Every finding on record at Atherton Baptist Home

Based on interview and record review, the facility failed to ensure the physician reviewed and took timely action on a medication regimen review (MRR, consists of a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) irregularity (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) identified by the facility's pharmacy consultant for two of five sampled residents (Resident 24 and 58) under unnecessary medications care area by failing to:1 a. Consider a gradual dose reduction (GDR, a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) with the goal of discontinuing Resident 24's Escitalopram (Lexapro, medication used to treat depression and generalized anxiety disorder) 20 milligrams (mg, unit of measurement) and adjusting the medication administration time to the daily time (instead of at bedtime)b. Clarify and add parameter to the Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) instructions for Resident 24's use of Hydrocodone/Acetaminophen (Norco, a combination medication that contains an opioid [sometimes called narcotics, are medication prescribed by physicians to treat persistent to severe pain] and an analgesic).2. Indicate the reason for disagreeing with the pharmacist recommendation for Resident 58 to have a gradual dose reduction for the use of Ativan (Lorazepam - a medication used for anxiety (an emotion characterized by feelings of fear, dread, and uneasiness, often as a reaction to stress). These deficient practices increased the risk that Residents 24 and 58 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy possibly leading to impairment or decline in their mental, functional, and psychosocial wellbeing.Findings: 1. During a review of Resident 24's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses including but not limited to dementia (progressive brain disorder that slowly destroys memory and thinking skills) with psychotic (mental health disorder which a person loses touch with reality) disturbance, depression (severe feelings on sadness and hopelessness), pain in right hip, and anxiety disorder (a feeling of nervousness, panic, and fear). During a review of Resident 24's Care Plan, revised on 4/7/2025, the Care Plan indicated Resident 24 used antidepressant medication Escitalopram related to major depressive disorder. The nursing staff interventions were to administer antidepressant medications as ordered by the physician and monitor/document side effects and effectiveness every shift. During a review of Resident 24's Care Plan, revised 4/7/2025, the Care Plan indicated Resident 24 had potential for alteration in comfort related to pain. The nursing staff interventions were to administer Norco oral tablet 5-325 milligrams (mg – unit of measurement) 0.5 tablet by mouth at bedtime for pain management. Not to exceed three (3) grams/24 hours and observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care. During a review of Resident 24's Order Summary Report, the Order Summary Report indicated as follows: On 4/17/2025, Hydrocodone-Acetaminophen oral tablet 5-325 mg: Give 0.5 tablet by mouth every eight hours as needed for moderate-severe pain (four to ten) not to exceed 3 grams/24 hours on all acetaminophens. On 4/28/2025, Escitalopram 20 mg tablet: Give 1 tablet by mouth at bedtime for major depressive disorder manifested by verbalization of sadness. During a record review of Resident 24's Minimum Data Set (MDS, a resident assessment and tool), dated 10/13/2025, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired. The MDS indicated Resident 24 required partial/moderate assistance (helper does less than half the effort) for shower/bathe self and tub/shower transfer. The MDS indicated Resident 24 received scheduled pain medication regimen. The MDS also indicated Resident 24 did not have any mood or behaviors and was taking medications such as an antidepressant, antipsychotic (drugs that work by altering brain chemistry to help reduce psychotic symptoms like hallucinations, delusions, and disordered thinking), and opioid. During a record review of Resident 24's MAR for the month of December 2025, the MAR indicated Resident 24 did not have any verbalizations of sadness for all three shifts for the month of December. During a review of the Consultant Pharmacist's (CP) Medication Regimen Review for recommendations between 12/10/2025 and 12/11/2025, the MRR indicated Resident 24 had two medications for review: Hydrocodone/Acetaminophen and Escitalopram. The CP indicated for Hydrocodone/Acetaminophen to: Clarify and add this parameter to the MAR instructions: Hold if respiratory rate is less than 12 (and notify physician) and Add a space on the MAR (above the dose) to document the respiratory rate. The CP indicated Escitalopram 20 mg at bedtime for depression manifested by verbalizing sadness (ordered April) does not appear to be showing behaviors to: 1.Consider a dose reduction to 10 mg daily with the goal of discontinuance. 'Irritability' and 'anger' are listed as possible side effects and Resident 24 was also receiving Seroquel (an atypical [second-generation] antipsychotic [drug that treats a form of mental illness] medication used in the treatment of schizophrenia [a chronic and severe mental disorder that affects how a person thinks, feels, and behaves], bipolar disorder [mental disorder characterized by episodes of mania (extreme highs) and depression (extreme lows)] , and major depressive disorder] at bedtime for 'aggressive behavior'. 2. Consider adjusting the administration time to the daily time (instead of at bedside). The CP also indicated if a gradual dose reduction was contraindicated, to specify why. During a concurrent review and interview on 1/16/2026 at 10:46 AM with Licensed Vocational Nurse 1 (LVN 1) of Resident 24's Order Summary Report and Nursing Notes were reviewed. LVN 1 stated the Director of Nursing (DON) was in charge of the MRR. LVN 1 stated neither an indication that the physician was notified nor any changes regarding Resident 24's MRR were done. LVN 1 stated MRR was conducted to ensure if residents were receiving the right medications and if there were contraindications to other medications. LVN 1 stated it was important to follow up with the CP's MRR recommendations to ensure safety in terms of medication for adverse reactions. During an interview on 1/16/2026 at 12:01 PM with the DON, the DON stated the physician usually likes the MRR presented to the physician when the physician comes to the facility. The DON stated the facility did not have a specific time frame to complete the MRR. The DON stated that the CP said the MRR could be completed in a few weeks but there was no specific time frame. The DON stated the MRR should at least be completed within the month. The DON stated there needed to be a follow up to see if the physician agreed with the CP's recommendations. The DON stated it was important to follow up with the MRR to avoid any adverse reactions. The DON stated the CP recommendations were for regulations and were not specific to the residents' needs. The DON stated the MRR was to avoid unnecessary use or avoid any adverse reactions. The DON stated the MRR was a collaboration and looks after a specific area for the resident medications. During a concurrent review and interview on 1/16/2026 at 12:13 PM with the DON, Resident 24's Order Summary Report and Nursing Notes were reviewed. The DON stated there were no notes to indicate whether the physician was notified and if the physician wanted to follow or decline the CP's MRR on 12/11/2025 (37 days after monthly MRR). The DON stated the importance of adding respiratory rate parameters were due to respiratory rate depression that could occur when a resident took Hydrocodone-Acetaminophen. The DON also stated it was important to follow up with the physician for a GDR to avoid any adverse reactions that could result in the resident such as drowsiness, dyskinesia (movement disorder that often appears as uncontrolled shakes, tics, or tremors), and confusion. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review (Monthly Report), dated December 2016, the P&P indicated the recommendations are acted upon and documented by the facility staff and or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician visit. During a review of the facility's P&P titled, Tapering Medications and Gradual Drug Dose Reduction, revised July 2022, the P&P indicated the physician will review periodically whether current medications are still necessary in their current doses; for example, whether an individuals' conditions or risk factors are sufficiently prominent or enduring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medications, or with a lower dose. 2. During a review of Resident 58's admission Record, the admission Record indicated the resident was admitted on [DATE] with the following but not limited to diagnoses of dementia, depression, anxiety and impulse disorder (a mental health condition marked by a persistent inability to resist strong urges or impulses that lead to repetitive, harmful behaviors, causing significant distress and problems in daily life). During a review of Resident 58's MDS, dated [DATE], the MDS indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS also indicated Resident 58 required substantial/ maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, lower body dressing, putting on/taking off footwear, and personal hygiene but required partial/moderate assistance with shower/bathe self and upper body dressing. The MDS indicated Resident 58 has anxiety disorder and is taking antianxiety medication. Resident 58 did not have mood or behavior symptoms. During a review of Resident 58's Care Plan with focus Risk for Adverse reactions related to polypharmacy (the use of multiple medications, typically defined as five or more at once), revised on 4/28/2025, the Care Plan indicated to review pharmacy consult recommendations and follow up as indicated. During a review of Resident 58's Physician Orders, dated 9/12/2025, the Physician Orders indicated the following: Lorazepam Give 0.25 mg by mouth in the afternoon (1 PM) for anxiety as manifested by self-report of constant worrying. Lorazepam tablet 1 mg by mouth in the evening (6 PM) for Anxiety as manifested by self-report of constant worrying. During a review of Resident 58's MRR, dated 12/11/2025, the MRR indicated Resident 58 is taking Lorazepam 0.25 mg PM (1PM) and 1 mg PM (6PM). The MRR indicated to consider a dose reduction, discontinuing the 1 PM dose or decreasing the 6 PM dose to 0.5 mg. The MRR also indicated if a gradual dose reduction is contraindicated, please specify why. During an interview on 1/15/2026 at 4:02 PM, the facility's MRR, dated 12/11/2025, was reviewed. The DON stated the MRR with the GDR for Resident 58 was not but should have been addressed by the resident's primary care physician. The DON also stated Resident 58 can experience adverse drug reactions. During an interview on 1/16/2025 at 10:39AM, the facility's P&P titled, Consultant Pharmacist Reports, dated 12/2016 was reviewed. The DON stated the GDR for Resident 58 needs to be reported to the physician within a week. The DON also stated the P&P does not have a time frame but should indicate a time frame of a week. During a review of the facility's P&P titled, Consultant Pharmacist Reports, dated 12/2016, the P&P indicated recommendations are acted upon and documented by the facility staff and or the prescriber. P&P also indicated physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician visit.

Based on observation, interview and record review, the facility failed to provide supervision for two of three sampled residents (Residents 12 and 18) under the accidents care area in accordance with facility policy when:1.Resident 12 was observed sliding off the wheelchair unattended in the activity room and unsupervised during a fall on 1/12/2026 in the resident's bedroom.2.Resident 18 was observed unattended in the activity room.This deficient practice placed Resident 12 and 18 at risk for accident and/or injury which had the potential to result in harm like fractures (break in bone), hospitalization, and death.Findings: 1. During a review of Resident 12's admission Record, the admission Record indicated the facility initially admitted Resident 12 on 3/29/2022 and was readmitted on [DATE] with diagnoses that included but not limited to dementia (a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life), repeated falls (an unintentional coming to rest on the ground or another surface, which can cause injury), reduced mobility (having difficulty moving around freely, easily, or without pain), unsteadiness on feet (feeling of being wobbly, off balance, or unstable while walking or standing), generalized muscle weakness (widespread decrease in physical strength affecting most or all muscles), difficulty walking (having abnormal or uncontrolled way of moving on foot), and osteoporosis (bone disease that makes bones weak, brittle, and more likely to fracture. During a review of Resident 12's Minimum Data Set (MDS-a resident assessment tool), dated 10/22/2025, the MDS indicated Resident 12 had intact cognitive (mental abilities that help us think, learn, remember, and solve problems) skills for daily decision making. The MDS indicated Resident 12 used a walker (mobility aid, a frame with wheels or legs that provides support for people with difficulty walking) and a wheelchair (chair with wheels) for mobility. The MDS indicated Resident 12 required set up or clean up assistance (Helper sets up or cleans up; resident completes activity) with eating, oral and personal hygiene. The MDS indicated Resident 12 required partial/moderate assistance (Helper lifts, holds, or supports trunk or limbs but provides less than half the effort) with toileting hygiene, upper and lower body dressing, putting on/taking off footwear, from sitting to standing position from chair, wheelchair or side of the bed, toilet transfer (ability to get on and off a toilet or commode) and walking 10 feet (ft. - unit of measure used for measuring height, length and distance), walking 50 feet with two turns, and walking 150 feet. The MDS also indicated Resident 12 required substantial/maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathing self. During a review of Resident 12's Care Plan initiated 12/24/2025, the Care Plan indicated Resident 12 is at risk for falls related to history of falls. The care plan indicated interventions including anticipating and meeting the resident's needs and reviewing information on past falls, attempting to determine cause of falls and alter or remove any potential causes. During a review of Resident 12's Progress Notes, dated 1/12/2026, the Progress Notes indicated that Resident 12's bed alarm (safety device designed to alert staff when a resident attempts to leave the bed without assistance. It typically consists of a sensor pad placed on the bed or under the mattress that detects changes in pressure or movement. When the resident gets up or shifts in a way that indicates they may exit the bed, the alarm sounds or sends a signal to staff.) went off. The Progress Notes also indicated staff went in the room and observed Resident 12 on the floor in a side lying position, with a bump on the left side of the forehead and discoloration below the knee. During a concurrent observation and interview on 1/13/2025 at 9:11 AM in the activity room, Resident 12 was observed sliding off her wheelchair and no facility staff were in the activity room. The Infection Prevention Nurse (IPN) stated that there were no staff present in the activity room. The IPN stated it was not acceptable that there was no staff present as residents may need help and may fall. During an interview on 1/16/2026 at 9:05 AM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated Resident 12 was a fall risk and was on the fall prevention program. LVN 3 stated it was reported from previous shift that Resident 12 had a fall incident in her room on 1/12/2026 during evening shift. LVN 3 stated that there should be staff present in the activity room to ensure residents are not left unattended. LVN 3 stated the residents might need assistance and may fall if left unattended and unsupervised. During a concurrent interview and record review on 1/16/2026 at 9:35 AM with the Director of Nursing (DON), the fall care plan initiated 12/24/2025 and change in condition (COC-record made by healthcare professional that details significant, new, or unexpected change in a patient's physical, mental, or behavioral health) notes dated 1/12/2026, were reviewed. The care plan indicated Resident 12 was at risk for falls related to history of falls and interventions included frequent visual monitoring during medication pass, activities of daily living care, mealtimes, activity, and therapy. The DON stated according to the COC, dated 1/12/2026, timed at 9:49 PM, Resident 12 was noted on the floor. The DON stated it cannot be determined the last time Resident 12 was last seen by staff on 1/12/2026 prior to the fall. The DON stated the care plan was not followed. On 1/16/2026 at 9:45 AM, an attempt to contact Certified Nursing Assistant 2 (CNA2) and LVN 4 were made via phone call. Both CNA2 and LVN 4were the staff taking care of Resident 12 on 1/12/2026 evening shift. There was no response. On 1/16/2026 at 10 AM, an attempt to contact CNA2 and LVN 4 were made via phone call. There was no response. During an interview with the DON on 1/16/2026 at 10:05 AM, the DON stated there should be staff present when residents are in the activity room to ensure the safety of residents who were fall risks. 2 During a review of Resident 18's admission Record, the admission Record indicated the facility initially admitted Resident 18 on 9/10/2021 and readmitted on [DATE] with diagnoses including but not limited to hypertensive chronic kidney disease (a medical condition referring to damage to the kidney due to chronic high blood pressure), age related physical debility (progressive physical decline experienced by older adults due to aging), unsteadiness on feet, and generalized muscle weakness. During a review of Resident 18's MDS, the MDS dated [DATE] indicated Resident 18 had moderate cognitive impairment with daily decision making. The MDS indicated Resident 18 used a walker and wheelchair for mobility. The MDS indicated Resident 18 required set up or clean up assistance with eating, oral hygiene, and toilet transfer. The MDS indicated Resident 18 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting and personal hygiene, walking 10 ft, walking 50 ft with two turns and walking 150 ft. The MDS indicated Resident 18 required partial/moderate assistance with shower/bathing self, upper and lower body dressing, and putting on/taking off footwear. The MDS further indicated Resident 18 had occasional urinary incontinence (involuntary leakage or loss of bladder control) and had frequent bowel incontinence (inability to control bowel movements). During a concurrent observation and interview on 1/13/2025 at 9:11 AM in the activity room, Resident 18 was observed unattended. No facility staff were observed in the activity room. The IPN stated that there were no staff present in the activity room, which was not acceptable, as residents may need help and may fall. During an interview on 1/15/2026 at 2:50 PM with Resident 18, inside his room, Resident 18 stated he was in the activity room last Tuesday (1/13/2026) at around 9 AM. Resident 18 stated four other residents were in the activity room. Resident 18 stated there were no staff in the activity room. Resident 18 stated he felt anxious and uneasy as there were no staff to help him when he needed to use the restroom. Resident 18 stated that when he needs to go to the restroom, he must do so immediately to prevent any accidents (a person cannot control when they pass urine or stool). During an interview on 1/16/2026 at 9:05 AM with LVN 3, LVN 3 stated residents should not be left on their own, unsupervised in the activity room. LVN 3 stated the residents may need something and might try to move/stand that can cause them to fall and sustain injuries. During an interview on 1/16/2026 at 9:35 AM, the DON stated there should be staff present when residents are in the activity room to ensure the safety of residents who were fall risks and should be included in the policy and procedure for the Activity Program. During a review of the facility's policy and procedures (P&P) titled Safety and Supervision of Residents, revised 7/2017, the P&P indicated:The facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.The type and frequency of resident supervision may vary among residents and over time for the same resident.During a review of the facility's P&P titled Falls and Fall Risk, Managing, revised 3/2018, the P&P indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The P&P indicated that resident conditions that may contribute to the risk of falls include, but not limited to:Delirium and other cognitive impairmentLower extremity weaknessFunctional impairmentsincontinence

Based on observation, interview, and record review, the facility failed to ensure the care plan was implemented for one (1) of 1 sampled resident (Resident 47), under language and communication care area, by failing to put on the resident's hearing aid and provide a pencil and paper for communication.This deficient practice had the potential for Resident 47 from expressing her needs in a manner that the staff can understand, which could result in a delay in the provision of the resident's necessary care and services.Findings:During a review of Resident 47's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of dementia (a progressive state of decline in mental abilities), muscle weakness, and need for assistance with personal care.During a review of Resident 47's Minimum Data Set (MDS - a resident assessment tool), dated 10/20/2025, the MDS indicated the resident was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 47 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with lower body dressing, shower/ bathe self and toileting hygiene but required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing, putting on/taking off footwear, personal hygiene and chair/bed to chair transfer. The MDS indicated Resident 47 has moderate difficulty (speaker has to increase volume and speak distinctly) in hearing.During a review of Resident 47's Care Plan with focus communication problem related to hard of hearing, revised 1/16/2025, the Care Plan indicated the following staff interventions:Provide assistive communication devices (hearing amplifier) and writing board.Resident requires staff to put on her hearing aid with communication.During a concurrent observation in Resident 47's room with Infection Preventionist Nurse (IPN) on 1/13/2026 at 8:44 AM, Resident 47 was observed sitting in her wheelchair and asked to be put back to bed. The IPN replied to Resident 47 and the resident yelled, I can't hear you. IPN stated and was observed attempting to look for a writing board. Resident 47 was noted to be without hearing aids and without a writing board/paper and pencil at bedside.During an interview on 1/16/2026 at 9:34 AM, the IPN stated on 1/13/2026, Resident 47 was not wearing any hearing aids and did not have any writing materials for communication. The IPN also stated Resident 47 should have hearing aids on and a writing board/pad, or pencil and paper, so the resident is able to communicate her needs with the staff. During an interview on 1/16/2026 at 10:22 AM, the facility's Policy and Procedure (P&P) titled, Care of Hearing-Impaired Resident, dated 2001, was reviewed. The Director of Nursing (DON) stated the resident should have a writing pad or pen and paper to write, if able, when communicating with the staff. The DON also stated that this makes communicating easier so the staff can meet the needs of the resident. During a review of the facility's P&P titled, Care of Hearing-Impaired Resident, dated 2001, the P&P indicated when interacting with the hearing impaired, staff will implement the following but not limited to providing pencil and paper or tablet to communicate in writing, if the resident is able. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Plans, dated 2001, the P&P indicated the comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and are services provided for the resident.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan (a document that outlines a resident's care goals and the activities that will be performed to achieve those goals) for one (1) of 18 sampled residents (Resident 8) by failing to address Resident 8's central venous catheter (CVC, a type of access used for hemodialysis [HD-a procedure removing excess fluid and metabolic waste and products or toxic substances from the bloodstream]), in accordance with the facility's care plan policy.This deficient practice had the potential to not be able to provide specific interventions to address risk for having a CVC, such as accidental dislodgement (displacement/removal of a device thought to be securely in position), which could result in serious harm to Resident 8.Findings:During a review of Resident 8's admission Record, the admission Record indicated the facility initially admitted the resident on 6/25/2011 and was readmitted on [DATE] with diagnoses that included but not limited to end stage renal disease (ESRD-condition in which the kidneys stop functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life) with dependence on renal (kidney) dialysis (a treatment that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly), and hypertension (high blood pressure).During a review of Resident 8's Minimum Data Set (MDS-a resident assessment tool) dated 12/29/2025, the MDS indicated Resident 8 had intact cognitive (ability to think, remember, and make decisions) skills for daily decision making. The MDS indicated Resident 8 was independent (residents complete the activity by themselves with no assistance from a helper) with eating, oral/toileting/personal hygiene, upper and lower body dressing, rolling left and right, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed to chair transfer, toilet transfer, and walking 10 feet (ft.- unit of measure used for measuring height, length and distance), walking 50 feet with two turns, and walking 150 feet. The MDS indicated Resident 8 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with putting on/taking off footwear and tub/shower transfer. The MDS indicated Resident 8 required partial/moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with showering/bathing self. The MDS further indicated Resident 8 was on dialysis and had intravenous access (a medical technique that involves inserting a small, flexible tube [catheter] or needle into a vein to create a direct, temporary, or long-term, route into the bloodstream.During an observation and interview on 1/13/2026 at 4:03 PM in Resident 8's room, Resident 8 was observed sitting on her recliner chair. Resident 8 stated she was on HD every Monday-Wednesday-Friday and had a CVC for her access. Resident 8 stated there was an emergency kit (E-Kit, a portable collection of essential, sterile supplies used to temporarily manage, secure, or repair a catheter line if it becomes damaged, leaks, or if the dressing falls off. It is designed to be kept immediately available to prevent infection and stop air from entering the bloodstream before professional medical help is reached) on the shelf next to her bedside table. Resident 8 was observed pointing to the shelf right next to her bedside table on the right side of the bed.During a concurrent interview and record review on 1/15/2025 4:44 PM with the Director of Nursing (DON), the policy and procedures (P&P) titled, Access and Care of Hemodialysis Catheters, revised 2/2023 and Care of a Resident with End Stage Renal Disease, revised 9/2010 were reviewed. The DON stated the P&Ps did not specifically address care of the CVC when accidental dislodgement occurs. The DON stated that for best practice, the P&P should include how to manage the CVC in the event it gets dislodged or damaged.During the same concurrent interview and record on 1/15/2025 at 4:44 PM with the DON, the care plans focused on: Potential for complications of HD related to ESRD, revised on 7/22/2025 and Resident 8's ESRD care plan, revised 1/9/2026, were reviewed. The DON stated Resident 8 has a CVC on the right upper chest. The DON stated Resident 8 did not have and should have a care plan developed specifically for CVC to address the potential risks and complications and its interventions. The DON stated there should be a care plan for care of the CVC addressing not only risk of infection but also dislodgement. The DON stated the care plan should guide the staff on what interventions to perform in the event of an accidental dislodgement. The DON stated the failure to develop a care plan for the CVC represented a lack of comprehensive planning which could result in staff not knowing how to manage and care for Resident 8 if the CVC was accidentally pulled out and resulted in hemorrhage (bleeding).During a review of the care plan focused on Resident 8 has ESRD, revised 1/9/2026, the care plan interventions did not indicate presence and management of HD CVC access.During a review of the facility's P&P titled, Care of a Resident with ESRD, the P&P indicated residents with ESRD will be cared for according to currently recognized standards of care, education and training of staff specifically including how to recognize and intervene in medical emergencies such as hemorrhage and septic infections (a serious condition in which the body responds improperly to an infection).During a review of the facility's P&P titled, Comprehensive Person-Centered Care Plans, revised 3/2022, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change.

Based on observation, interview, and record review, the facility failed to ensure the personal belongings were documented in the inventory list (a comprehensive, itemized record of all goods, raw materials, and finished products of the resident) in accordance with the facility's Policy and Procedure (P&P) for one (1) of 1 sampled resident (Resident 18) under personal property care area.This deficient practice has the potential to cause Resident 18 to lose his personal belongings and prevent the facility from being able to replenish them.Findings:During a review of Resident 18's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the following but not limited to diagnoses of age-related physical debility (a state of profound weakness, lack of energy, and diminished strength), unsteadiness on feet, and muscle weakness.During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool), dated 10/24/2025, the MDS indicated the resident was moderately impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 18 required partial/moderate assistance (helper does less than half the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) with slower/bathe self, upper body dressing, lower body dressing and putting on/ taking off footwear but required supervision/touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with toileting hygiene, and personal hygiene.During a review of Resident 18's Inventory List, dated 11/10/2024, the inventory list indicated the resident has 1 extender (device that seizes, snatches, or picks up objects, often used for reaching items).During an observation on 1/13/2026 at 10:13 AM in Resident 18's room, Resident 18 stated he has two extenders, one long extender and one short extender. One of the extenders was observed on top of the bed and the other one was on the floor, in between the resident's bed and the wall.During a concurrent review and interview with the Social Services Director (SSD) on 1/15/2026 at 3:36 PM, Resident 18's inventory list, dated 11/10/2024, was reviewed. The SSD stated that when Resident 18 was readmitted on [DATE], the resident had two (2) extenders; however, the inventory list only indicated one extender. The SSD also stated that the facility needs to ensure all residents' belongings are accounted for on the inventory list. The SSD added that if residents' belongings go missing, the facility can replenish them.During an interview on 1/16/2026 at 10:32 AM, the facility's Policy and Procedure (P&P) titled, Personal Property, revised 11/2010, was reviewed. The Director of Nursing (DON) stated that residents' personal items are to be documented in the inventory. The DON also stated that this process ensures residents' personal items do not go missing, and if they do, the facility can address the issue.During a review of the facility's P&P titled, Personal Property, revised 11/2010, the P&P indicated the resident's personal belonging and clothing shall be inventoried and documented upon admission and as such items are replenished.

Based on observation, interview, and record review, the facility failed to monitor, assess, and inform the physician regarding a skin discoloration (bruises - an injury appearing as an area of discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) on the resident's left arm for one of one sampled resident (Resident 16) receiving anticoagulant medications (medications that prevent blood from clotting excessively) in accordance with professional standards of practice (authorized, authoritative guidelines established by professional bodies to define the expected behaviors, skills, ethics, and knowledge required for competent practice). This deficient practice had the potential to result in a lack of or delay in assessing for possible complications of Resident 16's skin discoloration which could lead to undetected bleeding and hospitalization. Findings:During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included transient cerebral ischemic attack (stroke-a temporary episode of blockage of blood flow to the brain), unspecified atrial fibrillation (afib-irregular, rapid heartbeat), and essential hypertension (high blood pressure). During a review of Resident 16's Minimum Data Set (MDS- a resident assessment tool), dated 11/20/2025, the MDS indicated Resident 16 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 16 required setup or clean-up assistance with eating, oral/toileting hygiene, and personal hygiene. The MDS indicated Resident 16 required supervision or touching assistance with sit to lying, sit to stand, chair/bed-to-chair transfer, walking 150 feet (ft- unit of measurement), and toilet transfer. The MDS also indicated Resident 16 required partial/moderate assistance (helper does less than half the effort) with shower/bathe self, upper body dressing, and lower body dressing. During a review of Resident 16's Order Summary Report, dated 12/24/2025, the Order Summary Report indicated the following physician orders:Aspirin EC (medication used to prevent blood clots and lower the risk for a heart attack or stroke) Tablet Delayed Release 81 milligrams (mg- unit of measurement) give 1 tablet by mouth one time a day for cardiac (heart) protector, give with food, with a start date of 11/13/2025.Xarelto (rivaroxaban- a blood thinner used to prevent and treat dangerous blood clots) Oral Tablet 10 mg give 1 tablet by mouth in the evening for afib, give with meal, with a start date of 1/2/2025. Monitor for any signs and symptoms of bleeding related to (r/t) Xarelto and Aspirin- check every (q) shift for bleeding gums, nose bleeds, bruising, coughing up blood, stained mucus, black stools. If present report to physician (MD), with a start date of 1/2/2025. During a review of Resident 16's Care Plan, dated 4/22/2025, the Care Plan indicated Resident 16 was on anticoagulant therapy Xarelto r/t afib. The Care Plan intervention included the following:Administer anticoagulant medications as ordered by the physician. Monitor for side effects and effectiveness q shift.Daily skin inspection. Report abnormalities to the nurse.Monitor [NAME] any signs and symptoms of bleeding r/t Xarelto and aspirin- check q shift for bleeding gums, nose bleeds, bruising, coughing up blood stained mucus, black stools. If present report to MD. During a concurrent observation and interview on 1/13/2026, at 9:50 AM, with Resident 16 in Resident 16's room, Resident 16 was observed sitting on her chair watching television. Resident 16 stated she was taking Xarelto and Aspirin which would give her bruises. Resident 16 pulled up her left sleeve and stated she had a dark purple bruise on the resident's left upper arm. During a concurrent interview and record review on 1/14/2026, at 3:25 PM with Licensed Vocational Nurse 1 (LVN 1), Resident 16's Point of Care (POC- the delivery and documentation of clinical services, such as nursing care, therapy, or diagnostics, directly at the resident's location (bedside, room) at the moment it occurs) Response History form (the detailed, real-time record of care documentation captured directly at the resident's bedside) dated 1/14/2026 was reviewed. LVN 1 stated Resident 16 bruised easily because the resident was taking Xarelto and Aspirin. LVN 1 stated Resident 16 was monitored for signs of bleeding every shift. LVN 1 stated Certified Nursing Assistants perform body checks when they assist the residents with their activities of daily living (ADL- basic self-care tasks like eating, bathing, dressing, and using the toilet). LVN 1 stated Resident 16's POC Response History form indicated Resident 16 had an old discoloration on 1/14/2026, at 9:52 AM. LVN 1 stated she was not aware that Resident 16 had a bruise on the resident's left arm. During an interview on 1/14/2026, at 4:18 PM, with the Infection Prevention Nurse (IPN), IPN stated Resident 16 had a bruise on the resident's left arm. During an interview on 1/15/2026, at 11:28 AM, with CNA 1, CNA 1 stated she reports new bruises she sees on residents during ADL care to the LVN. CNA 1 stated Resident 16 has had the bruise on her left lower arm for approximately three (3) months. CNA 1 stated she informed an unknown LVN three months ago about the bruise and was informed by the LVN that the bruise was already reported to the MD. CNA 1 stated she did not report the bruise on Resident 16's left lower arm anymore because CNA 1 though it was an old bruise from 3 months ago that was already reported. CNA 1 stated it was important to report skin discoloration or bruises to the LVN so the MD can be notified and the cause of bruise can be investigated. During an interview on 1/15/2026 at 12:02 PM, with LVN 1, LVN 1 stated signs and symptoms of bleeding on a resident taking anticoagulants should be reported to the MD right away to make sure the resident was not bleeding internally. LVN 1 stated it was also important to find out the cause of the bleeding because sometimes it could also be a sign that the resident was abused (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) or had a fall. During an interview and record review on 1/15/2026, at 12:10 PM, with the IPN, Resident 16's Progress Notes dated from 10/25/2025 to 1/13/2026 were reviewed. The IPN stated there was no documentation of discoloration or bruising on Resident 16's left lower arm from 10/25/2025 to 1/13/2026. The IPN stated the discoloration on Resident 16's left lower arm was a change in condition and the MD should have been notified as soon as possible or by the end of the shift. The IPN stated it was important to notify the MD of any signs and symptoms of bleeding in case the resident's anticoagulant medications need to be changed. During an interview on 1/16/2026, at 12:27 PM, with the Director of Nursing (DON), the DON stated the signs and symptoms of bleeding observed by the CNA should be reported immediately to the LVN. The DON stated LVNs should assess and provide the necessary interventions to prevent complications as soon as signs and symptoms of bleeding are observed or reported to the licensed nurse. The DON stated the MD should be notified immediately and no more than 24 hours after signs and symptoms of bleeding were reported. The DON stated if bleeding was not assessed and reported to the MD, the resident can have complications like hemorrhage (an escape of blood from a ruptured blood vessel) which was an emergency and could result in hospitalization. During a review of the facility's P&P, titled, Acute Condition Changes-Clinical Protocol, revised on 3/2018, the P&P indicated the following:Direct care staff, including nursing assistants will be trained to recognizing subtle but significant changes in the resident and how to communicate these changes to the Nurse. Nursing assistants are encouraged to use the Stop and Watch Early Warming Tool (a simple, visual communication aid used in healthcare to help staff quickly spot and report subtle signs of a resident's condition deteriorating to nurses or managers) to communicate subtle changes in the resident to the nurse. During a review of the facility's policy and procedure (P&P), titled, Anticoagulation-Clinical Protocol, revised on 11/2018, the P&P indicated the following:As part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; for example, those with a recent history of atrial fibrillation.Assess for any signs or symptoms related to adverse drug reactions due to the medications alone or in combination with other medications. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in urine), hemoptysis (coughing up blood), or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.

Based on interview and record review, the facility failed to follow its policy to ensure resident's drug regimen was free from unnecessary medication use for one (1) of five (5) sampled residents (Resident 2), under unnecessary medications care area, by failing to have a specific indication for Resident 2's use of Seroquel (quetiapine- an antipsychotic medication to treat mental condition by helping balance certain chemicals in the brain). This deficient practice had the potential to increase the risk for Resident 2 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medication (drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), possibly leading to impairment or decline in the resident's mental, functional or psychosocial status.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (progressive decline in mental ability severe enough to interfere with daily life), depression (a common, serious mental health condition characterized by a persistent low mood, loss of interest in activities, and a sense of numbness or emptiness), and anxiety disorder (a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear, worry, or dread that interferes with daily life).During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 10/31/2025, the MDS indicated Resident 2 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 2 required setup or clean-up assistance with eating and oral hygiene. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, upper/lower body dressing, personal hygiene, roll left and right, sit to lying, sit to stand, and toilet transfer. Resident 2 did not have any mood or behavior symptoms.During a review of Resident 2's Order Summary Report, dated 12/24/2025, the Order Summary Report indicated a physician order for the following:Seroquel oral tablet 25 milligrams (mg-unit of measurement) give 1 tablet by mouth two times a day for psychosis (significant loss of contact with reality) manifested by (m/b) periods of paranoia (an intense, irrational distrust and suspicion of others, often with the unfounded belief that people are trying to harm, deceive or conspire against them), with a start date of 1/2/2025. Monitor behavior of psychosis m/b periods of paranoia behavior every shift, with a start date of 1/29/25.During a review of Resident 2's Care Plan, dated 1/29/2025, the care plan indicated Resident 2 used psychotropic medications Seroquel related to (r/t) psychosis. The care plan indicated interventions to monitor/record occurrence of target behavior (a specific observable, and measurable action selected for change, assessment, or intervention) symptoms periods of paranoia and document per facility protocolDuring a concurrent interview and record review on 1/16/2026, at 9:59 AM, with Licensed Vocational Nurse 1 (LVN 1), Resident 2's physicians orders were reviewed. LVN 1 stated Resident 2 was ordered Seroquel for psychosis and paranoia. LVN 1 stated Resident 2's paranoid behavior included seeing things that were not there, saying that someone took her daughter or was going to hurt her or take her away from her place. LVN 1 stated Resident 2's behavior of seeing things were hallucinations and not paranoia. LVN 1 stated Resident 2's specific paranoid behavior was not indicated in Resident 2's physician order. LVN 1 stated Resident 2's order for behavior monitoring for Seroquel did not and should have indicated the specific paranoid behavior that needed to be monitored. LVN 1 stated this will ensure all the licensed nurses are monitoring the same behavior which will ensure accurate evaluation if the medication is effective or not.During an interview on 1/16/2026, at 10:31 AM, with LVN 2, LVN 2 stated Resident 2's behavior was being monitored because she was taking Seroquel for paranoia. LVN 2 stated Resident 2's paranoid behavior included agitation, aggressive behavior, and accusing staff of taking her things away. LVN 2 stated Resident 2's behavior monitoring order did not indicate the specific type of paranoia that needed to be monitored by facility staff. LVN 2 stated that the specific paranoid behavior should be specified in Resident 2's physician's order so that Resident 2's behavior could be managed. LVN 2 stated it was important to monitor Resident 2's specific paranoid behavior to determine if her Seroquel medication needed to be reevaluated by the physician.During an interview on 10/16/2026, at 3:04 PM, with the Director of Nursing (DON), the DON stated Resident 2's Seroquel was ordered for episodes of seeing things that are not there. The DON stated Resident 2's Seroquel order should indicate the specific paranoid behavior that needed to be monitored. The DON stated the specific behaviors of residents on antipsychotic medications should be monitored to make sure that the medication was working and to provide interventions when the resident displayed the behavior.During a review of the facility's policy and procedure (P&P), titled, Antipsychotic Medication Use, revised on 7/2022, the P&P indicated the following:Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavior symptoms have been identified and addressed.Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others.The attending physician and facility staff will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications.

Based on interview and record review, the facility failed to ensure two (2) of 2 sampled residents (Residents 1 and 2) received proper pain management by failing to have pain scale parameters to pain medications ordered when: Resident 1, who had returned from the general acute care hospital (GACH) after a right hip hemiarthroplasty (a surgical procedure that involves replacing half of the hip joint), had a physician's order for Tramadol Hydrochloride (drug commonly used to treat severe pain) as needed (PRN) for pain without a pain scale parameter (mild, moderate, or severe pain). Resident 2 had a physician's order for Tramadol Hydrochloride and Tylenol Extra Strength (drug which reduces fever and relieves minor aches and pain) PRN for pain without a pain scale parameter.This deficient practice had the potential for Residents 1 and 2's pain not to be managed which could result in negatively affecting the residents' overall well-being. Findings: 1. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with the diagnoses including but not limited to atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), dementia (progressive brain disorder that slowly destroys memory and thinking skills), and age-related osteoporosis (weakening of bones, leading to a decrease in bone density and an increased risk for fractures). During a review of Resident 1's care plan, dated 10/1/2025, the record indicated Resident 1 was at risk for alteration in comfort related to pain. The staff's intervention was to monitor/record/report to nurse when resident complaints of pain or requests for pain treatment. During a review of Resident 1's Minimum Data Set (MDS, a resident's assessment tool), dated 10/6/2025, the record indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity) for sitting to lying, toilet transfer, and walking 50 feet. During a review of Resident 1's Radiology Results Report, dated 12/12/2025, the report indicated Resident 1 had an acute nondisplaced subcapital femoral fracture (a type of fracture that occurs below the femur's [bone of the thigh] head). During a review of Resident 1's GACH record, dated 12/13/2025, the record indicated Resident 1 had a surgical procedure for right hip hemiarthroplasty. During a review of Resident 1's Order Summary Report, dated 12/19/2025, the order indicated as follows:Tramadol Hydrochloride (HCl) oral tablet 50 milligrams (mg, unit of measurement): Give one (1) tablet by mouth every eight (8) hours as needed for pain; Hold for respiratory rate (RR) less than 12.Tramadol HCl oral tablet 50 mg: Give 1 tablet by mouth two times a day for pain management; Hold for RR less than 12. Tylenol Extra Strength (pain reliever medication) oral tablet 500 mg: Give 1 tablet by mouth two times a day for pain management; not to exceed (NTE) three (3) grams (gm, unit of measurement)/24 hours.During an interview on 12/22/2025 at 1:19 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 returned from GACH on 12/19/2025 after her right hip arthroplasty surgery. LVN 1 stated the physician had ordered routine Tramadol and Tylenol and PRN Tramadol for pain. LVN 1 stated there was a scale for mild, moderate, or severe pain, so pain medications were administered from lower to higher ratings depending on how the resident categorized their pain level. LVN 1 stated based on Resident 1's pain level, LVN 1 would need to clarify the Tramadol order with the physician and get an alternative. During a concurrent interview and record review of Resident 1's Order Summary Report on 12/22/2025 at 1:56 PM with LVN 1, LVN 1 stated the PRN Tramadol order did not have a scale and only indicated as needed for pain. LVN 1 stated since there was no pain scale noted on the physician's order for the PRN Tramadol, the pain medication could be administered if the resident complained of any pain from level 1 through 10. During a concurrent interview and record review of Resident 1's Order Summary Report on 12/22/2025 at 3:11 pm with LVN 2, LVN 2 stated PRN Tramadol should specify moderate to severe pain. LVN 2 stated Resident 1 should not receive Tramadol for mild pain. LVN 2 stated the licensed nurse would over medicate Resident 1 if Resident 1 complained of mild pain and Tramadol 50 mg was administered. LVN 2 stated that over medicating a resident could cause the respiratory rate to slow down which could result in vital organs to shut down. During a concurrent interview and record review of Resident 1's Order Summary Report on 12/22/2025 at 3:48 PM with the Director of Nursing (DON), the DON stated pain medications orders should include the dose, frequency, routine, and parameter for the pain rate. The DON stated Tramadol was usually used for breakthrough pain and given for moderate pain. The DON stated there should always be parameters for pain medication and there was no parameter for Resident 1's pain medication Tramadol. The DON stated pain scale parameters were included to ensure the licensed nurses administered the right medication for the right rate of pain. The DON stated residents could have side effects such as drowsiness if they were over medicated with pain medication. The DON stated residents could experience ineffective pain relief if they were undermedicated with pain medication. 2. During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE], with the diagnoses including but not limited to dementia, muscle weakness, and pain in right hip. During a review of Resident 2's care plan, dated 3/20/2025, the care plan indicated Resident 2 had an alteration in comfort related to chronic pain. The staff interventions were to administer Tylenol Extra Strength tablet 500 mg by mouth every six (6) hours as needed for pain, administer analgesia (relief or absence of pain) Tylenol, Lidocaine (topical anesthetic to provide localized pain relief), Tramadol as per orders, and monitor/record/report to nurse resident complaints of pain or requests for pain treatment. During a review of Resident 2's Order Summary Report, dated 3/27/2025, indicated as follows:Tylenol Extra Strength tablet 500 mg: Give one tablet by mouth every 6 hours as needed for pain not to exceed 3 grams/24 hours. Tylenol Extra Strength tablet 500 mg: Give one tablet by mouth two times a day for pain management NTE 3 gm/24 hrs.Tramadol HCl oral tablet 50 mg: Give one tablet by mouth every eight hours as needed for pain management (hold if RR is less than 12 and call physician). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathing self, upper and lower body dressing, and sitting to standing. During a concurrent interview and record review of Resident 2's Order Summary Report on 12/22/2025 at 4:50 PM with the DON, the DON stated Resident 2 had two PRN pain medications, Tylenol and Tramadol. The DON stated both of Resident 2's PRN pain medications should have and did not have pain scale parameters. The DON stated the pain medication parameters were important to ensure the licensed nurses knew which pain medication to administer based on the resident's pain level. During a record review of the facility's policy and procedure (P&P) titled, Medication Orders, revised 11/2014, the policy indicated PRN Medication Orders - When recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration. During a record review of the facility P&P titled Pain assessment and Management, reviewed October 2022. The policy indicated the purposes of this procedure are to help the staff identify pain in the residents and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. In general guidelines number 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary.

Based on observation, interview, and record review, the facility failed to label food items in the kitchen with item name, opened and expiration date as indicated in the facility's policy and procedure. This deficient practice had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness such as food poisoning with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization . Findings: During a concurrent observation and interview on 11/7/2024 at 7:49 AM with dietary supervisor (DS) in the walk-in refrigerator of the main kitchen, the following were observed: a. Four trays of marinated fish fillet have no labels for the name of the food item, date, and time it was prepared and no label of use-by date. b. Three trays of prepared Jello have no lids to cover the trays of the Jello, there were no labels for the name of the food item, date, and time it was prepared and no label of use-by date. c. One loaf of banana bread in the metal container has no wrapping, no lid, and there was no label for the name of the food item, date, and time of prepare and the use by date. DS stated all the food trays should always be labeled with the food item name, preparation date and time, and the use by date for each food item. DS stated all the ready to eat food items are supposed to be covered with lids or shrink wrap (transparent plastic film used to cover/ enclose food items) to prevent food contaminations. During a concurrent observation and interview on 11/7/2024 at 8:09 AM with dietary service director (DD) and DS in the walk-in freezer, the following were found: a. Three (3) bags of frozen meat were randomly sitting on top of two paper boxes, the 3 bags of frozen meat were not labeled with food item name, there were no purchase date, no expiration date and no best use by date. b. Two (2) packages of snap pea not labeled with expiration date. c. Two packages of breakfast waffles not labeled with food item name, and no use by date. d. One bag of cream puffs with no food item name and no expiration date. DD and DS stated all food items were supposed to be labeled with food item name and labeled with the used by date. During a concurrent observation and interview on 11/7/2024 at 8:23 AM with DD and DS in the dry food storage area next to the main freezer observed one bag of buttermilk biscuit mix and was not labeled with used by date. During a review of the facility's policy and procedure (P&P) titled, Food and Supply Storage, revised on 1/2024, the P&P indicated all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The policy and procedure also indicated cover, label and date unused portions and open packages.

Based on observation, interview and record review, the facility failed to provide interventions to prevent accidents (any unexpected or unintentional incident, which results or may result in injury or illness ) for three (3) of 3 sampled residents (Resident 61, 29, and 24) by failing to: 1. Ensure a functional bed sensor pad (alerting device intended to monitor a resident's movement) for Resident 61's use, as indicated on the physician's order and failed to ensure resident's call light was within reach, as indicated on the fall care plan. 2. Identify and eliminate all foreseeable accident hazards and include care plan interventions to address underlying cause of fall for Resident 24 who had a history of falls on 5/25/2024, 7/13/2024, 8/30/2024, and 9/27/2024. 3. Ensure Resident 29's sensor pad alarm was properly positioned and turned on and worked at all times. These deficient practices placed Residents 61, 24, and 29 at risk for falls and injury which had the potential to result in serious consequences like fractures (break in the bone), hospitalization , and death. Findings: 1. During a review of Resident 61's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body needs for blood and oxygen), paroxysmal atrial fibrillation (PAF, is a type of irregular heartbeat, or arrhythmia [an irregular heartbeat, or a problem with the rate or rhythm of your heart], that occurs in brief episodes that last less than seven days), muscle weakness, and unsteadiness on feet. During a review of Resident 61's Minimum Data Set (MDS, a federally mandated assessment tool), dated 11/4/2024, the MDS indicated Resident 61 had severe cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 61 needed partial/ moderate assistance (helper does less than half the effort, helper lifts, hold, or supports trunk or limbs but provides less than half the effort) with toileting hygiene, sit to stand, chair/bed -to chair transfer, toilet transfer. Resident 61 also needed supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity) with oral hygiene, roll left and right, sit to lying, lying to sitting on side of the bed, and walk 10-150 feet. During a review of Resident 61's Physician's Orders, dated 10/8/2024, the Physician's Order indicated bed sensor pad at all times every shift for unsafe behavior manifested by getting up unassisted and record number of episodes. During a review of Resident 61's Fall Care Plan (CP), dated 8/13/2024, the CP indicated Resident 61 was at risk for self-injury from fall related to medical conditions, sensory alterations, balance, gait, assistive devices, cognition, mood/behavior, safety awareness, compliance, and medications. Goal indicated will follow safety suggestions and limitation with supervision and verbal reminders for better control of risk factors. Interventions included: Ensure that adaptive devices: walker are within reach. Encourage and assist placement of proper non-skid footwear. Observe for non-verbal signs of restlessness that may precipitate movement and attempts to stand/walk unattended. Observe for unsteady /unsafe transfer or ambulation and provide stand by or balance support as needed. Keep call light within reach at all times. Answer promptly and notify Resident 61 that help is coming. During an observation in Resident 61's Room on 11/7/2024 at 11:28 AM, Resident 61's call light was not within her reach. The call light was observed on the top drawer of the bedside table which was on the opposite side of the bed. The pad alarm machine box was hanging on the right side of the bed. The pad alarm did not make a sound/alarm when Resident 61 was trying to get out of her bed multiple times. During a concurrent observation in Resident 61's room and interview with Certified Nurse Assistant 1 (CNA 1) on 11/7/2024 at 11:29 AM, CNA 1 observed and stated the pad alarm did not make a sound /alarm when Resident 61 was observed trying to get out of her bed. CNA 1 stated Resident 61's call light was not within her reach and was placed on the top drawer of the bedside table which was on the opposite side of the bed. During a concurrent observation and interview with CNA 1 on 11/7/2024 at 11:32 AM, CNA 1 stated the pad alarm was placed on the left side of the bed and should have been placed in the middle of the bed where Resident 61was laying down for it to work. During an interview with CNA 1 on 11/7/2024 at 11:34 AM, CNA 1 stated, it was important for the pad alarm to make a sound/alarm to alert the staff , prevent Resident 61 might end up from falling. During a review of facility's policy and procedure (P&P) titled, Safety and Supervision of Residents revised on 7/2017, the P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. It also indicated to reduce accidents risks and hazards shall include the following: ensuring that interventions are implemented. During a review of facility's P&P titled, Falls and Managing Fall Risk, revised on 3/2018, the P&P indicated position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. 46919 2. During a review of Resident 24's Admission Record, the Admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included muscle weakness, difficulty in walking, benign paroxysmal vertigo unspecified ear (a common inner ear disorder that can cause vertigo or a false sense of spinning or movement), and history of falling. During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24 was assessed having moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 24 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, upper/lower body dressing, and putting on/taking of footwear. Resident 24 also required partial moderate assistance with sit to stand, chair/bed-to-chair transfer (ability to transfer to and from a bed to a chair), toilet transfer, and walking 10 feet (ft- unit of measurement). The MDS indicated Resident 24 had a one (1) fall with no injury since the last prior assessment on 6/6/2024. During a review of Resident 24's Morse Fall Scale Assessment form, dated 9/27/2024, the form indicated a total fall risk score of 65 (a score of 51 or above indicated high risk for falls). During a review of Resident 24's Interdisciplinary (IDT- a group of healthcare professionals who work together to help people receive the care they need) Note, dated 5/25/2024, the IDT Note indicated, At 6:15 AM, heard sensor pad. Entered into resident's room and found resident on the floor on his left side in front of his recliner. Certified Nursing Assistant (CNA) put resident in his recliner .color pale with abrasion (when the surface layer of the skin has been broken) to right cheek measuring 0.3 centimeter (cm-unit of measurement) x 0.3 cm color red and skin tear to right eyebrow area measuring 0.2 cm x 0.2 cm with blood drainage. During a review of Resident 24's IDT Note, dated 7/13/2024, the IDT Note indicated, At 12:10 PM, heard sensor pad alarm in room [ROOM NUMBER], 2 staff check and found Resident on the floor in side lying position in front of bathroom .Resident was noted with laceration (a deep cut or tear in the skin) in back of head size 4 cm x 1 cm, with small amount of bleeding .complain of (c/o) pain 5/10 .asked Resident what happened Resident, Resident stated 'I fell , I don't know how. Called Medical Doctor 1 (MD 1) and reported the incident with new order to transfer to General Acute Care Hospital (GACH) via regular ambulance. During a review of Resident 24's IDT Note, dated 8/30/2024, the IDT Note indicated, At 9:15 AM, summoned to room [ROOM NUMBER] by CNA, observed resident on the floor, sitting position, in front of the bed with wheelchair (w/c) behind him, alert, and verbally responsive .Upon investigation, resident stated he slid from his w/c resulting for him to sit on the floor .CNA reported that heard an alarm and when went to the resident's room, observed resident on the floor. Per CNA, he saw resident sitting in a w/c wheeling himself on the station. Sensor pad was on and functioning well. During a review of Resident 24's IDT Note, dated 9/24/2024, the IDT Note indicated, At 11:33 AM, I heard sensor pad alarm going off. When I enter Res. room notice res. sitting on the floor at the end of the footrest of the recliner chair, notice call light on his lap. Sensor pad alarm turn off alarm and working properly. When I asked Res. what happen, Res. stated I slide from the recliner chair when I was trying to stand up to reach for my W/C he stated this recliner is very tricky. During an interview with Resident 24, on 11/4/2024, at 3:48 PM, Resident 24 stated he was admitted to the facility after sustaining a fall. Resident 24 stated he had fallen four times in the facility. Resident 24 stated he fell by the bathroom but could not remember why he fell . During an interview with Licensed Vocational Nurse 1 (LVN 1), on 11/6/2024, at 11:40 AM, LVN 1 stated Resident 24 had a history of falls prior to admission. LVN 1 stated Resident 24 has fallen four (4) times in the facility since admission. LVN 1 stated Resident 24 fell in front of his recliner the first time he fell on [DATE]. LVN 1 stated Resident 24 was found on the floor in a side lying position in front of the bathroom the second time he fell on [DATE]. LVN 1 stated Resident 24 slid off his wheelchair and was found sitting on the floor in front of his bed the third time he fell on [DATE]. LVN 1 stated Resident 24 was found sitting on the floor after he slid from his recliner when he tried to reach for his wheelchair the fourth time he fell on [DATE]. LVN 1 stated the sensor pad alarm alerted staff each time Resident 24's fell . LVN 1 stated the interventions in the care plan should be resident-centered. LVN 1 stated it was the responsibility of the licensed nurses and the Care Plan Coordinator (CPC) to revise the care plan. LVN 1 stated the care plan should be reviewed by the CPC to assess if the interventions were effective or if it needed to be updated. During a concurrent review of Resident 24's care plan, dated 5/25/2024, and interview with the CPC on 11/6/2024, at 12 PM, CPC stated the care plan indicated Resident 24 was found on the floor on his left side on 5/25/2024. CPC stated Resident 24's care plan intervention did not and should have indicated interventions such as specific safety measures related to the risk and cause of the fall to prevent fall reoccurrence. During a concurrent review of Resident 24's care plan, dated 8/30/2024, and interview with the CPC on 11/6/2024, at 12:02 PM, CPC stated the care plan indicated Resident 24 slid from the wheelchair during self-propel on 8/30/2024. CPC stated Resident 24's care plan intervention did not and should have indicated interventions to include wheelchair safety during self-propel and transfer to prevent fall reoccurrence. During a concurrent review of Resident 24's care plan, dated 9/27/2024, and interview with the CPC on 11/6/2024, at 12:04 PM, CPC stated the care plan indicated Resident 24 was noted sitting on the floor in his own room on 9/27/2024. CPC stated the care plan problem did not indicate Resident 24 was found at the footrest of the recliner chair. CPC stated the care plan interventions did not and should have indicated safety measures when Resident 24 tries to stand up from recliner to transfer to the wheelchair and when sitting on the recliner to prevent fall reoccurrence. During a concurrent interview with the CPC and record review, on 11/6/2024, at 12:06 PM, Resident 24's care plan titled, Falls, was reviewed. The CPC stated Resident 24's care plan did not include interventions on wheelchair safety or how to prevent Resident 24 from sliding off the recliner. The CPC stated the facility staff should be proactive in preventing falls for Resident 24. The CPC stated Resident 24's care plan for falls should be specific to Resident 24's fall risk because he tends to slip and fall in his room. The CPC stated the care plan interventions should be reassessed if not effective to meet the goal. During an interview with the Director of Nursing (DON), on 11/7/2024, at 10:44 AM, the DON stated Resident 24's had a history of falls and hi specific needs to prevent falls should be included in the care plan for prevent falls from recurring. 3. During a review of Resident 29's Admission Record, the Admission Record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (a brain disorder that results in memory loss, poor judgment, and confusion), history of falling, and unsteadiness on feet. During a review of Resident 29's Care Plan titled, Falls, dated 7/26/2024, the care plan indicated Resident 29 needed supervision to substantial assistance with activities of daily living (ADLs). It indicated Resident 29 ambulates using a walker with staff, has impaired cognition, and has poor safety awareness. It indicated Resident 29 needs cueing and reminder for safe functioning related to dementia, hypertension (HTN- high blood pressure), PAD, CKD, hyperlipidemia, osteoporosis, macular degeneration, edema, osteoarthritis (OA- a progressive disorder of the joints, caused by a gradual loss of cartilage), Vitamin B deficiency, and CAD. The care plan indicated the following interventions to minimize risk of fall or injury daily: Sensor pad alert as ordered. Explain risks and benefits to resident and representative. Bed and chair sensor pad alarm at all times. Monitor proper placement and function of sensor pad every (q) shift. During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29 was assessed having severely impaired cognitive skills for daily decision making. Resident 29 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shoer/bathe self, and lower body dressing. Resident 29 required partial/moderate assistance with sit to stand, chair/bed-to-chair transfer, and toilet transfer. Resident 29 required supervision or touching assistance with walking 10 feet and walking 50 feet with two turns. The MDS indicated Resident 29 had a one (1) fall with injury (except major) since the last prior assessment on 7/8/2024. During a review of Resident 29's Physician's Orders form, dated 11/6/2024, the Physician's Orders form indicated an order, with a start date of 6/5/2024, for bed and chair sensor pad alarm at all times- every shift for unsafe behavior manifested by (m/b) getting up unassisted and record number of episodes. During a review of Resident 29's Morse Fall Scale Assessment form, dated 10/21/2024, the form indicated a total fall risk score of 70 (a score of 51 or above indicated high risk for falls). During a concurrent observation of Resident 29 and interview with an unidentified staff member, on 11/4/2024, at 10:55 AM, Resident 29 was observed sitting on a chair outside her room. Resident 29 had a white cord hanging from her chair. The unidentified staff member walked by and stated the white cord was the sensor pad alarm. Resident 29 attempted to stand up and the sensor pad alarm did not go off. The unidentified staff member checked the white box that was connected to the sensor pad alarm and stated the sensor pad was not turned on. During a concurrent observation of Resident 29 and interview LVN 1 on 11/6/2024, at 3:41 PM, Resident 29 was observed sitting on a chair outside her room. Resident 29 was observed shifting and attempting to stand up from her chair. LVN 1 stated Resident 29 always sits on the chair outside her room. LVN 1 stated the chair had a sensor pad alarm because Resident 29 had a history of falls and tends to stand up without assistance from staff. LVN 1 observed Resident 29 attempt to stand up from the chair. The sensor pad alarm did not go off. LVN 1 checked the white box connected to the sensor pad alarm and stated the sensor pad alarm was off. LVN 1 stated the sensor pad alarm should always be on when Resident 29 is sitting on her chair. LVN 1 observed Resident 29 attempt to stand up from the chair again. The sensor pad alarm did not go off. LVN 1 checked the white box and stated the sensor pad alarm was on but did not know why the alarm did not go off. LVN 1 asked Resident 29 to stand up and repositioned the sensor pad alarm. LVN 1 asked Resident 29 to stand up again and the sensor alarm pad went off. LVN 1 stated the sensor pad needs to be completely underneath Resident 29 for the alarm to go off when Resident 29 stands. LVN 1 stated the sensor pad alarm was important because it notifies the staff when Resident 29 moves and tries to get up from her seat without assistance. LVN 1 stated it was important for Resident 29's sensor pad alarm for the safety of the Resident and to prevent falls. LVN 1 stated it was the responsibility of the CNAs and the Charge Nurses (CN) to make sure the sensor pad alarm was on and in the right position. During an interview with the DON, on 11/7/2024, at 11:01 AM, the DON stated the sensor alarm pad needs to always be on to know when the residents need assistance. The DON stated it was important to provide the residents assistance in a timely manner to prevent falls in the facility. The DON stated it was the responsibility of the CNAs and the CNs to make sure the sensor pad alarms are turned on. During a review of the facility's policy and procedure (P&P), titled, Falls and Fall Risk, Managing, revised on 3/2018, the P&P indicated the following: Based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will implement a Resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each Resident at risk or with a history of falls. Examples of initial approaches might include exercise and balance training, rearrangement of room furniture, improving footwear, changing the lighting, etc. If falling recurs despite initial interventions, stall will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, cased on assessment of the nature of category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g. hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the Resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. If the Resident continues to fall, stall will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on interview and record review, the facility failed to ensure resident received reasonable accommodation of needs for one of 22 sampled residents (Resident 9) by failing to ensure resident was in a comfortable position during meals. This deficient practice resulted in Resident 9 in feeling exhausted and uncomfortable while eating. Findings: During a record review of Resident 9's Admission Record, the Admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of spinal stenosis (a tightening of the spinal canal that causes nerve pain), osteoporosis (weakening of bones, leading to a decrease in bone density and an increased risk for fractures), and reduced mobility. During a record review of Resident 9's Minimum Data Set (MDS, a federally mandated resident assessment and tool), dated 10/29/2024, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was moderately impaired. The MDS indicated Resident 9 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for eating. During a record review of Resident 9's care plan, dated 8/26/2024, the care plan indicated Resident 9 had a potential for alteration in nutrition related to lack of coordination, spinal stenosis (narrowing of the spine which puts pressure on the spinal cord and nerves), and decline in activities of daily living. The care plan interventions were to assess likes and dislikes, provide needed assistance during meals, and monitor through nutrition alert meeting as needed. During an observation on 11/4/2024 at 12:10 PM in the dining room, Resident 9 was sitting on the dining chair and the dining table was at Resident 9's eye level. Resident 9 held the lunch plate on her lap with her left hand while she used her right hand to feed herself. During a concurrent observation in the dining room and interview on 11/4/2024 at 12:17 PM with Restorative Nursing Aide (RNA 1), RNA 1 stated Resident 9 was hunched and sitting in the chair. RNA 1 stated every time Resident 9 was straightened up she would go back to the hunched position. RNA 1 stated they had tried to add cushion to her chair to make her higher so she could eat on the table, but Resident 9's feet would hang on the chair and Resident 9 did not like her feet to hang. RNA 1 stated the table was high for Resident 9. RNA 1 stated Resident 1 was eating with her plate on her lap. RNA 1 stated Resident 9 ate with her plate on her lap all the time. During an observation on 11/4/2024 at 12:24 PM of Resident 9 in the dining room, Resident 9 finished eating lunch and placed her plate and cup on the table, she sighed and stated, I'm exhausted. During an interview on 11/7/2024 at 8:53 AM with Resident 9, Resident 9 stated when she ate in the dining room, she could not reach her food on the dining table. Resident 9 stated staff put her plate on the table, and she tried to eat on the table. Resident 9 stated she got tired, and it was not comfortable eating on the table since the table was so high for her. Resident 9 stated it was hard to eat with the plate on the table since she had to tilt her head back each time she ate. Resident 9 stated it was horrible since the table was too high. Resident 9 stated, It's like feeding a midget. Resident 9 stated it was ideal for her to eat at the table instead of holding her plate on her lap while eating but felt that holding her plate was better than reaching up to the table while eating. Resident 9 stated when she reached up to the table to eat, it hurt all over her bones and was not comfortable. Resident 9 stated she was always placed at the regular table where it was too high for her. Resident 9 stated, I don't think people realize it, it's hard for me to eat like that. During an interview on 11/7/2024 at 9:35 PM with the Director of Nursing (DON), the DON stated residents should eat at their comfortable level. The DON stated the table should be above the waist and the residents' hands should be resting comfortably on the table. The DON stated the table should not be positioned at the residents' face while eating since this was not the proper way for a resident to be positioned while eating. The DON stated this could result in a bad posture while eating, cause discomfort and place the residents at risk for aspiration (inhaling small particles of food or drops of liquid into the lungs). During a record review of the facility's Policy and Procedure titled, Quality of Life - Accommodation of Needs, revised 11/2010, the policy indicated the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis.

Based on interview and record review, the facility failed to follow its Change in a Resident's Condition or Status policy by failing to notify the physician regarding a significant weight loss for one of three sampled residents (Resident 31) as indicated on the care plan. This deficient practice had the potential to result in delayed provision of necessary care and services. Findings: During a record review of Resident 31's Admission Record indicated Resident 31 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of hyperlipidemia (a condition in which there are high levels of fat particles in the blood), dementia (progressive brain disorder that slowly destroys memory and thinking skills) and left artificial hip joint. During a record review of Resident 31's Weight Tracking System Report, the record was as follows: - 5/29/2024 184 lbs - 6/3/2024 184 lbs - 6/6/2024 161 lbs (-23 lbs in three days, 12.5% weight loss) - 6/10/2024 160 lbs (-24 lbs, 13.0% weight loss) During a record review of Resident 31's Nutrition Risk Assessment, dated 6/3/2024, the record indicated care planned weight goal was to maintain weight 184 lbs plus or minus six (6) lbs by the next review. During a record review of Resident 31's Interdisciplinary Notes, dated 6/10/2024, the record indicated a weekly weight loss of 23 lbs and the physician was notified of the weight loss (4 days after). During a record review of Resident 31's Registered Dietician Notes, dated 6/11/2024, the record indicated Resident 31 was referred to nutrition alert due to 24 pounds, 13.0% weight loss in the past week. During a record review of Resident 31's Minimum Data Set (MDS, a federally mandated resident assessment and tool), dated 8/26/2024, the record indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 31 required substantial/ maximal assistance (helper does more than half the effort) for shower/bathe self, upper and lower body dressing, and chair/bed-to-chair transfer. During a record review of Resident 31's nutrition care plan, dated 9/25/2024, the care plan indicated monitor weekly weights per facility protocol, report significant changes in weight to physician and registered dietician. During an interview on 11/6/2024 at 3:28 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident was 184 lbs upon admission on 5/28/2024. LVN 2 stated on 6/3/2024 Resident 31 was still 184 lbs, then three days later Resident 31 weighed 161 lbs (-23 lbs). LVN 2 stated five (5) lbs weight loss in one week or one month needed to be reported to the physician. LVN 2 stated the physician needed to assess Resident 31 for her weight loss. LVN 2 stated the physician and registered dietician needed to be contacted as soon as the weight loss was noted. During a concurrent record review of Resident 31's electronic medical records with LVN 2, LVN 2 stated there was no physician notification on 6/6/2024 for Resident 31's weight loss. LVN 2 stated the physician should have been contacted as soon as they were contacted by the Restorative Nursing Aide of Resident 31's weight. LVN 2 stated the licensed nurses still needed to notify the physician since Resident 31's weight loss was more than 5 lbs. LVN 2 stated the physician should have been informed since Resident 31 might not be eating, have a poor appetite, require laboratory work, and require physician intervention to determine the reason why Resident 31 lost weight. During an interview on 11/7/2024 at 9:41 PM with the Director of Nursing (DON), the DON stated weight loss was a change of condition. The DON stated significant weight loss was 5% weight loss or weight gain in one month or 10% weight loss or weight gain in 6 months. The DON stated the physician should have been informed of planned and unplanned weight loss. The DON stated the standard of practice was for the licensed nurses to notify the physician of the weight loss within the shift or endorsed to the next shift to notify the physician. The DON stated there was going to be a delay in treatment for weight loss when the physician was not notified. During a record review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 2/2021, the policy indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. Notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to maintain confidentiality of the resident's electronic health record (EHR) for one (1) of 22 sampled residents (Resident 45) by failing to turn off the computer screen and leaving it unattended, exposing the resident's EHR which included the resident's medical condition, list of medications, and other information regarding resident care to others not authorized to view. This deficient practice had the potential to result in the violation of Resident 45's privacy and confidentiality. Findings: During a review of Resident 45's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), benign prostatic hyperplasia (BPH, also known as an enlarged prostate, is a noncancerous condition in which the prostate gland becomes larger than normal), and insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep) During a review of Resident 45's Minimum Data Set (MDS, a federally mandated assessment tool), dated 8/27/2024, the MDS indicated Resident 45 was assessed to have moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 45 was assessed to be needing substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, toilet transfer, tub/shower transfer, and walk 10-150 feet. During observation in front of Resident 45's room on 11/6/2024 at 11:02 AM, Licensed Vocational Nurse 1 (LVN 1) went inside Resident 45's room. LVN 1 did not turn off the computer monitor on top of the medication cart which was parked along the hallway where other residents and/ or facility staff were passing by. During a concurrent observation and interview with LVN 1 on 11/6/2024 at 11:08 AM, LVN 1 was observed leaving Resident 45's room and proceeded to use the computer on top of the medication cart after administering medication to Resident 45. LVN 1 stated, I should have closed the chart monitor (computer monitor) for Residents 45's privacy. It is important to turn off computer because of Health Insurance Portability and Accountability Act (HIPAA- a federal law that protects sensitive health information from disclosure without the patient's consent) and to protect the privacy of Resident 45's medical record. During an interview with LVN 2 on 11/6/2024 at 11:25 AM, LVN 2 stated, the licensed nurses must ensure that the staff close the EHR/ computer monitor on the top of the medication cart to prevent exposure of residents' information. LVN 2 stated it is the residents' rights not to have the resident's health information exposed to others. During a review of the facility's policy and procedure titled, Confidentiality of Information and Personal Privacy, revised on 10/2017, the P&P indicated the facility will protect and safeguard resident confidentiality and personal privacy. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Access to resident personal and medical records will be limited to authorized staff and business associates.

Based on interview and record review, the facility failed to provide Restorative Nursing Services (a program available in nursing homes to help residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) as ordered by the physician to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for one of three sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for decline in physical functions and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in the extremities (a limb of the body, such as the arm or leg) for not receiving the ordered exercises. Findings: During a review of Resident 2's Admission Record, the record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD, disease that causes obstructed airflow from the lungs), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen). During a review of Resident 2's Physician's Order, dated 11/16/2023, the record indicated RNA for bilateral upper extremities (BUE, both arms from shoulder to hands) / bilateral lower extremities (BLE, both legs from hip to foot) active range of motion (AROM, the ROM that can be achieved when opposing muscles contract and relax, resulting in joint movement) five (5) times a week as tolerated. During a review of Resident 2's Restorative Nursing Assistant (RNA) Daily Charting, the record indicated Resident 2 received RNA services for BUE and BLE AROM as tolerated as follows for the month of September 2024. - Week 1: 11/3/2024, 11/5/2024, and 11/6/2024 - Week 2: 11/10/2024, 11/12/2024, and 11/13/2024 - Week 3: 11/17/2024, 11/19/2024, and 11/20/2024 - Week 4: 11/24/2024, 11/26/2024, and 11/27/2024. During a review of Resident 2's RNA Daily Charting, the record indicated Resident 2 received RNA services for BUE and BLE AROM as tolerated as follows for the month of October: - Week 1: 10/1/2024, 10/3/2024, 10/4/2024 - Week 2: 10/8/2024, 10/10/2024, 10/11/2024 - Week 3: 10/15/2024, 10/17/2024, 10/18/2024 - Week 4: 10/22/2024, 10/24/2024, 10/25/2024 - Week 5: 10/29/2024, 10/31/2024. During a review of Resident 2's RNA Daily Charting, the record indicated Resident 2 received RNA services for BUE and BLE AROM as tolerated as follows for the month of November: - Week 1: 11/1/2024 - Week 2: 11/3/2024, 11/5/2024, 11/7/2024. During a review of Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment and tool), dated 9/13/2024, the record indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort) for upper and lower body dressing, personal hygiene, roll left and right, sit to lying, and lying to sitting on side of bed. The MDS also indicated Resident 2 had three days of active range of motion for the restorative program performed. During a review of Resident 2's activity of daily living (ADL) function rehabilitation care plan, dated 9/25/2024, the care plan indicated staff interventions were to encourage independence in ADLs by providing cues and monitor for continued independence, allow to participate with ADLs to tolerance, and RNA for AROM to BUE/BLE five times a week as tolerated. During a concurrent review of Resident 2's care plan, physician order, RNA Daily Charting, and Resident 2's electronic medical record and interview on 11/7/2024 at 8:34 AM with the Care Plan Coordinator (CPC), CPC stated Resident 2's care plan indicated Resident 2 had RNA services five times a week for upper and lower extremities as tolerated. CPC also stated the physician had ordered RNA services to be done five times per week. CPC stated RNA services were only being done three (3) times a week and not 5 times a week per physician order. CPC stated there were no notes indicating Resident 2's refusal of RNA services for the missing two times per week for RNA services. During a concurrent review of Resident 2's RNA Daily Charting interview on 11/7/2024 at 9:12 AM with Restorative Nursing Aide 1 (RNA 1), RNA 1 stated Resident 2 received RNA services 5 times a week. RNA 1 stated Resident 2 would refuse to complete RNA services once a month. RNA 1 stated Resident 2's refusals for RNA services should be documented on the chart. RNA 1 stated she did not see any notes for Resident 2 refusing RNA services. RNA 1 stated it was important for Resident 2 to receive her RNA services to prevent her from becoming contracted since Resident 2 spent most of her time in bed and refused to get out of bed. During a concurrent review of Resident 2's Physician's Order Summary on 11/7/2024 at 9:52 AM with Director of Occupational Therapy (DOT), DOT stated the physician had ordered RNA services for upper and lower extremity exercises and range of motion. DOT stated the physician ordered RNA services 5 times throughout the week to maintain functional status throughout. DOT stated 5 times per week RNA services was recommended for maintenance of general functional status, range of motion, and activity tolerance since Resident 2 generally choose to stay in bed. DOT stated based on the physician's order, the RNA should have followed the physician's order unless the resident refused services which should be documented in the Refused section. During a review of the facility's Policy and Procedure (P&P) titled, Resident Mobility and Range of Motion, revised 7/2017, the policy indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion. During a record review of the facility's P&P titled, Restorative Nursing Services, revised 7/2017, the policy indicated restorative goals may include, but are not limited to supporting and assisting the resident in participating in the development and implementation of his/her plan of care.

Based on interview and record review, the facility failed to ensure the drug regimen for one (1) of five sampled residents (Resident 17) was free from unnecessary drugs by failing to assess the continued need for Tylenol (acetaminophen- used relieve mild to moderate pain from headaches, muscle aches, and to reduce fever) after it was not administered as needed for pain for more than ninety (90) days. This deficient practice had the potential for Resident 17 to suffer adverse reactions from unnecessary drug including bleeding easily and bruising. Findings: During a review of Resident 17's Admission Record, the Admission record indicated Resident 17 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included major depressive disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified pain, and anxiety disorder (fear characterized by behavioral disturbances). During a review of Resident 17's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/6/2024, the MDS indicated Resident 17 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 17 required setup or clean-up assistance with eating. Resident 17 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, and toilet transfer. Resident 17 did not receive as needed pain medications as needed and did not have the presence of pain. During a review of Resident 17's Physician's Orders, dated 11/7/2024, the Physician's Orders indicated an order, with a start date of 4/10/2024, for Tylenol Extra Strength 500 milligram (mg- unit of measurement) 1 tablet (tab) by mouth twice daily for pain management. Resident 17 also had an order, with a start date of 10/27/2020, for Tylenol Extra Strength 500 mg 1 tab by mouth every four hours for pain as needed, last dose 4/16/2024. During a review of Resident 17's care plan During a review of Resident 17's Physician's Orders, dated 11/7/2024, the Physician's Orders indicated an order, with a start date of 6/18/2019, to assess pain level every shift: Pain scale: 0=no pain 1-3= mild pain 4-7= moderate pain 8-10= severe pain During a concurrent interview and record review with the Director of Nursing (DON), on 11/7/2024, at 3:56 PM, Resident 17's Medication Record from 8/2024, 9/2024, 10/2024, and 11/2024, was reviewed. The DON stated Resident 17 was assessed for pain every four (4) hours. The DON stated Resident 17 was assessed to have a pain level of 0 from 8/2024, 9/2024, 10/2024, and 11/2024. During the same concurrent interview and record review with DON, on 11/7/2024, at 3:56 PM, the DON stated Resident 17's Medication Record indicated Resident 17 did not receive any Tylenol Extra Strength 500 mg 1 tab by mouth every four hours as needed for pain from 8/2024, 9/2024, 10/2024, and 11/2024. The DON stated Resident 17's pain was managed by the Tylenol dose she received twice daily. The DON stated Resident 17's order for Tylenol Extra Strength 500 mg 1 tab by mouth every four hours as needed for pain medication was considered unnecessary if it has not been administered to Resident 17 for more than 90 days. During a review of the facility's policy and procedure (P&P), titled, Medication Utilization and Prescribing-Clinical Protocol, revised on 7/2016, the P&P indicated the following: The physician and staff will review the rationale for existing medications that lack a clear indication or are being used intermittently on a PRN (as needed) basis. The physician and staff will adjust existing medications based on their efficacy and the continued presence of relevant conditions and risks. The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to ensure that the medication and dosage are still relevant and are not causing undesired complications.

Based on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to properly label the medications with the date opened of one (1) of 8 sampled residents as indicated on the facility policy. This deficient practice had the potential for adverse reaction if these improperly labeled medications were administered to Resident 45. Findings: During a review of Resident 45's Admission Record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), benign prostatic hyperplasia (BPH, also known as an enlarged prostate, is a noncancerous condition in which the prostate gland becomes larger than normal), and insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep) During a review of Resident 45's Minimum Data Set (MDS, a federally mandated assessment tool), dated 8/27/2024, the MDS indicated Resident 45 was assessed to have moderately impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 45 was assessed to be needing substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, toilet transfer, tub/shower transfer, and walk 10-150 feet. During a review of Resident 45's Physician's Order dated 6/30/2024 indicated carbidopa 25 milligrams (mg, unit of measure) - levodopa 100mg (is commonly used to treat Parkinson's disease). Take 1 tab by mouth 3 times a day for Parkinson's disease. During an observation of Resident 45's medication administration with Licensed Vocational Nurse 1 (LVN 1) on 11/6/2024 at 11 AM, there was no label of date opened on the medication bottle of carbidopa- levodopa was observed. During a concurrent observation and interview with LVN 1 on, 11/6/2024 at 11:05 AM, LVN 1 observed Resident 45's medication bottle carbidopa- levodopa has no date open written on the medication container. LVN 1 stated, the facility should have labeled the medicine bottle with date the bottle was opened/ firs used. LVN 1 stated If we are the one who opened the medicine bottle, we should have written down the date open on the container. During an interview with LVN 1 on 11/12/2024 at 11:06 AM, LVN 1 stated, it is important to write or label the medicine container with the date it was opened, and the reason is for the staff to find out the date that the medication was received and to account the number/ amount of medications inside the container. During an interview with LVN 2 on 11/6/2024 at 11:21 AM, LVN 2 stated, licensed nurse counts the pills inside the medicine bottle and document in a log if the medication is from an outside pharmacy including all over- the - counter (OTC) provided by family. LVN 2 stated, We do not count the medications if the medicine container came in sealed from the facility's pharmacy. We log it on the logbook. The staff who started to administer the medication to the resident and opened the medicine bottle should write the date opened on the medication container. During an interview with LVN 2 on 11/6/2024 at 11:22 AM, LVN 2 stated, It is important to label the medication container to make sure that medications were given as directed, to prevent missing medications, and account every pill inside the medication bottle. During a review of the facility's policy and procedure titled, Administering Medications revised 4/2019, indicated the expiration /beyond use date on the medication label is checked prior to administering. The policy also indicated when opening a multi-dose container, the date opened is recorded on the container.

Based on observation, interview and record review, the facility failed to provide food that accommodated food preferences for one (1) of two sampled residents (Resident 40). This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition. Findings: During a review of Resident 40's Admission Record, the Admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses that included unspecified atrial fibrillation (afib- irregular and often very fast heartbeat that can lead to blood clots in the heart), heart failure (a serious condition in which the heart does not pump blood as efficiently as it should), and essential hypertension (high blood pressure). During a review of Resident 40's History and Physical examination (H&P), dated 5/16/2024, the H&P indicated Resident 40 did not have the capacity to understand and make decisions. During a review of Resident 40's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/16/2024, the MDS indicated Resident 40 was assessed having intact memory and cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 40 required setup or clean-up assistance with eating and oral hygiene. Resident 40 was independent (completes the activity by themself with no assistance from a helper) with sit to stand and toilet transfer. During a review of Resident 40's Physician's Orders, dated 11/6/2024, the Physician's Orders indicated an order, with a start date of 7/1/2021 for regular diet; okay to substitute to mechanical soft () three times a day. During a review of Resident 40's care plan titled, Nutrition. dated 8/28/2024, the care plan indicated Resident 40 had the potential for alteration in nutrition and the intervention indicated to offer alternative meal when available if Resident 40 does not like what is being served and order food, but cannot decide that to eat. The care plan also indicated Resident 40 had the potential for weight loss due to (d/t) poor appetite and the intervention indicated to provide diet as ordered. During an observation of Resident 40, in the dining room, on 11/4/2024, at 12:04 PM, Resident 40 was sitting on the dining table with green tea, water and apple juice in front of her. Certified Nursing Assistant 3 (CNA 3) placed Resident 40's food tray in front of Resident 40. Resident 40's food tray included a dinner roll, sweet potatoes, green beans, ground chicken arrabiata, and chopped lemon dill tilapia. CNA 3 walked back to the serving table and returned to Resident 40 with a bowl of chicken congee and chicken noodle soup. During a review of Resident 40's tray card (a card that contains information about a resident's meal service, including allergy, dislikes, preferences, standing orders (written instructions that specifies dietary guidelines for residents who meet certain criteria), special utensil requirements), dated 11/4/2024 lunch, the tray card indicated a standing order for Jello, 4 fluid ounce (fl oz- unit of measurement) apple juice, congee (rice porridge), 4 fl oz hot tea (green tea), 4 ounce (oz- unit of measurement) soy milk, and 1/4 cup white rice. During a concurrent interview and review with the Director of Staff Development (DSD), on 11/4/2024, at 12:40 PM, Resident 40's tray card for lunch was reviewed. The DSD stated Resident 40 was not served white rice, soy milk, and Jello with the rest of her meal. During an interview with CNA 3, on 11/9/2024, at 10:33 AM, CNA 3 stated Resident 40 wrote down her food preference in the morning of 11/4/2024. CNA 3 stated she did not read Resident 40's lunch tray card on 11/4/2024. CNA 3 stated she did not check if there were missing food items on Resident 40's food tray before giving it to Resident 40. CNA 3 stated it was important that Resident 40 is provided with the food requested to eat because of her history of weight loss. During an interview with the Director of Nursing (DON), on 11/7/2024, at 10:41 AM, the DON stated the food preferences of the residents should always be followed for the residents' dignity. Furthermore, the DON stated residents with a history of weight loss should be provided with food that they prefer to encourage them to eat. During a review of the facility's policy and procedure (P&P), titled, Resident Dining Profile and Food Preferences, revised on 1/2024, the P&P indicated Residents on a modified/therapeutic diet are offered similar choices as the main meal in compliance with their diet restrictions. The P&P indicated food substitutions are provided when the Resident chooses not to consume meal items served and should be of equal nutritional value to the planned menu item. The P&P further indicated individual Resident choice at or between meals takes precedence over recorded preferences unless the requested item contains a recorded food allergen or is not consistent with the diet order. Reasonable accommodations regarding meal planning and need for recipes and purchased items outside the scope of the planned menu will be made for those residents with extensive dislikes, food allergies and/or special dietary needs. During a review of the facility's P&P, titled, Quality of Life-Accommodation of Needs, revised on 11/2010, the P&P indicated the facility's environment and staff behaviors are directed toward assisting the Resident in maintaining and/or achieving independent functioning, dignity and well-being. The P&P also indicated, The residents individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. During a review of the facility's P&P, titled, Resident Rights, revised on 2/2021, the P&P indicated Employees shall treat all residents with kindness, respect, and dignity. The P&P indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence and to be treated with respect, kindness, and dignity.

Based on interview and record review the facility failed to ensure the physician addressed the medication regimen review (MRR/Drug Regimen Review - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) to indicate a reason for disagreeing with the pharmacist recommendation for gradual dose reduction (GDR- the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) of Ativan (lorazepam- a medication used for anxiety [feeling of fear, dread, or uneasiness that can be mild or severe]) for one of 22 sampled residents (Resident 17) on 10/25/2024. This deficient practice had the potential to result in adverse medication outcome for potential unnecessary medications to Resident 17. Findings: During a review of Resident 17's Admission Record, the Admission Record indicated Resident 17 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included major depressive disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest), unspecified pain, and anxiety disorder (fear characterized by behavioral disturbances). During a review of Resident 17's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/6/2024, the MDS indicated Resident 17 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 17 required setup or clean-up assistance with eating. Resident 17 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, and toilet transfer. Resident 17 did not have any mood or behavioral symptoms. During a review of Resident 17's Physician's Orders form, dated 11/7/2024, the Physician's Orders form indicated an order, with a start date of 10/23/2024, for Ativan 0.5 milligrams (mg- unit of measurement) tablet (tab)- 1/2 tab=0.25 mg by mouth (po) every (q) evening at 1 PM for anxiety manifested by (m/b) restlessness. The Physician's Orders also indicated an order, with a start date of 10/25/2024, for Ativan 1 mg tab- 1.5 mg by mouth every evening for anxiety disorder unspecified m/b restlessness. During a review of Resident 17's Care Plan titled, Psychotropic Drugs (medications that impact the brain and nervous system's chemical makeup to treat mental illnesses), dated 9/30/2024, the care plan indicated Resident 17 had the potential for drug related complications associated with the use of psychotropic medication to manage mood/behavior related to depression, psychosis (a mental state where a person has difficulty distinguishing reality from what is real), anxiety, and impulse disorder (a condition that makes it difficult to control actions or reactions). The care plan indicated an intervention to attempt/initiate gradual dose reduction as recommended by pharmacy consultant and as ordered by MD. During a review of Resident 17's Interdisciplinary (IDT- a coordinated group of experts from different fields) Note, dated 10/25/2024, the IDT Note indicated, Informed Physician Assistant 1 (PA 1) regarding pharmacy recommendation, he made new orders to change current dosage of Ativan 1.5 mg q 7PM to Ativan 1.5 mg q 6PM and change mirtazapine (a drug used to treat depression) 45 mg to mirtazapine 30mg q hour of sleep (hs). Informed Medical Doctor 1 (MD 1) with the orders and agreed to continue with it. Daughter 1 (DTR 1) is aware and agreed. Noted new orders and carried out. Endorsed to oncoming shift. During a concurrent interview and record review with the Director of Nursing (DON), on 11/7/2024, at 11:17 AM, Resident 17's Note to Attending Physician/Prescriber form, printed on 10/18/2024, was reviewed. The DON stated PC 1's drug recommendation on the Note to Attending Physician/Prescriber form indicated Resident 17 takes lorazepam 0.25 mg PM (4:00 PM) and 1.5 mg q PM (7:00 PM). Please consider a dose reduction, perhaps decreasing the 7PM dose to 1mg. If a gradual dose reduction is contraindicated, please specify why. During the same interview with the DON on 11/7/2024, at 11:17 AM, facility's policy and procedure (P&P), titled, Consultant Pharmacist Reports, dated 12/2016, was reviewed. The DON stated the P&P indicated, Recommendations are acted upon and documented by the facility staff and or the prescriber. Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing by the next physician date. The DON stated PA 1 and MD were notified of PC 1's drug recommendation report as soon as it was received. The DON stated Resident 17's family was also informed regarding PC 1's recommendation and requested for only the mirtazapine dose to be decreased. The DON stated PA 1 decreased Resident 17's mirtazapine from 45 mg to 30 mg and changed the Ativan administration time from 7PM to 6PM but did not decrease the Ativan dose as recommended by PC 1. The DON stated the MD sees residents in the facility every Wednesday but does not know why the MD did not indicate the reason why the drug recommendation was not accepted. The DON stated there was no documented explanation from the MD for not decreasing Resident 17's Ativan dose from 1.5 mg to 1mg.

Based on interview and record review, the facility failed to develop a resident centered care plan to address functional assistance needed with Activities of Daily Living (ADL) for one of two sampled residents (Resident 1) in accordance with the facility policy. This failure had the potential for Resident 1 not to receive interventions specific to the residents needs, which could result in injury and fall. Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included dementia (the impaired ability to remember, think or make decisions that interferes with doing everyday activities), difficulty in walking and fracture (break in the bone) of the right femur (thigh bone). A review of Resident 1's History and Physical Examination, dated 3/15/23, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment care screening tool), dated 12/13/23, indicated the resident was severely impaired with cognitive (difficulty with or unable to make decisions, learn, remember things) skills for daily decision making. Resident 1 needed substantial/maximal assistance (helper does more than half the effort; helper lifts or holds trunk or limbs and provides more than half the effort) with walking, transfers (how resident moves to and from bed, chair, wheelchair, standing position), dressing and personal hygiene & required setup or clean-up assistance with eating. During an interview on 1/17/24 at 2:13 PM with Restorative Nursing Assistant (RNA), RNA stated that Resident 1 needed two-person assistance with walking. During a concurrent record review of Resident 1's ADL Function Care Rehab Care Plan and interview on 1/17/24 at 3:46 PM with Physical Therapist (PT), Resident 1's care plan indicated Resident 1 needed Substantial assist with walking. PT stated, I understand substantial assist as the resident only needing one person assist with ambulation (walking). PT also stated care plan should have indicated that the resident was max assist to totally dependent with two people for ambulation. PT stated, It is not safe for the resident to ambulate with only one person since she might fall and sustain further injury. During an interview on 1/17/24 at 4:04 PM with Care Plan Coordinator (CPC), CPC stated, I inputted substantial assist with ambulation in Resident 1's care plan since that is what is reflected on the resident's MDS. CPC stated, I should have made the care plan entry more specific, clear, and easy to understand by facility staff especially since I believe that the resident should ambulate with two-person assistance for her safety and to prevent her from falling. During a record review of Resident 1's Interdisciplinary Team (IDT) Conference Record, dated 1/12/24, IDT Conference Record indicated that the resident required up to extensive to total assistance with ADLs. A review of Resident 1's Falls Care Plan, dated 1/8/24, indicated, Consult with therapy regarding current functional status and follow all recommendations and the restorative programs. A review of the facility's policy and procedure titled, Care Area Assessments, revised November 2019 indicated to Include specific interventions, including those that address common causes of multiple issues. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to: 1. Label food in the kitchen with item name, opened and expiration date, and discard expired food as indicated on the facility's policy and procedure. a. Two opened packages of bread (English muffin and white loaf bread) in the working station were not labeled to indicate date food items were opened. b. Three trays of blueberry dessert, cornbread, and chocolate cake placed on a rack in the dry storage room were not labeled with item name and date when they were made. c. An opened box of cinnamon streusel coffee mix and corn flakes crumbs were not labeled to indicate date when it was opened. d. A container with brown grains in the dry storage did not have a label to indicate the food item. e. Four packages of mandarin orange sauce were not labeled to indicate expiration date. f. A package of chocolate chip cookies was not labeled to indicate expiration date. g. A tray of expired left over Boston cream pie dated [DATE] was not discarded. 2. Ice cream freezer log did not have a documentation for temperatures taken from [DATE] to [DATE] and Freezer 1 has no temperature documented for [DATE]. 3. The facility failed to follow infection control measures in the kitchen when: a. A personal tumbler with tea was in Freezer 1. b. An open box of gloves was placed on top of food container and tray of disposable utensils. c. A book and opened package of table napkins were in the main freezer storage. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness ([food poisoning] with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization . Findings: 1. During a concurrent observation in the kitchen and interview with the Dining Services Director (DND) and Kitchen Staff 2 (KS 2) on [DATE] at 8:45 AM, there was no label on the two opened packages of bread (English muffin and white loaf bread) in the working station. DND stated, We label the bread after opening the bag and before putting it back in the refrigerator. KS 2 stated, No, I do not have label on the breads. Are we supposed to label them? During a concurrent observation in the kitchen and interview with the DND on [DATE] at 8:53 AM, there were no labels to include the date and name of the item of the three trays of blueberry dessert, cornbread, and chocolate cake placed on a rack in the dry storage room were made. DND stated, The food trays needed to be labeled with the food item and date it was prepared every time. During a concurrent observation in the dry storage room and interview with the DND on [DATE] at 8:59 AM, in the dry storage were the following: a. An opened box of cinnamon streusel coffee mix and corn flakes crumbs without a label to indicate when it was opened. b. A container with brown grains did not have a label to indicate the food item. DND stated, he could not verify what was inside the container because it did not have a label to identify the food item. The DND stated the container should have been labeled with the food item. DND stated the opened box of cinnamon streusel coffee mix and corn flakes crumbs was not and should have an open date label. During a concurrent observation in the kitchen and interview with the DND on [DATE] at 11:30 AM, there was no label to indicate the date when the milk container inside the refrigerator was opened. DND stated, the kitchen staff should label the milk container with the date it was opened. During a concurrent observation in the main freezer storage and interview with the DND on [DATE] at 11:38 AM, in the main freezer storage were the following: a. There were four packages of mandarin orange sauce with no expiration date. b. A package of chocolate chip cookies with no expiration date. c. A tray of expired left over Boston cream pie dated [DATE]. DND stated all food items stated the food items were supposed to be labeled with item name and dated with the open and used by date. A review of the facility's policy and procedure titled, Food and Supply Storage, dated ,d+[DATE], indicated all food, non- food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Cover, label and date unused portions and open packages. Discard food past the use - by or expiration date. Dry storage store foods in their original packages. Foods that must be opened must be stored in NSF approved containers that have tight - fitting lids. Label both the bin and the lid. Hang scoop. Scoops may be stored in bins on a scoop holder. The food level must be no closer than one inch below the handle of the scoop. 2. During a concurrent observation in the kitchen and interview with the Kitchen Staff 1(KS 1) on [DATE] at 8:39 AM, Freezer 1 had no temperature recorded on the freezer log on [DATE]. KS 1 stated, There was no thermometer inside the freezer that is why there is no temperature recorded for Freezer 1 this morning. During a concurrent observation in the kitchen and interview with the DND on [DATE] at 8:49 AM, the ice cream freezer log did not have a documentation for temperatures taken from [DATE] to [DATE]. DND stated, The staff should be checking the freezer temperature and log it in every shift, in the morning and in the afternoon. A review of the facility's policy and procedure titled, Cold Storage Temperatures, dated ,d+[DATE], indicated temperatures of food storage areas and cold food vendors are monitored and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies. Each refrigerated storage unit shall have an independent thermometer in addition to the built in thermometer. The thermometer shall be placed in the warmest part of the unit, typically near the door, readily accessible and placed so that it is not in the direct line of the air stream from the unit's fan. Supervisor each morning at opening and evening at closing, record temperatures of each storage unit, initial each entry. 3. During a concurrent observation and interview with the DND on [DATE] at 11:27 AM, There was a personal tumbler with tea in Freezer 1. DND stated, Personal item should not be in the freezer. During a concurrent observation and interview with the DND on [DATE] at 11:32 AM, there was a set of keys left in the small delivery cart containing clean plates. DND stated the keys were for the doors in the kitchen and it should not have been left in the delivery cart. DND stated, The person in charge in the morning should have it on them all the time. During a concurrent observation and interview with the DND on [DATE] at 11:35 AM, an opened box of gloves was placed on top of the tray of the disposable utensils. DND stated, It should not be there. During a concurrent observation in the freezer storage and interview with the DND on [DATE] 11:48 AM, there was a book and opened package of table napkins in the main freezer storage. DND stated, the items should not have been stored there. A review of the facility's policy and procedure titled, Associate Security Policies for Department, revised ,d+[DATE], indicated jackets, sweaters, handbags, cell phones and other personal items are to be stored in appropriate locations as defined by management. These items must not be stored in food production or service areas. Department keys are never loaned or borrowed. All keys should remain on the person to which they are assigned. Any extra keys should be secured in the unit safe.

Based on observation, interview, and record review, the facility failed to ensure an effective infection prevention and control program to prevent infectious disease outbreak (a sudden rise in the number of cases of a disease) for four (4) of 4 sampled residents (Residents 1, 2, 3 and 8) by failing to: 1. Control the spread of unknown gastrointestinal (GI, relating to, affecting, or including both stomach and intestine) outbreak when Residents 1, 2, and 3 were not placed on contact isolation precautions (intended to prevent transmission of infectious agents, which are spread by direct or indirect contact with the resident or resident's environment) on the onset of GI symptoms. Resident 1 was not placed on contact isolation until 4 days after onset of diarrhea (loose watery stool). Residents 2 and 3 were not placed on isolation until two (2) days after onset of diarrhea and vomiting. 2. Ensure Certified Nurse Assistant 1 (CNA 1) wear gloves and isolation gown on 4/19/2023 while pushing Resident 8's wheelchair inside the resident's room, who was on contact isolation precaution. 3. Ensure CNA 1 wear gloves and isolation gown in the resident's room while feeding Resident 8 who was on contact isolation precaution on 4/19/2023. These deficient practices placed 82 residents, facility staff and visitors at risk for contracting GI infection and resulted to nine (9) residents (Residents 1,2, 3, 4, 5, 6, 7, 8, and 9) experiencing GI symptoms (vomiting and/ or diarrhea). On 4/19/2023 timed at 3:15 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Director of Nursing (DON) regarding the facility's failure to recognize and report a GI outbreak of two (2) or more residents within a 24-hour period, collect stool specimens as soon as the residents experienced GI symptoms, obtain the orders from the Attending Physician to send the specimen to the lab for viruses and bacterial infection testing, and failure to control the spread of unknown GI outbreak. On 4/20/2023 at 4:59 pm, the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the AIT (Administrator in Training) and DON. The acceptable IJ Removal Plan included the following: 1) [NAME] Baptist Homes will recognize a possible outbreak and will report the GI outbreak of 2 or more residents within a 24-hour period who are experiencing symptoms of GI infection according to CDPH guidelines. [NAME] Baptist Home will report to Local Health Department and CDPH when this outbreak occurs within 24 hours via phone or email. (Reference material: Recommendations for the prevention and control of Viral Gastroenteritis outbreaks in California Long -Term Care Facilities [DATE] and Acute Communicable Disease Control [ACDC] Manual revised June 2019 - Centers for Disease Control and Prevention [CDC]). a. Resident 1 had one episode of loose stool and vomiting on 4/13/2023. Attending Physician and family were notified on 4/13/2023. Attending Physician ordered laboratory work. Charge Nurse started monitoring and recording resident's condition every shift and documenting in medical progress note. Resident was placed in contact isolation on 4/17/2023. Documentation continued for an additional 48 hrs. b. Resident 2 had 3 episodes of vomiting on 4/15/2023. Attending Physician and family were notified on 4/15/2023. Charge Nurse started monitoring and recording resident's condition every shift and documenting in medical progress note. Resident was placed on contact isolation on 4/17/2023. Documentation continued for an additional 48 hrs. c. Resident 3 had two episodes of vomiting on 4/15/2023. Attending Physician and family were notified on 4/15/2023. Charge Nurse started monitoring and recording resident's condition every shift and documentation in medical progress note. Resident was placed on contact isolation on 4/17/2023. Documentation continued for an additional 48 hrs. The DON and Director of Staff Development (DSD) educated the licensed nurses and CNA staff on 4/17/2023 about the importance of knowing how to recognize possible signs of GI infection and deciding when to place the residents in isolation with signs and symptoms of GI infection immediately. At the same time, staff were educated on reporting to DON immediately. (Training provided by using reference training material noted above). The DON will then report to Local public health and CDPH within 24 hours of any suspected outbreak. On 4/20/2023 DON and AIT reviewed and updated the phone numbers for reporting to the CDC. If in case the ACDC was not answering by phone, the facility must report by email. 2) [NAME] Baptist Homes will collect stool specimens as soon as the residents experience GI symptoms and obtain the orders from the Attending Physician to send the specimen to the lab for viruses and bacterial infection testing, following the instruction from the public health nurse and CDC guidelines. Findings: 1. During a concurrent review of the facility's undated Gastroenteritis (an inflammation of the lining of the stomach and intestines) Illness Outbreak Line List (provides a template for data collection and active monitoring of both residents and staff during a suspected gastroenteritis outbreak) and interview with the DON on 4/19/2023 at 8:04 am, the DON verified the following: a. Resident 1 experienced diarrhea and vomiting on 4/13/2023. b. Resident 2 and 3 experienced vomiting on 4/15/2023 c. Resident 4 experienced diarrhea and Residents 5, 6 and 7 experienced vomiting on 4/16/2023 d. Resident 8 experienced diarrhea on 4/17/2023 e. Resident 9 experienced watery diarrhea on 4/18/2023 The DON stated the GI outbreak was reported to CDPH on 4/17/2023 and local public health on 4/18/2023. The DON stated the GI outbreak should have been reported to CDPH and local public health sooner. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included unspecified atrial fibrillation (a serious abnormal heart rhythm characterized by rapid and irregular beating), heart failure (a chronic condition in which the heart cannot pump blood as well as it should) and essential hypertension (abnormal high blood pressure that is not the result of a medical condition). A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 1/11/2023, indicated Resident 1's cognitive (mental processes, ability to understand and make decision) skills for daily decision making was severely impaired. Resident 1 required limited assistance for transfers, dressing and eating. Resident 1 required extensive assistance for toilet use and personal hygiene. A review of Resident 1's Interdisciplinary (IDT, involving two or more disciplines or fields of study) notes, dated 4/13/2023, timed at 10:52 am, indicated Resident 1 had greenish yellow emesis (vomiting) on his shirt. Interdisciplinary notes further indicated according to Resident 1, he had vomited once in the morning, A review of Resident 1's IDT notes, dated 4/17/2023, timed at 2:35 pm, indicated Resident 1 was placed on contact isolation precaution (4 days from GI symptoms onset) due to episode of vomiting on 4/13/2023. During an interview on 4/19/2023 at 8:01 am, the DON stated, Resident 1 had diarrhea and vomiting on 4/13/2023. The DON stated, an unnamed facility staff called the physician (MD) who ordered laboratory work which included a comprehensive metabolic panel (CMP, blood tests that give an overall picture of your body's metabolism and chemical balance) and complete blood count (CBC, a test that counts the cells that make up your blood). The DON stated the MD did not order a stool culture (checks for presence of abnormal bacteria in the digestive tract/gastrointestinal tract that may cause diarrhea and other problems). The DON stated, Resident 1 was placed on isolation precaution on 4/17/2023, 4 days after resident presented with vomiting and diarrhea. The DON stated isolation precaution was not and should have been initiated for Resident 1 prior to 4/17/2023 but facility staff did not report Resident 1's GI symptoms to the DON not until 4/17/2023. The DON stated, Resident 1 should have been placed on contact isolation immediately on the onset of GI symptoms on 4/13/2023 to prevent spread of infection amongst other residents residing in the facility. A review of Resident 2's Admission Record indicated the resident was initially admitted to the facility on [DATE], with diagnoses that included essential hypertension, unspecified dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and hyperlipidemia (have too many lipids [fats] in the blood). A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognitive skills for daily decision making were severely impaired. Resident 2 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance))for transfers, dressing and eating. Resident 2 required extensive assistance for toilet use and personal hygiene. A review of Resident 2's IDT notes, dated 4/15/2023, timed at 3:13 am, indicated Resident 2 was found seated at the edge of bed and stated, I threw up in the bathroom. A review of Resident 2's IDT notes, dated 4/15/2023, timed at 2:09 pm, indicated monitoring for episodes of nausea and vomiting. The Interdisciplinary notes further indicated Resident 2 had two episodes of vomiting during the shift. A review of Resident 3's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included unspecified dementia, essential hypertension, and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). A review of Resident 3's MDS, dated [DATE], indicated Resident 3's cognitive skills for daily decision making was severely impaired. Resident 3 required limited assistance for transfers, dressing, eating, toilet use and personal hygiene. A review of Resident 3's Interdisciplinary notes, dated 4/15/2023, timed at 10:06 pm, indicated Resident 3 was being monitored for an episode of vomiting after lunch. A review of Resident 3's Interdisciplinary notes dated, 4/15/2023, timed at 10:19 pm, indicated that after Resident 3 took two scoops of mashed potato during dinner, Resident 3 vomited medium amount of brown colored emesis. During an interview on 4/19/2023 at 1:07 pm, the DON stated on 4/15/2023 Residents 2 and 3 presented with vomiting. The DON stated, MD did not order a stool culture for Residents 2 and 3. The DON stated, Residents 2 and 3 were placed on contact isolation precautions on 4/17/2023, 2 days after both residents presented with vomiting. The DON stated, Residents 2 and 3 should have been placed on contact isolation immediately on the onset of GI symptoms on 4/15/2023. 2. A review of Resident 8's Admission Record indicated the resident was initially admitted to the facility on [DATE], with diagnoses of unspecified dementia, difficulty walking and hypertension. A review of Resident 8's MDS, dated [DATE], indicated Resident 8 was severely impaired with cognitive skills for daily decision making. Resident 8 required limited assistance for eating and extensive assistance (resident involved in activity, staff provide weight-bearing support) for transfers, dressing toilet use and personal hygiene. During an observation outside of Resident 8's room on 4/19/2023 at 9:00 am, signage was posted on the wall near the resident's door indicating Resident 8 was on contact precaution. There was an isolation cart directly outside for personal protective equipment (PPE, used to prevent or minimize exposure to hazards). CNA1 entered Resident 8's room only wearing a mask. CNA1 was not wearing a gown or gloves. During an interview on 4/18/2023 at 9:01 am, CNA1 stated, Resident 8 was on contact precautions but was allowed to leave the room and go to the beauty salon, which was in the facility's basement. CNA1 stated she does not wear PPE when entering Resident 8's room but usually wears a gown or gloves when assisting Resident 8 to the restroom and cleaning Resident 8 after use of the restroom. During a concurrent observation and interview on 4/18/2023 at 9:04 am, CNA1 stated Resident 8's beauty salon schedule was canceled and had to wheel Resident 8 back to her room. CNA1 did not put on gloves or isolation gown once inside room. CNA1 stated she did not but was supposed to wear gloves because she was touching the handle of Resident 8's wheelchair. During an interview on 4/18/2023 at 9:14 am, License Vocational Nurse 1 (LVN 1) stated, she was not sure if staff have to wear gloves and gowns when pushing a wheelchair for a resident that was on contact precautions. During a concurrent observation in Resident 8's room and interview on 4/19/2023 at 12:47 pm, CNA1 was observed assisting Resident 8 with setting up the meal tray for the resident. CNA1 was observed not wearing an isolation gown or gloves while in the resident's room. CNA1 stated she was rushing because Resident 8 needed assistance with feeding and should have put on PPE. During interview on 4/19/2023 at 12:55 pm, the DON stated, if a resident was on contact isolation precaution, staff must wear an isolation gown and gloves. The DON also stated PPE needs to be donned (put on) right before entering a room on contact isolation, to protect self. The DON stated the staff must put on PPE when setting up a food tray and when pushing resident's wheelchair to prevent spread of infection amongst other residents residing in the facility. A review of the facility's policy and procedure (P&P) titled, Outbreak of Communicable Diseases, revised September 2022, indicated all Employees and Staff: a. Follow standard precautions at all times, and transmission-based precautions as indicated; and b. Report all symptoms relating to the current disease outbreak to the supervisor A review of the facility's P&P titled, Unusual Occurrence Reporting, revised December 2007, indicated the facility will report the following events to appropriate agencies: a. An outbreak of any communicable disease. The P&P indicated unusual occurrences shall be reported via telephone to appropriate agencies required by current law and or regulations withing twenty-four (24) hours of such incident or as otherwise required by federal and [NAME] regulations. A review of the CDC guidelines titled, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, dated 2007, indicated Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens (organism that causes disease), especially those that have been implicated in transmission through environmental contamination https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html