Every finding on record at Avalon Care Center - Honolulu, LLC

Based on observations, interviews, record reviews, the facility failed to ensure the resident's right to a dignified existence for 1 of 2 residents (Resident) (R) 124) sampled for dignity. As a result of this deficiency, the resident was not promoted the right to the maintenance or enhancement of the resident's quality of life. Findings include:On 06/01/26 at 12:23 PM, concurrent interview and observation were done with R124. Observed R124 self-propelling himself to the dining area from Physical Therapy activities. Observed urinary drainage bag hanging under the wheelchair, with a privacy/dignity bag covering about a third of the drainage bag. When R124 was asked about why urinary drainage bag was not fully covered, R124 stated that he was also concerned about it, and R124 also stated that drainage bag should always be covered. R124 proceeded to reach for the urinary bag under wheelchair and adjusted privacy bag to cover urinary drainage bag but was unable to resolve issue. On 06/03/26 at 12:53 PM, concurrent observation and interview were done with R124 in the dining room. Observed R124 with a urinary leg bag securely attached to right leg. R124 mentioned that RN11 changed urinary bag to a leg bag and resident was also instructed that urinary bag needs to be changed to leg bag every time R124 leaves the room. R124 stated that he was concerned abouty his privacy since resident prefers to use short pants and stated, I do not feel comfortable using the leg bag since it does not have any privacy bag covering it. R124 also explained that leg bag is always exposed to other people around him when R124 is outside room. On 06/03/26 at 01:13 PM, interview was done with RN11. Asked RN11 if urinary bag should have privacy bag that can cover the entire bag to provide privacy for the resident, RN11 agreed that all urinary bags should always be fully covered with privacy bags. On 06/04/26 at 10:02 AM, interview was conducted with Director of Nursing (DON). Asked DON if urinary bags should have privacy bags to provide privacy for the resident, DON confirmed that all urinary bags should always be fully covered with privacy or dignity bags. DON also explained that the facility is in the process of ordering new sets of urinary leg bags that comes with dignity or privacy bags to provide privacy for the residents. Review of facility policy titled Resident Rights, Respect and Dignity with a revision date of 09/20/22 stated, .1. The resident has a right to be treated with respect and dignity.

Based on observation and interview, the facility failed to ensure appropriate treatment/care of the catheter to prevent urinary tract infection for 1 of 2 residents (Resident (R) 144) sampled. As a result of this deficient practice, residents are at risk of a urinary tract infection. Findings include: On 06/03/26 at 08:29 AM, observed Resident (R) R144 seated in a wheelchair in the entrance of the resident's assigned room. R144's catheter bag was out of the privacy bag (approximately the bottom third of the catheter bag bag) and was resting directly on the floor, along with the tubing. R144 moved the wheelchair and ran over the exposed catheter bag. Alerted Registered Nurse (RN) 15 of the situation. RN15 secured the catheter bag and tubing off the floor. Inquired with RN15 if it was okay for the catheter bag and tubing to be in direct contact with the floor. RN15 confirmed appropriate treatment/care of the catheter bag and tubing was to ensure it was not in direct contact with the floor.

Based on observation and interview, the facility failed to provide a safe and sanitary environment as evidenced by a pill cutter with white and brown sediments, located in 1 of 3 medication carts checked. This deficient practice could potentially put residents at risk of contamination that receive medication(s) being cut by this equipment.Findings include:On 06/03/26 at 08:10 AM, the facility's station 1C medication cart was checked and a pill cutter, located in the top drawer of the medication cart, was observed to have large amounts of white/brown sediments in the interior portion of the cutter. The Registered Nurse (RN) 6 administering medications from this cart was concurrently interviewed. RN6 confirmed seeing the white and brown sediments in the pill cutter and stated it was from not cleaning it. RN6 also stated that the cutter should be cleaned after each use.

Based on observation, interviews, and record review, the facility failed to implement the person-centered care plan for one of three residents (Resident (R)1) sampled for accidents. R1 did not receive the six-time-a-week active range of motion (AROM) exercises as noted in the care plan. This deficient practice has the potential to affect all residents requiring ROM exercises to maintain their strength and mobility.Findings Include:Cross reference to F688R1 was admitted to the facility on [DATE] with a diagnosis of but not limited to weakness, pain, and history of falling.05/21/26 at 10:00 AM, observed R1 sitting on her rollator in the activities room not participating in the balloon toss activity. When R1 was asked why she was not participating in the activity, R1 shook her head and motioned that she could not lift her arms. 05/21/26 at 10:30 AM, record review of R1's electronic health record (EHR) noted that she was a fall risk but also had mobility issues related to her weakness. Review of the care plan, which was initiated on 02/20/26 detailed that R1 was to have AROM Program-RNA (restorative nurse aide) to encourage ROM exercise to BUE (bilateral upper extremity) using 3 lbs (pounds) dowel weights for 10 reps x3 sets, 6x a week as tolerated. Review of R1's AROM Program activities from 02/20-05/20/26 found R1 had at the most four interventions in some weeks, with R1 refusing treatments, and not being offered the intervention. On 05/21/26 at 12:20 PM, interview with MDSC (Minimum Data Set Coordinator), who is also in charge of the RNA program confirmed R1's six-times-a-week frequency for AROM and acknowledge that R1 did not receive the frequency of AROM activities as noted in the plan of care. MDSC verbalized that providing AROM for residents is important to maintain their mobility. On 05/22/26 at 10:00 AM, a follow-up interview with MDSC also noted that they were not addressing R1's refusal and was leaving it to the nursing staff to take care of as the RNAs did not have the time due to being short of staff and being pulled to do other duties to encourage and educate R1. MDSC also confirmed that the R1's refusals should have been addressed and part of the care plan.05/22/26 at 11;00 AM, review of the facility's comprehensive care plan policy with date of 11/2017, it states in the policy section, the facility interdisciplinary team (IDT) will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, physical, and psychosocial needs that are identified in the comprehensive assessment. In the Guidelines section, it reads 13. If a resident or resident representative refuses care or treatment deemed necessary by the facility, the facility will attempt to find an alternative to address the identified need. The medical record will reflect the facility's attempts and education provided to the resident and the representative. Review of the facility's Quality of Care Restorative Nursing Programs policy, with revised date of 06/2018, in the Purpose section, The facility provides services, care and equipment to assure that a resident maintains and/or improves his/her level of range of motion and mobility maintains or improve function unless it is unavoidable based on resident's clinical condition.On 05/22/26 at 01:00 PM, interview with the Director of Nursing (DON) confirmed that the AROM six-times-a-week should have been carried out as it is important to maintain the residents' strength and mobility. DON also acknowledged that R1's refusals should have been addressed and documented and care planned.

Based on observation, interviews, and record review, the facility failed to implement the active range of motion (AROM) exercises for one of three resident (Resident (R)1) sampled for accidents. R1 did not receive the six-time-a-week AROM exercises as noted in the care plan. This deficient practice has the potential to affect all residents requiring ROM exercises to maintain their strength and mobility.Findings Include:R1 was admitted to the facility on [DATE] with a diagnosis of but not limited to weakness, pain, and history of falling.05/21/26 at 10:00 AM, observed R1 sitting on her rollator in the activities room not participating in the balloon toss activity. When R1 was asked why she was not participating in the activity, R1 shook her head and motioned that she could not lift her arms. 05/21/26 at 10:30 AM, record review of R1's electronic health record (EHR) noted that she was a fall risk but also had mobility issues related to her weakness. Review of the care plan, which was initiated on 02/20/26 detailed that R1 was to have AROM Program-RNA (restorative nurse aide) to encourage ROM exercise to BUE (bilateral upper extremity) using 3 lbs (pounds)dowel weights for 10 reps x3 sets, 6x a week as tolerated. Review of R1's AROM Program activities noted the following:Week of 2/20/26-2/28/26, R1 had two AROM interventions, two days marked as RR (resident refused) and three days marked NA (not applicable)Week of 03/01/26-03/07/26, R1 did not have any AROM intervention, three days marked as RR, three days marked as NA, and Tuesday marked as X.Week of 03/08/26-03/14/26, R1 had one AROM intervention, three days marked as RR, one day marked as NA, Tuesday marked with an X, and one without any indicator.Week of 03/15/26-03/21/26, R1 had four AROM interventions, two days marked as NA, and Tuesday marked with an X.Week of 03/22/26-03/28/26, R1 had two AROM interventions, two days marked as RR, two days marked as NA, and Tuesday marked with an X.Week of 03/29/26-04/04/26, R1 did not have any AROM intervention, four days were marked as NA, two days marked as RR, and Tuesday marked with an X.Week of 04/05/26-04/11/26, R1 had three AROM interventions, two days marked as NA, one day marked as RR, and Tuesday marked with an X. Week of 04/12/26-04/18/26, R1 had two AROM interventions, three days marked as NA, one day marked as RR, and Tuesday marked with an X.Week of 04/19/26-04/25/26, R1 had two AROM interventions, three days marked as NA, one day marked as RR, and Tuesday marked with an X.Week of 04/26/26-05/02/26, R1 had two AROM interventions, three days marked with RR, one day without any indicator, and Tuesday marked with an X.Week of 05/03/26-05/09/26, R1 had two AROM interventions, one day marked as NA, three days marked as RR, and Tuesday marked with an X.Week of 05/10/26-05/16/26, R1 had three AROM interventions, one day marked as NA, two days marked as RR, and Tuesday marked with an X.On 05/21/26 at 12:20 PM, reviewed with MDSC (Minimum Data Set Coordinator), who is also in charge of the facility's Restorative Nursing Program, R1's AROM activity documentation and MDSC confirmed that R1 should have been getting six-times-a-week of AROM exercises as noted in the care plan. MDSC also noted that the RR meant R1 refused tx, NA meant not applicable, which she further denoted that it was not done. MDSC also explained that the X on the Tuesdays meant that they RNA's (Restorative Nurse Aides) do not perform the AROM duties on that day as they focus on getting the residents' weights. MDSC also stated that there should not be any blanks. When asked why there was so many NAs, MDSC explained that they try to staff the facility with two RNAs, but they are often pulled to do other duties when the facility is short of staff, thus they cannot complete all the residents' ROM activities. On 05/22/26 at 10:00 AM, a follow up interview with MDSC also confirmed that their process of addressing the residents' refusals is notifying the Charge Nurse or Unit Manager and they will be the one to assess why the resident is refusing and provide the needed education to the resident and family. When asked why the RNAs are not providing education and encouragement, MDSC stated that they do not have the time and are being pulled to do other duties.On 05/22/26 at 11:45 AM, interview with RNA1 confirmed that they are short of staff and will do what they can to provide the residents with ROM activities. RNA1 stated that they should have two RNAs daily, but most of the time there is only one as the other RNA will be pulled to do other duties. When asked if she was familiar with R1's AROM needs and why R1 kept refusing tx, RNA1 said it is mostly because R1 was tired and sleepy after breakfast and wanted to do the activity later in the day. RNA1 further stated that they should be going back to do the activity with R1, but they just do not have the time to circle back with each resident or provide the encouragement or re-education they need. RNA1 acknowledged that AROM activities are important to prevent contractures and maintain the resident's level of strength.On 05/21/26 at 01:00 PM, interview with the Director of Nursing (DON) confirmed that the RNA 6x a week should have been carried out as it is important for maintaining the residents' mobility. DON further stated that the resident refusals should have been addressed and education provided to R1 of the importance of AROM. DON also acknowledged that the RNAs should have revisited R1 and continued to offer the activity. 05/22/26 at 11;00 AM, review of the facility's Quality of Care Restorative Nursing Programs policy, with revised date of 06/2018, in the Purpose section, The facility provides services, care and equipment to assure that a resident maintains and/or improves his/her level of range of motion and mobility maintains or improve function unless it is unavoidable based on resident's clinical condition.

Based on observation and interview, the facility failed to ensure appropriate protective and preventive measures for communicable diseases and infections were implemented. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (additional measures used to help stop infection transmission when a patient/resident has been found to be infected or colonized with certain infectious agents) by wearing the proper personal protective equipment (PPE), followed standard precautions (the basic level of practices used to prevent the spread of infection) by performing hand hygiene, and had PPE and PPE disposal receptacles readily available both inside and/or outside the rooms. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. Findings include: 1) On 03/31/25 at 10:28 AM, Certified Nurse Aide (CNA) 48 was observed coming out of R78's room wearing only a surgical mask. R78 is in quarantine because she tested positive for COVID. Inquired of CNA48 if she is supposed to wear other personal protective equipment (PPE) such as a shield, N95, gown and gloves when going into R78's room. CNA48 stated no that she was delivering diapers. On 03/31/25 at 10:30 AM, an interview was conducted with Registered Nurse (RN) 93. Inquired if staff are expected to use gown, gloves, N95 and face shield when going into resident's room who has COVID. RN93 stated staff are expected to use PPEs mentioned when going into a room where a resident is positive for COVID. Shared observation and asked if this was okay as CNA stated she was delivering diapers and RN93 confirmed it was not, staff are expected to use PPEs. 2) On 03/31/25 at 12:50 PM, observed R89 resting/sleeping in her bed. Inquired of Registered Nurse (RN) 21 if R89 was going to eat her lunch (covered lunch tray was on her bedside table). RN21 stated she would get another staff to assist her to move resident up in her bed so that she can help her with her meal. Resident woke up at brief intervals. Two RNs, RN21 and RN65, put on PPEs (gown, gloves and mask) as R89 had enhanced barrier precautions (EBP). Resident was moved up in her bed by RN21 and RN65 using her draw sheet. Resident's head of bed was raised and resident was positioned comfortably as staff spoke to her. RN21 moved resident's personal items from the bed side table to her small dresser top near her bed. RN21 moved two pillows from her bed onto a metal chair near R89's bed. RN21 then started to feed resident. R89 took one very small amount of mashed potatoes with gravy. R89 did not appear to want to eat any more but did want to drink some milk when it was offered by RN21. RN21 opened the milk container and noticed she did not have a straw available for resident to use. RN21 took off her gloves, went to the door and requested a straw from staff in the hallway. At this time, RN21 also got a new pair of clean gloves. RN21 threw away the dirty gloves and put on the clean gloves, RN21 did not perform hand hygiene. At this time surveyor shared observation with RN21 and asked if she should have done anything after taking off her dirty gloves and she stated, I thought my hands were clean. RN21 also did not identify need to change gloves after positioning resident prior to assisting her with her meal. Review of facility's policy titled Infection Prevention and Control Program (IPCP) revised on 06/08/22 states Purpose The facility will establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. Standard Precautions . 2. Staff will perform hand hygiene, even if gloves are used: a. Before and after contact with the resident: . d. After removing PPE;. 3) On 04/01/25 at 08:16 AM, observed CNA16 wearing full PPEs of face shield, N95, gown and gloves who had brought out a breakfast tray from a quarantined room with a resident who was positive for COVID. CNA16 returned R78's breakfast tray to the cart before doffing PPEs. Inquired if residents with COVID have paper products instead of a tray. CNA shared the tray on the cart was from the resident who has positive for COVID. 4) On 04/02/25 at 09:05 AM, went to R39's room to observe if resident's call light was within his reach. Resident was observed sleeping in his bed and call light was observed on the ground. Inquired with RN94 if call light should be near resident. RN94 confirmed the call light is to be left with the resident before staff leave the room. RN94 picked up the call light and put it on the resident's bed. RN94 did not clean the call light before putting it on the resident's bed. 5) On 04/02/25 at 09:27 AM, R18 was observed sitting in the hallway outside of her room in her wheelchair. R18 has an indwelling urinary catheter that had a privacy bag hanging from the wheelchair that was resting on the ground. On 04/02/25 at 09:30 AM, interviewed Director of Nursing (DON) who was walking in the hallway near R18. Inquired of DON if R18's privacy bag for her indwelling urinary catheter bag should be resting on the ground and she said No and I will get a new one. On 04/02/25 at 01:13 PM, interviewed facility Infection Preventionist (IP) nurse in the Director of Nursing's office. Inquired regarding PPEs use for residents with COVID versus EBP for doffing PPEs and she stated there is no difference. Inquired about placement of trash cans outside of COVID positive patient's bedroom door and IP nurse stated there is no room in the resident's room for the trash can and that is why it is kept in the hallway. Inquired about staff coming out of resident's room who is on Contact Precautions and there is no rubbish can for used PPEs, surveyor shared an observation with IP that another surveyor had of staff who walked across the hallway and took off their PPEs and threw it away in the rubbish can. IP stated staff are not to do this they are to take off PPEs and dispose of it in the trash can that is right outside the room or dispose of inside the room. On 04/ 03/25 at 10:10 AM, observed facility had posted instructions from the Centers for Disease Control and Prevention (CDC) Use personal protective equipment (PPE) when caring for patients with confirmed or suspected COVID-19 dated 06/03/20 which stated Doffing (taking off the gear): More than one doffing method may be acceptable. Training and practice using your healthcare facility's procedure is critical. Below is one example of doffing. 1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak). 2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in gentle manner, avoiding a forceful movement. Reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose in trash receptacle. * 3. HCP may now exit patient room . 51870 6) On 03/31/25 at 11:45 AM, observed R387 with indwelling catheter, secured to his right leg, draining yellow urine, partially covered with a dignity bag and resting on the floor without a barrier. On 03/31/25 at 12:00 PM, interviewed CNA45, and showed her the catheter on the floor. CNA45 confirmed that catheter should not be on the floor, and it was also full and needed to be emptied. On 04/02/25 at 11:00 AM, interview with DON confirmed that catheter care included the catheter not being on the ground for risk of infection. 43245 7) On 03/31/25 at 12:28 PM, observed CNA78 delivering R86's lunch tray to her. It was noted at this time by the transmission-based precautions (TBP) signage outside the door, that R86 was on Contact Precautions (precautions intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment). Review of the TBP signage outside the door noted that gloves and a gown should be donned (put on) prior to entering the room. Observation of CNA78 noted that she was not wearing gloves or a gown as she delivered R86's lunch tray, pressed up against R86's bed as she cut R86's food, and set up her lunch for her. Interview was done with CNA78 at 12:33 PM outside R86's room. When asked about R86's TBP, CNA78 stated that she was told by nurses earlier that morning that she did not need to wear any PPE unless she was touching the resident. CNA78 could not verbalize the difference between Contact Precautions (TBP) and Enhanced-Barrier Precautions (protective precautions but not TBP), or when each would be used. 8) On 03/31/25 at 12:42 PM, observed signage outside of room [ROOM NUMBER] indicating that both residents in the room were on Enhanced-Barrier Precautions requiring staff to don PPE if in direct contact with residents. Also noted that resident in 105B was on Contact Precautions. Made observations at this time that neither room had a trash receptacle for used/dirty PPE disposal either directly inside or directly outside the rooms. Observed CNA78 exit room [ROOM NUMBER], cross the hallway with her dirty gown on, stop at the trash receptacle outside the room across the hall, doff (take off) her used PPE, and throw it away. On 04/02/25 at 08:45 AM, made observation outside room [ROOM NUMBER] that staff were exiting the room to grab clean gloves from the top drawer of the PPE cart outside the room. Also observed that not every room had a PPE cart outside of it. Concurrent interview was done with CNA92 outside room [ROOM NUMBER]. When asked about the availability of gloves, CNA92 stated that gloves are available in the rooms but only in the bathroom, and if there is a PPE cart outside the room, gloves are available inside the top drawer as well. CNA92 agreed that if there is no PPE cart outside the room, and a resident is in (or blocking) the bathroom, it can be difficult to access a clean pair of gloves.

Based on observations, interviews, and record reviews, the facility failed to accommodate the needs of six of six sampled residents (Residents (R) 19, R54, R338, R36, R136 and R39) by not ensuring that call devices were placed within residents' reach and positioned so the residents could activate them. As a result of this deficient practice the residents were placed at risk of not having their emergent needs met in a timely manner and prevented them from achieving independent functioning with regards to calling for help. This deficient practice has the potential to affect all the residents in the facility who can activate a call light. Findings include: 1) R19 is an [AGE] year-old female, admitted to the facility on [DATE]. A review of R19's electronic health record (EHR) noted diagnoses of, but not limited to, legal blindness and Parkinson's with dementia. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/25 noted that R19 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that R19 had intact cognitive function. On 03/31/25 at 08:40 AM, R19's call device cord was observed to be wrapped around the bed rail, located on the upper right side of R19's bed, with the call button portion of the device facing downward against the side of the bed. R19's bilateral arms were observed to be bent at the elbows with her hands positioned near her face. Placement of the device was out of her reach. On 03/31/25 at 02:25 PM, observed call device placement on the right edge of R19's bed. R19's bilateral arms observed to be bent at the elbows. R19 was unable to straighten her right arm on request and stated that she cannot move her left arm. Placement of the device was out of her reach. On 04/01/25 at 07:16 AM, observed call device cord wrapped around the right upper bed rail with the call button facing downward against the side of the bed. Registered Nurse (RN) 9 was interviewed and stated that R19 holds the call device but does not press it, however, she should still have access to it. On 04/02/25 at 07:33 AM, observed call device placement on the right edge of R19's bed. Placement of the device was out of R19's reach. On 04/03/25 at 07:05 AM, observed call device cord wrapped around the right upper bed rail with the call button facing downward against the side of the bed. Placement of the device was out of R19's reach. 2) R54 is a [AGE] year-old male admitted to the facility on [DATE]. A review of R54's EHR noted diagnoses of, but not limited to, metabolic encephalopathy (impaired brain function due to chemical imbalance), fracture of thoracic 11 - thoracic 12 vertebra (middle section of the spine), and muscle weakness. An admission MDS with an ARD of 03/04/25 noted that R54 had a BIMS score of 15, which indicated that R54 had intact cognitive function. On 04/01/25 at 07:23 AM, observed the call device at the top of a pillow located at R54's head of bed. State Agency (SA) asked R54, What do you do when you need help? R54 answered that he rings the call bell. SA then asked if he could demonstrate how to use it. R54 was unable to locate the call device and it was out of his reach. On 04/01/25 at 07:28 AM, RN19 was interviewed near R54's bed and stated that R54 is sometimes able to use the call device and sometimes is not able. RN19 confirmed the call device was not within R54's reach and proceeded to give it to him. 3) R338 is an [AGE] year-old female admitted to the facility on [DATE]. A review of R338's EHR noted diagnoses of, but not limited to, closed supracondylar fracture of left humerus (a break in the upper arm bone, located just above the elbow joint), history of falls, chronic pain of both knees, and osteoporosis (disease that weakens bones). A MDS with an ARD of 03/17/25 noted that R338 had a BIMS score of 14, which indicated that R338 had intact cognitive function. On 04/01/25 at 09:47 AM, observed Certified Nurse Aide (CNA) 50 assisting R338 in her bed. When CNA50 left R338's room, observed R338's call device located above her pillow at the head of her bed. Asked R338, When you need help, how do you call the staff? R338 answered that she presses the call button. Requested R338 to show the call device and resident unable to locate it. On 04/01/25 at 10:04 AM, CNA50 was interviewed outside of R338's room. CNA50 stated that R338 should have the call device on her chest and made sure R338 had it before she left the room. Observed CNA50 then go into R338's room and ask R338, Where is your call bell? Observed R338 move her right hand around the bed until she found the call device cord and proceeded to pull the cord until she reached the call button. Placement of the call device was out of her reach. On 04/02/25 at 02:15 PM, a review of the facility policy titled, Resident Call System noted under the section titled, Guidelines: 3. The call system will be accessible to residents while in bed other sleeping accommodations within the resident room . 37954 4) On 03/31/25 at 10:15 AM, observed R36 resting in her room in her bed. Observed call light was hanging from the side of her bed, out of reach for the resident. On 04/02/25 at 09:23 AM, observed R36 in her bed sleeping. Observed R36's call light was on the ground. At this time interviewed CNA and inquired if resident's call light is to be within reach of resident and she confirmed this, stated they (staff) leave the call light near the resident before leaving the resident. CNA cleaned the cord and call light with a wipe and placed on resident's bed. Call light was not attached to R36's blanket to prevent it from falling onto the floor again. 5) On 03/31/25 at 02:30 PM, an interview was done with R136 in her room at the bedside. R136 was observed lying on her call light cord. Inquired of R136 why her call light cord was behind her back and she stated she puts it there to make sure it will not fall on the ground because she will have to reach down to pick it up which she explained would be hard for her do. On 04/01/25 at 09:54 AM a dressing change was observed for R136 of her right foot and at this time R136 was seen with her call light cord placed behind her on her bed. 6) On 03/31/25 at 09:30 AM, observed R39 in his room in bed resting. Observed R39's call light was on a wooden shelf behind his bed. On 04/02/25 at 09:05 AM, observed R39 asleep in his bed. Observed R39's call light was on the ground next to resident's bed. Inquired of RN94 where R39's call light should be and she said near the resident. RN94 picked up R39's call light from the ground and placed it near the resident on his bed. Call light was not attached to R39's blanket to prevent it from falling onto the floor again. On 04/03/25 at 10:37 AM, an interview was done with (Director of Nursing) DON in the Administrator's office. Inquired of resident's call light and she confirmed the call light is to be within reach for the resident who is left in their room in bed. Shared observation that a resident's (R39) call light was observed on the wooden shelf behind his bed and she stated she knew which resident surveyor was speaking of because he is the only one who has the wooden shelf behind his bed. Inquired if the call lights can be clipped to the sheet so that it does not fall to the ground and DON stated she has gotten clips for the call lights and had them passed out.

Based on interviews and record review the facility failed to ensure sufficient nursing staff were available to provide restorative services for one of three residents (Resident (R) 29) sampled for limited range of motion (ROM). As a result, R29 did not receive consistent restorative nurse aide treatment and services to maintain and/or prevent a decline in ROM. This deficient practice puts 30 residents in the RNA program at risk for a decline in ROM. Findings include: Cross reference to F688, Increase/Prevent Decrease in ROM/Mobility. The facility failed to provide consistent application of splint and ROM exercises for R29. On 04/03/25 at 08:31 AM, observed R29 eating breakfast with assistance from Certified Nurse Aide (CNA) 75, in bed her left arm was folded with fisted hand on chest and no splint. Inquired with CNA75 if R29 has a splint for her hand and knee, CNA75 reported R29 should be wearing her splint daily but the facility did not have an RNA today. CNA75 proceeded to explain that she could put the splint on. Inquired with R29 in her native language, Korean, if the facility had been helping her with her exercises and stretches, she stated no and that she would like to continue her exercises and stretches. On 04/03/25 at 08:37 AM, interview with MDS Director (MDSD) 67 was done. MDSD67 confirmed she oversaw the RNA program and R29 gets services daily. RNA reported that R29's services should continue even under transmission based precautions (TBP) and that she may not be getting services due to RNA staff called to floor as CNA. MDSD67 explained that there are limited number of staff that are trained to provide RNA services. If RNA staff are working as a CNA they are not able to see everyone or are too busy with their CNA duties to provide RNA services. Review of the list of staff able to provide RNA services are a total of five staff, two assigned RNA staff and three CNAs that can cover. On 04/03/25 at 08:53 AM, an interview and concurrent record review with Nursing Scheduler (NS) was done. NS confirmed there was no RNA staff today, 04/03/25. NS reported that the facility is supposed to have two RNA staff but most days they only have one available. For CNA, there are usually 11-12 CNAs on the floor depending on the census with a maximum of 9-10 residents per CNA. Concurrent review of the day shift Nursing Assignment from 03/26/25 to 04/03/25 document one RNA staff from 03/26/25 to 04/02/25 and no RNA staff on 04/03/25. NS was not able to fill the RNA positions due to the availability of CNAs those days (CNA staff calling in sick). One of the two regular RNA staff were on vacation during the sampled timeframe. On 04/03/25 at 09:59 AM, an interview with CNA39 was done. CNA39 stated she was trained to provide RNA services but has not provided RNA services in a long time. Inquired if CNA39 would be able to provide RNA services when assigned as a CNA, CNA39 reported she would not have the time to do both and stated resident needs would get neglected due to the amount of time spent in providing RNA services. On 04/03/25 at 10:54 AM, an interview with CNA75 was done. CNA75 stated she was trained to provide RNA services and has not provided RNA services in a long time due to needing CNAs on the floor. Inquired if CNA75 would be able to provide RNA services when assigned as a CNA, CNA75 stated it would be too much. On 04/03/25 at 11:26 AM, an interview with Director of Nursing (DON) was done. DON reported if there is not enough CNAs on the floor they would need to ask the RNAs to work as CNAs and there would be no coverage for RNA.

Based on observation and interview, the facility failed to ensure personal information was protected for one of one randomly sampled resident (Resident (R) 88). The Electronic Health Record (EHR) was left open. As a result of this deficient practice, residents are at risk of their health information not remaining private. Findings include: On 04/02/25 at 07:40 AM, observed station one's medication cart in the hallway. The EHR on the cart was left open and R88's list of medications was visible and was not protected. On 04/02/25 at 07:45 AM, interviewed Registered Nurse (RN) 81 on what their policy is for the EHR, RN81 replied, I'm sorry, I forgot to close it. It should be locked every time we walk away.

Based on record review and interview, the facility failed to ensure the comprehensive resident assessment accurately reflected the resident's status for one of 21 residents sampled (Resident (R) 77) for accuracy of assessment. R77's admission comprehensive assessment did not include oxygen (O2) therapy as a respiratory treatment R77 was receiving at the facility. As a result, R77's O2 therapy was not care planned, O2 physician orders were not reviewed, and her O2 tubing was overlooked. Findings include: Cross reference to F695, Respiratory Care. The facility failed to ensure R77's respiratory care was consistent with professional standards. R77's O2 tubing was not labeled with the date it was last replaced and the physician orders did not include parameters and delivery method. Cross reference to F656, Development of the Care Plan. The facility failed to ensure R77's comprehensive care plan included O2 therapy. Review of R77's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/04/25 under Section O. Special Treatments, Procedures, and Programs, O2 was not checked off as a treatment performed on admission. On 04/02/25 at 02:06 PM, an interview and concurrent record review with MDS Director (MDSD) 67 and MDSD43 was done. The MDSDs reported if a resident has O2 therapy, it would be documented in the MDS under Section O. MDSD67 confirmed R77 had O2 therapy when the admission assessment was completed and it should have been documented on R77's admission MDS, ARD 03/04/25, Section O. MDSD67 confirmed it was not done.

Based on interviews and record review, the facility failed to furnish a copy of the baseline care plan (BCP) for one of two residents (Resident (R) 385) sampled for care plan meetings. The facility not providing the BCP to the residents does not keep them informed of the initial plan for delivery of care and services residents are to receive. Findings include: On 04/01/25 at 12:10 PM, interview with R385 completed. R385 stated doing ok and has plans to go home on Monday. R385 has been at facility for about a week with right leg injury and has been getting physical therapy and occupational therapy and stated it has been manageable. When asked if the facility discussed with him his plan of care, he responded no. He also stated he did not receive a copy of his care plan. On 04/01/25 at 01:00 PM, record review of R385's electronic health record (EHR) did not show that he was given a copy of his baseline care plan (BCP). On 04/02/25 at 10:00 AM, interview with Director of Nursing (DON) completed. DON stated that the care plan discussion was done at the welcome meeting with the Interdisciplinary Team (IDT). DON provided a copy of the IDT Care Plan Conference/Welcome Meeting Form, which showed that R385 and his wife was in attendance. When asked if the resident was provided a copy of his care plan, she responded, not that I see in the chart.

Based on observation, record reviews and interviews the facility failed to develop a person-centered comprehensive care plan for one of two residents (Resident (R) 77) sampled for respiratory, one of two residents (R390) sampled for dialysis, and one of one resident (R387) sampled for catheter care. As a result of this deficient practice, staff did not have the information necessary to adequately care for R77's oxygen (O2) therapy, R390's dialysis needs and post-treatment, and R387's catheter care. Findings include: 1) Cross tag to F695, Respiratory Care. The facility failed to ensure R77's respiratory care was provided consistent with professional standards. R77's O2 tubing was not labeled with the date it was last replaced and the physician orders did not include parameters and delivery method. On 04/02/25 at 02:06 PM, an interview and concurrent record review with MDS Director (MDSD) 67 was done. MDSD67 confirmed R77's comprehensive care plan did not include O2 therapy. MDSD67 reported if a resident was admitted to the facility with O2 therapy, nursing staff or the MDS staff would input it in the care plan. On 04/02/25 at 04:07 PM, an interview with Director of Nursing (DON) was done. DON confirmed R77 should have had a care plan for her O2 therapy, and the care plan would include the physician orders. Review of the facility's policy and procedure regarding respiratory care, number 695, dated 07/2018, documented, The resident's individualized care plan will identify the interventions for oxygen therapy, based on the resident's assessment and orders, such as, but not limited to: i. Type of oxygen delivery system; ii. When to administer, i.e. [for example] continuous or intermittent and/or when to discontinue; iii. Equipment setting for the prescribed flow rates; iv. Monitoring of SpO2 [oxygen saturation] levels and/or vital signs, as ordered; and v. Monitoring for complications i.e. skin integrity issues related to the use of a nasal cannula. 51870 2) Cross reference to F698, Dialysis. On 04/02/25 at 09:00 AM, observed R390, who was admitted to the facility on [DATE], right upper arm fistula pressure dressing still on from yesterday's Hemodialysis (HD) treatment. R390 also stated that staff will take it off when they have time and don't really check for the thrill and bruit. On 04/02/25 at 9:30 AM, record review of R390's care plan noted a focus on HD that was initiated on 03/20/25, with interventions to monitor, document, and report as needed any signs and symptoms of infection to access site redness, swelling, warmth or drainage, but did not include intervention to assess access site for thrill and bruit. The Treatment Administration Record (TAR) showed the dialysis fistula checks for thrill and bruit were being done every shift. On 04/02/25 at 10:00 AM, interview with DON confirmed that they should be checking for the thrill and bruit before and after dialysis and every shift. Asked DON to show R390's care plan to see if there were interventions of checking for the thrill and bruit and confirmed it was not included in the resident's care plan but was noted in physician's orders. DON proceeded to add the interventions to care plan. 3) On 03/31/25 at 11:00 AM, observed R387 with indwelling catheter, secured to right leg, draining clear yellow urine, covered with bag, but bag noted on the floor without any barrier. Concurrent interview with R387, stated he came in without a catheter but asked for one because he was having a hard time urinating standing up. R387 was admitted to the facility on [DATE]. On 04/02/25 at 08:23 AM, record review of R387's minimum data set (MDS) bladder/bowel section noted that R387 is always continent. Review of progress note dated 03/26/25, stated bladder scan and straight cath [cathetor] every shift. R387 had 600 milliliters (ml) of urine retention on scan, indwelling catheter was inserted. Physician's orders dated 03/26/25 noted to insert foley catheter for urinary retention. Review of comprehensive care plan found no catheter focus, goals, and interventions. On 04/02/25 at 11:00 AM, interview with DON, verified that R387 was having retention issues as much as 600 ml of urine retention on bladder scan and so indwelling catheter was inserted on 03/26/25. Asked DON to review care plan and DON confirmed that there was no catheter care initiated and should have been added in the plan of care. Review of the facility's Comprehensive Care Plans policy, dated 11/2017, in the guidelines section, it stated The care plan will be comprehensive and person-centered. It will drive the type of care and services that a resident receives and will describe the resident's medical, nursing, physical .needs and preferences; as well as how the facility will assist in meeting these needs and preferences. In the Policy section, it also stated, The facility interdisciplinary team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, physical .that are identified in the comprehensive assessment.

Based on interview and record review the facility failed to update Resident (R) 136's care plan to include a new intervention to treat resident's moisture-associated skin damage (MASD) with an antifungal once identified, for one of four residents sampled for skin conditions (non-pressure). The deficient practice put R136 at risk for worsening of fungal infection with MASD to her sacrum and buttocks which could lead to a pressure injury and pain. Findings include: Cross reference to F684, Quality of Care - Despite identifying R136 had a fungal infection and MASD to her sacrum and buttocks, that had worsened since admission, the facility failed to acquire a physician order for antifungal to treat the area and update R136's care plan.

Based on observation, interview, and record review, the facility failed to care plan and implement residents' individual activity preferences and accommodate special needs for two of two residents (Resident (R) 19 and R338) sampled for activities. This deficient practice has the potential of not supporting the physical, mental, and psychosocial well-being of residents and not creating a meaningful life for residents residing in the facility. Findings include: 1) R338 is an [AGE] year-old female admitted to the facility on [DATE]. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/25 noted that R338 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated that R338 had intact cognitive function. On 04/01/25 at 09:45 AM, R338 stated that no one comes to her room to offer activities and feels bored. She also stated that she cries when she is bored and proceeded to cry. A facility notice posted in the main elevator stated, Group Activities and Dining has been cancelled due to Covid in the facility. Recreation services will provide daily temporary 1:1 in room visits . On 04/02/25 at 08:41 AM, Recreation Director (RD) 1 was interviewed and stated that since approximately 02/26/25 group activities in the facility were cancelled because of Covid. In its place, one-on-one in-room activities were being provided. On 04/01/25 at 02:39 PM, a review of R338's recreation care plan, with a start date of 03/12/25, did not list one-on-one in-room visits as an intervention. A review of R338's MDS, Section F: Preferences for Routine and Activities, with an ARD of 03/17/25 noted: Question D. How important is it to you to keep up with the news? Answer marked 1. Very important. Question F. How important is it to you to participate in religious activities? Answer marked 1. Very important. Question G. How important is it to you to go outside to get fresh air? Answer marked 1. Very important. Question H. How important is it to you to participate in religious activities? Answer marked 1. Very important. The resident preferences above were not listed on the recreation care plan dated 03/12/25. On 04/01/25 at 03:03 PM, a review of an assessment form used by the Recreation department titled, ACT My Ways -V3, completed on 03/12/25 11:27 AM, contained question number 30: Activities has met and reviewed resident activity preferences not marked as completed. On 04/02/25 at 08:41 AM, RD1 was interviewed in the dining room. RD1 reviewed R338's care plan, with a start date of 03/12/25, and confirmed that no intervention for one-on-one activities in the resident room was listed. RD1 also confirmed that the activities noted as very important by R338 on the MDS, Section F: Preferences for Routine Activities, with an ARD of 03/17/25, was also not listed on the care plan. RD1 confirmed that question number 30: Activities has met and reviewed resident activity preferences on the ACT My Ways -V3 form completed on 03/12/25 at 11:27 AM was not completed. RD1 stated that marking the box as complete for question number 30 means activity preferences were reviewed with the resident. RD1 proceeded to say that she does not complete question number 30 because when the form is submitted, there is no pop-up message indicating the question was not completed and therefore, assumed that not completing it was okay. RD1 also stated that she is unable to bring R338 outside to get fresh air because all the residents cannot currently go out from their room, and if one resident is brought outside, that would be unfair to the other residents. RD1 stated that she did not ask Administration at the facility if providing one-on-one activities outside of the residents' rooms were allowable and was not doing that currently. During the interview with RD1 in the dining room, residents were observed receiving one-on-one therapy by the facility's Rehab Therapy staff. On 04/02/25 at 01:00 PM, a Point of Care (POC) Response History document noting one-on-one activities completed with R338 from 03/13/25 - 04/02/25 was reviewed. Activities noted as very important to R338 on the MDS, Section F: Preferences for Routine Activities, with an ARD of 03/17/25 were not found on the POC Response History document. 2) R19 is an [AGE] year-old female, admitted to the facility on [DATE]. A review of R19's EHR noted that she was blind. A MDS with an ARD of 02/15/25 noted that R19 had a BIMS score of 15, which indicated that R19 had intact cognitive function. On 04/02/25 at 11:43 AM, RD1 was interviewed with a concurrent review of R19's care plan dated 03/03/25 and POC Response History document noting one-on-one activities completed for R19 from 03/06/25 - 04/01/25 (27 days). RD1 stated that to accommodate R19's blindness, activities provided include sensory stimulation, scents, hand massage, trivia, and playing music/listening to the radio. RD1 acknowledged that those activities were not and should have been listed in the care plan. Upon review of the POC Response History document with RD1, Cards/Board Games/Puzzles was marked as being done 1 of 27 days. SA questioned RD1 on how the resident was able to participate in that activity due to her blindness. RD1 responded that trivia was conducted verbally. The POC document also noted Providing Leisure Supplies was marked as done 4 of 27 days. RD1 defined this category as providing music/radio for R19 to listen to. RD1 stated that providing more of the one-on-one activities she identified to accommodate R19's blindness should have been implemented. On 04/02/25 at 02:25 PM, a review of the facility policy titled, Activities noted under the section titled, Guidelines: 4. The activity program .are designed to meet the assessed needs and interests of each resident ., 5. Activity programs are provided in coordination with the resident's comprehensive assessment, functional ability, and preferences.

Based on record review and interviews, the facility failed to provide resident centered needed care and services for two of six residents (Resident (R) 77 and R136), R77 who was one of one sampled for constipation/diarrhea and R136 who was one of four residents sampled for skin conditions (non-pressure). The facility did not follow the physician ordered bowel regimen for R77. This deficient practice put R77 at potential risk for discomfort and fecal impaction. The facility failed to treat R136's Moisture-associated skin damage (MASD) with fungal infection to her sacrum and to her bilateral buttocks from 03/29/25 until 04/03/25 which the facility identified as worsening. This put R136 at risk for harm from possibly developing a pressure injury and pain. Findings include: 1) R77 was admitted to the facility on [DATE] with diagnosis of, not limited to, constipation. Review of R77's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/04/25, assessed R77's Brief Interview of Mental Status (BIMS), a 14 out of 15 (cognitively intact). Review of R77's person-centered comprehensive care plan documented The resident has constipation or potential for constipation r/t [related to] decreased mobility, pain, narcotic medication use for pain .The resident will have a normal bowel movement at least every 1-2 days through the review date .Administer stool softeners as per orders. Monitor for side effects and effectiveness .Monitor/document/report PRN [as needed] s/sx [signs/symptoms] of complications related to constipation .Record bowel movement pattern each day. Describe amount, color and consistency. On 04/01/25 at 11:03 AM, an interview with R77 was done. R77 reported she gets constipated often for about three or more days. R77 stated she finds it difficult to make a bowel movement sometimes even with the routine medications for her bowel movement. Review of R77's physician ordered bowel regimen included MiraLAX powder (polyethylene glycol 3350) give 17 grams by mouth, mix with 4-8 ounces of water or juice, two times a day for constipation; Sennosides-Docusate Sodium oral tablet 8.6-50 milligrams (mg.), give two tablets by mouth two times a day for constipation; MiraLAX powder give 17 grams by mouth, mix with 4-8 ounces of liquid, as needed for no bowel movement results in three days; and Dulcolax suppository (bisacodyl) insert 10 mg. rectally as needed for no bowel movement results from MiraLAX, notify doctor if ineffective. Review of R77's daily recorded bowel movement in the Electronic Health Record (EHR) found R77 did not have a bowel movement from 03/16/25 to 03/18/25 (three days), 03/20/25 to 03/24/25 (five days), and 03/30/25 to 04/01/25 (three days). On 04/02/25 at 03:56 PM, a concurrent record review and interview with Director of Nursing (DON) was done. DON reported the EHR would trigger on the resident's dashboard if a resident did not have a bowel movement for three days to notify the nurse to administer any as needed bowel regimen medication. Concurrent review of R77's daily recorded bowel movement, DON confirmed R77 did not have bowel movements on 03/16/25 to 03/18/25, 03/20/25 to 03/24/25, and 03/30/25 to 04/01/25. DON stated R77 should have gotten the prescribed as needed MiraLAX on 03/18/25, on 03/22/25, and on 04/01/25, and confirmed through review of R77's Medication Administration Record (MAR) that she was not administered the medications on those days. Review of the facility's bowel program guidelines dated 12/02/20 included: 1. Bowel movement frequency will be assessed daily by the nurse. 2. Resident assessed as having inadequate bowel function manifested by absence of regular bowel movement in excess of three days will be assessed by the nurse . 3. When needed, a bowel protocol will be implemented as established by physician's orders . 37954 2) Cross reference to F657 Care Plan Timing and Revision - Despite identifying worsening of R136's MASD with a fungal infection to her sacrum and bilateral buttocks the facility failed to update R136's care plan and aquire a physician order for an antifungal to treat R136's fungal infection from 03/29/25 until 04/03/25. On 03/31/25 at 03:09 PM, an interview was held with R136 at her bedside. Inquired with R136 if she had any skin breakdown such as rash or pressure injury to her back and buttocks and she confirmed she had MASD to her bottom and rash on her back which she explained was from a reaction she had from the adult briefs. R136 explained facility staff switched out the adult briefs for the pull up type and she stated her rash was getting better. On 04/03/25 at 10:24 AM, record review of R136's electronic health record (EHR) revealed R136 is a [AGE] year-old female who was admitted to the facility on [DATE] and her diagnoses include, but are not limited to, encounter for orthopedic aftercare following surgical amputation, type 2 diabetes mellitus with hyperglycemia, and other specified soft tissue disorders. Reviewed documentation of resident's skin assessments with pictures which revealed resident's MASD had gotten worse since admission. First wound evaluation of R136's MASD was done on 03/14/25 at 19:11 (07:11 PM). Dimensions documented included area at 21.3 cm^2 (centimeter), length 9.57 cm and width 4.69 cm. Continued record review found second wound evaluation dated 03/26/25 at 12:53 PM of R136's MASD revealed it had gotten worse, no measurements were included in this documentation but a picture was. The Woundcare Nurse Registered Nurse (RN) 24 documented under Progress section notes Resident reports itchiness to brief. Switched resident to pull upbrief (sic.) 3/25/25, resident reports relief of itchiness. Resident with fan in room to help circulate air. RN24 documented the practitioner was notified along with resident/responsible party. RN24 documented under Treatment section Dressing Appearance None Cleansing Solution Normal Saline Debridement None Primary Dressing Antifungal Secondary Dressing No secondary dressing Modalities None Additional Care Moisture barrier, Moisture control. Continued record review found third wound evaluation of R136's MASD was done on 04/01/25 which included the following dimension measurements area 122.22 cm^2 +473 %, length 24.67 cm +158 % and width 23.18 cm +394 %. Below this box of measurements included the following statement *Negative percentage values indicate wound is getting smaller. R136's measurements included positive percentages which indicates the wound was getting bigger. Continued review of R136's EHR revealed she had an order for Moisture-associated skin damage (MASD) to her sacrum extending to her bilateral buttocks that was being treated by Apply Triad Paste cleanse with NSS [Normal Saline Solution] and pat dry before application every shift for 14 days *[W1] Indicate status to surrounding skin (I)ntact (E)rythmatous (M)acerated *[W2] Assess for s/sx [signs and symptoms] of infection or other complication (+) Complication noted, notify MD (-) No complication noted. Order start date 03/14/25 at 2300. This treatment was stopped on 03/28/25 with the last entry of treatment on 03/28/25 Eve1. After this treatment there were no other physician orders found to treat R136's MASD to her sacrum and her bilateral buttocks on 03/29/25 - 04/03/25 at 10:24 AM. Concurrent record review of R136's care plan did not include any updates to treat R136's MASD with an antifungal. Focus The resident has MASD to sacrum r/t [related to] incontinence Date Initiated: 03/18/2025 Revision on: 03/18/2025 Goal The resident's MASD will heal by review date. Date Initiated: 03/18/2025 Revision on: 03/27/2025 Target Date: 06/14/2025 Interventions/Tasks Avoid scratching and keep hands and body parts from excessive moisture. Date Initiated: 03/18/2025 Increase out of bed activity as tolerated. Date Initiated: 03/18/2025 On 04/03/25 at 10:37 AM, interviewed DON in the Administrator's office. Inquired about R136's MASD which had gotten worse since admission. DON stated resident has Baza ordered (antifungal cream) for MASD to apply every day and evening shift. Subsequent to the interview with the DON, on 04/03/25 at 11:59 AM, reviewed R136's orders and found an order for Baza Antifungal External Cream 2% had been ordered for R136 on 04/03/25 at 11:07 AM and an update to the care plan that included The resident has MASD to sacrum with fungal rash r/t incontinence and Interventions/Tasks Apply tx [treatment] as ordered by MD. Date Initiated: 04/03/2025. R136 had not received treatment from 03/29/25 till 04/03/25, after DON was interviewed by surveyor about resident's MASD worsening. Focus The resident has MASD to sacrum with fungal rash r/t incontinence Date Initiated: 03/18/2025 Revision on: 04/03/2025 Goal The resident's MASD will heal by review date. Date Initiated: 03/18/2025 Revision on: 03/27/2025 Target Date: 06/14/2025 Interventions/Tasks Apply tx as ordered by MD. Date Initiated: 04/03/2025

Based on observations, interviews, and record review, the facility failed to ensure one of three residents (Resident (R) 29) sampled for limited range of motion (ROM) received the appropriate treatment, equipment, and services to maintain and/or prevent a decline in ROM, as evidenced by inconsistent application of splint and ROM exercises. This puts R29 at risk of a decline in ROM and further contractures. Findings include: Cross reference to F725, Sufficient Nursing Staff. The facility failed to ensure sufficient nursing staff were available to ensure restorative nursing assistance was provided. R29 was admitted to the facility on [DATE] with diagnoses, not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness or paralysis on left side of the body) and neuralgia and neuritis (nerve inflammation or damage). R29's room was under Transmission Based Precautions (TBP), Droplet Precautions, due to her roommate with positive COVID-19 from 05/25/25 to 04/05/25. On 03/31/25 at 02:02 PM, observed R29 in bed her left arm was folded with fisted hand on chest and no splint. On 03/31/25 at 02:29 PM, an interview with R29's Resident Representative (RR) 2 was done. RR2 reported the facility is supposed to assist R29 with exercises and stretches to left knee, arm, and hand but does not think they have done it in a while. On 04/02/25 at 08:15 AM, observed R29 eating breakfast (assistance with staff) in bed her left arm was folded with fisted hand on chest and no splint. At 11:34 AM, observed R29 in bed her left arm was folded with fisted hand on chest and no splint. Review of R29's electronic health record (EHR) found R29 has a passive range of motion (PROM) and active range of motion (AROM) program with assistance from Restorative Nurse Aides (RNA) initiated on 02/17/25. The physician order for PROM includes the RNA to provide PROM exercise to left upper extremity (LUE) with gentle stretching to bilateral lower extremity (BLE) three sets of 10 repetitions seven times a week as tolerated. For AROM, R29 to be encouraged to due right upper extremity (RUE) exercises using two-pound (lbs.) dumbbell three sets of 10 repetitions four times a week (Monday, Wednesday, Thursday, Friday) as tolerated. R29's EHR further found R29 has a physician order for splint to left hand and left elbow and splint to left knee. R29's care plann specified her splint program documenting, RNA to assist with applying left elbow splint and left hand grip orthosis up to 4-6 hours (On: 6am off: 10am-12p) and left ankle brace x3 hours (on 6am, off: 9am) daily as tolerated. Review of documentation of R29's PROM, AROM, and splint program provided from 03/25/25 to 04/02/25 documented R29 did not receive RNA services on 03/26/25, 03/27/25, and from 03/29/25 to 04/02/25. R29 only received services once during that sampled time, on 03/28/25. On 04/03/25 at 08:31 AM, observed R29 eating breakfast with assistance from Certified Nurse Aide (CNA) 75, in bed her left arm was folded with fisted hand on chest and no splint. Inquired with CNA75 if R29 has a splint for her hand and knee, CNA75 reported R29 should be wearing her splint daily but the facility did not have an RNA today. CNA75 proceeded to explain that she could put the splint on. Inquired with R29 in her native language, Korean, if the facility had been helping her with exercises and stretches, she stated no and that she would like to continue her exercises and stretches. On 04/03/25 at 08:37 AM, interview with MDS Director (MDSD) 67 was done. MDSD67 confirmed she oversaw the RNA program and R29 receives services daily. RNA reported that R29's services should continue even under TBP and that she may not be getting services due to RNA staff called to floor as CNA.

Based on observation and interview the facility failed to provide an environment free of accident hazard for one of two sampled resident (Resident (R) 25) observed for accidents. R25 was observed pushed in her wheelchair with her leg rests not in place putting the resident at risk for an accident that could result in harm. Findings include: On 03/31/25 at 10:43 AM, R25 was observed pushed in her wheelchair by Physical Therapy Assistant (PTA) 5 and Occupational Therapy Assistant (OTA) 7 from the end of the hall to the hallway where her room is located. R25 was seen pushed without her leg rests on her wheelchair and observed holding her feet up. Surveyor stopped staff and asked PTA5 and OTA7 where resident's leg rests were for her wheelchair. PTA5 stated they were crunched for time and leg rests are in her room. PTA5 and OTA7 proceeded to R25's room. On 03/31/25 at 10:46 AM, interviewed Physical Therapist (PT) 1 who was in the hallway outside of R25's room. Inquired of PT1 what rehab staff are to do with the foot rests for residents who are receiving PT services. PT1 explained there is a holder on the back of the wheelchair where you can place the foot rests. PT1 and surveyor went into R25's room and inquired with R25 if we could look at the wheelchair she was sitting on. PT1 was able to move R25's wheelchair and saw there is no holder on the back of R25's wheelchair. Inquired with PT1 if this is something they can request to have put onto the wheelchair since PT1 identified the wheelchair as belonging to the facility. PT1 confirmed this is something the facility can order and put on the back of the wheelchair. Inquired how staff manage the foot rests when they are working with the residents and PT1 explained staff will work with the residents and have them walk and then the staff will go back to the room and get the foot rests when they are needed. PT1 explained it might be hard for residents without good cognition to keep their feet up when wheelchair is being pushed and some residents are weak and cannot keep their feet up. On 04/02/25 at 09:45 AM, inquired with OTA7 where R25 was located when they started pushing resident in her wheelchair and OTA7 stated the gym on the first floor. At this time asked Director of Nursing (DON) to measure the distance from the gym to the resident's room. The gym to the elevator on the first floor was 39 feet (ft.) and from the elevator on the second floor to resident's room was 107 ft. which is a total of 146 ft. R25 was pushed in the wheelchair without the leg rests. On 04/03/25 at 12:49 PM, interviewed Director of Rehab (DOR) in the first floor gym. DOR stated she is also a physical therapist. She confirmed staff should have had leg rests on the wheelchair when pushing a resident in their wheelchair. DOR stated staff receive training on safety when working with residents.

Based on observations, interviews, and record reviews, the facility failed to ensure respiratory care was provided consistent with professional standards for two of two (Resident (R) 77 and R10) sampled for respiratory. R77's comprehensive assessment did not include oxygen (O2) therapy, it was not included in her care plan, her nebulizer and O2 tubing was not labeled with the date it was last replaced and the physician O2 orders did not include parameters and delivery method. R10's O2 tubing was not labeled with the date it was last replaced. This deficient practice put R77 and R10 at risk for respiratory complications. Findings include: 1) Cross reference to F641, Accuracy of Assessments. The facility failed to ensure R77's comprehensive assessment reflected she had O2 therapy. Cross reference to F656, Development of the Care Plan. The facility failed to ensure R77's comprehensive care plan included O2 therapy. R77 was admitted to the facility on [DATE] with diagnoses of, not limited to, cough, allergic rhinitis, and asthma. Review of R77's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/04/25, assessed R77's Brief Interview of Mental Status (BIMS), 14 out of 15 (cognitively intact). Under Section O. Special Treatments, Procedures, and Programs, O2 was not checked off as a treatment performed on admission. Review of R77's hospital discharge summary prior to admission to the facility dated 03/03/25 documented diagnosis of possible reactive airway disease versus chronic obstructive pulmonary disease. On 03/31/25 at 09:45 AM, during an initial observation and interview with R77, R77 reported she had the nebulizer (a machine that turns liquid medicine into a mist that can easily be inhaled, connected to a facemask) and O2 therapy since she was admitted to the facility. She reported the facility had not changed the tubing for the nebulizer or O2 since she received them, and that the facility did not label the tubing. Observed O2 tubing and nebulizer with no label indicating the date the tubing was last replaced. The O2 concentrator was on, and the flow rate was 2.5 liters per minute (LPM) and R77 was observed to utilize the nasal cannula (a device that delivers extra oxygen through a tube and into the nose). On 04/01/25 at 11:28 AM, a follow-up observation of R77's nebulizer and O2 tubing was made. Observed orange labels that were not on the O2 tubing and nebulizer tubing when an observation was made on 03/31/25. The O2 concentrator was on, and the flow rate was 2.5 liters per minute (LPM) and R77 was observed to have the nasal cannula not in use. The orange labels had instructions to change the tubing on Saturday and included a back date of Saturday, 03/28/25. R77 stated a staff member changed the tubing and added the labels yesterday, 03/31/25. Review of R77's physician orders confirmed R77 was admitted with O2, Supplemental Oxygen as needed for SOB [shortness of breath] Titrate to keep SP02>90% [oxygen saturation], the order did not include the oxygen flow rate, specify for what duration, and delivery method. On 03/13/24, continuous O2 at bedtime was ordered .every evening and night shift for patient needs O2 to sleep, the order did not specify the oxygen flow rate, specify for what duration, and delivery method. On 03/28/25, albuterol sulfate inhalation nebulization solution 2.5 milligrams (mg.) /3 milliliters (ml.) 0.083% (Albuterol Sulfate) . 3ml inhale orally via nebulizer four times a day for SOB was ordered but started on 03/29/25. On 04/02/25 at 02:06 PM, an interview and concurrent record review with MDS Director (MDSD) 67 and MDSD43 were done. The MDSD67 confirmed R77's admission MDS assessment did not include O2 therapy, it was not care planned, and the physician orders did not include all the requirements for a O2 therapy order. MDSD43 reported the orders should have the oxygen flow rate, for example 2LPM and deliver method, such as, nasal cannula or face mask. Review of R77's Medication Administration Record (MAR) for the month of March 2025, documented R77 was administered O2 during the evening and night shift daily. The as needed supplemental O2 was not administered during the month of March. On 04/02/25 at 04:07 PM, an interview with Director of Nursing (DON) was done. Inquired what time nursing staff are to administer R77's O2 for bedtime, DON reported when she is sleeping and confirmed the order did not specify the duration. This surveyor described the two observations of the O2 concentrator on while R77 was awake, and DON confirmed it should have been turned off or documented in the MAR that supplemental O2 was administered. DON further confirmed R77's nebulizer tubing and O2 tubing should be labeled and the O2 tubing should be changed once a week. 37954 2) On 03/31/25 at 10:50 AM, observed R10 sleeping in her bed with her oxygen concentrator on and resident wearing a nasal cannula. Observation of oxygen tubing from the oxygen concentrator attached to the nasal cannula and tubing from the sterile saline to the oxygen concentrator did not have any marking to identify the date they were initiated. On 04/02/25 at 09:11 AM, observed R10's oxygen tubing, from the oxygen concentrator attached to the nasal cannula and tubing from the sterile saline to the oxygen concentrator, which now had an orange sticker dated 03/29/25 and timed at 0700 (07:00 AM) which stated, Change Saturday. On 04/03/25 at 09:49 AM, interviewed DON in the Administrator's office. Inquired why staff would back date a resident's oxygen tubing. Surveyor shared observation that occurred on 03/31/25 of a resident's oxygen tubing that had been observed with no sticker identifying when the tubing was initiated and then second observation, of same resident, that tubing was labeled with a Change Saturday sticker with a 03/29/25 date. Inquired of DON why staff would do this and she was not able to explain why. DON confirmed tubing is to be changed out every Saturday.

Based on observations, interviews, and record reviews, the facility failed to ensure that one of two residents (Resident (R) 390) sampled for dialysis, was provided with professional standards of practice. The facility failed to remove R390's pressure dressing after two hours from the completion of R390's Hemodialysis (HD) treatment. This deficient practice puts residents on dialysis at risk for access clotting and complications. Findings include: Cross reference to F656, Development of Comprehensive Care Plans. On 04/02/25 at 09:00 AM, observed R390 with right upper arm fistula pressure dressing still on from yesterday's HD treatment. R390 stated that staff will take it off when they have time and do not really check for the thrill and bruit (a thrill is a palpable sensation felt over the fistula and bruit is a swooshing sound heard with a stethoscope which indicates good blood flow and fistula function). R390 stated he will usually be the one that takes it off. R390 stated he came back from dialysis yesterday at 04:30 PM. On 04/02/25 at 9:30 AM, record review of R390's care plan noted, HD focus that was initiated on 03/20/25, interventions included to monitor, document, and report as needed any signs and symptoms of infection to access site redness, swelling, warmth or drainage, but did not include any interventions to assess for thrill and bruit in care plan. Treatment Administration Records (TAR) showed the dialysis fistula checks for thrill and bruit check were being done every shift. On 04/02/25 at 09:05 AM, interview with Registered Nurse (RN) 30 completed. RN30 stated they remove the dressing when R390 comes back after dialysis. RN30 stated, We follow the orders and observe the access site for any signs and symptoms of redness, bleeding, and for the thrill/bruit. RN30 also noted the last assessment was done last night at 12:10 AM, and that he has not done his assessment yet this morning. RN30 was asked by surveyor to accompany surveyor to R390's room to confirm that R390's dressing was still on. When asked, why the dressing was still on, RN30 replied, I'm not sure, I will have to check our facility's policy. On 04/02/25 at 10:00 AM, interview with Director of Nursing (DON) confirmed that they should be checking for the thrill and bruit before and after dialysis and every shift. DON also stated that they should be removing the dressing but was not sure how soon after dialysis they must remove it. On 04/02/25 at 12:00 PM, observed R390's right arm fistula without pressure dressing. On 04/02/25 at 03:02 PM, interview with a dialysis charge nurse (DCN) from a dialysis facility was completed. DCN confirmed that the recommendations to remove the fistula pressure dressing is two hours after dialysis treatment. When asked why after two hours, DCN replied, This is to prevent clotting. If left too long, it will most likely end up clotting the access. On 04/02/25, record review of the facility's policy on Quality of Care, Dialysis, with revised date of 04/2018, it stated that the facility will provide residents, who require, dialysis, care and service consistent with professional standards of practice in the Guidelines section of the policy, it also states, 13. Facility will monitor and document the status of the resident's access site upon return from the dialysis treatment center to observe for bleeding or other complications. The facility did not meet this guideline as evident by pressure dressing not removed after two hours from R390's return from dialysis treatment.

Based on observations, interviews, and record review, the facility failed to implement a thorough process in narcotic log documentation and reconciliation for two of four medication carts observed. This deficient practice hinders the process necessary to promptly identify loss or potential diversion of the controlled medications used to meet the needs of the residents. In addition, the facility failed to implement a process that assures the accurate and timely disposition of discontinued and/or expired medications. This deficient practice hinders the promotion of safe administration practices that decrease the risk for medication errors. These deficient practices have the potential to affect all residents in the facility who take medications. Findings include: 1) On 04/02/25 at 09:33 AM, an inspection of medication cart 1C was done with Registered Nurse (RN) 56. Observed a blister pack card of Oxycodone (a narcotic) IR 5 milligrams (mg) with 22 pills remaining for Resident (R) 236. Review of the Controlled Drug Record noted that there should have been 24 pills remaining. Concurrent interview with RN56 revealed that she had administered one pill to R236 at 09:18 AM but had neglected to sign it out on the Controlled Drug Record. RN56 also stated that she had dropped a tablet and wasted it but had neglected to sign that wasted tablet out of the inventory count on the Controlled Drug Record. When asked what the normal process was to sign off/document narcotics, RN56 answered that narcotics are signed off on the Controlled Drug Record after they administer it because they [the resident] might refuse it. On 04/02/25 at 10:00 AM, an interview was done with Director of Nursing (DON) in the Training Room. When asked about narcotic administration and documentation, DON stated that narcotics should be signed out on the Controlled Drug Record upon preparation of the medication, when they pop it, prepare it. DON confirmed staff should not be signing narcotics out after administration, agreeing that if a resident refuses a narcotic that is signed out, then the medication is wasted and documented on the Controlled Drug Record as refused. Review of the Controlled Substances policy and procedure, last updated 11/17, revealed the following: 4. When a controlled medication is administered, the licensed nurse . immediately enters the following information on the accountability record when removing dose from controlled storage . Date and time of administration . Amount administered . 5. Administer the controlled medication and document dose administration on the MAR [medication administration record]. 2) On 04/02/25 at 09:06 AM, an inspection of medication cart 2B was done with RN28. Observed a 100-count box of Ferrous Gluconate 324 mg with an expiration date of 3/25 that was more than half-filled. Also observed a 30-count blister pack card of Methocarbamol for R67. Concurrent interview with RN28 confirmed that the Ferrous Gluconate was expired, and that R67 had been discharged from the facility. On 04/02/25 at 09:18 AM, an interview was done with RN65 (who also served as 1 of 2 Assistant Directors of Nursing) at Nurses' Station 2. RN65 confirmed that the expired Ferrous Gluconate should have been removed from the medication cart and disposed of. Regarding the Methocarbamol, RN65 confirmed that R67 had been discharged from the facility to home on 03/17/25 and stated that usually all medications are sent home with residents upon discharge. Concurrent record review noted that the Methocarbamol had been discontinued on 02/28/25. RN65 confirmed the medication should have been pulled from the medication cart at that time and placed in the medication room for disposal.

Based on observations, interviews, and record review, the facility failed to ensure staff implemented interventions to reduce accident hazard. Specifically, the staff did not lock a wheelchair which resulted in a fall. This deficient practice resulted in a major injury (left [CONDITION(S)]) and a potential for Resident (R)3 to lose the ability to walk and/or stand from a seated position. This deficient practice has the potential to affect resident that is dependant on staff to ensure a safe environment. Findings include: 1) The facility reported R3's fall and left [CONDITION(S)] to the State Agency (SA) on 06/30/22 at 01:00 PM. The Facility Reported Incident (FRI) Event Report provided documented, Resident admitted to the facility for hospice level of care Resident is alert and able to make most needs known On 06/17/22 around 15:45 pm resident had an unwitnessed fall. RN assessed resident and complained of left hip pain. Post fall vital signs and neuorcheck were within normal limits, MD was notified and ordered left hip X-ray. Xray resulted in left intertrochanteric femoral fracture. MD was notified and ordered [MEDICATION(S)]: 20 mg/ml give 0.25 ml TID (three times a day) for pain management, Hospice and son were notified and had no further recommendations .At the time of the incident resident was about to be showered. While staff were preparing items, resident tried to self transfer from bed to wheelchair and fell . Resident stated she was trying to get out of bed and denied mistreatment. Staff interviews were also conducted with no abnormal findings. Abuse and neglect ruled out. While conducting an observation of R3 on 07/21/22 at 10:05 AM, R8 (R3's roommate) informed this surveyor that R3 had a bad fall. R8 stated R3 fell because Certified Nurse Aide (CNA)39 did not lock the wheelchair. When R3 went to sit in the chair, the chair slid away and R3 fell so hard you could hear it. R8 also stated when she told R3's Resident Representative (RR)1 she fell because the wheelchair was not locked, the facility had not informed RR1 the wheelchair was not locked. On 07/22/22 at 11:00 AM, conducted a review of the facility's internal investigation for R3's fall. The a witness statement (written on 06/30/22) by Certified Nurse Aide (CNA)39's documented R3's wheelchair was at the end of the resident's bed, and it was not locked. CNA39 heard a thud and turned to see R3 on the ground. On 07/22/22 at 01:48 AM, conducted an interview with RR1 regarding R3's fall. RR1 confirmed the facility did not inform him R3's wheelchair was not locked and contributed to R3 falling. RR1 stated he was not aware of the true circumstances of R3's fall until R8 informed him that the wheelchair was not locked. RR1 stated prior to the fall, R3 could walk on flat surfaces, up stairs, and stand-up from a seated position (bed) independently. RR1 stated after the fall, R3 has not walked and cannot stand. Furthermore, RR1 stated R3 did not have behaviors (irritable, combative, and loud) or difficulty sleeping until after the fall. RR1 felt this was due to the fact she lost her ability to walk, the pain from the fractured left hip, having to remain in bed all the time, and the overall loss of independence. RR1 reported prior to the fall, R3 had no issues sleeping, but after the fall R3 had stayed up for approximately 16 hours. On 07/25/22 at 09:05 AM, review of R3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/11/22 documented in Section G. Functional Status, (identifies the resident's self-performance and amount of support needed with activities of daily living) C. Walk in room (how the resident walks between locations in his/her room) R3 required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with assistance requiring one person. There was a significant change MDS with an ARD of 06/30/22 which revealed walking in the room did not occur. Review of R3's orders did not document any orders or recommendations for physical therapy or rehabilitation to regain R3's ability to walk and stand from a seated position after the fall occurred. R3's care plan documented a care plan intervention to provide R3 with daily gentle range of motion as tolerated was initiated on admission. On 07/22/22 at 02:02 PM, conducted an interview with the Director of Nursing (DON) and Administrator regarding the event report submitted to the SA regarding R3's fall and subsequent left [CONDITION(S)]. The DON confirmed R3's fall was due to an unlocked wheelchair, the Event Report submitted to the SA did not disclose that the wheelchair was unlocked, the left [CONDITION(S)] was not identified until 13 days after the fall due to a staff erroneously reading/reporting the findings of the x-ray, and R3 will not receive physical therapy services to regain her previous physical abilities due to the resident's hospice status. 2) Cross reference to F609- Reporting of Alleged Violations The facility failed to ensure all results of an investigation were reported to the State Agency. The report did not include the fall was preventable as it was due to staff not locking the wheelchair. In addition, the report did not include the misread x-ray results by the staff, delay in identifying the fracture, or delay in appropriate treatment. 3) Cross reference to F609- Reporting/Investigation, F726 Competent Nursing R3's x-ray results were inaccurately read by the nursing staff and reported to the physician as negative, with no for findings on 06/17/2022. As a result of this deficiency, there was a 13-day delay in identifying and treating her for a [CONDITION(S)]. R3's pain was not managed appropriately, and R3 has the potential to lose her ability to walk and stand from a seat position.

Based on interviews and record review, the facility failed to ensure staff was competent in accurately evaluating and reporting the results of an x-ray. The nursing staff read Resident (R)3 hip x-ray negative after a fall, which resulted in a 13-day delay in identifying the fracture. Due to the deficiency, there was delay in appropriate pain management. In addition, R3 has the potential to lose her ability to walk and stand from a seat position, which will prevent her from reaching and maintaining her highest practicable physical, mental, and psycho-social well-being. Findings include: On 06/30/22 at 01:00 PM, the facility submitted an Event Report to the State Agency (SA) that documented an incident that occurred on 06/17/22 at 3:45 PM involving Resident (R)3 falling and sustaining a left hip fracture. The Incident Outcome and Notification portion of the form documented the physician, responsible party, and Administrator was notified on 06/30/22 (R3 fell on [DATE]). The Event Report documented the initial report was completed on 06/30/22 at 01:00 PM and completed report was done on 06/30/22. The completed report to the SA failed to include R3's left hip fracture was not identified by the facility until 6/30/22 or receive appropriate treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the facility's completed investigation witness statement of R3's fall documented RN10 endorsed the incident to RN21 who assisted in reading the x-ray results and they both saw that there were no findings on R3's x-ray and put the report in the physician's communication binder and RN22 witnessed RN10 putting R3's x-ray results in the physician's binder. However, witness statements for RN21 and RN22 documented they had no part in reading or filing the x-ray report in the MD's binder. On 07/21/22 at 12:40 PM conducted a review of the mobile x-ray findings which the x-ray was taken on 06/17/22 due to pain in left hip, after falling. Significant findings clearly documented, an acute complete intertrochanteric fracture (breaks of the femur that are outside the hip structure) present with moderate displacement resulting in varus (inward) angulation (of the femur). On 07/21/22 at 02:43 PM, conducted a review of the MD's communication binder at nursing station 2. There was no documented communication regarding R3's left hip fracture. At 02:48 PM, conducted an interview and concurrent record review with the Mobile Imaging staff (MI)5 that performed R3's x-ray on 06/17/22. MI5 confirmed the x-ray was taken on 06/17/22 and the results were available for review the same day. Review of a nursing progress note written on 06/17/22 at 05:13 PM by Registered Nurse (RN)10 documented, 3-11 shift. Resident had an unwitnessed fall and Head to toe assessment done; No change in LOC (loss of consciousness); Transferred back to bed via two persons assist. Fall protocol initiated. Neuro checks started; Called MD .and made aware of situation and resident request of Xray. Ordered for Xray stat, result No findings, put in MD's binder. Son was notified via phone. A nursing progress note written on 06/18/22 at 12:40 AM by RN10 documented, 3-11 shift. Residents alert, oriented four to time, place, and person. She had unwitnessed fall when trying to get out of wheelchair. Residents felt pain left hip side so x-ray was done by doctors ordered and the FINDING is NORMAL.AND the printed results put in (MD binder) .Endorsed. A progress note written on 06/30/22 at 01:20 AM by Recreation Assistant (RA)1 documented, Significant change due to left hip fracture from her fall . was the first documentation R3 had a hip fracture as a result of the fall on 06/17/22. On 06/30/22 at 12:30 PM, a nursing progress note written by the Director of Nursing (DON) documented, (MD) was notified about left hip x-ray results from 6/17/20 that shows left intertrochanteric femoral fracture. (MD) ordered: [MEDICATION(S)] 0.25 ml PO (by mouth)/sublingually (under the tongue) TID (three times a day). Son .was notified and aware of fracture and new pain management order . On 06/30/22 at 01:00 PM, R3 was ordered non-weight bearing to lower left extremity (LLE) and a warm compress to be applied to R3's left hip. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Tylenol tablet 650 mg as needed for mild pain and fever temperature greater than 100 degrees Fahrenheit ordered on 05/04/22 (upon admission) -A warm compress to be applied to R3's left hip was ordered on 06/30/22 -[MEDICATION(S)] Sulfate Solution 20 mg/ml three times a day for pain management was ordered on 06/30/22 Review of R3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -06/17/22 at 04:00 PM -06/19/22 at 06:36 PM -06/21/22 at 08:59 PM -06/22/22 at 10:30 AM -06/29/22 at 08:26 AM -06/30/22 at 09:00 AM and 02:00 PM. R3 did not receive Acetaminophen 650 mg for pain in June 2022 prior to 06/17/22 when R3 sustained the left hip fracture. On 07/22/22 at 01:40 PM, conducted an interview with the physician. The physician stated he does not recall seeing the x-ray report in his communication binder. He stated he was initially verbally informed by a nurse at the facility that R3 fell and there were no findings on the x-ray results. The physician could not recall the exact date when he was notified R3, did in fact have a left hip fracture. He said he would have given orders for pharmaceutical, and non-pharmaceutical interventions shortly after notification. Record review documented orders for R3's injuries were ordered on 06/30/22 at 01:00 PM. On 07/22/22 at 01:48 AM, conducted an interview with RR1 regarding R3's fall. RR1 stated on 06/17/22 the facility notified him that R3 had fallen, an x-ray was taken, and R3 did not sustain an injury. Then approximately 2 weeks later, the facility called to informed him a second x-ray was done and it showed that R3 had a fractured left hip. RR1 stated when the facility called the first time, they informed him that R3 had an unwitnessed fall, staff was getting clothes from R3's closet (to bathe), staff's back was facing R3, and R3 fell trying to stand and get into the wheelchair. RR1 stated he went to visit R3 and R4 (one of R3's roommates) informed him that she witnessed the fall and R3 fell because staff did not lock the wheelchair wheels, the wheelchair moved when she tried to sit in it, and R3 fell . RR1 stated the way the facility explained the fall to him implied R3 fell because of standing unsupervised and not because staff did not lock the wheelchair. On 07/22/22 at 02:02 PM, conducted an interview with the DON and Administrator regarding R3's fall and subsequent left hip fracture. The DON confirmed R3 fell on [DATE], an x-ray was completed on 06/17/22 and RN10 did not competently report the correct findings on the x-ray to the physician. The DON also confirmed that there was a delay in treatment and pain management for R3's fracture from 06/17/22 to 06/30/22. Furthermore, the DON confirmed R3 will not receive any rehabilitative services (physical therapy and occupational therapy) due to the resident's hospice status and there is a high probability R3 will not recover her ability to walk or stand from a seated position. 2. Cross Reference to F609: Reporting of Alleged Violations and F689: Free of Accident/Hazards The facility failed to include in the State Agency report there was an error in reading R3's x-ray report and that it was reported negative to the physician which delayed appropriate pain management.

Based on interviews and record review (RR), the facility failed to provide adequate supervision to one resident (R)1, who was a high risk for falls. The interventions to prevent falls were not effective. R1 had 25 documented falls from January 1, 2021 through October 4, 2021 which resulted in harm. On 10/07/21 R1 requested to go to the Emergency Department after a nosebleed at which time she was admitted for acute care. Hospital x-ray results revealed R1 had a fractured (fx) vertebrae in her lumbar spine and a fx rib. It is unknown when the fractures occurred. As a result, R1 was not able to meet her highest practicable physical well being. This deficient practice could affect any resident at risk for falls and puts them at risk of serious harm. Findings include: 1) On 10/11/21 the Office of Healthcare Assurance (OHCA) received a report from an outside agency that an investigation would be conducted for potential abuse/neglect of R1 by the facility. The report included R1 had bruises to her Left (L) and Right (R) hands, R side neck and shoulder area, R elbow, R upper arm and left forearm. 2) R1 is a [AGE] year old long term care resident admitted to the facility 05/29/20. She has multiple diagnoses which includes but not limited to [CONDITION(S)], pulmonary embolism (blood vessel in the lung gets blocked), hypertension, history of falling, stroke with right sided weakness, dementia, major depressive disorder, [CONDITION(S)] (irregular heart rate) and [CONDITION(S)] (over 300 pounds). R1 had been on a blood thinner due to her history of pulmonary embolism and [CONDITION(S)] (can cause blood clots). When R1 fell it would require two to four staff to get her up safely with the Hoyer transfer lift. 3) Reviewed R1's Medical Data Sheet dated September 11, 2021 which revealed the following: Cognitive Pattern: R1 showed cognitive impairment with a BIMS (Brief Interview for Mental Status, a test used to determine how well you are functioning cognitively) score of 03. The score ranges from 00-15 with 15 being the highest with no cognitive impairment and 00-07 indicates severe cognitive impairment. Functional status: R1 required one person physical assist for toilet use, dressing, bed mobility, transfers and locomotion. R1 used a walker and was assessed to be not steady, but able to stabilize without staff assistance. R1 required Substantial/Maximal assistance (helper does more than 50% the effort. Helper lifts, or holds trunk or limbs and provides more than half the effort.) for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer and toilet transfer. She required supervision for walking 10 feet. 4) Review of R1's active care plan (CP) on 10/27/21 revealed the following: The resident is at risk for falls due to weakness; .history of multiple falls; unsteady gait; failure to call for assistance; has periods of forgetfulness. Episodes of being impulsive with getting up unassisted. The interventions for fall prevention included: Anticipate needs, offer assistance w/toileting during safety rounds. Provide reassurance and remind resident that you will return to assist with toileting. Assist resident to toilet every 2 hours while awake. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During safety rounds, staff to assist the resident to sit in the wheelchair instead of sitting at the edge of the bed. Educate staff to follow care plan to offer toileting needs every hour and to document if resident refuses. Encourage resident to sit in hallway while sitting up and working on crossword puzzles for frequent visual observations . Ensure commonly used items .are within reach of resident prior to leaving room. Ensure resident is in the middle of the bed during routine rounds. Ensure resident is not sitting way too close at the edge of the bed. Continue to offer to sit on the wheelchair whenever possible. Ensure resident is wearing appropriate footwear .prior to transfers or ambulating. Offer assistance to bathroom during frequent safety rounds. Provide reassurance that you will return routinely. Ask R1 is [sic] she needs anything prior to exiting the room. Provide calm and quiet environment at night. Staff to allow resident enough time for toileting and emptying the bladder. Staff to check that resident's wheelchair is locked when left beside her bed. Staff to encourage resident to sit on the wheelchair instead of the side of the bed to prevent sliding from bed to the floor. Staff to anticipate toileting needs every hour or more frequently and offer toileting to the resident per rounding process. The resident needs a safe environment with personal items within reach at all times. Use Dycem non-slip mat when assisting resident from sitting to a standing position. 5) Reviewed facility event reports on 10/27/21 which revealed R1 had twenty five documented falls (witness and unwitnessed) since January 1, 2021. The event reports included details of the fall and any injuries noted. 01/07/21 03:30 PM Un-witnessed Fall: Found on floor sitting position. Slid off bed. Redness and bruise lower back pain on the buttocks 01/12/21 08:30 PM Un-witnessed Fall: Found on floor supine middle of room. Tried to get out of wheelchair (w/c), but not locked. 01/15/21 01:30 PM Un-witnessed Fall: Found sitting in bathroom (BR). 01/17/21 09:00 PM Un-witnessed Fall: Found sitting with walker in front of her. skin discoloration on right buttocks. 01/26/21 05:30 PM Witnessed Fall: Found sitting on floor. Tried to transfer from w/c to bed. 02/05/21 07:00 PM Witnessed Fall: Found sitting between the closet and other bed. Went to get diapers in closet. 02/08/21 10:15 PM Witnessed Fall: Slid to floor from bed. Tried to sit in her w/c 03/06/21 02:20 AM Un-witnessed Fall: Found sitting on floor. Tried to use walker. C/o (complain of) 3/10 (pain scaled, 10 being highest) buttock pain. 03/07/21 04:30 PM Un-witnessed Fall: Found on floor beside bed. Trying to transfer from w/c that was unlocked. 04/07/21 07:30 PM Witnessed Fall: Found sitting on floor by maintenance staff. Went to get brief from closet. 05/11/21 09:45 PM Un-witnessed Fall: Found lying on floor, went to closet for something. Using single point cane for ambulation. 05/16/21 02:50 PM Un-witnessed Fall: Found sitting on floor, tried to get in unlocked w/c. Scab to right knee and bruise to left knee. 05/26/21 07:10 PM Un-witnessed Fall: Found sitting on BR floor. Lost balance holding on to sink. 05/27/21 09:36 PM Witnessed Fall: Moving to w/c and slid down. 06/12/21 02:15 PM Witnessed Fall: Attempting to transfer to w/c. fell on buttocks and then slowly on her back. c/o pain Right (R) shoulder 07/18/21 09:30 AM Un-witnessed Fall: Found sitting on floor. Was trying to sit down on bed and slid down. 07/28/21 01:45 AM Un-witnessed Fall: Found inside the BR, sitting on floor. Lost balance while washing hands. Walker device in position besides resident. 08/20/21 02:15 PM Un-witnessed Fall: fell down and found on floor .in the BR door .with her walker in front of her .slightly hit head on floor .noted slight redness to back of head. 08/30/21 10:34 AM Un-witnessed Fall: Wanted to go to BR. Sitting on floor by bed. 09/16/21 05:30 AM Fall during staff assist: Slid to floor during staff assist. 09/18/21 12:00 PM Witnessed Fall: slid to floor .found sitting leaning against the bed. 09/19/21 10:50 PM Un-witnessed Fall: Found sitting on the floor. 10/03/21 07:30 PM Un-witnessed Fall: Found laying on floor next to bed. Attempting to use commode by self. Bump on back of head. 4/10 pain back of head. 10/04/21 04:45 PM Un-witnessed Fall: Found sitting on floor. Said slid from bed to floor. 10/04/21 08:40 PM Witnessed Fall: Assisted Fall from bed to floor. 6) RR of nursing checks of R1's skin post falls included: Bruise to right lower back-skin checks started 05/01/21 through 09/25/21. Bruise to left knee-skin checks started 05/31/21 through 09/25/21. Skin and Wound Evaluation form dated 05/16/21 documented the bruise to be 11.8 cm (centimeters) length x 5.1 cm width. Skin and Wound Evaluation form dated 05/25/21 documented bruise to be 13.5 cm x 8.6 cm with a hematoma. Bruise to back of head extending to the neck right side-skin checks started 10/01/21 and ended 10/07/21, the day R1 transferred to the ED. Skin and Wound Evaluation form dated 10/04/21 measured the wound to be 3.8 cm length and 4.7 cm width. Bruise to neck- skin checks started 10/06/21 evening shift and ended 10/07/21 when transferred. Skin and wound evaluation form measured the bruise to be 12.7 cm length and 7.9 cm width. 7) RR of R1's hospital x-ray results revealed the following: 10/07/21 CT lumbar spine: Suspected subtle nondisplaced fracture involving the anterior cortex of L1 vertebral body. (fx L1 spine) 10/07/21 CT chest: bilateral pneumonia, subacute appearing right posterior 11th rib fracture 10/08/21 CT head without contrast: Occipital scalp soft tissue hematoma. 8) On 10/28/21 at 09:30 AM during an interview the Unit Manager (UM), she said R1 needed help with ADLs, and she could stand, but her balance was not good. She was extensive assist for transfers and was incontinent. She would use the toilet and bedside commode. The UM went on to say R1 was not compliant with using the call light when she needed help so the staff have to check on her frequently. She said R1 wouldn't comply, and she [UM] would notice her standing up to get to the commode. It was a short distance, but because of the balance issue, she is not safe standing by herself. The UM said they could not see R1's room from the nurses station. Inquired if there had been discussion of moving R1 closer to the station, and the UM said R1 didn't want to move, and they couldn't make her. We encouraged her to sit by the nursing station to do her crossword puzzles instead of in her room, but she liked to stay in her room. The UM said the RN's even park the medication cart close to her room so they can watch here between passing meds.We have a lot of interventions to prevent falls, but most haven't been effective. Inquired if the facility staffs with 1:1 sitters for safety and in what circumstances. The UM said Yes, we would use a sitter with a resident with dementia that was restless or wanders. The UM said to her knowledge 1:1 monitoring for R1 had not been discussed and staffing can be an issue. Inquired why R1 did not have a 1:1 sitter and she replied because she stays in her room, doesn't move around. She's mostly in bed or in the w/c. The UM validated R1 had dementia. 9) On 10/28/21 at 10:14 AM during an interview with the Director of Nursing (DON), she said she spoke with R1's family member (FM)1 who had been upset about her frequent falls. She said FM1 had seen R1 at the hospital and was upset the way she looked with bruise from her neck to fingertips. The DON said they were in the process of getting an appointment for R1 to have a CT scan of the head prior to her transfer. The DON confirmed the hospital had called to report R1 had a L1 compression fracture of the spine, and that the FM reported R1 also had a fractured rib. The facility did not have or obtain copies of R1's hospital records. The DON said the facility does at times use sitters and that staffing can be a challenge. The DON said the facility did not have a policy or guidelines regarding sitter use. 10) On 10/27/21 reviewed the Facility Assessment which included: Part 1 Resident Profile; The following are common diseases, conditions, physical and cognitive disabilities, or combinations of conditions in the facility that may require complex medical care and management. Psychiatric/Mood disorders: Impaired Cognition, Depression .Anxiety Disorder, Behavior that needs interventions.Due to a high number of residents with dementia and/or other types of psychiatric disorders, several of our residents require one to one supervision at times. Other physical disorders may also make a resident high risk for falls. Careful consideration is given for these residents when scheduling staff on the floor or the types of admissions on the unit. Part 3 Facility resources needed to provide competent support and care for our Resident Population Every Day .The facility will have sufficient nursing staff .to assure resident safety and attain or maintain the highest practicable physical, mental, and psychological well being of each resident, as determined by the resident assessments and individual plans of care and considering the number, acuity and diagnosis of the residents. The staff position table included In addition to nursing staff, other staff needed for behavioral healthcare and services (list other staff positions/roles): 1:1 as indicated.

Based on observation, electronic medical record (EMR) reviews and staff interviews, the facility failed to provide an accurate assessment by staff that are qualified to assess the resident with non-pressure-related skin problem for 1 of 33 residents (R #3) on the Stage 2 survey census sample. Findings include: Cross to F309 On 06/08/2016 at 9:12 AM interviewed the MDS Coordinator (MDS)#1 regarding the coding for R#3 activity of daily living (ADL) functions, as this resident triggered for ADL decline. According to MDS #1 the CNAs document point of care (POC) onto their iPad when providing care and services for each resident's ADL functions (e.g bed mobility - limited asst or extensive asst). The MDS#1 further stated that, unless there is a discrepancy the RN primarily relies on the POC data and doesn't assess the residents in person. MDS #1 stated, We can see the residents in the dining room or in the hallway, so we look at them. On 06/08/2016 at 1:18 PM went to observe R #3 to rule out possible activity of daily living (ADL) decline. The resident was wheeled back to his/her room after lunch by an RNA. The RNA assisted R #3 to transfer from the wheelchair to the toilet and back to the wheelchair. The R #3 was able to be left on the toilet, self cleaned, and called for the RNA when was ready to transfer back to the wheelchair. After the RNA placed R #3 at the bathroom sink to wash his/her hands and do oral hygiene, the RNA then called CNA #3 to take over from there. When CNA #3 brought the resident out from the bathroom and removed his/her lap blanket, R #3 legs were visualized with redness and large blackish raised areas to the outer sides of his/her legs. Queried CNA #3 regarding R #3 legs and she stated that she didn't know that R# 3's legs were in that condition. When CNA#3 started to assess R #3's legs, the resident stated Don't touch, be gentle because this area very sensitive and hurts when touched. The CNA #3 asked R #3 if anyone hit his/her legs or was handled roughly, and R #3 assured CNA #3 that it was not due to abuse by anybody. The CNA #3 also stated that she didn't notice that R #3's legs were in that condition and only noticed now as she attempted to place socks onto the resident. The CNA #3 stated that she would call maintenance to pad R #3's wheelchair foot rests as the resident may be banging his/her legs on the sides of the foot rests. On 06/08/2016 at 2:27 PM interviewed LN # 1 at the Unit 2 nursing station to see if she was apprised of the condition of R #3's legs. According to LN #1, she wasn't aware that R #3 had any problems with his/her legs and was unable to find any documentation in the EMR. CNA #3 was also at the Unit 2 nursing station and stated that LN #1 was not always the Unit 2 supervisor, and that maybe the other nurses knew about R #3's legs. Then accompanied LN #1 to R #3's bed to look at his/her legs as LN #1 did not assess yet. The resident was lying in bed taking a nap and wearing compression socks with white socks over the compression socks. As LN #1 started to remove the socks to assess R #3's legs the resident guarded the leg with his/her hand and stated that the area hurts when touched and need to be gentle. LN #3 then started to slowly remove the sock one at a time. As LN #1 assessed R #3's legs she stated, Looks like ecchymosis to both legs with darkened areas and the right leg looking more like a blood blister. Queried LN #1 about which CNA regularly provided care to R #3 and she stated that CNA #3 is the usual CNA for R #3 , but that the CNAs float to different units. Interviewed the oncoming evening shift CNA #4, to ask if knew about R #3's condition to his/her legs. CNA #4 stated that she noticed R #3's legs worsening on Saturday (06/04/16), and was just reassigned to Unit 2. Inquired of CNA #4 if she informed the charge nurse about R #3's reddened legs and she stated that R #3 has had problems and discoloration to her legs for awhile now, off and on, and the nurses knew about it. I apply protectant lotion to resident's legs and if looks unusual will tell nurse. On 06/09/2016 at 7:12 AM interviewed LN #4 who was the night shift charge nurse. Queried LN #4 about the condition of R #3's legs. LN #4 stated that she didn't know about R #3's legs and that the CNAs did not inform her that there was a problem with R #3's legs. The last skin assessment done on R #3 was on 06/02/16 by LN #1 and the skin assessment was done from head to toe. Interviewed LN #1 about the 06/02/16 skin assessment, and according to her there was no discoloration to R #3's legs nor [MEDICAL CONDITION]. Queried LN #1 if R #3 had this problem with his/her legs before, and LN #1 stated yes. LN #1 had to look through R #3's EMR for documentation on the last time the condition to his/her legs occurred. LN #1 provided the skin assessment forms done on R #3 on the dates of 09/12/2015, 10/03/2015 and 06/02/2016. On 09/12/2015 R #3 had large discoloration of Right forearm, discoloration of right lower leg; and large discoloration of left lower leg. The skin issues were new and the MD was updated and gave order for Vitamin C 500 mg BID and continue to monitor. The nurses progress notes also document on 9/12/15 at 1600 the same as the skin assessment sheet and that the resident denied any pain or discomfort. The 10/03/15 skin assessment form documented that R #3's skin was dry, warm and intact with no skin issues. The 06/02/16 skin assessment form documented that R #3's skin was dry and he/she had buttock rash. On 06/09/2016 at 10:07:15 AM reviewed R #3's EMR under Progress Notes tab and found that the LN #3 documented on 06/08/2016 at 16:13:44: Noted bluish reddish discolorations to right lower leg measuring 8 cm x 7 cm over ecchymotic area and also bluish/reddish discoloration to left lower leg measuring 3 cm x 4 cm. Also noted [MEDICAL CONDITION] 3+ to BLE. Resident is on with [MEDICATION NAME] 20 mg , BID. Resident denied staff hitting her. C/O pain at 2/10 when area is touched. MD notified with order to apply ted hose on in am and off in the evening. RP notified. This same information was also on the skin assessment sheet completed by LN #3 on 06/08/2016. The only other documentation prior to the discovery of R #3's leg condition was on 06/03/2016 at 21:43, Orders Administration Note: [MEDICATION NAME] Tablet 325 mg ; Give 2 tablet by mouth every 4 hours as needed for Mild Pain Do Not Exceed 3 G/24 HR. for leg pain On 06/09/2016 at 2:05:22 PM reviewed R #3's EMR and under the Progress Notes tab it was documented on 06/09/16 at 06:41, Discoloration to bilateral lower extremities, no active bleeding, skin is intact. will cont to monitor. On 06/09/2016 at 2:17 PM interviewed the CNAs on R #3's unit regarding R #3's legs with discoloration and ecchymosis and they stated: CNA #1 with CNA #4 present in R #3's room, R #3's legs were like that off and on. CNA #1 also stated that if they see anything unusual they report to the nurse. CNA #4 nodded in agreement. CNA #5 worked with R #3 in April and R #3 had the bluish/reddish discoloration to the legs. CNA # 5 always endorsed to the oncoming CNA about R #3's legs but that the CNAs didn't know that no one reported to the nurses as they endorsed to each other. CNA #2 stated that during May, R #3 didn't have bluish/reddish discolorations and the nurse working then also assessed. Looked in R #3's EMR with LN #1 at Unit 2 nursing station and unable to find any documentation regarding R #3's discoloration/condition of her legs in April through June 2016. The resident's most recent minimum data set (MDS) 3.0 done on 04/25/2016 documents under skin conditions, note that R# 3 did not have any skin conditions, also the application of non-surgical dressings (with or without topical medications) other than to feet was not marked. There was no care plan developed.

Based on observations, staff interviews and electronic medical record (EMR) reviews, the facility failed to ensure that 1 of 33 residents (R #3), of the Stage 2 survey sample, obtained the highest level of functioning and well-being by not providing the necessary care and services for non-pressure-related skin ulcers. Findings include: On 06/08/2016 at 1:18 PM went to observe R #3 to rule out possible activity of daily living (ADL) decline. The resident was wheeled back to his/her room after lunch by an RNA. The RNA assisted R #3 to transfer from the wheelchair to the toilet and back to the wheelchair. The R #3 was able to be left on the toilet, self cleaned, and called for the RNA when was ready to transfer back to the wheelchair. After the RNA placed R #3 at the bathroom sink to wash his/her hands and do oral hygiene, the RNA then called CNA #3 to take over from there. When CNA #3 brought the resident out from the bathroom and removed his/her lap blanket, R #3 legs were visualized with redness and large blackish raised areas to the outer sides of his/her legs. Queried CNA #3 regarding R #3 legs and she stated that she didn ' t know that R #3's legs were in that condition. When CNA # 3 started to assess R #3's legs, the resident stated Don't touch, be gentle because this area very sensitive and hurts when touched. The CNA asked R #3 if anyone hit his/her legs or was handled roughly, and R #3 assured CNA #3 that it was not due to abuse or hitting against anything. The CNA #3 also stated that she didn't notice that R #3's legs were in that condition and only noticed now as she attempted to place socks onto the resident. The CNA #3 stated that she would call maintenance to pad R #3's wheelchair foot rests as the resident may be banging his/her legs on the sides of the foot rests. On 06/08/2016 at 1:59 PM reviewed R #3's EMR and care plans developed for skin were: residents name has potential for pressure ulcer development related to impaired mobility Interventions included: Weekly treatment documentation to include measurement of each area of skin breakdown W, L, D, type of tissue exudate. residents name has potential for impairment to skin integrity related to friable skin secondary to Aspirin use and [MEDICATION NAME] use, incontinence Interventions included: Avoid scratching and keep hands and body parts from excessive moisture; encourage good nutrition and hydration in order to promote healthier skin; Heel elevation; Staff to do gentle handling during care due to thin and fragile skin; Ted hose; Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any hard surface On 06/08/2016 at 2:27 PM interviewed LN #1 at the Unit 2 nursing station to see if she was apprised of the condition of R #3's legs. According to LN #1, she wasn't aware that R #3 had any problems with his/her legs and was unable to find any documentation in the EMR. CNA #3 was also at the Unit 2 nursing station and stated that LN #1 was not always the Unit 2 supervisor, and that maybe the other nurses knew about R #3's legs. Then accompanied LN #1 to R #3's bed to look at his/her legs as LN #1 did not assess yet. The resident was lying in bed taking a nap and wearing compression socks with white socks over the compression socks. As LN #1 started to remove the socks to assess R #3's legs the resident guarded the leg with his/her hand and stated that the area hurts when touched and need to be gentle. LN #3 then started to slowly remove the sock one at a time. As LN #1 assessed R #3's legs she stated, Looks like ecchymosis to both legs with darkened areas and the right leg looking more like a blood blister. Queried LN #1 about which CNA regularly provided care to R #3 and she stated that CNA #3 is the usual CNA for R #3, but that the CNAs float to different units. Interviewed the oncoming evening shift CNA #4, to ask if knew about R #3's condition to his/her legs. CNA #4 stated that she noticed R #3's legs worsening on Saturday (06/04/16), and was just reassigned to Unit 2. Inquired of CNA #4 if she informed the charge nurse about R #3's reddened legs and she stated that R #3 has had problems and discoloration to her legs for awhile now, off and on, and the nurses knew about it. I apply protectant lotion to resident's legs and if looks unusual will tell nurse. On 06/09/2016 at 7:12 AM interviewed LN #4 that was the night shift charge nurse. Queried LN #4 about the condition of R #3's legs. LN #4 stated that she didn't know about R #3's legs and that the CNAs did not inform her that there was a problem with R #3's legs. The last skin assessment done on R #3 was on 06/02/16 by LN #1 and the skin assessment was done from head to toe. Interviewed LN #1 about the 06/02/16 skin assessment, and according to her there was no discoloration to R #3's legs nor [MEDICAL CONDITION]. Queried LN #1 if R #3 had this problem with his/her legs before, and LN #1 stated yes. LN #1 had to look through R #3's EMR for documentation on the last time the condition to his/her legs occurred. LN #1 provided the skin assessment forms done on R #3 on the dates of 09/12/2015, 10/03/2015 and 06/02/2016. On 09/12/2015 R #3 had large discoloration of Right forearm, discoloration of right lower leg; and large discoloration of left lower leg. The skin issues were new and the MD was updated and gave order for Vitamin C 500 mg BID and continue to monitor. The nurses progress notes also document on 9/12/15 at 1600 the same as the skin assessment sheet and that the resident denied any pain or discomfort. The 10/03/15 skin assessment form documented that R #3's skin was dry, warm and intact with no skin issues. The 06/02/16 skin assessment form documented that R #3's skin was dry and he/she had buttock rash. On 06/09/2016 at 10:07:15 AM reviewed R #3's EMR under Progress Notes tab and LN #3 documented on 06/08/2016 at 16:13:44, Noted bluish reddish discolorations to right lower leg measuring 8 cm x 7 cm over ecchymotic area and also bluish/reddish discoloration to left lower leg measuring 3 cm x 4 cm. Also noted [MEDICAL CONDITION] 3+ to BLE. Resident is on with [MEDICATION NAME] 20 mg , BID. Resident denied staff hitting her. C/O pain at 2/10 when area is touched. MD notified with order to apply ted hose on in am and off in the evening. RP notified. This same information was also on the skin assessment completed by LN #3 on 06/08/2016. Previous documentation prior to the findings above was on 06/03/2016 at 21:43, Orders Administration Note: [MEDICATION NAME] Tablet 325 mg; Give 2 tablet by mouth every 4 hours as needed for Mild Pain Do Not Exceed 3 G/ 24 HR. for leg pain On 06/09/2016 at 2:05:22 PM reviewed R #3's EMR and under the Progress Notes tab documentation on 06/09/16 at 06:41 noted, Discoloration to bilateral lower extremities, no active bleeding, skin is intact. will cont to monitor. On 06/09/2016 at 2:17 PM interviewed the CNAs on R #3's unit regarding R #3's legs with discoloration and ecchymosis and they stated: CNA #1 with CNA #4 present in R #3's room, R #3's legs were like that off and on. CNA #1 also stated that if they see anything unusual they report to the nurse. CNA #4 nodded in agreement. CNA #5 worked with R #3 in April and R #3 had the bluish/reddish discoloration to the legs. CNA #5 always endorsed to the oncoming CNA about R #3's legs but that the CNAs didn't know that no one reported to the nurses as they endorsed to each other. CNA #2 stated that during May, R #3 didn't have bluish/reddish discolorations and the nurse working then also assessed. Looked in R #3's EMR with LN #1 at Unit 2 nursing station and unable to find any documentation regarding R #3's discoloration/condition of her legs in April through June 2016.

Based on interviews with complainant, Director of Nursing, Administrator, and pharmacist along with record reviews the facility failed to ensure that 1 resident remain free of significant medication errors. Findings Include: 1) In a record review on 3/15/16 of resident admission paperwork, it was noted that resident was admitted to the facility on [DATE]. He was transferred from an acute care hospital with a [DIAGNOSES REDACTED]. 2) In an interview with complainant on 3/15/16, resident was being treated by an Oncologist for [MEDICAL CONDITION]. He was being treated with a combination of [MEDICATION NAME] 250 mg (4 tablets or 1000 mg) once per day along with [MEDICATION NAME] 10 mg per day. Complainant stated that the facility failed to follow the directions written on the prescribed medication, administering [MEDICATION NAME] 1000 mg PO every 6 hours, crushing the medication, and mixing with pudding, which complainant stated was not what was written on the bottle. Per complainant the facility failed to listen to him when he expressed his concern that the wrong dosage of medications was being given and that it was not to be given with food or crushed. He stated that he felt that staff and situations at the facility caused his father harm, discomfort, and neglect. He noted this on the 2nd or 3rd day after his father was admitted but nothing was done until it was too late. The complainant stated that because the facility did not carry the medication prescribed to treat his father, he was told that family would have to bring in the supply from resident's personal pharmacy. He stated that he brought in the bottle of [MEDICATION NAME] 250 mg which had instructions on the label to take 4 tablets 1 time per day. The bottle also said not to crush and not to take with food. Complainant stated that the bottle said daily but in the beginning they gave 16 tables a day. I kept arguing with them asking don't you question before you open the bottle. Complainant stated that he was told the nurses have a procedure to confirm. He stated that he kept telling them but it looked really clear, no one checked it properly. Complainant went on to explain, When we brought the medications in from the hospital, one of the nurses asked when we were going to bring in more [MEDICATION NAME] We said we'd bring it when they release it. The nurse said that they were going to run out. This was around the 2nd or 3rd day. He stated that when he called Pharmacy #2 to refill the medication, they asked why he needed more and said that the bottle was pretty full. Pharmacy #2 confirmed that the medication was given wrong. Complainant added We were also told by his Oncologist that if he was taking [MEDICATION NAME] he also needed to take [MEDICATION NAME], but it wasn't given right away. Complainant stated that he did attend the Care Conference and brought the issue of medications up and was told that they were on top of it. He stated that his father was getting weak but it was hard to determine if it was from the medication or his condition. I talked to his doctor and he said that the medication could be detrimental, it was a hormone blocker so it should be given with [MEDICATION NAME]. Complainant also stated that he noticed the nurses were crushing the [MEDICATION NAME] and giving it with food. He stated that he told the nurses it must be taken whole and not mixed with food. I even screamed at them once when the nurse told me he had a hard time swallowing it so she crushed it up good in the food. I kept saying no He further stated that when we got the DON involved it was too late, he went to the hospital. 3) In a review of the Medication Administration Record [REDACTED]. The prescribed dosage as written on the bottle and the manufacturer's specification stated that 1,000 mg of [MEDICATION NAME] PO per day be administered. 4) The following are instructions for taking [MEDICATION NAME] obtained from (http://www.janssen.com): * Take your prescribed dose of [MEDICATION NAME] one time a day. *Take [MEDICATION NAME] on an empty stomach. Do not take [MEDICATION NAME] with food. Taking [MEDICATION NAME] with food may cause more of the medicine to be absorbed by the body than is needed and this may cause side effects. *No food should be eaten 2 hours before and 1 hour after taking [MEDICATION NAME]. *Swallow [MEDICATION NAME] tablets whole. Do not crush or chew tablets. * Take [MEDICATION NAME] tablets with water. * [MEDICATION NAME] may cause serous side effects including: hypertension, low blood potassium levels * Tell your health care provider if you get any of the following symptoms: dizziness, fast heartbeats, feel faint or lightheaded, headache, confusion, muscle weakness, pain in your legs, swelling in your legs and feet, liver problems, hot flushes, diarrhea, vomiting, cough, shortness of breath, urinary tract infection, bruising, low red blood cells ([MEDICAL CONDITION]) and low blood potassium levels, high blood sugar levels, high blood cholesterol and triglycerides * Adrenal problems may happen if you stop taking [MEDICATION NAME], get an infection, or are under stress. * [MEDICATION NAME] (abiraterone acetate) is a prescription medicine that is used along with [MEDICATION NAME] 5) In an interview with the Director of Nursing (DON) , she stated that the practice of medication reconciliation was for the admitting nurse to look at the Medication Administration Record [REDACTED]. The nurse then notifies the MD of medications on the transferring facility paperwork and faxes the order to the pharmacist. 6) When asked if the facility has a policy for using patients' own medications, the DON stated that if a resident had his own medications, the facility would put a sticker on the bottle to read the same as the MAR indicated [REDACTED]. 7) When asked what the procedure was for medications prescribed by an outside physician and pharmacy, she stated that even if the medication comes from a different pharmacy and MD, the receiving MD is considered the prescribing doctor. 8) In an interview with the Director of Nursing (DON) and the Administrator on 3/16/16 at 12:35 P.M. when asked if staff nurses follow standard procedures for admitting residents and reconciling medications the DON stated that yes they did. When asked what their resource or policy is on reconciling medications she stated that they use drug books on the floor and the pharmacy as a resource. She stated that the nurse was not familiar with the medication ([MEDICATION NAME]). When asked if it was standard practice for the nurses to look up any medication that they are unfamiliar with she stated the family made it clear what the drug was for. When asked what the facility expectations are for nurses to look up unfamiliar drugs, she stated In this case I don't know if they knew or didn't know. 9) In a phone interview with the pharmacist on 3/16/16, when asked how they check the medications for new admissions to the facility, he stated that the orders are faxed to the pharmacy upon admission and are usually reviewed right away. When asked if he noted that the resident was getting a high dose of [MEDICATION NAME], he stated yes, I called the nurse and she confirmed that this was the right dose. He said that he had written a note to clarify the dose on August 18th, 2016. When asked if he spoke with the attending physician or prescribing physician he stated that it is their practice to call the facility to clarify the dose, we just asked them to check if it was correct. He stated that he did not write down who he talked to at the facility to clarify the dose. He then stated that the consult pharmacist probably checked the medications when he/she went but he was not sure who it was, he had no notes from the consultant and stated that the notes would be in the residents chart. He further stated that usually we don't make recommendations, we would talk to the MD first. When asked if he had talked to the MD he stated no, the MD didn't call and I didn't ask the MD to call. 10) In a record review of Admission Physician orders [REDACTED].M., it was noted that on admission the resident had a [DIAGNOSES REDACTED]. Included in the medication list written in by nursing was: [MEDICATION NAME] 1,000 mg PO Q6HRS -(may use own supply). No order for [MEDICATION NAME] was noted. 11) Per the DON, the resident was transferred from an acute care hospital and the acute care hospital had the medication listed wrong on their discharge paperwork, causing the error. When asked if the nurse would look up the medication to check what the appropriate dose, route, any side effects, etc . after she saw that the medication bottle had a different dose and further instructions, she stated that they go by the discharge medication list that they receive from the hospital. 12) In a review of the Medication Administration Records (MAR) for August and September of 2015 it was noted that: * Resident was admitted [DATE]. No medications were administered on that date. * On 8/18/15 an order for [REDACTED]. * The MAR indicated [REDACTED] * On 8/26/15 an order was written for [MEDICATION NAME] 250 mg (250 MG OWN SUPPLY) TABLET Oral every Six Hours Starting 8/26/15) (1 dose was missed on 8/28/15 at 2:00 A.M.) * On August 26th [MEDICATION NAME] 1,000 mg was administered at 2:00 A.M. (the order read 250 mg). No D/C date for above order * On 9/01/15 an order was written for [MEDICATION NAME] Tablet 250 mg. Give 250 mg by mouth every 6 hours to start on 9/01/15. This order was discontinued on 9/01/15. * On 9/1/15 an order was written for [MEDICATION NAME] Tablet 250 mg. Give 250 mg by mouth every 6 hours (own supply). Start on 9/01/15. Discontinued on 9/08/15. * On 9/01/15 [MEDICATION NAME] 250 mg was administered 2 X at 8:00 A.M., then 1 dose at 2:00 P.M., and 1dose at 8:00 P.M. as reflected in MAR indicated [REDACTED] 13) In a review of nursing notes from 9/04/15 ( 3-11 shift) documentation stated No adverse reaction from [MEDICATION NAME] noted. No SOB. Resident denies pain and discomfort. Denies abdominal discomfort. * On 9/4/15 at at 2:43 PM [MEDICATION NAME] Max Suspension 400-400-40 MG/5 ML PO 30 ml was administered to the resident for upset stomach. 14) On 9/05/15 resident was transferred to an acute care hospital with a [DIAGNOSES REDACTED]. * Resident was hospitalized in an acute care facility from 9/05/15 through 9/07/15. Resident was transferred back to the facility on [DATE]. 15) On 9/07/15 an order was obtained for [MEDICATION NAME] Tablet 250 mg. Give 250 mg by mouth every 6 hours *Family to supply* to start on 9/07/15. Order discontinued on 9/09/15. 16) On 9/07/15 [MEDICATION NAME] 250 mg was administer at 8:00 A.M., 2:00 P.M., (6:00 P.M. second MAR), and 8:00 P.M. (The 6 hour time frame was not followed as the time between the 2nd and 3rd dose was 4 hours and the time between the 3rd and 4th dose was 2 hours). 17) On 9/08/15, [MEDICATION NAME] 250 mg was administered at 12:00 A.M., 2:00 A.M., two doses at 8:00 A.M., one dose at 12:00 P.M., and one dose at 6:00 P.M. (resident received 6 doses in 18 hours) * On 9/8/15 [MEDICATION NAME] 250 mg every 6 hours was discontinued 18) Nursing notes on 9/09/15 at 11:49 P.M. stated Followed up with Oncologist to clarify [MEDICATION NAME] dosage/frequency. [MEDICATION NAME] 250 mg tablets PO (4 tabs) to be given on an empty stomach and do not crush. Charge nurse aware. 19) On 9/09/15 an order for [REDACTED]. Do not crush. Start date as 9/09/15. Discontinued on 9/16/15. 20) On 9/09/15, [MEDICATION NAME] 250 mg was administered at 12:00 A.M., and another 1,000 mg was administered at 8:00 A.M. (1250 mg delivered on this date) 21) Surveyor informed the DON and Administrator on 3/16/16 that the pharmacist stated that he called and talked to the nurse because he felt the dose of [MEDICATION NAME] was too high. He stated that he just verified this dose was correct with the nurse, to which the DON responded when I spoke with the complainant, crushing the meds was not a concern at that time, just the dosage. Like I said we were following the standard procedure for every resident. She further stated that the transfer summary and the physician transfer summary is what we go by. When asked how they reconcile the medications she stated The attending physician reconfirmed the medications and gave the facility the order. The attending physician is considered the prescriber and that's how all nursing facilities do it. When asked about the procedure for crushing pills and if the nurses needed an order to crush and/or give with food, she responded , The nurses that may have crushed the pills are not here to validate. I talked to the staff about medication administration and asked if they had any questions. 22) When asked what if anything changed in their process for admission reconciliation of medications since this incident occurred, she responded two nurses verify the med orders and confirm with the attending physician. When asked if this was the same procedure before the incident, the DON answered yes, that has been our standard procedure and most facilities do it this way. 23) When asked if it would be standard practice to notify the physician who prescribed the medication that was brought in by the resident to clarify any discrepancies between the bottle and the paperwork sent by the discharging hospital, the DON stated no, the admitting doctor is our prescribing physician.