Every finding on record at Antelope Valley Care Center

Based on interview and record review, the facility failed to administer medications as ordered by the physician for one of three sampled residents (Residents 1).This deficient practice had the potential to delay Residents 1's care and negatively affect the resident's health and well-being Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 5/21/2024 and readmitted on [DATE], with diagnoses including cerebral infarction (the death of brain tissue caused by a blocked or narrowed blood vessel that cuts off blood and oxygen supply), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial loss of movement on one side of the body) following cerebral infarction affecting left non-dominant side, and diabetes mellitus type two (DMI II-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/30/2026, the MDS indicated Resident 1 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS indicated Resident 1 required substantial assistance (helper does more than half of the effort) from facility staff with toileting hygiene, lower body dressing, and rolling left and right in bed. During a review of Resident 1's Order Summary Report for 5/2026, the Order Summary Report indicated the following physician orders. -5/8/2026: left inguinal area (area of the body located just above the thighs and below the main lower abdomen) extending to perineal area (the diamond-shaped area located at the bottom of the pelvis, between the thighs) MASD. Wash with soap and water, gently pat dry. Apply zinc oxide (a medication used to support skin healing by reducing inflammation and blocking moisture) 20 percent (%-unit of measurement) then sprinkle with antifungal (a type of medicine used to treat and prevent fungal infections) powder two times a day for 21 days. -5/8/2026: left ischium MASD. Wash with soap and water. Gently pat dry. Apply zinc oxide 20% then sprinkle with antifungal powder two times a day for 21 days. -peri rectum MASD pink and moist. Wash with soap and water. Gently pat dry. Apply zinc oxide 20% then sprinkle with antifungal powder two times a day for 21 days. -right ischium MASD. Wash with soap and water. Gently pat dry. Apply zinc oxide 20% then sprinkle with antifungal powder two times a day for 21 days. During a concurrent interview and record review on 8/25/2026 at 1:57 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Treatment Administration Record (TAR), dated 5/2026, and Progress Notes for 5/2026 were reviewed. The TAR indicated on 5/9/2026, 5/14/2026, 5/15/2026, 5/16/2026, and 5/22/2026 for 5 p.m. administration time, there were no licensed staff initials in the box for Resident 1's treatment orders for MASD to demonstrate the treatment was administered. LVN 1 stated there was no documented evidence on the TAR dated 5/2026 and Progress Notes to indicate that Resident 1 received MASD treatment on 5/9/2026, 5/14/2026, 5/15/2026, 5/16/2026, and 5/22/2026 for 5 p.m. administration time. LVN 1 stated this failure had the potential to cause wound infection and delay wound healing.During an interview on 8/25/2026 at 3:41 p.m. with the Director of Nursing (DON), the DON stated failure to administer Resident 1's treatments had the potential to exacerbate Resident 1's wounds. During a review of the facility-provided policy and procedure (P&P) titled, Administering Medications, last reviewed on 8/4/2026, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.24. Topical medications used in treatments are recorded on the resident's treatment record (TAR).

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one person towards another) when on 7/8/2026, at 8:30 a.m., while Resident 1 was seated in a wheelchair, Resident 1 used his (Resident 1) left palm and struck Resident 2's forehead while Resident 2 was also seated in a wheelchair in the hallway.As a result, on 7/8/2026, at 8:30 a.m., Resident 2 was subjected to physical abuse while under the care of the facility. Resident 2 sustained a reddened forehead with a bump (any raised area or swelling) measuring approximately one inch long and one inch wide and Resident 2 had facial grimace, yelled and had guarding behavior of covering her (Resident 2) forehead due to pain (pain level not specified). On 7/8/2026, at 8:55 a.m., Resident 2 was transferred and presented with a head injury and forehead hematoma (a closed wound where blood collects and fills a space inside your body) at General Acute Care Hospital 1 (GACH 1) for further evaluation and treatment.Findings:During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted Resident 1 on 3/27/2019, with diagnoses that included metabolic encephalopathy (a brain dysfunction caused by an underlying condition), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities), and difficulty in walking.During a review of Resident 1's Change in Condition (CIC - a document used to record and report any significant changes in a resident's status), dated 4/26/2026, the CIC indicated Resident 1 had behavioral symptoms (outward, observable actions that deviate from typical norms and disrupt daily functioning) and physically punched staff's (admission Clerk [AC]) jaw. The CIC indicated the facility transferred Resident 1 to GACH 2 for psychiatric evaluation (a structured assessment process used to diagnose mental health conditions and create effective treatment plans).During a review of Resident 1's CIC, dated 5/6/2026, the CIC indicated Resident 1 had behavioral symptoms of aggression (any physical or verbal behavior intentionally aimed at causing harm, pain, or destruction to another person) towards staff (Licensed Vocational Nurse 5 [LVN 5]) with increased confusion. The CIC indicated the Physician ordered to transfer Resident 1 to GACH 2.During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings), dated 5/11/2026, the H&P indicated Resident 1 had agitation (a feeling of irritability, mental distress or severe restlessness), behavioral changes and was transferred to the GACH (not specified) for evaluation.During a review of Resident 1's CIC, dated 5/20/2026, the CIC indicated Resident 1 had physical aggression towards staff during activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The CIC indicated Resident 1 struck Certified Nursing Assistance (CNA) 2's face during ADLs. The CIC indicated the physician was notified with orders for a consult with a psychiatrist (a licensed medical doctor who specializes in mental health), urinalysis (UA - urine test), complete blood count (CBC - a routine blood test that measures the number and types of cells in your blood), and complete metabolic panel (CMP - a standard blood test that measures 14 different substances to give your doctor a snapshot of your overall health).During a review of Resident 1's Progress Notes, dated 5/20/2026, timed at 9:45 a.m., the Progress Notes indicated on 5/20/2026, at 9:40 a.m., Resident 1 was seated in the wheelchair in the hallway and CNA 2 was checking Resident 1's blood pressure (the force of the blood pushing against the walls of the arteries as the heart pumps it through the body) when Resident 1 struck CNA 2's face.During a review of Resident 1's Order Summary Report, dated 5/20/2026, the Order Summary Report indicated a physician's order to monitor Resident 1 for behavior of striking out staff during ADLs every shift.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 1 had severely impaired cognitive skills (resident had lost the ability to think, learn, remember, or make decisions to the point that resident cannot live independently and require full-time supervision or help with daily tasks like eating and dressing) for daily decisions. The MDS indicated Resident 1 needed maximum assistance from staff for dressing and personal hygiene. The MDS indicated Resident 1 used a walker (a mobility [the ability to move freely and easily] aid that helps provide stability and balance while a resident walks) and a wheelchair.During a review of Resident 1's Medication Administration Record (MAR - flowsheet that indicates medications given to a resident), dated 7/2026 (whole month of July 2026), the MAR indicated Resident 1 had four episodes of striking staff on 7/3/2026.During a review of Resident 1's CIC, dated 7/8/2026, at 8:30 a.m., the CIC indicated Resident 1 had an episode of physical aggression on 7/8/2026. The CIC indicated a staff (Physical Therapy Assistant [PTA]) observed Resident 1 engaged in a physical altercation (a dispute between individuals in which one or more people sustain a bodily injury). The CIC indicated Resident 1 used the palm of his (Resident 1) hand and struck Resident 2 on the left side of the head. The CIC indicated the Physician was notified on 7/8/2026 at 8:43 a.m. and ordered haloperidol (medication used to treat nervous, emotional, and mental conditions) injection (the act of putting a medicine into the body using a syringe [a simple pump to inject or withdraw liquids] and a needle) five milligram per milliliter (Mg/ML - a unit of measurement), Ativan (medication used for short-term relief of severe anxiety and or panic attacks) injection two (2) mg/ml, and an order to notify the psychiatrist immediately for Resident 1.During a review of Resident 1's Progress Notes, dated 7/8/2026, timed at 8:42 a.m., the Progress Notes indicated Resident 1 had uncontrollable hitting and striking of staff on 7/8/2026. The Progress Notes indicated Quality Assurance Nurse (QAN) 1 called the Physician with an order for Ativan 1 milligram (mg - metric unit of measurement, used for medication dosage and/or amount) and Haldol 1 mg intramuscular (IM - inside the muscle) injection (the act of using a needle and syringe to force liquid medicine, fluids, or vaccines directly into a person's body) stat due to agitation and psychiatrist to arrange for Resident 1 to go to GACH (not specified) for behavioral evaluation (a systematic method used to observe, measure, and understand how an individual acts in specific situations).During a review of Resident 1's Progress Notes, dated 7/8/2026, timed at 7:10 p.m., the Progress Notes indicated an ambulance picked up Resident 1 at 7:10 p.m. (on 7/8/2026), and transferred to GACH 3 for behavioral evaluation.During a review of Resident 2's undated admission Record, the admission Record indicated the facility admitted Resident 2 on 1/3/2026, with diagnoses that included other sequalae of cerebral infarction (the residual, long-term symptoms or complications that persist after a patient has suffered a stroke [brain attack]), unspecified dementia and generalized muscle weakness.During a review of Resident 2's History of Present Illness (HPI), dated 1/4/2026, the HPI indicated Resident 2 had the capacity to make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 2 used a walker and a wheelchair.During a review of Resident 2's CIC, dated 7/8/2026, the CIC indicated Resident 2 had a .raised bump. on his head. The CIC indicated the Physician was notified and ordered to transfer Resident 2 to GACH 1 for computed tomography (CT - a diagnostic imaging test that combines X-rays [medical imaging that uses radiation to take pictures of the inside of your body] with computer processing to create detailed pictures of the inside of your body) scan of the head. The CIC indicated Resident 2 had a raised area on the front of the head with increasing pain when bump was touched.During a review of Resident 2's Pain Observation/Assessment, dated 7/8/2026, the Pain Observation/Assessment indicated Resident 2 had nonverbal (not involving or using spoken or written words) signs of discomfort with sharp pain to the head as evidenced by wincing (an involuntary, slight grimace or flinch) and yelling out when the raised area in the forehead was touched.During a review of Resident 2's Comprehensive Skin Evaluation/Assessment, dated 7/8/2026, the Comprehensive Skin Evaluation/Assessment indicated a raised area measuring approximately one inch in length and one inch wide noted on the frontal area (refers to the front section of the skull [the bony frame of the head] and scalp [the skin and hair that covers the top and back of the head]) of Resident 2's head.During a review of Resident 2's Progress Notes, dated 7/8/2026, timed at 8:30 a.m., the Progress Notes indicated, on 7/8/2026, Resident 2 was in the hallway near Resident 1 when Resident 1 struck Resident 2. The Progress Notes indicated Registered Nurse (RN) 1 assessed Resident 2 who had a raised area in the forehead and displayed nonverbal signs of discomfort including wincing and yelling out when forehead was touched.During a review of Resident 2's Progress Notes, dated 7/8/2026, the Progress Notes indicated that on 7/8/2026 at 8:45 a.m., Emergency Medical Services (EMS - the system of professionals provide pre-hospital medical care and transport in emergencies) and Fire Station A (FSA) arrived at the facility and transferred Resident 2 to GACH 1 at 8:55 a.m. (on 7/8/2026) for further evaluation and treatment.During a review of Resident 2's GACH 1 Emergency Documentation, dated 7/8/2026, the Emergency Documentation indicated on 7/8/2026, at 9:31 a.m., Resident 2 presented with a head injury and forehead hematoma.During a review of Resident 2's GACH 1 CT brain/head, dated 7/8/2026, timed at 11:15 am., the CT scan indicated Resident 2 had mild left forehead scalp soft tissue swelling (a buildup of fluid, blood, or inflammation in the layers of skin and tissue on the outside of the skull).During a review of Resident 2's Progress Notes, dated 7/8/2026, timed at 3:22 p.m., the Progress Notes indicated Resident 2 returned to the facility.During an interview on 7/9/2026, at 8:46 a.m., with the Director of Staff Development (DSD), the DSD stated on 7/8/2026, at 8:30 a.m., she (DSD) was inside her (DSD) office when the PTA passed by her (DSD) office and reported that Resident 1 hit Resident 2. The DSD stated she (DSD) walked out of her (DSD) office and followed the PTA and noticed Resident 2 seated on a wheelchair outside of Room A, holding her (Resident 2) forehead. The DSD stated the PTA went with Resident 1 and she (DSD) stayed with Resident 2. The DSD stated Resident 2 was upset while holding her (Resident 2) forehead and Resident 2 verbalized that Resident 1 hit her (Resident 2). The DSD moved Resident 2's hand from her (Resident 2) forehead and noticed a bump.During an interview on 7/9/2026, at 8:53 a.m., with the PTA, the PTA stated on 7/8/2026, at 8:30 a.m. she (PTA) was walking towards the gym when she (PTA) passed by the hallway and noticed something from the corner of her (PTA) eye. The PTA stated when she (PTA) turned her (PTA) head, she (PTA) witnessed Resident 1 who was seated in a wheelchair swung his (Resident 1) left arm and with an open hand Resident 1's left palm hit Resident 2's left forehead. The PTA stated she (PTA) also heard a thud sound (a dull, heavy sound made when a solid, heavy object hits another surface) when Resident 1's left palm hit Resident 2's left forehead. The PTA stated she (PTA) saw Resident 2 grimaced and grabbed her (Resident 2) forehead right away. The PTA stated she (PTA) reported to the DSD that Resident 1 and Resident 2 were fighting and she (PTA) separated Resident 1 away from Resident 2. The PTA stated physical abuse is when someone hurts somebody physically. The PTA stated the incident between Residents 1 and 2 was abuse.During an observation and interview on 7/9/2026, at 9:24 a.m., at Resident 2's bedside, Resident 2 laying on bed with a forehead bump and fading bruise. Resident 2 stated her (Resident 2) forehead still hurts when touched. Resident 2 stated she (Resident 2) cannot remember how she (Resident 2) got hurt.During an interview on 7/9/2026, at 9:30 a.m., with Registered Nurse (RN) 1, RN 1 stated on 7/8/2026, at 8:30 a.m., she (RN 1) was in Nursing Station B when the incident happened in the hallway of Nursing Station A. RN 1 stated Quality Assurance Nurse (QAN) 1 reported to her (RN 1) that Resident 1 struck Resident 2 in the face. RN 1 stated she (RN 1) noticed Resident 1 getting combative (the tendency to be argumentative, hostile, or physically aggressive) and swinging his (Resident 1) arms at everyone. RN 1 stated she (RN 1) took care of Resident 1 first and went to Resident 2 and noticed the bump on her (Resident 2) forehead. RN 1 stated Resident 2 made pain-related noise (unspecified). RN 1 stated Resident 2 did not verbalize her (Resident 2) pain level. RN 1 stated a cold pack (or ice pack) was applied, and Resident 2 refused pain medication. RN 1 stated physical abuse is when someone physically hits another person. RN 1 stated based on the definition of abuse, Resident 1 abused Resident 2.During an interview on 7/9/2026, at 9:56 a.m., with the DSD, the DSD stated Resident 1 abused Resident 2. The DSD stated that because Resident 1 hit Resident 2, Resident 2 had a forehead injury and was transferred to GACH 1.During an interview on 7/9/2026, at 9:59 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she (LVN 1) was regularly assigned to Resident 2. LVN 1 stated on 7/8/2026, at 8:30 a.m., she (LVN 1) administered medication (not specified) to Resident 2's roommate (not specified) inside Resident 2's room. LVN 1 stated Resident 2 was outside the room in the hallway seated in a wheelchair. LVN 1 stated after medication administration she (LVN 1) went out of Resident 2's room and noticed Resident 2 in Nurses Station A with an icepack on her (Resident 2) forehead. LVN 1 stated Resident 2 cannot verbally report the pain level but appeared in pain due to facial expression of grimace and yelling and her (Resident 2) body language of guarding her (Resident 2) forehead. LVN 1 stated the incident was a resident-to-resident abuse and Resident 2 got hurt in the situation.During an interview on 7/9/2026, at 10:06 a.m., with Quality Assurance Nurse 1 (QAN 1), QAN 1 stated on 7/8/2026, just after 8:30 a.m. the DSD informed her (QAN 1) of the incident. QAN 1 stated the DSD took Resident 2 in Nursing Station A and she (QAN 1) stayed with Resident 1 until the Unit Coordinator (UC) came and wheeled Resident 1 to Nursing Station C. QAN 1 stated Resident 1 was still agitated and still tried to hit her (QAN 1) and the UC for two minutes. QAN 1 stated she (QAN 1) notified the Physician, and the Physician ordered Ativan and Haldol IM. QAN 1 stated Resident 1 calmed down after a while until he (Resident 1) was picked up through 5150 (an involuntary 72-hour psychiatric hold allowing designated medical professionals or police to legally hold a person in a hospital for up to three days if they are deemed a danger to themselves or others or are unable to care for their basic needs) the night of 7/8/2026. QAN 1 stated Resident 1 had agitation in the past. QAN 1 stated the incident between Resident 1 and Resident 2 was abuse.During an interview on 7/9/2026, at 10:14 a.m., with the Assistant Director of Nursing (ADON) 1, the ADON 1 stated the incident between Resident 1 and Resident 2 was an abuse incident. ADON 1 stated Resident 2 had swollen and reddened forehead.During an interview on 7/9/2026, at 10:18 a.m., with the Administrator (ADM), the ADM stated he (ADM) was the Abuse Coordinator and the facility's policy was that all residents have the right to be free from abuse. The ADM stated Resident 1 abused Resident 2 because Resident 1 struck Resident 2.During a concurrent interview and record review on 7/9/2026, at 11:01 a.m., with QAN 2, Resident 1's CICs, dated 4/26/2026, 5/6/2026, and 5/20/2026 were reviewed. QAN 2 stated the CIC, dated 4/26/2026, indicated Resident 1 had behavioral signs and punched AC's jaw. QAN 2 stated the CIC, dated 5/6/2026, indicated Resident 1 had behavioral signs of increased confusion and aggression towards staff and Resident 1 struck LVN 5's face. QAN 2 stated the CIC, dated 5/20/2026, indicated Resident 1 had physical aggression while seated in the hallway and struck CNA 2's face during ADLs. QAN 2 stated Resident 1 had three episodes of striking a staff.During a review of facility's policy and procedure (P&P), titled, Abuse, Neglect, Exploitation (taking unfair advantage of someone or something for personal gain or profit) and Misappropriation (using someone else's money, property, or ideas for a purpose the owner never intended) Prevention Program, dated 5/2024, and last reviewed on 5/20/2026, the P&P indicated, Residents have the right to be free from abuse, neglect. This includes but is not limited to . physical abuse. 1. Protect residents from abuse . but not necessarily limited to: . b. other resident.During a review of facility's P&P, titled, Identifying Types of Abuse, dated 5/2024, and last reviewed on 5/20/2026, the P&P indicated, Abuse of any kind against a resident is strictly prohibited. Physical Abuse: 1. Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking.During a review of facility's P&P, titled, Recognizing Signs and Symptoms of Abuse/Neglect, dated 5/2024, and last reviewed on 5/20/2026, the P&P indicated, All types of resident abuse . are strictly prohibited. 4. The following are signs and symptoms of abuse/neglect that should be promptly reported. This listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. a. Signs of physical abuse: . (5) Bruises, including those found in unusual locations such as the head, neck, lateral locations on the arms or posterior trunk and torso, . and/or (6) Facial injuries, including broken or missing teeth, facial fractures (break in a bone), black eyes, bruising, or swelling, or bleeding of the mouth and cheeks.

Based on interview and record review, the facility failed to follow professional standards of nursing practice for two of four sampled residents (Resident 1 and Resident 2) by failing to: Ensure Certified Nursing Assistant (CNA) 2 reported Resident 1's unwitnessed fall on 6/4/2026 to the licensed nurses. Ensure CNA 2 did not move Resident 1 until the licensed nurses had assessed the resident following Resident 1's unwitnessed fall.Ensure licensed nurses appropriately assessed and monitored Resident 1's medical status following the resident's Change of Condition (COC - when there is a sudden change in a resident's condition) on 6/4/2026 related to the resident's fall. Ensure licensed nurses appropriately assessed and monitored Resident 2's medical status following the resident's Change of Condition (COC) on 6/9/2026 related to the alleged physical abuse against CNA 4. These deficient practices had the potential to result in the failure to identify continued or worsening clinical deterioration thereby placing Resident 1 and Resident 2 at risk for adverse health outcomes and compromised safety.Findings: a. During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted Resident 1 on 9/24/2024 with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood sugar level is too high), chronic obstructive pulmonary disease (COPD - a progressive, long-term lung condition that damages the airways and air sacs, making it hard to breathe), and spondylopathy (any disease or disorder of the spine). During a review of Resident 1's Physician Order, dated 12/25/2024, the Physician Order indicated apixaban (also known as Eliquis - a prescription anticoagulant medication, taken by mouth, that acts as a blood thinner) 2.5 milligrams (mg - unit of measurement), every 12 hours for atrial fibrillation (a type of irregular heartbeat). During a review of Resident 1's Care Plan Report on Falls, last revised on 1/15/2026, the Care Plan Report indicated Resident 1 was a high risk for falls with or without injury related to antihypertensive medications (a prescribed medication that lowers a person's blood pressure [the force of person's blood pushing against the walls of arteries as heart pumps it throughout the body]), diuretic medication (used to help the body eliminate excess salt and water through urine), hypoglycemia (low blood sugar), and unsteady gait. Resident 1's Care Plan Interventions indicated to anticipate and meet the resident's needs, monitor for changes in condition affecting risk for falls, notify Resident 1's physician, and monitor the resident for delayed injury for 72 hours. During a review of Resident 1's Fall Risk Observation and Assessment, dated 3/30/2026, the Fall Risk Observation and Assessment indicated Resident 1 had a total score of 12. A fall risk score of nine to 15 indicated Resident 1 was a moderate risk for falls. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/30/2026, the MDS indicated Resident 1's cognitive (refers to the mental processes involved in gaining knowledge, understanding, and thinking) skills for daily decision making was intact. The MDS indicated that Resident 1 required partial and moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for shower and bathing. The MDS indicated that Resident 1 required setup assistance (resident completes activity while the helper assists prior to or following the activity) with eating, toileting, and oral hygiene. During a review of Resident 1's Change in Condition (COC - when there is a sudden change in a resident's condition) Evaluation, dated 6/6/2026, the COC Evaluation indicated the resident had a fall that resulted to a blue discoloration with diffused yellow edges on the right iliac crest (the curved top ridge of the hip bone) and right buttocks. During an interview on 6/30/2026 at 11:59 a.m. with Resident 1, Resident 1 stated on 6/4/2026, CNA 2 brought him into the shower room for his regular shower. Resident 1 stated CNA 2 placed him inside the shower cubicle, turned on the shower, and then stepped out closing the shower curtain behind her. Resident 1 stated he stood up to scrub his body and when he sat back down, he slipped and the shower chair rolled back. Resident 1 stated he informed CNA 2 that he hit his back on the shower chair's armrest and landed on his buttocks. Resident 1 stated CNA 2 pulled him up by the arm and sat him down on the shower chair. Resident 1 stated there were no licensed nurses who came to assess him after the fall. Resident 1 stated that he did not request to take the shower by himself, CNA 2 just wheeled him in the shower and stepped out of the shower area. During an interview on 7/1/2026 at 11:25 a.m. with CNA 2, CNA 2 stated Resident 1 had a shower on 6/4/2026. CNA 2 stated she assisted Resident 1 into the shower room. CNA 2 stepped out and closed the shower curtain but stated Resident 1's feet were visible under the shower curtain. CNA 2 stated Resident 1 was observed sitting on the floor with the shower chair behind the resident. CNA 2 stated she used her right arm, grabbed Resident 1's right arm, and pulled the resident up using a gait belt (an assistive device used to help safely transfer or assist a person). CNA 2 stated she assisted Resident 1 back up to the shower chair, assisted him (Resident 1) in dressing up, and then transferred the resident to the wheelchair. CNA 2 stated she did not call for assistance before moving Resident 1, following the resident's fall inside the shower room. CNA 2 stated she did not notify the licensed nurses about Resident 1's fall. CNA 2 acknowledged and stated Resident 1 should be visible during shower to assist and anticipate the resident needs. During an interview on 6/30/2026 at 12:33 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated there were no reported resident falls on 6/4/2026 at the station she was working at. LVN 2 stated she was not aware of Resident 1's fall in the shower room on 6/4/2026. During a concurrent interview and record review on 7/1/2026 at 1:17 p.m. with Registered Nurse (RN) 1, Resident 1's Progress Notes, dated 6/4/2026 to 6/9/2026, were reviewed. RN 1 stated CNA 2 should have reported Resident 1's unwitnessed fall to the licensed nurses to ensure Resident 1 was assessed and monitored. RN 1 stated Resident 1 should be monitored every shift for 72 hours after a change of condition. RN 1 stated Resident 1's Progress Notes indicated there was no documented evidence that the resident was assessed and monitored on the following shifts: 6/4/2026 (7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift, and 11 p.m. to 7 a.m. shift),6/5/2026 (7 a.m. to 3 p.m. shift, 3 p.m. to 11 p.m. shift, and 11 p.m. to 7 a.m. shift),6/6/2026 (3 p.m. to 11 p.m. shift),6/7/2026 (11 p.m. to 7 a.m. shift). RN 1 stated care not documented was considered not provided. RN 1 stated that failure to document Resident 1's medical status monitoring following a change of condition could put Resident 1's safety at risk. During a concurrent interview and record review on 7/1/2026 at 3:14 p.m. with the Director of Nursing (DON), Resident 1's 72-hour Neuro (a prefix that relates to the nervous system [brain, spinal cord, and all the nerves], which is the body's command center) Check List, dated 6/6/2026 to 6/8/2026, were reviewed. The DON stated Resident 1's 72-hour Neuro Check List indicated there was no documented evidence that the resident was assessed and monitored on 6/6/2026 at 3:20 p.m. The DON stated Resident 1 was a fall risk resident. The DON stated Resident 1's fall should be reported to the licensed nurses to ensure the resident was assessed and monitored following an unwitnessed fall. The DON stated moving Resident 1 from the ground to the chair before a licensed nurse had assessed the resident following an unwitnessed fall could cause more injury to the resident. The DON further stated Resident 1 was on an anticoagulant medication that could cause undetected internal bleeding following an unwitnessed fall. The DON acknowledged and stated the facility failed to follow the facility's policy and procedure on fall management that included reporting falls to the licensed nurses. The DON further stated the facility failed to assess, monitor, and document Resident 1's medical status following an unwitnessed fall. During a review of the facility's policy and procedure (PnP) titled, Fall Prevention and Management Program, last reviewed on 5/20/2026, the PnP indicated the purpose .to develop, implement, monitor, and evaluate residents using an interdisciplinary approach. The program will use strategies that foster resident independence and increase quality of life while promoting safety for residents and staff. The program focuses on reducing incidence of resident falls and mitigating risk of falls through a resident focused team approach. The PnP indicated a fall is any occasion in which a person verbalizes he or she has had a fall or when a person is found on the floor. The PnP indicated following a residents fall, the licensed nurse will notify the RN supervisor and assess the resident for injuries and necessary treatment.if there is no apparent injury, assist resident off the floor. The PnP indicated .document resident condition after fall for 72 hours in nursing progress notes. Licensed nurse will document ongoing assessments to include neuro checks for unwitnessed falls.and response to care and treatment each shift. During a review of the facility's PnP titled, Charting and Documentation, last reviewed on 5/20/2026, the PnP indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The PnP indicated documentation in the medical record will be objective, complete and accurate. During a review of the facility's PnP titled, Change in a Resident's Condition or Status, last reviewed on 5/20/2026, the PnP indicated the nurse will notify the resident's attending physician or physician on call when there has been a (an).accident or incident involving the resident. need to alter the resident's medical treatment significantly. The PnP indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical or mental condition or status. b. During a review of Resident 2's undated admission Record, the admission Record indicated the facility admitted the resident on 2/25/2026 with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood sugar level is too high), age-related osteoporosis (a condition where bones become brittle, weak, and highly porous as a person gets older), and muscle weakness. During a review of Resident 2's History of Present Illness and Physical Exam (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 2/26/2026, the H&P indicated Resident 2 had the capacity to make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 5/21/2026, the MDS indicated Resident 2's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact. The MDS indicated Resident 2 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on rolling to the left side and right side, sit to lying position (the ability to move from sitting on side of bed to lying flat on the bed), and lying to sitting position (the ability to move from lying on the back to sitting on the side of the bed and with no back support). The MDS indicated Resident 2 was dependent on facility staff on self-care including eating, oral (mouth) hygiene, toileting hygiene, shower, dressing up, and personal hygiene. During an interview on 6/30/2026 at 2:20 p.m. with LVN 3, LVN 3 stated that on 6/9/2026, LVN 4 reported Resident 2's allegation against CNA 4. LVN 3 stated CNA 4 allegedly went on top of Resident 2 and rough handled the resident. LVN 3 stated she did not document the assessment and monitoring in the resident's medical record following the resident's alleged abuse. LVN 3 stated she did not notify Resident 2's attending physician and family about the resident's alleged physical abuse from CNA 4. During a telephone interview on 7/1/2026 at 10:16 a.m. with LVN 4, LVN 4 stated on 6/9/2026 between 1 a.m. to 2 a.m., Resident 2 reported that CNA 4 punched her (Resident 2) on the face. LVN 4 stated she did not document her assessment and monitoring on Resident 1's medical record following the resident's alleged abuse. LVN 4 stated she waited for the DON's instructions. LVN 4 stated she sent a text message to the DON but did not receive a response from the DON. LVN 4 stated she did not notify Resident 2's attending physician and family about the resident's alleged physical abuse from CNA 4. During a concurrent interview and record review on 7/1/2026 at 1:17 p.m. with RN 1, Resident 2's medical records were reviewed. RN 1 stated there was no documented evidence of Resident 2's assessment and monitoring on 6/9/2026 to 6/30/2026 related to Resident 2's allegation of abuse against CNA 4. RN 1 stated there was no documented evidence that Resident 2's attending physician and family were notified about the resident's alleged physical abuse from CNA 4. RN 1 stated care not documented was considered not provided. RN 1 stated that failure to document Resident 1's medical status assessment and monitoring following an alleged physical abuse could result in emotional distress and put Resident 2's safety at risk. During an interview on 7/1/2026 at 3:14 p.m. with the DON, the DON stated on 6/12/2026, Resident 2 reported that CNA 4 was rough on the resident while changing the resident's disposable brief. The DON stated Resident 2 did not have a Change of Condition (COC - when there is a sudden change in a resident's condition) and the resident's reported concern was documented as a grievance. The DON stated that on 6/9/2026 LVN 4 sent him (the DON) a text message indicating Resident 2's allegation that CNA 4 went on top of Resident 2 and punched the resident. The DON stated he read LVN 4's text message on 6/30/2026, 21 days after LVN 4 reported the alleged abuse. The DON stated Resident 2 should be monitored every shift for 72 hours after a change of condition. The DON stated Resident 2 was not assessed and monitored following an alleged physical abuse that could result in Resident 2's medical status decline, emotional distress, and put the resident's safety at risk. The DON acknowledged and stated the facility failed to ensure Resident 2 was assessed and monitored following the resident's allegation of abuse against CNA 4. During a review of the facility's policy and procedure (PnP) titled, Comprehensive Assessments, last reviewed on 5/20/2026, the PnP indicated comprehensive assessments are conducted to assist in developing person-centered care plan. During a review of the facility's PnP titled, Charting and Documentation, last reviewed on 5/20/2026, the PnP indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The PnP indicated documentation in the medical record will be objective, complete and accurate. During a review of the facility's PnP titled, Change in a Resident's Condition or Status, last reviewed on 5/20/2026, the PnP indicated the nurse will notify the resident's attending physician or physician on call when there has been a (an).significant change in the resident's physical, emotional, mental condition. need to alter the resident's medical treatment significantly. The PnP indicated unless otherwise instructed by the resident, a nurse will notify the resident's representative when. there is a significant change in the resident's physical, mental, or psychosocial status. The PnP indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical or mental condition or status.

Based on interviews and record review, the facility failed to report the allegation of an employee-to-resident physical abuse (any intentional act causing injury or trauma to another person through bodily contact) to the State Survey Agency (SSA) for one of four sampled residents (Resident 2). On 6/9/2026, an allegation that Certified Nursing Assistant (CNA) 4 pushed and punched Resident 2 on the face was reported to Licensed Vocational Nurse (LVN) 3, LVN 4, and the Director of Nursing (DON). The SSA did not receive the report from the Abuse Coordinator for the allegation of abuse. This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse.Findings: During a review of Resident 2's undated admission Record, the admission Record indicated the facility admitted the resident on 2/25/2026 with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood sugar level is too high), age-related osteoporosis (a condition where bones become brittle, weak, and highly porous as a person gets older), and muscle weakness. During a review of Resident 2's History of Present Illness and Physical Exam (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 2/26/2026, the H&P indicated Resident 2 had the capacity to make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 5/21/2026, the MDS indicated Resident 2's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making was intact. The MDS indicated Resident 2 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on rolling to the left side and right side, sit to lying position (the ability to move from sitting on side of bed to lying flat on the bed), and lying to sitting position (the ability to move from lying on the back to sitting on the side of the bed and with no back support). The MDS indicated Resident 2 was dependent on facility staff on self-care including eating, oral (mouth) hygiene, toileting hygiene, shower, dressing up, and personal hygiene. During an interview on 6/30/2026 at 2:20 p.m. with LVN 3, LVN 3 stated that on 6/9/2026, LVN 4 reported CNA 4 allegedly went on top of Resident 2 and rough handled the resident. LVN 3 stated LVN 4 informed her that the alleged abuse was reported already (LVN 3 could not remember to whom the alleged abuse was reported to). LVN 3 stated she did not follow up on Resident 2's reported allegation of abuse against CNA 4. During a telephone interview on 7/1/2026 at 10:16 a.m. with LVN 4, LVN 4 stated on 6/9/2026 between 1 a.m. to 2 a.m., Resident 2 reported that CNA 4 punched her (Resident 2) on the face. LVN 4 stated she reported the alleged abuse to Registered Nurse (RN) 2 and sent a text message to the DON. LVN 4 stated she did not get a response from the DON. LVN 4 stated she did not report Resident 2's allegation of abuse to the SSA. During a concurrent interview and record review on 7/1/2026 at 1:17 p.m. with RN 1, Resident 2's medical records were reviewed. RN 1 stated there was no documented evidence of Resident 2's assessment and monitoring on 6/9/2026 to 6/30/2026 related to Resident 2's allegation of abuse. RN 1 stated she did not receive a report regarding Resident 2's allegation of abuse against CNA 4. During an interview on 7/1/2026 at 3:14 p.m. with DON, the DON stated Resident 2's allegation against CNA 4 was not reported to the SSA. The DON stated not reporting Resident 2's allegations of abuse could negatively affect the resident's psychosocial wellbeing (a dynamic relationship between a person's psychological state [thoughts, feelings, and mental health] and their social environment) and cause the resident emotional distress. The DON further stated allegations of abuse that were not reported could cause the abuse to continue. The DON acknowledged and stated the facility failed to report Resident 2's allegation of abuse against CNA 4 within two hours. During a concurrent interview and record review on 7/1/2026 at 3:40 p.m. with the Administrator (ADM), the facility's policy and procedure (PnP) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 5/20/2026, was reviewed. The PnP indicated if resident abuse. is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The PnP defined immediately as within two hours of an allegation involving abuse. The ADM stated he was the facility's Abuse Coordinator. The ADM acknowledged and stated the facility failed to report the allegation of abuse within two hours.

During an interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had a moderate risk for falls (as indicated in Resident 1's Fall Risk Observation and Assessment), was free from falls and injury by failing to ensure Resident 1 was supervised and assisted while taking a shower in the shower room. As a result, on 6/4/2026 between 9 a.m. to 10 a.m., Resident 1 fell to the ground while taking a shower in the shower room. Resident 1's fall was not reported to the licensed nurses until 6/6/2026, two days following the fall, when Resident 1 complained of right lower back and right buttock pain. Resident 1's fall resulted in a bluish discoloration with diffused yellow edges on the right iliac crest (the curved top ridge of the hip bone) and right buttock. Findings: During a review of Resident 1's undated admission Record, the admission Record indicated the facility admitted Resident 1 on 9/24/2024 with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood sugar level is too high), chronic obstructive pulmonary disease (COPD - a progressive, long-term lung condition that damages the airways and air sacs, making it hard to breathe), and spondylopathy (any disease or disorder of the spine). During a review of Resident 1's Physician Order, dated 12/25/2024, the Physician Order indicated apixaban (also known as Eliquis - a prescription anticoagulant medication, taken by mouth, that acts as a blood thinner) 2.5 milligrams (mg - unit of measurement), every 12 hours for atrial fibrillation (a type of irregular heartbeat). During a review of Resident 1's Care Plan Report on Falls, last revised on 1/15/2026, the Care Plan Report indicated Resident 1 was a high risk for falls with or without injury related to antihypertensive medications (a prescribed medication that lowers a person's blood pressure [the force of person's blood pushing against the walls of arteries as heart pumps it throughout the body]), diuretic medication (used to help the body eliminate excess salt and water through urine), hypoglycemia (low blood sugar), and unsteady gait. Resident 1's Care Plan Interventions indicated to anticipate and meet the resident's needs, monitor for changes in condition affecting risk for falls, notify Resident 1's physician, and monitor the resident for delayed injury for 72 hours. During a review of Resident 1's Fall Risk Observation and Assessment, dated 3/30/2026, the Fall Risk Observation and Assessment indicated Resident 1 had a total score of 12. A fall risk score of nine to 15 indicated Resident 1 was a moderate risk for falls. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/30/2026, the MDS indicated Resident 1's cognitive (refers to the mental processes involved in gaining knowledge, understanding, and thinking) skills for daily decision making was intact. The MDS indicated that Resident 1 required partial and moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for shower and bathing. The MDS indicated that Resident 1 required setup assistance (resident completes activity while the helper assists prior to or following the activity) eating, oral hygiene, and toileting. During a review of Follow up Question Report, Resident 1's Bathing Task, dated 6/4/2026, the Bathing Task indicated Resident 1 was provided shower with partial or moderate assistance. During a review of Resident 1's Change in Condition (COC - when there is a sudden change in a resident's condition) Evaluation, dated 6/6/2026, the COC Evaluation indicated the resident had a fall that resulted to a blue discoloration with diffused yellow edges on the right iliac crest (the curved top ridge of the hip bone) and right buttocks. During a review of Resident 1's General Acute Care Hospital (GACH) History and Physical (H&P - a medical examination that involves a doctor taking a resident's medical history, performing a physical exam, and documenting their findings) Note, dated 6/9/2026, the H&P indicated Resident 1 complained of persistent right flank and lower lumbar pain with visible bruising following a fall. The Assessment section of the H&P indicated Resident 1 had ecchymosis (bruise) and tenderness on the right lower flank region. During an interview on 6/30/2026 at 11:50 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 6/6/2026, Resident 1 complained of right lower back pain, neck pain, and dizziness. CNA 1 stated Resident 1 reported that he (Resident 1) had a fall on 6/4/2026 inside the shower room. CNA 1 stated she checked Resident 1's back and observed a purplish bruise on the right lower back. CNA 1 stated she immediately notified Licensed Vocational Nurse (LVN) 1. During an interview on 6/30/2026 at 11:59 a.m. with Resident 1, Resident 1 stated on 6/4/2026, CNA 2 brought him into the shower room for his regular shower. Resident 1 stated CNA 2 placed him inside the shower cubicle, turned on the shower, and then stepped out closing the shower curtain behind her. Resident 1 stated he stood up to scrub his body and when he sat back down, he slipped and the shower chair rolled back. Resident 1 stated he informed CNA 2 that he hit his back on the shower chair's armrest and landed on his buttocks. Resident 1 stated CNA 2 pulled him up by the arm and sat him down on the shower chair. Resident 1 stated there were no licensed nurses who came to assess him after the fall. Resident 1 stated that he did not request to take the shower by himself, CNA 2 just wheeled him in the shower and stepped out of the shower area. During an interview on 7/1/2026 at 11:25 a.m. with CNA 2, CNA 2 stated Resident 1 had a shower on 6/4/2026. CNA 2 stated she assisted Resident 1 into the shower room. CNA 2 stated Resident 1 preferred to shower alone. CNA 2 stepped out and closed the shower curtain but stated Resident 1's feet were visible under the shower curtain. CNA 2 stated Resident 1 was observed sitting on the floor with the shower chair behind the resident. CNA 2 stated she used her right arm, grabbed Resident 1's right arm, and pulled the resident up using a gait belt (an assistive device used to help safely transfer or assist a person). CNA 2 stated she assisted Resident 1 back up to the shower chair, assisted him in dressing up, and then transferred the resident to the wheelchair. CNA 2 stated she did not call for assistance before moving Resident 1, following the resident's fall inside the shower room. CNA 2 stated she did not notify the licensed nurses about Resident 1's fall. CNA 2 acknowledged and stated Resident 1 should be visible during shower to assist and anticipate the resident needs. During a concurrent interview and record review on 7/1/2026 at 1:17 p.m. with Registered Nurse (RN) 1, Resident 1's Progress Notes, dated 6/4/2026 to 6/9/2026, and Medication Administration Record (MAR) dated 6/1/2026 to 6/30/2026, were reviewed. RN 1 stated during resident showers, the CNA should be inside the shower cubicle for resident safety while personal space for resident independence was still provided. RN 1 stated there was no documented evidence of Resident 1's fall on 6/4/2026. RN 1 further stated there was no documented evidence Resident 1 was assessed and monitored following a fall from 6/4/2026 to 6/5/2026. RN 1 stated Resident 1's MAR indicated the resident was on an anticoagulant medication, which increased Resident 1's risk for bleeding. RN 1 stated that failure to supervise and assist Resident 1 during shower resulted in Resident 1's fall with injury. RN 1 further stated that CNA 2's failure to report Resident 1's fall could result in an undetected injury, which may cause Resident 1 adverse health outcomes and compromised safety. During an interview on 7/1/2026 at 3:14 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was a fall risk resident. The DON stated Resident 1 should be supervised and assisted during showers while respecting resident privacy. The DON stated Resident 1's fall should be reported to the licensed nurses to ensure the resident was assessed and monitored following an unwitnessed fall. The DON stated Resident 1 had an unreported and unwitnessed fall that resulted to Resident 1's bruised lower right back. The DON further stated Resident 1 was on an anticoagulant medication that could cause undetected internal bleeding following an unwitnessed fall. The DON acknowledged and stated the facility failed to supervise and assist Resident 1 during shower. The DON further stated the facility failed to report Resident 1's fall to the licensed nurses. During a review of the facility's policy and procedure (PnP) titled, Fall Prevention and Management Program, last reviewed on 5/20/2026, the PnP indicated the purpose .to develop, implement, monitor, and evaluate residents using an interdisciplinary approach. The program will use strategies that foster resident independence and increase quality of life while promoting safety for residents and staff. The program focuses on reducing incidence of resident falls and mitigating risk of falls through a resident focused team approach. The PnP defined a fall as to suddenly go down onto the ground or floor from a higher level to a lower level that is not purposeful. The PnP indicated a fall is any occasion in which a person verbalizes he or she has had a fall or when a person is found on the floor. The PnP further indicated the interdisciplinary team (IDT - a collaborative group of professionals from different disciplines - such as physicians, nurses, therapists, and social workers - who work together to create and implement a single, unified care plan for a resident) will further update care plans to identify and minimize the risk for falls. During a review of the facility's PnP titled, Bath, Shower/Tub, last reviewed on 5/20/2026, the PnP indicated for the nursing staff to assist the resident when bathing as needed, encouraging independence whenever possible. The Documentation section of the PnP indicated to record any refusals, resident concerns, skin issues, or unusual observations and to report significant findings to the nurse promptly.

Based on interview and record review, the facility failed to revise and update the comprehensive care plan to reflect current wound orders for left and right arm gangrenous (tissue in a living body that is dead, decaying, or rotting, usually caused by a severe lack of blood supply) wound and intervention for one of three sampled resident (Resident 1).This deficient practice had the potential to delay care and services that were specific to the Resident 1's needs.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 2/5/2026 with diagnoses including encounter for change or removal of surgical wound dressing and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 3/4/2026, the MDS indicated that Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated that Resident 1 required dependent assistance from staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 1's Order Summary Report (OSR) dated 2/26/2026, the OSR included the following orders: 1. Left arm gangrenous wound: Cleanse with NS cover with abdominal pad, wrap with rolled gauze every day shift. 2. Right arm gangrenous wound: Cleanse with NS cover with abdominal pad, wrap with rolled gauze every day shift. During a concurrent interview and record review on 5/4/2026 at 10:19 a.m. with Treatment Nurse 2 (TXN 2), Resident 1's care plan report and OSR were reviewed. TXN 2 stated that care plans should be updated and include supplements for wound healing, treatment orders and should be resident-centered. TXN 2 stated that Resident 1's care plan was not updated with the treatment orders for gangrenous left and right arm wounds. During an interview and record review on 5/4/2026 at 12:18 p.m. with the Director of Nursing (DON), Resident 1's care plan was reviewed. The DON stated that treatment nurses are responsible for initiating and updating care plans related to wounds. The DON stated that Resident 1's care plan did not include the wound order from the doctor. The DON further stated that care plans are a guide for nursing staff and if there is no care plan there is no guide for nurses to follow. During a review of facility's policy and procedure (P&P), titled, Care Plan, Comprehensive Person-Centered, dated 5/2024, the P&P indicated, Assessments of resident are ongoing and care plans are revised as information about the residents and resident' condition change. 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.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Background Screening Investigations, for one of seven sampled staff (Certified Nursing Assistant [CNA] 1) when the facility failed to run a background (a screening process that verifies a person's history [employment, education, credit] to confirm accuracy) and criminal check (a specific type of background check, searches public records for convictions or felony/misdemeanor arrests) prior to staff employment.This deficient practice had the potential to affect the residents' safety.Findings: During a review of CNA 1's Orientation schedule, dated 12/20/2005, the Orientation schedule indicated CNA 1's date of hire was 12/20/2005.During a review of the facility-provided record titled, InfoLink Screening Services Inc., dated 10/26/2006, the InfoLink Screening Services Inc. indicated CNA 1's background and criminal check was received on 10/26/2006 and completed on 10/30/2006. During a concurrent interview and record review on 4/15/2026 at 12:50 p.m. with the Director of Staff Development (DSD), of the CNA 1's employee file the DSD stated CNA 1's hire dated was 12/20/2005 and the background check was done on 10/30/2006. The DSD stated background checks are done prior to staff being hired. The DSD stated the background checks need to be cleared prior to the staff orientation or being scheduled for orientation. The DSD stated if background checks are not done prior to being hired there is potential for criminal background, theft or abuse that can place the residents at risk. During an interview on 4/15/2026 at 4:40 p.m. with the Director of Nursing (DON), the DON stated background checks are done prior to employment. The DON stated if background checks are not done prior to employment there is a potential to not have a clear picture of the employee the facility will not know if the employee has a background that impacts the safety of the residents if they have a criminal background. The DON stated it is the facility's goal to hire staff with clean background records. During a review of the facility's P&P titled, Background Screening Investigations, last reviewed on 5/30/2025, the P&P indicated the facility conducts employment background screening checks, reference checks and criminal convictions investigation checks on all applicants for positions with direct access to residents (direct access employees).2. The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment.

Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) maintained acceptable parameter of nutritional status when the facility failed to follow up with the Medical Doctor when Registered Dietitian (RD- a credentialed food and nutrition expert who uses evidence-based science to help people improve their health, manage diseases, and create personalized meal plans) made recommendations on 2/17/2026 and 3/18/2026.This deficient practice had the potential for Resident 1 to have an unintentional weight loss. Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 12/30/2025 and readmitted Resident 1 on 1/28/2026 with diagnosis that included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), heart failure (a chronic condition where the heart muscle is too weak or stiff to pump blood efficiently, meaning it cannot meet the body's needs for oxygen), and hyperlipidemia (a common condition characterized by abnormally high levels of fats (lipids), such as cholesterol and triglycerides, circulating in the blood).During a review of Resident 1's Order Summary Report (ORS), dated 12/30/2025, the ORS indicated Consistent Carbohydrate (CCHO- a structured eating plan designed to manage blood sugar levels, primarily for people with diabetes [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing] or prediabetes) No Added Salt (NAS), International Dysphagia Diet Standardization Initiative (IDDSI- a global standard that classifies foods and drinks into 8 clear, color-coded levels [0-7] based on thickness and texture) level 6 (Soft & Bite-Sized food designed for people with chewing difficulties), IDDSI 0 thin consistency (the standard consistency for liquids that flow freely and quickly, exactly like water).A review of Resident 1's Weight and Vitals Summary, the Weight and Vital Summary indicated Resident 1 weighed: - 12/31/2025 178 lbs. - 1/6/2026 176 lbs. - 1/15/2026 173 lbs. - 1/21/2026 170 lbs. - 2/5/2026 153 lbs. - 2/17/2026 147 lbs. - 3/4/2026 145 lbs.- 3/11/2026 146 lbs.- 3/18/2026 141 lbs. During a review of Resident 1's OSR dated 1/2/2026, the ORS indicated Boost Glucose Control in the evening for supplement 237 milliliters (ml- a unit of measurement) orally every evening with medication pass. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/6/2026, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS indicated that Resident 1 was dependent (helper does all of the effort) with toileting, and personal hygiene, required substantial assistance (helper does more than half the effort) with upper and lower body dressing, and putting on and taking off footwear, and partial assistance ( helper does less than half the effort) with oral hygiene, and required setup or clean-up assistance ( helper sets up or cleans up, resident completes activity) with eating.During a review of Resident 1's OSR dated 1/28/2026, the ORS indicated furosemide (used to help the body get rid of unneeded water and salt through increased urination) oral tablet 40 milligrams (mg- a unit of measurement) give one tablet by mouth in the morning for heart failure for 30 days. During a review of Resident 1's OSR dated 2/5/2026, the ORS indicated fortified (are everyday foods that have extra vitamins and minerals added to them during manufacturing to make them more nutritious), CCHO, NAS, IDDSI 6: soft and bite sized texture, IDDSI :0 thin consistency, magic cup (a high-calorie, high-protein frozen nutritional supplement designed to help individuals gain weight or prevent involuntary weight loss due to illness or malnutrition) all meals. During a review of Resident 1's Nutritional Risk assessment dated [DATE], the Nutritional Risk Assessment indicated continue fortified CCHO, NAS, IDDSI 6 texture and thin liquids, add Boost Glucose control once a day and consider appetite stimulant. During a review of Resident 1's OSR dated 2/24/2026, the ORS indicated megestrol acetate suspension 400 mg/10ml give 10 ml by mouth one time a day for appetite stimulant. During a review of Resident 1's Weight Variance assessment dated [DATE], the Weight Variance Assessment indicated Resident 1 had a five lbs. weight loss in one week. The RD's recommendations included continuing with fortified, CCHO, NAS, IDDSI 6 texture and thin liquids, add liquacel (a concentrated liquid protein supplement designed to help people increase their protein intake easily) two times a day continue with magic cup three times a day, continue with boost two times a day, continue appetite stimulant.During a review of Resident 1's OSR dated 3/20/2026, the ORS indicated liquaCel oral liquid give 30 ml by mouth two times a day for supplement.During a concurrent interview and record review on 4/15/2026 at 4 p.m. with the RD of Resident 1's Nutritional Risk assessment dated [DATE] and OSR, the RD reviewed the Nutritional Risk assessment dated [DATE] and the RD stated she (RD) saw Resident 1 on 2/17/2026 and recommended for Resident 1 to consider an appetite stimulant. The RD stated she input her recommendations and provide the recommendations to the Quality Assurance (QA) Nurse (QA 1) at the end of the day. The RD reviewed Resident 1's OSR and the RD stated the appetite stimulant was ordered on 2/24/2026, the RD stated it was ordered a week later. The RD stated the appetite stimulant should have been started when the RD recommended it on 2/17/2026 because there is a potential for Resident 1 not to get the required nutrition and for continued weight loss. The RD stated she (RD) saw Resident 1 on 3/18/2026 Resident 1 had 5 lbs. weight loss then added liquacel, a protein supplement. The RD reviewed OSR and the RD stated the liquacel was ordered on 3/20/2026 there was a delay of 2 days which had the potential for Resident 1 not to meet his recommended nutritional level and risk for weight loss. During an interview on 4/15/2026 at 4:20 p.m. with the QA 1, the QA 1 stated she is the QA nurse for station 3. QA 1 stated she (QA 1) gets the RD recommendations via email. QA 1 reviewed her own emails and stated she (QA 1) received the RD recommendations for Resident 1 on 2/18/2026 to add an appetite stimulant. QA 1 stated Resident 1 had a room change on 2/18/2026 and the RD's recommendations must have been missed due to the room change and was not ordered until 2/24/2026. The QA 1 stated recommendations should be followed up with the Medical Doctor within 24 hours, but we have at least 72 hours to follow up. QA 1 stated the recommendation was not followed up within the 72 hours and had the potential for nutritional deficiency and weight loss and possible delay in the care. During a concurrent interview and record review on 4/15/2026 at 4:40 p.m. of Resident 1's Nutritional Risk assessment dated 2/17 /2026 with the Director of Nursing (DON), the DON reviewed the Nutritional Risk assessment dated [DATE] and stated the Nutritional Risk Assessment indicated to add an appetite stimulant. The DON reviewed Resident 1's OSR and stated the appetite stimulant was ordered one week later, a delay of one week. The DON stated the RD recommendations should be reported to the doctor as soon as possible or within 24 hours after it was communicated and should be ordered. The DON stated there is a potential for a decrease in appetite and weight loss. During a review of the facility's Policy and Procedures (P&P) titled, Weight Assessment and Intervention, last reviewed on 5/30/2025, the P&P indicated resident weight are monitored for undesirable or unintended weight loss or gain. 1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The Evaluation includes:a. The resident's target weight rangeb. The residents' calorie, protein, and other nutrient needs compared with the resident's current intake;c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. Whether and to what extent weight stabilization or improvement can be anticipated.

Based on observation, interview, and record review, the facility failed to ensure residents received the intravenous catheter (IV-a flexible plastic tube that is inserted into a vein to deliver fluids and medications) care consistent with professional standards of practice for three of four sampled residents (Resident 1, 2 and 3), by failing to: 1. Ensure Resident 1's IV was assessed and monitored for potential complications.2. Ensure peripherally inserted IV was labeled and dated for Resident 2 and Resident 3.These failures had the potential to delay the provision of necessary care and services for Residents 1,2, and 3 and to negatively affect the residents' well-being. Cross reference F842. Findings: 1a. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 8/26/2024 and readmitted on [DATE] with diagnoses including cervical disc disorder at C5-C6 level with myelopathy, anemia (a condition where the body does not have enough healthy red blood cells), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and cerebral infarction (-stroke, loss of blood flow to a part of the brain). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 10/5/2024, the H&P indicated, Resident 1 had the capacity to make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/19/2026, the MDS indicated Resident 1 had intact cognitive functioning (resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions). The MDS indicated Resident 1 required supervision (helper provides verbal cutes or contact guard assistance) from the facility staff with personal hygiene. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) from the facility staff with upper and lower body dressing. During a concurrent observation and interview on 4/2/2026 at 10:30 a.m. with Resident 1 in Resident 1's room, Resident 1 was observed with left wrist double lumen (two separate internal channels) intravenous catheter secured with transparent adhesive dressing and covered with mesh gauze (specialized, low-adherent dressing). Resident 1 stated he (Resident 1) could not recall the exact date the IV catheter was inserted. During a concurrent interview and record review on 4/2/2026 at 2:03 p.m. with the Assistant Director of Nursing (ADON), Resident 1's Progress Notes and Assessment forms, dated 2026, were reviewed. The ADON indicated there was no documented evidence to indicate when and by whom Resident 1's IV catheter was inserted. The ADON stated there was no documented evidence to indicate if Resident 1's IV catheter was a peripheral IV or peripherally inserted central catheter (PICC-a long, flexible, thin tube inserted into a vein and threaded to a large vein near the heart). The ADON stated there was no documented evidence to indicate that Resident 1's IV catheter was assessed and monitored by the facility staff. The ADON stated the facility staff failed to identify, assess, and monitor Resident 1's IV catheter. The ADON stated it was facility's responsibility to monitor Resident 1's IV catheter for potential complications. The ADON stated the failure to assess and monitor Resident 1's IV catheter had the potential for Resident 1 to experience adverse effects without facility staff's knowledge. During a review of the facility-provided policy and procedure titled, Intravenous Therapy, last reviewed on 5/30/2025, the P&P indicated, The facility will adhere to accepted standards of practice regarding infusion practices. 13. IV sites are checked every four (4) hours or as per facility protocol and PRN for signs and symptoms of infection or inflammation. 15. The IV documentation is recorded in the nurses' notes and/or Medication Administration Record. 16. The nurse will notify the practitioner to assess the need for continuation of the catheter if not being used for IV fluids or medications and will discontinue as per the practitioner's order. During a review of the facility-provided policy and procedure titled, Peripheral and Midline IV Dressing Changes, last reviewed on 5/30/2025, the P&P indicated, The purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. 6. Assess the peripheral/midline access device at least every 4 hours (every 1-2 hours for residents with cognitive impairment) . c. Assess the patency of the vascular device. d. Palpate and inspect the skin, dressing, and securement device for signs of complications.During a review of the facility-provided policy and procedure titled, Peripheral IV Catheter Insertion, last reviewed on 5/30/2025, the P&P indicated, The purpose of the procedure is to provide guidelines for the safe and aseptic insertion of a peripheral intravenous catheter for the administration of intravenous fluids and/or medications.Documentation: The following information should be recorded in the resident's medical record: 1. Date and time of the procedure; 2. Number of venipuncture attempts (maximum of two); 3. Type, length, and gauge of catheter; 4. Type of antiseptic agent used; 5. Site of insertion (be specific to name of vein, area of limb);. 9. Condition of the IV site; . 11. Resident's response to procedure; and 12. Signature and title of the person recording the date. 2a. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 4/5/2024 and readmitted on [DATE] with diagnoses including rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), type two diabetes mellitus (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's H&P, dated 6/13/2025, the H&P indicated, Resident 2 had the capacity to make decisions. During a review of Resident 2's MDS, dated [DATE] the MDS indicated Resident 2 had intact cognitive functioning (resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions). The MDS indicated Resident 2 was dependent (helper does all of the effort) on facility staff for oral hygiene, toilet hygiene, and personal hygiene.During a review of Resident 2's Order Summary Report, the report indicated the following physician's order:-4/2/2026: Assess peripherally inserted IV (PIV) access site every eight hours and document every shift. -4/2/2026: Flush PIV with Normal Saline (a sterile solution of salt in water, used for diluting intravenous medications) 0.9 percent (%-one part of every hundred) five milliliters (ml-unit of measurement) before and after medication use. -3/26/2026: Ceftriaxone Sodium Solution Reconstituted (medication used to treat bacterial infections) one gram (gm-unit of measurement) intravenously in the evening for posterior cervical site abscess (a swollen area within body tissue, containing an accumulation of pus) for 14 days. During a concurrent observation and interview on 4/2/2026 at 11:40 a.m. with Registered Nurse (RN) 1 in Resident 2's room, Resident 2 was observed with right forearm PIV. RN 1 stated there was no label on Resident 2's PIV to indicate the date of the PIV insertion. 2b. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 3/27/2026 with diagnoses including acute kidney failure (the sudden loss of kidney function), type two diabetes mellitus, and heart failure (a heart disorder which causes the heart to not pump the blood efficiently). During a review of Resident 3's Order Summary Report, the report indicated the following physician's order:-4/1/2026: Flush PIV with Normal 0.9 % 10 ml before and after medication use.-4/1/2026: Normal Saline Intravenous Solution 0.9%. Use 500 ml intravenously only for hypotension for one day. Given bolus (a single dose of medication is given all at once). -4/1/2026: Normal Saline Intravenous Solution 0.9%. Use 75 milliliters per hour (ml/hr.-unit of measurement) intravenously every hour for hypotension until 4/3/2026 for total of 2 liters (L-unit of measurement). During a review of Resident 3's Care Plan, initiated on 4/2/2026, the Care Plan indicated Resident 3 required IV hydration related to hypotension (low blood pressure). During a concurrent observation and interview on 4/2/2026 at 11:45 a.m. with RN 1 in Resident 3's room, Resident 3 was observed with left forearm PIV. RN 1 stated there was no label on Resident 3's PIV to indicate the date of the PIV insertion. During an interview on 4/2/2026 at 2:03 p.m. with the ADON, the ADON stated the PIV should be labeled, dated and changed every 72 hours or as needed. The ADON stated the purpose of labeling was to ensure the facility staff were able to identify when the PIV needs to be changed. The ADON stated the failure to label and date the PIV had the potential for Resident 2 and Resident 3 to develop an infection at the PIV site. During a review of the facility-provided policy and procedure titled, Peripheral IV Catheter Insertion, last reviewed on 5/30/2025, the P&P indicated, The purpose of the procedure is to provide guidelines for the safe and aseptic insertion of a peripheral intravenous catheter for the administration of intravenous fluids and/or medications. Steps in the Procedure: . 15. Place label on one side of the catheter (not over insertion site). Include the date and time of catheter insertion, initials, and length and gauge of catheter on the label.

Based on interview and record review, the facility failed to ensure the medical records for one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure accurate documentation of the peripheral intravenous catheter (peripheral IV-a flexible plastic tube that is inserted into a vein to deliver fluids and medications) insertion for four of four sampled residents (Residents 1, 2, 3, and 4). This deficient practice had the potential for inaccurate medical interventions for Residents 1, 2, 3, and 4. Cross reference F694. Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 8/26/2024 and readmitted on [DATE] with diagnoses including anemia (a condition where the body does not have enough healthy red blood cells), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and cerebral infarction (stroke, loss of blood flow to a part of the brain). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 10/5/2024, the H&P indicated, Resident 1 had the capacity to make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/19/2026, the MDS indicated Resident 1 had intact cognitive functioning (resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions). The MDS indicated Resident 1 required supervision (helper provides verbal cutes or contact guard assistance) from the facility staff with personal hygiene. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) from the facility staff with upper and lower body dressing. During a review of Resident 1's Order Summary Report, the report indicated the following physician's order:-3/4/2026: Sodium Chloride 0.9 percent (%- one part in every hundred). Use 100 milliliters per hour (ml/hr.-unit of measurement) intravenously two (2) liters (L-unit of measurement) for hydration for one day. During a concurrent interview and record review on 4/2/2026 at 11:05 a.m. with the Assistant Director of Nursing (ADON), Resident 1's Progress Notes, dated March 2026, were reviewed. The ADON stated there was no documented evidence to indicate when Resident 1's PIV was inserted. b. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 4/5/2024 and readmitted on [DATE] with diagnoses including rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), type two diabetes mellitus (DM II-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 6/13/2025, the H&P indicated, Resident 2 had the capacity to make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognitive functioning. The MDS indicated Resident 2 was dependent (helper does all of the effort) on the facility staff for oral hygiene, toilet hygiene, and personal hygiene. During a review of Resident 2's Order Summary Report, the report indicated the following physician's order:-4/2/2026: Assess PIV access site every eight hours and document every shift. -4/2/2026: Flush PIV with Normal Saline (a sterile solution of salt in water, used for diluting intravenous medications) 0.9 % five milliliters (ml-unit of measurement) before and after medication use. During a concurrent interview and record review on 4/2/2026 at 11:05 a.m. with the Assistant Director of Nursing (ADON), Resident 2's Progress Notes, dated April 2026, were reviewed. The ADON stated there was no documented evidence to indicate when Resident 2's PIV was inserted. c. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 3/27/2026 with diagnoses including acute kidney failure (the sudden loss of kidney function), type two diabetes mellitus, and heart failure (a heart disorder which causes the heart to not pump the blood efficiently). During a review of Resident 3's Order Summary Report, the report indicated the following physician's order:-4/1/2026: Flush PIV with Normal 0.9 % 10 ml before and after medication use.-4/1/2026: Normal Saline Intravenous Solution 0.9%. Use 500 ml intravenously only for hypotension for one day. Given bolus (a single dose of medication is given all at once). -4/1/2026: Normal Saline Intravenous Solution 0.9%. Use 75 milliliters per hour (ml/hr.-unit of measurement) intravenously every hour for hypotension until 4/3/2026 for total of 2 liters (L-unit of measurement). During a review of Resident 3's Care Plan, initiated on 4/2/2026, the Care Plan indicated Resident 3 required IV hydration related to hypotension (low blood pressure). During a concurrent interview and record review on 4/2/2026 at 11:05 a.m. with the Assistant Director of Nursing (ADON), Resident 3's Progress Notes, dated March 2026, were reviewed. The ADON stated there was no documented evidence to indicate when Resident 3's PIV was inserted. d. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 1/7/2026 with diagnoses including cerebral infarction, hemiplegia, and type 2 diabetes mellitus. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had severely impaired cognitive functioning. The MDS indicated Resident 4 was dependent on facility staff for personal hygiene, toileting hygiene, and lower body dressing. During a review of Resident 4's Care Plan, initiated on 3/28/2026, the Care Plan indicated Resident 4 was receiving antibiotic (medication used to treat bacterial infection) for recurrent urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 4's Order Summary Report, the report indicated the following physician's order:-3/28/2026: Zosyn Intravenous Solution 3-0.375 gram(gm)/50ml. Use 3.375gm intravenously every eight hours for UTI for seven days.During a concurrent interview and record review on 4/2/2026 at 11:05 a.m. with the Assistant Director of Nursing (ADON), Resident 4's Progress Notes, dated March 2026, were reviewed. The ADON stated there was no documented evidence to indicate when Resident 4's PIV was inserted. During an interview on 4/2/2026 at 2:03 p.m. with the ADON, the ADON stated the facility staff should document in resident's Progress Notes when the PIV is inserted, where it is inserted, technique used, and reason for the IV therapy. The ADON stated it was important to have complete documentation of the PIV insertion for facility staff to monitor the PIV site and provide care as needed. The ADON stated the failure to document the insertion of the PIV had the potential for Resident 1 to develop infection at the PIV site. During a review of the facility-provided policy and procedure titled, Peripheral IV Catheter Insertion, last reviewed on 5/30/2025, the P&P indicated, The purpose of the procedure is to provide guidelines for the safe and aseptic insertion of a peripheral intravenous catheter for the administration of intravenous fluids and/or medications.Documentation: The following information should be recorded in the resident's medical record: 1. Date and time of the procedure; 2. Number of venipuncture attempts (maximum of two); 3. Type, length, and gauge of catheter; 4. Type of antiseptic agent used; 5. Site of insertion (be specific to name of vein, area of limb);. 9. Condition of the IV site; . 11. Resident's response to procedure; and 12. Signature and title of the person recording the date. During a review of the facility-provided policy and procedure titled, Charting and Documentation, last reviewed on 5/30/2025, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record: . c. Treatments or services performed.

Based on interview and record review the facility failed to develop and implement a person-centered care (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of four sampled residents (Resident 1) by failing to develop a care plan to address Resident 1's Intravenous Gamma-Globulin (IVGG- a therapy used to treat immune-related disorders by strengthening the immune system) infusion for cervical disc disorder at cervical vertebra (C)5-C6 level with myelopathy (a severe, often progressive condition involving spinal cord dysfunction). This failure had the potential to delay care and negatively affect Resident 1's well-being.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 on 8/26/2024 and readmitted on [DATE] with diagnoses including cervical disc disorder at C5-C6 level with myelopathy, anemia (a condition where the body does not have enough healthy red blood cells), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and cerebral infarction (-stroke, loss of blood flow to a part of the brain). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 10/5/2024, the H&P indicated, Resident 1 had the capacity to make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/19/2026, the MDS indicated Resident 1 had intact cognitive functioning (resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions). The MDS indicated Resident 1 required supervision (helper provides verbal cutes or contact guard assistance) from the facility staff with personal hygiene. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) from the facility staff with upper and lower body dressing. During a review of Resident 1's Order Summary Report, the report indicated the following physician's order:-9/16/2025: IVGG for cervical disc disorder at C5-C6 level with myelopathy as ordered by the physician. Weekly supplied by Infusion Company 1. Administered by Infusion Nurse. -3/26/26: Appointment for infusion on 4/6/26. Infusion Company 1 to infuse in-facility. During a concurrent interview and record review on 4/2/2026 at 2:03 p.m. with the Assistant Director of Nursing (ADON), Resident 1's Care Plan was reviewed. The ADON stated Resident 1's Care Plan did not address Resident 1's IVGG infusions for cervical disorder at C5-C6 level with myelopathy. The ADON stated that even though the IVGG infusion was provided by a different company, it was still the facility's responsibility to monitor and implement necessary care for Resident 1. The ADON stated the purpose of the Care Plan was to guide the facility staff to monitor and provide appropriate care for Resident 1. The ADON stated the failure to address Resident 1's diagnoses of cervical disease and IVGG infusion had the potential to delay care for Resident 1. The ADON stated there was a potential for Resident 1 to experience adverse reaction. During a review of the facility-provided policy and procedure titled, Care Plans, Comprehensive Person-Centered last reviewed on 5/30/2025, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure the oxygen tubing (a long, flexible plastic tube designed to safely deliver oxygen from a source directly to a patient through a nasal cannula or mask) and the humidifier solution container (a bottle container filled with water that connects to the oxygen supply system to add moisture to the dry medical oxygen) were changed according to the facility's policy and procedures (P&P) for one of three sampled residents (Resident 3).This deficient practice had the potential to result in bacterial and mold growth which could result in Resident 3 developing a respiratory infection.Findings:During a review of Resident 3 admission Record (AR), the AR indicated the facility admitted Resident 3 on 3/11/2026 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), pneumonia (an infection/inflammation in the lungs), and asthma (chronic lung condition that makes it difficult to breathe).During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 3/18/2026, the MDS indicated Resident 3 had the ability to understand and be understood. During a review of Resident 3's Order Summary Report (ORS), dated 3/23/2026, the ORS indicated oxygen at 2 liters per minute via nasal canula every shift for COPD. During a review of Resident 3's Care plan (CP), dated 3/12/2026, the CP indicated Resident 4 requires the use of continuous oxygen related to shortness of breath with interventions that included to change humidification and oxygen tubing as indicated, change oxygen tubing and label tubing once a week or as needed if damaged or soiled and to observed oxygen precautions.During an observation on 3/23/2026 at 11 a.m. in Resident 3's room observed Resident 3 in bed wearing a nasal cannula (a lightweight, flexible tube used to deliver supplemental oxygen directly into a person's nostrils), oxygen tubing and humidifier solution container noted with no dates.During a concurrent interview and observation on 3/23/2026 at 11:13 a.m. with Unit Clerk (UC) 1, the UC 1 stated the oxygen tubing and humidifier solution concentrator does not have the date of when it was last changed. UC 1 stated the oxygen tubing and humidifier solution concentrator needs to have a date to know it is clean and if there is no date on them, we cannot say it has been changed. UC 1 stated the oxygen tubing and humidifier solution concentrator are changed every Friday. UC 1 stated the oxygen tubing can be dirty and can lead to a risk for infection. During an interview on 3/23/2026 at 3:51 p.m. with the Director of Nursing (DON), the DON stated the policy does not indicate that oxygen tubing needs to be labeled but it is an internal policy that has been changed. The DON stated for oxygen tubing and the humidifier must be labeled with the date it has been changed on the tubing and the concentrator as well as on the bag that the oxygen tubing does in. The DON stated oxygen tubing and humidifier solution concentrator are good for one week to decrease the infection and or bacterial growth they must be changed weekly. The DON stated all oxygen tubing are changed on Friday by the unit clerk. The DON stated if not dated we cannot say it was changed and potential for bacterial growth and if the humidifier is not changed it can be empty and cause redness and irritation for the residents.During a review of the facility's P&P titled, Oxygen Administration, last reviewed on 10/30/2025, the P&P indicated replace oxygen supplies and tubing typically every 7 to 14 days or per manufactures guidelines

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) by failing to develop a care plan to address Resident 1's nutrition related to early dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) schedule.This failure had the potential for delays in the delivery of necessary care, services and could potentially result in hypoglycemia (low blood sugar) to Resident 1. Cross reference F684. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/25/2026, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease (ESRD-irreversible kidney failure) with dependence on renal dialysis. During a review of Resident 1's Care Plan, dated 2/25/2026 on activities of daily living (ADL-activities such as bathing, dressing and toileting a person performs daily), the Care Plan indicated Resident 1 was dependent on staff for eating.During a review of Resident 1's Care Plan, dated 2/25/2026, on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), the Care Plan indicated dietary consultation for meal planning as indicated.During a review of Resident 1's Order Recapitulation Report, dated 2/25/2026, the Order Recapitulation Report indicated dialysis schedule every Monday, Wednesday and Friday at 8:45 a.m., with pick up time from Skilled Nursing Facility (SNF) at 8 a.m.During a review of Resident 1's Care Plan, dated 2/26/2026, on risk of malnutrition (a condition caused by an imbalance between the nutrients your body needs to function and the nutrients it receives), the Care Plan indicated the following interventions:Allow adequate time for meal consumption.Assists with meals/fluids as neededMonitor meal intakeProvide diet as orderedDuring a review of Resident 1's Order Recapitulation Report, dated 2/26/2026, the Order Recapitulation Report indicated feeding assistance.During a review of Resident 1's Pre-Hemodialysis Communication Observation/ Assessment, dated 2/27/2026, the Pre-Hemodialysis Communication Observation/Assessment indicated Resident 1 was picked up at 7:50 a.m., and time of last meal was left blank.During a review of Resident 1's Progress Notes, dated 2/27/2026, timed at 8:30 a.m., the Progress Notes indicated the transportation picked up Resident 1 who had not yet have her (Resident 1) breakfast. The Progress Notes indicated that the Dietary Supervisor (DS) was informed, made sack lunch (a portable meal prepared and packed into a paper or plastic bag to be eaten later), sent to dialysis center and provided to the resident.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 3/4/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily).During an interview on 3/13/2026, at 8:58 a.m., with the DS, the DS stated transportation picked up Resident 1 to go to dialysis center with no sack lunch provided. The DS stated they made a sack lunch and had it delivered to the dialysis center, but it was late. The DS stated that late meal intake can affect Resident 1's mood and health.During a concurrent interview, and record review on 3/13/2026, at 10:27 a.m., with the Assistant Director of Nursing (ADON), Resident 1's Care Plans were reviewed. The ADON stated there was no care plan developed to address Resident 1's breakfast intake in relation to early dialysis schedule. The ADON stated the facility did not implement the care plan intervention for malnutrition on allowing adequate time for meal consumption, assists with meals/fluids as needed, and provide diet as ordered. The ADON stated Resident 1 should have been fed by the outgoing shift (11 p.m., to 7 a.m.) before Resident 1's gets picked up for dialysis at 8 a.m. on 2/27/2026. The ADON stated Resident 1 should have a sack lunch with her (Resident 1) to take to the dialysis center. The ADON stated care plan should have been developed to address Resident 1's meal intake (breakfast) related to early dialysis schedule so Resident 1 could be fed early and have a sack lunch before leaving the facility. The ADON stated that without breakfast and sack lunch Resident 1 could have developed hypoglycemia in the dialysis center. During a review of facility's policy and procedure (P&P) titled, Nutritional Assessment and Care Planning, dated 3/2026 was reviewed. The P&P indicated, As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition.7. Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the residents' prognosis and per sonal preferences.8. Individualized care plans shall address to the extent possible:a. The identified causes of impaired nutrition;b. The resident's personal preferences;c. Goals and benchmarks for improvement; andd. Time frames and parameters for monitoring and reassessment.

Based on interview and record review, the facility failed to ensure a resident received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure Resident 1 was fed, had breakfast and was provided with a sack lunch (a lunch which is prepared before arriving at the place where it is to be eaten) before getting picked up by transportation to go to the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) center on 2/27/2026.This failure had the potential to place Resident 1 at risk of hypoglycemia (low blood sugar). Cross reference F656. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/25/2026, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease (ESRD-irreversible kidney failure) with dependence on renal dialysis. During a review of Resident 1's Order Recapitulation Report, dated 2/25/2026, the Order Recapitulation Report indicated dialysis schedule every Monday, Wednesday and Friday at 8:45 a.m., with pick up time from Skilled Nursing Facility (SNF) at 8 a.m.During a review of Resident 1's Order Recapitulation Report, dated 2/26/2026, the Order Recapitulation Report indicated feeding assistance.During a review of Resident 1's Progress Notes, dated 2/27/2026, timed at 8:30 a.m., the Progress Notes indicated the transportation picked up Resident 1 who had not yet had her breakfast. The Progress Notes indicated that the Dietary Supervisor (DS) was informed, made sack lunch, sent to dialysis center and provided to the resident.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 3/4/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily).During an interview on 3/13/2026, at 8:58 a.m., with the DS, the DS stated transportation picked up Resident 1 to go to dialysis center with no sack lunch provided. The DS stated they made a sack lunch, and had it delivered to the dialysis center on 2/27/2026, but it was late. The DS stated the facility's process was upon admission, nursing staff will inform the Kitchen Staff of the dialysis schedule. The DS stated residents who go to dialysis early in the morning will be provided early breakfast and the sack lunch will be provided in a thermal bag delivered to the nursing station the night before the scheduled dialysis so the nurse can give it to the resident before leaving the facility for dialysis. The DS stated that late meal intake can affect Resident 1's mood and health. The DS stated he (DS) cannot recall how late the sack lunch was prepared.During an interview on 3/13/2026, at 9:17 a.m., with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 had necrotic (dead or dying tissue, often appearing black, leathery, or gray with potential foul-smelling drainage, usually caused by severe infection, trauma, or lack of blood flow) hands and needs to be fed. RN 1 stated on 2/27/2026, Certified Nursing Assistant 1 (CNA 1) reported that transportation was at the facility at 7:30 a.m., to pick up Resident 1 to go to the dialysis center but CNA 1 had not yet fed Resident 1 her (Resident 1) breakfast. RN 1 stated when she (RN 1) went into Resident 1's room, Resident 1 was already picked up. RN 1 stated CNA 1 reported that Resident 1 was upset so she (RN 1) had reported to the DON and notified Family Member 1 (FM 1) and FM 1 also got upset. RN 1 stated she (RN 1) understood why Resident 1 and FM 1 got upset. RN 1 stated Resident 1 who had an early dialysis schedule should have had an early breakfast and have a sack lunch, and CNA 1 should have fed Resident 1 prior to the pick-up time. RN 1 stated the facility failed to communicate Resident 1's early pick up schedule for dialysis to the kitchen staff. RN 1 stated the incident could have been prevented. RN 1 stated the admission nurse should have notified the Dietary/Kitchen Staff of Resident 1's early dialysis schedule.During an interview on 3/13/2026, at 10:27 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 1 should have been fed by the outgoing CNA before 8 a.m., pick up time for dialysis and should have been provided sack lunch to take to dialysis center. The ADON stated the facility failed to inform the kitchen staff of the early dialysis schedule. The ADON stated the kitchen should have prepared Resident 1's early breakfast and sack lunch should have been prepared ahead of the dialysis pick up time.During an interview on 3/13/2026, at 10:15 a.m. with the Assistant Dietary Supervisor (ADS), the ADS stated the kitchen opens at 5 a.m., daily. The ADS stated the nurses did not communicate to the kitchen Resident 1's early dialysis pick up schedule. The ADS stated the incident could have been prevented.During an interview on 3/13/2026, at 10:27 a.m., with the ADON, the ADON stated without eating breakfast and without sack lunch, Resident 1 could have experience hypoglycemia (low blood sugar) in the dialysis center.During a review of facility's policy and procedure (P&P), titled, Nutritional Assessment and Care Planning, dated 3/2026, was reviewed. The P&P indicated, 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition.3. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: a. Nursing: . 5. Current clinical conditions and recent events that may have affected a resident's nutritional status and risk factors; . 9. Usual meal and snack patterns;During a review of facility's P&P, titled, Care of a Resident with End Stage Renal Disease, dated 9/2010, the P&P indicated, Resident with ESRD will be cared for according to currently recognized standards of care.1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents.2. Education and training of staff includes, specifically: a. The nature and clinical management of ESRD (including infection prevention and nutritional needs).

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to ensure Registered Nurse 1 (RN 1) documented interventions provided to Resident 1 when Resident 1 was picked up by transportation to go to the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) center on 2/27/2026, without breakfast and without sack lunch (a lunch which is prepared before arriving at the place where it is to be eaten). This failure had the potential to result in confusion in Resident 1's care and Resident 1's medical records containing inaccurate documentation.Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to ensure Registered Nurse 1 (RN 1) documented interventions provided to Resident 1 when Resident 1 was picked up by transportation to go to the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) center on 2/27/2026, without breakfast and without sack lunch (a lunch which is prepared before arriving at the place where it is to be eaten). This failure had the potential to result in confusion in care and the medical records containing inaccurate documentation.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/25/2026, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and end stage renal disease (ESRD-irreversible kidney failure) with dependence on renal dialysis. During a review of Resident 1's Order Recapitulation Report, dated 2/25/2026, the Order Recapitulation Report indicated dialysis schedule every Monday, Wednesday and Friday at 8:45 a.m., with pick up time from Skilled Nursing Facility (SNF) at 8 a.m.During a review of Resident 1's Order Recapitulation Report, dated 2/26/2026, the Order Recapitulation Report indicated feeding assistance.During a review of Resident 1's Progress Notes, dated 2/27/2026, timed at 8:30 a.m., the Progress Notes indicated the transportation picked up Resident 1 who had not yet have her (Resident 1) breakfast. The Progress Notes indicated that the Dietary Supervisor (DS) was informed, made sack lunch, sent to dialysis center and provided to the resident.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 3/4/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 was dependent on staff for all activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily).During an interview on 3/13/2026, at 8:58 a.m., with the DS, the DS stated transportation picked up Resident 1 to go to dialysis center with no sack lunch provided. The DS stated they made a sack lunch and had it delivered to the dialysis center on 2/27/2026, but it was late. The DS stated that late meal intake can affect Resident 1's mood and health.During an interview on 3/13/2026 at 9:17 a.m., with RN 1, RN 1 stated Resident 1 had necrotic (dead or dying tissue, often appearing black, leathery, or gray with potential foul-smelling drainage, usually caused by severe infection, trauma, or lack of blood flow) hands and needs to be fed. RN 1 stated on 2/27/2026, Certified Nursing Assistant 1 (CNA 1) reported that transportation was at the facility at 7:30 a.m., to pick up Resident 1 to go to the dialysis center but CNA 1 had not yet fed Resident 1 her (Resident 1) breakfast. RN 1 stated when she (RN 1) went into Resident 1's room, Resident 1 was already picked up. RN 1 stated CNA 1 reported that Resident 1 was upset so she (RN 1) had reported to the DON and notified Family Member 1 (FM 1) and FM 1 also got upset. RN 1 stated she (RN 1) understood why Resident 1 and FM 1 got upset. RN 1 stated Resident 1 who had an early dialysis schedule should have had an early breakfast and have a sack lunch, and CNA 1 should have fed Resident 1 prior to the pick-up time. RN 1 stated she (RN 1) did not document what happened on 2/27/2026 and did not document her (RN 1) notification to FM 1 and DON. RN 1 stated the facility failed to communicate Resident 1's early pick up schedule for dialysis to the kitchen staff. RN 1 stated she (RN 1) failed to document her interventions to Resident 1 on 2/27/2026.During a concurrent interview, and record review on 3/13/2026, at 10:27 a.m., with the Assistant Director of Nursing (ADON), Resident 1's Progress Notes dated 2/27/2026, were reviewed. The ADON stated there was no documentation from RN 1 on 2/27/2026. The ADON stated RN 1 should have documented especially when she (RN 1) had notified FM 1 and DON. The ADON stated that without breakfast and sack lunch Resident 1 could have developed hypoglycemia in the dialysis center. The ADON stated Resident 1's medical record was not complete.During a review of facility's policy and procedure (P&P) titled, Charting and Documentation, dated 5/2024, was reviewed. The P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.2. The following information is to be documented in the resident medical record:a. Objective observations;b. Medications administered;c. Treatments or services performed;d. Changes in the resident's condition;e. Events, incidents or accidents involving the resident; andf. Progress toward or changes in the care plan goals and objectives.3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on interview and record review, the facility failed to ensure a resident was discharged in a safe and orderly manner for one of three sampled residents (Resident 1), by failing to: 1. Ensure Resident 1's post-discharge destination could meet Resident 1's needs prior to the discharge on [DATE].2. Involve Resident 1's Representative in the development of the discharge plan and informed of the final discharge plan. These deficient practices had the potential for Resident 1 not to receive necessary care and services and negatively affecting Resident 1's well-being.Findings:During a review of Resident 1's admission Record, the admission record indicated the facility admitted Resident 1 on 5/14/2025 with diagnoses including heart failure (a progressive condition where the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs), encounter for palliative care (specialized medical care for people with serious illnesses, focusing on relieving symptoms, pain, and stress to improve quality of life), unspecified dementia (a progressive state of decline in mental abilities), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/15/2025, the MDS indicated Resident 1's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was severely impaired. The MDS indicated Resident 1 required moderate assistance (helper does less than half the effort) from the facility staff with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 1's Order Summary Report, the report indicated the following physician's order:-5/15/2025 at 6:49 p.m.: Transfer resident to Board and Care 1 (a small residential home providing 24-hour non-nursing care, meals, and supervision to residents). During an interview on 2/2/2026 at 1 p.m. with the Director of Nursing (DON), the DON stated there was no documented evidence to indicate the facility staff had evaluated Board the Board and Care Facility and communicated with them (Board and Care 1) prior to Resident 1's discharge on [DATE]. The DON stated the facility staff failed to verify and ensure Resident 1 was discharged to a facility that met the required standards and would be able to ensure provision of care to Resident 1. The DON stated the facility staff relied on the information provided by the palliative care provider and did not complete proper assessment and evaluation. The DON stated Resident 1 was inappropriately discharged . The DON stated Resident 1 was placed at risk of not receiving necessary care to have his (Resident 1) needs met. The DON stated there was a potential for Resident 1 not to receive correct medications, pain assessment and management, negatively affecting Resident 1's well-being. During an interview on 2/2/2026 at 1:17 p.m. with Resident 1's Power of Attorney (POA-legally authorized person to make financial, legal, or medical decisions on behalf of the resident), POA stated that on 5/15/2026, the facility's previous Administrator (Administrator 1) had contacted him (POA) to inform that Resident 1 would be transferred back to the previous Skilled Nursing Facility (SNF) 1.The POA stated that the facility did not contact him (POA) to inform that the discharge plans had changed and that Resident 1 was discharged to a different facility. The POA stated that Resident 1 was discharged without POA's consent and knowledge. The POA stated that two days after Resident 1's discharge, he (POA) contacted Administrator 1 and was informed that Resident 1 was discharged on 5/16/2025 to Board and Care 1. The POA stated after multiple attempts he (POA) was able to contact the Board and Care 1 and request transfer of Resident 1 to a General Acute Care Hospital (GACH).During a concurrent interview and record review on 2/2/2026 at 2:10 p.m. with the DON, Resident 1's Notice of Transfer or Discharge form, dated 5/15/2025, and Discharge Summary, dated 5/15/2025 were reviewed. The Notice of Transfer or Discharge form indicated Resident 1 was unable to sign the form to indicate that he (Resident 1) had received the form. The Discharge Summary indicated Resident 1 was unable to sign the form to indicate that he (Resident 1) had received the discharge summary. The DON stated there was no documented evidence to indicate that Resident 1's POA was provided the Notice of Transfer or Discharge form and the Discharge Summary. The DON stated Resident 1 could not make decisions and the risks and benefits of discharge plan should have been discussed with Resident 1's POA. The DON stated the facility staff failed to follow Resident 1's rights and placed Resident 1 at risk to be placed in a facility without Resident 1's representative's knowledge. The DON stated Resident 1's POA should have been involved in the discharge process to make sure Resident 1's wishes were followed. The DON stated there was a potential for Resident 1 to be transferred to a facility that was not appropriate for Resident 1's care. During a review of the facility's policy and procedure (P&P) titled, Discharge, last revised on 5/30/2025, was reviewed, the P&P indicated, 1. When the facility anticipates a resident's discharge to a private residence, another nursing care facility (i.e., skilled, intermediate care, ICF/IID, etc.), a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his or her new living environment.4. Every resident will be evaluated for is or her discharge needs and will have an individualized post-discharge plan. 5. The post discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the residents and his or her family and will include: a. Where the individual plans to reside; b. Arrangements that have been made for follow-up care and services; A description of the resident's stated discharge goals; d. The degree of caregiver/support person availability, capacity and capability to perform required care; e. How the IDT will support the resident or representative in the transition to post-discharge care; f. What factors may make the resident vulnerable to preventable readmission, and g. How does factors will be addressed. 7. The resident/representative will be involved in the post-discharge planning process and informed of the post-discharge plan.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of three sampled residents (Residents 1 and 2) by failing: To follow physician order to hold (temporarily stopping certain medications as instructed by a healthcare provider) metoprolol (medication used to treat hypertension [HTN-high blood pressure]) for systolic blood pressure (sbp- the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats) below 110/60 millimeters of mercury (mmHg-a standard unit of pressure). On 1/9/2026, at 9 a.m., Licensed Vocational Nurse 4 (LVN 4) administered metoprolol to Resident 1 who had a blood pressure of 104/76 mmHg.To ensure LVN 3 administer pantoprazole (medication used to treat too much acid in the stomach) and insulin lispro (medication used to lower blood sugar) to Resident 1 on 1/8/2026.To ensure LVN 3 administer famotidine (medication used to reduce acid in the stomach), gabapentin (medication used to treat nerve pain) and levothyroxine (medication used to treat underactive thyroid [releases hormones that control energy, heart rate, temperature, and weigh]) to Resident 2 on 1/8/2026.These failures had the potential to result in medication errors and could cause to Resident 1's hypotension (low blood pressure), hyperglycemia (elevated blood sugar) and could result in Resident 2's uncontrolled hypothyroid and pain.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/11/2025, with diagnoses that included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertensive heart disease (refers to heart conditions caused by long-term high blood pressure) with heart failure (heart cannot pump enough blood to meet the body's needs, often causing fatigue, fluid buildup, and shortness of breath).During a review of Resident 1's Order Summary Report, dated 11/11/2025, the Order Summary Report indicated metoprolol succinate extended release oral tablet 50 milligram (mg- metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth daily for HTN, hold for sbp less than 110 mmHg or hold for heart rate less than 60 beats per minute.During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 11/13/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 11/18/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 1/2026, the MAR indicated on 1/9/2026, at 9 a.m. LVN 4 administered metoprolol to Resident 1 who had a blood pressure of 104/76 mmHg.During a concurrent interview, and record review on 1/21/2026, at 10:03 a.m., with LVN 1, LVN 1 stated metoprolol should have been held on 1/9/2026, at 9 a.m., because Resident 1's sbp was below 110 mmHg. LVN 1 stated Resident 1's blood pressure could drop because LVN 4 administered metoprolol.During an interview on 1/21/2026, at 10:35 a.m., with the Director of Staff Development (DSD) stated Resident 1's blood pressure could further drop because LVN 4 administered metoprolol.During an interview on 1/21/2026, at 10:44 a.m., with the Director of Nursing (DON), the DON stated LVN 4 should have checked the physician order first before medication administration. The DON stated Resident 1 could experience hypotension because LVN 4 administered metoprolol.b. During a review of Resident 1's Order Summary Report, dated 11/11/2025, the Order Summary Report indicated the following orders:1. Pantoprazole sodium oral tablet delayed release 40 mg, give one tablet by mouth in the morning for gastroesophageal reflux disease (GERD- condition caused by the frequent backflow of stomach acid into the esophagus, leading to irritation) on an empty stomach.2. Insulin lispro injection (the delivery of medication or fluids directly into the body's tissues or bloodstream using a needle and syringe) solution 100 units per milliliter, inject as per sliding scale (a chart or formula that tells a person how much insulin to take based on their current blood sugar level) subcutaneously (beneath the skin) before meals for diabetes.During a review of Resident 1's MAR dated 1/2026, the MAR indicated on 1/8/2026, at 6:30 a.m., pantoprazole and insulin lispro were blank.During an interview on 1/21/2026, at 10:44 a.m. with the DON, the DON stated Resident 1 could experience hyperglycemia (elevated blood sugar) and GERD because LVN 3 did not administer the pantoprazole and insulin.During a concurrent interview, and record review on 1/22/2026, at 9:22 a.m. with the Quality Assurance nurse (QAN), Resident 1's Order Summary Report, dated 11/11/2025, and MAR dated 1/2026 were reviewed. The QAN stated pantoprazole and insulin lispro were left blank. The QAN stated there was no record blood sugar on 1/8/2026, at 6:30 a.m., when the insulin lispro was due and at 8:10 a.m., Resident 1's blood sugar was high at 221 mg/dl. The QAN stated Resident 1 could experience GERD and hyperglycemia.c. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 5/9/2024, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition), unspecific (unconfirmed) hereditary (the passing of genetic information from parent to child) and idiopathic (unknown cause) neuropathy (nerve damage) and unspecific hypothyroid.During a review of Resident 2's Physician Order, dated 8/22/2025, the Physician Order indicated the following orders:Famotidine oral tablet 20 mg, give one tablet by mouth in the morning for GERD before meals.Gabapentin oral capsule 300 mg, give one capsule by mouth in the morning for neuropathy.Levothyroxine sodium oral tablet 50 micrograms (mcg- one-millionth of a gram), give one tablet by mouth in the morning for hypothyroidism given before breakfast.During a review of Resident 2's H&P, dated 11/28/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were moderately impaired.During a review of Resident 2's MAR dated 1/2026, the MAR indicated on 1/8/2026 at 6 a.m. a.m., gabapentin and levothyroxine were blank.During a review of Resident 2's MAR dated 1/2026, the MAR indicated on 1/8/2026 at 6:30 a.m., famotidine was blank.During a concurrent interview. and record review on 1/22/2026. at 9:22 a.m. with the QAN, Resident 2's Physician Order, dated 8/22/2025, and MAR, dated 1/8/2026, were reviewed. The QAN stated on 1/8/2026, Resident 2's famotidine, gabapentin and levothyroxine were left blank. The QAN stated blank in MAR indicated medication was not administered. The QAN stated Resident 2 could experience GERD, increase in neuropathic pain and uncontrolled hypothyroid.During an interview on 1/22/2026, at 9:40 a.m., with the DON, the DON stated blank in MAR indicated medication not administered. The DON stated Resident 2 could experience acid reflux because LVN 3 did not administer famotidine. The DON stated Resident 2 could experience pain because LVN 3 did not administer gabapentin. The DON stated Resident 2 could experience uncontrolled hypothyroidism and affect Resident 2's metabolism because LVN 3 did not administer levothyroxine.During a review of facility's policy and procedure (P&P), titled, Administering Medications, dated 5/2024, was reviewed. The P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was given pain medication as per physician's order.This failure had the potential to result in Resident 3's increased risk for drowsiness (sleepiness) and sedation (the use of medication to make a person calm, relaxed, or sleepy during a procedure).Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 12/13/2017, with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), left knee pain and shortness of breath.During a review of Resident 3's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/30/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions.During a review of Resident 3's Order Summary Report, dated 12/19/2025, the Order Summary Report indicated the following orders:Percocet (medication used to treat pain) oral tablet 5-325 milligram (mg-metric unit of measurement, used for medication dosage and/or amount) give one tablet by mouth every four hours as needed for moderate pain level of four to six out of ten pain level.Percocet oral tablet 10-325 mg give one tablet by mouth every four hours as needed for severe pain level of seven to ten out of ten pain level.During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool) dated 12/29/2025, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact.During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 1/2026, the MAR indicated on 1/2/2026, at 8:16 p.m., Licensed Vocational Nurse 1 (LVN1) administered Percocet 10-325 mg to Resident 3 with a pain level of four.During a concurrent interview, and record review on 1/22/2026, at 9:22 a.m., with the Quality Assurance Nurse (QAN), Resident 3's Physician Order, dated 12/19/2025, and MAR dated 1/2/2026, were reviewed. The QAN stated on 1/2/2026, Resident 3's pain level was four out of ten and LVN 1 administered Percocet 10-325 mg instead of 5-325 mg as per physician order. The QAN stated LVN 1 should look at the physician order first and follow the physician order. The QAN stated Resident 3 could have increased risk for drowsiness because of administering 10 mg instead of 5 mg Percocet.During an interview on 1/22/2026, at 9:40 a.m., with the Director of Nursing (DON), the DON stated LVN 1 should look at the Physician Order first and follow the order. The DON stated if LVN 1 looked at the order, he (LVN 1) would have administered 5 mg of Percocet because Resident 3's pain level was four. The DON stated Percocet had slight sedative effects and Resident 3 could be drowsier because of receiving higher dose of pain medicine.During a review of facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated 2001, and last reviewed on 5/2024, the P&P indicated, The purposes of this procedure are to help the staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain.Implementing Pain Management Strategies1. Establish a treatment regimen that is specific to the residents based on consideration of the following: a. The residents' medical condition; b. Current medication regimen;.6. The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications.

Based on interview and record review, the facility failed to notify the Physician of resident's refusal of buspirone hydrochloride (medication used to treat generalized anxiety disorder [GAD - excessive, persistent worry that interferes with daily life, not just normal stress]) for one of three sampled residents (Resident 1).This failure had potential for Resident 1's delays in the delivery of necessary care and services and had the potential to increase Resident 1's level of anxiety.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/19/2025, with diagnoses that included recurrent (reappears repeatedly over time) enterocolitis (when both your small intestine and large intestine get inflamed [swollen and irritated]) due to clostridium difficile (C. diff - a highly contagious bacteria that causes severe diarrhea), generalized muscle weakness and essential hypertension (high blood pressure that is not due to another medical condition).During a review of Resident 1's Order Summary Report, dated 11/20/2025, the Order Summary Report indicated buspirone hydrochloride oral tablet five milligrams (mg - metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth every eight hours for anxiety manifested by repetitive verbalization about health.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/26/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 was dependent on staff for showering and toileting. The MDS indicated Resident 1 had anxiety disorder and was on antianxiety medications (medication that help calm the nervous system and the brain to reduce strong feelings of fear, worry, and panic).During a review of Resident 1's Medication Administration Record (MAR - flowsheet that indicates medications given to a resident), dated 12/2025, the MAR indicated Resident 1 had been refusing buspirone from 12/5/2025 to 12/11/2025, until it was discontinued on 12/11/2025.During a concurrent interview and record review on 12/16/2025 at 10:58 a.m. with the Assistant Director of Nursing (ADON), Resident 1's Physician Order, dated 11/20/2025, and MAR, dated 12/2025, were reviewed. The MAR indicated Resident 1 refused buspirone on 12/8/2025 to 12/11/2025 at 6 a.m. (four times), on 12/5/2025 to 12/9/2025 (five times), and on 12/11/2025 at 2 p.m. (total of 10 times). The ADON stated Resident 1's Physician should have been notified of Resident 1's refusal of buspirone. The ADON stated the facility did not have documented evidence that Resident 1's Physician was notified. The ADON stated the nurses should have completed a Change in Condition Evaluation (COC form - used to document any changes in a resident health status), notify the Physician and monitor Resident 1. The ADON stated the Physician should have been notified of the refusal so the Physician could have made changes with the medication order.During an interview on 12/16/2025 at 11:12 a.m. with the Director of Nursing (DON), the DON stated the nurses should have completed the Change in Condition Evaluation form to address Residents 1's refusal of medication, notify the Physician to obtain an order for a change of medication or change of medication dose. The DON stated Resident 1's anxiety level could increase without the therapeutic effect (positive result of a treatment) of the antianxiety medication.During an interview on 12/16/2025 at 11:25 a.m. with Resident 1, Resident 1 stated she (Resident 1) had been refusing buspirone because it was never effective. Resident 1 stated she (Resident 1) had notified the nurses that it was not effective, but the nurses kept on offering the medication.During a review of facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2001, and last reviewed on 5/2024, the P&P indicated, 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .f. refusal of treatment or medications two (2) or more consecutive times); .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) to address Resident 1's refusal of medication.This failure had potential for Resident 1's delays in the delivery of necessary care and services.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/19/2025, with diagnoses that included recurrent (reappears repeatedly over time) enterocolitis (when both your small intestine and large intestine get inflamed [swollen and irritated]) due to clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea), generalized muscle weakness and essential hypertension (high blood pressure that is not due to another medical condition).During a review of Resident 1's Order Summary Report, dated 11/20/2025, the Order Summary Report indicated buspirone hydrochloride (medication used to treat generalized anxiety disorder [GAD-excessive, persistent worry that interferes with daily life, not just normal stress]) oral tablet five milligram (mg - metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth every eight hours for anxiety manifested by repetitive verbalization about health.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/26/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 was dependent on staff for showering and toileting. The MDS indicated Resident 1 had anxiety disorder and was on antianxiety medications (medication that helps calm the nervous system and the brain to reduce strong feelings of fear, worry, and panic).During a review of Resident 1's Medication Administration Record (MAR- flowsheet that indicates medications given to a resident), dated 12/2025, the MAR indicated Resident 1 had been refusing buspirone from 12/5/2025 to 12/11/2025, until it was discontinued on 12/11/2025.During a concurrent interview and record review on 12/16/2025 at 10:58 a.m. with the Assistant Director of Nursing (ADON), Resident 1's Physician Order, dated 11/20/2025, MAR, dated 12/2025, and Care Plans were reviewed. The MAR indicated Resident 1 refused buspirone on 12/8/2025 to 12/11/2025 at 6 a.m. (four times), on 12/5/2025 to 12/9/2025, (five times), and on 12/11/2025 at 2 p.m. (total of 10 times). The ADON stated there was no care plan developed on Resident 1's refusal of buspirone. The ADON stated there should be a care plan developed to ensure facility was following up on Resident 1's refusal, to inform the Physician and to do a psychiatry consult (when a medical doctor asks a psychiatrist [a mental health physician] to evaluate a resident's mental health to provide an expert opinion and recommend a treatment plan) on Resident 1 behavior of refusal. The ADON stated the care plan guides the nurses on what care to provide Resident 1. The ADON stated buspirone is an antianxiety medication and if not administered could increase Resident 1's behavior of anxiety. The ADON stated without a care plan for refusal of medication care could not be provided.During an interview on 12/16/2025 at 11:12 a.m. with the Director of Nursing (DON), the DON stated the nurses should have developed a care plan on Resident 1's refusal of medication. The DON stated the care plan is part of Resident 1's care and provides intervention on how to address the problem of Resident 1's refusal. The DON stated Resident 1's anxiety level could increase without the therapeutic effect (positive result of a treatment) of the antianxiety medication.During an interview on 12/16/2025 at 11:25 a.m. with Resident 1, Resident 1 stated she (Resident 1) had been refusing buspirone because it was never effective. Resident 1 stated she (Resident 1) had notified the nurses that it was not effective, but the nurses kept on offering the medication.During a review of facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Plans, dated 12/2016 and last reviewed on 5/2024, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial (the connection between your mind/feelings [psycho] and your social life/environment [social]) and functional needs is developed and implemented for each resident.8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; . g. Incorporate identified problem areas;

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1), who was assessed as high risk for falls was free from falls and injury in accordance with the resident's care plan by failing to: 1. Ensure Resident 1, who was identified as a high fall risk, was not left unattended by Physical Therapist (a health professional trained to evaluate and treat residents who have conditions or injuries that limit their ability to move and to physical activities) 1 (PT 1) during a physical therapy (is a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) session on 1/5/2025. 2. Ensure Resident 1's fall mat (a soft, foam-based mat that reduces the impact of a fall and helps prevent injuries) was placed back on the floor before Physical Therapist 1 (PT 1) left Resident 1's room. 3. Ensure Resident 1's bed alarm (a device that contain sensors that trigger an alarm when a person tries to get out of bed) was placed between Resident 1 and Resident 1's mattress. As a result, on 1/5/2025 at 1:20 p.m., Resident 1 fell from the bed. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on 1/5/2025 and was diagnosed with scalp hematoma (a collection of blood that pools outside of a blood vessel [a tube through which the blood circulates in the body], usually caused by an injury or surgery) and scalp laceration (a cut on the head that occurs when the skin and underlying tissues are torn by blunt force or an injury). Findings: During a record review of Resident 1's Admission Record, the Admission Record indicated the facility admitted the resident on 3/12/2024 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side (the side of the body that is not used as much or is not as much effective as the same side on the other side of the body), benign prostatic hyperplasia (BPH - a condition that occurs when the prostate gland [a gland in the male reproductive system] enlarges, potentially slowing or blocking the urine stream), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1's Care Plan on falls, created on 3/12/2024, the Care Plan indicated Resident 1 was at risk for falls due to Resident 1's left side weakness. The Care Plan Intervention indicated the use of bed alarm, to keep within supervised view, and implement safety devices as ordered such as bilateral (having two sides or affecting both sides) raised safety floor mats. During a record review of Resident 1's Physician Order, dated 3/12/2024, the Physician Order indicated bed alarm when in bed. Resident 1's Physician Order indicated to monitor for placement and function of the bed alarm. During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/1/2024, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were severely impaired. The MDS indicated Resident 1 had functional limitation in range of motion (ROM - extent of movement of a joint) on one side of both the upper extremity (shoulder, elbow, wrist, and hand) and the lower extremity (hip, knee, ankle, and foot). The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk [part of the body to which the head, arms and legs connect] or limbs and provides more than half the effort) on rolling to the left or the right side. The MDS indicated Resident 1 was dependent on facility staff with lying to sitting on the side of the bed activity. The MDS indicated Resident 1's sit-to-stand activity was not attempted due to medical condition or safety concerns. The Bladder (a hollow organ that stores urine) and Bowel (a long tube-shaped organ that carries solid waste from the stomach out of the body) section of the MDS indicated Resident 1 had an indwelling urinary catheter (a flexible plastic tube [a catheter] inserted into the bladder to provide continuous urinary drainage). During a review of Resident 1's Fall Risk Observation and Assessment, dated 12/13/2024, the Fall Risk Observation and Assessment indicated the resident had a total score of 20. A total score of 16 to 42 represented high risk for falls. During a record review of Resident 1's Change in Condition (COC - when there is a sudden and significant change from a resident's health) Evaluation form, dated 1/5/2025, the COC Evaluation form indicated that on 1/5/2025 at around 1:20 p.m. PT 1 was inside Resident 1's room. PT 1 placed a knee brace (a medical device that stabilizes and supports the knee joint) on Resident 1's right leg then stepped out of Resident 1's room. The COC Evaluation form indicated Licensed Vocational Nurse 2 (LVN 2) heard Resident 1 screaming. LVN 2 and PT 1 went inside Resident 1's room and saw Resident 1 lying on the floor, bleeding (amount not specified) from the head. Resident 1's physician was notified and ordered to send Resident 1 to GACH 1. During a record review of Resident 1's Interdisciplinary Team (IDT, a team of healthcare professionals from different professional disciplines who work together to address and manage the needs of the resident) Fall Progress Notes, dated 1/6/2025, the IDT Fall Progress Notes indicated Resident 1 had an unwitnessed fall from his bed on 1/5/2025. Resident 1 was found lying on the floor, bleeding (amount not specified) from his head and was sent to GACH 1 for further evaluation and treatment. The IDT Fall Progress Notes indicated Resident 1 returned to the facility on [DATE]. During a record review of Resident 1's GACH 1 Emergency Department (ED- a hospital facility that treats patients with severe injuries or illnesses that require immediate care) Physician Note, dated 1/5/2025, the ED Physician Note indicated Resident 1 had four (4) feet (ft - unit of measure) fall from the bed and sustained a laceration to the forehead with bruising to the face. The Physical Exam section indicated Resident 1 had hematoma to the left forehead (part of the face above the eyebrows) with laceration on the lateral (away from the middle of the body) left eyebrow. Resident 1's lateral left eyebrow had two Steri-strip (a type of wound closure tape) on it. During a record review of Resident 1's GACH 1 computed tomography (CT, a procedure that uses a computer to make a series of detailed pictures of areas inside the body) of the head, dated 1/5/2025, the CT indicated Resident 1 had a large hematoma and contusion (a bruise or injury to the soft tissue caused by a direct blow or impact) to the left frontal (forehead) scalp extending over the left periorbital region (the area around the eyes). During a concurrent observation and interview on 1/14/2025 at 11:51 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 1 with a large, round, protruding, bluish black hematoma on the left forehead. Resident 1 was observed with dry, scabbed (covered with a dry, crusty layer that forms over a cut or wound during healing) laceration on the left eyebrow. Resident 1's bed alarm was observed on the floor under Resident 1's bed. LVN 1 stated Resident 1 was a fall risk. LVN 1 stated the bed alarm was used to alert facility staff that the resident was trying to get out of bed. LVN 1 stated the bed alarm should have been placed between Resident 1 and Resident 1's mattress. LVN 1 stated the facility staff will not be alerted, and Resident 1 had the potential to fall. During a telephone interview on 1/14/2025 at 4:15 p.m., with PT 1, PT 1 stated that on 1/5/2025, at around 1:20 p.m., he (PT 1) provided physical therapy to Resident 1 and applied the knee brace on Resident 1's right leg. PT 1 stated he removed Resident 1's fall mat from Resident 1's bedside during the physical therapy session for easy access to Resident 1. PT 1 stated he then left Resident 1's room to inform LVN 2 about Resident 1's knee brace. PT 1 stated that on 1/5/2025 Resident 1's privacy curtain was closed, and Resident 1 was out of his (PT 1) sight. PT 1 stated he then heard Resident 1 yelling. PT 1 stated he returned to Resident 1's room with LVN 2 and saw Resident 1 lying on the floor on the right side of Resident 1's bed. PT 1 stated Resident 1 had bleeding on the left forehead. PT 1 stated he did not return Resident 1's fall mats beside Resident 1's bed because he was not done with Resident 1's physical therapy session. PT 1 stated Resident 1's fall mats should be placed back beside Resident 1's bed before leaving Resident 1's bedside. PT 1 stated Resident 1's fall risk interventions were not implemented and that resulted to Resident 1's fall and injury. During an interview on 1/14/2025 at 4:30 p.m., with the Director of Nursing (DON), the DON stated Resident 1 had a fall on 1/5/2025 and sustained a head injury. The DON stated Resident 1's bed alarm should be between Resident 1 and the mattress. The DON stated Resident 1's fall interventions that included the fall mats and bed alarm should be in place to prevent Resident 1's fall with injury. The DON stated the facility failed to follow the fall interventions in accordance with Resident 1's fall care plan such as to implement safety devices (fall mats and bed alarm) as ordered. During a record review of the facility's policy and procedure (PnP) titled, Fall Prevention and Management Program, last reviewed in 11/22/2024, the PnP indicated a licensed nurse assess all residents on admission, quarterly, and after each fall related incident to identify risk factors for fall and initiate a plan of care for residents. The PnP indicated residents assessed as high risk for falls will be given interventions of safety floor mats at bedside, and alarm in bed and in wheelchair. During a record review of the facility's PnP titled, Managing Falls and Fall Risk, last reviewed in 11/22/2024, the PnP indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to prevent the resident from falling and to try to minimize complications from falling. The PnP indicated staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. The PnP indicated position-change alarms (any physical or electronic device that monitors resident movement and alerts the staff when movement is detected) will not be used as the primary or sole intervention to prevent falls. The PnP indicated the use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

Based on interview, and record review, the facility failed to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) and injury for one of three sampled residents (Resident 1), who was identified as high fall risk by failing to: 1. Provide Resident 1 with bilateral (both sides of the body or two of something) bedside mats (Bedside mats, also known as a padded bedside fall mat or a bed mat, is a safety pad placed on the floor beside the bed to prevent injuries resulting from falls) as indicated in the resident ' s physician ' s orders. 2. Update Resident 1 ' s care plan to include an intervention of placing bilateral bedside mats at Resident 1 ' s bedside to prevent injuries to resident who was at high risk for falling. As a result on 7/22/2024 at 8:01 p.m., Resident 1 fell on the floor and required immediate transfer to General Acute Care Hospital 1 (GACH 1). Resident 1 was diagnosed with a left intertrochanteric fracture (a type of hip fracture that occurs in the upper part of the femur) and underwent a left hip open reduction and internal fixation (a surgical procedure to treat broken bones by realigning the bones and securing them in place with hardware). Findings: During a record review of Resident 1 ' s Admission Record, it indicated the resident was admitted to the facility on [DATE] with a medical history including traumatic subdural hemorrhage (a serious condition that occurs when blood collects beneath the outermost membrane surrounding the brain) without loss of consciousness, history of falling and difficulty in walking. During a record review of Resident 1 ' s Minimum Data Set (MDS- a standardized care screening tool) dated July 8, 2024, the MDS indicated Resident 1 ' s cognition was severely impaired. The MDS indicated Resident 1 was dependent on staff for oral hygiene, toileting, upper dressing, lower dressing, and personal hygiene. The MDS indicated Resident 1 had a history of falls prior to admission to the facility. During a record review of Resident 1 ' s Fall Risk assessment dated [DATE], it indicated the resident was a high risk for falls. During a record review of Resident 1 ' s Order Summary Report dated 7/1/2024, the Order Summary Report indicated an order for the resident to have bilateral bedside mats and low bed for safety and fall precaution. During a record review of Resident 1 ' s care plan (CP) dated 7/2/2024, the CP indicated the resident was at risk for unavoidable falls due to history of falls, status post subdural hematoma (type of bleeding near the brain that can happen after a head injury), status post craniotomy (a surgical procedure that involves making a hole in the skull), dementia (memory loss), impaired cognition, unable to communicate needs, unable to stop a fall require dependent assist with transfers, toileting, and seizures. The goal indicated to minimize complications related to fall to extent possible. The interventions included to anticipate and meet resident ' s needs, educate, and remind the resident to call for assistance with all transfers. In addition, interventions included to keep the resident ' s bed in low position with breaks locked and to keep personal items frequently within reach and supervise view as much as possible. During a record review of Resident 1 ' s care plan revised on 7/23/2024, the CP indicated Resident 1 had an unwitnessed fall, and the resident was provided with a soft touch call light (a soft touch pad or call switch enables individuals with limited movement to summon help). Resident 1 ' s care plan for 7/2/2024 and 7/22/2024 did not include an intervention to provide Resident 1 with bilateral bedside mats as ordered by the physician. During a record review of Resident 1 ' s Change of Condition dated 7/22/2024 at 8:01 p.m., the record indicated Resident 1 had a fall. Certified Nurse Assistant (CNA 1) reported to Licensed Vocational Nurse (LVN 1) that Resident 1 was observed on the floor. Registered Nurse 1 (RN 1) found resident lying supine (lying on the back). Resident 1 was unable to explain what happened. A head-to-toe assessment (a health evaluation that examines a patient ' s physical condition from head to toe) was completed and the resident expressed having left hip pain by grimacing (to make an expression of pain, strong dislike). The physician was notified and placed an order to send Resident 1 to higher level of care. During a record review of Resident 1 ' s Interdisciplinary Notes dated 7/23/2024, the Notes (from the facility) indicated on 7/22/2024 at approximately 8:01 p.m., Resident 1 was found lying on the floor in his room next to his bed. Upon Registered Nurse interview and post fall assessment, Resident 1 was unable to state what happened. Resident 1 had pain in the left hip and leg with orders for the resident to be sent to the hospital for further evaluation. A record review of Resident 1 ' s General Acute Care Hospital (GACH) Emergency Department Notes dated 7/22/2024, indicated Resident 1 was brought in by emergency medical services with a history of weakness, GERD (Gastroesophageal [relating to or involving the stomach and esophagus] reflux disease), hypertension (elevated blood pressure), epilepsy, presenting after a fall that occurred just prior to arrival, resulting in injury to the left hip. The fall was unwitnessed, and the resident was unsure how it occurred. Resident 1 was found on the ground in front of his bed by nursing staff. The level of pain was moderate. Resident 1 had a fracture of the hip that required admission to the hospital for surgical repair. A record review of Resident 1 ' s GACH Operative Report dated 7/22/2024, indicated Resident 1 had a left hip intertrochanteric fracture (a type of hip fracture that occurs in the upper part of the femur). Resident 1 underwent a left hip open reduction and internal fixation (a surgical procedure to treat broken bones by realigning the bones and securing them in place with hardware). During an interview with the Director of Nurses (DON) on 7/31/2024 at 10:00 a.m., the DON stated, not all residents who are a fall risk need to have bilateral bedside mats. The DON stated, she did not know Resident 1 had an order for bilateral bedside mats. The DON stated, the bedside mats should have been incorporated into the resident ' s plan of care since the physician had placed an order for the resident to have bedside mats. During an interview with Certified Nurse Assistant (CNA 1) on 7/31/2024 at 12:00 p.m., CNA 1 stated on 7/22/2024 (she does not remember the time), she observed Resident 1 on the floor next to his bed. CNA 1 stated she went to get help. CNA 1 stated Resident 1 was very confused at the time, complained of pain on the left hip and was transferred to the hospital. CNA 1 stated Resident 1 did not have bedside mats. During an interview with Licensed Vocational Nurse (LVN 1) on 7/31/2024 at 4:00 p.m., LVN 1 stated she was notified by RN 1 that Resident 1 was found on the floor by his bed on 7/22/2024 (did not indicate time). LVN 1 stated she went to help the resident, and she asked the resident what happened. LVN 1 stated Resident 1 was confused and could not tell her exactly what happened. LVN 1 stated she placed a pillow under Resident 1 ' s head. LVN 1 stated Resident 1 did not have the bilateral bedside mats in place at the time of the fall and was not aware of the resident ' s order to have bilateral bedside mats. LVN 1 stated, if there was an order from the doctor, then this order should have been carried out by placing bilateral bedside mats and incorporated in Resident 1 ' s care plan. LVN 1 stated the purpose of the bilateral floor mats is to prevent injuries in the event the resident fell . A record review of the facility ' s Policy and Procedure titled, Falls and Fall Risk, managing dated March 2018, indicated based on previous evaluations and current data, the staff will identify the interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complication from falling. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. A record review of the facility ' s Policy and Procedure titled, Care Plan, Comprehensive Person-Centered dated March 2022, indicated a comprehensive, person-centered care plan should include measurable objectives and timetables to meet resident ' s physical, psychosocial and functional needs.

Based on interview and record review, the facility failed to follow its policy and procedure titled, Change of Condition (COC - a major decline in a resident ' s status), which indicated the facility will notify the resident ' s attending physician (MD) when there was a significant change in the resident ' s condition, or when there was a need to transfer the resident to a general acute care hospital (GACH) for one of six sampled residents (Resident 1) who had a COC that started on 5/27/2024 at 9 a.m. As a result, Resident 1 was not transferred to the GACH until 5/28/2024 at 5:48 p.m. (20 hours after the COC was first observed) and was diagnosed with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection), bacteremia (the presence of bacteria [microscopic living organisms that have only one cell] in your blood), and a central venous catheter (a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided (threaded) into a large vein above the right side of the heart called the superior vena cava) related bloodstream infection (sepsis-an infection caused by bacteria entering the bloodstream). Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 5/16/2024 with diagnoses that included dependent on renal dialysis (hemodialysis - a procedure to remove waste products and excess water from the blood when the kidneys stop working properly), chronic kidney disease (when the kidneys have become damaged over time), and metabolic encephalopathy (is a problem in the brain that is caused by a chemical imbalance in the blood that is caused by an illness or organs that are not working as well as they should). A review of Resident 1 ' s Care Plan titled, Dialysis: hemodialysis and is at risk for bleeding at access site, chest pain, deficient and or excess fluid volume, edema (swelling caused by fluid trapped in your body ' s tissues), hypertension (high blood pressure), hypotension (low blood pressure), infection, nausea (feeling of sickness with an inclination to vomit) and or vomiting, pruritis (severe itching of the skin), shortness of breath, weakness, weight fluctuation, developed on 5/16/2024, indicated staff will monitor Resident 1 for edema, chest pain, signs or symptoms of infection, nausea or vomiting, elevated blood pressure, or shortness of breath and report abnormal findings to physician. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/21/2024, indicated Resident 1 had the ability to be understood and had the ability to understand. The MDS indicated Resident 1 was dependent (helper does all the effort and the assistance of two or more helpers is required for the resident to complete the activity) on staff for showering, and personal hygiene. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) putting on and taking off footwear, toileting, and oral hygiene. A review of Resident 1 ' s Change of Condition notes entered by LVN 1, dated 5/27/2024 at 9 a.m. indicated Resident 1 ' s dialysis site was draining yellow exudate. The notes indicated Resident 1 did not complained of soreness to the site with no pain only. The notes further indicated LVN 1 was awaiting a response from MD. A review of Resident 1 ' s Progress notes entered by RN 2, dated 5/27/2024 at 6:34 p.m., indicated staff reported that upon assessment there was yellow exudate observed outside Resident 1 ' s dialysis port dressing, located on the upper right chest area of the dressing. The notes indicated the area was cleansed and a small dressing was placed on the site. A review Resident 1 ' s Physician ' s Order dated 5/28/2024, at 3 p.m., indicated Resident 1 was to be sent out non-emergent (not requiring emergency care) due to dialysis site draining purulent (with pus) yellow exudate one time only. A review of Resident 1 ' s Progress notes entered by LVN 1, dated 5/28/2024 at 4:28 p.m. indicated MD 2 gave ordered Resident 1 to be sent non-emergent to emergency room for yellow exudate draining from the dialysis site. The notes indicated Resident 1 was currently at dialysis and transportation was set up to take Resident 1 to emergency room when Resident 1 returned from dialysis. A review of Resident 1 ' s Progress notes entered LVN 2, dated 5/28/2024 at 5:48 p.m. indicated Resident 1 left the facility via a non-emergent transportation with the following vital signs (measurements of the body's most basic functions: pulse [the number of times the heart beats within a certain time period, usually a minute], and blood pressure [BP- the force of your blood pushing against the walls of your arteries (below 120 millimeter [mm- a unit of measurement]) systolic and 80 mm Hg diastolic [120/80 mm HG]) BP: 95/60 mm Hg, pulse: 100 beats per minute, and 92 percent (%) oxygen saturation (the amount of oxygen being carried by red blood cells and normal level is usually 95% or higher). A review of Resident 1 ' s GACH Emergency Department (ED) Documentation dated 5/28/2024 at 6:17 p.m., indicated Resident 1 presented to the ED where he presented with a fever of 102.02 Fahrenheit ( F- a measurement of temperature of hotness or coldness, 91.8 to 100.8 F normal temperature), redness, swelling and drainage from his dialysis port. GACH 1 diagnosed Resident 1 with the following requiring Resident 1 ' s dialysis port to be removed on 5/29/2024 which was noted with pus drainage: septic shock, bacteremia, and a central venous catheter related bloodstream infection. The report indicated Resident 1 had a fever for approximately 2 days. The report indicated Resident 1 was in severe distress, his/her skin was erythema (any abnormal redness of the skin) to the right medial (towards the middle or center) clavicle (collarbone) area four centimeters (cm- unit of measurement) above the insertion site of dialysis port. A review of Resident 1 ' s Discharge summary, dated 6/6/2024, indicated Resident 1 presented with fatigue, fever, and chills, was in septic shock (a condition in which the blood pressure fails and the organs of the body fail to receive sufficient oxygen) requiring vasopressors (a drug that healthcare providers use to make blood vessels constrict or become narrow in people with low blood pressure). The Discharge summary indicated Resident 1 ' s infected dialysis port was removed on 5/29/2024 and noted with pus drainage. The Discharge summary indicated a peripherally inserted central catheter (PICC- a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) was requested, and Resident 1 was to be on six weeks of cefazolin (antibiotic- medication used to treat bacterial infections) six grams (g - a unit of measure)daily, and zyvox (an antibacterial drug used to treat infections) 600 milligrams (mg - unit of measurement) orally twice a day until 6/16/2024. During an interview on 5/30/2024 at 2:01 p.m. with LVN 2, LVN 2 stated she received a report from LVN 1 indicating Resident 1 ' s dialysis port had yellow drainage and might be infected. LVN 2 stated when Resident 1 came back from the dialysis center, the site was red, but no drainage was observed. During an interview on 5/30/2024 at 2:44 p.m., with RN 2, RN 2 stated on 5/27/2024 at around 6 p.m. LVN 1 accompanied RN 2 to Resident 1 ' s bed and showed him (RN 2), Resident 1 ' s dialysis port. RN 2 stated the port was observed with some swelling and pus was oozing out of it. RN 2 stated when he pushed on the reddened site, more pus came out. RN 2 stated he asked LVN 1 when the pus started and LVN 1 did not know because it was unclear when it started. RN 2 stated he asked LVN 1 to contact Resident 1 ' s MD. During an interview on 5/30/2024 at 3:50 p.m., with LVN 1, LVN 1 stated on 5/27/2024 she (LVN 1) observed drainage on Resident 1 ' s chest near Resident 1 ' s dialysis port. LVN 1 stated she contacted MD 1 and MD 2 but none of them responded. LVN 1 stated she did not insist on the phone and did not text the MDs. LVN 1 stated she informed LVN 2 (the incoming LVN for the next shift) to await a call from MD 1 and MD 2, regarding Resident 1 ' s COC. LVN 1 stated the next morning on 5/28/2024, there was still no response from either MD 1 or MD 2. LVN 1 stated she called MD 2 on 5/28/2024 and MD 2 ordered Resident 1to be transferred via a non-emergent transportation to the GACH. LVN 1 stated when she received the order, Resident 1 was still at the dialysis center and the resident was not transferred till later in the evening. During an interview on 5/31/2024 at 10:23 a.m., Treatment Nurse 1 (TN 1) stated she (TN 1) could not recall the date but thought on Sunday (5/26/2024) Resident 1 called her and asked if TN 1 could look at his (Resident 1 ' s) upper chest. TN 1 stated she observed visible pus to the top right area of Resident 1 ' s dialysis port site. TN 1 stated the site was covered with gauze. TN 1 stated she did not notify Resident 1 ' s MD of the COC. TN 1 stated the MD should have been notified immediately. TN 1 stated due to the presence of pus around Resident 1 ' s port, the MD should have been notified because to prevent the resident condition from getting worse. TN 1 stated if MD 1 did not answer the Medical Director (MD 2), should have been notified, to prevent Resident 1 becoming septic (serious condition in which the body responds improperly to an infection). During an interview on 5/31/2024 at 11:10 a.m., with RN 2, RN 2 stated LVNs were the ones to notify the MDs of residents ' COCs, since they (LVNs) were familiar with the residents. RN 2 stated RNs could also call. RN 2 stated when she observed pus around Resident 1 ' s port, she did not notify Resident 1 ' s MD. RN 2 stated she should have called the MD immediately and if there was no response she should have continue to call until she received a response. RN 2 stated she should have followed up after 2 hours if the MD did not respond, for possible orders including antibiotics or to send Resident 1 to a GACH for evaluation and treatment. RN 2 stated waiting a whole day for the MD to respond was too long, and placed the resident at risk for infection, sepsis, and death. RN 2 stated the best way was to transfer Resident 1 to a GACH and update the MD whenever the MD responded. During an interview on 6/4/2024 at 10:10 a.m., with MD 1, MD 1 stated he (MD 1), the Nurse Practitioner and MD 2 were covering the skilled nursing facility (SNF). MD 1 stated he did not get a call on 5/27/2024 regarding Resident 1 ' s COC. MD 1 stated if the nurses were unable to reach him via phone call or text, the nurses should have insisted. MD 1 stated there were three members of his team assigned to the facility and they always responded to calls/texts even if they were not on call. MD 1 stated if he was aware of the presence of pus at Resident 1 ' s port, he would have sent Resident 1 to the GACH for further evaluation, ordered blood cultures, started Resident 1 on antibiotics, and removed the source of the infection (the dialysis access). MD 1 stated any source of pus could be a risk for infection and Resident 1 could become septic (widespread infection by harmful bacteria). During an interview on 6/4/2024 at 4:16 p.m., with the Director of Nursing (DON), the DON stated Resident 1 had pus above his dialysis port. The DON stated if there was a COC, the staff had to keep attempting to contact the doctor. The DON stated if the doctor was not reachable, MD 2 should have been contacted. The DON stated if MD 2 did not respond and it was urgent, the resident should have been sent to the GACH. The DON stated not contacting the MD when there was a COC or not being able to get a hold of the MD placed the Resident at risk for worsening of COC and possible delay in the treatment. During an interview on 6/4/2024 at 5 p.m., MD 2 stated he (MD 2) was notified Resident 1 had pus near his dialysis site on 5/28/2024. MD 2 stated he gave orders for Resident 1 to be transferred to the GACH 1 on 5/28/2024. MD 2 stated there was no prior notification of Resident 1 ' s condition before 5/28/2024. MD 2 stated he and his team including the NP and MD 1 take turns being on call and were readily available. MD 2 stated even if one of them was not on call someone always responded to SNF calls. MD 2 stated Resident 1 required a GACH transfer because he had pus near his dialysis site which meant there was a risk for sepsis. A review of the current facility ' s P&P titled, Change in a Resident ' s Condition or Status, revised on 2/2021 indicated the facility will promptly notify the resident, his or her attending physician, and the resident ' s representative of changes in the resident ' s medical/mental condition and/or status. The P&P indicated the nurse will notify the resident ' s attending physician on call when there has been a significant change in the resident ' s physical/emotional/mental condition, or when there was a need to transfer the resident to a hospital/treatment center. The P&P indicated significant change of condition is a major decline or improvement in the resident ' s status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was dependent on staff for transfers and was a fall risk, was free from accidents by ensuring Resident 2 was provided a two-person assistance. On 4/16/2024 at 4:45 p.m., Certified Nursing Assistant 1 (CNA 1) transferred Resident 2 alone from the bed to the wheelchair using a Hoyer lift (brand name of an assistive medical device used to transfer residents by applying specially designed slings and pads under the resident to safely lift the resident from a bed to a chair or wheelchair and back). As a result, Resident 2 fell from the Hoyer lift and in the process of the fall the metal sling bar of the Hoyer lift that held the sling straps spun around hitting Resident 2 on his head. Resident 2 complained of severe head and back pains, requiring pain medication and transfer to General Acute Care Hospital 1 (GACH 1), where Resident 2 was complaining of neck pain and headaches. Resident 2 was admitted for five days in GACH 1 for further evaluation and treatment. Findings: A review of Resident 2's Admission Record indicated the facility admitted the resident on 10/9/2023 and readmitted on [DATE] with diagnosis including injury at unspecified level of cervical spinal cord (the neck region of the spinal column or backbone), quadriplegia (paralysis of all four limbs or of the entire body below the neck), and generalized muscle weakness. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/15/2024 indicated the resident was able to understand and be understood. The MDS indicated Resident 2 was dependent assist (helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity) on staff for bed-to-chair transfer. A review of Resident 2's Care Plan, developed on 10/9/2023, for resident's risk for Activities of Daily Living (ADL) and mobility decline and requiring assistance related to history of motor vehicle accident (MVA) with fracture (a broken bone) and quadriplegia, indicated Resident 2 needed assistance of two persons for morning (a.m.) and afternoon (p.m.) care and dependent assist for Hoyer lift transfer. A review of Resident 2's Fall Risk Observation/Assessment, dated 4/8/2024, indicated Resident 2's fall risk score was 22 (a score above 16 to 42 represented high fall risk). A review of Resident 2's Change of Condition notes (COC - a major decline in a resident's status), dated 4/16/2024 at 4:45 p.m., indicated Resident 2 had a fall on 4/16/2024. The COC indicated Resident 2 was sitting in an upright position on the floor in front of his wheelchair. Resident 2 stated he fell from the Hoyer lift and in the process of the fall the metal sling bar spun around and hit his head. There was no redness or swelling of the face head or back during assessment, but resident complained of severe head and back pains. The COC indicated Resident 2's pain status evaluation indicated a pain level of 10 out of 10 (a score of 0 means no pain, and 10 means the worst pain you have ever felt). A review of Resident 2's Medication Administration Record (MAR- a report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) for April 2024 indicated on 4/16/2024 at 5:01 p.m. Resident 2 was given oxycodone (medication used to relieve moderate to severe pain) 10 milligrams (mg- a unit of measurement) one tablet for pain of 10 out of 10. A review of Resident 2's Interdisciplinary Team (IDT) Notes dated 4/17/2024 at 9:12 a.m. for Fall/How it happened: 4/16/2024 at 4:45 p.m. indicated per CNA 1, Resident 2 was transferred into the wheelchair via Hoyer lift. As CNA 1 finished unhooking the Hoyer sling from the lift, Resident 2's bottom began to slide towards the front of the wheelchair sliding off the chair and onto the floor. The IDT Noted indicated CNA 1 said Resident 2 did not hit his head but was complaining of increased neck and back pains. Resident 2 requested to go to the emergency room (ER) due to pain. A review of Resident 2's GACH 1 Emergency Department notes dated 4/16/2024 at 6:24 p.m. indicated Resident 2's chief complaint as falling from Hoyer lift approximately three feet, hit head on the arm bar, had head pain, is paraplegic [sic]. The current level of pain is moderate, there was no loss of consciousness, confusion, seizure, or memory impairment, and no laceration associated with the injury. A review of Resident 2's GACH 1 Computed Tomography (CT scan is a diagnostic imaging procedure that uses a combination of X-rays [a type of medical imaging that creates pictures of the bones and soft tissues] and computer technology to produce images of the inside of the body), dated 4/16/2024 at 9:31 p.m., of Resident 2's brain and head indicated no evidence of acute infarction (death of tissue resulting from a failure of blood supply, commonly due to obstruction of a blood vessel by a blood clot or narrowing of the blood-vessel channel), and intracranial hemorrhage (a type of stroke that causes bleeding in your head). A review of Resident 2's GACH 1 CT dated 4/16/2024 at 9:31 p.m. of Resident 2's spine indicated no acute fracture or severe central canal (helps transport nutrients to the spinal cord) stenosis (narrowing) was detected. A review of Resident 2's GACH 1 Discharge Summary dated 4/21/2024 indicated discharge diagnoses that included headache and body aches. During an interview on 5/16/2024 at 10 a.m., Resident 2 stated about a month ago he (Resident 2) fell from the Hoyer lift. Resident 2 stated CNA 1 came in the room to get the resident out of the bed. Resident 2 stated CNA 1 placed the sling underResident 2 and began to crank the Hoyer lift. Resident 2 stated as he was being lowered onto the wheelchair, he began to slide down to the floor. Resident 2 stated his butt hit the base of the Hoyer lift and the floor. Resident 2 stated CNA 1 then went to get Certified Nursing Assistant 2 (CNA 2), then CNA 1 and CNA 2 started to pull Resident 2 by his arms. Resident 2 stated he told CNA 1 and CNA 2 to stop because they were hurting him. Resident 2 stated CNA 1 and CNA 2 used the sling but did not cross the bottom straps and he swung as they (CNA 1 and CNA 2) were lifting him up and hit his head on the metal sling bar. Resident 2 stated he then slipped off the Hoyer lift and hit his right buttock on the floor. Resident 2 stated he was in pain, was crying and was yelling for help and Licensed Vocational Nurse 1 (LVN 1) came in and assisted Resident 2 back into his bed. During an interview on 5/16/2024 at 2:32 p.m., LVN 1 stated cannot recall date or time but was standing outside of Resident 2's room doing the medication pass. LVN 1 stated CNA 2 walked out of Resident 2's room and stated Resident 2 fell . LVN 1 stated Resident 2 was sitting on the floor and the Hoyer lift was facing Resident 2 and the wheelchair was behind Resident 2. LVN 1 stated was told Resident 2 had fallen but not told how Resident 2 fell . LVN 1 stated that Registered Nurse Supervisor (RNS) came in and took over. During an interview on 5/16/2024 at 2:57 p.m., the Assistant Director of Nursing (ADON) stated the fall for Resident 2 would have been on the day the COC was written, not sure on the date or time. The ADON stated she spoke to Resident 2 privately after the fall and Resident 2 said CNA 1 was placing him from bed to wheelchair using the Hoyer lift. The ADON stated CNA 1 was moving Resident 2 alone without assistance. The ADON stated Resident 2 stated when CNA 1 had removed the sling off the Hoyer lift and stepped away he (Resident 2) slid off the wheelchair. During an interview on 5/20/2024 at 10:23 a.m., the Director of Nursing (DON) stated on 4/19/2024 she made it clear to all staff using Hoyer lift for transfer needs to be a two-person assist. The DON stated there was a training issue with CNA 1 because CNA 1 should have transferred Resident 2 with two-person assist. The DON stated there can be a risk for equipment not to be used properly. The DON stated CNA 1 did not position the resident in the wheelchair correctly and Resident 2 slipped off. The DON stated it would have been beneficial if Resident 2 had a two-person assist because Resident 2 was a risk for fall. A review of CNA 1's Orientation & Skills Checklist Certified Nursing Assistant, dated 12/14/2023, indicated CNA 1 was competent with the use of Hoyer lift using a two-person assist. A review of the facility's policies and procedures titled, Safe Lifting and Movement of Residents, last revised on 7/2017, indicated, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was incontinent (having no or insufficient voluntary control) of bladder, received the necessary care to promptly identify and treat urinary tract infection (UTI - an infection in any part of the urinary system) by failing to: a. Accurately label a cup (container) with Resident 1 ' s urine sample for laboratory test Resident 1 ' s physician (Physician 1) ordered on [DATE] to rule out UTI. b. Promptly notify Physician 1 that after a call from the laboratory on [DATE] about not doing the test because the urine cup was mislabeled and after Physician 1 ordering another urine test, the nurses were unable to obtain the urine sample because Resident 1 was not urinating (oliguric). c. Accurately document that Resident 1 ' s urine sample was not collected instead of documenting its collection on [DATE] at 9:26 p.m. d. Follow up with the laboratory between [DATE] and [DATE] about the status of Resident 1 ' s laboratory test result wrongly documented as collected on [DATE] at 9:26 p.m. and would have learned there was no sample submitted to the laboratory. e. Inform Physician 1 that after ordering the urine test for Resident 1 on [DATE], the licensed nurses were unable to obtain the urine sample using a straight catheter (a small hollow, flexible tube that is used to empty urine from the bladder intermittently) the same day it was ordered at 10:06 p.m. because Resident 1 was non-compliant. f. Explore the reason Resident 1 did not allow the nurses to obtain the urine sample with the straight catheter, assess for pain to urinate, abdominal pain, etc.). g. Make further attempts between [DATE] and [DATE] to obtain Resident 1 ' s urinary test sample and document the reason for not obtaining the urine sample and notify Physician 1 and Resident 1 ' s representative (RP) if unable to get the needed urine sample. h. Make further attempts between [DATE] and [DATE] to obtain Resident 1 ' s urinary test. i. Identify Resident 1 ' s pain during urination before RP notify the licensed nurse on [DATE] to obtain a medication order. j. Develop a plan of care for Resident 1 ' s suspected UTI since [DATE] with the interventions staff needed to implement including monitoring Resident 1 for signs and symptoms of UTI: lower abdominal pain, pain during urination, confusion, reduced volume of urine, urinary frequency, sensation of bladder fullness, characteristic of the urine (color, odor, volume, and clarity). As a result, on [DATE], at 1:30 p.m., RP noticed and informed the licensed nurses that Resident 1 was not acting like herself and requested to transfer Resident 1 to a hospital. Resident 1 was found lethargic (sluggish and apathetic [having little or no feeling or emotion]), the blood pressure, respiratory and heart rate, and the oxygenation were abnormal. Paramedics were called and transferred Resident 1 to General Acute Care Hospital 1 (GACH 1) at 2:05 p.m. where she was diagnosed with urinary tract infection (UTI - an infection in any part of the urinary system), emphysematous cystitis (EC, is a rare and life-threatening type of complicated UTI mostly seen in elderly females with diabetes, characterized by gas [from gas-forming bacteria - organisms that have only one single cell)] within the bladder lumen [the cavity of a tubular organ or part] and wall), hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine), distended (bloating and swelling) bladder, and sepsis (a life-threatening complication of an infection that can cause multiple organ failure). Resident 1 expired at GACH 1 on [DATE]. Findings: A review of Resident 1 ' s Admission Record, indicated Resident 1 was a female originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included dependence of hemodialysis treatment (process of removing excess water, solutes (substances that are dissolved in a solution), and toxins (poisonous substances) from the blood through a machine in people whose kidneys can no longer perform these functions naturally), essential primary hypertension (a condition in which the force of the blood against the artery walls is too high), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar) with diabetic chronic kidney disease (a type of kidney disease caused by diabetes), and unspecified dementia (a condition characterized by progressive or persistent loss of intellectual functioning). A review of Resident 1 ' s History and Physical (H&P), dated [DATE], indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated [DATE], indicated Resident 1 was cognitively intact (had no memory problem and was able to understand, and make decisions), needed extensive assistance with personal hygiene, dressing and bathing. Resident 1 was incontinent of urine (inability to control urination) and received hemodialysis treatments. A review of Resident 1 ' s SBAR (Situation-Background-Assessment-Recommendation - a written communication tool that helps provide essential, concise information, usually during crucial situations about the resident) Communication Form and Progress Note, dated [DATE], indicated Resident 1 exhibited increased confusion in the morning and Physician 1 ordered a urine laboratory test for culture and sensitivity (C&S, a culture test can identify bacteria or yeast [a fungus] causing a UTI. If bacteria multiply, an antibiotic sensitivity test can identify the antibiotic most likely to kill those bacteria). A review of the National Institute of Health (NIH -www.nih.gov) indicated UTIs can cause sudden confusion (also known as delirium) in older people. A review of Resident 1 ' s medication administration record (MAR), dated [DATE], indicated Resident 1 ' s urine sample was collected on [DATE] at 6:33 p.m. A review of Resident 1 ' s Laboratory Results Report, collected on [DATE], indicated Resident 1 ' s full name was not on the cup the urine was collected. A review of Resident 1 ' s Health Status Note, dated [DATE] timed at 2:01 p.m., indicated the laboratory called and informed a licensed nurse that the urine sample collected on [DATE] was mislabeled and requested to collect another urine sample. A review of Physician 1 ' s order for Resident 1, dated [DATE], indicated to collect (another) sample of urine for C&S. A review of Resident 1 ' s Health Status Note, dated [DATE] timed at 2:01 p.m., indicated the nursing staff were unable to collect the urine sample because Resident 1 was oliguric (production of abnormally small amounts of urine), and Resident 1 just went to dialysis treatment (to an outside dialysis provider). A review of Resident 1 ' s Care Plan, initiated [DATE], for the resident ' s risk for increase in confusion secondary to episodes of confusion. The interventions included anticipate and attend to daily needs to maintain dignity; ask questions that can be answered by yes or no; encourage family members and friends to visit resident; and notify the physician as needed. A review of Resident 1 ' s care plans indicated there was no plan of care developed to address the resident ' s possible UTI as Physician 1 suspected UTI and ordered urine test. A review of Resident 1 ' s MAR, dated [DATE], indicated Resident 1 ' s urine C&S was collected on [DATE], at 9:26 p.m. A review of Resident 1 ' s laboratory test results and nursing notes between [DATE] and [DATE], indicated no urine test results from the sample collected on [DATE] (the results of C&S take 24 to 48 hours). A review of Physician 1 ' s order for Resident 1, dated [DATE], indicated to collect (another) sample of urine for C&S. A review of Resident 1 ' s Health Status Notes dated [DATE], timed at 10:06 p.m. indicated the nursing staff tried to obtain a urine specimen using a straight catheter (a thin, hollow, flexible tube that are used to insert into the bladder to drain urine), but Resident 1 was non-compliant for the procedure. Obtaining the urine sample was endorsed to the next shift. The notes did not indicate if Physician 1 and the resident ' s representative were notified. A review of Resident 1 ' s Health Status Notes, dated [DATE] and [DATE], did not indicate nursing staff attempted to collect Resident 1 ' s urine. There was no documentation Physician 1 and RP were notified about inability to collect the urine sample. A review of Resident 1 ' s Health Status Note, dated [DATE], indicated Resident 1 continued to refuse allowing nurses to obtain the urine sample and Physician 1 was notified. The note did not indicate if Physician 1 gave new orders and if RP was notified. A review of Resident 1 ' s Health Status Note from [DATE] to [DATE], did not include if nursing staff attempted to obtain Resident 1 ' s urine and if Physician 1 and RP were notified. A review of Resident 1 ' s Health Status Note, dated [DATE], indicated Resident 1 complained to RP 1 that it felt like Resident 1 had to urinate and it hurt. RP reported to the Charge Nurse the Resident 1 ' s complaint. Physician 1 was notified and ordered for Pyridium (a pain medication used to relieve urinary urgency, pain, and discomfort caused by a UTI) 200 milligrams (mg - a unit of measure) three times a day for two days. The licensed nurse asked Physician 1 for a new order for urine laboratory test due to the lack of follow up the previous week ([DATE] through [DATE]). Physician 1 ' s ordered a urinary test. A review of Resident 1 ' s Health Status Note, dated [DATE], at 6:13 p.m., indicated Resident 1 ' s urine sample was collected on [DATE] and was picked up by the laboratory staff on [DATE]. A review of Resident 1 ' s Laboratory Results Report collected from Resident 1 on [DATE], indicated the C&S and the urinalysis (urine test) showed white blood cell (WBC - cells in the body responsible for protecting the body from infection) was greater than 182 WBC/ high power field (HPF - a unit of measure) the reference range (normal values) is zero to five WBC/HPF). A review of Resident 1 ' s Laboratory Results Report of the C&S that was pending for Resident 1, was reported on [DATE] and indicated Resident 1 ' s urine bacteria was greater than 100,000 colonies (a group of bacteria derived from the same mother cell) per milliliters (ml - unit of measure) of Proteus mirabilis (a type of bacteria) and 40,000 colonies per ml mixed bacterial morphotypes (any of a group of different types of individuals of the same species in a population) observed. A review of Resident 1 ' s Health Status Note, dated [DATE], at 1:30 p.m., indicated RP visited Resident 1 and informed the nurses Resident 1 was not acting like herself and requested to transfer Resident 1 to a hospital. The licensed nurse contacted Physician 1, who agreed and ordered to transfer Resident 1 to GACH 1. A review of Resident 1 ' s Health Status Note, dated [DATE], at 2:47 p.m., indicated at 1:40 p.m., Resident 1 was noted as lethargic and breathing rapidly. Resident 1 ' s blood pressure was ,d+[DATE] millimeters of mercury (mmHg, a unit of pressure; low blood pressure is a reading of less than ,d+[DATE] mmHg); the heart rate was 110 beats per minute (bpm, tachycardia in adults refers to a heart rate of more than 100 bpm); the oxygen saturation (O2 Sat, amount of oxygen circulating in the blood obtained) could not be obtained (when the O2 Sat is too low it cannot be read using a medical device that clips to the finger, called a pulse oximeter); the respiratory rate was 22 breaths per minute (normal breathing 12 to 20 breaths per minute). The licensed nurse administered Resident 1 oxygen at 15 liters per minute (L/min) through a non-rebreather mask (NRB, allow for the delivery of higher concentrations of oxygen). Resident 1 ' s O2 Sat reading was 90% (normal range ,d+[DATE] percent). The note indicated Emergency Medical Services (EMS, known also as paramedics, EMS, a system that responds to emergencies in need of highly skilled pre-hospital clinicians) was called and arrived at 1:45 p.m. and Resident 1 left the facility at 2:05 p.m. A review of Resident 1 ' s GACH 1 Emergency Documentation, dated [DATE], indicated Resident 1 was brought to the emergency department (ED) with altered mental status (a disruption in how the brain works that causes a change in behavior) and hypotension (low blood pressure). Resident 1 ' s Computed Tomography (CT - a diagnostic imaging exam that uses X-ray technology to produce images of the inside of the body) of the abdomen (area around the stomach) and pelvis (area around the hips) showed emphysematous cystitis, hydronephrosis, and distended bladder. A urinary indwelling catheter (a catheter that is left in the bladder and collects urine by attaching to a drainage bag) and antibiotics (medications that kill bacteria) were recommended. Resident 1 ' s urinary catheter drained thick, purulent (pus, liquid produced in infected tissue), and brown in color. Resident 1 was also diagnosed with sepsis (life-threatening complication of an infection). A review of Resident 1 ' s GACH 1 Nephrologist (branch of medicine that specializes in kidney care and diseases) Consultation, dated [DATE], indicated an assessment/plan of sepsis most likely secondary to UTI. A review of Resident 1 ' s GACH 1 Urology (branch of medicine and physiology [is the study of how the human body works] concerned with the function and disorders of the urinary system) Consultation, dated [DATE], indicated an assessment/plan of emphysematous cystitis and sepsis. A review of Resident 1 ' s GACH 1 Infectious Disease Consultation, dated [DATE], indicated an assessment and plan of sepsis from UTI and emphysematous cystitis. A review of Resident 1 ' s GACH 1 CT Cystogram Retrograde (a detailed X-ray of the bladder), dated [DATE], indicated extraperitoneal (located or taking place outside the peritoneal cavity) bladder rupture in the anterior (towards the front of the body) superior (towards the head or above something) bladder wall and is associated with multiple foci of air (gas bubbles in or on the bladder wall) like prior exam (emphysematous cystitis). A review of Resident 1 ' s GACH 1 Discharge Summary, dated [DATE], indicated Resident 1 was treated for septic shock (a widespread infection causing organ failure and dangerously low blood pressure). Resident 1 had recurrent (occurring often or repeatedly) sepsis. Resident 1 expired on [DATE]. On [DATE], at 3:16 p.m., during an interview, RP stated on [DATE], Resident 1 ' s blood pressure was low and was complaining of pain in her bladder area. RP stated Resident 1 was lethargic, was not herself, was barely talking, and giving only one-word answers and RP asked the nurses to take Resident 1 to the hospital. RP stated she visited Resident 1 in the past and she would complain of pain while urinating. During an interview with Licensed Vocational Nurse 2 (LVN 2), on [DATE], at 12:08 p.m., LVN 2 stated she was one of Resident 1 ' s main nurses. LVN 2 stated that when a urine sample was mislabeled, the lab will call the facility to inform them to recollect the urine sample. LVN 2 stated if a nurse is not able to obtain a urine sample, the task would be endorsed to the next shift. LVN 2 stated every time there is an attempt to collect urine, it should be endorsed and documented that the urine was not collected. A concurrent review of Resident 1 ' s Care Plan for confusion initiated [DATE], LVN 2 stated Resident 1 ' s care plan did not appear person-centered, and the interventions did not address identifying the cause of Resident 1 ' s confusion. During a concurrent interview and review of Resident 1 ' s MAR, lab tests result, physician ' s orders, and nursing notes with LVN 2, on [DATE], at 12:21 p.m., LVN 2 confirmed the first ([DATE]) urine sample was mislabeled and that between [DATE] and [DATE], there was no urine test results of the sample documented as collected on [DATE]. LVN 2 confirmed there was no documentation the licensed nurses were monitoring of Resident 1 ' s signs and symptoms of UTI such as confusion, lower abdominal pain, urine characteristics (color, odor, amount, pain during urination [dysuria], etc.) and there was no care plan for UTI. On [DATE], at 1:03 p.m., during an interview, Registered Nurse 1 (RN 1) stated urine collection should be documented when it is collected. RN 1 stated if urine is not collected it should be documented, endorsed, and followed up. RN 1 was unable to find documentation the licensed nurses monitoring of Resident 1 ' s signs and symptoms of UTI such as confusion, lower abdominal pain, urine characteristics (color, odor, amount, pain during urination [dysuria], etc.). RN 1 could not find a care plan for UTI. During a concurrent interview and review of Resident 1 ' s MAR, lab results, physician ' s orders, and nursing notes with RN 1, on [DATE], at 1:10 p.m., RN 1 stated the physician ordered on [DATE] another urine test for Resident 1. RN 1 stated there was an attempt on [DATE], at 10:06 p.m. to collect the sample with a straight catheter but Resident 1 refused and there was no evidence Physician 1 and RP were notified. During a concurrent interview and record review with RN 1, on [DATE], at 1:25 PM, Resident 1 ' s Health Status Note, dated [DATE] to [DATE], was reviewed and did not indicate attempts to collect Resident 1 ' s urine, notification to family, or notification to Physician 1. Further review of Resident 1 ' s Health Status Note, from [DATE] to [DATE], RN 1 stated there was no evidence Resident 1 ' s urine was collected. RN 1 stated there was no evidence Physician 1 and RP were notified. RN 1 stated that if it was not documented, it was not done. On [DATE], at 2:28 p.m., during an interview, Certified Nursing Assistant 2 (CNA 2) stated she took care of Resident 1 prior to the transfer to the hospital. CNA 2 stated she noticed Resident 1 was not as alert as before, was confused, not eating, not responding when spoken to, and looked tired. CNA 2 stated two weeks before Resident 1 ' s transfer to the hospital, she noticed Resident 1 had a rotten cheese smell coming from Resident 1 ' s vaginal area. CNA 2 further stated she informed the charge nurses and regretted not documenting her observation. During a concurrent interview with LVN 4 and review of Resident 1 ' s MAR, lab results, physician ' s orders, and nursing notes, on [DATE], at 3:42 p.m., LVN 4 confirmed Physician 1 ordered on [DATE] the lab test for urine C&S but the collection cup was not labeled correctly with Resident 1 ' s name. LVN 4 stated that Physician 1 ordered another urine C&S on [DATE], but there was no documentation it was done. LVN 4 further stated if the urine sample was sent correctly or if the licensed nurses followed-up with the physician, the Resident 1 ' s UTI could have been treated and possibly prevent Resident 1 ' s hospitalization or death. LVN 4 could not find a care plan for UTI. On [DATE], at 5:42 p.m., during a concurrent interview with the Director of Nursing (DON) and a review of Resident 1 ' s Care Plan, initiated on [DATE], the DON stated Resident 1 ' s care plan was generic and not person centered. The DON stated Resident 1 ' s care plan did not include UTI as contributing factor to Resident 1 ' s confusion. The DON stated Resident 1 ' s care plan interventions could have included getting labs done, determine the cause of confusion, monitor the resident ' s confusion, etc. On [DATE], at 4:40 p.m., a concurrent interview with the Director of Nursing (DON) and a review of Resident 1 ' s SBAR Communication Form and Progress Note dated [DATE] about Resident 1 ' s increased confusion, the lab result reports, nursing notes, and physician ' s orders was conducted. The DON stated the licensed nurses did not follow the physician ' s orders. The DON stated the licensed nurses did not report timely to the physician the inability to obtain urine samples, the lack of urination, and the resident ' s pain when trying to void. The DON stated the licensed nurses did not explore the reason why Resident 1 was non-compliant and not allowing to obtain the urine sample with the straight catheter (pain). The DON stated Physician 1 should have been updated on the inability to collect Resident 1 ' s urine. The DON stated the ways to detect a UTI include pain during urination, abnormal vital signs, odor, and confusion. The DON stated prior to Resident 1 ' s transfer to the GACH, Resident 1 ' s vital signs were bottoming out. The DON stated it ' s possible if Resident 1 ' s Urinalysis (UA - is the physical, chemical, and microscopic examination of urine) and urine culture and sensitivity were collected, it would have been possible to treat if it was determined that Resident 1 had a UTI. The DON further stated there was no documentation the licensed nurses monitored Resident 1 for signs and symptoms of UTI. The DON could not find a care plan for UTI. On [DATE], at 9:30 a.m., during an interview, Physician 1 stated when a resident is experiencing new onset of confusion, a urinalysis and urine C&S is ordered to rule out UTI because elderly people develop confusion from UTI. Physician 1 stated when a resident is refusing labs, the physician and family should be notified. Physician 1 stated it is important to notify the family of the resident ' s refusal to have the family help convince the resident to get the test done. Physician 1 stated if there was a one-time order for urine collection and the resident refuses, the nursing staff should notify the physician and request a renewal of the order. Physician 1 stated he does not recall if he was made aware of Resident 1 ' s refusals to provide a urine sample. Physician 1 stated Resident 1 ' s admitting diagnosis at GACH 1 was sepsis from UTI which does not happen overnight. Physician 1 stated if the UTI was identified sooner and treatment was done timely, Resident 1 ' s condition would not have complicated. A review of the facility ' s policy and procedure (P&P) titled, Specimen Collection, revised on ,d+[DATE], indicated specimen collections must be placed in their proper container, securely sealed, and properly labeled for transfer to the laboratory. A review of the facility ' s P&P titled, Change in a Resident ' s Condition or Status, revised ,d+[DATE], indicated the nurse will notify the resident ' s attending physician or physician on call when there has been a refusal of treatment two or more consecutive times. A review of the facility ' s P&P titled, Charting and Documentation, revised ,d+[DATE], indicated documentation of procedures and treatments should include care-specific details, including items such as: - The date and time the procedure/treatment was provided. - The name and title of the individual(s) who provided care. - The assessment data and/or any unusual findings obtained during the procedure/treatment, if applicable. - Whether the resident refused the procedure/treatment. - Notification of family, physician, or other staff, if indicated; and - The signature and title of the individual documenting. A review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised ,d+[DATE], indicated the comprehensive, person-centered care plan should describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights (including the right to refuse treatments). The facility ' s P&P further indicated, when possible, interventions should address the underlying source(s) of the problem.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received immediate basic life-saving support, including cardiopulmonary resuscitation (CPR, any medical intervention used to restart a person's heartbeat and breathing after one or both have stopped), as per the resident ' s advance directives (a written instruction, such as a living will or durable power of attorney for health care, relating to the provision of health care when the individual is incapacitated). For Resident 1, who had chronic obstructive pulmonary disease (COPD - inflammatory lung disease that causes obstructed airflow from the lungs), shortness of breath, and Coronavirus Disease 2019 (COVID-19, - a highly contagious respiratory disease that spreads from person to person through droplets released when an infected person coughs, sneezes, or talks), the facility failed to: 1. Provide Resident 1 immediate CPR, on [DATE] at 3:34 p.m., when Occupational Therapist 1 (OT 1) found Resident 1 in bed with no blood pressure (BP) reading using a wrist BP cuff; no oxygen saturation (O2 Sat, measurement of the amount of oxygen in the bloodstream) or heart rate reading using a pulse oximeter (electronic device that measures the saturation of oxygen carried in the blood and the heart rate); and was not responding (arousing) upon tapping the resident ' s shoulder and shaking her upper body. OT 1 did not call for help until 3:39 p.m. After OT 1 called for help, Physical Therapist 1 (PT 1), OT 1, and Registered Nurse 1 (RN 1) did not start CPR until 3:43 p.m. because staff were checking Resident 1 ' s clinical record to find out the Code Status (level of medical interventions a person wishes to have started if their heart or breathing stops) in the advance directives (to determine if CPR should be administered). 2. Immediately call paramedics when Resident 1 was found with no evidence of life (no BP, no O2 Sat, and no heartrate) and before checking Resident 1 ' s Code Status per facility ' s policy and procedure. Licensed Vocational Nurse 1 (LVN 1) called paramedics at 3:44 p.m. At 3:51 p.m., paramedics arrived and took over the CPR. As a result, Resident 1 did not receive the necessary emergency life-saving services immediately. The paramedics pronounced Resident 1 ' s death at the facility at 4:19 p.m. on [DATE]. On [DATE] at 3:37 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) under 42 CFR S483.24(a)(3) Cardiopulmonary Resuscitation (CPR) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to provide CPR immediately to Resident 1 (when found unresponsive, without BP, O2 Sat, and heartrate) and failure to call paramedics immediately. On [DATE] at 3:32 p.m., the ADM provided an acceptable IJ Removal Plan which included the following summarized actions: 1. On [DATE], after 4 p.m., the DON provided a one-on-one in-service (staff training) and competency (measurable pattern of knowledge, skills, abilities, behaviors in order to perform occupational functions successfully) training on CPR, facility ' s Code Blue (an announcement that means a resident is having a medical emergency, usually cardiac or respiratory arrest) policy and procedures with emphasis on immediate, urgent response to an unresponsive (not arousable and not reacting to touch, voice, pain), unconscious (without awareness, sensation, or thought process), or pulseless resident to OT 1, PT 1, Certified Nursing Assistant 1 (CNA 1), CNA 2, LVN 2, LVN 3, and RN 1. 2. CPR card of OT 1, PT 1, CNA 1, CNA 2, LVN 2, LVN 3 and RN 1 were provided to the team. They were checked and validated. 3. On [DATE], the DON initiated an in-service to all non-licensed staff and skills competency to licensed nurses on facility ' s policy and procedure on CPR and facility ' s ' written policy and procedure for code blue. The in-service included the following steps for resident found unconscious or pulseless by staff: a. Call for help continuously until help arrives, use of call light. b. Staff who found the resident should check for pulse, breathing presence and level of consciousness (measurement of persons responsiveness to stimuli from environment). c. Any responder should immediately notify the license nurse. d. Activate code blue by paging through overheard system at least three times of the location of the resident that requires CPR and call emergency number 911. e. Initiate CPR immediately when resident is unresponsive and confirm with no blood pressure, no signs of breathing, no respiration, and no pulse. f. Responder to bring the crash cart (emergency cart - a wheeled container carrying medicine and equipment for use in emergency) to the resident location. 4. All code status of residents in the facility were reviewed. Hard charts (paper clinical records) were color-coded to identify full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive), visually with green stickers versus do not resuscitate (DNR - instructs health care providers not to do CPR if a patient's breathing stops or if the patient's heart stops beating) with orange sticker for quick determination of code status. 5. On [DATE], the DON initiated an in-service to Rehabilitation Department (Rehab. Dept.) on identifying residents that require immediate emergency care including CPR while providing rehabilitation (rehab.) treatment. 6. On [DATE] and [DATE], the DON and the Quality Assurance (QA) Training Resource provided training to 195 out of 247 active employees on different emergency case scenarios that require CPR and code blue simulation to licensed staff, non-licensed staff, and rehab. department. Staff currently on medical leave will be on scheduled in-service training upon return to work but not later than [DATE]. The training will include: a. Importance of immediate timely response. b. Activation of code blue by paging over head the location of resident. c. How to call emergency services via 911. d. Responder responsibility during code blue. e. Third party American Heart Association (AHA - organization that provides lifesaving tools and information to save and improve lives) Basic Life Support (BLS - type of care provided to anyone who is experiencing cardiac arrest[when the heart suddenly and unexpectedly stops pumping], respiratory arrest [a medical event where the ability of a person to breathe stops], or a blocked airway] instructor for CPR certification with hands-on (actively involved with participation) training of all employees. 7. All shift RN Supervisors will conduct daily observation during emergency situations involving a resident ' s change of condition (COC). 8. The Director of Staff Development (DSD) met with different staff and gave scenarios of unresponsive residents that may require CPR and how to activate code blue emergency response to validate the level of skills and understanding of the licensed and non-licensed nursing staff with focus on timely response to resident with COC. 9. DON and the DSD to provide in-service monthly for three months on Code Blue emergency response to Rehab. Department, non-licensed, and licensed staff. 10. The DON and/or designee to monitor the Rehab. Department, non-licensed, and licensed staff daily for three months thru observation during actual emergency situations for timeliness of response in calling emergency medical assistance when COC of resident requiring 911 is noted. Any noncompliance to be corrected immediately by re-educating the identified staff. Any pattern or trend will be reviewed in the Quality Assessment and Assurance (QA&A - established for the purpose of improving the safety and quality of health services) for further quality improvement and revision of plan as needed. On [DATE] at 4:36 p.m., while onsite and after verifying the facility ' s full implementation of the IJ Removal Plan, the SSA accepted the IJ Removal Plan and removed the Immediate Jeopardy situation in the presence of the ADM and the DON. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on [DATE] with diagnoses including COPD, shortness of breath, and COVID-19. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated [DATE], indicated the resident was able to remember, understand and make decisions. The MDS indicated Resident 1 required extensive assistance with one-person physical assist with moving in bed, dressing, using the toilet, and personal hygiene. The MDS indicated resident was receiving oxygen (O2). A review of the Physician ' s Order for Resident 1, dated [DATE], indicated to attempt resuscitation (CPR), full treatment with long-term artificial nutrition. A review of the Physician ' s Order for Resident 1, dated [DATE], indicated to administer 02 at two liters per minute (2 L/minute) via nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside both opening of the nose) for shortness of breath. A review of Resident 1 ' s Antigen Test (a test to check for COVID-19) result, dated [DATE], indicated resident was positive for COVID-19. A review of the Physician ' s Order for Resident 1, dated [DATE], indicated to isolate (separate from others to prevent transmission of infection) the resident because of the COVID-19 diagnosis. A review of Resident 1 ' s Situation - Background - Assessment - Recommendation (SBAR - tool to aid in facilitating and strengthening communication between nurses and doctors) Communication Form and Progress Note, dated [DATE], indicated, at 3:40 p.m., CNA 1 called LVN 2 to Resident 1 ' s room because the resident was unresponsive. LVN 2 found the resident not breathing, pulseless, and the pupil (round opening located in the center of the eye which change size to let light into the eye dilate or constrict) were not moving. RN 1 was called to Resident 1 ' s room and started chest compressions. The SBAR form indicated LVN 1 called paramedics at 3:45 p.m. (through review of the video surveillance, time is 3:44 p.m.), paramedics arrived at 3:51 p.m. who took over the CPR. The SBAR indicated CPR was provided by paramedics for 11 minutes until paramedics pronounced Resident 1 dead at 4:19 p.m. A review of Resident 1 ' s nursing Progress Notes, dated [DATE] and timed 3:43 p.m., indicated RN 1 was called to Resident 1 ' s room and found the resident unresponsive, not breathing and with no heartbeat. RN 1 started chest compressions (CPR). During an interview on [DATE] at 10:06 a.m., OT 1 stated when he entered Resident 1 ' s room on [DATE] at 3:40 p.m., the resident was breathing heavily, with eyes half open and half close, and was not responding when called. OT 1 stated he tapped Resident 1 ' s left shoulder but the resident still did not respond so he checked the resident ' s radial (wrist) pulse which was very weak. OT 1 stated he placed the pulse oximeter on Resident 1 ' s left index finger and the blood pressure cuff on the left wrist to check for oxygen saturation, pulse, and blood pressure but obtained no reading. OT 1 stated he saw PT 1 in the hallway and asked him to call the nurse. OT 1 stated he did not remember Resident 1 ' s code status until RN 1 arrived and informed him that Resident 1 was a full code, and then he started CPR. During an interview on [DATE] at 10:15 a.m., PT 1 stated he was walking in the hallway on [DATE] at around 3:40 p.m., when he saw OT 1 standing in Resident 1 ' s door and told him he did not think Resident 1 had a pulse. PT 1 stated he went inside the room, checked the resident ' s pulse, and did not feel the pulse. Resident 1 was not breathing, and the eyes were open. PT 1 said he went out of the room to the Nurse ' s Station to get a nurse. PT 1 stated he did not know Resident 1 ' s code status at that time. PT 1 stated as he was walking to the Nurse ' s Station, he met LVN 2 in the hallway and informed her Resident 1 had no pulse. PT 1 stated LVN 2 went inside the room right away and came out to call RN 1. PT 1 stated he started CPR when RN 1 came in and informed them Resident 1 was a full code. During an interview on [DATE] at 10:52 a.m., LVN 2 stated CNA 1 called her about Resident 1 not looking good and having a weak pulse. LVN 2 went to Resident 1 ' s room and was informed by PT 1 the resident had no pulse and was not responding. LVN 2 stated she went inside and checked Resident 1 ' s left carotid (artery on the side of the front of the neck just below the jaw) pulse and felt no pulse. LVN 2 went out of the room to call RN 1. LVN 2 stated she did not know Resident 1 ' s Code Status and CPR was started once RN 1 came and informed them the resident was a full code. On [DATE] at 11:27 p.m., during an interview, the DON stated the rehabilitation staff should know the resident ' s code status and should have initiated the CPR once Resident 1 was found unresponsive with no pulse. The DON stated the staff should have had a faster response time to help increase the probability of successful resuscitation. On [DATE] at 3:47 p.m., during an interview, RN 1 stated she was at the RN ' s office in front of Nurse ' s Station 1 when CNA 1 told her Resident 1 was not responding. RN 1 stated she checked Resident 1 ' s physical medical record (chart) and found out the resident was a full code. RN 1 stated she overhead paged (sent announcement through electronic sound amplification heard throughout the facility) Code Blue in Resident 1 ' s room and responded with the crash cart. RN 1 stated anyone can call a Code Blue and paramedics. RN 1 also stated LVNs should know their residents ' code status ahead of time. On [DATE] at 12:20 p.m., during an interview, LVN 2 stated she responded to Resident 1 ' s room on [DATE] at 3:43 p.m. after CNA 1 informed her that resident did not look good and had a weak pulse. LVN 2 stated CPR and calling paramedics were not done immediately because they wanted to make sure of Resident 1 ' s code status. LVN 2 stated they could call paramedics even if resident ' s code status was do not resuscitate (DNR). LVN 2 stated LVN 1 called 911 on [DATE] at 3:45 p.m. On [DATE] at 1:20 p.m., during an interview, LVN 3 stated she saw Resident 1 with LVN 2 on [DATE] at around 3 p.m. LVN 3 stated LVN 2 asked Resident 1 how she was doing to which she (the resident) responded she was okay. On [DATE], at 2:46 p.m., in the presence of the ADM and the DON in the ADM ' s office, a (CCTV, closed-circuit television) surveillance video titled, D12 (in front of Resident 4 ' s room), dated [DATE], was reviewed. The following timeline was observed: - 15:31:45 - OT 1 was outside Resident 1 ' s room donning (putting on) personal protective equipment (PPE-gown, face shield, and gloves) - 15:34:06 - OT 1 went inside Resident 1 ' s room with a pulse oximeter and wrist blood pressure machine on his left hand and a rolling folded walker to his right hand. - 15:39:59 - OT 1 peaked out of Resident 1 ' s room. PT 1 was in front of the resident ' s room walking in the hallway. CNA 1 was standing right across resident ' s room carrying a white linen sheet and a BP machine. - 15:40:05 - PT 1 stood by Resident 1 ' s doorway. - 15:40:17 - PT 1 went inside Resident 1 ' s room while CNA 1 walked towards Nurses ' Station 1. - 15:40:43 - PT 1 came out of Resident 1 ' s room, walked back to Nurses ' Station 1, and met CNA 1 walking back to Resident 1 ' s room. - 15:41:01 - PT 1 continued walking towards Nurses ' Station 1 and met LVN 2 in the hallway and both walked towards Resident 1 ' s room. - 15:41:09 - LVN 2 stood by Resident 1 ' s doorway. - 15:41:28 - LVN 2 went inside Resident 1 ' s room while CNA 1 walked back to Nurses ' Station 1. - 15:41:39 - LVN 2 walked out of Resident 1 ' s room back to Nurses ' Station 1. - 15:41:41 - PT 1 walked out of Resident 1 ' s room and stayed outside the room. - 15:42:01 - CNA 1 walked in the hallway back to Resident 1 ' s room with crash cart while LVN 2 and PT 1 stood outside the Resident 1 ' s room - 15:42:19 - RN 1 was running to Resident 1 ' s room from Nurses ' Station 1 - 15:43:04 - PT 1 went inside Resident 1 ' s room while RN 1, LVN 1, LVN 2, CNA 1 and Housekeeping Supervisor (HSKS) donned PPE. - 15:44:29 - LVN 1 was using her cellphone outside of Resident 1 ' s room - 15:45:03 - CNA 3 brought an oxygen tank to Resident 1 ' s room. On [DATE] at 3:11 p.m., during an interview after viewing the CCTV surveillance video, the DON stated OT 1 was in Resident 1 ' s room from 3:34 p.m. to 3:39 p.m. The DON stated OT 1 should have called right away and PT 1 should have responded urgently. The DON stated she did not see the urgency in responding to an emergency in the video when staff were walking back to Nurses ' Station 1 to call the nurse. On [DATE] at 3:16 p.m., an interview with the DON and a concurrent review of the facility ' s policy and procedures titled, Cardiopulmonary Resuscitation (CPR), dated [DATE], was conducted. The policy indicated, 1. When arriving on scene, verify that there are no imminent threats. 2. Determine unresponsiveness by tapping and gently shaking resident and shouting, Are you okay? If the resident does not respond within 10 seconds, start chest compression if the resident has no pulse and is not breathing. 3. If the resident does not respond, call out for help. If someone else is in the vicinity, direct him/her to call 911 immediately. 4. Delegate another individual to check the residents order and advance directive (a legal document indicating a resident ' s wishes about receiving medical care if no longer able to make medical decisions) for CPR or no CPR order. The DON stated OT 1 did not follow the steps of CPR per facility ' s policy and procedure. The DON stated OT 1 should have called for help when the resident did not respond to him after he checked for responsiveness, and the facility staff did not call 911 before checking for the code status. On [DATE] at 9:51 a.m., during an interview, OT 1 stated he got his BLS (CPR) certificate by attending an online course which did not require him to do a hands-on training or return demonstration. On [DATE] at 12:41 p.m., during an interview, the DON stated that on [DATE], there was a delay in response, in calling for help, in calling paramedics, and in initiating CPR on Resident 1. On [DATE] at 11:34, during an interview, the ADM stated the facility did not have a Code Blue policy before [DATE] when Resident 1 died . The ADM stated they developed and approved one on [DATE]. On [DATE], at 12:14 p.m., during an interview with the DSD and concurrent review of OT 1 ' s BLS certificate, the DSD confirmed the BLS certificate was from an online course with no hands-on training. The DSD stated it was important to have a hands-on training for BLS to provide the correct life-saving measures. A review of LVN 2 ' s BLS certificate indicated it was also from an online course with no hands-on training. A review of Resident 1 ' s Paramedic Report dated [DATE], indicated CPR was in progress by staff for 10 minutes prior to paramedic ' s arrival. The report indicated the following timeline and interventions: - 15:46:52 - 911 was called for cardiac arrest - 15:51:36 - paramedics arrived at Skilled Nursing Facility 1 (SNF 1), provided bag-mask ventilations (provided oxygen using a close fit mask) - 15:52:26 - CPR provided and 15 liters of oxygen per minute given - 15:58:37 - epinephrine (medication used in cardiac arrest) given - 16:03:07 - epinephrine given - 16:08:58 - epinephrine given - 16:19:2 8- pronounced dead A review of facility ' s policy and procedure titled, Emergency Care, undated but reviewed on [DATE], indicated, If in the opinion of the charge nurse, a patient exhibits such serious symptoms that failure to obtain the most rapid therapeutic intervention by a physician would place the patient in great jeopardy .call 911.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from physical abuse when Certified Nursing Assistant 1 (CNA 1) failed to remove Resident 2 away from Resident 1 from an escalating conflict. On 5/17/2022 at around 12:15 pm, inside the room of Residents 1, 2, and 3, CNA 1 was feeding Resident 3. Resident 2, a roommate, who was on a wheelchair was talking and encouraging Resident 3 to eat. Resident 1 said foul words and got agitated at Resident 2. Instead of wheeling Resident 2 out, CNA 1 left the room, then Resident 1 threw a fork at Resident 2. This deficient practice resulted in an injury to Resident 2 who sustained three cuts to the left ear requiring a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: A review of Resident 1 ' s Admission Record indicated the facility originally admitted Resident 1 on 8/28/2021 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1 ' s History and Physical, dated 9/3/2021 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (a standardized assessment and care screening tool), dated 3/10/2022, indicated Resident 1 ' s cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 required supervision (oversight, encouragement, or cueing) with eating with setup help only and extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assistance with bed mobility, dressing, and toilet use. A review of Resident 2 ' s Admission Record indicated the facility originally admitted Resident 2 on 10/6/2021 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 ' s cognition was intact. Resident 2 required extensive assistance with locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair), dressing, toilet use, and personal hygiene with one-person physical assistance. The MDS indicated Resident 2 was not steady and only able to stabilize with staff assistance when moving from seated to standing position and surface-to-surface transfer (transfer between bed and chair or wheelchair) and no impairment with upper and lower extremity in range of motion. The MDS indicated Resident 2 normally used mobility devices like a walker and wheelchair. A review of Resident 3 ' s Admission Record indicated the facility admitted Resident 3 on 5/2/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3 ' s History and Physical, dated 5/3/2022, indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 ' s cognition was impaired. Resident 3 required extensive assistance with one-person physical assistance with bed mobility, dressing, eating, and personal hygiene. A review of Resident 2 ' s Situation, Background, Assessment, Recommendation (SBAR) Communication Form and progress note (a standardized, safe, simple way for nurses and doctors to share patient information in a sharp, clear way), dated 5/17/2022 at 1:45 p.m., indicated that on 5/17/2022 Resident 1 threw a fork at roommate Resident 2 which led to a laceration (a deep cut or tear in skin or flesh) to the (left) ear. A review of Resident 2 ' s Nursing Progress Notes indicated the following: - On 5/17/22 at 1:45 p.m., Resident 1 threw a fork at roommate Resident 2 ' s head which led to a laceration to the ear. - On 5/17/22 at 2:22 p.m., three cuts were noted to Resident 2 ' s left ear measured at 1 centimeter (cm - unit of measurement) in length by 0.1 cm in width, 1 cm in length by 0.5 cm in width, and 0.5 cm in length by 0.5 cm in width. A review of Resident 2 ' s Physician Order, dated 5/17/2022 and with an end date on 5/21/2022, indicated to clean Resident 2 ' s left ear with normal saline (sterile water), pat dry and apply triple antibiotic and leave open to air every day shift for wound management for three days. A review of Resident 2 ' s Treatment Administration Record for month of 5/2022 indicated the facility administered wound management to Resident 2 ' s left ear every day shift on 5/18/2022, 5/19/2022, and 5/20/2022. During an interview on 6/1/2022 at 9:40 a.m., Resident 2 stated it was unprovoked assault (an attack occurring without any identifiable cause). Resident 2 stated it happened around lunch time. Resident 2 cannot recall the exact date. Resident 2 stated CNA 1 was in the room helping Resident 3 to eat. Resident 2 talked to Resident 3 saying when he (Resident 3) was going to eat his food because Resident 3 was not eating. Resident 2 stated he did not recall why CNA 1 stepped out of the room. Resident 2 stated he wheeled (he was on a wheelchair) himself towards the door and when he passed by Resident 1 ' s bed, Resident 1 threw the fork at him. Resident 2 stated he wheeled himself out and yelled for help in the hallway. During an interview on 6/1/2022 at 10:25 a.m., Resident 1 stated he did not recall exactly what happened but Resident 2 called him racial slurs and told Resident 2 that he should stop talking and to shut up. Resident 1 stated he felt mad and threw the fork at Resident 2. Resident 1 stated this had not happened before and felt he was provoked. During an interview on 6/1/2022 at 11:37 a.m., CNA 1 stated she was assigned to Resident 2 and Resident 3 and there was another CNA assigned to Resident 1. CNA 1 stated she was in the room before the incident happened between Resident 1 and Resident 2. CNA 1 stated it happened around 12:15 p.m., during lunch time. CNA 1 stated the curtain was drawn up to Resident 3 ' s foot of the bed that separated Resident 1 and Resident 3, and Resident 2 was on his wheelchair by his own bed next to Resident 3 ' s bed. CNA 1 stated she was assisting Resident 3 with eating lunch. CNA 1 stated Resident 2 was encouraging Resident 3 to eat. CNA 1 stated Resident 1 did not like Resident 2 talking to Resident 3 because Resident 2 should mind his own business. CNA 1 stated Resident 2 continued to encourage Resident 3 to eat and Resident 1 started cursing at Resident 2 and Resident 3. CNA 1 stated she thought Resident 1 did not know she was in the room, and she told Resident 1 that he should not say those foul words and Resident 1 got upset and started cursing at her. CNA 1 stated Resident 1 was starting to get agitated, so she walked out of the room to inform her charge nurse because Resident 1 had previously swung at her during a separate incident. CNA 1 stated that as soon as she stepped out of the room and into the hallway, Resident 2 came out and yelled that he was bleeding because Resident 1 threw a fork at him. During an interview on 6/30/2022 at 4:45 p.m., Registered Nurse 1 (RN 1) stated that when one of the residents gets agitated towards another resident, the facility ' s practice was to immediately separate the residents to avoid a resident hitting another resident. RN 1 stated that if he was in that situation, since he knew Resident 2 was on a wheelchair, he would remove Resident 2 from the room away from Resident 1 for Resident 2 ' s safety. During an interview on 7/7/2022 at 10:30 a.m., the Assistant Director of Nursing (ADON) stated CNA 1 should have moved Resident 2 out of the room since he was on his wheelchair. The ADON stated that by removing Resident 2 to the hallway or somewhere, it would have helped deescalate Resident 1 ' s agitation. A review of the facility ' s current policy and procedure titled, Abuse Program, reviewed and approved on 4/29/2022, indicated it is the facility ' s policy to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff from other agencies serving the resident, family members or legal guardians, friends, or other individuals. Under Training section, indicated that the facility will train each employee on understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms included aggressive or catastrophic reactions of residents and outburst or yelling.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received supervision and assistance to prevent accident, by failing to: 1. Monitor Resident 1 for safe swallowing since he was identified with swallowing difficulties on [DATE]. 2. Develop a plan of care with interventions addressing Resident 1's swallowing problem identified on [DATE]. 3. Notify Resident 1's physician on [DATE] about Resident 1's difficulty swallowing, pocketing food (holding food in the mouth for an extended amount of time without swallowing), lack of teeth or dentures while on a regular texture diet. 4. Provide Resident 1 with feeding assistance as indicated on Resident 1's care plan created [DATE] that indicated Resident 1 needed extensive assistance (full assistance from an individual to aid in performing the complete task) from staff during meals for safety. As a result, on [DATE] at 8:39 p.m., Resident 1 had a choking episode while eating a sandwich without assistance. Resident 1 became unresponsive, did not have heartbeat, was given cardiopulmonary resuscitation (CPR - an emergency life-saving procedure done when someone's breathing and the heartbeat have stopped), but was ultimately pronounced deceased after unsuccessful attempts to resuscitate (bring back to life). On [DATE] at 6:19 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident, §483.25(d) Accidents) in the presence of the Administrator (ADM) and the Director of Nursing (DON) for the facility's failure to prevent Resident 1's fatal choking episode. On [DATE] (two days later from when the IJ situation was called) at 2:11 p.m., the ADM provided an acceptable IJ Removal Plan which included the following: 1. Immediate in-services to licensed nurses started on [DATE], that included the following: a. Documentation of Change of Condition (COC) re: swallowing difficulty b. Appropriate interventions to address swallowing difficulty c. Physician notification d. Speech Therapy (therapeutic treatment of impairments and disorders of speech, communication and swallowing) evaluation e. Monitor resident on diet texture tolerance and document f. Assistance during meals will be provided g. Written care plans to address swallowing difficulty h. Notification of physician for any need of resident's diet change including downgrade of diet texture [texture modification when food is mashed or pureed (very smooth, crushed or blended food) to make it safer to eat] for trial 2. Immediate in-service to the Dietary Services Department started on [DATE], that included the following: a. Education given to dietary supervisor emphasis on no diet texture changes will be served to resident without current physician order. b. All trial diet texture must have physician order c. Training given to dietary staff to serve only current diet texture per physician order. No changes in diet texture will be made without physician order 3. All residents were evaluated for risk of choking, swallowing problems, and their diets texture. 4. Charge Nurse and/or Unit Manager will notify Certified Nurse Assistants (CNAs) of residents with swallowing problem or any changes on resident's diet texture. 5. Residents identified with current swallowing difficulty and changed diet texture will be monitored by Restorative Nurse Assistants (RNA) during meals. Any concerns identified will be communicated to Charge Nurse and/or Unit Manager for immediate follow up. The staff who identified the swallowing concern will communicate through Communication Log for follow up with primary care physician and monitoring as needed. On [DATE] at 6:00 p.m., while onsite and after verifying the facility's full implementation of the IJ Removal Plan, CDPH removed the IJ situation in the presence of the ADM and the DON. Findings: A review of Resident 1's Admission Record indicated the facility originally admitted the resident, a [AGE] year-old male, on [DATE] with a readmitted [DATE]. Resident 1's diagnoses included [CONDITION(S)] (loss of kidney function) with heart failure (occurs when the heart muscle does not pump blood as well as it should), [CONDITION(S)] (irregular heartbeat), and generalized muscle weakness. A review of Resident 1's History and Physical exam completed by the attending physician on [DATE], indicated the resident was not fully oriented (a person's level of awareness of self, place, time, and situation). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-planning tool) dated [DATE] indicated Resident 1 had moderately impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). Resident 1 needed one-person extensive assistance with eating and had no natural teeth or tooth fragments. A review of Resident 1's Physician's Order dated [DATE] indicated resident had an order for CCHO (consistent carbohydrate diet that focuses on consuming the same number of carbohydrates every day to keep blood sugar levels stable), low salt diet, regular in texture with thin liquid consistency. A review of Resident 1's Progress Note completed by the Dietary Supervisor (DS), dated [DATE], timed at 5:38 p.m. indicated Resident 1 was observed with an episode of swallowing difficulty. DS spoke with Resident 1 regarding temporarily downgrading his diet texture from regular diet to pureed diet (texture-modified diet that consists of food with a soft, pudding like consistency) and dietary department will temporarily send Resident 1 pureed meals. A review of Resident 1's Progress Notes completed by Licensed Vocational Nurse 1 (LVN 1) dated [DATE] and timed at 6:14 p.m., indicated Resident 1 was noted with difficulty swallowing. DS was informed and the diet would be temporarily changed from regular to pureed diet due to Resident 1 not having teeth and no dentures. Resident 1 would be monitored for tolerance of texture and would be observed for signs and symptoms of choking for three days. A review of Resident 1's Progress Notes completed by Registered Nurse 1 (RN 1) dated [DATE], timed at 9:51 p.m., indicated RN 1 was walking down Nursing Station 1 hallway at 8:42 p.m. and witnessed LVN 2 at bedside speaking with Resident 1. LVN 2 asked Resident 1 if he was okay and Resident 1 verbalized no while coughing. Resident 1 had a half-eaten sandwich in his hand. Resident 1 was asked if he was choking, and he verbalized yes and continued to cough. Resident 1 was sat up and [MEDICATION(S)] Maneuver (an emergency technique that involves abdominal thrusts used to eject an object, such as food, from the trachea [windpipe] of a choking person) was performed. Resident 1 then slumped over, stopped breathing, and lost consciousness. Chest compressions (act of applying pressure to someone's chest in order to help blood flow through the heart in an emergency situation) began at 8:44 p.m. and Resident 1's oral cavity (inside of the mouth) was assessed with no visible blockage found. Paramedics (individual trained to give emergency medical care to people who are injured or ill) arrived at 8:51 p.m. and continued CPR. A review of Resident 1's SBAR (Situation-Background-Assessment-Recommendation - a form that provides a framework for communication between members of the health care team about a patient's condition) Communication form, dated [DATE], indicated during medication pass (administering medications to the residents) at 8:39 p.m., Resident 1 requested pain medication. While LVN 2 was verifying the pain medication order, he heard Resident 1 coughing and immediately attended to Resident 1 and asked if he was okay. Resident 1 verbalized no. LVN 2 sat Resident 1 upright, and Resident 1 spat out a small piece of food. LVN 2 tapped Resident 1's back and performed [MEDICATION(S)] Maneuver. Soon after, Resident 1 lost consciousness and became pulseless (no heartbeat) and CPR was initiated. Paramedics arrived at 8:51 p.m. and continued performing CPR. At 9:12 p.m., Resident 1 was pronounced dead. A review of Resident 1's meal tray card (card that contains information about the food being served to the resident) from [DATE], under the alert section of the meal tray card, indicated Resident 1 needed feeding assistance during meals. A review of the Prehospital Care Report (paramedics report) dated [DATE], indicated paramedics arrived at the facility at 8:46 p.m. on [DATE]. Paramedics took over CPR upon arrival to the facility. OPA (oropharyngeal airway - a medical device used to open or maintain a person's airway) was placed and Resident 1's airway was suctioned, and pieces of sandwich were removed. The paramedics placed an IV (intravenous line - is a soft, flexible tube placed inside a vein, that delivers fluids, medication, and nutrients directly into a person's bloodstream) and an IO (intraosseous access - a rapid method to administer medications into the bone marrow [the soft, spongy tissue that has many blood vessels and is found in the center of most bones]) on Resident 1 and administered emergency medications to revive Resident 1. Resident 1 was pronounced dead at 9:10 p.m. During an interview and concurrent record review of Resident 1's electronic medical records, on [DATE] at 1:45 p.m. with the DON, she stated Resident 1 had a choking episode on [DATE] at 8:39 p.m. The DON stated Resident 1 was coughing while eating a sandwich in his room. LVN 2 performed [MEDICATION(S)] Maneuver, but Resident 1 slumped over and became unresponsive. DON stated on [DATE], two days prior to the choking episode, LVN 1 and the DS had both documented witnessing Resident 1 having swallowing difficulties. DON stated there was no documentation Resident 1's physician had been notified of Resident 1's swallowing difficulty on [DATE]. DON stated Resident 1 remained with an order for a regular diet. On [DATE] at 2:40 p.m., during an interview, the DS stated she was asked by LVN 1 to go to Resident 1's room on [DATE] at approximately 4:00 p.m. to check if Resident 1 was having difficulty eating. DS stated she noticed Resident 1 did not have teeth or dentures and was having difficulty chewing and swallowing. LVN 1 was in the room and requested the diet to be downgraded. DS stated she spoke with Resident 1 about doing a diet texture trial with a pureed diet and the resident agreed. The DS stated Resident 1 received a pureed dinner on [DATE]. DS stated by the time she started work on the morning of [DATE], she received a report from nursing staff that Resident 1 did not like his pureed meal and wanted to go back to his regular diet. DS stated she started sending Resident 1 a regular diet for lunch on [DATE]. During a follow-up interview with the DS on [DATE], she stated she did not inform Resident 1's physician or the Registered Dietitian (RD) about the resident's swallowing difficulties and the pureed diet trial (LVN 1 requested) on [DATE]. DS stated she also did not communicate with anyone that Resident 1 was going back to being served a regular diet for lunch on [DATE]. DS stated if there was an order or need for feeding assistance it will be placed under the alert section of the tray card to inform the nursing staff. During an interview with LVN 2 on [DATE] at 3:45 p.m., LVN 2 stated on [DATE] around 8:30 p.m., he went to Resident 1's room to see if he was ready for his evening medication. LVN 2 stated he observed Resident 1, by himself, sitting up in bed and eating a sandwich. Resident 1 asked him for pain medication, and he (LVN 2) went to get it from the medication cart. Upon returning with the pain medication, LVN 2 stated Resident 1 started coughing and the coughing started getting worse. LVN 2 asked Resident 1 if he was okay, and Resident 1 was able to say no. LVN 2 stated he then tried tapping Resident 1's back, but the coughing persisted so he began to perform [MEDICATION(S)] Maneuver. LVN 2 stated as he was performing [MEDICATION(S)] Maneuver, Resident 1 gradually started becoming deadweight. LVN 2 further stated, RN 1 happened to be passing by and came in the room to assist. RN 1 checked Resident 1's pulse and could not find any, so they began CPR. LVN 2 stated staff had called 911 and when the paramedics arrived, they took over CPR. Resident 1 was not able to be resuscitated and was pronounced dead. LVN 2 stated there was no staff in the room to provide feeding assistance and supervision for safety while Resident 1 was eating his sandwich. LVN 2 stated he was unaware that Resident 1 needed feeding assistance since he could move both arms and can bring food to his mouth. LVN 2 stated it was not communicated to him by any of the other staff that Resident 1 had any difficulty swallowing. On [DATE] at 11:15 a.m., during an interview with MDS Nurse and concurrent review of Resident 1's MDS dated [DATE] and Resident 1's care plans from [DATE] to [DATE], the MDS Nurse stated there was no care plan developed for the incident on [DATE] where Resident 1 exhibited signs and symptoms of swallowing difficulties. The MDS Nurse further stated there was no care plan in place to address Resident 1's lack of teeth and dentures. MDS Nurse stated that facility staff should have developed a plan of care for Resident 1's swallowing difficulties and lack of teeth/dentures to ensure that interventions are developed to assist with providing care due to the identified health concerns. On [DATE] at 2:02 p.m., during an interview with LVN 1, she stated on [DATE], while doing rounds at approximately 4:00 p.m., she observed Resident 1 having chewing difficulty and pocketing food. LVN 1 stated she called DS and requested a pureed meal for dinner. LVN 1 stated she did not notify Resident 1's physician regarding Resident 1's difficulty with chewing and swallowing. LVN 1 further stated Resident was not monitored for further swallowing difficulties. LVN 1 stated looking back, she should have notified the physician of the change in Resident 1's condition, obtained orders for diet downgrade to address Resident 1's difficulty in chewing and swallowing food. LVN 1 stated she should have created a care plan including resident specific interventions to address Resident 1's pocketing of food and difficulty in chewing and swallowing food, as identified on [DATE]. On [DATE] at 5:30 p.m., during an interview with the DON, she stated the events on [DATE] regarding Resident 1's swallowing difficulty should have been reported to Resident 1's physician for further orders. LVN 1 should have completed an SBAR on [DATE] regarding resident's chewing and swallowing issues, notified the physician for a diet texture change and for swallowing evaluation. A review of the facility's undated policy and procedures titled, Resident Safety Policy indicated the facility will always monitor resident safety. A review of the facility's policy and procedure titled, Dysphagia (difficulty or discomfort in swallowing) - Clinical Protocol, last revised [DATE], indicated the staff and physician will identify individuals with a history of swallowing difficulties or related diagnoses such as dysphagia, as well as individuals who currently have difficulty chewing or swallowing food. The policy and procedure further indicated if a modified consistency diet or other restrictions are indicated, nursing will obtain an order for such restrictions from the physician.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident A) who had [DIAGNOSES REDACTED]. 1. Failure to assess Resident A's oxygen saturation (percentage of oxygen in the blood) prior to and during physical therapy (PT) treatment to identify if resident was tolerating the PT treatment. 2. Failure to administer oxygen as ordered by the physician, when the resident had episodes of shortness of breath during physical therapy treatment. 3. Failure to consistently assess Resident A's vital signs (Body temperature, heart rate, respiratory rate, and blood pressure) every shift and prior to physical therapy exercises as a baseline indicator of a resident's health status. 4. Failure to address timely Resident A's low hemoglobin and hematocrit (low red blood cell that carries oxygen in the body) dated (MONTH) 2, (YEAR), until (MONTH) 9, (YEAR), seven days later. These failures resulted in Resident A to have a change of condition on (MONTH) 14, (YEAR). Resident A had dizziness, vomited, pale and an oxygen saturation level of 67 percent (Normal range 95 to 100 percent) during physical therapy ambulation, which subsequently her health deteriorated and required cardiopulmonary resuscitation and emergency transport to a general acute care hospital (GACH). Resident A died within minutes after transfer to the GACH from the change of condition. Findings: On (MONTH) 1, (YEAR), at 11:07 a.m., an unannounced complaint visit was conducted regarding a quality of care concern. On (MONTH) 21, (YEAR), Resident A's closed record was reviewed. Resident A was admitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident A's undated Initial History and Physical indicated Resident A had the capacity to understand and make decisions. A review of Resident A's Order Summary Report, indicated the following physician orders: - (MONTH) 31, (YEAR), monitor oxygen saturation every shift for [MEDICAL CONDITION] ([MEDICAL CONDITION], the heart is unable to provide adequate blood flow to other organs, such as the brain, liver, and kidneys) and [MEDICAL CONDITION]. - (MONTH) 31, (YEAR), oxygen at two (2) liters per minute via nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) as needed for shortness of breath (SOB). (MONTH) titrate between two to four (4) liters per minute to maintain saturation greater than 92 percent (%) as needed for [MEDICAL CONDITION] and [MEDICAL CONDITION]. (MONTH) use oxygen via nasal cannula as needed. -[DATE], (YEAR), Physical Therapy (PT) orders for evaluation and treatment focusing on: Therapeutic exercises and activities, gait training, pre-gait training, neuro re-education, safety skills training, patient/caregiver training daily/split daily/twice daily as needed six (6) times per week for 60 days as tolerated for treatment of [REDACTED]. - (MONTH) 1, (YEAR), Occupational Therapy (OT) orders for evaluation and treatment focusing on: Endurance, building tasks, progressive activities of daily living (ADL, routine activities people do every day) retraining, safety education, functional bed mobility/transfer training, patient/caregiver training, therapeutic exercises/activities, neuro muscular reprogramming (NMR, a protocol for correcting the abnormal coordination that cause most musculo-skeletal pain and joint misalignment), conservation/work simplification technique and compensatory strategy training daily as needed six (6) times per week for 60 days for lack of coordination as tolerated. A review of Resident A's care plan dated (MONTH) 31, (YEAR), titled Alteration in health maintenance related to multiple comorbidities Diagnoses: [REDACTED]. The interventions included to administer medications as ordered, evaluate efficacy of medications administered, observe for stable vital signs and report any changes of condition, and rehabilitation evaluation and treatment. The care plan did not address when the vital signs will be taken to ensure the resident has stable vital signs. A review of Resident A's care plan dated (MONTH) 31, (YEAR), titled High risk for shortness of breath, chest pain, [MEDICAL CONDITION] (swelling), or elevated blood pressure as resident has [DIAGNOSES REDACTED]. The care plan did not address when the vital signs will be taken. A review of Resident A's history and physical examination [REDACTED]. (Reference range 11.2 to 15.7 gram per deciliter (g/dL) A review of Resident A's physician progress notes [REDACTED]. (Hematocrit Reference range 34.1 to 44.9 percent (%). A review of Resident A's facility blood test result dated (MONTH) 2, (YEAR), indicated hemoglobin 8.6 and hematocrit 25.9. A review of Resident A's nurses' Progress Notes dated (MONTH) 9, (YEAR), (seven days after the facility received the lab result dated (MONTH) 2, (YEAR)) at 9:46 a.m. indicated, (Nurse Practitioner's name) in facility made aware of current labs results of hemoglobin 8.6 and hematocrit 25.9 with no new orders. A review of Resident A's Physical Therapy Plan of Care indicated the start of care was from (MONTH) 1, (YEAR), until (MONTH) 14, (YEAR). The record indicated Resident A was admitted with post-surgical hip repair, co-morbidities a medical history of [REDACTED]. Resident A had [MEDICAL CONDITION] and may have shortness of breath, fatigue, swollen legs, and rapid heartbeat. Under the precautions indicated Resident A had balance precaution, including fall risk, low endurance, needed frequent rests, oxygen at two liters per minute via nasal cannula as needed for shortness of breath. (MONTH) titrate between two to four liters per minute to maintain saturation greater than 92%. Weight bearing as tolerated on right lower extremity. A review of Resident A's Physical Therapy Daily Treatment Note dated (MONTH) 14, (YEAR), untimed indicated Resident A had gait training exercise, after 20 feet of gait training, the resident's knees buckled and exhibited an immediate change of condition. A review of Resident A's nurses' Progress Notes dated (MONTH) 14, (YEAR), at 12:05 p.m. late entry for 10 a.m., indicated, Resident A was talking with PT aid during therapy and doing exercises. The note indicated when an attempt to get the resident up she started being light headed and sat back down in her chair then resident proceeded to vomit about 300 cubic centimeters (cc) of liquid and food. Resident A was brought back to her room and placed in bed. Another Progress Note entry dated (MONTH) 14, (YEAR), at 11 a.m., from a Registered Nurse indicated responded to emergency code for Resident A in bed around 10:10 a.m., noted Resident A with oxygen saturation reading of 67 %. Oxygen was placed with a non-rebreather mask (a device use for the delivery of higher concentrations of oxygen) at 15 liters per minute, and then went up to 77 % Resident A was with eyes open and unable to nod as communication with staff. Charge Nurse called [DATE] (emergency number, to summoned paramedics) and medical doctor gave order to send the resident to the general acute care hospital (GACH). Cardiopulmonary resuscitation (CPR, a medical technique for reviving someone whose heart has stopped beating) was initiated. Paramedics came on second rotation of CPR. Resident A became responsive on fourth rotation of CPR with pulse and respirations present. Resident A was then transferred out to GACH. A review of Resident A's Situation, Background, Assessment and Recommendation (SBAR, a techniques that can be used to facilitate prompt and appropriate communication) dated (MONTH) 14, (YEAR), at 11:38 a.m., indicated that the last complete vital signs of Resident A was taken on (MONTH) 13, (YEAR), at 10:23 p.m. Resident A's blood pressure was ,[DATE] (Normal range ,[DATE]), heart rate was 83 beat per minute (bpm) (Normal ranges 60 to 100 bpm), respiration 18 breath per minute (Normal range 12 to 18 breathe per minute), body temperature 98.0 degrees Fahrenheit (F) (Normal body temperature 97XXX,[DATE].5 °F) and oxygen saturation was 97 %. There was no documented evidence that Resident A vital signs were taken before and during the physical therapy treatment on (MONTH) 14, (YEAR). A review of Resident A's medical records indicated no documentation of resident's vital signs at 11 p.m. to 7 a.m. shifts on the following dates: (MONTH) 4, (YEAR), (MONTH) 8, (YEAR), (MONTH) 10, (YEAR) and (MONTH) 14, (YEAR). The last oxygen saturation was taken on (MONTH) 14, (YEAR) at 3 a.m., and the reading was 97 %. A review of Resident A's titled Pre-Hospital Care Report, obtained from fire department dated [DATE], indicated the call from the facility was received at 10:09 a.m., and dispatched at 10:09 a.m. The ambulance crew was at the scene at 10:10 a.m. The record indicated Resident A had an altered level of consciousness. The reason for the arrest was respiratory in nature. The estimated time of arrest was 10:20 a.m. Resident A was transported to GACH. A review of Resident A's Emergency Record, obtained from GACH dated [DATE], at 10:32 a.m., indicated the cardiopulmonary resuscitation continues and was terminated at 10:53 a.m. Resident A was pronounced dead. On (MONTH) 27, (YEAR), at 1:35 p.m., during an interview the Physical Therapist Assistant (PTA) stated he had been working with Resident A for a week. The PTA stated Resident A would sometimes get fatigued and had increased anxiety. The PTA stated Resident A sometimes would be out of breath during therapy sessions. PTA stated he did not communicate to nursing staff that resident had episode of shortness of breath, during therapy. PTA stated that Resident A did not use oxygen and he did not check the resident's oxygen levels prior to and during treatment exercises. PTA stated resident's vital signs should be taken prior to therapy. PTA stated on (MONTH) 14, (YEAR), he just looked at the electronic record for the vital signs recorded from the night before. The PTA stated that when he was ambulating Resident A in the hallway, resident's knees collapsed. The PTA stated he held on to her belt and her. The PTA stated he placed Resident A on a wheelchair, and then she vomited and turned pale. The PTA stated when the nurses took her oxygen saturation; it was in the low 80's. On (MONTH) 27, (YEAR), at 2:15 p.m., the Physical Therapist 1 (PT 1) was interviewed. The PT 1 stated the PTA would look at the nurses' notes and communication through the electronic record. The PT 1 stated the therapists should be aware of precautions and as needed oxygen and oxygen pulse oximetry should be conducted before activities. The PT 1 stated that Resident A's vital signs were within normal limits during previous sessions and that was why they did not check her vital signs prior to therapy session. On (MONTH) 17, (YEAR), at 10:15 a.m., during an interview and concurrent review of Resident A's medical record with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, there was no documented evidence that Resident A's vital signs were taken prior to the physical therapy session before her change of condition, on (MONTH) 14, (YEAR). LVN 1 stated the facility staff should have conducted vital signs beginning of every shift. LVN 1 stated the physical therapists should have monitored Resident A's oxygen saturation especially if the resident had an order for [REDACTED].>On (MONTH) 17, (YEAR), at 10:39 a.m., during a telephone interview with the Director of Nursing (DON), the DON stated Resident A's vital signs should be taken before therapy. The DON was asked to review Resident A's record and locate the vital signs taken prior to the physical therapy session on (MONTH) 14, (YEAR). The DON stated CNA 1 was a new employee and she was not documenting on a timely fashion and she entered the vital signs late. The DON stated she had spoken with the PT and he stated that Resident A's vital signs were always stable and they do not take vital signs if there were no concerns. On (MONTH) 28, (YEAR), at 9:13 a.m., the DON was interviewed. The DON stated that Resident A's hemoglobin and hematocrit had remained the same as the hospital and that was why the physician did not order any iron supplements. On (MONTH) 4, (YEAR), at 1:56 p.m., during a telephone interview with DON, the DON stated that the CNAs should take the vital signs once every shift, which was three times daily in a 24-hour period. A review of Resident A Certification of Death, dated (MONTH) 10, (YEAR), indicated Resident A's causes of death were the sequelae of [MEDICAL CONDITION] and other significant conditions contributing to the death were [MEDICAL CONDITIONS], hypertension (high blood pressure), [MEDICAL CONDITION] ([MEDICAL CONDITION] disease), [MEDICAL CONDITIONS] (low blood count), and [MEDICAL CONDITION]. A review of Resident A Case Report, obtained from department of coroner dated (MONTH) 6, (YEAR), indicated medical doctor certified Resident A death as an accident, and listed cause of death as: A. Sequelae of [MEDICAL CONDITION] (Weeks). Other conditions: [MEDICAL CONDITIONS], hypertension, [MEDICAL CONDITION], [MEDICAL CONDITIONS], and [MEDICAL CONDITION] A review of the facility's undated policy titled [MEDICAL CONDITION] Policy and Procedure, indicated, as part of the initial assessment, the physician will help identify individuals with a history of [MEDICAL CONDITION] or other chronic respiratory conditions. Treatment/Management. Key objectives of [MEDICAL CONDITION] management include. Prevent disease progression, where possible. Relieve symptoms. Improve exercise tolerance. Improve health status, where possible. Prevent and treat exacerbations. Prevent and treat complications. Reduce mortality; and minimize side effects from treatments. The physician and staff will manage [MEDICAL CONDITION], and address causes and exacerbating factors. This includes promoting adequate hydration and nutritional status, stabilizing cardiac function, seeking and addressing causes of [MEDICAL CONDITION], etc. The physician may prescribe treatments and ancillary treatments as indicated: for example, [MEDICATION NAME] agent, short acting beta2, corticosteroids, supplemental oxygen, diuretics, and antibiotics as indicated. Supplemental oxygen has been demonstrated to be helpful in treating [MEDICAL CONDITION] associated with [MEDICAL CONDITION] and related conditions such as cor pulmonale and primary [MEDICAL CONDITION] hypertension. Oxygen therapy during exercise may help increase walking distance and endurance. Oxygen may be administered as long-term continuous therapy, during exercise, or to relieve acute dyspnea (for example, nasal-prong oxygen at flow rates of ,[DATE] liters/minute in stable individuals). The staff and physician will identify and treat acute exacerbations of [MEDICAL CONDITION]; for example, recognizing and reporting when an individual with [MEDICAL CONDITION] has a change in function or activity tolerance, increased dyspnea, sputum production, cough, increasing lethargy or confusion, increased wheezing, increased respiratory or heart rates, etc . A review of the facility's undated policy titled Timely Physician Notification Policy, indicated, It is the policy of this facility to provide the highest level of care possible by ensuring that each resident receives care for a change of condition in a timely manner with proper notification of the primary physician or medical director if necessary. Examples of changes of condition are abnormal labs. Procedure: In the case of a non-emergency change of condition notify the primary physician immediately. If the primary physician does not return the call within one hour, then call the physician again. If there is not response from the primary physician within thirty minutes, then call the physician's exchange and notify the on call physician. If the on call physician does not respond within one hour, then contact the facility's medical director. A review of the facility's undated policy titled Oxygen Order Policy, indicated, To ensure that resident oxygen saturation remains 92% and above. Initiate oxygen ordered by the physician. Monitor oxygen saturation every shift as ordered by the physician. (MONTH) titrate ,[DATE] liters per minute via nasal cannula to maintain oxygen saturation 92% and above as ordered by the physician. According to The Guide to Physical Therapist Practice 3.0 http://guidetoptpractice.apta.org/content/1/SEC29 indicated the physical therapist uses test and measures to determine whether an individual has an adequate ventilatory pump and oxygen uptake/carbon [MEDICATION NAME] eliminaton system to meet oxygen demands at rest, during movement and during the perfomance of purposeful activity.

Based on observation, interview, and record review, the facility failed to ensure its residents receive treatment and care in accordance with the person-centered plan of care consistent with professional standards of practice for one of 24 sample residents (Resident 21), who was administered daily iron supplement ([MEDICATION NAME] sulfate) and [MEDICATION NAME] (combination of [MEDICATION NAME] and [MEDICATION NAME] - narcotic medication to treat moderate to severe pain, including: 1. Failure to accurately monitor and manage pain as indicated in the plan of care and policy and procedure. 2. Failure to monitor constipation as side effect from two medications used daily. 3. Failure to prevent abdominal pain related to constipation. As a result, on 9/20/17, Resident 21 developed severe abdominal pain, was transferred to a General Acute Care Hospital (GACH) on 9/20/17, where she was found with increased formed stool throughout the colon suggestive of constipation. The Computerized Tomography (CT Scan, a non-invasive test in which a computer is scanned across parts of the body) of the abdomen and pelvis indicated the stool in the large intestine, last part of the large intestine, and rectum is markedly compacted. Findings: On 9/19/17, at 8:45 a.m., during the initial tour of the facility, accompanied by Licensed Vocational Nurse 11 (LVN 11), Resident 21was moaning in pain all over her body. LVN 7, the medication nurse, stated she gave Resident 1 pain medication 15 minutes prior for pain severity of 7/10 (rating pain scale from zero to 10. zero indicating no pain, and 10 indicating the worst possible pain). On 9/20/17, at 9:25 a.m. Resident 21 was observed in bed moaning in pain on the lower abdomen. Resident 21 was unable to give a numerical rating of the pain but indicated, It hurts a lot. A review of the Admission Record, indicated Resident 21 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].>- [MEDICATION NAME] sulfate 325 milligrams (mg) three times a day for [MEDICAL CONDITION] dated July 3, 2017. - [MEDICATION NAME] two tablets every six hours as needed for moderate to severe pain, dated 6/27/17. - [MEDICATION NAME] (loosens stools) suppository 10 milligrams (mg) daily as needed for constipation, if no results eight hours after Milk of Magnesia is given dated June 27, 2017. A review of Resident 21's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 7/4/17, indicated Resident 21 was moderately impaired in making daily decisions, was unable to make needs known, required two-person total assistance for bed mobility and transfers, was dependent on a gastrostomy tube (GT - a soft tube surgically inserted into the stomach through the abdominal wall to administer medications and nutrition) for feeding, and was always incontinent of bowel and bladder functions. A review of the care plan dated 7/5/17, developed for Resident 21's potential for alteration in bowel elimination, related to immobility and use of [MEDICATION NAME] sulfate (a medication to increase iron levels in the blood with constipation as side effect), indicated the goal that Resident 21 would have a bowel movement regularly in the next three months. The interventions included monitoring bowel movements amount and consistency and medications causing constipation. The plan of care did not address the frequent use of [MEDICATION NAME] and its constipating side effects. A care plan dated 7/5/17, developed for Resident 21's alteration in comfort, included in the interventions identifying frequency, location, quality, onset, and manner of expressing pain, and administer [MEDICATION NAME] every six hours as needed for moderate to severe pain. The interventions did not include monitoring for abdominal pain from constipation. A review of the Narcotic and Hypnotic Record and the Medication Administration Record [REDACTED]. During the month of 9/2017, [MEDICATION NAME] was administered once on 9/3/17. A review of the bowel elimination record for the month of September 1 to 20, 2017, indicated the resident had routine normal bowel movements. During an interview with LVN 7 on September 20, 2017 at 9:35 a.m., she stated Resident 21 had been given pain medication approximately an hour and a half ago. LVN 7 stated the pain medication lasts for an hour and a half and then does not work anymore. LVN 7 stated most of the time Resident 21 is asleep and when staff move her she starts whining. LVN 7 stated the Unit Manager (LVN 11) will try to obtain a referral to see the pain management physician. LVN 7 stated the resident has had the same pain intensity since the beginning of the week on September 18, 2017. LVN 7 stated Resident 21's physician had not been called and stated she wanted to give the resident some time. LVN 7 stated she wanted to discuss Resident 21's pain with the Unit Manager (LVN 11) the day before on September 19, 2017, but she got busy with her work. A review of the bowel and bladder elimination record for the month of September 2017, indicate Resident 21 had a soft semi-formed, medium size bowel movement on September 20, 2017 at 1:34 a.m. but there was no documentation to indicate if the resident's abdominal pain was relieved as a result of the bowel movement. During an interview with Resident 21 on September 20, 2017 at 11:25 a.m., when asked if her pain had lessened since she received pain medication, she stated, My pain didn't go nowhere. LVN 7 asked Resident 21 if she remembered telling her the pain had lessened. Resident 21 stated, I did not tell you that. Resident 21 stated her pain, at that moment, was at least 5/10. A review of the progress notes dated September 20, 2017 at 12:34 p.m. by RN 6 indicated Resident 21 was crying and when asked where the pain was the resident touched all over the lower abdomen. A rectal exam was done and the resident was identified with full, hard bowel inside. During an interview with the Pain Management Nurse Practitioner (PMNP), on September 20, 2017 at 2:30 p.m., she stated Resident 21's pain medication would be changed and the resident would be placed on a bowel management program. In addition to the new medications, a kidney, ureter (urine passage), bladder x-ray (KUB) was ordered to assess for constipation and possible bowel impaction. During an interview with LVN 7 on September 20, 2017 at 3:00 p.m., she stated Resident 21 had pain this week since Monday, September 19, 2017. LVN 7 stated Resident 21 was whining on Monday. LVN 7 was unable to state the location of the pain on the other days she assessed Resident 21 as having pain, because the pain location was not recorded on the computer documentation. A review of Resident 21's Interdisciplinary Team (IDT- a group of experts from several different fields) note dated September 20, 2017 at 3:48 p.m., indicated the following: Abdomen distended with resident guarding abdomen. RN able to pull 210 milliliters of residual (from the [DEVICE], residual is the amount of tube feeding not absorbed. If there is a large residual this indicates a resident is not digesting the tube feeding.) Enteral feeding put on hold per order to hold for residual greater than 30 milliliters. Physician contacted regarding resident's complaint of pain. Orders received from pain management consult. KUB to evaluate bowel patterns. Resident at risk for constipation due to pain management administration. During an interview with LVN 7 on September 20, 2017 at 4:35 p.m. she stated the KUB had not been ordered on the computer yet, as she was busy, but was going to enter the order. The Director of Nurses (DON) was notified that the order had not been entered into the computer. The DON stated she would order the test to rule out bowel obstruction immediately. During an interview with the DON on September 20, 2017 at 5:30 p.m., three hours after the stat KUB was ordered by the PMNP, she stated Resident 21 was going to be sent to the hospital for the KUB test because this would be faster than waiting for the x-ray technician to arrive at the facility to conduct the xray. A review of Resident 21's SBAR Communication Form, dated September 20, 2017 at 5:31 p.m., indicated Resident 21 was complaining of abdominal pain and nothing helps to relieve the pain. The Nursing Notes section indicates Resident 21 complains of abdominal pain, PRN pain medication not relieving resident's pain. A review of the General Acute Care Hospital (GACH) Emergency Record dated September 20, 2017 at 6:20 p.m. indicates Resident 21 was brought in by ambulance from the facility for abdominal pain unable to make a bowel movement for 24 hours. The resident's pain level was of 10 of 10. A review of Resident 21's Computerized Tomography (CT Scan, a non-invasive test in which a computer is scanned across parts of the body) of the Abdomen and Pelvis, completed September 20, 2017 at 11:23 p.m., indicated Resident 21 had increased formed stool throughout the colon suggestive of constipation with no evidence of bowel obstruction. The CT indicated the stool in the descending colon, sigmoid colon and rectum is markedly hyperdense. A review of Resident 21's MAR for September 2017, indicated Resident 21 received Milk of Magnesia as needed bowel management on September 20, 2017, at 1:20 p.m. after the survey began and after the resident's abdominal pain was brought to the attention of LVN 7. A review of the facility's policy and procedure titled, Pain - Clinical Protocol, Revised June 2013, indicated the following: 1. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain. 2. The physician will help identify causes of pain; for example, by examining the resident directly, reviewing the resident's history, and via discussion with the resident and staff. 3. For the individual who is receiving opioid (Narco) [MEDICATION NAME], the physician will order a regimen of laxatives and other measures to prevent constipation. 4. If the resident's pain is complex or not responding to standard interventions, the Attending Physician may consider a psychiatric evaluation or referral to a pain clinic or specialist. A review of the facility's undated policy and procedure titled, Bowel Care - Constipation indicated the facility will assess any resident that is clinically at risk for constipation based on medication administration. Such medications that will be reviewed are narcotics that are known to cause constipation. The following procedures will be initiated for any residents with no substantial bowel movement within three days. Any resident on a narcotic, unless contraindicated, will be given [MEDICATION NAME] as ordered. Constipation Risk Assessment will be completed on all residents upon admission, any requiring narcotics, and residents that trigger as high risk. The policy indicates that a resident at risk for constipation will be placed on routine laxatives per physician's orders [REDACTED].

Based on interview and record review the facility failed to ensure one out of one sample resident (Resident 1) was provided with necessary care and services by failing to: 1. Develop a plan of care that directed the Certified Nursing Assistants and the licensed nursing personnel to implement necessary interventions for the use of an arm sling for Resident (1). 2. Provide ongoing assessment and monitoring of Resident (1) who used a sling for immobilizing the right upper extremity, and was at risk for skin breakdown, in order to ensure a skin condition was resolving. 3. Provide necessary care to prevent the progression of a skin infection of Resident 1 who was immobile and was a high risk for skin trauma due to use of anticoagulant (a medication used to help prevent blood to clots) therapy. 4. Obtain and or clarify the physician's order for the care of Resident 1's sling, in order to prevent complications from the use of the device. 5. Provide Resident 1's family member (FM) 1 education regarding skin care required after discharge from the SNF. This deficient practice resulted in Resident 1 developing a candidiasis (a yeast-like parasitic fungus) infection, skin breakdown under the right armpit, and required hospitalization in a general acute care hospital (GACH) for 5 days. Findings: A review of Resident 1's general acute care hospital (GACH) operative report, dated August 27, 2015, indicated an immobilizer was placed after surgery. A review of Resident 1's admission record indicated she was originally admitted to the skilled nursing facility on May 18, 2015 and readmitted on [DATE] with [DIAGNOSES REDACTED]. of anticoagulants, and diabetes mellitus (abnormally high levels of the sugar glucose in the blood.) A review of Resident 1's initial skilled nursing facility (SNF) admission assessment dated [DATE], indicated a discoloration was noted on the right armpit area. A review of nursing admission notes dated September 6, 2015, did not note that Resident 1 was admitted to the SNF with a sling. A review of Resident 1's physician's progress notes on September 6, 2015, September 14, 2015, September 16, 2015, and September 17, 2015 indicated resident had a sling to right upper extremity and skin was warm and dry, no rash or [DIAGNOSES REDACTED] (a superficial reddening of the skin as a result of injury or irritation causing dilatation of the blood capillaries) present. A review of the skin trauma (injury) risk assessment dated [DATE], indicated Resident 1 was at high risk due to poor nutrition, three or more predisposing [DIAGNOSES REDACTED]. The current use of a device (sling) was not identified on assessment. A review of Resident 1's Restorative Nursing Assistance (RNA-Restorative Aide to help residents recover their physical emotional and mental health by providing rehabilitation care) range of motion (ROM) screening, (a tool to determine the mobility of joints) dated September 8, 2015, indicated how to appropriately perform ROM for non-weight bearing (the amount of weight a patient puts on the arm) upper extremities. The screening did not indicate Resident 1 had a sling or how to perform ROM while using a sling. A review of the interdisciplinary team (a coordinated group of experts from several different fields) review (ITR) dated September 8, 2015, with family member (FM) 1 indicated Resident 1 had a right shoulder immobilizer (sling). A review of Resident 1's Minimum Data Set (MDS-comprehensive assessment) dated September 13, 2015; indicated Resident 1's cognitive status was moderately impaired. The MDS also indicated Resident 1 needed extensive assistance with a minimum of one person assist for bed mobility, dressing, personal hygiene, and was totally dependent on 1 person to physically assist with bathing. The MDS indicated Resident 1 had an impairment of both upper extremities. The MDS also indicated the resident had a shoulder joint replacement. A review of Resident 1's care plan initiated on September 14, 2015, titled Limitations in joint mobility related to status [REDACTED]. A review of Resident 1's care plan initiated on September 14, 2015, also indicated Resident 1 was at High risk for skin discoloration/hematoma (a collection of blood outside of a blood vessel), skin tears/skin breakdown due to use of anticoagulants (medication to prevent blood from clotting), and use of device. Intervention approaches included monitor skin condition at least once a day, notify physician if skin redness discoloration impairments are noted, handle gently during care, and good skin care. The type of device utilized for Resident 1 was not indicated on care plan. A review of Resident 1's care plan initiated on September 14, 2015, titled impaired skin integrity related to [MEDICAL CONDITION] (swelling) included an approach to monitor increasing in size and to report to physician promptly. The care plan did not address the discoloration noted on the right armpit area during the initial SNF admission assessment of September 6, 2015. A review of Resident 1's physician's order summary dated September 5, 2015 indicated [MEDICATION NAME] (an anticoagulant), five milligrams by mouth in the evening was ordered and a new order was obtained on September 14, 2016, for [MEDICATION NAME] two milligrams by mouth in the evening every Thursday. A review of Resident 1's international normalized ratio (INR- a calculation used to monitor blood thinning medications) results dated September 14, 2015, was 2.3 (high), indicating the resident was more likely to experience skin changes. The reference range is between 0.8 and 1.2. The National Institutes of Health/U.S. National Library of Medicine, MedlinePlus, regarding the use of [MEDICATION NAME] ([MEDICATION NAME]), indicates that a physician must be called immediately if a purplish or darkened color to skin, skin changes, ulcers, or an unusual problem in any area of the skin or body, or color or temperature change in any of the body is experienced by the patient. Resident 1's initial skilled nursing facility (SNF) admission assessment dated [DATE], indicated a discoloration was noted on the right armpit area, but there was no documented evidence on the progress notes of September 2015 to indicate the physician was notified. A review of Resident 1's physician's order summary dated September 16, 2015, indicated no range of motion to the right shoulder, non-weight bearing on right shoulder every day shift for non-weight bearing until October 18, 2015. A review of Resident 1's physician's order summary also indicated RNA for range of motion to the right elbow towards flexion and extension (bending and straightening the elbow) every day, 5 days a week for 90 days every day shift. There was no physician order to remove the resident's sling as part of providing daily care needs to the resident or to assess and monitor the resident's skin status in relation to the sling use. A review of occupational and physical therapy plans of care, dated September 8, 2015, did not indicate Resident 1 was utilizing a sling/immobilizer. A review of occupational therapy discharge summary, dated September 16, 2015, indicated incorporation of assistive/adaptive equipment into safety skills education. Resident was discharged to RNA program. The type of device was not indicated in discharge summary and to whom discharge instructions were given to. A review of an ITR dated September 18, 2015, indicated rehabilitations services have been transferred to RNA program and RNA's have been educated and trained appropriately regarding ROM and exercises. The ITR did not specify how to care for Resident 1 for the use of the sling as part of providing daily care needs to the resident or to assess and monitor the resident's skin in relation to the sling. A review of Certified Nursing Assistant (CNA) daily flow sheets for September 7, 2015 to September 21, 2015, indicated Resident 1 was receiving partial and full bed baths and was dependent on full staff assistance. The daily flow sheets did not specify Resident 1's sling was removed or the resident's skin was observed when providing daily care needs, to determine the resident's skin status. There was no documented evidence in Resident 1's licensed nurses notes, certified nursing notes, rehabilitation notes, RNA notes or progress notes from September 6, 2015, when the resident was readmitted to the facility to September 21, 2015, when the resident was discharged home, to indicate the status of the resident ' s discoloration of the right armpit. There was no documented evidence the staff members considered if the resident required intervention, for the armpit discoloration, if the discoloration was resolving, and no documented evidence of ongoing assessment to include for example; the size of the area, color, drainage in an attempt to ascertain the condition of the right armpit skin. A review of the Licensed Personnel Progress notes dated September 21, 2015, at 6:50 p.m. indicated Resident 1 was discharged home. A review of the licensed nurse discharge note, dated September 21, 2015, does not note the shoulder staples, shoulder dressing, right axilla discoloration, or that resident had a right upper extremity sling. A review of nursing notes dated September 21, 2015, and discharge notes did not indicate education was provided to Resident 1 or FM 1 regarding sling care, to ensure Resident 1 received skin care required after discharge from the SNF. A review of Resident 1's GACH emergency room (ER) assessment dated [DATE], at 2:50 p.m., indicated the resident was evaluated and treated at the GACH ER 44 hours after the resident was discharged from the SNF. Resident 1 was diagnosed with [REDACTED]. A review of GACH physician's consultation dated September 26, 2015, indicated Resident 1 was admitted to the GACH and was diagnosed with [REDACTED]. Resident 1 was treated with [MEDICATION NAME] powder (antifungal powder medication), [MEDICATION NAME] (antifungal medication), and was being administered [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic). A review of the GACH transfer records dated September 28, 2015, indicated Resident 1 and FM 1 refused to return to the SNF and Resident 1 was discharged home with FM 1. On October 21, 2016, during an interview at 12:00 p.m., the director of rehabilitation (DOR) stated, residents who have an immobilizer (sling) and have an order for [REDACTED]. The DOR stated a physician's order for removal of and the frequency of is required to remove the immobilizer. When the DOR was asked regarding checking the resident's skin when an immobilizer is removed, the DOR stated the skin assessment is under nursing care and the nurses check for orders regarding removing the immobilizer. On October 21, 2016, during an interview at 12:30 p.m., LVN 1 stated usually there are orders on how to care for residents who are using an immobilizer. A review of Resident 1's physician order summary dated September 16, 2015, did not include an order to remove the sling or to assess the skin or specify how to provide care to the resident who used a sling. On October 21, 2016, during a concurrent interview and record review of Resident 1's medical record at 2:00 p.m., the director of nursing (DON) stated she could not locate the RNA notes. The DON also stated when a resident has a hard immobilizer/brace the skin is checked every two hours. The DON stated Resident 1 had passive range of motion. The DON recalled upon admission Resident 1 had skin issues under her breasts. The DON stated while reviewing notes for activities of daily living, Resident 1 always received a bed bath. The DON stated when monitoring for skin discoloration it should be addressed in the care plan and documented in the Medication Administration Record [REDACTED]. There was no documentation on the MAR indicated [REDACTED]. On October 21, 2016, during an a concurrent interview and record review at 2:50 p.m., licensed vocational nurse (LVN) 2 recalled taking Resident 1 ' s sling off for activities of daily living and bed baths. LVN 2 also stated there was some discoloration under the armpit at admission. LVN 2 stated there is no documentation related to the discoloration to the right armpit noted on the admission note. LVN 2 further stated no orders were indicated on the MAR indicated [REDACTED]. On October 21, 2016, during an interview at 3:05 p.m., LVN 3 stated she cared for Resident 1 during her admission. LVN 3 stated she fixed Resident 1's sling during repositioning. LVN 3 also stated she did not look under the resident ' s armpit. LVN 3 stated she did not remove the sling to assess the resident ' s skin. On November 7, 2016, during an interview at 10:30 a.m., the physician stated she does not recall receiving a call from the nursing staff regarding a skin issue or for clarification of the sling order for Resident 1. On November 8, 2016, during an interview at 10:53 p.m., LVN 4 stated he recalled LVN 4 stated he recalled the report was to not remove the sling at all. LVN 4 also stated Resident 1 and FM 1 would get upset when staff would touch the arm. LVN 4 stated Resident 1 would scream when staff attempted to touch or look under the sling. LVN 4 stated he did not check the physician order regarding the sling. LVN 4 stated he should have looked at the orders related to the sling but had become busy. On November 17, 2016, at 9:30 a.m., Registered Nurse (RN) 1 stated she is no longer employed at the SNF. RN 1 stated she does not recall Resident 1. RN 1 stated while employed at the SNF, the role of the RN supervisor was to ensure the LVN completed assessments correctly. A review of the facility's policy and procedure dated May 17, 2016, titled Skin Assessment Clinical Guideline indicated skin assessments are to be completed on admission and as needed. The following will be completed by: 1. Upon admission an assessment will be completed by a licensed nurse and documented. The assessment will include but is not limited to: trunk, observation of suspected deep tissue injuries, bruising, discoloration of skin, rashes, dry skin, surgical incisions and/or scars. 2. On a daily basis: CNAs will observe skin during a.m., and p.m. care, bathing, showers, during turning and incontinent care and will report skin concerns to the charge nurse immediately. 3. On as needed basis: Licensed nurses are to do skin assessment/reassessment of all residents identified as high risk for skin breakdown. The licensed nurse will document assessment, intervention and outcome. 4. If a problem with integrity is noted the nurse will document problem, notify the physician and family, initiate treatment per physician orders and intimate a plan of care entry. The nurse needs to review and revise the care plan to respond to new problems or needs. A review of the facility's Use of rehab equipment and adaptive equipment undated policy and procedure indicated will use rehab equipment(s) and/or adaptive equipment(s) in conjunction with their professional clinical skills, experience, judgements, ability and knowledge in compliance with applicable statutes, regulations, rules, and directives of regulatory bodies having jurisdiction over facility and all currently acceptable and approved methods and practices of the professional specialty of therapy in which the particular individual providing the service is involved. A review of the facility's undated policy and procedure titled, Admission Procedures, indicated the registered nurse (RN) should thoroughly review the admission orders [REDACTED]. A review of a manufacturers Arm Slings instructions includes a warning issued to follow the facility's policy and procedure for frequency of patient monitoring. The manufacturer recommends that this product be removed a least every two hours to check for skin integrity, proper circulation and range of motion.

Based on interview, and record review, the facility failed to ensure that Resident 2 and Resident 3 would not be subjected to physical abuse by Resident 1 who exhibited recurrent aggressive and violent behaviors towards 2 out of 3 sampled residents (Resident 2 and 3), by failing to: 1. Implement Resident 1's care plan to keep the resident away from other residents when agitated. 2. Identify specific risks for Resident 2, and Resident 3 as indicated in the facility policy. As a result, Resident 1 pushed Resident 2 causing him to fall. Resident 2 sustained a fracture to his right femur (the bone of the thigh, articulating (forming a joint) at the hip and the knee) in the fall. Resident 2 was transferred to the general acute care hospital (GACH), had an open reduction internal fixation (ORIF- a surgical procedure to repair the fractured bone), and required hospitalization for three days. This violation also placed Resident 2 at risk for potential complications associated with having surgery, under general anesthesia, that included bleeding, infection, and [MEDICAL CONDITION]. A review of the literature indicated that the risk and complications associated with a surgery under general anesthesia included bleeding, [MEDICAL CONDITION], and pneumonia and kidney failure during or after an operation, [MEDICAL CONDITION] ([MEDICAL CONDITION]-occurs when blood clots develop in the large veins of the leg. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung, called a [MEDICAL CONDITION] embolism) and cause infection (Savel, Richard H., Postoperative Care. Hospital Medicine 2nd Ed. Philadelphia: Lippincott, Williams, & Wilkins, 2005. 261- 269). Resident 1 also had a history of [REDACTED]. Resident 1 sustained an avulsion fracture (a bone fracture which occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma) to his right fourth finger in the same altercation. This deficient practice resulted in physical harm for two out of 3 sampled residents (2, 3) and had the potential to result in harm to other residents in the facility. Findings: 1a. According to the admission record, Resident 1 was admitted to the skilled nursing facility (SNF) on May 31, 2013, with [DIAGNOSES REDACTED]. changes, and impaired reasoning), an unspecified mood disorder, and [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). The Minimum Data Set (MDS - a comprehensive assessment and screening tool) assessment, dated May 26, 2015, indicated Resident 1 was moderately impaired in cognitive skills for daily decision-making. Resident 1 has problems with temporal orientation (orientation to year, month, and day). Resident 1 is sometimes understood and sometimes understands. The MDS indicated that Resident 1 needed only supervision in activities of daily living. The only support Resident 1 needed was setup help only. A review of Resident 1's physician's orders [REDACTED]. 1. [MEDICATION NAME] tablet 10 milligrams (mg) at bedtime for dementia without behavioral disturbance, dated June 19, 2014. 2. [MEDICATION NAME] tablet 10 mg two times a day (BID) for dementia without behavioral disturbance, dated June 19, 2014. 3. [MEDICATION NAME] Syrup 500 mg by mouth BID for mood disorder manifested by irritability, dated September 10, 2014. 4. [MEDICATION NAME] 0.25 mg BID for dementia manifested by physical aggression, dated November 27, 2014. A review of Resident 1's care plan, dated August 25, 2015, indicated problems with behavioral patterns: physical aggression. The goal was that the resident will not have more than three episodes of physical aggression each week until next review. One of the interventions listed was: Keep resident away from other residents when agitated. According to the admission record, Resident 2 was admitted to the skilled nursing facility (SNF) on October 27, 2013 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a comprehensive assessment and screening tool) assessment, dated March 28, 2015, indicated Resident 2 was moderately impaired in cognitive skills for daily decision-making. Resident 2 has problems with temporal orientation (orientation to year, month, and day). Resident 2 is sometimes understood and sometimes understands. Resident 2 needs extensive assistance (resident involved in activity, staff providing weight-bearing support) for walking inside his room and in the corridor. Resident 2 also needs extensive assistance for dressing, toilet use and personal hygiene. Resident 2 needed one staff person available to assist in activities of daily living. A review of Resident 2's physician's orders [REDACTED]. 1. [MEDICATION NAME] tablet 0.5 by mouth BID for [MEDICAL CONDITION] manifested by striking out at staff and other residents. Target behaviors are: hitting, threatening, screaming at and cursing others, and rummaging, dated April 15, 2015. 2. [MEDICATION NAME] tablet 0.5 mg by mouth every 8 hours PRN for anxiety manifested by restlessness (frequent attempts of getting out of bed or wheelchair unassisted, agitation (yelling), and wandering, dated July 19, 2015. 3. [MEDICATION NAME] tablet 5 mg by mouth BID for dementia, dated September 2, 2014. A review of Resident 2's care plan, dated July 17, 2014, indicated problems with behavioral patterns: delusions that people want him to go through their things.The goal was: resident will not have more than one episode each week until next review. One of the interventions was to keep the resident away from other resident's when agitated. A review of the Resident to Resident Altercation Investigation, dated April 28, 2014, indicated there was an altercation between Resident 1 and Resident 2. According to this investigation report, Resident 1 and Resident 2 were talking to each other in the hallway in their wheelchairs. Resident 1 stood up in his wheelchair and using his right hand, punched Resident 2 once in the forehead. There were no serious injuries at this time. A review of the Notice of Room Change record, dated February 18, 2015, indicated Resident 1 was moved to room [ROOM NUMBER]. The reason for this room change was Reorganizing station. A review of the Notice of Room Change record, dated June 10, 2015, indicated Resident 2 was moved to room [ROOM NUMBER], where Resident 1 also resided. Resident 1 had an altercation with Resident 2 previously on April 28, 2014. The reason for this room change was more appropriate roommates. Even though Resident 1 had an altercation with Resident 2 on April 28, 2014, Resident 2's IDT (interdisciplinary team) Notes, dated April 15, 2015, did not identify the risks associated with Resident 1 and Resident 2 being placed in the same room as indicated in the facility's policy and procedure, Safety and Supervision of Residents, revised December 2007. The facility's policy and procedure titled, Safety and Supervisions of Residents, revised December 2007, indicated the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. A review of the skilled nursing facility (SNF) Investigation Report, dated August 31, 2015 indicated, on August 31, 2015, at 8:35 a.m., Certified Nursing Attendant (CNA 1) responded to a chair alarm sounding in Resident 1's room. CNA 1 entered the room. Resident 2 said he hit me in the face twice. The Investigation Report, dated August 31, 2015, also indicated Resident 2 was referring to Resident 1. Resident 1 was standing near Resident 2 and before CNA 1 intervened, Resident 1 pushed Resident 2, and Resident 2 fell to the ground. Resident 2 was transferred to a GACH. A review of Resident 2's GACH Discharge Summary, dated September 2, 2015 indicated Resident 2 had an ORIF of the right hip. Resident 2's Discharge Summary also indicated Resident 2 was hospitalized for [REDACTED]. On September 10, 2015 at 5:00 p.m., during an interview with the administrator, he stated that he did not know why Resident 1 and Resident 2 were placed in the same room, even though the two residents had already had an altercation in 2014. The administrator stated that this may have been an oversight on the facility's part. On September 30, 2015 at 2:00 p.m., during an interview with CNA 1, she stated that when she entered Resident 1 and 2's room on August 31, 2015, just prior to the incident, Resident 1 and Resident 2 were in the room and no other staff were in the room at the time just prior to Resident 1 striking Resident 2. CNA 1 stated she did not physically attempt to stop Resident 1 because she was afraid for her own safety and before she could call for help, Resident 1 pushed Resident 2, causing Resident 2 to fall. On September 30, 2015 at 2:30 p.m., during an interview with the Director of Staff Development (DSD), when asked what interventions are done to ensure residents are kept away from agitated residents, she stated interventions included hourly and 2 hour monitoring by CNAs (Certified Nursing Assistant), and sometimes 1 to 1 monitoring if needed. On January 13, 2016 at 3:55 p.m., during an interview with the administrator, he stated that neither he, nor the Director of Nursing (DON) could provide documentation of who authorized the transfer of Resident 2 into the same room as Resident 1, with a history of a previous altercation on April 28, 2014. 1 b. A review of the Entity Reported Incident (ERI), dated March 25, 2014, indicated Resident 1 had a history of [REDACTED]. A review of the ERI dated March 25, 2014, received by the Department of Public Health, indicated that on March 23, 2014 an altercation occurred between Resident 1 and Resident 3. According to the admission record, Resident 3 was admitted to the skilled nursing facility (SNF) on November 21, 2009 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a comprehensive assessment and screening tool) assessment, dated June 4, 2014, indicated Resident 3 was moderately impaired in cognitive skills for daily decision-making. Resident 3 needs extensive assistance for walking inside his room and in the corridor. Resident 3 also needs extensive assistance for dressing, toilet use and total dependence for personal hygiene. Resident 3 needed two staff person assist in walking and one person assistance in dressing and personal hygiene. A review of the GACH Emergency Physician Record, dated March 23, 2014, indicated Resident 3 had a 3 centimeter (cm) (a unit of measure) laceration (a deep cut or tear in skin or flesh) to the left outer eye and required 5 stitches to repair the injury. A review of Resident 1's GACH hand Radiology report, dated March 24, 2014, indicated Resident 1 had sustained an avulsion fracture to his right fourth finger during the March 23, 2014 altercation between Resident 1 and Resident 3. A review of the SNF doctor's orders for Resident 3, dated March 23, 2015, 3:45 p.m. indicated, Cleanse sutures with N/S pat dry (left eye). Apply [MEDICATION NAME] QHS (at bedtime) for 7 days then re-evaluate. On September 3, 2015 at 2:15 p.m., during an interview with CNA 1, she stated that more than a year ago that Resident 1 had had an altercation with another resident. She said she did not remember which resident the altercation was with. On September 3, 2015 at 3:30 p.m., during an interview with Licensed Vocational Nurse (LVN 1), she stated that Resident 1 is unpredictable even when being monitored. The facility's policy and procedure titled, Safety and Supervisions of Residents, revised December 2007, indicated the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident.

Based on observation, interview, and record review, the facility failed to prevent the development of multiple pressure ulcers with infection that progressed to Stage IV pressure ulcers (the most severe form of the wound, as it has spread to the underlying bone or muscle) for one out of 24 sample residents (13) by failing to: 1. Ensure Resident 13 who assessed at a risk to develop pressure ulcers was provided with care and services that included turning and repositioning every two hours and/or as often as necessary as indicated in the plan of care. 2. Ensure Resident 13 was provided and consumed the nourishment needed to prevent the development of pressure ulcers and to promote wound healing, evaluate the resident's level of food consumption, and plan accordingly to assure the resident would not be malnourished. 3. Inform the physician about the resident's poor food intake to evaluate the need for alternative feeding plan with consent from the resident and/or the responsible party such as tube feeding or [MEDICATION NAME] nutrition (feeding a person intravenously, bypassing the usual process of eating and digestion) as appropriate when the resident was unable to consume and refused foods and fluids served in order to meet the resident's caloric, protein and fluid needs. Resident 13 developed Stage I pressure ulcers that progressed to Stage III on the right and left buttocks, and Stage IV on the coccyx (tailbone) and the [MEDICATION NAME] area (back). Resident 13 was transferred to the general acute care hospital (GACH) with [DIAGNOSES REDACTED]. The resident was discharged back to the facility after being hospitalized for [REDACTED]. Findings: According to the admission record Resident 13 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. kidney failure), pressure ulcers, and acute osteo[DIAGNOSES REDACTED] (bone infection of short duration). The Nursing Admission assessment dated [DATE], indicated the resident had skin redness to her right and left buttock. The Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated January 22, 2015, indicated Resident 13's cognitive skills for daily decision-making were intact, and required extensive assistance from staff with activities of daily living. The resident was assessed with [REDACTED]. The MDS indicated the resident was at risk to develop pressure ulcers, and had two sites of Stage I (skin redness) pressure ulcers. The MDS dated [DATE], indicated the resident was assessed with [REDACTED]. Slough (a mass of dead tissue separating from an ulcer) may be present but does not obscure the depth of tissue loss). A review of the resident's care plan dated January 9, 2015 for skin integrity, at risk for skin breakdown related to refusal to turning and repositioning, and refusal to get out of bed for recreational. The approach plan included alternating pressure pads mattress, encourage to be out of bed daily as tolerated, and to encourage consuming 80 to 90 percent of meals. The care plan did not address how the staff will encourage the resident to turn and reposition to promote wound healing. The physician's orders [REDACTED]. The Skin Condition Report dated January 12, 2015 indicated left buttock excoriation (any superficial loss of substance, as that produced on the skin by scratching), measured length 2.5 centimeters (cm) and width 2.5 cm, and depth of 0.1 superficial. Another, Skin Condition Report dated January 12, 2015 indicated right buttock excoriation that measured length 2 cm, width 2 cm, and depth of 0.1 cm superficial. The documentation indicated the right and left buttock excoriations merge into one site. A review of the Interdisciplinary Wound Management Care Plan dated January 16, 2015 indicated altered skin integrity, right and left buttock redness. The approaches included to reposition the resident every two hours or as often as necessary. The Interdisciplinary Wound Management Care Plan dated January 28, 2015 indicated altered skin integrity, Stage II pressure ulcer (partial thickness skin loss) to coccyx measured 2.5 cm by 2.5 cm, the short term goal indicated the pressure ulcer will improve in size and stage until resurfacing without any complications daily times 90 days. The approaches included to assess factors that have led to the development of pressure ulcer, provide/encourage adequate nutrition and hydration to promote healing process and reposition every two hours or as often as necessary. The Wound Management Update for the coccyx pressure ulcer indicated the following: 1. February 27, 2015, coccyx Stage III, reposition every two hours, low air loss mattress or pressure reducing mattress. 2. March 13, 2015, coccyx Stage III measured 2.1 cm by 3 cm with light drainage. 3. March 20, 2015, coccyx Stage III measured 2 cm by 3 cm with light drainage. 4. March 27, 2015, coccyx Stage III measured 2 cm by 2.5 cm, depth 0.2, 50 percent (percent) slough, and 50 percent granulation (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process). 5. April 2, 2015, coccyx Stage III measured 2 cm by 2.5 cm, depth 0.2 cm, 40 percent slough and 60 percent granulation tissue. 6. April 7, 2015, coccyx Stage IV measured 2 cm by 2 cm, depth 0.1 cm, and necrotic tissue liquefying. 7. April 16, 2015, coccyx Stage III measured 1.5 cm by 2 cm, with 80 percent red granulating and 20 percent yellow liquefying tissue. 8. April 23, 2015, coccyx Stage III measured 2.2 cm by 2.0 cm, depth 0.1 cm, with slough. 9. April 28, 2015, coccyx Stage III measured 2.2 cm by 2.0 cm, with yellow slough. 10. May 6, 2015, coccyx Stage III present as unstageable, measured 4.0 cm by 4.1 cm, depth 0.9 cm, 40 percent pink, 50 percent deep purple, and 10 percent yellow tissue. The Interdisciplinary Wound Management Care Plan dated March 13, 2015, indicated altered skin integrity, mid back pressure ulcer, measured 3.5 cm. by 2 cm. The approaches indicated assess factors that have led to the development of decubitus ulcer and to reposition resident every two hours or as often as necessary/indicated. The Wound management Update for mid back pressure ulcer indicated the following: 1. March 20, 2015, mid back Stage III, measured 1.5 cm by 0.5 cm, with drainage and yellow in color. 2. March 27, 2015, mid back Stage III, measured 1.2 cm by 0.8 cm, depth 0.2 cm, 50 percent yellow necrotic tissue and 50 granulating tissue. 3. April 2, 2015, mid back Stage III, measured 1.0 cm by 0.8 cm, depth 0.1 cm with 70 percent yellow necrotic tissue. 4. April 9, 2015, mid back Stage III, measured 1.2 cm by 0.8 cm, depth 0.2 cm, with thin yellow necrotic tissue. 5. April 16, 2015, mid back Stage III, measured 1.5 cm by 1 cm, depth 0.2 cm. 6. April 23, 2015, mid back Stage III, measured 2 cm by 1.8 cm by 0.2 cm, with yellow necrotic tissue. There was a Wound Consultant documentation dated May 6, 2015 indicated unstageable coccyx pressure ulcer measured 4.1 cm by 4.1 cm, depth 0.9 cm and mid back pressure ulcer, measured 2.4 cm by 2.5 cm, and depth of 1.0 cm. On June 1, 2015, at 9:50 a.m., during treatment observation done by Licensed Vocational Nurse 11 (LVN 11), Resident 13 was observed with Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) pressure ulcer to her coccyx (tail bone) measured by LVN 11 as 2 cm in length by 3.5 cm in width, and 0.3 cm in depth, with light purplish discoloration on surrounding skin, and the wound bed had yellow slough (dead tissue). Another pressure ulcer was observed on resident ' s mid-spine ([MEDICATION NAME] area), measured 3 cm by 2.5 cm, depth 0.8 cm, with 1.2 cm undermining (a closed passageway under the surface of the skin that is open only at the skin surface) at 12 O'clock, 0.7 cm undermining at three O'clock, 0.4 cm undermining at six O'clock and 0.7 cm undermining at nine O ' clock. The pressure ulcer wound bed had yellow slough and light purplish color on surrounding skin. A review of resident meal consumption recorded on the Nursing Assistant Daily Flow Sheet from January 9 to April 2015, indicated Resident 13 had consumed less than 50 percent of her meal. For example: 1. During the month of January 2015, the resident's food consumption was less than 50 percent 11 times for breakfast, times, 12 times for lunch and 16 times for dinner. During this month the resident refused meal four times. 2. During the month of February 2015, the resident's food consumption was less than 50 percent seven times for breakfast, 16 times for lunch and eight times for dinner. During this month the resident refused meal two times. 3. During the month of March 2015, the resident's food consumption was less than 50 percent two times for breakfast, seven times lunch, and eight times dinner. 4. During the month of April 2015, the resident's food consumption was less than 50 percent six times for breakfast, 18 times for lunch, and 13 times for dinner. A review of the laboratory test result for [MEDICATION NAME] (a blood test to measure the amount of protein in body), and Pre [MEDICATION NAME] (is a blood test to detect whether a person is getting proper nutrition, specifically protein, it also a test to identify malnutrition) indicated the following: 1. On February 10, 2015, [MEDICATION NAME] 3.9 gram per deciliter (reference range 3.5 to 5.2 gram/dL). 2. on March 10, 2015, [MEDICATION NAME] 3.6 g/dL. 3. On April 9, 2015, [MEDICATION NAME] 2.8 g/dL, and Pre [MEDICATION NAME] was 10 milligram per deciliter (mg/dL- reference range 20 to 40 mg/dL). When Resident 13's pressure ulcers were deteriorating, her food consumption was less than 50 percent, when she refused to eat on repeated occasions, and when the laboratory test results indicated her [MEDICATION NAME] and pre-[MEDICATION NAME] levels were low, there was no documented evidence that indicated the interdisciplinary team (IDT), which included the physician, had offered the resident and/or her representative the option for alternative means of feeding that included tube feeding or [MEDICATION NAME] nutrition as appropriate to meet the resident's caloric, protein and fluid needs, and to promote wound healing. A review of the physician's orders [REDACTED]. According to Resident 13's Consultation Report from the GACH dated May 14, 2015, indicated the following findings: 1. Decubitus ulcer over the [MEDICATION NAME] spine with compressed T-12 vertebra (the 12th [MEDICATION NAME] vertebra). The documentation indicated not able to rule out osteo[DIAGNOSES REDACTED] due to proximity of the pressure ulcer to the compressed vertebra. 2. Compression fracture T-12 rule out secondary to osteo[DIAGNOSES REDACTED] versus [MEDICAL CONDITION]. The note indicated the resident did not want surgery. 3. Malnutrition. 4. Multiple pressure ulcers The GACH laboratory result for Pre-[MEDICATION NAME] indicated 9 mg/dL (reference range 20 to 40 mg/dL. Resident 13 was admitted to the GACH from May 13, 2015 for intravenous antibiotic and return to the facility on [DATE]. A review of Resident 13's physician's orders [REDACTED]. Resident's family member may bring food from home. The resident had no other nutritional supplement in between meals or during medication pass to increase her meal intake, to promote wound healing. During an interview with Resident 13 in the presence of treatment assistant and LVN 11 on June 1, 2015, at 9:50 a.m., she stated she did not refuse to be turned or repositioned, and/or to get out of bed except after her [MEDICAL TREATMENT]; and when she is eating she did not want to be turned. Resident 13 stated the facility staff did not come to ask her or to assist her to be turned or repositioned on a regular basis. During an interview and record review with registered dietitian (RD) on June 1, 2015, at 1:45 p.m., she stated she was aware of Resident 13's poor meal intake and her wounds were deteriorating. The RD stated the resident should have been offered meal substitutes every time she ate less than 50 percent of her meal. The RD was unable to provide documentation that alternative nutritional options were recommended to the resident and/or responsible party. During an interview with Resident 13 on June 1, 2015, at 9:50 a.m., she stated she did not refuse to be turned or repositioned, and/or to get out of bed except after her [MEDICAL TREATMENT]; and when she is eating she did not want to be turned. On June 2, 2015 at 5 p.m., during an interview and record review with director of nurses (DON), she stated that Resident 13 was non-compliant with turning and repositioning and with her diet intake. However, the DON was unable to provide documented evidence when and what other alternative interventions were attempted when the resident refused to be turned, repositioned and refused to consume the food and fluid served. The DON was also unable to provide information related to the evaluation of the current plan of care and to seek alternative interventions to promote wound healing. Cross refer to F325.

Based on observation, interview, and record review, the facility failed to prevent a severe weight loss of 17 pounds. This was a weight loss of 12.5 percent in three months for one out of 24 sample residents (13), by failing to: 1. Continuously assess and monitor a resident's nutritional status by means of daily weight records and inform the physician for timely intervention when the resident experienced progressive weight loss; 2. Identify a resident at nutritional risk and address risk factors for impaired nutritional status including non-compliance to eat; 3. Identify, implement, monitor, and modify care plan interventions (as appropriate), consistent with the resident's assessed needs, choices and goals, to maintain acceptable parameters of nutritional status; 4. Notify the physician as appropriate when the resident's meal intake was below 50 percent and obtain instructions to manage weight loss; and 5. Identify and apply relevant approaches including placing the resident on a special feeding program and/or provide nutrition by means of an alternative feeding plan with consent from the resident or the responsible party such as tube feeding or [MEDICATION NAME] nutrition as appropriate when the resident was unable to consume and refused foods and fluids served in order to meet the resident's caloric, protein and fluid needs. Resident 13 developed multiple pressure ulcers that progressed to Stage IV (the most severe form of the wound, as it has spread to the underlying bone or muscle) on the coccyx (tailbone) and on the [MEDICATION NAME] area (on the back). Resident 13 was transferred to the general acute care hospital (GACH) and diagnosed with [REDACTED]. Findings: According to the admission record, Resident 13 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with [DIAGNOSES REDACTED]. kidney failure), pressure ulcers, and acute osteo[DIAGNOSES REDACTED] (bone infection of short duration). The Minimum Data Set (MDS, an assessment care screening tool), dated January 22, 2015 indicated Resident 13's cognitive skills for daily decision-making were intact, required extensive assistance from staff with activities of daily living, and supervision for eating. The resident's weight was 131 pounds, and 65 inches tall. The MDS indicated the resident had no episodes of care rejection, at risk to develop pressure ulcer, and assessed with [REDACTED]. The MDS dated [DATE] indicated Resident 13 weighed 123 pounds, and had two site of Stage III (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss) pressure ulcers. The MDS indicated the resident had no episodes of care rejection. According to the MDS assessments dated January 22, 2015, and April 20, 2015, Resident 13 had a weight loss of eight pounds from the baseline admission body weight dated January 22, 2015. This was a weight loss of 6.1 percent in in three months. Resident 13 had a care plan dated January 9, 2015, for at risk for significant weight changes as manifested by therapeutic diet, non-adherence to therapeutic diet and [MEDICAL CONDITION]. The approaches diet as order, offer food preference, provide substitute per resident's request and monitor food intake and record. The above plan of care did not include interventions to offer Resident 13 food substitutes not only when the resident requested but also at regular set intervals. In addition, the plan of care did not address the resident's food preferences, how and when the resident would be provided substitutes including on dates she was away from the facility to receive [MEDICAL TREATMENT] (process to remove waste products from the blood) treatments to prevent the risk of missed meals. Resident 13 had another care plan dated January 13, 2015, and May 21, 2015, for nutritional risk related to poor/variable intake, pressure ulcers, low [MEDICATION NAME] level, and non-compliance to diet. The approaches included diet as ordered, to encourage resident to eat 75 percent of each meal, assist/feed resident, encourage compliance with diet, and remind resident and family member of complication of non-adherence. A review of the resident meal consumption recorded on the Nursing Assistant Daily Flow Sheet from January 9 to April 2015, indicated Resident 13 had consumed less than 50 percent of her meal and did not achieve the state goal to consume 75 percent of each meal. For example: 1. During the month of January 2015, the resident's food consumption was less than 50 percent; 11 times for breakfast, 12 times for lunch, and 16 times for dinner. During this month the resident refused meal four times. 2. During the month of February 2015, the resident's food consumption was less than 50 percent; seven times for breakfast, 16 times for lunch and eight times for dinner. During this month the resident refused meal two times. 3. During the month of March 2015, the resident's food consumption was less than 50 percent; two times for breakfast, seven times for lunch, and eight times for dinner. 4. During the month of April 2015, the resident's food consumption was less than 50 percent; six times for breakfast, 18 times for lunch, and 13 times for dinner. 5. From May 1 to 13, 2015, the resident's food consumption was less than 50 percent; seven times for breakfast, four times for lunch, and eight times for dinner. During this period the resident refused meal three times. The above meal consumption recorded by the nursing assistants indicated Resident 13's food consumption was less than 50 percent. There was no documented evidence that indicated the licensed nursing staff and the registered dietician (RD) assessed, evaluated and analyzed the declined meal consumption and reported to the physician in order to obtain treatment instructions. In addition, the licensed nursing staff and/or the RD did not identified the resident's choices and preferences for food substitutes to be provided to the resident in order to maintain acceptable parameters of nutritional status. On May 29, 2015, at 8:20 a.m., during breakfast observation, Resident 13 was in her room, lying in bed having breakfast. Her breakfast tray had two sunny-side up eggs, two pieces of toast, 8 ounces (oz) of milk, 6 oz of juice, 8 oz of water, 6 oz of pudding and one box of cold cereal. The resident was alert and able to carry on an appropriate conversation. On May 29, 2015, at 12:40 p.m., during lunch observation, Resident 13 was in her room, lying in bed, having lunch. She was eating Asian food brought by her family member. The resident's meal tray from the facility was observed untouched inside the facility tray cart. There was no documented evidence that indicated the licensed nursing staff had assessed the resident to identify why her meal was untouched and placed inside the facility tray cart without an attempt to be fed by the nursing staff. A review of the Resident 13's monthly Weight Record and Vital Signs records indicated the following: 1. On January 9, 2015, Resident 13's weight was 131 pounds. This was the resident's baseline body weight on admission. 2. On February 6, 2015, the resident's weight was 135 pounds (four pounds weight gain from admission in one month). 3. On March 4, 2015, the resident's weight was 133 pounds (two pounds weight gain from the previous admission in two months). 4. On April 3, 2015, the resident's weight was 122 pounds. There was a weight loss of 9 pounds since the baseline admission weight of January 9, 2015. This was a weight loss of 6.8 percent in approximately three months. 5. On May 8, 2015, the resident's weight was 118 pounds. From February 6, 2015, to May 8, 2015, Resident 13 had a weight loss of 17 pounds. This was a weight loss of 12.5 percent in three months. A weight loss of greater than 10 percent is considered severe weight loss (State Operations Manual (SOM) Page 317). A review of the test result for [MEDICATION NAME], and Pre [MEDICATION NAME] indicated the following: 1. On February 10, 2015, [MEDICATION NAME] 3.9 gram per deciliter (reference range 3.5 to 5.2 gram/dL). 2. On March 10, 2015, [MEDICATION NAME] 3.6 g/dL. 3. On April 9, 2015, [MEDICATION NAME] 2.8 g/dL, and Pre [MEDICATION NAME] was 10 milligram per deciliter (mg/dL) (reference range 20 to 40 mg/dL). When Resident 13's [MEDICATION NAME] and pre-[MEDICATION NAME] levels were low, and she had progressive weight losses, there was no documented evidence that indicated the interdisciplinary team (IDT), that included the licensed nursing staff, the registered dietician and the physician, had evaluated the effectiveness of the current plan of care; or had monitored and evaluated the nutritional value of foods brought by the resident's family, and update the care plan with new interventions including offering the resident and/or her representative the option for alternative means of feeding such as tube feeding or [MEDICATION NAME] nutrition as appropriate to meet the resident's caloric, protein and fluid needs in order to maintain the resident's nutritional status. A review of the physician's orders [REDACTED]. A review of the GACH Consultation dated May 14, 2015 indicated [DIAGNOSES REDACTED]. The GACH laboratory result for Pre-[MEDICATION NAME] indicated 9 mg/dL (a test to assess the severity of illness resulting from malnutrition). Resident 13 was readmitted to the facility on [DATE]. At the time of the readmission, the resident weighed 117 pounds. Resident 13 had a weight loss of 14 pounds from January 22, 2015, to May 18, 2015, baseline body weight. This was a weight loss of 10.6 percent over approximately four months. Resident 13 had a physician's orders [REDACTED]. Ice cream with lunch and dinner. Family member may bring food from home. According to the licensed nurse the previous renal diet was changed to regular diet because of the resident's choice. When the resident's family members were allowed to bring food from home, there was no documented evidence that indicated a dietary assessment of this food's nutritional value was made. In addition, Resident 13 was not assessed for the need to be on be on extra nourishment in between meals to receive extra protein and calories in order to maintain acceptable parameters of of nutritional status. On May 27, 2015, an order was received to provide Resident 13 with feeding assistance three times a day. There was no documented evidence that indicated the resident was placed on a feeding program prior to May 27, 2015, especially when the resident's food consumption dropped to less than 50 percent and had a weight loss of eight pounds on April 20, 2015. During an interview and record review with registered dietitian (RD) on June 1, 2015, at 1:45 p.m., she stated she was aware of Resident 13's poor meal intake. The RD stated the resident should have been offered food substitutes every time she ate less than 50 percent. However, she was unable to provide documentation that a meal substitute was offered every meal the resident ate less than 50 percent, and the resident response documented. The RD stated she did not recommend a calorie count, and was not sure if the resident's weight was taken before or after her [MEDICAL TREATMENT] to identify true weight loss. The RD stated she thought the resident had nourishment in between meals or additional protein supplements during medication pass. During an interview on June 2, 2015 at 5 p.m., and record review with the director of nurses (DON), she stated Resident 13 was non-compliant with her diet. However, the DON was unable to provide evidence of close monitoring of the resident's food and fluid consumption, or that her current plan of care was evaluated to seek alternative interventions to prevent weight loss and promote wound healing. Cross Refer to F314