Every finding on record at Barton Hospital D/P SNF

Based on interview and record review, the facility failed to meet State licensure requirements for Staff Development -Confidentiality of patient information as outlined in the California Code of Regulations, Title 22 when they failed to effectively provide an ongoing educational program to ensure staff possess the necessary skills and knowledge regarding the confidentiality and appropriate use of Protected Health Information (PHI).This failure resulted in a staff member accessing hospital records out of personal interest, not for patient care purposes and the breach of PHI.Findings:An investigation into a facility reported incident confirmed that a staff member admitted to using the facility computer to access her ex-husband's hospital records for personal reasons.The facility report titled Notice of Breach of Protected Health Information (PHI), dated 6/8/26 indicated, that a breach occurred on:5/4/265/5/265/7/265/12/26The Breach included access to a Patient's name, medical record, date of birth , phone number and clinical notes that included hospital notes, labs and patient status. The report further indicated that the staff member acknowledged that the access was for personal reasons.During an interview on 6/16/26 at 2:06 p.m., the Director of Nursing (DON) stated that the expectation is that staff do not access patient files that do not apply to the facility. The DON further stated that staff had annual HIPAA (Health Insurance Portability and Accountability ACT to protect the privacy and security of individuals' health information) training but nevertheless accessed the PHI for her personal use. The DON stated staff should only access files for residents that the facility is planning on caring for.A review of the California State law, Title 22, S72517(a)(6), indicated (a) Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include but not be limited to:. (6) Confidentiality of patient information.During a review of the facility's policy and procedure titled, HIPAA Privacy Rule - Confidentiality, dated 2026, indicated, Authorized users of health care and personal information include those Staff who have a job-related need to know and are: a) Providing direct care and treatment to the patient/resident, or b) Required to use healthcare or personal information to perform their assigned job responsibilities or to meet legal, regulatory, or other obligations of BHS ([NAME] Healthcare System), or are c) Specifically authorized by the patient/resident to have access to their confidential information.

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety for a census of 45, when:1.Food items were found expired and with no open dates in the resident's refrigerator and2. Crumbs and debris were found in clean and sanitized areas in the kitchen.These failures had the potential to cause food-borne illnesses to a vulnerable population.1.During an observation on 4/8/26 at 4:45 p.m., of the resident's refrigerator, the following was noted: a. one-gallon plastic bag full of expired individual butters (expiration date 3/20/26); b. one bottle of cranberry cocktail juice with an open date of 12/10/25; c. one opened bottle of cranberry juice, undated and unlabeled (no resident's name and no open date and expiration or used-by date); and d. one opened and undated jar of mayonnaise.During a concurrent interview on 4/8/26 at 4:45 p.m. with Licensed Nurse (LN 4), LN 4 confirmed the unlabeled and outdated items in the residents' refrigerator and stated the resident's items from home were expected to be labeled to identify the resident and make sure they [residents] are safe. LN 4 stated the expectation was that food should have open dates and not be expired or unlabeled to avoid patient getting sick.During an interview on 04/8/2026 at 4:53 p.m. with LN 3, LN 3 stated the expectation was that food from home stored in the residents' refrigerator should have the resident's name and be dated so they [residents] do not get sick.During an interview on 04/8/2026 at 4:57 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated, resident food should be labeled with the name, room number, date and time the food item went in the fridge to avoid harmful bacteria growth.During an interview on 4/9/26 at 7:45 a.m. with the Dietary Manager (DM), the DM indicated staff were expected to follow policy for food dated from kitchen to other departments policy, and stated, The used by date and the expiration date provided on the package should be written on the food items. The DM stated staff were expected to also follow the policy for food brought in by family. During an interview on 4/9/26 at 7:45 a.m. with Dietary Aide (DA 1), DA 1 stated received and used by dates are written on bags and confirmed expired items are expected to be thrown away. During an interview on 4/10/26 at 12:10 p.m. with the Director of Nursing (DON), the DON stated the expectation was that food should be labeled and expired food should be removed from the residents' refrigerator to avoid food-borne illnesses to residents. A review of the facility's policy and procedure titled Food handling and storage from outside SNF [Skilled Nursing Facilities], dated 11/2025, indicated, 3. Food of any type, once opened, will remain in the refrigerator for no more than 7 days.6. Anything found in the refrigerator without a name and/or date will be immediately discarded.2. During a concurrent kitchen inspection tour and interview on 4/9/26 at 7:51 a.m. with the DM, food preparation utensils were found stored in a metal bin with crumbs and debris. The DM confirmed the utensils were lying in debris and stated the bin was expected to be clean and free of debris. During an interview on 4/10/26 at 10:20 a.m. with the Infection Prevention Nurse (IP), the IP indicated crumbs and debris in clean and sanitized areas were not safe and could harbor bacteria that could make a resident sick. During an interview on 4/10/26 at 12:10 p.m. with the DON, the DON stated the expectation was that crumbs and debris should not be inside a clean area to avoid illness to residents.A review of the facility's policy and procedure titled (P&P), Departmental Safety : Food Service, dated 2023, the P&P indicated, .Dishes .1.Ensure cleanliness and serviceability .2. Store properly in kitchen service area.

Based on observation, interview, and record review, the facility failed to store medications in accordance with professional standards for a census of 45, whenAn expired bottle of carboxymethylcellulose sodium 0.5% solution (artificial tears eye drops for dry eyes) was still being administered to Resident 17;An open tube of hydrocortisone cream 1% (a topical steroid used to reduce inflammation and itching caused by conditions like allergic rashes) for general resident use was found without an open date; An open bottle of Resident 20's ascorbic acid (Vitamin C) had a smudged illegible expiration date written on it;A treatment cart containing prescription creams and ointments was left unlocked in the hall accessible to residents;Treatment Cart 1 contained a tube of Mupirocin 2% ointment (a prescription antibiotic to treat skin infections) without resident's name and unlabeled Premarin 0.625 milligram tube (hormonal cream) and multiple ointments and creams were found inside Treatment Cart 1 and available for residents' use with expiration dates of 2024 and 2025. This failure placed facility's residents at risk for receiving medications and treatments that may have reduced potency, compromised safety, and increased the potential of administering ineffective medications and treatments to residents.A review of Resident 17's admission Record indicated she was admitted to the facility in 2024. A review of Resident 17's Order Summary Report, dated 2/25/24, indicated she was prescribed artificial tears eye drops, to instill 2 drops twice a day for dry eyes. A review of Resident 20's admission Record indicated she was admitted to the facility in 2024. A review of Resident 20's Order Summary Report indicated she was prescribed vitamin C 500 milligram (mg) daily on 11/19/24. During a concurrent observation and interview on 4/7/26 at 1:15 p.m. with Licensed Nurse (LN) 1 at the medication cart, a review of medications storage was conducted: 1. Resident 17's eye drops had an expiration date of 4/5/26 written on the box. LN 1 stated the eye drops had expired, and Resident 17 should not have gotten the drops past 4/5/26 because according to policy, eye drops were considered expired thirty days after opening. LN 1 pointed to a guide affixed to the top of the medication cart that indicated, Eye Drops – Discard 30 days after opening. A review of Resident 17's Medication Administration Record (MAR - a daily documentation record used by a licensed nurses to document medications and treatments given to a resident) indicated she had been given the expired eye drops through the morning of 4/8/26. 2. LN 1 confirmed the hydrocortisone cream had been opened, but no open date was written on the box or tube. LN 1 also stated the medication was available for residents use if ordered by the physician. LN 1 pointed to the guide the facility had posted on the cart that indicated, Date and initial all items when opened. 3. LN 1 confirmed the expiration date on the vitamin C bottle was smudged and illegible and stated the nurses would not know when the vitamins expired. During an interview and record review on 4/9/26 at 10:01 a.m. with the Director of Nursing (DON) and the Patient Safety and Quality Nurse (PSQN), medications were reviewed from the medication cart. DON acknowledged the guidance on the medication cart indicated eye drop medications were to be discarded after 30 days and further stated using expired eye drops could have adverse effects on the patients' eyes. PSQN stated expired medications could lead to ineffectiveness of the medication. DON stated hydrocortisone creams were to be labeled upon opening and asserted if they were not labeled, they should be discarded because no one would know if the medication was expired or not. DON stated vitamins with unknown expiration dates could cause unwanted side effects for the resident. A review of the facility's policy and procedure titled, Medication Administration and Monitoring, revised 5/2025, indicated, .the medication nurse is responsible for all medications stored in the medication cart. The document further indicated medications are to be dated when opened and discarded by the expiration date. 4.During an observation on 4/7/26, at 12:09 p.m., Treatment Cart 1 was observed in the 400's hall. The cart was unlocked, unattended, and facing towards the hall. Multiple prescription ointments and creams were observed in unlocked middle drawer. Several residents were observed moving in their wheelchairs in the hall. During a concurrent observation and interview on 4/7/26 at 12:12 p.m., LN 3 stated he was assigned to administer treatments in this hall and had the key for the treatment cart. LN 3 acknowledged that the treatment cart was unlocked and unattended and accessible for residents and visitors. LN 3 stated that it was not safe to keep the treatment cart unlocked with prescription ointments and creams and the cart should have been locked. During an interview with DON, on 4/9/26 at 1:39 p.m., the DON stated that treatment carts containing medicated ointments and creams should never be left unlocked. The DON stated nursing staff were expected to keep the medication and treatment carts locked if they were unattended and away. The DON added, Residents can access and it's not safe. A review of the facility's policy titled, Medication Administration and Monitoring, dated 5/2025, All medications will be administered.in accordance with established [name of the facility] policies and procedures, State and Federal regulations.All medications will be stored in lockable containers, carts, or specific locked medication storage areas.Medication cart must be locked when not in use. An unlocked cart is never left unattended. 5. During a concurrent observation and interview with LN 3 on 4/7/26 at 12:15 p.m., an inspection of the Treatment Cart 1 identified the following undated and expired medications: a. An undated tube of Mupirocin 2% ointment with an open date of 10/29/24 and expiration date of 9/2025; b. An undated tube of Premarin 0.625 milligram tube (hormonal cream); c. An unlabeled and undated tube of Permethrin 5% cream 60 gram (medication for treatment of lice or scabies) with expiration date of 5/2025; d. A tube of Betamethasone Dipropionate 0.005 % ointment (a strong steroid medication used for skin itching, redness, and inflammation) with expiration date of 5/31/25, and e. Three tubes of lubricating jelly 59 each with an open date of 10/8/2024. Each tube indicated it was for single use only and it was sterile [free of germs] in unopened undamaged package. During a concurrent interview on 4/7/26 at 12:15 p.m., LN 3 validated that all ointments, creams, and lubricating jelly were available for residents' use. LN 3 stated all expired ointments and creams should be discarded and not be used past their expiration date because they might not be effective. During an interview with DON on 4/9/26 at 1:39 p.m., the DON stated that all medications, including ointments and creams should be dated after the opening and expired medications should be discarded and not in use. The DON stated nursing staff were expected to check expiration dates of ointments and creams during treatments administration. The DON stated that expired ointments could have decreased potency and should not been administered. A review of the facility's policy titled, Medication Administration and Monitoring, Product Dating and Expiration, dated 5/2025, Non repackaged.solids will be dated when opened and discarded by the expiration date or after 1 year of opening, whichever comes first.Multi-dose vials will be dated and initialed when opened. Discard when empty.or the manufacturers expiration date.

Based on interview and record review, the facility failed to ensure the administration time for morphine (a narcotic controlled medication) on the Medication Administration Record (MAR) matched with the Controlled Drug Record (CDR - a log used to track the administration and disposition of Schedule II drugs, substances with a high potential for abuse) for one of 13 sampled residents (Resident 5).This failure resulted in inconsistency in morphine administration for Resident 5 and had the potential to impact accountability of the controlled drug.A review of Resident 5's admission Record indicated she was admitted to the facility in 2022, with diagnoses that included chronic pain and osteomyelitis (a serious infection in the bone, caused by bacteria or fungi, resulting in inflammation and tissue damage, and is often very painful).A review of Resident 5's Order Summary Report, dated 3/27/25, indicated she was prescribed morphine sulfate extended release 15 milligram (mg-a unit of measure) two tablets by mouth at bedtime for chronic pain.A review of Resident 5's MAR, dated March 2026, indicated she was to take her morphine at 9 p.m. The nurses administering the medication documented 2 tablets of morphine were given at 9 p.m. on 3/29/26 and 3/31/26.A review of Resident 5's CDR, dated March 2026, indicated that on two dates, 3/29/26 and 3/31/26, the morphine was administered to Resident 5 at 7:50 p.m., an hour and 10 minutes before the scheduled time.During an interview on 4/9/26 at 10:16 a.m. with the Director of Nursing (DON) and Patient Safety and Quality Nurse (PSQN), DON stated if a resident is prescribed regularly scheduled morphine for pain management, the administration window is one hour before or one hour after the time specified on the MAR. DON confirmed the administration times on the MAR and CDR are supposed to match to account for oversight of narcotic medications, and it was not acceptable to administer a narcotic more than an hour before it was due - if given too early, it could cause harmful effects. PSQN said it had potential to cause respiratory depression (a life-threatening condition where breathing is too slow or ineffective, leading to low oxygen levels frequently caused by excessive drug amounts).A review of the facility's policy and procedure titled, Skilled Nursing Facility Medication Administration and Monitoring, revised 5/2025, indicated, Medications will be administered within one hour of the ordered time on the Medication Administration Record. The document further indicated, When there is a discrepancy in the narcotic count, an investigation will ensue. If the medication cannot be reconciled, the Controlled Drug Discrepancy Report form will be completed, two nurses will sign the form, and the form will be turned into the Director of Nurses.A review of a facility document titled, Pharmacy Products and Services Agreement (contract between the pharmacy on CDR and the facility), dated 6/15/21, indicated, Consultant shall assist Facility in developing and implementing safeguards and systems to control, account for, and periodically reconcile controlled medications.

Based on observation, interview, and record review, the facility failed to ensure that wheelchairs were maintained in safe condition when found with cracked and exposed armrest for three of 13 sampled residents (Resident 13, Resident 30, and Resident 43). This failure had the potential to place Resident 13, Resident 30, and Resident 43 at risk for injury and infection. A review of Resident 13's admission Record (AR), dated 4/10/26 (print date), indicated Resident 13 was admitted in Winter 2023 with the diagnoses which included right artificial hip joint (replaced joint for damaged hip), polymyalgia rheumatica (severe stiffness of neck, shoulders and hips), and chronic pain. A review of Resident 13's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/30/26, the MDS indicated Resident 13 had no memory impairment and was dependent on a wheelchair and walker. A review of Resident 13's Resident Care Guide (RCG) [Care Plan], dated 3/26, the RCG indicated, Resident 13 frequently used her wheelchair for short distances around the facility. During an observation on 4/8/26 at 9:29 a.m. in Resident 13's room, Resident 13's wheelchair arm handles were found with cracks on the surface and with exposed foam inside cushion. Resident 13 confirmed the cracks and exposed foam and stated the wheelchair was uncomfortable and would like it changed. During a review of Resident 30's AR, dated 4/10/26 (print date), the AR indicated Resident 40 was admitted in Winter 2025 with the diagnoses which included history of falling and failure to thrive (gradual decline in physical and mental functioning). A review of Resident 30's MDS, dated [DATE], indicated Resident 30 had no memory impairment and was dependent on a wheelchair and walker. A review of Resident 30's RCG, dated 3/26, the RCG indicated, Resident 30 was often found propelling his wheelchair around the facility. During an observation and interview on 4/8/2026 at 12:19 p.m., Resident 13's wheelchair arm handles were found with cracks on the surface and with exposed foam inside cushion. Resident 30 indicated he preferred the wheelchair arm handles to be not cracked to avoid his arm being pinched, and stated, So it looks better. A review of Resident 43's AR, dated 4/10/26 (print date), the AR indicated Resident 43 was admitted in Winter 2023 with diagnoses which included pain in right knee, right artificial knee joint (replaced joint for damaged knee), and chronic pain. A review of Resident 43's MDS, dated 1/2/2026, the MDS indicated Resident 43 had no memory impairment and was dependent on a wheelchair and walker. A review of Resident 43's RCG, dated 1/25, the RCG indicated Resident 43 used a wheelchair for mobility and should be encouraged to use her wheelchair instead of walker due to severe knee pain. During an observation on 4/9/26 at 2:15 p.m., Resident 43 was being pushed throughout the facility hallway by a family member. Resident 43's wheelchair arm handles were found with surface cracks and exposed inside foam cushion. During a concurrent observation and interview on 4/9/26 at 5:25 p.m., Resident 43 sat in her wheelchair accompanied by a family member. Resident 43's wheelchair arms were found with cracks on the surface with exposed foam inside cushion. Resident 43 and family agreed that the cracks and exposed foams could cause discomfort or skin issues and should be replaced. During a concurrent observation and interview on 4/9/26 at 4:39 p.m. with the Physical Therapist (PT), the PT confirmed Resident 13's, Resident 30's, and Resident 43's wheelchair arm pads were cracked and exposed and were expected to be replaced to avoid discomfort. The PT stated wheelchair repair concerns were expected to be reported by staff. The PT was unable to provide a wheelchair repair request log when asked. During a concurrent interview on 4/9/26 at 5:30 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated wheelchair with cracked and exposed pads could cause injury and pain. CNA 3 further stated cracked and unrepaired arm pads could cause skin irritation and the expectation was to report disrepair to the nurse or supervisor. During an interview on 4/10/26 at 10:20 a.m. with the Infection Prevention Nurse (IP), the IP stated the expectation was that wheelchairs remained clean for the residents, and cracked arm pads were not safe and could cause skin tears and infection. During an interview on 4/10/26 at 12:10 p.m. with the Director of Nursing (DON), the DON stated wheelchairs were expected to be in good repair and cracked and exposed wheelchair arm pads were considered uncleanable and could cause discomfort or infection to residents. During a review of the facility's policy and procedure (P&P) titled, SNF Equipment Cleaning, dated month 8/2024, the P&P indicated, Purpose: .to reduce the risk of transmission of infection and to always ensure cleanliness of patient care items and equipment. equipment is routinely monitored for damage that could hinder function, result in uncleanable surfaces, or adversely affect functionality.

Based on observation, interview, and record review, the facility failed to maintain electrical equipment in a safe condition for a census of 45 residents, when the facility did not routinely remove lint buildup from the dryer in the laundry room.This failure had the potential to affect residents' safety due to fire hazard.During a tour of the laundry room on 4/9/26 at 2:45 p.m., accompanied by Infection Prevention Nurse (IP), a thick layer of lint accumulation was observed in the lint trap compartment of the dryer. The IP stated the lint trap was to be cleaned on a regular basis to remove lint accumulation and validated that lint compartment had accumulated lint. The IP was unable to provide documentation or a log confirming routine lint removal from lint compartment. The IP stated she did not inspect the laundry room for cleanliness and explained that laundry room was managed by Director of Environmental Services.During a concurrent observation and interview with the Director of Environmental Services (DES) on 4/9/26 at 3:02 p.m., the DES acknowledged that the lint compartment had accumulation of lint and added, looks like it was not cleaned today. The DES stated that dryer needed to be inspected and cleaned of lint accumulation every day. The DES was unable to provide documentation or a log confirming routine lint removal. The DES confirmed the facility did not have formalized schedule requiring routine inspection and cleaning of dryer lint compartment. The DES stated the facility did periodical inspection of the laundry area, but there were no documents available when the last inspection of dryer lint compartment was done.A review of the facility's policy titled, Clean Linen Room Cleaning Procedure, dated 11/5/21 indicated, Purpose: To maintain the hospital linen room in a clean, safe, sanitary and outstanding condition. The policy had no specific procedures or guidance addressing routine cleaning and maintenance of laundry equipment, including dryers to prevent lint accumulation.

Based on interview and record review, the facility failed to ensure the Physician Orders for Life Sustaining Treatment (POLST, a form signed by the resident or representative and physician, outlining specific treatment wishes and end-of-life preferences) was signed by Public Conservator (PC, a legally recognized and authorized surrogate decision maker) for one of 13 sampled residents (Resident 33), when Resident 33's POLST form indicated Do Not Resuscitate (DNR) status, but lacked the required name and signature of PC.This failure had the potential for Resident 33 not to receive treatment and care in the event of a medical emergency and deprived the resident's Public Guardian ability to make informed decisions affecting Resident 33's care.A review of the admission record indicated the facility admitted Resident 33 in 2019 with multiple diagnoses which included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills) and hearing loss.A review of Resident 33's physician order dated 9/23/19 indicated that Resident 33 did not have capacity to make decisions. The physician order indicated, .surrogate decision maker: [Name of the County] Public Guardian. A further review of Resident 33's clinical record contained a document titled, Letter of Conservatorship, dated 1/2/2020. The letter indicated that Public Guardian was court appointed conservator for Resident 33 and had Exclusive authority to give consent for and to require the conservatee [Resident 33] to receive medical treatment that the conservator in good faith based on medical advice determines to be necessary.A review of the clinical record for Resident 33 contained a POLST form indicating that Resident 33's code status was Do Not Resuscitate (do not prolong life during an emergency). The POLST form was signed by two physicians on 12/20/22. Section D of the POLST did not list the name as required by instructions and did not indicate if Resident 33's DNR status was discussed with Legally Recognized Decisionmaker (LRD). The POLST form did not contain the signature of Resident 33's Legally Recognized Decisionmaker. The back portion of the POLST contained the instructions for completion of the form which indicated, A legally recognized decisionmaker may include a court-appointed conservator or guardian.POLST must be signed by a physician and the patient or decisionmaker to be valid.During an interview on 4/8/26 at 4:22 p.m., with Licensed Nurse (LN 3), LN 3 explained that in order for the POLST to be valid, the form must be signed by physician and public guardian if the resident lacked capacity to make decisions and had no family members identified.During a concurrent interview and record review conducted on 4/8/26 at 4:27 p.m., with Director of Nursing (DON) and Director of Patient Safety and Quality (DPSQ), Resident 33's POLST form was reviewed. The DON validated that the POLST dated 12/20/22 was not completed properly with required sections left blank and was not signed by Resident 33's appointed Public Guardian.During a further review of Resident 33's clinical records on 4/8/26 at 4:27 p.m., with DON and DPSQ, the DON explained that on 12/22/22 the facility conducted a care conference addressing Resident 33's progressive decline in functioning and decreased food intake. The DON stated that Resident 33's code status was changed to DNR and the new POLST addressing DNR status was discussed with appointed Public Guardian who participated in the care conference by phone. The DON stated that Public Guardian did not want to sign the new POLST with DNR status. When the DON was asked if Resident 33's Public Guardian agreed with DNR status, the DON stated, Not really. He did not want to take that responsibility. The DON explained that Resident 33 did not have Advance Directive (AD, a legal document in which persons specify their wishes for their health needs if they were no longer able to make decisions for themselves). The DON added that Public Guardian explained that in absence of AD, he assumed that the resident wanted to be full code [all life-saving measures, including cardio-pulmonary resuscitation-CPR] and he refused to sign. The DON was asked if POLST form was considered valid in the absence of resident's appointed Public Guardian, and the DON replied, We informed him. The DPSQ agreed that without Public Guardian's signature, the POLST with DNR status was not valid.During a follow up interview and record review with DON on 4/9/26, at 11:16 a.m., the DON stated Resident 33's functional decline was addressed by her physician on 12/20/22 and 1/21/23.A review of the physician progress notes dated 12/20/22 indicated that Resident 33 was Stable with current medications.Currently full code on her POLST form.I would support switching her to DNR.Nursing is already initiated evaluation.through the ethics committee. The physician's note did not indicate if Resident 33's DNR status was addressed with Public Guardian. A review of Resident 33's physician progress notes dated 1/21/23 indicated, Stable with current medications.With review of ethics committee and her public guardian, she was changed from full code to DNR. The DON stated she did not recall if Resident 33's code status was discussed during one of the ethics committees.On 4/9/26 the facility was requested to provide a policy addressing POLST and the DON stated there was no specific policy addressing POLST available. The DON explained, We follow state requirement and explanation on the POLST form. During an interview on 4/9/26 at 12:01 p.m., the DPSQ stated there was no documented evidence that Resident 33's DNR status was discussed during one of the ethics committees in 2022 or later. The DPSQ stated that per Chief Medical Officer, two (2) physicians can sign DNR without guardian's approval in emergency situations, when the resident has to go to surgery or something emergent. The DPSQ explained that on 12/20/22 Resident 33 did not have planned surgery and there was no emergency situation with the resident's health.On 4/10/26 at 12:35 p.m., the DPSQ provided a policy titled, Health Care Decisions for Unrepresented Patients, dated 3/17/21. The policy indicated that its purpose was to provide a process for making ethically, legally, and medically appropriate treatment decisions on behalf of persons who lack health care decision capacity and for whom there is no surrogate decision-maker. If a patient is incapacitated, a surrogate maker can be designated. This person can be.a court-appointed conservator of the person. The policy further indicated, This policy may be used when the following conditions are met: The patient has been determined by the primary physician.to lack capacity to make health care decisions.No agent, conservator, or guardian has been designated to act on behalf of the patient.

Based on observation, interview, and record review, the facility failed to ensure physician's order was followed for one of 13 sampled residents (Resident 7), when monthly weights were not obtained as ordered. This failure had the potential risk for Resident 33 to have unrecognized weight loss.A review of Resident 7's admission Record indicated Resident 7 was admitted in Fall 2024 with the diagnoses which included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills) and Crohn's Disease (an immune disorder where the immune system attacks healthy gut tissue). A review of Resident 7's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/12/26, the MDS indicated that Resident 7 did not have the capacity to make decisions and was at risk for weight loss. A review of review of Resident 7's Order Summary Report, dated 4/10/26, indicated Weigh resident monthly. CNAs [Certified Nursing Assistants] to document in POC [Plan of Care]. Every day shift every 30 day(s) for monthly weights (measurement in pounds [lb.] and ounces [oz]). A review of Resident 7's Weight and Vital Summary (WVS), dated 4/10/26, reflected Resident 7's weight had not been measured for the month of December 2025 and February 2026. The WVS further showed Resident 7 had a 13 lb. 4 oz. decline in December 2025 and a 3 lb. 4 oz. decline in February. During a concurrent observation and interview on 4/9/26 at 2:20 p.m. with Certified Nursing Assistant (CNA) 4 in Resident 7's room, Resident 7 was found with a partially eaten pureed diet at her bedside. CNA 4 stated Resident 7 was on a pureed diet.hasn't been eating today. CNA 4 further stated Resident 7's weights were expected to be obtained monthly using a Hoyer lift (a lift system to provide accurate weights for bedbound residents). During an interview on 4/9/26 at 5:30 p.m. with CNA 3, CNA 3 stated Resident 7 had a risk for weight loss and that the expectation was to weigh Resident 7 monthly. During a concurrent interview and record review on 4/10/26 at 10:15 a.m. with Licensed Nurse (LN 5), Resident 5's weight record and orders were reviewed. LN 5 confirmed Resident 7 had not been weighed in December 2025 and February 2026 and that the expectation was for Resident 7's weight to be obtained monthly to monitor weight or boost increase Resident 7's calories. During an interview on 4/10/26 at 12:10 p.m. with the Director of Nursing (DON), the DON stated weights were expected to have been completed monthly if the order indicated monthly weights and that monitoring the weight was important so staff could recognize the changes and the actions needed for the residents. A review of the facility's policy and procedure (P&P) titled, Assessment and Reassessment, dated 2025, indicated, To ensure residents are provided adequate and appropriate care data collection and analysis are ongoing.information from the resident's medical history.will provide * a unique path toward achieving or maintaining his or her highest practical level of well-being.

Based on observation, interview, and record review, the facility failed to ensure psychotropic medications (medications that affect mood and behavior) were administered in accordance with acceptable standards of practice for one of 13 sampled residents (Resident 6), when Resident 6 was administered Citalopram (an antidepressant medication) without documentation of a diagnosis of depression or other clinically appropriate indication for use.This failure placed Resident 6 at risk for unnecessary exposure to psychotropic medications and potential adverse effects (unwanted, uncomfortable, or dangerous effects) related to the use of Citalopram. A review of the admission record indicated the facility admitted Resident 6 in 2024 with multiple diagnoses which included high blood pressure, diabetes mellitus (elevated blood glucose), and fracture of right upper arm.A review of Resident 6's clinical record contained a physician order dated 10/22/25 for Citalopram 10 milligram (mg, a dose of measurement) every day for depression as manifested by feeling of hopelessness and lack of interest. A review of Resident 6's profile did not indicate that the resident had diagnosis of depression.A further review of Resident 6's clinical record indicated that Resident 6 was initially prescribed Citalopram 40 mg every day for depression upon admission on [DATE]. Resident 6's clinical record indicated that the Citalopram dose was gradually decreased to 30 mg, then to 20 mg, and then to 10 mg.A review of physician's admission history for Resident 6 dated 4/5/24 and physician's progress notes dated 8/1/24, 9/29/24, 12/8/24, 12/31/24, 2/24/25, 4/17/25, 7/6/25, 10/16/25, 11/18/25, 1/26/26, and 3/26/26 did not contain depression listed on resident's profile as one of the resident's diagnoses.A review of the Minimum Data Set (MDS, a federally mandated assessment) dated 4/11/26 indicated that Resident 6 was cognitively intact. According to MDS section for mood assessment, Resident 6 never experienced symptoms of depression, including Little interest or pleasure in doing things. Feeling down depressed or hopeless. Resident 6's list of diagnoses listed in MDS assessment did not contain diagnosis of depression.A review of MDS assessments dated 4/11/24, 7/11/24, 1/9/25, 4/10/25, 7/10/25 indicated Resident 6's depression score as 00. Resident 6's list of diagnoses listed in MDS assessment dated [DATE], 7/11/24, 1/9/25, 4/10/25, 7/10/25 did not contain diagnosis of depression.A review of Psychotropic Medication Evaluations (MUE's, a clinical review used to determine whether medications that affect mood, behavior, or thinking were appropriate, necessary, safe, and effective) from June 2025 through December 2025 indicated Resident 6 had 0 episodes of hopelessness and lack of interest. The MUE's did not contain the diagnosis of depression and required indication for administration of Citalopram.During an observation and interview on 4/6/26 at 11:10 a.m., Resident 6 was observed in her room, working on sudoku crossword. Resident 6 was pleasant, smiling, and answered appropriately to all questions in the language other than English. Resident 6 explained that she was very private person and liked to stay in her room watching news or working on crosswords.During a follow up observation and interview on 4/7/26 at 4:30 p.m., Resident 6 was in her room, listening to the news. When Resident 6 was asked about Citalopram, the antidepressant medication that she was taking, Resident 6 started laughing. Resident 6 stated, I don't think I have depression. Resident 6 explained that her family did not visit her frequently, but she had friends who visited her, and she talked to them on the phone. Resident 6 stated that sometimes she would go to activities for bingo or other games. Resident 6 explained, I am not very social person, never been, plus that fact that I do not speak English well, so I like to stay in my room. I prefer to stay in my room - working on puzzles, crosswords, listening to news. Resident 6 stated she was not aware that she had diagnosis of depression and added, I don't think I feel hopeless and lacking interest in life, it's my choice not to go to activities.During an interview with Licensed Nurse (LN 3) on 4/7/26 at 5 p.m., LN 3 stated Resident 6 was talking Citalopram for depression. When LN 3 was asked to describe Resident 6's symptoms of depression, LN 3 stated, She's always calm and pleasant. I have not seen her crying or complaining of being depressed.During an interview with Certified Nursing Assistant (CNA 2) on 4/10/26 at 10:35 a.m., CNA 2 described Resident 6 as calm, very quiet. CNA 2 stated, She's never sad, and I have not seen her crying or talking that she's depressed.We offer activities, and she decides if she wants to go or not.During a concurrent interview and record review on 4/10/26 at 8:35 a.m., with Director of Nursing (DON), the DON stated that Resident 6 was taking Citalopram for depression since her admission to facility in 2024. Upon reviewing Resident 6's clinical records, including list of diagnoses, the DON validated that the resident's clinical records did not include a diagnosis of depression. The DON confirmed that multiple physician progress notes did not indicate that the resident had depression. The DON stated that depression was not listed on Resident 6's MDS assessments since 2024. The DON reviewed Resident 6's records and stated that diagnosis of depression was listed on Resident 6's profile before the resident's admission to facility but was not carried over to her list of diagnoses upon admission to the facility. The DON stated that residents receiving antidepressant medications were required to have a documented diagnosis of depression reflected in their clinical profile. The DON validated that Resident 6 did not have documented diagnosis of depression. The DON stated there was no pharmacy consultant's recommendations to the prescribing physician to clarify the diagnoses of depression that was missing on Resident 6's active diagnoses list.During a telephone interview and record review on 4/10/26 at 10:50 a.m., with Pharmacy Consultant (PC) and DON present, the PC stated that any resident receiving antidepressant therapy was required to have a documented diagnosis of depression listed in their profile. The PC stated Resident 6 was prescribed Citalopram 10 mg for depression. The PC stated she had limited access to Resident 6's clinical records and was not aware that the resident did not have a diagnosis of depression listed in her profile.A review of the facility's policy titled, Psychotropic Drug Use, with revision date of 1/2026, indicated the purpose of the policy was to outline proper procedures and proper documentation for psychotropic medications use. The policy indicated, Psychotropic medications are defined as Anti-Psychotics, Anti-Depressants, Hypnotics, and Anti-Anxieties. The policy did not specify that residents will be administered psychotropic medication to treat specific condition or diagnosis documented in resident's clinical records.

Based on observation, interview, and record review, the facility failed to provide standard quality care to one resident (Resident 4) of a sample of 13 when catheter placement and care were not included in Resident 4's care plan, orders, treatment record, and urine output log.This failure increased the potential for Resident 4 to get a urinary tract infection (UTI - an infection caused by bacteria entering the urinary tract, including the bladder and kidneys) and be readmitted to the hospital.Findings:A review of Resident 4's admission Record [AR] indicated she was admitted to the facility on [DATE] with diagnoses that included the removal of the left cancerous kidney (a disease condition caused by an uncontrolled division of abnormal cells) and acute right kidney failure. The AR indicated Resident 4 was her own responsible party. A review of Resident 4's nursing Progress Notes, dated 3/24/26, indicated she was admitted to the hospital for a UTI.A review of nursing Progress Notes, dated 4/1/26, indicated Licensed Nurse (LN 1) performed Resident 4's nursing admission assessment upon her return to the facility from the hospital on 4/1/26. The progress note indicated the hospital inserted Resident 4's urinary catheter (an indwelling tube inserted into the urethra- a tube allowing urine to drain out into a urine bag) on 3/27/26 to monitor exact urine output.A review of Resident 4's Interim Care Plan, dated 4/1/26, indicated LN 1's documentation that Resident 4 had an indwelling urinary catheter, with no further information. A review of the facility's policy and procedure titled, Assessment and Reassessment, revised 11/2025, indicated, The interim care plan is started within 24 hours of admission by the admitting nurse. The interim care plan is based on the medical doctor orders, the initial nursing assessment . It must minimally contain information about.devices, toileting needs.[and] guides all care until the comprehensive care plan is completed. A review of Resident 4's Care Plan Report, dated 4/9/26, indicated no goal had been entered regarding an individual plan of care for her catheter.A review of Resident 4's Order Summary Report, dated 4/9/26, indicated no medical orders were written for her catheter care.A review of Resident 4's Treatment Administration Record (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident), dated April 2026, indicated no orders for the catheter care (e.g. cleaning).A review of Resident 4's urinary output log indicated no data was entered for urinary output amounts from 4/1/26 to 4/10/26.A review of the facility's policy and procedures titled, Intake and Output, revised 11/2024, indicated, If residents have an indwelling catheter, Intakes and Outputs will be documented in the Electronic Health Record.During a concurrent interview and record review on 4/10/26 at 9:03 a.m. with Licensed Nurse (LN 2), LN 2 stated Resident 4 was sent to the hospital the last week of March 2026 for a UTI and stated there was concern for the resident's remaining kidney. LN 2 looked for a urinary catheter order and stated it was not in Resident 4's records, nor could she find treatment instructions for catheter care in the TAR and stated the orders should have been written. LN 2 stated the nurses know how to perform cleaning of the urinary catheter, but there was nowhere for them to document the care on the TAR. LN 2 stated that the lack of catheter orders was not up to quality standards of practice.During a concurrent interview and record review on 4/10/26 at 9:15 a.m. with the Director of Nursing (DON), DON looked at Resident 4's care plan, orders, treatments, and urinary output log, and confirmed she could not find the order for the catheter, nor its care or urinary output amounts. DON stated the orders should have been entered soon after Resident 4's readmission from the hospital on 4/1/26. DON stated that since the catheter was not in the care plan, staff would not be aware she had one and needed catheter care. DON stated the failure to include the presence of the catheter could cause inadequate or missed nursing care, leading to recurrence of Resident 4's UTI and a second hospitalization. DON also stated Certified Nursing Assistants should have had an order to measure and chart urinary output amounts each shift, but confirmed no charting was completed for urinary output from 4/1/26 through 4/10/26.A review of the facility's policy and procedures titled, Insertion, Management and Removal of an Indwelling Urinary Catheter, revised 5/5/23, indicated, The physician or advanced practice professional is responsible for writing the order for.management.of the urinary catheter. The Registered Nurse (RN) is responsible for following the provider's orders. The document further described the daily care procedure for indwelling catheters: Catheter care performed daily and as needed (i.e., when soiled) with approved wipe product. and ensure documentation is completed for cleaning the catheter as well as the amount of urine.

Based on observation, interview, and record review, the facility failed to ensure residents' confidentiality was maintained for one resident (Resident 52) for a census of 45 when a computer screen was open and unattended by staff; publicly displaying Resident 52's private medical information.This failure decreased the facility's ability to protect Resident 52's private health information.Findings:A review of Resident 52's admission Record indicated he was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and gangrene (a serious, potentially fatal condition involving tissue death caused by lack of blood supply or severe bacterial infection) of the left foot.A review of Resident 52's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/9/2026, indicated his Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 14 out of 15, showing his cognition was intact.A review of Resident 52's admission packet, signed by Resident 52 on 4/6/26, indicated his Resident Rights [involved]. confidentiality of information including medical records.During a concurrent observation and interview on 4/8/26 at 8:09 a.m. in the hallway, an unattended medication cart's computer screen displayed a section of Resident 52's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), which included Resident 52's code status (a medical order that specifies what type of life-saving measures a patient desires) and medications he was taking. Licensed Nurse (LN 1) finished administering medications to Resident 52 and returned to the medication cart and stated she had partially closed the computer's screen flap to conceal his medical information. LN 1 stated she should not have left the unattended computer screen open, and that it was a breach of privacy because visitors or other residents could view the resident's medications.During an interview on 4/9/26 at 10:10 a.m. with the Director of Nursing (DON), DON stated nurses are expected to lock the computer screen each time they leave the cart to administer medication to residents, which effectively blanks out the screen. DON stated LN 1 violated the Health Insurance Portability and Accountability Act (HIPAA - a federal law that mandates strict standards for protecting the privacy and security of patient health information in healthcare settings), which could expose Resident 52's private health information to anyone walking down the hallway.A review of the facility's policy and procedure titled, HIPAA Privacy Rule-Confidentiality, revised 4/3/25, indicated the facility's purpose was to .ensure management and staff are committed to efforts to protect the privacy and security of our patients. The document further indicated, [Facility name] shall expect all employees to comply with privacy and security policies [by] .securing patient records containing individually identifiable health information so that they are not readily available to those who do not need them.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent an avoidable fall accident for one of three sampled residents (Resident 1), who was identified at high risk for falls.This failure resulted in Resident 1 falling, hitting his head and fracturing his right femur (thighbone), causing severe pain, and transfer to the hospital. Resident 1 was placed on comfort care in the hospital and died on [DATE], 3 days after the fall incident.A review of the admission record indicated the facility admitted Resident 1 in November of 2025 with multiple diagnoses which included aftercare following right hip arthroplasty (a surgical procedure to replace the fractured joint and restore mobility) and dementia (when a person has progressive decline in mental abilities and has trouble remembering, learning new things, concentrating or making decisions). Resident 1's medical history indicated he had history of frequent falls.A review of Order Summary Report indicated the following orders dated [DATE], SAFETY DEVICE: Bed Pad Alarm [a pad with sensors that will alarm when a resident stands up unassisted by alerting staff] .every shift.Clip alarm [a device, similar to bed pad] while in wheelchair.A review of the Fall Risk Evaluation dated [DATE] indicated that Resident 1 had a score of 16 (total score of 10 or above represented high risk for falls). The clinical evaluation indicated Resident 1 had decreased muscular coordination and required to use assistive devices, including walker and wheelchair.A review of Resident 1's admission Minimum Data Set (MDS, an assessment tool), dated [DATE] indicated that Resident 1 had severely impaired cognitive status.A review of care plan initiated on [DATE], indicated Resident 1 was at risk for falls. The care plan goal indicated Resident 1's risks for falls and injuries will be reduced. The care plan interventions directed staff to assist resident with ambulation and transfers, utilize devices (bed pad and clip alarms) to ensure safety, evaluate resident's environment to identify factors known to increase fall risks. The care plan did not address Resident 1's poor safety awareness and did not include hourly checking and monitoring.A review of the SBAR (an acronym for Situation, Background, Assessment, Recommendation, a communication tool used between members of the health care team) dated [DATE] at 4:11 p.m., indicated that Resident 1 experienced a change in condition (COC). The SBAR indicated, Staff saw resident walk out from his room and fell on the hallway. Assessed resident and he seems in a lot of pain. Cannot move his lower extremities. The COC note indicated Resident 1 was transferred to emergency department (ED) for evaluation.A review of Post Fall Evaluation Note (PFEN) dated [DATE] at 5:36 p.m., indicated that Resident 1 had a witnessed fall on [DATE] at 4:15 p.m. The PFEN indicated, Resident [1] was found ambulating [walking] in hallway directly outside of his room without device or staff assist. Resident has poor balance and difficulty walking and requires one person for all walking and transfers.Resident was unsteady and was not using.walker [assistive device for standing and walking]. Resident lost his balance and fell to the right landing on his right side and hitting the back of his head. The PFEN indicated that Resident 1 experienced pain is his right hip and back of head from the fall.A review of ED physician's note dated [DATE] at 10:22 p.m., indicated that Resident 1 had severe deformity (body part appear or function differently than how it is supposed to be) of the right femur (thighbone).A review of CT (computed tomography, an imaging procedure) result performed at ED on [DATE], indicated that Resident 1 had displaced fracture of right femur, further away from where he had joint replacement surgery on [DATE]. The CT result indicated that bone fracture resulted in hemorrhage (ruptured blood vessels) into Resident 1's intramuscular (within a muscle) area.A review of ED nursing progress note dated [DATE] at 8:08 p.m., indicated that Resident 1 was airlifted via Emergency Medical Services helicopter for further evaluation and treatment to another hospital.During an interview on [DATE] at 10:20 a.m., the Director of Nursing (DON) stated that Resident 1 was admitted to facility for rehabilitation after joint replacement surgery. The DON stated Resident 1 had unsteady balance, required staff's assistance with transfer and ambulation, and was at high fall risk. The DON stated that on [DATE] Resident 1 was observed by Licensed Nurse (LN 1) ambulating in the hall unsupervised and without walker and fell in the hall hitting his right side. The DON explained that the facility used a bed pad alarm as one of the safety measures. The DON stated that pad alarm was supposed to alert staff when Resident 1 attempted to get up from his bed, but on that day, the alarm did not go off, and staff were not aware that Resident 1 got out of his bed and started ambulating. The DON stated that in addition to utilizing pad alarms, the staff were to round on residents every hour, to assess and assist with their needs, especially on residents identified at high risk for falls. The DON explained that during hourly rounding staff would check on residents visually, but the visual checks were not documented.During a tour of Hall 4 accompanied by DON on [DATE] at 10:35 a.m., another resident (Resident 2) was observed standing in the doorway to her room attempting to walk into the hall. The bed pad alarm in the resident's room was beeping loudly and the call light above room was blinking. A loud beeping sound was coming from the device at the nursing station alerting staff that Resident 2 got out of bed, but no staff were present in the hallway and at the nursing station. The DON stated Resident 2 was identified at high risk for falls and had pad alarm to alert staff when she attempted to get out of bed.During a continued interview on [DATE] at 10:40 a.m., in Resident 2's room, the DON demonstrated how the bed pad alarm sent alerts to staff when resident moved in bed or attempted to get up. The DON stated that the facility was not able to establish why the bed pad alarm in Resident 1's room did not go off and Resident 1 got up and injured himself. The DON explained that the pad alarm was retested after Resident 1's fall and it worked fine without any functional issues.During an interview on [DATE] at 10:45 a.m., LN 1 stated that Resident 1's cognition and safety awareness were impaired, and he was not able to use a call light to call for assistance. LN 1 stated that Resident 1 was at increased risk for falls and required to have staff assistance when getting out of bed and ambulating. LN 1 stated the facility utilized bed pad alarm and chair clip as safety measures to alert staff when Resident 1 attempted to get up from bed.During a continued interview on [DATE] commencing at 10:45 a.m., LN 1 explained that on [DATE] around 4:15 p.m., she was at the nursing station with other staff. LN 1 added, I looked and saw Resident [1] standing in the doorway. Initially I thought somebody was behind him. He did not have a walker. He teetered a few times and by the time I got there, he fell in the hallway on his right side. LN 1 stated Resident 1's room was further away from nursing station. LN 1 stated that Resident 1's bed pad alarm did not go off when Resident 1 got up unassisted from bed.During an interview on [DATE] at 11:10 a.m., with a Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 1 was always confused and sometimes attempted to get out of bed. CNA 1 stated that Resident 1 was not allowed to get up by himself, even with a walker. CNA 1 explained that on [DATE] Resident 1 was up in wheelchair for a long time and seemed very tired. CNA 1 stated when she transferred Resident 1 to bed, the bed pad alarm gave two short beeps indicating that it was activated. CNA 1 stated she reported to the nurse when she left for lunch, and another CNA was covering for her residents. CNA 1 stated she started rounding on her assigned residents after her lunch and when left another resident's room, she saw Resident 1 already on the floor in the hallway. CNA 1 added, He was moaning and yelling when we attempted to move him, but unable to verbalize pain. CNA 1 stated that according to LN 1, Resident 1's alarm did not go off. CNA 1 added, Normally it's blaring loud when the resident attempts to get up.During an interview on [DATE] at 11:57 a.m., with Physical Therapist (PT), PT stated Resident 1 had physical therapy every day. The PT stated Resident 1 became stronger after receiving therapy for a few weeks but still required to have staff's assistance with transfers. The PT added, Staff had to keep close eye on him because he had fallen so many times at home. His balance was not good. The PT explained that on [DATE], before Resident 1's fall incident, Resident 1 did not do well [with therapy] .We tried to stand up, and he needed maximum assistance and continued falling backward. The PT added, I don't know how to explain that he walked from his bed which is next to window all the way into hallway.During a follow up interview on [DATE] at 11:25 a.m., pad alarm functionality was discussed with DON with the presence of Quality &Patient Safety. The DON explained that pad alarms did not require checking for functionality and were guaranteed to work for 30 days after which they were to be replaced. The DON added, I don't know what happened that the alarm did not go off and the resident fell and fractured his leg.During a telephone interview on [DATE] at 9:35 am., Resident 1's 'At risk for falls' care plan dated [DATE] was discussed with DON. The DON was asked if Resident 1's care plan fall prevention interventions were individualized. The DON stated that the care plan was based on Resident 1's MDS assessment and addressed the resident's risk for falls. The DON did not provide answer when asked if care plan interventions should address hourly checks and monitoring related to the resident's poor safety awareness.A review of the facility's policy titled, Fall Risk Assessment/Fall prevention, dated 11/2025, indicated, It is the policy of this facility to assess residents for risk of falls upon admission.in order to identify residents at risk for future falls and prepare a plan of care to reduce the potential for future falls.Prevention interventions will be initiated immediately and documented on the care plan.Residents will be placed in high visibility rooms and may have one or more alarms to alert staff of unassisted attempts to transfer themselves. The policy indicated that fall injury prevention intentions will be customized to each resident.A policy addressing resident's safety, supervision, and accident prevention was requested multiple times but was not provided.

Based on interview and record review, the facility failed to assess and evaluate the resident's clinical condition and risk factors for developing urinary tract infection (UTI, an infection in the bladder and urinary tract) for one of 5 sampled residents (Resident 1), when the resident experienced weakness and difficulties with urination. This failure had the potential to delay the provision of care and treatment for Resident 1 and placed the resident at risk for unnecessary pain and emotional distress. A review of the admission Record indicated the facility admitted Resident 1 in early 2025 with multiple diagnoses which included history of prostate cancer (cancer of the prostate gland, located below the bladder) and acute kidney failure (AKF, a condition when kidneys fail to filter waste and extra water suddenly potentially causing health problems; one of the causes of AKF is blockage of urinary tract).A review of Resident 1's Minimum Data Set (MDS, - a federally mandated resident assessment tool), dated 6/19/25, indicated Resident 1 was cognitively intact. The MDS assessment indicated Resident 1 had ability to urinate but was frequently incontinent.During a concurrent observation and interview on 7/22/25, commencing at 2:30 p.m., Resident 1 was observed sitting in wheelchair in his room. Resident 1 was alert and oriented and answered all questions appropriately. Resident 1 stated that last week he started having lots of pain in his lower abdomen, the bladder area. Resident 1 described that the pain was sharp and when asked to rate the pain on a scale of zero (0) to 10, where 10 is the worst pain he had ever experienced, the resident stated the pain was 10 out of 10. Resident 1 added, I could not urinate. Had urge but only a few drops would come out. Resident 1 stated he had a history of frequent UTI's, and he knew the symptoms of UTI. Resident 1 stated he and his wife told his nurse that he was in pain and was unable to urinate, and felt like I had another UTI, and asked to be sent to emergency department (ED).During a continued interview on 7/22/25, at 2:30 p.m., Resident 1 explained that nurses used a bladder scanner (a portable electronic ultrasound device used to measure the amount of urine in a bladder) in the past to check if he was retaining the urine due to blockage, but that particular evening his nurse did not scan his bladder, did not check his blood pressure, and did not offer pain medications.During a continued interview on 7/22/25, at 2:30 p.m., Resident 1 stated that his blood pressure was very high when he arrived at ED. Resident 1 explained that the physician tested his urine at ED and he was diagnosed with UTI. Resident 1 added that he was sent back to facility with a prescription for antibiotic (medications to treat infection).A review of Resident 1's clinical records contained a nursing progress note dated 7/17/25, at 9:57 p.m., which indicated, Was called .to assess the resident. Resident is alert and oriented .Family member (wife) is at bedside stated that his husband is acting different (facing [sic] out and weak), and that his husband can't pee. The nurse documented that the resident was transferred to ED.A review of Resident 1's clinical records contained no documented evidence the nurse assessed the resident's pain, his vital signs, including blood pressure, heart rate, respiratory rate, and temperature. There was no documented evidence the nurse assessed resident's abdomen for distension or used a bladder scanner to check if he was retaining urine. During a concurrent interview and record review on 7/22/25, at 1:17 pm., with the Director of Nursing (DON), the DON acknowledged that the Resident 1's electronic clinical records did not contain resident's assessment. The DON stated that nursing notified her that evening regarding Resident 1's condition and added, The resident was fine.This was his wife's request to send the resident to ED. The DON stated the facility documented resident's assessment on a paper document that was sent with the resident to ED.During an interview and record review with DON on 7/22/25, at 1:43 p.m., the DON provided a document titled, SBAR [situation, background, assessment, recommendation, communication tool for MD [Medical Doctor], transfer to ER/Acute/Other facility, dated 7/17/25. The instruction on SBAR document directed the nurse Situation: State the problem .when it happened or started, and how severe. Background: Pertinent background information related to the situation.include the following: .most recent vital signs.Other clinical information.Assessment: What is the nurse's assessment of the situation? The nurse documented, Pt [patient's] wife reports pt [patient] acting different.patient is weak & spacing out.History of UTI. The SBAR document did not contain the information when the resident started experiencing issues with weakness, spacing out, and inability to urinate, how severe the problem was, did not include vital signs, and had no resident's assessment as instructed.During a review of the document with DON on 7/22/25, at 1:43 pm., the DON acknowledged that the SBAR document was not completed properly. The DON validated there was no resident's assessment, no vital signs, and other information related to Resident 1's issues with spacing out and inability to urinate. The DON agreed that the resident had multiple medical conditions which could possibly increase his risk for UTI or urine blockage. The DON added that the expectation for the nurse was to assess the resident's mental status, vital signs, pain, and a bladder scan to assess if the resident retained urine, but it was not done. The DON validated that Resident 1 was diagnosed with UTI when he was sent to ED and the physician prescribed the antibiotics to treat his infection.

Based on observation, interview, and record review, the facility failed to protect two residents (Resident 1 and Resident 2) from abuse, when the staff witnessed Resident 1 hitting Resident 2 in the head and Resident 2 grabbing Resident 1's forearm. In addition, the facility failed to assess and document Resident 1's skin injury and the treatment that was provided. This failure resulted in Resident 2 being hit on the head and Resident 1 receiving skin tears to right forearm and had the potential to result in emotional distress for Resident 1 and Resident 2. Findings: A review of the admission record indicated the facility admitted Resident 1 in 2021 with multiple diagnoses, which included dementia (a progressive state of decline in mental abilities) and depression. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/8/25, indicated the resident scored 10 out of 15 for Brief Interview for Mental Status (BIMS, an assessment tool used to screen and identify memory, orientation, and judgement status of the resident), which indicated moderate impaired cognition. A review of Resident 1's interdisciplinary care plan dated 5/20/25 indicated, RESIDENT TO RESIDENT ALTERCATION, Resident displayed inappropriate treatment of another resident; Resident received inappropriate treatment from another resident. The nursing interventions directed staff to ensure safe environment and perform body check for injuries. A review of the admission record for Resident 2 indicated the facility admitted the resident in 2015 with multiple diagnoses which included dementia and anxiety. A review of Resident 2's MDS dated [DATE] indicated the resident BIMS of 10, which indicated moderate impaired cognitive status. A review of Resident 2's interdisciplinary care plan, dated 5/20/25 indicated, RESIDENT TO RESIDENT ALTERCATION, Resident displayed inappropriate treatment of another resident; Resident received inappropriate treatment from another resident. A review of the nursing alert notes for Resident 1, dated 5/20/25, at 5:02 p.m., indicated, Residents were gathered in dining room with activity staff present. This resident . walked down .and tapped another resident [Resident 2] . in the head with an open hand. The note further indicated that Resident 2 grabbed Resident 1's arm and dug in his nails leaving several deep scratches. The note indicated that first aid to Resident 1 was administered. A review of Resident 1's clinical record, including skin and wound assessments failed to reveal the facility staff assessed and documented the resident's skin injury obtained during the altercation with Resident 2. There was no documented evidence that nursing staff documented the location, measurements, description of the injuries, and treatment that was provided. During an interview on 6/3/25, at 9:30 a.m., the Director of Nursing (DON) validated that there was a witnessed altercation between Resident 1 and Resident 2 on 5/20/25. The DON stated the facility had difficulty to determine who was the victim and added, [Resident 1] was the one that initially tapped [Resident 2] on his head, but he ended up being injured. During an observation and interview on 6/3/25, at 10:05 a.m., Resident 1 was observed laying in his bed. Resident 1 responded appropriately to questions asked. Resident 1 was observed having a few scattered bruises and three scabs on his right forearm. Resident 1 explained, This guy [Resident 2's name] grabbed my arm and my skin got ripped. You see, my skin is so thin .was bleeding . lots of blood. My arm was sore. Resident 1 added, He [Resident 2] took offence on something I had said. I don't remember what I said. During an observation and interview with Resident 2 on 6/3/25, at 10:15 a.m., Resident 2 was observed in his bed. When Resident 2 was asked about the altercation with Resident 1, the resident stated, My memory is gone completely . I can't recall if I hurt him and I don't remember if he hurt me. If I did, I can't recall. During an interview with facility staff (FS) on 6/3/25, at 11:04 a.m., the FS stated that the altercation between Resident 1 and Resident 2 happened on 5/20/25, around 5 p.m. The FS stated Resident 1 was standing in front of Resident 2 and both were swinging their arms like attempting to punch each other and then [Resident 2] suddenly grabbed [Resident 1's arm. The FS stated the incident happened very quickly after which Resident 1's forearm started bleeding and the resident's nurse was notified of the skin injuries. During an interview with Licensed Nurse (LN 1) on 6/3/25, at 11:30 a.m., LN 1 stated she was notified by FS that [Resident 1] hit [Resident 2] in the head after which [Resident 2] grabbed [Resident 1's] forearm and squeezed hard. LN 1 stated Resident 1 had three skin tears and they were bleeding. LN 1 stated the photo of skin tears was taken on 5/20/25 and the description of the injuries to Resident 1's forearm should be found under skin and wound assessment in the resident's clinical record. Upon reviewing the record, LN 1 was not able to locate the assessment, description of skin tears or picture of Resident 1's injuries. During a follow up interview and record review with DON on 6/3/25, at 12 p.m., the DON provided a document titled, [Name of the facility] skilled nursing new skin condition and explained that this checklist was used every time the nurses observed resident having a new skin issue. The DON stated that per LN 1's documentation, Resident 1's skin and wound assessment and a progress note about the wound were completed and signed on 5/20/25 and validated that the resident's clinical record did not reflect any wound/skin assessment documentation dated 5/20/25. The DON stated the expectation was that nurses followed the facility protocol and documented skin tears assessment in Resident 1's clinical record. A review of the facility's 'Abuse Policy,' with the revision date of 8/24, indicated, It is the policy of the Skilled Facility to promote an environment free from any type of abuse for all of its residents .After identification of any type of abuse, a full head to toe assessment must be done on the resident/s and documented in the medical record . Any bruising .skin tear .will be documented .Any visible injuries should be photographed.

Based on interview and record review, the facility failed to provide adequate supervision when staff left Resident 1 unattended to prevent an avoidable accident from occurring for 1 of 3 sampled residents (Resident 1). This failure resulted in Resident 1 falling and sustaining a hip fracture (broken bone). Findings: During a review of Resident 1 ' s Admission Record (front page of the chart that contains a summary of basic information about the resident), the Admission Record indicated, Resident 1 was admitted to the facility in December 2024 with multiple diagnoses which included Alzheimer ' s Disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1 ' s Minimum Data Set (MDS- a resident comprehensive assessment tool), dated 3/15/25, indicated, Resident 1 ' s decisions were poor and cues/supervision were required. The MDS further indicated, Resident 1 needed partial to moderate assistance while eating. During a review of Resident 1 ' s Fall Risk Assessment, dated 3/13/25, it indicated Resident 1 was at high risk for falls and Resident 1 had 3 or more falls in the past three months. During a review of Resident 1 ' s Care Guide, dated 3/20/25, indicated, Please do not leave me unattended .I may try to self transfer . During a review of Resident 1's nursing progress notes, it indicated Resident 1 had an unwitnessed fall on 4/12/25 and sustained a left hip fracture. Resident 1 was found down at 400 nurses station .CNA [Certified Nursing Assistant] set up dinner while resident was seated .patient found lying L lateral [left side] .ED [emergency department] was contacted for assistance . During a review of Resident 1 ' s x-ray results, dated 4/12/25, indicated Pelvic/hip pain following trauma .displaced (to move from its usual place) .fracture left hip. During a review of facility ' s reported incident (FRI) to the department, dated 4/17/25, the FRI indicated, . [Resident 1] underwent surgery for an intermedullary nailing [surgical procedure used to stabilize broken bones] on 4/13/25. The resident returned to our facility on 4/15/25 as a skilled resident where she is receiving physical [focus on restoring, maintaining and improving a person ' s ability to move and function] and occupational therapy [focus on improving a person ' s ability to perform tasks, develop skills and maintain independence in their daily routine] to help her return to her prior level of functioning, and skilled nursing for pain management and surgical site care. During an interview on 4/29/25 at 2:05 p.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated she left Resident 1 at the nurse ' s station to answer a call light. CNA 1 confirmed she did not let any staff know that Resident 1 was by herself. CNA 1 further confirmed all other staff were busy in other resident rooms. CNA 1 stated, Resident 1's fall could have been prevented if there was another pair of eyes on her. During an interview on 4/29/25 at 2:25 p.m., the Interim Director of Nursing (IDON) acknowledged that Resident 1 should be supervised during all meals and confirmed the CNA left Resident 1 unattended. IDON further acknowledged the fall could have been prevented if someone was watching Resident 1. During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment/Fall Prevention dated 8/2024, the P&P indicated, It is the policy of this facility to .prepare a plan of care to reduce potential for future falls .If the Fall Risk Evaluation total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls .Prevention interventions will be initiated immediately .

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 hit Resident 1 on the face as witnessed by Resident 2 ' s one-on-one sitter. This failure reduced the facility's potential to protect Resident 1's right to be free from physical abuse and had the potential for Resident 1 to suffer physical and emotional injury. Findings: During a review of Resident 1 ' s Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including intestinal adhesions (scar-like tissue that form inside the abdomen), severe protein-calorie malnutrition (lack of sufficient protein and calories), weakness, hypertension (high blood pressure) and encounter for surgical aftercare following surgery on the digestive system. During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/2/25, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 11 out of 15, which indicated moderate memory impairment, with 15 indicating no memory impairment. During a review of Resident 1 ' s Progress Note (PN), dated 2/20/25, the PN indicated, at approximately 0430 [4:30 a.m., after midnight] resident ' s roommate walked over and slapped her in the right side of the face unprovoked . During a review of Resident 2 ' s AR, the AR indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia with other behavioral disturbance (a progressive state of decline in mental abilities), hypercalcemia, unspecified psychosis not due to a substance or known physiological condition (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), anorexia (eating disorder that causes a severe and strong fear of gaining weight) and Alzheimer ' s disease with late onset (a disease characterized by a progressive decline in mental abilities.) During a review of Resident 2 ' s PN from her initial admission, PN indicated that on 12/22/24, Resident 2 struck staff on three separate occasions. During a review of Resident 2 ' s entry MDS, dated [DATE], cognitive patterns section assessment was not completed. During a review of Resident 2 ' s Discharge Return Anticipated MDS, dated [DATE] cognitive patterns section assessment was not completed due to Resident 2 ' s unplanned discharge. Resident 2 ' s behavior MDS dated [DATE], indicated Resident 2 exhibited physical and verbal behavioral symptoms directed towards others, had rejected evaluation or care, and had been wandering, respectively. During a review of Resident 2 ' s PN, dated 2/20/25, the PN indicated, Resident [2] while being supervised by one-on-one sitter struck another resident/roommate [Resident 1] in the face unprovoked. Resident [1] that was struck was sitting on bed . During a telephone interview on 3/22/25 at 12:54 p.m. with Patient Safety Technician (PST, sitter), PST stated Resident 2 was walking toward the hallway when Resident 2 suddenly turned and struck Resident 1 in the face. PST reported he was positioned behind and to the side of Resident 2 at the time. The PST stated, Resident 1 ' s bed was near the doorway and Resident 1 was sitting upright at the foot of the bed. The PST confirmed he witnessed Resident 2 strike Resident 1 in the face. During an interview on 3/22/25 at 12:59 p.m. with Interim Director of Nursing (IDON), IDON stated that all residents have the right to be free from abuse. During an interview on 3/22/25 at 1:45 p.m. with Resident 1, Resident 1 stated that when Resident 2 struck out, the motion caused the material of Resident 2 ' s clothing to hit her in the right eye, which she described as painful at the time. Resident 1 stated that, at the time of the incident, she was sitting at the foot of her bed. Resident 1 expressed frustration, stating she was upset because Resident 2 was supposed to have a one-on-one staff monitor, yet Resident 2 was still able to strike her. She added that Resident 2 had been heading toward the door when she suddenly turned and hit her. During an interview on 3/22/25 at 2:34 p.m. with IDON, IDON confirmed the incident between Resident 1 and Resident 2 met the facility ' s definition of abuse, as outlined in their P&P. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Policy, dated 8/2024, the P&P indicated, . It is the policy of the Skilled Nursing Facility to promote an environment free from any type of abuse for all its residents .

Based on interview and record review, the facility failed to respond in a timely manner to a medication irregularity for one of 16 sampled residents (Resident 8), when the facility did not follow up on a Pharmacy Consultant (PC) recommendation to discontinue nitrofurantoin (antibiotic, a medication to treat infections) for 56 days. This failure placed Resident 8 at an increased risk for developing adverse drug consequences (unwanted, uncomfortable, or dangerous effects) from the prolonged use of an antibiotic medication. Findings: A review of the admission record indicated the facility admitted Resident 8 earlier this year with multiple diagnoses which included chronic pain and a history of urinary tract infections (UTI-an infection of the urinary track which includes the kidney, bladder, or urethra). A review of the physician order dated 2/4/23 indicated, Nitrofurantoin . 50 MG [milligram, unit of measurement] .Give 1 capsule by mouth one time a day for UTI prophylactic (a medication used to prevent disease). A review of the clinical record for Resident 8 contained a pharmacy consultant (PC) report titled, Consultation Report, dated 8/8/23. The PC report indicated a recommendation to discontinue nitrofurantoin and initiate another medication while monitoring for signs and symptoms of UTI. The PC documented, Rationale for Recommendation: The potential for developing pulmonary fibrosis [a serious lung disease that occurs when lung tissues becomes damaged and scarred resulting in difficulty to breathe], hepatotoxicity [liver damage], C difficile infection [inflammation of the colon resulting in diarrhea and pain], and peripheral neuropathy [a condition peripheral nerves become damaged resulting in pain, numbness, and weakness in the hands and feet] increases with duration of use. The section of the report with the information of the physician's response to the pharmacist's recommendation, signature, and the date was blank. A review of Resident 8's clinical records indicated there was no documented evidence the facility acted upon the recommendation to discontinue nitrofurantoin and order another antibiotic recommended by PC. A review of Resident 8's medication administration records (MARs) for August 2023 and September 2023 indicated that the resident continued to receive nitrofurantoin 50 mg every morning after the PC wrote the recommendation to discontinue the medication. A review of Resident 8's MARs from October 1 through October 4, 2023 indicated Resident 8 continued receiving nitrofurantoin 50 mg every morning. During a concurrent interview and record review on 10/3/23, at 11:40 a.m., the facility's Infection Preventionist (IP) confirmed that the facility did not act upon a pharmacist recommendation dated 8/8/23 to discontinue nitrofurantoin. The IP added, We had no DON for three (3) months, and it was missed. A review of the facility's policy titled, Medication Regimen Review, with a revision date of 8/17/23, indicated, The Consultant Pharmacist will conduct MRRs [medication regiment reviews] and will make recommendations based on the information available in the residents' health record .Facility should encourage Physician/Prescriber .and the Director of Nursing to act upon the recommendations contained in the MRR .Facility should encourage Physician/Prescriber to either accept and act upon the recommendations .or reject .recommendations .and provide an explanation as to why the recommendation was rejected. During an interview on 10/4/23, at 2:05 p.m., the DON stated that the facility should have acted upon the pharmacy consultant's recommendation to discontinue nitrofurantoin within 72 hours after receiving the report and added, We missed it.

Based on observation, interview, and record review, the facility failed to provide treatment and services to maintain mobility and prevent further decrease in range of motion for two of 16 sampled residents (Resident 22 and Resident 34), when: 1. Resident 22's physician's order and care plan's interventions for the management of his left arm weakness and left hand contracture (shortening and hardening of muscles and ligaments leading to deformity, rigidity of joints, and loss of motion) were not followed, and 2. Resident 34 did not receive restorative nursing assistant (RNA, exercises to improve or maintain resident's functional abilities) services consistently per physical therapy (PT) recommendations and her care plan's interventions. These failures placed Resident 22 and Resident 34 at risk for further complications and decline in their physical functioning and mobility. Findings: 1. A review of the admission record indicated the facility admitted Resident 22 in 2019 with multiple diagnoses including brain bleed (stroke) resulting in resident's left-sided paralysis, muscle weakness, and left hand contracture. A review of a physician order dated 12/21/21 indicated Resident 22 was to wear a sling for comfort to support his weakened left arm during the day. A review of Resident 22's Minimum Data Set (MDS, a standardized assessment tool used to plan resident's care) dated 9/21/23 indicated the resident had no cognitive impairment. The section of the MDS titled Functional Limitations in Range of Motion, indicated that Resident 22 had impairment of upper extremity, including shoulder, elbow, wrist, and hand) on one side. A review of 'Resident [22's] Care Guide' (care plan) dated 9/28/23 indicated, I wear a .sling to support my left upper extremity .When out of bed, I wear a soft L [left] hand roll with my .sling .to prevent contracture .Please, remember to help me don my .sling when I am out of bed. During a concurrent observation and interview on 10/2/23, at 12:25 p.m., Resident 22 was sitting in his wheelchair in his room. Resident 22's left hand fingers were curled into his palm and he did not have a hand roll. Resident 22 did not have a sling on and used his right hand to support his left arm to it from slipping off the wheelchair's armrest. When the resident was asked if he had any assistive devices to support his left arm, Resident 22 stated he used to have a sling but did not know where it was or what happened to it. Resident 22 added, I've lost it a while ago, I think three or four months ago . I think laundry lost it. I asked . my CNAs to look for it, and they couldn't find it. Resident 22 stated that it was more comfortable to have a sling on to support his left arm, but nobody offered to look for it or to order a new sling. During an observation of Resident 22's room, a sign 'Sling and Splint Schedule' was noted taped to the door to resident's closet. The sign indicated, Wear L [left] arm sling during day for comfort as tolerated. Next to that sign was posted another sign with instructions for 'Sling Tips' directing nursing staff to don the sling whenever the resident wanted to wear his sling. During a concurrent observation on 10/3/23, at 11:30 a.m., Resident 22 was sitting in the dining room in his wheelchair. There was no sling to support Resident 22's left arm and from time to time the resident was noted to support his left arm with his right arm. During an interview on 10/3/23, at 12:10 p.m., Licensed Nurse (LN 1) stated she was familiar with Resident 22's care. LN 1 stated that Resident 22's left arm was flaccid (limp and weak) and added that the resident should have a sling when he is in his wheelchair to support the arm. LN 1 stated she did not notice if Resident 22 had it on earlier when she administered his medications. LN 1 stated Resident 22's left hand was contracted and he was to hold onto a soft roll to prevent his contracture from worsening. During an interview on 10/3/23, at 12:17 p.m., Certified Nursing Assistant (CNA 1) stated that Resident 22 had to wear a sling and a little spongy ball in his left hand to prevent further contracture. CNA 1 stated a sling and hand roll were stored in the resident's room in a little basket. During an observation on 10/3/23, at 12:30 p.m., Resident 22 was observed in the wheelchair in his room. Resident 22 did not have the sling to support his left arm and there was no soft roll in his left hand. Resident 22 stated, I need to support my left arm because it sometimes slips of the wheelchair. Resident 22 added that he had to hold onto a little foamy ball to prevent his fingers from curling more. During a concurrent interview on 10/3/23, at 12:47 p.m., the facility's Physical Therapist (PT) and Occupational Therapist (OT) stated that Resident 22 received therapy services at present. The OT stated that the resident had to wear the sling for his left arm. The OT explained that the resident had a foamy soft hand roll to manage his left-hand contracture and needed frequent reminders to grab and hold onto it to prevent his hand contracture from worsening. The OT stated that she had not seen Resident 22 wearing his sling lately and added, Sometimes things get misplaced. During an observation on 10/4/23, at 11:20 a.m., Resident 22 was observed sitting in wheelchair in without his sling and soft roll. During an interview on 10/4/23, at 11:28 a.m., LN 2 stated she was familiar with Resident 22 and his care. LN 2 stated the resident had a physician order to wear the sling to support his paralyzed left arm while he was in his wheelchair. LN 2 stated Resident 22 was not wearing the sling lately and was not able to explain why the physician's order was not followed and the resident had not been wearing the sling. During an interview on 10/4/23, at 2:02 p.m., the Director of Nursing (DON) stated that Resident 22 should have had his left arm sling on every day to maintain his comfort and good body position. The DON stated the expectation for nursing staff was to follow a physician order and follow the care plan's interventions reminding the resident to keep a hand roll to prevent further contractures to his left hand. The DON added that if the sling was lost, the facility should have ordered a new sling as soon as possible and if the resident refused to wear the sling, his physician should have been notified. 2. A review of the admission record indicated the facility admitted Resident 34 a year ago with multiple diagnoses including multiple sclerosis (a chronic disease of the central nervous system affecting person's vision, balance, mobility, and emotions). Resident 34's history indicated that the resident had multiple falls with injuries in the past related to the resident's weakness and poor balance. A review of Resident 34's MDS assessment dated [DATE] indicated the resident had no cognitive impairment. Resident 34's functional status assessment indicated that she had weakness on both lower extremities and required staff's assistance to ambulate. A review of Resident 34's 'Care Guide' (care plan) revised 7/13/23 indicated that the resident had progressive lower extremities weakness and impaired balance. The care plan indicated that to maintain her strength, balance, and safety, Resident 34 received RNA services two times a week using the exercise bike and ambulating with her walker. The care plan's goal indicated that Resident 34 will maintain her functional independence and mobility. A review of the physical therapist discharge summary dated 8/23/23 indicated that Resident 34 met maximum potential and was discharged from physical therapy services on 8/18/23. The PT discharge summary indicated that the resident was referred to restorative nursing services to improve her mobility and decrease risk for falls. The discharge summary contained instructions for RNA staff to follow while ambulating and exercising Resident 34. A review of Resident 34's weekly nursing assessments dated 8/27/23, 9/4/23, 9/11/23, and 10/1/23 indicated that the resident was on RNA program. During an observation and interview on 10/2/23, at 9:19 a.m., Resident 34 was observed lying in her bed. Resident 34 stated she was dizzy and lightheaded when she attempted to stand up and walk and required staff's assistance. Resident 34 stated she had had multiple falls in the past. When Resident 34 was asked if she was on RNA program, the resident replied, Sometimes they exercise me on that bike. During a continued interview, Resident 34 stated the staff assisting her to the bathroom were the only exercises she received lately. During an interview on 10/4/23, at 8:47 a.m., RNA 1 stated that Resident 34 had been on the RNA program for a long time. RNA 1 explained that Resident 34's RNA program included ambulating and exercising on the bike twice a week. RNA 1 stated that the residents, including Resident 34 have not been receiving RNA services for weeks because she had been working the floor as certified nursing assistant (CNA). RNA 1 explained that she was the only RNA in the entire facility trained to provide RNA services and added, When I'm working as CNA, residents don't get their exercises. RNA 1 stated she had not offered RNA services to Resident 34 in three weeks. A review of the RNA Program report provided by the RNA 1 indicated that Resident 34 was offered RNA exercises four times in the month of August 2023, instead of eight times. A review of the RNA program report indicated that Resident 34 was offered RNA exercises one time in the month of September 2023 instead of eight times. There was no documented evidence that Resident 34 was offered RNA services from 10/1 through 10/4/23. During an interview with DON on 10/4/23, at 2:15 p.m., the DON stated that the facility had issues with providing their residents with RNA services and acknowledged that residents' care plans were not followed consistently. The DON stated that the facility had one trained RNA and she was pulled from the RNA program to take over CNAs assignments frequently. The DON stated RNA program was important for Resident 34 to help her stay safe and to prevent worsening of the resident's mobility and added, It's our goal that residents don't lose their ability to walk. A review of the facility's policy and procedure titled, Restorative Care Program, with the revision date of 4/21, indicated the purpose of the policy was To maintain [residents] quality of life. The policy further indicated that the facility offered a Restorative Nursing program to any resident .who is identified as needing the services .to improve and/or maintain joint ROM [Range of Motion], normal body alignment and overall functional strength, mobility .to increase resident self-esteem .to minimize the effects of disability.

Based on observation, interview, and record review, the facility failed to implement an individualized comprehensive care plan for 1 of 3 sampled residents (Resident 1) when hourly safety checks were not documented for Resident 1. This failure had the potential for Resident 1 not being properly monitored when Resident 1 fell and sustained a left [CONDITION(S)]. Findings: Resident 1 was admitted to the facility in mid 2020 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's interdisciplinary care plan (ICP) dated 11/17/20, indicated, Problem: At risk for injury related to high fall risk . The ICP also indicated interventions that included: Provide safe, hazard free environment. A review of the most recent quarterly Minimum Data Set (MDS, an assessment tool) dated 1/20/21, indicated Resident 1 scored 2 in Cognitive (thinking) Skills for Daily Decision Making indicating she was moderately impaired. The MDS further indicated Resident 1 was impaired on one side of her lower extremities, and required supervision when walking. A review of a Fall Risk Evaluation, dated 1/20/21, indicated Resident 1 scored 14 and was categorized as at risk for falls. A review of Resident 1's resident care guide (individualized care plan) dated 1/27/21, indicated, Nursing concerns . [Resident 1] had a .lack [of] insight into safety . The care plan also indicated interventions which included: Please make sure to do visual checks every hour . A review of Resident 1's nurse practitioner note, dated 2/11/21 at 3 p.m., indicated, .[Resident 1] had been walking in the hallway, which is very common for her .when she reached for a [late meal] cart and then slipped forward and fell on her left side, striking her leg, left arm and head against the floor and cart. She was immediately thereafter in pain in her left lower extremity .X-ray revealed a displaced and angulated left femoral neck [hip bone] fracture. A review of Resident 1's post fall evaluation dated 2/11/2021 at 5:29 p.m., indicated, .Activity at the time of fall: ambulating. Reason for the fall was evident.: at risk. Poor safety awareness. Pre-Fall: Fall Risk score: 14 .Safety teaching documented before the fall: No. Did an injury occur as a result of the fall: Yes .Did fall result in ER [emergency room ] Visit/hospitalization : Yes . During an interview on 2/24/21 at 12:05 p.m., Staff 5 stated Resident 1 was ambulatory without assistive devices and usually ambulated through hallways 300 and 400. Staff 5 also stated it was expected for staff, To keep an eye on the resident [1]. During an interview on 2/24/21 at 12:50 p.m., Staff 6 stated they were in the nurses station when they, Heard metal [a] bang sound. Staff 6 saw Resident 1 on the floor. During an interview on 3/11/21 at 2:20 p.m., Staff 5 acknowledged with a fall risk evaluation of 14, Resident 1 was a high fall risk. Staff 5 further acknowledged it was expected for the Certified Nursing Assistants (CNAs) to visually check Resident 1 hourly. Staff 5 confirmed no documented evidence the hourly visual check was implemented. During an interview on 3/11/21 at 2:40 p.m., Staff 7 acknowledged Resident 1's Section G (functional status) of MDS were coded as requiring, Supervision. Staff 7 confirmed Resident 1's walk in corridor and locomotion on unit required, Oversight, cue, visual check, and redirect. During an interview on 3/12/21 at 12:18 p.m., Staff 4 confirmed no documented evidence Resident 1's hourly visual check was implemented. Staff 4 stated it was expected for staff to communicate and carryout interventions in the care plan. During an interview on 3/16/21 at 12:21 p.m., Staff 1 acknowledged it is the nurse's responsibility that care plans are implemented consistent with resident needs and goals. A review of facility policy titled, Assessment and Reassessment revised September 2020, indicated, 'Policy: To ensure residents are provided adequate and appropriate care .Care Planning in the SNF: The Care Plan addresses needs resulting from the resident's condition and .will help guarantee their [residents], Highest practical level of wellbeing.' A review of the facility policy titled, Fall Risk Assessment/Fall Prevention revised November 2019, indicated, It is the policy of this facility to .prepare a plan of care to reduce potential for future falls .If the Fall Risk Evaluation total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls .Prevention interventions will be initiated immediately .

Based on interview and record review, the facility failed to follow a physician order for [REDACTED]. This failure increased the risk of fractures for Resident 1. Findings: Resident 1 was admitted to the facility in 2018 with fractures, weakness and [MEDICAL CONDITION] (decreased bone strength). A review of the Physical Therapy discharge note, dated 9/20/18, indicated for Goal 5, the resident did not meet goals for stand by assistance and use of gait belt (a waist belt that helps the resident to be stabilized with staff assist) because of low blood pressure and varying levels of stability and balance. The Physical Therapist (PT) recommended 2 person assist for transfers. A review of the Interdisciplinary Progress Notes (IDT) dated 3/11/19, indicated Resident wanted to go to Bingo today. Prepped to walk in hallway with walker and W/C (wheel chair) .Suddenly, her legs buckled and she almost went down. The Restorative Nursing Assistant (RNA) notified staff and cautioned that two persons were necessary when ambulating. A review of the Physicians Orders dated 6/1/19 - 6/30/19, indicated in the Ambulation section that two staff members assist was necessary at all times. The resident's Weekly Summary noted that Resident 1 had been assessed and the level of of assistance/support provided had been Ambulation Level of Assistance/Support provided: stand by assist. A Progress Notes dated 6/8/19 at 10:30 p.m., indicated that the resident had a fall while transferring to the bed from the bathroom. A Certified Nurses Assist (CNA) witnessed and found that the resident had deformity of the right distal tibia (lower leg) and severe swelling of the right distal tibia just below the knee. The note indicated that [MEDICATION NAME] (a narcotic pain medication) was administered for pain and the resident was transferred to the ED (Emergency Department). Review of the resident's Progress Notes dated 6/15 at 6:20 p.m., indicated the resident had returned to the facility with a [DIAGNOSES REDACTED]. A Progress Notes dated 6/17/19 at 6:37 p.m., indicated the resident was very uncomfortable, sad and discouraged. another note for 6/17/19 at 11:09 p.m., indicated the resident had pain that was very hard to control despite doses of narcotic pain med every four hours. A Physicians Note, dated 6/18/19, indicated that Resident 1 had fractured both legs in the past year, before admission to the facility. The physician further noted that the earlier fractures has been refractured and that her pain is not controlled despite doses of powerful pain medication. The physician ordered the resident be transferred to hospice for control of pain. The physician had discussed this with the resident and she agreed. A review of the resident's Progress Notes for 6/24/19 at 7:35 a.m., indicated the resident was no longer responsive. A note for 7:45 a.m., indicated the resident had passed away. In an interview with the Medical Director on 6/25/19 at 1:25 p.m., he stated that if it was ordered two person assist it should be two person assist. He stated had ordered the level of assistance had been recommended by the orthopedic doctor. He added that ambulating by herself was not a good idea because the resident was at high risk for fractures. In an interview with the Director of Nursing (DON), on 6/25/19 at 2:25 p.m., the DON stated PT should have updated the order for two person assist. She also stated it was the responsibility of PT to make recommendations and should have notified the Charge Nurse who would contact the doctor. The DON stated that was not done in this case. A review of the facility policy for unusual occurrences, dated 2/16, indicated it was the policy of the facility to provide a safe environment for residents. Review of the Nurse Practice Act, Rules and Regulations, Board of Registered Nursing,1997, documented The practice of Nursing within the meaning of this chapter means those functions, included health care that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or treatment thereof .including Direct and indirect patient care services that ensure the safety .protection of patients.