Every finding on record at Almond Vista Healthcare

Based on observation, interview, and record review, the facility failed to follow an infection prevention and control program designed to provide a safe and sanitary environment for one of three sampled Residents (Resident 4) when Licensed Vocational Nurse (LVN) 3, Certified Nursing Assistant (CNA) 3 and CNA 4 were observed assisting Resident 4 who was on Enhanced Barrier Precautions (EBP - special infection-control practices to prevent the spread of germs that are resistant to antibiotics) up in bed for lunch without wearing the required Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments).This failure placed residents at risk for cross-contamination (when harmful germs, bacteria, allergens, or chemicals are accidentally transferred from one person, object, or place to another) and infection (an invasion of the body by germs that cause disease).During an observation on 7/17/26 at 12:42 pm, LVN 3 and CNA 3 were observed in the room with an EBP designation sign on the door. LVN 3 and CNA 3 wore masks and gloves and assisted Resident 4 up in bed. CNA 4 entered the room wearing a mask without wearing a gown or gloves carrying Resident 4's lunch tray. LVN 3 and CNA 3 then exited the room.During an observation and interview on 7/17/26 at 12:45 pm, with LVN 3 and CNA 3, LVN 3 and CNA 3 were exiting Resident 4's room. LVN 3 stated Resident 4 was on EBP and all staff needed to wear a mask, gown, and gloves while providing patient care to Resident 4. LVN 3 stated she and CNA 3 were helping Resident 4 up in bed which was considered resident care and required them to wear masks, gloves, and a gown. LVN 3 and CNA 3 stated they should have worn a gown per facility's policy and procedure on infection control. LVN 3 stated not wearing appropriate PPE could cause cross contamination. LVN 3 observed CNA 4 in the room with Resident 4 holding Resident 4's lunch tray with one ungloved hand and trying to fix Resident 4's bed sheets with one gloved hand. CNA 4 had no gown on. LVN 3 instructed CNA 4 on appropriate PPE for EBP and instructed CNA 4 that he should be wearing a gown if physically assisting Resident 4.During a concurrent interview and record review on 7/17/26, at 1:00 p.m., with the Infection Preventionist (IP), The IP stated Resident 4 was on EBP. The IP stated when a resident is on EBP staff should wear a mask, gloves, and gown when providing direct patient care. The IP stated that moving a resident up in bed would be considered direct patient care. The IP stated not wearing appropriate PPE for residents with EBP could cause spreading of multi drug resistant organisms (MDRO - germs that have learned how to survive even when treated with several types of antibiotics or medicines that usually kill them). During a concurrent interview and record review on 7/17/26, at 1:30 pm, with the Director of Nursing (DON), the facility policy and procedure (P&P), titled, Enhanced Barrier Precautions, dated 8/2022, was reviewed. The DON stated her expectation was for all staff to abide by the P&Ps for IP practices. The DON stated if staff sees other staff not abiding by IP practices, they should correct the staff member and tell management or IP so the staff member can be re-educated. The DON stated moving a resident up in bed is considered direct patient care and LVN 3, CNA 3, and CNA 4 should have all been wearing masks, gloves, and gowns while assisting Resident 4. During a review of the facility's P&P, titled, Enhanced Barrier Precautions, dated 8/2022, the policy indicated, . 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing). 9. Staff are trained prior to caring for residents on EBPs. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.

Based on observation, interview, and record review, the facility failed to ensure a person-centered comprehensive care plan was implemented for one of four sampled residents (Resident 1) when Resident 1 was diagnosed with cellulitis of the right foot surgical wound and started on antibiotics with no implementation of a comprehensive care plan.This failure had the potential for Resident 1's needs to go unmet. (cross reference F658)During a concurrent observation and interview on 2/16/26 at 10:03 a.m. with Resident 1, Resident 1 was lying in bed, there was gauze secured by an ace bandage on his right foot and the second, third and fourth toes had surgical pins (small, thin metal rods used to hold broken bone pieces together while they heal) sticking out. Resident 1 stated he had foot surgery in mid-February on his right foot. Resident 1 stated about a week and a half after surgery a CNA had come into his room to get him up for a shower. Resident 1 stated the CNA had placed a clear plastic trash bag over his right foot and secured it with tape to keep his dressing dry during the shower. Resident 1 pointed to a role of clear plastic bags he kept at bedside inside a wash basin and stated those were his shower supplies. Resident 1 stated when he took his shower, the tape had slid down causing water to enter the plastic bag. Resident 1 stated after his shower he removed his foot out of the bag and there was approximately three inches of water in the bottom of the bag and his dressing was wet. Resident 1 stated the nurses did not change or reinforce his wet dressing. Resident 1 stated he had the wet dressing in place for four to five days until he went for a post-operative visit with the podiatrist (foot and ankle specialist). Resident 1 stated his foot was red and swollen at the physician's office and he was started on antibiotics (medications used to kill or stop growth of bacteria causing infection) for an infection.During a review of Resident 1's admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare (ongoing care and treatment a patient receives after musculoskeletal surgery), pain in right ankle and joints of right foot, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) right ankle and foot and arthropathy (disease or abnormality affecting the joints).During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was not cognitively impaired.During a concurrent interview and record review on 3/16/26 at 12:06 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had foot surgery on 3/18/26. Resident 1's Order Summary Report (OSR), dated 3/16/26 was reviewed, the OSR indicated, . keep sterile surgical bandages clean and dry. No bandage change needed. Notify the office if there is a problem with the bandage. Order date 2/18/2026. Amoxicillin-Pot Clavulanate Tablet 875-125 mg [unit of measurement] Give 1 tablet by mouth every 12 hours for bacterial infection for 14 days. Order date 3/4/2026 . LVN 1 stated Resident 1 had a post-operative appointment with the podiatrist on 3/3/26 and was started on antibiotics the day after the appointment. LVN 1 reviewed Resident 1's care plans and stated there was no care plan related to Resident 1's foot infection or antibiotic.During a concurrent interview and record review on 3/16/26 at 2:11 p.m. with the Treatment Nurse (TN), Resident 1's OSR, dated 3/16/26 was reviewed, the TN stated Resident 1 was started on antibiotics after his post-operative appointment on 3/3/26 for a bacterial infection. The TN stated she had noted swelling to Resident 1's right foot around the time of his appointment with the POD and the resident had voiced his concern regarding his wound. The TN was unable to locate a care plan for Resident 1's foot infection or antibiotic. The TN stated Resident 1 should have a care plan in the medical record with interventions addressing the ordered treatment.During a concurrent telephone interview and record review on 3/18/26 at 11:35 a.m. with the Director of Nursing (DON), the DON reviewed Resident 1's OSR and stated the order was for Resident 1's sterile post-operative dressing to be kept dry with no bandage change necessary. Resident 1's Office Visit, dated 3/3/26, written by the POD, was reviewed. The Office Visit, indicated, . Postoperative Exam. Date of Surgery: 2/18/26. right 2nd, 3rd, 4th toe arthrodesis [joint fusion-a surgical procedure that permanently connects two or more bones]. returns 13 days post surgery. last Wednesday he wet his dressings in the shower and didn't think they needed to be changed or if it was a serious matter. Operative Lower Extremity Exam. Dressing are soiled and malodorous [very strong, unpleasant or foul smell]. Absorbable sutures [specialized threads used by doctors and surgeons to sew together the edges of a wound or surgical incision] mostly intact holding appropriate tension with some dehiscence [separation of wound edges] noted proximally to the 2nd toe incision, otherwise skin edges are coapted [joining the edges of a surgical wound to promote healing] well. No drainage, dehiscence, or ecchymosis [bruising]. +erythema [positive for redness] noted to dorsal midfoot [top surface of the middle part of the foot] with increased warmth. Skin maceration [occurs when skin is in contact with moisture for too long] noted. Assessment/Plan. Oral abx [antibiotics] prescribed for cellulitis [common, potentially serious bacterial (microorganisms) infection of the deeper layers of the skin and tissue]. The DON stated Resident 1's POD documented in the note Resident 1's wound had cellulitis and was started on antibiotics. The DON reviewed Resident 1's care plans and stated there was no care plan entered for cellulitis or antibiotic use. The DON stated it was important to document in the care plan the diagnosis, the treatments and what to monitor the resident for.During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, . A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan . Include measurable objectives and time frames. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including. which professional services are responsible for each element of care. reflects currently recognized standards of practice for problem areas and conditions. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to ensure services provided meet professional standards of practice for one of four sampled residents (Resident 1) when the nursing staff failed to keep Resident 1's surgical dressing dry and did not notify the physician the bandage was soiled according to the physician's post-operative order.This failure had the potential to cause Resident 1's wound to dehisce (surgical complication where the edges of a closed incision separate) or become infected (pathogens enter the wound and cause symptoms such as pain, increased redness and swelling). (cross reference F657)During a concurrent observation and interview on 2/16/26 at 10:03 a.m. with Resident 1, Resident 1 was lying in bed, his right foot was covered in gauze secured by an ace bandage with the second, third and fourth toes exposed and surgical pins (small, thin metal rods used to hold broken bone pieces together while they heal) sticking out. Resident 1 stated he had foot surgery in mid-February on his right foot. Resident 1 stated about a week and a half after surgery a CNA had come into his room to get him up for a shower. Resident 1 stated the CNA had placed a clear plastic trash bag over his right foot and secured it with tape to keep his dressing dry during the shower. Resident 1 pointed to a roll of clear plastic bags he kept at bedside inside a wash basin and stated those were his shower supplies. Resident 1 stated when he took his shower, the tape had slid down his leg causing water to enter the plastic bag. Resident 1 stated after his shower he removed his foot out of the bag and there was approximately three inches of water in the bottom of the bag and his dressing was wet. Resident 1 stated he notified the nurses his dressing was wet, but the nurses did not change or reinforce his dressing. Resident 1 stated he had the wet dressing in place for four to five days until he went for a post-operative visit with the podiatrist (POD-foot and ankle specialist). Resident 1 stated his foot was red and swollen at the podiatrist's office and he was started on antibiotics (medications used to kill or stop growth of bacteria causing infection) for an infection.During a review of Resident 1's admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare (ongoing care and treatment a patient receives after musculoskeletal surgery), pain in right ankle and joints of right foot, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the right ankle and foot and arthropathy (disease or abnormality affecting the joints). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was not cognitively impaired.During an interview on 3/16/26 at 11:28 a.m. with CNA 1, CNA 1 stated she was taking care of Resident 1. CNA 1 stated she had not given Resident 1 a shower because he preferred them on night shift. CNA 1 stated the process for giving a shower when a resident needs to keep their dressing dry was to take a plastic trash bag and place around the foot and secure it with tape to keep water from making the dressing wet.During a concurrent interview and record review on 3/16/26 at 12:06 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had foot surgery on 3/18/26. Resident 1's Order Summary Report (OSR), dated 3/16/26 was reviewed, the OSR indicated, . keep sterile surgical bandages clean and dry. No bandage change needed. Notify the office if there is a problem with the bandage. Order date 2/18/2026. Amoxicillin-Pot [potassium] Clavulanate [an antibiotic] Tablet 875-125 mg [unit of measurement] Give 1 tablet by mouth every 12 hours for bacterial infection for 14 days. Order date 3/4/2026 . LVN 1 stated Resident 1 had a post-operative appointment with the podiatrist on 3/3/26 and was started on antibiotics the day after the appointment. Resident 1's Progress Note, dated 3/8/26, was reviewed and indicated, . Pt [patient] reports his foot became wet in the shower approximately one week ago and states he believes it is infected. Pt complains of pain and swelling to the affected foot. Foot wrapped to prevent it from getting wet for Saturday nights shower. LVN 1 stated Resident 1 was convinced his wound became infected from getting wet in the shower. LVN 1 stated Resident 1 frequently refused his diabetes medication placing him at a higher risk for wound infection. LVN 1 reviewed Resident 1's care plans and stated there was no care plan related to Resident 1's foot infection or antibiotic.During a concurrent interview and record review on 3/16/26 at 1:49 p.m. with Resident 1's Physician (PHY), Resident 1's Office Visit, dated 3/3/26, written by the POD, was reviewed. The note indicated, . last Wednesday he wet his dressings in the shower and didn't think they needed to be changed or if it was a serious matter . Assessment/Plan. Oral abx [antibiotics] prescribed for cellulitis [common, potentially serious bacterial (microorganisms) infection of the deeper layers of the skin and tissue]. The PHY stated the POD had started Resident 1 on antibiotics for cellulitis. The PHY stated when specialists ordered medications or treatment, she would approve them so the facility can follow the orders. The PHY stated she was unsure if the resident's dressing could be wet or not, but the facility was supposed to follow the post-operative instructions and orders from the specialists.During a concurrent interview and record review on 3/16/26 at 2:11 p.m. with the Treatment Nurse (TN), the TN reviewed Resident 1's OSR, dated 3/16/26 and stated the orders specified to keep the dressing clean and dry and if the dressing became wet, the nurse should have contacted the physician on call for orders. The TN stated the dressing should not be left wet for an extended period unless ordered because it was a surgical wound and could have complications if left wet. The TN stated Resident 1 had a post-operative appointment on 3/3/26 and was started on antibiotics after the appointment for a bacterial infection. The TN stated she had noted swelling to his right foot around the time of his appointment, but she thought it did not appear infected. The TN stated Resident 1 had voiced his concern regarding his wound to her. Resident 1's progress note, dated 3/8/26, was reviewed and indicated, . Pt [patient] reports his foot became wet in the shower approximately one week ago and states he believes it is infected. Pt complains of pain and swelling to the affected foot. Foot wrapped to prevent it from getting wet for Saturday nights shower. The TN stated the note did not indicate which shower day the resident was referring to.During a concurrent telephone interview and record review on 3/18/26 at 11:35 a.m. with the Director of Nursing (DON), the DON reviewed Resident 1's OSR and stated the order was for Resident 1's sterile post-operative dressing to be kept dry with no bandage change necessary. The DON stated Resident 1 usually wrapped his own feet with plastic bags to shower and would take two-to-three-hour showers, increasing the risk of moisture in the bandage. The DON stated there were no nurses' notes indicating if Resident 1's bandage became wet during a shower. The DON stated if Resident 1's dressing had become wet; her expectation would have been for the nurses to call the physician for new orders. Resident 1's Office Visit, dated 3/3/26, written by the POD, was reviewed. The Office Visit, indicated, . Postoperative Exam. Date of Surgery: 2/18/26. right 2nd, 3rd, 4th toe arthrodesis [joint fusion-a surgical procedure that permanently connects two or more bones]. returns 13 days post surgery. last Wednesday he wet his dressings in the shower and didn't think they needed to be changed or if it was a serious matter. Operative Lower Extremity Exam. Dressing are soiled and malodorous [very strong, unpleasant or foul smell]. Absorbable sutures [specialized threads used by doctors and surgeons to sew together the edges of a wound or surgical incision] mostly intact holding appropriate tension with some dehiscence [separation of wound edges] noted proximally to the 2nd toe incision, otherwise skin edges are coapted [joining the edges of a surgical wound to promote healing] well. No drainage, dehiscence, or ecchymosis [bruising]. +erythema [positive for redness] noted to dorsal midfoot [top surface of the middle part of the foot] with increased warmth. Skin maceration [occurs when skin is in contact with moisture for too long] noted. Assessment/Plan. Oral abx [antibiotics] prescribed for cellulitis [common, potentially serious bacterial (microorganisms) infection of the deeper layers of the skin and tissue]. The DON stated skin maceration was caused by moisture, but she was unsure if the resident's dressing had gotten wet or not. The DON stated Resident 1 was diagnosed with cellulitis at the appointment according to the POD's note. The DON reviewed Resident 1's care plans and stated there was no care plan entered for cellulitis or antibiotic use. The DON stated the physician's order should specify the type and location of infection according to the order sent from the doctor. The DON stated the expectation for the staff to keep a resident's extremity dressing dry during a shower would be to use plastic wrap around the dressing secured with tape. The DON reviewed Resident 1's electronic medical record and stated there was no order in place to monitor the dressing for cleanliness or dryness. During a review of Resident 1's Office Visit, dated 3/10/26, the note indicated, . Reason for Visit. Recheck. Post-Operative Note. two weeks and six days post right second, third, and fourth toe repair. He reports the forefoot dressing came off and the foot was soaked in water for an unknown period. He notes persistent swelling and burning between the lesser toes. taking [brand name of antibiotic] . Assessment & Plan. Finish [name of antibiotic] . The DON stated she did not have any documentation indicating the dressing had become wet in the facility shower, but stated Resident 1 was sometimes noncompliant with allowing the staff to check his dressing.During a telephone interview on 3/18/26 at 11:40 a.m. with the DON, the DON stated she was unable to locate a policy and procedure for following physician orders or professional standards of practice. The DON stated Resident 1's POD did not send the facility an order for the antibiotic directly and the facility did not get a copy of the POD's note the day of the visit, so Resident 1's antibiotic arrived to the facility directly from the pharmacy and was started on 3/4/26 after the PHY approved it.During a review of the facility's Job Description. Licensed Vocational Nurse (LVN), undated, the job description indicated, . The LVN implements the established plan of care of each assigned group of Resident's. ESSENTIAL JOB FUNCTIONS. Perform assigned resident care duties in a manner that provides for the physical, psycho-social, and spiritual needs. Correctly differentiates between normal and abnormal clinical findings and intervenes in accordance with clinical standards of practice per physicians orders.During a review of the facility's Job Description. Director of Nursing (DON), undated, the job description indicated, . The Director of Nursing . Manages facility employees in the provision of care and services according to professional standards of nursing practice.During a review of the facility's policy and procedure (P&P) titled Wound Care, dated 10/2010, the P&P indicated, . purpose of this procedure is to provide guidelines for the car of wounds to promote healing. Review the resident's care plan to assess for any special needs of the resident. Report other information in accordance with facility policy and professional standards of practice.During a review of professional reference from https://www.registerednursing.org/does-nurse-always-follow-doctors-orders/ titled, Does a Nurse Always Have to follow a Doctor's Orders? dated 1/30/24, the reference indicated, .nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed neglect .

Based on observation, interview, and record review, the facility failed to ensure the designated Infection Preventionist (IP-professional who ensures healthcare workers and residents are doing all the things they should to prevent infections) had training on Enhanced Barrier Precaution (EBP-an infection control measure in nursing homes aimed at preventing the spread of multidrug-resistant organisms (MDROs-germ that is resistant to many antibiotics) measurement for residents with indwelling medical devices (temporary or permanent devices inserted into the body to serve a specific function, such as fluid drainage, ventilation, or feeding) and open wounds. This failure resulted in the IP not meeting the qualifications that would ensure residents were provided with quality care to prevent or minimize the transmission or spread of MDRO transmitted from person to person) and/or other infections to all residents and staff. Findings: During an interview on 4/30/25 at 10:38 a.m. with License Vocation Nurse (LVN) 1, LVN 1 stated, EBP measures were the same as contact precaution (set of practices used in healthcare settings to prevent the spread of infections transmitted through direct or indirect contact with a patient or their environment). LVN 1 stated EBP was important to prevent spreading infection to staff and other residents. LVN 1 stated, the IP was responsibility for making sure the facility staff were educated on EBP. LVN 1 stated the IP should have been implementing EBP measurement throughout the facility. LVN 1 stated he cannot confirm whether he has/has not received EBP. LVN 1 stated residents with EBP measurement should have Personal protective equipment (PPE- equipment worn to minimize exposure to a variety of hazards) and EBP signage posted outside the room. During an interview on 4/30/25 at 11:10 a. m with the IP, the IP stated she took over the position as an IP within the last month. The IP stated EBP measurements should have been implemented for residents with an indwelling medical device (temporary or permanent devices inserted into the body to serve a specific function, such as fluid drainage, ventilation, or feeding) and open wounds (injuries where the skin and potentially underlying tissues are broken, exposing internal structures). The IP stated staff members should have worn gowns and gloves when providing care for residents on EBP measurements. The IP stated residents with EBP measurement should have an EBP signage outside the door. The IP stated, I didn't have a sign. The IP stated she felt signage was important to reduce potential spread of infection when a resident had an indwell medical device and open wounds. The IP stated the staff should have put on PPE when they are changing linen on the bed, showering, changing briefs and any direct care. The IP stated she should have monitored and made sure there was an EBP signage on the door. During an interview on 4/30/25 at 6:35 p.m. with the Director of Nursing (DON), the DON stated, staff members should have worn PPE when providing direct care for residents with EBP measurements. The DON stated EBP measurement was important to prevent the spread of infection for staff and residents. The DON stated residents with indwell medical devices and open wounds should have a PPE bin and EBP signage posted outside the door. The DON stated staff members should have worn PPE gowns and gloves for residents with indwell medical devices and open wounds. The DON stated the facility did not have EPB signage and PPE bins for residents with indwell medical devices and open wounds. During a concurrent interview and record review on 5/2/25 at 4: 4:42p.m, with the IP, the facility's job description (JD) titled, Infection Control Nurse dated 3/1/2014 was reviewed. The JP indicated, The primary purpose of the Infection Control Nurse is to plan, organized, develop, coordinate and direct our infection control program and its activities in accordance with the current federal, state and local standard, guidelines and regulation that govern such programs and as may be directed by the Administrator and the Infection Control Committee to ensure that an effective infection control program is maintained at all times .Ensure that the facility is in compliance with current CDC .develop and maintain and periodically update infection control precautions . The IP stated she did not follow the job description for the IP. The IP stated EBP measurement was not initiated in the facility. The IP stated the facility did not have an EBP program. The IP stated she needed more education and onboarding for the roles/responsibilities as an IP for the facility. The IP stated, At this moment she does not have the tools/knowledge to be able to fulfill the roles and responsibilities as an IP in the facility. During a current interview and record review on 5/06/25 at 10:34 a.m. with the DON, the facility's JP, titled Infection Preventionist dated 3/21/14 was reviewed. The DON stated the IP did not implement the EBP program in the facility. The DON stated the IP should have maintained an IP program. The DON stated she did not follow the job description. During an interview on 5/6/25 at 12:03 p.m. with the Administrator (ADM), the ADM stated his role was to ensure the IP received all the training and tools needed to be successful at her current job. The ADM stated he should have provided the IP tool and training to make sure she was successful. The ADM stated he should have gotten the IP additional training for her current role. The ADM stated the IP should have implement EBP measurement for residents who needed it. The ADM stated the IP should have more training on EBP measurement and did not follow her job description. During a concurrent interview and record review at 5/06/25 at 10:40 a.m. with the DON, the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions dated 8/2022 was reviewed. The P&P indicated, Enhanced Barrier precautions (EBP) are utilized to prevent the spread of multi-drug resistant organism (MDROs) EBP are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .9. Signs are posted in the door wall or wall outside the resident room indicating the type of precaution and PPE required . the DON stated the facility did not have an active EBP program. The DON stated she was unsure why EBP measurement was not implemented full prior to current IP. The DON stated we did not follow our policy for EBP measurement. During a review of the facility's policy and procedures (P&P) titled, Enhanced Barrier Precautions dated 8/2022, the P&P indicated, Enhanced barrier precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents .5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or discontinuation of the indwelling medical device that places them at increased risk .Staff are trained prior to caring for residents on EBPs 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required . During a professional reference review retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated 4/2/24, the professional reference review from CDC indicated, . enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities . EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following .Wounds or indwelling medical devices, regardless of MDRO colonization status .Infection or colonization with an MDRO .examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing .transferring .providing hygiene .device care or use: central line, urinary catheter, feeding tube .wound care .

Based on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) were developed and implemented to meet the needs of 15 out of 38 sampled residents ( Resident 2, 7, 16, 53, 54, 58, 67, 69, 132, 203, 204, 206, 208, 209, and 212) when: 1. Resident 2 did not have a CP for the use of his vape pen (pen-shaped electronic device used for inhalation of a vaporized substance like nicotine or cannabis). This failure had the potential for the for Resident 2's vaping (the inhaling of an aerosol (mist) created by an electronic cigarette (e-cigarette) or other vaping device) goals and care to not be met. 2. Resident 69 and 204 urinary catheter (a flexible tube that is inserted into the bladder to drain urine) care, Resident 209 hemodialysis (dialysis [a process of removing excess water, and waste products from the blood] or kidney transplant is required to survive), catheter (permacath - a type of central venous catheter specifically designed for hemodialysis), and Resident 212's Peripherally inserted central catheter (PICC - a thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein above the right side of the heart) line care was not developed or implemented. These failures placed Residents 69, 204, 209 and 212 at increased risk of complications from improper management and monitoring of their critical medical devices. 3. Resident 203's seizure (when the brain's electrical activity becomes abnormal causing changes in movement, behavior, or awareness) precaution CP which included the use of padded bed rails as a safety intervention was not implemented. This failure had the potential for Resident 203 to sustain injuries during seizures. 4. Residents 7, 206, 208 and 209 CP for the use of oxygen were not implemented and initiated. This failure potentially placed Resident 7, 206, 208 and 209 at risk of inadequate oxygenation and not having their oxygen needs met. 5. Residents 16, 53, 54, 58, 67, 69, 74, 204, and 209 CP for enhanced barrier precautions (EBP- an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities) were not developed and implemented. This failure put residents at risk of cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and had the potential to transfer infections to other residents. 6. Resident 132 antipsychotic medication (a medication used to help people with mental health conditions) CP was not updated. This failure had the potential risk for Resident 132 to result in inadequate monitoring of medication efficacy, potential side effects, and overall patient care needs. Findings: 1. During a concurrent interview and record review on 4/30/25 at 1:35 p.m. with License Vocation Nurse (LVN) 1, LVN 1 stated, Resident 2 did not have comprehensive care plan for vape pen. LVN 1 stated Resident 2 should have a comprehensive CP for the use of his vape pen. LVN 1 stated Resident 2's care was guided by the comprehensive care. LVN 1 stated Resident 2's vaping needs could have been missed without a comprehensive CP. LVN 1 stated the nurses were responsible for developing the comprehensive CP. During an interview on 4/30/25 at 6:20 p.m. with the Director of Nursing (DON), the DON stated she expected resident CP to be placed in the system within 24 hours of admission. The DON stated if a resident had a new condition, she expected it to be care planned by the end of the shift or end of the day. The DON stated Resident 2's CP for the use of vape pen was important for staff to ensure Resident 2 was safe while using his vape pen. During a review of Resident 2 s Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses: anoxic brain damage (a brain injury caused by a complete lack of oxygen supply), tremors ( an involuntary, rhythmic shaking of a body part), nonpsychotic mental disorder (mental health conditions where symptoms are distressing and impair functioning, but do not involve a loss of contact with reality or psychotic symptoms like hallucinations or delusions), unspecified convulsions ( rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), myoclonus (a sudden, involuntary muscle jerk or spasm, often described as a brief, shock-like movement), falls and lack of coordination. During a review of Resident 2's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/12/25 the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 2 had no cognitive impairment. 48739 2. During a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident 69's room, Resident 69 was observed being fed by CNA 11. Resident 69 was wearing a gown, with the head of the bed elevated, right and left bed rails up at the head of bed, and a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bag was hung on the lower bed rail with no covering on the catheter bag. CNA 11 stated Resident 69's catheter bag should have had a cover for Resident 69's privacy. During a review of Resident 69's AR dated 5/1/25, the AR indicated Resident 69 was admitted to the facility from an acute care hospital on 3/14/25 with diagnoses of cerebral palsy (abnormal development or damage to the pats of the brain that control movement, balance, and posture), acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), chronic kidney disease (a condition when the kidneys suddenly are unable to filter waste products from the blood), sepsis (a serious condition in which the body responds improperly to an infection), dysphagia (difficulty swallowing) and resistance to multiple antimicrobial (a substance that kills microorganisms such as bacteria) drugs, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 69's MDS dated [DATE], the MDS section C indicated Resident 69 had a BIMS score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 69 was severely impaired. During a concurrent interview and record review on 5/01/25 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 69's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated, . change [urinary] Catheter bag every (q) week . every Sun. order date . 04/06/25 . [urinary] catheter care every shift (QS) . order date . 04/06/25 . change [urinary] catheter every (q) month one time a day every 1 month(s) starting on the 6th for 1 day(s) . order date . 04/06/25 . Resident 69's Care Plan (CP), dated 5/1/25 was reviewed. The CP indicated, . presence of indwelling catheter . date initiated: 04/28/25 . created on: 04/28/25 . [urinary] cath bag change q week . date initiated: 04/28/25 . [urinary] catheter care QS . dated initiated 04/28/25 . LVN 2 stated Resident 69 should have had a care plan for urinary catheter care when it was placed so all staff would have known how care for the catheter should have been done. During a concurrent observation and interview on 4/28/25 at 12:31 p.m. with Resident 204 in Resident 204's room, Resident 204 was observed in bed wearing a gown, with a Fall risk band and Allergy band on resident's wrists, head of bed elevated, moaning in pain. Resident 204 stated his catheter bag was bothering him. Observed Resident 204's catheter bag on the floor with no dignity cover. During a review of Resident 204's AR, dated 5/1/25, the AR indicated Resident 204 was admitted to the facility from an acute care hospital on 4/22/25 with diagnoses of difficulty walking, spinal stenosis (a narrowing of the spine that causes pressure on the spinal cord and nerves and can cause pain), DiGeorge syndrome (a genetic condition caused by a missing piece of chromosome 22 which can cause heart defects and learning difficulties), dysphagia (difficulty swallowing) and urinary incontinence (inability to control urination). During a review of Resident 204's MDS, dated [DATE], the MDS section C indicated Resident 204 had a BIMS score of nine which suggested Resident 204 was moderately impaired. During a concurrent interview and record review on 5/01/25 at 11:54 a.m. with LVN 2, Resident 204's Physician Order Summary Report, dated 5/1/25 was reviewed. The Physician Order Summary Report indicated, . [urinary] catheter care QS every shift . order date . 4/23/25 . Resident 204's CP, dated 5/1/25 indicated no care plan for catheter care was developed. LVN 2 stated residents with a urinary catheter should have had a care plan so all staff would have known how care should have been provided. During a concurrent observation and interview on 4/29/25 at 9:09 a.m. with Resident 209 in Resident 209's room, Resident 209 was observed dressed, lying in bed with the head of his bed elevated, wearing an O2 nasal cannula set at a rate of 2.5L/min. Resident 209 stated had had been at the facility for two weeks. Resident 209 stated he had chest tubes (a hollow, flexible tube placed into the chest to drain blood, fluid, or air from around the lungs or heart) placed while he was in the hospital and was now on O2, mostly at night. During a review of Resident 209's AR, dated 5/1/25, the AR indicated Resident 209 was admitted to the facility from an acute care hospital on 4/14/25 with diagnoses of acquired loss of limb (surgical removal of finger, toe, hand, foot, arm or leg) below the knee, osteomyelitis (infection [the invasion and growth of germs in the body] in the bone), end stage renal disease (a condition where the kidneys can no longer function on their own and dialysis or kidney transplant is required to survive), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), and Pleural Effusion (a buildup of fluid between the tissues that line the lungs and the chest). During a review of Resident 209's MDS, dated [DATE], the MDS section C indicated Resident 209 had a BIMS score of 14, which indicated Resident 209 was cognitively intact. During a concurrent interview and record review on 5/01/25 at 1:00 p.m. with LVN 2, Resident 209's order Summary Report, dated 5/1/25 was reviewed. Resident 209's Order Summary Report indicated no order for hemodialysis catheter monitoring was found in Resident 209's chart. Resident 209's CP, dated 5/1/25 was reviewed. The CP indicated, . the resident needs dialysis hemo r/t renal failure . date initiated: 4/28/25 . LVN 2 stated Resident 209 had been on dialysis since 4/16/25. LVN 2 stated Resident 209 should have had a care plan for catheter care since starting dialysis. LVN 2 stated Resident 209's CP was important for Resident 209's dialysis catheter so staff would have watched for signs and symptoms of infection and bleeding. During a concurrent observation and interview on 4/29/25 at 10:36 a.m. with Resident 212 in Resident 212's room, Resident 212 was observed dressed sitting on the side of his bed, watching TV. Resident 212 stated he had a wound vacuum (wound vac - a device to remover pressure over the area of a wound to help with wound healing) device on his right lower leg, and chest. Resident 212 stated he had been at the facility for one week. Resident 212 stated he had a PICC line in his right arm and had a history of drug use and MRSA (Methicillin Resistant Staphylococcus Aureus - a bacteria that does not get better with the type of antibiotics [a medication that inhibits or destroys infections caused by bacteria] that usually cure staph infections). Resident 212 stated he was on antibiotics and could not be discharged with a PICC line due to his history of drug use. Right arm PICC line observed with dressing clean, dry, intact and dated. Resident 212 stated he had a two- and one-half-inch hole in his chest and cellulitis (a deep infection of the skin caused by bacteria) in his right lower leg. Observed chest wound with wound vac cover over hole. Observed left arm in a cast (a protective shell of fiberglass, plastic, or plaster, and bandage that is molded to protect broken or fractured limb(s) as it heals). Resident 212 stated he was in a car accident on 3/28/25 and broke his hand and right ankle. Resident 212 stated staff wore a gown and gloves when they changed his dressings. Observed vape pens (battery-operated vaping device that heats a liquid until it becomes an aerosol [mist], which is inhaled) on Resident 212's bedside table. Resident 212 stated he goes outside two to three times a day to vape with no supervision. During a review of Resident 212's AR, dated 5/1/25, the AR indicated Resident 212 was admitted to the facility from an acute care hospital on 4/19/25 with diagnoses of cellulitis of right lower limb, cellulitis of chest wall, type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), Methicillin Resistant Staphylococcus Aureus infection, and fracture of shaft of right fibula (a break in the lower leg bone from below the knee to the outside of the ankle). During a review of Resident 212's MDS, dated [DATE], the MDS section C indicated Resident 212 had a BIMS score of 15 which indicated Resident 212 was cognitively intact. During concurrent interview and record review on 5/01/25 at 1:05 p.m. with LVN 2, Resident 212's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated, . change intravenous (IV- into or within a vein) extension set and injection cap q week every night shift every Sun with IV site dressing change . order date 4/19/25 .change IV site transparent dressing q week, measure external length of catheter every night shift every Sun . order date 4/19/25 . Resident 212's CP, dated 5/1/25, the CP indicated, .[NAME] is at risk for health hazards r/t continuous use of nicotine (Vape Pen) . date initiated 4/28/25 . active infection: MRSA wound . date initiated: 4/30/25 .educate resident/representative on infection control practices . date initiated: 4/30/25 . No care plan for Resident 212's PICC line care was found in Resident 212's chart. LVN 2 stated Resident 212 should have had a CP for PICC line care to watch for signs and symptoms of infection and bleeding. LVN 2 stated Resident 212 should have had his CP for MERSA infection and vape pen use on admission for resident's safety. 3. During a concurrent observation and interview on 4/28/25 at 12:20 p.m. with Resident 203, in Resident 203's room, Resident 203 was observed dressed, lying in bed, right and left head rails up, with no padding on the bed rails, eating her meal. Resident 203 stated she had been at the facility long enough. Resident 203's Mother (RP 1) and husband (RP 2) were sitting in chairs on both sides of Resident 203's bed. RP 1 stated Resident 203 had lots of confusion since 4/21/25. RP 1 stated Resident 203 had a seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness] disorder), muscle weakness, and hit her head. RP 1 stated Resident 203 had a brain bleed. Resident 203 stated she was doing good, and staff were ok with her physical therapy treatment. RP 1 stated Resident 203 had a 50/50 chance of getting better. During a review of Resident 203's AR, dated 5/1/25, the AR indicated Resident 203 was admitted to the facility from an acute care hospital on 4/21/25 with diagnoses of traumatic subdural hemorrhage (bleeding in the area between the brain and the skull), contusion (bruising) and laceration (cut) of cerebrum (the part of the brain in the front area of the skull), difficulty walking, dysphagia (difficulty swallowing), cognitive communication deficit (difficulty with thinking and how someone uses language), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), alcohol use, and cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged). During a review of Resident 203's MDS, dated [DATE], the MDS section C indicated Resident 203 had a BIMS score of 3, which suggested Resident 203 was severely cognitively impaired. During a concurrent interview and record review on 5/01/25 at 12:05 p.m. with LVN 2, Resident 203's CP. Dated 5/1/25 was reviewed. The CP indicated, . the resident has potential impairment to skin integrity related to (r/t) current physical level . date initiated: 04/25/25 . pad bed rails, wheelchair arms or any other source of potential injury if possible . date initiated: 04/25/25 . the resident has a seizure disorder r/t disease process (epilepsy) date initiated 4/30/25 . the resident will remain free from injury related to seizure activity . date initiated 4/30/25 . seizure precautions . protect from injury . Resident 203's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated . levetiracetam . give 1 tablet by mouth two times a day for seizure for 30 days . order date . 4/21/25 . no orders for monitoring were reviewed. LVN 2 stated seizure residents were monitored for seizure activity and to make sure they were safe. LVN 2 stated Resident 203's CP should have been followed for padding the bed rails and arm rests of her wheelchair. LVN 2 stated whoever put in Resident 203's CP should have notified staff. LVN 2 stated nurses should have passed the information to other staff during reports if there were changes to the resident's CP or to the resident. During a concurrent observation and interview on 5/01/25 at 1:50 p.m. with CNA 7 in Resident 203's room, Resident 203 was observed dressed, sitting on top of her bed, watching television (TV). No bed rail padding was observed on Resident 203's bed rails. CNA 7 was the Sitter, watching the residents. CNA 7 stated she was not aware if padding on bed rails was necessary for residents with a seizure diagnosis. During an interview on 5/06/25 at 11:33 a.m. with the DON, the DON stated for seizure precautions, they tried and keep resident's beds low to the ground, in a low position. The DON stated the facility did not have full bed rail pads, but only the small ones for the bed's head rails. The DON stated she was not sure if residents with seizures needed bed rail padding. 4. During a concurrent observation and interview on 4/28/25 at 3:34 p.m. in Resident 206 in Resident 206's room, Resident 206 was observed dressed in a gown wearing non-slid socks, and wearing her oxygen (O2) nasal cannula set at a rate of 2.5 Liters per minute (L/min - a unit of measurement), sitting in her wheelchair watching TV. Resident 206 stated she had been at the facility for one day. Resident 206 did not want to state why she was at the facility, but stated staff was taking good care of her. During a review of Resident 206's AR, dated 5/1/25, the AR indicated Resident 206 was admitted to the facility from an acute care hospital on 4/22/25 with diagnoses of metabolic encephalopathy (a condition where brain function is disturbed due to different diseases or toxins [poisons] in the blood), respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), dysphagia (difficulty swallowing), and difficulty walking. During a review of Resident 206's MDS, dated [DATE], the MDS section C indicated Resident 206 had a BIMS score of five, which suggested Resident 206 was severely impaired. During a concurrent interview and record review on 5/1/25 with LVN 2, Resident 206's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated there were no physician orders for Resident 206's oxygen use. During a review of Resident 206's Baseline Care Plan dated 4/22/25 indicated . Health Conditions/Special Treatments . Oxygen therapy - while a resident . Resident 206's CP, dated 5/1/25 indicated no care plan for oxygen therapy was found in Resident's 206's CP. LVN 2 stated Resident 206 should have had a care plan and physician's order for oxygen use. LVN 2 stated a physician's order was important as oxygen was part of medications and treatment which required an physician's order. LVN 2 stated the CP was needed for staff to know how to provide oxygen (O2) care, change O2 nasal cannulas and clean the O2 concentrator. LVN 2 stated every care plan was specific to the residents relating to their care. LVN 2 stated if there was no care plan for oxygen use, the CP was not individualized to the resident's needs. During a concurrent observation and interview on 4/28/25 at 3:09 p.m. with Resident 208 in Resident 208's room, Resident 208 was observed sitting in bed, dressed, wearing an O2 nasal cannula with her O2 rate set at 2.5 L/min. Resident's son, FM 2 was present in the room. Resident 208 stated staff were respectful, and she was receiving physical therapy (PT). Besides the food not being good, Resident 208 had no other complaints or concerns. During a review of Resident 208's AR, dated 5/1/25, the AR indicated Resident 208 was admitted to the facility from an acute care hospital on 4/5/25 with diagnoses of myocardial infarction (a medical emergency when one or more areas of the heart muscle do not get enough blood flow and oxygen and begins to die), respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), Congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), and depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life). During a review of Resident 208's MDS, dated [DATE], the MDS section C indicated Resident 208 had a BIMS score of 15, which indicated Resident 208 was cognitively intact. During a concurrent interview and record review on 5/01/25 at 12:53 p.m. with LVN 2, Resident 208's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated there were no physician orders for Resident 208's O2 use. Resident 208's CP, dated 5/1/25 was reviewed. The CP indicated there was no care plan for Resident 208's O2 use. LVN 2 stated Resident 208 did not have physician orders, or a CP for O2 use. LVN 2 stated Resident 208 should have had orders, and a CP for O2 use. LVN 2 stated the physician's order was important for O2 use as it was part of Resident 208's medications and treatment, which required a physician's order. LVN 2 stated a CP was needed to know how to provide O2 care, change the O2 nasal cannula, and clean the O2 concentrator. LVN 2 stated every care plan was specific to the residents relating to their care. LVN 2 stated if there was no care plan for Resident 208's need, then it was not individualized to the resident. During a concurrent observation and interview on 4/29/25 at 9:09 a.m. with Resident 209 in Resident 209's room, Resident 209 was observed dressed, lying in bed with the head of his bed elevated, wearing an O2 nasal cannula set at a rate of 2.5L/min. Resident 209 stated had had been at the facility for two weeks. Resident 209 stated he had chest tubes (a hollow, flexible tube placed into the chest to drain blood, fluid, or air from around the lungs or heart) placed while he was in the hospital and was now on O2, mostly at night. During a review of Resident 209's AR, dated 5/1/25, the AR indicated Resident 209 was admitted to the facility from an acute care hospital on 4/14/25 with diagnoses of acquired loss of limb (surgical removal of finger, toe, hand, foot, arm or leg) below the knee, osteomyelitis (infection [the invasion and growth of germs in the body] in the bone), end stage renal disease (a condition where the kidneys can no longer function on their own and dialysis [a process of removing excess water, and waste products from the blood] or kidney transplant is required to survive), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), and Pleural Effusion (a buildup of fluid between the tissues that line the lungs and the chest). During a review of Resident 209's MDS, dated [DATE], the MDS section C indicated Resident 209 had a BIMS score of 14, which indicated Resident 209 was cognitively intact. During a concurrent interview and record review on 5/01/25 at 1:00 p.m. with LVN 2, Resident 209's order Summary Report, dated 5/1/25 was reviewed. Resident 209's Order Summary Report indicated, . continuous O2 at 2-3 liters per minute (LPM) via nasal cannula (NC) to keep O2 saturation (sats) greater than (>) 90 percent (%) . order date 4/14/25 . Resident 209's CP, dated 5/1/25 was reviewed. Resident 209's CP indicated there was no care plan for Resident 209's O2 use. LVN 2 stated Resident 209 should have had a care plan for O2 use. LVN 2 stated the CP was needed for staff to know how to provide O2 care, change O2 cannulas and clean the O2 concentrator. The LVN stated every care plan was specific to the residents relating to their care. LVN 2 stated if there was no care plan for O2 use, the CP was not individualized to the resident's needs. During an interview on 4/30/25 at 11:10 a.m. with the Infection Preventionist (IP), the IP stated there should have been a physician's order and care plan for residents who used oxygen. The IP stated the order and care plan should have been put into the resident's chart as soon as the resident was admitted . The IP stated if there was no order for O2 use, there was a risk of harm to residents if the resident needed O2 and it was not given because there was no physician's order. The IP stated the it was important to have a care plan to know how to care for the residents. During an interview on 5/02/25 at 2:52 p.m. with the Assistant Director of Nursing (ADON), the ADON stated residents on oxygen needed a physician's order and a care plan for oxygen use. The ADON stated a physician's order would have shown the resident needed the medication and let the nurses know to give the resident oxygen. The ADON stated a care plan showed how to monitor, follow up, give continuous care, or discontinue the treatment. The ADON stated if there was no order the nurse could have missed giving the medication and oxygen was considered a medication. The ADON stated staff would not have monitored the effectiveness of the treatment, known the reason for the treatment, what to do to make the treatment better, and if the treatment was effective or not if there was no individualized care plan for the residents. During a review of Resident 7's Admission Record (AR- document containing resident personal information), dated 4/30/25, the AR indicated, Resident 7 was admitted to the facility on [DATE], with diagnoses which in included chronic obstructive pulmonary disease (lung diseases that cause airflow obstruction and breathing problems), dyspnea (shortness of breath), [NAME] syndrome (immune system attacks moisture producing glands in the body), and anxiety (mental health disorder characterized by excessive and persistent worry and unease). During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/23/25, the MDS assessment indicated Resident 7's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 14 out of 15 which indicated Resident 7 had no cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). The MDS assessment indicated Resident 7's Functional Abilities had impairment on both sides of her upper extremities. During a concurrent observation and interview on 4/28/25 at 2:57 p.m. with Resident 7 in Resident 7's room, Resident 7 was observed in bed with her nasal cannula tubing (flexible, clear tube that connects to an oxygen source) tied to the bed rail. Resident 7 stated she wore her oxygen at night or as needed. Resident 7 stated she relied on facility staff to assist her with activities of daily living (everyday self-care tasks necessary for independent living). During a concurrent interview and record review on 4/28/25 at 3:51 p.m. with Licensed Vocational Nurse (LVN) 17, Resident 7's Care Plan, dated 4/28/25 were reviewed. LVN 17 stated she was Resident 7's nurse. LVN 17 stated Resident 7 wore her oxygen at night or as needed. LVN 17 stated she could not locate an oxygen care plan to reflect Resident 7's oxygen use and requirements. LVN 17 stated it was important Resident 7's care plan reflected her oxygen use and requirements to ensure she received the correct treatment from everyone on her care team. During an interview on 4/28/25 at 4:31 p.m. with the Respiratory Therapist (RT), the RT stated she was familiar with Resident 7's oxygen use and requirements. The RT stated Resident 7 wore oxygen at night and as needed. The RT stated Resident 7 did not have a care plan to reflect her oxygen use and requirements. The RT stated all staff were responsible to ensure care plans reflected resident oxygen use and requirements. The RT stated it was important Resident 7 had a care plan to indicate she wore oxygen at night and as needed to ensure her oxygen was administered and monitored as prescribed. During an interview on 5/1/25 at 10:55 a.m. with the Director of Nursing (DON), the DON stated oxygen use and requirements were expected to be care planned. The DON stated all staff were responsible to ensure Resident 7's care plan reflected her oxygen use and requirements. The DON stated it was important Resident 7's care plan included her oxygen use and requirements to ensure Resident 7 received her oxygen as prescribed by the physician. The DON stated care plan's ensured monitoring of treatments, interventions and goals were in place. The DON stated Resident 7 was at risk for not receiving her oxygen medication as ordered without a care plan in place. The DON stated not receiving oxygen as ordered could lead to serious medical condition. During a review of Resident 7's Care Plan, dated 4/30/25, the Care Plan indicated, Resident [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure daily nurse staffing information contained all required information when the total number and actual hours worked by Registered Nurses (RN), Licensed Vocational Nurses (LVN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) were not separated for 169 residents and visitors to view. This failure resulted in 169 residents and visitors not knowing how many direct care hours were provided daily for each resident by licensed and unlicensed staff. Findings: During an observation on 4/28/25 at 11:15 a.m. the facility's document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 4/28/25, was observed posted in the hallway. The document did not contain all required information when the total number worked by RNs and LVNs/LPNs hours were not separated. During an observation on 5/1/25 at 10:35 a.m. the facility's document titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 5/1/25, the document was observed posted in the hallway. The document did not contain all required information when the total number worked by RNs and LVNs/LPNs hours were not separated. During a concurrent interview and record review on 5/2/25 at 3:02 p.m. with the Director of Staff Development (DSD) and the Human Recourses (HR), the facility's documents titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 4/28/25-5/2/25 were reviewed. The DSD and the HR stated they were responsible for the posted daily nurse staffing information. The DSD stated she was responsible to calculate the scheduled CNA DHPPD hours. The HR stated he was responsible to calculate the actual CNA DHPPD hours. The DSD stated the Director of Nursing (DON) was responsible for licensed nursing staff hours and signed the document for accuracy when it was completed. The document indicated scheduled CNA DHPPD hours and actual CNA DHPPD hours. The DSD and the HR could not identify or state the scheduled number and actual hours worked by RNs. The DSD and the HR could not identify or state the scheduled number and actual hours worked by LVNs/LPNs. The DSD stated it was important residents and visitors were aware of staffing numbers. The DSD stated residents and visitors had a right to know how many direct care hours were provided per patient per day by licensed nursing staff. The DSD stated residents and visitors could not identify how many licensed nursing direct care hours were scheduled or provided per patient per day on the documents. During a concurrent interview and record review on 5/2/25 at 4:20 p.m. with the DON, the facility's documents titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 4/28/25-5/2/25 were reviewed. The DON could not identify or state the scheduled number and actual hours worked by RNs or LVNs/LPNs. The DON stated to determine the scheduled number and actual hours worked by RNs or LVNs/LPNs residents or visitors would need to perform a calculation to determine the DHPPD hours for licensed staff. During a concurrent interview and record review on 5/2/25 at 4:27 p.m. with the Administrator (ADM), the facility's documents titled, Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 4/28/25-5/2/25 were reviewed. The ADM could not identify or state the scheduled number and actual hours worked by RNs or LVNs/LPNs. The ADM stated it was important licensed and unlicensed nursing staff hours were separated so residents and visitors were aware of how many hands-on hours were being provided by licensed and unlicensed staff to them each day. During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, dated 8/2022, the P&P indicated, .direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift .

Based on observation, interview, and record review the facility failed to ensure the garbage was disposed of properly for 159 of 169 residents who received food from the kitchen when one gray plastic container and four beige dumpsters were found uncovered with brown cardboard boxes and clear, white and black plastic bags stacked higher than the container rim. This failure had the potential to attract or harbor pests which could increase the risk of cross contamination (the unintentional transfer of harmful bacteria or other contaminants from one food, surface, or object to another, often leading to foodborne illnesses and the growth of microorganisms). Finding: During a concurrent observation and interview on 4/28/25 at 10:11 a.m. with the Maintenance Director (MAIN) outside of the kitchen at the dumpsters, one gray plastic container and four beige dumpsters were found uncovered with brown cardboard boxes and clear, white and black plastic bags stacked higher than the container rim. The MAIN stated the dumpsters were emptied daily except on Sunday. The MAIN stated the service must be running late as they usually arrive between 8:00 a.m. and 9:00 a.m. The MAIN stated the dumpster lids should be always closed to keep rodents out and prevent the spread of infection. The MAIN stated if the lids were not kept closed it could create an odor which was not homelike, and the residents could pull out trash which could create an infection risk or cross contamination issue. During an interview on 4/30/25 at 2:37 p.m. with the Assistant Certified Dietary Manager (ACDM), the ACDM stated garbage lids should always be covered to reduce pests and rodents. The ACDM stated the risk of having uncovered garbage lids could lead to the attraction of rodents and pests. During an interview on 5/1/25 at 12:36 p.m. with the Infection Control Nurse (IP), the IP stated garbage lids should be closed to ensure nothing is touching the lid. The IP stated if the lid is not closed, there would be a risk of cross contamination as residents would have access to the trash. During an interview on 5/2/25 at 3:19 p.m. with the Director of Nursing (DON), the DON stated the garbage should be taken out and disposed of in the garbage bins with lids closed. The DON stated the lids should be closed to prevent things from getting in and prevent attracting pests. The DON stated the reason the garbage was not covered was the service came late on Monday and the facility does not have garbage service on Sunday. The DON stated the facility did not follow their garbage policy and procedure P&P. During a concurrent interview and record review on 5/2/25 at 3:42 p.m. with the Administrator (ADM) in his office, the facility P&P titled Food-Related Garbage and Refused Disposal dated 10/2017 was reviewed. The P&P indicated .5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests .7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter . The ADM stated the garbage was overflowing and the facility may have had more garbage last week. The ADM stated the garbage lids should have been closed. The ADM stated the facility did not follow their P&P. During a review of the facility's Job Description (JD): Administrator, dated 3/1/14, the JD indicated obtain outside resources to provide services 'under arrangement' when required services cannot be provided by facility staff. Negotiate contract terms and supervise the provision of services to ensure they are of acceptable quality and meet the needs of residents and the facility. Review P&P developed by every department to ensure consistency with .compliance with federal laws and regulations, as applicable, and to allocate sufficient resources to implement the policies . During a review of the facility's JD: Maintenance Director (MAIN), dated 3/1/14, the JD indicated the MAIN is responsible to maintain the facility is in good repair at all times .Ensure that the exterior of the building is in good repair, including clean garbage cans and refuse area . During a review of professional reference review retrieved from https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.141#:~:text=Waste%20disposal.&text=Any%20receptacle%20used%20for%20putrescible,regard%20to%20the%20aforementioned%20requirements.&text=All%20sweepings%2C%20solid%20or%20liquid,employment%20in%20a%20sanitary%20condition. OSHA.gov, an article titled 1910.141 (a)(4) Waste Disposal, dated 6/8/11, the article indicated 1910.141 (a)(4)(i) Any receptable used for .refuse shall be so constructed that it does not leak and may be thoroughly cleaned and maintained in a sanitary condition. Such a receptable shall be equipped with a solid tight-fitting cover .1910.141 (a)(4)(ii) All .refuse, and garbage shall be removed in such a manner as to avoid creating a menace to health and as often as necessary or appropriate to maintain the place of employment in a sanitary condition.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections when: 1. Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission of infections) were not implement for (Resident 10, 16, 20, 21, 33, 36, 42, 44, 58, 67, 69, 74,76, 78, 100, 102, 106, 120, 121, 122, 124, 131, 205, 209, and 353) indwelling medical devices (medical devices inserted into the body and left in place for a period of time) and pressure injuries (bedsores or pressure ulcers-localized skin and tissue damage caused by prolonged pressure, often over bony areas). This resulted in ineffective isolation precautions being implemented and had the potential to result in the transmission of infections and pathogens which could lead to infections, hospitalization s or death. 2. Resident 204's urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bag was laying on the floor. This failure had the potential to put Resident 204 at risk of infection in his bladder due to cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) from the catheter bag and tubing becoming contaminated. Findings: 1. During a concurrent observation and interview on 4/28/25 at 4:29 p.m. in Resident 78's room, Resident 78 had an indwelling medical device to the right upper arm. Resident 78 stated staff would sometimes wear personal protective equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when providing care for him. EBP signage was not posted, and PPE was not available outside the room. During a review of Resident 78 s Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 78 was admitted to the facility on [DATE] with diagnoses: heart failure (HF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type 2 diabetes mellitus (DM2- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), orthopedic (focusing on wound care, pain management, physical therapy, and lifestyle adjustments to promote healing and recovery) aftercare, pressure ulcer (localized areas of tissue damage caused by prolonged pressure on the skin), sepsis (a life-threatening condition that arises when the body's response to an infection damages vital organs). During a review of Resident 78's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 4/19/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 78 had no cognitive impairment. During a review of Resident 78's Order Summary titled, [Facility Name] Order Summary Report (OSR) dated 5/1/25 the OSR indicated, Sodium Chloride Flush: use 10 ml [milliliter-unit of measurement] intravenously (a way of giving drug or other substance through a needle or tube inserted into the vein) . During an observation on 4/28/25 at 2:59 p.m. in Resident 106's room, Resident 106 had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine) and peripherally inserted central catheter (PICC - long, thin, flexible tube inserted into a vein in the arm and threaded to a larger vein near the heart) was to the right upper arm. EBP signage was not posted outside the door and PPE was not available outside the room. During a review of Resident 106 s Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 106 was admitted to the facility on [DATE] with diagnoses: encephalopathy ( any disorder or disease of the brain that impairs its normal function, leading to a change in mental state), sepsis (a life-threatening condition that occurs when the body's response to an infection damages its own tissues and organs), bacteremia (the presence of bacteria in the bloodstream), hydronephrosis (a condition where the kidneys swell due to a buildup of urine) and hypertension (high blood pressure). During a review of Resident 106's Minimum Data (Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/30/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 106 had no cognitive impairment. During a review of Resident 106's Order Summary Report (ORS), dated 5/1/25, the ORS indicated, .[column]indwelling catheter: insert/change indwelling catheter .[column]order date:3/25/25 .[column]change IV [intravenous-within the vein] extension set and injection cap q[every] week . 51059 During a review of Resident 100's Admission Record (AR- document containing resident personal information), dated 4/30/25, the AR indicated, Resident 100 was admitted to the facility on [DATE], with diagnoses which in included dysphagia (difficulty swallowing), cerebral infarction (death of brain tissue due to a lack of blood and oxygen), gastrostomy status (a feeding tube inserted directly into the stomach through the abdominal wall), and aphasia (difficulty speaking). During a review of Resident 100's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/4/25, the MDS assessment indicated Resident 100's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 4 out of 15 which indicated Resident 100 had severe cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a review of Resident 100's Order Summary Report, dated 5/6/25, the Order Summary Report indicated, Resident 100 had a gastrostomy tube (a feeding tube inserted directly into the stomach through the abdominal wall). During a review of Resident 120's Admission Record (AR- document containing resident personal information), dated 4/30/25, the AR indicated, Resident 120 was admitted to the facility on [DATE], with diagnoses which in included dysphagia (difficulty swallowing), gastrostomy status (a feeding tube inserted directly into the stomach through the abdominal wall), and aphasia (difficulty speaking). During a review of Resident 120's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 4/15/25, the MDS assessment indicated Resident 120's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 99 out of 15 which indicated Resident 120 was unable to complete the assessment. During a review of Resident 120's Order Summary Report, dated 5/6/25, the Order Summary Report indicated, Resident 120 had a gastrostomy tube. During a review of Resident 121's Admission Record (AR- document containing resident personal information), dated 4/30/25, the AR indicated, Resident 121 was admitted to the facility on [DATE], with diagnoses which in included dysphagia (difficulty swallowing), cognitive communication deficit (trouble speaking), and hypertension (high blood pressure). During a review of Resident 121's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 3/31/25, the MDS assessment indicated Resident 121's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 12 out of 15 which indicated Resident 121 had moderate cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a review of Resident 121's Order Summary Report, dated 5/6/25, the Order Summary Report indicated, Resident 121 had a gastrostomy tube. During a review of Resident 124's Admission Record (AR- document containing resident personal information), dated 4/30/25, the AR indicated, Resident 124 was admitted to the facility on [DATE], with diagnoses which in included liver cell carcinoma (liver cancer), chronic viral hepatitis C (long term infection of the liver), and palliative care (medical care that focuses on providing pain relief and other symptoms of a serious illness). During a review of Resident 124's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 4/14/25, the MDS assessment indicated Resident 124's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 14 out of 15 which indicated Resident 124 had severe cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a review of Resident 124's Order Summary Report, dated 5/6/25, the Order Summary Report indicated, Resident 124 had .MRSA [Methicillin-resistant Staphylococcus aureus is a multidrug resistant organism that is resistant to antibiotics] -open wound of left hip . stage 4 pressure injury to coccyx. During an observation on 4/28/25 at 2:15 p.m. in Resident 100's room, the doorway leading into Resident 100's room was observed with no EBP or contact isolation signage or personal protective equipment (PPE). Resident 100 was observed lying in bed with continuous tube feed being administered via gastrostomy tube. Inside Resident 100's room no EBP or contact isolation signage or PPE was observed. During an observation on 4/28/25 at 2:27 p.m. in Resident 120's room, the doorway leading into Resident 120's room was observed with no EBP or contact isolation signage or PPE. Resident 120 was observed lying in bed with continuous tube feed being administered via gastrostomy tube. Inside Resident 120's room no EBP or contact isolation signage or PPE was observed. During a concurrent observation and interview on 4/28/25 at 2:33 p.m. with Licensed Vocational Nurse (LVN) 3 in Resident 120's room, LVN 3 entered the room with no PPE. LVN 3 stated she heard the tube feeding machine beeping from the hallway and came in to check it. LVN 3 touched Resident 120's tube feeding pump and tube feeding tubing with no gloves or gown. During an observation on 4/28/25 at 3:11 p.m. in Resident 121's room, the doorway leading into Resident 121's room was observed with no EBP or contact isolation signage or PPE. Resident 121 was observed lying in bed with continuous tube feed being administered via gastrostomy tube. Inside Resident 121's room no EBP or contact isolation signage or PPE was observed. During a concurrent observation and interview on 4/28/25 at 3: 21 p.m. with Resident 124 in Resident 124's room, the doorway leading into Resident 124's room was observed with no EBP or contact isolation signage or PPE. Resident 124 was observed lying in bed. Resident 124 stated he was admitted to the facility with an open wound to the left hip that would not heal. Resident 124 stated he had an open wound to his coccyx. Resident 124 stated the facility and hospice provided wound care. Inside Resident 124's room no EBP or contact isolation signage or PPE was observed. During a concurrent observation and interview on 4/30/25 at 11:29 a.m. with Registered Nurse (RN) 1, in Resident 124's room, RN 1 performed wound care on Resident 124. RN 1 stated all staff needed to wear gown and gloves when providing direct patient care to residents with indwelling lines or wounds to prevent the introduction and spread of infection. 51134 During an observation on 4/29/25 at 4:47 p.m. at Resident 10 ' s room, observed Resident 10 in the room asleep with indwelling foley catheter (also known as urinary catheter, a hallow tube inserted into the bladder to drain or collect urine) in place. Did not observe an enhanced barrier precaution (an infection control intervention designed to reduce transmission of infections and include the use of personal protective equipment, specifically gowns and gloves, during high-contact resident care activities) sign in place in the room. During a review of Resident 10 ' s Admission Record (AR) dated 5/6/25, the AR indicated Resident 10 was admitted into the facility on [DATE]. During a review of Resident 10 ' s Minimum Date Set (MDS- a resident assessment tool) dated 2/17/25, the MDS Section C (section that reviews a resident ' s cognitive pattern), the Brief Interview for Menal Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was a 15 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact) indicating Resident 10 was cognitively intact. During a review of Resident 10 ' s Care Plan (CP) Report dated 4/30/25, the CP Report indicated, Focus: Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: urinary catheter. Date initiated: 04/30/2025 . During an observation on 4/29/25 at 9:50 a.m. in Resident 10 ' s room, observed Resident 10 ' s indwelling foley catheter in place. Did not observe an enhanced barrier precaution sign at Resident 10 ' s door. During an observation on 4/30/25 at 9:42 a.m. in Resident 10 ' s room, did not observe an enhanced barrier precaution sign in place. During a review of Resident 20 ' s Admission Record (AR) dated 5/2/25, the AR indicated Resident 10 was admitted into the facility on [DATE]. During a review of Resident 20 ' s CP Report dated 4/30/25, the CP Report indicated, Focus: Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: Indwelling catheter. Date initiated: 04/30/2025 . During an observation on 4/29/25 at 9:38 a.m. at Resident 21 ' s room, did not observe an enhanced barrier precaution sign in place. During a review of Resident 21 ' s AR dated 5/6/25, the AR indicated Resident 21 was admitted into the facility on [DATE]. During a review of Resident 21 ' s MDS dated [DATE], the MDS Section C indicated Resident 21 ' s BIMS score was a 3 out of 15 indicating Resident 21 had severe cognitive impairment. During a review of Resident 21 ' s CP Report dated 4/30/25, the CP Report indicated, Focus: Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: pressure ulcer [localized damage to the skin and/or underlying tissue usually over a bony prominence]. Date initiated: 04/30/2025 . During an observation on 4/29/25 at 2:15 p.m. in Resident 33 ' s room, observed a suprapubic catheter [a tube inserted into the bladder through a small incision in the lower abdomen used to drain urine] in place. Did not observe an enhanced barrier precaution sign in place. During a review of Resident 33 ' s AR dated 5/1/25, the AR indicated Resident 33 was admitted into the facility on [DATE]. During a review of Resident 33 ' s MDS dated [DATE], the MDS Section C indicated Resident 33 ' s BIMS score was a 14 out of 15 indicating Resident 33 was cognitively intact. During an observation on 4/29/25 at 10:47 a.m. at Resident 36 ' s room, did not observe an enhanced barrier precaution sign in place. During a review of Resident 36 ' s AR dated 5/6/25, the AR indicated Resident 36 was admitted into the facility on [DATE]. During a review of Resident 36 ' s MDS dated [DATE], the MDS Section C indicated Resident 36 ' s BIMS score was a 99 indicating Resident 36 was unable to complete the interview. During a review of Resident 36 ' s CP Report dated 4/30/25, the CP Report indicated, Focus: Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: Chronic wound [a wound that fails to heal within the expected timeframe and does not progress through the normal stages of healing]. Date initiated: 05/01/2025 . During an observation on 4/29/25 at 10:27 a.m. at Resident 42 ' s room, did not observe enhanced barrier precaution sign in place. During a review of Resident 42 ' s AR dated 5/1/25, the AR indicated Resident 42 was admitted into the facility on [DATE]. The AR indicated, .Diagnosis Information . Pressure ulcer of other site, stage 3 [full-thickness loss of skin; dead and black tissue may be visible] . pressure ulcer of sacral [sacrum] region, stage 4 [full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone] . pressure ulcer of sacral region, unspecified stage [referred to as unstageable, a pressure ulcer where the physician is unable to definitively determine the stage due to the presence of eschar (thick, dry, leathery layer of dead tissue) or slough (dead, non-viable tissue)] . pressure ulcer of other site, unstageable . pressure ulcer of other site, stage 2 [partial-thickness loss of skin, presenting as a shallow open sore or wound] . During a review of Resident 42 ' s CP Report dated 4/30/25, the CP Report indicated, Focus: Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: urinary catheter and pressure ulcer(s). Date initiated: 04/30/2025 . During an observation on 4/29/25 at 8:44 a.m. at Resident 44 ' s room, did not observe an enhanced barrier precaution sign in place. During a review of Resident 44 ' s AR dated 5/6/25, the AR indicated Resident 44 was admitted into the facility on [DATE]. The AR indicated, Diagnosis Information . Pressure ulcer of right buttock, stage 4 . with an onset date of 9/12/23. During a review of Resident 44 ' s MDS dated [DATE], the MDS Section C indicated Resident 44 ' s BIMS score was a 12 out of 15 indicating Resident 44 had moderate cognitive impairment. During a review of Resident 44 ' s CP Report dated 5/1/25, the CP Report indicated, Focus: Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: Chronic wound. Date initiated: 05/01/2025 . During an observation on 4/29/25 at 9:02 a.m. in Resident 76 ' s room, Resident 76 was receiving care from a certified nursing assistant (CNA). Observed Resident 76 ' s gastrostomy tube (feeding tube inserted directly into the stomach through the abdominal wall). Did not observe an enhanced barrier precaution sign in place. During a review of Resident 76 ' s AR dated 5/1/25, the AR indicated Resident 76 was admitted into the facility on [DATE]. The AR indicated a diagnosis of gastrostomy (a surgical procedure where a tube is inserted into the stomach through a small opening in the abdomen to deliver nutrition and medications) with an onset date of 3/21/22. During a review of Resident 76 ' s MDS dated [DATE], the MDS Section C indicated Resident 76 ' s BIMS score was a 99 indicating Resident 76 was unable to complete the interview. During a review of Resident 76 ' s CP Report dated 4/30/25, the CP Report indicated, Focus: Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: enteral tube [devices used to deliver nutrition, hydration and medications directly into the digestive system when a person cannot eat or drink normally] feeding. Date initiated: 04/30/2025 . During an observation on 4/29/25 at 10:44 a.m. in Resident 97 ' s room, observed a urinary catheter in place. Did not observe enhanced barrier precaution sign in place. During a review of Resident 97 ' s AR dated 5/6/25, the AR indicated Resident 97 was admitted into the facility on [DATE]. During a review of Resident 97 ' s MDS dated [DATE], the MDS Section C indicated Resident 97 ' s BIMS score was a 12 out of 15 indicating Resident 97 had moderate cognitive impairment. During a review of Resident 97 ' s CP Report dated 4/30/25, the CP Report indicated, Focus: Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: urinary catheter. Date initiated: 04/30/2025 . During an observation on 4/29/25 at 1:06 p.m. in Resident 102 ' s room, did not observe an enhanced barrier precaution sign in place. During a review of Resident 102 ' s AR dated 5/6/25, the AR indicated Resident 102 was admitted into the facility on [DATE]. During a review of Resident 102 ' s MDS dated [DATE], the MDS Section C indicated Resident 102 ' s BIMS score was 11 out of 15 indicating Resident 102 had moderate cognitive impairment. During a review of Resident 102 ' s CP Report dated 5/1/25, the CP Report indicated, Focus: Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: Chronic wound. Date initiated: 05/01/2025 . During an observation on 4/29/25 at 10:21 a.m. in Resident 122 ' s room, did not observe an enhanced barrier precaution sign in place. During a review of Resident 122 ' s AR dated 5/6/25, the AR indicated Resident 122 was admitted into the facility on [DATE]. The AR indicated a diagnosis of gastrostomy with an onset date of 7/15/22. During a review of Resident 122 ' s MDS dated [DATE], the MDS Section C indicated Resident 122 ' s BIMS score was 6 out of 15 indicating Resident 122 had severe cognitive impairment. During a review of Resident 122 ' s CP Report dated 4/30/25, the CP Report indicated, Focus: Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: urinary catheter and tube feeding [medical procedure where tube is inserted into the stomach or small intestine to provide nutrition to individuals who cannot or will not eat adequately]. Date initiated: 04/30/2025 . During an observation on 4/29/25 at 9:36 a.m. at Resident 131 ' s room, did not observe an enhanced barrier precaution sign in place. During a review of Resident 131 ' s AR dated 5/6/25, the AR indicated Resident 131 was admitted into the facility on [DATE]. The AR indicated Resident 131 had a diagnosis of pressure ulcer of left heel, stage 4 with an onset date of 2/4/25. During a review of Resident 131 ' s MDS dated [DATE], the MDS Section C indicated Resident 131 ' s BIMS score was a 15 out of 15 indicating Resident 131 was cognitively intact. During a review of Resident 131 ' s CP Report dated 5/1/25, the CP Report indicated, Focus: Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: Chronic wound. Date initiated: 05/01/2025 . During a review of Resident 353 ' s AR dated 5/6/25, the AR indicated Resident 353 was admitted into the facility on [DATE]. During a review of Resident 353 ' s MDS dated [DATE], the MDS Section C indicated Resident 353 ' s BIMS score was 99 indicating Resident 353 was unable to complete the interview. During an observation on 4/29/25 at 9:53 a.m. in Resident 353 ' s room, did not observe an enhanced barrier precaution sign in place. During a review of Resident 353 ' s CP Report dated 5/1/25, the CP Report indicated, Focus: Enhanced Barrier Precautions: [history] of MDRO [multidrug resistant organisms that are resistant to many antibiotics]. Date initiated: 05/01/2025 . 51223 During a concurrent observation and interview on 4/28/25 at 2:31 p.m. with Resident 67 in the resident's room, the resident was sitting on her bed with two exposed nephrostomy (a thin catheter placed into your kidney to drain urine) tubes connected to drainage bags. Enhanced Barrier Precaution (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms MDROs in nursing homes) signage was not posted on the door or wall outside of the resident's room and Personal Protective Equipment (PPE- protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission) was not available outside the resident's room. Resident 67 stated her kidneys stopped working and the physician placed nephrostomy tubes. Resident 67 stated that the tubes and drainage bags were exchanged at the hospital every two months. Resident 67 stated she had been hospitalized due to nephrostomy tube/drain complications. During a review of Resident 67's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 67 was admitted to the facility on [DATE] with diagnoses: Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), Heart Failure (HF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Type 2 Diabetes Mellitus (DM2- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), Bladder cancer, nephrostomy, Chronic Kidney Disease (CKD- a condition in which the kidneys are damaged and can't filter blood as well as they should), Anxiety Disorder (differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety), Recurrent Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 67's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 4/21/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 67 had no cognitive impairment. During an observation on 4/28/25 at 3:56 p.m. in Resident 16's room, the resident lay in bed with gastrostomy tube (GT-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding that hung on a bedside pole and a FC bag hung on the bed frame. EBP signage was not posted on the door or wall outside of the resident's room and PPE was not available outside of the resident's room During a review of Resident 16's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 16 was admitted to the facility on [DATE] with diagnoses: Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), Dementia (a progressive state of decline in mental abilities), Heart Failure (HF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Chronic Kidney Disease (CKD- a condition in which the kidneys are damaged and can't filter blood as well as they should), (GT Status, Pressure Ulcer of Sacral Stage 2 (localized partial-thickness loss of skin, presenting as a shallow open sore or wound over the triangular shaped bone at the base of the back). During a review of Resident 16's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 2/8/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 3 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 16 had severe cognitive impairment. During an observation on 4/28/25 at 4:34 p.m. in the Resident 58's room, an uncovered urinary catheter (FC-a device that drains urine (pee) from your urinary bladder into a collection bag outside of your body when you can't pee on your own) bag hung from the bed frame uncovered which displayed clear deep yellow liquid in the bag. EBP signage was not posted on the door or wall outside of the resident's room and PPE was not available outside of the resident's room During a review of Resident 58's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/2/25, the AR indicated Resident 58 was admitted to the facility on [DATE] with diagnoses: Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Type 2 Diabetes Mellitus (DM2- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), Chronic Kidney Disease (CKD- a condition in which the kidneys are damaged and can't filter blood as well as they should), Mood Disorder (a mental health condition that primarily affects your emotional state that can cause persistent and intense sadness, elation and/or anger) Anxiety Disorder (differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety), Recurrent Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 58's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/25/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 8 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 58 had moderate cognitive impairment. 48739 During a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident 69's room, observed no EBP sign on the door of Resident 69's room. Resident 69 was observed lying in bed with the head of his bed raised, being fed by CNA 11 who was standing next to Resident 69 wearing no gown or gloves. A urinary catheter bag hung on the lower bed rail next to CNA 11, with no covering on

During an observation, interview and record review, the facility failed to ensure five out of 22 sampled residents (Resident 20, Resident 353, Resident 112 and Resident 118) had a comfortable and homelike environment when: 1.Resident 20's personal belongings inventory was not updated and was observed wearing Resident 353's shirt and Resident 112's personal belongings were not inventoried. These failures had the potential to result in a loss of Resident 20, Resident 353, and Resident 112's personal belongings. 2. Dining Hall (DH) 1, the only available dining space, was used to store 20 cardboard boxes that contained mattresses and lighting fixtures. This failure resulted in Resident 118 not having access to a comfortable and homelike dining environment which led to Resident 118 feeling like DH 1 was crowded. Findings: 1. During an observation on 4/29/25 at 9:53 a.m. in Resident 353 ' s room, Resident 353 observed lying in bed, wearing personal belongings that included a t-shirt. During a concurrent observation and interview on 4/30/25 at 8:55 a.m. with Licensed Vocational Nurse (LVN) 20 and family member of Resident 20 (FM1) in Resident 20's rooms, observed resident lying in bed with eyes closed, covered with a sheet and wearing a shirt with Resident 353's name on it. LVN 20 confirmed Resident 20 was wearing his roommate's, Resident 353, shirt and stated Resident 20 should not be wearing Resident 353's shirt. LVN 20 stated it important to make sure this does not happen because it can lead to a loss of the a resident's personal belongings. FM1 stated has observed on several occasions Resident 20 Resident 353's shirt and unsure why because Resident 20 has plenty of his own clothes. During a review of Resident 20's Admission Record (AR) dated 5/1/25, the AR indicated Resident 20 was admitted into the facility on [DATE]. During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool) dated 3/25/25, the MDS Section C (section that reviews a resident ' s cognitive pattern), the Brief Interview for Menal Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 99 indicating Resident 20 was unable to complete the interview. During a review of Resident 20's Inventory of Personal Effects dated 12/18/24, the Inventory of Personal Effects indicated Resident 20 did not have personal belongings. During a review of Resident 353's AR dated 5/2/25, the AR indicated Resident 353 was initially admitted into the facility on [DATE]. During a review of Resident 353's MDS dated [DATE], the MDS Section C the BIMS score was a 3 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision-making skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact) indicating Resident 353 had a severe cognitive impairment. During a review of Resident 353's Inventory of Personal Effects dated 10/31/24, the Inventory of Personal Effects indicated, .resident arrived back from acute [hospital] with no belongings. During an interview on 5/1/25 at 7:51 p.m. with FM1, FM1 stated the staff does not complete an updated personal belongings inventory of Resident 20 ' s clothes when FM1 has brought them into the facility. FM 1 stated he does not like when Resident 20's clothes are mixed with other residents and that is why FM1 takes Resident 20's clothes home to wash them and will return them to the facility. During an interview on 5/2/25 at 9:14 a.m. with LVN 7, LVN 7 stated a resident's personal belongings inventory must be completed every time a family member removes a residents' clothes and when family brings in clothes. LVN 7 stated personal belongings inventory should have been updated for Resident 20 and Resident 353. LVN 7 stated it is important to update personal belongings inventory to prevent loss of items. During an interview on 5/2/25 at 9:30 a.m. with Certified Nursing Assistant (CNA) 13, CNA stated when a resident's personal belongings are removed from their room and/or returned, a personal belongings inventory should be completed. CNA 13 stated it is important to complete personal belongings inventory especially for residents who share a room to keep track of a resident ' s items and to ensure items do not get lost. During an interview on 5/2/25 at 2:57 p.m. with LVN 13, LVN 13 stated Resident 20 and Resident 353 are not able to speak for themselves. LVN 13 stated it is important to have personal belongings updated for both residents cannot speak for themselves and staff need to prevent the loss of personal belongings. During a concurrent interview and record review on 5/2/25 at 3:41 p.m. with the Director of Nursing (DON) Resident 20 ' s Inventory of Personal Effects 12/18/24 was reviewed. Resident 20's Inventory of Personal Effects indicated the resident did not have personal belongings. The DON stated this inventory list is not accurate because Resident 20 did have clothes, and the Inventory of Personal Effects stated he does not. The DON stated it is important to update the inventory of personal belongings, so staff know what a resident has and to prevent loss of items. The DON stated Resident 20 should not have been wearing Resident 353's shirt and want to be respectful of the residents ' personal belongings. 49949 During an interview on 4/28/25 at 3:55 p.m. in Resident 112's room, Resident 112 stated she was missing one night gown, one sweatpant, a pair of slippers and socks. Resident 112 stated, I have been in and out of the hospital and they have not updated the inventory list since I have been here. During an interview on 4/30/25 at 2:07 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 the inventory list (document that details all the items should have been done during admission and updated with each re-admission to the facility. CNA 3 stated that an updated inventory list was needed to ensure the residents get their personal items return to them and to keep a record of items. CNA 3 stated the facility was responsible for making sure Resident 112's personal property was protected from theft and loss. CNA 3 stated it was not homelike to have personal items missing or lost. During an interview and record review on 4/30/25 at 2:39 p.m. with LVN 6, LVN 6 stated Resident 112 went out to the hospital on 3/21/25 and return to the facility on [DATE]. LVN 6 stated an inventory list of personal items should have been done each time Resident 112 returned to the facility. LVN 6 stated an inventory list should have been made so Resident 112 to keep a list of items she had in case the items went missing. LVN 6 stated CNAs were responsibility to update the inventory list. LVN 6 stated, the facility was responsibility to protect the resident personal items from theft and loss. LVN 6 stated the facility was the resident's home. LVN 6 stated residents have the right to keep their items from being lost and missing when they were at the facility. LVN 6 stated, missing personal items could have made residents mad, upset, angry and depressed. LVN 6 stated, losing personal items was not a homelike environment. During an interview and record review on 5/2/25 at 11:14 a.m. with the Director of Nursing (DON), the DON stated an inventory list should have been done with each new admission and re-admission. The DON stated CNAs were responsible for inputting the items into the inventory list. The DON stated any staff member could have update the inventory list. The DON stated it was important to update the inventory list to keep record of items in case personal items went missing. The DON stated residents could have been upset or angry and sad when personal items went missing. The DON stated Resident 112 was readmitted on [DATE] and the inventory list should have been updated. The DON stated. It important to make sure we have accurate list of her belongings. The DON stated we did not follow our policy and procedure when the inventory list was not updated. During an interview on 5/6/25 at 11:56 a.m. with the Administrator (ADM), the ADM stated, it was important to update the inventory list to keep track of all personal items. The ADM stated the inventory list kept records of the residents' personal items in case it went missing. The ADM stated residents could have been upset or angry when their personal items went missing. The ADM stated the CNAs should have been updating the inventory list during admission, re-admission and as needed. The ADM stated the inventory list should have been updated when residents brought in more items into the facility. The ADM stated we did not follow our policy when the inventory list was not updated. During a review of Resident 112 s Admission Record (document containing resident demographic information and medical diagnosis) dated 3/24/25, the admission record indicated Resident 112 diagnoses included cellulitis (bacterial infection of the skin and underlying tissues) of left lower limb, hypertension (high blood pressure), difficulty in walking, weakness, and sepsis ( life-threatening condition that arises when the body's response to an infection damages its own tissues and organs). During a review of Resident 112s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/20/25, the MDS, indicated Resident 112's had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 112 was cognitively intact. During a record review of Resident's 112's Census List (CL) dated 5/6/25, the CL indicated, Effective Date: 1/31/2025 .Action Code: Actual Admission .Effective Date: 3/21/25 .Action Code: Transfer out to Hospital .Effective Date:3/24/25 .Action Code: Transfer in from Hospital . During a review of Resident 112's inventory list titled, Inventory of Personal Effects (IPE) dated 1/31/25, the IPE indicated Resident signed and dated the inventory list on 1/31/25 and no other inventory list was provided. During a review of the facility's policy and procedures (P&P) titled, Personal Property dated revision 8/22, the P&P indicated, 1. Residents are permitted to retain and use personal property possession, including furniture and clothing .3. Residents are encourage to use personal belongings to maintain a homelike environment .10.The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary . 51059 2. During a review of Resident 118's Admission Record (AR- document containing resident personal information), dated 4/30/25, the AR indicated, Resident 118 was admitted to the facility on [DATE], with diagnoses which in included hemiplegia and hemiparesis (paralysis and weakness on one side of the body), major depressive disorder (persistent sadness, loss of interest or pleasure), and anxiety disorder (feelings of worry, nervousness or unease). During a review of Resident 118's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 3/24/25, the MDS assessment indicated Resident 118's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 9 out of 15 which indicated Resident 118 had moderate cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a concurrent observation and interview on 4/28/25 at 11:42 a.m. with Resident 118 in Dining Hall (DH) 1, 20 carboard boxes were observed in DH 1. The 20 cardboard boxes were stacked along the entry way in DH 1 and in front of the interior window. The 20 cardboard boxes blocked the interior window and view into the hallway. The boxes were labeled with manufacturer labels, foam mattress, bariatric mattress, and lighting fixture. Resident 18 stated DH 1 was crowded, and it would be nice if there were no boxes in DH 1. Resident 18 stated DH 1 felt like a cafeteria. Resident 118 stated the 20 carboard boxes had been in DH 1 for, as long as I can remember. Resident 118 stated Dining Hall (DH) 2 was being remodeled and not being used. During an interview on 4/30/25 at 2:58 p.m. with the Maintenance Director (MAIN), the MAIN stated the 20 cardboard boxes in DH 1 contained mattress and lighting fixtures. The MAIN stated DH 1 was being used to store mattresses and lighting fixtures temporarily and were planned to be in DH 1 for 1-2 more months. The MAIN stated DH 2 was being remodeled and not in use. MAIN stated the 20 cardboard boxes were previously in outdoor storage, but due to flooding was moved into DH 1. The MAIN could not state how long the 20 cardboard boxes had been stored in DH 1. The MAIN stated he was responsible for the storage of equipment. The MAIN stated DH 1 was not a homelike environment for all residents that dined in DH 1. During an interview on 4/30/25 at 7:33 p.m. with the Registered Dietician (REGD), the REGD stated the 20 cardboard boxes had been in DH 1 for approximately, a couple months. The REGD stated the MAIN was responsible for the storage of equipment within the facility. The REGD stated the 20 cardboard boxes in DH 1 made the environment feel like storage or a cafeteria. The REGD stated DH 1 was not a homelike environment for the residents who dined at the facility. The REGD stated it was important to have a homelike dining environment to promote social dining and increased intake at meals. During an interview on 5/1/25 at 10:55 a.m. with the Director of Nursing (DON), the DON stated DH 1 and DH 2 were being remodeled and could not state how long the 20 cardboard boxes were in DH 1. The DON stated the 20 cardboard boxes in DH 1 did not promote a homelike environment. During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2/2021, the P&P indicated, .when assisting with care, residents are supported in exercising their right. For example, residents are .provided with a dignified dining experience .

Based on observation, interview and record review, the facility failed to maintain safe food preparation standards when Worcestershire sauce and Dutch Cocoa powder with expired labeled use by (UB) dates were found in the walk-in refrigerator and dry storage. This failure had the potential for 159 of 169 sampled residents to be served food prepared with expired ingredients which could increase the risk of food contamination and the development of food borne illness. Findings: During a concurrent observation and interview on [DATE] at 9:48 a.m. with the Registered Dietician (RD) in the kitchen walk-in refrigerator, Worcestershire sauce labeled with a Use by (UB) [DATE] and a manufacturer's expiration date of [DATE] was observed. The RD stated the correct UB date should be labeled to ensure food was safe to use. The RD stated food used after the UB date could have bacteria. During a concurrent observation and interview on [DATE] at 10:02 a.m. with the RD in the dry storage area, a container of Dutch Processed Cocoa labeled with a UB: [DATE] and a manufacturer's expiration date: [DATE] was observed. The RD stated the dates of each item should be checked before every use. The RD stated she was not aware whether the facility had a scheduled day to check the food inventory to discard food with expired UB dates. During an interview on [DATE] at 2:10 p.m. with the Dietary Aide (DA), the DA stated the DA would check all items delivered from the supplier. The DA stated he would label all food with a received date and UB date. The DA stated most foods have a manufacturer's expiration date that he would circle and then label the received date. The DA stated if a food did not have a manufacturer's expiration date, he would label the UB date following the Dry Goods Storage Guideline. During an interview on [DATE] at 2:37 p.m. with the Assistant Certified Dietary Manager (ACDM), the ACDM stated food should be labeled with the opened/received date and UB date. The ACDM stated the risk of using expired food could cause resident illness and the nutritive value could be decreased. During a review of the facility's Job Description (JD): Dietary Aide (DA), dated [DATE], the JD indicated an essential job function to practice safety policies and procedures of the department and facility. During a review of the facility's JD: Dietary Services Manager, dated [DATE], the JD indicated the position was to effectively manage the Dietary Department to assure that food service to residents was safe .and provide for their nutritional needs .Oversee and ensure that all food items were correctly stored, including rotation of supplies, labeling and dating. During a review of the facility's JD: Registered Dietitian Nutritionist, dated ,d+[DATE], the JD indicated the RD works closely with the Dietary Department to maintain good nutritional standards and process improvement. This position is responsible for overseeing regulatory compliance for county and state regulations .demonstrate the ability to instruct staff in correct procedures to be followed in the Dietary Department. During a review of the facility's policy and procedure (P&P) titled, Dry Goods Storage Guidelines, dated 2023, the P&P indicated This storage length is to be followed unless you have manufacturer's recommendation indicating otherwise .Cocoa mixes opened on shelf 1 year .Sauces-bottled (Worcestershire) opened-refrigerated 1 month .Spices, ground opened on shelf 2 years .Storage guidelines are based on the FoodKeeper App (U.S. Department of Health & Human Services). During a review of the facility's P&P titled, Labeling and Dating of Foods, dated 2023, the P&P indicated all food items in the storeroom .need to be labeled and dated. Newly opened food items will need to be closed and labeled with an open date and used by date that follows the various storage guidelines within this section-specifically the 'Dry Goods Storage Guidelines' . During a review of the facility's P&P titled, Storage of Food and Supplies, dated 2023, the P&P indicated 8. Food stores should be arranged in food groups to facilitate storing, locating, and taking inventories .All food will be dated-month, day, year. All food products will be used per the times specified in the Dry Food Storage Guidelines (Section 6, page 6.9) No food will be kept longer than the expiration date on the product. 9. Dry food items which have been opened, such as .spices .will be tightly closed, labeled and dated. These items are to be used per times specified in the Dry Food Storage Guidelines (Section 6, page 6.9) . During a review of Food and Drug Administration (FDA) Food Code 2022, dated 2022, ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking indicated on page 419, Date marking (a mark to indicate the date or day by which food is to be consumed on the premises .or discarded ) is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding (the practice of keeping food at or below 41 degrees Fahrenheit to prevent bacteria growth and food-borne illness.

Based on observation, interview, and record review, the facility failed to ensure residents received supervision and assistance devices to prevent accidents for three of 29 sampled residents (Residents 2, 74 and 212) when staff did not provide supervision during the use of vape pen (pen-shaped electronic device used for inhalation of a vaporized substance like nicotine or cannabis). This failure had the potential to place Residents 2, 74, and 212 at risk of injury due to no supervision. Findings: During an interview on 4/28/25 at 10: 12 a.m. in Resident 2's room, Resident 2 stated he went outside to smoke his vape pen without staff supervision. Resident 2 stated he was concerned for his safety due to his history of falls. During a concurrent interview on 4/30/25 at 1:35 p.m. with License Vocation Nurse (LVN) 1, LVN 1 stated, Resident 2 had a vape pen. LVN 1 stated Resident 2 should have supervision when using his vape pen. LVN 1 stated, it was important to supervise residents when they are using vape pen for safety reasons and to prevent falls. LVN 1 stated CNAs were responsible for monitoring and watching residents during use of vape pens. During an interview on 4/30/25 at 6:19 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Smoking Policy-Residents dated 8/2022 was reviewed. The P&P indicated, To prevent accidents associated with e-cigarettes and to respect the rights of resident who do not want to be expose to second-hand aerosol, residents are permitted to use e-cigarettes with supervision . The DON stated residents that were independent and able to handle the vape pens were able to smoke at the patio. The DON stated, there were no set times for vaping and no monitor or supervision for residents. The DON stated residents were at risk for secondhand exposure from Resident 2's smoking from his vape pen. The DON stated we did not follow our policy and procedure During a review of Resident 2 s Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 78 was admitted to the facility on [DATE] with diagnoses: anoxic brain damage (a brain injury caused by a complete lack of oxygen supply), tremors ( an involuntary, rhythmic shaking of a body part), nonpsychotic mental disorder (mental health conditions where symptoms are distressing and impair functioning, but do not involve a loss of contact with reality or psychotic symptoms like hallucinations or delusions), unspecified convulsions ( rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), myoclonus (a sudden, involuntary muscle jerk or spasm, often described as a brief, shock-like movement), falls and lack of coordination. During a review of Resident 2's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/12/25 the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 2 had no cognitive impairment. 48739 During a concurrent observation and interview on 4/29/25 at 9:50 a.m. with Resident 74 in Resident 74's room, Resident 74 was observed sitting in bed wearing a gown. Resident 74 stated she had been at the facility for one week. Resident 74 stated the facility was a non-smoking facility, so she used a vape pen. Resident 74 stated there were a group of smokers who used to smoke cigarettes, but now used vape pens. A vape pen was observed on Resident 74's bedside table and a box of cigarettes was observed inside her bedside drawer. Resident 74 stated she did not have matches. Resident 74 stated she went with a group to vape with no supervision from staff. During a review of Resident 74's AR, dated 5/2/25, the AR indicated Resident 74 was readmitted to the facility from an acute care hospital on 4/25/25 with an original admission on 4/2/25. Resident 74 had diagnoses of encephalopathy (damage or disease that affects the brain), tubulointerstitial nephritis (a kidney condition that causes inflammation and swelling between the kidney tubulos [kidney filters] that can impair the kidney's ability to produce urine and filter blood), heart disease, and type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high). During a review of Resident 74's MDS, dated [DATE], the MDS section C indicated Resident 74 had a BIMS score of 15, which indicated Resident 74 was cognitively intact. During a concurrent interview and record review on 5/01/25 at 12:44 p.m. with LVN 2, Resident 74's Order Summary Report, dated 5/2/25 was reviewed. The Order Summary Report indicated, . nicotine patch 24 hour 21 mg/HR (milligram per hour - unit of measurement) apply 1 patch transdermally (on the skin) one time a day for smoking cessation . and remove per schedule . revision date 4/13/25 . Resident 74's CP, dated 5/2/25 was reviewed. The CP indicated, . (Resident name) is at risk for health hazards related to (r/t) continuous use of nicotine (Vape Pen) . date initiated: 4/28/25 . LVN 2 stated Resident 74 had an order for a nicotine patch and should have had a care plan for smoking or vape pen use at admission. LVN 2 stated the facility was a non-smoking facility and many residents are non-compliant (failure or refusal to follow a rule). LVN 2 stated we offered resident nicotine patches to help them stop smoking. LVN 2 stated residents were informed on admission that this was a non-smoking facility. LVN 2 stated staff saw residents go outside and the residents did not always let staff know they were going outside to smoke. LVN 2 stated she did not know who smoked. LVN 2 stated she had not seen vape pens in resident's rooms, but residents were able to keep their vape pens with them. During a concurrent observation and interview on 4/29/25 at 10:36 a.m. with Resident 212 in Resident 212's room, Resident 212 was observed dressed sitting on the side of his bed, watching TV. Resident 212 stated he had been at the facility for one week. Observed vape pens on Resident 212's bedside table. Resident 212 stated he goes outside two to three times a day to vape with no supervision. During a review of Resident 212's AR, dated 5/1/25, the AR indicated Resident 212 was admitted to the facility from an acute care hospital on 4/19/25 with diagnoses of cellulitis of right lower limb, cellulitis of chest wall, type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), Methicillin Resistant Staphylococcus Aureus infection, and fracture of shaft of right fibula (a break in the lower leg bone from below the knee to the outside of the ankle). During a review of Resident 212's MDS, dated [DATE], the MDS section C indicated Resident 212 had a BIMS score of 15 which indicated Resident 212 was cognitively intact. During concurrent interview and record review on 5/01/25 at 1:05 p.m. with LVN 2, Resident 212's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated no orders for nicotine patch in Resident 212's chart. Resident 212's CP, dated 5/1/25, the CP indicated, . (Resident name) is at risk for health hazards r/t continuous use of nicotine (Vape Pen) . date initiated 4/28/25 LVN 2 stated she was not aware if Resident 212 used a vape pen. LVN 2 stated Resident 212 should have had his CP for vape pen use on admission for resident's safety. During an interview on 4/30/25 at 3:31 p.m. with CNA 1, CNA 1 stated staff encouraged residents not to smoke. CNA 1 stated residents did not have designated smoking times and did not inform staff if they were going outside to smoke. CNA 1 stated residents asked the CNAs to take them outside, but there was no supervision if they went outside to vape. CNA 1 stated there were lots of outside areas residents could have gone to when the residents went outside. CNA 1 stated smoking supplies were not kept with the residents. CNA 1 stated resident's vape pens should not have been kept with resident. CNA 1 stated staff would have reported to the nurse if they found smoking items in the resident's room. During an interview on 4/30/25 at 6:20 p.m. with the DON, the DON stated technically the facility was a non-smoking facility. The DON stated they had residents who vaped. The DON stated the staff made sure the residents who vaped were independent, and cognitively okay to handle vaping. The DON stated there were designated areas on the patios for resident to vape in. The DON stated there was no set time or vaping schedules. The DON stated there was no supervision for alert residents who vaped. The DON reviewed the facility P&P titled, Smoking Policy - Residents, dated 8/2022. The DON stated the facility was not following the Smoking P&P on supervision. The DON stated the facility did not document discussion of risks and education with vaping. The DON stated residents needed education to understand the risks of using vape pens, smoking, and handling the vape pen. During an interview on 5/02/25 at 10:39 a.m. with the DSD, the DSD stated the CNAs put residents in chairs and took the residents outside, and the nurses and activities staff also took residents outside. The DSD stated residents did not aways inform staff they went outside to vape. The DSD stated residents were not supervised by the CNAs when they vaped. The DSD stated sometimes the activities staff would have gone outside with residents. The DSD stated she did not feel there was a risk for resident's safety using a vape pen without supervision. During an interview on 5/02/25 12:32 p.m. with the Activities Director (AD) the AD stated the facility was a smoking facility until three or four years ago. The AD stated it was difficult to monitor the residents when they smoked, and the staff did not have to monitor residents when they used vape pens. The AD stated nurses first offered residents to use nicotine patches and residents are not allowed cigarettes or lighters. The AD stated he did not feel it was a safety issue for non-supervision of residents while they vaped. The AD stated residents were able to have the vape pens in their room but had to use them outside. During a review of the facility P&P titled, Smoking Policy - Residents, dated 8/2022, the P&P indicated, . electronic cigarettes . electronic cigarettes (e-cigarettes) . are considered a risk for residents related to . nicotine overdose by ingestion or contact with the skin . explosion or fire caused by the battery . residents are permitted to use e-cigarettes with supervision and in designated smoking areas only . residents who wish to use e-cigarettes are instructed on battery safety and tips to avoid battery explosions per FDA recommendations. Instruction specific to e-cigarette safety is documented in the resident care plan . During a review of the facility's policy and procedure (P&P) titled, Smoking Policy-Residents dated 8/2022, the P&P indicated, Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking .2. To prevent accidents associated with e-cigarettes and to respect the rights of resident who do not want to be expose to second-hand aerosol, residents are permitted to use e-cigarettes with supervision and in designated smoking areas only .

Based on observation, interview and record review, the facility failed to meet professional standards of practice for 7 of 41 sampled residents (Residents 7, 16, 149, 205, 206, 207, and 208) when: 1. Resident 7, 16, 206 and 208's oxygen (a colorless, odorless, tasteless gas essential to living organisms) therapy did not have an active order to reflect as needed use, and Resident 7's nasal cannula tubing (n/c-flexible, clear tube that connects to an oxygen source) was not stored in a respiratory bag when not in use, and Resident 7's nasal cannula tubing had not been changed in 24 days. This failure had the potential to result in the incorrect administration of oxygen therapy and infection which could lead to serious medical condition. 2. Resident 149 had diarrhea, and the staff did not collect stool (fecal) culture (a lab test to find organisms in the stool (feces) that can cause gastrointestinal symptoms and disease) for five days. 3. Resident 207 and Resident 208's oxygen tubing were unlabeled with the date the tubing was changed. This failure put Resident 207 and Resident 208 at risk of infection 4. Resident 205's tube feeding (TF - a liquid form of nutrition that is carried through your body through a flexible tube) flush (water [fluid] that is pushed through the feeding tube to keep it clean and prevent clogs) bag was not labeled with the date and time it was hung (set up for administration). This failure had the potential to result in Resident 205 receiving an expired flush which put Resident 205 at risk of food born illness and infection. Findings: 1. During a review of Resident 7's Admission Record (AR- document containing resident personal information), dated [DATE], the AR indicated, Resident 7 was admitted to the facility on [DATE], with diagnoses which in included chronic obstructive pulmonary disease (lung diseases that cause airflow obstruction and breathing problems), dyspnea (shortness of breath), [NAME] syndrome (immune system attacks moisture producing glands in the body), and anxiety (mental health disorder characterized by excessive and persistent worry and unease). During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool) assessment, dated [DATE], the MDS assessment indicated Resident 7's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 14 out of 15 which indicated Resident 7 had no cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). The MDS assessment indicated Resident 7's Functional Abilities had impairment on both sides of her upper extremities. During a review of Resident 7's Order Summary Report, dated [DATE], the Order Summary Report indicated, Resident 7 had no active oxygen therapy orders. During a review of Resident 7's After Visit Summary, dated [DATE], the After Visit Summary indicated, Resident 7's most recent discharge from the hospital was on [DATE]. During a concurrent observation and interview on [DATE] at 2:57 p.m. with Resident 7 in Resident 7's room, Resident 7 was observed in bed with her nasal cannula tubing tied around the bed rail. The nasal cannula tubing and nasal prongs (two small, soft tips that are inserted into the nostril and connected to the nasal cannula tubing to deliver oxygen therapy) were exposed to the environment. The nasal prongs and nasal cannula tubing were observed touching Resident 7's left bed rail, bedside table and phone. Resident 7's nasal cannula tubing was labeled [DATE] and connected to the oxygen concentrator (a medical device that delivers concentrated oxygen). The oxygen concentrator was turned on to 1 LPM (liters per minute- a unit of measurement to indicate how many liters of oxygen are flowing into the nasal cannula in one minute). Resident 7 stated she wore her oxygen at night and as needed. Resident 7 stated she relied on facility staff to assist her with activities of daily living (everyday self-care tasks necessary for independent living). During a concurrent interview and record review on [DATE] at 3:51 p.m. with Licensed Vocational Nurse (LVN) 17, Resident 7's Order Summary Report dated [DATE] was reviewed. LVN 17 stated she was Resident 7's nurse. LVN 17 stated Resident 7 needed supplemental oxygen therapy at night and as needed but could not state how many LPM of oxygen therapy Resident 7 received. LVN 17 stated she would need to review the physician order to state how many LPM of oxygen therapy Resident 7 received as night or as needed. LVN 17 stated she could not locate an active physician order for Resident 7's oxygen use and requirements within the Order Summary Report. LVN 17 stated Resident 7 should have had a physician order to indicate duration and dosage of oxygen therapy. LVN 17 stated oxygen was a medication and required a physician order to administer. LVN 17 stated it was important Resident 7 had an active physician order that reflected her oxygen therapy use. LVN 17 stated nasal cannula tubing was expected to be stored in a respiratory bag when not in use. LVN 17 stated nasal cannula tubing was expected to be changed weekly. During an interview on [DATE] at 4:31 p.m. with the Respiratory Therapist (RT), the RT stated she was familiar with Resident 7 and her oxygen therapy requirements. The RT stated Resident 7 wore her oxygen as needed at night. The RT stated Resident 7 was recently readmitted to the facility after being hospitalized and the oxygen therapy order was not renewed. The RT could not sate the date Resident 7 was readmitted to the facility from the hospital. The RT stated all as needed oxygen therapy orders needed an active physician order. The RT stated Resident 7 was at risk for not receiving her oxygen therapy as needed with no active physician order. The RT stated nasal cannula oxygen tubing was expected to be changed weekly. The RT stated it was the LVN and the RT's responsibility to ensure nasal cannula tubing was changed weekly. The RT stated Resident 7's nasal cannula tubing label from [DATE] was overdue and should have been changed. The RT stated Resident 7 was at risk of getting an infection if the nasal cannula tubing was not changed as per policy weekly. The RT stated all nasal cannula tubing was expected to be stored in a respiratory bag when not in use. The RT stated Resident 7 nasal cannula tubing was exposed to the environment when not stored in a respiratory bag and could lead to an infection or serious medical condition. During an interview on [DATE] at 10:38 p.m. with the Infection Preventionist (IP), the IP stated all nasal cannula oxygen tubing was expected to be changed weekly on Sunday evening by the LVN. The IP stated all members of the healthcare team were responsible to ensure nasal cannula oxygen tubing was changed once a week per facility policy. The IP stated all nasal cannula oxygen tubing was expected to be stored inside a respiratory bag when not in use. The IP stated Resident 7 was at risk of infection with her nasal cannula tubing not having been changed since [DATE]. The IP stated Resident 7 was at risk of infection with her nasal cannula tubing being exposed to the environment and not being stored in a respiratory bag when not in use. During an interview on [DATE] at 10:55 a.m. with the Director of Nursing (DON), the DON stated oxygen was a medication and all medications required a physician's order to administer. The DON stated Resident 7 required an active physician order to administer oxygen therapy. The DON stated Resident 7 was at risk for the incorrect administration of oxygen therapy which could lead to breathing problems and cause a serious medical condition. The DON stated it was expected all nasal cannula tubing be changed weekly and be stored within a respiratory bag when not in use. The DON stated Resident 7 was at risk for infection with nasal cannula tubing not being changed for 24 days and not being stored within a respiratory bag. 51223 During an observation on [DATE] at 3:56 p.m. at Resident 16's room, the doorway had a posted Oxygen in Use/No Smoking sign. Resident 16 was lying in bed with the head of the bed elevated, an oxygen concentrator flow meter was set to 2 LPM and the oxygen tubing and n/c laid on top of the mattress above the resident's pillow. During a review of Resident 16's AR, dated [DATE], the AR indicated Resident 16 was admitted to the facility on [DATE] with diagnoses: COPD, Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), Dementia (a progressive state of decline in mental abilities), Heart Failure (HF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Chronic Kidney Disease (CKD- a condition in which the kidneys are damaged and can't filter blood as well as they should), Pressure Ulcer of Sacral Stage 2 (localized partial-thickness loss of skin, presenting as a shallow open sore or wound over the triangular shaped bone at the base of the back). During a review of Resident 16's MDS, dated [DATE], the MDS indicated a BIMS score of 3 (,d+[DATE] severe cognitive impairment, ,d+[DATE] moderate cognitive impairment, ,d+[DATE] no cognitive impairment), indicating Resident 16 had severe cognitive impairment. During an interview on [DATE] at 4:03 p.m. with Certified Nurse Aide (CNA) 6, CNA 6 stated Resident 16 had an order for continuous oxygen. CNA 6 stated it was the licensed nurse (LN) responsibility to verify the resident was wearing oxygen as ordered. During a review Resident 16's Order Summary Report, dated [DATE], the Order Summary Report indicated there was no physician order for oxygen. During an interview on [DATE] at 4:05 p.m. with LVN 8, LVN 8 stated Resident 16 was on continuous oxygen. During an interview on [DATE] at 4:31 p.m. with the Respiratory Therapist (RT), the RT stated she was familiar with Resident 7 and her oxygen therapy requirements. The RT stated Resident 7 wore her oxygen as needed at night. The RT stated Resident 7 was recently readmitted to the facility after being hospitalized and the oxygen therapy order was not renewed. The RT could not state the date Resident 7 was readmitted to the facility from the hospital. The RT stated all as needed oxygen therapy orders needed an active physician order. The RT stated Resident 7 was at risk of not receiving her oxygen therapy as needed with no active physician order. The RT stated nasal cannula oxygen tubing was expected to be changed weekly. The RT stated it was the LVN and the RT's responsibility to ensure nasal cannula tubing was changed weekly. The RT stated Resident 7's nasal cannula tubing label from [DATE] was overdue and should have been changed. The RT stated Resident 7 was at risk of getting an infection if the nasal cannula tubing was not changed as per policy weekly. The RT stated all nasal cannula tubing was expected to be stored in a respiratory bag when not in use. The RT stated Resident 7 nasal cannula tubing was exposed to the environment when not stored in a respiratory bag and could lead to an infection or serious medical condition. During an interview on [DATE] at 10:38 p.m. with the Infection Preventionist (IP), the IP stated all nasal cannula oxygen tubing was expected to be changed weekly on Sunday evening by the LVN. The IP stated all members of the healthcare team were responsible for ensuring nasal cannula oxygen tubing was changed once a week by facility policy. The IP stated all nasal cannula oxygen tubing was expected to be stored inside a respiratory bag when not in use. The IP stated Resident 7 was at risk of infection with her nasal cannula tubing not having been changed since [DATE]. The IP stated Resident 7 was at risk of infection with her nasal cannula tubing being exposed to the environment and not being stored in a respiratory bag when not in use. During an interview on [DATE] at 10:55 a.m. with the Director of Nursing (DON), the DON stated oxygen was a medication and all medications required a physician's order to administer. The DON stated Resident 7 required an active physician order to administer oxygen therapy. The DON stated Resident 7 was at risk for the incorrect administration of oxygen therapy which could lead to breathing problems and cause serious medical conditions. The DON stated it was expected all nasal cannula tubing be changed weekly and be stored within a respiratory bag when not in use. The DON stated Resident 7 was at risk for infection with nasal cannula tubing not being changed for 24 days and not being stored within a respiratory bag. During an interview on [DATE] at 11:10 a.m. with the IP, the IP stated oxygen should have physician orders. The IP stated oxygen orders should be written upon admission. The IP stated if oxygen was indicated after admission, the LN would contact the physician to obtain an order for oxygen. The IP stated the risk of a resident being administered oxygen without an order could result in harm to the resident if the resident was wearing oxygen, but oxygen was not indicated. During a concurrent interview and record review on [DATE] at 11:15 a.m. with LVN 7 at the nurses' station two, Resident 16's Hospital Discharge Summary (DC) dated [DATE] and Order Summary Report were reviewed. The DC indicated the resident had COPD and should be administered 2LPM continuous oxygen via n/c. The Order Summary Report dated [DATE] indicated the residents did not have an oxygen order. LVN 7 stated she thought Resident 16 was on oxygen. LVN 7 stated the residents should have a physician order for oxygen. LVN 7 stated the resident could be at risk for respiratory failure if oxygen was administered and the resident was a carbon dioxide (CO2) retainer (individuals, often those with chronic lung conditions like COPD, who struggle to exhale CO2 effectively, leading to its build-up in the blood) as it could lead to respiratory failure. During a concurrent observation and interview on [DATE] at 11:27 a.m. with LVN 7 at Resident 16's bedside, the resident was lying asleep in bed wearing the n/c with the oxygen concentrator on and set at 2LPM. LVN 7 stated the oxygen order should have been entered to ensure staff were aware of the residents' care needs. During an interview on [DATE] at 3:44 p.m. with the RT, the RT stated oxygen orders should be on the residents' chart. The RT stated the facility has had issues with oxygen orders being renewed and entered in the resident's chart when the resident was readmitted to the facility after hospitalization . The RT stated the LN was responsible for verifying oxygen orders upon admission. During a concurrent observation and interview on [DATE] at 3:34 p.m. with Resident 206 in Resident 206's room, Resident 206 was observed dressed in a gown wearing non-slid socks, and wearing her oxygen (O2) nasal cannula set at a rate of 2.5 Liters per minute (L/min - a unit of measurement), sitting in her wheelchair watching TV. Resident 206 stated she had been at the facility for one day. Resident 206 did not want to state why she was at the facility. During a review of Resident 206's AR, dated [DATE], the AR indicated Resident 206 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of metabolic encephalopathy (a condition where brain function is disturbed due to different diseases or toxins [poisons] in the blood), respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), dysphagia (difficulty swallowing), and difficulty walking. During a review of Resident 206's MDS, dated [DATE], the MDS section C indicated Resident 206 had a BIMS score of five, which suggested Resident 206 was severely impaired. During a concurrent interview and record review on [DATE] with LVN 2, Resident 206's Order Summary Report, dated [DATE] was reviewed. The Order Summary Report indicated there were no physician orders for Resident 206's oxygen use. During a review of Resident 206's Baseline Care Plan dated [DATE] indicated . Health Conditions/Special Treatments . Oxygen therapy - while a resident . Resident 206's CP, dated [DATE] indicated no care plan for oxygen therapy was found in Resident's 206's CP. LVN 2 stated Resident 206 should have had a physician's order and care plan for oxygen use. LVN 2 stated a physician's order was important as oxygen was part of medications and treatment which required a physician's order and informed staff on how oxygen was to be provided. During a concurrent observation and interview on [DATE] at 3:09 p.m. with Resident 208 in Resident 208's room, Resident 208 was observed dressed sitting in bed, wearing an oxygen nasal canula with oxygen infusing at 2.5 L/min. No label with date oxygen tubing was connected was observed. Resident 208 did not want to answer questions. Resident 208's son (FM 2) was present in the room. FM 2 stated Resident 208 had been in the facility three times due to three surgeries for heart attacks. Resident 208 had been in the facility for two days. During a review of Resident 208's AR, dated [DATE], the AR indicated Resident 208 was initially admitted to the facility from an acute care hospital on [DATE] and readmitted to the facility on [DATE] with diagnoses of myocardial infarction (a medical emergency when one or more areas of the heart muscle do not get enough blood flow and oxygen and begins to die), respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), Congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), and depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life). During a review of Resident 208's MDS, dated [DATE], the MDS section C indicated Resident 208 had a BIMS score of 15, which indicated Resident 208 was cognitively intact. During a review of Resident 208's Order Summary Report, dated [DATE], the Order Summary Report indicated there were no orders from the physician for oxygen administration. During a concurrent interview and record review on [DATE] at 12:53 p.m. with LVN 2, Resident 208's Order Summary Report, dated [DATE] was reviewed. The Order Summary Report indicated there were no physician orders for Resident 208's oxygen use. LVN 2 stated Resident 208 did not have physician orders for oxygen use. LVN 2 stated Resident 208 should have had orders for oxygen use. LVN 2 stated the physician's order was important for oxygen use as it was part of Resident 208's medications and treatment, which required a physician's order. LVN 2 stated staff needed to know how to provide oxygen care at the correct rate. During an interview on [DATE] at 2:52 p.m. with the Assistant Director of Nursing (ADON), the ADON stated residents on oxygen needed a physician's order. The ADON stated a physician's order showed that the resident needed oxygen, which was considered medication, and informed nurses to give the resident oxygen at the correct rate. The ADON stated if there was no order, the nurse could have missed giving the oxygen or could have given the oxygen at an incorrect rate which could have been harmful to the resident. During an interview on [DATE] at 3:14 p.m. with the DON, the DON stated that when a resident needs oxygen, the LN should call the physician to obtain an order. The DON stated it was important to obtain a physician order for oxygen, so nurses knew that oxygen was needed and the dose to administrate. The DON stated she would expect the resident who was administered oxygen to have a physician order. During a review of the facility's JD: DON, dated [DATE], the JD indicated the DON assumes full time administrative authority, responsibility and accountability for the delivery of nursing services in the facility. Manages facility employees in the provision of care and services according to professional standards of nursing practice, consistent with facility philosophy of care and county, state and federal laws and regulations .' During a review of the facility's JD: LVN, dated [DATE], the JD indicated the LVN responsibilities include total care for the chronically ill and technologically dependent residents, administration of medications .Administer medications in a proficient manner .Job Functions: Assure that the rights of residents are respected and maintained . During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated ,d+[DATE], the P&P indicated, .medications are administered in a safe and timely manner, and as prescribed .medications are administered in accordance with prescriber orders . During a review of the facility's P&P titled Oxygen Administration, dated ,d+[DATE], the P&P indicated 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse . 49949 2. During an observation and interview on [DATE] at 4:38 p.m. in Resident 149's room, CNA 14 was wearing PPE while providing care for. CNA14 stated Resident 149 was on contact precautions (measures used to prevent the transmission of infectious agents through direct or indirect contact with a resident or their environment) for clostridium difficile (c-diff-a bacterium (germ) that causes diarrhea and colitis (inflammation of the colon)). During an interview on [DATE] at 4:39 p.m. in Resident 149's room, Resident 149 stated he was having diarrhea and was not sure how long he had the symptoms. Resident 149 stated he did not feel good. During an interview on [DATE] at 10: 38 a.m. with License Vocation Nurse (LVN) 1, LVN 1 stated Resident 149 stool sample was collected and sent to the laboratory on [DATE]. LVN 1 stated he did not follow up on the stool sample. LVN 1 stated the facility had started a new contract with a new laboratory and no stool sample was collected for the new laboratory. LVN 1 stated he should have called the old laboratory to get the result for Resident 149's stool sample. LVN 1 stated we should have collected a stool sample and sent it to the new lab. LVN 1 stated it was important to get the results to prevent delay in diagnosis and right treatment. During an interview on [DATE] at 5:12 p.m. with the Infection Preventionist (IP), the IP stated Resident 149 was admitted to the facility with diarrhea. The IP stated we have a new lab this week and the stool sample was sent out three days ago. The IP stated we should have sent out the new stool sample to the new laboratory on [DATE]. The IP stated delayed in lab results could have potential for delayed in treatment and care. During a concurrent interview and record review on [DATE] 07:09 p.m. with the DON, the facility's policy and procedure (P&P), titled Infection Prevention and Control Program (IPCP) dated ,d+[DATE] was reviewed. The P&P indicated, Coordination and Oversight .the infection prevention and control committee is responsible for reviewing and providing feedback on potential issues and trends .whether antibiotic usage patterns need to be change . weather information about cultures or antibiotic resistance is transmitted accurately and in a timely fashion and whether there is an appropriate follow up of acute infection . The DON stated Resident 149 had diarrhea started when he was admitted and was told his diarrhea was chronic. The DON stated the physician was notified on [DATE]. The DON stated the physician ordered a stool sample culture on [DATE] and it should have been done as soon as possible. The DON stated the stool sample should have been back in a timely manner. The DON stated it was important to get the lab results back in a timely manner to make sure Resident 149 was being treated correctly for his active infection. The DON stated there could be the possibility Resident 149 did not need the antibiotic. The DON stated we did not follow our policy and procedure. During a review of Resident 149 s Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated [DATE], the AR indicated Resident 149 was admitted to the facility on [DATE] with diagnoses: bacteremia (the presence of bacteria in the bloodstream), pressure ulcers (localized injuries to the skin and underlying tissue caused by prolonged pressure, often over bony prominences), protein-caloric malnutrition ( nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and difficulty walking. During a review of Resident 149's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated [DATE], the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 15 (,d+[DATE] severe cognitive impairment, ,d+[DATE] moderate cognitive impairment, ,d+[DATE] no cognitive impairment), indicating Resident 149 had no cognitive impairment. During a review of Resident 149's Physician Order dated [DATE], the PO indicated, [box]Order Summary: [band name] HCI oral Capsule 250 mg-give 1 capsule by moth four time a day for possible infection for 14 days . During a review of Resident 149's [Facility Name] Progress Note (PN), date [DATE], the PN indicated, Primary Care Provider Feedback: Recommendations: stat [immediately] lab orders: stool culture . During a review of professional reference review retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC8739406/, an article titled, Why Test Results Are Still Getting Lost to Follow-up: a Qualitative Study of Implementation Gaps dated [DATE], the article indicated, Lack of timely follow-up of abnormal test results is common and has been implicated in missed or delayed diagnosis, resulting in potential for patient harm . 48739 3. During a concurrent observation and interview on [DATE] at 3:08 p.m. with Resident 207 in Resident 207's room, Resident 207 was observed laying in bed wearing a gown and wearing a nasal cannula with oxygen flowing at a rate of 1.5 L/min, no label was observed on the oxygen tubing indicating when it was connected to the concentrator. Resident 207 was unable to answer questions. During a concurrent observation and interview on [DATE] at 3:19 p.m. with CNA 10 in Resident 207's room, Resident 207's oxygen tubing was observed to be without a label indicating when it was connected to the oxygen concentrator. CNA 10 stated Resident 207's oxygen tubing was not labeled with the date it was connected. CNA 10 did not know why the tubing needed to be labeled with the date. CNA 10 stated the nurses were responsible for changing and labeling residents' oxygen tubing. During a review of Resident 207's AR, dated [DATE], the AR indicated Resident 207 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of fracture of left femur (a break in the bone of the thigh), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and encounter for orthopedic (relating to the bones) aftercare. During a review of Resident 207's MDS, dated [DATE], the MDS section C indicated Resident 207 had a BIMS score of 10, which indicated Resident 207 was moderately impaired. During an interview on [DATE] at 11:45 a.m. with LVN 2, LVN 2 stated Resident 207's oxygen tubing should have been labeled with the date it was changed. LVN stated oxygen tubing should be changed every seven days and as needed. LVN 2 stated it was part of infection control. LVN 2 stated the resident could have gotten germs on them, and there was a risk of infection if the tubing was not cleaned or changed weekly. During a concurrent observation and interview on [DATE] at 3:09 p.m. with Resident 208 in Resident 208's room, Resident 208 was observed dressed sitting in bed, wearing an oxygen nasal cannula with oxygen infusing at 2.5 L/min. No label with date oxygen tubing was connected was observed. Resident 208 did not want to answer questions. Resident 208's son (FM 2) was present in the room. FM 2 stated Resident 208 had been in the facility three times due to three surgeries for heart attacks. Resident 208 had been in the facility for two days. During a concurrent observation and interview on [DATE] at 3:16 p.m. with CNA 10 in Resident 208's room, Resident 208's oxygen tubing was observed to be without a date the tubing was connected. CNA 10 stated Resident 208's oxygen tubing had no date label. CNA 10 stated Resident 208's oxygen tubing should have been labeled with the date it was connected to the oxygen machine. During an interview on [DATE] at 11:10 a.m. with the IP, the IP stated resident's oxygen tubing should have been labeled. The IP stated residents should have had an order to change the oxygen tubing every Sunday. The IP stated the oxygen tubing was to be changed weekly and should have been dated so everyone knew when the tubing was put on the resident. The IP stated there was a risk for infection to the resident if the oxygen tubing was not changed weekly. During an interview on [DATE] at 12:53 p.m. with LVN 2, LVN 2 stated Resident 208's oxygen tubing should have been labeled with the date it was changed. LVN stated oxygen tubing should be changed every seven days and as needed. LVN 2 stated it was part of infection control. LVN 2 stated the resident could have gotten germs on them, and there was a risk of infection if the tubing was not cleaned or changed weekly. During an interview on [DATE] at 10:39 a.m. with the DSD, the DSD stated resident's oxygen tubing should have been changed weekly. The DSD stated the nurse was ultimately responsible for changing and dating the resident's oxygen tubing. The DSD stated the RT and nurse changed the resident's oxygen tubing. The DSD stated if the resident's oxygen tubing was not changed weekly, it was an infection control problem and put residents at risk for infection. 4. During a concurrent observation and interview on [DATE] at 3:44 p.m. with Resident 205 in Resident 205's room, Resident 205 observed in bed covered with head of bed elevated. Resident 205 stated staff were taking good care of her, and she had no problems to discuss. Observed Resident 205's artificial nutrition (nutrition provided to the body through a vein or a tube inserted in the stomach, when a person can no longer take in food by mouth) infusing via Resident 205's G-tube. Resident's bag of fluids for g-tube flush was observed without a date, time and initials of when it was hung. During a review of Resident 205's AR, dated [DATE], the AR indicated Resident 205 was admitted to the facility from an acute care hospital on [DATE]

Based on observation, interview and record review, the facility failed to ensure a completed physician informed consent (the process in which residents are given important information of the possible risk and benefits of psychoactive medications) for the use of psychotropic medication (medication used to treat mental and behavioral disorders) was obtained for four of thirteen sampled residents (Resident 58, Resident 115, Resident 132 and Resident 203) when: 1. Resident 58, Resident 115, and Resident 132 were administered antipsychotic medication and informed consent was not obtained prior to medication administration. 2. Resident 203's antipsychotic consent did not have a diagnosis for the listed medication, and boxes were not marked indicating Resident 203 and/or Resident 203's Responsible Party (RP) was provided information about the listed medication from the physician and gave consent to receive the medication. These failures resulted in the violation of Resident 58, Resident 115, Resident 132 and Resident 203's and/or Resident 203's RP right to be informed of, in advance, of their anti-psychotic medication treatment risks and benefits by a physician or alternative treatment options which could lead to negative side effects. Findings: 1a. During a review of Resident 132's Admission Record (a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/6/25, the AR indicated, Resident 132 was admitted to the facility on [DATE], with diagnoses which included dementia (gradual decline in cognitive abilities), anxiety disorder (differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety), and palliative care (medical care focused on providing relief from symptoms of condition). During a review of Resident 132's Minimum Data Set assessment tool (MDS-resident assessment tool which indicated physical and cognitive abilities), dated 2/20/25, the MDS assessment indicated Resident 132's Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 8 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), assessment score was 12 out of 15 which indicated Resident 132 had moderate cognitive impairment. During a review of Resident 132's Order Summary Report (OSR), dated 5/6/25, the OSR indicated Resident 132 received Seroquel (a psychotropic medication that is a classified as an antipsychotic used to treat agitation and/or anxiety) oral tablet 50 MG (milligrams- a measurement of weight of how much medicine is in the tablet) from 5/16/25 to 8/16/24, Seroquel oral tablet 25 MG from 11/6/24 to 11/22/24 which was revised to Seroquel 50 MG on 11/6/24 with an end date of 11/22/24. The OSR indicated Resident 132 had an active order for .Seroquel oral tablet 100 MG . start date 12/8/24 with no end date . During an interview on 5/6/25 at 10:46 a.m. with Licensed Vocational Nurse (LVN) 11, LVN 11 stated Seroquel was a psychotropic medication that was classified as an antipsychotic. LVN 11 stated all antipsychotic medication required a completed consent before administration of the medication. LVN 11 stated a new consent was needed for antipsychotic medication dose increases or decreases. LVN 11 stated antipsychotic medication consents needed to accurately reflect the name of the medication, use, dose, duration and monitoring interventions. LVN 11 stated antipsychotic consents were important because it ensured the resident received education from the physician. LVN 11 stated antipsychotic consents were important because it ensured the resident was aware of the benefits and risk of the medication. During an interview on 5/6/25 at 10:50 a.m. with LVN 6, LVN 6 stated it was expected all residents had a consent for each antipsychotic mediation. LVN 6 stated it was the responsibility of all members of the healthcare team to ensure an antipsychotic consent was present before administering an antipsychotic medication. LVN 6 stated residents were at risk of not knowing the risks, benefits or side effects of antipsychotic medication if they did not have a consent. During a concurrent interview and record review on 5/6/25 at 11:03 a.m. with the Assistant Director of Nursing (ADON), Resident 132's Medical Record (MR), dated 5/6/25 was reviewed. The ADON stated Resident 132 was his own RP, made his own medical decisions and signed his own consents. The ADON stated Resident 132 received Seroquel. The ADON could not locate a consent for the administration of Seroquel. The ADON stated Resident 132 did not have any consents since admission for Seroquel. The ADON stated Seroquel was an antipsychotic medication and required a consent prior to administration. The ADON stated a Seroquel consent was needed for every dose change. The ADON stated Resident 132 had the right to receive informed consent prior to the administration of the antipsychotic medication. The ADON stated informed consent ensured the physician provided antipsychotic medication education which included risks versus benefits, alternative treatment options and choice to decline treatment. The ADON stated Resident 132 was at risk of not having his medical decisions upheld if he did not want to take the medication. During a concurrent interview and record review on 5/6/25 at 12:23 pm. with the Director of Nursing (DON), Resident 132's MR, dated 5/6/25 was reviewed. The DON stated Resident 132 had received Seroquel since admission of varying doses. The DON could not locate a consent for Seroquel in Resident 132's MR. The DON stated antipsychotic medication consents were expected to be obtained on admission and with every dose increase or decrease per facility policy. The DON stated it was important to have antipsychotic medication consents prior to medication administration to ensure the resident was aware of the proposed medication, dose, duration, risks, benefits, and alternative options. The DON stated a consent ensured the physician provided education to the resident and the resident agreed to the proposed treatment. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated, .drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics . resident's, families and/or the representative are involved in the medication management process. Psychotropic medication management includes . residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives . During a review of the facility's P&P titled, Antipsychotic Medication Use, dated 7/2022, the P&P indicated, .residents and/or resident representatives) will be informed of the recommendation. Risks, benefits, purpose and potential adverse consequences of antipsychotic medication use. Residents (and/or representatives) may refuse medications of any kind . During a review of the facility's P&P titled, Informed Consent, dated 5/2025, the P&P indicated, .before initiating the administration of psychotherapeutic drugs .facility staff shall verify that the resident's health record contains documentation that the resident has given informed consent for the proposed treatment .the facility shall also ensure that the patient has the right to accept or refuse the proposed treatment . During a review of the facility's P&P titled, Resident Rights, dated 5/2025, the P&P indicated, .resident's right to be notified of his or her medical condition and of any changes in his or her condition . be infirmed of, and patriciate in, his or her care planning and treatment .participate in decision-making regarding his or her care . 51223 During a review of Resident 58's AR, dated 5/2/25, the AR indicated Resident 58 was admitted to the facility on [DATE] with diagnoses: Mood Disorder (a mental health condition that primarily affects your emotional state that can cause persistent and intense sadness, elation and/or anger) Anxiety Disorder, Recurrent Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The AR indicated Resident 58 was his own responsible party and an ex-wife was the emergency contact #1. During a review of Resident 58's MDS, dated [DATE], the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 8 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 58 had moderate cognitive impairment. During a review of Resident 58's Fax Request for Physician's Order, dated 8/15/24, the physician order indicated This resident can make needs known but CAN NOT make medical decisions and was signed by the physician 8/15/24. During a review of Resident 58's Informed Consent (IC) for Anti-Anxiety Medications, dated 11/21/24, the IC indicated the facility staff obtained verbal consent from the resident for Aripiprazole 2mg daily for neurocognitive disorder due to general medical condition. The physician certified they had provided the information listed on the form to the resident or his/her responsible party (RP) and have received IC for the use of the medication listed on 11/25/24. During a review of Resident 58's IC for Anti-Depressant Medications, dated 12/6/24, the IC indicated the facility staff obtained verbal consent from the resident for Aripiprazole 2mg daily for behavior disturbances. The physician certified they had provided the information listed on the form to the resident or his/her RP and have received IC for the use of the medication listed on 12/10/24. The second IC for Anti-Depressant Medications form, dated 12/6/24, indicated the facility staff obtained verbal consent from the resident for Fluoxetine 20mg for Major Depression manifested by (m/b) expressions of sadness. The physician certified they had provided the information listed on the form to the resident or his/her RP and have received IC for the use of the medication listed on 12/10/24. During a review of Resident 58's OSR, dated 5/1/25, the OSR indicated Prozac oral capsule 10mg (Fluoxetine HCl) Give 20 mg by mouth one time a day for Depression m/b expression of sadness had an order date of 8/1/23 and a start date of 8/2/23. Th OSR indicated Aripiprazole tablet 2 mg give 1 tablet by mouth one time a day for neurocognitive disorder due to general medical condition with behavior disturbance had an order date of 11/21/24 and a start date of 11/22/24. During an interview on 5/2/25 at 8:55 a.m. with the Medical Records Assistant (MRA), the MRA stated medical records reviews IC to ensure completion before uploading the document into the resident's chart. The MRA stated the nurse should fill out the form completely. The MRA stated the IC was often missing the dose frequency, the date of resident signature or a checked box identifying the resident had given consent for the medication. The MRA stated incomplete IC forms are not valid. During a concurrent interview and record review on 5/2/25 at 10:16 a.m. with LVN 10 at the nurses' station 3, Resident 58's AR, Fax Request for Physician Order dated 8/14/24, ICs dated 11/21/24 and 12/6/24, OSR, and Medication Administration Record (MAR) were reviewed. The AR indicated Resident 58 was his own responsible party and able to make his own decisions. The Fax Request for Physician Order dated 8/14/24, indicated the resident can make needs known but CAN NOT make medical decisions. The IC dated 11/21/24 indicated the facility staff obtained verbal consent from the resident for Aripiprazole 2mg daily for neurocognitive disorder due to general medical condition. The IC dated 12/6/24 indicated facility staff obtained verbal consent from the resident for Fluoxetine 20mg for Major Depression m/b expressions of sadness. The OSR indicated Prozac oral capsule 10mg (Fluoxetine HCl) Give 20 mg by mouth one time a day for Depression m/b expression of sadness was ordered 8/1/23 with a start date of 8/2/23. The OSR indicated Aripiprazole tablet 2 mg give 1 tablet by mouth one time a day for neurocognitive disorder due to general medical condition with behavior disturbance was ordered 11/21/24 with a start date of 11/22/24. The MAR indicated the resident was administered Aripiprazole daily as of 11/22/24. LVN 10 stated the IC was required for psychotropic medication upon initial prescription and with any change in dosage whether an increase or decrease of dose. LVN 10 stated IC should be obtained from the residents if they have capacity or the resident's responsible party (RP) if the resident lacks capacity. LVN 10 stated psychotropic medication should not be administered until IC was completed. LVN 10 stated the AR indicated the resident was his own responsible party and able to make decisions. LVN 10 stated on 8/15/24 the physician order indicated the resident cannot make medical decisions and the IC should not have been obtained from the resident. LVN 10 stated the resident has been administered a different dose of antipsychotic medication as of 11/21/24. LVN 10 stated the facility should have obtained IC from the next of kin or medical power of attorney, not the resident. LVN 10 stated residents who are administered anti-psychotropic medication without IC were at risk of not being aware of potential side effects or understanding why the medication was necessary. During a telephone interview on 5/2/25 at 11:13 a.m. with the Pharmacy Consultant (PC), the PC stated the LN obtained informed consent for psychotropic medication. The PC stated that each psychotropic medication should have updated consent each time there was a dose increase so the residents would be aware of the risks, benefits and potential side effects of the medication. During a concurrent interview and record review on 5/2/25 at 12:01 p.m. with ADON in ADON's office, Resident 58's EHR was reviewed. The OSR dated 6/26/23 indicated RESIDENT CAPACITY: This resident does NOT have capacity to understand and make decision due to confusion. Resident 58's OSR, dated 8/2/23, indicated Prozac Give 20 mg by mouth one time a day for Depression m/b expressions of sadness were ordered. Resident 58's Fax Request for a Physician Order date 8/19/24 indicated the resident .CAN NOT make medical decisions. The IC, dated 11/21/24, indicated an RN and LVN obtained verbal consent from the resident for Abilify 2mg daily for behavioral disturbance. The OSR, dated 11/22/24, indicated Abilify 2mg Give 1 tablet by mouth one time a day for neurocognitive disorder due to general medical condition with behavior disturbance was ordered. The IC, dated 12/6/24, indicated an RN and LVN obtained verbal consent from the resident for Ability 2mg daily and fluoxetine 20mg. The ADON stated the residents did not have the capacity to make medical decisions and the facility should have called the family for informed consent. During a concurrent interview and record review on 5/2/25 at 12:51 p.m. with ADON in the ADON's office, Resident 115's OSR and IC were reviewed. The IC, dated 12/22/22, indicated Paroxetine 60 mg po daily for depression m/b sad facial expression. The OSR, dated 3/23/24, indicated Paroxetine HCl Tablet 40 MG Give 1 tablet by mouth one time a day for Bipolar 2 disorder, depressed episode, full remission was ordered. The IC, dated 1/2/24, indicated mirtazapine 15 mg at bedtime for depression m/b by insomnia was signed by the resident. The OSR, dated 8/29/24, indicated Mirtazapine Tablet 7.5 MG Give 1 tablet by mouth at bedtime for Bipolar 2 disorder. depressive episode in full remission was ordered. The IC, dated 12/10/24, indicated Mirtazapine 7.5mg at bedtime for Mood Disorder, m/b inability to sleep. The resident signed the form but did not date or check consent. The IC, dated 12/10/24, indicated Paroxetine 40mg daily bipolar, resident signed form but did not date or check the box indicating consent. The ADON stated all areas of the IC need to be completed with box checked to ensure the consent is valid. The ADON stated the IC is not valid if the consent is not dated. The ADON stated the risk of administering psychotropic medication to the resident without IC could harm the resident and/or the resident may develop side effects. During a review of Resident 58's Medication Administration Report (MAR), dated 5/6/25, the MAR indicated on 8/2/23 Resident 58 was administered Prozac (Fluoxetine HCl) Give 20mg by mouth one time a day for Depression m/b expression of sadness. The MAR indicated on 11/21/24 Resident 58 was administered Aripiprazole Give 1 tablet by mouth one time a day for neurocognitive disorder due to general medical condition with behavior disturbance. During a review of the facility's Job Description (JD): Assistant Director of Nursing (ADON), dated 3/1/14, the JD indicated the ADON assumes full time administrative authority, responsibility and accountability for the delivery of nursing services in the facility under the direction of the Director of Nursing. Manages facility employees in the provision of care and services according to professional standards of nursing practice, consistent with facility philosophy of care and county, state and federal laws and regulations, as applicable .Monitor practice for effective implementation .Job Functions: Demonstrate competency in the protection and promotion of resident rights . During a review of the facility's JD: Director of Nursing (DON), dated 3/1/14, the JD indicated the DON assumes full time administrative authority, responsibility and accountability for the delivery of nursing services in the facility. Manages facility employees in the provision of care and services according to professional standards of nursing practice, consistent with facility philosophy of care and county, state and federal laws and regulations .Essential Job Functions: .Monitor practice for effective implementation .Conduct quality assessment and assurance activities, including regulatory compliance rounds, in all departments to monitor performance and to continuously improve quality .Job Functions: demonstrate knowledge of, and respect for the rights, dignity and individuality of each resident in all interactions. Demonstrate competency in the protection and promotions of resident rights . During a review of the facility's JD: Licensed Vocational Nurse (LVN), dated 3/1/14, the JD indicated the LVN responsibilities include total care for the chronically ill and technologically dependent residents, administration of medications .Administer medications in a proficient manner .Job Functions: Assure that the rights of residents are respected and maintained . During a review of the facility's P&P titled, Policy Informed Consent, revised 5/2025, the P&P indicated the purpose of the policy was to assure that the resident's health record contains documentation that the resident gave informed consent prior to the initiation or administration of psychotherapeutic drugs .Policy-Before initiating the administration of psychotherapeutic drugs .facility staff shall verify that the resident's health record contains documentation that the resident has given informed consent for the proposed treatment or procedure . During a review of the facility's P&P titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated 3. Residents, families and/or the representative are involved in the medication management process . 48739 2. During a concurrent observation and interview on 4/28/25 at 12:20 p.m. with Resident 203, in Resident 203's room, Resident 203 was observed dressed, lying in bed, bilateral head rails up, with no padding on rails, eating her meal. Resident 203 stated she had been at the facility long enough. Resident 203's Mother (RP 1) and husband (RP 2) were sitting in chairs on both sides of Resident 203's bed. RP 1 stated Resident 203 had lots of confusion since 4/21/25. RP 1 stated Resident 203 had a seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness] disorder), muscle weakness, and hit her head. RP 1 stated Resident 203 had a brain bleed. Resident 203 stated she was doing good, and staff were ok with her physical therapy treatment. RP 1 stated Resident 203 had a 50/50 chance of getting better. During a review of Resident 203's AR dated 5/1/25, the AR indicated Resident 203 was admitted to the facility from an acute care hospital on 4/21/25 with diagnoses of traumatic subdural hemorrhage (bleeding in the area between the brain and the skull), contusion (bruising) and laceration (cut) of cerebrum (the part of the brain in the front area of the skull), difficulty walking, dysphagia (difficulty swallowing), cognitive communication deficit (difficulty with thinking and how someone uses language), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), alcohol use, and cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged). During a review of Resident 203's MDS, dated [DATE], the MDS section C indicated Resident 203 had a BIMS score of 3 , which suggested Resident 203 was severely cognitively impaired. During a review of Resident 203's OSR, dated 5/1/25, the OSR indicated . quetiapine fumarate tablet 25 mg give 1 tablet by mouth . for restlessness . order date . 4/21/25 . During a concurrent interview and record review on 5/1/25 at 11:45 a.m. with LVN 2, Resident 203's Informed Consent for Anti-Psychotic Medications, dated 4/22/25 was reviewed. The Informed Consent for Anti-Psychotic Medications indicated, . Medical Condition/Psychiatric Diagnosis . section was not filled in. Section Informed Consent Verification box, giving consent for the listed medication, and indicting that the resident or resident representative understood the information provided, was not marked. The box certifying the physician provided the listed information to the resident or the representative and received consent for the listed medication, was not marked. LVN 2 stated there was no mention of psychiatric diagnoses for Resident 203's antipsychotic medication use. During a concurrent interview and record review on 5/02/25 at 2:52 p.m. with the ADON, Resident 203's Informed Consent for Anti-Psychotic Medications, dated 4/22/25 was reviewed. The Informed Consent for Anti-Psychotic Medications indicated, Medication: Quetiapine . Medical Condition/Psychiatric Diagnosis . section was not filled in with a diagnosis.Potential Expected Benefits: . section not completed. Informed Consent Verification . box, giving consent for the listed medication, and indicating that the resident or resident representative understood the information provided, was not marked. The box certifying the physician provided the listed information to the resident or the representative and received consent for the listed medication, was not marked. The ADON stated the nurses were responsible for making sure resident medication consents were signed. The ADON stated there was no diagnosis for Resident 203's quetiapine use. The ADON stated the authorization box was not checked for Resident 203's consent to take an antipsychotic medication. The ADON stated Resident 203's quetiapine medication consent was not a valid consent. During an interview on 5/06/25 at 11:33 a.m. with the DON, the DON stated a review of Resident 203's medication should have been done to be sure they had an appropriate diagnosis for anti-psychotic medication use. The DON stated her expectation was consents had a valid diagnosis and be a valid completed consent. The DON stated a valid consent would have needed to have a diagnosis. The DON stated her expectation was nurses looked at consents prior to administering antipsychotic medications. The DON would not state the risk for anti-psychotics and psychotropics given without proper consent. The DON stated it was hard to say what the risks were. The DON stated the resident's consent should have had a valid diagnosis and staff should have known why they were giving the medication so they could have monitored for behaviors or side effects of the medication. During a review of the facility's P&P titled, Informed Consent, dated 5/2025, indicated, . to assure that the resident's health record contains documentation that the resident gave informed consent prior to the initiation or administration of psychotherapeutic drugs . before initiating the administration of psychotherapeutic drugs . facility staff shall verify that the resident's health record contains documentation that the resident has given informed consent for the proposed treatment . During a review of the facility P&P titled, Antipsychotic Medication Use, dated 7/2022, indicated, . residents (and/or resident representatives) will be informed of the recommendation, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use .

Based on observation, interview, and record review, the facility failed to promote dignity for four of 27 residents when Resident 33, Resident 69, Resident 204, and Resident 58 did not have a privacy bag placed over their catheter collection bag exposing the urine collected. This had the potential to result in a loss of dignified existence for Resident 33, Resident 69, Resident 204, and Resident 58. Findings: During an observation on 4/29/25 at 2:15 p.m. in Resident 33 ' s room, observed resident with suprapubic catheter (a tube inserted into the bladder through a small incision in the lower abdomen used to drain urine) in place with no privacy bag over the drainage collection bag. During an observation on 4/30/25 at 1:32 p.m. in Resident 33 ' s room, observed Resident 33 with suprapubic catheter in place with no privacy bag over the drainage collection bag. During a review of Resident 33 ' s Admission Record (AR) dated 5/1/25, the AR indicated Resident 33 was admitted into the facility on [DATE]. The AR indicated, .Diagnosis information .other mechanical complication of indwelling urethral catheter [type of urinary catheter inserted through the urethra and into the bladder where it remains in place for a period of time to drain urine] . hydronephrosis [condition where one or both kidneys swell due to build up or urine] . calculus of kidney [solid masses that form in the kidneys] . overreactive bladder [condition characterized by a strong, sudden urge to urinate, frequently and often uncontrollably, even when the bladder is not full] .hesitancy of micturition [difficulty starting or maintaining a urine stream during urination] .nocturia [waking up more than once during the night to urinate] . During a review of Resident 33 ' s Minimum Data Set (MDS- a resident assessment tool) dated 4/1/25, the MDS Section C (section that reviews a resident ' s cognitive pattern), the Brief Interview for Menal Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was a 14 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact) indicating Resident 33 was cognitively intact. During a review of Resident 33 ' s Order Summary Report (OSR) dated 5/2/25, the OSR indicated, an active order for suprapubic catheter with a start date of 3/28/23. During a concurrent observation and interview on 4/30/25 at 1:32 p.m. with Licensed Vocation Nurse (LVN) 1 in Resident 33 ' s room, Resident 33 observed to have suprapubic catheter in place with no privacy bag over the catheter bag. LVN 1 confirmed there was no privacy bag on catheter bag and stated, there should be [a cover] for privacy. During an interview on 4/30/25 at 1:34 p.m. with Resident 33 in the resident ' s room, Resident 33 stated she would like a privacy cover on her catheter bag because if she runs it over with her wheelchair it will be secured and for privacy. During an interview on 5/2/25 at 9:21 a.m. with LVN 7, LVN 7 stated it is best practice to place a privacy bag cover on a resident ' s drainage collection bag for the resident ' s privacy. During an interview on 5/2/25 at 3:39 p.m. with the Director of Nursing (DON), the DON stated Resident 33 ' s foley catheter bag should have had a privacy bag on it. The DON stated her expectation is for all residents with a foley catheter to have a privacy bag on the catheter bag because it is important for the residents dignity. 48739 During a concurrent observation and interview on 4/28/25 at 12:26 p.m. with Certified Nursing Assistant (CNA) 11 in Resident 69's room, Resident 69 was observed in bed wearing a gown, head of bed elevated with a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) bag hung on the lower rail of the bed without a dignity covering (a cover put over a urinary catheter bag to preserve one's privacy and dignity). Resident 69 was being fed by CNA 11 who stated Resident 69 was non-verbal. Resident 69 did not answer any questions. CNA 11 stated Resident 69's catheter bag should have had a cover for Resident 69's privacy. During a review of Resident 69's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/1/25, the AR indicated Resident 69 was admitted to the facility from an acute care hospital on 3/14/25 with diagnoses of cerebral palsy (abnormal development or damage to the pats of the brain that control movement, balance, and posture), acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), chronic kidney disease (a condition when the kidneys suddenly are unable to filter waste products from the blood), sepsis (a serious condition in which the body responds improperly to an infection), dysphagia (difficulty swallowing) and resistance to multiple antimicrobial (a substance that kills microorganisms such as bacteria) drugs, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 69's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/21/25, the MDS section C indicated Resident 69 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 69 was severely impaired. During a concurrent observation and interview on 4/28/25 at 12:31 p.m. with Resident 204 in Resident 204's room, Resident 204 was observed in bed wearing a gown, with a Fall risk band and Allergy band on resident's wrists, head of bed elevated, moaning in pain. Resident 204 stated his catheter bag was bothering him. Resident 204 stopped moaning when answering questions. Observed Resident 204's catheter bag on the floor with no dignity cover. During a review of Resident 204's AR, dated 5/1/25, the AR indicated Resident 204 was admitted to the facility from an acute care hospital on 4/22/25 with diagnoses of difficulty walking, spinal stenosis (a narrowing of the spine that causes pressure on the spinal cord and nerves and can cause pain), DiGeorge syndrome (a genetic condition caused by a missing piece of chromosome 22 which can cause heart defects and learning difficulties), dysphagia (difficulty swallowing) and urinary incontinence (inability to control urination). During a review of Resident 204's MDS, dated [DATE], the MDS section C indicated Resident 204 had a BIMS score of nine which suggested Resident 204 was moderately impaired. During an interview on 4/30/25 at 11:10 a.m. with the Infection Preventionist (IP), the IP stated Resident 69 and Resident 204's catheter bags should have been covered. The IP stated the catheter bags needed a covering to protect Resident 69 and Resident 204's privacy and dignity. The IP stated the catheter bag should not have been on the floor due to bacteria on the floor. The IP stated if the catheter bag touched the floor, there was a risk of infection for Resident 69 and Resident 204. During an interview on 5/01/25 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated residents with urinary catheters should have had dignity bags covering their catheter bag. LVN 2 stated it was a dignity issue and was not respectful to be showing off resident's urine in the catheter bag. During an interview on 5/02/25 at 10:39 a.m. with the Director of Staff Development (DSD), the DSD stated resident's urinary catheter bags should have been covered. The DSD stated it was important to have resident's catheter bags covered for the resident's privacy and dignity. The DSD stated the CNAs will empty the urinary collection bag and should have covered the catheter bag after emptying it. The DSD stated the nurse and CNA were responsible for making sure the catheter bag was not touching the floor for infection control and to be sure there was no cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) to the residents. During a review of the facility's policy and procedure (P&P) titled, Dignity, dated 2/2021, indicated, . residents are treated with dignity and respect at all times . demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents . helping the resident to keep urinary catheter bags covered . During a review of the facility's P&P titled, Resident Rights, dated 2/2021, indicated, . federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . a dignified existence . be treated with respect, kindness, and dignity . During a review of the facility's job description document titled, Certified Nurse Assistant (CNA), dated 3/1/14, indicated, . the Certified Nurse Assistant provides nursing and nursing related services to residents . protects and promotes resident rights . provide care in a manner that protects and promotes resident rights, dignity, self-determination . 51223 During an observation on 4/28/25 at 4:34 p.m. in Resident 58's room, the resident was lying in bed with an uncovered urinary catheter bag hanging on the bed frame exposing clear dark yellow fluid in the bag. The dark blue urinary catheter dignity bag (a device used to discreetly cover and hold a urine drainage bag) was found lying on the ground underneath the resident's bed. During a review of Resident 58's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/2/25, the AR indicated Resident 58 was admitted to the facility on [DATE] with diagnoses: Congestive Heart Failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Type 2 Diabetes Mellitus (DM2- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), Chronic Kidney Disease (CKD- a condition in which the kidneys are damaged and can't filter blood as well as they should), Mood Disorder (a mental health condition that primarily affects your emotional state that can cause persistent and intense sadness, elation and/or anger) Anxiety Disorder (differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety), Recurrent Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 58's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/25/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 8 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 58 had moderate cognitive impairment. During an interview on 4/30/25 at 11:10 a.m. with the Infection Control (IP) Nurse, the IP stated the urinary bag should be covered with a dignity bag. The IP stated the dignity bag covered the urinary bag to maintain the resident's privacy and protect the resident's dignity. The IP stated if the urinary bag was uncovered the resident may feel embarrassed. During an interview on 5/1/25 at 09:56 a.m. with the Certified Nurse Assistant (CNA) 5, CNA 5 stated the urinary catheter should have a privacy bag to keep it private. CNA 5 stated the use of a dignity bag would maintain the resident's dignity. CNA 5 stated there would be a risk of embarrassment for the resident or others as no one wants to see a bag with pee. During an interview on 5/2/25 at 3:06 p.m. with the Director of Nursing (DON), the DON stated urinary catheter bags should have a dignity cover. The DON stated the dignity cover is important to maintain the residents' dignity. The DON stated if the dignity cover was not in place, other people would be able to see the urine in the bag and could become a dignity issue with a potential for the resident to feel embarrassed. During a review of the facility's Job Description (JD): Certified Nurse Assistant (CNA)-SNF or Sub-acute, dated 3/1/14, the JD indicated an essential job function: Elimination/Toileting- .provide catheter care according to the facility procedure and infection control practices .Provide care in a manner that protects and promotes resident rights, dignity . During a review of the facility's JD: DON, dated 3/1/14, the JD indicated the DON assumes full time administrative authority, responsibility, and accountability for the delivery of nursing services in the facility. Manages facility employees in the provision of care and services according to professional standards of nursing practice .enable each resident to attain or maintain the highest practicable physical, mental and psycho-social well-being . During a review of the facility's JD: Licensed Vocational Nurse (LVN), dated 3/1/14, the JD indicated the Essential Job Functions: perform assigned resident care duties in a manner that provides for the physical, psycho-social, and spiritual needs of the chronically ill and technologically dependent resident . During a review of the facility's policy and procedure (P&P) titled, Dignity dated 2/2021, the P&P indicated 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered .

Based on observation, interview, and record review the facility failed to ensure the medication error rate was less than five percent when the facility ' s medication error rate was 7.41 percent. There were 27 opportunities for errors and two medication errors occurred with two of five sampled residents (Resident 134 and Resident 26) when: 1.Resident 134 was administered the incorrect dose of K2 Plus D3 (potassium vitamin and vitamin D) Oral Tablet [PHONE NUMBER] MCG [microgram]-UNIT This failure resulted in Resident 134 receiving the incorrect dose of medication. 2.Licensed Vocational Nurse (1) did not follow the order for Lidocaine External Patch 4 % (topical anesthetic that numbs pain by blocking the nerve signals to the skin) for Resident 26. This failure had the potential to result in ineffective pain management for Resident 26. Findings: 1. During a medication pass observation on 4/20/25 at 7:40 a.m. with LVN 11 in front of Resident 134 ' s room at the medication cart, LVN 11 removed K2 D3 90 mcg + 125 mcg (5000 iU [international units- measurement used to quantify vitamins]) from the medication cart. After the medication was removed from the cart, LVN 11 verified the medication bottle with the order and removed one vitamin tablet from the bottle and placed it in a medication cup. Once all medications were pulled, LVN 11 entered Resident 134 ' s room, informed Resident 134 of all the medications he was given and the resident self-administered all medications. During a review of Resident 134 ' s Order Summary Report (OSR) dated 5/6/25, the OSR indicated, . K2 Plus D3 Oral Tablet [PHONE NUMBER] MCG-UNIT (Vitamin D & K) Give 1 tablet by mouth two times a day for supplement . Order Status: Active . Start Date: 04/08/2025 . During a concurrent interview and record review on 4/20/25 at 11:05 a.m. with LVN 11, Resident 134 ' s Order Details (undated) was reviewed. The Order Details indicated, .K2 Plus D3 Oral Tablet [PHONE NUMBER] MCG-UNIT LVN 11 then pulled the medication bottle used to administer for this order from the medication cart and stated the medication that was given was K2 D3 90 mcg + 125 mcg (5000 iU) and does not match the order. LVN 11 stated Resident 26 did not receive the correct dose of the medication. LVN 11 stated it is important to check the medication bottle to confirm it matches the order and the resident receives the adequate amount. 2. During a medication pass observation on 4/20/25 at 8:13 a.m. with LVN 1 in front of Resident 26 ' s room at the medication cart, LVN 1 removed a box of Lidocaine patches that contain individual Lidocaine foil packages from the medication cart drawer and confirmed the order with the box. Once the box was removed, LVN 1 removed one packet of Lidocaine patch from the box, opened the packet and kept the Lidocaine patch in the foil package. LVN 1 entered Resident 26 ' s room, and asked Resident 26 if she would like the lidocaine patch placed on her back or right wrist. Resident 26 stated she wanted the patch on her right wrist and LVN 1 removed the patch from the foil package and placed the Lidocaine patch on Resident 26 ' s right wrist. LVN 1 did not label the patch with a time of placement and the initials of who placed it. During a review of Resident 26 ' s OSR dated 5/6/25, the OSR indicated, .Lidocaine External Patch 4% (Lidocaine) Apply to Back topically one time a day for Back Pain 12 hours on and 12 hours off and remove per schedule . Order Status: Active . Start Date: 10/12/2023 . During a concurrent interview and record review on 4/20/25 at 1:30 p.m. with LVN 1, Resident 26 ' s Order Details (undated) was reviewed. The Order Details indicated, .Order Summary: Lidocaine External Patch 4% (Lidocaine) Apply to Back topically one time a day for Back Pain 12 hours on and 12 hours off and remove per schedule . LVN 1 stated the order was not followed when Lidocaine patch was placed on Resident 26 ' s right wrist. LVN 1 stated it is important to follow the physician ' s order for accuracy and safety. During an interview on 5/2/25 at 3:46 p.m. with the Director of Nursing (DON), the DON stated the K2 Plus D3 order was not followed and the incorrect dose was administered. The DON stated the Lidocaine patch was applied incorrectly and the order was not followed. The DON stated the expectation is for medication orders to be followed and for the physician to be notified if there needs to be a change in the order. During a review of Job Description Licensed Vocational Nurse (LVN) dated 3/1/14, the Job Description LVN indicated, .Administer medications in a proficient manner, including pain management . During a review of the facility ' s policy and procedure (P&P) Administering Medications dated 4/2019, the P&P indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame . 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, or is unavailable for administration, the person preparing or administering the medication will; contact the prescribers, the resident ' s Attending Physician or the facility ' s Medical Director to discuss the concerns .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .

Based on observation, interview, and record review the facility failed to appropriately store and label medication for three of eight medication carts and one of four medication storage rooms and had incomplete 41 of 106 Narcotic (substance used to treat moderate to severe pain) medication disposal sheets when: 1. Medication cart on station three had: one of four eye drops (Resident 354) with no open date, two dabigatran (blood thinner medication that can treat and prevent blood clots) bottles (Resident 355 and Resident 356) opened with no open date labeled, one bottle of morphine (narcotic medication used to treat pain) with no patient label for Resident 357, four of 11 inhalers (a handheld medical device used to deliver medication directly into the lungs through inhalation) (Resident 355 and Resident 354) with no open date, and one inhaler (Resident 356) with no patient label and open date. 2. Medication cart on station one had: one of eight resident insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) bottles (Resident 38) with no open date, one unlabeled bottle of Diphenhydramine (medication to treat the symptoms of allergies and allergic reactions), four of 12 eye drop medication bottles (Resident 120, Resident 132, Resident 46, Resident 38) with no open date, one cyclosporin ophthalmic (used to increase tear production in people with dry eye disease) medication with no patient label and no open date, two of 11 inhalers (Resident 140 and Resident 16) with no patient label, one of 11 inhalers (Resident 16) with a discontinued order, and one of six eye drop packets (Resident 16) with no open date. 3. Medication cart on station two had: two of eight insulin bottles (Resident 34 and Resident 26) with no open date, four of 12 inhalers (Resident 31, Resident 138, Resident 29, and Resident 131) with no open date, three of five breathing treatment boxes (Resident 97, Resident 21, and Resident 131) with no open dates, and one of five breathing treatment boxes (Resident 21) expired. 4. Station two medication storage room had a discontinued medication for Resident 98 in the refrigerator. These failures had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications and result in adverse reactions from medications stored incorrectly, expired and improperly labeled. 5. Narcotic count sheets for narcotics due for disposal and stored in medication room one were not signed appropriately. This failure had the potential to result in a loss of narcotics due to incomplete documentation. Findings: 1. During a concurrent observation and interview on [DATE] at 11:50 a.m. with Licensed Vocational Nurse (LVN) 12 at one of three medication carts on station three, observed Azelastine Drop 0.05% (eye drop solution) medication for Resident 354 with no open date. LVN 12 stated only saw expiration date on the medication and no open date. During a record review of Resident 354 ' s Order Details (undated), the Order Details indicated, .Order Summary: Azelastine HCL Ophthalmic [eye] Solution . Instill 1 drop in both eyes every 12 hours for dry eyes. The Order Details indicated the medication had a start date of [DATE] and indefinite end date. During an observation on [DATE] at 11:58 a.m. with LVN 12 at one medication cart on station three, observed two bottles of dabigatran for Resident 355 and Resident 356 with no open date. During an interview on [DATE] at 12:14 p.m. with LVN 12, LVN 12 stated it is important for dabigatran medication to have an open date to ensure the medication is not expired and has not passed its date of use. During a review of Resident 355 ' s Order Details (undated), the Order Details indicated, Order Summary: Dabigatran Etexilate Mesylate Oral Capsule 150 mg [milligram] . Give 1 capsule by mouth two times a day for atrial fibrillation [irregular and very rapid heart rhythm], do not chew, crush or open capsule. The Order Details indicated the start date for the medication was [DATE] with an indefinite end date. During a review of Resident 356 ' s Order Details (undated), the Order Details indicated, Order Summary: Dabigatran Etexilate Mesylate Oral Capsule 150 mg . Give 1 capsule by mouth every 12 hours for clot [semi-solid mass of blood cells and other substances that form in the blood vessel] prevention. Take with full glass of water. Do not break, chew or open capsule. The Order Details indicated the start date for the medication was [DATE] with an indefinite end date. During a concurrent observation and interview on [DATE] at 12:01 p.m. with LVN 12 at one medication cart on station three, observed a medication bottle of morphine for Resident 357 with no patient label on the bottle. LVN 12 confirmed there was no patient label on the bottle but there should have been one. LVN 12 stated it is important to have a patient label on the medication bottle to prevent medication error and ensure correct medication is given to the right patient. During a review of Resident 357 ' s Order Details (undated), the Order Details indicated, Order Summary: Morphine Sulfate (Concentrate) solution 20 MG [milligram-unit of measure]/ML [milliliter- unit of measure] . Give 0.25 mL by mouth every 4 hours as needed for moderate to severe pain with pain scale of 6-,d+[DATE]. The Order Details indicated the start date for the medication was [DATE] with an indefinite end date. During an observation on [DATE] at 12:08 p.m. with LVN 12 at one medication cart on station three, observed two inhalers, tiotropium (medication used to control symptoms of chronic obstructive pulmonary disorder [COPD- chronic lung disease causing difficulty in breathing] by relaxing your airways and keeping them open) and fluticasone-salmeterol (combination of two medications used to help control symptoms of asthma [chronic lung condition characterized by recurrent episodes of wheezing, shortness of breath, chest tightness and coughing] and improve breathing) aerosol (suspension of fine solid particles or liquid droplets in air or another gas) ,d+[DATE], for Resident 355 and two inhalers, Ipratropium-Albuterol (medication used to treat and prevent symptoms caused by ongoing lung disease) and Budesonide/Formoterol aerosol (medication used to help control symptoms of asthma and improve lung function), for Resident 354 with no open date on the inhaler. Observed one inhaler of ciclesonide (long-acting corticosteroid medication that works over time to lower inflammation in the lungs) for Resident 356 with no patient label and no open date on the inhaler. During a review of Resident 355 ' s Order Details (undated), the Order Details indicated, Order Summary . (Tiotropium Bromide Monohydrate) 2 puff inhale orally one time a day for COPD. The Order Details indicated the medication start date was [DATE] with an indefinite end date. During a review of Resident 355 ' s Order Details (undated), the Order Details indicated, Order Summary . (Fluticasone-Salmeterol) 1 puff inhale orally two times a day for COPD, rinse mouth well after use. The Order Details indicated the medication start date was [DATE] with an indefinite end date. During a review of Resident 354 ' s Order Details (undated), the Order Details indicated, Order Summary .Ipratropium-Albuterol Inhalation Aerosol Solution ,d+[DATE] MCG [microgram]) 1 inhalation inhale orally every 12 hours for COPD rinse mouth after use. The Order Details indicated the medication start date was [DATE] with an indefinite end date. During a review of Resident 354 ' s Order Details (undated), the Order Details indicated, Order Summary . (Budesonide-Formoterol Fumarate Dihydrate) 1 inhalation inhale orally every 12 hours for COPD rinse mouth after use. The Order Details indicated the medication start date was [DATE] with an indefinite end date. During a review of Resident 356 ' s Order Details (undated), the Order Details indicated, Order Summary . (Ciclesonide) 1 puff inhale orally every 12 hours for cough/SOB [shortness of breath]. Rinse mouth with water and spit out after each use to reduce the risk of fungal infection. The Order Details indicated the medication start date was [DATE] with an indefinite end date. During an interview on [DATE] at 5:07 p.m. with the Contracted Pharmacist (CP), CP stated the pharmacy is responsible for labeling all inhaler boxes and the inhalers themselves that do not come in foil packaging with patient labels. CP stated inhalers that do not have patient labels must be discarded and pharmacy must be notified for a new inhaler with a patient label can be sent out. 2. During an observation on [DATE] at 1:49 p.m. with LVN 13 at one of three medication carts on station one, observed one bottle of Insulin Glargine (a long-acting synthetic insulin used to treat type 1 diabetes [condition where pancreas makes little or no insulin which leads to high blood sugar levels] and type 2 diabetes [long term condition where the body has trouble controlling blood sugar and using it for energy]) for Resident 38 with no open date written on the bottle. Observed an unlabeled bottle of Diphenhydramine with pills inside. Diphenhydramine was written on the bottle in black ink with no pharmacy label. Observed five eye drop bottles with no open dates written on the bottle that included: gentamicin solution 3% (antibiotic used to treat certain bacterial infections of the eye) for Resident 120, latanoprost solution 0.005% (prescription eye medication used to lower high eye pressure) for Resident 132, azelastine drop for Resident 46, and latanoprost solultion 0.005% for Resident 38. Observed cyclosporin ophthalmic emulsion 0.05% with no patient label and no open date. Observed two inhalers, Fluticasone/Vilanterol inhaler (medication combination to help control symptoms of asthma and improve lung function) for Resident 140 and fluticasone for Resident 16, with no resident label. Observed fluticasone for Resident 16, with an expired order and no open date, in the cart. During a review of Resident 38 ' s Order Details (undated), the Order Details indicated, Order Summary . (Insulin Glargine) Inject 40 unit subcutaneously [under the skin] at bedtime for DM [Diabetes Mellitus] type 2 Hold for [Blood Sugar less than] 110. The Order Details indicated the medication start date was [DATE] with an indefinite end date. During a review of Resident 120 ' s Order Details (undated), the Order Details indicated, Order Summary: Gentamicin Sulfate Solution 0.3% Instill 1 drop in both eyes three times a day for 7 days. The Order Details indicated the medication start date was [DATE] with an end date duration of 7 days. During a review of Resident 132 ' s Order Details (undated), the Order Details indicated, Order Summary: Latanoprost Ophthalmic Solution 0.005% . Instill 1 drop in left eye one time a day . The Order Details indicated the medication start date was [DATE], with an indefinite end date. During a review of Resident 46 ' s Order Details (undated), the Order Details indicated, Order Summary: Azelastine HCL Ophthalmic Solution 0.05% . Instill 1 drop in both eyes two times a day for eye irritation and dryness. The Order Details indicated the medication start date was [DATE], with an indefinite end date. During a review of Resident 38 ' s Order Details (undated), the Order Details indicated, Order Summary: Latanoprost Solution 0.005% Instill 1 drop in both eyes at bedtime The Order Details indicated the medication start date was [DATE] with an indefinite end date. During a review of Resident 140 ' s Order Details (undated), the Order Details indicated, Order Summary . (Fluticasone Furoate-Vilanterol) 1 inhalation orally one time a day for asthma, rinse mouth well after use. The Order Details indicated the medication start date was [DATE] with an indefinite end date. During a review Resident 16 ' s Order Summary Report (OSR) dated [DATE], the OSR indicated, . (Fluticasone Propionate HFA) 1 puff inhale orally every 12 hours for wheezing rinse mouth and spit out after every use . Order Status: Discontinued . Start Date: [DATE] . During an interview on [DATE] at 2:11 p.m. with LVN 13, LVN 13 stated it is important to place an open date and patient label on the medication itself and not just the box because if the medication is separated from the box could lead to a medication error. LVN 13 stated with the Diphenhydramine bottle, it should have had an appropriate pharmacy label because if there is no label will not know if the medication is Diphenhydramine. During an interview on [DATE] at 10:53 a.m. with Pharmacist Consultant (PC), PC stated the bottle of Diphenhydramine should not have been in the medication cart and should have had an appropriate pharmacy label. PC stated it is important to have a pharmacy label on the medication because it is unknown if it is the correct medication. During an interview on [DATE] at 3:49 p.m. with the Director of Nursing (DON), the DON stated the expectation is for the nurse is to remove an expired or discontinued medication from the medication cart. The DON stated it is important to remove discontinued or expired medication from the medication cart to prevent a medication error. The DON stated it was inappropriate for the bottle of Diphenhydramine to remain in the medication cart with no pharmacy label. The DON stated the expectation to have proper labels on all medication. 3. During an observation on [DATE] at 2:35 p.m. with LVN 15 at one of two medication carts on station two, observed two insulin bottles, Insulin Glargine for Resident 34 and Insulin Glargine for Resident 26, with no open date. Observed four inhalers, Albuterol Sulfate (medication used to prevent and treat wheezing and SOB caused by breathing problems) for Resident 31, Ipratropium-Albuterol for Resident 138, Tiotropium Bromide for Resident 29, and Albuterol Sulfate for Resident 131, with no open date. Observed four breathing treatment medication boxes, six packages of Levalbuterol nebulizer (device for producing a fine spray of liquid) for Resident 97, 30 vials of Albuterol for Resident 20, 13 vials of Albuterol nebulizer for Resident 21, and one of five packets of Ipratropium solution albuterol for Resident 131, with opened foil pouches and no open date on the pouches. During an interview on [DATE] at 2:49 p.m. with LVN 15, LVN 15 stated open dates should be placed on the medication itself because if the medication was separated from the box will not know when the medication was opened. During a review of Resident 34 ' s Order Details (undated), the Order Details indicated, Order Summary . (Insulin Glargine) Inject 45 unit subcutaneously every 12 hours for DM (Hold if FSBS [fasting blood sugar less than] 100). The Order Details indicated the start date was [DATE] with an indefinite end date. During a review of Resident 26 ' s Order Details (undated), the Order Details indicated, Order Summary: Insulin Glargine Subcutaneous Solution . Inject 20 unit subcutaneously at bedtime for DM 2 . The Order Details indicated the start date was [DATE] with an indefinite end date. During a review of Resident 34 ' s Order Details (undated), the Order Details indicated, Order Summary . (Insulin Glargine) Inject 45 unit subcutaneously every 12 hours for DM (Hold if FSBS [fasting blood sugar less than] 100). The Order Details indicated the start date was [DATE] with an indefinite end date. During a review of Resident 31 ' s Order Details (undated), the Order Details indicated, Order Summary . (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for asthma. The Order Details indicated the start date was [DATE] with an indefinite end date. During a review of Resident 138 ' s Order Details (undated), the Order Details indicated, Order Summary . (Ipratropium-Albuterol) 1 puff inhale orally at bedtime for shortness of breath and wheezing AND 1 puff inhale orally every 6 hours as needed for SOB and wheezing. The Order Details indicated the start date was [DATE] with an indefinite end date. During a review of Resident 29 ' s Order Details (undated), the Order Details indicated, Order Summary . (Tiotropium Bromide Monohydrate) 2 puff inhale orally one time a day related to UNSPECIFIED ASTHMA . The Order Details indicated the start date was [DATE] with an indefinite end date. During a review of Resident 131 ' s OSR dated [DATE], the OSR indicated, . (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for sob/wheezes . Order Status: Active . Start Date: [DATE] . During a review of Resident 97 ' s OSR dated [DATE], the OSR indicated, .Albuterol Sulfate Nebulization Solution .3 mL inhale orally via nebulizer every 6 hours as needed for shortness of breath/congestion .Order Status: Active . Start Date: [DATE] . During a review of Resident 20 ' s Order Details (undated), the Order Details indicated, Order Summary . Albuterol Sulfate Inhalation Nebulization Solution . 3 mL inhale orally via nebulizer every 8 hours . The Order Details indicated the start date was [DATE] with an indefinite end date. During a review of Resident 21 ' s OSR dated [DATE], the OSR indicated, .Albuterol Sulfate Nebulization Solution .3 mL inhale orally via nebulizer every 6 hours as needed for shortness of breath .Order Status: Active . Start Date: [DATE] . During a review of Resident 131 ' s OSR dated [DATE], the OSR indicated, .Ipratropium-Albuterol Inhalation Solution . 3 mL inhale orally every 6 hours as needed for SOB .Order Status: Active . Start Date: [DATE] . During an interview on [DATE] at 3:14 p.m. with LVN 15, LVN 15 stated it is important to have an open date placed on breathing treatment medications that come in a foil pouch and are open because they have a stricter expiration date. During an interview on [DATE] at 3:49 p.m. with the Director of Nursing (DON), the DON stated breathing treatment medications that are removed from a foil pouch need to have an open date. The DON stated this is important because the expiration date for the medication will depend on when the medication was removed from the foil pouch During a review of the manufacturer guidelines titled Patient Information Leaflet Levalbuterol Inhalation Solution, USP (undated), the Patient Information Leaflet Levalbuterol Inhalation Solution, USP indicated, . When a Levalbuterol Inhalation Solution, USP foil pouch is opened, use vials within 2 weeks. When Levalbuterol Inhalation Solution, USP vials are removed from the foil pouch, use them right away or within 1 week . During a professional reference review of Medication Guide (dabigatran etexilate) Capsules dated 2023, the Medication Guide (dabigatran etexilate) Capsules indicated, .After opening the bottle, uses [dabigatran] capsules within 4 months. Safely throw away any unused [dabigatran] capsules after 4 months . https://pro.boehringer-ingelheim.com/us/products/[brand name]/bipdf/[brand name]-capsules-us-mg 4. During a concurrent observation and interview on [DATE] with LVN 16 in station two medication room, observed a bottle of Oseltamivir suspension for Resident 98 in the medication refrigerator. LVN 16 stated this medication was completed. LVN 16 stated because the medication order was completed, this medication should have been removed from the refrigerator. LVN 16 stated it is important to remove medications of expired residents to make room for additional medications and to prevent medication error. During a review of Resident 98 ' s OSR dated [DATE], the OSR indicated, . (Oseltamivir Phosphate) Give 12 mL by mouth every 12 hours for Influenza for 5 days.3 mL inhale orally every 6 hours as needed for SOB .Order Status: Completed . Start Date: [DATE] .End Date: [DATE] 5. During a concurrent observation and interview on [DATE] at 5:01 p.m. with the DON in station one medication storage room, observed the locked cabinet for the narcotic medications due for disposal. After the locked cabinet was opened, observed two bins of narcotic medications due for disposal. Observed 41 narcotic count sheets that had incomplete documentation. Did not observe the sign off by the LVN and DON and the date the medication was removed from the cart. The DON confirmed the documentarian was incomplete and a sign off between herself and the LVN responsible for the medication was not completed. The DON stated it is important to correctly collect and sign off on Narcotic medication count sheets due for disposal with the LVN to ensure the medication and count sheet numbers match and are accurate. During an interview on [DATE] at 10:26 a.m. with PC, PC stated the process for narcotic medication disposal is the DON will coordinate with the LVN of the medication cart and review narcotic medication due for disposal. Once the medication is identified, the LVN and DON will count the medication and ensure the medication count matches with the narcotic count sheet. Once the count is completed, both the LVN and DON will sign and date the narcotic count sheet and DON will collect the medication and count sheet and place in the double locked cabinet in station one medication storage room. PC stated with the 41 narcotic count sheets that did not have the LVN and DON sign off and date, the process was not followed. PC stated it is important to follow the process because there is a potential for medication to go missing or diversion. During a review of the facility ' s policy and procedure (P&P) titled Disposal of Medications and Medication-Related Supplies Controlled Substance Disposal dated ,d+[DATE], the P&P indicated, .E. The [administrator], nurse(s) and/or pharmacist witnessing the destruction ensures that the following information is entered on the [individual controlled substance accountability record/book]: 1) Date of destruction. 2) Resident ' s name. 3) Name and strength of medication. 4) Prescription number. 5) Amount of medication destroyed. 6) Signatures of witnesses . During a review of the facility ' s P&P titled Labeling of Medication Containers dated ,d+[DATE], the P&P indicated, .2. Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy .6. Labels for over-the-counter drugs include all necessary information, such as: a. The original label indicating the name, strength, and quantity of the medication; b. The expiration date when applicable; and c. Directions for use and appropriate accessory/cautionary statements . During a review of the facility ' s P&P titled Storage of Medications dated ,d+[DATE], the P&P indicated, .4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . During a review of the facility ' s P&P titled Administering Medications dated ,d+[DATE], the P&P indicated, . 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container .

Based on observation, interview and record review, the facility failed to ensure residents had a means to contact caregiver for two of the 22 sampled residents (Resident 206 and Resident 253) when call lights were not within reach of Resident 206 and Resident 253. This failure did not allow Resident 206 and 253 to call for assistance and put Resident 206 and 253 at risk of not having their needs met and falls. Findings: During a review of Resident 253 s Admission Record (AR) (document containing resident demographic information and medical diagnosis) dated [DATE] , the AR indicated Resident 253 was admitted to the facility on [DATE] with diagnoses of cellulitis (a bacterial infection of the skin and underlying tissues) of lower limbs, asthma (a chronic lung disease that causes inflammation and narrowing of the airways, making it difficult to breathe), atrial fibrillation (a common heart rhythm disorder where the heart's upper chambers (atria) beat irregularly and too quickly), hyperlipidemia (an elevated level of lipids (fat) in your blood) , hypertension (high blood pressure) and difficulty in walking. During a review of Resident 253 s Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE], the MDS, indicated Resident 253's had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of ,d+[DATE] ) score of 6 (a score of ,d+[DATE] suggests severe cognitive impairment, ,d+[DATE] suggests moderately impaired, ,d+[DATE] suggests cognitively intact) indicating Resident 253 was severely cognitively impaired. During a review of Resident 253's Care Plan Report (CPR) dated [DATE] was reviewed, The CPR indicated, [box]Focus: The resident is at risk for falls r/t [related to] confusion, decondition [the decline in physical function caused by inactivity, often due to bedrest or a sedentary lifestyle] .[box]Interventions; be sure the residents call lights is within reach and encourage the resident to use it for assistance when needed . During a concurrent observation and interview on [DATE] at 3:01 p.m. in Resident 253' s room, Resident 253 was in bed in a flat position and his call light was at the nightstand table not within reach. Resident 253 stated he cannot reach his call light. Resident 253 stated he needed the call light to call the staff member for help. During a concurrent observation and interview on [DATE] at 3:07 p.m. with CNA 8, CNA 8 stated the call light should have been within reach of Resident 253. CNA stated the call light was at the nightstand and confirmed it was not within reach of Resident 253. CNA 8 stated Resident 253 was not able to ask for help without his call light. CNA 8 stated CNAs should have made sure the call light was next to Resident 253 and within reach after providing care. CNA 8 stated all the staff members were responsible for making sure the call lights were within each. CNA stated Resident 253 could not make his needs known and could have fallen from the bed trying to reach for the call light. During an interview on [DATE] at 11:21 a.m. with LVN 14, LVN 14 stated, all call lights should have been within reach so residents could call for help. LVN 14 stated residents were at risk for not making their needs know and falls when they were not able to call for help. LVN 14 stated Resident 253 could have fallen out of bed and hurt himself while trying to reach for the call light. LVN 14 stated residents need the call light to ask for assistance to use restroom. LVN 14 stated residents could have an accident and felt embarrassed if they soiled themselves. LVN 14 stated residents could have been upset and angry if they were not able to ask for help. LVN 14 stated all the staff members were responsible for making the call lights within reach of the residents. During an interview on [DATE] at 11:05 a.m. with the (DSD), the DSD stated all call lights should have been within reach of residents. The DSD stated the call lights were needed to make sure the residents were safe and to ask for help. The DSD stated residents would not be able to call for help when the call lights were not within reach. The DSD stated residents were at risk of falls when they could not get the help they needed. During a concurrent interview and record review at [DATE] at 10:47a.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Answering the Call Light dated ,d+[DATE] was reviewed. The P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's request and needs .Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor . The DON stated, call lights should be within reach and not at the nightstand away from Resident 253's reach. The DON stated Resident 253 could not ask for help if his call light was not within reach. The DON stated we did not follow our policy and procedure. 48739 During a concurrent observation and interview on [DATE] at 3:34 p.m. with Resident 206 in Resident 206's room, Resident 206 was observed dressed in a gown wearing an oxygen nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen), non-slid socks, seated on the side of her bed in her wheelchair, watching television (TV) with her bedside table placed in front of her. Resident 206 stated she wanted to get back into bed but did not know where her call light was. Certified Nursing Assistant (CNA) 11 was called into Resident 206's room and found Resident 206's call light wrapped around the bed rail on the other side of the bed from where Resident 206 was seated. CNA 11 stated the call light should have been next to Resident 206, where she could reach it. CNA 11 stated there was no other way the Resident 206 could have called for help unless she yelled for help. During a review of Resident 206's AR, dated [DATE], the AR indicated Resident 206 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of metabolic encephalopathy (a condition where brain function is disturbed due to different diseases or toxins [poisons] in the blood), acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), dysphagia (difficulty swallowing), and difficulty walking. During a review of Resident 206's MDS, dated [DATE], the MDS section C indicated Resident 206 had a BIMS score of five, which indicated Resident 206 was severely cognitively impaired. During a review of Resident 206's Care Plan (CP), undated, the CP indicated, . the resident is at risk for falls . be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . During an interview on [DATE] at 10:39 a.m. with the Director of Staff Development (DSD), the DSD stated call lights should have been placed within reach of each resident. The DSD stated the nurse, CNA, or anyone assisting the resident was responsible for making sure the call light was within resident's reach. The DSD stated it was not acceptable for the Resident 206's call light to be out of reach of the resident and it was not acceptable for CNA to say Resident 206 could have yelled for help. The DSD stated if residents' call lights were not within reach of the residents, it could have been a safety issue. The DSD stated if the residents felt they had a need and needed staff to attend to them, they should have been able to call the staff. The DSD stated if a resident could not get help, it could be a fall risk. The DSD stated the CNAs were in and out of resident's rooms daily and should have been sure the call lights were within Resident 206's reach. The DSD stated she did not do auditing or monitoring of resident's call light placement. The DSD stated call light placement were basic nursing knowledge. During a review of the facility policy and procedure (P&P) titled, Answering the Call Light, dated ,d+[DATE], indicated, . the purpose of this procedure is to ensure timely responses to the resident's requests and needs . ensure that the call light is accessible to the resident .

Based on observation, interview, and record review, the facility failed to ensure resident's drug regimen was free from unnecessary drugs for two of 53 residents (Resident 132 and Resident 203) when: 1. Resident 132 did not have antipsychotic (a type of drug used to treat symptoms of psychosis) medication monitoring in place for Seroquel (an antipsychotic medication that treats mental health conditions) and did not have behavior monitoring in place while receiving Haloperidol (antipsychotic medication used to treat certain types of mental disorders). This failure resulted in Resident 132 not receiving antipsychotic medication and behavior monitoring which had the potential to result in adverse consequences and complications which could lead to serious medical condition. 2. Resident 203 did not have adequate indications for the use of quetiapine, an antipsychotic medication. This failure had the potential for Resident 203 to receive an unnecessary psychotropic medication and put Resident 203 at risk of adverse (harmful or unfavorable) side effects from the use of the medication. Findings: 1. During a review of Resident 132's Admission Record (AR- document containing resident personal information), dated 5/6/25, the AR indicated, Resident 132 was admitted to the facility on [DATE], with diagnoses which in included dementia (gradual decline in cognitive abilities), anxiety (feelings of worry, unease, and anticipation of potential danger) and palliative care (medical care focused on providing relief from symptoms of condition). During a review of Resident 132's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/20/25, the MDS assessment indicated Resident 132's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 12 out of 15 which indicated Resident 132 had moderate cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a review of Resident 132's Order Summary Report (OSR) dated 5/6/25, the OSR indicated, .Haloperidol Oral Tablet 1 [milligram] . Give 1 tablet by mouth every 12 hours for Dementing [adjective describing something that causes or is characterized by dementia. A condition involving cognitive decline and memory loss] illnesses with associated behavioral symptoms . State Date: 02/27/2025 . The OSR did not indicate what specific behaviors to monitor for Haloperidol. During a review of Resident 132's Order Summary Report (OSR), dated 5/6/25, the OSR indicated, Resident 132 had an active order for .Seroquel oral tablet 100 MG [milligrams- a measurement of weight of how much medicine is in the tablet] . with a start date of 12/8/24. The OSR did not include Seroquel medication monitoring orders. During a review of Resident 132's Care Plan (CP) Report dated 5/23/24, the CP Report indicated, [Resident] uses psychotropic [drugs that can affect a person's mental state] medications ([Quetiapine - ] [Haloperidol as needed] [related to] psychosis [severe mental condition in which though, and emotions are so affected that contact is lost with reality] with agitation. Date initiated: 05/23/2024 . During an interview on 5/6/25 at 10:46 a.m. with Licensed Vocational Nurse (LVN) 11, LVN 11 stated Seroquel was an antipsychotic medication, and all antipsychotic medications required monitoring orders. LVN 11 stated it was important to ensure antipsychotic mediations were monitored to assess for adverse consequences. During an interview on 5/6/25 at 11:03 a.m. with the Assistant Director of Nursing (ADON), the ADON stated behavior monitoring must be done for both as needed and routine antipsychotic medications. The ADON stated with every new antipsychotic order, there will be a new order for behavior monitoring. During a concurrent interview and record review on 5/6/25 at 11:03 a.m. with the ADON, Resident 132's record on Point Click Care (define) was reviewed. The ADON stated she was unable to locate behavior monitoring for Haloperidol. The ADON stated behavior monitoring must be done because it will go with the psychotropic medication order. The ADON stated it is important to have behavior monitoring to determine if a dose reduction or removing the resident from the medication can be done. During a concurrent interview and record review on 5/6/25 at 11:03 a.m. with the Assistant Director of Nursing (ADON), Resident 132's OSR, dated 5/6/25 was reviewed. The ADON stated Resident 132 had an active order for Seroquel medication. The ADON stated Seroquel was an antipsychotic medication. The ADON stated she could not locate Seroquel medication monitoring orders within the OSR. The ADON could not locate any Seroquel medication monitoring within Resident 132's electronic medical chart. The ADON stated all antipsychotic medications, including Seroquel needed monitoring orders. The ADON stated all members of the healthcare team were responsible for ensuring antipsychotic medication monitoring orders were in place. The ADON stated it was important to have antipsychotic medication monitoring orders in place to ensure behaviors were monitored and no side effects occurred. The ADON stated without Seroquel medication monitoring orders Resident 132 was at risk of not being assessed or monitored for adverse consequences. During an interview on 5/6/25 at 12:23 p.m. with the Director of Nursing (DON), the DON stated behavior monitoring should be ordered for residents on antipsychotic medications. The DON stated it is important to have behavior monitoring in place because if not in place, if a resident has an unwanted side effect, staff will not know the side effect is related to the antipsychotic medication the resident has received. During a concurrent interview and record review on 5/6/25 at 12:23 p.m. with the Director of Nursing (DON), Resident 132's OSR, dated 5/6/25 was reviewed. The DON stated Resident 132 had received Seroquel medication since admission. The DON stated Seroquel was an antipsychotic medication. The DON stated she could not locate Seroquel medication monitoring orders. The DON stated all members of the healthcare team were responsible to ensure antipsychotic medication monitoring orders were in place. The DON stated it was important to have antipsychotic medication monitoring order in place to monitor for potential side effects of the medication. The DON stated Resident 132 was at risk for serious medical condition with no medication monitoring in place. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated, .resident's receiving psychotropic medications are monitored for adverse consequences . During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use dated 7/2022, the P&P indicated, .2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others . 11. For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are .b. persistent or likely to reoccur without continued treatment; and c. not sufficiently relived by non-pharmacological [behavioral] interventions . the staff will observe, document, and report to the attending physician and adverse consequences of antipsychotic medications to the attending physician . nursing staff shall monitor for and report any .side effects and adverse consequences of antipsychotic medications to the attending physician . 2. During a concurrent observation and interview on 4/28/25 at 12:20 p.m. with Resident 203, in Resident 203's room, Resident 203 was observed dressed, lying in bed, right and left head rails up, with no padding on the bed rails, eating her meal. Resident 203 stated she had been at the facility long enough. Resident 203's Mother (RP 1) and husband (RP 2) were sitting in chairs on both sides of Resident 203's bed. RP 1 stated Resident 203 had lots of confusion since 4/21/25. RP 1 stated Resident 203 had a seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness] disorder), muscle weakness, and hit her head. RP 1 stated Resident 203 had a brain bleed. Resident 203 stated she was doing good, and staff were ok with her physical therapy treatment. RP 1 stated Resident 203 had a 50/50 chance of getting better. During a review of Resident 203's AR, dated 5/1/25, the AR indicated Resident 203 was admitted to the facility from an acute care hospital on 4/21/25 with diagnoses of traumatic subdural hemorrhage (bleeding in the area between the brain and the skull), contusion (bruising) and laceration (cut) of cerebrum (the part of the brain in the front area of the skull), difficulty walking, dysphagia (difficulty swallowing), cognitive communication deficit (difficulty with thinking and how someone uses language), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), alcohol use, and cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged). During a review of Resident 203's MDS, dated [DATE], the MDS section C indicated Resident 203 had a BIMS score of 3, which suggested Resident 203 was severely cognitively impaired. During a concurrent interview and record review on 5/01/25 at 12:05 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 203's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated, . quetiapine fumarate . give 1 tablet by mouth two times a day for restlessness for 30 days . A review of Resident 203's Medication Administration Record (MAR), dated 4/1/25 to 4/30/25 was reviewed. The MAR indicated, . antipsychotic medication: for (quetiapine) enter the number of times the targeted behavior occurred each shift manifested by (mb) restless every shift . order date . 4/22/25 . A review of Resident 203's CP, dated 5/1/25 was reviewed. The CP indicated, . the resident uses psychotropic medications . date initiated: 4/25/25 . discuss with physician (MD), family re ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy . date initiated: 4/25/25 . the resident is at risk for falls related to (r/t) confusion, . psychoactive drug use . LVN 2 stated resident 203 was taking quetiapine, for restlessness and agitation. LVN 2 stated the physician had not reviewed Resident 203's medication. LVN 2 stated there was no mention of an antipsychotic diagnoses or previous antipsychotic medication use. During a concurrent interview and record review on 5/01/25 at 1:15 p.m. with the Pharmacist Consultant (PC) Resident 203's Order Summary Report, dated 5/1/25 was reviewed. The Order Summary Report indicated, . quetiapine fumarate . give 1 tablet by mouth two times a day for restlessness for 30 days . The PC stated for new admissions, the off-site Pharmacist would have completed a chart review of the resident's medications, diagnoses, labs, orders and appropriateness of the medications, and would give a recommendation to the DON. The PC stated Resident 203's diagnosis of restlessness was not a valid diagnosis for taking quetiapine. The PC stated he found no other diagnosis that would be appropriate for Resident 203 to take quetiapine. The PC stated he would have tried to discontinue this medication for Resident 203, and that non-pharmaceutical measures should have been used first. The PC stated if Resident 203 did not have a psychiatric history, he would have recommended discontinuing the medication. The PC stated he did not find any diagnosis or reasoning to put Resident 203 on the antipsychotic medication quetiapine. During an interview on 5/06/25 at 11:33 a.m. with the DON, the DON stated for antipsychotic orders, the Interdisciplinary Team (IDT) would have completed a review of the resident's medication to be sure they had an appropriate diagnosis. The DON stated the Admissions Pharmacist Consultant would have completed a new admission review to catch any errors on resident's medications. The DON stated her expectation was for nurses to look at physician orders, consents and indications prior to administering antipsychotic medications. The DON would not state the risk for psychotropics given without proper consent or indication. The DON stated it was hard to say what the risks to the resident would be. The DON stated the resident's consent should have had valid diagnosis and indication and staff should know why they are giving the medication so they could have monitored the resident for behaviors or side effects. During a review of the facility P&P titled, Antipsychotic Medication Use, dated 7/2022, indicated, . residents will not receive medications that are not clinically indicated to treat a specific condition . residents will only receive antipsychotic medications when necessary to treat specific conditions or which they are indicated and effective . the attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others . residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use . diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident . antipsychotic medications will not be used if the only symptoms are one or more of the following . restlessness . 51059 2. During a review of Resident 132's Admission Record (AR- document containing resident personal information), dated 5/6/25, the AR indicated, Resident 132 was admitted to the facility on [DATE], with diagnoses which in included dementia (gradual decline in cognitive abilities), anxiety (feelings of worry, unease, and anticipation of potential danger) and palliative care (medical care focused on providing relief from symptoms of condition). During a review of Resident 132's Minimum Data Set (MDS- a resident assessment tool) assessment, dated 2/20/25, the MDS assessment indicated Resident 132's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment score was 12 out of 15 which indicated Resident 132 had moderate cognitive deficit (a decline in thinking abilities, like memory, reasoning, and problem-solving). During a review of Resident 132's Order Summary Report (OSR), dated 5/6/25, the OSR indicated, Resident 132 had an active order for .Seroquel oral tablet 100 MG [milligrams- a measurement of weight of how much medicine is in the tablet] . with a start date of 12/8/24. The OSR did not include Seroquel medication monitoring orders. During an interview on 5/6/25 at 10:46 a.m. with Licensed Vocational Nurse (LVN) 11, LVN 11 stated Seroquel was an antipsychotic medication and all antipsychotic medications required monitoring orders. LVN 11 stated it was important to ensure antipsychotic mediations were monitored to assess for adverse consequences. LVN 11 stated residents were at risk of negative side effects and complications if they were not monitored and assessed as ordered by the physician. During a concurrent interview and record review on 5/6/25 at 11:03 a.m. with the Assistant Director of Nursing (ADON), Resident 132's OSR, dated 5/6/25 was reviewed. The ADON stated Resident 132 had an active order for Seroquel medication. The ADON stated Seroquel was an antipsychotic medication. The ADON stated she could not locate Seroquel medication monitoring orders within the OSR. The ADON could not locate any Seroquel medication monitoring within Resident 132's electronic medical chart. The ADON stated all antipsychotic medications, including Seroquel needed monitoring orders. The ADON stated all members of the healthcare team were responsible to ensure antipsychotic medication monitoring orders were in place. The ADON stated it was important to have antipsychotic medication monitoring orders in place to ensure behaviors were monitored and no side effects occurred. The ADON stated without Seroquel medication monitoring orders Resident 132 was at risk of not being assessed or monitored for adverse consequences. During a concurrent interview and record review on 5/6/25 at 12:23 p.m. with the Director of Nursing (DON), Resident 132's OSR, dated 5/6/25 was reviewed. The DON stated Resident 132 had received Seroquel medication since admission. The DON stated Seroquel was an antipsychotic medication. The DON stated she could not locate Seroquel medication monitoring orders. The DON stated all members of the healthcare team were responsible to ensure antipsychotic medication monitoring orders were in place. The DON stated it was important to have antipsychotic medication monitoring order in place to monitor for potential side effects of the medication. The DON stated Resident 132 was at risk for serious medical condition with no medication monitoring in place. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated, .drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-psychotics, anti-depressants, anti-anxiety medications, and hypnotics .resident's, families and/or the representative are involved in the medication management process. Psychotropic medication management includes .adequate monitoring for efficacy and adverse consequences .resident's receiving psychotropic medications are monitored for adverse consequences . During a review of the facility's P&P titled, Antipsychotic Medication Use , dated 7/2022, the P&P indicated, .the staff will observe, document, and report to the attending physician and adverse consequences of antipsychotic medications to the attending physician . nursing staff shall monitor for and report any .side effects and adverse consequences of antipsychotic medications to the attending physician .

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of seven sampled residents (Resident 57) when Resident 57 toenails were not cut for more than eight months. This failure resulted in result in resident 57's toenails to become long which had the potential to result in Resident 57 toenails to become painful, ingrown or to break off causing infection. Findings: During a concurrent observation and interview on 4/29/25 at 11:35 a.m. in Resident 57's room, License Vocation nurse (LVN) 1 stated Resident 57 had long toenails. During an interview on 04/29/25 at 11:35 a.m. in Resident 57's room, Resident 57 stated, he requested to have his toenails cut. Resident 57 stated he was worried about getting an infection and scratching staff members from having long toenails. Resident 57 stated he did not remember when the last time he had an appointment with the Podiatrist (foot physician). Resident 57 stated he had been waiting for a long time to see the Podiatrist. During a concurrent interview and record review at 4/29/25 at 12:49 p.m. at the nurse's station with LVN 1, LVN 1 stated he was not sure when the last time Resident 57 had his toenails cut. LVN 1 stated Resident 57 had a physician order (PO- a written or verbal instruction from a doctor (or other authorized healthcare provider) that directs healthcare staff to provide specific care or treatment to a resident) written on 6/3/22 for the Podiatrist visit every 61 days. LVN 1 stated the last time Resident 57 was seen by the Podiatrist was on 7/9/24. LVN 1 stated Resident 57 refused the Podiatrist visit on 9/22/24. LVN 1 stated he was not able to provide any other documents to support Resident 57 refusal of the Podiatrist visits. LVN 1 stated it was important to keep the nails cut to prevent the toenails from getting long and causing ingrown toenails. LVN 1 stated Resident 57 could have a toenail infection and could have scratched himself and caused an infection. During an interview and record review on 5/01/25 at 12:25 p.m. with the Social Services Assistant (SSA) the SSA stated she was responsible for scheduling the transportation. The SSA stated nurses were responsible for scheduling the appointment with the Podiatrist. The SSA stated Resident 57 was seen by the Podiatrist on 7/9/24. The SSA stated Resident 57 should have been seen by the podiatrist every 61 days. The SSA stated the podiatrist was at the facility on 3/25/25 and should have seen Resident 57. The SSA stated the Podiatrist was scheduled to see residents every other month. The SSA stated it was important for residents to receive toenail cut for their quality of care. The SSA stated long toenails could have caused scratches, infections and the toenails could have fallen out. The SSA stated residents with long toenails would not be able to wear their shoes and it could have caused pain and discomfort. The SSA stated Resident 57 should have been seen by the Podiatrist. During an interview on 5/2/25 at 10:52 a.m. with the Director of Staff Development (DSD), the DSD stated she expected the Certified Nursing Assistant (CNA) to notify the nurses about long toenails. The DSD stated residents with long toenails could have ingrown toenails which can cause an infection. The DSD stated Resident 57 should have been seen by the Podiatrist so he could have his toenails cut. The DSD stated the nurses should have notified the Social Service Director so Resident 57 could have been added on the list to be seen by the Podiatrist. The DSD stated Resident 57's long toenails were not acceptable. During an interview on 5/2/25 at 3:26 p.m. with the Podiatrist, the Podiatrist stated he was the work for the facility for one year. The Podiatrist stated residents should have been scheduled every 61 days to have their toenails cut. The Podiatrist stated the Social Service Director was responsible for making the schedule. The Podiatrist stated Resident 57 was not scheduled to have his toenails cut. The Podiatrist stated residents with long toenails could have caused an ulcer (open sores). The Podiatrist stated residents with long toenails could have broken off their toes and caused an infection which could have led to an amputation (the surgical removal of a limb or part of a limb due to various reasons like trauma, medical conditions, or disease.) The Podiatrist stated residents with long toenails with poor circulation took a long time to heal when their toenails fell off. The Podiatrist stated Resident 57 should have gotten his toenails cut every 61 days and he should have been seen when he wanted his toenails cut. During an interview and record review on 5/2/25 at 4:36 p.m. with the Infection Preventionist (IP), the IP showed a photo of his Resident 57's long toenails. The IP stated Residents 57's toenails should not have been long. The IP stated the nurses should have made an appointment with the Podiatrist. The IP stated the Podiatrist should have made a visit to cut his nail every month. The IP stated Resident 57's long toenails could cause an infection when he scratched himself. During a concurrent interview and record review on 5/6/25 at 10:51 a.m. with the Director of Nursing (DON) Resident's 57's long toenail photo was reviewed. The DON stated Resident 57's toenails were long. The DON stated Resident 57 should have been seen by the Podiatrist every 61 days and as needed. The DON stated Resident 57's long toenails could have caused scratches and could have caused an infection. The DON stated Resident 57 should have been added to the list of Residents to been seen by the Podiatrist when he requested his toenails to be cut. The DON stated Resident 57 could have felt frustrated when his toenails were not cut. The DON stated there should have been a progress nurse note when resident refused the Podiatrist services. The DON read the policy and procedure and stated we did not follow our policy. During a review of Resident 57's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses: anemia ( a condition where the blood has fewer red blood cells or the red blood cells contain less hemoglobin (a protein that carries oxygen) than normal, resulting in a reduced ability to carry oxygen throughout the body), osteoarthritis (common condition where the cartilage that cushions the ends of bones in joints gradually wears away, leading to pain, stiffness, and limited movement), bed confinement, anxiety (natural human emotion characterized by feelings of worry, nervousness, or unease, often in anticipation of a future threat). During a review of Resident 57's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/13/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 57 was cognitively intact. During a record review of Resident's 57 Physician Order (PO) dated 6/2/2022, the PO indicated, [box] Order Summary: Podiatry service for t/x of hypertrophic toenails &[and]/or other foot problems Q [every] 61 days PRN [as needed] . During a review of the facility's Podiatry List titled, [Facility name] w/ [with] Consent and Medicare dated 12/17/24, the Podiatry List indicated, Resident 57 was not added on the list. During a review of the facility's Podiatry List titled, [Facility name] w/ [with] Consent and Medicare dated 1/10/25, the Podiatry List indicated, Resident 57 was not added on the list. During a review of the facility's Podiatry List titled, [Facility name] w/ [with] Consent and Medicare dated 3/25/25 the Podiatry List indicated, Resident 57 was not added on the list. During a review of the facility's Podiatry List titled, [Facility name] w/ [with] Consent and Medicare dated 12/17/24, the Podiatry List indicated, Resident 57 was not added on the list. During a review of Resident 57's Social Services Progress Note (SSPN) dated 7/14/25, the SSPN indicated, [box]Podiatry in the facility on 7/9/24. Resident was seen for services, refer to chart notes . During a review of Resident 57's Social Services Progress Note (SSPN) dated 9/22/24 the SSPN indicated, [box] Podiatry in the facility on 9/11/24. Resident refused services . During a review of the facility's policy and procedures (P&P) titled, Toenails, Care of dated 2/2018, the P&P indicated, The purpose of this policy is to ensure that residents are provided toenails care in line with standard of practice .3. Refer resident with needs for podiatry services to podiatry .

Based on observation, interview, and record review, the facility failed to review, revise, and implement a person-centered comprehensive care plan for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 had a left hip hemiarthroplasty (a surgical procedure where only one half of a joint is replaced, typically the ball portion of the hip joint, while the socket remains intact) on [DATE] and the care plan did not indicate how often Resident 1's left hip dressing should be changed, how Resident 1 should bathe, and if Resident 1 can bear weight on the left leg. This failure placed Resident 1 at an increased risk to develop a surgical site infection to the left hip, further injury to the left hip, and had the potential to result in Resident 1's care needs to go unmet. 2. Resident 2 experienced a fall on [DATE] and sustained a one-inch laceration (a cut or open wound, typically caused by tearing of the skin or soft tissue) to the left eyebrow and the care plan did not indicate how to provide care to Resident 2's left eyebrow laceration. This failure placed Resident 2 at an increased risk to develop an infection to the left eyebrow and had the potential to result in Resident 2's care needs to go unmet. Findings: During an observation and interview on [DATE] at 10:08 a.m. with Resident 1 in Resident 1's room, Resident 1 was in bed with a palm size dressing (a gauze applied to a wound or injury to protect it, promote healing, and control bleeding) on Resident 1's left hip. Resident 1 stated he fell and broke his hip. Resident 1 stated his pain level was 8 (scale used to measure the level of pain a person is experiencing with a score of 0 indicating no pain up to a score of 10 indicating worse pain imaginable). Resident 1 was unable to recall when staff changed the dressing, when he was bathed, and when staff assisted him out of bed. During a review of Resident 1's Admission Record (AR), dated [DATE], the AR indicated, Resident 1 was admitted on [DATE] with a history of Nontraumatic Subdural Hemorrhage (a type of bleeding in the brain where blood collects between the inner layer of the dura mater; the outermost protective layer surrounding the brain), Encounter for Surgical Aftercare following Surgery on the Nervous System and Fracture of Left Femur (broken upper leg bone). During a review of Resident 1's Minimum Data Set (MDS; process for clinical assessment of all residents of long term care nursing facilities), dated [DATE], the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 9 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated Resident 1 was dependent (helper does all the effort) with transfer from bed to chair and required substantial/maximal assistance (helper does more than half the effort) with bathing. During a review of Resident 1's Progress Notes (PN), dated [DATE], the PN indicated, Interdisciplinary (IDT; a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) Progress Notes: On [DATE] this resident c/o (complained of) pain to left hip which was reported during therapy session. An order for x-ray (a type of imaging test that uses electromagnetic radiation to create pictures of the inside of the body, particularly bones and internal organs) and ultrasound (a diagnostic imaging technique that uses high-frequency sound waves to create images of internal organs and structures) were ordered. The ultrasound indicated PVD (Peripheral Vascular Disease; a circulatory condition where blood vessels outside the heart and brain narrow, become blocked, or spasm, leading to reduced blood flow and potential tissue damage in the arms, legs, and other organs) and the x-ray showed a fx (fracture) to the left hip. MD (Medical Doctor) was notified and sent to the hospital for evaluation . During a review of Resident 1's Operative Note (ON), dated [DATE], the ON indicated, PROCEDURE(S) PERFORMED: Left hip hemiarthroplasty . During a review of Resident 1's Order Summary Report (OSR), dated [DATE], the OSR indicated, apply skin prep (a protective barrier applied to the skin to prevent irritation, damage, or maceration; the softening and breakdown of tissue due to prolonged exposure to moisture from adhesives) and dry dressing QOD (every other day) to left hip surgical site, allow steri-strips (thin, adhesive strips used to help close small cuts or wounds, often as an alternative to stitches) to fall off on their own, do not remove . During an interview on [DATE] at 10:11 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was able to make his needs known but was confused. CNA 1 stated she did not know Resident 1 had hip surgery. CNA 1 stated Resident 1 was able to walk with supervision. CNA 1 stated she was going to give Resident 1 a bed bath. CNA 1 stated she did not know if Resident 1's left hip dressing can get wet during bathing. CNA 1 stated the charge nurse should know how to care for Resident 1's left leg. During a concurrent interview and record review on [DATE] at 10:15 a.m. with Licensed Vocational Nurse (LVN), Resident 1's Care Plan Report (CPR), dated [DATE] was reviewed. The CPR did not indicate how often Resident 1's left hip dressing should be changed. The CPR did not indicate whether Resident 1 can get the incision wet during bathing. The CPR indicated, Follow MD (Medical Doctor) orders for weight bearing status. See MD orders and/or PT (physical therapy) treatment plan. LVN stated Resident 1 was able to make his needs known but was oriented to himself only (not aware of place or time) and had a craniotomy (surgical opening into the skull) and left hip surgery. LVN stated there were no orders to keep Resident 1's left hip dressing dry. LVN stated it was assumed the dressing can get wet during bathing if there were no order to keep the dressing dry. LVN stated she did not know if Resident 1's left hip dressing should be changed or how often. LVN 1 stated she did not know if Resident 1 can bear weight on his left leg. LVN stated she would have to review Resident 1's physical therapy (a healthcare discipline that utilizes a variety of methods including exercises, physical modalities, and assistive devices to help patients regain or improve their physical abilities) progress notes to see how much weight Resident 1 can apply to the left leg. LVN stated the care Resident 1 required should be on Resident 1's CPR. During a review of Resident 2's Admission Record (AR), dated [DATE], the AR indicated, Resident 2 was admitted on [DATE] with a history of Alzheimer's Disease (a progressive brain disorder that primarily affects memory, thinking, and reasoning skills) and Dementia (the progressive loss of cognitive function, including memory, thinking, and reasoning, that significantly impairs a person's ability to perform daily activities) During a review of Resident 2's Progress Notes (PN), dated [DATE], the PN indicated, IDT fall: The resident has had an actual fall, sustained laceration to above left eyebrow on [DATE] . Send to ER (emergency room ) for evaluation . During a review of Resident 2's Procedure Note (PN), dated [DATE], the PN indicated, PROCEDURE NOTE: Laceration Repair of left eyebrow . Description of Wound (s): 5 cm (centimeter; unit of measurement) simplelinear (a straight line). Width: 1 (cm) Depth: Full thickness (wounds that extend past the two layers of skin). Length: 5 (cm) wound . The wound was reapproximated (to bring separated parts back together, often to close a wound) in one layer (s) utilizing # 4 sutures (total of four stiches) . During a review of Resident 2's Order Summary Report (OSR), dated [DATE], the OSR indicated, apply skin prep to left eyebrow laceration and leave OTA (out to air) every day shift QOD (every other day) for wound care . The OSR dated [DATE] indicated, Staple/Suture removal within ,d+[DATE] days from ER (emergency room ) visit on [DATE] . During a review of Resident 2's Care Plan Report (CPR), dated [DATE], the CPR did not indicate how to provide care to Resident 2's left eyebrow laceration. During an interview on [DATE] at 11:20 a.m. with the Director of Nursing (DON), the DON stated the IDT should have discussed the treatment plan for Resident 1 and Resident 2 after they returned from the hospital and updated their care plans and did not. The DON stated the IDT was required to review, revise, and implement a comprehensive person-centered care plan for Resident 1 and Resident 2 to meet their needs after a change in condition. The DON stated staff should be able to refer to Resident 1 and Resident 2's care plans and know what care was to be provided as ordered by the physician. The DON stated wound care was provided by the Treatment Nurse (a licensed staff member dedicated to provide wound care) but the Treatment Nurse was not always available. The DON stated staff should not have to look through the resident's EMR (electronic medical records) in different areas to find the information they needed to implement the required care. During an interview on [DATE] at 11:25 a.m. with the Administrator (ADM), the ADM stated the IDT needed to revise and update Resident 1 and Resident 2's care plan when they returned from the hospital and did not. The ADM stated a comprehensive person-centered care plan was required for Resident 1 and Resident 2, so staff understood what care was to be provided to meet their needs. The ADM stated the IDT was required to review, revise, and implement a comprehensive person-centered care plan for each resident after a change in condition to meet their needs. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated ,d+[DATE], the P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay .

Based on observation, interview and record review, the facility failed to ensure one of five residents (Resident 1) was free from accident hazards, when Resident 1 was assessed to be a high risk for falls, had a history of falls on 5/9/24, and 7/28/24, and had a physician order for a floor mat to prevent injury in the event of fall and the floor mat was not placed beside the bed. Nursing staff failed to implement the Care Plan intervention for use of the floor mat to prevent injury. These failures resulted in Resident 1 experiencing a fall from her bed on 1/11/25 and suffering an avoidable injury, pain and being sent to the acute care hospital for higher level of care. Resident 1 was diagnosed with a broken left hip and required administration of fentanyl (a medication for severe pain) to control the pain. Resident 1 experienced discomfort and decreased mobility where was no longer able to turn herself from side to side because of the left hip fracture. Resident 1's Physicians did not recommend surgery for Resident 1, and she was placed on hospice care. Findings: During a review of Resident 1's facility Progress Notes (PN), dated 1/11/25 at 6 p.m., the PN indicated, . [Resident 1] was found on the floor next to her bed lying on her right side. There was a skin tear on her left forearm. A bruise noted on her right hip. The resident was c/o [complain/of] left leg pain. Staff assisted the resident back into bed. The skin tear was cleansed with NS [normal saline- a mixture of water and salt] and a dressing was applied. Neuro checks [neurological checks - a physical exam to assess the brain and nerves] were started. MD [Medical Doctor] was notified of the fall and an order was received for bilateral [both] hips and pelvis [bones between the lower abdomen and upper thighs that connect to the spine and legs] x-ray. Family member [name] was notified of the unwitnessed fall . During a review of Resident 1's acute hospital record ED (Emergency Department) Provider Notes (EDPN), dated 1/12/25, the EDPN indicated, Resident 1 arrived in the ED from the facility for evaluation after an unwitnessed [by facility staff] ground level fall on 1/11/25. The EDPN indicated, . On exam . did appear to have discomfort upon pushing on her lateral [outside] aspect of left hip. However, she refused to straighten the extremity [leg] and pushed me away mid [in the middle of] exam. XR [x-ray] pelvis with questionable displaced [not lined up] left femur [thigh bone] fracture [broken bone] but difficult to interpret due to positioning. After discussion with daughter, she was agreeable for repeat imaging of XR pelvis with treatment of her pain and agitation . Repeat image does show evidence of impacted[the ends of the bone are jammed together] left femoral neck [narrow bridge of bone connecting the rounded top of thigh bone to the long straight section of thigh bone] fracture . discussed case with (orthopedic [doctors who specialize in surgery of bones, joints and muscles] physician) who does not recommend surgery given it would not be considered helpful as patient is non-ambulatory/bed bound [does not walk/remains in bed] . Daughter chose against surgery and was agreeable to pursue hospice care [end of life care] . Plan and Disposition: . Discharge . Care Timeline . Arrived 1100 [11 a.m.] . discharged 2002 [8:02 p.m.] . During a review of Resident 1's acute hospital record, Images, dated 1/12/25, the Images indicated, Resident 1 received an x-ray of the pelvis for injury and was found to have a basicervical intertrochanteric left femoral fracture (a specific type of hip fracture where the break is at the bottom of the bone that connects the hip joint to the thigh bone, right where it meets the wider part of the thigh bone). During a review of Resident 1's acute hospital record ED Provider Notes Meds (medications) Administered, dated 1/12/25, the ED Provider Notes Meds Administered indicated on 1/12/25 at 3:06 p.m. Resident 1 was administered 50 mcg (micrograms a unit of measurement) fentanyl (a medication for severe pain) intravenously (a way to deliver medicine directly into a vein using a needle or plastic tube) for pain. During a review of Resident 1's Admission Record (AR-a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 1/13/25, the AR indicated, Resident 1 was admitted on [DATE] with a diagnoses which included senile degeneration of brain (a group of symptoms causing a decline in thinking, reasoning, remembering, imagining, learning words, and using language), syncope and collapse (passing out falling down), fall on same level, dysarthria (difficulty speaking due to the muscles used for speech being weak) and anarthria (condition causing a person to completely lose their ability to speak). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive [mental processes of thinking, learning, remembering and understanding] and physical function), assessment dated [DATE], Resident 1's MDS assessment indicated, Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 03 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated, Resident 1 had a severe cognitive impairment (a person that has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a review of Resident 1's Care Plan (CP - a detailed document that outlines a patient's specific healthcare needs, goals and nursing interventions required to meet those goals), dated 1/15/23, the CP indicated, . Focus . The resident at risk for fall r/t [related/to] Confusion, weakness, and impaired mobility . per staff resident has been trying to get up to the w/c [wheelchair] on her own . Date initiated: 5/30/24 . Created On: 1/15/23 . Revision on: 7/29/24 . Intervention for 7/28/24 Staff to monitor patient's position while in bed . Place floor mats [a soft mat that lays beside a bed to prevent an injury] on floor next to bed Date initiated: 1/30/23 . Revision on: 7/29/24 . Staff will look for another room where floor mats can be utilized . During a concurrent observation and interview on 1/16/25 at 10:55 a.m. with Resident 2 in Resident 2's room. Resident 2 was observed lying on her back, her bed at a 30-degree angle, with her eyes open. Resident 2 was Resident 1's roommate and was in the first bed closest to the door (A bed). Resident 2 stated, she had been Resident 1's roommate since August 2024 and was present when Resident 1 fell off her bed onto the floor on 1/11/25. Resident 2 stated, Resident 1 was trying to walk when she fell , Resident 2 stated, Resident 1 does not walk or get out of bed to a wheelchair, but she was able to sit up without help. Resident 2 stated, no fall mats were present when Resident 1 fell , and the bed was lower now than when Resident 1 fell . Resident 2 stated, the bed was replaced yesterday. Resident 2 stated, the day of the fall a Certified Nursing Assistant (CNA) was in their room changing a resident in the third bed (C- bed) and the curtain was closed around C bed. Resident 2 stated, Resident 1 sat up and moved to the edge of the bed then fell to the floor. Resident 2 stated, Resident 1 landed onto the floor between Resident 1 and Resident 2's beds. Resident 2 stated, she called out to the CNA in their room saying Resident 1 fell and was on the floor. Resident 2 stated an X-ray was done on Resident 1 in the room. Resident 2 stated, Resident 1 calls out in pain when staff were changing her clothing or her brief (absorbent undergarments that can help with bladder or bowel leakage) since the fall. During a review of Resident 2's AR, dated 1/16/25, the AR indicated, Resident 2 was admitted on [DATE]. During a review of Resident 2's MDS assessment dated [DATE], Resident 2's MDS assessment indicated, Resident 2's BIMS assessment score was 10 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). During a concurrent observation and interview on 1/16/25 at 11:10 a.m. with Resident 1 in Resident 1's room, the three beds in the room were against the left wall and Resident 1 was in the center bed (B-bed). Resident 1 did not answer verbally when greeted, but waved hello and nodded her head indicating yes when asked her name. Resident 1 shook her head indicating no, when asked if she remembered when she fell . During an interview on 1/16/25 at 11:11 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was familiar with Resident 1. LVN 2 stated, Resident 1 was a high fall risk. LVN 2 stated, Resident 1 had fallen from her bed multiple times. LVN 2 stated, Resident 1 now had fall mats in place, to prevent further injury due to falls. LVN 2 stated, Resident 1 used to have fall mats in place. LVN 2 stated, she did not know why they were removed. LVN 2 stated, Resident 1 was a total care patient and was completely dependent (unable to perform activities of daily living without assistance) on staff. LVN 2 stated, she did not know who decided the type of fall interventions residents were assigned. During a review of Interdisciplinary Progress Notes (IPN), dated 5/10/24, the IPN indicated, . IDT [Interdisciplinary Team - a group of individuals with unique knowledge that work together to address complex issues] meeting for incident on 5/9/24: Resident had an unwitnessed fall in room, was found on floor next to bed, Resident is confused and could not state what happened. Apparently, Resident rolled out of bed, no injury noted, no c/o pain . will provide floor mats to sides of bed . During a review of IPN, dated 5/13/24, the IPN indicated, . IDT meeting for incident on 5/9/24: Resident had an unwitnessed fall in room, was found on floor left side next to bed . During a review of Resident 1's Post Fall Evaluation (PFE), dated 7/28/24 at 1:30 p.m., the PFE indicated, . Fall Details: Date/ Time of Fall: 07/28/2024 1:30 PM Fall was not witnessed. Fall occurred in the Resident's room. Resident was attempting to self-toilet at time of fall . Floor mat was on floor: No . During a review of Interdisciplinary Progress Notes (IPN), dated 7/29/24, the IPN indicated, . IDT fall . Resident had a fall on 7/28/24 when she was found on the floor in her room . Risk factors . Senile Degeneration of the Brain . Dysarthria/anarthria [slurred sleech/inability to speak . Weakness . Hx [history] of falls . Previous Interventions: Floor mats, increased monitoring . IDT recommendations . Staff to monitor patient's positioning in bed . IDT Attendees . Admin [Administrator], DON [Director of Nursing], DSD [Director of Staff Development] . During an interview on 1/16/25 at 11:34 a.m. with Certified Nursing Assistant (CNA) 2, the CNA stated, she has been working with Resident 1 since the Resident was admitted in 2023. CNA 2 stated, she was not working at the time of Resident 1's fall. CNA 2 stated, she had witnessed Resident 1 sit at the side of the bed and re-oriented Resident 1 to sit back in the bed to prevent a fall. CNA 2 stated, Resident 1 had fall mats in place sometime in the past, but they had been removed until yesterday (1/15/25). CNA 2 stated, she did not know why the fall mats were removed. CNA 2 stated, she believed the mats were important to prevent injury. CNA 2 stated, if Resident 1 were to stand and fall the mats would soften the fall. During an interview on 1/16/25 at 2:58 p.m. with CNA 1, CNA 1 stated, she was the CNA responsible for Resident 1's care when Resident 1 fell on [DATE]. CNA 1 stated, she was changing a Resident in the last bed furthest from the door and the privacy curtain was closed, so could not see Resident 1. CNA 1 stated, Resident 1 was in her bed when she passed by her to change the Resident in C bed. CNA 1 stated, Resident 2 called out to her Resident 1 fell and was on the floor. CNA 1 stated, Resident 1 fell out of the bed on the right side onto the floor. CNA 1 stated Resident 1 would sit up then attempt to walk, but her legs could not hold her weight. CNA 1 stated, she had never seen the fall mats in the room before. CNA 1 stated since Resident 1's injury her mobility had decreased, and she no longer turned herself. CNA 1 stated, Resident 1's care was changed due to her hip fracture and since Resident 1 cannot have surgery, she must be moved slowly to prevent pain. During an interview on 1/16/25 at 3:06 p.m. with LVN 1, LVN 1 stated, she was the nurse responsible for Resident 1 at the time of the fall on 1/11/25. LVN 1 stated, Resident 1 had fallen before and was a high fall risk. LVN 1 stated, CNA 1 came to her at the nurse's station around 5:30 p.m. and told her Resident 1 was on the floor. LVN 1 stated, Resident 1 was lying on the floor between A and B bed on her right side. LVN 1 stated Resident 1 had a skin tear on left forearm and complained of pain everywhere. LVN 1 stated, Resident 1 turned to her back, and there was a small bruise on her right hip. LVN 1 stated, Resident 1 had her legs up with knees bent and would not extend her legs. LVN 1 stated the physician was called for an x-Ray order. LVN 1 stated if a fall mat was in place, it could have lessened the impact of the fall. During a review of Resident 1's PFE, dated 1/11/25 at 5:25 p.m., the PFE indicated, . Fall Details: Date/ Time of Fall: 01/11/2025 5:25 PM Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: Attempting to walk Reason for the fall was evident. Reason for fall: Trying to get out of bed unassisted Did an injury occur as a result of the fall: Yes . The resident was c/o left leg pain . Floor mat was on floor: No . During a review of IPN, dated 1/13/25, the IPN indicated, . Met to discuss fall that resident had on the evening of 1/11 /25 when she was found on the floor on her right side, next to her bed. She c/o pain to left hip. MD was notified and received order for x-Ray. The results came back on 1/12/25 with a nondisplaced left femur fx [fracture] and MD was notified and gave order to send to ER for evaluation. Resident later returned from ER, no surgery recommended and suggested possible hospice referral. Resident was initially placed on q [every] 15 min monitoring x [for] 24 hrs [hours] but was extended to 72 hrs after fracture dx [diagnosis]. Floor mats were placed after fall. Staff was attempting to make a room change to an A bed, but the family prefers she stays where she is. Resident has dx [diagnosis] of senile degeneration of the brain and is confused . During an interview on 1/16/25 at 3:37 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had a physician order for fall mats ordered on 1/31/23. The DON stated the order was never discontinued. The DON stated a new order was requested from the physician for fall mats on 1/13/25. The DON stated a new order was not necessary. The DON did not know why the fall mats were not in place for Resident 1 at the time of the fall on 1/11/25. The DON stated her expectation was for nursing staff to know what interventions were in place and follow the interventions. The DON stated her expectation was for the fall mat to be in place for the safety of Resident 1. During a review of Resident 1's Physician Order (PO), dated 1/31/23, the PO indicated, . Order Summary . Floor Mat Due to Fall Risk . Supply Last Order Date . 01/31/23 . During a concurrent interview and record review on 1/21/25 at 11:15 a.m., Resident 1's Fall Risk Evaluation (FRE),, dated 12/16/24, was reviewed. The FRE indicated, . [Resident 1] . History of falls (past 3 months) . 1-2 falls in past 3 months . Level of consciousness / mental status . disoriented x 3 at all times . Ambulation/elimination status . Bedbound [unable to move around safely]/incontinent [having no control over urination or bowels] . The DON stated, Resident 1's fall risk score was 14, and a 14 was considered a high fall risk. During a concurrent interview and record review on 1/25/25 at 11:20 a.m. with the DON, Resident 1's CP, dated 1/16/25, was reviewed. The CP indicated . Place floor mats on floor next to bed Date initiated: 1/30/23 . Revision on: 7/29/24 . Staff will look for another room where floor mats can be utilized . The DON stated, Resident 1's fall mats were just never put back when Resident 1's roommates changed, and the fall mats could have been utilized again. The DON stated, the fall mats should have been put back in place. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated March 2018, the P&P indicated, .Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Unintentional change in position coming to rest on the ground , floor or onto the next lower surface . or identified when a resident is found on the floor or ground . Fall Risk Factors: . Resident conditions that may contribute to the risk of falls include: . delirium [a mental state of confusion, and difficulty thinking or remembering] and other cognitive impairment . pain . lower extremity weakness . functional impairments . Based on observation, interview and record review, the facility failed to ensure one of five residents (Resident 1) was free from accident hazards, when Resident 1 was assessed to be a high risk for falls, had a history of falls on 5/9/24, and 7/28/24, and had a physician order for a floor mat to prevent injury in the event of fall and the floor mat was not placed beside the bed. Nursing staff failed to implement the Care Plan intervention for use of the floor mat to prevent injury. These failures resulted in Resident 1 experiencing a fall from her bed on 1/11/25 and suffering an avoidable injury, pain and being sent to the acute care hospital for higher level of care. Resident 1 was diagnosed with a broken left hip and required administration of fentanyl (a medication for severe pain) to control the pain. Resident 1 experienced discomfort and decreased mobility where was no longer able to turn herself from side to side because of the left hip fracture. Resident 1's Physicians did not recommend surgery for Resident 1, and she was placed on hospice care. Findings: During a review of Resident 1's facility Progress Notes (PN), dated 1/11/25 at 6 p.m., the PN indicated, . [Resident 1] was found on the floor next to her bed lying on her right side. There was a skin tear on her left forearm. A bruise noted on her right hip. The resident was c/o [complain/of] left leg pain. Staff assisted the resident back into bed. The skin tear was cleansed with NS [normal saline- a mixture of water and salt] and a dressing was applied. Neuro checks [neurological checks - a physical exam to assess the brain and nerves] were started. MD [Medical Doctor] was notified of the fall and an order was received for bilateral [both] hips and pelvis [bones between the lower abdomen and upper thighs that connect to the spine and legs] x-ray. Family member [name] was notified of the unwitnessed fall . During a review of Resident 1's acute hospital record ED (Emergency Department) Provider Notes (EDPN), dated 1/12/25, the EDPN indicated, Resident 1 arrived in the ED from the facility for evaluation after an unwitnessed [by facility staff] ground level fall on 1/11/25. The EDPN indicated, . On exam . did appear to have discomfort upon pushing on her lateral [outside] aspect of left hip. However, she refused to straighten the extremity [leg] and pushed me away mid [in the middle of] exam. XR [x-ray] pelvis with questionable displaced [not lined up] left femur [thigh bone] fracture [broken bone] but difficult to interpret due to positioning. After discussion with daughter, she was agreeable for repeat imaging of XR pelvis with treatment of her pain and agitation . Repeat image does show evidence of impacted[the ends of the bone are jammed together] left femoral neck [narrow bridge of bone connecting the rounded top of thigh bone to the long straight section of thigh bone] fracture . discussed case with (orthopedic [doctors who specialize in surgery of bones, joints and muscles] physician) who does not recommend surgery given it would not be considered helpful as patient is non-ambulatory/bed bound [does not walk/remains in bed] . Daughter chose against surgery and was agreeable to pursue hospice care [end of life care] . Plan and Disposition: . Discharge . Care Timeline . Arrived 1100 [11 a.m.] . discharged 2002 [8:02 p.m.] . During a review of Resident 1's acute hospital record, Images, dated 1/12/25, the Images indicated, Resident 1 received an x-ray of the pelvis for injury and was found to have a basicervical intertrochanteric left femoral fracture (a specific type of hip fracture where the break is at the bottom of the bone that connects the hip joint to the thigh bone, right where it meets the wider part of the thigh bone). During a review of Resident 1's acute hospital record ED Provider Notes Meds (medications) Administered, dated 1/12/25, the ED Provider Notes Meds Administered indicated on 1/12/25 at 3:06 p.m. Resident 1 was administered 50 mcg (micrograms a unit of measurement) fentanyl (a medication for severe pain) intravenously (a way to deliver medicine directly into a vein using a needle or plastic tube) for pain. During a review of Resident 1's Admission Record (AR-a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 1/13/25, the AR indicated, Resident 1 was admitted on [DATE] with a diagnoses which included senile degeneration of brain (a group of symptoms causing a decline in thinking, reasoning, remembering, imagining, learning words, and using language), syncope and collapse (passing out falling down), fall on same level, dysarthria (difficulty speaking due to the muscles used for speech being weak) and anarthria (condition causing a person to completely lose their ability to speak). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive [mental processes of thinking, learning, remembering and understanding] and physical function), assessment dated [DATE], Resident 1's MDS assessment indicated, Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 03 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated, Resident 1 had a severe cognitive impairment (a person that has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a review of Resident 1's Care Plan (CP - a detailed document that outlines a patient's specific healthcare needs, goals and nursing interventions required to meet those goals) , dated 1/15/23, the CP indicated, . Focus . The resident at risk for fall r/t [related/to] Confusion, weakness, and impaired mobility . per staff resident has been trying to get up to the w/c [wheelchair] on her own . Date initiated: 5/30/24 . Created On: 1/15/23 . Revision on: 7/29/24 . Intervention for 7/28/24 Staff to monitor patient's position while in bed . Place floor mats [a soft mat that lays beside a bed to prevent an injury] on floor next to bed Date initiated: 1/30/23 . Revision on: 7/29/24 . Staff will look for another room where floor mats can be utilized . During a concurrent observation and interview on 1/16/25 at 10:55 a.m. with Resident 2 in Resident 2's room. Resident 2 was observed lying on her back, her bed at a 30-degree angle, with her eyes open. Resident 2 was Resident 1's roommate and was in the first bed closest to the door (A bed). Resident 2 stated, she had been Resident 1's roommate since August 2024 and was present when Resident 1 fell off her bed onto the floor on 1/11/25. Resident 2 stated, Resident 1 was trying to walk when she fell , Resident 2 stated, Resident 1 does not walk or get out of bed to a wheelchair, but she was able to sit up without help. Resident 2 stated, no fall mats were present when Resident 1 fell , and the bed was lower now than when Resident 1 fell . Resident 2 stated, the bed was replaced yesterday. Resident 2 stated, the day of the fall a Certified Nursing Assistant (CNA) was in their room changing a resident in the third bed (C- bed) and the curtain was closed around C bed. Resident 2 stated, Resident 1 sat up and moved to the edge of the bed then fell to the floor. Resident 2 stated, Resident 1 landed onto the floor between Resident 1 and Resident 2's beds. Resident 2 stated, she called out to the CNA in their room saying Resident 1 fell and was on the floor. Resident 2 stated an X-ray was done on Resident 1 in the room. Resident 2 stated, Resident 1 calls out in pain when staff were changing her clothing or her brief (absorbent undergarments that can help with bladder or bowel leakage) since the fall. During a review of Resident 2's AR, dated 1/16/25, the AR indicated, Resident 2 was admitted on [DATE]. During a review of Resident 2's MDS assessment dated [DATE], Resident 2's MDS assessment indicated, Resident 2's BIMS assessment score was 10 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). During a concurrent observation and interview on 1/16/25 at 11:10 a.m. with Resident 1 in Resident 1's room, the three beds in the room were against the left wall and Resident 1 was in the center bed (B-bed). Resident 1 did not answer verbally when greeted, but waved hello and nodded her head indicating yes when asked her name. Resident 1 shook her head indicating no, when asked if she remembered when she fell . During an interview on 1/16/25 at 11:11 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was familiar with Resident 1. LVN 2 stated, Resident 1 was a high fall risk. LVN 2 stated, Resident 1 had fallen from her bed multiple times. LVN 2 stated, Resident 1 now had fall mats in place, to prevent further injury due to falls. LVN 2 stated, Resident 1 used to have fall mats in place. LVN 2 stated, she did not know why they were removed. LVN 2 stated, Resident 1 was a total care patient and was completely dependent (unable to perform activities of daily living without assistance) on staff. LVN 2 stated, she did not know who decided the type of fall interventions residents were assigned. During a review of Interdisciplinary Progress Notes (IPN), dated 5/10/24, the IPN indicated, . IDT [Interdisciplinary Team - a group of individuals with unique knowledge that work together to address complex issues] meeting for incident on 5/9/24: Resident had an unwitnessed fall in room, was found on floor next to bed, Resident is confused and could not state what happened. Apparently, Resident rolled out of bed, no injury noted, no c/o pain . will provide floor mats to sides of bed . During a review of IPN, dated 5/13/24, the IPN indicated, . IDT meeting for incident on 5/9/24: Resident had an unwitnessed fall in room, was found on floor left side next to bed . During a review of Resident 1's Post Fall Evaluation (PFE), dated 7/28/24 at 1:30 p.m., the PFE indicated, . Fall Details: Date/ Time of Fall: 07/28/2024 1:30 PM Fall was not witnessed. Fall occurred in the Resident's room. Resident was attempting to self-toilet at time of fall . Floor mat was on floor: No . During a review of Interdisciplinary Progress Notes (IPN), dated 7/29/24, the IPN indicated, . IDT fall . Resident had a fall on 7/28/24 when she was found on the floor in her room . Risk factors . Senile Degeneration of the Brain . Dysarthria/anarthria [slurred sleech/inability to speak . Weakness . Hx [history] of falls . Previous Interventions: Floor mats, increased monitoring . IDT recommendations . Staff to monitor patient's positioning in bed . IDT Attendees . Admin [Administrator], DON [Director of Nursing], DSD [Director of Staff Development] . During an interview on 1/16/25 at 11:34 a.m. with Certified Nursing Assistant (CNA) 2, the CNA stated, she has been working with Resident 1 since the Resident was admitted in 2023. CNA 2 stated, she was not working at the time of Resident 1's fall. CNA 2 stated, she had witnessed Resident 1 sit at the side of the bed and re-oriented Resident 1 to sit back in the bed to prevent a fall. CNA 2 stated, Resident 1 had fall mats in place sometime in the past, but they had been removed until yesterday (1/15/25). CNA 2 stated, she did not know why the fall mats were removed. CNA 2 stated, she believed the mats were important to prevent injury. CNA 2 stated, if Resident 1 were to stand and fall the mats would soften the fall. During an interview on 1/16/25 at 2:58 p.m. with CNA 1, CNA 1 stated, she was the CNA responsible for Resident 1's care when Resident 1 fell on [DATE]. CNA 1 stated, she was changing a Resident in the last bed furthest from the door and the privacy curtain was closed, so could not see Resident 1. CNA 1 stated, Resident 1 was in her bed when she passed by her to change the Resident in C bed. CNA 1 stated, Resident 2 called out to her Resident 1 fell and was on the floor. CNA 1 stated, Resident 1 fell out of the bed on the right side onto the floor. CNA 1 stated Resident 1 would sit up then attempt to walk, but her legs could not hold her weight. CNA 1 stated, she had never seen the fall mats in the room before. CNA 1 stated since Resident 1's injury her mobility had decreased, and she no longer turned herself. CNA 1 stated, Resident 1's care was changed due to her hip fracture and since Resident 1 cannot have surgery, she must be moved slowly to prevent pain. During an interview on 1/16/25 at 3:06 p.m. with LVN 1, LVN 1 stated, she was the nurse responsible for Resident 1 at the time of the fall on 1/11/25. LVN 1 stated, Resident 1 had fallen before and was a high fall risk. LVN 1 stated, CNA 1 came to her at the nurse's station around 5:30 p.m. and told her Resident 1 was on the floor. LVN 1 stated, Resident 1 was lying on the floor between A and B bed on her right side. LVN 1 stated Resident 1 had a skin tear on left forearm and complained of pain everywhere . LVN 1 stated, Resident 1 turned to her back, and there was a small bruise on her right hip. LVN 1 stated, Resident 1 had her legs up with knees bent and would not extend her legs. LVN 1 stated the physician was called for an x-Ray order. LVN 1 stated if a fall mat was in place, it could have lessened the impact of the fall. During a review of Resident 1's PFE, dated 1/11/25 at 5:25 p.m., the PFE indicated, . Fall Details: Date/ Time of Fall: 01/11/2025 5:25 PM Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: Attempting to walk Reason for the fall was evident. Reason for fall: Trying to get out of bed unassisted Did an injury occur as a result of the fall: Yes . The resident was c/o left leg pain . Floor mat was on floor: No . During a review of IPN, dated 1/13/25, the IPN indicated, . Met to discuss fall that resident had on the evening of 1/11 /25 when she was fou [TRUNCATED]

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received adequate supervision to prevent accidents when Resident 1 was admitted on [DATE] from an acute care hospital with known history of difficulty swallowing, assessed need for strict aspiration precautions (safety measures to prevent patients from breathing in foreign objects, like food or liquids, into their lungs), Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents of long term care nursing facilities) indicating moderate cognitive deficits (a stage of dementia where a person has significant difficulty with complex tasks and navigating new places) and need for assistance with meals and a care plan was not developed to address nursing staff to provide supervision during meals. Resident 1 was permitted to feed himself, unsupervised. These failures resulted in Resident 1 choking during dinner on 5/30/24 and Resident 1 was transported to an acute care hospital for higher level of care. Resident 1 was diagnosed with Respiratory Failure (a serious condition that occurs when the lungs can't get enough oxygen into the blood or remove enough carbon dioxide from the body), Aspiration Pneumonia (a lung infection that occurs when food, liquid, saliva, vomit, or other foreign objects are inhaled into the lungs instead of being swallowed), Severe Protein Calorie Malnutrition (a significant inadequate intake of nutrition) and Chronic Kidney Disease Stage III (3; a moderate level of kidney damage) . and subsequently died on 6/7/24. Findings: During a review of Resident 1's Progress Notes (PN), dated 5/30/24, the PN indicated, Nurse (Licensed Vocational Nurse 1) was called by Certified Nursing Assistant (CNA) at 5:46 p.m. for patient not responding to verbal command, observed patient sitting in his wheelchair with his head down, tap patient shoulders, patient not responding, per CNA patient was just finished with his dinner and was yelling to the Sitter (one individual assigned to supervise one resident; Resident 1's roommate at the time) then suddenly stop and start gasping for air . mouth swept with no foreign object noted, weak pulse and noticing patient gasping for air. Heimlich (a first-aid technique that uses quick, upward thrusts to dislodge a foreign object from a choking person's airway) was performed immediately .911 (three-digit telephone number 9-1-1 has been designated as the Universal Emergency Number ) was notified at 5:50 p.m.CPR (cardiopulmonary resuscitation - life saving measure of chest compressions and rescue breathing) started at 5:53 p.m. EMT (Emergency Medical Technicians; a person trained to care for patients at the scene of an emergency and taking patients by ambulance to a hospital) arrived and took over at 6:05 p.m. Resident was transferred out to [acute hospital] at 6:15 p.m. During a review of Resident 1's Certificate of Death (COD), dated 7/2/24, the COD indicated, .Cause of Death: Respiratory Failure, Aspiration Pneumonia, Severe Protein Calorie Malnutrition and Chronic Kidney Disease Stage III . During a review of Resident 1's hospital Discharge Summary (DS), dated 6/9/24, the DS indicated, .Death Summary for 06.07 (6/7/24): He (Resident 1) passed away on 06/07 (6/7/24). Cause of death: respiratory failure secondary to aspiration pneumonia, CKD (Chronic Kidney Disease) stage 3, Severe protein calorie malnutrition . During an interview on 12/3/24 at 4:12 p.m. with Certified Nursing Assistance (CNA) 3, CNA 3 stated, she was assigned to Resident 1 on 5/30/24. CNA 3 stated, Resident 1 had behaviors of yelling, making grunting noise, was combative, hard to redirect, and not cooperative. CNA 3 stated, Resident 1 was able to feed himself and required assistance with setting up his meals. CNA 3 stated, on 5/30/24 after dinner time, she was picking up trays when the Sitter called for assistance to Resident 1's room. CNA 3 stated, she went to Resident 1's room and saw Resident 1 slumped over in his wheelchair and was unresponsive. CNA 3 stated, LVN 1 came to Resident 1's room and initiated Heimlich maneuver and CPR. During an interview on 10/9/24 at 9:15 a.m. with Director of Nursing (DON), DON stated, Sitter was unavailable for interview. DON stated, Sitter was on a leave of absence (an extended period of unpaid time away from work). DON stated, LVN 1 was unavailable for interview. DON stated, LVN 1 resigned (someone who has voluntarily decided to leave their employment) on 6/3/24. During a review of Resident 1's admission Record (AR), dated 10/9/24, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a history of Metabolic Encephalopathy (a group of neurological disorders that occur when a chemical imbalance in the blood affects the brain), Type 2 Diabetes Mellitus (a chronic disease that occurs when the body does not produce enough insulin; a hormone that lowers the level of glucose; a type of sugar in the blood or does not use it properly, resulting in high blood sugar levels), Cerebral Infarction without Residual Deficits (brain tissue damage due to a blockage of blood flow with no lasting neurological impairments or symptoms), Dysphagia (difficulty swallowing), Psychoactive Substance Abuse (the compulsive use of psychoactive drugs; substances that, when taken in or administered into one's system, affect mental processes, e.g. perception, consciousness, cognition or mood and emotions despite negative consequences), Schizophrenia (a chronic mental illness that affects a person's ability to think, feel, and behave normally), and Chronic Kidney Disease (an ongoing condition where the kidneys are damaged and cannot filter blood properly). During a review of Resident 1's MDS, dated 5/28/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS - an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 9 (a score of 0 - 7 indicated severe impairment, 8 - 12 indicated moderate impairment, and 13 - 15 indicated minimal to no impairment). During a review of Resident 1's MDS for Functional Abilities and Goals (FAAG), dated 5/28/24, the FAAG indicated, Resident 1 required .Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently . when eating. During a review of Resident 1's Order Summary Report (OSR), dated 5/24/24, the OSR indicated, .CCHO (Consistent Carbohydrate Diet - is a diet that involves eating the same amount of carbohydrates each day to help manage blood sugar levels) diet Mechanical soft (a texture-modified diet that consists of foods that are soft and easy to chew and swallow) texture, Thin liquids consistency for diabetic diet . During a review of Resident 1's hospital Speech Language Pathology (SLP - a specialty that involves diagnosing and treating communication and swallowing disorders) Progress Note (SLP PN), dated 5/17/24, the SLP PN indicated, .ST REC (Speech Therapy recommendation): Mechanical soft diet w/ (with) ground meats and thin liquids w/ strict aspiration precautions including 1:1 (one individual assigned to supervise one resident) supervision for small bites/slow pace and assist as needed, ensure clear oral cavity at completion of meal . During a review of Resident 1's hospital Speech Language Pathology Progress Note (SLP PN), dated 5/23/24, the SLP PN indicated, .ST recommendation a Mechanical Soft Diet with Ground Meats and Thin Liquids with supervision due to impulsivity . During a review of Resident 1's Speech Therapy SLP Evaluation and Plan Treatment (SLP E&P), dated 5/24/24, the SLP E&P indicated, .Clinical Impressions: Pt (patient) tolerating current Mech (Mechanical) Soft, thin liquid diet c (with) no overt s/s (signs and symptoms) aspiration. Pt. reports similar diet previously. Pt is believed to be at baseline level . During a review of Resident 1's hospital Transfer: Interfacility From/& To Skilled Nursing Facility (SNF), Sub-Acute & Rehabilitation TRANSFER FORM (IFT; a form used to communicate patient information from one facility to another), dated 5/23/24, the IFT indicated, .NURSING INFORMATION. Eating: Assistance . was checked. During a review of Resident 1's Resident Diet System (RDS - a tool developed for dietary departments in assisted living and skilled nursing communities designed to help improve communication and increase efficiency), undated, the RDS indicated, .Diagnosis: dysphagia, assistance with meals . During a review of Resident 1's Tray Ticket (TK; a printed list of a patient's meal order and preferences for each meal), dated 12/4/24, the TK indicated, .Assistance: Assisted: . was left blank. During a review of Resident 1's Care Plans (CP), dated 10/9/24, the CP indicated, there was no care plan for assisting Resident 1 with meals. During an interview on 12/3/24 at 3:30 p.m. with the facility's Speech Language Pathologist (SLP- a specialist who diagnose and treats a wide range of speech, language, cognitive, and swallowing disorders), SLP stated, during her assessment (gathering of information) of Resident 1 on 5/24/24, Resident 1 did not demonstrate impulsive behaviors that would indicate Resident 1 required supervision at the time of the observation. SLP stated, during the observation, Resident 1 was able to feed himself independently and was able to swallow adequately. SLP stated,[EJ35] [ST36] she should have obtained Resident 1's 5/17/24 and 5/23/24 hospital SLP evaluations and recommendations to accurately assess Resident 1 to provide the appropriate recommendation. SLP stated, SLP would have recommended Resident 1 was supervised during mealtime. SLP stated, there was a missed opportunity to assess Resident 1 accurately to make the appropriate recommendation. During an interview on 10/15/24 at 11:47 a.m. with Medical Doctor (MD), MD stated, Resident 1 was impaired (problems with a person's ability to think, learn, remember, and make decisions) with a history of substance (drug) abuse and was admitted to the psychiatric unit (a hospital setting where people receive short-term or in-patient treatment for severe mental health issues) on several occasions. MD stated, Resident 1 had a high risk for aspiration. MD stated, it was possible to aspirate on the recommended diet due to brain damage from drug use, impaired gag reflex (a natural bodily response that prevents choking and swallowing something unpleasant) and eating too fast. During an interview on 12/3/24 at 6:00 p.m. with DON, DON stated, Resident 1's 5/17/24 and 5/23/24 hospital SLP evaluations and recommendations were not available at the facility. DON stated, Resident 1 was admitted on [DATE] from the acute care hospital and the hospital's SLP PN records was not sent with Resident 1. DON stated, Resident 1 was assessed by the facility's SLP on 5/24/24 and SLP did not recommend supervision during mealtimes. DON stated, SLP should have obtained and reviewed Resident 1's 5/17/24 and 5/23/24 hospital SLP evaluations and recommendations to make an accurate assessment and provide the proper recommendation. DON stated, Resident 1's 12/4/24 Tray Ticket and 5/28/24 MDS code for eating assistance was broad (vague). DON stated, a care plan was not developed for Resident 1 to address the type of assistance Resident 1 required during meals. DON stated, individualized care plans were required to include specific interventions to provide the appropriate level of assistance to prevent choking. DON stated, the aspiration could have been avoided had Resident 1 been provided proper supervision during dinner on 5/30/24. During an interview on 12/4/24 p.m. at 3:39 p.m. with Administrator (ADM), ADM stated, the expectation and standard of practice to ensure residents were provided the appropriate level of care was to review all pertinent (relevant) information available. ADM stated, staff was required to obtain all necessary information to accurately assess the needs of Resident 1 and make the appropriate recommendations. ADM stated, staff was required to develop resident centered care plans with specific interventions. ADM stated, Resident 1's information should have been thoroughly reviewed and a resident centered care plan should have been developed with specific interventions to address the needs of Resident 1 during mealtime. ADM stated, the aspiration could have been avoided had Resident 1 been adequately supervised during dinner on 5/30/24. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/34273953/ titled, Interventions to prevent aspiration in older adults with dysphagia living in nursing homes: a scoping review, dated 7/17/21, the professional review indicated, Dysphagia is [a] highly prevalent condition in older adults living in nursing homes. There is also evidence indicating that aspiration is one of the major health risks for these older adults, which is more likely to result in respiratory infections, aspiration pneumonia and sudden bolus death . Interventions to prevent aspiration in older adults with dysphagia living in nursing homes included: more bedside evaluation, modification of dietary, creating an appropriate environment for swallowing, providing appropriate feeding assistance, appropriate posture or maneuver for swallowing, appropriate rehabilitation program, medication treatment, and stimulation treatment . Nursing home residents respond well to person-centered interventions that have a comprehensive consideration of their degree of aspiration risk, health condition, individual feelings and cognitive state.

Based on interview and record review, the facility neglected to provide goods and services when they did not obtain and administer a medication ordered that was necessary to avoid physical harm and psychosocial distress to one of three sampled Residents (Resident 1) when Resident 1 was ordered an antiviral medication upon admission which was not acquired by the facility nor administered for seven days. This failure resulted in Resident 1 being neglected by staff and experienced psychosocial harm and anxiety which prompted Resident 1 to leave the facility against medical advice (AMA) for fear of physical harm due to the gap in the administration of his medication regimen and potential for risk of a worsening viral infection. Findings: During a review of Resident 1 ' s History and Physical (H&P), dated 2/21/23, the H&P indicated, Resident 1 had history of a [virus - Viruses are microscopic organisms that can infect humans, a virus that attacks the body's immune system]. During a review of Resident 1 ' s Minimum Data Set (MDS - an evaluation of a resident's cognitive [ability to process and comprehend information] and functional status), dated 2/25/23, the MDS indicated the Brief Interview for Mental Status (BIMS) score (an assessment of a resident's cognitive status for memory recall) was 12 (a score of 13 - 15 indicated the resident is cognitively intact, 8 - 12 indicated moderately impaired, and 0 - 7 indicated severe impairment). During a review of Resident 1 ' s Order Summary Report (OSR), dated 2/28/23, the OSR indicated, [brand name] oral tablet 200-25 MG (milligrams - unit of measurement) (anti-viral medication) Give 1 tablet by mouth one time a day for [virus]. Order date 2/20/23. Start date 2/21/23. During a review of Resident 1 ' s Medication Administration Record (MAR), dated 2/1/23 - 2/28/23, the MAR indicated, on 2/21/23, 2/22/23, 2/23/23, 2/24/23, 2/25/23, 2/26/23, and 2/27/23, Resident 1 was not administered [brand name] oral tablet 200-25 MG. During a review of Resident 1 ' s Progress Notes (PN), dated 2/21/23, 2/22/23, 2/23/23, 2/24/23, 2/25/23, 2/26/23, and 2/27/23, the PN indicated, [brand name] oral tablet 200-25 MG was on order and waiting for pharmacy to deliver. During an interview on 11/28/23 at 1:08 p.m. with Resident 1, Resident 1 stated he was admitted to the facility on [DATE] through 2/27/23. Resident 1 stated, he was not administered his anti-viral medication as ordered from 2/20/23 through 2/27/23. Resident 1 stated he asked staff for the anti-viral medication daily and each time he was informed that the anti-viral medication was on its way from the pharmacy. Resident 1 stated he went one week without the anti-viral medication and it was hazardous (harmful) to his health and safety to miss doses of his medications. Resident 1 stated that not taking his medication daily would worsen his viral infection and this worried him greatly. During an interview on 11/30/23 at 4:50 p.m. with Director of Nursing (DON), DON stated it was standard of practice to notify the physician when a medication was unavailable according to policy and procedure in order to ensure medications were administered as ordered. DON stated there was an increased risk for worsening Resident 1 ' s viral infection if the anti-viral medication was not administered as ordered. During an interview on 1/2/24 at 5 p.m. with Resident 1, Resident 1 stated he was disgusted with the situation at the facility where he went to get physical therapy. The physician ordered his antiviral medication for him through the [name of hospital] pharmacy which was not picked up by the facility. The medication was returned to stock and then it was refilled for pick up. Resident 1 stated the medication was never picked up so it was restocked again. Resident 1 stated he was at the facility for 7 days and never got his medication, so he left against medical advice AMA). He stated, If I don ' t take my medications, I risk my long term health. Resident 1 stated this was neglect. During an interview on 1/10/24 at 2:37 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she was assigned to provide care to Resident 1 on 2/21/23, 2/23/23, 2/24/23, and 2/25/23. LVN 3 stated [brand name] oral tablet 200-25 MG was unavailable at the facility since the medication was expensive and required pharmacy verification for approval. LVN 3 stated the verification was given to the Director of Nursing at the time. LVN 3 stated it was standard of practice to notify the physician when a medication was unavailable according to policy and procedure in order to ensure medications were administered as ordered. LVN 3 stated there was an increased risk for worsening Resident 1 ' s viral infection if the anti-viral medication was not administered as ordered. During an interview on 1/11/24 10:08 a.m. with the Administrator (ADM), ADM stated it was standard of practice to notify the physician when a medication was unavailable according to policy and procedure in order to ensure medications were administered as ordered. ADM stated if a medication was unavailable, the medication can be delivered from another pharmacy the facility was contracted with. ADM stated facility staff and pharmacy staff were expected to communicate with one another to ensure residents received their medications as ordered. During an interview on 1/23/24 at 12:55 p.m. with Resident 1, Resident 1 stated he spoke to nursing, the doctor, and the administrator on a daily basis to follow up on his medication. Resident 1 stated he was told the medication was being sent to the facility and he should speak to the doctor. Resident 1 stated he spoke to the doctor but the doctor was very vague. Resident 1 stated he felt a sense of helplessness and wasn ' t being cared for. Resident 1 stated it was depressing and exasperating, then became angry and furious after going a week without his antiviral medication. Resident 1 stated he knew it would be hazardous to his health if he went any longer without his medication. Resident 1 stated he felt discriminated against due to his diagnosis. During a review of the facility ' s P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. During a review of the facility ' s policy and procedure (P&P) titled, Resident Rights, dated 2/2021, the P&P indicated, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity . 1. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: c. be free from abuse, neglect, misappropriation of property, and exploitation . During a review of the facility ' s P&P titled, Unavailable Medications, dated 8/2014, the P&P indicated, Policy .The facility must make every effort to ensure that medications are available to meet the needs of each resident . Procedures. B. Nursing staff shall: 1). Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. a. If the nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction . During a review of the facility P&P titled, Pharmacy Services Overview, dated 4/2019, the P&P indicated, Policy Interpretation and Implementation. 1. Pharmaceutical (a variety of medicines used to prevent, diagnose, treat or cure disease) services consists of: a. The processes of receiving and interpreting prescriber ' s orders; acquiring, receiving, storing, controlling, reconciling, compounding (the process of combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient [e.g., intravenous antibiotics]), dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications . 2. The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents ' needs, are consistent with current standards of practice, and meet state and federal requirements. 3. Pharmacy services are available to residents 24 hours a day, seven days a week. 4. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident ' s medication is not available for administration . During a review of the professional reference titled, HIGHLIGHTS OF PRESCRIBING INFORMATION, dated 1/2022, the information reviewed indicated, Dosage Recommendations for Treatment of [viral] Infection. Inform [viral] infected patients that it is important to take [brand name] with other antiretroviral drugs for the treatment of [viral] on a regular dosing schedule with or without food and to avoid missing doses as it can result in development of resistance . How should I take [brand name]? Take [brand name] exactly as your healthcare provider tells you to take it. If you take [brand name] to treat [viral] infection, you need to take [brand name] with other [viral] medicines. Your healthcare provider will tell you what medicines to take and how to take them. Take [brand name] 1 time each day with or without food . Do not change your dose or stop taking [brand name] without first talking with your healthcare provider. Stay under a healthcare provider ' s care when taking [brand name]. Do not miss a dose of [brand name] .

Based on observation, interview and record review, the facility failed to ensure residents' environment was free from accident hazards for one of two sampled residents (Resident 1) when nursing staff was aware of Resident 1's behavior of swinging a large 10-inch speaker call-light [the type of call light residents in the facility use] and did not replace the large 10-inch speaker call-light to prevent accidents. This failure resulted in an avoidable injury to Resident 1's both eyes on 3/9/22 from the swinging of the speaker call-light, causing swelling and bruising which worsened over several days. Findings: During a concurrent observation and interview, on 3/15/22, at 12:59 p.m., in Resident 1's room, Resident 1 was in bed and had a black discoloration on both of her eyes. Resident 1 did not answer questions and had a blank stare. Resident 1 had a small push button call light device on the side of the bed. During a review of Resident 1's Face Sheet (a document which contains patient brief medical history and contact details), dated 10/9/20, the Face Sheet indicated, Resident 1 was an [AGE] year-old female, admitted in the facility with diagnoses of Dementia, Anxiety Disorder, Restlessness, Agitation, Hemiplegia (paralysis on one side of the body) During a review of Resident 1's Minimum data set (MDS- a resident assessment tool that indicates physical and cognitive abilities) assessment, dated 1/13/22, the MDS section C (an assessment to determine residents' attention, orientation, and ability to register and recall new information) indicated, Resident 1 was severely impaired. The MDS section E (identifies behavioral symptoms . cause distress to the resident, or distressing or disruptive to facility residents, staff members or the care environment) indicated Resident 1 had a behavior of hitting. The MDS section G (an assessment of a resident's functional status) indicated, Resident 1 was totally dependent with activities of daily living. During an interview on 3/15/22, at 1:02 p.m., with Resident 2 [Resident 1's roommate]. Resident 2 stated Resident 1 does not answer questions. Resident 2 stated the facility staff did not hit Resident 1 in reference to the bruising of both eyes. Resident 2 stated Resident 1 had a behavior of hitting herself with the call light and she hit herself with the call light and bruised her eyes. Resident 2 stated Resident 1 had the big call light prior to having the small call light. Resident 2 stated the facility replaced Resident 1's big call light yesterday to a small call light. During a review of Resident 2's MDS assessment, dated 1/13/22, the MDS indicated, Resident 2's Brief Interview for Mental Status (BIMS- is a structured evaluation aimed to evaluate cognition in elderly patients) scored 13 of 15 which indicated Resident 2 was cognitively intact. During an interview on 3/15/22, at 1:10 p.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 1 had a history of self-inflicted injury from hitting herself with the call light. CNA 3 stated Resident 1 had the big call light and used the call light to hit herself. During an interview on 3/15/22, at 1:31 p.m., with CNA 2, CNA 2 stated she had provided care and was familiar with Resident 1. CNA 2 stated Resident 1 had self-inflicted injury from hitting herself with the call light. CNA 2 stated Resident 1 would swing the call light and would continue to swing the call light even if you will try to remove the call light form her. CNA 3 stated the call light should have been replaced with the small push button call light to prevent injury. During an interview on 3/15/22, at 1:45 p.m., with License Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse assigned to Resident 1 on Thursday 3/10/22. LVN 1 stated on 3/10/22 CNA 1 notified her Resident 1 had bruising on her left eye. LVN 1 stated CNA 1 told her Resident 1's bruised and swollen left eye started on 3/9/22. LVN 1 stated CNA 1 did not notify the license nurse assigned to Resident 1 and should have notified the licensed nurse assigned to Resident 1 on 3/9/22. LVN 1 stated on 3/10/22, she notified the Director of Nursing of Resident 1's bruised left eye. LVN 1 stated she did not do an SOC 341 form (Report of Suspected Dependent Adult/Elder Abuse) on 3/10/22, because Resident 1 had hit herself before in the forehead with the speaker call light which caused a bump on her forehead, and she concluded the swollen and bruised left eye was caused by Resident 1 hitting herself with the speaker call light. LVN 1 stated on 3/12/22 Resident 1's both eyes were bruised and swollen. LVN 1 stated she notified the DON and did the SOC 341 form, because she does not want the incident to come back to her, knowing she was aware of Resident 1's bruised and swollen eyes. LVN 1 stated Resident 1 still had the speaker call light on 3/12/22. LVN 1 stated the speaker call light should have been replaced with the small push button call light to prevent injury but was not. During an interview on 3/15/22, at 2:06 p.m., with CNA 1, CNA 1 stated she was the CNA assigned to Resident 1 on 3/9/22 and noticed Resident 1 had bruised and swollen left eye. CNA 1 stated on 3/10/22 Resident 1's bruised left eye had spread to her nose bridge, and she notified LVN 1. CNA 1 stated she did not notify the licensed nurse assigned to Resident 1 on 3/9/22 because she was busy. CNA 1 stated she should have notified the licensed nurse. CNA 1 stated on 3/9/22 and 3/10/22 Resident 1 had the speaker call light. During a review of Resident 1's Progress Notes, dated 3/10/22, the Progress Notes indicated, CNA [CNA 1] reported to the nurse [LVN 1] that she noted some swelling on her [Resident 1] left upper eyelid on 3/9/22 and today in AM note bruising around eye. Nurses assessed and notified ADON [Assistant Director of Nursing], and DON. Patient had a history of having call light near and swings it, where it has inflicted bruising before . During a review of Resident 1's Progress Notes, dated 3/12/22, the Progress Notes indicated, Patient bruising on left eye was reported on 3/10/22 by CNA [CNA 1], nurse noticed bruising on right eye 2/12/22 during AM. DON, Administrator was notified that nurse will file a SOC 341[a process to report suspected dependent adult/elder abuse] bruising on both eyes that has swelling . During an interview on 3/15/22, at 2:15 p.m., with the Maintenance Supervisor (MS), the MS stated he was asked by the DON to replace the speaker call light from Resident 1's room to a small push button call light, because Resident 1 had injured herself by swinging the speaker call light. The MS stated the push button call light was small and will unlikely cause injury to Resident 1. The MS stated the speaker call light was replaced on 3/14/22 to a push button call light. During a concurrent interview and record review, on 3/15/22, at 12:29 p.m., with the Director of Nursing (DON), Resident 1's Progress Notes, dated 4/5/21 at 2:03 p.m., was reviewed. The Progress Notes indicated, Patient has bump on forehead d/t [due to] patient having a call light and was swinging it around and hit forehead, DON, MD [Medical Doctor] and family notified . Resident 1's Care Plan, dated 4/5/21 was reviewed. The Care Plan indicated, Resident 1 has a small lump with discoloration to forehead r/t [related to] hitting self with call light . Interventions . Monitor for forehead signs of healing . The DON stated Resident 1 does not know how to use the speaker call light and had a history of swinging the call light which caused injury to herself. The DON stated Resident 1's speaker call light should have been replaced with the push button call light. The DON stated CNA 1 should have notified the nurse assigned to Resident 1 when she first noticed the injury to Resident 1's left eye. During a review of Resident 1's Facial Bone X-ray (an imaging creates pictures of the bone in the face), performed in the facility dated 3/12/22, the Facial Bone X-ray indicated, No gross acute fracture . During a review of Resident 1's Care Plan, dated 3/12/22, the Care Plan indicated, Resident 1 had a small bruise above left eyebrow which has spread to left and right eye, believe to be from hitting herself with call light (per Roommate) . Interventions .Change type of call light, when available . During a review of Resident 1's Interdisciplinary Progress Notes (IDT- a group of healthcare professionals from various disciplines who work in collaboration to address patients' healthcare needs), dated 3/15/22, the IDT indicated, .Resident is dependent for care . Resident has a history of throwing call light. When roommate was interviewed, she stated she saw her [Resident 1] hitting herself on the face with the call light . During a review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated 4/2021, the P&P indicated, Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility- wide priorities. Facility approached to safety. Our facility-oriented approach to safety addresses risks for groups of residents. Safety risk and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting process; Quality Assurance and Performance Improvement (QAPI- a systemic, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes) reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. When accidents hazards are identified, the QAPI/Safety Committee shall evaluate and analyze the cause (s) of the hazard and develop strategies to mitigate or remove the hazards to the extent as possible. Employees shall be trained on potential accidents hazard and demonstrate competency on how to identify and report accidents hazards, and try to prevent avoidable accidents . The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accidents hazards or risks for individual residents . During a review of the facility's policy and procedure (P&P) titled, Dementia- Clinical Protocol, dated 11/2018, the P&P indicated, .For the individual with confirmed dementia, the IDT [Interdisciplinary Team- a group of professionals and direct care staff with the primary responsibility for the development for a service plan for the patient] will identify a resident-centered care plan to maximized remaining function and quality of life The IDT will identify and document the resident's condition and level of support during care planning, and review changing needs as they arises . The staff will monitor the individual with dementia for changes in condition and decline in function and will report this findings to the physician, The IDT will adjust interventions and the overall plan depending on the individual's response to those interventions, progression of dementia, development of new acute medical condition or complications . During a review of the facility's job description titled, Certified Nursing Assistant (CNA)- SNF or Sub Acute Department: Nursing, dated 2014, the job description indicated, The Certified Nurse Assistant provides nursing and nursing related services to residents consistent with each resident's comprehensive resident assessment and plan of care. All residents care is provided in a manner that meets the resident's physical, mental and psychosocial needs and enables the individual to attain or maintain the highest practicable level of functioning . Essential Job Function: Communicate with Charge Nurse about assigned residents regularly throughout shift . Report injury to resident or self to Charge Nurse immediately . During a review of the professional reference titled Staying Safe Steps to take for a person living with dementia [general term] retrieve from https://www.alz.org/media/documents/alzheimers-dementia-staying-safe-with-alzheimers-b.pdf, undated, indicated, Make safety a priority before it's a problem. Safety is essential for everyone, but the need for a comprehensive safety plan is particularly important for a person living with Alzheimer ' s [a specific disease of memory problems which is under dementia] as the disease progress. Alzheimer's causes a number of changes in the brain and body that may affect safety . these can include judgement: forgetting how to use household appliance . Behavior: become easily confused . Physical ability: having trouble with balance. Sense: experiencing changes in vision, hearing . Taking measures to improve safety can prevent injuries and help person with dementia feel at ease .Evaluate your environment a person living with dementia may be more prone to safety hazards in certain areas of the home . Beware of dangerous objects and substance even the most basic appliance or household object can be dangerous. Consider how you can ensure these items do not become safety hazards .

Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of three sampled residents, Resident 1 (R1), when R1 did not receive one-on-one supervision on 7/29/20 in accordance with the assessed need and care plan and the facility policy and procedure on smoking. These failures resulted in R1 being permitted to smoke outside unsupervised, falling from her wheelchair onto her right arm and shoulder; having to be transported to an acute care hospital (ACH) for evaluation with fracture to the right humerus (largest bone of the upper arm) and greater tuberosity (the prominent area of bone at the top of the humerus and is the attachment for the two large powerful rotator cuff muscle), treatment for pain and splint/cast (a device used to support and immobilize a broken bone) for the fracture. R1 was transported back to the skilled nursing facility (SNF) and had decreased mobility of the right arm. Findings: During an observation on 8/13/20 at 2:39 p.m., R1 was in her room, laid in bed with her eyes closed. R1 had a splint on her right arm. During an interview on 8/13/20 at 4 p.m., with License Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse assigned to Resident 1 on 7/29/20, when Resident 1 had a fall from her wheelchair outside the facility in the smoking area. LVN 1 stated Resident 1 was anxious to go outside and smoke on that day. LVN 1 stated the certified nursing assistant (CNA) assigned to supervise Resident 1 smoking was not available to accompany R1 and was providing care to another resident. LVN 1 stated she gave the cigarette and lighter to R1 and R1 wheeled herself outside the facility to smoke. LVN 1 stated R1 was not safe to smoke outside unsupervised. LVN 1 stated she should not have given R1 her cigarette and lighter. LVN 1 stated she should have waited for the CNA to supervise R1 smoking instead of permitting R1 to go outside to smoke unsupervised. During a review of R1's Progress Notes, dated 7/29/20 at 8:20 a.m., R1's Progress Notes indicated, Resident [R1] wanted to go out to smoke for the scheduled smoke break. Resident became very anxious and refused to wait for staff to supervise the smoke break. Resident wheeled herself out of the unit . resident fell out of wheelchair . Progress notes dated 7/29/20 at 8:47 a.m., indicated, She fell because she refused to wait for staff to go out for her smoke break . she complained of right shoulder pain . she was sent to the ER [emergency room ] for eval [evaluation] . During a review of R1's [name of acute hospital] Diagnostic Radiology, dated 7/29/20, indicated, .XR [xray - specialized equipment to take an image of the inside structures of the body] Shoulder Complete Minimum 2 views right . Clinical Information: Injury and pain . Findings: Acute comminuted fracture (broken bone into 3 or more places) of the right humeral neck and head [upper right arm and shoulder] . During a review of R1's [name of acute hospital] Patient Education & Visit Summary (hospital discharge summaries serve as the primary documents communicating a patient's care plan to the post-hospital care team) dated 7/29/20, indicated, .Presenting Complaint: BIBA [brought in by ambulance] from [name of skilled nursing facility], with right arm pain . Patient Diagnosis: Fall from wheelchair; Fracture of surgical neck humerus . Humerus Fracture treated with Immobilization . Printed Prescription [MEDICATION(S)] and acetaminophen . During a review of R1's Face Sheet (a document containing resident profile information) indicated, R1 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (a portion of the brain that has restricted blood supply or stroke), [CONDITION(S)] (is a language disorder that affects the ability to communicate, it's most often caused by a stroke), and generalized muscle weakness. During a review of R1's Minimum Data Set (MDS- an assessment of healthcare and functional needs) assessment, dated 6/30/20, Resident 1's Brief Interview for Mental Status (BIMS- assessment of cognitive status) scored 5 of 15 points which indicated R1 was severely cognitively impaired, MDS section G (assessment of functional status) .locomotion on unit . Supervision- oversight . locomotion off unit Supervision- oversight . Mobility device .Wheelchair . During a review of Resident 1's Care Plan, dated 4/7/20, indicated, R1 needed assistance with smoking . Care Plan, dated 1/13/20 indicated The Resident [R1] is at risk for falls and injuries due to the following risk factors: decline in functional status, impaired mobility . During a concurrent interview and record review, on 8/13/20 at 4:43 p.m., with the Director of Nursing (DON), the Smoking Policy, dated 10/24/17. indicated, To respect resident choice to smoke and to maintain a safe and healthy environment for both smokers and non-smokers . Resident smoking is only allowed during scheduled times . All smoking sessions will be supervised by Facility Staff members only . Residents are not permitted to keep smoking materials such as lighters, matches or any other related items in their possession .R1's Smoking Assessment (an assessment tool used to evaluate resident safety during smoking) dated 7/9/20, was reviewed. R1's smoking assessment indicated, R1 needed one-on-one assistance for safety The DON stated the fall could have been prevented if supervision and assistance was provided and the license nurse did not give R1 her cigarettes until the CNA assigned to supervise smoking was ready to accompany R1. During an interview on 8/18/20, at 12:30 p.m., with CNA 1, CNA 1 stated she was assigned to supervise R1 during smoking on 7/29/20. CNA 1 stated she was providing care to another resident and was not ready to supervise R1 on 7/29/20 at the time R1 requested to go out and smoke. CNA 1 stated she heard staff members yelling and when she stepped outside the facility, she saw R1 on the ground. CNA 1 stated the fall could have been prevented if the license nurse waited for her to provide supervision to R1 before giving the cigarettes and the lighter. During an interview on 8/18/20, at 6:30 p.m., with LVN 2, LVN 2 stated she was outside the Red Zone unit (area in the facility dedicated to care for residents with the Coronavirus [COVID-19- a contagious serious respiratory infection transmitted from person to person]). LVN 2 stated she was performing hand washing inside the tent (area in the facility where staff washed their hands before entering and exiting the Red Zone). LVN 2 stated she saw R1 on her wheelchair coming out of the Red Zone unsupervised. LVN 2 stated she told R1 to wait for a staff member to supervise her smoking. LVN 2 stated R1 did not listen to her and just passed by her. LVN 2 stated she heard a loud noise and when she stepped outside the tent, she saw R1 on the ground. LVN 2 stated she could not stop R1 from going out the facility unsupervised because she was in the middle of washing her hands. LVN 2 stated R1 was assessed as a high fall risk and it was not safe for her to smoke outside unsupervised. During a concurrent interview and record review on 8/25/20, at 2:09 p.m., with the Assistant Director of Nursing (ADON), Resident 1's Smoking assessment dated [DATE], was reviewed. Resident 1's Smoking Assessment indicated, Resident 1 needed one-on-one assistance during smoking sessions for safety. R1's Fall Risk Assessment, dated 3/29/20, was reviewed. R1's Fall Risk Assessment indicated, Resident 1 was assessed as a Moderate risk for falls. ADON stated it was not safe for Resident 1 to smoke outside the facility unsupervised based on the smoking assessment and fall assessment. During a review of the facility's policy and procedure titled, Fall Management, dated 11/2012, indicated, It is the policy of this facility that our physical environment remains as free of accident hazards as possible. Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls . Residents, who have sustained a fall, will be placed on the facility's heightened awareness program . outlined on the care plan . During a review of the professional reference titled, Nursing home resident smoking policies dated 2008, https://pubmed.ncbi.nlm.nih.gov/ 890/ indicated .Objective: To identify nursing home standards related to resident smoking through a nationwide survey of directors of nursing. Methods: A national survey was distributed online and was completed by 248 directors of nursing. The directors of nurses answered questions concerning resident smoking including the criteria utilized to determine an unsafe resident smoker. For those residents identified as unsafe, the questions asked were specifically related to monitoring, staff involvement, safety precautions and policy. Results: The results of the survey demonstrated a consistent policy practiced among facilities across the United States. The monitoring of nursing home residents is based on a resident's mental acuity, physical restrictions and equipment requirements. Once a resident was identified as a smoker at risk of harm to self or others, staff involvement ranged from distributing cigarettes to direct supervision. Conclusion: Monitoring policies of nursing home residents who smoke starts with identifying those residents at risk based on an assessment of mental acuity, physical restrictions and equipment requirements. Those that are identified as being at risk smokers have their cigarettes controlled and distributed by nursing staff and are supervised by facility staff when smoking. This policy is implemented through written policy as well as staff education .

Based on interview and record review, the facility failed to ensure pain management was provided consistent with professional standards of practice and facility policies and procedures for one of three sampled residents when Resident 9's oxycodone (narcotic used for severe pain) was not given as ordered by the physician, and failed to perform pain assessment. These failures resulted in Resident 9 experiencing constant and unrelieved pain, causing Resident 9 to leave the facility against medical advice. Findings: During a review of Resident 9's Admission Record dated 1/17/20, the document indicated Resident 9 admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 9's Order Summary Report, dated 1/17/20, the document indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 9's Progress Notes dated 1/16/20, at 8:14 p.m., the document indicated . Resident was yelling and throwing stuff in the room because she needs the pain med, told resident that we are working to get code [code for obtaining medication from the pharmacy] for her pain med . During a review of Resident 9's Progress Notes dated 1/16/20, at 9:56 p.m., the document indicated Resident arrived at 16:55 [4:55 p.m.] from . via gurney . upon arrival resident was doing good no behavior, wound vac [treatment that creates vacuum around wound and drains excess fluid] changed and resident tolerated well, after that resident was upset because of pain medication, called pharmacy five times to get the Cubex [computer controlled drug dispensing machine] and after got the Cubex couldn't find the resident under the Cubex list, noc [night] shift nurse informed . During a review of Resident 9's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] During a telephone interview on 3/13/20, at 7:45 p.m., with Licensed Vocational Nurse (LVN) 7, LVN 7 stated on 1/16/20, Resident 9 did not receive oxycodone after she requested pain medication because the facility did not have any tablets on hand, and was unable to retrieve it from the Cubex (automated medication dispensing system). LVN 7 stated, We sent order to pharmacy, we asked for Cubex code, we got into machine and the name of resident was not there. Pharmacy told nurse to call customer care at 9:27 p.m. Called tech support, pharmacy didn't put resident name in list until 11:37 p.m. LVN 7 acknowledged Resident 9 was not given pain medication for over seven hours after she requested for pain medication (med). When asked about Resident 9's initial pain assessment, LVN 7 stated the staff did not conduct a pain assessment for Resident 9. During a concurrent telephone interview and record review on 3/17/20 at 2:38 p.m. with Registered Nurse (RN) 3, a review of Resident 9's Order Summary Report and Progress Notes occurred. RN 3 stated on 1/16/20, Resident 9 arrived at the facility around 5 p.m. and did not receive oxycodone for pain until around 11:58 p.m. RN 3 acknowledged Resident 9 was in pain for 7 hours without pain meds. RN 3 stated, Patient was yelling, throwing stuff, I spoke with her sister . I was by myself taking care of other residents, I tried my best to get the pain pill for her. RN 3 acknowledged it was not appropriate for Resident 9 to go for 7 hours with her pain unrelieved. RN 3 stated, It can affect patient mentally, physically, patient is not going to feel good at all. It can affect blood pressure. When asked about the pain assessments for Resident 9 on 1/16/20, RN 3 stated she was unable to provide documentation of Resident 9's pain assessment upon admission and pain assessment upon Resident 9's request for pain medication on 1/16/20 at approximately 5 p.m. During a telephone interview on 3/18/20 at 1:57 p.m., with the Pharmacy Manager (PM), the PM stated on 1/16/20 at 5:51 p.m., the pharmacy received an oxycodone order. The PM stated, We have to have nurse call pharmacy to request for control authorization. First time facility called was at 9:55 p.m. no record of facility calling prior . 10:03 p.m., another pharmacist gives another code because nurse said code not working, we have Cubex manager that help resolve problems for Cubex . During a telephone interview on 3/19/20 at 11:20 a.m., with the Cubex Manager (CM), the CM stated, Oxycodone was not pulled from the Cubex, I don't know why nurse did not pull from Cubex . we did give authorization. If nurse logged in to Cubex, it would show that she logged in, but there was no history for that patient . During a telephone interview on 3/20/20 at 3:36 p.m., with Resident 9, Resident 9 stated, . They would not come when I pushed my call light or cry out in pain . I did not get my pain meds at all that night, I was in pain. I was going through withdrawals. It was horrific, that situation will last with me in my memory, I will have to get therapy over it. I kept thinking I would walk right into the freeway and thought I had to get out of here. I kept sinking into a lower state of depression the whole time I was there. During a concurrent telephone interview and record review on 3/20/20 at 4:18 p.m., with the DON, the DON stated she was not aware oxycodone was not dispensed from the facility Cubex on 1/16/20. The DON stated, I don't know how resident [Resident 9] could've been administered oxycodone if it didn't come from Cubex . The DON stated, No, it's not acceptable for resident to go so long without pain meds. Pain can raise blood pressure, agitation . no, not in line with pain management policy. The DON also acknowledged an initial pain assessment was not completed for Resident 9 upon admission. The DON stated, . no pain assessment done. Pain assessments should be completed when patient admitted , pain medications should be given timely . During a review of the facility's Policy and Procedure titled, Medication Administration-General Guidelines, the document indicated . Medications are administered in accordance with good nursing principles and practices . During a review of the facility's Policy and Procedure titled, Pain Management, dated 11/28/17, indicated, . Pain assessment begins at admission by the licensed nurse and reassessments are performed throughout the patient's length of stay. Pain is assessed at least every shift, when a patient complains of pain .

Based on observation, interview and record review, the facility failed to ensure effective pain management was provided for one of three sampled residents (Resident 1) consistent with professional standards of practice, a person-centered care plan, the facility's policy and resident pain tolerance preferences when: 1. Resident 1's [MEDICATION NAME] (medication to treat moderate to severe pain) pain medication was not available for administration as ordered by the physician for four days. 2. The facility did not conduct a comprehensive assessment for pain, did not develop and/or implement a baseline person centered pain care plan with interventions, goals and resident preferences for pain treatment on admission. These failures resulted in Resident 1's unrelieved pain and suffering which required transfer to the hospital for pain relief on three separate occasions within 26 days of admission to the skilled nursing facility. Findings: 1. During a review of the clinical record for Resident 1, the Admission record, dated 9/17/19, indicated the resident's original admission was on 8/9/19 with [DIAGNOSES REDACTED]. During an interview with the Director of Nursing (DON), on 9/17/19 at 1:03 p.m., she stated prior to Resident 1's transfer to the acute care hospital on [DATE], Resident 1 had complained the nurses were not changing his abdominal wound dressing the way he wanted it to be done. The DON stated she and the social worker had met with Resident 1 and he had not voiced complaints about his pain not being controlled. The DON stated she was not aware Resident 1's pain medication [MEDICATION NAME] was not available. During a concurrent observation and interview with Resident 1, on 9/17/19, at 1:10 p.m., he stated his abdominal pain was not managed very well when he was originally admitted (8/9/19) to the facility. Resident 1 stated there was a four-day period when one of his pain medications ([MEDICATION NAME]) had not been refilled or reordered. Resident 1 stated he was sent to the emergency roiagnom on another occasion because the pain medications were not effective. Resident 1 pulled up the bottom edge of his shirt and exposed his abdomen which was covered with a clear plastic bag. The clear plastic bag covered the entire middle and right side of his abdomen, was attached to his skin and covered a wound opening located in the mid upper portion of his abdomen. The abdominal wound was discharging moderate amounts of semi liquid and liquid brown stool. A drainage tube from the large plastic bag's bottom edge was attached to the drainage bag hanging from the bottom rail of the resident's bed. To the left of the clear plastic bag was a [MEDICAL CONDITION] (a surgical procedure which brings one end of the large intestine out through the abdominal wall allowing stool to drain) covered with a separate smaller [MEDICAL CONDITION] bag draining smaller amounts of brown liquid and semi liquid stool. During an interview with Resident 1, on 9/17/19, at 1:10 p.m., he stated approximately two weeks after his first admission to the Skilled Nursing Facility (SNF) there had been a problem getting a pain medication, [MEDICATION NAME], for a period of four days. Resident 1 stated he had been getting [MEDICATION NAME] and [MEDICATION NAME] (pain medication) for abdominal pain since he was admitted to the facility. Resident 1 stated the nurses told him they were trying to contact his physician to get the medication. Resident 1 stated he had changed his physician just prior to that four day period (8/22, 8/23/, 8/24, 8/25/19) and the nurses told him the new current physician needed to re-order the pain medication. Resident 1 stated on Sunday night (8/25/19) he called his physician himself and requested to be sent to the emergency room because his abdominal pain was not treated effectively with just the [MEDICATION NAME]. Resident 1 stated he talked to the DON and a social worker when he returned from the emergency roiagnom on [DATE] about the pain medication ([MEDICATION NAME]) not being available for the four days and his issues with pain management. During an interview with Resident 1, on 9/17/19, at 1:10 p.m., he stated he had been taking [MEDICATION NAME] since 2010, routinely, for generalized pain. Resident 1 stated his tolerance level for pain scored was a five out of ten (on a pain scale 0-10 with 0 being no pain and 10 the worst imaginable) and he was able to tolerate a pain level of five. During an interview with Resident 1, on 9/17/19, at 1:10 p.m., Resident 1 stated he had been transferred to the emergency room (ER) on three occasion for unmanaged pain. The first time he was transferred to the ER was on 8/17/19 for uncontrolled pain to his abdominal wound approximately a week after his admission of 8/9/19. The second time he was transferred to the ER was on 8/25/19 approximately seven to ten days after the last time he was transferred to the ER 8/17/19. Resident 1 stated he was experiencing severe abdominal pain 10 out of 10 and the facility did not have his prescribed pain medication [MEDICATION NAME] (medication to treat moderate to severe pain) available for four consecutive days 8/22, 8/23, 8/24, and 8/25/19. Resident 1 stated the licensed nurses were telling him they were trying to contact his doctor without success. Resident 1 stated he used his phone and called the doctor and was able to speak with him right away. Resident 1 stated the doctor informed him that he would call the facility and instruct the nurses to send him to the ER for pain relieve. Resident 1 stated the third time he was transferred to the ER was for severe pain (10 out of 10) above his abdominal wound accompanied by nausea and vomiting. Resident 1 stated his pain medications were not working at all. Resident 1 stated he was hospitalized on his third ER visit. During a review of the clinical record for Resident 1, the MDS (a resident assessment tool used to identify cognitive and physical function) assessment, dated 8/15/19, indicated Resident 1's Brief Interview for Mental Status (BIMS-an assessment of cognitive status for memory and judgement) score was 13 of 15, which reflected no cognitive deficits. The MDS assessment dated [DATE], indicated Resident 1 had pain frequently and indicated his worst pain level over the past five days was a seven out of ten. The MDS assessment indicated the Care Area Assessment (CAA-the review of conditions, symptoms, and other areas of concern that are commonly identified or suggested by MDS findings) for pain had been triggered (identified) for care planning. During a review of the clinical record for Resident 1, the Progress notes dated 8/17/19, at 4:36 p.m., indicated, .(at 11:34 a.m., [MEDICATION NAME]) given per patient (Resident 1) c/o (complaint) 7/10 pain in abdominal area . (at 11:34 a.m., [MEDICATION NAME]) given per patient (Resident 1's) c/o 10/10 pain in abdominal area . Change in Condition .Pain (uncontrolled) Skin wound (abdominal area) .resident (1) has been complaining of pain since beginning of shift (2 p.m.) . [MEDICATION NAME] was given and (brand name-[MEDICATION NAME]) an hour after. Patient (1) requested to be sent out to ER (emergency room ) .Per MD (Medical Doctor) okay to send out . Resident 1's progress notes dated 8/17/19, at 4:40 p.m., indicated, .called MD (Medical Doctor), new order to send patient out . During a review of the clinical record for Resident 1, the Transfer/discharge report dated 8/17/19, at 4:50 p.m., indicated Resident 1 was sent to the acute care hospital ER, reason for transfer, Resident 1's vital signs and the last time the Resident 1 had been given [MEDICATION NAME] and [MEDICATION NAME]. The Transfer/Discharge Report indicated Resident 1 was given [MEDICATION NAME] at 3:36 p.m. and [MEDICATION NAME] at 2:37 p.m., no pain assessment information was documented on the Transfer/ Discharge report. During a review of the clinical record for Resident 1, the Doctor's recap (recapitulation) orders dated 8/9/19, indicated, ([MEDICATION NAME]) Tablet 5-325 MG (milligram- a dry unit of measure ([MEDICATION NAME]/[MEDICATION NAME] (pain medication for moderate pain)) Give 1 tablet by mouth every 4 hours as needed for moderate/severe pain . (start date of) 8/9/19 (order start date) 8/10/19 . [MEDICATION NAME] .Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for pain . ([MEDICATION NAME]) end date 8/26/19 . During a review of the clinical record for Resident 1, the Progress notes dated 8/26/19, indicated, (at) .12:05 a.m., Change in condition/s .abdominal pain .(at) 12:35 a.m., patient initial complain was pain 10/10 with no relief from [MEDICATION NAME] 50 mg (milligrams - unit of measurement). Patient was requesting ([MEDICATION NAME]/[MEDICATION NAME]) 5-325 mg which at this time was out of refills from previous MD (medical doctor). Current MD was called and pharmacy was working on getting a new order .patient called MD from personal phone and c/o pain and leaking ([MEDICAL CONDITION]) drainage bag .MD called facility and gave order to send patient out for further evaluation .(at) 1:59 p.m., call received (at the facility) from (hospital) ER . patient is coming back . pt (patient (1)) concerns .(facility) not having enough pain medication, improper and not the right [MEDICAL CONDITION] bag applying to his ([MEDICAL CONDITION] wound) .(at) 3:31 p.m., SS (Social Service) and DON met with resident (1) to discuss (his) concerns. Resident (1) voiced concerns with ([MEDICAL CONDITION]) and fistula (an abnormal or surgically made passage between a hollow or tubular organ and the body surface) drainage bag being put on wrong . multiple complaints . During a review of the clinical record for Resident 1, the Transfer/Discharge report dated 8/26/19, indicated reason for transfer, Patient has leaking drain bag c/o pain 10/10 . During a review of the clinical record for Resident 1, the Progress notes dated 9/4/19, at 10:39 a.m., indicated, .Writer called MD regarding patients current condition patient is complaining of abdominal pain 10/10 not relieved after taking pain medication at 9:33 a.m . Patient has had emesis (vomiting) x (times) 2 . MD gave orders to send patient to (acute care) to be further evaluated . During a review of the clinical record for Resident 1, the transfer/discharge report dated 9/4/19, indicated reason for transfer, abdominal pain not relieved (with) pain med . During an interview with Licensed Vocational Nurse (LVN) 1, on 9/17/19, at 2:45 p.m., LVN 1 stated she was the admitting nurse when Resident 1 was admitted on [DATE]. LVN 1 stated Resident 1 was taking [MEDICATION NAME] and [MEDICATION NAME] for complaints of abdominal wound pain. LVN 1 stated she sent Resident 1 to theER on [DATE] for complaints of abdominal pain and to have the [MEDICAL CONDITION] bag over his abdominal wound changed. During an interview with the DON, on 9/17/19 at 3 p.m., she stated if a medication was not available, the nurses could call the pharmacy and have the pharmacy get a verbal order from the physician. The DON stated, The nurses should know that. The DON stated Resident (1's [MEDICATION NAME]/[MEDICATION NAME]) 5-325 mg was not available for four days (8/22 -8/25/19) and the nurses did not notify her. The DON stated Resident 1 did not receive his prescribed [MEDICATION NAME]/[MEDICATION NAME] 5-325 mg during that time period which resulted in Resident 1 experiencing severe pain and required Resident to be transferred to the hospital for pain management. During an interview with the DON, on 9/17/19, at 4:20 p.m., she reviewed Resident 1's Medication Administration Record [REDACTED]. The DON stated the licensed nurses should have contacted her or the medical director when Resident 1's [MEDICATION NAME] was not available, and they did not do that. During a telephone interview with the DON, on 10/11/19, at 2 p.m., she stated the Interdisciplinary Team (IDT) (facility department managers, including the director of nursing, licensed nurses, Minimum Data Set (MDS) assessment coordinators, who review resident care needs and create recommendations to be implemented in the Resident's plan of care) assess resident's pain management quarterly. The DON reviewed Resident 1's clinical record and was unable to find documentation of pain assessments. During a telephone interview with LVN 2, on 10/15/19, at 4:10 p.m., LVN 2 stated she sent Resident 1 to the acute care hospital on [DATE] and it was because his abdominal dressing was leaking. LVN 2 stated she did not remember if pain was an issue when she sent him to the acute care hospital. LVN 2 stated there was some hold up with getting a pain medication because Resident 1 had changed physicians. LVN 2 stated Resident 1 was not happy about his pain management and he had been on [MEDICATION NAME] (a medication used to treat severe pain) prior to admission to the facility. LVN 2 stated if pain medication was not available for a resident, nurses were to notify the DON to have the resident sent to the acute care hospital. LVN 2 stated she did not remember if she contacted the doctor or the DON regarding Resident 1's unhappiness with his pain management. During a review of the clinical record for Resident 1, the Progress notes dated 8/25/19, at 12:36 a.m., indicated LVN 3 had documented .Called Dr. (surname) phone (number) regarding pt. (Resident 1) requesting to be sent out due to c/o (complaint of) severe pain to abdomen and unavailable pain medication (brand name for [MEDICATION NAME]-a medication for pain), spoke with representative, she (representative) stated that Dr. (surname) is not available .going to page the on call Dr . The progress note dated 8/25/19 did not have documentation which indicated LVN 3 spoke to a physician about Resident 1's complaint of abdominal pain or about the unavailable [MEDICATION NAME]. During a review of the clinical record for Resident 1, the Progress notes dated 8/25/19, at 2:33 p.m., indicated LVN 6 contacted Resident 1's physician's office and left a message in regard to laboratory results but not about Resident 1's abdominal pain and unavailable pain medication, [MEDICATION NAME]. During a review of the clinical record for Resident 1, the Progress notes dated 8/25/19, at 2:48 p.m., indicated LVN 2 had documented, .Indicators of pain vocal complaints of pain. Pain score: 10 (10 of 10). reports that pain occurs daily. Non-medication interventions refused . During a review of Resident 1's acute care hospital, titled .EMERGENCY DEPARTMENT NOTE dated 8/25/19, at 11:31 p.m. indicated, .CHIEF COMPLAINT .Abdominal pain .patient w/ (with) chronic abdominal pain. Rated a 9 on evaluation. States has been w/o (without) chronic pain medication (brand name ([MEDICATION NAME]) 10 mg) w/ last dose 3 days ago (8/22/19) . The acute care hospital emergency room document indicated on 8/25/10, at 11:57 p.m., one tablet of [MEDICATION NAME] 10 mg was administered to Resident 1. During a telephone interview with the DON, on 9/29/19, at 3:05 p.m., she stated the normal routine for a medication refill, or a reorder of pain medication was to fax a continuance (a controlled substance prescription) to the pharmacy. The DON stated a continuance of narcotics required a physician's signature and the pharmacy would let the staff know if they were unable to contact the physician. The DON stated if the pharmacy was not able to contact the physician, the staff could call the physician's office, call the DON, or contact the facility's medical director. The DON stated the medical director could sign the prescription for a couple days supply of medication. The DON stated she reviewed Resident 1's clinical record and there was documentation the nurse called the resident's physician but there was no documentation of a response from the physician or a follow up call by the nurse. The DON stated, Don't know what happened on this. The DON stated there was no documentation on the MAR indicated [REDACTED]. During a telephone interview with LVN 3, on 10/11/19 at 3:30 p.m., LVN 3 stated she remembered Resident 1 had not had his [MEDICATION NAME] available for a three to four days because his physician needed to sign the continuance form for the medication. LVN 3 stated she had not notified the DON or the pharmacy about Resident 1's [MEDICATION NAME] not being available. LVN 3 stated Resident 1 asked for the [MEDICATION NAME] and she explained to the resident that the medication could not be reordered until the doctor signed for it. LVN 3 stated Resident 1 stated he was okay with the [MEDICATION NAME] as long as the nurses gave it to him when he requested the medication. During an interview with LVN 5, on 10/25/19, at 10:35 a.m., he stated there was a three to four day period when Resident 1's [MEDICATION NAME] was not available. LVN 5 stated Resident 1's physician needed to sign a continuance for the [MEDICATION NAME] pain medications. LVN 5 stated it was the nurse's responsibility to contact Resident 1's physician for a pain medication renewal order. LVN 5 stated a nurse could call the medical director to order or sign for a medication if a resident's physician was unavailable. LVN 5 stated Resident 1 also had [MEDICATION NAME] ordered for pain but the [MEDICATION NAME] did not provide effective relief for Resident 1's pain. LVN 5 stated Resident 1 was upset about his unrelieved pain medication regimen which was the reason the resident changed physicians. During a telephone interview with the Consultant Pharmacist (CP)1, on 10/25/19, at 12:40 p.m., he stated a new order, or a continuance was needed if a resident changed physicians. The CP stated if a pain medication was not available, the nurses needed to contact the physician or contact the pharmacy who would reach out to the doctor for a refill or a new order. During a telephone interview with Resident 1, on 11/1/19, at 11:13 a.m., he stated during the four day period when his [MEDICATION NAME] was unavailable, he asked the nurses every shift if the medication had been reordered. Resident 1 stated the nurses would tell him they would call or fax the doctor and pharmacy as they could not give him the [MEDICATION NAME] until the physician signed a prescription. Resident 1 stated his pain level was never below an 8 (out of 10) during those three days. Resident 1 stated the [MEDICATION NAME] he was given was not effective because he had built up a tolerance to it. Resident 1 stated the nurses did not conduct assessments to evaluate for the effectiveness of pain medication. Resident 1 stated the [MEDICATION NAME] was effective to control his pain when he was given it. Resident 1 stated his abdominal pain felt like someone was standing on his belly, and he was in constant pain. Resident 1 stated he called the on call physician on 8/25/19, late in the evening, and told the physician about the situation with his pain. Resident 1 stated the on call physician talked to the nurse and he (Resident 1) was sent to the emergency room . During an interview with Registered Nurse (RN) 2, on 11/12/19, at 2:10 p.m., RN 2 stated whenever she went to check the effectiveness of Resident 1's pain medication, he was always sleeping and snoring, and she did no conduct a pain assessment on Resident 1's pain level. During a telephone interview with the CP 2, on 12/5/19, at 11:25 a.m., she reviewed Resident 1's records and stated she could not find a faxed request from the facility for a renewal or refill of Resident 1's [MEDICATION NAME] from 8/21/19 through 8/24/19 but CP 2 stated on 8/25/19 LVN 2 called the pharmacy about the medication not being available. CP 2 stated the pharmacy notified Resident 1's physician on 8/25/19 and he ordered Resident 1's [MEDICATION NAME] 5/325 mg medication. During a review of the professional reference for pain management from the join commission dated 12/21/2018, indicated, .If the patient's or resident's assessed needs warrant a pain treatment plan, the organization develops a pain treatment plan based on evidence-based practices and the patient's or resident's clinical condition, past medical history, and pain management goals .Based on the patient's or resident's condition, the organization reassesses and responds to the patient's or resident's pain through the following: - Evaluation and documentation of response(s) to pain intervention(s) - Progress toward pain management goals including functional ability (for example, improved pain, improved or preserved physical function, quality of life, mental and cognitive symptoms, sleep habits) .Reassessment should be completed to determine if the intervention is working . Unidimensional reassessment based on pain intensity rating alone is inadequate . During a review of the facility policy and procedure titled, PAIN MANAGEMENT revised date 11/28/17, indicated, .This facility recognizes a patient's right to be free of pain and promotes pain relief .to help the patient attain or maintain his or her highest practicable level of well-being and to prevent or manage pain to the extent possible .Manage or prevent pain, consistent with the comprehensive assessment and plan of care .The licensed nurse communicate the adequacy of pain management and/or changes in pain significance to the physician during the patient's length of stay .A plan of care is developed for patients, documented and updated as needed . 2. During a review of the clinical record for Resident 1, the Admit/Readmit assessment dated [DATE], at 3:12 p.m. indicated, Pain Assessment, Resident 1 experienced pain daily, which limited his day to day activities and made it hard to sleep at night. The pain assessment also indicated Resident 1 was on [MEDICATION NAME] and [MEDICATION NAME] as needed for pain. The pain assessment had no documentation of the numeric pain assessment rating of 0-10 (0 indicated no pain and a 10 was the worst pain imaginable) to define the severity of the pain or a verbal description of Resident 1's pain. During an interview with Resident 1, on 9/17/19, at 1:10 p.m., he stated his abdominal pain was not managed well when he was originally admitted to the facility. Resident 1 stated there was a four day period when his [MEDICATION NAME] pain medications had not been refilled or reordered. Resident 1 stated as a result of this, he called his primary doctor himself and requested to be sent to the emergency room to receive pain medications. Resident 1 stated he was sent to the emergency roiagnom on two other occasions because the pain medications were not effective. During a review of the clinical record for Resident 1, the Progress note dated 8/17/19, at 4:36 p.m., indicated .Change in Condition .Pain (uncontrolled) Skin wound .resident has been complaining of pain since beginning of shift, [MEDICATION NAME] was given and (brand name- [MEDICATION NAME]) an hour after. Patient requested to be sent out to ER .Per MD (Medical Doctor) okay to send out . Resident 1's progress notes dated 8/17/19, at 4:40 p.m., indicated, .called MD (Medical Doctor), new order to send patient out . During a review of the clinical record for Resident 1, the Progress note dated 8/26/19, at 12:05 a.m., indicated there had been a change in condition for Resident 1. The note indicated, The change in Condition/s reported .Abdominal pain, The progress notes dated 8/26/19 at 12:35 a.m., indicated, Patient initial complaint was pain 10/10 with no relief from [MEDICATION NAME] 50 mg (milligram-a dry unit of measure). Patient was requesting (brand name for [MEDICATION NAME]-a medication for moderate to severe pain) .Which at this time was out of refills from previous MD (medical doctor) .order to send patient out for further evaluation. During a review of the clinical record for Resident 1, the Progress note dated 9/4/19, at 10:39 a.m., indicated, .Writer called MD regarding patients current condition patient is complaining of abdominal pain 10/10 not relieved after taking pain medication at 9:33 a.m .MD gave orders to send patient to (acute care) to be further evaluated . During an interview on 10/25/19, at 9:35 a.m., with the DON, she reviewed Resident 1's clinical record and was unable to find a pain baseline care plan for Resident 1's initial admission to the facility during the time period 8/9/19 through 9/4/19. The DON stated the baseline care plan for pain management was not developed or initiated. During an interview on 10/25/19, at 11:30 a.m., with the MDS Coordinator (MDSC), she reviewed Resident 1's clinical record and was unable to find a baseline care plan for pain developed or initiated during the resident's original admission from 8/9/19 to 9/4/19. The MDSC stated a baseline care plan for pain was not developed or initiated for Resident 1 until 9/16/19 after he was readmitted to the facility from the third acute care hospital stay. During an interview on 10/25/19, at 11:40 a.m., with the MDS Assistant (MDSA), she reviewed Resident 1's MDS assessment dated [DATE] and stated pain was a triggered care area. The MDSA stated she missed the pain trigger care area and should have reviewed the pain baseline care plan to ensure a care plan had been developed, I take responsibility (for no care plan). During a review of the clinical record for Resident 1, the initial baseline care plan dated 8/9/19 at 3:09 p.m., indicated, .Other Medications (brand name for [MEDICATION NAME]) 1 tablet by mouth every 4 hours as needed. There were no interventions or goals identified or documented for the medication use. During a telephone interview on 11/21/19, at 3:15 p.m., with LVN 7, she stated she remembered Resident 1 would ask for his pain medication every four hours. LVN 7 stated Resident 1 should have had a care plan developed for pain management. LVN 7 stated a care plan was important because the staff needed to know the interventions developed in order to manage a resident's care needs. During a telephone interview on 11/26/19 at 10:45 a.m., with the MDSA, she stated when a comprehensive care plan was developed, she started with the baseline care plan and added interventions based on the resident's care needs obtained by interviews with the nurses who cared for the resident. The MDSA stated a care plan based on a resident's identified needs was important for managing and monitoring the effectiveness of the interventions and that was not done. During a review of the facility policy and procedure titled, CARE PLAN, Baseline and Comprehensive revised 11/17, indicated, .It is the policy of this facility to develop, upon admission and following completion of the Admission Nursing Assessment, an interim and comprehensive care plan for the resident .A comprehensive person-centered care plan consistent with resident's rights will include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when 1. The facility placed 9 of 10 sampled Residents (Residents 3, 7, 10, 20, 44, 65, 564, 565, and 566) at serious risk for infection and Forty-three additional residents (Residents 1, 5, 11, 16, 26, 33, 34, 36, 41, 42, 47, 49, 57, 58, 73, 76, 89, 92, 93, 94, 99, 107, 122, 125, 135, 137, 141, 567, 568, 569, 570, 571, 572 and 573) identified as potentially at risk due to their requiring blood glucose testing with the use of the glucometer (a small portable device used to measure sugar in the blood) machine. When five of five sampled licensed nurses did not disinfect the facility glucometers machine with a disinfectant solution effective against blood borne pathogens (microorganisms (any organism too small to be viewed by the eye) that are transmitted through human blood and cause disease in humans, include, but are not limited to, [MEDICAL CONDITION] virus (a serious liver infection, transmitted by infected blood, contaminated needles or exposed to infected blood (HBV)) and human immunodeficiency virus (HIV - life threatening infection, transmitted through direct contact with HIV-infected body fluids, blood)). This deficient practice placed Residents 3, 7, 10, 20, 44, 65, 564, 565, 566, 1, 3, 5, 7, 10, 11, 16, 20, 26, 33, 34, 36, 41, 42, 44, 47, 49, 57, 58, 65, 73, 76, 89, 92, 93, 94, 99, 107, 122, 125, 135, 137, 141, 564, 565, 566, 567, 568, 569, 570, 571, 572 and 573 at risk for serious potential harm for blood borne infections due to their requiring blood glucose testing with the use of the shared glucometer machines. Because of the serious potential harm of infection with blood borne pathogens as a result of this deficient practice, an Immediate Jeopardy situation (IJ) was called on 7/11/19 at 4:13 p.m., with the facility Administrator (ADM), Director of Nursing (DON) and Clinical Consultant Director (CCD). The facility submitted a Plan of Removal to address the IJ situation which included in-service training for all licensed nurses on the proper disinfection of the glucometer with the approved blood borne pathogen germicidal disinfectant. The removal plan emphasized the following, never to use alcohol or hand sanitizer to clean glucometers, only the manufacturer recommended disinfectant wipes were to be used to clean and disinfect glucometers; glucometers were to be cleaned and disinfected after each use and prior to performing additional finger sticks on any other residents, risk of harm to the resident if glucometers are not appropriately cleaned and disinfected prior to performing finger sticks on another resident and the Director of Staff Development (DSD) immediately stocked all medication carts with the manufacturer recommended disinfecting wipes on 7/11/19 at 5 p.m. The Plan of Removal was accepted on 7/12/19 at 4:00 p.m. The interventions to address the IJ situation on the Plan of Removal were fully implemented. The IJ was removed on 7/16/19 at 8:43 a.m., with the ADM, DON and CCD. 2. Restorative Nursing Assistant (RNA), Certified Nursing Assistant (CNA) 11, 26, and 27 did not perform hand hygiene before and after glove use and between serving residents during meal service for 31 of 31 sampled residents (Resident 89, 99, 121, 129, 87, 15, 93, 17, 87, 22, 121, 124, 136, 158, 10, 11, 14, 15, 37, 40, 49, 55, 85, 89, 129, 142, 151, 1, 8,119 and 24). 3. Resident 136, 133 and 51's indwelling urinary catheter bag (flexible tube inserted in the bladder to drain urine and leads to a drainage bag) was touching the ground. This failure placed Residents 136, 133 and 51 at risk for catheter associated urinary tract infection (an infection in of the bladder). 4. CNA 28 did not clean Resident 660's urinal after urine was emptied and returned the urinal to Resident 660 ready for use; CNA 28 failed to perform hand hygiene after the removal of gloves and failed to perform hand hygiene before handling Resident 660's personal items. 5. Licensed Vocational Nurse (LVN) 16 did not perform hand hygiene before and after glove use, did not disinfect wound treatment tray and cellphone after providing wound care to Resident 110. 6. Resident 5's oxygen tubing was outdated. 7. RN 2 failed to perform hand hygiene after blood sugar testing for Resident 566 and 565. These failures had the potential to place residents, and staff at risk for the spread of infectious diseases. Findings: 1. During a concurrent medication pass observation and interview with Registered Nurse (RN) 3, on 7/10/19, at 11:34 a.m., at Station 1 north, RN 3 stated station 1 north had one glucometer machine that was shared by all residents requiring blood glucose monitoring. RN 3 disinfected the glucometer with an alcohol prep pad prior to use on Resident 3. RN 3 used the glucometer to measure Resident 7's blood sugar level and disinfected the glucometer with an alcohol prep pad after use. During a review of the clinical record for Resident 7, the Admission Record undated, indicated Resident 7 had a [DIAGNOSES REDACTED]. The Order Summary Report dated 4/2019, indicated, .FSBS (finger stick blood sugar) Glucose (sugar) monitoring . using test strips and lancets before meals and at bedtime for DM (diabetes mellitus) . During a medication pass observation with RN 3, on 7/10/19, at 11:56 a.m., in Station 1 north, RN 3 used the glucometer machine to measure Resident 44's blood sugar level and disinfected the glucometer with an alcohol prep pad. During a review of the clinical record for Resident 44, the Admission Record undated, indicated Resident 44 had a [DIAGNOSES REDACTED]. The Order Summary Report dated 4/2019, indicated, . FSBS Glucose monitoring . using test strips and lancets . before meals and at bedtime . During an glucometer disinfection observation and interview with RN 3, on 7/10/19, at 12:01 p.m., RN 3 stated the facility process of obtaining a blood glucose was for the license Nurses to wash their hands, wear gloves and prepare items needed to perform a blood sugar test. RN 3 stated her practice would start by wiping the residents finger with an alcohol prep pad, allow the alcohol on the finger to dry, then poke the finger with a lancet (sharp needle used to prick the skin) and apply blood to the test strip (small disposable plastic test strip) in the glucometer machine. RN 3 stated she disinfects the glucometer machine with an alcohol prep pad before and after each resident use. RN 3 stated she used to use (brand name) wipes but, We don't have it anymore (brand name) wipes. I'm not sure if it was expensive and now we use the alcohol prep pad. That's what I do. During a medication pass observation on 7/10/19, at 12:14 p.m., in nursing station 3 hallway, RN 1 disinfected the glucometer machine with alcohol prep pads and proceeded to perform a blood glucose test on Resident 564. During a review of the clinical record for Resident 564, the Admission Record dated 7/2019, indicated Resident 564 had a [DIAGNOSES REDACTED]. During a medication pass observation with Licensed Vocational Nurse (LVN) 2, on 7/10/19, at 3:30 p.m., in Station 1 north, LVN 2 used the glucometer machine to perform Resident 65's blood sugar test. After the blood sugar test, LVN 2 disinfected the glucometer with an alcohol prep pad and placed the glucometer in the medication cart drawer. During a review of the clinical record for Resident 65, the Order Summary Report dated 4/2019, indicated, . FSBS Glucose monitoring .using test strips and lancets . before meals and at bedtime . During a medication pass observation on 7/10/19, at 4:18 p.m., RN 2 disinfected the glucometer machine with alcohol prep pads and performed a blood sugar test on Resident 566. After the blood sugar test RN 2 did not wash her hands and proceeded to disinfect the glucometer machine with alcohol prep pads and placed the glucometer in the medication cart drawer. During a review of the clinical record for Resident 566, The Order Summary Report dated 7/2019, indicated, .FSBS Glucose monitoring .using test strips and lancets .before meals and at bedtime for DM (Diabetes Mellitus) . During a medication pass observation with LVN 2, on 7/10/19, at 4:23 p.m., in Station 1 north, LVN 2 walked into Resident 20's room and used the glucometer machine to test Resident 20's blood sugar without disinfecting the glucometer machine prior to use. LVN 2 returned back to the medication cart and disinfected the glucometer machine with an alcohol prep pad and placed the glucometer in the medication cart drawer. During a review of the clinical record for Resident 20, the Admission Record undated, indicated Resident 20 had a [DIAGNOSES REDACTED]. The Order Summary Report dated 6/2019, indicated, .FSBS Glucose monitoring . using test strips and lancets .for DM . During a medication pass observation on 7/10/19, at 4:27 p.m., in nursing station 3 hallway, RN 2 did not perform hand hygiene after performing a blood sugar test on Resident 565 and proceeded to disinfect the glucometer machine with alcohol prep pads and placed the glucometer in the medication cart drawer. During a review of the clinical record for Resident 565, the Admission Record undated, indicated Resident 565 had a [DIAGNOSES REDACTED]. FSBS Glucose monitoring . using test strips and lancets before meals and at bedtime for DM . During an interview with RN 2, on 7/10/19, at 4:33 p.m., she stated the facility had one glucometer machine in each medication cart and the glucometer machine was shared by all resident who needed blood sugar testing. RN 2 stated she used alcohol prep pads to disinfect the glucometer machine after each blood sugar test. RN 2 stated the use of alcohol prep pads to disinfect the glucometer was taught during new hire orientation to the facility. RN 2 stated, I think it (alcohol prep pads) will kill blood borne pathogens. During a concurrent medication pass observation and interview with LVN 2, on 7/10/19, at 4:34 p.m., LVN 2 used the glucometer machine to test Resident 10's blood sugar. LVN 2 returned back to the medication cart and disinfected the glucometer machine with alcohol prep pad. LVN 2 stated he had always used alcohol prep pad to disinfect the glucometer machine. During a review of the clinical record for Resident 10, the Admission Record undated, indicated Resident 10 had a [DIAGNOSES REDACTED]. The Order Summary Report dated 7/2018, indicated, . Blood Glucose checks .before meals and at bedtime . During a concurrent medication pass observation and interview with LVN 3, on 7/10/19, at 4:34 p.m., near Resident 3's room, LVN 3 disinfected the glucometer machine with an alcohol prep pad after performing a finger stick on Resident 3. LVN 3 stated she used whatever was on hand to wipe the glucometer after use. LVN 3 stated she used the bleach wipes (at times) but didn't have them at the time so she used the alcohol prep pad to clean the glucometer. During a review of the clinical record for Resident 3, the Admission Record undated, indicated Resident 3 had a [DIAGNOSES REDACTED]. During a concurrent medication pass observation and interview with LVN 12, on 7/10/19, at 4:41 p.m., in station 3, LVN 12 stated she was assigned to pass medications for station 3, and had four diabetic residents requiring blood glucose testing. LVN 12 stated there was one glucometer machine that was shared by all residents who required blood sugar testing. LVN 12 stated she would demonstrate the process of disinfecting the glucometer in-between resident use. LVN 12 then entered Resident 89's room holding the glucometer with bare hands and placed her left palm underneath the automatic (brand name (hand sanitizer)) foam dispenser. LVN 12 rubbed the hand sanitizer foam onto the glucometer with her bare hands while walking back to the medication cart and dried the glucometer with a facial tissue. LVN 12 stated, I do that after each resident (blood sugar test). I want that alcohol on there (glucometer), the (brand name alcohol) is supposed to kill blood borne pathogen its alcohol. During an interview record review with the DON, on 7/10/19, at 5:32 p.m., the DON stated the facility practice was to disinfect the glucometer machines with wipes that contained bleach. The DON stated an alcohol prep pad should not be used to disinfect the glucometer because it does not kill blood borne pathogens. During a concurrent interview and record review with the Director of Staff Development (DSD), on 7/11/19, at 11:31 a.m., she stated alcohol prep pads were appropriate to use to disinfect the glucometer. The DSD stated she conducted an in-service education training for staff on how to disinfect the glucometer in-between resident use. The facility document titled Lesson Plan dated 1/7/19 indicated, .Disinfect (after each use) after cleaning the exterior surfaces following the manufacturers' directions using a cloth/wipe with either an EPA ( Environmental Protection Agency) -registered detergent/germicide with a tuberculocidal (effectively kills bacteria that affects the lungs) and HBV/HIV ([MEDICAL CONDITION] virus, Human immunodeficiency virus (virus in the blood) label claim . The DSD reviewed the manufacturer's guidelines manual of the glucometer machine titled, (Brand of glucometer) Blood Glucose Monitoring System User Instruction Manual undated, which indicated, .cleaning and disinfecting the meter (glucometer machine) between patient use .To disinfect the meter, dilute 1 mL (milliliter (unit of measurement)) of household bleach (5-6% sodium hypochlorite solution) in 9 mL of water to achieve a 1:10 dilution (final concentration of 0.5-0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. Please note that there are commercially available 1:10 bleach wipes from a variety of manufacturers . The DSD stated she had not read the manufactures recommendations for disinfecting the glucometer machines. The DSD stated the glucometer should be disinfected as indicated in the instruction manual. The DSD stated the potential for infection would be high when a glucometer was not disinfected appropriately. The DSD stated, It could cause infection to the resident and place the resident at risk of spreading blood borne pathogens. During an interview with the DON, on 7/11/19, at 12:35 p.m., the DON stated all equipment should be disinfected with bleach. The DON stated an alcohol prep pad and (brand name (hand sanitizer)) foam would not kill blood borne pathogens. The DON stated the glucometer machine should not be dried with a facial tissue after disinfecting the device. The DON stated, It (Glucometer machine) should instead air dry as specified by the manufacturer guidelines to ensure the dwell time (amount of time surface must remain wet to kill blood borne pathogens) was sufficient. The DON stated there was a potential risk of spreading blood borne pathogens to all resident needing blood sugar testing when the glucometer was not disinfected with the appropriate disinfectant. During a concurrent interview and record review with the DON, on 7/11/19, at 3:17 p.m., the DON reviewed the facility document titled Order Listing report of all the residents currently on blood sugar monitoring. The DON reviewed the clinical record for Residents (Residents 1, 5, 7, 10, 11, 16, 20, 26, 33, 34, 36, 41, 42, 44, 47, 49, 57, 58, 65, 73, 76, 89, 92, 93, 94, 99, 107, 122, 125, 135, 137, 141, 564, 565, 566, 567, 568, 569, 570, 571, 572 and 573) the Order Listing report for all 42 residents indicated, . FSBS monitoring . The DON confirmed the glucometer machines were shared with all residents requiring blood sugar testing and placed these residents at serious potential risk for contracting undetected blood borne infections. During a review the facility policy and procedure titled, CLEANING AND DISINFECTION OF GLUCOMETER revised 11-2017, indicated, .The CDC (Centers for Disease Control) stated HBV could survive for several days in dried blood on environmental surfaces or on contaminated instruments and equipment. The following policy provides guidance for cleaning and disinfection of glucometers in between resident use. 1. Disinfect (after each use) after cleaning the exterior surfaces following the manufacturers' directions using a cloth/wipe with either and EPA-registered detergent/germicide with a tuberculocidal and HBV/HIV label claim . During a review of the Centers for Disease Control (CDC) Professional Reference titled, Blood Glucose Meters dated 5/2017 (www.cdc.gov.injectionsafety/providers/blood-glucose-monitoring_faqs.html) indicated, . Infectious agents, such as HBV, can be transmitted through indirect contact transmission, even in the absence of visible blood (4). Indirect contact transmission is defined as the transfer of an infectious agent (e.g., HBV) from one patient to another through a contaminated intermediate object (e.g., blood glucose meter) or person (e.g., healthcare personnel hands) . If blood is transferred from the patient to the meter, and the meter is not cleaned and disinfected after use, subsequent patients can be exposed to this blood when the meter is used on them. Indirect contact transmission can also occur even if the patient never directly contacts the meter. Healthcare personnel hands can become contaminated with blood at various points while performing assisted blood glucose monitoring including pricking the patient's finger or handling the test strip. Blood can then be transferred to the meter when healthcare personnel handle the meter to obtain the reading. If the meter is not cleaned and disinfected after use, the blood remaining on the meter can be transferred to subsequent patients via healthcare personnel hands when they handle the meter and then assist with finger stick procedures .The disinfection solvent you choose must be effective [MEDICAL CONDITION].[MEDICAL CONDITION], and [MEDICAL CONDITION] virus. Outbreak episodes have been largely due to transmission of [MEDICAL CONDITION] and [MEDICAL CONDITION]. However, of the two, [MEDICAL CONDITION] virus is the most difficult to kill. Please note that 70% [MEDICATION NAME] solutions are not effective against [MEDICAL CONDITION] blood borne pathogens . 2. During a breakfast meal observation, on 7/9/19, at 8:25 a.m., in dining room [ROOM NUMBER], there were six residents (Resident 89, 99, 121,129, 87 and 15) seated around dining tables waiting for the breakfast to be served. Restorative Nursing Assistant (RNA) 1 began serving breakfast trays to the residents. RNA 1 put on a pair of gloves without performing hand hygiene. RNA 1 opened the food cart, obtained a breakfast tray and closed the food cart while wearing the same gloves. RNA 1 served the breakfast tray to Resident 89 and began removing the plate cover, touching the rim of the milk and juice glasses when she removed the lids with the same gloves. RNA 1 took of the gloves and placed them on the plate cover in front of Resident 89's meal tray. RNA 1 did not perform hand hygiene after removing glove. RNA 1 put on a new pair of gloves without washing her hands and proceeded serving meal tray to Resident 99, 121, 129, 87 and 15 while wearing the same gloves and not performing hand hygiene. During a lunch meal observation, on 7/9/19, at 12:00 p.m., in dining room [ROOM NUMBER], CNA 11 was feeding Resident 8, stopped feeding the resident and stood up from the dining room, proceeded to walk to the kitchen door, touched the doorknob and walked into the kitchen. CNA 11 returned to the dining room table and continued to feed Resident 8 without performing hand hygiene. At 12:08 p.m., CNA 11 stopped feeding Resident again and walked back into the kitchen, came back to the dining room with a cup of water and tray slip. CNA 11 set the cup of water and tray slip next to Resident 8 and continued to feed the Resident 8 without performing hand hygiene. At 12:10 p.m., CNA 11 stopped feeding Resident 8 and walked back into the kitchen for the third time, came back into the dining room with a bowl of potatoes, set it next to Resident 1 and proceeded to feed Resident 8 without performing hand hygiene. During a lunch meal observation, on 7/9/19, at 12:07 p.m., in dining room [ROOM NUMBER], Certified Nursing Assistant (CNA) 26 was observed pushing Resident 119's reclining chair to the dining room table. CNA 26 sat next to Resident 119 and began feeding Resident 119 without performing hand hygiene. During an interview with CNA 26, on 7/9/19, at 12:13 p.m., in dining room [ROOM NUMBER], CNA 26 stated she did not perform hand hygiene after pushing Resident 119's recliner chair. CNA 26 stated she should have sanitized her hands before assisting Resident 119 with her meal to prevent cross contamination and infection control. During an observation on 7/9/19, at 12:14 p.m., in dining room [ROOM NUMBER], CNA 27 was feeding Resident 24. CNA 27 repositioned Resident 24's recliner chair and pillow. CNA 27 did not perform hand hygiene after the handled the chair and pillow and continued to feed Resident 24. CNA 27 walked to the dining room cabinet and took out two clear plastic cups from the cabinet and proceeded feeding Resident 24 without performing hand hygiene. During an interview with CNA 27, on 7/9/19, at 12:20 p.m., CNA 27 stated she did not perform hand hygiene in-between tasks when feeding Resident 24. CNA 27 stated she should have performed hand hygiene in between tasks to prevent cross contamination. During an interview with CNA 11, on 7/9/19, at 12:25 p.m., CNA 11 stated she did not perform hand hygiene during the times she returned from the kitchen and into the dining room. CNA 11 stated she should have performed hand hygiene when she came back and forth from the kitchen to feed Resident 8. CNA 11 stated she did not perform hand hygiene in between Resident 8 and Resident 1. CNA 11 stated not performing hand hygiene could lead to cross contamination. During a lunch meal observation, on 7/9/19, at 12:26 p.m., in dining room [ROOM NUMBER], there were 21 residents seated around the dining tables waiting for lunch to be served. Restorative Nursing Assistant (RNA) 1 started serving trays to residents. RNA 1 donned a pair of gloves without performing hand hygiene. RNA 1 opened the food cart, obtained a breakfast tray and closed the food cart. RNA 1 set up the meal tray for Resident 93. RNA 1 removed the plate cover and touched the rim of the milk and juice glasses when she removed the lids. RNA 1 took of her gloves and placed them on the plate cover in front of Resident 93's meal tray. RNA 1 did not perform hand hygiene after removing glove. RNA 1 proceeded the same pattern of serving meal tray to Resident (Residents 17, 87, 22, 121, 124, 136, 158, 10, 11, 14, 15, 37, 40, 49, 55, 85, 89, 129, 142 and 151 without performing hand hygiene. During an interview with RNA 1, on 7/10/19, at 9:30 a.m., RNA 1 stated she should have performed hand hygiene in between the use of gloves during meal service. During an interview with the DSD, on 7/10/19, at 11:15 a.m., DSD stated nursing staff should have performed hand hygiene before and after the use of gloves to prevent cross contamination. During an interview with Assistant Director of Nursing (ADON), on 7/10/19, at 3:00 p.m., ADON stated nursing staff should have performed hand hygiene in between tasks and before and after the use of gloves to prevent cross contamination. The facility's policy and procedure titled Hand Hygiene P&P dated 1/10/19, indicated, Policy: All employees are required to practice effective hand hygiene . Employees are required to wash their hands thoroughly: . After touching objects that may be soiled and after removing gloves; after removing gloves; . The facility's policy and procedure titled, GLOVES, WEARING (NON-STERILE) dated 1/19, indicated, It is the policy of this facility that non sterile gloves will be worn, when it is likely that hands will be contact with body substances (blood, feces, wound drainage, sputum, vomitus etc.). Gloves are NOT a substitute for hand washing. Hands must be washed every time gloves are removed . The facility policy and procedure titled Dining Program dated 11/12, indicated, .Hygiene: Hand washing should be completed for the resident's and staff prior to and after mealtime . 3. a. During an observation in nursing station 2, on 7/9/19, at 8:47 a.m., Resident 136 had an indwelling urinary catheter bag hanging underneath his wheelchair. The urinary bag was dragging on the ground as he propelled his wheelchair to his room. During a concurrent observation in Resident 136's room and interview with LVN 16, on 7/9/19, at 8:52 a.m., Resident 136 sat on his wheelchair near his bed and urine was leaking from the urinary catheter bag. LVN 16 stated Resident 136's urinary catheter bag contained approximately 600 ml (milliliters) of urine. LVN 16 stated the urinary catheter bag should not be dragging on the floor in order to prevent urine leakage and to prevent urine infections. LVN 16 stated all staff was responsible to ensure proper placement of the catheter bag. During an observation in Resident 133's room, on 7/9/19, at 9:18 a.m., Resident 133 was lying in bed with a urinary catheter bag hanging on the bed rail touching the floor. During a concurrent observation in Resident 133's room, and interview with LVN 4, on 7/9/19, at 9:30 a.m., LVN 4 stated Resident 133 was total care needing assistance to get out of bed. Resident 133's catheter bag had approximately 250 ml of urine and was touching the floor. LVN 4 stated the catheter bag should not touch the floor because it could cause an infection. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 7/10/19, at 2:24 p.m., the ADON reviewed Resident 136's clinical record and stated resident 136 was admitted to the facility with a [DIAGNOSES REDACTED]. The ADON stated the indwelling catheter was ordered on [DATE]. ADON reviewed Resident 133's clinical record and stated Resident 133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. ADON stated Resident 133 has a supra pubic catheter (tube inserted into bladder through the belly to drain urine) related to these diagnoses. ADON stated the catheter bag should not touch the floor, it could cause a urinary tract infection. 3. b. During an observation, on 7/11/19, at 5:27 p.m., Resident 51 sat on his wheelchair and his indwelling urinary catheter bag was hanging on the side of the bed and touching the floor. During an interview with CNA 3, on 7/11/19, at 5:29 p.m., CNA 3 stated the indwelling urinary catheter bag should not have touched the floor to prevent infection. During an interview with Registered Nurse (RN) 2, on 7/11/19, at 5:37 p.m., she stated the indwelling urinary catheter bag should not have touched the floor to prevent urinary tract infection. During an interview with the DON, on 7/11/19 at 12:19 p.m., the DON stated the indwelling urinary catheter bag should not have touched the floor, it could lead to a urinary tract infection. The DON stated it was the nursing staff responsibility to make sure that the indwelling urinary catheter bag was not touching the floor. The facility document titled Care of Residents with Catheter/tubing dated 11/9/18, indicated . Empty drainage bags regularly (at least once per shift) . Keep drainage bag below level of bladder and off the floor at all times . Review of the professional reference titled, GUIDELINE FOR PREVENTION OF CATHETER-ASS[NAME]IATED URINARY TRACT INFECTIONS 2009 DATED 6/19, from https://www.cdc.gov/infectioncontrol/guidelines/cauti/ . Proper Techniques for Urinary Care Maintenance . Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor . Empty the collecting bag regularly using a separate, clean collecting container for each patient . 4. During an observation on 7/9/19, at 9:30 a.m., in Resident 660's room, a urinal full of urine was on top of Resident 660's bedside table. CNA 28 donned a pair of gloves and emptied the urinal in the bathroom. CNA 28 hung the urinal on Resident 660's bedside rails without cleaning the urinal. CNA 28 removed her gloves and rearranged Resident 660's personal items on the bedside table without performing hand hygiene. During an interview with CNA 28, on 7/10/19, at 10:40 a. m., she stated Resident 660's urinal should have been washed and rinsed before returning it for Resident 660's use. CNA 28 stated she should have performed hand hygiene after the use of gloves when she emptied the urinal and before she fixed Resident 660's personal items on the bedside table. During an interview with the DSD, on 7/11/19, at 3 p.m., the DSD stated the CNA should have washed and rinsed Resident 660's urinal before returning to the resident for use. The DSD stated CNA should have washed her hands after the use of gloves. The facility's policy and procedure titled BEDPAN/URINAL dated 11/12, indicated, Policy (Name of the facility) will provide containers for elimination maintaining infection Control standards . Urinal . 4. Cleanse urinal and return to unit . 6. Urinals are single patient use equipment and will be disposed of when damaged or excessively stained . The facility's policy and procedure titled Hand Hygiene P&P dated 1/10/19, indicated, Policy: All employees are required to practice effective hand hygiene . Employees are required to wash their hands thoroughly: . After touching objects that may be soiled and after removing gloves; after removing gloves; . 5. During a concurrent wound care observation for Resident 110 and interview with LVN 16, on 7/12/1,9 at 9:25 a.m., LVN 16 washed and dried his hands and donned a pair of gloves in the resident's room sink before Resident 110's right foot wound care treatment. LVN 16 then, adjusted the angle of the resident's right foot, handled the cellphone connected to the computer and took a picture of Resident 110's right foot while wearing the same gloves. LVN 16 then changed gloves without sanitizing hands and stored the sanitized cellphone inside the treatment cart. LVN 16 then gathered and placed wound care supplies on a treatment tray and placed the treatment tray on Resident 110's bedside table. LVN 16 change his gloves without performing hand washing then proceeded to perform the wound dressing. LVN 9 completed the treatment and did not sanitize the treatment tray that was used inside the resident's room and store it inside the treatment tray. During an interview with the LVN 16, on 7/12/19 at 1:30 p.m., LVN 16 stated, he should have washed his hands in between the change of gloves during the wound treatment and should have sanitize the cellphone and the treatment tray after their use. LVN 16 stated the facility expected him to do hand hygiene in between the change of gloves during wound care. The facility's policy and procedure titled Hand Hygiene P&P dated 1/10/19, indicated, Policy: All employees are required to practice effective hand hygiene . Employees are required to wash their hands thoroughly: . After touching objects that may be soiled and after removing gloves; after removing gloves . The facility's policy and procedure titled, GLOVES, WEARING (NON-STERILE) dated 1/19, indicated, It is the policy of this facility that non sterile gloves will be worn, when it is likely that hands will be contact with body substances (blood, feces, wound drainage, sputum, vomitus etc.) . Gloves are NOT a substitute for hand washing. Hands must be washed every time gloves are removed .<br (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure Licensed Nurses (LN) possessed specific competencies required for the use of Insulin Flex Pens (a dial-a-dose device, pre-filled insulin pen for discreet insulin medication administration) for three of seven sampled resident's (Resident 141, Resident 564 and Resident 567) when one of four LN (Registered Nurse (RN)) 1 failed to follow the manufacturer's instructions of use for administering insulin with the Flex Pen. RN 1 did not use the indicated needle attachment made for use with Insulin (medication for the treatment of [REDACTED]. This practice placed residents on Insulin at risk for unsafe administration of insulin medication, complications with their blood sugars and potential for inaccurate insulin dosing. Because of the serious potential harm as a result of this unsafe practice of administering insulin, an Immediate (IJ) was called on 7/11/19 at 4:13 p.m. with the facility Administrator (ADM), Director of Nursing (DON) and Clinical Consultant Director (CCD). The facility's Plan of Removal for the IJ included removing the insulin flex pens from all the medication carts, replacement with new insulin flex pens with the appropriate needle, licensed nurses were in-serviced on proper use of the insulin flex pen with return demonstration of competency using guidelines provided by the Skilled Nursing Consultant Pharmacist and notification of physician's for the residents involved. The Plan of Removal was accepted on 7/12/19 at 4:00 p.m. The Plan of Removal was verified to be fully implemented and medication pass validated competency of licensed nurses to safely administer insulin with the Flex Pen and the IJ was removed on 7/16/19 at 8:43 a.m. with the facility Administrator (ADM), Director of Nursing (DON) and Clinical Consultant Director (CCD). Findings: During a medication pass observation on 7/10/19, at 12:06 p.m., near nursing station 3, RN 1 used a non-intended syringe with needle to withdraw 3 units (a unit of measurement) of insulin [MEDICATION NAME] (a rapid acting insulin used to lower blood sugar level) from the insulin flex pen and administered the insulin to Resident 141. During an interview with RN 1, on 7/10/19, at 12:15 p.m., she stated, I don't trust the insulin pen that is why I withdraw insulin from the insulin pen (using a non-intended syringe with needle), that way I get the right amount of insulin. During a review of the clinical record for Resident 141, the Admission Record dated 5/19, indicated Resident 141 had a [DIAGNOSES REDACTED]. The Order Summary Report dated 6/17, indicated Insulin [MEDICATION NAME] Solution 100 Unit/ml (milliliters) Inject 3 units subcutaneously (under the skin) with meals for DM (diabetes mellitus) . Insulin [MEDICATION NAME] Solution 100 Unit/ml Inject as per sliding scale (dosage based on blood sugar result) . During a medication pass observation on 7/10/19, at 12:14 p.m., in the nursing station 3 hallway, RN 1 cleaned the glucometer (device used to measure the amount of sugar in the blood) with alcohol prep pads and performed a blood sugar (the concentration of sugar in the blood) check on Resident 564. Resident 564's blood sugar was 196 (according to the diabetic association dated 1/2019 normal blood sugar level range from 70 to 120). RN 1 used a non-intended syringe with needle to withdraw 5 units of insulin [MEDICATION NAME] from the insulin flex pen and administered to Resident 564. During a review of the clinical record for Resident 564, the Admission Record dated 7/19, indicated Resident 564 had a [DIAGNOSES REDACTED]. The Order Summary Report dated 7/19, indicated, Insulin [MEDICATION NAME] Solution 100 UNIT/ML Inject 5 unit subcutaneously before meals for monitor blood sugar . Insulin [MEDICATION NAME] Solution 100 UNIT/ML Inject as per sliding scale . During a medication pass observation on 7/10/19, at 12:28 p.m., in nursing station 3 hallway, RN 1 used a non-intended syringe with needle to withdraw 2 units of insulin [MEDICATION NAME] from the insulin flex pen and administered to Resident 567. During a review of the clinical record for Resident 567, the Admission Record dated 7/19, indicated Resident 567 had a [DIAGNOSES REDACTED]. The Order Summary Report dated 7/19, indicated Insulin [MEDICATION NAME] Solution 100 UNIT/ML Inject as per sliding scale . The facility document titled Registered Nurse (RN) JOB DESCRIPTION dated 8/11, indicated DUTIES AND RESPONSIBILITIES . Prepares orders and administer medications as ordered by the physician in accordance with government regulations and facility policies and procedures . KNOWLEDGE, SKILLS, ABILITIES AND QUALIFICATIONS . Must be able to operate departmental equipment, as appropriate . Must be knowledgeable of nursing/medical practices and procedures . During a telephone interview with the Facility Pharmacy Consultant (FPC), on 7/11/19, at 10:12 a.m., he stated the licensed nurses should not have used a non-intended syringe with needle to withdraw insulin from the insulin flex pen and should have followed the manufacturers recommendations. The FPC stated the insulin flex pen was specifically manufactured to contain a small amount of air inside the flex pen. The FPC stated the use of a non-intended syringe with needle to withdraw insulin from an insulin flex pen would add more air inside the flex pen and could lead to incorrect or under dosing for the subsequent insulin dose administered to residents. The FPC stated the licensed nurse that used the non-intended syringe with needle to withdraw insulin from the insulin flex pen should be re-educated. During an interview with the Director of Staff Development (DSD), on 7/11/19, at 11:31 a.m., she stated RN 1 should not have used a non-intended syringe with needle to withdraw insulin from the insulin flex pen. The DSD stated the nurse should follow manufacturers recommendations on the correct use of the insulin flex pen devise. The DSD stated the use of a non-intended syringe with needle to withdraw insulin from the insulin flex pen would add more air inside the insulin flex pen and could result in insulin dosing errors. During an interview with the DSD, on 7/11/19, at 11:35 a.m., the DSD stated she conducted an in-service education class titled Care of Residents with Diabetes for Licensed Nurses on 6/8/18, and during the in-service she demonstrated how to properly use the insulin flex pen. The DSD stated the in-service education did not include a posttest or skills checks after the in-service to ensure Licensed Nurses understood the education. The DSD stated she did not conduct evaluations or return demonstration to evaluate competency after the in-service education. The DSD reviewed the in-service education attendance roster which contained RN 1's signature. The DSD stated RN 1 had attended the in-service training. The DSD stated she did not ensure Licensed Nurses possessed the knowledge necessary to safely use the insulin flex pen. The DSD reviewed staff competencies and was unable to find Licensed Nurses annual competency on insulin flex pen medication administration. The facility document titled, Director of Staff Development JOB DESCRIPTION dated 8/2011, indicated, DUTIES AND RESPONSIBILITIES . Monitors and supervises continuity between classroom and clinical application by skill checks and individual training (for Licensed Nurses) . The facility policy and procedure titled, Knowledge and Skills Competency Evaluation dated 5/2015, indicated, . To ensure that all individuals who work within the facility demonstrate the requisite knowledge and skills to fulfill their assigned responsibilities in a safe and professional manner . Employees will be evaluated as part of their annual performance review . Evaluations may also take place after a new procedure, technique, product or equipment is implemented . During an interview with the Director of Nursing (DON), on 7/11/19, at 12:19 p.m., she stated the DSD provided the in-service and training for all the licensed nurses on how to use the insulin flex. The DON stated RN 1 should not have used a non-intended syringe with needle to withdraw insulin from the insulin flex pen. The DON stated, It's not the standard of practice and could lead to inaccurate dosing. The DON stated RN 1 should have followed the manufacturers guidelines on how to properly use the insulin flex pen device. The DON stated the person responsible for conducting Licensed Nurses competencies was the DSD and she did not know if competencies were done and documented for the use of the insulin flex pen. During a review of the manufacturer instructions document titled, [MEDICATION NAME] KwikPen (flex pen) Quick Guide, dated (YEAR), https://www.[MEDICATION NAME].com/insulin-[MEDICATION NAME]-kwikpen-us-ifu-pdf ., indicated, Step 1 .Pull off the pen cap . Remove the protective tab from the needle and screw it onto your . Pen tightly. It is important that the needle is placed on straight .Never place a disposable needle on your KwikPen until you are ready to take the injection .Step5 .Remove the needle from the KwikPen after each injection to prevent infection, insulin leakage and to ensure proper dosing. .If KwikPen is not working .Screw on a new Kwikpen needle . During a review of professional reference document titled, Institute for safe medication practices, (YEAR), Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults indicated, Insulin as a High-Alert Medication, Medications that are associated with the highest risk of injury when used in error are known as high-alert medications . Removal of insulin from the cartridge is not recommended by manufacturers . A variety of a type of errors have been associated with insulin therapy, including incorrect use of insulin delivery devices .Many errors result in serious [DIAGNOSES REDACTED] (low blood sugar values or [MEDICAL CONDITION] (high blood sugar values) .Misuse of insulin pen devices .Insulin cartridges within pens have been misused as multiple-dose vials when staff who preferred to administer insulin using a conventional syringe attempted to withdraw an insulin dose from the pen's cartridge. This practice could introduce air into the cartridge or reservoir, leading to subsequent insulin under-doses and subcutaneous injection of air .

Based on observation, interview and record review the facility failed to ensure residents with known risk for falls received adequate supervision and assistances to ensure residents were free from accidents and injury for one of two sampled residents (Resident 15) when Certified Nurse Assistant (CNA 22) left Resident 15 unsupervised in her room during the mechanical lift (Stand-Up Lift device) preparation procedure which resulted in Resident 15 falling forward and fracturing (broken bone) her right hand little finger. Findings: During a review of the clinical record for Resident 15, the face sheet (a document containing resident profile and [DIAGNOSES REDACTED]. (a progressive nervous system disorder that affects movement). During a review of Resident 15's Minimum Data Set (required assessment of resident cognitive and physical abilities and needs) assessment dated [DATE], Section G Functional Status indicated Resident 15 needed extensive physical assistance for bed mobility, transfers, dressing, toilet use, was total dependent on staff for personal hygiene needs, and used a wheelchair as a mobility device with one-person physical assistance. The Brief Interview for Mental Status was (BIMS) indicated 13 (cognitively intact). During a review of Resident 15's Fall Risk assessment dated [DATE], indicated a Score of 10 which identified Resident 15 at moderate risk for falls. During a review of the Hospital emergency room (ER) clinical record for Resident 15, the After Visit Summary dated 4/8/19 indicated, Reason for Visit: Fall . Diagnosis: [REDACTED]. During a review of Resident 15's Diagnostic Imaging Report dated 4/8/19, indicated, FINDINGS: At least mild generalized osteopenia (bones are weaker and breaks easily) Intra-articular fracture (the bone break crosses into the surface of a joint) through the base of the right fifth proximal phalanx including new fracture . [MEDICATION NAME] (restricted to a localized region) soft tissue swelling . acute (sudden) fracture (traumatic fracture) of the right fifth proximal phalanges base. During a breakfast observation of Resident 15 in Dining room [ROOM NUMBER], on 7/9/19, at 8:30 a.m., Resident 15 was eating breakfast with the use of her right hand and a splint (a padded strip of metal or plastic used to immobilize a fractured finger) on the right little finger. Resident 15 was greeted and was unable to respond to greeting. Restorative Nursing Assistant (RNA) 1 stated Resident 15 was unable to speak. RNA 1 stated Resident 15 used a communication board to communicate with others. During an interview with the Director of Nursing (DON), on 7/10/19, at 5:30 p.m., the DON stated she conducted the investigation of the fall with fracture that occurred on 4/8/19 around 10:30 a.m. The DON stated the fall occurred when Resident 15 asked CNA 22 for a her brief change. The DON stated Resident 15 required two staff members for assistance with transfers and required a mechanical lift device for safety with transfers. The DON stated the facility process for mechanical lift transfers required two staff members to be present during the actual resident transfer but only one CNA was needed to prepare the resident for the transfer. The DON stated once the CNA was ready to perform the transfer an additional staff member would be called to provide the two staff member assistance. The DON stated when CNAs prepared residents for transfer using the mechanical lift, the mechanical lift sling (cloth device used to lift resident with the mechanical lift) would be positioned on the resident's back and hooked (attached) to the lift and at that time the CNA would call for another CNA to assist her. The DON stated in Resident 15's case CNA 22 had not connected the sling that was positioned behind Resident 15 to the mechanical lift. The DON stated Resident 15 thought the sling was hooked onto the mechanical lift and moved forward and fell out of the wheelchair. The DON stated the fall happened so fast the CNA 22 was not able to prevent it. The DON stated CNA 22 left Resident 15 in the room unsupervised to go find someone to help her with the transfer and during that time Resident 15 fell and received the fracture. The DON stated CNA 22 was not available for interview because CNA 22 was no longer employed with the facility. During a review of the mechanical lift manufacturer's manual titled, Owner's Operator and Maintenance Manual undated, indicated, . (company name) recommends that two assistants be used for all lifting preparation and transferring to and from procedures . During an interview with the Director of Staff Development (DSD), on 7/10/19, at 6:14 p.m., the DSD stated she had interviewed CNA 22 after the fall incident occurred and CNA 22 informed her that on 4/8/18 at around 10 a.m., Resident 15 needed a brief change. CNA 22 positioned the mechanical lift sling on Resident 15's back and positioned the mechanical lift in front of Resident 15. Resident 15's mechanical sling was not yet hooked to the mechanical lift when CNA 22 left the room to get another CNA to spot (supervise) her while using the mechanical lift. CNA 22 found Licensed Vocational Nurse (LVN) 1 and asked LVN 1 for assistance with Resident 15's transfer. The DSD stated when LVN 1 and CNA 22 went back to Resident 15's room Resident 15 was already on the floor. During a concurrent interview with the DSD and record review of the In-service training on 7/10/19 at 6:20 p.m., The DSD reviewed the In-service lecture training documents dated 3/26 and 3/29/19 and stated the Mechanical Lift/Safe Transfer policy and procedure training specified all lifts were a two-person task from start to finish for the resident and staff safety. The DSD stated when Resident 15 was prepared for transfer by Stand-Up Lift mechanical lift there should have been two staff members to do the transfer throughout the procedure. The DSD stated CNA 22 had not hooked the Resident 15's sling to the mechanical lift when CNA 22 left the room to get another CNA to spot her. The DSD stated CNA 22 should not have come out of the room and left Resident 15 unsupervised. The DSD stated if the transfer of Resident 15 was done by two staff, the fall could have been prevented. During a review of the facility document titled In-Service LESSON PLAN dated 3/26/19 and 3/29/19, indicated AT THE END OF THIS INSERVICE THE PARTICIPANTS WILL BE ABLE TO: UNDERSTAND THE USE OF ALL MECHANICAL LIFTS PER POLICY AND PR[NAME]EDURES . PR[NAME]EDURE: ALL LIFTS ARE A TWO PERSON TASK FROM START TO FINISH FOR RESIDENT/STAFF SAFETY . During a telephone interview with Licensed Vocation Nurse (LVN) 1, on 7/11/19, at 9:10 a.m., LVN 1 stated, she was doing a medication pass near Resident 15's room. LVN 1 stated CNA 22 prepared Resident 15 for transfer with the use of the Sit -to- Stand mechanical lift. LVN 1 stated she was asked by CNA 22 to help do a brief change for Resident 15. LVN 1 stated when CNA 22 and she entered Resident 15's room Resident 15 was already on the floor. LVN 1 stated CNA 22 should have made sure two staff members were present to do the mechanical lift transfer, so the fall could have been prevented. LVN 1 stated they were short staff and the licensed nurses would also help with resident care but they had other duties and were not always available to help the CNAs. During a concurrent interview with the DON and review of the Investigation Summary of Resident 15's Fall, on 7/15/19, at 3:10 p.m., the DON stated she was the person who conducted the investigated of the incident. The DON stated she did not know the DSD had interviewed CNA 22 after the incident. The DON stated she was not aware CNA 22 came out of the resident's room to call for another CNA for assistance. The DON stated, If that was what happened, (Resident 15) should not have been left unhooked and unsupervised. The DON stated once the DSD educated the staff to do the mechanical transfer with two staff from start to finish then, the education should have been followed by the staff. During an interview with LVN 12, on 7/15/19, at 4:36 p.m., LVN 12 stated Resident 15 could use her two hands to hold to the Sit -to-Stand mechanical lift handle but her legs could not hold her weight. LVN 12 stated, the lift allowed Resident 15 to be lifted standing up for the brief change and needed two staff members to do the lift transfer safely. During a review of the clinical record for Resident 15, the document's titled, Weight and Vitals Summary dated 7/4/19 indicated, Resident 15 weighed 198.2 pounds. During a review of the facility's policy and procedure titled, LIFTING RESIDENTS BY USE OF MECHANICAL DEVICE dated 11/12 indicated, Policy: It is the policy of (name of facility) to utilize portable lifting equipment to transfer residence in safe and comfortable manner and based on individual resident's needs or plan of care. Procedure: [NAME] the following instruction are general safety measures and do not include specific instructions for use of each specific type of lifting machine. In addition, a minimum of 2 staff members should be used to reduce risk of staff or resident injury .

Based on staff interview, and clinical and administrative document reviews, the facility failed to follow the California Standard Admission Agreement (a skilled nursing facility's (SNF's) admission contract required by state law, which included admission and discharge rights, and other obligations of each person (or party) signing the admission contract), when one of one resident (Resident 1) was refused readmission to the facility, after 6 days of in-patient hospitalization and after being determined to be stable to return to the SNF. For Resident 1, this failure denied the resident of his right to be readmitted to his home of more than three years, denied his right to a safe and orderly discharge, and affected his psychosocial and emotional health. Findings: Resident 1 was a [AGE] year old male who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1's medications included [MEDICATION NAME] 40 milligrams (mg) once a day (a water pill used to treat excessive fluid accumulation and [MEDICAL CONDITION] (swelling) of the body caused by heart failure) and [MEDICATION NAME] 10 mg once a day for depression. The comprehensive annual Minimum Data Set (MDS) assessment (a federally mandated comprehensive assessment of residents in a skilled nursing facility to identify functional abilities and health problems) dated 11/24/13, indicated Resident 1 could not recall words or remember the correct day of the week. Resident 1 had no verbal or physical behavioral symptoms such as cursing, hitting, kicking, or grabbing that were directed toward others. The care plan with a revision date of 5/16/14, indicated Resident 1 "Is/has potential to be verbally aggressive related to ineffective coping skills, uses inappropriate language, and is easily annoyed." The interventions included medications, identifying triggers, and for staff to intervene before Resident 1's agitation escalated. The document titled "Report of Suspected Dependent Adult/Elder Abuse" dated 9/25/14, indicated, "On 9/25/14 at 10:20 a.m., Resident 1 was observed entering the library and appearing to be agitated. He became aggressive with another resident ...Police Department contacted ...police removed resident from facility '5150' ... "(a section of the California Welfare and Institutions Code which authorizes a qualified officer or clinician to involuntarily confine a person suspected to have a mental disorder that makes him or her a danger to themselves, a danger to others, and/or gravely disabled). On 10/2/14 at 9:11 a.m., during a telephone interview, Social Services Worker 1 (SSW 1) from the Behavioral Health Center (BHC), stated Resident 1 was taken to the emergency roiagnom on [DATE], by the local law enforcement under 5150, after he was found "choking" another resident at the facility. SSW 1 stated Resident 1 was admitted to BHC for further psychiatric evaluation and treatment. The BHC's History and Physical (H & P) dated 9/25/14, indicated Resident 1 required additional hospitalization for safety and stabilization as well as medication titration and would be discharged back to the facility. According to SSW 1, Resident 1 did not display physical aggression and did not make verbal threats towards anybody at the BHC during his admission on 9/25/14, and the following days thereafter. SSW 1 stated, "On 9/26/14, I started discharge planning and contacted the Director of Nurses (DON). The DON told me Resident 1 could not return to the facility because he was taken out of the facility by the police. When I asked the DON where Resident 1 would return to, she told me to call the District Attorney's office." SSW 1 stated on 9/29/14, Resident 1 was deemed medically stable to return to the facility. SSW 1 stated, "I called the facility again and spoke with the administrator and the DON. I told them Resident 1 was deemed medically stable and ready for discharge. The administrator and the DON refused to readmit Resident 1. SSW 1 stated she then contacted other Board and Care (B & C - specially regulated homes providing assisted living services, living quarters, and proper care to less than 6 people), but (Resident 1) was adamant and repeatedly requested to go back to the facility where he lived for the past three years. "He kept on begging to be sent back home to the facility. He was upset and emotionally traumatized. I contacted (Resident 1's) brother, but he told me he could not care for the resident due to his own personal and health needs." The BHC's psychiatrist's progress notes dated 9/29/14, indicated "Patient has not exhibited any behavioral outbursts or aggression towards others for the past several days of his hospitalization . Patient appears to be at baseline and ready for discharge today, however, the skilled nursing facility was refusing to take the patient back." On 10/2/14 at 9:18 a.m., during a telephone interview, the Ombudsman (an advocate for residents or patients in a long-term health care facility) stated the facility's refusal to readmit Resident 1 back to the facility caused undue distress upon Resident 1 and put him at risk for " homelessness." The Ombudsman stated, "The respite center can only keep Resident 1 for 24-48 hours and after that, he has nowhere else to go and he will be homeless." The Ombudsman stated Resident 1 ended up in a "temporary" respite center against his will and without his routine medications necessary to treat his various illnesses including a heart problem. On 10/2/14 at 9:30 a.m., during an interview, the administrator stated Resident 1 was transported back to the facility on [DATE]. He stated he came to the facility and refused to admit Resident 1 because he was a threat to the safety and well-being of all the residents at the facility. The administrator stated although Resident 1 had no prior incidents of physical aggression for the three years he lived at the facility, he acted out without reason or provocation and choked another resident in full view of the other resident's family. The administrator stated Resident 1's physician was at the facility on the day of the incident (9/25/14), and "verbally" told him Resident 1 was not appropriate for long term care at the facility. On 10/2/14 at 11:32 a.m., during an interview, the facility's Social Services Director (SSD) stated Resident 1 had lived at the facility for approximately three years and had no past, present, or future discharge plans prior to the incident on 9/25/14. The SSD stated, "Resident 1 had months upon months of angry verbalizations under his breath, but never struck out. He was seen by a mental health practitioner once a week on Thursdays and according to his reports, there were no indications Resident 1 would physically harm himself or other people." On 10/2/14 at 11:45 a.m. during an interview, the Director of Nurses (DON) stated Resident 1's physical aggression towards another resident on 9/25/14, was an isolated incident. The DON stated Police was called and escorted Resident 1 out of the facility. The DON stated, "I did not know where the police was going to take Resident 1, so I did not give a 7-day bed-hold notice." (A 7-day bed-hold notice is a written notice explaining the resident's right to have his/her bed held for up to seven days. The facility must readmit the resident if he/she returns within the 7 days, and allow him/her to return to the first available bed after the 7 days are up). When asked to describe Resident 1's known behavior(s), the DON stated, "Resident 1 was just generally a grumpy person. He cusses at others under his breath but he never hit, struck, or choked anyone. He made verbal threats but he was not assaultive or physically aggressive." The DON stated she received a phone call from SSW 1 on 9/26/14, whereupon she was informed Resident 1 was admitted to the Behavioral Health Center (BHC). The DON stated, "I still did not send a 7 day bed-hold, we were not going to take him back. On 9/29/14, the administrator and I were on a conference call with SSW 1. She informed us Resident 1 was ready to be discharged from the BHC, and the administrator and I told her we will not readmit Resident 1 for safety reasons." On 10/2/14 at 2:00 p.m., during a clinical record review, Resident 1's physician's progress notes dated 10/2/14 (7 days after the incident), indicated "... (Resident 1's name) with multiple medical problems is not appropriate for long term care at this time. He is dangerous to himself and other residents' safety and well-being." On 10/17/14 at 1:00 p.m., during a telephone interview, the Board and Care owner (BCO) stated, SSW 1 called her on 9/26/14 and 9/29/14, and inquired about placement of Resident 1 at her facility. The BCO stated, "On 9/30/14, I went to the Behavioral Health Center to evaluate Resident 1. I had a male bed available, however, he refused to go with me and I wasn't going to force him and take him to my home against his will. He kept on telling me his home was the facility and he wanted to go back there." The BCO stated she received another call on 10/3/14, and was asked to pick up Resident 1 from the respite center. The BCO stated she picked up Resident 1 and took him to her Board and Care without any personal belongings, clothing, or medications (since 9/25/14, nine days). According to the BCO, Resident 1 was sad, upset, and had no interest to talk or eat. The BCO stated, "I was worried about him so I took him to a private medical group where they took blood tests and we are still waiting for his prescriptions to be filled as of today." When asked to speak with Resident 1, the BCO gave the phone to the resident who stated, "I want to go home... (name of facility)... please..." On 12/19/14, during administrative document review, the facility census list for 10/1/14, indicated there were 7 male beds open and available for admission. There was no documentation of 7 day bed hold offered or communicated to Resident 1 (self-responsible). The facility's refusal to readmit Resident 1 to the facility after he was deemed medically stable by the appropriate mental health practitioner and physician, resulted in Resident 1's transfer to a respite center against his will and without the medications or treatments necessary for his mental, emotional, and physical well-being. Resident 1 was placed in a situation of temporary homelessness, which affected his overall psychosocial and emotional well-being.

Based on staff interview, clinical record and administrative document review, the facility failed to ensure Resident 1 was free from a significant medication error when [MEDICATION NAME] (MS) (a medication to control pain) was not administered as prescribed and policies and procedures were not in place to protect resident safety when 1 of 1 Residents (Resident 1) was administered 100 mg of MS, an overdose 20 times the ordered dose, in error by the facility's licensed vocational nurse (LVN 1). This failure had a direct proximate cause of Resident 1's death. Findings: The facility violated the regulation by failing to ensure Resident 1 was free from a significant medication error when [MEDICATION NAME] (MS) (a medication to control pain) was not administered as prescribed and policies and procedures were not in place to protect resident safety. Resident 1 had been prescribed 5 milligrams (mg) of MS for pain control. Resident 1 had been given 100 mg of MS, an overdose 20 times the ordered dose, in error by the facility's licensed vocational nurse (LVN 1). Resident 1 developed respiratory distress and became unresponsive as a result of the overdose of medication. Resident 1 died as a direct result of MS toxicity. Review of Resident 1's clinical records on [DATE] indicated Resident 1 had been admitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. Resident 1 had received hospice services beginning [DATE] at the facility for comfort and pain control. The hospice staff on [DATE] described Resident 1 as alert and oriented, minimally responsive verbally and required total assistance for basic care and nutrition needs. Resident 1 was described by hospice staff as "unable to take medication(s) unless administered by someone else." Resident 1's physician orders [REDACTED]. Dose Ordered: 0.25 ml/5 mg PO (by mouth) q (every) 6 h (hours) ATC (around the clock) 6 am 12 pm 6 pm 12 MN for Pain." On [DATE] at 10:50 a.m., during a telephone interview, LVN 1 stated on [DATE] at 12 noon she went into Resident 1's room. Resident 1 was awake and alert and able to respond appropriately to her questions with "yes" or "no." LVN 1 stated on [DATE] at 12 noon she had poured the liquid [MEDICATION NAME] into a plastic cup to measure the dose. LVN 1 stated she administered 100 mg (5.0 ml) of [MEDICATION NAME] instead of 5 mg (0.25 ml) to Resident 1. LVN 1 stated she realized her error when she documented the MS administration on the "Drug Accountability Record" (a document that tracks the time and amount of each dose of [MEDICATION NAME] given to every resident) after giving Resident 1 the medication. LVN 1 stated she then notified the Director of Nursing (DON), the hospice nurse and the resident's family of the error at 1 p.m. Review of professional reference, "Davis's Drug Guide for Nurses, Eleventh Edition," identified MS as a "High Alert" medication. The guide indicated, "Some medications, because of a narrow therapeutic (effective) range or inherent toxic nature, have a high risk of causing devastating injury or death if improperly ordered, prepared, stocked, dispensed, administered or monitored....they require special attention due to the potential for serious, possibly fatal consequences. These have been termed high-alert medications to communicate the need for extra care and safeguards." Davis's guide for MS "Nursing Implications" indicated: "High Alert...clarify doses that greatly exceed normal range. Have second practitioner independently check original order and dose calculations... administer oral solution with properly calibrated measuring device...older adults are more sensitive to the effects of opioid [MEDICATION NAME] and may experience side effects and respiratory complications more frequently." Davis's Guide indicated: "[MEDICATION NAME] starting dose for moderate to severe pain...30 mg q 3 to 4 hours... Review of professional reference, "Institute for Safe Medication Practices" website www.ismp.org dated 2012 included liquid concentrate narcotics on their list of "High Alert" medications. The website indicated, "High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. ...the consequences of an error are clearly more devastating to patients. We hope you will use this list to determine which medications require special safeguards to reduce the risk of errors." On [DATE] at 12:45 p.m., during an interview, the DON stated, Resident 1 had been given 100 mg of MS on [DATE] in error by a facility licensed nurse. The DON stated Resident 1 should have received 5 mg of [MEDICATION NAME] (0.25 ml), not 100 mg (5.0 ml). On [DATE] at 3:34 p.m., during an interview, the DON stated there was no policy or procedure for signing the drug accountability record before or after giving a narcotic medication such as MS. The DON stated the facility had no policy for licensed nurses to have a high alert medication double checked by another nurse prior to administration. On [DATE] at 4:20 p.m., during an interview, the Director of Staff Development (DSD) stated newly hired licensed nurses are provided orientation to medication administration, but not specifically to high risk narcotic administration. The DSD stated there had not been a system in place in [DATE] for double checking high alert medications. Review of facility document "Lesson Plan - Inservice, Title: Medication Administration" dated [DATE] did not indicate inclusion of safe guards for "High Alert" medications. Resident 1's nurse's notes dated [DATE] at 1:10 p.m. indicated Resident 1 was alert, blood pressure (B/P) was ,[DATE], heart rate (HR) was 117 and respiratory rate (RR) was 24. Resident 1's hospice notes dated [DATE] at 1:30 p.m. indicated Hospice Nurse (HN) 1 had arrived and assessed Resident 1. The hospice note indicated Resident 1 was not able to speak but was "able to track with eyes" in response to verbal stimulation. The document indicated Resident 1's blood pressure (B/P) had been ,[DATE], and heart rate (HR) 113 (high) and respirations (RR) were 20 per minute (within normal limits.) On [DATE] at 9:50 a.m. during a telephone interview, LN 2 stated she went into Resident 1's room on [DATE] at 2:15 p.m. LN 2 stated Resident 1 was not responding to her verbal questions or directions at that time. LN 2 stated the unresponsiveness was unusual for Resident 1 as normally he would respond with one or two word answers to her questions. LN 2 stated Resident 1 tried to open his eyes when she had then rubbed his legs. Resident 1's hospice note dated [DATE] at 3 p.m. indicated Resident 1 had responded "slower to verbal stimuli." The nursing note indicated Resident 1 no longer opened his eyes to verbal stimuli. On [DATE] at 7:05 a.m., during a telephone interview, HN 1 stated he had placed a needle into Resident 1's vein (IV) on [DATE] at 3 p.m. in order to administer [MEDICATION NAME] (a narcotic antagonist) (a medication to reverse the effects of [MEDICATION NAME]) 0.2 mg I.V. HN 1 stated [MEDICATION NAME] had been ordered by the hospice physician due to the change in Resident 1's ability to respond to stimulation after the administration of MS at noon on [DATE]. HN 1 stated after Resident 1 had received the dose of [MEDICATION NAME] he then began to speak in response to questions asked. Resident 1 then had followed activity with his eyes and nodded his head in response to questions as well as responded with one word answers. HN 1 stated when he had left the facility at 5 p.m. Resident 1 had been sleeping, was easily awakened by verbal stimuli and opened his eyes but did not verbalize. At this time the hospice notes indicated Resident 1's B/P was ,[DATE], HR was 96 (per minute), and RR had been 20 (per minute). HN 1 stated prior to leaving the facility he instructed LN 2 to monitor Resident 1's condition closely and HN 1 had notified Resident 1's daughter of his condition. On [DATE] at 9:50 a.m., during a telephone interview, LN 2 stated she went into Resident 1's room on [DATE] at 6 p.m. LN 2 stated Resident 1 had loud, wet sounding breathing that she could "hear across the room without a stethoscope (instrument for amplification to listen to breath sounds)." LN 2 stated Resident 1 had not responded to her voice. Resident 1's vital signs had changed to a B/P of ,[DATE] (low) HR had increased from 96 to 142/minute and had a RR of 21/minute. LN 2 stated Resident 1 did not have the use of supplemental oxygen at that time. LN 2 stated she then measured Resident 1's oxygen saturation level (a test that shows how much oxygen is transported by the blood to the tissues in the body) and it was "very low" at 37%. LN 2 stated she then called for a second nurse who placed an oxygen mask on Resident 1. LN 2 stated she then phoned and asked a hospice nurse to return to the facility due to the decrease in Resident 1's level of consciousness and significant decrease in the oxygen saturation level which now had required the administration of supplemental oxygen. Review of professional reference, "Mosby's Diagnostic and Laboratory Test Reference, Ninth Edition" indicated, "oxygen saturation... normal findings 95% or greater...critical values 75% or less...causes of low oxygen saturation levels...severe hypoventilation (e.g. oversedation)." On [DATE] at 7:07 a.m., during a telephone interview, HN 2 stated she had been called to the facility to check on Resident 1 on [DATE] and had arrived shortly after 6 p.m. HN 2 stated Resident 1 at that time had not responded to her questions and would not follow her verbal directions. Resident 1's breathing rate had increased to 30 to 40 times per minute, and Resident 1 had foam around his mouth and was diaphoretic (sweaty). HN 2 stated this had been a definite change in Resident 1's condition compared with earlier visits. HN 2 stated she had then notified Physician 1 of Resident 1's change in condition. HN 2 stated Resident 1 was then transferred to the acute care hospital at 7:25 p.m. by ambulance. Review of the acute hospital emergency room notes dated [DATE], indicated Resident 1 arrived to the hospital emergency roiagnom on [DATE] at 7:29 p.m. and had been described as "unresponsive to verbal/tactile stimuli." The emergency room physician's documentation for Resident 1 dated [DATE] at 7:45 p.m. indicated Resident 1's status was "not responsive." The physician notes indicated Resident 1's breath sounds were loud, and wet sounding with wheezes though out his lungs. The physician note indicated Resident 1 had been evaluated by the emergency room physician and had received supplemental oxygen by mask, and treatments to ease his breathing. Resident 1's emergency room nurse's notes dated [DATE] at 11:12 p.m. indicated the facility had been notified of the hospital's plan to transfer him back to the facility and of Resident 1's condition. Resident 1's condition was described in the nursing notes as "still having difficulty breathing, congested, unresponsive to verbal and tactile stimuli." The notes indicated the emergency room physician and Resident 1's family had agreed to the transfer of Resident 1 back to the facility. On [DATE] at 9 a.m., during a telephone interview, Licensed Nurse (LN) 3 stated she had been on duty in the facility on [DATE] at 12:20 a.m. when Resident 1 returned from the emergency room . LN 3 stated Resident 1 had returned wearing an oxygen mask and described his breathing as fast and labored. Resident 1 did not respond to any verbal questions or follow verbal directions. Resident 1 did not make any purposeful movement when moved from the transport stretcher to the bed. LN 3 stated the resident's oxygen saturation was "very low" at 50%. LN 3 stated she left Resident 1's room to obtain an oxygen tank which would deliver a high percentage of oxygen. LN 3 stated when she returned to the room minutes later, Resident 1 had not been breathing and no pulse could be found. LN 3 stated she then called the house supervisor to assess the resident. LN 3 stated the house supervisor pronounced Resident 1 dead at 12:55 a.m. LN 3 stated she then notified the hospice staff and Resident 1's family of his death. On [DATE] at 12 noon. during a telephone interview, the Facility Consultant Pharmacist (FCP) confirmed 5 ml of [MEDICATION NAME] 20 mg/1 ml would have been 100 mg, not 5 mg. The FCP stated he had not seen a dose that large (l00 mg) routinely given. The toxicology report dated [DATE] indicated Resident 1's [MEDICATION NAME] level was recorded as 0.40 mg/L (Effective Level: 0XXX,[DATE].12 mg/L (Liter) and potentially Toxic 0XXX,[DATE].5 mg/L). The Coroner's report dated [DATE] indicated, " CAUSE OF DEATH: [MEDICATION NAME] Intoxication."