Every finding on record at Bayshire Rancho Mirage

Based on interview and record review the facility failed to receive a physician order for the use of oxygen, including the specific indication of its use, for 1 out of 3 residents reviewed (Resident 1).This failure resulted in Resident 1 being treated with oxygen without a physician order. Findings:On November 25, 2025, at 8:43 a.m. an unannounced visit was made to the facility for a quality-of-care issue.Resident 1 was admitted to the facility on [DATE], with a diagnosis of a urinary tract infection (UTI). Resident 1 was discharged from the facility on November 19, 2025. Resident 1 had a Brief Interview for Mental Status (A cognitive assessment) score of 9, indicating moderate cognitive impairment.A review of Resident 1's Minimum Data Set (MDS-a comprehensive clinical and functional assessment), dated October 19, 2025, Section O, Respiratory Treatments, indicated Resident 1 received intermittent (not continuous) oxygen therapy upon admission and while a resident of the facility.A review of Resident 1's admission physician orders dated October 12, 2025, untimed, indicated there were no orders for the use of oxygen during Resident 1's stay at the facility.A review of Resident 1's care plans (Individualized plan of care specific to resident's healthcare needs), indicated no care plan for oxygen use.On November 25, 2025, at 2:21 p.m., in an interview with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1's care, as she had been her CNA multiple times, and Resident 1 frequently used oxygen. On November 25, 2025, at 2:30 p.m., in an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had performed skin assessments and treatments on Resident 1, and she observed Resident 1 using oxygen.A review of Resident 1's, Infectious Diseases Progress Note, dated, November 16, 2025, at 11:13 p.m., by Medical Doctor (MD) 1, indicated, . Seen (Resident 1) at bedside on O2 (oxygen) . via NC (nasal cannula-tube with prongs that delivers oxygen through the nose). On November 25, 2025, at 4:06 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, treatment orders include the indication of why the treatment is ordered. The DON verified oxygen use is a treatment that requires a physician order. The DON verified Resident 1 did use oxygen during her stay at the facility and did not have a physician order for oxygen use.On December 2, 2025, at 9:39 a.m., a telephone interview was conducted with the DON, who stated the process to receive oxygen orders includes the nurse contacting the physician and notifying the physician of the residents need for oxygen. The physician would give the nurse an order for resident to use oxygen including the indications for use, the nurse would then transcribe (document) the order in the resident's medical record.A facility Policy & Procedure, Medication Orders, revised November 2014, indicated, .Supervision by a Physician .A current list of orders must be maintained in the clinical record of each resident.Recording Orders.Oxygen orders - When recording orders for oxygen, specify the rate of flow, route and rational (indication) .

Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications and devices in accordance with the facility's policies and procedures and/or manufacturer's instructions when: 1. One discontinued medication was stored in the Red Medication Cart with other active medications available for use; 2. A total of three expired medications and devices were stored in the Red Medication Cart, IV Cart (a cart used to store medications and supplies needed for intravenous medications given through a vein), Treatment Cart (a cart used to store medication and supplies needed for wounds treatment), and Medication Room; and 3. A total of three medications with incorrect expiration dates were stored in the IV Cart and refrigerator in the Medication Room. These failures had the potential for residents to receive discontinued, expired, or ineffective medications, leading to medication errors and compromised treatment outcomes. Findings: 1. On April 21, 2025, at 3:35 p.m., during an inspection of Red Medication cart in the Red Hall with Licensed Vocational Nurse (LVN 3), a blister card containing Calcium Acetate (supplement) 667 mg (milligram, unit of measurement) capsules were observed stored in active stocks, despite the order being discontinued. The label on the blister card indicated it was prescribed for Resident 24 with the direction to give one capsule by mouth with meals for supplement. The pharmacy fill date (the date the pharmacy dispensed the medication) on the label indicated 03/22/2025 (March 22, 2025) and four capsules remained in the blister card. During a concurrent interview and record review with LVN 3, LVN 3 verified the order for calcium acetate 667 mg capsules was discontinued on April 5, 2025. LVN 3 further stated the order had been changed to calcium acetate 667 mg tablets, with the direction to give three tablets before meals for supplement. Two blister cards containing the tablets for the active order were observed stored in the same medication cart. LVN 3 acknowledged the discontinued medication should not have been stored in the medication cart and should have been removed from the medication cart and properly disposed of in the pharmaceutical waste bin located in the medication room. The facility's policy and procedure (P&P) titled Discontinued Medications, revised November 2022, was reviewed, and indicated: .Staff shall destroy discontinued medications .Discontinued medications are destroyed .with facility policy and state regulations . 2a. On April 21, 2025, at 4:13 p.m., during an inspection of Red Medication cart in the Red Hall with LVN 3, an unused 3-mL Basaglar KwikPen (Insulin Glargine - a long-acting insulin used to prevent high blood sugar) 100 units/mL (units per milliliter, unit of measurement) for injection was observed stored at a room temperature with the open date written for 3/7/25 (March 7, 2025). The label on the insulin pen indicated it was prescribed for Resident 24 with the direction to Inject 6 units subcutaneously (Sub-Q - injection given in the fatty tissue under the skin) every night at bedtime for DM (Diabetes Mellitus - a condition where the body has trouble regulating blood sugar levels). During a concurrent interview with LVN 3, LVN 3 verified the insulin pen was expired. LVN 3 stated it should not have been stored in the medication cart beyond 28 days and should have been removed and properly disposed of in the pharmaceutical waste bin located in the medication room. The facility's P&P titled, Medication Labeling and Storage, revised February 2023, was reviewed, and indicated: .multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date . A review of the manufacturer's Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for BASAGLAR KwikPen, revised November 2023, indicated: .Storage and Handling .Not In-Use (Unopened) Room Temperature .28 days . 2b. On April 22, 2025, at 9:15 a.m., during an inspection of IV cart with the Assistant Director of Nursing (ADON), a total of six syringes of expired Heparin Lock Flush Solutions (solution to keep the IV line open by preventing blood clots from forming, and help fluids or medications keep flowing freely), 50 USP units/5mL (USP units per milliliter, unit of measurement) in 0.9% sodium chloride were identified. The manufacturer's expiration dates on the syringes indicated June 2024. During a concurrent interview with the ADON, the ADON confirmed the Heparin lock flush syringes were expired. The ADON stated it should not have been stored in the IV cart and should have been removed and properly disposed of in the pharmaceutical waste bin located in the medication room. 2c. On April 22, 2025, at 10:08 a.m., during an inspection of the Treatment cart conducted with LVN 4, a bottle of Adapt Stoma Powder (drug used to absorb moisture from broken or irritated skin around a stoma, a surgically created opening on the abdomen) was observed stored with the manufacturer's expiration date of June 2024. During a concurrent interview with LVN 4, LVN 4 confirmed the medication was expired and acknowledged the expired treatment medication should not have been stored in the treatment cart and should have been removed and properly disposed of in the pharmaceutical waste bin located in the medication room. 2d. On April 22, 2025, at 3: 26 p.m., during an inspection of the medication room conducted with the Director of Nursing (DON), additional expired Heparin lock flush syringes were identified in the bottom cabinet located under the sink. One partial and one full box of Heparin lock flush syringes had the manufacturer's expiration date of June 2024. During a concurrent interview with DON, the DON confirmed the Heparin lock flush syringes were expired. The DON stated the expired syringes should not have been stored in the medication cabinets and should have been removed and placed in the designated disposal cabinet for medications located in the same medication room. The facility's P&P titled Medication Labeling and Storage, revised February 2023, was reviewed, and indicated: .If the facility has .outdated .medications ., the dispensing pharmacy is contacted for instructions regarding returning or destroying these items . The facility's P&P titled Discarding and Destroying Medications, revised April 2019, was reviewed, and indicated: .Medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals .Staff shall contact the provider pharmacy if they are unsure of proper disposal methods for medications . 3a. On April 22, 2025, at 9:28 a.m., during an inspection of the IV cart conducted with ADON, the following IV diluent bags (small IV fluid bags used to dilute medications) for Resident 24 were observed stored out-of-overwrap (outside of the manufacturer's overwrap) without a documented beyond-use date (BUD - the date after which a medication that has been opened, mixed, or prepared should no longer be used, as its safety and effectiveness may no longer be guaranteed): - Nine bags of [NAME] 0.9% Sodium Chloride (NS - normal saline) 100 mL (milliliter, unit of measurement) sterile single-dose VIAFLEX (type of container) containers were observed for Resident 24 with the direction to use as directed with daptomycin (drug used to treat infection). The label indicated the pharmacy fill date of 03/28/2025 (March 28, 2025), and the expiration date of 4/26 (April 2026), matching the manufacturer's expiration date; and - Six bags of [NAME] NS 100 mL sterile single-dose VIAFLEX containers were observed for Resident 24 with the direction to use as directed with ceftriaxone (drug used to treat infection). The label indicated the pharmacy fill date of 03/28/2025 (March 28, 2025), and the expiration date of 4/26 (April 2026), matching the manufacturer's expiration date. On April 24, 2025, at 3:34 p.m., a telephone interview was conducted with Pharmacist 1. The Pharmacist 1 stated the pharmacy was not aware of this storage limit until the question was raised. According to a reference from the American Society of Health-System Pharmacists (ASHP - a nationally recognized organization that provides evidence-based guidance on safe medication use and storage practices in healthcare setting)'s publication titled, Applying Stability Data in Sterile Compounding, in the 7th edition of Extended Stability for Parenteral Drugs, dated on September 29, 2022, indicated: .Table 7: Manufacturer Storage of Commercial IV Solution Containers after Removal from Protective Overwrap .Viaflex containers .Volume ? 100 mL .Maximum Storage Time (Room Temperature) 30 d (days) . 3b. On April 22, 2025, at 9:59 a.m., during an inspection of the Medication Room conducted with the ADON, a total of eight compounded Ceftriaxone bags for IV infusion were observed stored in the medication refrigerator with the expiration date of 04/21/26 (April 21, 2026) which was one year from the pharmacy's fill date of 04/21/2025 (April 21, 2025). The labels on the bags indicated the medications were for Resident 24, with the direction to administer ceftriaxone 1 gm (gram - unit of measurement) (50ml) intravenously over 30 minutes once daily via PICC (peripherally inserted central catheter - a type of long, thin tube placed in a large vein in the arm to give medications or fluids over a long period of time) line using gravity tubing (a way to give fluids or medicine through an IV by using gravity) as directed at bedtime for bone infection. During a concurrent interview with ADON, the ADON stated the compounded IV medications were provided by a compounding pharmacy, contracted with the dispensing pharmacy to supply IV medications to the facility. On April 24, 2025, at 3 p.m., during a telephone interview with Pharmacist 2, the Pharmacist 2 stated the expiration date on the label was incorrect and the BUD for the compounded ceftriaxone IV bags should have been 10 days. The Pharmacist 2 stated the compounding pharmacy follows the USP <797> (the United States Pharmacopeia - a set of standards issued by the USP that provides guidelines to ensure the safe preparation, handling, and storage of sterile compounded medications) BUD limits for Category 2 CSPs (compounded sterile preparations - made in sterile condition) with the maximum storage of 10 days at refrigerator. A review of the undated reference titled, USP-797, provided by Pharmacist 2, indicated: .Table 13. BUD Limits for Category 2 CSPs: Compounding method: aseptically processed CSPs, no sterility testing performed and passed, prepared from only sterile starting components: 10 days at refrigerator . The facility's P&P titled, Medication Labeling and Storage, revised February 2023, was reviewed, and indicated: .For medications that are prepared or compounded for intravenous infusion, the label contains .date after which the mixture cannot be used . 3c. On April 22, 2025, at 3: 26 p.m., during an inspection of refrigerator in the medication room with the DON, a refrigerated Emergency Kit (E-kit, a sealed container with various medications for use in emergencies) was observed with the label on the outside of the E-kit container indicating an expiration date of 6/26 (June 2026). One of the medications stored in the E-kit was Cathflo Activase (medication used to break down blood clots and help unblock IV tubes, inserted to vein) 2 mg with the manufacturer's expiration date of October 2025. During a concurrent interview with the DON, the DON confirmed the expiration date of the Cathflo and stated the earliest expiration date of the medications stored in the E-kit should be indicated on the outside of the E-kit container to ensure no resident receives expired medication. On April 24, 2026, at 3:15 p.m., during a telephone interview with the facility's Consultant Pharmacist (CP), the CP stated he had checked the facility's E-kit during his visit. The CP also confirmed the earliest expiration date should have been indicated on the outside of E-kit container. On April 24, 2025, at 3:34 p.m., during a telephone interview with Pharmacist 1, Pharmacist 1 confirmed the E-kit had been provided by his pharmacy and acknowledged the earliest expiration date should have been written on the outside of the E-kit. The facility's P&P titled, Emergency Medications, dated April 2021, was reviewed and indicated: .The consultant pharmacist shall inspect the emergency medication kits monthly and record the findings on the record maintained with each kit . The facility's P&P titled, Medication Labeling and Storage, revised February 2023, was reviewed, and indicated: .labeling of medications .dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices .The medication label includes, at a minimum .expiration date .If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed in accordance with professional standards of practice when: 1. Four half (,d+[DATE]) size sheet steam drip metal pans and three eight quarts (8-qts - a unit of measurement) pitchers were stored wet; 2. One cup of undated cut fruits and one five pound (5-lb) tub low fat cottage cheese with an expiration date of [DATE], were found stored in the satellite kitchen refrigerator; and 3. One undated open bottle of reduced fat ultra filtered milk was found stored in the resident's refrigerator. These failures had the potential to cause food-borne illnesses (stomach illness resulting from ingestion of contaminated food) in a medically vulnerable population who received food prepared in the kitchen. Findings: 1. On [DATE], at 9:01 a.m., an initial tour of the main kitchen was conducted with the Dietary Manager (DM). Four ,d+[DATE] size sheet steam drip metal pans and three 8-qts pitchers were observed stored wet. During a concurrent interview with the DM, she stated the ,d+[DATE] size sheet steam drip metal pans and the 8-qts pitchers should not be stored wet. On [DATE], at 9:03 a.m., during an interview with the Registered Dietician (RD), the RD stated all dishes should be air-dried after every wash. She also stated the dishes should not be stored or stacked wet. She stated moist or wet dish can harbor bacteria that could result in food-borne illnesses. The facility policy and procedure titled, DISHWASHING PROCEDURE, revised [DATE], indicated, .Air dry dishes by racking or putting on single trays lined with mesh . A review of Food and Drug Administration (FDA - agency responsible for protecting public health by ensuring the safety of the food supply) Food Code 2022, Section ,d+[DATE].11, titled, Equipment and Utensils, Air-Drying Required, indicated, .After cleaning and SANITIZING, EQUIPMENT and UTENSILS .Shall be air-dried . 2. On [DATE], at 9:51 a.m., an initial tour of the satellite kitchen tour was conducted with the Dietary Aide (DA). One undated cup of cut fruits and one 5-lb tub of low-fat cottage cheese with an expiration date of [DATE], were found stored in the refrigerator. During a concurrent interview with the DA, she stated the cup of fresh fruits should have a date and the low-fat cottage cheese should have been discarded on [DATE]. On [DATE], at 9:03 a.m., during an interview with the RD, she stated the cut fruits were prepared in the main kitchen and delivered to the satellite kitchen for storage in the refrigerator. She stated the cut fruits should have a date when they were prepared before they were stored in the refrigerator. She stated the date will help the staff ensure the food is fresh and safe for resident consumption. The RD also stated, the kitchen staff should check all the food in the refrigerator. She stated the kitchen staff should check for expiration dates every day. She stated there should be no expired food in the refrigerator. 3. On [DATE], at 10:11 a.m., an inspection of the resident's refrigerator located in the dining area was conducted with the DA. One undated open bottle of reduced fat ultra filtered milk labeled with a resident's name was found in the refrigerator. During a concurrent interview with the DA, she stated the staff should put a date on the resident's food when they put them in the refrigerator. She stated the resident's reduced fat ultra filtered milk should have been dated when it was opened. On [DATE], at 1:46 p.m., the Certified Nurse Assistant (CNA) was interviewed. The CNA stated the staff should label resident's food with the room number, resident's name and the date it was received before storing them in the resident's refrigerator. On [DATE], at 9:03 a.m., during an interview with the RD, she stated all open food containers should have an open date. The RD stated the staff should label all food brought from home with an open date or the date the food was brought in the facility. She stated resident's food should be good for three to five days from the open date. The facility policy and procedure titled, FOOD STORAGE, revised [DATE], indicated, .Any expired or outdated food products should be discarded .All food products should be inspected for safety and quality and should be dated upon receipt, when open, and when prepared .Remember to cover, label and date .

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with professional standards of practice for one of five residents observed for medication administration (Resident 17) when the staff turned on the nebulizer machine (a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) before the resident placed the facemask over nose and mouth. This failure had the potential to result in the resident receiving less than the prescribed amount of medication, leading to ineffective drug therapy and a medication error due to inadequate medication administration. Findings: On April 21, 2025, at 9:01 a.m., during a medication administration observation with Licensed Vocational Nurse (LVN 1), LVN 1 was observed administering sodium chloride 3% inhalation solution (medication used in a nebulizer to help loosen mucus in the lungs, making it easier to clear from the lungs) to Resident 17 via nebulizer. It was observed LVN 1 added the inhalation solution into the nebulizer cup. LVN 1 then walked over to the nebulizer machine, which was located behind the resident's recliner, where the resident was seated, and turned on the machine. Mist began to be released immediately after the machine was turned on. LVN 1 then handed the face mask to Resident 17 from behind the recliner. Resident 17 was observed applying the face mask while mist was already being emitted from the nebulizer. A review of Resident 17's medical record titled Admission Record, indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD, lung disease causing difficulty breathing) with acute exacerbation (sudden worsening of the existing COPD symptoms with increased difficulty breathing, increased mucus production and coughing), pneumonia (lung infection), chronic respiratory failure with hypoxia (chronic lung condition with deficiency of oxygen). A review of Resident 17's medical record indicated there was a physician order on April 9, 2025, for Sodium Chloride Inhalation Solution 3%, with the direction to inhale 1 inhalation solution via nebulizer two times a day for COPD. On April 21, 2025, at 3:20 p.m., during an interview with LVN 1, LVN 1 stated due to limited space and clutter around the resident's recliner, he turned on the nebulizer machine first and handed the facemask from behind the recliner to the resident as quickly as possible. LVN 1 confirmed the mist was already being released from the mask after turning on the machine, before the resident had secured the mask. LVN 1 stated he should have observed the resident properly place the facemask over the nose and mouth before turning on the nebulizer machine. LVN 1 acknowledged some medication might have dispersed into the room and the resident might not have received the full dose of medication. On April 24, 2025, at 2:45 p.m., during an interview with the Director of Nursing (DON), the DON stated the staff should have first observed the resident properly apply the face mask before turning on the nebulizer machine. The DON acknowledged there was a likelihood some medication was released into the airs within the resident's room and the resident might have inhaled less than the prescribed dose. The facility's policy and procedure titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised, October 2010, was reviewed, and it indicated: .Dispense medication into nebulizer cup .Turn on the nebulizer and check the outflow port for visible mist .Ask the resident to hold the mouthpiece gently between his/her lips (or apply face mask) . The National Institutes of Health (NIH, the United States' primary biomedical and public health research agency) publication titled, How to use a nebulizer, dated October 2021 indicated: .Put the prescribed amount of medicine into the nebulizer cup. Place the mouthpiece in your mouth and close your lips around it to form a tight seal. If uses a mask, make sure it fits snugly against the face and covers the nose and mouth. Turn on the nebulizer machine. You should see a light mist coming from the back of the tube opposite the mouthpiece or from the mask .

Based on observation, interview, and record review, the facility failed to ensure the tubing, feeding bottle, and water bag were labeled and dated for one of two residents (Resident 238) who receive enteral feeding (nutrition provided through a tube inserted into the stomach). This failure had the potential to cause food borne illness to Resident 238. Findings: On April 21, 2025, at 9:24 a.m., Resident 238 was observed receiving Jevity 1.2 CAL tube feeding nutrition and water through an electronic pump delivery system (e-pump), while sitting up in bed. The Jevity bottle, water bag and tubing were observed not labeled and dated. On April 21, 2025, at 9:36 a.m., in an concurrent observation and interview, Licensed Vocational Nurse (LVN) 2 confirmed the Jevity bottle, water bag and tubing were not labeled and dated. She stated these should have been labeled with date, time and the resident's name. On April 24, 2025, at 9:25 a.m. an interview with the Director of Nursing (DON) was conducted. The DON stated that the tubing, tube feed bottles, and water bag should be labeled with resident's name, orders, date and time it was opened. Resident 238's record was reviewed. Resident 238 was admitted to the facility on [DATE], with diagnoses which included dysphasia (condition that affects your ability to produce and understand spoken language), encephalopathy (a disease process that alters brain function) and cervical spine fracture (broken neck). A review of Resident 238's physician orders indicated .one time a day Jevity 1.2 60ml(milliliters-unit of measure)/hr for 10 hours Flush 20ml/hr for 10 hours, off at 1800 (6:00 pm) and on at 0400 .Change G-Tube Enteral Feeding Bag and Tubing every day . A review of (name of brand) Jevity 1.2 Cal product information, dated 7/22/2024, indicated, .consume within 24 hours . A review of Lippincott procedures, dated 2022, titled, Initiating Enteral Nutrition, indicated, .Label the container and administration set with the date and time it was first hung .

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the residents when three medications with holding parameters were not administered in accordance with the physician's orders for one resident (Resident 14). This failure had the potential to significantly lower the blood pressure to cause dizziness, confusion, fainting and a fall. Findings: On April 24, 2025, a review of Resident 14's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included hypertension (HTN - high blood pressure) and atrial fibrillation (AFib - irregular heartbeat). A review of Resident 14's medical record indicated there were physician's orders for the following medications: - Benazepril (blood pressure medication) 5 mg (milligram, unit of measurement) with the direction to give 1 tablet by mouth at bedtime every 2 days for HTN, and hold for SBP (systolic blood pressure - the top number in blood pressure reading which measures how hard the heart pumps blood into arteries) less than 110 (mmHg, milliliter of mercury - unit of blood pressure measurement), dated March 21, 2025; - Terazosin (blood pressure medication) 5 mg with the direction to give 1 capsule by mouth at bedtime for HTN, and hold for SBP less than 110, dated March 21, 2025; and - Amiodarone (medication for irregular heart rhythm) 400 mg with the direction to give 1 tablet by mouth every 12 hours for AFib, hold for SBP less than 110 and/or HR (heart rate) less than 60. A review of Resident 14's Medication Administration Record (MAR), for March 2025 and April 2025, indicated Benazepril, Terazosin, and Amiodarone were administered to Resident 14 when the SBP was below 110 on the following dates and times: For Benazepril 5 mg: - March 23, 2025, at 2100 (9 p.m.), SBP 103; - March 25, 2025, at 2100 (9 p.m.), SBP 109; and - April 6, 2025, at 2100 (9 p.m.), SBP 104. For Terazosin 5 mg: - March 23, 2025, at 2100 (9 p.m.), SBP 103; - March 25, 2025, at 2100 (9 p.m.), SBP 109; - April 9, 2025, at 2100 (9 p.m.), SBP 96; and - April 13, 2025, at 2100 (9 p.m.), SBP 106. For Amiodarone 400 mg: - March 26, 2025, at 2100 (9 p.m.), SBP 93; - April 3, 2025, at 0900 (9 a.m.), SBP 108; - April 4, 2025, at 0900 (9 a.m.), SBP 105; - April 6, 2025, at 2100 (9 p.m.), SBP 104; - April 9, 2025, at 2100 (9 p.m.), SBP 96; and - April 13, 2025, at 2100 (9 p.m.), SBP 106. On April 24, 2025, at 2:45 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON verified the medications were documented as administered on the MAR for March 2025 and April 2025, despite the physician's order to hold the dose if the resident's SBP was below 110 mmHg. The DON acknowledged the physician's orders were not followed, and doses should have been held when the resident's SBP was below 110 mmHg. On April 24, 2025, at 3:15 p.m., during a concurrent interview with the facility's Consultant Pharmacist (CP), the CP stated he had not reviewed these medications since they were ordered after his most recent medication regimen review, completed on March 16, 2025. The CP stated if he had identified the holding parameters were not being followed for the blood pressure (BP) medications, he would have recommended for the physician to review the BP readings. The CP further stated he would have advised adjusting the medications or dosages as necessary to ensure safe administration. A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated: .Medications are administered in accordance with prescriber orders .

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for one of five residents (Resident 14) when two medications from the same therapeutic (drug) class, proton pump inhibitors (PPI - a class of drug that reduce the amount of acid made by the stomach), were ordered and administered for the same indication. This deficient practice had the potential for unnecessary duplicate therapy or additive medication adverse effects including bone fractures and gastrointestinal (stomach and intestines) infections. Findings: On April 24, 2025, a review of Resident 14's Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included gastroesophageal reflux disease (GERD - condition in which the stomach acid and contents flow back up into the esophagus and causes heartburn). A review of Resident 14's medical record indicated there was a physician orders for the following medications: - Pantoprazole (medication called proton pump inhibitor, PPI) 40 mg (milligram, unit of measurement), give 1 tablet by mouth in the morning for GERD, dated March 21, 2025; and - Omeprazole 20 mg (medication called PPI), give 1 tablet by mouth at bedtime for GERD, dated March 21, 2025. A review of Resident 14's Medication Administration Record (MAR), for March 2025 and April 2025 indicated both Pantoprazole 40mg and Omeprazole 20mg were administered daily from March 22 through April 23, 2025, with exception of April 8 and April 10, when Omeprazole 20 mg was not administered due to unavailability, as documented on the MAR with chart code 11 (med not available). There was no documented clinical rationale to justify the use of two different proton pump inhibitors, Pantoprazole 40mg in the morning and Omeprazole 20mg at bedtime, for the management of GERD. On April 24, 2025, at 2:45 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON verified both Pantoprazole and Omeprazole were documented on the MAR as administered daily. The DON acknowledged the medications are from the same therapeutic class and have similar mechanisms of action (how the drug works to produce a desired effect in the body). On April 24, 2025, at 3:15 p.m., during a telephone interview with the facility's Consultant Pharmacist (CP), the CP stated he had not reviewed these medications since they were ordered after his most recent medication regimen review, completed on March 16, 2025. The CP added he would have questioned the duplicate PPI medication use and would have asked for clinical justification. The CP also stated if there was no documented clinical justification, he would have recommended the physician to discontinue one of the PPI medications and, if clinically indicated, adjust the dosing regimen of the remaining PPI to be administered twice daily. The CP further stated there is no benefit in administering two different PPI medications, as they belong to the same therapeutic class and have similar mechanism of action. The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed and it indicated: .If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident .the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns . A review of Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Pantoprazole tablets, revised January 2025, retrieved from DailyMed (internet database operated by the U.S. National Library of Medicine providing labeling for prescription and nonprescription drugs), indicated: .Protonix (brand name for pantoprazole) is a proton pump inhibitor indicated for short-term treatment of GERD .Dosage for GERD .40 mg once daily for up to 8 weeks .suppresses the final step in gastric (stomach) acid production .Bone Fracture: Long-term and multiple daily dose PPI therapy may be associated with an increased risk for osteoporosis-related (a disease that weakens the bones) fractures of the hip, wrist or spine . A review of Prescribing Information for Omeprazole tablets, revised September 2012, retrieved from DailyMed, indicated: .Prilosec (brand name for omeprazole) is a proton pump inhibitor indicated for treatment of GERD .Dosage for GERD: 20mg once daily for 4 to 8 week .suppresses gastric acid secretion .PPI therapy may be associated with increased risk of Clostridium difficile associated diarrhea .Bone fracture: Long-term and multiple-daily dose PPI therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist or spine . A review of the National Institute of Health (NIH)'s National Library of Medicine (NLM, a nationally recognized source of medical information), titled Interchangeable Use of Proton Pump Inhibitors Based on Relative Potency, dated December 16, 2019, indicated: .consensus conferences have suggested that PPIs are more similar than different .The World Health Organization Collaborating Centre for Drug Statistics Methodology proposed that 20 mg omeprazole .40 mg pantoprazole .were equivalent for the treatment of GERD .

Based on observation, interview, and record review, the facility failed to ensure the [NAME] followed the recipe for preparing pureed bread for dinner on April 21, 2025. This failure had the potential to compromise the nutritional needs for one resident (Resident 138) reviewed for pureed diet. Findings: On April 21, 2025, at 3:54 p.m., the Cook, with the presence of the Dietary Manager (DM), was observed to prepare pureed bread for a resident who was on pureed diet (Resident 138). The [NAME] had the recipe for pureed bread in front of her as she read the directions. The [NAME] was observed conducting the following: a. Put five (5) slices of white bread, cut in small pieces, in the blender, and added three quarters (3/4) cup of regular milk and turned on the blender. b. Turned off the blender, used a wooden spoon to stir the contents in the blender which was of thick consistency. c. Added three more cups of regular milk and turned on the blender. d. Poured the contents of the blender in a metal container and added two spoonsful of thickener to the mixture and stirred it with the wooden spoon. The [NAME] used a disposable spoon to measure the thickener instead of using the appropriate measuring spoon. The pureed bread was runny and with a watery consistency. The [NAME] stated she followed the recipe for pureed bread and it was the right consistency. The DM who was present during the observation was asked to check the pureed bread made by the Cook. The DM used the wooden spoon to stir the pureed bread and stated it had the right consistency for pureed bread. The Registered Dietician (RD) was called to verify the consistency of the pureed bread. On April 21, 2025, at 4:08 p.m., the RD walked in the kitchen to verify the consistency of the pureed bread made by the Cook. The RD stated the pureed bread made by the [NAME] was watery and did not have the right consistency for pureed diet. She stated pureed diet should have a pudding-like consistency which is cohesive with no lumps. She stated when you scoop the pureed food with a spoon, the puree should hold its shape and form. She stated when you tilt the spoon, the puree will slide off easily. On April 24, 2025, at 9:03 a.m., during an interview with the RD, she stated the [NAME] did not follow the recipe for making pureed bread. She stated the [NAME] should have followed the recipe for pureed diet to get the right consistency and thickness. During review of the facility document titled, PUREED Bread Products, revised October 06, 2021, indicated, .Yields .5 (five servings) .Ingredients .Bread product .5 Each .Broth*, Milk*, or Juice* .3/4 cup .Thickener**, food .1 1/2 (one and a half) Tsp (teaspoon) .Directions .Remove portions required form the regular prepared recipe and place in food processor. Gradually add liquid to bread while processing and process until smooth. All liquid may not be required .Ensure mixture achieves smooth, lump free and extremely thick consistency . A review of the facility policy and procedure titled, STANDARDIZED RECIPES, revised August 31, 2018, indicated, .Standardized recipes will be used .Recipes note how to prepare the food items in order to preserve vitamins, taste, and appearance . A review of the facility policy and procedure titled, Mechanically Altered Diet Explanation (3 Levels), revised May 6, 2019, indicated, .Puree all foods to the consistency of smooth, moist mashed potatoes or pudding-like consistency .

Based on interview and record review the facility failed to ensure the Notice of Discharge (a notice informing the resident of their pending discharge date , and their rights to appeal the discharge) was provided to the Long Term Care (LTC) Ombudsman, following resident being notified of their pending discharge date for 5 out of 5 residents' (Residents 1, 2, 3, 4 & 5). This failures could have resulted in Residents 1, 2, 3, 4 & 5 not to be aware of their rights to appeal the discharge and the Ombudsman to not to be able to inform the residents of their rights and options to appeal prior to the resident being discharged . Findings: On March 15, 2024, at 10:00 a.m., an unannounced visit was made to the facility to investigate a Quality-of-Care issue. 1. A review of Resident 1's face sheet, indicated the resident was admitted to the facility on [DATE], with a diagnosis of a cerebral infarction (Brain tissue death due to blood vessel blockage), with a BIMS (Brief Interview for Mental Status- an interview used to assess cognitive intactness) score of 0 (severe cognitive impairment). A review of Resident 1's Doctor's (Drs) orders, dated, March 19, 2024, untimed, indicated, . LCD (Last Cover Date for insurance) DC (Discharge) (March 19, 2024) . A review of Resident 1's Notice of Transfer/Discharge, dated, March 11, 2024, untimed, indicated the resident was notified of his discharge date , and signed the notice of discharge on the same date, March 11, 2024, with a pending date of discharge March 13, 2024. A review of Resident 1's, Discharge Summary, dated, March 19, 2024, at 8:53 a.m., indicated the resident discharged from the facility on March 18, 2024, at 10:00 a.m. 2. A review of Resident 2's face sheet, indicated the resident was admitted to the facility on [DATE], with a diagnosis of a fractured left femur (upper leg bone), and a BIMS score of 12 (cognitively intact). A review or Resident 2's Drs orders, dated, March 15, 2024, untimed, indicated, . LCD (March 18, 2024) DC (Discharge) to . (Assisted living facility) . A review of Resident 2's, Notice of Transfer/Discharge, dated, March 13, 2024, untimed, indicated the resident was notified of his discharge date and signed the notice of discharge on the same date, March 13, 2024, with a pending date of discharge on March 18, 2024. A review of Resident 2's, Discharge Summary, dated, March 17, 2024, at 5:32 p.m., indicated the resident discharged from the facility on March 18, 2024, at 1:30 p.m. 3. A review of Resident 3's face sheet, indicated the resident was admitted to the facility on [DATE], with a diagnosis of fracture to the left femur (upper leg bone), and a BIMS score of 0 (severe cognitive impairment). A review of Resident 3's Drs orders, dated, February 13, 2024, untimed, indicated, . LCD (March 14, 2024), DC (March 15, 2024) . A review of Resident 3's, Notice of Transfer/Discharge, dated, March 11, 2024, untimed, indicated the resident's representative was notified via telephone call of the resident's discharge date on March 11, 2024, with a pending discharge date of [DATE]. A review of Resident 3's, Discharge Summary, dated, March 15, 2024, at 3:49 p.m., indicated the resident discharged from the facility on March 15, 2024, at 2:00 p.m. 4. A review of Resident 4's face sheet indicated the resident was admitted to the facility on [DATE], with a diagnosis of a urinary tract infection, and a BIMS score of 3 (Severe cognitive impairment). A review of Resident 4's Drs orders, dated, February 8, 2024, untimed, indicated, . Discharge to home with wife . no date given. A review of Resident 4's, Notice of Transfer/Discharge, dated, March 8, 2024, untimed, indicated the resident was notified of his discharge date , and signed the notice of discharge on the same date, March 8, 2024, with a pending discharge date of [DATE]. A review of Resident 4's, Discharge Summary, dated, March 11, 2024, at 3:27 p.m., indicated the resident discharged from the facility on March 12, 2024, at 12:00 p.m. 5. A review of Resident 5's face sheet, indicated, resident was admitted to the facility on [DATE], with a diagnosis of depression, and a BIMS score of 15 (cognitive intactness). A review of Resident 5's Drs orders, dated, February 23, 2024, untimed, indicated, .LCD (February 25, 2024) DC home . A review of Resident 5's, Notice of Transfer/Discharge, dated, February 22, 2024, untimed, indicated the resident was notified of her discharge date , and signed the notice of discharge on the same date, February 22, 2024, with a pending discharge date of [DATE]. A review of Resident 5's, Discharge Summary, dated, February 25, 2024, at 5:24 a.m., indicated the resident discharged from the facility on February 25, 2024, at 12:00 p.m. A review of Resident 5's, Discharge Notifications to the Ombudsman, dated, March 01, 2024, indicated, the Ombudsman was notified of Resident 5's discharge on February 25, 2024, on March 01, 2024. On March 15, 2024, at 10:51 a.m., an interview was conducted with the Social Services Director (SSD), who stated the resident &/or resident's representative are notified of their pending discharge, via a Notice of transfer/discharge, form, they sign and are given a copy at the time of their notification. The SSD further stated, once a month, at the end of the month, a copy of all the notice of transfer/discharges are faxed to the LTC Ombudsman for notification. On March 15, 2024, at 3:57 p.m., an interview was conducted with LVN 1 who stated, at the time of discharge, the resident is provided with a copy of their notice of discharge, then a copy is put in the Social Services box, to be faxed to the LTC Ombudsman for notification. On April 3, 2024, at 9:15 a.m., an interview was conducted with the Administrator who stated, Social Services was notifying the LTC Ombudsman of facility-initiated discharges all together once a month, not at the time the resident was notified of their pending discharge date . On April 9, 2024, at 3:50 p.m., an interview was conducted with the SSD, who stated she notified the LTC Ombudsman of all the March facility-initiated discharges in one fax (facsimile - electronic transmission) on April 1, 2024, but did not keep the fax confirmation. A facility policy and procedure titled, Notification to Ombudsman of Transfer and Discharge, revised April 2017, indicated, .Resident discharge to home or other entity .Social Services .will provide notice of discharge .Social services .will ensure receipt of signed notice of discharge .Social Services .will fax notification to Ombudsman .Social Services .to ensure delivery of notice to Ombudsman .Resident transfer to hospital .Social services .will send notification reprt to Ombudsman at a routine interval established by facility (monthly) . A facility Policy and Procedure, titled, Transfer or Discharge Notice, revised, December 2016, indicated, .A copy of the notice (of discharge) will be sent to the Office of the State Long-Term Ombudsman on monthly basis .

Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary team (IDT) assessed and documented for Resident 49 being capable of self-administering medications, prior to having the medication stored at the resident's bedside for administering it himself. This had the potential for inadequate drug therapy by allowing the resident to administer doses below or above the prescribed dose by the physician. Findings: On January 10, 2024, at 2:10 p.m., during inspection of the medication cart located in Red Hall, there was a manufacturer box for albuterol (medication to treat difficulty in breathing) aerosol inhaler, which had a pharmacy label to indicate it belonged to Resident 49, without the inhaler inside, stored in the bottom drawer of the cart. In a concurrent interview, the Licensed Vocational Nurse (LVN) 1 stated the albuterol inhaler was kept at the resident's bedside inside the resident's room for resident to self-administer the medication. LVN 1 stated there was no order for the resident to keep the medication at bedside for self-administration. On January 10, 2024, at 2:35 p.m., it was noted the inhaler was stored in the drawer of the side table next to the resident's bed. The inhaler was not labeled to indicate it belonged to Resident 49. In a concurrent interview, the Infection Preventionist (IP) stated there was no self-administration of medication for the resident done by the Interdisciplinary Team (IDT). On January 10, 2024, medical record of Resident 49 was reviewed, and the following was noted: The resident was admitted on [DATE], with diagnoses that included asthma (condition that causes difficulty in breathing); There was a physician order on December 4, 2023, for albuterol sulfate aerosol inhaler 108 microgram per actuation with the direction to inhale two puffs by mouth every six hours for shortness of breath; and The electronic medication administration record (eMAR) of the resident for January 2024, indicated the medication was administered daily every six hours. The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed and it indicated: .Residents may self-administer their own medications only if the Attending Physician in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely .

Based on observation, interview, and record review, the facility failed to develop a care plan for one of one resident reviewed for oxygen use (Resident 16) and for one of three residents reviewed for edema [swelling] (Resident 165). This failure had the potential to negatively impact the residents' quality of care and had the potential for staff to not be aware of the residents' care needs and provide appropriate treatment. Findings: 1. On January 8, 2024, at 11:53 a.m., Resident 16 was observed in bed, with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 16's oxygen administration was observed at three liters per minute (LPM). In a concurrent interview, Resident 16 stated she uses O2 continuously due to shortness of breath and she takes it off at times during the day. Resident 16's record was reviewed. Resident 16 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - a disease that causes obstructed airflow). The physician's order dated January 4, 2024, indicated, .Oxygen Therapy Continuous - 2 Liters Per/Minute Via Nasal Cannula. May Titrate Oxygen Up to 5 Liters To Maintain O2 Sats > 90% every shift for (SOB [short of breath] Related: COPD) . On January 10, 2024, at 9:03 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 16 had a physician's order for oxygen. In a concurrent review of Resident's 16's record, LVN 1 stated there was no documentation a care plan for oxygen was initiated for Resident 16. LVN 1 stated Resident 16 should have had a care plan for oxygen administration. On January 10, 2024, at 9:20 a.m., the Director of Nursing (DON) was interviewed. The DON confirmed a care plan for oxygen administration for Resident 16 was not initiated. The DON stated a care plan for O2 administration should have been developed for Resident 16. 2. During a concurrent observation and interview, on January 8, 2024, at 12:55 p.m., with Resident 165 in her room, Resident 165 was observed lying in bed awake, alert, and able to verbalize her needs. Resident 165 was observed wearing a left arm compression sleeve (a type of medical garment used to increase blood flow, reduce pain and swelling). Resident 165 was observed with some edema (swelling) of her left hand. Resident 165 stated she had a history of lymphedema (a condition caused by a blockage in the lympahatic system, part of immune and circulatory system) for five years. She stated she had a history of breast cancer, and sometimes the edema was bad. During a review of Resident 165's record, Resident 165 was admitted to the facility on [DATE], with diagnoses which included fracture of fourth lumbar vertebra (bones in the spine). The nursing notes dated January 3, 2024, entered at 10:39 p.m., indicated, .Resident noted to have edema to left upper extremity. Encourage elevation. Resident stated she has edema due to (d/t) history of breast cancer to left breast . The nursing progress notes from January 4, 2024 to January 8, 2024, did not indicate licensed nurse observation and monitoring of Resident 165's left arm edema and the presence of the left arm compression sleeve. The initial social service evaluation dated January 4, 2024, indicated Resident 165 was alert and oriented to person, place, time, and situation. The baseline care plans upon admission did not include the identified assessment of edema on Resident 165's left upper extremity. During a concurrent observation and interview, on January 9, 2024, at 9:05 a.m., with Resident 165, indicated Resident 165 was awake, alert, and able to verbalize her needs. Resident 165's left hand was observed without edema. She stated she felt better having no swelling on her left arm. She stated she wore her compression sleeve all day and all night. During a concurrent observation and interview, on January 9, 2024, at 9:45 a.m., conducted with the Director of Nursing (DON) in the resident's room, the DON acknowledge Resident 165 was wearing a left arm compression sleeve. During a concurrent interview and record review, on January 9, 2024, at 10:05 a.m., with the DON, the nurse's notes from January 3, 2024 to January 9, 2024, were reviewed. The DON confirmed on January 3, 2024, the licensed nurse documented Resident 165 had edema on her left upper extremity. The DON stated there were no further monitoring and assessments of Resident 165's edema on every shift after January 3, 2024. The DON further stated there was no assessment of Resident 165's compression sleeve. A review of Resident 165's care plans indicated there was no documented evidence the baseline care plan for Resident 165's edema and compression sleeve was developed. The DON stated the licensed nurse who admitted Resident 165 should have initiated the baseline care plan for Resident 165's edema of her left upper extremity. He stated there was no physician's order for the compression sleeve. He stated the physician should have been contacted by the licensed staff. During a concurrent observation and interview, on January 10, 2024, at 10:30 a.m., Resident 165 was observed lying in bed, awake, alert, and able to verbalize her needs. Resident 165 stated she just returned from physical therapy. Resident 165 was observed with her left arm compression sleeve on and without edema on the left hand. The facility's policy and procedure titled, Care Plans - Baseline, dated December 2016, was reviewed. The policy indicated, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty eight (48) hours of admission .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan .

Based on observation, interview, and record review, the facility failed to implement the care plan in using the dignity bag for resident's indwelling urinary catheter (catheter used to drain urine from the bladder into a bag outside the body) drainage bag for one of one resident reviewed (Resident 164). This failure resulted in Resident 164's indwelling urinary catheter drainage bag's urine being visibly exposed to visitors entering the room and the drainage bag did not have protection from contact with the bed and other equipment at the resident's bedside. Findings: On January 8, 2024, at 12:25 p.m., Resident 164 was in a room designated with contact isolation precautions (steps healthcare facility visitors and staff need to follow before going into a patient's room to stop germs from spreading by touching the patient or surfaces in the room). The personal protective equipment (PPE - used to minimize exposure to hazards that cause serious illnesses) cart was observed outside the room. During a concurrent observation and interview on January 8, 2024, at 12:28 p.m., with Resident 164 in his room, Resident 164 was observed lying in bed awake, alert, and able to verbalize his needs. Resident 164 stated he had infected wounds on his right foot. A wound vac (device used to remove excess fluid and promote healing of the wounds) was observed on resident's right side of his foot dressing. Resident 164 was observed with an indwelling urinary catheter attached to a drainage bag containing yellow urine. The indwelling urinary catheter drainage bag's bottom was touching the floor. The drainage bag was uncovered. During a concurrent observation and interview on January 8, 2024, at 12:30 p.m., with the Director of Nursing (DON), in Resident 164's room, the DON stated the resident's indwelling urinary catheter drainage bag was on the floor. He stated the drainage bag should not be touching the floor and should be covered with the dignity bag. During a concurrent observation and interview on January 8, 2024, at 12:40 p.m., with the Infection Preventionist (IP) in Resident 164's room, the IP stated the indwelling urinary catheter drainage bag should not be touching the floor and should be covered with the dignity bag. On January 8, 2024, Resident 164's record was reviewed. Resident 164 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - kidney disease), and acute Osteomyelitis (bone infection)) of right ankle and foot, and recent right amputation of second and third toes with Methicillin Resistant Staphylococcus Aureus (MRSA - a serious infection that can lead to sepsis or death). During a review of Resident 164's record, indicated a care plan for indwelling urinary catheter, with goal and interventions. The care plan indicated, .Place indwelling urinary catheter bag in dignity/privacy bag . On January 10, 2024, at 10:23 a.m., a concurrent interview and record review was conducted with the DON. The DON reviewed Resident 164's care plan for indwelling urinary catheter. The care plan indicated a goal and interventions which included .Place indwelling urinary catheter bag in dignity/privacy bag . The DON acknowledged the care plan intervention of placing the indwelling urinary catheter drainage bag in dignity/privacy bag was not followed. The facility's policy and procedure titled, Care Plans, Comprehensive Person - Centered, dated December 2016, was reviewed. The policy indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .

Based on observation, interview, and record review, the facility failed to notify the physician of resident's left upper extremity edema and the compression sleeve, for one of one resident reviewed (Resident 165). This failure had potential to affect Resident 165's blood circulation on her left upper extremity and can lead to skin breakdown and other complications. Findings: During concurrent observation and interview, on January 8, 2024, at 12:55 p.m., with Resident 165 in her room, Resident 165 was observed lying in bed awake, alert, and able to verbalize her needs. Resident 165 was observed wearing a left arm compression sleeve (a type of medical garment used to increase blood flow, reduce pain and swelling). Resident 165 was observed with edema (swelling) of her left hand. Resident 165 stated she had a history of lymphedema (a condition caused by a blockage in the lympahatic system, part of immune and circulatory system) for five years. She stated she had a history of breast cancer. She stated sometimes the edema was bad. Resident 165's record was reviewed. The record indicated Resident 165 was admitted to the facility on [DATE], with diagnoses which included fracture of fourth lumbar vertebra (bone in the spine). The nursing notes dated January 3, 2024, entered at 10:39 p.m., indicated, .Resident noted to have edema to left upper extremity. Encourage elevation. Resident stated she has edema due to (d/t) history of breast cancer to left breast . The physician's orders dated January 3, 2024, indicated there was no specific orders for monitoring of Resident 165's edema of left upper extremity and instructions for the care of compression sleeve. The nursing progress notes from January 4, 2024 to January 8, 2024, did not indicate licensed nurse observation and monitoring of Resident 165's left arm edema and the presence of the left arm compression sleeve. During a concurrent observation and interview, on January 9, 2024, at 9:05 a.m., with Resident 165, Resident 165 was awake, alert, and able to verbalize her needs. Resident 165's left hand was observed without edema. She stated she felt better having no swelling on her left arm. She stated she wore her compression sleeve all day and all night. During a concurrent observation and interview, on January 9, 2024, at 9:45 a.m., conducted with the Director of Nursing (DON) in Resident 165's room, the DON acknowledge Resident 165 was wearing a left arm compression sleeve. During a concurrent interview and record review, on January 9, 2024, at 10:05 a.m., with the DON, the nurse's notes from January 3, 2024 to January 9, 2024, were reviewed. The DON confirmed on January 3, 2024, the licensed nurse documented Resident 165 had edema on her left upper extremity. The DON stated there were no further monitoring and assessments of resident's edema on every shift after January 3, 2024. The DON stated there was no assessment of Resident 165's compression sleeve. A review of the physician's orders from January 3, 2024 to January 9, 2024, indicated there was no physician's order for monitoring of Resident 165's edema every shift and compression sleeve instructions. The DON stated the licensed nurse who admitted Resident 165, should have informed the physician regarding Resident 165's edema of the left upper extremity and the resident's compression sleeve. He stated there was no physician's order for the compression sleeve, and the monitoring of resident's left upper extremity edema. During a concurrent observation and interview, on January 10, 2024, at 10:30 a.m., Resident 165 was observed lying in bed, awake, alert, and able to verbalize her needs. Resident 165 stated she just returned from physical therapy. Resident 165 was observed with her left arm compression sleeve on and without edema on the left hand. The facility's policy and procedure titled, Admission Assessment and Follow Up: Role of the Nurse, dated September 2012, indicated, .The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident .Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings .

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the residents when: 1. Two medications for Resident 18 were not administered as ordered by the physician; and 2. One discontinued controlled substance (CS) medication was stored in the medication cart stored with other active medications available for use. This failure had the potential for inadequate medication treatment that could cause the resident to experience pain and constipation, in addition to the potential for ineffective medications to be administered to the resident. Findings: 1. On January 9, 2024, at 8:20 a.m., during a medication pass observation with the Licensed Vocational Nurse (LVN) 2, it was observed, LVN 2 prepared and administered, for Resident 18, her morning medications that included one potassium chloride (potassium supplement) ER (extended release) 8 MEq (milliequivalent - unit of measurement) tablet after crushing a total of eight medications. The eight medications that were administered to the resident by LVN 2 were as follows: One tablet of amiodarone (medication for irregular heart rhythm) 200 mg (milligram -- unit of measurement); One tablet of Eliquis (a blood thinner) 5 mg; One tablet of carvedilol (medication to control blood pressure) 3.125 mg; One tablet of ezetimibe (medication for high cholesterol) 10 mg; One tablet of losartan (medication to control blood pressure) 50 mg; One tablet of metformin (medication to control blood sugar) 500 mg; One tablet of potassium chloride ER 8 MEq; and One tablet of rosuvastatin (medication for high cholesterol) 10 mg. On January 9, 2024, the medical record of Resident 18 was reviewed, and the following was noted: There was a physician order on December 28, 2023, for docusate sodium (brand name: Colace - medication to treat constipation) 100 mg with the direction to give the resident one capsule by mouth one time a day for bowel management; There was a physician order on December 21, 2023, for lidocaine external patch 5 % (topical patch for pain relief) to be applied to the resident's left knee one time a day and be removed per schedule; and The electronic medication administration record (eMAR) for January 2024, indicated the morning dose of docusate sodium 100 mg and lidocaine 5 % patch were documented as administered to the resident; The eMAR for January 2024, also indicated the lidocaine topical patch was to be applied at 9 a.m., and removed at 9 p.m., each day. On January 9, 2024, at 11 a.m., it was observed Resident 18 still had on her left knee the lidocaine patch that was applied the day before. In a concurrent interview, LVN 2 stated he did not administer the lidocaine patch for the resident because the resident's lidocaine patches ran out, and the resident was going home later that day. LVN 2 stated he did not administer the resident's morning dose of Colace because the resident was going home later that day. LVN 2 stated it was a mistake and he should not have documented as administered the lidocaine patch and the Colace dose in the resident's medical record. The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed, and it indicated: .Medications are administered in accordance with prescriber orders, including any required time frame . 2. On January 10, 2024, at 1:45 p.m., during an inspection of the medication cart located in Green Hall with LVN 3, there was a blister pack containing alprazolam (medication to treat anxiety) 0.5 mg tablets for Resident 15 stored in the CS drawer of the cart with other active controlled substance (CS) medications. In a concurrent interview, LVN 3 was not able to find in the resident's medical record an active, ongoing order for alprazolam 0.5 mg. The resident's medical record was reviewed, and it indicated there was a physician order on November 16, 2023, for alprazolam 0.5 mg with the direction to give the resident one tablet every 23 hours as needed for anxiety for 14 days as manifested by episodes of verbalization of feeling anxious. There was no additional order to renew alprazolam 0.5 mg.

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for one resident (Resident 214), when two medications in the same therapeutic class were ordered by the physician and administered to the resident. This failure had the potential for the resident to receive excessive dose of medications and unwanted adverse effects. Findings: On January 10, 2024, medical record of Resident 214 was reviewed, and the following was noted: The resident was admitted to the facility on [DATE], with the diagnoses that included glaucoma (increased pressure in the eyeball that causes gradual loss of sight); There was a physician order on December 28, 2023, for Travatan Z (a medication applied directly to eye to treat glaucoma) 0.004 % eye drop with the direction to instill one drop in both eyes once at bedtime for glaucoma; There was a physician order on December 28, 2023, for latanoprost (brand name: Xalatan - a medication applied directly to eye to treat glaucoma) 0.005 % eye drop with the direction to instill one drop in both eyes once at bedtime for glaucoma; and The electronic medication administration record (eMAR) of the resident for January 2024, indicated both Travatan Z and latanoprost eye drops were administered daily from January 1 to January 10, 2024. Lexicomp, a nationally recognized drug reference, indicated: .Travatan Z .Mechanism of Action . A selective FP (prostaglandin receptor F) prostanoid receptor agonist which lowers intraocular pressure by increasing trabecular meshwork and outflow . Latanoprost .Mechanism of Action . Latanoprost is a prostaglandin F2-alpha analog believed to reduce intraocular pressure by increasing the outflow of the aqueous humor . Avoid combination .Coadministration of latanoprost with additional prostaglandins or prostaglandin analogs (having similar structure) is not recommended . On January 11, 2024, at 2:25 p.m., in an interview, the Pharmacist-in-Charge (PIC) of the provider pharmacy stated the pharmacy identified the therapy duplication with having both Travatan Z and Xalatan ordered at the same time. The PIC stated the pharmacy sent a note to indicate and clarify the therapy duplication along with the delivery of the resident's medications without Travatan Z which was placed on hold. The PIC agreed there was a therapy duplication. On January 11, 2024, at 2:45 p.m., in an interview, the Director of Nursing (DON) was not aware there was a request from the pharmacy to clarify the therapy duplication with Travatan Z and Xalatan. The DON confirmed the resident's eMAR there was documentation both Travatan Z and Xalatan were administered daily in January 2024. The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed and it indicated: .If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident .the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns .

Based on observation, interview, and record review, the facility failed ensure residents were free from medication error rate greater than 5 % during medication pass observation when: - Two medications for Resident 18 were not administered; - One long-acting extended-release formulation medication was crushed and administered; and - One long-acting extended-release formulation medication was administered without a full glass of water being offered. This failure had the potential for inadequate medication treatment that could cause the resident to experience pain, constipation, and stomach upset. The medication error rate was 12.9 percent. Findings: On January 9, 2024, at 8:20 a.m., during a medication pass observation with the Licensed Vocational Nurse (LVN) 2, it was observed, LVN 2 prepared and administered, for Resident 18, her morning medications that included one potassium chloride (potassium supplement) ER (extended release) 8 MEq (milliequivalent - unit of measurement) tablet after crushing a total of eight medications. The eight medications that were administered to the resident by LVN 2 were as follows: One tablet of amiodarone (medication for irregular heart rhythm) 200 mg (milligram -- unit of measurement); One tablet of Eliquis (a blood thinner) 5 mg; One tablet of carvedilol (medication to control blood pressure) 3.125 mg; One tablet of ezetimibe (medication for high cholesterol) 10 mg; One tablet of losartan (medication to control blood pressure) 50 mg; One tablet of metformin (medication to control blood sugar) 500 mg; One tablet of potassium chloride ER 8 MEq; and One tablet of rosuvastatin (medication for high cholesterol) 10 mg. On January 9, 2024, the medical record of Resident 18 was reviewed, and the following was noted: There was a physician order on November 19, 2023, for potassium chloride ER 8 MEq with the direction to give the resident one tablet by mouth two times a day for supplement; There was a physician order on December 28, 2023, for docusate sodium (brand name: Colace - medication to treat constipation) 100 mg (milligram - unit of measurement) with the direction to give the resident one capsule by mouth one time a day for bowel management; There was a physician order on December 21, 2023, for lidocaine external patch 5 % (topical patch for pain relief) to be applied to the resident's left knee one time a day and be removed per schedule; and The electronic medication administration record (eMAR) for January 2024 indicated the morning dose of potassium chloride 8 MEq, docusate sodium 100 mg, and lidocaine 5 % patch were documented as administered to the resident. On January 9, 2024, at 11 a.m., in an interview, LVN 26 stated he did not administer lidocaine patch for the resident because it was not available to administer, and the resident was going home later that day. LVN 2 stated he did not administer the resident's morning dose of Colace because the resident was going home later that day. LVN 2 stated it was a mistake and he should not have documented as administered the lidocaine patch and the Colace dose in the resident's medical record. LVN 2 stated the resident preferred the medications to be crushed and they had been crushed and administered ever since. LVN 2 did not indicate there was a physician order to crush long-acting formulation of potassium chloride and administer to the resident. LVN 2 stated he did not offer fluid after administration of crushed medications that included potassium chloride. The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed, and it indicated: .Medications are administered in accordance with prescriber orders, including any required time frame . According to the manufacturer's prescribing information for potassium chloride ER tablet: . Take potassium chloride extended-release tablets with meals and with a glass of water or other liquid. Do not take on an empty stomach because of its potential for gastric irritation . Swallow tablets whole without crushing, chewing, or sucking .

Based on observation, interview, and record review, the facility failed to ensure: 1. One medication stored at bedside for self-administration was properly labeled for Resident 49; and 2. Opened insulin lispro KwikPen (an injectable pen containing insulin, a hormone that regulates blood sugar) dated with 28-day expiration date was not available for use past the expiration date. This had the potential for wrong, and ineffective medications to be administered to residents. Findings: 1. On January 10, 2024, at 2:10 p.m., during inspection of the medication cart located in Red Hall, there was a manufacturer box for albuterol (medication to treat difficulty breathing) aerosol inhaler, which had a pharmacy label to indicate it belonged to Resident 49, without the inhaler inside, stored in the bottom drawer of the cart. In a concurrent interview, the Licensed Vocational Nurse (LVN) 1 stated the albuterol inhaler was kept at the resident's bedside inside the resident's room for resident to self-administer the medication. On January 10, 2024, at 2:35 p.m., it was noted the inhaler was stored in the drawer of the side table next to the resident's bed. The inhaler was not labeled to indicate it belonged to Resident 49. In a concurrent interview, the Infection Preventionist (IP) stated the resident's inhaler would be secured in a locked box. The IP also confirmed there was no label on the resident's albuterol inhaler to indicate it belonged to the resident. The facility's policy and procedure titled, Labeling of Medication Containers, revised, April 2019, was reviewed, and indicated: .All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations . Labels for individual resident medications include all necessary information, such as: a. the resident's name; b. the prescribing physician's names; c. the name, address, and telephone number of the issuing pharmacy; d. the name, strength, and quantity of the drug; e. the prescription number (if applicable); f. the date that the medication was dispensed; g. appropriate accessory and cautionary statements; h. the expiration date when applicable; and i. directions for use . 2. On January 10, 2024, at 2:10 p.m., during inspection of the medication cart located in Red Hall, there was a 3-ml insulin lispro (a fast-acting insulin used to prevent high blood sugar) 100 Unit/ml (unit of measurement) KwikPen for injection with the open date, 12/11/23, that belonged to Resident 49. The pen also had the following instruction on the label: Discard 1/8/24. Discard unused portion after 28 days. On January 11, 2024, at 9:30 a.m., the IP agreed the multidose insulin pen was only good for 28 days after opening. The facility's policy and procedure titled, Injectable Medications, revised, October 2018, was reviewed, and it indicated: .Multiple use vials (MDV) will expire according to the manufacturer's expiration date printed on the vial except when special considerations are specified by the manufacturer .All other MDV medications will expire 28 days after opening per USP Guidelines unless otherwise specified . According to the manufacturer's prescribing information for insulin lispro 100 units/ml KwikPen: .Storage and Handling .In-Use (Opened) .28 days Room temperature only (Do not refrigerate) .

Based on observation, interview, and record review, the facility failed to maintain and implement infection prevention and control practices when the resident's indwelling urinary catheter (catheter used to drain urine from the bladder into a bag outside the body) drainage bag was touching the floor for one of one resident reviewed (Resident 164). This failure increased the potential to expose Resident 164 for further development of infection and transmission of communicable diseases. Findings: On January 8, 2024, at 12:25 p.m., Resident 164 was observed in a room designated with contact isolation precautions (steps healthcare facility visitors and staff need to follow before going into a patient's room to stop germs from spreading by touching the patient or surfaces in the room). The personal protective equipment (PPE - used to minimize exposure to hazards that cause serious illnesses) cart was observed outside the room. During a concurrent observation and interview on January 8, 2024, at 12:28 a.m., with Resident 164 in his room, Resident 164 was observed lying in bed awake, alert, and able to verbalize his needs. Resident 164 stated he had infected wounds on his right foot. A wound vac (device used to remove excess fluid and promote healing of the wounds) was observed on resident's right side of his foot dressing. Resident 164 was observed with indwelling urinary catheter attached to a drainage bag containing yellow urine. The bottom of the indwelling urinary catheter drainage was touching the floor. The drainage bag was uncovered. During a concurrent observation and interview on January 8, 2024, at 12:30 p.m., with the Director of Nursing (DON), in Resident 164's room, the DON stated the resident's indwelling urinary catheter drainage bag was on the floor. He stated the indwelling urinary drainage bag should not be touching the floor and should be covered with the dignity bag. During a concurrent observation and interview on January 8, 2024, at 12:40 p.m., with the Infection Preventionist (IP), in Resident 164's room, the IP stated the indwelling urinary catheter drainage bag should not be touching the floor and should be covered with the dignity bag. On January 8, 2024, Resident 164's record was reviewed. Resident 164 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - kidney disease), and acute osteomyelitis (bone infection) of right ankle and foot, and recent right amputation of second and third toes with Methicillin Resistant Staphylococcus Aureus (MRSA - a serious infection that can lead to sepsis or death) During a review of the facility's policy and procedure titled, Catheter Care, Urinary, dated September 2014, indicated, .The purpose of this procedure is to prevent catheter-associated urinary tract infections .Be sure the catheter tubing and drainage bag are kept off the floor .

Based on observation, interview, and record review, the facility failed to maintain the kitchen grill in sanitary and safe operating condition, when the equipment was covered with blackish materials. This failure had the potential to cause cross contamination and unsanitary condition in the kitchen. Findings: During the initial tour of the kitchen, conducted on January 8, 2024, beggining at 9:30 a.m., with the Culinary Director (CD), the kitchen equipment was observed. During a concurrent observation and inteview on January 8, 2024, at 10:49 a.m., with the CD, the kitchen grill was observed with blackish materials on the surface and at the sides of the grill. The kitchen grill was situated next to the kitchen griddle being used by the cook for food preparation. The CD stated the kitchen grill had not been used for a long time. He further stated the grill should have been cleaned even if not in use. During a review of the facility's policy and procedure titled, GRILL - GAS, dated August 31, 2018, indicated, .SANITATION OF EQUIPMENT .frequency: After each use .Scrape grill to loosen burned-on-particles .clean grill surface .

Based on interview and record review, the facility failed to protect other residents from potential abuse while the investigation was in progress, for two of seven residents reviewed (Resident 1 and Resident 2), when: 1. The Certified Occupational Therapy Assistant (COTA); and 2. Certified Nurse Assistant (CNA) were allowed to continue to work pending the results of the alleged abuse. These failures had the potential to place the other residents in the facility at risk for abuse. Findings: 1. During a review of Resident 1's Progress Notes (PN), dated October 4, 2023 (late entry for October 3, 2023), the PN indicated Resident 1 stated the COTA was rough with him during a shower on September 27, 2023. During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure) and generalized muscle weakness. During an interview on October 16, 2023, at 10:25 a.m., with the COTA, she stated the Physical Therapy Director (PTD) called her on October 3, 2023, at 5:36 p.m. The COTA stated the PTD told her Resident 1 claimed physical abuse against her. The COTA stated she was taken off Resident 1's schedule and was told to come to work. The COTA stated she was not placed on leave and worked on October 4, 2023. During an interview on October 16, 2023, at 11:18 a.m., with the Physical Therapy Assistant (PTA), she stated to her knowledge, the COTA was allowed to work while the investigation on the abuse allegation was on-going. The PTA stated she thought the COTA should have been taken off the schedule pending the investigation. The PTA stated she was not sure why the COTA was allowed to work while the investigation was still pending. The PTA stated the COTA was removed from Resident 1's scheduled therapies. During an interview on October 16, 2023, at 11:30 a.m., with Resident 1, in his room, Resident 1 stated the COTA was abusive to him. Resident 1 stated the COTA came to his room intentionally slamming things around. Resident 1 stated the COTA offered him to shower. Resident 1 stated the COTA was rough handling the shower chair and they had some verbal exchanges in the shower stall. Resident 1 stated when the COTA brought him back in his room and he went to bed, the COTA slammed the wheelchair to the wall. During an interview on October 16, 2023, at 11:49 a.m., with the Physical Therapy Director (PTD), she stated the COTA was not taken off the schedule and was allowed to work. The PTD stated she asked the administrator (ADM) about taking the COTA off the schedule and was told by the ADM not to remove the COTA from the schedule. The PTD stated the COTA was not assigned to Resident 1 after the allegation. During a review of the Labor Log (LL), dated November 3, 2023, the LL indicated, the COTA worked on the following days: - October 4, 2023; - October 5, 2023; and - October 6, 2023. 2. During an interview on October 16, 2023, at 4:11 p.m., with the CNA, the CNA stated she was told by the Social Service Assistant (SSA) and the ADM not to go to Resident 2's room. The CNA stated she was told Resident 2 accused her of verbal abuse. The CNA stated she was not taken off the schedule. The CNA stated she did not continue to care for Resident 2. During an interview on October 16, 2023, at 4:27 p.m., with the Social Service Director, she stated the CNA was immediately removed from the assignment and Resident 2's care was changed. The SSD stated the CNA stayed and was allowed to work. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included hypertension and atrial fibrillation (irregular, fast heart rate). Resident 2 was discharged to the hospital for an unrelated issue on October 4, 2023, and was not available for interview. During a review of the Labor Allocation (LA), for the pay period of October 1, 2023 to October 15, 2023, the LA indicated, the CNA worked on the following days: - October 4, 2023; - October 5, 2023; - October 6, 2023; - October 7, 2023; - October 8, 2023; and - October 9, 2023. During an interview on October 16, 2023, at 1:45 p.m., with the Assistant Director of Nursing (ADON) she stated from her understanding, if a staff was the alleged abuser, the staff should be removed from the work schedule pending the results of the investigation to protect the alleged victim and other residents from potential abuse. During an interview on October 16, 2023, at 5:07 p.m., with the ADM, she stated neither staff accused of allegedly abusing the resident were removed from the schedule. The ADM was asked how the facility protected the other residents from potential abuse if the staff was allowed to work while the investigation was pending. The ADM stated the facility policy and procedure for abuse did not indicate the staff should be suspended or relieved from work while the investigation was in progress. During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, revised January 2023, the P&P indicated, .Policy Interpretation and Implementation .The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented by removing the accused employee from any continued services/treatments .

Based on interview and record review, for one resident reviewed (Resident A), the facility failed to develop and implement an individualized, resident-centered interventions, according to Resident A's Physical Therapy (PT) evaluation, to provide adequate supervision and assistance to prevent accidents. This failure resulted in Resident A having an accident on (MONTH) 4, 2019, and to suffer a fracture on the left tibia (break in the large bone located on the front portion of the leg) and left fibula (break in the calf bone). Findings: On (MONTH) 6, 2019, an unannounced visit was conducted to investigate a facility reported incident and a complaint. A review of Resident A's medical record was conducted. Resident A was a 90+ year old female admitted to the facility on (MONTH) 24, 2019, with [DIAGNOSES REDACTED]. Resident A's history and physical documented by the physician on (MONTH) 25, 2019, indicated Resident A was not oriented to time, place, person and situation, with inappropriate mood and affect. Resident A's Physical Therapy (PT) evaluation and Plan of Treatment dated (MONTH) 25, 2019, indicated the following: - Resident A's bilateral lower extremities were impaired; - Resident A's static standing (standing without movement) was poor; - Resident A had total dependence on transfers; and - Resident A's safety awareness was impaired. In addition, the PT evaluation indicated Resident A's short term and long term goals were for the resident to safely ambulate using her two-wheeled walker. The MDS (Minimum Data Set- an assessment tool), dated (MONTH) 3, 2019, indicated the following: - Section G0110 (1B) ADL (Activities of Daily Living) Self-Performance on Transfer, Resident A needed extensive assistance (resident involved in activity, staff provide weight-bearing support); - Section G0110 (2B) ADL Support Provided on Transfer, Resident A needed two-person physical assist; and - Section G0400 Range of Motion, Resident A had functional limitation on both lower extremity including the hip, knee, ankle, and foot. Resident A's Fall Risk assessment dated (MONTH) 25, 2019, indicated the resident was confined to chair and not able to attempt balance without physical help. Resident A was assessed at risk for falls. The facility's Investigation Report, dated (MONTH) 6, 2019, indicated, when Resident A attempted to sit down in the shower chair, the resident struck her left leg against the wall. Resident A developed a hematoma (a localized bleeding outside of blood vessels due to trauma) below the left knee. Resident A's physician's orders [REDACTED]. - at 10:38 a.m., X-ray of the left leg related to hematoma (a localized bleeding outside of blood vessels due to trauma); and - at 11:07 a.m., monitor hematoma to left lower leg. Resident A was transferred to an emergency room (ER) on (MONTH) 4, 2019, after the left leg x-ray result showed [MEDICAL CONDITION] and fibula. On (MONTH) 18, 2019, at 11:30 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she was assigned and gave the shower to Resident A on (MONTH) 4, 2019. CNA 1 stated it was the first time she was assigned to Resident A. CNA 1 stated she did not receive any instructions from the charge nurse nor did she ask the Physical Therapy (PT) staff, regarding Resident A's care and the assistance needed for her ADLs and transfer activity. CNA 1 stated she assisted Resident A for transfer by herself to the shower room, and after Resident A had a shower, she had Resident A stand up by herself while holding on to the grab bar in the shower room so she could pull up the new diaper and pants of the resident. CNA 1 stated after drying the resident's buttocks and pulled up the diaper and pants, she was about to pull the wheelchair for Resident A to sit when the resident told her I cannot stand, and I need to sit. CNA 1 stated she told Resident A to hold on, but Resident A let go of the grab bar and fell back. CNA 1 pulled the wheelchair towards Resident A and was able to catch half of her buttocks in the wheelchair. CNA 1 stated after she wheeled Resident A back to her room, the resident complained of pain on her left foot. CNA 1 noticed the resident's left leg felt odd, it was loose when moved. CNA 1 further stated Resident A had a bump on the left lower knee and it was getting bigger, so she immediately called her charge nurse to assess the resident's left leg. CNA 1 stated it happen so fast, she may have pushed the wheel chair too hard and too fast to catch Resident A, made the resident push her knee to the wall. On (MONTH) 18, 2019, at 9:20 a.m., a concurrent interview and record review was conducted with the Physical Therapy (PT). The PT stated she evaluated Resident A on (MONTH) 25, 2019. The PT verified Resident A's performance on static (no movement) standing was Poor (maximum assistance with upper extremities support to stand, 75% support assistance should be coming from the caregiver). The PT stated standing while holding on to the grab bar was an example of static standing. The PT stated based on Resident A's evaluation, the resident could not stand on her own and hold on to the grab bar. The PT further stated the resident needed assistance from the caregiver for static standing. The PT added that Resident A had behavior changes. There were days she will cooperate with the therapy and all of a sudden she will refuse and not cooperate, or there were times the resident would get tired and become weak. The PT stated considering Resident A's response to the therapy and her changing behavior and condition, it is not safe for Resident A to stand by herself and just hold on to the grab bar. On (MONTH) 18, 2019, at 10:40 a.m., a record review and interview was conducted with LVN 2. Resident A's care plans dated (MONTH) 25, 2019, indicated, - .Focus .The resident has an ADL Self Care Performance Deficit . Interventions/Task .PT/OT evaluation and treatment as per MD (physician) orders .The resident requires assistance for ADLs .The resident requires assistance to dress .The Resident requires staff assistance with bathing/showering .; and - .Focus .The resident is at risk for falls . Goal .The resident will not sustain injury . Interventions/Tasks .OT eval (evaluation) and treat (treatment) as ordered .PT evaluate and treat as ordered . LVN 2 stated Resident A's care plan did not specify what level of assistance was needed while providing ADL's to Resident A, nor specific interventions were developed to prevent the resident from having a fall. LVN 2 stated there should be input from different department as applicable in developing the care plans for the residents. On (MONTH) 18, 2019, at 10:15 a.m., the Rehabilitation Director (RD) was interviewed. The RD stated his department does not communicate to the nurses the result of evaluations conducted by the PT/OT. The RD stated it is not being done in this facility. The RD stated the nurses could read the PT/OT evaluation and notes after it is filed in the medical records. The RD further stated some licensed nurses and CNAs would ask the PT/OT regarding their residents but it is not consistent. The RD stated it is important to have communication between the two departments so everyone would be in the same page to provide safe care to the residents. On (MONTH) 21, 2019 at 9:22 a.m., the Regional Director of Clinical Operations (RDCO) was interviewed. The RDCO stated she was a Registered Nurse and was the interim Director of Nursing for the facility. The RDCO stated in developing the care plan for the residents, there should be involvement of different department as applicable. The RDCO further stated for Resident A's care plan on ADLs and fall risk, there should be an input from the rehab department. In a concurrent record review of Resident A's care plan, The RDCO stated the care plan for ADL was not clear. The RDCO stated the care plan did not specify the extent of assistance needed by the resident like one-person or two-person assist. The RDCO stated the care plan should have indicated the level of assistance needed for Resident A. The RDCO stated the care plan for fall risk was not clear. The RDCO stated the care plan did not specify what fall risk interventions were in placed to prevent Resident A from having a fall. The RDCO stated the care plan should have the fall risk interventions developed for Resident A. The facility's policy and procedure titled, Comprehensive Care Plan, dated (MONTH) (YEAR), indicated, .A comprehensive, person-centered Care Plan will be developed for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that have been identified through a comprehensive assessment . The comprehensive care plan is based on a comprehensive assessment which includes, but is not limited to, the MDS, Care Area Assessments, clinical assessments and data collection forms, Therapy Evaluations, psychosocial and cognitive evaluations, physician assessments/consults . Each resident's comprehensive care plan will describe . Identified resident issues, conditions, risk factors and safety issues . Interventions that will be implemented to enable each resident to meet his/her objectives . The facility's policy and procedure titled, Fall Prevention, dated (MONTH) (YEAR), indicated, .Resident's Care Plan shall reflect that he/she is at a higher risk for falls and identifies approaches that are to be taken . On (MONTH) 13, 2019, at 3:45 p.m., Resident A's family member stated the orthopedic surgeon told him Resident A is not a candidate for surgery because of her age and medical condition. Resident A suffered physical harm, pain, and loss of function as a result of having an accident on (MONTH) 4, 2019, due to the facility's failure to develop and implement a comprehensive person-centered care plan that includes specific interventions to address and meet Resident A's needs for adequate supervision and assitance to prevent accidents.

Based on interview and record review, the facility failed to develop and implement an individualized, resident-centered interventions, according to Resident A's Physical Therapy (PT) evaluation, to provide adequate supervision and assistance to prevent accidents. Additionally, the PT evaluation of Resident A's needs for level of supervision and assistance was not communicated to the Certified Nursing Assistant (CNA) 1. These failure resulted in Resident A having an accident on (MONTH) 4, 2019, and to suffer a fracture on the left tibia (break in the large bone located on the front portion of the leg) and left fibula (break in the calf bone). Findings: On (MONTH) 6, 2019, an unannounced visit was conducted to investigate a facility reported incident and a complaint. A review of Resident A's medical record was conducted. Resident A was a 90+ year old female admitted to the facility on (MONTH) 24, 2019, with [DIAGNOSES REDACTED]. Resident A's history and physical documented by the physician on (MONTH) 25, 2019, indicated Resident A was not oriented to time, place, person and situation, with inappropriate mood and affect. Resident A's Physical Therapy (PT) evaluation and Plan of Treatment dated (MONTH) 25, 2019, indicated the following: - Resident A's bilateral lower extremities were impaired; - Resident A's static standing (standing without movement) was poor; - Resident A had total dependence on transfers; and - Resident A's safety awareness was impaired. In addition, the PT evaluation indicated Resident A's short term and long term goals were for the resident to safely ambulate using her two-wheeled walker. The MDS (Minimum Data Set- an assessment tool), dated (MONTH) 3, 2019, indicated the following: - Section G0110 (1B) ADL (Activities of Daily Living) Self-Performance on Transfer, Resident A needed extensive assistance (resident involved in activity, staff provide weight-bearing support); - Section G0110 (2B) ADL Support Provided on Transfer, Resident A needed two-person physical assist; and - Section G0400 Range of Motion, Resident A had functional limitation on both lower extremity including the hip, knee, ankle, and foot. Resident A's Fall Risk assessment dated (MONTH) 25, 2019, indicated the resident was confined to chair and not able to attempt balance without physical help. Resident A was assessed at risk for falls. The facility's Investigation Report, dated (MONTH) 6, 2019, indicated, when Resident A attempted to sit down in the shower chair, the resident struck her left leg against the wall. Resident A developed a hematoma (a localized bleeding outside of blood vessels due to trauma) below the left knee. Resident A's physician's orders [REDACTED]. - at 10:38 a.m., X-ray of the left leg related to hematoma (a localized bleeding outside of blood vessels due to trauma); and - at 11:07 a.m., monitor hematoma to left lower leg. Resident A was transferred to emergency room (ER) on (MONTH) 4, 2019, after the left leg x-ray result showed [MEDICAL CONDITION] and fibula. On (MONTH) 18, 2019, at 11:30 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she was assigned and gave the shower to Resident A on (MONTH) 4, 2019. CNA 1 stated it was the first time she was assigned to Resident A. CNA 1 stated she did not receive any instructions from the charge nurse nor did she ask the Physical Therapy (PT) staff, regarding Resident A's care and the assistance needed for her ADLs and transfer activity. CNA 1 stated she assisted Resident A for transfer by herself to the shower room, and after Resident A had a shower, she had Resident A stand up by herself while holding on to the grab bar in the shower room so she could pull up the new diaper and pants of the resident. CNA 1 stated after drying the resident's buttocks and pulled up the diaper and pants, she was about to pull the wheelchair for Resident A to sit when the resident told her I cannot stand, and I need to sit. CNA 1 stated she told Resident A to hold on, but Resident A let go of the grab bar and fell back. CNA 1 pulled the wheelchair towards Resident A and was able to catch half of her buttocks in the wheelchair. CNA 1 stated after she wheeled Resident A back to her room, the resident complained of pain on her left foot. CNA 1 noticed the resident's left leg felt odd, it was loose when moved. CNA 1 further stated Resident A had a bump on the left lower knee and it was getting bigger, so she immediately called her charge nurse to assess the resident's left leg. CNA 1 stated it happen so fast, she may have pushed the wheel chair too hard and too fast to catch Resident A, made the resident push her knee to the wall. On (MONTH) 18, 2019, at 9:20 a.m., a concurrent interview and record review was conducted with the Physical Therapy (PT). The PT stated she evaluated Resident A on (MONTH) 25, 2019. The PT verified Resident A's performance on static (no movement) standing was Poor (maximum assistance with upper extremities support to stand, 75% support assistance should be coming from the caregiver). The PT stated standing while holding on to the grab bar was an example of static standing. The PT stated based on Resident A's evaluation, the resident could not stand on her own and hold on to the grab bar. The PT further stated the resident needed assistance from the caregiver for static standing. The PT added that Resident A had behavior changes. There were days she will cooperate with the therapy and all of a sudden she will refuse and not cooperate, or there were times the resident would get tired and become weak. The PT stated considering Resident A's response to the therapy and her changing behavior and condition, it is not safe for Resident A to stand by herself and just hold on to the grab bar. On (MONTH) 13, 2019, at 2:13 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated he worked on evening shift (3 p.m. to 11 p.m.). LVN 1 stated he was familiar with Resident A's care and he was assigned to the resident several times. LVN 1 verified he worked on (MONTH) 3, 2019, and was assigned to Resident A. LVN 1 stated Resident A was unstable and could not stand on her own, even if she was holding on to something. On (MONTH) 18, 2019, at 10:40 a.m., a record review and interview was conducted with LVN 2. Resident A's care plans dated (MONTH) 25, 2019, indicated, - .Focus .The resident has an ADL Self Care Performance Deficit . Interventions/Task .PT/OT evaluation and treatment as per MD (physician) orders .The resident requires assistance for ADLs .The resident requires assistance to dress .The Resident requires staff assistance with bathing/showering .; and - .Focus .The resident is at risk for falls . Goal .The resident will not sustain injury . Interventions/Tasks .OT eval (evaluation) and treat (treatment) as ordered .PT evaluate and treat as ordered . LVN 2 stated Resident A's care plan did not specify what level of assistance was needed while providing ADL's to Resident A, nor specific interventions were developed to prevent the resident from having a fall. LVN 2 stated there should be input from different department as applicable in developing the care plans for the residents. On (MONTH) 18, 2019, at 10:15 a.m., the Rehabilitation Director (RD) was interviewed. RD stated his department does not communicate to the nurses the result of evaluations conducted by the PT/OT. The RD stated it is not being done in this facility. The RD stated the nurses could read the PT/OT evaluation and notes after it is filed in the medical records. The RD further stated some licensed nurses and CNAs would ask the PT/OT regarding their residents but it was not consistent. The RD stated it is important to have communication between the two departments so everyone would be in the same page to provide safe care to the residents. After the fall on (MONTH) 4, 2019, Resident A was admitted to an acute hospital emergency room (ER). The ER notes indicated Resident A's left lower leg was swollen and the resident .hold (sic) the left lower extremity slightly flexed at the hip and knee, refuses to range (to move) at all secondary to pain . On (MONTH) 13, 2019, at 3:45 p.m., Resident A's family member stated the orthopedic surgeon told him Resident A is not a candidate for surgery because of her age and medical condition. Resident A suffered physical harm, pain, and loss of function as a result of having an accident on (MONTH) 4, 2019, due to the facility's failure to provide adequate supervision and assistance.

Based on observation, interview, and record review, the facility failed to ensure that two of 10 sampled residents (Residents 7 and 13) received the necessary care and services to prevent the development and and provide treatment of [REDACTED]. Resident 7 developed a Stage II pressure sore to the left plantar area of her foot (bottom of the foot), one week after admission, and developed pressure sores to the left achilles (back of ankle) and left calf (lower leg) within two weeks of admission. The facility also failed to ensure that Dakin's Solution (a solution for the treatment of [REDACTED]. Findings: 1. Resident 7, a [AGE] year-old female, was admitted on [DATE], from the acute hospital with [DIAGNOSES REDACTED]. The medical record for Resident 7 was reviewed on April 22, 2013, at 10:35 a.m. The physician documented on February 13, 2013, that the patient "has decision making capacity." On February 12, 2013, at 10:30 p.m., an Admission Assessment-Nursing was completed for Resident 7. The Admission Assessment indicated Resident 7 required extensive assistance with Activities of Daily Living (ADL's), and an immobilizer to the left leg (prevents bending). The skin integrity assessment did not indicate any wounds, only a blanchable redness (reddened area that temporarily turns white or pale when pressure is applied) with an old scar on the right buttocks and a blister on top of her right foot. On February 13, 2013, at 12:36 a.m., a Braden Scale for Predicting Pressure Sore Risk was completed. Resident 7 scored 14 points which categorized her as "moderate" risk for developing pressure sores. A review of Resident 7's Care Plan, initiated February 13, 2013, indicated she was at risk for skin breakdown related to immobility, incontinence and immobilizer. The interventions included, "Evaluate skin condition on a daily basis, keep resident clean and dry, provide adequate nutrition and hydration, provide clean and dry linens, turn and reposition resident frequently as needed." A Review of "Medicare Daily Charting" dated February 19, 2013, indicated Resident 7 developed an unstageable wound to the right plantar area (Subsequent documentation indicated wound was to the left plantar area - sole of the foot.). Wound bed was documented with purplish discoloration, and no drainage. A "Weekly Wound Documentation Progress Sheet" indicated the wound to be a pressure ulcer to the left plantar foot area, facility acquired on February 19, 2013. The pressure sore was documented as unstageable, 1.3 centimeters (cm) length by 0.3 cm width. Review of the Treatment Administration Record indicated treatment was initiated on February 20, 2013, and discontinued on March 28, 2013. Review of "Weekly Wound Documentation Progress Sheet" dated February 25, 2013, indicated Resident 7 also developed a fluid filled blister to the left lateral foot with a purplish discoloration in addition to the pressure sore located on the plantar area. In an interview with the Director of Staff Development (DSD), on April 23, 2013, at 11:05 a.m., the DSD was asked how Resident 7 was able to develop a pressure ulcer to the plantar area of her left foot. The DSD replied, "From the brace she had on her leg. We were not allowed to remove it." At 11:10 a.m., on the same day, the Licensed Vocational Nurse (LVN) entered the room and stated, "I found the wound on the bottom of her (Resident 7) foot. The brace wrapped around the back of the leg to the bottom of the foot. We weren't allowed to remove the brace so I was digging around under the brace to look at her skin and that is when I noticed some redness on the bottom of the foot. I called the doctor and he ordered the brace to be padded". The brace was padded only on the plantar foot region, leaving the rest of the leg in contact with the immobilizer. The LVN was then asked how the facility provided patient care in the presence of an immobilizer. The LVN replied, "We work around it". The DSD replied concurrently, "We follow the doctor's order." At 12 noon the DSD stated she was unable to locate an order indicating the brace could not be removed. "It may have been a verbal order or something, I spoke to a physical therapist and she said the brace was a hinged brace and could have been removed." On April 25, 2013, a facility policy and procedure dated December 2008, titled, "Verbal Orders", was reviewed. It indicated "1. The nurse receiving the verbal order must write it on the physician's order sheet as v.o (verbal order) or t.o. (telephone order)." The facility failed to ensure that Resident 7's left leg was evaluated on a daily basis, as indicated on the plan of care dated February 13, 2013, to assess the resident's skin status on the left leg. No interventions were implemented related to the continued use of the immobilizer which was identified the immobilizer as a contributing factor to the resident's risk for skin breakdown. Further review of "Progress Notes Type: Health Status Note" dated February 25, 2013, at 2:27 p.m., documented an unstageable pressure sore to the left achilles caused by the immobilizer, measuring 2 cm in length by 2 cm in width. A Review of the Treatment Administration Record indicated treatment was initiated on February 26, 2013, and discontinued on April 9, 2013. An additional wound to the left lower calf, unstageable 4 cm x 1.4 cm was documented on the same note. Per the Treatment Administration Record, treatment was initiated on February 26, 2013 at 7:00 a.m., and continued as of April 25, 2013. A Review of the facility policy titled, "Policy and Procedure for the Prevention and treatment of [REDACTED]." There was no evidence in the medical record that dietary was notified on February 25, 2013, after the resident was identified with two unstageable pressure sores, and that additional nutritional interventions to promote increased calories and protein were implemented. Review of Resident 7's care plan created on February 21, 2013, indicated that she was at "nutritional risk" due to her [DIAGNOSES REDACTED]. The interventions for this care plan included, "Encourage protein foods to promote [MEDICATION NAME] lab to normal range for resident, monitor daily intakes, monitor weights weekly until skin breakdown is healed and stable x4 (four times), supplements as ordered." On April 22, 2013, at 12:32 p.m., during an observation of Resident 7's lunch meal tray no fluids were observed on the tray. The resident was provided with 4 ounces of juice by a facility staff member as the resident did not have any other fluids to consume. The resident was observed to only consume a small bowl of canned fruit and the 4 ounces of fluid. On April 23, 2013, at 10:35 a.m., in an interview with the Certified Dietary Supervisor (CDS), she was asked what the process was for ensuring a resident is getting enough nutrients to meet their assessed nutritional needs when they are not requesting/consuming an adequate amount of nutrients during meals. The CDS stated that residents are interviewed and a list of their likes and dislikes are recorded. She further stated residents are also encouraged to eat as much as possible. The CDS was also asked if a list of "at risk" residents is maintained in order to follow their menu selections for nutritional adequacy. The CDS stated a list of "at risk" residents was not maintained but staff have been instructed to report when someone is not eating well. On April 23, 2013 at 2:25 p.m., the wound site on the left calf was observed. The immobilizer was removed, the RN removed the Band-Aid covering the wound to the left lower calf. The wound was dry, with granulated tissue noted to the wound bed. Resident 7 stated to the RN, "The doctor told me yesterday I don't have to wear the brace anymore (immobilizer to left leg), I don't want to put it back on". The RN checked the physician's order and confirmed the immobilizer had been discontinued on April 22, 2013. 2. During an observation of wound care of Resident 13's sacral ulcer (lower back) on April 22, 2013, at 1145 a.m., the LVN was observed using normal saline to cleanse the site. A review of Resident 13's treatment orders identified a physician's order was written on April 16, 2013, at 1040 a.m., to "Cleanse the sacral ulcer with Dakin's Solution." Following Resident 13's wound care on April 22, 2013, the LVN contacted the pharmacy and arranged for the Dakin's Solution to be delivered to the facility. In a concurrent interview, the LVN stated the pharmacy indicated it had not received notice of the correct concentration of the Dakin's Solution and none had previously been provided to the facility. LVN acknowledged she did not have the Dakin's Solution available for Resident 13's wound care.