 10's RNA services with specific measureable goals and documented interventions according to the facility's policy and procedure. 4. Implement the facility's Restorative Nursing Care Delivery Process to have the therapist periodically observe the effectiveness of Resident 10's RNA program and adjust as needed. As a result of these failures, Resident 10 was assessed on 10/11/17 as having developed a contracture (limitation in the extent of movement of a joint) to the left hand, causing pain with movement. Findings: a. On 10/10/17 at 12:24 p.m., Resident 10 was observed during RNA treatment with RNA 2. RNA 2 starting the session with cleaning the inside of Resident 10's left hand using hand sanitizing wipes. RNA 2 threaded the wipes through Resident 10's left thumb and fingers without opening the hand. Resident 10's left thumb was bent into the left palm. RNA 2 stated Resident 10 did not have a splint (a semi rigid device to prevent or maintain a body part in a functional position) for the left hand. When RNA 2 attempted to open Resident 10's left hand, Resident 10 groaned and resisted the attempt to open the hand. RNA 2 stated Resident 10 had pain to the left hand and required a warm up. RNA 2 then proceeded to slightly extend Resident 10's left fingers and bend the left wrist. RNA 2 then performed PROM to the left elbow; however, Resident 10 refused PROM to the left shoulder. RNA 2 then proceeded to perform PROM to the right arm. At the end of the session, RNA 2 returned to Resident 10's left hand to perform PROM. RNA 2 extended the middle and tip joints of the left fingers. Resident 10's left fingers did not extend fully due to limited motion at the large knuckle joint. A review of the Admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and re admitted on [DATE]. Resident 10's [DIAGNOSES REDACTED]. A review of Resident 10's Minimum Data Set (MDS a standardized assessment and care planning tool) dated 6/16/17 and 9/30/17 indicated Resident 10 was severely impaired in cognition (thinking and memory skills) for daily decision making. The MDS assessments also indicated Resident 10 required extensive assistance with one person physical assist with transfers, personal hygiene, and dressing, and had no impairment to her both her arms. A review of the Occupational Therapy Initial Evaluation dated 3/6/17 indicated the range of motion for Resident 10's right and left arms were within functional limits. A review of the Occupational Therapy Treatment Encounter Notes from 3/8/17 to 3/24/17 indicated Resident 10 received treatment for [REDACTED]. A review of the Occupational Therapy Discharge Summary dated 3/24/17 indicated Occupational Therapist 1 (OT 1) recommended a RNA program for passive range of motion to both arms in order to maintain joint mobility and reduce risk of joint contracture. A review of Resident 10's physician's orders [REDACTED]. A care plan addressing Resident 10's need for PROM to both arms and legs by RNA was not developed until 10/5/17. During an interview on 10/11/17 at 8:49 a.m., RNA 2 stated Resident 10 developed tightness to the left hand for the past three months. RNA 2 stated the Director of Staff Development (DSD who was the RNA supervisor) was informed of Resident 10's left hand in the monthly RNA meeting. RNA 2 stated that RNA 3 usually worked with Resident 10. During an interview on 10/11/17 at 9:16 a.m. via telephone, OT 1 confirmed that Resident 10's Occupational Therapy Initial Evaluation dated 3/6/17 indicated that Resident 10's range of motion for both arms were within functional limits. OT 1 described within functional limits as the ability to use the arms for daily tasks. OT 1 stated that the Occupational Therapy Encounter Notes did not indicate Resident 10 had any contractures in either arm. OT 1's Occupational Therapy Discharge Summary dated 3/24/17 recommended a RNA program for PROM to both arms in order to maintain joint mobility and reduce risk of joint contractures. OT 1 was unable to recall training the RNA on PROM exercises for Resident 10. OT 1 stated the therapists did not typically train RNAs individually for each resident. During an interview on 10/11/17 at 10:00 a.m., RNA 3 stated the therapist did not train RNA 3 on the exercises for Resident 10. RNA 3 stated Resident 10 tolerated PROM well except for the pain in the left thumb. RNA 3 stated Resident 10 did not have the left thumb contracture when discharged from therapy services. RNA 3 notified the DSD when Resident 10's thumb began forming a contracture on an unspecified date. During an interview on 10/10/17 at 2:52 p.m., the Director of Rehabilitation (DOR) stated the rehabilitation therapists do not provide training to RNAs. The DOR stated the therapists do not work with the RNA's on an individual basis for each resident because active range of motion and passive range of motion were basic skill sets for every RNA. The DOR was unsure who determined the RNA's competency. A review of the facility's guidebook revised 8/2016 titled Restorative Nursing Care Delivery Process included the procedure when transitioning a resident from skilled rehabilitation to restorative nursing care. The procedure indicated that therapists would educate restorative nursing assistants in two to three visits at a minimum, to ensure adequate training, return demonstration, and problem solving prior to discharge from skilled therapy. During an interview with DSD and DOR on 10/11/17 at 10:20 a.m., the DSD stated Resident 10's RNA order dated 4/18/17 was for PROM to both legs, 5 times per week as tolerated for 90 days. The DSD stated Resident 10 did not receive RNA services for both arms as recommended on the Occupational Therapy Discharge Summary on 3/24/17. The DOR stated Resident 10 did not have contractures to both arms when discharged from Occupational Therapy based on OT 1's discharge summary and treatment documentation. The DOR and the DSD both confirmed Resident 10 did not have orders for RNA for both arms until 9/22/17. The DSD denied receiving verbal report during the monthly RNA meetings that Resident 10 was experiencing a decline in range of motion. During an observation on 10/11/17 at 10:52 a.m. at Resident 10's bedside, the DOR performed an assessment of both arms. Resident 10 was observed with the left thumb bent toward the palm. The DOR described the left thumb as having a flexion contracture (shortening of muscle tissues and tendons in a joint, forcing a joint into a bent position), which was not functional for daily tasks. The DOR also stated Resident 10 had contractures to the left fingers due to the inability to fully extend each finger when providing PROM. A review of the facility's policy and procedure revised on 3/15/16 titled NSG232 Restorative Nursing, indicated practice standards included developing restorative nursing programs appropriate to the patient's identified needs. The policy indicated the facility should develop specific measurable goals and document goals and interventions on the patient's restorative care plan and implement the restorative nursing program according to the specifics on the care plan. A review of the facility's Restorative Nursing Care Delivery Process document dated 10/1/10 indicated the Restorative Nursing Assistant will continue until a patient's (resident's) condition has changed warranting a new evaluation of the restorative nursing program. The process indicates for programs designed by rehabilitation, the therapist will periodically observed the effectiveness of the program and adjust as needed. b. A review of the admission record indicated RSR 45 was originally admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Occupational Therapy (OT) Initial Evaluation dated January 5, 2017, indicated within functional limit range of motion (ROM) to RSR 45's right upper extremity. A review of RSR 45's MDS dated [DATE], indicated the resident sometimes understood and sometimes made herself understood. RSR 45 required total one person physical assistance with dressing and personal hygiene. The MDS also indicated RSR 45 had functional limitation in range of motion (impairment) to one side of the upper and lower extremities. A review of the OT Initial Evaluation dated August 3, 2017, indicated RSR 45 had limited ROM (impairment) of the right upper extremity (shoulder, wrist, middle finger, ring finger, and little finger). A review of RSR 45's physician order [REDACTED]. 1. Restorative Nursing Assistant (RNA) to provide active ROM (AROM) to right shoulder and elbow five times a week as tolerated for 90 days. 2. RNA to apply right upper extremity modified resting hand splint for two to four hours seven times a week as tolerated for 90 days. A review of RSR 45's care plan revised on September 7, 2017, indicated the resident was at risk for decline in ROM. The goal indicated to prevent /reduce risk of deformity and/or contracture progression and/or formation for 90 days. The intervention indicated to monitor for pain, stiffness, and resistance during exercises, report pain during exercise, stiffness and declined in joint mobility to physician, and to provide RNA for Active ROM exercises on right shoulder and elbow five times a week or as tolerated. The care plan did not address treatment/services to RSR 45's right hand. On October 4, 2017 at 9:05 a.m., during an observation, RSR 45 was sitting in her wheelchair, awake, alert and oriented to person. On October 12, 2017 at 11:30 a.m. during an interview, RSR 45's responsible party (RP 1) stated RSR 45 did not have a contracture on her right fingers when she was first admitted to the facility. RP 1 stated that she first noted RSR 45's right finger becoming contracted a few months ago (could not remember the exact time). RP 1 notified the nursing staff, but nothing was done about it until recently. On October 12, 2017 at 12 p.m. during an observation, RSR 45 was sitting in her wheelchair, awake, alert, and oriented to person and place. RSR 45's right hand fingers were contracted. RSR 45's right hand splint was on the resident's bed. During a concurrent interview, RSR 45 stated she did not like her right hand splint to be applied, because it was painful. A review of the facility's revised policy dated March 15, 2016, titled Restorative Nursing indicated the restorative program was to help the patient attain and maintain optimal physical, mental, and psychosocial functioning. The policy indicated the following practice standards: 1. Develop restorative nursing programs appropriate to the patient's identified needs 2. Develop specific measurable goals and document goals and interventions on the patient's restorative care plan 3. Implement the restorative nursing program according to the specifics on the care plan 4. Document daily on the restorative nursing record.

Based on observation, interview and record review, the facility failed to provide the necessary care and treatment to three of 25 sample residents (12, 16, 6) by failing to: A. Effectively manage pain for Resident 12, who suffered with severe, prolonged right foot and leg pain by failing to: 1. Notify Resident 12's physician as requested by the resident two weeks earlier, to ensure the resident's right foot and leg pain that was not controlled by the pain medication, was evaluated and treated promptly. 2. Promptly reassess in accordance with standard nursing practice, Resident 12's right foot and leg pain when the resident reported to the staff her right leg and foot felt numb, cold and had severe, constant pain, in order to determine if additional interventions were required to relieve the resident's pain. 3. Promptly notify and consult with Resident 12's physician or nurse practitioner when the resident's right leg and foot pain, was not relieved as manifested by groaning, moaning, crying, and screaming of pain for one and a half hours after she was administered a narcotic pain medication, to obtain effective pain control interventions, and to determine if the resident required additional medical assessment, and treatment. 4. Promptly administer additional pain medication as ordered by the physician, after Resident 12 reported to the licensed nurse right leg and foot pain level rating increased after the administration of a narcotic pain medication, to ensure pain relief was attained. 5. Implement Resident 12's care plan regarding pain to: a. Assess if resident has pain to include the site, pain scale (0 to 10), type of pain b. Reassess the resident 30 minutes to 1 hour after pain medication is given to determine if relief is noted, and to refer accordingly c. Elevate resident's legs as tolerated when sitting, to promote comfort. 6. Assess upon readmission to the facility specific characteristics of pain such as the primary location, quality, character, onset, duration, aggravating or alleviating factors, effectiveness of the current pain management regimen, history of pain management, effects of the pain, and the patient's goals for pain and acceptable or tolerable level of pain, in order to determine if the resident's pain control needs changed or if the resident required additional pain control interventions. 7. Implement the care plan for Resident 12 who had [MEDICAL CONDITION] (swelling due to retention of fluids) of the right leg and foot, left leg and foot, and who was receiving diuretic (medication used to decrease [MEDICAL CONDITION] by increasing urinary output) to ensure the resident was assessed, monitored, and was provided with non-pharmacological intervention such as elevation of the [MEDICAL CONDITION] legs and feet to alleviate pain. B. Assess and evaluate Resident 16's pain as a result of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). C. Ensure a Resident 6's pacemaker (is a small device that's placed in the chest or abdomen to help control abnormal heart rhythms) was monitored to assure the effective functioning as indicated in the plan of care. This deficient practice resulted in unnecessary, prolonged, pain and suffering of Resident 12, due to a delay in medical care for untreated right leg and foot pain. The resident reportedly felt despair, helpless, had increased feelings of sadness, hopelessness and stress, due to the unbearable, constant pain, had the potential to negatively affect Resident 16's physical comfort and psychosocial well-being, and had the potential to result in undetected non-functioning pacemaker/heart function of Resident 6. Findings: 1. A review of Resident 12's history and physical from the general acute care hospital (GACH) dated July 22, 2016, indicated Resident 12, had [MEDICAL CONDITION] (severe kidney disease), received [MEDICAL TREATMENT] ( a way to treat advanced kidney failure) three times a week, and was treated for [REDACTED]. A review of the admission record indicated Resident 12 was originally admitted to the skilled nursing facility (SNF) on January 5, 2016 and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Initial Nursing assessment dated [DATE], indicated Resident 12 was not experiencing pain or showing signs/symptoms of pain. A review of the physician's orders [REDACTED]. 1. [MEDICATION NAME] 50 mg one tablet by mouth every eight hours as needed for moderate to severe pain dated August 19, 2016. 2. Tylenol No: 3 ([MEDICATION NAME]-[MEDICATION NAME]) 300/30 milligrams (mg) two tablets by mouth every four hours as needed for moderate pain dated August 20, 2016. The physician's orders [REDACTED]. A review of the care plan dated August 21, 2016, indicated Resident 12 exhibited or was at risk for alterations in comfort. The care plan goals indicated the following: the resident is to achieve acceptable level of pain control, will not exhibit non-verbal indicators of pain, and will not experience pain for 90 days. The interventions included to: 1. Evaluate pain characteristics: quality, severity, location, precipitating, relieving factors, utilize pain scale (measures a patient's pain intensity or other features). 2. Medicate resident with [MEDICATION NAME]-APAP, [MEDICATION NAME], and [MEDICATION NAME] as ordered for pain and monitor for effectiveness 3. Report to the physician as indicated 4. Monitor for non-verbal signs/symptoms of pain and medicate as ordered. 5. Assist the resident to a position of comfort utilizing pillows as appropriate positioning devices. 6. Monitor for non-verbal signs of pain: increase in agitation, grimace, and resistance to care. 7. Reassess resident 30 minutes to 1 hour after pain medication is given if there's relief noted. 8. Assess resident with complaint of pain to include, site, scale (0 to 10), and refer accordingly. A review of Resident 12's care plans dated August 21, 2016, did not specify the resident had pain in the right leg and right foot. A review of Resident 12's history and physical examination [REDACTED]. A review of the Minimum Data Set (MDS) assessment (an assessment and screening tool) dated August 26, 2016, indicated Resident 12 was usually understood, usually understands others, was able to recall after cueing, and required extensive physical assistance for her care needs. The resident did not have presence of pain. The MDS indicated the resident had a pressure reducing device for bed, surgical wound care, and application of dressings to feet with or without topical medications, and required oxygen and [MEDICAL TREATMENT]. On October 4, 2016, from 9:50 a.m. to 10:25 a.m., during an observation and interview with Resident 12, in the presence of Certified Nursing Assistant (CNA) 1, the resident was sitting in the wheelchair in her room with both feet resting on the footrests, not elevated. Both of the resident's legs and feet were swollen. The resident had bandages/dressings applied to the right lower leg and right foot dated October 4, 2016. The resident stated her right leg and right foot was very painful. The resident stated her pain level was 10 out of 10, (a pain level rating scale of 0 being no pain and 10 being the worst possible pain, excruciating pain). At 10:05 a.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 12 had a right foot blister and the resident's right foot and leg were swollen. The resident stated at times her right foot feels numb and cold. The resident was crying, moaning, groaning, yelling and screaming in pain. Resident 12 stated I can't handle it. I can't handle it. It hurts so bad. O Lord, have mercy. It throbs when I am in pain. The resident also stated that she felt hopeless and was in despair because of her pain. The resident stated that her right leg and foot were very tender and she felt it was warm and stated that it was red. The resident stated she told the staff members every day for a period of two weeks, about the pain, and wanted to see the doctor or go to the hospital, but nothing was done. At 10:25 a.m., LVN 1 came to the resident's room and administered Tylenol No: 3, two tablets, but did not ask the resident to rate her pain level before she gave the tablets, and left the room. On October 4, 2016, between 9:50 a.m. to 10:25 a.m., during an interview with CNA 1, he stated Resident 12 Was always yelling and screaming. A review of Resident 12's PRN (as necessary) Pain Medication Flow Sheet indicated on October 4, 2016, at 10:20 a.m., LVN 1 administered an unspecified number of tablets of Tylenol No: 3, to the resident, but indicated the resident and had a pain rating level of eight, for pain of the bilateral lower extremities (BLE). The non-pharmacological treatment section was blank. According to the flowsheet, the pain rating level for cognitively intact residents were as follows: zero was no pain, one to two was mild pain, three to four was moderate pain, five to six was moderate/severe pain, seven to eight was severe/horrible pain, and nine to ten was excruciating pain. On October 4, 2016, at 10:50 a.m., during an interview LVN 1 was asked about the documentation on the PRN Pain Medication Flow Sheet, indicating on October 4, 2016, at 10:20 a.m., Resident 12's pain level was eight. LVN 1 stated she documented the resident's pain level rating as 8 out of 10, because the resident's pain level usually was eight. However, when asked why she did not assess the resident's pain level prior to administering the Tylenol No: 3, she was not able to provide an explanation. On October 4, 2016, at 12 p.m., the Surveyor was sitting at Nursing Station Three and heard Resident 12 screaming and crying from her room, through the hallway. Upon entering the resident's room and observed the resident screaming and crying, repeatedly. When asked about her pain, the resident stated her pain was still a level of 10 out of 10. The resident was still sitting in the wheelchair, in the same position, with her feet on the footrests, not elevated. LVN 1, who was in the hallway, outside the resident's room, was asked if she reassessed Resident 12's pain level after giving Tylenol No: 3, or if the resident had been given any additional pain medication, she stated she would give the pain medication now. On October 4, 2016 at 12 p.m., a review of the PRN Pain Management Flow Sheet did not indicate a reassessment of Resident 12, was done thirty minutes to 1 hour after Tylenol No: 3 was administered, to determine if pain relief was noted, as the care plan indicated. There was no documented evidence in Resident 12's licensed nurses' notes, progress notes or PRN Pain Management Flow Sheet of October 4, 2016, to indicate the resident was administered additional pain medication until after LVN 1 was asked about the resident's pain, at 12 p.m Resident 12 remained in pain of level 10, for over an hour and a half after giving Tylenol No: 3, but there was no indication LVN 1 notified or consulted with the physician or the nurse practitioner, until October 4, 2016, at 3 p.m. when the nurse practitioner ordered a vascular consult and a pain management consult. A review of the PRN Pain Management Flow Sheet indicated LVN 1 administered Resident 12 [MEDICATION NAME] 50 milligrams (mg) for pain at 12 p.m., as the physician ordered, and at 1 p.m. the resident went to [MEDICAL TREATMENT]. There was no indication a reassessment of Resident 12, was done thirty minutes to 1 hour after the [MEDICATION NAME] 50 mg was administered to determine if pain relief was noted. A review of Resident 12's progress notes of October 4, 2016, at 10:28 p.m., indicate the physician ordered [MEDICATION NAME]( a medication used to relieve moderate to moderately severe pain), 5/325 milligrams (mg) one tablet by mouth every six hours if needed for moderate pain and [MEDICATION NAME] 10/325 mg one by mouth every 6 hours if needed for severe pain, in order to obtain effective pain control. There was no documentation Resident 12 was administered [MEDICATION NAME] 10/325 mg until October 6, 2016, at 7 a.m., even though the resident continued to have unrelieved pain level ratings, for example, October 4, 2016 at 5 p.m., pain rating- 5, October 5, 2016 at 7:45 a.m., pain rating- 7, October 5, 2016, at 9:20 a.m., pain rating - 8, and October 5, 2016, at 6 p.m., pain rating was 7. On October 4, 2016, at 12 p.m. Resident 12's pain was unrelieved by the Tylenol No: 3, but there was no documented evidence in the progress notes or licensed nurses notes of October 4, 2016, to indicate a pain assessment was done in accordance with standards of nursing practice, in order to determine if additional pain control interventions were necessary to relieve the resident's right leg and foot pain. There was no documented evidence in the October 4, 2016 progress notes or licensed nurses notes to indicate the resident was assessed by an appropriate professional such as a physician or nurse practitioner in an attempt to determine if medical intervention was required to resolve the resident's pain unrelieved pain. Comprehensive initial assessment of pain should include: Pain Characteristics such as primary location, quality, onset, duration, severity, alleviating factors, aggravating factors, effectiveness of the current pain management regimen, history of the pain management, effects of the pain and the patient's goals for pain and acceptable or tolerable level of pain, American Journal of Nursing October 2016, Volume 116, No: 10. A review of the Nursing Home to Hospital (General Acute Care Hospital- GACH) Transfer Form dated October 5, 2016, indicated Resident 12 went to the GACH for uncontrolled pain of the right lower leg, despite pain medication. The resident was administered [MEDICATION NAME] (a pain reliever used to treat moderate to severe pain) 4 mg/milliliter, at 2:12 p.m. for right lower leg pain and was prescribed Bactrim (an antibacterial-decreases bacteria) 800 mg - 160 mg one tablet every 12 hours for [MEDICAL CONDITION]. The resident returned to the SNF on the same day at 3:36 p.m. with instructions to make an appointment the physician in two days. A review of an arterial ultra sound (device used in medical imaging) of both lower extremities report for Resident 12, dated October 6, 2016 at 7:53 p.m., for unspecified pain, indicated there was evidence of high grade stenosis (narrowing) or occlusion (blockage or closing of a blood vessel) of the right superficial femoral artery (the chief artery of the thigh) with moderate to moderately severe arterial insufficiency distally( blockage of a major artery, resulting in less blood flow to a body part situated away from the obstruction). On October 7, 2016, at 10:39 a.m. the physician ordered the resident to be transferred to the GACH for evaluation of the arterial doppler (a noninvasive test that can be used to estimate your blood flow through blood vessels) result of both lower extremities. A review of the SNF progress notes dated October 7, 2016, indicated at 11:45 a.m., the resident complained of seven out of 10 pain rating in bilateral lower extremities and [MEDICATION NAME] was 10/325 mg was given. At 12:30 p.m., Resident 12 was transferred to the GACH emergency room (ER). A review of the emergency records from the GACH dated October 7, 2016, indicated the resident appeared in distress due to pain, uncomfortable. [MEDICAL CONDITION] was present to bilateral (both) lower extremities, abnormal pulse findings, pedal (foot) pulses not palpable (not felt), posterior tibial (back of the lower leg) pulses not palpable, and scattered healing ulcerations. A review of the physician consultation report dated October 11, 2016 for ulceration in the right lower extremity indicated Resident 12 was admitted to the hospital for [DIAGNOSES REDACTED] (is a serious, uncommon disease in which calcium accumulates in small blood vessels of the fat and skin tissues that causes painful skin ulcers and may cause serious infections that can lead to death) ischemic lower extremity with ischemic ulcer. A review of a IR angiogram(imaging equipment to guide the physician in carrying out a diagnostic or therapeutic procedure), dated October 10, 2016, indicated Resident 12 had right lower extremity run-off (a study of blood flow); percutaneous [MEDICATION NAME] angioplasty (a procedure that can open up a blocked blood vessels) of the right anterior tibial (lower leg) and tibiopeoneal arteries (arteries in the legs). The resident had gangrenous (dead tissue caused by a critically insufficient blood supply and can lead to amputation if not treated), changes in dorsum (top) of the right foot, foot pain. As shown by ultrasound was a significant improvement in velocity of flow in the posterior tibial and peroneal arteries distally. A review of the Discharge Summary from the GACH's hospital dated October 14, 2016, indicated Resident 12 was discharged on [DATE]. The discharge [DIAGNOSES REDACTED]. According to the record, Resident 12 had been complaining of lower extremity pain for around a month. She stated that the pain got unbearable so they called the physician from the skilled nursing facility so the physician decided to bring her to the ER. In the ER, she was evaluated and found to have severe [MEDICAL CONDITION]. She was admitted on [DATE], [MEDICATION NAME] Radiology (providing minimally invasive image-guided [DIAGNOSES REDACTED]. On October 4, 2016, at 4:12 p.m. in an interview and record review with the director of nurses, (DON) she stated there was no care plan to address Resident 12's right leg and foot pain because no assessment was completed. Resident 12 had a delay of over 32 hours in receiving her pain medication from October 4, 2016, at 10:28 p.m. when the physician ordered [MEDICATION NAME] to relieve the resident's uncontrolled pain, until October 6, 2016, at 7 a.m. when the resident was administered [MEDICATION NAME]. A review of the GACH discharge report dated October 14, 2016, indicated Resident 12's report of severe uncontrolled pain began one month before, but medical assessment and treatment to resolve the underlying cause of her uncontrolled pain was delayed until October 10, 2016, when she was provided an angioplasty of right lower extremity, also improving the resident's pain control. A review of the facility's Pain Management Policy revision date of March 15, 2016, indicates patients will be evaluated as part of the nursing assessment process for the presence of pain with a change in pain status. Patients receiving interventions for pain will be monitored for the effectiveness of providing pain relief. The care plan will be evaluated for effectiveness until satisfactory pain management is achieved. a2. A review of the care plan dated August 21, 2016, indicated Resident 12 exhibited or was at risk for fluid volume excess as evidenced by [MEDICAL CONDITION] on the right lower extremity, four plus [MEDICAL CONDITION] and four plus [MEDICAL CONDITION] on the left lower extremity. The goal was not to experience any signs and symptoms of fluid overload as evidenced by the absence of [MEDICAL CONDITION] and dyspnea (difficulty of breathing) for 30 days. The interventions included to administer medications as ordered and monitor for side effects, report as indicated to the physician. Assess and monitor for symptoms of [MEDICAL CONDITION], shortness of breath (SOB), and weight gain. Elevate legs as tolerated when sitting. Monitor intake and output as indicated. Notify the physician if [MEDICAL CONDITION] continues or increases. A review of the Order Summary Report (physician's orders [REDACTED]. 1. [MEDICATION NAME] (diuretic- a medication used to increase passing of urine) 80 milligrams (mg) one tablet by mouth one time a day for [MEDICAL CONDITION] dated August 19, 2016. 2. Right lower leg four plus (4+) [MEDICAL CONDITION]. Monitor for pain, signs and symptoms of infection, and skin integrity every day and shift for 14 days dated September 27, 2016. 3. Right anterior foot open blister. Cleanse with normal saline (NS). Pat dry. Apply Xeroform then cover with dry dressing. Monitor for signs and symptoms of infection dated September 27, 2016. On October 4, 2016, from 9:50 a.m. to 10:25 a.m., during an observation and interview with Resident 12 in the presence of CNA 1, the resident was sitting in the wheelchair in her room with both feet resting on the footrests not elevated. Both legs and feet were swollen and dry. The resident's right leg and right foot had a bandage/dressing applied that was dated October 4, 2016. According to the resident, her right leg was very painful. She stated that her pain level was 10 out of 10. At 10:05 a.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 12 had a right foot blister and and the resident's right foot and leg were swollen. The resident stated at times her right foot feels numb and cold. The resident was crying, moaning, groaning, yelling and screaming in pain. She stated I can't handle it. I can't handle it. It hurts so bad. O Lord, have mercy. It throbs and pulls when I am in pain. On October 4, 2016, at 12 noon, the resident was still sitting in the wheelchair, in the same position as before, with both feet not elevated. The Treatment Administration Record (TAR) dated October 2016, indicated the facility monitored Resident 12's right lower leg as four plus [MEDICAL CONDITION] and monitored for pain, signs and symptoms of infection and skin integrity. From October 1 to October 3, 2016, the resident did not have pain and no signs and symptoms of infection. The TAR indicated on October 4, 2016, the resident had a pain level of seven out of 10. On October 4, 2016, at 4:55 p.m., during an interview with Registered Nurse 1 (RN 1), she stated both legs should be elevated since the resident has [MEDICAL CONDITION]. A review of the Guideline For Physician/Mid-Level Provider Notification urgency grid dated January 2, 2014, indicated to notify the Physician/Mid-Level Provider: 1. For general pain, new or severe, and any pain not responsive to prescribed medication, requires urgent notification 2. For general pain new mild, or moderate requires routine notification. The facility's policy and procedure titled Pain Management dated March 15, 2016, indicated resident will be evaluated as part of the nursing assessment process for the presence of pain upon admission/re-admission, quarterly, with change in condition or change in pain status, and as required by the state thereafter. The nurse will notify the physician/mid-level provider as appropriate and obtain treatment orders as indicated. At a minimum of daily, residents will be evaluated for the presence of pain by making an inquiry of the resident or by observing the signs of pain. If a resident has a change in pain status, complete a pain evaluation (electronic) or paper. Residents receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief. Document effectiveness of PRN medications, ineffectiveness of routine or PRN medications including interventions, follow-up, and physician/mid-level provider notification, and non-pharmacological interventions and effectiveness. The care plan will be evaluated for effectiveness until satisfactory pain management is achieved. Contact the physician/mid-level provider to report findings and obtain revised treatment orders, if indicated. Review the non-pharmacological approaches for effectiveness. Revise the care plan as indicated. c. According to the Admission Record, Resident 6 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated July 12, 2016, indicated Resident 6 was severely impaired, and required extensive assistance with activity of daily living. A review of Resident 6's Physician order [REDACTED]. A review of Resident 6's Medication Administration Record [REDACTED]. A review of Resident 6's MAR for July 17, 2016 to July 31, 2016, for the month of August, and September 2016, indicated [MEDICATION NAME] was administered and indicated the apical pulse was to be entered however, it was not consistently checked. A review of Resident 6's care plan for cardiovascular symptoms or complications related to [DIAGNOSES REDACTED]. The interventions included to monitor for chest pain, monitor vital signs, monitor apical pulse, observe for shortness of breath, and chest pain. A review of Resident 6's care plan for risk of complications related to pacemaker/insertion initiated on July 16, 2016 and revised on July 26, 2016, indicated the goals included not to develop any pacemaker related complications and internal defibrillator over the next 90 days. The interventions included appointment with cardiologist, internal defibrillator checks, monitor signs and symptoms of pacemaker complications such as shortness of breath, weakness, low heart rate, monitor pulse every shift and as needed, and pacemaker checks as ordered. On October 11, 2016 at 10:20 a.m., during an interview, Registered Nurse 2 (RN 2) stated apical pulse should be checked when Resident 6 was receiving [MEDICATION NAME] medication and has a pacemaker. On October 11, 2016 at 2:30 p.m., during and interview, the Director of Nursing (DON) stated the nurses should have checked the apical pulse for two to three weeks after Resident 6's pacemaker was inserted. The DON was unable to locate documented evidence the apical pulse was checked. The DON also stated that when Resident 6 was on [MEDICATION NAME], apical pulse should have been checked consistently. On October 12, 2016 at 10:30 a.m., during an interview, RN 2 stated the apical pulse is checked by the sternum (the breastbone). On October 12, 2016 at 10:35 a.m., during an interview, Licensed Vocational Nurse 19 (LVN 19) stated the apical pulse is checked by the left fifth intercostal space (between the ribs). According to Lippincott's Visual Encyclopedia of Clinical Skills (2009), indicated the apical pulse is in the left fifth intercostal space of the midclavicular line (pg 449). A review of the facility's revised January 2, 2014, policy and procedure title, Pacemaker, indicated for post-operative patients (two to three weeks), provide and/or assist patient with daily care of pacemaker, inspect site daily, and to check apical pulse for one minute daily. Pulse rate should be the same as pacemaker rate or faster. Notify physician if pulse is more than five to ten beats lower than pacemaker's setting. b. According to the admission record, Resident 16 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. of the spine). A review of Resident 16's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated August 15, 2016, indicated the resident was cognitively intact, and required total one-person assist with bed mobility, dressing, and hygiene. The MDS also indicated Resident 16 had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, and muscle) upon admission measuring 4 centimeter (cm) length by 3 cm width by 1.5 cm depth. A review of Resident 16's physician order [REDACTED]. 1. [MEDICATION NAME] tablet 25 milligram (mg) by mouth one time a day before therapy, dated August 23, 2016. 2. [MEDICATION NAME] tablet 50 mg by mouth every four hours as needed for severe pain, dated August 23, 2016. 3. [MEDICATION NAME] tablet 25 mg by mouth every four hours as needed for moderate pain, dated August 23, 2016. 4. [MEDICATION NAME] capsule 300 mg by mouth at bedtime for neuropathic (disease of nerves) pain, dated August 26, 2016. 5. Tylenol tablet 325 milligram (mg), give two tablets by mouth every 4 hours as needed for mild pain, dated August 22, 2016. A review of Resident 16's plan of care did not indicate that a plan of care regarding pain management with measurable goals, objectives, and individualized interventions was developed. A review of the Medication Administration Record [REDACTED]. On October 6, 2016 at 12:36 p.m., during an interview, Licensed Vocational Nurse 14 (LVN 14) stated that there was no daily assessment for October 2, 3, 4, and 5, 2016 because the facility was currently using a new form, PRN (as needed) pain management flow sheet. The new form was designed to assess pain when administering the pain medication. LVN 14 also stated she received the information from another licensed personnel. On October 6, 2016 at 12:39 p.m., during an interview, LVN 3 stated that every resident was to be assessed for pain every shift. On October 6, 2016 at 3:52 p.m., during an interview, the director of nursing (DON) stated that Resident 16's pain assessment should have been done every shift. She also stated that she reviewed the resident's clinical record and could not find documented evidence that the licensed personnel assessed the resident's pain on October 2, 3, 4, and 5, 2016. On October 11, 2016 at 2:32 p.m., during an interview, Resident 16 stated that sometimes the nursing staff would ask her if she was in pain, but would not assess for pain every shift probably because the nursing staff changed all the time. A review of the revised care plan dated March 15, 2016 and titled Pain Management indicated that at a minimum of daily, patients will be evaluated for the presence of pain by making an inquiry of the patient or by observing for signs of pain.

Based on observation, interview and record review, the facility failed to ensure residents' environment remains as free of accident hazards as is possible for six of 25 sample residents (Residents 9, 5, 25, 6, 23, 12) and for one Random sample Resident (RSR 36), by failing to: 1. Prevent a fall based on a plan of care with effective and useful interventions for Resident 9. Resident 9 had a history of [REDACTED]. The facility failed to continuously monitor and supervise Resident 9 on October 4, 2015. As a result, the resident had a fall and sustained a laceration to the forehead and a nasal (nose) fracture. Resident 9 was transferred to the general acute care hospital (GACH) and received suture repair to the laceration of the forehead. This deficient practice resulted in injury to Resident 9, and had the potential for further injuries from head trauma and the fall, and placed the resident at risk for another fall event. 2. Ensure that the sharp containers in the shower room would not overflow and be replaced once the container is already ¾ full in accordance with the policy; at the time of the observation, the facility had 53 residents identified as using and having access to the shower room; and failed to ensure Resident 12's closet drawer was not in disrepair to prevent an injury. 3. Ensure television sets were anchored properly to prevent accidents in the event of an earthquake. 4. Ensure that residents at high risk for falls were monitored and fall prevention devices were applied as directed on the plan of care (Residents 5, 6, and 23, and Random Sample Resident (RSR)36) to prevent falls. Findings: a. According to the admission record, Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 9's Annual Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated June 23, 2015, indicated the resident was severely impaired in cognition, required extensive one-person assist with transfer, toilet use and personal hygiene, bathing, and when moving between locations in her room and the adjacent corridor on the same floor; if in a wheelchair, self-sufficiency once in the chair. The MDS also indicated the resident was not steady, was only able to stabilize with staff assistance when moving from a seated to a standing position, walking, moving on and off the toilet, and transferring between bed and chair or wheelchair. The MDS failed to indicate that Resident 9 had a history of [REDACTED]. The Care Area Assessment (CAA) dated June 23, 2015 indicated Resident 9 had difficulty maintaining a sitting balance, had cognitive impairment, and had seizure disorder. After the analysis of findings, the decision was to proceed with care planning. A review of the Admission Fall Risk Review dated October 2, 2015, indicated Resident 9 had a balance problem for sitting/standing. The fall risk review also indicated the resident was at risk for fall. A review of Resident 9's plan of care initiated on August 11, 2015, for at risk for fall due to cognitive loss, lack of safety awareness, and [DIAGNOSES REDACTED]. The interventions were not individualized to the resident's needs due to Resident 9's cognitive status (confused), diagnosis (dementia), and lack of safety awareness. A review of the daily and every shift charting dated October 2, 2015, indicated Resident 9 was alert and confused upon readmission to the facility. A review of the device and physical restraint review note dated October 2, 2015 indicated Resident 9 had a history of [REDACTED]. A review of the Situation, Background, Assessment, Request (SBAR) post fall progress note dated October 4, 2015, indicated Resident 9 was confused and unable to describe the incident. A review of the Comprehensive pain assessment dated [DATE], after the fall incident indicated a pain level of 0 on a 0 to 10 pain scale (0 being no pain and 10 being the most severe pain). A review of the event summary report dated October 6, 2015, indicated Resident 9 fell out of the wheelchair face forward to the floor on October 4, 2015 at 2:15 p.m. while sitting in the hallway. The resident sustained [REDACTED]. The report also indicated that the fall was unwitnessed. A review of the non-witnessed statement dated October 4, 2015, indicated Resident 9's assigned Certified Nursing Assistant 10 (CNA 10) was charting at nursing station 2 at 2 p.m. and heard a noise at 2:15 p.m. in the hallway. CNA 10 checked at the origin of the noise and saw Resident 9 on the floor and reported it to the charge nurse. The licensed nurse notified the physician who ordered to transfer Resident 9 to the GACH emergency roiagnom on [DATE]. The interventions for fall prevention were not effective and useful to prevent the fall that resulted in a laceration to the forehead and nasal fracture. For example, there were no interventions to continuously monitor and supervise the resident while sitting on the wheelchair, or there were no interventions to apply a device on the wheelchair to prevent the resident from falling due to difficulty maintaining sitting balance. The result of the computerized tomography scan dated October 4, 2015 and timed 4:45 p.m., indicated fractures of the nasal bones with minimal displacement. A review of the GACH discharged summary October 4, 2015 provided on October 7, 2016, indicated that Resident 9 was sent to the emergency department for injuries sustained as the result of a mechanical fall. The summary was inconsistent with the information provided to the Survey team regarding the fall incident. The summary indicated the resident was reaching for a table while in bed and fell out of bed. The physical examination indicated a horizontal forehead laceration, mid-forehead approximately 3 cm in diameter, bruising and swelling to the bridge of nose, no septal hematoma (a collection of blood within the part of the nose between two nostrils). The final [DIAGNOSES REDACTED]. Resident 9 was readmitted back to the facility on the same date, October 4, 2015. The physician was notified and new orders to continue current orders (neurocheck per protocol) and Keflex (an antibiotic) 500 milligram one capsule oral three times a day for 7 days for laceration of forehead were obtained on October 4, 2015. There were more than three attempts with administrative staff to identify the nursing staff that transferred Resident 9 to the GACH for an interview, without success. The nursing staff assignment record provided by the facility on October 13, 2016, did not include the 3 p.m. to 11 p.m. shift of the staff working at Station 2 the day of the fall incident. On October 7, 2016, at 12:04 p.m., during an interview, Licensed Vocational Nurse 3 (LVN 3) stated Resident 9 had some level of confusion and no safety awareness prior to the fall incident. According to LVN 3, Resident 9 would attempt to stand up unassisted from the wheelchair, but was unable because she had no strength. The staff would place Resident 9 near the nursing station because the staff could not leave her alone due to the resident's lack of safety awareness. On October 7, 2016, at 2:32 p.m., during an interview, the Director of Nursing (DON) stated Resident 9 was sitting in the wheelchair near the nursing station for line of sight (safety precautions). She stated the staff should have assessed fall precaution interventions while the resident was sitting in the wheelchair considering the fact that Resident 9 was participating in activities while sitting in the wheelchair, was using the wheelchair for locomotion, and was receiving restorative nursing assistance for ambulation. When asked regarding the resident's fractured nose, the DON stated that the facility should have known about the fractured nose because upon admission or re-admission of a resident to the facility, the facility received a discharge summary from the GACH to find out what was done in the GACH. She also stated that if Resident 9's discharge summary was not available at the time of re-admission after the fall incident, the medical records staff should have followed through and requested the GACH discharge summary. According to the DON, the facility did not report Resident 9's injury to the Department of Public Health because the staff were not aware of the injuries. On October 13, 2016, at 2:39 p.m., during an interview, CNA 10 stated he was assigned to Resident 9 the day of the fall incident. CNA 10 stated Resident 9 was usually confused, would sometimes attempt to get out of bed unassisted, and would attempt to self-propel while sitting in the wheelchair. CNA 10 stated after lunch, he asked the resident if she wanted to go to bed or the toilet, and the resident stated no. CNA 10 left Resident 9 in the hallway and proceeded to make his rounds. The morning of the fall incident, Resident 9 was sitting near the nursing station and CNA 10 notified other staff to keep an eye on her because the resident sometimes tried to self-propel around. In the afternoon, prior to making his rounds, CNA 10 stated that he did not notify the staff because the resident was calm and not moving. He was in another resident's room when he heard staff saying that Resident 9 fell , went to assist Resident 9 back to bed. She was bleeding from the nose, looked sad, did not make any facial grimaces, and was quiet. A review of the neurological intervention flow sheet indicated a recommended schedule of every hour for four hours, then every four hours for four, then every shift to make a total of a 72 hour evaluation period. There were no neurological assessments done on October 5, 2015, and October 6, 2015, during the 11 p.m. to 7 a.m. shift. A review of the device and physical restraint review note dated October 4, 2015, after the fall, indicated the IDT's (interdisciplinary team - team of health professionals) recommendation was to apply an anti-tilt (to prevent from tilting) device on Resident 9's wheelchair. A review of the IDT notes dated October 7, 16, 23, and 30, 2015, did not indicate Resident 9 had suffered a nasal fracture. On October 5, 2016, at 4:02 p.m., and on October 11, 2016, at 8:59 a.m., during interviews and review of Resident 9's medical record, the DON stated that no interventions were added in the current plan of care for risk for falls. She also stated that Resident 9's plan of care was not updated to include the IDT's recommendation for the new intervention for falls (anti-tilt device). There was no plan of care regarding fracture of the nasal bones. The DON stated that she was not aware that the discharge instructions on fractured nose were available in Resident 9's clinical record. The DON stated if the discharge instructions regarding a broken nose were in Resident 9's clinical record, most likely the licensed personnel from the facility and GACH talked about it. There was no documented evidence provided that services and treatment were being administered to the fractured nose. Also, there was no documented evidence Resident 9 was being monitored for bleeding from the nose, swelling, nasal stiffness, and complications related to a fracture of the nasal bones. A review of the facility's revised policy dated March 15, 2016, and titled Fall Management indicated the following: 1. Resident determined to be at risk for fall will receive appropriate interventions to reduce risk and minimize injury 2. To develop individualized plan of care 3. To update the care plan to reflect new interventions 4. Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury. b. According to the Admission Record, Resident 5 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment and care screening tool) dated September 30, 2016, indicated Resident 5 was cognitively intact, and required extensive assistance and one person physical assist for bed mobility, transfer, dressing, and hygiene care. The MDS did not indicate resident had a fall prior to readmission. A review of the Fall Risk Review dated March 1, 2016, indicated Resident 5 was at risk for falls. The assessment form indicated any yes responds meant the resident is at risk for fall. A review of the Change of Condition dated September 11, 2016, indicated Resident 5 slid off the bed onto the floor when he tried to get his shoe out from under the bed. A review of the Change of Condition dated September 14, 2016, indicated Resident 5 was standing in the bathroom and felt dizzy. He lost balance, fell back and hit the back of his head to the rail causing skin tear. A review of the Physician Order dated September 24, 2016, indicated for a bed alarm when in bed to alert resident not to get up unassisted, to monitor placement and functionality every shift. A review of Resident 5's care plan for Risk For Falls: Impaired mobility, Parkinson's Disease, and lack of safety awareness, initiated on September 22, 2015 and was revised on September 26, 2016, indicated the goal was not to have a fall with injury for 90 days. The interventions included to monitor for changes in medical, pain, mental status, place call light within reach at all times, maintain a clutter-free environment in the resident's room, monitor for and assist toileting needs. The care plan was not updated to include bed alarm when in bed to alert resident not to get up unassisted, to monitor placement and functionality every shift. After the fall incident on September 11, 2016, the same care plan was revised on September 12, 2016 to include interventions of x-ray of bilateral hips, upper legs and lower back, and for the rehabilitation department to screen (assess) Resident 5. After the fall incident on September 14, 2016, the same care plan was revised on September 14, 2016 to include interventions of x-ray of skull, neurologist consult, neurocheck per protocol for 72 hours, and orthostatic blood pressure every shift for 72 hours. A review of the Neurological Evaluation Flow Sheet dated September 14, 2016, indicated the flow sheet was not completely done. September 16, 2016 from seven to three morning shift through September 17, 2016 seven to three morning shift was not completed. A review of the medication administration record (MAR) for the month of September 2016, indicated orthostatic blood pressure was not completed for September 16, 2016 on the seven to three (morning shift), three to eleven (afternoon shift), and eleven to seven (night shift) on September 17, 2016. On October 5, 2016 at 10:30 a.m., during an interview, the Director of Nursing (DON) stated the neurological evaluation and orthostatic blood pressure should have been completed. A review of the MAR for the month of September and October 2016, indicated the bed alarm was assessed for placement and functionality. However, on October 12, 2016 at 7:25 a.m., Resident 5 was observed getting out of bed and the bed alarm did not alarm. The Certified Nursing Assistant 10 (CNA 10) for Resident 5 was in the room assisting the other resident and was not aware Resident 5 was getting out of bed. On October 12, 2016 at 7:30 a.m., during an interview, Registered Nurse 4 (RN 4) checked the alarm and stated the battery needed to be changed; Resident 5 did not have a yellow wristband on to indicate he is a fall risk. RN 4 also stated the alarms are usually checked every shift and resident should have had the yellow wristband on for identification to be a fall risk. According to the facility's revised March 15, 2016 policy and procedure title,Falls Management, indicated the standard of practice included to review and revise the care plan regularly. If resident falls, for all unwitnessed falls and witnessed falls with head injury, perform neurological assessment. Document falls and update the care plan to reflect new interventions. According to another facility's undated policy and procedure title, Fall Prevention/Monitoring Program, indicated resident that was determined to be at higher risk will received appropriate interventions to reduce risk and minimize injury. Interventions to include placing a yellow wristband on resident to assist with easily identifying those residents at higher risk for falls. c. According to the Admission Record, Resident 6 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment and care screening tool) dated July 12, 2016, indicated Resident 6 was severely impaired, and required extensive assistance with one person assist with transfer, bed mobility, and activity of daily living. The MDS did not include resident's fall in March 22, 2016. A review of the quarterly Fall Risk Review dated December 28, 2015, indicated resident was at risk for fall. The assessment form indicated any yes response meant the resident is at risk for falls. A review of the Event Summary Report dated March 22, 2016, indicated Resident 6 was found sitting on the floor near the foot of the bed. A review of the Fall Risk Review for Post Fall dated March 22, 2016, indicated resident was at risk for fall. A review of Resident 6's Neurological Evaluation Flow Sheet dated March 22, 2016, indicated the flow sheet was not completely done. The neurological evaluation recommended to perform every 1 hour for four hours, every 4 hours for four times, then once a shift to make a total of 72 hours of evaluation period. The last hour of the every hour was not completed. Two out of four of the four hours were not completed. Seven out of nine shifts did not perform the evaluation. A review of Interdisciplinary Team (IDT) Notes dated March 25, 2016, indicated IDT recommended neurological evaluation, orthostatic blood pressure for 72 hours, toileting program (scheduled toileting), and a Physical Therapy evaluation. A review of Resident 6's care plan for an actual fall, initiated on March 26, 2016, revised and resolved on April 12, 2016, indicated the goal included not to have a fall with injury for 90 days. The interventions included to continue low bed with floor mat, neurological evaluation, orthostatic blood pressure, pharmacy to review medication, physical therapy eval. On September 30, 2016 at 9:50 a.m., Resident 6 was observed sleeping in bed and the floor mat was on the resident's right side of the bed. On October 12, 2016 at 10:00 a.m., during an interview, Director of Nursing (DON) stated she was unable to locate the pharmacy medication review. The DON stated the neurological evaluation and pharmacy medication review should have been done. According to the facility's revised March 15, 2016 policy and procedure title,Falls Management, indicated the standard of practice included to review and revise care plan regularly. If resident falls, for all unwitnessed falls and witnessed falls with head injury, perform neurological assessment. Document falls and update care plan to reflect new interventions. d. On September 29, 2016 between 4:30 p.m. to 4:45 p.m., during the initial tour, the television sets in Rooms 81, 82, 83, 84, 85, 86, and 87, were not secured on the dresser. These television appliances were easily moved and could accidentally fall on the residents if pushed, or in the event of an earthquake, possibly causing injury to a resident. On September 29, 2016 at 5:00 p.m., during an interview, Registered Nurse 3 (RN 3) stated the televisions should be secured onto the dresser to prevent them from falling and causing residents' injuries. On September 29, 2016 at 5:10 p.m., during an interview, the Maintenance Supervisor stated he was not aware that the televisions were not secured to the dressers. At the same time, RN 3 requested the Maintenance Supervisor to secure the televisions onto the dressers in all of the residents' rooms. e. A review of the admission record indicated Resident 23 was admitted to the facility on [DATE] and readmitted on [DATE], from a general acute care hospital (GACH) with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated September 19, 2016, indicated Resident 23 had severe impairment in cognitive skills for daily decision-making, required one person extensive assistance with bed mobility. In the area of walking and transfer, this activity did not occur (activity did not occur or family and/or non-facility staff provided care 100 percent of the time for that activity over a seven day period). Resident 23's MDS also indicated the resident had a fall with fracture within the last six months prior to admission to the facility. During an observation in the presence of registered nurse (RN 7) on October 4, 2016 at 10:00 a.m., Resident 23 was observed lying in the bed with one landing mat to Resident 23's left side on the floor. There was no landing met to the right side of Resident 23. RN 7 stated she did not know why Resident 23 had only one landing mat and stated she would check Resident 23's chart. RN 7 was unable to provide documentation that having a landing mat to only one side of the resident's bed was preferred over having a landing mat to both sides of the resident's bed. A review of Resident 23's Care Plan, dated September 12, 2016, indicated Resident 23 is at risk for falls due to recent fall. Resident 23's Care Plan indicated Resident 23 will have no falls with injury for ninety days. Placing of landing mats were not listed as an intervention to achieve this goal. A review of the facility policy and procedure titled, Falls Management, indicated the facility should develop an individualized plan of care. f. A review of the admission record indicated RSR 36 was admitted to the facility on [DATE] and readmitted on [DATE], from a general acute care hospital (GACH) with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated September 20, 2016, indicated RSR 36 had severe impairment in cognitive skills for daily decision-making, required one person total dependence (full staff performance every time during an entire seven day period) with bed mobility, bed transfer, dressing, eating, and toilet use. During an observation in the presence of the registered nurse (RN 1) on September 29, 2016 at 5:00 p.m., RSR 36 was observed lying in the bed with one landing mat to RSR 36's right side on the floor. There was no landing met to the left side of RSR 36. RN 1 stated she did not know why RSR 36 had only one landing mat and stated she would check RSR 36's chart. RN 1 was unable to provide documentation that having a landing mat to only one of the resident's floor sides was preferred over having a landing mat to both sides of the resident. During the same observation in the presence of RN 1 on September 29, 2016 at 5:00 p.m., RSR 36's bed was not placed in the lowest position. RN 1 lowered the bed at least six inches so that the bed was closer to the ground. A review of RSR 36's Care Plan, dated August 4, 2016, indicated RSR 36 was at risk for falls due to recent stroke and history of multiple falls and seizure. RSR 36's Care Plan indicated the resident will have no falls with injury for ninety days. One of the interventions was to utilize a low bed with floor mats. A review of RSR 36's Fall Risk dated August 30, 2016, indicated a score of 8 (low risk). During an interview with LVN 4, on October 12, 2016 at 11:40 a.m., she stated she did not know what RSR 36's fall score number signified, whether the resident was at low or high risk for fall. During an interview with RN 11, on October 13, 2016 at 8:00 a.m., she stated a resident was at high risk for fall if they had had a fall prior to entering the facility or after having a fall while living in the facility. RN 11 stated a score of twelve or higher indicated a resident was at high risk for fall while a resident with a score less than twelve was a low risk for fall. A review of the facility's revised policy dated March 15, 2016, and titled Fall Management indicated a resident determined to be at risk for fall will receive appropriate interventions to reduce risk and minimize injury; develop an individualized plan of care, and updated to reflect new interventions. g. On September 29, 2016, at 2:40 p.m., during an initial tour with Registered Nurse 2 (RN 2), the sharps container in the shower room in Station 2 was overflowing with used razors; three used razors were on the shower room floor just beneath the sharps container. On concurrent interview, RN 2 stated that the sharps container should not be overflowing and should be replaced once the container is already ¾ full. At the time of the observation, the facility census was 161 residents with 53 residents identified as using and having access to the shower room. A review of the facility's policy on waste management indicated that sharps container must be replaced when ¾ full. h. According to the admission record, Resident 12 was originally admitted on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the care plan dated August 21, 2016, indicated the resident had a [DIAGNOSES REDACTED]. The interventions included to assess the environment for safety hazards; avoid injuries related to decreased sensation (unable to feel pain to areas). The Minimum Data Set (MDS) assessment (an assessment and screening tool) dated August 26, 2016, indicated the resident's cognitive patterns were severely impaired, no mood and behavior signs and symptoms, needed extensive assistance from staff members for all care needs. The resident used a wheelchair as a mobility device. The resident did not have presence of pain. On October 4, 2016, between 9:50 a.m. to 10:25 a.m., during an observation in the presence of Licensed Vocational Nurse 2 (LVN 2), the drawer handle that was located at the bottom of the closet was broken. One end of the handle was loosely attached to the drawer and the other end was dangling. On October 4, 2016, at 10:05 a.m., during an interview with LVN 2, he stated the handle should have been fixed.

Based on interview and record review, the facility failed to ensure the resident maintained acceptable parameters of weight loss for one of three sampled residents (Resident 1). For Resident 1, the facility did not have a systematic approach to evaluate, develop, and implement pertinent care plan approaches/interventions to optimize Resident 1's nutritional status and prevent weight loss. This deficient practice resulted in a severe weight loss of 24 pounds (9.5%) in one month for Resident 1, and the resident was transferred to a general acute care hospital due to weight loss, where the resident required intravenous fluids (administered directly into vein, used to treat dehydration, corrects electrolyte imbalance). Findings: A review of the admittance record indicated Resident 1 was admitted , on November 12, 2015, with [DIAGNOSES REDACTED]. A review of the weights and vitals summary sheet indicated Resident 1 weighed 233 pounds upon admission. The initial Minimum Data Set (MDS - an assessment and care planning tool), dated November 19, 2015, indicated Resident 1 was able to hear, see, and understand adequately. The MDS indicated Resident 1 required minimum assistance with setting up the meal tray and had the ability to feed himself. A review of the physician's admission orders [REDACTED]. The activities of daily living (ADL) meal records, dated November 2015, indicated Resident 1 ate an average of 100% of his meals. A review of the interdisciplinary plan of care form, dated November 17, 2015, indicated Resident 1 was pleased with his diet and food, and he would like larger portions. A review of the dietary/nutritional assessment, dated November 17, 2015, indicated Resident 1 ate well, chewed and swallowed food okay. Resident was feeding himself, and he was on a therapeutic diet. A review of the registered dietician (RD 1) care plan, dated November 17, 2015, indicated Resident 1 had altered nutritional status related to mechanically altered diet. The care plan goal indicated the resident was to have adequate nutritional intake with the interventions including monitoring weights and report significant weight loss to the medical doctor (MD) and dietician, and a dietary evaluation. A review of the nursing care plan, dated November 26, 2015, indicated the focus area for Resident 1 was nutritional risk due to [DIAGNOSES REDACTED]. The care plan goal indicated the resident would consume at least 75-100% of meals for 90 days, and would have no weight variance noted for 30 days. The care plan interventions indicated weekly weights for four weeks, and alert physician or dietician regarding any changes. A review of the Weight Variance Report, dated December 2015 (a specific day was not documented), indicated Resident 1 had a weight loss of six pounds since admission. A review of the nursing nutritional risk care plan revised, on December 3, 2015, indicated the interventions were to offer alternative food choices if less than 50% of meals was consumed at mealtime, and supervise, cue, and assist as needed at all meals. A review of RD 1's nutritional status care plan, dated December 8, 2015, reflected a six pound weight loss and the goal indicated Resident 1 would not have a significant weight change for 90 days. The intervention indicated the nursing staff to monitor weight. A review of the Laboratory Report, dated December 8, 2015, indicated a low [MEDICATION NAME] (protein that nourishes tissues, frequently used to help evaluate nutritional status, overall health status) level of 3.1 (normal range 3.5 - 5.7). During an interview with the current registered dietician (RD 2), on June 1, 2016, at 12:30 p.m., she stated the [MEDICATION NAME] level was important to reflect the resident's food intake and nutritional status. A review of the ADL meal record, dated December 20 - 31, 2015, indicated Resident 1 ate an average of 20% of his meals. The clinical record indicated the care plan was not updated or revised until January 19, 2016, (over 2 weeks later) to address Resident 1's low [MEDICATION NAME] level and decrease in food consumption. During an interview with RD 2, on June 1, 2016, at 12:35 p.m., regarding Resident 1's change in meals consumed, she stated she was not the RD for Resident 1 during this time. RD 2 stated normally she would get more information from staff, family, and interview the resident to find out his food preferences. RD 2 stated she would call the physician to notify him of the resident's decrease in food consumption and get orders for labs. A review of the ADL meal record, dated January 2016, indicated Resident 1 ate an average of 38% of his meals, which was less than the care plan goal. A review of the interdisciplinary team note indicated a swallow evaluation was conducted, on January 14, 2016, and resulted with Resident 1 exhibiting good oral intake and no swallowing concerns. On January 19, 2016, an entry was made on RD 1's nutritional status care plan, which indicated Resident 1 refused his meals, and had poor oral intake (this contradicted the the IDT note dated January 14, 2016). The goal for this entry was to improve food consumption to 75% or greater for 90 days and the intervention was to monitor the weight and meal intake. A review of the Medication Administration Record, [REDACTED]. A review of the Laboratory Report for Resident 1, dated January 22, 2015, indicated the [MEDICATION NAME] level decreased again to an abnormal level of 2.8 (normal range 3.5 - 5.7) and the protein was low at 6.2 (normal range 6.4 -8.9). There was no documented evidence regarding the facility's response to the low [MEDICATION NAME] and low protein. A review of the Weights and Vitals Summary sheet indicated Resident 1 weighed 229 pounds on December 26, 2015 and 205 pounds on January 25, 2016. This indicated a 24 pound weight loss, which was a 9.5% severe weight loss. A review of the facilities weight and height policy, effective date 6/1/01, revised 11/30/15, indicated the residents were weighed on admission and /or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team. The purpose of the care plan indicated to determine possible causes of significant weight change. During an interview with the Director of Nursing, on June 1, 2016, at 2:45 p.m., when asked about the concerns of the different care plans, she stated the facility did not have a policy on care planning. A review of the general acute care hospital's patient transfer record, dated February 1, 2016, indicated Resident 1 was transferred to the hospital with the chief compliant of poor oral intake, and a 20 pound weight loss. A review of the Discharge Summary, dated February 2, 2016 indicated Resident 1 was placed on intravenous fluids and intravenous antibiotics, and on February 4, 2016, was tolerating oral feedings.

Based on observation, interview and record review, the facility failed to ensure that residents' pain was continuously assessed, monitored, promptly and effectively managed as long as the pain persists in order to prevent suffering from pain, failed to immediately notify the physician and obtain treatment instructions when the scheduled pain medications were not effective to achieve sustained relief until the next scheduled pain medication administration time for four of 26 sample residents (12,22,6,1) and failed to ensure ace bandages were applied to a resident's lower extremities as ordered by the physician to promote circulation, reduce [MEDICAL CONDITION] (a swelling caused by fluid retention -excess fluid is trapped in the body's tissues that may cause pain due to pressure exerted to nerve endings), and prevent the potential for pain from the [MEDICAL CONDITION] for five out of 26 sample residents (12, 22,6,1,19). Findings: a. According to the admission record, Resident 12 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. violent and involuntary muscular contractions that make the body appear to shake associated with brain disorder). The Pain assessment dated [DATE], indicated the resident was not experiencing pain at that time due to effective pain management. The Minimum Data Set ((MDS) a standardized comprehensive assessment of the resident's problems and conditions) dated July 8, 2011, indicated the resident was severely impaired in her cognitive skills for daily decision making and required extensive assistance from staff with all activities of daily living. On August 3, 2011, at 11 a.m., the resident was observed lying in bed with closed fists. When asked to open her hands, she was unable to do so. the resident was not interviewable. On August 4, 2011, at 6:35 a.m., the resident could be heard crying and screaming in her room, from the nurse's station. Upon entering the resident's room, Licensed Vocational Nurse 5 (LVN) was attempting to apply a roll of gauze in the resident's left hand, to prevent further contracture. LVN 5 when asked stated she was trying to place the left hand roll, and that was the reason the resident was screaming. The resident stopped screaming when LVN 5 stopped attempting to apply the left hand roll. The resident had a physician's orders [REDACTED]. There was a physician's orders [REDACTED]. The order was discontinued on June 23, 2011, and the resident was referred to occupational therapy. A review of the Occupational Therapy (OT) Evaluation Note dated June 23, 2011, indicated the resident was referred by the RNA due to distress and pain during splinting. The note also indicated the resident would be provided with alternative splinting and pain management to maintain skin hygiene and for contracture management. A care plan was initiated on the same date for OT treatment secondary to contracture and hygiene. The care plan goal indicated as per the RNA referral the resident was crying during right hand roll application and the resident would be monitored for pain management and an alternative splinting technique if possible. The approaches included OT treatment three days a week for two weeks and orthotic fitting and training. The care plan did not address what the pain management intervention would be. There was no plan of care initiated for pain management to monitor and assess the resident's verbal and nonverbal signs and symptoms of pain or discomfort, in order to administer pain medication as ordered, or to notify the physician for other treatment instruction(s) if the pain was not relieved, in accordance with the facility's policies and procedures (see below). A review of the Occupational Therapy daily documentation (note) indicated the following: 1. On June 23, 2011, with no specific time when the documentation was written, the note indicated the resident was pre-medicated with Tylenol but the resident kept crying when the hand roll was applied. The note indicated the physician would be contacted to increase pain medication if possible. The note also indicated the resident appeared distressed when moved and touched with or without pain medication. However, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The pain assessment flow sheet was contradictory to the note, indicating the resident had no pain. There was no documentation the physician was notified of the resident's continued reaction of pain during hand splinting. 2. On June 24, 2011, the note indicated the resident was pre-medicated with Tylenol. The note also indicated the resident cries during hand roll application and finger-stretching, but can tolerate two hours of splints. There was no documentation that indicated the resident's pain level was assessed (on a pain scale). Even though the note indicated the resident was pre-medicated with Tylenol, the MAR indicated [REDACTED]. The pain flow sheet was contradictory to the note, indicating the resident had no pain. 3. One June 27, 2011, the note indicated the resident was pre-medicated but crying when touched and during mobilization; the hand roll was tolerated for 30 minutes. This was the third day that the resident received treatment from the OT, and the resident was crying during the treatment. However, there was no documented evidence the resident's crying episodes were assessed for the intensity/level of pain the resident was experiencing when the hand stretching and splinting was being done. Additionally, there was no documented evidence the resident received the PRN pain medication, and the physician was not notified of the resident's continued reaction of pain during the hand splinting. 4. On June 29, 2011, and June 30, 2011, the note indicated the right hand splint was applied/attempted. The resident kept crying and refusing the splint. The note indicated the resident managed to take off the splint. The MAR indicated [REDACTED]. According to the OT's daily documentation during the above five days, the resident was crying when she received the OT treatments. However, there was no documentation the resident was assessed to identify the resident's pain level and to relay that information to the physician for management of the resident's continued pain before, during, and after, the hand splinting. On August 3, 2011, at 2:55 p.m., an interview was conducted with the Registered Occupational Therapist (ROT) who evaluated the resident for treatment and hand splinting from June 23, 2011, to June 30, 2011. When asked if she knew the reason(s) why the resident was crying during hand splint application, she stated the resident cries because of pain. She stated the charge nurse was informed of this, and the resident was supposed to be pre-medicated before splinting. When asked if she saw the nurse administer the pain medication to the resident, she had no answer. On August 3, 2011, at 3:10 p.m. during an interview, LVN 4, who was regularly assigned to the resident, was asked if she had administered pain medication to the resident. According to LVN 4, administered pain medications would be documented on the back side of the MAR. However, LVN 4 was unable to provide documentation on the MAR indicated [REDACTED]. According to the facility's pain management policy and procedure (revised on August 31, 2009), the licensed nurse is to complete a comprehensive pain assessment that includes description of pain, location, intensity, quality, frequency/onset, duration, and the effect the pain has on function/quality of life, the current medication, the treatment and response to current medication. The licensed nurse is to assess the resident utilizing the non-verbal cues such as facial grimacing, moaning, etc.... to indicate the severity of pain if the resident cannot verbally indicate the pain intensity. The licensed nurse would develop a plan of care for pain management. The licensed nurse should administer the pain medication as ordered, and document on the MAR indicated [REDACTED]. If the pain was a new onset, changed in nature, not relieved with current medication the nurse would notify the physician for a review of the pain medication and pain management plan. According to the California Board of Registered Nursing, pain is considered "The Fifth Vital Sign" and the Registered Nurse is responsible for ensuring pain is assessed and treated effectively, promptly, and as long as the pain persists. b. According to the admission record, Resident 22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) a standardized comprehensive assessment of the resident's problems and conditions) dated June 21, 2011, indicated the resident was severely impaired in her cognitive skills for daily decision making and requires limited to extensive assistance from staff with all activities of daily living. The resident had the following physician's orders [REDACTED]. 1. [MEDICATION NAME] (an antipsychotic medication) 25 milligrams (mg) daily at 5 p.m. for dementia with agitation manifested by screaming. 2. Tylenol 325 mg two tablets every six hours as needed for pain headache. A care plan was initiated on June 13, 2011, for altered behavioral symptoms as manifested by screaming. The approaches included to withdraw calmly if the resident resisted, and approach again at a later time. On August 8, 2011, at 8:35 a.m., the resident was heard from the hallway screaming loudly, "No! No! No!" The Evaluator went to the resident's room, and observed the privacy curtain closed. Staff were heard telling to the resident that her son was coming. The resident continuously screamed "No! No!" then suddenly the privacy curtain was pulled back. The resident was observed dressed and sitting in a wheelchair. When asked, the Certified Nursing Assistant 2 (CNA 2) stated that the resident always screamed during care. When CNA 2 asked the resident if she was in pain, the resident stated she had a headache. However, during this observation while the resident was heard screaming behind the privacy curtain, CNA 2 did not ask the resident if she was in pain, or report to the licensed nurse so that the resident could receive her pain medication, or attempt to calm the resident as indicated in the care plan. The facility's policy and procedure for pain management indicated if pain is not relieved with current medication, etc., the nurse is to notify the physician for a review of the medication and pain management plan. According to the California Board of Registered Nursing, pain is considered "The Fifth Vital Sign" and the Registered Nurse is responsible for ensuring pain is assessed and treated effectively, promptly, and as long as the pain persists. c. According to the admission record, Resident 6 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was severely impaired in her cognitive pattern, had impairment on both sides of her upper and lower extremities, and required extensive to total assistance from staff with the activities of daily living. The resident had the following physician's orders [REDACTED]. 1. [MEDICATION NAME] (also known as Tynenol is a medication used to relieve pain and reduce fever), 650 mg via GT every 4 hours as necessary for pain dated May 11, 2011. 2. [MEDICATION NAME] 650 mg one suppository per rectum every 6 hours as necessary for pain dated May 25, 2011. 3. Restorative Nursing Assistant (RNA) to apply right elbow splint for 2-3 hours everyday seven times per week or as tolerated dated June 21, 2011. 4. [MEDICATION NAME] (a medication used to relieve moderate to severe pain) one tablet via gastrostomy tube (GT) every four hours as necessary for severe pain dated May 23, 2011, 2011. 5. [MEDICATION NAME] one tablet via GT every 9 a.m., for pain dated June 21, 2011. There was a plan of care initiated on May 23, 2011, for moderate pain, with a goal that the resident would verbalize and/or show decreased physical signs of pain with pain-relieving strategies. The approaches included to administer pain medication as ordered ([MEDICATION NAME] 650 mg as necessary every 6 hours via GT, [MEDICATION NAME] one tablet via GT every four hours as necessary for severe pain), and to monitor response using a pain scale related to medications. On August 3, 2011, at 12:15 p.m., the Evaluator heard loud moaning and/or crying. The resident was observed in her room sitting in a geri-chair. She had a right arm splint, and was moaning/crying while pointing at her splinted right arm with her left hand. At that time, Licensed Vocational Nurse 1 (LVN 1) was informed of the resident's pain. He stated he administered routine [MEDICATION NAME] one tablet at 9 a.m., and the next dose of [MEDICATION NAME] would be adminitered after four hours since the ordered is every four hours. The resident kept on moaning and crying, and pointing to her right arm after LVN 1 stepped out of her room. On August 3, 2011, at approximately 12:30 p.m., Registered Nurse 5 (RN 5) was informed about LVN 1's response, and RN 5 stated she would call the physician and would talk to LVN 1. At 12:40 p.m., LVN 1 administered [MEDICATION NAME] one tablet to the resident via the GT. When LVN 1 was asked about the degree of the resident's pain, he stated the resident was not communicable, but it appeared that the resident had severe pain. On August 4, 2011, at 3:05 p.m. during an interview, LVN 1 stated he did not administer Tylenol 650 mg to the resident on August 3, 2011, at 12:15 p.m., when he was informed about the resident's pain because Tylenol is not as effective as [MEDICATION NAME]; and he did not administer [MEDICATION NAME] because the resident had a physician's orders [REDACTED]. He stated he should have called the physician to inform him that the medication ordered to be administered every four hours was not effective to manage or control the resident's pain. A review of the facility's procedure for pain management indicated if pain is not relieved with current medication, etc., the nurse is to notify the physician for a review of the medication and pain management plan. According to the California Board of Registered Nursing, pain is considered "The Fifth Vital Sign" and the Registered Nurse is responsible for ensuring pain is assessed and treated effectively, promptly, and as long as the pain persists. d. According to the admission record, Resident 19 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was severely impaired in her cognitive patterns (The ability to remember, think coherently, and organize daily self-care activities), and required limited to extensive assistance from staff with the activities of daily living. There was a physician's orders [REDACTED]. There was a plan of care developed on April 15, 2011, for the risk of [MEDICAL CONDITION] as manifested by [MEDICAL CONDITION] on BLE. One of the approaches was to apply ace wrap to BLE in the morning and to remove it in the evening. On August 8, 2011, at 10:15 a.m., the resident was observed sitting in a wheel chair in the dining room, and both legs were not wrapped with the ace bandages as ordered by the physician. During an interview with RN 5 at the same time, she stated the resident's legs had degree two [MEDICAL CONDITION] and should have been wrapped with the ace bandages as ordered by the physician. e. According to the admission record, Resident 1 was readmitted on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had intact cognitive patterns, needed extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. The MDS indicated the resident had been on a scheduled pain medication regimen, did not receive PRN (as necessary) pain medications, and did not receive non-medication intervention for pain. There was a plan of care initiated on March 16, 2011, for pain related to occasional pain and moderate pain of the right shoulder. The goal was the resident will verbalize and/or show decreased physical signs of pain. The approaches included to assess the level of pain using a pain-rating scale, implement non-pharmacological interventions of repositioning, relaxation techniques, and reassuring words/gestures, administer pain medication as ordered, monitor response using pain scale related to medications, treatments, procedures, and evaluate the need to provide medications prior to treatment or therapy (such as 30 minutes before therapy and established schedules.) The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On August 3, 2011, between 8 a.m. to 10 a.m., during the initial tour of the facility with Registered Nurse 2 (RN 2), Resident 1 was observed alert, lying in bed with facial grimacing. The resident complained of right shoulder pain to RN 2 and the pain was rated 10 on a pain rating scale of 0-10 (zero being no pain and 10 as very severe, horrible pain). RN 2 requested another staff member to inform the charge nurse that the resident was in pain, and who responded she would. On August 3, 2011, at 11:45 a.m. after approximately one and one-half hours, the resident was observed lying in bed, again with facial grimacing, and she was still complaining of shoulder and back pain rated at a level of 8 out of 10. She stated that no body had given her any pain medication since the resident was observed at 10 a.m. that morning in the presence of RN 2. On August 3, 2011, at 11:50 a.m., during an interview, RN 2 stated the licensed nurse did not administer the pain medication because it was not due since the resident had received [MEDICATION NAME] at 6 a.m. According to RN 2, the next dose would be at 2 p.m. RN 2 also stated there was no PRN (as needed) medication ordered. When asked if the licensed nurse notified the physician regarding the resident's continued pain, she stated they did not notify the physician to inform him that the resident's pain was not controlled and to obtain an order for [REDACTED]. A review of the clinical record revealed there was no documented evidence that the resident's unrelieved pain was assessed or addressed. Nor was the physician notified of the resident's unrelieved pain in order to obtain treatment instructions when the [MEDICATION NAME] administered for pain at 6 a.m. was not effective to achieve sustained control/relief of the pain until the next scheduled pain medication administration time. The facility's policy and procedure titled "Pain Management" dated August 31, 2009, indicated the licensed nurse will notify the physician of pain assessment findings and obtain order(s) for pharmacological interventions, if indicated. If pain is of new onset, changed in nature, not relieved with current medication, etc., the nurse will notify the physician for a review of the medication and pain management plan. According to the California Board of Registered Nursing, pain is considered "The Fifth Vital Sign" and the Registered Nurse is responsible for ensuring pain is assessed and treated effectively, promptly, and as long as the pain persists.