Every finding on record at Atlantic Memorial Healthcare Center

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received effective pain management by failing to ensure Licensed Vocational Nurse (LVN) 1 addressed Resident 1's pain when the resident developed dysuria (painful urination) on 6/10/2026.This failure put Resident 1 at risk of unrelieved pain and for delay of care.During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted on [DATE] to the facility with diagnoses including Parkinson's Disease(a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), myasthenia gravis(chronic autoimmune[ body gets confused and produces proteins that attack normal cells]disorder that causes muscles to feel weak and tire out easily), hypertension(HTN- high blood pressure), and chronic kidney disease(kidneys are damaged and lose their ability to filter waste and extra water from the blood).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/26/2026, the MDS indicated Resident 1 had moderately impaired cognitive skills (noticeable problems with thinking and required increased assistance with activities of daily living [ADL- activities such as bathing, dressing and toileting a person performs daily]) and was dependent on staff with bathing.During a review of Resident 1's History and Physical (H&P-physician's comprehensive and initial assessment of a patient) dated 5/23/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Change in Condition Evaluation (COC-a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) dated 6/10/2026 at 7:22 p.m , the COC indicated Resident 1 was complaining of dysuria with a pain scale( tool using numbers to measure and describe pain) of 5 out of 10 ( 0- no pain, 1 to 3 mild pain, 4 to 6 moderate pain and 7 to 10 severe pain).During a review of Resident 1's Care Plan titled, Resident is having dysuria, initiated on 6/10/2026, the Care Plan indicated interventions including monitoring of pain levels, providing medication, treatment as ordered and notifying the physician if the pain did not improve.During a review of Resident 1's Order Summary Report dated 5/21/2026, the Order Summary Report indicated an order for Acetaminophen (medicine used to relieve pain) 325 milligrams (mgs.- unit of measurement) 2 tablets by mouth every 4 hours as needed for mild pain (1-3) not to exceed 3 grams(GM- unit of measurement) in 24 hours.During a concurrent interview and record review on 6/16/2026 at 10:56 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 1's COC dated 6/10/2026, Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 6/10/2026 and Order Summary Report were reviewed. LVN 2 stated Resident 1 complained of dysuria 5/10 pain scale on 6/10/2026 and there was no pain medicine administered to Resident 1 when the resident complained of dysuria on 6/10/2026 at 7:22 p.m. LVN 2 stated there was no new order addressing Resident 1's pain level of 5. LVN 2 stated LVN 1 should have notified the physician of Resident 1's level of pain, for appropriate pain medication intended for pain level of 5. LVN 2 stated Resident had a physician order for Acetaminophen 325 mgs. 2 tablets for mild pain (pain level of 1 to 3). LVN 2 stated Resident 1's pain level could increase and resident's pain would likely linger affecting her quality of life.During a telephone interview on 6/16/2026 at 4:05 p.m., with LVN 2, LVN 2 stated Resident 1 was complaining of pain during urination on 6/10/2026. LVN 1 stated she did not administer any pain medicine when Resident complained of dysuria 5/10 pain level on 6/10/2026 at 7:22 p.m. LVN 2 stated she could not remember why she did not give pain medicine to Resident 1. LVN 1 stated she should have called the physician for appropriate medication when Resident 1 was complaining of pain 5/10. LVN 1 stated Resident 1's pain level could continue to increase if her pain was not addressed properly.During a concurrent interview and record review on 6/16/2026 at 1:41 p.m., with RN Supervisor (RNS)1, Resident 1 COC dated 6/10/2026 at 7:26 p.m. and MAR dated 6/10/2026 were reviewed. RNS 1 stated LVN 1 should have notified the physician of Resident 1's pain scale of 5/10 because Acetaminophen was intended for mild pain (pain scale 1 to 3) and there was no other pain medicine ordered for Resident 1.RNS 1 stated the licensed nurse should have notified the physician to obtain medication appropriate for pain scale of 5/10. RNS 1 stated Resident 1's pain could get worse and could put Resident 1 at risk for hospitalization.During an interview on 6/16/2026 at 4:36 p.m., with the Director of Nursing (DON), the DON stated LVN 1 should have notified the physician because the pain level was 5/10 and asked for an appropriate medication for pain. DON stated Acetaminophen was only for pain scale of 1-3. DON stated Resident 1 could suffer more pain because pain should be addressed to ensure the resident will be free of pain.During a review of facility's policy and procedure (P&P) titled, Pain Recognition and Management, revised 12/2023, the P&P indicated t consulting the physician if pain management is ineffective or for additional interventions if pain is not relieved by current orders.

Based on observation, interview, and record review, the facility failed to implement their policy and procedures (P&P) to maintain and observe infection control practices by failing to:1. Ensure Resident 69 was on airborne isolation (a set of infection-control measures used in hospitals to prevent the spread of diseases caused by tiny germs that can float in the air and travel long distances) precautions for shingles (painful, blistering skin rash).2. Ensure Medication Cart 1 B was kept clean and in sanitary condition.These failures had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and placed all residents at risk for spread of infection.Findings: 1. During a review of Resident 69's admission Record, the admission Record indicated Resident 69 was admitted to the facility on [DATE] with diagnoses including immunodeficiency (a group of conditions that make it hard for the body to fight infections) and malignant neoplasm of pancreas (pancreatic cancer). During a review of Resident 69's Minimum Data Set (MDS- a resident assessment tool) dated 2/18/2026, the MDS indicated Resident 69's cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 69 required maximal assistance (helper does more than half) with toileting, showering, and lower body dressing During a review of Resident 69's Change in Condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) dated 3/7/2026, the COC indicated Resident 69 had a rash, fluid-filled blister on right flank (a side of a person's body between the ribs and hip). The COC indicated Resident 69 was transferred to General Acute Care Hospital (GACH) on 3/7/2026 for treatment of the blisters. During a review of Resident 69's Order Summary Report dated 3/7/2026, the Order Summary Report indicated an order for Valacyclovir HCL (medication used to treat shingles) three times a day for shingles. During a concurrent observation and interview on 3/10/2026 at 9:50 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 69's room was observed to have a contact isolation (a set of infection control practices in healthcare settings used to prevent the spread of infection) sign outside of her (Resident 69) room. LVN 3 stated Resident 69 was in isolation for shingles. During a concurrent interview and record review on 3/12/2026 at 1:47 a.m., with the Infection Prevention Nurse (IPN), the IPN stated Resident 69 was sent out to GACH on 3/7/2026 for fluid-filled blisters on her right flank and was diagnosed with shingles. The IPN stated Resident 69 was placed on contact isolation. The IPN stated Resident 69 should have been placed on airborne precautions because Resident 69 is immunocompromised which puts her at risk for infection. During a concurrent interview and record review on 3/13/2026 at 11:09 a.m., with the Director of Nursing (DON), the DON stated Resident 69 should have been placed on airborne isolation according to their P&P for patients with known or suspected to be infected with pathogens transmitted by the airborne route. The DON stated Resident 69 is immunocompromised which puts her (Resident 69) at higher risk for infection, so it was important for Resident 69 to be on the appropriate isolation. During a review of the facility's (P&P) titled, IPCP Standard and Transmission-Based Precautions, dated 4/2025, indicated, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. The P&P indicated Airborne Precautions are used for patients known or suspected to be infected with pathogens transmitted by the airborne route (e.g., disseminated herpes zoster). 2. During a concurrent observation and interview on 03/11/2026 at 11:02 a.m. with LVN 4 at Medication Cart 1 B, Medication Cart 1 B was observed with multiple spills of a sticky substance, threads of human hair, and brown stains at the bottom of the cart. LVN 4 stated the medication cart should be clean and kept in sanitary condition and there was no excuse not to clean the cart when it was very dirty. During an interview on 03/12/2026 at 3: 40 p.m., with the DON, the DON stated the medication cart should be free from dirt and sticky spills. The DON stated the med cart should be kept clean, and staff should clean their medication cart after their shift and not wait for the next shift to clean it. The DON stated it is an infection control risk and if the label medication is soiled, the label may be misread by the nurse. During a review of the facility's P&P titled Equipment and Supplies for administering medication, undated, the P&P indicated It is the policy of this facility to maintain equipment and supplies necessary for the preparation and medication administration of medication to residents. The P&P indicated that the charge Nurse on duty ensures that equipment and supplies relating to medication administration are clean and orderly.

Based on observation, interviews, and record review, the facility failed to ensure staff prepared and handled ready-to-eat foods (any food intended to be eaten without needing further cooking, washing, or preparation to make it safe) using sanitary practices and maintain proper cold handling temperatures for potentially hazardous foods (items that support rapid bacterial growth and require strict temperature controls).These failures had the potential to result in foodborne illnesses (any illness resulting from eating contaminated/spoiled foods), which could result in serious complications for all residents in the facility including hospitalization or death.Findings:During a concurrent observation and interview on 03/112026 at 11:55 a.m. with cook (CK) 1, CK 1 was observed preparing a peanut butter and jelly sandwich. CK 1 was observed spreading peanut butter and jelly onto bread using bare hands without wearing gloves or utilizing utensils to prevent direct hand contact with ready-to-eat food. CK 1 acknowledged that gloves should be worn when handling ready-to-eat food. CK 1 stated I should have worn gloves. CK 1 stated that not wearing gloves could contaminate the food and make the residents sick. During an interview on 03/11/2026 at 12:05 p.m. with the Dietary Supervisor (DS), the DS stated staff are required to wear gloves or use utensils when handling ready-to-eat foods to prevent contamination and ensure sanitary food preparation. The DS stated that not wearing gloves could place residents at risk for foodborne illnesses such as vomiting and diarrhea. The DS stated the residents are elderly and more susceptible to complications from foodborne illness, which could result in more serious outcomes such as hospitalization or decline in condition. During a concurrent observation and interview on 3/11/2026 at 12:10 p.m. with the DS, a temperature check of the milk and watermelon juice using the facility thermometer registered at 46.5 degrees Fahrenheit (F) for the milk and 48.0 degrees Fahrenheit (F) for the watermelon juice during cold holding (the practice of storing perishable food at safe, low temperatures 41 degrees Fahrenheit (F) or lower to prevent germs from growing). The DS stated cold food items are required to be maintained at or below 41 degrees Fahrenheit (F) to prevent bacterial growth. The DS acknowledged that the milk and watermelon juice were above acceptable temperature ranges and stated, Those items should be 41 degrees Fahrenheit or below. The DS stated failure to maintain proper cold holding temperatures could allow bacteria to grow and place residents at risk for foodborne illness.During a review of the facility's policy and procedures (P&P) tilted Glove Use Policy, dated 2023, the P&P indicated, The appropriate use of gloves is essential in preventing food borne illness. Wearing disposable gloves is one of the acceptable ways that any food, ready-to-eat food, or otherwise, may be prepared and served.During a review of the facility's policy and procedures (P&P) titled Food Handling, dated 2023, the P&P indicated, Food & Nutrition Services personnel should never use bare hand contact with any foods, ready to eat or otherwise.During a review of the facility's P&P titled Meal Service, dated 2023, the P&P indicated, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures.Milk, Puddings, Salads, and Juice 41 degrees or less.During a review of facility P&P titled food Safety and Food Storage (Revised 11/2024) the P&P indicated, when preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce or eliminate potential hazards.Holding - staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA Food Code. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger zone.During a review of the 2022 U.S. Food and Drug Administration Food Code 3-501.16 titled Time/Temperature control for safety food, hot and cold holding indicated, except during preparation, cooking or cooling, time/temperature control for safety food shall be maintained at 135degrees F or above, and at 41 degrees F or below.

Based on observation, interview and record review, the facility failed to develop and implement a resident centered Care Plan for one of three sampled residents (Resident 1) who had a diagnosis of left upper extremity (LUE) deep vein thrombosis ([DVT] a blood clot in a deep vein). The facility failed to: 1. Implement Resident 1's Responsible Party (RP) 1 request to display signage over Resident 1 ' s bed instructing nursing staff to avoid taking blood pressures in Resident 1's left upper extremity. 2. Ensure Resident 1's Care Plan included the location of Resident 1's DVT to include the LUE and specific instructions on how to assess for complications of a DVT, which included assessment of the area to detect pain, swelling, warmth, and discoloration in the affected extremity, as well as signs of pulmonary embolism ([PE] a serious condition where a blood clot or other substance obstructs an artery in the lungs, blocking blood flow and oxygen delivery, which are usually caused by a DVT) such as difficulty breathing, cough, and chest pain. These failures had the potential for Resident 1 to suffer complications from a DVT due to the staff not being aware or assessing Resident 1's DVT and placed Resident 1 at risk for PE, unnecessary hospitalization s, and/or death. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] and with diagnoses including atrial fibrillation (an abnormal heart rhythm), acute embolism (an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck) and thrombosis of the left upper extremity deep veins During a review of Resident 1's History and Physical (H&P) dated 3/20/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 3/24/2025, the MDS indicated Resident 1's cognitive skills for daily decision making were severely impaired. The MDS further indicated Resident 1 had active diagnosis of deep vein thrombosis ([DVT] a blood clot deep in a vein) during the assessment period. During a review of Resident 1's untitled Clinical Record (Care Plan section), Resident 1's Care Plans had no interventions indicating to place signage over Resident 1 ' s bed instructing nursing staff to avoid taking blood pressures in Resident 1's left upper extremity per RP 1's request nor had interventions indicating the location of Resident 1's DVT to include the LUE and specific instructions on how to assess for complications of a DVT, which included assessment of the area to detect pain, swelling, warmth, and discoloration in the affected extremity, as well as signs of pulmonary embolism such as difficulty breathing, cough, and chest pain. During an interview on 4/18/2025 at 10 a.m., RP 1 stated upon Resident 1's admission to the facility, she informed the nursing staff to place a sign over Resident 1's bed indicating not to take Resident 1's blood pressure on her left arm. RP 1 stated during her last visit, she did not see a sign over Resident 1's bed. RP 1 stated she was afraid the nursing staff will accidently take Resident 1's blood pressure on her left arm which could cause complications such as dislodging the clot. RP 1 stated she wanted the staff to respect and implement her wishes to keep Resident 1 safe. RP 1 stated I feel ignored and disrespected, I am afraid the staff will not properly assess Resident 1 for complications of a DVT. During a concurrent observation and interview on 4/21/2025, at 12 p.m., with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, there was no sign above Resident 1's head indicating not to take Resident 1's blood pressure on her left arm. LVN 1 stated she was not aware nor informed that Resident 1 had a left arm DVT and of the RP 1's request to not take Resident 1's blood pressure on her left arm. LVN 1 stated taking Resident 1's blood pressure on her left arm placed Resident 1 at risk for DVT complications which include dislodgement of the clot and PE. LVN 1 stated if Resident 1 had an accurate Care Plan, she would be able to better provide resident centered care and assessments. During an interview on 4/21/2025 at 2:44. p.m., the MDS Nurse stated Resident 1's Care Plan did not include the location of Resident 1's DVT nor had interventions to include placing a sign over Resident 1's bed indicating not to take Resident 1's blood pressure on her left arm. The MDS nurse stated Resident 1's Care Plan was very generic and did not provide enough information for the nursing staff to properly care for and assess Resident 1. The MDS nurse stated Resident 1's RP request to place a sign over Resident 1's bed should be honored and implemented. During an interview on 4/21/2025 at 4:30 p.m., the Director of Nursing (DON) stated Resident 1's RP is part of the care planning process, and her request should be implemented in Resident 1's care. The DON stated failure to ensure Resident 1's Care Plan was accurate, complete, and resident centered, placed Resident 1 at risk for complications of a DVT which included PE. The DON stated Resident 1 did not receive appropriate assessments which included assessing her arm for swelling, warmth, decreased pulses and pain to her left upper arm due to the nursing staff not being aware of Resident 1's left upper arm DVT. During a review of an online article titled, Ankle Brachial Index, from the Journal of Wound, Ostomy and Continence Nursing (JWOCN), dated 2012, the article indicated applying compression with the blood pressure cuff may dislodge clot. https://web.as.uky.edu/biology/faculty/[NAME]/NSTA-2012-workshops/STEM%20cardio%20NSTA%20Workshop/ankle-brachial%20index-3.pdf During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 10/4/2016, the P&P indicated the resident (resident representative) has the right to be informed of and participate in, your treatment, including the right to participate in the development and implementation of your person-centered plan of care. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, revised 12/2023, the P&P indicated it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The P&P further indicated the facility IDT includes but is not limited to the following professionals, attending physician, or non-physician practitioner involved in residents' care, registered nurse with responsibility for the resident, nurse aide with responsibility for the resident, member of the food and nutrition services staff, to the extent practicable, resident and or Resident representative, other appropriate staff or professionals as determined by the resident ' s needs or as requested by the resident.

Based on interview and record review, the facility failed to: 1. Define resident-specific, objectively measurable target behaviors related to the use of risperidone (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 16.) 2. Ensure divalproex (a medication used to treat mood swings) was used only for conditions or diagnoses as documented in the clinical record in one of five residents sampled for unnecessary medications (Resident 16.) 3. Failing to define specific measurable target behaviors and to ensure a resident did not receive routine psychotropic medication (any medication capable of affecting the mind, emotions, and behavior) unless the medication was necessary to treat a diagnosed specific condition that was documented in the clinical record for Resident 43 and Resident 10. This failure had the potential to result in the use of unnecessary psychotropic medication for Resident 43 and 10 that can lead to side effects and adverse consequences such as a decline in quality of life and functional capacity. The deficient practices of failing to define target behaviors related to the use of risperidone and failing to ensure divalproex was only used for conditions or diagnoses as documented in the clinical record increased the risk that Resident 16 could have experienced adverse effects related to his psychotropic (medications that affect brain activities associated with mental processes and behavior) medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in his mental or physical condition or functional or psychosocial status. Findings: A review of Resident 16's Admission Record (a record containing diagnostic and demographic resident information), dated 1/16/25, indicated he was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a progressive state of decline in mental abilities.) A review of Resident 16's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 10/24/24, indicated this resident had fluctuating capacity to understand and make decisions. A review of Resident 16's Order Summary Report (a summary of all current physician orders), dated 1/23/25 indicated, on 10/23/24, Resident 16's attending physician prescribed divalproex 125 milligrams (mg - a unit of measure for mass) by mouth three times daily for mood disorder/bipolar manifested by mania/hyperactivity and risperidone 1 mg by mouth at bedtime for psychosis manifested by agitation. A review of Resident 16's psychiatric evaluation notes, dated 11/2/24, did not list 'mood disorder or bipolar disorder among current psychiatric conditions and did not discuss behaviors of mania or hyperactivity. A review of Resident 16's clinical record indicated there were no other physician's notes documenting a diagnosis of mood disorder or bipolar disorder. A review if Resident 16's available care plans, last revised 10/24/24, indicated no specific, measurable behaviors were care planned to define agitation related to the use of divalproex. During an interview on 1/23/25 at 11:02 AM with the Director of Nursing (DON), the DON stated the behavior of agitation could mean several things like resisting care, striking out, screaming etc . The DON stated the facility failed to define clear, measurable targeted behavior(s) for the use of Resident 16's risperidone either in the order or in the resident's care plan related to the use of risperidone. The DON stated it is important to have clearly defined problematic behaviors so the effectiveness of the medication can be objectively monitored and periodically reassessed. The DON stated, if problematic target-behaviors are not clearly defined, Resident 16 may receive risperidone for longer than necessary or at a higher dose than necessary leading to adverse effects like drowsiness, constipation, urinary retention, and increased fall risk. The DON stated all psychotropic medications must have a clearly documented indication or diagnosis related to their use. The DON stated she was unable to find any documentation of a mood disorder, mania, hyperactivity, or bipolar disorder from Resident 16's physician or psychiatry notes. The DON stated this concern may have been on the resident's chart when he was admitted , but stated she could not find any documentation that the facility's psychiatrist had since confirmed this diagnosis. The DON stated the use of divalproex without a clear indication increased the risk that Resident 16 could experience adverse effects related to the use of divalproex including drowsiness and increased risk of fall. 3. During a review of Resident 43's Admission Record, the Admission Record indicated, Resident 43 was admitted to the facility on [DATE] and last re-admission was on 5/14/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities)and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 43's History and Physical (H&P), dated 11/26/2024, the H&P indicated, Resident 43 had no capacity (ability) to understand and make decision due to worsening of dementia. During a review of Resident 43's Minimum Data Set (MDS -resident assessment tool), dated 12/29/2024, the MDS indicated Resident 43 required dependent assistance (Helper does all of the effort) from one or more staff for bed mobility, transfer, eating, hygiene care, and maximal assistance (Helper does more than half the effort) from one staff for dressing. The MDS section E (behavior) indicated, Resident 43 did not have any potential indicator for psychosis and there was no hallucination (an experience involving the apparent perception of something not present) or delusion (having false or unrealistic beliefs). The MDS section E indicated, Resident 43 did not have physical and verbal behavioral symptoms directed toward others. The MDS section E indicated, Resident 43 did not have behavior related to rejection of care and there was no change of behavior since prior assessment. During a review of Resident 10's Admission Record, it indicated Resident 10 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of altered mental status, schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that interfere with daily life) and mood affective disorder (a group of mental health conditions characterized by significant and persistent disturbances in mood). During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 was dependent on nursing staff for toileting, showering, putting on and taking off shoes and personal hygiene. The MDS indicated Resident 10 was dependent on nursing staff for personal hygiene, sitting, lying flat, sitting, and transferring. The MDS indicated Resident 10 needed substantial to maximal assistance from nursing staff with oral hygiene, upper and lower body dressing The MDS indicated Resident 10 did not attempt to walk due to medical condition or safety concerns. During a review of Resident 10's Order Summary, the Order Summary indicated, Resident 10 had an order for olanzapine (an antipsychotic medication used to treat schizophrenia and bipolar disorder) 5 milligrams, give one tablet by mouth at bedtime for schizophrenia manifested by manic episodes such as visual hallucinations, started on 1/21/2023. During an interview on 1/23/2025, at 9:49 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated, she did not have any issue with providing care to Resident 43. CNA 1 stated, he did not want to get cleaned up occasionally, but Resident 43 let her provide hygiene care when she offered him several times. CNA 1 stated, Resident 43 was diagnosed with dementia, and this was not unusual for the residents with dementia. CNA 1 stated, Resident 43 was calm and cooperative. CNA 1 stated, she did not witness any aggressive behaviors from Resident 43. During an interview on 1/23/2025, at 10:25 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Resident 43 was on Quetiapine Fumarate [Seroquel- an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia (a mental illness that is characterized by disturbances in thought)and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)] to manage psychosis manifested by disorganized thoughts (Hallucinations and delusions can make person's thoughts and feelings confused and disorganized). LVN 2 stated, she was not sure what behavior she was monitoring. LVN 2 stated, confusion, aggression, and agitation could happen from dementia. During a concurrent interview and record review on 1/23/2025, 10:36 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's Order Summary Report (OSR), dated 1/23/2025 was reviewed. The OSR indicated, Seroquel 25 milligram (mg) one tablet by mouth one time a day for psychosis manifested by disorganized thoughts was initially ordered on 10/7/2024 and increased to one and a half tablet by mouth twice a day on 11/19/2024. RNS 1 stated, she believed it was increased due to increase of episodes of disorganized thoughts. RNS 1 stated, monitoring disorganized thoughts was not specific measurable target behavior. RNS 1 stated, inaccurate monitoring could contribute to increase in dose unnecessarily. RNS 1 stated, disorganized thoughts could be anything from confusion, hallucination, and delusion. During a phone interview on 1/23/2025, at 12:36 p.m., with Facility Pharmacy Consultant (FPC), FPC stated, monitoring disorganized thoughts was not specific behavior to monitor because it was too general, and nursing staff should have clarified with prescriber. FPC stated, dementia and PTSD should be ruled out before prescribing Seroquel for Resident 43 to avoid unnecessary medication. FPC stated, the resident should not suffer from side effects and adverse reaction from the medication. During a phone interview on 1/23/2025, at 12:36 p.m., with Psychiatric Nurse Practitioner (PNP)1, PNP 1 stated, she did not realize that staff was monitoring disorganized thoughts that was not specific behavior for psychosis. PNP 1 stated, she increased Seroquel dose because staff reported Resident 43's psychosis episodes were increased. PNP 1 stated, she prescribed Seroquel for aggression and psychosis manifested by Resident 43 tried to hit staff. PNP 1 stated, she agreed to rule out other possible causes for aggression such as dementia and PTSD to prevent Resident 43 suffering from side effects and adverse reaction unnecessarily. During an interview on 1/24/2025 at 9:10 a.m. with CNA 1, CNA 1 stated does know any of Resident 10's behavioral problems. CNA 1 stated she observed Resident 10 crying and depressed. During a concurrent interview and record review on 1/24/2025 at 11:01 a.m., with LVN 5, Resident 10's Care Plan, dated 8/20/2022 the care plan indicated monitoring for manic episodes such as visual hallucination. Resident 10's MAR, indicated had manic episodes manifested by visual hallucinations on 1/1/2025 to 1/4/2025, 1/6/2025 to 1/11/2025, 1/13/2025 to 1/21/2025, and 1/23/2024 to 1/24/2025. LVN 5 stated she could not find any documentation of what the visual hallucinations were and could not state what the visual hallucinations were. During an interview on 1/24/2025, at 11:43 a.m., with Director of Nursing (DON), DON stated, all behavioral monitoring related to psychotropic medication should be specific to its indication of medication use, otherwise the resident would not receive proper dose. DON stated, all documentation should reflect and support medication use, otherwise the medication may not be necessary to use. During a review of Resident 43's Order Summary Report (OSR), dated 1/23/2025, the OSR indicated, monitor and document number of psychotic behavior as evidenced by psychosis manifested by disorganized thoughts every shift for Seroquel was ordered on 7/22/2024. During a review of Resident 43's Care Plan (CP), revised 12/17/2024, the CP Focus indicated, antipsychotic medication use (Seroquel) related to disease process manifested by disorganized thoughts: PNP 1 added 25mg Seroquel in the morning on 10/8/2024 and increased to 37.5mg twice a day. The CP Interventions indicated, monitor side effects of drowsiness, dry mouth, stiff or tight muscles, and allergic reaction. The CP Interventions indicated, document episodes of behavior. During a review of Resident 43's Behavioral Health Nurse Practitioner (BHNP) Follow up Visit Note, dated 11/18/2024, the BHNP Note indicated, Resident 43 had dementia with behavioral disturbance and increased Seroquel for aggressive behavior and anxiety. During a review of Resident 43's Behavioral Health Nurse Practitioner (BHNP) Follow up Visit Note, dated 12/09/2024, the BHNP Note indicated, Resident 43 had dementia with behavioral disturbance and continued with Seroquel for aggressive behavior and anxiety. During a review of the facility's Policy and Procedure (P&P) titled Psychotropic Medications, revised 12/2023, the P&P indicated, Policy: It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Psychotropic medications shall not be administered for the purpose of discipline or convenience .Procedure:1. Psychotropic medications shall not be administered for the purpose of discipline or convenience. They are to be administered only when required to treat the resident's medical symptoms and will be considered only after nonpharmacological interventions have been attempted and failed . 3. The LN shall review the classification of the drug, the appropriateness of the diagnosis, its indication, behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician. A review of the facility's policy Psychotropic Drug Use, revised August 2017, indicated It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record . The Licensed Nurses shall review the classification of the drug, the appropriateness of the diagnosis, its indication/behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician . 44898 46537

Based on interview and record review, the facility failed to obtain informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with divalproex (a medication used to treat mood swings) in one of five residents sampled for unnecessary medications (Resident 16). This failure of failing to obtain informed consent prior to initiating treatment with medications used to treat problematic behaviors could have prevented Resident 16 from exercising his right to decline treatment with divalproex. This increased the risk that Resident 16 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to divalproex, such as drowsiness, dizziness, and increased risk of falling, possibly leading to impairment or decline in his mental or physical condition or functional or psychosocial status. Findings: During a review of Resident 16's Admission Record, the Admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnosis including unspecified dementia (a progressive state of decline in mental abilities.) During a review of Resident 16's History and Physical (H&P- a record of a comprehensive physician's assessment), dated 10/24/2024, the H&P indicated Resident 16 had fluctuating capacity to understand and make decisions. During a review of Resident 16's Order Summary Report (a summary of all current physician orders), dated 1/23/2025 indicated, on 10/23/2024, Resident 16's attending physician prescribed divalproex 125 milligrams (mg - a unit of measure for mass) by mouth three times daily for mood (emotion) disorder/bipolar (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional high) manifested by mania/hyperactivity. During a review of Resident 16's clinical record indicated there was no documentation that Resident 16 or any responsible party received education regarding the risks and benefits of divalproex prior to its initiation on 10/23/2024. During an interview with the Director of Nursing (DON) on 1/23/2025 at 11:02 a.m., The DON stated the facility failed to obtain informed consent prior to initiating behavioral management therapy with divalproex for Resident 16. The DON stated the facility staff were probably confused about the necessity to obtain informed consent for the use of this medication since it is not an antipsychotic (medication to treat mental disorder) , antidepressant (medication to treat depression), anti-anxiety medication, or hypnotic although it was being used for behavioral management. The DON stated failure to educate the resident or their responsible party regarding the risks and benefits of medication used for behavioral management could prevent the resident or their responsible party from exercising their right to refuse treatment. The DON stated without informed consent, Resident 16 could have taken divalproex for longer than necessary leading to adverse effects affecting his quality of life. During a review of the facility's policy and procedure (P&P) titled Psychotropic Drug Use, revised August 2017, indicated Upon change of condition or initiation of a new order for psychoactive medications, the Licensed Nurses shall complete the Verification of Informed Consent form prior to the initiation of the new medications.

Based on interview and record review, the facility failed to develop and implement a person-centered and individualized care plan for one of two sampled residents (Resident 63) who was unvaccinated (not having received a vaccine) and exposed to Influenza A (a contagious viral infection that attacks the respiratory system and can cause widespread outbreak). This failure had the potential to result in an inadequate monitoring, and not receiving care specific to resident's needs causing a delay of care to Resident 63. Findings: During a review of Resident 63's Admission Record, the Admission Record indicated Resident 63 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). During a review of Resident 63's Minimum Data Set (MDS- a resident assessment tool) dated 10/27/2024, the MDS indicated Resident 63 had an intact cognition ((ability to think, understand, learn, and remember) and required set-up or clean up assistance (helper sets up or cleans up) with eating, oral hygiene, toileting hygiene, bathing, personal hygiene and bed mobility. During a review of Resident 63's Care Plan titled Resident is at risk for severe acute respiratory infection ( infections of part of the body involved in breathing) related to Covid 19 (an infectious disease caused by the SARS-CoV-2 virus), Influenza (flu), and pneumonia (lung infection) vaccine refusal undated, the Care Plan indicated the facility offered Covid 19, influenza, pneumonia vaccines on 8/22/2024 education, information, risks and benefits were explained but resident refused. The Care plan's goal indicated the resident will be free of infection through the review date and interventions included monitoring of changes in condition, vital signs (measurements of the body's most basic functions), increased restlessness, anxiety, and air hunger (strong, uncomfortable feeling of not being able to get enough air). During a review of facility's Residents' Vaccination Record, the Residents' Vaccination Record indicated Resident 63 was unvaccinated for Influenza vaccine due to refusal. During a concurrent interview and record review on 1/24/2025, at 3:33 p.m. with Registered Nurse Supervisor (RNS 1), reviewed Resident 63's Care Plan. RNS 1 stated Resident 63 did not have a care plan that addressed Resident 63's recent exposure to Influenza from roommate. RNS 1 stated Care Plan is important to addressed problem or concern and communicate to facility staff interventions to meet resident's needs, and precautions need to observe. During a concurrent interview and record review on 1/24/2025, at 3:03 p.m. with Infection Preventionist Nurse (IPN) reviewed Resident 63's electronic health record. The IPN verified there was no Care plan developed to address Resident 63 recent exposure to Influenza. The IPN stated Resident 63 was unvaccinated for Influenza and there should be a care plan to ensure the staff would know how to take care of the resident and would be able to monitor any change of condition. During an interview on 1/23/2025, at 5:26 p.m. with the Director of Nursing (DON), the DON stated care plan is important to ensure all staff would know the plan of care and how to take care of the resident. During a review of facility's policy and procedure (P&P) titled Care plan and Care Plan Update revised 2/2023, the P&P indicated Care plan will be initiated based on identified problem and medical change of condition. The P&P indicated Anytime one of the team members recognized the care needs of the resident had changed, the nurse should be made aware, physician, resident and responsible party will be notified of the significant change.

Based on observation, interview and record review, the facility failed to ensure communication device (communication board) are accessible to residents for one of four sampled residents (Resident 42) who was nonverbal and lack the capacity to speak. This failure had the potential of placing Resident 42 at risk of not able to communicate needs to staff and misinterpretation. Findings: During a review of Resident 42's Admission Records, the Admission Record indicated Resident 42 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cognitive (ability to think, understand, learn, and remember) communication deficit (difficulty in communicating effectively due to impairments in cognitive processes like attention, memory, reasoning, organization, and perception) and dysphagia (difficulty swallowing). During a review of Resident 42's Minimum Data Set ([MDS] resident assessment tool) dated11/12/2024, the MDS indicated Resident 42's daily decision-making skills were severely impaired (lack the ability to make decisions and understand others) The MDS indicated Resident 42 required a one-person physical assist with activities of daily living ([ADLs] task such as eating, oral hygiene, bathing, dressing, grooming and toileting) etc. During a review of Resident 42's History and Physical (H&P) dated 10/15/2024, the H&P indicated Resident 42 has no capacity to understand and make decisions. During a review of Resident 42's care plan titled Resident at risk for a communication problem dated 10/13/2024, the care plan intervention indicated to anticipate and meet Resident 42's needs, communication board, encourage resident to continue stating thoughts even if resident is having difficulty, and focus on a word or phrase that makes sense or responds to the feeling resident was trying to express. During an observation on 1/22/2025 at 10:12 a.m., observed Resident 42 lying flat in bed, attempted to communicate with Resident 42 received no response from the resident. Observed no communication device in Resident 42's room. During a concurrent observation and interview on 01/23/25 at 08:50 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated, have not used a communication device with Resident 42 in the past to explain care to the resident. LVN 4 went to the nurses' station to look for communication device but was unable to locate one. LVN 4 went to resident bedside with Registered Nurse (RN) 1, there was no communication device by Resident 42's bedside. During a concurrent interview and record review on 01/23/25 at 11:34 a.m. with RN 1, reviewed Resident 42's care plan titled Resident at risk for a communication problem. RN 1 stated Resident 42 was supposed to have a communication assistive device to help encourage Resident 42 with communications during care. RN 1 stated Resident 42 did not have one at the bedside.

Based on observation, interview, and record review, the facility failed to provide activities of daily living (activities related to personal care including bathing, showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) to one of four sampled residents (Resident 51). Facility failed to: a. Provide personal hygiene to Resident 51 b. Provide assistance to Resident 51 with morning care, personal hygiene and setting up breakfast tray. This deficient practice resulted in Resident 51 expressing feelings of unkempt, hands dirty, did not feel comfortable eating breakfast in the morning, and low self-esteem. Findings: a. During a review of Resident 51's Admission Records, Admission Record indicated Resident 51 was initially admitted to facility on 3/19/2024 and readmitted on [DATE] with diagnoses including urinary tract infection (infection of the bladder), abnormalities of gait, need for assistance with activities of daily living (ADL) During a review of the Minimum Data Set (MDS resident assessment tool) 11/126/24, indicated Resident 51 had cognitive (ability to think, understand, learn, and remember) impairment. The MDS also indicated Resident 51 required one person assistance in activities of daily living such as dressing, eating, toilet use and personal hygiene. During a review of Resident 51's History and Physical (H&P) dated 1/7/2025, the H&P indicated Resident 51 does not have the capacity to make decisions. During a review of Resident 51's Care plan, undated, the Care Plan indicated goal included Resident 51 will be kept clean and odor free. The Care Plan interventions included to provide shower and supervision as needed and bed bath in between schedule days. During a review of Resident's 51's ADL record (record that indicates activities of daily living provided to Resident 51) dated 3/2024, the ADL record indicated Resident 51 had not been receiving ADL cares including showers/bath on scheduled shower days, personal hygiene was not provided for Resident 51. b. During a concurrent observation and interview on 1/23/2025 at 07:33 a.m., with Resident 51, observed Resident 51 lying down flat in bed with a food tray on the tray table left open with scrambled egg, one banana, muffin, and cereal and, a glass of milk. Resident 51 stated she cannot eat without washing her hands. Resident 51 stated she was unable to pour milk on her cereals. Resident 51's roommate (unknown) stated staff always leave the food tray and does not set it up for the residents and help Resident 51 to sit up in bed. Resident 51 stated she cannot eat lying down flat in bed as it was uncomfortable. On 01/23/25 at 11:29 A.M. during interview RN 1, stated residents should be cleaned before breakfast comes out but if the breakfast tray comes out before the resident is cleaned, the nurse should assist the resident to set up the tray, position resident in a comfortable position, by assisting the resident to sit up well for feeding. During an interview on 01/23/25 at 11:40 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated she did not set up and left Resident 51's breakfast tray because she needed to feed another resident. During a review of facility's policy and procedure (P&P) titled' Activities of Daily Living (ADLs), dated 2/2023, indicated Each resident of the facility receives and must be provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care. This will include nursing staff conduct routine resident monitoring to ensure resident safety and well-being. Staff will ensure ADL are monitored, assisted with, and provided to residents who are unable to perform ADL.Ensure the following ADL are performed, supervised, and assisted including. a. Bathing showering/ and personal hygiene b. Eating/feeding c. Dressing d. Grooming e. Oral hygiene

Based on interview and record review, the facility failed to provide the necessary service and care on one of four sampled residents ( Resident 18 and Resident 45) by failing to: 1.Monitor occurrence of bowel movement(movement of feces through the bowel and out the anus) for Resident 79 and provide necessary medications for constipation( a condition in which stool becomes hard, dry, difficult to pass and bowel movements become infrequent) as ordered by the physician. This failure had the potential to put Resident 79 at risk for fecal impaction (hardened stool that's stuck in the rectum or lower colon) that could lead to bowel obstruction(partial or complete blockage of small or large intestines which is life threatening). Findings: During a review of Resident 79's Admission Record, the Admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included myocardial infarction (MI-heart attack), asthma(chronic lung disease caused by swelling and muscle tightening around the airways), sequelae of cerebral infarction (aftermath of a stroke) and hypertension(HTN-high blood pressure). During a review of Resident 79's MDS dated [DATE], the MDS indicated the resident had impaired cognitive skills and required moderate assistance (helper does less than half) with bed mobility, transfer to and from a bed to a chair, oral hygiene, toileting hygiene, bathing, personal hygiene and dressing. During a review of Resident 79's Change of Condition ( COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional condition) Evaluation dated 1/21/2025 timed at 9:00 a.m., the COC indicated the resident had two episodes of vomiting. During a review of Resident 79's Activity of Daily Living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) Task for bowel movement/bowel continence, the ADL Task indicated the resident had no bowel movement on 1/16/2025, 1/17/2025, 1/18/2025, 1/19/2025, 1/202025. During a review of Resident 79's Care Plan titled Bowel/ Bladder Incontinence related to confusion, disease process and impaired mobility, initiated 1/6/2025. The Care Plan indicated interventions that included monitoring, documenting and reporting to physician possible medical causes of incontinence such as constipation, loss of bladder tone and weakening of control muscles. During an interview on 1/23/2025, at 3:01 p.m. with Certified Nursing Assistant (CNA4), CNA4 stated on 1/21/2025, Resident 79 did not eat breakfast and vomited . CNA 4 stated the charge nurse will be notified if a resident had no bowel movement for more than two days. CNA4 stated she did not check Resident 79's ADL task for occurrences of bowel movement for the past days and was not aware the resident had no bowel movement for more than 3 days CNA4 stated the resident could have abdominal pain, nausea and vomiting and would not feel good if the resident had not had any bowel movement for more than 3 days. During a concurrent interview and record review of Resident 79's electronic chart on 1/22/2025, at 3:31 p.m. with Licensed Vocational Nurse (LVN 3), LVN3 confirmed the resident did not have a bowel movement on 1/16/2025,1/17/2025, 1/18/2025, 1/19/2025, and 1/20/2025 and the physician was not notified about it. LVN 3 stated on 1/21/2025, Resident 79 did not eat breakfast and vomited twice around breakfast. LVN 3 stated if a resident had no bowel movement for three days, the CNAs were supposed to notify the licensed nurses, and the physician should be notified. LVN 3 stated the Resident 79 was not on stool softener and was given a Dulcolax ( laxative) suppository on 1/21/2025 for constipation LVN 3 stated Resident could develop fecal impaction or intestinal obstruction due to constipation. During a concurrent interview and record review of Resident 79's ADL Task for bowel movement on 1/23/2025, at 4:08 p.m. with RN Supervisor (RNS 2), RNS 2 stated the resident had no bowel movement starting 1/16/2025 to 1/20/2025.RN2 stated the charge nurses are supposed to monitor residents' frequency of bowel movement and stated if the resident had no bowel movement for five days the resident could get really sick and infection could occur, Resident 79 had an episode of vomiting during dinner on 1/21/2025. During an interview on 1/23/2025, at 4:42 p.m. with RN 3 , RN 3 stated all licensed nurses should be monitoring residents' frequency of bowel movement. RN 3 stated on the third day a resident had no bowel movement ,and an alert appeared on the electronic chart and the physician should have been notified to obtain orders for treatment or medication, RN3 stated Resident 79's constipation could have been prevented and symptoms of nausea and vomiting could be related to the constipation. During an interview on 1/24/2025, at 5:26 p.m. Certified Nursing Assistant. with Director of Nursing (DON), DON stated residents who had no bowel movement for three days and more could cause abdominal discomfort, bloating , nausea, vomiting and could affect their appetite. During a review of facility's Job Description of Certified Nursing Assistant (CNA), the Job Description of CNA indicated the CNA will assist the resident with bowel and bladder functions and to inform Nurse Supervisor/ Charge Nurse of any changes in the resident's condition so that appropriate information can be entered in the resident's care plan. During a review of facility's Job Description of Registered Nurse (RN), the Job Description of RN indicated the RN will ensure that assigned certified nursing assistants (CNAs) are aware of resident care plan. The Job Description of RN indicated to ensure the CNAs refer to the resident's care plan prior to administering daily care to the resident.

Based on observation, interview and record review, the facility failed to ensure that a resident received continuous oxygen as ordered by the physician for two of three sampled residents (Resident 48 and Resident 70) by: a. Failing to ensure Resident 48 received oxygen at two liters per minute (lpm) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) continuously as ordered by the physician. b. Resident 70 nasal cannula was connected to an oxygen concentrator (medical device that help you take in oxygen) These failures had the potential to result in Resident 48 and Resident 70 receiving inaccurate amount of oxygen and cause complications associated with oxygen therapy. Findings: During a review of Resident 48's Admission Record, the Admission Record indicated, Resident 48 was initially admitted to the facility on [DATE] and last re-admission was on 3/23/2023 with diagnoses including malignant neoplasm(cancer) of right lung and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 48's History and Physical (H&P), dated 4/10/2024, the H&P indicated, Resident 48 had the capacity (ability) to understand and make decision. During a review of Resident 48's Minimum Data Set (MDS -resident assessment tool), dated 10/20/2024, the MDS indicated Resident 48 required supervision or touching assistance (helper provides verbal cues and /or touching/steadying and /or contact guard assistance as resident completes activity) from one staff for dressing, transfer, walking, partial/moderated assistance (helper does less than half the effort) from one staff for toileting hygiene, and bed mobility. During an observation on 1/21/2025, at 10:42 a.m., in Resident 48's room, Resident 48's oxygen concentrator (a medical device that gives you extra oxygen) was set on three lpm with humidifier (add moisture to the air to prevent dryness) and his nasal cannula was on the floor. During an observation on 1/21/2025, at 1:05 p.m., in Resident 48's room, Resident 48's oxygen concentrator was set on three lpm with humidifier and the nasal cannula was still on the floor. Resident 48 was eating lunch and was not wearing nasal cannula. During an interview on 1/21/2025, at 1:08 p.m., with Licensed Vocational Nurse (LVN) 1 in Resident 48's room, LVN 1 stated, Resident 48 should be on oxygen of two lpm via nasal cannula continuously per physician 's order. LVN 1 stated, Resident 48's nasal cannula should be in a bag when it was not used otherwise it should be considered as contaminated. LVN 1 stated, oxygen is considered as a medication and should be administrated as ordered to receive right dose. During a concurrent interview and record review on 1/23/2025, at 10:36 a.m., with Registered Nurse Supervisor (RNS) 1, reviewed Resident 48's Order Summary Report, dated 1/3/2025, the Order Summary Report indicated, to apply oxygen via nasal cannula two liter per minute continuous to keep oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage) at or above 90 percent (%). RNS 1 stated, Resident 48 was not compliant with wearing nasal cannula, but staff should have checked on him to ensure he was wearing nasal cannula and oxygen concentrator was set at two liter per minute as ordered. During an interview on 1/24/2025, at 11:43 a.m. with Director of Nursing (DON), DON stated, staff should have ensured that Resident 48 was receiving oxygen as physician ordered because it was considered as medication. The DON stated, Resident 48 was diagnosed with COPD and providing too much oxygen could be dangerous for the residents with COPD due to hypercapnia (too much [carbon dioxide- a waste product that your body gets rid of when you exhale] in the blood). The DON stated, carbon dioxide triggered breathing for the residents with COPD, but providing too much oxygen would be triggered less breathing which can lead carbon dioxide retention in the body. The DON stated, hypercapnia could lead to drowsiness, respiratory distress (a person is having trouble breathing), and death. The DON stated, the resident's nasal cannula should not be on the floor for infection control. The DON stated, the facility did not have a specific policy and procedure regarding how to provide care for residents with COPD. During a review of Resident 48's Care Plan (CP), revised 1/14/2023, the Care Plan focus indicated, Resident 48 had oxygen therapy related ineffective gas exchange due to COPD. The Care Plan interventions indicated, give oxygen two liter per minute via nasal cannula to maintain O2 Sat above 92% and monitor for signs and symptoms of respiratory distress. 45269 b. During a review of Resident 70's Admission Record, the Admission Record indicated Resident 70 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including enterocolitis (inflammation of intestines) due to clostridium difficile ( dangerous bacteria that can cause inflammation of the colon), end stage renal disease(ESRD- irreversible kidney failure), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and myocardial infarction(MI- heart attack). During a review of Resident 70's Minimum Data Set (MDS- a resident assessment tool) dated 1/4/2025, the MDS indicated Resident 70 had moderately impaired cognitive skills (ability to think, understand, learn, and remember) and was dependent on staff with bed mobility, transfer to and from a bed to chair, toileting hygiene, bathing, dressing and oral hygiene. During a review of Resident 70's Order Summary Report , the Order Summary Report indicated an order for oxygen support at two liters per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath and to keep oxygen saturation ( O2 Sat- a measurement of how much oxygen the blood carrying as a percentage) greater than 95 percent [%]). During a review of Resident 70's Care Plan undated regarding oxygen therapy related to congestive heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) the care plan indicated intervention including to monitor for signs and symptoms of respiratory distress, monitor O2 Sat, skin color and report to the physician as needed. During an observation on 1/21/2025, at 10:53 a.m., Resident 70 was lying in bed and wearing a nasal cannula, and nasal prongs were on the left cheek of the resident. Observed nasal cannula was not connected to an oxygen source. During a concurrent observation and interview on 1/21/2025, at 11:10 a.m. and subsequent interview on 1/21/2025, at 4:03 p.m., with Licensed Vocational Nurse (LVN3), LVN 3 verified the nasal cannula was not connected to the oxygen concentrator(medical device that help you take in oxygen) LVN 3 stated Resident 70 returned from dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment around 8:30 a.m. and he was supposed to check and ensure the resident's vital signs ( measurements of the basic functions of the body) were within normal limit, oxygen is connected to the oxygen concentrator and no bleeding present on the hemodialysis access( a way to reach the blood for hemodialysis). LVN 3 stated he thought the nasal cannula was connected to the oxygen contractor and had seen Resident 70 around 9:52 a.m. when he administered resident's medications. LVN 3 stated he should have checked if the nasal cannula was connected to the oxygen concentrator because the resident could develop shortness of breath that could lead to respiratory distress (a condition where the body needs more oxygen). During an interview on 1/23/2025, at 11:37 a.m. with Infection Preventionist Nurse (IPN), IPN stated the licensed nurse should have assessed Resident 70 as soon as he arrived at the facility after dialysis treatment to ensure the resident 's vital signs are stable, no presence of bleeding on the hemodialysis access and to ensure the tubing of the nasal cannula is connected to the oxygen concentrator. IPN stated Resident 70 could develop respiratory distress if Resident 70 is not receiving oxygen as ordered by the physician. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen, Use of, revised 5/2021, the P&P indicated, It is the policy of this facility to promote resident safety in administering oxygen. The following guidelines will be observed in oxygen administration . 2. The tubing should be kept off the floor. Labeled and dated bags should be provided for cannulas and masks to be placed in when not in use. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration-General Guidelines, updated 11/2021, the P&P indicated, Medications are administered in accordance with written orders of the attending physician.

Based on observation, interview, and record review, the facility failed to accurately account for one dose of hydrocodone/apap (a controlled medication used to treat pain) 10/325 milligrams (mg - a unit of measure for mass) affecting Resident 190 in one of two inspected medication carts (Station 1B Cart.) This failure increased the risk of diversion (any use other than that intended by the prescriber) of controlled medications and the risk that Resident 190 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization . Findings: During a concurrent observation interview on 1/22/25 at 11:04 a.m. with the Licensed Vocational Nurse (LVN 1), observed Station 1B Cart, the following discrepancies were found between the Controlled Medication Count Sheet (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): 1. Resident 190's Controlled Medication Count Sheet for hydrocodone/apap 10/325 mg indicated there were 14 doses left, however, the medication card contained 13 doses. During a concurrent interview, LVN 1 stated she administered the missing dose of hydrocodone/apap 10/325 mg to Resident 190 this morning around 7:40 a.m. and forgot to sign the Controlled Medication Count Sheet at that time, LVN 1 stated the narcotic log should be signed at the time of administration to the resident to accurately account for the narcotic medications. LVN 1 stated if narcotics are not signed off there is a risk of medication diversion or overdose to the resident possibly resulting in medical complications. During a review of the facility's policy and procedures (P&P) titled Controlled Medications, revised December 2019, indicated When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record . Date and time of administration, Amount administered, Signature of nurse administered the dose, completed after the medication is given.

45269 Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for one of 21 sampled residents (Resident 6 and Resident 242). Resident 6 and Resident 242 was prescribed an antibiotic drug without meeting the Mc Geer Criteria (a set of clinical definitions used for surveillance in long-term care facilities (LTCF) These criteria define the resident symptoms and other clinical criteria that are used to meet infection surveillance definitions.). This failure had the potential to result in Resident 6 and Resident 242 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 6's Admission Record, the Admission record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to a chronic ulcer (a non-healing wound on the skin) of the buttock, duodenal ulcer (a sore in the first part of the small intestines) and rectal fistula (an infected anal gland that forma an abscess). During a review of Resident 6's History and Physical (H&P), dated 3/27/2024, the H&P indicated Resident 6 was able to make his own medical decisions. During a review of Resident 6's Minimum Data Set (MDS-resident assessment tool), dated 10/27/2024, the MDS indicated Resident 6 was dependent on nursing staff for toileting, showering, lower body dressing, and putting on and taking off shoes. The MDS indicated Resident 6 needed substantial to maximal assistance from nursing staff with transferring to the shower, bed and chair. The MDS indicated Resident 6 needed partial to moderate assistance from nursing staff with rolling from left to right, sitting, lying down and standing. During a review of Resident 6's Order Summary, the Order Summary, indicated Resident 6 had an order for Ciprofloxacin (medication used to treat bacterial infections) 500 milligrams one tablet by mouth two times a day for abnormal wound culture and sensitivity with right (a bone in the lower hip) ischial surgical wound for 21 days starting 1/13/2025 to 2/3/2025. During a concurrent interview and record review on 1/23/2025 at 9:41 a.m., with the Infection Preventionist (IP), Resident 6's Surveillance Data Collection Form was reviewed. The Surveillance Data Collection Form indicated, on 1/13/2025 Resident 6 did not meet the criteria for cellulitis, soft tissue or wound infection and the Medical Doctor was made aware. IP stated if the Mc Geer's Criteria is not met the IP calls the doctor and let them know the resident does not meet the Mc Geer's criteria and to asks the doctor if they want to continue the antibiotic order and the response is documented in the progress notes. IP stated there is no documentation in the progress notes that indicates the doctor was notified. IP stated Antibiotic Stewardship is used to limit the usage of antibiotics especially if the resident is without ant signs and symptoms of an infection. IP stated Resident 6 can develop resistance to antibiotics and side effects, multi drug resistant organism (MDRO), and can damage the gut by changing the intestinal flora. IP stated the Director of Staff Development (DSD) was responsible for Antibiotic Stewardship. During an interview on 1/23/2025 at 11:26 a.m. with the DSD, DSD stated she informed the doctor Resident 6 did not meet the criteria and the doctor stated to continue with the antibiotics. DSD stated Antibiotic Stewardship is used to avoid unnecessary antibiotic use and to monitor residents' signs and symptoms of an infection. DSD stated if residents do not meet the criteria the resident is at risk for unnecessary antibiotic use. DSD agreed Resident 6 can develop resistance to antibiotics if prescribed unnecessarily. During an interview on 1/23/2025 at 12:53 p.m. with the Wound Care Doctor (WCD), WCD stated he does not know what the Mc Geer's criteria is and was not aware Resident 6 did not meet the criteria for cellulitis, soft tissue or wound infection. During an interview on 1/23/2025 at 1:03 p.m., with the DSD, DSD stated she did not notify the WCD who ordered the medication and should have made the ordering doctor aware that the resident did not meet the criteria for cellulitis, soft tissue or wound infection. During an interview on 1/24/2025 at 4:38 p.m. with the Director of Nursing (DON), DON stated the IP should have documented in the Nursing Progress Notes that she notified the doctor and asked the doctor if the antibiotic can be discontinued. DON stated the IP should have documented what the doctor said in the Nursing Progress Notes. During a review of the facility's policy and procedure (P&P) titled, Unnecessary Medications, dated 8/2019, the P&P indicated, An unnecessary drug is any drug used in excessive doses, including duplicate therapy; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. B. During a review of Resident 242's Admission Record, the Admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included end stage renal disease (ESRD-irreversible kidney failure), cerebral infarction (stroke), hyperlipidemia( condition where there are high levels of fats in the blood), and hypertension(HTN-high blood pressure). During a review of Resident 242's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognitive skills( problems with a person's ability to think, learn, remember, use judgement, and make decisions) and required substantial assistance ( helper does more than half the effort) with toileting hygiene, bathing, dressing, personal hygiene and transfer to and from a bed to chair. During a review of Resident 242's Medication Administration Record (MAR), the MAR indicated Levaquin ( medicine used to treat infection) tablet 500 milligrams (mgs.- unit of measurement) give one tablet by mouth one time a day for Pneumonia for 9 days with an order date of 1/14/2025. The MAR indicated the resident received Levaquin for 9 days. During a review of Resident 242's of Radiology Results Report dated 1/14/2024, the Radiology Report ( chest-x-ray) indicated the resident had a mild prominence of interstitial densities(inflammation and scarring) centrally compatible with interstitial pneumonia (lung disease that causes inflammation and scarring in around the air sac in the lungs)versus bronchiolitis (chest infection that causes inflammation in the small airways of the lungs). During a review of Resident 242's Surveillance Data Collection Form , the Surveillance Data Collection Form indicated the resident's date of onset of symptoms was 1/13/2025. The Surveillance Data Collection Data Form indicated the had met only 2 criteria to use Levaquin(antibiotic) and resident had no other symptoms to meet the criteria. During a concurrent interview and record review of Resident 242 electronic chart on 1/24/2025, at 10:21 a.m. with Director of Staff Development (DSD), DSD stated she was in charge of Antibiotic Stewardship ( set of practices that ensure antibiotics are used appropriately and only when necessary)in the facility. DSD confirmed Resident 242 did not meet the criteria of Mc [NAME] Criteria (guidelines used for surveillance of infections, identification of infections in long term care facilities and used retrospectively to count true infection)and there was no documentation about the physician being notified that resident's symptoms did not meet criteria to use Levaquin. DSD stated the resident can develop multi drug resistant organism(MDRO-microorganisms usually bacteria that are resistant to multiple antibiotics and can be difficult to treat and spread quickly) and could be an unnecessary medication if it was not meeting Mc [NAME] Criteria. During a concurrent interview and record review of Resident 242's electronic chart and Surveillance Data Collection Form for Levaquin on 1/23/2925, at 11:01 a.m. with Infection Preventionist Nurse (IPN). IPN stated the facility used Mcgeer Criteria for their antibiotic surveillance and Resident did not have cough, no sputum production(process of coughing up mucus or phlegm from the respiratory tract), fever or leukocytosis( condition where there are more white blood cells in the blood indicating an infection). IPN stated Levaquin was ordered because of pneumonia (infection in the lung) shown in the chest x-ray result. IPN stated the resident use of antibiotic did not meet the Mc [NAME] criteria and the resident could develop resistance to most antibiotics and this could change the intestinal flora ( bacteria or microorganisms that live inside the intestines to help digest food)of the resident by killing the good bacteria. During a review of facility's policy and procedure (P&P) titled Unnecessary Medications updated 8/2019, the P&P indicated each resident 's medication regimen must be free from unnecessary drugs. The P&P indicated an unnecessary drug is any drug used without adequate indications for its use. During a review of facility's P&P titled Antibiotic Stewardship reviewed 12/2023, the P&P indicated the facility will implement an Antibiotic Stewardship Program (ASP- coordinated effort to improve how antibiotics are prescribed and used with the goal of ensuring antibiotics are only used when necessary and appropriate) that will promote appropriate use of antibiotics while optimizing treatment efficacy , resident safety and reducing treatment related costs.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 79) Medication Administration Record(MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) indicated Resident 79 did not receive his medication on 1/21/2025 for 9:00 a.m. due to nausea and vomiting. This failure indicated an inaccurate Medication Administration Record and had the potential to negatively affect Resident 79's care. Findings: During a review of Resident 79's Admission Record, the Admission Record indicated the resident was admitted on [DATE] to the facility with diagnoses that included myocardial infarction (MI-heart attack), asthma( chronic lung disease caused by swelling and muscle tightening around the airways), sequelae of cerebral infarction (aftermath of a stroke) and hypertension(HTN-high blood pressure). During a review of Resident 79's MDS dated [DATE], the MDS indicated the resident had impaired cognitive skills and required moderate assistance (helper does less than half) with bed mobility, transfer to and from a bed to a chair, oral hygiene, toileting hygiene, bathing, personal hygiene and dressing. During a review of Resident 79's Change of Condition ( COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional condition) Evaluation dated 1/21/2025 timed at 9:00 a.m., the COC indicated the resident had two episodes of vomiting. During a review of Resident 79's MAR dated 1/21/2025 for 9:00 a.m., the MAR indicated the following medications were signed and administered, 1. Ascorbic Acid ( vitamin C) liquid 500 milligrams ( mgs.- unit of measurement) 2.5 milliliter (ml-unit of measurement) one time a day. 2. Multivitamins-Mineral tablet one tablet by mouth one time a day for supplement. 3. Tamsulosin Hydrochloride(medicine to treat enlarged prostate gland) .4 mg. one capsule by mouth one time a day for benign prostatic hyperplasia ( BPH-enlarged prostate gland often causing issues with urination). 4. Ropinirole hydrochloride ( medicine to treat restless legs syndrome).25 mg. one tablet by mouth two times a day for restless leg syndrome (RLS-condition that causes a very strong urge to move the legs related uncomfortable feelings ). During a concurrent interview and record review of Resident 79's electronic chart on 1/22/ 2025, at 3:31 p.m. with Licensed Vocational Nurse (LVN 3),LVN 3 stated he signed all the medications due at 9:00 a.m. on 1/21/2025 but Resident 79 did not take it because of the vomiting and abdominal pain. LVN 3 stated he did not notify the physician when resident did not take his medications because he did not think it through that time. LVN 3 stated the licensed nurse should sign his name in the MAR after each medicine is administered. LVN 3 stated signing his name in the MAR indicated he administered these medicines and stated his documentations were inaccurate because the medications were not administered. During an interview on 1/24/2025, at 3:03 p.m. with Infection Preventionist Nurse (IPN), IPN stated MAR should be signed by licensed nurses after administering a medicine because to ensure accurate and proper documentation of medicines received by the resident. IPN stated inaccurate documentation of MAR had the potential to cause miscommunication to the other nurses and physicians which could affect the care of the resident negatively. During an interview on 1/24/2025, at 5:26 p.m. with Director of Nursing (DON), DON stated licensed nurses should observe the five rights of medication (right patient, right drug, right time, right dose and right route- regarded as a standard for safe medication practices). DON stated licensed nurses should sign the MAR after medication administration and document refusal of medication and notification of physician in the chart to ensure the documentation is accurate. DON stated MAR is a legal document and inaccurate documentation could affect the care of the resident. During a review of facility's Job Description of Licensed Vocational Nurse/ Licensed Practical Nurse , dated 12/17/2021, the Job Description of Licensed Vocational Nurse indicated to chart nurses' notes in professional and appropriate manner that is timely, accurately and thoroughly reflects the care provided to the resident. During a review of facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines updated 11/2021, the P&P indicated the individual who administered the medicine will record the administration on the resident's MAR after the medication pass is completed. The P&P indicated if a dose of regularly scheduled medication is withheld, refused, not available or given at a time other than the scheduled time, the space provided in the front of the MAR for that dosage is initialed and circled or an explanatory note is entered in the chart.

Based on observation, interview, and record review, the facility failed to observe infection control practices by failing to: a. Ensure Resident 70's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was kept in a sanitary manner. b. Ensure positive result of Influenza test (test to detect the presence of flu virus) of Resident 79 was relayed to the physician in a timely manner. c. Ensure droplet precaution (actions designed to reduce/prevent transmission of viruses spread or transmittable through air droplets by coughing, sneezing, talking and close contact with an infected patient's breathing) was initiated and observed when Resident 70 tested positive for Influenza A (Flu- a contagious viral infection that attacks the respiratory system and can cause widespread outbreak) and symptomatic (showing symptoms of flu). These failures had the potential to transmit and spread infection to residents, visitors, and staff. Findings: a.During a review of Resident 70's Admission Record, the Admission Record indicated Resident 70 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including enterocolitis (inflammation of intestines) due to clostridium difficile ( dangerous bacteria that can cause inflammation of the colon), end stage renal disease(ESRD- irreversible kidney failure), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and myocardial infarction(MI- heart attack). During a review of Resident 70's Minimum Data Set (MDS- a resident assessment tool) dated 1/4/2025, the MDS indicated Resident 70 had moderately impaired cognitive skills (ability to think, understand, learn, and remember) and was dependent on staff with bed mobility, transfer to and from a bed to chair, toileting hygiene, bathing, dressing and oral hygiene. During an observation on 1/21/2025, at 10:53 a.m., observed Resident 70 was lying in bed and wearing a nasal cannula, and nasal prongs were on the left cheek of the resident. Observed nasal cannula was not connected to an oxygen source. During a concurrent observation and interview on 1/21/2025, at 11:10 a.m. and subsequent interview on 1/21/2025, at 4:03 p.m. with Licensed Vocational Nurse (LVN 3), LVN 3 verified the nasal cannula was not connected to the oxygen concentrator (medical device that help you take in oxygen). LVN 3 stated Resident 70 returned from dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) around 8:30 a.m. and the charge nurse was supposed to check and ensure Resident 70's vital signs are within normal limit, oxygen is connected and no bleeding present on the hemodialysis access( a way to reach the blood for hemodialysis ). Observed LVN 3 took the nasal cannula from the bottom of the bed and offered Resident 70 to wear the nasal cannula instead of the nasal cannula the resident was wearing. LVN 3 stated they usually store nasal cannula not in use by resident in a plastic bag. LVN 3 stated he will replace the nasal cannula because it was on the floor, was dirty and could be contaminated. During an interview on 1/23/2025, at 11:37 a.m. with Infection Preventionist Nurse (IPN), IPN stated the licensed nurse should have changed the nasal cannula before offering it to Resident 70 to prevent resident from getting infection from possible contamination. During a review of facility's policy and procedure (P&P) titled Use of Oxygen revised 5/2021, the P&P indicated labeled and dated bags should be provided for cannulas and masks to be placed in when not in use and the oxygen tubing should be kept off the floor. b. During a review of Resident 79's Admission Record, the Admission Record indicated Resident 79 was admitted to the facility on [DATE] with diagnoses that included myocardial infarction (MI-heart attack), asthma (chronic lung disease caused by swelling and muscle tightening around the airways), sequelae of cerebral infarction (damage to the brain from interruption of its blood supply) and hypertension (HTN-high blood pressure). During a review of Resident 79's MDS dated [DATE], the MDS indicated Resident 79 had impaired cognitive skills and required moderate assistance (helper does less than half) with bed mobility, transfer to and from a bed to a chair, oral hygiene, toileting hygiene, bathing, personal hygiene, and dressing. During a review of Resident 79's Change in Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional condition) Evaluation dated 1/21/2025 timed at 6:13 p.m., the COC indicated the resident had a fever of 101.4 Fahrenheit ( F- unit of measurement). During a review of Resident 79's COC Evaluation dated 1/22/2024 timed at 2:22 p.m., the COC indicated Resident 79 developed a non- productive cough (dry cough without mucus or phlegm). During a review of Resident 79's Care Plan titled Resident was at risk for severe acute respiratory infection related to Covid, Influenza, pneumonia vaccine refusal initiated 1/2/2025 and was revised on 1/23/2025, the Care Plan indicated Resident 79 was at risk for severe acute respiratory infection related to Covid, Influenza, pneumonia vaccine refusal. The Care Plan's interventions included observing for signs and symptoms such as fever, cough, difficulty of breathing, chills, sore throat, and congestion. During a review of Resident 79's Care Plan titled Resident had a respiratory (referring to the lungs) infection due to Influenza A initiated 1/23/2025, the Care Plan goal indicated Resident 79 will be free from signs and symptoms of respiratory infection by review date. The Care Plan interventions included to implement droplet isolation (a set of precautions used to prevent the spread of infections that are transmitted through respiratory droplets) for Influenza A and to start Tamiflu (anti-viral medicine). During a review of Resident 79's Influenza A and B Panel Test result, the result indicated the specimen for the Influenza A and B Panel test was collected on 1/21/2025, at 6:35 p.m. received by the laboratory on 1/22/2025, at 10:24 a.m. and reported to the facility on [DATE] at 9:18 a.m. The Influenza A and B Panel test indicated Resident 79 was positive for Influenza A. During a review of Resident 79's Progress Notes dated 1/23/2025 timed at 7:44 p.m., the Progress Notes indicated the physician was notified about the positive Influenza test and droplet isolation was observed. During a concurrent interview and record review on 1/24/2025, at 8:29 a.m., with Registered Nurse Supervisor (RN 1), RN 1 stated the laboratory provider called her on 1/23/2025, at around 9:00 a.m. or 10:00 a.m. because Resident 79 tested positive for Influenza A. RN 1 stated she called Resident 79 physician at around 10:00 a.m. and then sent a text message on her personal cellphone but Resident 79 physician did not respond or called back. RN 1 stated if the physician would not call back, staff should call the Medical Director. RN 1 stated she did not place a call to notify the Medical Director after Resident 79's physician failed to return her call. RN 1 stated residents and staff could get exposed to Influenza virus which can cause an outbreak (sudden increased of cases of a disease above what is normally expected) and cause a delay of care to Resident 79. During an interview on 1/24/2025, at 11:28 a.m. with IPN, IPN stated she was aware Resident 79 was positive for Influenza A on 1/23/2025 at around 11:00 a.m. or 12:00 p.m. IPN stated RN 1 should have called the physician and if no response, she should have called the Medical Director of the change in condition and positive Influenza A test result because it was an urgent matter and could cause a delay of care to Resident 79. IPN stated they should have followed up the result of Influenza A and B Panel test sent on 1/22/2025 when Resident 79 developed fever and cough because the residents in the facility are vulnerable to develop serious illness. c. During an observation on 1/23/2025, at 3:30 p.m. in Resident 79's room, no signage for droplet precautions was posted on the front of the entryway or isolation cart was present before entering the room. During an interview on 1/24/2025, at 8:29 a.m. with RN 1, RN 1 stated she did not initiate droplet precaution on 1/23/2025 and left at 3:30 p.m. RN 1 stated Resident 79 was still in the same room with his roommate when she left the facility at 3:30 p.m. RN 1 stated Resident 79 did not have to be in a private room if they followed the three feet away distance from the resident. RN 1 stated she did not initiate the droplet precautions for Resident 79 because she was waiting for instructions from the Director of Nursing (DON) and IPN. RN 1 stated licensed nurses did not need an order to start isolation precautions for a resident who tested positive for Influenza. During a concurrent interview and record review of facility's census on 1/23/2025 at 11:28 a.m. with IPN, IPN stated Resident 79 was unvaccinated for Influenza due to refusal. IPN stated once they identified the resident had infectious disease like Influenza, they isolate the resident as soon as they obtained a positive Influenza result. IPN stated she knew Resident 79 was positive for Influenza on 1/23/2025 at around 11:00 a.m. because RN 1 notified her. IPN stated they did not move the resident right away as they observed the guideline of three to six feet distance away to the affected resident to prevent transmission. IPN stated Resident 79 was moved on 1/23/2025 at 6:34 p.m. IPN confirmed there were available beds on 1/23/2024 and census indicated there were 83 residents and 14 empty beds. IPN stated they should have placed Resident 79 on droplet precautions as soon as the positive result for Influenza was received on 1/23/2025 because other residents and staff would be at risk in contracting the Influenza which could lead to an outbreak. During a review of an online article Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities | Influenza (Flu) | CDC dated 9/17/2024, the online article indicated Droplet precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility. During a review of facility's policy and procedure (P&P) titled IPCP Standard and Transmission-Based Precautions revised 3/2024, the P&P indicated Droplet precautions are used for patients known or suspected to be infected with pathogens (microorganisms) transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking. The P & P indicated to implement source control by placing a mask on the patient and ensure appropriate patient placement

Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (measures used by the facility to ensure antibiotics [drug to treat infection] are used only when necessary and appropriate) for one of five sampled residents (Resident 6). This failure had the potential to result in Resident 6 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 6's Admission Record, the Admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic ulcer (a non-healing wound on the skin) of the buttock, duodenal ulcer (a sore in the first part of the small intestines) and rectal fistula (an infected anal gland that forms an abscess). During a review of Resident 6's History and Physical (H&P), dated 3/27/2024, the H&P indicated Resident 6 was able to make his own medical decisions. During a review of Resident 6's Minimum Data Set (MDS-resident assessment tool), dated 10/27/2024, the MDS indicated Resident 6 was dependent on nursing staff for toileting, showering, lower body dressing, and putting on and taking off shoes. The MDS indicated Resident 6 needed substantial to maximal assistance from nursing staff with transferring to the shower, bed, and chair. The MDS indicated Resident 6 needed partial to moderate assistance from nursing staff with rolling from left to right, sitting, lying down, and standing. During a review of Resident 6's Order Summary, the Order Summary, indicated Resident 6 had an order for Ciprofloxacin (medication used to treat bacterial infections) 500 milligrams (mg-unit of measurement) one tablet by mouth two times a day for abnormal wound culture and sensitivity (laboratory tests to check for infection) with right ischial (a bone in the lower hip) surgical wound for 21 days starting 1/13/2025 to 2/3/2025. During a concurrent interview and record review on 1/23/2025 at 9:41 a.m., with the Infection Preventionist (IP), Resident 6's Surveillance Data Collection Form was reviewed. The Surveillance Data Collection Form indicated, on 1/13/2025 Resident 6 did not meet the criteria for cellulitis (skin infection), soft tissue or wound infection and the medical doctor was made aware. IP stated if the McGeers Criteria (a document to identify whether the symptoms meet the criteria for definitive infection) is not met the IP calls the doctor and lets the doctor know the resident does not meet the McGeers criteria and asks the doctor if they want to continue the antibiotic order and the response is documented in the progress notes. IP stated there was no documentation in the progress notes that indicates the medical doctor was notified. IP stated Antibiotic Stewardship is used to limit the usage of antibiotics especially if the resident is without any signs and symptoms of an infection. IP stated Resident 6 can develop resistance to antibiotics and side effects, multi drug resistant organisms (MDRO- bacteria that are resistant to multiple antibiotics and can cause serious infections), and the antibiotic can damage the gut (stomach) by changing the intestinal flora. IP stated Director of Staff Development (DSD) was responsible for Antibiotic Stewardship. During an interview on 1/23/2025 at 11:26 a.m. with the (DSD), DSD stated she informed the medical doctor regarding Resident 6 not meeting the McGeers Criteria and the doctor stated to continue with antibiotics. DSD stated she did not document the doctor's response in the progress notes. DSD stated antibiotic stewardship is used to avoid unnecessary antibiotic and to monitor residents for signs and symptoms of an infection. DSD stated if residents do not meet the criteria the resident is at risk for unnecessary antibiotic use. DSD agreed Resident 6 can develop resistance to antibiotics if prescribed unnecessarily. During an interview on 1/23/2025 at 1:03 p.m., with the DSD, DSD stated she did not notify the Wound Care Doctor (WCD) who ordered Ciprofloxacin 500 milligrams. DSD stated she should have made the ordering doctor aware that Resident 6 did not meet the McGeers Criteria for cellulitis, soft tissue, or wound infection. During an interview on 1/24/2025 at 4:38 p.m. with the Director of Nursing (DON), the DON stated the IP should have documented in the Nursing Progress Notes that she notified the doctor and asked the doctor if the antibiotic can be discontinued. The DON stated the IP should have documented what the doctor said in the Nursing Progress Notes. During a review of the facility's policy and procedure (P&P) titled , Antibiotic Stewardship date revised 1/2022, the P&P indicated, It is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment-related costs. This policy will include basic elements about antibiotic resistance and opportunities for improvement .Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration. Cross referenced F-757

Based on interview and record review, the facility failed to address one of three sampled residents ' (Resident 1) concerns with documented resolution and follow up. This failure had the potential to violate the resident ' s right to have their grievance addressed. Findings: During a review of Resident 1's Admission Record, dated 7/15/2024, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including ESRD (End Stage Renal Disease-irreversible kidney failure), anxiety disorder, major depressive disorder (MDD- a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 6/30/2024, the MDS indicated Resident 1 had the cognition (ability to learn reason, remember, understand, and make decisions) to recall information after cueing or prompting and required supervision or contact guard (minimal touching for stability) assistance when walking. During a concurrent interview and record review on 11/27/2024 at 1:30 p.m., with the Social Services Assistant (SSA), Resident 1 ' s medical record was reviewed. The SSA stated Resident 1 received hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) three days a week, and is transported using an ambulance company. The SSA stated, after Resident 1 returned from hemodialysis on 7/3/2024, Resident 1 stated they were uncomfortable with a driver of the transportation company. The SSA stated they reported this concern to the Social Services Manager (SSM) 1. SSM 1 told the SSA to file the complaint with the transportation vendor. The SSA stated the transportation vendor was contacted, but there is no documentation in Resident 1 ' s medical record documenting the situation or resolution. The SSA stated the concern should have been documented in the medical record. During a concurrent interview and record review on 11/27/2024 at 2:24 p.m., with the Social Services Manager (SSM) 2, the Grievance logs from June 2024 to November 2024 were reviewed. SSM 2 stated there is no documentation about Resident 1 ' s concern in the Grievance Logs. SSM 2 defined grievance as if the resident vocalizes a concern or issues that we feel might happen in the future. During an interview on 11/27/2024 at 3:16 p.m., with the Director of Nursing Services (DON), the DON stated residents have a right to express any concerns or grievances without retaliation because the facility wants the resident to feel safe. The DON stated it is important to document the residents' concerns including what happened, and that the resident was updated and they were agreeable. During a review of the facility ' s policy and procedure (P&P), titled Grievances, last revised December 2023, The P&P indicated The Grievance Official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any resident ' s right while the alleged violation is being investigated.

Based on observation, interview and record review, the facility failed to revise a resident centered care plan for one of three sampled residents (Resident 1) who was at risk for developing permanent foot drop (difficulty in lifting the front part of the foot) extremity by failing to: a. Ensure Resident 1's responsible party (RP) 1 received clear and consistent communication from the Interdisciplinary Team ([IDT] health care professionals who work together with the resident and or RP to plan the residents plan of care) summarizing the changes in Resident 1's insurance payer sources and how it would affect Resident 1's physical therapy plan. b. Ensure all members of Resident 1's direct care team (bedside licensed nurses, Certified Nurse Assistants [CNAs] and Restorative Nurse Assistants [RNA] were provided education on how and when to use the Ankle Foot Orthosis ([AFO]custom made orthotic [provides support to joints] device to provide support and stabilize the lower extremity encompassing the foot, ankle and leg below the knee) vs. Pressure Relief Ankle Foot Orthosis ([ PRAFO] supportive device worn on the foot and calf to help prevent pressure injuries boot and supports foot). These deficient practices resulted in: 1. A delay in Resident 1 being fitted for the appropriate foot orthosis and had the potential for Resident 1 to suffer permanent foot drop. 2. The direct care staff not being informed by IDT of the reason for the specific usage of Resident 1's orthotic devices which could lead to a delay in care. 3. RP 1 not having a clear understanding of Resident 1's plan of care leading to stress, distrust and frustration toward the facility. Findings: During a review of Resident 1's Admission Record (Face Sheet) the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including compartment syndrome (painful buildup of pressure around your muscles, requiring surgery to relieve) of left lower extremity, lack of coordination, major depressive disorder (serious mood disorder that affects how a person feels, thinks, and acts). During a review of Resident 1's History and Physical (H&P) dated 9/5/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/9/2024, the MDS indicated Resident 1 had moderate cognitive impairment and always had the ability to be understood and to understand others. The MDS indicated had functional limitation in range of motion on the left lower extremity. Resident 1 required partial/moderate assistance (helper does less than half the effort) for toilet hygiene, showering/bathing and personal hygiene. The MDS indicated Resident 1 had a major surgical procedure that requires active care during the skilled nursing facility stay. During a review of Resident 1's Order Summary Report (Physician's Orders), dated 9/26/2024 the Order Summary Report indicated left AFO for foot drop/compartment syndrome. During a review of Resident 1's Order Summary Report (Physician's Orders), dated 11/8/2024 the Order Summary Report indicated Vendor A to evaluate and provide custom molded left AFO to correct ankle/foot deformity and improve dorsiflexion to provide support during ambulation. During a review of Resident 1's Clinical Record (Care Plan section), initiated on 9/5/2024, the Care Plan indicated Resident 1 has actual impairment to skin related to surgical wound, status post fasciotomy (surgical procedure that involved cutting open the fascia[connective tissue that surrounds muscles, nerves and blood vessels] to relieve pressure), the Care Plan goal indicated Resident 1 will have no complications related to skin injury through a review date of 12/23/2024. The Care Plan's interventions indicated for Resident 1 to have a follow-up appointment with physician 1, a follow up appointment with the vascular surgeon, and to follow up with General Acute Care (GACH) wound healing and limb preservation center. During a review of Resident 1's Clinical Record (Care Plan section), initiated on 9/19/2024, the Care Plan indicated Resident 1 had alteration in musculoskeletal system related to risk of foot drop, the Care Plan goal indicated Resident 1 will remain free of complications related to fracture, such as contracture formation (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), embolism (obstruction or blockage in a blood vessel) and immobility through review date of 12/23/2024. The Care Plan interventions included PRAFO boots to left foot, educate family/resident/caregivers on joint conservation techniques, referral to orthotist for better treatment of foot drop. During a review of Resident 1's Interdisciplinary Team Meeting Note (IDT), dated 9/18/2024, the IDT notes indicated therapy services plan of care as follows: reviewed progress of therapy with daughter, discussed concerns for left foot drop status post fasciotomy, and daughter will follow up with physician on 9/19/2024. The IDT note indicated the following: resident and/or resident representation (RP) have been notified of their right to participate in the development and implementation of her person centered plan of care, including the right to see care plan and sign off after significant changes are made; the resident and or RP have been notified of their right to receive a written summary of the residents plan of care, including the baseline care plan. During a review of Resident 1's Physical Therapy Notes, dated 10/18/2024, the Physical Therapy Notes indicated physician 1 requested the following: therapy to work on aggressive range of motion to left ankle to improve dorsiflexion ([DF] upward movement of the foot and ankle), requesting a new left AFO for walking with more dorsiflexion, add padding under toes of current AFO to promote more DF. The note indicated physician 1 is okay with black Pressure Relief Ankle Foot Orthosis (PRAFO- a device that helps prevent and manage pressure-related problems in the feet and ankles, used for residents whom spend long periods in bed or a wheelchair, not designed for prolonged walking or standing) when at rest but it would be okay with a new one to provide more DF stretch, requests relayed to social services to obtain authorization for another orthotic appointment and rehab team made aware. During a review of Resident 1's Physical Therapy Notes, dated 10/22/2024, the Physical Therapy note indicated the following precautions: left lower extremity weight bearing as tolerated as of 9/26/2024, black PRAFO only at rest (no gait training), must gait train with [NAME] Solid AFO with DF assist (padding under big toe). During a review of Resident 1's IDT note dated 10/23/2024, the note indicated the following : DON spoke with RP 1 to discuss the plan of care for Resident 1, RP 1 stated physician 1 visited Resident 1 in facility an recommended a different boot and more days for rehabilitation treatment for foot drop, DON explained to RP 1 that Resident 1 I on part B, to receive therapy three times a week at the moment. The Social Services Director (SSD) has submitted different authorizations for different orthosis vendors DON informed RP 1 that due to Resident 1's being custodial status, the process is different and may take longer. The Director of Rehabilitation (DOR) spoke with Resident 1's nurse practitioner (NP) 1 regarding Resident 1's therapy treatment and was informed that NP 1 may increase Resident 1's physical therapy day after new boot has arrived. During an interview on 11/4/2024, at 12:34 p.m., the RP1 stated her primary concern in Resident 1's care is the prevention and management of Resident 1's foot drop. RP 1 stated she was in communication with multiple individuals including the DON, the DOR, physical therapist (PT)1 related to the management and prevention of Resident 1's foot drop. RP 1 stated, upon Resident 1's admission an IDT meeting was held sometime in September and a plan of care was discussed. RP 1 stated the plan of care was not finished and it was dependent on the result of Resident 1's post-surgical follow up appointments. RP 1 stated after the IDT, Resident 1 had several physician appointments with the vascular surgeon and wound care physician in which the physicians recommended continued physical therapy to prevent foot drop. RP 1 stated Resident 1 experienced several changes in payer sources directly affecting the frequency of physical therapy services in addition to requiring multiple adjustments to made to Resident 1's AFO and PFO orthosis. RP 1 stated she felt confused and frustrated not receiving a clear revised plan of care reflecting all the changes in Resident 1's plan of care. RP 1 stated, I feel like I was having so many conversations with different people in the healthcare team such as the DON, DOR and PT that was very stressful, confusing, and frustrating. RP 1 stated it seems the IDT was unaware of the modifications that were needed for Resident 1's AFO to properly prevent and manage foot drop. RP 1 stated, I had authorizations sent to me by insurance that I did not know had to be given to the facility to schedule another orthosis fitting because no one told me. During a concurrent observation and interview on 11/8/2024 at approximately 12:30 p.m., with Vendor 1 in Resident 1's room, Resident 1 was observed lying in bed. Vendor 1 stated he just finished fitting Resident 1 for the appropriate orthotic boot. Vendor 1 stated when Resident 1 was initially fitted and molded for the boot, Resident 1's left foot was not positioned in the correct way causing the boot not to fit properly and did not provide the appropriate support the foot to prevent foot drop. Vendor 1 stated the boot will be ready and arrive to the facility in about two weeks. During an interview on 11/8/2024, at 1 p.m., Resident 1 stated she must wear a boot on her left foot to prevent foot drop. Resident 1 stated her boot is not fitting properly and was just finished being fitted for the correct one. Resident 1 stated her daughter is the RP 1 and makes the decisions in her care. Resident 1 stated she has had problems with her boots fitting and had to wait on authorizations from insurance company to authorize modifications to the boot. Resident 1 is not sure what her plan of care because of the many doctors she sees and her boots not fitting. During an interview on 11/8/2024 at 1:58 p.m., with the Physical Therapist (PT), PT 1 stated Resident 1 is at risk for worsening foot drop. PT 1 stated when Resident 1 was admitted to the facility, Resident 1 did not have any ankle support devices to prevent foot drop. PT 1 stated once Resident 1 was cleared by her vascular surgeon for physical therapy on her left foot, Resident 1 was fitted for an orthotic boot which arrived on approximately 10/11/2024. PT 1 stated when the boot arrived, it did not properly fit Resident 1 and was restrictive to Resident 1's movements. PT 1 stated, Resident 1 has required an additional fitting which was delayed to miscommunication with RP 1 and insurance changes. PT 1 stated Resident 1's current orthotic device which she is using do not provide her with proper support aimed to prevent worsening foot drop. PT 1 stated on 10/18/2024 Resident 1 was assessed by physician 1 who stated padding should be added under the toes to promote Dorsiflexion. PT 1 stated Resident 1's physician orders nor care plan have not been revised reflect the additional padding placed to support Resident 1's toes. The care plan does not address the improper fit of Resident 1's current orthotic brace and that the Resident 1 is awaiting a new brace to arrive. PT 1 stated the IDT has not met to discuss changes. The care plans and physician orders do not indicate the specific use of the AFO boot vs the PRAFO boot. During an interview on 11/13/2024 at 12:39 p.m., with Certified Nurse Assistant (CNA), CNA 1 stated she is Resident 1's assigned CNA for the day shift. CNA 1 stated, I see that Resident 1 had a boot and a splint on her left leg, but I do not know what it is for. During an interview on 11/13/2024 at 12:45 p.m., with the Restorative Nursing Assistants (RNA) 1 and 2, RNA 1 and 2 stated they are the RNAs assigned to Resident 1's care. RNA 1 and 2 stated, Resident 1 wears a brace on her left foot to prevent injury. RNA 1 and 2 did not know the reason for the device was to prevent foot drop for worsening. RNA 1 and RNA 2 stated the information was not provided to them by the IDT and it would be beneficial to know why Resident 1 was using a brace to ensure we are provided her the proper care, and it will give us information to notify the nurse if there is something wrong. During an interview on 11/13/2024 at 1:10 p.m., with Licensed Vocational Nurse (LVN), LVN 1 stated she is Resident 1's assigned licensed nurse for the day shift. LVN 1 stated, Resident 1 wears a brace and a special shoe to prevent foot drop on her left leg, but physical therapy department handles it usage and application. LVN 1 stated she did not receive specific training on the different types of orthotic devices and boots Resident 1 uses. LVN 1 stated the licensed nurses should be included on Resident 1's plan of care to ensure the proper usage and application of the boot incase the licensed nurses must remove the boot during the night shift or hours the physical therapy department available in the facility. LVN 1 stated, Resident 1 is recovering from a wound on her left lower leg so nursing assesses any changes in the skin of her lower leg that may demonstrate infection of decreased circulation. LVN 1 stated there may be a possibility for nursing to remove the orthosis during the time PT is not available. During an interview on 11/13/2024 at 2 p.m., with the Director of Rehabilitation (DOR), the DOR stated Resident 1 was delayed in being refitted for the AFO orthosis due to miscommunication between the facility and RP 1. The DOR stated the facility was waiting on authorization from Resident 1's insurance to refit the orthosis. The DOR stated RP 1 received the needed authorizations from the orthotic vendor but did not know to give the facility a copy which caused the delay in Resident 1 receiving the proper support for to treat her foot drop. During a subsequent interview on 11/13/2024 at 2:10pm, with the DOR, the DOR stated upon his review of Resident 1's physical therapy notes, the listed precautions indicating the specific usage of PRAFO boots vs AFO were not reflected in Resident 1's care plan or physician orders. DOR stated it is important for the Resident 1's care plan to reflect the proper usage of orthotic boots. DOR stated he will be calling Resident 1's physician 1 to clarify orders. During an interview on 11/13/2024 at 2:58 p.m., with the Minimum Data Set (MDS) Nurse, the MDS Nurse stated she is part of the IDT team and helps to coordinate IDT team meetings with residents and/or their RP. The MDS nurse states she assists developing care plans that are resident centered and specific to goals and reflects changes in the residents' plan of care. The MDS nurse stated the IDT consists of nurse, social services, dietary services, activities department, RNAs and CNAs. The MDS nurse stated it is important for the IDT to work together with the resident and or the RP to develop the residents' plan of care. The MDS nurse stated it is important for all members of the healthcare team, including those providing direct daily care to the resident (licensed nurses and CNAs) to be informed of the resident's care plan goals and interventions to ensure the proper care and services are provided. The MDS nurse stated the healthcare team should revise the care as needed to reflect any changes or new problems affecting the resident and their plan of care. During a subsequent interview on 11/13/2024 at 3:10 p.m., with the MDS nurse, the MDS nurse stated the care plans did not reflect the specific indications of when to use the PRAFO vs AFO boot. The care plans did not reflect that RP 1 was provided updates or informed of the necessary modifications to be made on Resident 1's orthotics. During an interview on 11/13/2024 at 4 p.m., with the DON, the DON stated upon her review of Resident 1's physical therapy notes she was not aware of the modifications made to Resident 1's orthosis to ensure the prevention of foot drop. The DON stated the last IDT meeting was held on 10/23/2024 to include the RP 1. The DON stated RP1 speaks with many members of the IDT independently which can cause confusion and misunderstandings in Resident 1's plan of care. The DON stated Resident 1's care plan should have been updated to reflect the pending arrival of Resident 1's properly fitted orthosis. The DON stated the care plans should also reflect the specific instructions indicating the proper usage of the current boot, which includes the work around of adding the padding under Resident 1's toes to provide support. The DON stated, the care plan should indicate when direct care staff should use the AFO and the PRAFO boot. The DON stated the IDT team including CNAs, and licensed nurses should be aware of Resident 1's plan to care to perform the appropriate assessments and to deliver the needed services. The DON an updated and revised care plan will help to ensure the IDT members and RP 1/Resident 1 have a clear understanding of Resident 1's plan of care. The DON stated failing to update and revise Resident 1's care plan can lead to miscommunication within the IDT team lead and between the IDT and RP 1 which can result in a delay in care and services and distrust and frustration from RP 1. During a review of the facility's policy and procedure (P&P) titled, Care Planning, revised May 2007, the P&P indicated the IDT team shall develop a comprehensive care plan for each resident. The IDT includes but is not limited to the following professionals: attending physicians, or non-physician practitioner (NPP), registered nurse responsible for resident, nurse aide responsible for resident, member of food and nutrition services staff, to extent practicable, resident and or RP, other appropriate staff or professional in disciplines as determined by resident's needs or requested by resident. During a review of the facility's P&P titled, Resident Rights, dated 10/4/2016, the P&P indicated the Resident Rights include the right to be informed of and participate in your treatment including the right to be fully informed of your total health status, including but not limited to your medical condition, the right to participate in the development and implementation of your person centered plan of care, the right to receive information in a form and manner you can understand. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, revised 8/2017, the P&P indicated the IDT will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to follow through with the Preadmission Screening and Resident Review ([PASRR] guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual disability, to ensure their needs will be met ) recommendation to obtain a PASRR level II (results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care) evaluation for two (2) of 19 sampled residents (Residents 12 and 64) who was diagnosed with a mental illness prior to admission in the facility. This deficient practice had the potential to result in inappropriate placement, and Residents 12 and 64 not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: A.During a review of Resident 64's Admission Record, dated 4/21/2022, the Admission Record indicated Resident 64 was admitted to the facility with diagnoses of anxiety (a feeling of worry, nervousness), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion) and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). During a review of Resident 64's Minimum Data Set ([MDS] - a standardized assessment and care screening tool) dated 10/26/2023, the MDS indicated Resident 64 was alert and oriented and able to make independent decisions about her activities of daily living. The MDS section D indicated Resident 64 felt lonely and isolated at times. The MDS section N indicated Resident 64 received antipsychotic (a type of psychiatric medication which are available on prescription to treat [psychosis when people lose some contact with reality]) medications on a routine basis. During a review of Resident 64's physician orders (PO) dated 12/21/2023, the PO indicated to monitor for episodes of mood, anxiety, and depression disorders .every shift. The PO indicated Resident 64 had an order to take Depakote 500mg twice a day (used to certain psychiatric conditions), Seroquel 150 mg at bedtime (used to treat certain mental/mood disorders), and Trazadone 50 mg daily (to treat depression, anxiety, or a combination of depression and anxiety). During a review of Resident 64's care plan (CP) revised on 12/4/2023, the CP indicated Resident 64 was at risk for impaired thought processes manifested by psychosis and persistent mood disorder (psychiatric disorders). The CP indicated the goal was to maintain a current level of cognitive function. The CP interventions were to provide psychosocial support as needed and monitor for any changes in cognitive functions. The CP indicated Resident 64 had the potential for a mood problem related to feeling down and trouble concentrating. The CP interventions were to provide behavior consults as needed. The CP indicated Resident 64 was on psychotropic medications related to schizophrenia and the interventions were to administer medications as ordered. During a review of Resident 64's psychiatric progress note (PN) dated 7/5/2023, the PN indicated Resident 64 had a history of bipolar disorder diagnosed [DATE], anxiety diagnosed [DATE] and schizophrenia disorders (undated). During a review of Resident 64's PASRR Level 1 screening dated 12/22/2023, the Level 1 screening was positive, and it indicated a Level 11(2) screening was required. During a review of Resident 64's PASRR Level 2 screening dated 12/26/2023, the Level 2 screening evaluation indicated a Level 2 was not scheduled because Resident 64 had no serious mental illness. During an interview on 1/24/2023 at 4:20 pm with the MDS coordinator, the MDS coordinator stated she is sure Resident 64 had a psychiatric diagnosis and stated Resident 64 Level 1 PASSR was positive, that required a Level 2 examination. The MDS coordinator stated Resident 64 sees a psychiatrist (prior to entering the facility) who manages her psychiatric medications. During an interview on 1/24/2024 at 4:35 p.m. with the Infection Prevention Nurse (IPN), IPN stated someone called her from the state at the facility for a Level 2 examination for Resident 64 and she told them that Resident 64 was not exhibiting any behaviors like delirium. The IPN stated, they will close the case (state) on Resident 64. The IPN stated if Resident 64 stopped taking her antipsychotic medications, she would exhibit psychiatric symptoms. The IPN stated she is not familiar with the services offered for a Level 2 PASRR. The IPN stated she thinks Resident 64 could benefit from a Level 2 PASRR. During an interview on 1/26/2024 11:47 a.m. with the Director of Nurses (DON), the DON stated a Level 2 PASRR was required for Resident 64 and the reason documented for not doing it, is not true. The DON stated Resident 64 should have had a Level 2 PASRR examination based on her history of a psychiatric diagnosis. B.During a review of Resident 12's Admission Record (facesheet) dated 11/15/2019, the facesheet indicated Resident 12 was admitted to the facility with diagnoses of schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), depression ( mental health disorder characterized by a persistent depressed mood ) and hypertension (high blood pressure). During a review of Resident 12's Minimum Data Set ([MDS] - a standardized assessment and care screening tool) dated 11/18/2023, the MDS section C indicated Resident 12 was had mild cognitive impairment (the stage between the expected decline in memory and thinking) regarding ADL's. During a review of Resident 12's care plan (CP) revised on 12/2/2023, the CP indicated Resident 12 had the potential for a mood problem related to her psychiatric diagnosis. The CP indicated the goal is for Resident 12 was to have improved sleep. The CP indicated interventions were to have behavioral health consults as needed and to monitor for anxiety and depression. The CP revised on 5/23/2023, indicated Resident 12 was taking psychotropic medication related to schizophrenia. The CP interventions indicated to monitor/report/record and side effects from the medication. During a review of Resident 12's physician orders summary (PO) dated January 2024, the PO indicated Resident 12 had an order for a psychiatrist consult as needed. The PO indicated that Resident 12 was taking Zyprexa (an antipsychotic medication that can treat several mental health conditions like schizophrenia) 5mg (unit of measurement) by mouth at bedtime for schizophrenia. During a review of Resident 12's PASRR Level 1 screening dated 12/22/2023, the Level 1 screening was positive, and it indicated a Level 11(2) screening was required. During a review of Resident 12's PASRR Level 2 screening dated 12/26/2023, the Level 2 screening indicated a Level 2 was not scheduled because Resident 12 had no serious mental illness. During an interview on 1/26/2024 at 11:47 a.m. with the Director of Nurses, the DON stated it is the responsibility of the MDS coordinator to make sure the PASRR diagnosis is correct. The DON stated it is important the PASRR is done, and the recommendations are correct to make sure the resident is receiving the right care and is in the right facility setting. The DON stated a resident may require more care because of their psychiatric issues. The DON stated Resident 12 has a psychiatric diagnosis and is on antipsychotic medications. The DON stated, Resident 12's Level 1 evaluation was positive. During a review of the facility policy and procedure (P&P) titled PASSR dated 12/2022, the P&P indicated, it is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the state. The P&P indicated PASRR Level II is a comprehensive evaluation required as a result, of a positive Level I Screen. The P&P indicated a Level II is necessary to confirm the indicated diagnosis noted in the Level I Screen and to determine whether placement or continued stay in a Nursing Facility is appropriate. The P&P indicated Social Services (SS) shall contact the appropriate State Agency (SA) for referral of specialized care and services the resident may require.

46036 Based on observation, interview, and record review, the facility failed to follow their policy and procedure for dating oxygen tubing and nasal cannula (([NC], a device that deliver extra oxygen through a tube and into the nose) by ensuring the oxygen tubing was maintained weekly for three (3) of 19 sampled residents (Residents 33, 12 and 235) who were receiving oxygen therapy. This deficient practice placed residents at risk of respiratory infections by directly transferring potentially pathogenic (disease causing) organisms through the tubing onto the mucous membranes (moist inner lining of body cavities such as the nose) inside the residents' nasal passages, causing complications associated with oxygen therapy. Findings: A. During an observation on 1/23/2024 at 8:44 a.m. during the initial tour, Resident 33's oxygen nasal tubing that was not labeled or dated and was on Resident 33's bedside table. During a review of Resident 33's Admission Record dated 11/29/2017, the Admission Record indicated Resident 33 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease ([COPD] a condition involving narrowing of the airways and difficulty or discomfort in breathing), schizophrenia (a serious mental condition involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion) and sepsis (infection in the bloodstream). During a review of Resident 33's Minimum Data Set ([MDS] - a standardized assessment and care screening tool) dated 12/22/2023, the MDS indicated Resident 33 had severe cognitive (ability to remember, learn, concentrate and [NAME] decisions) impairment. During a review of Resident 33's physician orders dated 1/22/2024, the Physician's orders indicated Resident 33 had an order for oxygen at two (2) lpm ([lpm] a unit in the category of Volume flow rate) for shortness of breath continuously. During a concurrent observation and interview on 1/23/2024 at 11:00 a.m. with Licensed Vocational Nurse (LVN 3), LVN 3 stated, Resident 33's nasal cannula tubing was changed on 1/19/2024 and the tubing should be dated to indicate the date. LVN 3 confirmed Resident 33's oxygen tubing was not dated. B. During an observation on 1/23/2024 at 12:54 p.m. in the dining room Resident 12 was observed sitting in a wheelchair wearing oxygen nasal tubing that was not dated. During a review of Resident 12's Admission Record dated 11/15/2019, the facesheet indicated Resident 12 was admitted to the facility with diagnoses of schizophrenia, depression ( mental health disorder characterized by a persistent depressed mood ) and hypertension (high blood pressure). During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12 had mild cognitive impairment. During a review of Resident 12's physician orders dated 1/4/2024, the physician's orders indicated Resident 12 had an order for oxygen 2 liters per minute for oxygen. During a concurrent observation and interview on 1/23/2024 at 12:55 p.m. with LVN 3, LVN 3 stated, Resident 12's oxygen tubing was not dated, but it should be. LVN 3 stated, it is important to date the oxygen tubing so the staff will know if it was clean and to follow infection control practices. LVN 3 stated she will remove Resident 12's oxygen tubing and replace it because she doesn't know how long the resident has been using it, since it is not dated. (C) During a review of Resident 235's Admission Record, the Admission Record indicated Resident 235 was admitted to the facility on [DATE], with diagnoses including emphysema (gradual damage of lung tissue), transient ischemic attack (temporary period of symptoms such as extreme weakness caused by blockage of blood flow), and muscle weakness. During a review of Resident 235's history and physical, the history and physical indicated, Resident 235 has the capacity to understand and make decisions. During a review of Resident 235's MDS, dated [DATE], the MDS indicated, Resident 235's cognitive skills was moderately impaired. During a review of Resident 235's order summary report dated 1/4/2024, the record indicated, Resident 235 had a physician's order to apply oxygen via nasal cannula at 3 LPM continuous to keep saturation (a clinical measure of the amount of oxygen in patient's blood) at or above 90% every shift. During a review of Resident 235's care plan dated 1/04/2024, the care plan indicated that Resident 235 had oxygen therapy related to hypoxemia (low levels of oxygen in your blood), and emphysema. The care plan's interventions indicated oxygen settings: apply oxygen via NC at 3 LPM continuous to keep saturation at or above 90%. During a concurrent observation and interview on 1/23/2024 at 11:26 a.m., with LVN 1, Resident 235's oxygen tubing was undated and was laying on another resident's bed. LVN 1 stated, the oxygen tubing should be placed in bag when not in use. LVN 1 stated, there is no date and label on the oxygen tubing. LVN 1 stated, charge nurses are responsible for checking if a resident's oxygen tubing is dated and labeled because the NC should be changed every 7 days. LVN 1 stated, nurses should provide bags for cannulas so they can use the bag to keep the NC clean when residents are not in the room. During an interview on 1/25/2024 at 3:45 p.m. with the Infection Preventionist (IP), the IP stated all oxygen tubing should be dated so the staff will know when it was placed on the resident. The IP stated if the oxygen tubing is not changed, the resident could develop a respiratory infection. The IP stated it is the responsibility of the licensed nurse to change the oxygen tubing every 7 days and date the oxygen tubing. During an interview on 1/26/2024 at 11:26 a.m., with Director of Nursing Services (DON), DON stated, if oxygen tubing nasal cannula are not in use, they should place it in plastic bag belonged to the resident. If the oxygen tubing NC was laying on other resident's bed, it is contaminated, and we will need to throw it away because it can potentially lead to respiratory infection. All oxygen tubing should be labeled and dated with started or changed date of the oxygen tubing and we change the oxygen tubing when it is contaminated or every 7 days. During a review of the facility policy and procedure (P&P) titled Use of Oxygen dated 5/2021, the P&P indicated oxygen cannula or mask will be changed at least every 7 days, as well as the disposable humidifier. The P&P indicated tubing, masks, humidifiers, and other disposables used for Oxygen administration will be dated in an identifiable fashion.

Based on observation, interview and record review, the facility failed to follow its policy, to implement safety measures to prevent falls and injury for one of three sampled residents (Resident 1). Resident 1, who had a high risk for falls, had no floor mats, as indicated in the the facility's policy and procedure. These deficient practices, resulted in Resident 1 falling having an unsupervised fall and requiring a transfer to a general acute care hospital (GACH), admitted to the intensive care unit (ICU) with a scalp laceration (deep cut), traumatic subdural hematoma (a collection of blood outside the brain) with loss of consciousness (interruption of awareness of oneself and ones surroundings), a closed [MEDICAL CONDITION] bone (a break of the bone in the base of the skull), and an intraparenchymal hematoma of the brain ([MEDICATION NAME] bleeding within brain parenchyma). Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care screening tool, dated 12/19/18, indicated Resident 1's Brief Interview for Mental Status ((BIMS) a mental status test) score was 14 which indicated Resident 1 had no cognitive impairment 9thought process). According to the MDS, under Section G110, the resident was assessed requiring one-person physical assist during bed mobility, toilet use, transferring, locomotion on and off the unit, personal hygiene and dressing. The MDS indicated Resident 1 required supervision with eating, used a walker and a wheelchair for mobility. A review of Resident 1's Initial Fall Risk Screen, dated 12/12/18, indicated the Resident 1 had a score of 6 (total score of 5 or more in category requires a care plan to address risks prevention and minimizing risk). According to the Initial Fall Risk Screen, Resident 1 had a balance problem while standing or walking, required the use of an assistive device, such as a wheelchair and received a sedative medication daily. A review of Resident 1's care plan, dated 12/12/18 and titled, Risk for Falls, secondary to weakness. The staff's approach plan included to avoid rearranging furniture, ensure call light was within reach, encourage resident to use call light for assistance, ensure a safe environment, bed in low position, side rails as ordered, and sensor alarm in bed and/or wheelchair. The goal indicated for Resident 1 to be free of falls through review date of 12/26/18. A review of a telephone order, dated 12/13/18, and timed at 10:04 p.m., indicated for Resident 1 to have a sensor alarm on the bed and/or wheelchair to remind resident to call for assistance as needed and to alert staff of unsupervised ambulation (walking). A review of the progress notes written by the Social Services Director (SSD), dated 12/19/18 and timed at 4:45 p.m., indicated Resident 1 was moved from room [ROOM NUMBER] to room [ROOM NUMBER], to allow deep cleaning of room [ROOM NUMBER]. The progress note also indicated a voicemail was left for Resident 1's responsible party. A review of a late entry progress note, written by a Registered Nurse (RN 1), dated 12/22/18 and timed at 1:29 a.m., indicated RN 1 heard a bed alarm and found Resident 1 on the floor in a back lying position. According to the progress note, Resident 1 was not responding verbally, eyes were closed and the resident was moaning, grimacing, and moving arms and legs. Resident 1 sustained a large bump with a laceration to the back of the head that was bleeding heavily, RN 1 documented that pressure and an ice pack was applied to the bleeding site. The progress note indicated Resident 1's blood pressure was taken and 911 was called. n 12/27/18 at 9:41 a.m., during an interview with the GACH Registered nurse (RN 2), she stated that Resident 1 was on the Neuro-unit after being transferred from the intensive care unit (ICU) due to an unwitnessed fall. RN 2 stated that Resident 1 had a [MEDICAL CONDITION] that required four staples (specialized staples used to close skin wounds). Resident 1's physician has delayed the neuro-surgery due to Resident 1 being on a blood thinner Eliquis (an anticoagulant (blood thinner) that reduces blood clotting). At 9:53 a.m., on 12/27/18 Resident 1 was observed at the GACH on the neuro-step down unit in bed asleep. Resident 1 was observed with a swelling to her scalp, a large swollen hematoma in the back of her head with staples to close the laceration. Resident 1 was also observed with a large purple bruise on the base of her head that extended down the right side of her neck, as well as two bruises on her right upper extremity. On 12/28/18 at 5:47 a.m., during an interview regarding what happened on the day of the fall, RN 1 stated that she was passing medications and heard the bed alarm and went to Resident 1's room. RN 1 stated she found the resident on her back with a lot of blood all over the floor, on her arms and hands. RN 1 stated she called the other nurse (LVN 1) and a CNA (Certified nursing assistant (CNA 3)) for help. RN 1 stated she did not conduct a neurological assessment (examination to assess the sensory neuron and motor responses, especially reflexes, to determine whether the nervous system or brain was impaired). RN 1 stated she did not know how long Resident 1 was down on the floor and there were no floor mats next to the bed. RN 1 stated she did not document Resident 1's fall incident on the day it occurred because she had to leave the facility to work at another job. On 12/28/18 at 5:49 a.m., during an interview, the facility's Maintenance supervisor (MS) stated that a housekeeper called him for help to clean Resident 1's room. The MS stated when he arrived to clean the room there was a lot of blood on the the floor between the bed and the wall. The MS stated there were no floor mats next to Resident 1's bed. At 6:01 a.m., on 12/28/18 during an interview, CNA 3 stated RN 1 called for help and when she arrived to Resident 1's room the resident was on the floor covered in blood on her head, gown and hands. CNA 3 stated that Resident 1 had a high risk for falls and was recently moved from a room near the nursing station, to the current room. A review of RN 1's hand written declaration, dated 12/28/18 and timed at 6:32 a.m., indicated that she found Resident 1 on her back with a lot of blood all over the floor, on the resident's arms and hands. RN 1 documented that she left the room and called for assistance, but did not conduct a neurological assessment on Resident 1 because she did not have a flashlight. RN 1 documented Resident 1 was not found on a floor mat, but the bare floor until the paramedics came. At 6:16 a.m. on 12/28/18, during an interview, LVN 1 stated that she was called by RN 1 for an emergency, to assist with Resident 1. LVN 1 stated she saw a lot of blood on the floor and RN 1 was applying pressure to the back of Resident 1's head. LVN 1 stated that she did not observe RN 1 perform a neurological assessment on Resident 1. LVN 1 also confirmed that Resident 1 did not have floor mats and stated she was not sure why the mats were not there. At 7:08 a.m., on 12/28/18, during an interview, a Registry Certified Nursing Assistant (RCNA 1) RCNA 1 stated she was assigned to Resident 1 during the shift and responded to the emergency call for Resident 1. RCNA 1 stated that RN 1 told her to leave because everything was taken care of. RCNA 1 confirmed that Resident 1 did not have floor mats and stated Resident 1's bed was in the lowest position. RCNA 1 also stated that Resident 1 was a high risk for falls. On 12/28/18 at 7:46 a.m., during an interview, RCNA 2 stated she heard the overhead page of a code blue (resident emergency) announced in the facility. RCNA 2 stated she ran to Resident 1's room and observed the resident on the floor with blood on her hands and head. RCNA 2 confirmed that Resident 1 had no floor mats next to the bed. On 12/28/18 at 8:02 a.m., during an interview, the Director of Nursing (DON) stated that she was informed by RN 1 about Resident 1's fall with a head injury. The DON also stated that the nurse was supposed to obtain vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a resident's body functions) and complete a neurological check after the fall. The DON stated that Resident 1 was at risk for falls and was unsteady on her feet. The DON also stated that Resident 1's fall was discussed during the daily meeting and the Administrator was made aware. On 12/28/18 at 9:36 a.m., during an interview, the Director of Rehabilitation stated that Resident 1 had a moderate to high risk for falls, and her gait (manner of walking) was impaired. A review of the Paramedic Run Sheet, dated 12/21/18, indicated the paramedics were called at 6:58 a.m., and arrived at Resident 1 at 7:09 a.m. The Paramedics' documented, Patient found supine (face up) on ground. GCS 4-1-1 (Glasgow Coma Scale (GCS) the summation of scores for the eye movement, verbal, and motor responses (severe [MEDICAL CONDITION] GCS score of 8 or less)), complaint of AL[NAME] (altered level of consciousness) following what appears to be a fall. Patient has hematoma and laceration to back of the head. Staff was unclear on normal GCS, staff states patient walks with assistance, unknown when patient fell or how long patient was on the ground. Patient was combative and resisted dressing of laceration and c-spine precautions. The Paramedics', documented Resident 1's blood pressure as 140/84 (normal reference range (NRR) is 120/70-80), pulse of 160 (NRR 60-100), respirations 24 (breaths per minute (bpm) NRR 12-20), and the oxygen saturation was 95 percent (%) (NRR 95-100 %). A review of the GACH's Emergency department (ED) report, dated 12/21/18 and timed at 8:01 a.m., indicated Resident 1 had head trauma with a left parietal/occipital subdural hematoma measuring 13 millimeters (mm) in thickness with associated midline shift, a thin subdural hematoma along the left tentorium measuring 2 mm in thickness, and a large occipital scalp hematoma laceration with associated [MEDICAL CONDITION] bone extending to the inferior base of the skull. The ED's report indicated Resident 1's medical condition placed her at an increased risk of decompensation (showing signs of deterioration regarding daily functioning) and death. A review of the GACH records dated 1/10/19 and timed at 1:46 p.m., indicated Resident 1 was intubated (the process of inserting a tube, through the mouth and then into the airway to assist with breathing during anesthesia) and prepped for neuro surgery. Resident 1 had an operation performed of a left frontal craniotomy (surgical removal of part of the bone from the skull) with an evacuation of subdural hematoma with an implantation of an external shunt and reconstruction cranioplasty. A review of the facility's policy titled, Fall Risk Assessment indicated to ensure that the facility identifies each resident at risk for accidents and/or fall, and adequately plans care and implements procedures to prevent accidents. Any resident identified as high risk will have a prevention protocol initiated and documented on the care plan within 72 hours of admission. Prevention protocol examples but not limited to provided supervision, bed in low position, lower side rails and floor mats.

Based on interview and record review, the facility failed to ensure that a resident with a low blood pressure was not given medications that further lowered the blood pressure and ensure the licensed nurse clarified the physician orders [REDACTED]. Resident 1 had a low blood pressure of 82/49 millimeter per mercury (mm/Hg, normal range for blood pressure is more than 120/80 mmHg and less than 140/90 mmHg) and then 106/48 mm/Hg (the diastolic blood pressure or DBP, the bottom number of the blood pressure, was low) 50 minutes later, and the licensed vocational nurse (LVN 1) continued to administer [MEDICATION NAME] (a medication that lowers blood pressure) and [MEDICATION NAME]-[MEDICATION NAME] (a combination drug of medication that lowers blood pressure and a diuretic (water pill)) to Resident 1. LVN 1 also administered to Resident 1 four doses of narcotic pain medications, two tablets of 5-325 mg of [MEDICATION NAME] in the morning and in the afternoon, when the resident's blood pressure was already low. LVN 1 did not inform and involve the registered nurse to assess Resident 1 further and did not notify the physician regarding the resident's change of condition prior to the administration of these medications. This deficient practice resulted in Resident 1 to be transferred to an acute care hospital via 911-Paramedics for [MEDICAL CONDITION] (low blood pressure) and to receive intravenous fluids of normal saline (a sterile salt solution) to increase her blood pressure. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's care plan, initiated on 5/26/17, indicated Resident 1 had hypertension. The interventions included checking the resident's vital signs as ordered and notifying the physician of any abnormal readings. A review of Resident 1's Initial History and Physical, signed by the physician on 5/27/17, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a care screening tool), dated 5/29/17, indicated that Resident 1's cognition (the ability to think and reason) was moderately impaired. The MDS indicated Resident 1 required extensive assistance (resident involved in activity; staff provide weight bearing support) with all activities of daily living. A review of Resident 1's physician order, dated 5/29/17, indicated to give the resident [MEDICATION NAME] Tablet 5 milligrams (mg), one tablet by mouth one time a day for hypertension and [MEDICATION NAME]-[MEDICATION NAME] 20-12.5 mg, one tablet by mouth one time a day for hypertension. The physician order [REDACTED]. The physician's orders [REDACTED]. A review of Resident 1's Physical Therapy (PT) Treatment Encounter Note, dated 5/29/17, and timed at 9:19 a.m., indicated that the physical therapy assistant (PTA) performed one hour of physical therapy to Resident 1. Resident 1 was seen by PTA in bed due to Lower BP (blood pressure. Resident 1's BP at rest was documented at 82/49 mmHg and heart rate at rest was 82 beats per minute or bpm (the normal range for heart rate is 60 to 100 bpm). A review of Resident 1's Medication Administration Record [REDACTED] A review of Resident 1's Progress Notes, dated 5/29/17, indicated documentation from LVN 1, timed at 2:05 p.m., that Resident 1 was observed to have a low BP of 85/38 mm/Hg around 10 a.m. The resident did not exhibit signs of dizziness. Resident 1 was repositioned to Trendelenburg position and resident's blood pressure was monitored hourly. Resident 1's blood pressure readings were 81/38 mmHg at 11 a.m., 88/45 mmHg at 12 p.m., and 96/52 mmHg at 2 p.m. The attending physician was notified and new orders (not specified) were carried out. The responsible party was made aware. The MAR, dated 5/29/17, indicated Resident 1 received [MEDICATION NAME] 5 milligrams (mg) tablet with a blood pressure of 106/48 mmHg and [MEDICATION NAME]-[MEDICATION NAME] 20-12.5 mg tablet with a blood pressure of 106/48 mmHg during the scheduled morning (9 a.m.) medication administration. The Medication Administration Audit report, dated 5/29/17, indicated [MEDICATION NAME] tablet was given at 10:10 a.m. and [MEDICATION NAME]-[MEDICATION NAME] tablet was given at 10:12 a.m. by a licensed vocational nurse (LVN 1). A review of Resident 1's Speech Therapy (ST) Encounter Note, dated 5/29/17, indicated Resident 1 was seen by the speech therapist during lunch at the bedside with a family member present (Family 1). The ST Treatment Encounter Note indicated the resident was observed with mild SOB (shortness of breath) and fatigue during the meal. A review of a Physician's Telephone Order, dated 5/29/17, and timed at 2:56 p.m. to 2:57 p.m., indicated a clarification of the BP medications ([MEDICATION NAME] and [MEDICATION NAME]-[MEDICATION NAME]) parameters that were confirmed by LVN 1 for Resident 1. The new hold parameters for both BP medications were changed from holding the BP medications for systolic blood pressure (SBP) of 100 mm/Hg to 110 mm/Hg. A review of Resident 1's Progress Notes, dated 5/29/17, and timed at 8 p.m., indicated documentation from a registered nurse (RN 2), who was monitoring Resident 1's low BP. The attending physician ordered to transfer Resident 1 to the emergency department if symptomatic and if systolic blood pressure is below 80 mm/Hg. At 7 p.m., RN 2 documented that Resident 1's BP was at 69/40 mm/Hg and pulse at 57 beats per minute. A 911 call was made and paramedics arrived at the facility at 7:20 p.m. and left with Resident 1 at 7:30 p.m. Family 1 was at the bedside during this time. A review of the acute hospital's History and Physical Exam, dated 5/30/17, indicated Resident 1 was brought to the emergency department (ED) on 5/29/17. Resident 1 presented to the ED with a blood pressure of 69/30 mm/Hg. Resident 1 denied any fever, chills, nausea, vomiting, abdominal pain, chest pain, shortness of breath, dizziness, and [MEDICAL CONDITIONS]. Resident 1 was noticed to have had episode of [MEDICAL CONDITION] at the facility of 60/30 mm/hg and then sent to the ED. The Impression and Plan indicated [DIAGNOSES REDACTED]., hypovolemic [MEDICAL CONDITION] (low sodium levels in the body) with normal osm (osmolality - a test that measures the concentration of all chemical particles found in the fluid part of blood) - patient on BP medication combo with [MEDICATION NAME], will discontinue. Resident 1 received normal saline at 75 milliliter per hour (ml/hr). A review of the acute hospital's Inpatient Summary, dated 5/31/17, indicated Resident 1's discharge [DIAGNOSES REDACTED]. During a telephone interview, on 6/8/17 at 10 a.m., Family 1 (Fam 1) stated that on 5/28/17, Fam 1 observed Resident 1 sleeping way too much. Fam 1 stated it was not Resident 1's usual behavior. Fam 1 stated the next day, on 5/29/17, Fam 1 observed Resident 1 still sleeping a lot more. Fam 1 stated she stayed at Resident 1's bedside the whole day of 5/29/17. During the interview, Fam 1 stated that Resident 1 had physical therapy in bed (on 5/29/17) because Resident 1 was too tired and Fam 1 observed Resident 1 falling asleep during the physical therapy. Fam 1 stated one of the licensed nurses (unable to recall name) checked Resident 1's blood pressure at around 10:30 a.m. and it was 85/48 mm/Hg. Fam 1 stated that late in the afternoon Fam 1 asked a licensed nurse (unable to recall name) to check on Resident 1's blood pressure again because Resident 1 was still sleeping way too much. Fam 1 stated Resident 1's blood pressure was 60/40 mm/Hg. Fam 1 stated the facility called 911 Paramedics and Resident 1 was transferred to the acute hospital. Fam 1 stated the [DIAGNOSES REDACTED]. During an interview, on 6/8/17, at 5:15 p.m., RN 1 was asked for her expert opinion as a licensed nurse that if a resident was being monitored for abnormally low blood pressures, would she still give narcotics or other blood pressure lowering medications. RN 1 stated she will check the blood pressure of the resident first manually for accuracy and if it was still abnormally low, she will notify the physician. RN 1 stated she will review the trend of the resident's blood pressure readings and compare the trend from the resident's baseline to have enough information to decide whether to give the medications or not. RN 1 stated she will inform the resident's physician first and ask if the medications are still okay to be given or not. When asked about some of the side effects of [MEDICATION NAME], RN 1 stated it can cause drowsiness and falls, and can lower the blood pressure. During a telephone interview, on 6/9/17, at 1:45 p.m., the physical therapy assistant (PTA) stated that he performed physical therapy with Resident 1 at the bedside on 5/29/17, at around 8:30 a.m., because the resident's blood pressure was low at 82/49 mm/Hg. PTA stated that he informed the charge nurse (LVN 1) that morning about Resident 1's low blood pressure. PTA stated he checked Resident 1's blood pressure again after physical therapy (before 9:19 a.m.) and the systolic blood pressure was still between 80's to 90's. During a telephone interview, on 7/7/17, at 10:45 a.m., LVN 1 stated it is a facility practice to administer the medications to a resident and document administration in the electronic record immediately after administration. LVN 1 stated that PTA informed him about Resident 1's low blood pressure in the morning. LVN 1 stated he took the blood pressure of Resident 1 in the morning, around 10 a.m. (unable to recall exact time), while FAM 1 was at the bedside and it was 85/38 mmHg. LVN 1 stated he positioned Resident 1 in Trendelenburg position and monitored the blood pressure of Resident 1 hourly as documented in the progress notes (11 a.m. and 12 noon) and then notified the physician. During the interview, LVN 1 stated he administered Resident 1's routine blood pressure medications in the morning of 5/29/17. LVN 1 stated he checked Resident 1's blood pressure before giving the [MEDICATION NAME] and [MEDICATION NAME]-[MEDICATION NAME] medications in the morning and the resident's blood pressure was 106/48 mm/Hg. LVN 1 stated he administered the medications because he followed the physician order [REDACTED]. During the interview, LVN 1 stated he administered narcotic pain medication to Resident 1 on 5/29/17, at 9:54 a.m. because Resident 1 stated she was in severe pain. LVN 1 stated he was unable to recall if he rechecked the blood pressure prior to giving the anti-hypertensive medications and the [MEDICATION NAME]. He stated, I could not remember which was first. LVN 1 stated he again administered [MEDICATION NAME] to Resident 1 around 2 p.m. for severe pain because the resident asked for her pain medication. LVN 1 stated he was aware that [MEDICATION NAME] can bring a resident's blood pressure down but Resident 1 was alert and crying in severe pain. LVN 1 stated I will still give it, because the resident was asymptomatic (did not exhibit signs and symptoms) with her low blood pressure. LVN 1 stated he did not call the physician to clarify if Resident 1 was stable enough to receive the narcotic pain medications. According to https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b52e2905-f906-4c46-bb24-2c7754c5d75b, updated 12/15/08, [MEDICATION NAME] causes a reduction in blood pressure .After oral administration the peak plasma concentrations (the highest level of drug that can be obtained in the blood) will be between 6 and 12 hours. According to https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=e7222f81-3e6b-dfe1-379a-83ca350f91a9, updated 6/6/17, indicated: Pharmacokinetics and Metabolism: Following oral administration of [MEDICATION NAME] HCL and [MEDICATION NAME] peak plasma concentrations are reached within 0.5 to 1.0 hours. [MEDICAL CONDITION] [MEDICATION NAME] HCL and [MEDICATION NAME] should be used cautiously in patients receiving concomitant therapy with other antihypertensives. The thiazide component of [MEDICATION NAME] HCL and [MEDICATION NAME] may potentiate the action of other hypertensive drugs. If [MEDICAL CONDITION] occurs, the patient should be placed in a supine position, and if necessary, treated with intravenous infusion of physiological saline. According to https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=aaef2d01-126d-4aab-9b2a-eee31a 0, updated 8/1/14, indicated: Overdosage: Signs and Symptoms Serious overdose with [MEDICATION NAME] ([MEDICATION NAME]) is characterized by respiratory depression (a decrease in respiratory rate) extreme somnolence ., skeletal muscle flaccidity, cold and clammy skin, and sometimes [MEDICAL CONDITION] and [MEDICAL CONDITION] . [MEDICAL CONDITION] is usually hypovolemic and should respond to fluids. During a telephone interview, on 7/10/17, at 9:35 a.m., the director of nurses (DON) stated the facility does not have a policy and procedure for administration of blood pressure medications.

An isolated incident of the facility's failure to ensure the physician's orders were followed in the care of a resident with a [MEDICAL CONDITION] ((trach) an incision to open the windpipe to assist with breathing) and to ensure the necessary equipment was available and accessible at the resident's bedside in case of an emergency situation, after the resident was complaining of difficulty in breathing. On 3/14/17 at 2:10 p.m., an Immediate Jeopardy was declared and the facility's administrator and director of nurses (DON) were notified of the immediacy. The facility submitted a plan of action (POA) on 3/14/17 at 3:50 p.m., which was accepted. The IJ was abated on 3/14/17 at 3:55 p.m., after the team confirmed that the facility's POA was implemented as following: 1.On 3/14/17, the facility's medical director was notified and came and assessed Resident 8 at 2:55 p.m. 2. A back up [MEDICAL CONDITION] kit, which included inner cannulas (flexible inner tubing of a trach), outer cannula (a tube that remains in place at [MEDICAL CONDITION] site to keep the windpipe open), and obturator (a plastic tube used to dilate the [MEDICAL CONDITION] site and ease in the insertion of the outer cannula), was placed at Resident 8's bedside with extra inner cannulas available at the bedside. 3. An in-service regarding [MEDICAL CONDITION] care was provided to all licensed nurses on 3/14/17. 4. Sterile gloves, suction catheter, sterile gauze, and oxygen concentrator tank were observed at Resident 8's bedside. Based on observation, interview, and record review, the facility failed to follow the physician's orders and the facility's policy in the care of one of 19 sampled residents (Resident 8) who had a [MEDICAL CONDITION]. The facility's nurses failed to provide [MEDICAL CONDITION] care, which included changing the inner cannula for Resident 8 and had the necessary [MEDICAL CONDITION] equipment accessible at the bedside for daily use and emergency situations. This deficient practice resulted in Resident 8 complaining of difficulty in breathing, not having his inner cannula changed per physician's orders, having excessive brown secretions draining from the [MEDICAL CONDITION] site and had the potential for adverse consequences that included the [MEDICAL CONDITION] dislodgement and/or obstruction with the inability to breathe, and or death. Findings: On 3/14/17, at approximately 9 a.m., during the facility's initial tour accompanied by a licensed vocational nurse (LVN 4), Resident 8 was observed in the room with a [MEDICAL CONDITION] intact. A suction machine was observed at the bedside with clear water inside the suction canister. At approximately 11:30 a.m., Resident 8 was seen in the hallway asking the director of staff development (DSD), for two inner cannulas. On 3/14/17 at 12:40 p.m., Resident 8 was found in his room having difficulty breathing, coughing, gasping for air, having pale skin color with difficulty in speaking due to increased secretions from the [MEDICAL CONDITION] site, and with audible garbled sounds (distorted speech). Resident 8 was observed with a paper towel draped under the [MEDICAL CONDITION] site to catch the mucus dripping from the [MEDICAL CONDITION]. There was no [MEDICAL CONDITION] equipment at Resident 8's bedside, such as extra inner cannulas, oxygen (O2), sterile gloves,[MEDICAL CONDITION] and/or obturator. During a concurrent interview, Resident 8, while crying, stated his inner cannula had not been changed since his admission on 3/12/17; even though, he had been asking staff for the inner cannulas, so he at least could change it himself. Resident 8 stated he was having difficulty breathing and stated, I get frustrated, because I had this thing (pointing toward his trach) for over [AGE] years and they don't help me. They have not changed my cannula since I got here two days ago. On 3/14/17 at 12:42 p.m., a licensed vocational nurse (LVN 7), who was the charge nurse for the station Resident 8 resided on, was interviewed about the type of equipment that should be available at the resident's bedside. LVN 7 replied, There should be a suction machine, [MEDICAL CONDITION] kit, and oxygen at the resident's bedside. On 3/14/17 at 12:43 p.m., during an interview, LVN 4 was asked what should be at a [MEDICAL CONDITION] resident's bedside, LVN 4 replied, Inner cannulas,[MEDICAL CONDITION] kits, including gauze and a suction machine should be at the bedside. However, a concurrent observation of Resident 8's bedside, with LVN 4, indicated there was a box of non-sterile gloves, one suction tip, and a suction machine. There were no other [MEDICAL CONDITION] at Resident 8's bedside, as verfied by LVN 4. A review of the facility's policy, titled [MEDICAL CONDITION] Replacement of Dislodge Tube, dated 5/2007, indicated dislodgement of a [MEDICAL CONDITION] can be a medical emergency and prompt action was necessary. According to the policy, the necessary equipment to perform this procedure included [MEDICAL CONDITION], sterile gloves, sterile curved hemostat (Kelly Clamp (curved forceps used for clamping or grasping)), and [MEDICAL CONDITION] kit. None of which were present at Resident 8's bedside or in the facility on 3/14/17, as verified by LVN 4. On 3/14/17 at 12:55 p.m., during an interview, the director of nurses (DON) was interviewed about Resident 8's [MEDICAL CONDITION] care and supplies. The DON stated, We [MEDICAL CONDITION] kit in the central supply room with extra inner cannulas in the treatment cart. On 3/14/17 at 1:23 p.m., during a concurrent observation and interview, with the central supply staff (CS), regarding obturators and [MEDICAL CONDITION] kits in the facility, the CS stated, The facility had borrowed four days [MEDICAL CONDITION] (which included extra inner cannulas [MEDICAL CONDITION]) from a sister facility. There were [MEDICAL CONDITION] with obturators and/or inner cannulas in the central supply room. During the concurrent observation of the treatment cart there were only a few inner cannulas present, but [MEDICAL CONDITION] or an obturator. A review of Resident 8's Admission Face Sheet indicated Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 8's nursing initial assessment, titled License Nurse Initial Admission Record, dated 3/12/17, indicated Resident 8 was alert and oriented to time, place, person, and purpose. The initial assessment indicated Resident 8 was able to understand, but his ability to make concrete requests was limited. The nursing assessment indicated Resident 8 had a [MEDICAL CONDITION] intact. A review of Resident 8's care plan, titled [MEDICAL CONDITION] care related to impaired breathing mechanics due to [DIAGNOSES REDACTED]. Resident 8's care plan goal was to not have abnormal drainage around [MEDICAL CONDITION]. The staff's interventions included to monitor the resident's level of consciousness, restlessness, and provide tracheal suctioning, provide [MEDICAL CONDITION] care and inner cannula changes. A review of Resident 8's physician's orders, dated 3/13/17, indicated [MEDICAL CONDITION] care and inner cannula change of [MEDICATION NAME] (a flexible [MEDICAL CONDITION]) should be provided with a tube size of 9.0 every day and as needed for dislodgement (to remove or force out of a particular place) and/or clogged. The physician's order also indicated the [MEDICAL CONDITION] care was to be provided every shift. A review of Resident 8's treatment administration record, dated 3/12/17, indicated [MEDICAL CONDITION] care should be provided every shift. There were no initials to indicate it had been done on 3/13/17 for the 3-11 p.m., and 11-7 a.m., shift. A review of the facility's policy and procedure titled, [MEDICAL CONDITION], Care and Cleaning of, dated 5/2007 indicated [MEDICAL CONDITION] care would be done at a minimum of once a day or as ordered by the physician. The policy indicated the required equipment for this procedure consists of a plastic bag for disposing of old dressing, [MEDICAL CONDITION] care kit, suction machine, sterile water or saline, hydrogen peroxide, sterile suction catheter, sterile gloves, two sterile empty bowls or containers, if not in the care kit, and sterile pipe cleaners [MEDICAL CONDITION], if not included in care kit. On 3/14/17 at 2:56 p.m., during an interview, the facility's medical director was interviewed regarding the need for emergency supplies at Resident 8's bedside. The medical director stated there should be an emergency kit at Resident 8's bedside that included inner cannulas and an obturator. On 3/15/17 at 7:45 a.m., during an observation, Resident 8 was having breakfast in the patio supervised by a staff member. During a concurrent interview, Resident 8 stated, while observed tearful, stated he was helped by a nurse to get the staff to obtain the [MEDICAL CONDITION]. Resident 8 stated that after the supplies were obtained, the facility's staff did provide [MEDICAL CONDITION] he had been waiting for. He stated, I am feeling better, I can breathe better now, I am very thankful for the nurse for helping me.