Every finding on record at Arrowhead Springs Healthcare

Based on interview and record review, the facility failed to inform residents, in writing, of services available and the charges for those services, including charges for items and services not covered by Medicare or Medicaid for three of four sampled residents (Resident 120, 121, and 122) when Resident 120, 121, and 122 did not receive written notification of their estimated out of pocket cost on the required Skill Nursing Facility Advance Beneficiary Notice of Non-coverage form (a form a facility gives a resident to let them know Medicare may stop paying for their stay or certain services).These failures had the potential to prevent residents from receiving the information necessary to understand their potential financial liability and make informed decisions regarding continued care.During a record review of Resident 122's Skill Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form, dated December 2, 2025, the SNF ABN form was missing the required cost-per-day amount for continued stay in the facility.During a record review of Resident 120's SNF ABN form, dated February 12, 2026, the SNF ABN form was missing the required cost-per-day amount for continued stay in the facility.During a record review of Resident 121's SNF ABN form, dated January 19, 2026, the ANF ABN form was missing the required cost-per-day amount for continued stay in the facility.During an interview on June 3, 2026, at 5:38 AM, with the Administrator (Admin) and the Admissions Concierge (AC), the Admin stated the facility does not include the cost of stay on the SNF ABN paperwork, and the AC verbally informs residents of the out-of-pocket cost. The AC stated the cost is posted in four locations throughout the facility and the residents are informed verbally.During an interview on June 3, 2026, at 7:28 AM, with the Admissions Director (AD), the AD confirmed residents were not provided written notice of their daily cost to remain in the facility once Medicare coverage ends.During a follow up interview on June 3, 2026, at 8:25 AM, with the AD, the AD stated the facility does not have a written policy addressing beneficiary notification and they just follow the regulation.

Based on interview and record review, the facility failed to update Pre-admission Screening and Resident Review (PASARR - a federally mandated program that requires all individuals seeking admission to a Medicaid-certified nursing facility to be screened to ensure individuals who are identified to have a significant mental illness (SMI), intellectual or developmental disability (I/DD)) are not inappropriately placed in nursing homes for long term care) for two of five sampled residents (Resident 17 and 76) for PASARR when: 1. Resident 17 did not have his diagnoses of post-traumatic stress disorder (PTSD - a mental health condition triggered by experiencing or witnessing a terrifying, shocking, or dangerous event) included in the PASARR assessment used to admit the resident into the skilled nursing facility.2. Resident 76 did not have his diagnoses of paranoid schizophrenia (a bran condition where a person loses touch with reality and becomes trapped in a world of intense fear, false beliefs, and imaginary sounds) included in the PASARR assessment used to admit the resident into the skilled nursing facility.These failures resulted in Resident 17 and Resident 76's conditions not being identified prior to admission and had the potential to result in Resident 17 and Resident 76's need for treatment and services not being accurately assessed, placing them at risk for inadequate care.1. During a review of Resident 17's admission Record (contains medical and demographic information), the admission Record, indicated Resident 17 was admitted on [DATE], with diagnoses which included cervical region spinal stenosis (narrowing of the back bone (spine) in the neck region where the nerves pass), PTSD and sleep apnea (sleep disorder where a person's breathing repeatedly stops and starts while sleeping).During a review of Resident 17's PASARR assessment dated [DATE] (PASARR assessment used to admit the resident into the facility), the PASARR indicated NO to the question 9, Diagnosed Serious Mental Illness [SMI]. Does the individual have a serious diagnosed mental disorder such as depressive disorder, anxiety disorder.During a concurrent interview and record review on June 4, 2026, at11:28 AM, with the Minimum Data Set Nurse (MDS 1), Resident 17's PASARR assessment, dated April 29, 2026, was reviewed. The MDS 1 acknowledged the PASARR assessment did not accurately indicate Resident 17 had PTSD. The MDS 1 stated it should have been identified that the PASARR did not include Resident 17's PTSD and a revision to the PASARR should have been completed. The MDS 1 further stated it was not done.2. During a review of Resident 76's admission Record, the admission Record, indicated Resident 76 was admitted on [DATE], with diagnoses which included hemiplegia (total loss of voluntary muscle function and movement on one side of the body) and hemiparesis (partial loss of voluntary muscle function and movement on one side of the body), cerebral infarction (brain tissue death due to lack of blood supply) and paranoid schizophrenia (a bran condition where a person loses touch with reality and becomes trapped in a world of intense fear, false beliefs, and imaginary sounds).During a review of Resident 76's PASARR assessment dated [DATE] (PASARR assessment used to admit the resident into the facility), the PASARR indicated NO to the question 26, Diagnosed Mental Illness Does the resident have a diagnosed mental disorder such as Schizophrenia/Schizoaffective Disorder.During a concurrent interview and record review on June 2, 2026, at 5:15 PM, with the MDS 1 and the MDS 2, Resident 76's PASARR assessment, dated March 29, 2019, was reviewed. The MDS 1 and the MDS 2 acknowledged the PASARR assessment did not accurately indicate Resident 76 had paranoid schizophrenia. The MDS 1 and the MDS 2 stated it should have been identified that the PASARR did not include Resident 76's Paranoid schizophrenia and a revision to the PASARR should have been completed. The MDS 1 further stated it was not done.During a concurrent interview and record review on June 4, 2026, at 11:50 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, PASRR dated February 2026, was reviewed. The P&P indicated, .2. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to resident with MI/MR (Mental illness/Mental retardation). The DON stated the P&P was not followed. The DON further stated the PASARR screening reassessment should have been done for Resident 17 and Resident 76.

Based on observation, interview and record review, the facility failed to provide the appropriate treatment to three Residents (Resident 2, 13 and 24) fed by enteral means. The three Residents did not receive the correct volume of enteral feeding (liquid nutrition through a soft tube that goes directly into your stomach or small intestine) ordered by the physician when:Resident 4 did not receive the physician ordered volume of enteral feeding (75 mL (milliliter)/hr. (hour), or 300 mL) during the observation period of 6:00 am to 10:00 am on June 1, 2026. The Licensed Vocation Nurse (LVN-1) also did not know how much of the enteral feeding was infused during the prior shift for the dose period starting at 2:00 pm on June 1, 2026, until the start of her shift at 7:00 am which is necessary to ensure that Resident 4 received the full dose of 1500 mL. Resident 13 did not receive the physician ordered volume of enteral feeding during the dose period of June 1, 2026, at 1:00 pm to June 2, 2026, at 10:00 am, when the resident only received 800 mL (milliliters, a unit of volume) of the ordered 1400 mL of enteral feeding (difference of 600 mL). Resident 24 did not receive the physician ordered volume of enteral feeding during the dose period of June 1, 2026 at 1:00 pm to June 2, 2026 at 10:00 am, when the resident only received 1200 mL of the ordered 1800 mL of enteral feeding (difference of 500 mL).This failure had the potential to result in malnutrition, weight loss and electrolyte imbalance for three of six residents who relied solely on enteral feeding for nutrition and hydration.Findings: 1.During a review of Resident 4's Face Sheet( contains demographic and medical information), indicated that Resident 4 was admitted to the facility, with a diagnosis of: Sequalae (the long term problems) of cerebral infarction (blocked blood vessel in the brain), pneumonitis (swelling or irritation of the lungs) due to inhalation of food and vomit and diabetes mellitus ( condition where the body cannot properly regulate blood sugar).During a review of Resident 4's Order Summary report, order date May 21, 2026, indicated Resident 4 had an order to receive Enteral feed order every shift Continuous via g-tube (gastrostomy tube- is a soft, flexible tube placed through a small opening in the belly straight into the stomach) [Brand name] Formula 1.2 @75mL/hr (hour) x (for) 20 hrs. to provide 1500 mL, 1800 kcals (a unit of energy measurement used in nutrition). Pump on at 2:00 pm. Off at 10:00 am or desired volume reached.During an observation on June 2, 2026, at 8:41 am, in Resident 4's room, Resident 4 was lying in bed, the enteral feed bottle was hung and indicated [Brand name] formula dated June 2, 2026, start time 0600 (6:00 am) infusing, formula measured above 1500 mL line. During an observation on June 2, 2026, at 11:15 am in Resident 4's room, Resident 4 was lying on the bed, with [Brand name] formula dated June 2, 2026, the enteral bottle was hung and indicated start time 0600 (6:00 am), measured at 1400 mL. Feeding pump was off, attached to resident.During a concurrent observation and interview on June 2, 2026, at 11:24 am with Licensed Vocation Nurse (LVN-1), in Resident 4's room, LVN-1 stated that the enteral feeding was turned off at 10:00 am per the physician's order. When asked how much formula Resident 4 received, LVN-1 stated we don't keep track, we turn it off when it is time. LVN-1 stated that the previous shift did not let her know how much had been infused so that she could ensure the correct volume was administered during her shift.During an interview on June 3, 2026, at 8:41 am, with Registered Dietitian (RD), the RD stated that the nursing staff should ensure that Resident 4 received the entire 1500 mL as ordered. RD further stated that there is not a record of how much formula was infused prior to 6:00 am on June 2, 2026. RD confirmed on June 2, 2026, from 6:00 am to 10:00 am, Resident 4 should have received 300 mL, but only 100 mL were given. During an interview on June 3, 2026, at 9:42 am with the Director of Nursing (DON), the DON stated that the nursing staff should provide the full dose of enteral feeding formula and extend the feeding duration when needed to provide the full dose.During a review of the facility's policy and procedure titled, Medication administration- General Guidelines, dated May 2022, indicated .Medications are administered in accordance with written orders of the prescriber.During a review of the facility policy and procedure titled, Enteral Feeding Administration, dated January 2026, indicated, it is the policy of this facility to administer enteral feeding at a constant controlled infusion rate per physician's orders. 2. During a record review of Resident 13's Face Sheet, Resident 13 was admitted to facility with a history of Parkinsons Disease (brain disorder that makes it hard to control movement), Cerebral palsy (condition that affects how the brain controls muscles and movement, causing problems with coordination, balance, or posture), and dysphagia (difficulty swallowing).During a record review of Resident 13's Order Summary report, order start date March 16, 2026, indicated Resident 13 had Enteral Feed order every shift Continuous via g-tube [Brand name] Formula 1.5 @70 mL/hr. x 20 hrs. (hours) to provide 1400 mL, 2100 kcals. Pump on at 2:00 pm. Off at 10:00 am or desired volume reached.During an observation on June 2, 2026, at 11:51 am, in Resident 13's room, [Brand name] formula dated June 1, 2026, at 1:00 pm was connected to the feeding pump. Feeding pump was turned off, Resident 13 was not in the room. 700 mL of formula remained in bottle. During an interview on June 2, 2026, at 3:29 pm, with LVN-2, LVN-2 stated that she hung formula bottle on June 1, 2026, at 1:00 pm. LVN-2 stated the order was for 1400 mL, so the resident should receive 1400 mL. When asked if Resident 13 received the full dose, LVN-2 stated, I can't say (Resident 13) got exactly 1400 mL, but I think she got close.During an interview on June 3, 2026, at 8:42 am, with the RD, the RD stated Resident 13 did not get the entire prescribed dose of enteral feeding for the dose period of June 1, 2026, at 1:00 pm and June 6, 2026, at 10:00 am. She stated the Resident received 800 mL of the prescribed 1400 mL, she did not get the remaining 600 mL. RD stated that the nursing staff should have continued to provide the enteral feeding to Resident 13 until the ordered dose was given.During an interview on June 3, 2026, at 9:42 am, with the Director of Nursing (DON), the DON stated that the nursing staff should provide the full dose of enteral feeding formula and extend the feeding duration when needed to provide the full dose.During a review of the facility's policy and procedure titled, Medication administration- General Guidelines, dated May 2022, indicated .Medications are administered in accordance with written orders of the prescriber.During a review of the facility policy and procedure titled, Enteral Feeding Administration, dated January 2026, indicated, it is the policy of this facility to administer enteral feeding at a constant controlled infusion rate per physician's orders. 3.During a record review of Resident 24's Face Sheet, Resident 24 was admitted to facility with Hemiplegia (one-sided weakness) and hemiparesis (one-sided weakness with limited movement) following Cerebral infarction, dysphagia following Cerebral infarction and Aphasia (difficulty speaking) following cerebral infarction.During a record review of Resident 24's Order Summary Report, order date February 17, 2026, indicated Resident 24 had Enteral Feed order every shift Continuous via g-tube [Brand name] Formula 1.5 @ 90 mL/hr. x 20 hrs. to provide 1800 mL, 2700 kcals. Pump on at 2:00 pm. Off at 10:00 am or desired volumed reached.During an observation on June 2, 2026, at 8:44 am, in Resident 24's room, Resident 24 was lying in bed and was unresponsive. The [Brand name] enteral feeding formula bottle was hung and dated June 1, 2026, 300 mL of formula remained in the bottle.During an observation on June 2, 2026, at 12:03 pm, in Resident 24's room, [Brand name] enteral feeding formula bottle dated June 1, 2026, start time 1:00 pm measured below 300 mL, feeding pump was turned off and disconnected from Resident 24. During an interview on June 2, 2026, at 3:22 pm with LVN-2, LVN-2 confirmed that Resident 24 did not receive the entire 1500 mL from the enteral feeding hung on June 1, 2026 at 1:00 pm to June 2, 2026 at 10:00 am, and that a second formula bottle should have been hung for the entire 1800 mL to be administered.During an interview on June 3, 2026 at 8:42 am with the RD, the RD confirmed that Resident 24 did not receive the ordered 1800 mL of enteral feeding formula from the dose period of June 1, 2026 at 1:00 pm to June 2, 2026 at 10:00 am, and that the LVN should have finished the entire 1500 mL formula bottle, and hung a second bottle in order to provide the additional 300 mL of formula for a total of 1800 mL that was ordered by the physician.During an interview on June 3, 2026, at 9:42 am with the Director of Nursing (DON), the DON stated that the nursing staff should provide the full dose of enteral feeding formula and extend the feeding duration when needed to provide the full dose.During a review of the facility policy and procedure titled, Medication administration- General Guidelines, dated May 2022, indicated .Medications are administered in accordance with written orders of the prescriber.During a review of the facility policy and procedure titled, Enteral Feeding Administration, dated January 2026, indicated, it is the policy of this facility to administer enteral feeding at a constant controlled infusion rate per physician's orders.

Based on observation, interview, and record review, the facility failed to ensure a resident was assessed and authorized to self - administered medications of 13 residents (Resident 47) reviewed for medication administration when three medications were found at the Resident 47's bedside within reach and readily accessible, without a completed self-administration of medications assessment (a clinical evaluation to determine if a resident can safely store, manage, and take their own medications independently or with minimal supervision), interdisciplinary team (IDT - a group of medical support professionals who work together to create and execute a patient - centered care plan) review, or physician authorization. This failure had the potential to result in improper medication use, medication errors and cause harm to Resident 47 due to unsupervised access to prescribed medications.During a review of Resident 47's admission Record (contains demographic and clinical information), it indicated Resident 47 was admitted to the facility on [DATE], with the diagnoses of chronic obstructive pulmonary disease (COPD - a chronic lung disease that makes it difficult to breathe, and displacement fractures of glenoid cavity of scapula of glenoid cattily of scapula right shoulder (broken bones in right shoulder).During an observation on June 1, 2026, at 11:36 AM, inside Resident 47's room, Resident 47 was lying in bed with the head of the bed elevated and wearing a sling on the right arm. Resident 47 stated, I fractured my right shoulder as the reason for wearing the sling. Three medications were observed unattended on the resident's bedside table: one tube of Diclofenac gel (a medication used to relieve pain and inflammation), one Tube of Nystatin (a medication used to treat fungal skin infections) cream and Fluticasone Propionate/Salmeterol inhaler (a medication used treat COPD). Resident 47 informed the surveyor that she uses the medications herself.During a concurrent observation and interview on June 1, 2026, at 11:49 AM, with License Vocational Nurse (LVN 5), LVN 5 stated Fluticasone Propionate/Salmeterol inhaler had a handwritten open date of May 16, 2026, with 52 doses remaining out of 60 doses. LVN 5 further stated Diclofenac gel, Nystatin cream and Fluticasone Propionate/Salmeterol inhaler belonged to Resident 47 and it was unsafe to leave the medications unattended on Resident 47's bedside table.During a review of Resident 47's MDS (Minimum Data Set - a standardized assessment tool that measures health status in nursing home residents) Section C (cognitive-involving consciousness intellectual activity patterns), dated May 19, 2026, the MDS indicated, Resident 47 had a BIMS (Brief Interview for Mental Status - tool used to screen how a resident is functioning cognitively) sore of 12 (a BIMS score 8-12 suggests resident is moderate cognitively impaired).During a concurrent record review and interview on June 4, 2026, at 11:05 AM, with the Director of Nursing (DON), Resident 47's electronic health records were reviewed. The DON stated Resident 47 did not have a self-administration of medication assessment, physician authorization, interdisciplinary team (IDT) review or care plan that supporting self - administration of medications.During a concurrent interview and record review on June 4, 2026, at 11:06 AM, with the DON, the facility's policy and procedure (P&P) titled, Self - Administration of Medication, dated February 2026, was reviewed. The P&P indicated, . 1. If a resident desire to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate. 2. The residents cognitive, communication, visual, and physical ability to carry out this responsibility will be evaluated. If the interdisciplinary team determines that this resident is unable to carry out this responsibility, the interdisciplinary team may withdraw the right. 3. If the resident is a candidate for self - administration of medications, this will be indicated in the chart. 4. Resident will be instructed regarding administration of medication by the nurse. 5. Nursing will be responsible for recording self - administered doses in the resident medication administration record. 6. Storage and location of drug administration (e.g., resident's room, nurses' station, or activities room) will comply with state and federal requirements for mediation storage. 7. Interdisciplinary team may include Medical Director or Primary Care Physician the Director of Nursing Services and other Nursing Representative, and Social Services. 8. Appropriate notation of these determinations will be place in the resident's care plan. The DON confirmed that the policy was not followed by the staff.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) assessments were accurately coded for one (1) of 26 residents (Resident 107) when Resident 107's assessment did not reflect the resident's status, care, and services in active diagnoses under Section I (Active Diagnosis section).This failure had the potential to cause inaccuracies in identifying Resident 107's care and support needs.During a review of Resident 107's admission Record (contains medical and demographic information), the admission Record, indicated Resident 107 was admitted on [DATE], with diagnoses which included end stage renal disease (kidneys can no longer filter waste and excess fluid from the blood), anxiety disorder (mental health condition characterized by excessive, persistent fear or worry that interferes with daily life) and anemia (body lacks enough healthy red blood cells to transport sufficient oxygen to tissues).During a concurrent interview and record review on June 4, 2026, at 11:48 AM, with the Director of Nursing (DON), Resident 107's MDS Annual Assessment (an assessment for a resident that must be completed every 366 days following the previous assessment), dated August 8, 2025, was reviewed. The MDS Annual Assessment under Section I titled Active Diagnoses. Psychiatric/Mood Disorder (health condition characterized by significant disturbances in thinking, emotional regulation, or behavior) 15700. Anxiety Disorder was left blank, indicating Resident 107 did not have an active diagnosis of anxiety disorder. The DON verified and stated the MDS was coded incorrectly, and Resident 107 did have the diagnosis of anxiety disorder.During a concurrent interview and record review on June 4, 2026, at 4:22 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Resident Assessment Instrument/MDS 3.0, dated February 2025, was reviewed. The P&P indicated, Purpose To ensure accurate, timely, and compliant completion of the Minimum Data Set (MDS) assessments . The DON stated the P&P was not followed.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR - a federally mandated program that requires all individuals seeking admission to a Medicaid-certified nursing facility to be screened to ensure individuals who are identified to have a significant mental illness (SMI), intellectual or developmental disability (I/DD)) was completed for one of five sampled residents (Resident 1) for PASARR when Resident 1 stayed more than 30 days in the facility.This failure had the potential to result in Resident 1's condition not being identified prior to admission and the need for treatments and services not being accurately assessed, placing Resident 1 at risk for unmet needs.During a review of Resident 1's admission Record (contains medical and demographic information), the admission Record, indicated Resident 1 was admitted on [DATE], with diagnoses which included right lower extremity deep vein thrombosis (blood clot in the deep vein of right leg), pneumonia (inflammation (immune system's natural, protective response to injury, infection or toxins) and fluid in lungs ) and cerebral infarction(brain tissue death due to lack of blood supply).During a review of Resident 1's PASARR assessment dated [DATE] (PASARR assessment used to admit the resident into the facility), the PASARR result of Level I screening indicated Exempted Hospital Discharge, which means the resident didn't have a PASSAR screening before hospital discharge and should have had a PASARR screening completed if the resident stayed more than 30 days in the skilled nursing facility. During a concurrent interview and record review on June 3, 2026, at 12:35 PM, with the Minimum Data Set Nurse (MDS 1), Resident 1's PASARR Level I screening result, dated April 15, 2026, was reviewed. The MDS 1 acknowledged she didn't know the meaning of the PASARR Level I screening result Exempted Hospital Discharge. The MDS 1 stated the PASARR screening should have been completed since Resident 1 stayed 49 days in the facility (19 days late to complete the PASARR screening). The MDS 1 further stated it was not done.During a concurrent interview and record review on June 4, 2026, at 11:52 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, PASRR dated February 2026, was reviewed. The P&P indicated, .1. A PASARR form shall be completed on every resident upon admission unless it is done by the hospital . The DON stated the P&P was not followed. The DON further stated the PASARR screening should have been done.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent with three medication errors of 36 observed opportunities, affecting two on thirteenth observed residents (Resident 123 and 45), resulting in an overall error rate of 8.3 percent when:1. Resident 123 was not given Omeprazole (a medication used to reduce stomach acid) as ordered.This failure had the potential for Resident 123 to have increased stomach discomfort or increased stomach acid. 2. Resident 45 received Vitamin D3 (a vitamin that helps with strong bones, muscles, and the immune health) 5000 IU (International Units- unit of measurement) instead of Vitamin D3 1000 units (unit of measure), as prescribed by the physician. This failure had the potential to cause Vitamin D toxicity (abnormally high levels of calcium in the blood, which can result in nausea, vomiting, altered mental status, cardiac abnormalities, and kidney damage). 3. Resident 45 had an order to receive Vitamin B12 (an essential water-soluble nutrient the body needs to form healthy red blood cells and maintain a functioning nervous system) 500 mcg (micrograms- unit of measurement) and it was not given within 60 minutes of the scheduled time This failure had the potential to delay the therapeutic effect of Vitamin B12 in Resident 45 and contribute to worsening symptoms like fatigue, dizziness, headache, nausea, and weight loss. 1. During a review of Resident 123's admission Record (contains demographic and clinical information), it indicated Resident 123 was admitted to the facility on [DATE], with the diagnoses of noninfective gastroenteritis (stomach and intestines become inflamed) and colitis (inflammation or irritation of the stomach and intestines that can cause abdominal pain, nausea, diarrhea, and digestive discomfort), protein-calorie malnutrition (resident is not getting enough nutrition, which can lead to weight loss, weakness, and poor overall health), and adult failure to thrive (a condition in which an older adult experiences weight loss, decrease appetite, weakness and decline functioning). During a review of Resident 123's Physician Orders, dated May 27, 2026, it indicated, Omeprazole Oral Tablet Delayed Release (Omeprazole) give 20 mg [milligram—unit of measurement] by mouth in the morning for GI (gastrointestinal) PPX (prophylaxis, prevention). During a concurrent observation and interview on January 3, 2026, at 5:43 AM, in Resident 123's room, a license Vocational Nurse (LVN 5) was preparing Resident 123's medication. LVN 5 stated that Omeprazole 20 mg was unavailable because it had not been delivered by the pharmacy and was not available in the medication room. LVN 5 further stated Omeprazole was an important medication used to reduced stomach acid and help prevent gastrointestinal irritation. During a concurrent interview and record review on June 4, 2026, at 10:56 AM, with the Director of Nursing (DON), Resident 123's, eMAR – Medication Administration Note (digital system used to track and document when residents receive medications), dated June 3, 2026, at 5:43 AM, was reviewed. The eMAR – Medication Administration Note indicated LVN 5 documented, Omeprazole Oral Tablet Delayed Release, Give 20 mg by mouth in the morning for GI PPX awaiting pharmacy. The DON confirmed Resident 123 missed one dose of Omeprazole on June 3, 2026. During a concurrent interview and record review on June 3, 2026, at 10:42 AM, with the DON, the facility's policy and procedure (P&P) titled, Preparation and General Guidelines, dated December 2019, was reviewed. The P&P indicated, .The facility has sufficient staff and medication distribution system to ensure safe administration of medications without unnecessary interruptions., Medication are administered in accordance with written orders of the prescriber . The DON confirmed that the policy was not followed by the staff. 2. During a review of Resident 45's face sheet (contains demographic and medical information), the face sheet indicated Resident 45 was admitted to the facility on [DATE], with diagnoses which included fracture of the left femur (a break in the thigh bone), chronic kidney disease stage 2 (a condition when the kidneys are damaged and cannot filter blood as they should), and atherosclerotic (the buildup of fats, cholesterol and other substances in and on the artery walls) heart disease. During a review of Resident 45's Physician Order, dated May 18, 2026, it indicated, Resident 45 had an order for Vitamin D3 oral tablet give 1000 units by mouth one time a day for supplement. During a medication administration observation on June 3, 2026, at 8:20 AM, in Resident 45's room, a Licensed Vocational Nurse (LVN 4) administered Vitamin D3 5000 IU orally to Resident 45, not the prescribed dose of Vitamin D3 1000 units. During a concurrent observation and interview on June 3, 2026, at 9:54 AM, with LVN 4, LVN 4 acknowledged and stated the wrong dose of Vitamin D3 was given to Resident 45. LVN 4 further stated Resident 45's prescribed dose of Vitamin D3 is 1000 units and took the correct medication bottle from the medication cart to demonstrate. During a concurrent interview and record review, on June 4, 2026, at 11:49 AM, with the Director of Nursing (DON) the facility's policy and procedure (P&P) titled, Medication Administration- General Guidelines, dated May 2022 was reviewed. The P&P indicated, Five rights. right dose. for each medication being administered. The DON stated the policy was not followed. 3. During a review of Resident 45's face sheet, the face sheet indicated Resident 45 was admitted to the facility on [DATE], with diagnoses which included fracture of the left femur, chronic kidney disease stage 2, and atherosclerotic heart disease. During a review of Resident 45's Physician Order, dated May 18, 2026, it indicated, Resident 45 had an order for Vitamin B12 oral tablet give 500 mcg by mouth one time a day for supplement. During a medication administration observation on June 3, 2026 at 8:22 AM, with LVN 4 in Resident 45's room, Resident 45's Vitamin B12 was scheduled to be administered at 9:00 AM. LVN 4 stated the Vitamin B12 was not in the medication cart and could not be administered at that time. During a review of Resident 45's Progress Notes, dated June 3, 2026, the Progress Notes indicated, . 10:50 AM. Vitamin B12 was administered. During a concurrent interview and record review, on June 4, 2026, at 11:47 AM, with the DON, the facility's P&P titled, Medication Administration- General Guidelines dated May 2022 indicated, .medications are administered within [60 minutes] of scheduled time. The DON stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure medications were stored and secure for one of 13 resident (Resident 47), when Fluticasone Propionate/Salmeterol inhaler (a medication used to help control and prevent symptoms of chronic obstructive pulmonary disease [COPD]), Nystatin cream (a medication used to treat fungal skin infections) and Diclofenac Sodium Topical gel (a medication used to relieve pain and inflammation) were found unattended and readily accessible on Resident 47's bedside table. This failure had the potential to result in improper medication use, medication errors, adverse drug reactions by Resident 47 or others. During a review of Resident 47's admission Record (contains demographic and clinical information), it indicated Resident 47 was admitted to the facility on [DATE] with the diagnoses of chronic obstructive pulmonary disease (COPD - a long term lung disease that makes it hard to breath because the airways are damaged or blocked), gastroesophageal reflux disease (GERD - [gastroesophageal reflux disease] without esophagitis (a condition where stomach acid frequently flows back into the esophagus), displacement fracture (broken) of glenoid cavity of scapula, right shoulder (fracture of the right shoulder).During a review of Resident 47's MDS (Minimum Data Set - a standardized assessment tool that measures health status in nursing home residents) Section C (cognitive-involving consciousness intellectual activity patterns), dated May 19, 2026, the MDS indicated, Resident 47 had a BIMS (brief Interview for Mental Status - tool used to screen how a resident is functioning cognitively) sore of 12 (a BIMS score 8-12 suggests resident is moderately impaired).During an interview with Resident 47 on June 1, 2026, at 11:25 AM, inside the resident's room, Resident 47 confirmed she was still using the three medications observed on the bedside table, including the Fluticasone Propionate/ Salmeterol inhaler, Nystatin cream, and Diclofenac Sodium topical gel 1% (one percent-strength of medication).During a concurrent observation and interview on June 1, 2026, at 11:49 AM, with License Vocational Nurse (LVN 5), LVN 5 confirmed the inhaler had a handwritten open date of May 16, 2026, with 52 doses remaining out of 60 doses. LVN 5 confirmed that the Diclofenac gel, Nystatin cream and inhaler belonged to Resident 47 and acknowledged that it was unsafe to leave medications unattended on Resident 47's bedside table.During a review of Resident 47's Physician Orders, dated May 15, 2026, the Physician Orders indicated, Advair Diskus Aerosol Powder Breath Activated 250 - 50 mcg [microgram-unit of measurement]/Dose (fluticasone - salmeterol) 1 inhalation inhale orally every 12 hours for bronchospasm (narrowing of the airways that can make it difficult to breath) PPX [prophylaxis] R/T [related to] COPD - chronic pulmonary disease.During a review of Resident 47's care plan [an individualize plan for resident's health condition, and service goals] for COPD, dated May 16, 2026, the care plan indicated, interventions, give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Monitor for difficulty breathing (Dyspnea) on exertion. Remind resident not to push beyond endurance.During a review of Resident 47's Physician Orders, dated May 15, 2026, the Physician Orders indicated, Diclofenac Sodium External Gel 1 %, (Diclofenac Sodium (topical) Apply to joint / pain/shoulder topically every 6 (six) hours as needed for pain 2 grams (unit of weight).During a review of Resident 47's care plan, dated May 15, 2026, the care plan indicated, Interventions Administer analgesia medication as per orders. Give 1/2 (half) hour before treatments of care. Monitor / document for side effects of pain medication. Observed for constipation; new onset or increase agitation, restlessness, confusion, hallucinations.Report occurrences to physician.During a concurrent interview and record review on June 4, 2026, at 10:49 AM, with the Director of Nursing (DON), the Physician Order, dated May 19, 2026, was reviewed. The Physician Order indicated, Nystatin external cream 100000 UNIT/GM (Nystatin (topically every day shift for rash apply 1 gram each armpit. The DON confirmed the medication observed on Resident 47's bedside table had been discontinued and acknowledged the medication should not have been left unattended in the resident's room.During a concurrent interview and record review on June 4, 2026, at 10:52 AM, with the DON, the Physician Order, dated May 28, 2026, at 1:46 PM, was reviewed. The Physician Order indicated Nystatin External powder 100000 Unit/GM Nystatin (topical) apply to R (right) underarm topically every day shift for MASD (moisture associated skin damage), (a skin irritation caused by excess moisture trapped against the skin, which can result in redness, rash, discomfort and breakdown of the skin) for 14 days. And was subsequently discontinued. The DON confirmed the mediation observed on Resident 47's bedside table had been discontinued and acknowledged the medication should not have been left unattended in the resident's room.During a concurrent interview and record review on June 4, 2026, at 10:58 AM, with the DON, the facility's policy and procedure (P&P) titled, Medication Storage in the facility dated Revised January 2018 the P&P indicated, Medications and biological are stored safety, securely, and properly , following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Procedures.C. All medications dispensed by the pharmacy are store in the container with the pharmacy label., F. Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart.I. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. The DON stated the policy was not followed by staff.

Based on observation, interview, and record review, the facility failed to ensure staff followed effective infection control practices for three (3) of 107 residents (Residents 60, 54, and 52) when one licensed vocational nurse (LVN 3) did not clean and disinfect a reusable medication tray (used to prepare and transport medication to residents) between medication administration.This failure had the potential for cross contamination (the transfer of harmful bacteria), which could expose residents to harmful organisms (capable of causing infection, illness, or adverse health effects) and lead to preventable healthcare associated infections (HAIs- infections that residents acquire while receiving care in a healthcare facility) for 107 highly vulnerable residents.During an observation on June 3, 2026, at 5:37 AM, in Resident 60's room, with LVN 3, after LVN 3 gave medication to Resident 60. LVN 3 then placed a used medication cup, a used spoon with applesauce on it, and a used water cup back onto the medication tray and returned it to the medication cart. LVN 3 discarded the used cups and spoon, removed gloves, and performed hand hygiene, without cleaning or disinfecting the medication tray. LVN 3 began preparing medications for Resident 54, on the same medication tray.During an observation on June 3, 2026, at 5:41 AM, in Resident 54's room, LVN 3 placed Resident 54's medication, in a medication cup on the same uncleaned medication tray. LVN 3 assisted Resident 54 in taking the medication with water and returned the used medication cup back on the medication tray before returning it to the medication cart.During an observation on June 3, 2026, at 5:49 AM, in Resident 52's room, LVN 3 threw Resident 54's medication cup in the trash and proceeded to prepare medication for Resident 52 without disinfecting the medication tray. LVN 3 prepared and placed Resident 52's two medication cups and a water cup directly onto the medication tray. During an interview on June 3, 2026, at 5:55 AM, with LVN 3, in Resident 52's room, LVN 3 stated infection control practices must include disinfecting supplies that are reusable between residents. LVN 3 further stated and acknowledged the medication tray should have been cleaned and disinfected after giving medication to one resident and before preparing medication for another resident to prevent cross-contamination from resident to resident.During a concurrent interview and record review on June 4, 2026, at 11:45 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Cleaning, Disinfection, and sterilization of Resident Care equipment, dated February 2026, indicated, Noncritical items. require routine cleaning and disinfection. frequency. between each resident use. The DON stated the policy was not followed.

Based on observation, interviews, and record reviews, the facility failed to ensure proper disposal of garbage when one of two lids in the outside recycling receptacles was not closed and overflowing with trash. This failure had the potential to attract pests. Findings: During a concurrent observation and interview on April 22, 2025, at 7:45 AM, with the Registered Dietician (RD), in the garbage storage area, located outside the facility, there were three garbage containers. One container (the recycling container- a large container for holding or transporting waste or items for recycling) was not closed and it was overflowing with open cardboard boxes. The RD stated the recycling container should be close and should not be overflowing. During an interview on April 24, 2025, at 7:55 AM, with the Administrator (Admin), the Admin verbalized his expectation is for staff to break down boxes and flatten out boxes for recycling receptacle to close, because of potential to attract pests. The Admin further stated, I know we should have the recycling bins closed. During a review, of the facility's policy and procedure (P&P) titled, Garbage and Trash, (undated), was reviewed. The P&P indicated, .3. Adequate, clean, vermin-proof areas must be provided for storage and rubbish. Trash, .2. Garbage and trash cans must be inspected daily. During a review of the FDA (Food and Drug Administration) Food Code 2022, 5-501.15, indicated, (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.

Based on observation, interview, and record review, the facility failed to ensure, supplies were kept in good condition for one out of twenty-five residents (Resident 54) when Resident 54's mattress was found peeled, discolored, and in disrepair. This failure had the potential for Resident 54 to experience physical discomfort, sleep disturbances, and increased risk of infections or skin breakdown. Findings: During an observation on April 21,2025, at 10:21 AM, in Resident 54's room, Resident 54 was awake lying in bed, half of the mattress at the foot of the bed, was peeled and discolored. During a concurrent observation and interview on April 21, 2025, at 04:50 PM, with the Administrator (ADMIN), in Resident 54's room, the ADMIN stated, Oh, we need to change this mattress right now. The ADMIN stated, Resident 54 has [name of the insurance company] insurance and Admin was going to contact them (the insurance company) to replace the mattress. During a review of Resident 54's Admission Record (contains medical and demographic information), the Admission Record indicated Resident 54 was admitted on [DATE], with diagnoses which included morbid obesity (a severe form of obesity characterized by a significantly excessive body weight that poses serious health risks) due to excess calories, type 2 diabetes mellitus (a chronic condition characterized by high blood sugar levels due to the body either not producing enough insulin or not using insulin properly) with other circulatory complications, anxiety disorder (a condition that causes excessive feelings of fear, dread, and worry that persist over time and interfere with daily life). During a concurrent interview and record review on April 22, 2025, at 03:15 PM, with the ADMIN, The ADMIN reviewed the facility's policy and procedure (P&P) titled, Physical Environment, undated. The P&P indicated, . 6. If equipment requires repair other than routine maintenance or servicing, the vendor through which the equipment was purchased will be contacted and arrangements made for repair/replacement. The ADMIN stated, Usually, we do call the vendor and take care of it right away.

Based on observation interview and record review the facility failed develop and implement comprehensive, person-centered care plans (a care plan that includes all the health problems, preferences and goals) for two of three residents (Residents 22 and 17) that were reviewed for care plans needs when: 1. Resident 22 did not have a care plan developed to address ongoing podiatry needs for long fingernails and toenails since admission, on October 4, 2024. 2. Resident 17 did not have a care plan developed for intravenous (IV) antibiotic therapy with Ceftazidime Intravenous Solution ( a strong antibiotic given through a vein (IV) that helps kill bacteria caused infection). These failures had the potential to result in unmet medical needs for Residents 22 and 17, and can cause delay in treatment and lack of coordinated care, placing Resident 22 and 17 at risk for complications. Findings: 1. During a Review of Resident 22's Admission Record (contains demographic and medical information), it indicated Resident 22 was admitted to the facility on [DATE], with diagnoses which included, difficulty walking (trouble walking which may be due to weakness, pain or poor balance), chronic diastolic (congestive) heart failure ( a long term heart condition that causes fatigue, shortness of breath and swelling) and transient ischemic attack (TIA) and cerebral infarction without residual deficits (mini-stroke, it happens when blood flow to the brain is briefly blocked. It may cause coordination problems, especially in the hands making it hard to do basic tasks). During a concurrent observation and interview on April 21, 2025, at 9:47 AM inside Resident 22's room, Resident 22 was lying on bed looking through the door. Resident 22 had long fingernails on both hands, his skin appeared dry. Resident 22 stated he asked the staff to cut his nails several times, but no one helped him. Resident 22 further stated he had not been seen by a podiatrist since he was admitted to the facility on [DATE]. During a review of Resident 22's Physician Order dated February 24, 2025, at 5:25 PM indicated, Nail care appointment with PCP (primary care physician), Dr. [name of the doctor] on March 17, 2025, at 1:20 PM [Name and name of the city where the hospital is located.] Pending transportation. One time only for nail care appointment . During a concurrent interview and record review on April 24, 2025, at 4:17 PM with the Assistant Director of Nurses (ADON), Resident 22's clinical records were reviewed. The ADON was not able to find documented evidence that Resident 22's had a care plan that address podiatry needs. The ADON stated staff did not initiate a care plan for Resident 22 for podiatry services and it should have been initiated upon admission on October 4, 2024. 50754 2. During a review of Resident 17's Admission Record, it indicated Resident 17 was admitted to the facility on [DATE], with diagnoses of acute osteomyelitis of the left ankle and foot (a serious bone infection that causes pain, swelling and redness and usually requires antibiotics through a vein to treat the infection deeply in the bone), end stage renal disease (the final stage of chronic kidney disease where the kidney stops working, making the body less able to fight infections and process medications) and immunodeficiency due to conditions classified elsewhere (a weakened immune system caused by another medical conditions. During a review of Resident 17's physician's order dated April 17, 2025, it indicated Resident 17 had an order for Ceftazidime 2 gram (unit of measurement) intravenously one time a day every Monday, Wednesday and Friday for OM (OM - Osteomyelitis, a serious infection in the bone) of the left foot for 12 days. Order end date April 30, 2025. During a further observation and interview on April 23, 2025, at 9:47 AM inside Resident 17's room. Resident 17 was observed lying in bed, awake, talking with his roommate and watching television. Resident 17's had a left hallux (pressure wound on the left big toe, this type of wound is caused by prolonged pressure that damages the skin) and. dry, cracked skin on both heels. Resident 17 stated he received antibiotic to treat the infection. During a concurrent interview and record review on April 24, 2025, at 4:29 PM with the ADON, Resident 17's clinical records were reviewed. The ADON was not able to find documented evidence that Resident 17 had a care plan that address IV antibiotic with Ceftazidime. The ADON stated staff did not initiated a care plan for Resident 17, for IV antibiotic therapy, and one should have been initiated when the antibiotic was started on April 18, 2025. During a concurrent interview and record review on April 24, 2025, at 4:32 PM with the ADON the facility's policy and procedure (P&P) titled Comprehensive Person-Centered Care Planning, revised February, 2025, was reviewed. The P&P indicated, It is the policy of this facility that the IDT shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. The ADON acknowledged stated the staff did not follow the care plan policy. The ADON further stated that the nurses should have developed a care plan to address the IV Antibiotic and the podiatry services.

Based on observations, interviews and record review, the facility failed to provide proper hygiene and grooming care (help with keeping the body clean and neat including cutting nails, brushing hair, shaving and general personal appearance) for one of eight residents (Resident 22) when Resident 22 had long thickened and yellow toenails curling over the tips on both feet, as well as long, untrimmed fingernails on both hands. This failure had the potential for Resident 22 to experience pain, skin breakdown, fungal infection (infection caused by germs [fungus] that grow on the skin or nails, in toenails, it can make them thick, yellow brittle and sometimes painful), refusal of mobility and negatively impacted Resident 22's dignity and quality of life. Findings: During a Review of Resident 22's Admission Record (contains demographic and medical information), it indicated Resident 22 was admitted to the facility on [DATE], with diagnoses which included difficulty walking (trouble walking which may be due to weakness, pain or poor balance), chronic diastolic (congestive) heart failure (long term heart condition that causes fatigue, shortness of breath and swelling) and history of transient ischemic attack (TIA) (mini-stroke, it happens when blood flow to the brain is briefly blocked. It may cause coordination problems). During a concurrent observation and interview on April 21, 2025, at 9:47 AM, inside Resident 22's room, Resident 22 was lying on bed looking through the door. Resident 22 had long fingernails on both hands and his skin appeared dry. Resident 22 stated he asked the staff to trim his nails for several times, but no one helped him. Resident 22 further stated he had not been seen by a podiatrist since he was admitted on [DATE]. During a review of Resident 22's physician's order, dated February 24, 2025, it indicated, Nail care appointment with PCP (primary care physician), Dr. [name of the doctor] on March 17, 2025, at 1:20 PM [Name and name of the city where the hospital is located.] Pending transportation. One time only for nail care appointment . During a further concurrent observation and interview on April 24, 2025, at 8:10 AM, with Certified Nursing Assistant (CNA 3), inside Resident 22's room, Resident 22 was lying in bed, just finished with his breakfast. Resident 22 informed CNA 3 he wanted his nails, including his toenails to be trimmed. While wearing gloves CNA 3, removed resident's yellow socks to observe his feet. Resident 22's toenails were visible long, yellow in color, thick in appearance, and curling at the edges. The skin on the feet appeared dry and cracked. CNA 3 stated Resident 22's toenails had not been trimmed and he had not received podiatry care recently. During a concurrent interview and record review on April 24, 2025, at 9:54 AM, with the Assistant Director of Nurses (ADON), the ADON reviewed Resident 22's LN -Skin Evaluation - PRN (as need it) / Weekly (a form used to document all ulcers, wounds and other skin problems) form, dated March 6, 2025. The Skin evaluation indicated, . Noted the ff (findings found) R/L (right and left) hypertrophic toenails (something abnormally enlarged or overgrown) mildly dry skin to R/L foot . The ADON stated the nurses should have followed up. The ADON was not able to find documented evidence in the nurses' progress notes that address staff followed up on Resident 22's feet hypertrophic nails. During an interview on April 24, 2025, at 9:52 AM with the ADON, the ADON stated Resident 22 was not diabetic and therefore his nail care included trimming of fingernails and toenails, may be performed by CNA's and licensed nursing staff as a part of routine grooming. The ADON further stated nail care is documented under Activities of Daly living (ADL's), specifically withing the hygiene and grooming section of the resident's care plan. During a further interview on April 24, 2025, at 9:58 AM with the ADON, the ADON was able to find documented evidence that Resident 22 attended a podiatry appointment on March 17, 2025. The ADON stated nursing staff is expected to assess and document nail condition during body assessments and initiate appropriate follow-up when needed. During a concurrent interview and record review on April 24, 2025, at 9:59 AM with the ADON, the facility's policy and procedure (P&P) Podiatry services, undated, was reviewed. The P&P indicated, Procedure . A. As part of the admission assessment the nurse will inspect the condition of the patient's feet and will notify the attending physician of the patient need for podiatry care if necessary . 1. Routine uncomplicated foot care, including trimming of nails will be managed by the license nurse as part of general hygiene regiment. The ADON sated the policy was on place and stated the staff failed to follow it, as Resident 22's nails had not been trimmed and no documentation was found to explain the delay. The ADON further stated nursing staff is responsible for identifying and addressing hygiene related needs, including nail care, during routine assessments.

Based on observation, interviews and record review, the facility failed to ensure the bilateral side rails (an adjustable metal or rigid plastic bars that attach to the bed) were in place for one of eight residents (Resident 58) reviewed for safety when a physician order to install bilateral side rails was not carried out for 37 days (March 17, 2025). This failure had the potential to place Resident 58 at risk for falls or injury. Findings: During a Review of Resident 58's Admission Record (contains demographic and medical information), it indicated Resident 58 was admitted to the facility on [DATE], with diagnoses which included kidney transplant status (a transplanted kidney), congestive heart failure (a chronic condition where the heart doesn't pump blood as well as it should) and pancytopenia (a condition where all types of blood cells are low, reducing the body's ability to fight infection, carry oxygen and control bleeding, making any injury more serious). During a concurrent observation and interview on April 22, 2025, at 12:47 PM, in Resident 58's room, Resident 58, was lying in bed checking his cellphone and very close to the left edge of the bed. The bed did not have bilateral side rails in place. A trapeze (a triangular device suspended above the bed that allows resident to grasp and use their upper body strength to assist with repositioning or mobility) was attached above the bed. Resident 58 stated he requested to have bilateral side rails approximately two months ago and he was told he needed to sign a waiver. Resident 58 further stated he signed the waiver, but no side rails had been installed. Resident 58 stated, I feel unsafe of falling at any time because the trapeze alone was not enough, especially due to his above the right knee leg amputation. During an interview on April 24, 2025, at 9:30 AM, with the Assistant Director of Nursing (ADON), the ADON stated Resident 58 had signed a consent form for bilateral side rails use on March 17, 2025. The ADON further stated a side rail safety assessment and a physician's order were completed on the same date. The ADON acknowledge the side rails were not implemented at that time. The ADON stated although the order was present since March 17, 2025, it was not carried out. During a review of Resident 58's Fall Risk Evaluation (an assessment tool used to identify how likely a resident is to experience a fall, based on mobility, balance, history of falls, medications and medical conditions), dated March 18, 2025, it indicated, . Score 13 . Category: High Risk (resident is on high risk for falls) . E. Gait/Balance/Ambulation . 1. Requires use of assistive devices (i.e. cane, walker, wheelchair). During a review of Resident 58's Physician Orders dated, March 17, 2025, it indicated, B (bilateral) siderails recommended for bed positioning bed mobility and pressure relief. During a review of Resident 58's Use of Bed Rail Record of informed Consent, dated March 17, 2025, it indicated, [Resident 58's name], . I have been fully informed about the use of rail, the possible negative outcomes of their use and have been provided a copy of FDA's (Food and Drug administration, is a federal agency that provides safety guidelines for medical devices, including bed rails, to help prevent injuries such as entrapment, suffocation or falls) clinical guidance related to the use of bedrails . I have been informed that the decision to use or to discontinue the use of bed rail will be made based on the interdisciplinary team's (a group of healthcare professionals who work together to plan, coordinate, and deliver care for a resident) assessment to ensure my safety . After careful consideration of the information provided to me, I hereby . Give my permission for the use of bed rails, signed by Resident 58 and staff. During a review of Resident 58's Bed Rail Safety Evaluation, dated March 17, 2025, it indicated, IDT (interdisciplinary team)recommendations: . a. Bed rail recommended. Proceed to resident education re: risks and benefits and confirm informed consent has been obtained prior to installation of bedrail . 1b. Justification (reason) For bed mobility and positioning as an enabler (is a device that helps a resident to do something more safety or easily, without limiting their movement [as bedrails). During a concurrent review and interview on April 24, 2025, at 12:24 PM, with the ADON, the facility's policy and procedure (P&P) titled Side Rails Use of, undated, was reviewed. The P&P indicated, 1. Resident will be assess upon admission for the use of side rails taking in consideration the following: entrapment, strangulation, suffocation, accidental suspension, major injury . 2. Side rails will be used for the purpose of bed mobility and positioning.3. If side rail is not use as an enabler, will be documented in the assessment. The ADON stated the policy was in place and the staff did not follow the policy as the Resident 58 side rails were not implemented despite a physician's order, completed safety assessment and documented justification for use as an enabler.

Based on observation, interview and record review the facility failed to maintain infection control practices for one of eight residents (Resident 74) when Resident 74's oxygen tubing (is a small, flexible plastic tube that connects an oxygen source [like a machine or a tank]) was found on the floor under the bed. This failure had the potential to spread infectious disease (disease cause by bacteria, viruses, fungi or parasite) to Resident 74. Findings: During a review of Resident 74's Admission Record (contains demographic and medical information), it indicated Resident 74 was admitted to the facility on [DATE], with diagnoses of acute chronic diastolic (congestive) heart failure (the heart can't pump blood well, so fluid can back up into the lungs, causing trouble breathing), paroxysmal atrial fibrillation (the heart has episodes of irregular beating) and muscle weakness (generalized) (when muscles are very weak and can make it hard to breathe deeply.) During a concurrent observation and interview on April 21, 2025, at 9:12 AM, with Licensed Vocational NUrse (LVN 1), inside Resident 74's room. Resident 74 was lying down in bed, awake and with the head of the bed elevated. There was an oxygen concentrator (a machine that delivers oxygen) turned on, next to the bed. The oxygen tubing was connected to a humidifier ( a container that adds moisture to the oxygen to keep the nose and throat from getting dry) and the nasal cannula (a soft, flexible tube with two small prongs that go in the nose) it was lying on the floor under Resident 74's bed. LVN 1 acknowledged the oxygen tubing was on the floor and stated it should not be there because it was contaminated. During a review of Resident 74's physician's order, dated January 14, 2025, it indicated, .Continuous oxygen (oxygen that is given without stopping, all day and night) at (1-2) L/ MIN (at flow rate of 1 to 2 liters per minute) via nasal cannula/ mask (a plastic mask that covers the nose and mouth) to keep oxygen saturation above 90% (the goal is to keep oxygen in the blood measured as a percentage at above 90%, is when the body is getting enough oxygen to function properly) every shift. During a concurrent interview and record review on April 23, 2025, at 9:37 AM, with the Infection Preventionist Nurse (IP) the facility's policy and procedure (P&P) titled, Oxygen, Use of, undated, was reviewed. The P&P indicated, It is the policy of this facility to promote resident safety in administered oxygen . Procedures: use the following guidelines will observe in oxygen administration . 2. Tubing should be kept off the floor. The IP stated the staff did not follow the facility's policy. The IP further stated that the oxygen tubing should not be touching the floor to prevent bacterial contamination ( harmful germs are present on something and can spread to people).

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents for one of three sampled residents Resident1 (R1) when: 1. Resident 1 fell out of bed, sent to acute hospital for open laceration to right side of head. 2. No floor mats at bedside as recommended. This failure contributed to Resident 1 sustaining an open injury to forehead and being set out to hospital for further evaluation and received staples. Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: urinary tract infection (urine infection), syncope and collapse (fainting, loss of consciousness), hypertension (high blood pressure), history of falling. During a concurrent interview and record review of Resident 1's Medical Record with Infection Prevention Nurse (IP), reviewed and verified the following: 1. Admission Fall Risk assessment dated [DATE], at 7:43PM: High Risk. 2. Situation Background Assessment Recommendation (SBAR) Note dated February 05, 2025, at 10:58PM: Fall with abrasion to Right side of head. Unwitnessed fall, resident was found on floor right side of bed. Resident is alert/oriented X2 (person, place, time and event), Resident in pain. Resident has cut on right side of head about 7cm with moderate bleeding. Resident is able to move all extremities with discomfort. Vital taken with first aid to injury. Resident said he was trying to roll on his side and found himself on the floor .[name] notified 10:58PM, sent to emergency room . 3. Interdisciplinary Team (IDT) Note February 07, 2025, at 6:12PM, Fall, episodes of confusion, resident received 4 staples to right side of head. Neuro checks, bed will remain in lowest position with the call light within reach, recommended bilateral floor mats to reduce the risk of injury from potential future falls.: 4. Careplan: Has had an actual fall with laceration wound to Right side of head poor balance, poor communication/comprehension, psychoactive drug use, unsteady gait .interventions bed in lowest position, floor mat, room assignment to the nurse station. During an observation on February 19, 2025, at 10:55 AM., in room [ROOM NUMBER]-A, Resident 1, (R1) wearing yellow colored fall risk band on right wrist. No Floor Mats noted on each side of bed. No Falling star noted on (R1) name tag outside of door. During an observation and interview on February 19, 2025, at 12:07PM, with Certified Nursing Assistant CNA (CNA1) CNA1 states, we know by the falling star next to their name, at the name doorway if they are a fall risk resident. I ask the charge nurse if any resident is a fall risk. Or we ask physical therapy, they do have a wrist band, Fall Risk. In the charting it will say required low bed or mats. According to the charting, Resident 1 should have had floor mats. The falling star on the door does alert you to any issues with Fall Risk residents.: Observation of electronic medical records, CAN 1 shows Resident 1 charting, it does show floor mat with falling star in system for resident. During an interview on February 19, 2025, at 12:19PM, with Certified Nursing Assistant CNA (CNA2) CNA2 states, the residents have yellow wrist band with Fall Risk, some have floor mats, and some have tab alarm. If a resident is a Fall Risk and I don't see any floor mats I will let the nurse and maintenance aware. We do have falling stars at doorways to notify us if a resident is a Fall risk. During an observation and interview on February 19, 2025, at 11:10AM, with License Vocational Nurse (LVN) right outside of (R1) room, LVN states, (R1) fell a couple days ago, on admission day. Interventions for falls, on admission the info comes from the admitting hospital, we monitor all residents for fall risk though. Fall High risk residents get a low bed and floor mats at bedside. So far since the initial fall, he has been ok. When asked, is there a reason why (R1) has no floor mats, he did have a fall in facility? LVN states, He should have had a floor mats. I will get maintenance to get him floor mats . all residents have fall risk bands. Observation LVN telling maintenance, Oh can you get me some floor mats. During an interview on February 19, 2025, at 12:43PM, with Infection Prevention Nurse (IP Nurse) IP Nurse states, (R1) was a High Fall Risk on admission. He did have a fall on admission, we did Change of Condition and sent him out to acute hospital. He came back with staples to head. He did have floor mats; he was moved to another room. We did a room change February 14, 2025; he should have had the floor mats during the room change. We will place the mats and the falling star at door. During a review of the facility's policy and procedure titled, Fall Management System revised [February 2025], the policy and procedure indicated, It is the policy of this facility to provide an environment that remains as free of accident hazard as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. 2. Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. A. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. During a review of the facility's policy and procedure titled, Change of Condition revised [December 2023], the policy and procedure indicated, It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain highest practicable physical mental and psychological well-being in accordance with the interdisciplinary comprehensive assessment and plan of care.

Based on observation, interview and record review the facility failed to follow its Activities of Daily Living ADLs policy and procedure for 4 of 10 sampled Residents (Resident's 1,2, 3 and 4) when: 1. Resident 1 used call light to get staff attention for help and assistance and it takes a 1 hour to answer and NOC shift doesn't even come at all. 2. Resident 2 was left soiled for a long period of time on NOC shift. 3. Resident 3 used call light needed assistance due to feelings of low blood sugar and waited 3 hours long to get assistance. 4. Resident 4 needed assistance with ADLS and wait time was well over an hour or closer to shift change. This failure had the potential to cause (Resident 1,2,3, and 4) health and safety to be at risk for skin break down when their care needs were not met. Findings: During interview and Records Reviewed with (Resident 1,2, 3, and 4) indicates as followed: 1. During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: epilepsy (nerve activity in brain is disturbed causing seizures), diabetes type II (body does not produce enough insulin), cerebral infarction (blood flow in interrupted in brain, stroke). During observation and interview on February 04, 2025, at 10:40AM, with Resident 1, Observation 1of 2 side tables on other side of room, resident unable to access that table. Resident 1 states, I call for assistance and it takes them 1 hour to answer and NOC (night or overnight) shift they don't even come at all. 2. During review of Residents 2's Admission Record (general demographics), the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses to include: fracture of left femur (broken thigh bone), diabetes type II (body does not produce enough insulin), history of falling. During an interview on February 04, 2025, at 10:57AM with Resident 2 (R2) R2 states, NOC shift I have sat in wet diaper for over an hour. Even my doctor said we are having trouble with NOC shift staff. 3. During review of Residents 3's Admission Record (general demographics), the document indicated Resident 3 was admitted to the facility on [DATE], with diagnoses to include: diabetes type II (body does not produce enough insulin), rhabdomyolysis (breakdown of muscle tissues leasing protein in blood), fibromyalgia (tender and painful joints), history of falling. During an interview on February 04, 2025, at 11:30AM with Resident 3 (R 3) R3 states, I have waited 3 hours on NOC shift to get assistance, but it can be on all shifts. You hear them talking out in the hall instead of assisting the residents. The nurse, I kept calling for help cause my sugar was low and they took too long to come check in on me. She finally came in and told me, Well I will check it when I come back , I told her I was not feeling good, my mom died because of this. 4. During review of Residents 4's Admission Record (general demographics), the document indicated Resident 4 was admitted to the facility on [DATE], with diagnoses to include: above knee amputation left and right legs (absence of legs), diabetes type II (body does not produce enough insulin), hypertension (high blood pressure). During an interview on February 12, 2025, at 1:44PM with Resident 4 (R4) R4 states, Call lights, long waits are brought up in the council meetings. This happens to me at nighttime shift, over an hour for them to answer or they don't even come. They check on us until 4AM closer to the other shift coming in. 2 months complaining about this and it's still happening. I need assistance to get up, they don't want myself to get in wheelchair, but if they don't come, I have to get myself up. Where are they .everyone is sleeping. During an interview on February 12, 2025, at 1:11PM, with Certified Nursing Assistant CNA (CNA1) CNA1 states, PM and NOC shift I did have a resident crying she was left soiled at night, the resident is no longer here. I found 3 residents from yesterday and just in a brief no gown. Who the CNAs where I don't know. I do notify the Director of Staff Development (DSD) of issues; the PM or NOC nurses only check if the light is on for long periods. During an interview on February 12, 2025, at 2:35PM, with Director of Staff Development (DSD), DSD states, I have not had any complaints from residents about care, I do go talk to the residents. We do have some complaints, but not daily, we will always have some here or there. I have not had any complaints from the staff. If something is brought up, we have in-service with call light and educate the staff. As soon as we see it, we answer the call light. The residents should not be waiting over an hour to get assistance. Activities does let me know if any issues in the council meeting. During an interview on February 12, 2025, with the Administrator (Admin) Admins states, We have not heard of any issues with long waits or call lights from the residents. Expectation of Call lights are to answer within 5 minutes or less. There is a monitor on the nurse station with sound and monitor. It sends a message out if its more than 7 minutes. We use an outside source to monitor the call light system, have not heard anything from them. We have guardian angels staff goes around daily checking on residents. In the council meetings, we have not gotten any concerns, NOC shift nurse back station has a phone automated system, they have a phone and get a text. During a review of the facility's policy and procedure titled, Activities of Daily Living ADLs, Services to Carry Out revised [[DATE]], the policy and procedure indicated, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities .2.Residents who are unable to carry out activities of daily living (ADL) will receive necessary services to maintain: Good nutrition, Grooming, Personal hygiene, Oral hygiene. During a review of the facility's policy and procedure titled, Call Light revised [[DATE]], the policy and procedure indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff. 1.Answer the light/bell within a reasonable time. 2.Turn off the call light/bell. 3.Listen to the resident's request/need.4. Respond to the request. If the item is not available or you are unable to assist, explain to the resident and notify the charge nurse for further instructions. During a review of the facility's policy and procedure titled, Resident Rights revised [[DATE]], the policy and procedure indicated, It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The Resident has the right: 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality.

Based on interview, and record review the facility failed to ensure that one of three sampled residents, (Resident 1) received treatment and care in accordance with professional standards of practice, when Resident 1 fell off the bed unto the floor during care by a Certified Nursing Assistant (CNA 2). This failure resulted in Resident 1 sustaining a laceration on her right eyebrow. Findings: During a review of Resident 1 ' Admission Record (general demographics) the document indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses that included age-related cataract (a condition of blindness), quadriplegia (a condition of loss of movement and feelings in both arms and legs, cerebral palsy (a condition that affects the movements and coordination) and history of falling (July 9, 2023). During an interview on October 22, 2024, at 12:15 PM, with the Certified Nursing Assistant (CNA 1), the CNA 1 stated, I usually call another CNA to help me change and turn her because she is not able to turn herself. During a concurrent interview and record review on October 22, 2024, at 12:25 PM, Resident 1 ' s clinical report, titled SBAR (Situation Background Assessment Recommendation) a communication tool, dated October 6, 2024, with the Director of Nursing (DON), the document indicated, fell from bed during patient care. Laceration 3 cm [(Centimeters) units of measurement] noted above right eye. The DON stated, The resident slipped onto the floor when a staff (CNA 2) was providing care to the resident. The DON further stated, The resident requires one to two persons assistance and so the staff (CNA 2) should have called for assistance with providing care to the resident. During an interview on October 22, 2024, at 12:20 PM, with Licensed Vocational Nurse (LVN), the stated, Usually, it requires two persons in turning, changing and transferring her (Resident 1) during care. A review of Resident 1 ' s care plan dated, July 10, 2023, was reviewed. The care plan indicated, Focus: ADL (Activities of daily living) Self Care Performance Deficit r/t(related to) severe cognitive/physical . Goal: ADL needs will be met with total care as required . Interventions: . May provide 1-2 person assist during ADL care . During a review of the facility ' s undated Policy and Procedure (P&P), titled, Quality of Care Falls and Fall Risk, Managing, the P&P indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling .

Based on observation, interview, and record review, the facility failed to implement their infection prevention and control program when Resident 1, on enhanced barrier precautions (EBP - an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of multidrug resistant organisms [MDRO - bacteria that have become resistant to certain antibiotics]), did not have identifiable enhanced barrier precautions signage outside the resident ' s room in accordance with the facilities policy and procedure and Centers for Disease Control and Prevention (CDC) guidance. This failure had the potential for staff to not identify that Resident 1 was on enhanced barrier precautions and required the use of a gown and gloves during high-contact resident care activities which increased Resident 1 ' s risk of either acquisition of or transmission of MDRO ' s. Findings: A review of Resident 1 ' s Admission Record (contains medical and demographic information) indicated Resident 1 was admitted on [DATE], with diagnoses which included end-stage renal disease (the last stage of kidney failure), dependence on renal dialysis (renal dialysis - a type of treatment that helps your body remove extra fluid and waste products rom your blood when the kidneys are not able to), and anemia (a deficiency of red blood cells). During a review of Resident 1 ' s nurses progress notes, a note dated April 16, 2024, indicated, To reduce the spread of MDRO in LTC facilities per CDC guidelines, Resident has been placed on IC: Transmission Based Precautions - Enhanced Barrier Precautions D/T [due to] ESRD [end-stage renal disease] with HD [hemodialysis]. Primary MD [medical doctor] agrees with recommendation, resident made aware and verbalized understanding . During an observation on May 24, 2024, at 12:52 PM, at Resident 1 ' s room, the resident ' s name was posted adjacent to the door and had an orange dot next to it. There was no signage on the door or area around the doorway indicating the resident was on Enhanced Barrier Precautions. Additionally, there was no Personal Protection Equipment (PPE - refers to protective clothing or other equipment worn to prevent exposure or spread of infection or illness.) available outside Resident 1 ' s doorway or in the immediate vicinity. During an interview on May 24, 2024, at 12:58 PM, with CNA 1, CNA 1 stated to determine if a resident was on enhanced barrier precautions, she looks for the Enhanced Barrier Precautions, sign posted at the entrance of the resident ' s room, or a PPE cart outside the resident ' s doorway. When asked what it meant if a resident had a round orange sticker next to their name, CNA 1 stated she thought it meant the resident had hepatitis but stated she was unsure. During an interview on May 24, 2024, at 1:10 PM, with the Director of Staff Development (DSD), the DSD stated all residents who were on enhanced barrier precautions were supposed to have an Enhanced Barrier Precautions sign posted at the entrance of the resident ' s room and an orange sticker next to the resident ' s name. During a concurrent observation and interview on May 24, 2024, at 1:16 PM, outside Resident 1 ' s room, with the Infection Preventionist (IP), the IP stated the facility identified which residents were on enhanced barrier precautions because they were all supposed to have an Enhanced Barrier Precautions sign outside the resident ' s doorway. The IP further they would place an orange dot sticker next to the resident ' s name. The IP observed Resident 1 ' s room and stated the resident was on enhanced barrier precautions and was supposed to have an Enhanced Barrier Precautions sign posted at the entryway of the residents room but did not. The IP stated she thought when the resident left the facility a few days ago, the sign was removed and never put back up once the resident returned to the facility. During a concurrent observation and interview on May 24, 2024, at 1:25 PM, in Resident 1 ' s room, Resident 1 stated she recieved dialysis through her central venous catheter (a flexible catheter that is threaded through your skin into a central vein). Resident 1 pointed to her right upper chest area to show where her central line was located. During a follow up interview on May 24, 2024, at 1:42 PM, with the IP, the IP stated the facility follows guidance provided by the Centers for Disease Control and Prevention (CDC) regarding infection control and transmission-based precautions. During a concurrent interview and record review on May 28, 2024, at 1:36 PM, with the IP, the facility ' s policy and procedure titled, IPCP Standard and Transmission-based precautions, revised March 2024, was reviewed. The Policy indicated, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions 3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs) .6. Implementation: a. The facility will implement a system to alert staff, residents, and visitors that a resident is on TBP. i. Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves) ii. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves .b. Make PPE, including gowns and gloves, available immediately outside of the resident room . The IP acknowledged the facility did not follow the policy and procedure. During a review of the Centers for Disease Control and Prevention (CDC) guidance titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated April 2, 2024, the guidance indicated, .This document is intended to provide guidance for PPE use and room restriction in nursing homes for preventing transmission of MDROs, including as part of a public health response .Implementation -When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility ' s expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies,. To accomplish this: -Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g. gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use o gown and gloves. -Make PPE, including gowns and gloves, available immediately outside of the resident room .

Based on observation, interview, and record review the facility failed to follow their policy and procedure for a thorough admission assessment when a surgical wound did not receive a treatment order on admission causing a delay in treatments for one of five sampled residents (Resident 1). This failure had the potential to place a clinically compromised Resident (Resident 1) health and safety at risk. When the surgical wound assessments and treatments to promote wound healing were started 4 days after admission. Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: fracture of T11-T12 vertebra (thoracic spine fracture), diabetes type II (body does not produce enough insulin, or resist insulin), obstructive sleep apnea (airflow blockage during sleep), hypertension (high blood pressure). During a review concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON), reviewed are as follows: 1. Skin Evaluation dated July 23, 2023 at 11:07: Mid back surgical incision length 30 width 1.0, Rash/redness under right breast, 1+ pitting edema, Xerosis(rough, dry skin) Right and Left feet, hyperpigmentation to Right and Left lower legs, Intravenous Left Arm, Pacemaker(battery-powered device to prevent heart from beating slow) in place, skin tear to Left lower arm covered with Mepilex(foam dressing) C/D/I dressing, ecchymosis(bruising) to Left upper arm, ecchymosis to Right lower abdomen, Spine surgery with 69 staples present, covered with mepilex AG C/D/I, dry scab on posterior aspect of neck fold. 2. No record of wound care physician notification of Skin Evaluation on July 23, 2023, for wound care treatments. 3. Treatment Administration Record (TAR) dated July 01, 2023-July 31, 2023: 2a. Order date 07/26/23: Ammonium Lactate external cream 12% apply to Right and Left foot every day .Treatment started on July 27, 2023. 2b. Order date July 26, 2023: Mid-back surgical site, cleanse with Normal saline pat dry, cover with dry dressing every day for 21 days .Treatment started on July 27, 2023. 2c. Order date July 26, 2023: Posterior aspect of neck fold moisture associated wound with scab; cleanse w/Normal Saline, pat dry, paint w/Betadine, may leave open to air every day, shift for 21 days .Treatment started on July 27, 2023. 2d. Order date July 27, 2023: Skin tear to left forearm (POA), Cleanse with Normal saline, pat dry, cover with foam dressing and change every other day and PRN x 21 days. Treatment started on July 29, 2023. During an interview on August 22, 2023, at 11:30 AM, with the Treatment Nurse, Treatment nurse stated, On Admission Resident 1 came in with the wounds, the skin assessment was done the following day, but the treatment orders were placed on the July 26, 2023. I don't know why the orders should have been placed when admission assessment was done, and it wasn't. During a concurrent interview and record review on August 22, 2023, at 12:11 PM, with the Director of Nursing (DON), of Resident 1's Medical Records, DON stated, Resident 1 came in on August 22, 2023, at 9:58 PM, there was an initial skin evaluation the following day from admission. I do see the treatments starting on July 27, 2023. I don't know why the wound care treatments were not done until days later from admission. I can agree that it should had been on initial skin assessment, we should have had and order for wound treatments sooner. During a concurrent interview and record review on August 22, 2023, at 12:14 PM, with the Operation Manager (OM), of Resident 1's Medical Records, when asked, Should the resident have had wound care treatments sooner rather than starting 4-5 days later from admission? Yes, resident should have had a wound treatment care sooner. During a review of the facility's policy and procedure titled, Wound Care & Treatment Guidelines (reviewed January 2023), the policy and procedure indicated, It is the policy of this facility to provide excellent wound care to promote healing. During a review of the facility's policy and procedure titled, Skin Management System (reviewed January 2023), the policy and procedure indicated, It is the policy of this facility that any resident who enters the facility without pressure ulcers will have appropriate preventative measures take to ensure that the resident does not develop pressure ulcers, or that residents admitted with wounds will not develop signs and symptoms of infection, unless the residents clinical condition makes the development unavoidable .1. Residents will have a head-to-toe skin assessment by a licensed nurse at the time of admission. Any skin lesions will be documented on the Nursing Admission Assessment. A treatment order will be obtained from the Attending for areas requiring treatment. i.e. pressure injury, surgical wounds, open skin tears, abrasions, lacerations etc. 7. Surgical wound sites will be checked for signs and symptoms of infection until staples are removed or areas have healed .

Based on observation, interview, and record review, the facility staff failed to provide safety precautions for one of three sampled residents (Resident 1). On March 5, 2016, while a staff was providing care to Resident 1, the staff was unsure of how much assistance the resident needed. This failure resulted in the resident falling out of bed causing a facial injury, swelling to her right cheek and facial pain. Finding: During an observation of Resident 1 on April 18, 2016 at 1:30 PM, the resident was lying in bed with eyes closed. Resident 1 was observed to have a tracheotomy (a surgically made hole that goes through the front of the neck and into the windpipe). Resident 1 was non-verbal and in a vegetative state (a state of brain dysfunction in which a person shows no signs of awareness). A review of Resident 1's clinical record, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS-a facility comprehensive assessment tool) Functional status (the measure of a person's ability to perform activities of daily living (ADLs) independently), dated January 3, 2016, indicated Resident 1 was assessed to be total dependent (full staff performance) and had total impairment on both upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip,knee, ankle, foot). Resident 1 required total assist with all of her ADLs activity. During a review of the nursing progress note, dated March 5, 2016 at 8:15 PM, the Initial Change of Condition for a witnessed controlled fall indicated, the CNA (Certified Nurses Assistant) reported that she was changing the patient, she was too heavy, and she began to fall from the bed .Right cheek red, ice applied. A review of the nursing progress note, dated March 6, 2015 at 3:12 AM, indicated monitoring for witnessed fall, redness and slight edema noted to right cheek, ice pack wrapped in towel and applied to cheek for 15 minutes. During a review of the nursing progress note dated March 6, 2015 at 9:32 AM, indicated, Norco (a narcotic medication used to treat pain)tablet 5-325 MG (milligrams), 1 table via [DEVICE] (A gastrostomy tube also called a [DEVICE]- is a tube inserted through the abdomen that delivers nutrition and medication directly to the stomach) given due to facial grimacing, swelling at the right cheek and body movement. During a review of the nursing progress note dated March 6, 2016 at 6:30 PM, documented, medicated x 1 for pain due to swelling on right face. During an interview with CNA 1 on April 20, 2016 at 10:10 AM, she stated on March 5, 2016 Resident 1 was lying in bed. I went in to change her (Resident 1), this was the first time I cared for her. CNA 1 stated, I went to change her diaper, I rolled the resident to the side, she was heavier than I thought and she started to slip off the bed. Further more CNA 1 stated Resident 1 slipped off the bed, her face was pushed into the side table by her bed causing the swelling on her cheek. CNA 1 stated Resident 1 fell off the bed. When asked how does she know how much assistance the resident's need, CNA 1 was not able to explain. During a review of the Legacy Morse Fall Risk Scale, (assessment for determining fall risk), dated December 29, 2015, indicated Resident 1 had a total sore of 50. A score of 45 and higher represents a high risk for falls. The instructions on the Legacy Morse Fall Risk Scale indicated, . used to determine fall risk factors and target interventions to reduce risk. A review of Resident 1's care plan entitled, Fall Risk, initiated on July 7, 2014, related to decrease safety awareness, PVS (persistent vegetative state), anxiety and seizures showed interventions which included, Complete a fall risk assessment on admission and quarterly or with changes of condition/decline. There was no documented evidence to indicate how to reduce falls for Resident 1. During an interview with the Assistant Director of Nurses (ADON) on April 18, 2016 at 3:30 PM, the ADON verified there was no interventions to reduce falls for Resident 1 prior to the fall incident on March 5, 2016. The ADON verified Resident 1 had a high fall risk score of 50. The ADON stated, Every resident is assessed for their fall risk and should have an individualized care plan to reduce the risk. The ADON stated Resident 1 was a total care. Resident 1 was dependent on staff for bed mobility and all of her ADLs activity. When asked regarding how the staff determines how much assistance the residents need, the ADON stated, It is up to the CNA's and it is patient specific. The ADON then added, When you look at a resident, you can tell if the resident is required for a one or two person assist, I think, it's based on the size of the resident and the size of the CNA. A review of the facility policy and procedure titled, Fall Prevention Program, dated June 2015, indicated, All residents' environments shall remain free of accident hazard as is possible and all residents will receive adequate supervision and assistive devices to prevent accidents. All resident shall be assessed for being at risk for falls. Any resident identified as being 'at risk' for falls shall have an individual plan of care that included intervention to prevent falls from occurring. In Procedure Fall Prevention Interventions, 1. As the resident's needs are identified, resident specific interventions will be implemented. Post Falls, 6. Appropriate interventions will be implemented in an attempt to prevent further falls.

Based on observation, interview, and record review, the facility failed to ensure that two of six sampled residents (Residents 1 and 2) were free from accident hazards. For Resident 1, the facility failed to ensure safety, when Resident 1's right foot was caught under the wheelchair while the Restorative Nursing Assistant (RNA 1) was pushing Resident 1's wheelchair forward. This failure resulted in Resident 1 sustaining an acute fracture (broken bone) of the right femur (thigh bone) and required treatment at the hospital. For Resident 2, the facility failed to ensure a two person assist was implemented while changing the resident's brief. This failure resulted in Resident 2 falling from the bed to the floor and sustaining a bump to her head. Findings: 1. During an observation of Resident 1 on November 16, 2015 at 2:15 PM, Resident 1 was lying in bed with a wound dressing noted on the right side of her hip. A review of the clinical record for Resident 1, indicated Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. joint replacement (surgery to replace a knee joint with a man-made joint). A review of the physical therapy note dated September 14, 2015, documented Resident 1 had weakness to bilateral lower extremities. A review of the Minimum Data Set (MDS- a facility comprehensive assessment tool), under Functional status (the measure of a person's ability to perform activities of daily living (ADLs) independently), dated July 4, 2015, indicated Resident 1 was assessed to have total impairment on both lower extremities (hip, knee, ankle, foot). During an interview with Resident 1 on November 16, 2015 at 2:15 PM, Resident 1 stated on November 2, 2015, she was up on the wheelchair. Resident 1 stated her right foot was not on the wheelchair foot rest. Resident 1 stated when RNA 1 pushed her wheelchair, her right foot got caught under the wheelchair causing a severe pain. A review of the nurse's progress notes, dated November 2, 2015 at 2:58 PM, indicated, when resident (Resident 1) was being assisted back on the wc (wheelchair) the RNA started to push the resident back to her room, when resident yelled out in pain stating she has a broken leg . A review of the nurse's progress notes, dated November 2, 2015 at 6:40 PM, indicated x-ray report showed an acute fracture of the distal femur (fractures of the thighbone that occur just above the knee joint) for Resident 1. Resident 1 was transferred to the acute hospital for further evaluation and treatment. During an interview with RNA 1 on November 20, 2015 at 2:15 PM, RNA 1 stated on November 2, 2015, she pushed Resident 1 on the wheelchair when suddenly Resident 1 was screaming in pain. RNA 1 stated that she immediately stopped pushing the wheelchair forward and observed Resident 1's right foot was off the foot rest and was bent backwards under the wheelchair. Further interview with RNA 1 on December 1, 2015 at 4:00 PM, RNA 1 stated that she should have double checked Resident 1's feet to ensure both feet were on the foot rest of wheelchair for safety, prior to pushing Resident 1 forward in the wheelchair. During an interview with the Director of Staff Development (DSD) on January 12, 2016 at 10:10 AM, she stated the staff were expected to check the resident's feet and/ foot rest for safety of the residents prior to pushing a resident on the wheelchair. The Director of Nursing (DON) was asked for a policy and procedure for accident prevention. The DON indicated that the policy and procedure was incorporated on the Comprehensive Fall Policy and Procedure. The facility policy and procedure titled, Comprehensive Fall Prevention Policy and Procedure, dated August 15, 2007, indicated, It is the policy of the facility to attempt to prevent unavoidable falls, accidents, and injuries through the use of staff education and training, removal of accident hazards from the environment, vigilant environmental surveillance programs, preventative maintenance programs, and appropriate assessment and evaluation of the resident's cognitive status, safety awareness, locomotion, and gait stability to prevent as many falls and injuries as possible. 2. A review of Resident 2's clinical record documentation indicated that Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Assessment Instrument (a tool used to assess a resident from head to toe) completed on November 12, 2015, indicated Resident 2 required a two person assist while toileting or transferring. During an interview with the Director of Nurses (DON) on November 25, 2015 at 2:50 PM, the DON stated Resident 2 required a two person assist while providing any type of cares, transfers or positioning. During an interview with the complainant on November 25, 2015 at 9:00 AM, the complainant stated Resident 2 could not move her legs or arms and could not talk. The complainant stated Resident 2 fell from the bed on November 19, 2015 and sustained a bump to her head. During an observation on November 25, 2015 at 3:00 PM, Resident 2 was in her room in bed. Resident 2 was observed on a ventilation machine (a machine designed to move breathable air into and out of the lungs). Resident 2 was nonverbal. During an interview with the Certified Nurse Assistant (CNA 2) on November 25, 2015 at 3:05 PM, CNA 2 stated Resident 2 was dependent on staff for bed positioning, transferring, and for all her activities of daily living. CNA 2 stated Resident 2 could not move her arms or legs. During an interview with Certified Nurse Assistant 1 (CNA 1) on December 18, 2015 at 8:00 AM, CNA 1 stated that on November 19, 2015 at approximately 5:30 AM, she was changing Resident 2 on her bed. CNA 1 stated Resident 2 was positioned a bit on the left side of the bed. CNA 1 stated when she rolled Resident 2 to her left side, Resident 2 fell off the other side of the bed to the floor. CNA 1 stated she was comfortable changing Resident 2 on her own. CNA 1 stated that she was unaware that Resident 2 was a two person assist. CNA 1 stated that Resident 2 could not move her arms or legs and could not talk with staff to make her needs known.During an interview with the Licensed Vocational Nurse 1 (LVN 1) on December 18, 2015 at 7:55 AM, LVN 1 stated that on November 19, 2015 at approximately 5:00 AM, CNA 1 reported that Resident 2 fell from the bed to the floor while being changed. LVN 1 stated Resident 2 sustained a bump to her head. During an interview with the Assistant Director of Nurses (ADON) on December 18, 2015 at 3:30 PM, the ADON stated it was the expectation of the facility for all staff to be aware of the type of care each resident received. The ADON stated it was the policy of the facility that staff ensured that all residents would be provided an environment that prevented residents from falling. During a review of the facility's policy titled, Fall Prevention Program, developed October, 2010, documented under policy All resident's environment shall remain free of accident hazards as is possible and all residents will receive adequate supervision and assistive devices to prevent accidents.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was free from accident hazards. On November 4, 2015, while a staff was providing care to Resident 3, the bed moved causing the resident to fall out of bed. This failure resulted in Resident 3 sustaining a wound to her right cheek and required treatment at the hospital. Findings: During an observation of Resident 3 on November 20, 2015 at 2:50 PM, Resident 3 was lying in bed, eyes closed and observed to have a wound on her right cheek open to air. Resident 3 was observed to have a tracheostomy (a surgically made hole that goes through the front of the neck and into the windpipe) and on a ventilator (machine that supports breathing). Resident 3 was also observed to have contractures (joint and muscle stiffness that restricts normal movement) on both hands and lower legs. Resident 3 was a non-verbal and in a vegetative state (disorder of consciousness in which patients with severe brain damage are in a state of partial arousal rather than true awareness). A review of the clinical record for Resident 3, indicated Resident 3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. structure) and persistent vegetative state. A review of the Initial History and Physical, dated July 31, 2015, indicated Resident 3 was tracheostomy dependent, does not have the capacity to understand and make decisions. A review of the Legacy Morse Fall Scale (assessment for determining fall risk), dated August 20, 2015, indicated Resident 3 had a total score of 50. A score of 45 and higher represents a high risk for falls. The instructions on the Legacy Morse Fall Scale .used to determine fall risk factors and target interventions to reduce risks. A review of the Minimum Data Set (MDS- a facility comprehensive assessment tool) Functional status (the measure of a person's ability to perform activities of daily living (ADLs) independently), dated August 21, 2015, indicated Resident 3 was assessed to be total dependent and had total impairment on both upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). Resident 3 required maximum to total assist with all her ADLs activity. A review of the nursing progress notes, dated November 4, 2015 at 11:09 PM, indicated that Resident (Resident 3) fell from the bed and face down on the floor. Resident has wound cut on the right cheek 6 x 6 cm (6 by 6 centimeter) . Resident was transferred to acute hospital. During an interview with the certified nurse assistant (CNA 1) on November 16, 2015 at 4:55 PM, CNA 1 stated on November 4, 2015, Resident 3 was lying in bed. CNA 1 turned Resident 3 on her side to change her soiled brief, rolling Resident 3 away from her (CNA 1) when suddenly, Resident 3 started jerking. CNA 1 stated while providing care to Resident 3, the bed moved away from her (CNA 1). CNA 1 stated she tried to pull back Resident 3 and tried to hold onto Resident 3, the bed continued to move away from her (CNA 1). CNA 1 stated she was not able to hold onto Resident 3. CNA 1 stated as a result of that incident, Resident 3 fell off to the other side of the bed and landed face down on the floor. Resident 3 sustained a cut to her right cheek. CNA 1 stated the bed was not locked. CNA 1 stated the bed should have been locked for safety to prevent movement while changing Resident 3. A review of the Interdisciplinary Progress Notes, dated November 5, 2015, indicated that on November 4, 2015 at 10:05 PM, Resident 3 had fallen out of bed during care. The incident occurred when CNA 1 turned Resident 3 to her side when the bed moved. Resident 3's bed was not locked at the time of the incident. Resident 3 fell out of bed and sustained a 6 x 6 cm laceration (open wound) to the right cheek. Resident 3 was sent to the hospital for evaluation and treatment on November 4, 2015. A review of the care plan for Fall Risk related to Incontinent and Impaired Cognition, dated December 31, 2014, the intervention which included complete fall risk assessment on admission and quarterly or with changes of condition or decline. There was no documented evidence to indicate how to reduce fall for Resident 3. Further review of the revised care plan dated August 26, 2015, there was still no indication the facility had developed interventions to prevent Resident 3 from falling. During an interview with the licensed vocational nurse (LVN 1) on January 6, 2016 at 4:40 PM, LVN 1 verified there was no intervention to reduce falls noted in the care plan, not until after Resident 3 fell on [DATE]. LVN 1 verified Resident 3 had a high fall risk score of 50. LVN 1 stated the interventions to reduce fall should have been reflected on Resident 3's care plan dated December 31, 2014 and/or August 26, 2015, knowing Resident 3 was at high risk for fall. LVN 1 stated the bed should have been locked for safety while providing care to Resident 3 on November 4, 2015. LVN 1 stated Resident 3 was a total care. Resident 3 was dependent on a staff for bed mobility and all her ADLs activity. A review of the facility policy and procedure titled Comprehensive Fall Prevention Policy and Procedure, dated August 15, 2007, indicated It is the policy of the facility to attempt to prevent unavoidable falls, accidents, and injuries through the use of staff education and training, removal of accident hazards from the environment, vigilant environmental surveillance programs, preventative maintenance programs, and appropriate assessment and evaluation of the resident's cognitive status, safety awareness, locomotion, and gait stability to prevent as many falls and injuries as possible. During an interview with the director of staff development (DSD) on January 7, 2016 at 2:43 PM, she stated that bed should have been locked for safety to prevent accident while providing care to Resident 3 on November 4, 2015.

Based on observation, interview and record review, the facility failed to ensure that range of motion (ROM - extent of movement in a joint) was maintained for 1 of 21 sampled residents (Resident 2) which resulted in Resident 2 to develop significant contractures (inability to extend or straighten joints) in both his arms and legs which resulted in Resident 2 to develop a reduction in range of motion. Findings: The clinical record for Resident 2 was reviewed on 3/6/12. Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 2 was observed on 3/6/12 at 9:15 AM in bed in his room during a wound treatment. During the observation, two licensed nurses turned him onto his side in order to perform the wound care, however, were unable to straighten out his legs or arms so pillows were used to position him. Both legs were bent at the knees and hips tighter than 90 degrees (right angle). Both arms were close against his chest with elbows bent so both hands were near his shoulders. A review of Resident 2's admission and assessment form dated 3/17/11, showed documentation in the section titled, "Musculoskeletal History," that "none of the above" was circled under "stiffness" and other characteristics. The section titled, "Musculoskeletal Assessment" was blank. There was no documentation to indicate that Resident 2 had contractures or limited ROM. A review of the physical therapy (PT) evaluation for Resident 2 dated 3/18/11, showed the ROM was WFL (Within Functional Limits - "normal" or no ROM limitations)" for both legs. The PT discharge charting dated 4/30/11 revealed the same status for the ROM of both legs, "WFL." The discharge summary indicated the RNA (restorative nurses aid) was to continue performing exercises to both legs "to decrease potential for joint contractures." The initial occupational therapy (OT) evaluation dated 3/18/11 for Resident 2, showed that Resident 2's ROM was WFL. The OT discharge documentation dated 4/30/11 revealed that the ROM status was "WFL." Resident 2's care plan for physical therapy treatment, dated 3/18/11, showed that the section for "has decline in range of motion," was not checked which indicated that Resident 2 did not have a decline in ROM. The care plan for Resident 2, dated 3/23/11, showed documentation with a goal, "will not develop contractures x 3 months" and was updated with dates of 6/11, 9/11, 12/11 and 3/12. However, there were no new interventions documented. Resident 2's physical restraint assessment and review form dated 3/23/11, showed "ROM limitations WFL." A review of the IDT (interdisciplinary team) assessment forms dated 5/9/11 and 9/29/11 for Resident 2 both revealed that there were no checkmarks in the section for contractures, which indicated that Resident 2 did not have contractures. Review of Resident 2's RNA range of motion care plan, dated 4/30/11, showed a goal, "decrease risk of contractures," with RNA visits to provide ROM on a frequency of 5 days per week. Review of another RNA care plan dated 9/1/11 indicated that the RNA was to place and monitor hand rolls for Resident 2, and that under "approach/action," the RNA was to "monitor for increased stiffness." Resident 2's rehabilitation progress notes by the OT, dated 8/4/11 and 11/9/11, showed documentation that the OT recommended the RNA program for passive ROM exercises on both arms "to prevent contracture." A review of physician's notes for Resident 2 revealed documentation by the cardiologist dated 12/12/11 and 1/4/12 which showed "contracted arms and legs" on the physical observation portion of the progress note. Review of Resident 2's MDS (minimum data set - a comprehensive assessment form), dated 3/20/11, 6/30/11, 9/30/11 and 12/28/11 were each coded "no impairment" in the section in which to indicate functional limitation in range of motion. During an interview with RNA 1, on 3/9/12, at 8:50 AM, she stated that Resident 2 was already contracted when she first saw him at the end of March 2011. Resident 2's clinical record was reviewed with RNA 1 and she confirmed that there was no documentation of existing contractures found prior to the cardiologist report dated 12/12/11. During an interview with the rehabilitation supervisor on 3/9/12, at 9:40 AM, she explained that the term "WFL" (within functional limits) used with ROM by the OT and PT, meant that Resident 2 was able to participate in passive exercises with a full ROM. The rehabilitation supervisor reviewed the initial evaluation and discharge forms completed by the OT and PT and confirmed that both initial evaluations, dated 3/18/11, indicated that Resident 2 had no contractures at that time. She also confirmed that there were no contractures indicated on the discharge summaries dated 4/30/11. During further interview, the rehabilitation supervisor reviewed the progress notes written by the OT on 8/4/11 and 11/9/11 and stated that the notes indicated that Resident 2 had no contractures. After reviewing the notes by the cardiologist dated 12/12/11 and 1/4/12 which showed documentation "contracted arms and legs," she stated that she did not actually know when the contractures occurred, but from the medical chart, she would have to conclude that the contractures occurred after 11/9/11 and before 12/12/11. During an interview with the DON on 3/9/12, at 11:30 AM, she reviewed the clinical record for Resident 2 and stated that Resident 2 currently has contractures. The DON also stated that there was no documentation regarding Resident 2's contractures in his clinical record other than the cardiologist notes dated 12/12/11 and 1/4/12. She stated that Resident 2 had no contractures on admission (3/17/11), but now has contractures. Review of the facility's policy titled, "Restorative Nursing Services," dated 10/2010, revealed, "Monthly Restorative Nursing Program evaluation will be conducted by a licensed therapist to evaluate potential treatment plan changes." A review of the facility's policy titled, "Prevention of Contracture," dated 10/2010, showed that Resident 2 should be assessed by a member of the rehabilitation department at least quarterly, and that, "A care plan to prevent contractures shall be established by the IDT (Interdisciplinary Team. The nursing staff shall document progress/lack of progress to the care plan problem of contractures on a weekly basis. If the contracture is worsening, additional interventions shall be developed by the IDT. If there is worsening of a contracture or the onset of loss of mobility, the nurse shall notify the physician and the resident/surrogate decision maker." Review of Resident 2's record showed that there was no documentation to indicate that the RNA program was evaluated by a licensed therapist monthly, nor was there documentation of Resident 2's assessment by a member of the rehabilitation team at least quarterly. (The last documented assessment by the rehabilitation department was on 11/9/11). Resident 2's record showed no documentation of a care plan developed by the IDT to prevent contractures nor was there documentation of any notification to the physician or resident's decision maker regarding the loss of mobility.