Every finding on record at Bayshire Riverwalk Post-Acute

Based on interview and record review, the facility failed to ensure four of four sampled Licensed Vocational Nurses (LVN 1, LVN 2, LVN 3, LVN 4), had competencies completed within the first 30 days of hire and annually. This failure had the potential for the facility's residents to be negatively impacted.Findings:During a concurrent interview and record review on 7/31/26 at 12:33 p.m. with Director of Staff Development (DSD), LVN 1, LVN 2, LVN 3, and LVN 4's employee files were reviewed. LVN 1's date of hire (DOH) was 6/30/26, LVN 2's DOH was 6/10/22, LVN 3's DOH was 12/8/25, and LVN 4's DOH was 6/10/22. DSD was unable to provide evidence that competencies [Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as; Resident Rights; Person centered care; Communication; Basic nursing skills; Basic restorative services; Skin and wound care; Medication management; Pain management; Infection control; Identification of changes in condition; Cultural competency ; and Enteral Nutrition] were completed for LVN 1, LVN 2, LVN 3, and LVN 4. DSD stated competencies should be completed within 30 days of hire and annually thereafter.During an interview on 8/4/26 at 11:55 p.m. with the Director of Nursing (DON), DON stated that competencies should be completed within 30 days of hire and then annually ensure that the nurses know the process. DON stated competencies for the newly hired nurses were to ensure the nurse knows how to handle resident with gastrostomy tube [is a flexible medical device placed through the skin of the abdomen directly into the stomach and administer medication] and to ensure they know how to pass medications safety.During a review of the facility's policy and procedure (P&P) titled Staffing, Sufficient and Competent Nursing, revised April 2025, the P&P indicated, The facility provides sufficient numbers of staff with the appropriate skills and competency necessary to provide nursing and related care and services for all resident in accordance with resident care plan and the facility assessment. 1. Licensed Nurses .are available .to provide competent resident care services including a. assuring resident safety; b. attaining or maintaining the highest practicable physical, mental, and psychosocial well-being of each resident; c assessing, evaluating, planning, and implementing resident care plans.

Based on interview and record review, the facility failed to ensure three of four sampled residents (Resident 2, Resident 3, and Resident 4) were free from significant medications errors when medications were not administered per physician orders. These failures had the potential for Resident 2, Resident 3, and resident 4 to suffer adverse outcomes.Findings:During a review of Resident 2's Minimum Data Set, (MDS - an assessment tool) dated 7/8/26, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness).During an interview on 7/30/26 at 3:08 p.m. with Resident 2, Resident 2 stated, some of the nurses will take vitals and inform me if they must hold the medications but it does not always happen like that. During a concurrent interview and record review on 7/31/26 at 12:04 with Director of Nursing (DON), Resident 2's Medication Administration Record, (MAR) for July 2026 was reviewed. The MAR indicated the following: Amiodarone [medication use to helps keep your heart rhythm normal] .Oral Tablet 100 MG [milligrams-unit of measure] . Give 1 tablet by mouth at bedtime . hold if HR [heart rate] is less than 60.On 7/7/26 at 9 p.m. Resident 2's Amiodarone was administered with a HR of 59.On 7/8/26 at 9 p.m. Resident 2's Amiodarone was administered with a HR of 56.On 7/12/26 at 9 p.m. Resident 2's Amiodarone was administered with a HR of 58.On 7/13/26 at 9 p.m. Resident 2's Amiodarone was administered with a HR of 56.On 7/19/26 at 9 p.m. Resident 2's Amiodarone was administered with a HR of 59.On 7/20 /26 at 9 p.m. Resident 2's Amiodarone was administered with a HR of 58. Metoprolol [medication used to treat high blood pressure, chest pain (angina), and heart failure] . 25 MG . Give 1 tablet by mouth at bedtime . hold if SBP (systolic blood pressure) less than 110 or HR < [less than]60.On 7/3/26 at 9 p.m. Resident 2's Metoprolol was administered with a HR of 59.On 7/6/26 at 9 p.m. Resident 2's Metoprolol was administered with a HR of 58.On 7/7/26 at 9 p.m. Resident 2's Metoprolol was administered with a HR of 59.On 7/8/26 at 9 p.m. Resident 2's Metoprolol was administered with a HR of 56.On 7/12/26 at 9 p.m. Resident 2's Metoprolol was administered with a HR of 58.On 7/13/26 at 9 p.m. Resident 2's Metoprolol was administered with a HR of 56.On 7/21/26 at 9 p.m. Resident 2's Metoprolol was administered with a HR of 59.Resident 3's Medication Administration Record, for July 2026 was reviewed. The MAR indicated the following: Amiodarone [medication use to helps keep your heart rhythm normal] .Oral Tablet 200 MG . Give 1 tablet by mouth two times a day . hold for SBP < 110 Or HR <60.On 7/22/26 at 9 a.m. Resident 3's Amiodarone was administered with a SBP of 100.On 7/23/26 at 5 p.m. Resident 3's Amiodarone was administered with a SBP of 108.On 7/28/26 at 9 a.m. Resident 3's Amiodarone was administered with a SBP of 98.DON confirmed the findings and stated the nurses do not look at the orders they just click chart (a task to check off). During a concurrent interview and record review, on 8/4/26 at 11:55 p.m. with DON, Resident 4's Medication Administration Record, (MAR) for July 2026 was reviewed. Metoprolol . 25 MG . Give 1 tablet by mouth two times a day. Hold if SBP <100 or HR less than 60.On 7/3/26 at 6 p.m. Resident 4's Metoprolol was not administered with a SBP 105.On 7/6/26 at 6 p.m. Resident 4's Metoprolol was not administered with a SBP 107.On 7/7/26 at 6 p.m. Resident 4's Metoprolol was not administered with a SBP 102. Midodrine . 5 MG . Give 1 tablet by mouth three times a day .Hold if SBP > [greater than] 120.On 7/5/26 at 12 p.m. Resident 4's Midodrine was administered with an SBP of 136.On 7/8/26 at 8 a.m. Resident 4's Midodrine was administered with an SBP of 128.On 7/10/26 at 8 a.m. Resident 4's Midodrine was administered with an SBP of 190.DON stated Metoprolol should on 7/3/26, 7/6/26 and 7/7/26 have been administered. DON stated on 7/10/26 Resident 4 was administered Metoprolol at the same time as the Midodrine with a SBP of 190. DON stated the Midodrine is given to increase blood pressure when given outside of parameters puts the resident at risk for stroke. DON stated the nurse needed critical thinking skills.During a review of the policy and procedure (P&P) titled Administering Medications, revise April 2019, the P&P indicated, Medications are administered in a safe manner, and as prescribed. 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. 4. Medications are administered in accordance with prescriber order, including any required time frames. 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vitals signs, if necessary.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), Nutritional Care Plan was implemented Resident 1 was given fluids without a physician order. This failure had the potential for Resident 1 to suffer adverse outcomes including aspiration pneumonia (severe lung infection) and respiratory failure. Findings:During a concurrent interview and record review, on 7/30/26 at 4:26 p.m. with the DON, Resident 1's Nutritional Care Plan, initiated on 7/11/26 was reviewed. The care plan indicated, Intervention. Diet: NPO (nothing by mouth) . Resident 1's Nutrition Risk Review Form, (NRRF) dated 7/11/26 was reviewed. The NRRF indicated, Diet Order . tube feeding . If Other Describe: NPO TF [tube feeding] order Glucerna 1.5 40 ml [milliliters-unit of measure] /hr [per hour] Water flush 30 mL [milliliters- unit of measure] q [every] 4 hours. Fluid consistency .NPO. Resident 1's Documentation Survey Report, (DSR) dated July 2026, was reviewed. The DSR indicated on 7/12/26 Resident 1 consumed 400 mL of fluids. DON confirmed the findings and gave no further comment.During a concurrent interview and record review, on 8/4/26 at 11:07 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated she worked with Resident 1 on Sunday 7/12/26 on day shift. CNA 1 stated Resident 1 did not have a physician order for thickened water. CNA 1 stated Resident 1 insisted she wanted water. CNA 1 stated she went to the kitchen and got Resident 1 the thickened liquids. CNA 1 stated Resident 1 consumed 400 ml of fluids on 7/12/26.CNA 1 stated, I gave [Resident 1] water I gave her thickened water. During an interview on 8/4/26 at 11:39 a.m. with the Certified Dietary Manager (CDM), CDM stated for thicken liquid kitchen staff is required to get the resident name and make sure the resident has an order for thickened liquids. CDM stated kitchen staff gets the resident name and double check the order. CDM stated if the resident does not have an order for thickened liquid staff do not give the thicken liquid.During a review of the facility's policy and procedure (P&P) Enteral Nutrition, revised November 2018, the P&P indicated, 3. The dietitian, with input from the provider and nurse: . 8. The dietitian monitors residents who are receiving enteral nutrition and makes appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings.During a review of the facility's P&P titled, Comprehensive Care Plan, revised August 2026, the P&P indicated, To ensure each resident has a person-centered comprehensive care plan that addresses the resident's holistic preferences, goals, and nursing, medical, physical, mental, and psychosocial needs identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure medical record documentation was accurate for one of three sampled residents (Resident 1). This failure resulted in an inaccurate medical record for Resident 1. Findings:During a review of Resident 1's Documentation Survey Report, (DSR) dated July 2026, the DSR indicated, Nutrition-Fluids- Document The Amount of Fluids Resident Consumed Each Shift (how much did the resident drink? (in mL [Milliliters-unit of measure]). the following entries were documented:On 7/11/26, during the night shift, the DSR indicated Resident 1 had consumed 260 mL of fluids.On 7/12/26, during the night shift, the DSR indicated Resident 1 consumed 280 mL of fluids.On 7/13/26 during the day shift, the DSR indicated Resident 1 consumed 500 mL of fluids.On 7/13/26, during the evening shift, the DSR indicated Resident 1 consumed 500 mL of fluids.On 7/14/26 during the day shift, the DSR indicated Resident 1 consumed 500 mL of fluids.On 7/14/26, during the evening shift, the DSR indicated Resident 1 consumed 500 mL of fluids.On 7/15/26, during the day shift, the DSR indicated Resident 1 consumed 500 mL of fluids.During a concurrent interview and record review, on 8/4/26 at 11:23 a.m. with CNA 2, Resident 1's DSR dated July 2026, was reviewed. CNA 2 confirmed she had documented Resident 1 consumed 500 ml of fluids on 7/13/26, 7/14/26 and 7/15/26. CNA 2 stated Resident 1 was on tube feedings (a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding) and could not having anything by mouth. CNA 2 stated she did not give fluids to Resident 1. CNA 2 stated she made a mistake in documentation on 7/13, 7/14, and 7/15.During an interview on 8/4/26 at 2:21 p.m. with CNA 3, CNA 3 stated he did not give Resident 1 fluids. CNA 3 stated Resident 1 was receiving tube feedings and could not have anything by mouth. CNA 3 stated he charted by mistake on 7/14. During an interview on 8/5/26 at 10:32 p.m. with CNA 4, CNA 4 stated she did not give Resident 1 fluids. CNA 4 stated Resident 1 was receiving tube feedings and could not have anything by mouth. CNA 4 stated she documented fluids by mistake on 7/11 and 7/12.During interview on 8/6/26 at 10:25 a.m. with CNA 5, CNA 5 could not recall Resident 1. CNA 5 stated residents with tube feeding do not get anything by mouth. CNA 5 stated no fluids was given to Resident 1. CNA 5 stated he had documented by mistake on 7/15.During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised July 2017, the P&P indicated, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 5. All documentation shall be accurate, complete, timely, and reflective of the care and services provided.

Based on interview and record review, the facility failed to check and obtain clinical parameters (heart rate) for one of three sampled residents (Resident 4) prior to administering Digoxin (medication use to treat heart failure and abnormal heart rhythm). This failure has the potential to result in digoxin toxicity (causes nausea, vomiting, eating disorder, fatal arrhythmia [irregular heartbeat]). Findings:During a concurrent interview and record review, on 7/31/26 at 10:50 a.m. with Assistant Director of Nursing (ADON), Resident 4's Medication Administration Record, (MAR) dated July 2026, was reviewed. The MAR indicated, Digox [sic] Oral Tablet 125 MCG [micrograms-unit of measure] . Give 1 tablet by mouth one time only related to Paroxysmal Atrial Fibrillation [a fast and irregular heart rhythm that starts and stops on its own] . for 1 day -Start Date- 07/08/2026 1425 [2:25 p.m.]On 7/8/26 at 2:33 p.m. Resident 4's digoxin was documented as administered. No heart rate obtained prior to administering digoxin. Digoxin Oral Tablet 125 MCG . Give 0.5 tablet by mouth one time a day for AFib with RVR (rapid ventricular response- a heart condition where chaotic electrical signals in the upper chambers cause the lower chambers to beat irregularly and fast usually over 100 beats per minute) related to Paroxysmal Atrial Fibrillation . -Start Date- 07/23/2026 0900 [9 a.m.] -D/C Date- 07/28/2026 2053 [8:53 p.m.]On 7/23/26 at 9 a.m. Resident 4's digoxin was documented as administered. No heart rate obtained prior to administering digoxin.On 7/24/26 at 9 a.m. Resident 4's digoxin was documented as administered. No heart rate obtained prior to administering digoxin.On 7/25/26 at 9 a.m. Resident 4's digoxin was documented as administered. No heart rate obtained prior to administering digoxin.On 7/26/26 at 9 a.m. Resident 4's digoxin was documented as administered. No heart rate obtained prior to administering digoxin.On 7/27/26 at 9 a.m. Resident 4's digoxin was documented as administered. No heart rate obtained prior to administering digoxin.On 7/28/26 at 9 a.m. Resident 4's digoxin was documented as administered. No heart rate obtained prior to administering digoxin.ADON stated she would expect to see a parameter for heart rate order for Digoxin. ADON confirmed no heart rate was obtained prior to administering Digoxin to Resident 4 on 7/8, 7/23. 9/24, 7/25, 7/26, 7/27, and 7/28. ADON stated the nurse should have called the physician to clarify if they would like parameter for the Digoxin and if they said no the nurse should document it in the medical record. During a review of the facility's Nursing 2023 Drug Handbook, 43rd edition, the Handbook indicated, Digoxin . Administration PO [by mouth] Before giving loading dose, obtain base-line date . Before giving drug, take apical -radial pulse for 1 minute. Record and notify prescriber of significant changes .During a review of the policy and procedure (P&P) titled Administering Medications, revise April 2019, the P&P indicated, Medications are administered in a safe manner, and as prescribed. 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequence for the resident or is suspected of being associated with adverse consequences, 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 interview and record the facility failed to respond to resident call lights (primary purpose is to allow patients to request immediate assistance from nursing or care staff. It serves as a vital safety tool used for pain medication requests, toileting assistance, personal help, or alerting staff to medical emergencies) in a timely manner for 11 of 11 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11). This failure had the potential for care needs to not be met, injuries to occur, and other negative outcomes.Findings:During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 5/2/26, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns]), the BIMS score was 14 (cognition intact).During an interview on 7/29/26 at 10:24 a.m. with Resident 1, Resident 1 stated, (Call light) Response time is terrible. Resident 1 stated response times to the call light can be anywhere from 45 minutes to an hour or more.During a review of Resident 2's MDS, dated [DATE], under the section titled, BIMS, the BIMS score was 13 (cognition intact).During an interview on 7/29/26 at 10:53 a.m. with Resident 2, Resident 2 stated she uses her call light when she needs assistance with care, assistance with going to the restroom, and with needing pain medication since she had a recent hip surgery procedure. Resident 2 stated the response time for when she uses the call light is typically long. Resident 2 stated the response time is typically 30 to 45 minutes.During a review of Resident 3's MDS, dated [DATE], under the section titled, BIMS, the BIMS score was 15 (cognition intact).During an interview on 7/29/26 at 11:06 a.m. with Resident 3, Resident 3 stated she uses the call light for when she needs assistance with care. Resident 3 stated at times the call light response can take longer than 30 minutes.During a review of Resident 4's MDS, dated [DATE], under the section titled, BIMS, the BIMS score was 15.During an interview on 7/29/26 at 11:24 a.m. with Resident 4, Resident 4 stated that waiting for a response to the call light can be frustrating. Resident 4 stated she uses her call light for assistance to the restroom and if it is not answered timely, she will have to go in her brief. Resident 4 stated the call light response is typically 20 to 45 minutes.During a review of Resident 5's MDS, dated [DATE], under the section titled, BIMS, the BIMS score was 15.During a review of Resident 6's MDS, dated [DATE], under the section titled, BIMS, the BIMS score was 11 (moderate cognitive impairment).During a review of Resident 7's MDS, dated [DATE], under the section titled, BIMS, the BIMS score was 15.During a review of Resident 8's MDS, dated [DATE], under the section titled, BIMS, the BIMS score was 15.During a review of Resident 9's MDS, dated [DATE], under the section titled, BIMS, the BIMS score was 13 (cognition intact).During a review of Resident 10's MDS, dated [DATE], under the section titled, BIMS, the BIMS score was 15.During a review of Resident 11's MDS, dated [DATE], under the section titled, BIMS, the BIMS score was 10 (moderate cognitive impairment).During a review of Resident 1's MONTHLY GRIEVANCE LOG (MGL - a standardized tracking system used to document and monitor resident or family complaints. It records the date, the issue reported, the investigation, and the final resolution to ensure facilities maintain compliance with federal and state patient rights regulations), dated June 2026 and July 2026, the MGL indicated:On 6/4/26 - Resident 9 had called for assistance, but no staff had responded. Resident 9 was later sent to the Emergency Department where he was found to have bowel movement up to his back and front causing a strong odor in the Emergency Department. The facility documented response to the grievance was to have staff re-educated regarding the concerns brought forth.On 6/8/26 - Resident 8 reported waiting for a call light response for one hour and 10 minutes. The facility documented response to the grievance was the Director of Staff Development (DSD) would provide re-education to staff about call light response.On 6/10/26 - Resident 10 reported being left in wet clothes all night and no response given when calling for assistance. The facility documented response was the DSD would provide re-education on call light response.On 6/10/26 - Resident 11 reported staff are not answering the call lights. The facility documented response was the DSD would provide re-education on call light response.On 6/30/26 - Resident 4 stated on 6/29/26 her call light was not answered for two hours. The facility documented response was the DSD would provide re-education on call light response.On 7/7/26 - Resident 7 stated no one is answering the call lights and he has fallen on the floor multiple times but gotten himself up. The facility documented response was the DSD would provide re-education on call light responseOn 7/12/26 - Resident 5 stated he waited more than two hours to get assistance. The facility documented response was the DSD would provide re-education on call light response.On 7/13/26 - Resident 6 stated call lights take up to 45 minutes to be answered. The facility documented response was the DSD would provide re-education on call light response.During a review of the facility Resident Council Minutes (RCM), the RCM indicated:On 4/8/26 - Resident council stated there are concerns with call light response/wait time as well as the call light being turned off without addressing the concern. The RMC indicated nursing in-services were given.On 5/13/26 - Resident council stated the call light waiting times are excessive.On 6/10/26 - Resident council stated the call light waiting time is excessive.On 7/8/26 - Resident council stated the call light waiting time is excessive. The RCM indicated ongoing nursing in-services were being done.During an interview on 7/29/26 at 1:07 p.m. with DSD, DSD stated, the most common complaints she receives from residents and family members are regarding call lights taking too long to be answered. DSD stated she responds to these complaints by conduction ongoing in-services. DSD stated she did not have any documented evidence of observations, interactions with residents/family, or any other method that would indicate her in-services for call light response had been effective.During an interview on 7/29/26 at 1:33 p.m. with Director of Nursing (DON), DON stated her expectation is for the resident call lights to be answered within 10 minutes at the most. DON stated her expectation for the DSD is to observe staff response to call lights after an in-service to ensure the in-service was effective.During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 9/2022, the P&P indicated, Purpose . The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Steps in the Procedure . Answer the resident call system timely. If the resident needs assistance, indicate the approximate time it will take for you to respond. If the resident's request is something you can fulfill, complete the task as soon as practicably possible.

Based on observation, interview, and record review, the facility failed to:1. Follow the physical therapy (type of treatment that helps regain normal movement and ease pain after an injury, surgery, or a medical condition that limits the ability to function) recommendation for non-weight bearing status (limiting the amount of weight or pressure placed on a specific limb) on right upper extremity (RUE) for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA 1) instructed Resident 1 to hold onto the grab bars with both hands while in the shower room.2. Ensure Resident 1 was sitting in the shower chair while being undressed in the shower room for one of three sampled residents (Resident 1).3. Ensure Resident 1 was standing on a dry non-slippery floor in the shower room for one of three sampled residents (Resident 1).These failures resulted in Resident 1 slipping and falling on wet shower floor, which resulted in two skin tears (traumatic wound where the top layer of skin separates from the lower layer) and bruising to left forearm (part of the arm extending from the elbow to the wrist of the fingertips), bump on the back of the head, pain on the head, left forearm and left knee, and was sent to the acute hospital for evaluation and treatment, and resulted in Resident 1 experiencing nervousness (temporary feeling of worry, often triggered by stressful situations) about showers.Findings:During a review of Resident 1's admission Record (AR), dated 12/8/25, the AR indicated, DIAGNOSIS (admission). FRACTURE (broken bone) OF ONE RIB (curved bone in the chest that form a cage to protect the heart and lungs), LEFT SIDE. COMPLETE ROTATOR CUFF TEAR (one of the shoulder tendons [bands that attach shoulder muscles to the arm bone] has detached entirely from the arm bone) OR RUPTURE (sudden, violent break or tear) OF RIGHT SHOULDER. MUSCLE WEAKNESS (GENERALIZED). ABNORMALITIES OF GAIT (walking pattern) AND MOBILITY. HISTORY OF FALLING.During a review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 12/14/25, the MDS indicated in Section C (Cognitive Pattens), Resident 1 had a BIMS (Brief Interview for Mental Status) score of 14 (score of 13-15 means cognitively intact [clear, functioning mental abilities). The MDS indicated in Section GG (Functional Abilities), Resident 1 had a functional limitation in range of motion (full, normal distance and direction a joint can move) on one side of her upper extremity (shoulder, elbow, wrist, hand), Resident 1 was dependent (helper does all of the effort) with lower body dressing (the ability to dress and undress below the waist), and Resident 1 required partial or moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with sit to stand (the ability to come to a standing position from sitting).During a review of Resident 1's Order Details (OD) (admission Order), dated 12/8/25, the OD indicated, Keep sling (fabric support used to hold an injured arm, shoulder, or collarbone in a stable, resting position) on 24 hrs (hours) on R (right) Arm (due to admitting diagnosis of Complete Rotator Cuff Tear or Rupture of Right Shoulder on 12/8/25).During a review of Resident 1's Visual/Bedside Kardex Report (VBKR - special instructions for nursing staff pertaining to resident's care), dated 12/9/25, the VBKR indicated, Special Instructions. Follow MD (medical doctor) orders for weight bearing status. Non-weight bearing (injured limb must not touch the ground or support any body weight) to R (right) upper extremity.During a review of Resident 1's PT (Physical Therapy) Evaluation & Plan of Treatment (PTEPT), dated 12/9/25, the PTEPT indicated, R shoulder fx (fracture). (Resident 1) is a fall risk, NWB (non-weight bearing) on R UE (upper extremity), R arm sling.During a review of Resident 1's Nursing admission Data Collection (NADC), dated 12/8/25, the NADC indicated, Resident 1 had a fall risk score of 16 (score of 10 or higher indicates high risk for falls).During a review of Resident 1's Care Plan (CP - written, individualized document detailing a resident's health conditions, specific needs, and the tailored actions or services required to manage them), dated 12/9/26 (date initiated), the CP indicated, Focus. (Resident 1) has alteration in musculoskeletal (human body system that provides the body with movement, stability, shape, and support) status r/t (related to) . R shoulder rotator cuff injury with R sling at all times. Interventions. Follow MD (medical doctor) orders for weight bearing status.During a review of Resident 1's CP, dated 1/5/26 (date initiated), the CP indicated, Focus. (Resident 1) is at risk for falls r/t h/o (history of) falling (at home), decrease mobility. Interventions. The resident (1) needs prompt response to all requests for assistance. PT evaluate and treat as ordered.During a review of Resident 1's Change in Condition Evaluation (CCE), dated 1/15/26 (date of fall incident at the facility), the CCE indicated, (Resident 1) had a fall in the shower room with CNA (1). (Resident 1) stated she slipped on the wet floor, hit her head hard on the wall, skin tear on her left forearm with moderate bleeding (no measurement indicated). Able to move all extremities except right arm d/t (due to) previous shoulder injury. CNA (1) stated (Resident 1) stood up but (Resident 1) was focused on removing (Resident 1's) pants by herself, slipped, lost her footing and had a fall. (Resident 1) complain of pain on head [sic] and left forearm. Hall (ambulance) was called, pain med (medication) administered. Arm wrapped. Skin Status Evaluation. bump on the back of the head. left forearm skin tear.During a review of Resident 1's Medication Administration Record (MAR), dated January 2026, the MAR indicated, Resident 1 complained of 6/ (over) 10 pain (pain level of 4-6 means moderate pain) (no location indicated) on 1/15/26 at 12:39 p.m. (date and time of fall incident) and was administered Oxycodone-Acetaminophen (pain medication) tablet 5-325 mg (milligrams [unit of mass]).During a review of Resident 1's Emergency Documentation (ED) (Acute Hospital), dated 1/15/26, the ED indicated, Chief Complaint ED: Fall 01/15/26. (Resident 1) presents following fall and Head injury, skin tear. (Resident 1) states she had a mechanical fall (fall caused by an outside force such as tripping, slipping, or stumbling) in the shower while (Resident 1) was being held by a new CNA (1). Complaining of left knee pain and she does have a skin tear to the left forearm. Impression and Plan. Acute (condition or symptoms of sudden onset) head injury. Blunt trauma (physical injury caused by non-penetrating impact). Fall. Fracture of humeral (relating to the region of the humerus or shoulder) head, right. Skin tear of upper extremity. discharged . 01/15/2026.During a review of Resident 1's Nursing Progress Note (NPN), dated 1/15/26, the NPN indicated, (Resident 1) came back to the facility at this time. noted the skin tear (no measurement indicated) with bruise (no measurement indicated) on (Resident 1's) left arm around elbow and forearm, also c/o (complained of) pain, medication given to help manage the pain (no location indicated).During a review of Resident 1's IDT (Interdisciplinary Team - a collaborative group working together to deliver integrated, patient-centered care) Post Event Analysis (IDTPEA), dated 1/16/26, the IDTPEA indicated, Date and time of the fall: 01/15/2026 . (Resident 1) had a fall in the shower room with CNA (1). (Resident 1) stated she slipped on the wet floor, hit her head hard on the wall (CNA [1] stated [Resident 1] hit her head on the grab bar) two skin tears on her left arm with moderate bleeding (no measurement indicated). Able to move all extremities except right arm d/t (due to) previous shoulder/neck injury. CNA (1) stated she stood up but (Resident 1) was focused on removing her pants by herself, slipped on the water, tangled her foot on her pant legs as she was trying to take them off and lost her footing and had a fall. (Resident 1) complain of pain on head [sic] and left forearm. Pain med (medication) administered and arm wrapped. (Resident 1) transferred to ER (Emergency Room) for evaluation. What was the resident's apparel at the time of the event? . Bare feet. CNA (1) states the resident (1) was holding the grab bars with both hands. Resident (1) is non weight bearing to the right hand. NEW Interventions put in place after event to prevent recurrence. Reeducate CNAs on having shower floor free from water from prior showers and having residents sit while undressing.During a review of Resident 1's VBKR, dated 1/16/26, the VBKR indicated, Special Instructions. SAFETY. Re-educate CNA having shower floor free from water from previous shower. High Fall Risk.During a review of Resident 1's Social Services Progress Note (SSPN), dated 1/16/26, the SSPN indicated, SSD (Social Services Director) went to visit with Resident 1) due to nervousness and fear after fall. (Resident 1) stated that she fell in the shower. (Resident 1) stated that she is a little nervous about showers, therapy, and ADL's (activities of daily living [routine self-care tasks such as bathing, dressing, eating, toileting, and moving around]). (Resident 1) stated that she does not want to have another fall.During a review of Resident 1's VBKR, dated 1/27/26, the VBKR indicated, Special Instructions. SAFETY. Re-educate CNA having. resident sitting while undressing.During a review of Resident 1's VBKR, dated 2/11/26, the VBKR indicated, Special Instructions. Bathing. Two associates at a time when offering shower. SAFETY. Re-educate CNA having shower floor free from water from previous shower and resident sitting while undressing.During an interview on 2/6/26 at 2:55 p.m. with Director of Nursing (DON), DON stated Resident 1 had a fall on 1/15/26 in the shower room. DON stated Resident 1 was with CNA 1 in the shower room, Resident 1 was standing up holding onto the grab bar, CNA 1 was helping Resident 1 get her pants down, Resident 1 let go of the bar and tried to get her left leg out of the pants that got tangled into her pants. DON stated the floor was a little bit wet so CNA 1 instructed Resident 1 to hold onto the grab bar with both hands, but Resident 1 lost her balance and fell backwards. DON stated Resident 1 bumped her head on the grab bar, landed on the floor pretty hard, got two large skin tears and was sent to the hospital. DON stated the shower floor was wet because there was a resident who previously showered in there.During an interview on 2/6/26 at 3:59 p.m. with DON, DON stated, It (Resident 1's fall on 1/15/26) could have been (prevented), unfortunately, it didn't.During a concurrent observation and interview on 2/6/26 at 4:11 p.m. with Resident 1 in Resident 1's room, Resident 1 was sitting on her wheelchair. Resident 1 stated prior admission to the facility, she had a fall incident in her apartment and sustained multiple fractures. Resident 1 stated she was admitted to the facility with a right shoulder fracture, had to wear a sling on her right arm, and could not use or bear weight on her right arm. Resident 1 stated on 1/15/26, she had a fall incident when she was in the shower room with CNA 1. Resident 1 stated while she was standing, CNA 1 pulled her pajamas down and while she was standing, CNA 1 stepped away and that was when she fell on the floor. Resident 1 stated she hit the right back side of her head on the wall causing Resident 1 to have a bruise and a bump on her head, and Resident 1 hit her left arm on the floor tile and cut her left elbow. Resident 1 stated she slipped because the shower floor was wet and slippery and Resident 1 was bare feet. Resident 1 stated the water was on when CNA 1 was undressing her in the shower room. Resident 1 stated on 1/15/26, she was not really able to stand without help. Resident 1 stated after her fall incident on 1/15/26, she developed a fear of falling again in the shower and she was feeling nervous about showers.During an interview on 2/9/26 at 12:15 p.m. with CNA 1, CNA 1 stated before CNA 1 took Resident 1 to the shower room on 1/15/26 around 11:30 a.m. Resident 1 was wearing a sling on one of her arms (right arm) and Resident 1 had difficulty moving one of her arms (right arm). CNA 1 stated she did not know if Resident 1 had any weight bearing restrictions on the upper extremities. CNA 1 stated (1/15/26) when she was transferring Resident 1 from the wheelchair to the shower chair, CNA 1 instructed Resident 1 to hold onto the grab bar with both hands while standing. CNA 1 stated the shower floor was a little wet. CNA 1 stated, It (water) could have been on (the shower head was pointing at the wall, with water dripping on the floor). CNA 1 stated she would usually turn on the water and wait for the water to get warm while she undresses the residents in the shower room. CNA 1 stated Resident 1 was trying to get her pants off one of her ankles while she was standing and fell. CNA 1 stated she should have wiped the shower floor dry to prevent Resident 1 from falling. CNA 1 stated she should have had Resident 1 sit down before taking off Resident 1's pants to prevent Resident 1's feet from getting stuck in the pants and Resident 1 losing her balance. CNA 1 stated she should have asked the nurse about Resident 1's weight bearing restrictions on the upper extremities before taking Resident 1 to the shower room on 1/15/26.During a concurrent interview and record review on 2/10/26 at 12:53 p.m. with Physical Therapist Assistant (PTA), Resident 1's Occupational Therapy Treatment Encounter Note ([NAME]), dated 1/15/26, was reviewed. The [NAME] indicated, NWB on RUE. PTA stated Resident 1 was non-weight bearing on her right upper extremity and can only use her left arm (non-affected side) to hold onto the grab bar in the shower. PTA stated Resident 1's fracture could have delayed healing or could get worse if the staff would go against the non-weight bearing restriction for Resident 1. PTA stated CNA 1 should have asked the nurse or therapy department about Resident 1's weight bearing restrictions on the upper extremities.During an interview on 2/17/26 at 2:34 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated he was the nurse assigned to Resident 1 when she had a fall incident on 1/15/26. LVN 1 stated he was in the nurse's station across the shower room, and CNA 1 called him into the shower room when Resident 1 fell. LVN 1 stated he saw Resident 1 on the floor with no shirt on, and her pants and briefs were partly taken off. LVN 1 stated Resident 1 stated she had slipped in the shower and Resident 1 hit her head on the wall. LVN 1 stated he assessed Resident 1 and noted a bump on her head (no measurement given), two left forearm skin tears (one measured an inch [site 1] and the other one was five centimeters [site 2]), purple discoloration (no measurement given) around Resident 1's left forearm, and limited range of motion on Resident 1's right upper extremity. LVN 1 stated after the fall incident, Resident 1 complained of pain (head and left forearm) and was given pain medication. LVN 1 stated after the fall incident, Resident 1 was crying.During an interview on 2/18/26 at 8:50 a.m. with Social Services Director (SSD), SSD stated during her psychosocial (refers to how one's individual thoughts, emotions, and behaviors are influenced by their social environment) visit on 1/16/26 with Resident 1, Resident 1 verbalized feeling a little nervous about showers, therapy and ADLs.During an interview on 2/18/26 at 9:10 a.m. with DON, DON stated to address Resident 1's feeling of nervousness about showers, the facility had let Resident 1 know she can have a bed bath, and the facility would have two associates be with Resident 1 to support her during a bed bath or a shower.During an interview on 2/18/26 at 10:05 a.m. with Family Member (FM) 1, FM 1 stated he was visiting Resident 1 on 1/15/26 (date of fall incident). FM 1 stated the facility staff called him into the shower room where Resident 1 was, FM 1 saw Resident 1 laying on the wet floor sobbing (intense, loud crying), there were no towels on the floor, Resident 1 had her pants down below her knees, was bare feet, and Resident 1's lower extremities (part of the body that includes the hip, thigh, knee, ankle, and foot) were wet.During an interview on 2/18/26 at 1:45 p.m. with DON, DON stated Resident 1 was non-weight bearing on her RUE on 1/15/26 (date of fall incident). DON stated on 1/15/26 in the shower room, CNA 1 asked Resident 1 to briefly stand to partially take Resident 1's pants off. DON stated it is the facility's common practice for all the CNAs to undress the residents in the shower room on the shower chair.During a review of the facility's P&P titled, Falls Management Policy, dated October 2025, the P&P indicated, Residents should be evaluated for the risk of falling so that interventions may be considered in order to: Promote resident safety Promote appropriate clinical and interdisciplinary assessment of falls and fall risk factors Coordinate management of acute and recurrent falls. Resident Centered Approaches. Initial interventions may include, but are not limited to room set up, reviewing the resident's balance, footwear review, lighting, call system orientation, personal items within reach, etc. (et cetera [and similar things]) . If a fall occurs with interventions in place, IDT should review the resident to determine if additional or different interventions should be implemented.

Based on observation, interview, and record review, the facility failed to ensure the call lights were answered timely for three of four sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential to result in Resident 1, Resident 2, and Resident 3's unmet care needs and emotional distress.Findings:During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 1/21/26, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 15 (13 to 15 points indicates the resident has cognitive intactness). The MDS indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having bowel movement).During a review of Resident 1's care plan with the focus on (Resident 1) has an ADL (Activities of Daily Living - basic self-care tasks like eating, bathing, transferring, and toileting) Self Care Performance Deficit r/t (related to) left femur (long leg bone) fracture (break in bone), initiated 1/15/26, the care plan indicated, a few of the interventions were to Encourage (Resident 1) to use call bell for assistance and (Resident 1) requires assistance for ADLs.During an interview on 2/11/26 at 9:32 a.m. with Resident 1, Resident 1 stated he used his call light for brief changes. Resident 1 stated he was on a diuretic (medication used to reduce excess fluid in the body by helping kidneys remove sodium and water through increased urination), so he was wet constantly. Resident 1 stated he would look at the clock to calculate call light wait time. Resident 1 stated he could wait up to 40 minutes for the call light to be answered. Resident 1 stated every time he would ask for something the staff would tell him they would notify someone else to get it and nobody ever did anything. Resident 1 stated it made him angry.During a review of Resident 2's MDS, dated 11/12/25, the MDS indicated, Resident 2's BIMS score was 15. The MDS indicated, Resident 2 needed patrial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement).During a review of Resident 2's care plan with the focus on (Resident 2) has an ADL Self Care Performance Deficit, initiated 12/18/25, the care plan indicated, a few of the interventions were to Encourage the (Resident 2) to use call bell for assistance. and (Resident 2) requires assistance for ADLs.During a review of Resident 3's MDS, dated 11/12/25, the MDS indicated, Resident 3's BIMS score was 15.During a concurrent observation and interview on 2/11/26 at 2:42 p.m. with Resident 2 and Resident 3 in Resident 2 and Resident 3's room, Resident 2 stated she used the call light for assistance to go to the restroom and for water. Resident 2 stated she looked at the clock observed across from her bed to calculate wait time. Resident 2 stated she had waited up to an hour for the call light to be answered. Resident 2 stated sometimes if a staff member did not answer the call light, she would yell out until someone came. Resident 3 stated she would get up to go to the nurses' station to find a staff member to help Resident 2 because Resident 2 had waited so long. Resident 2 stated the wait time made her feel like I am nothing.During an interview on 2/11/26 at 3:10 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated when multiple call lights were on, she would get to them when she could. CNA 1 stated if there was an emergency, a resident's call light might not be answered timely.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised October 2022, the P&P indicated, 1. Federal and state laws guarantee certain basic rights to residents Skilled Nursing communities. Resident Rights Provider Residents have certain rights and protections under the law, as follows: . The resident has the right to receive the services and/or items included in the plan of care. Respect: The resident has a right to a dignified existence, . Resident have the right to be treated with dignity and respect. Consistent with the individualized plan of care .During a review of the facility's P&P titled, Resident Call System and Door Alarm, revised October 2022, the P&P indicated, Associates should respond to resident call system alerts . in a reasonable and timely manner. B. Responding to resident call system alerts. 1. Follow these directions for responding to resident call systems alerts: a) When an associate receives a resident call system alert, he or she should respond within a timely manner.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact) when Certified Nursing Assistant (CNA) 1 hit Resident 1 on the right side of his face while CNA 1 and CNA 2 were changing Resident 1's adult brief. This failure resulted in Resident 1 crying and having redness on his face.Findings:During a review of the SOC-341 (Report of Suspected Dependent Adult/Elder Abuse), dated 8/26/25, the SOC-341 indicated, A CNA (2) stated another CNA (1) slapped a resident (Resident 1) in the face while providing care.During a review of Resident 1's Summary of the Incident (SI), documented by Administrator, dated 8/31/25, the SI indicated, 08/26/25 0540 (approximately) . (CNA 2) and (CNA 1) entered (Resident 1's) room and attempted to change (Resident 1). (CNA 2) was positioned on the right side of (Resident 1's) bed (closer to the room door) and (CNA 1) was positioned on the left side of (Resident 1's) bed (next to the window). (Resident 1) began hitting (CNA 2) and (CNA 1), and then (Resident 1) grabbed (CNA 1's) hands. (CNA 1) was able to pull her hands away from (Resident 1's) grip with (Resident 1) scratching (CNA 1's) right forearm. (CNA 1) looked down at her hand and hit (Resident 1) on the right side of his face with (CNA 1's) opened, left hand. Conclusion: Based on interviews and investigation the allegation (CNA 1 hitting Resident 1 on the right side of his face) is verified.During a review of Resident 1's admission Record (AR), dated 8/31/25, the AR indicated, DIAGNOSIS. ALZHEIMER'S DISEASE (loss of ability to think, remember, and reason effectively) . MAJOR DEPRESSIVE DISORDER (mood disorder [mental health condition that primarily affects a person's emotional state] that causes a persistent feeling of sadness and loss of interest) . LEGAL BLINDNESS (impaired ability to see objects clearly).During a review of Resident 1's Quarterly Minimum Data Set (MDS - an assessment tool), dated 6/17/25, the MDS indicated on Section C (Brief Interview for Mental Status), Resident 1 had a score of 3 (severely impaired cognition [difficulty remembering things, concentrating, making decisions and solving problems]). The MDS indicated on Section GG (Functional Abilities - capacity of an individual to perform tasks), Resident 1 waswheelchair bound (person requiring a wheelchair to get around). The MDS indicated, Resident 1 required substantial or maximal assistance (staff lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene (ability to maintain perineal hygiene [cleaning of the area between the anus and the genitals], adjust clothes before and after voiding [urinating] or having a bowel movement). The MDS indicated, Resident 1 required partial or moderate assistance (staff lifts, holds, or supports trunk or limbs, but provides less than half the effort) with rolling left and right on bed. The MDS indicated Resident 1 was unable to walk.During a review of Resident 1's Documentation Survey Report (DSR - ADL [Activities of Daily Living - basic self-care tasks needed to live independently] flowsheet), dated August 2025, the DSR indicated, on 8/25/25 night shift (10 p.m. to 6 p.m.), CNA 2 documented Resident 1 had no behavior symptoms.During a review of Resident 1's Care Plan (CP - personalized, written document that outlines an individual's specific health conditions, needs, goals, and preferences), initiated 5/24/24 and revised on 8/30/25, the CP indicated, (Resident 1) is/has episodes to demonstrate physical behaviors (swinging at staff when assisting with ADL function) r/t (related to) Alzheimer's disease. Interventions (any treatment or action that staff perform to enhance resident outcomes) . Provide physical and verbal cues to alleviate anxiety (feeling of worry); give positive feedback (to appreciate certain acts or behaviors), encourage to verbalize source of agitation (feeling of irritability, mental distress or restlessness).During a review of Resident 1's Change in Condition Evaluation (CCE), documented by Licensed Vocational Nurse (LVN) 1 on 8/26/25 at 7:14 a.m., dated 8/26/25, the CCE indicated, (LVN 1) were called from the office around 6:05 am regarding an allegation of a witnessed of physical abuse with the resident (1) and a CNA (1) involved. MD (Medical Doctor) was notified; on Neuro check (evaluates brain and nervous system [network of nerve cells and fibers that transmits nerve impulses between parts of the body] functioning) per policy and monitoring for any skin changes and psychosocial (mental and emotional state) changes. The CCE indicated there were no injuries noted on Resident 1.During an interview on 9/9/25 at 4:08 p.m. with Executive Director (ED), ED stated, (CNA 1) was interviewed three of four times, (CNA 1) did admit to the incident (CNA 1 hitting Resident 1 on the right side of his face on 8/26/25 at around 5:40 a.m.). ED stated the physical abuse incident (CNA 1 hitting Resident 1 on the right side of his face on 8/26/25 at around 5:40 a.m.) was substantiated (verified with investigation, and CNA 1 and CNA 2 interviews) on 8/31/25.During an interview on 10/8/25 at 2:45 p.m. with CNA 1, CNA 1 stated on 8/26/25 at around 5:45 a.m., CNA 1 was helping CNA 2 (CNA assigned to Resident 1 on 8/25/25 night shift) change Resident 1's brief. CNA 1 stated Resident 1 held CNA 1's hands and tried to bite CNA 1. CNA 1 stated, My one hand hit (Resident 1's) face (right side). CNA 1 stated after she hit Resident 1's face, Resident 1 was not fighting too much then CNA 1 and CNA 2 finished changing Resident 1's brief. CNA 1 stated maybe hitting Resident 1 on the right side of his face was considered physical abuse. CNA 1 stated she did not report the physical abuse incident (CNA 1 hitting Resident 1 on the right side of his face on 8/26/25 at around 5:40 a.m.) to anybody.During an interview on 10/8/25 at 4:31 p.m. with CNA 2, CNA 2 stated she was the CNA assigned to Resident 1 on 8/25/25 night shift (10 p.m. to 6 a.m.). CNA 2 stated on 8/26/25 at around 5:40 a.m., CNA 2 asked CNA 1 to help her change Resident 1's brief. CNA 2 stated Resident 1 agreed to have CNA 1 and CNA 2 change his adult brief. CNA 2 stated Resident 1 started getting agitated when CNA 1 and CNA 2 started changing Resident 1's adult brief and hit CNA 1 and CNA 2. CNA 2 stated CNA 1 raised her left hand and slapped Resident 1 on the right side of his face. CNA 2 stated Resident 1 did not try to bite CNA 1. CNA 2 stated, (CNA 1) did (hit Resident 1 on the right side of his face) out of anger. I saw (CNA 1's) expression (CNA 1) was really mad. CNA 2 stated CNA 1 told her, (Resident 1's) like this (agitated during ADL care). Next time we'll close the door. CNA 2 stated Resident 1 got upset and started to cry. CNA 2 stated she noticed redness on Resident 1's right cheek. CNA 2 stated she reported CNA 1 hitting Resident 1 on the right side of his face to the Administrator on 8/26/25 at around 6 a.m. when the Administrator arrived at the facility.During an interview on 12/1/25 at 4:33 p.m. with Administrator, Administrator stated on 8/26/25 at 6 a.m., CNA 2 reported, while CNA 2 and CNA 1 were changing Resident 1's adult brief (on 8/26/25 at around 5:40 a.m.), Resident 1 grabbed CNA 1's hands, CNA 1 was in pain and pulled her hand (left) away and hit Resident 1 on the face (right side). Administrator stated CNA 2 used the word hit but CNA 2 motioned like a slap. Administrator stated she went to see if CNA 1 was still in the building, but CNA 1 had already left. Administrator stated she informed LVN 1 (nurse assigned to Resident 1 on 8/25/25 night shift) of the physical abuse incident (CNA 1 hitting Resident 1 on the right side of his face on 8/26/25 at around 5:40 a.m.), to complete a skin assessment immediately, and to advise her of LVN 1's findings. Administrator stated she interviewed CNA 1 and CNA 2 twice (no dates provided). Administrator stated CNA 1 initially stated CNA 1 was pushing Resident 1's face away because Resident 1 was trying to bite CNA 1, but on CNA 1's second interview, CNA 1 did a demonstration of how she hit Resident 1's face, and she hit herself on the face with a slapping motion. Administrator stated CNA 1 and Administrator role played the incident (CNA 1 hitting Resident 1 on the right side of his face on 8/26/25 at around 5:40 a.m.) in an empty room, and CNA 1 hit Administrator on the right side of her face with CNA 1's left hand.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect & Exploitation Policy, dated October 2022, the P&P indicated, Residents have the right to be free from abuse, neglect, mistreatment, misappropriation of resident property, and exploitation.

Based on observation, interview, and record review, the facility failed to ensure the temperature was taken for a cup of soup prior to serving it to one of three sampled residents (Resident 1) after being heated up, by the nursing staff, in the microwave. This failure resulted in Resident 1 sustaining a second degree burn (damages the epidermis (surface of the skin)) and dermis (thick layer of living tissue below the epidermis containing blood vessels, nerve endings, sweat glands, hair follicles and other structures) layers of the skin and is characterized by blistering, deep redness, swelling, and intense pain) to his left-hand pointer finger.Findings:During a review of Resident 81's admission Record (AR), the AR indicated Resident 81 was admitted on [DATE] and had diagnoses of acquired absence (loss of a body part) of right finger(s), polyneuropathy (damages many nerves in the body, causing a combination of symptoms like numbness, tingling, pain and muscle weakness), and rheumatoid arthritis (disease causing joint redness, swelling, and pain).During a review of Resident 81's Nursing readmission Data Collection (NRDC) dated 11/2/25, the NRDC indicated, Hot liquids safety.contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to restricted joint mobility) in fingers, hands, wrists, elbows or shoulders.yes.weakness and/or paresis (muscular weakness caused by nerve damage or disease) in upper extremities.yes.loss of mobility/reduced movement in upper extremities.yes.risk determination.yes, the resident is at risk.care planning.the resident is at risk for hot liquid injury.assist resident with hot liquids.resident to use cup with lid.During a review of Resident 81's Minimum Data Set (MDS-resident assessment tool) dated 11/8/25, the MDS indicated, Brief Interview for Mental Status (BIMS).14 (indicating Resident 81 was cognitively intact (normal thinking, reasoning and processing of information)) .Functional Abilities.Functional Limitation in Range of Motion.Upper Extremity.2 (Impairment on both sides). During a review of Resident 1's Change in Condition (COC) dated 11/15/25, the COC indicated, burn to L (left) pointer finger.11/15/25.resident stated that they (Resident 81) were checking on instant soup and wanted to see if it was hot enough so they put their L pointer finger into the bowl, resident stated that due to neuropathy they were unable to tell if it was hot or not due to low sensation, when seeing therapy walk into room resident requested for therapist to call this writing nurse due to having open skin, upon observation skin around left pointer finger from first knuckle up and around nail has been removed, NP (nurse practitioner) & wife made aware.During a review of Resident 81's Wound Evaluation & Management Summary (WEMS) dated 11/20/25, the WEMS indicated, Patient has a history of neuropathy with very limited sensation to his fingers. Patient noticed he dipped his finger into something hot. Noted. he shouldn't have done that. This led to a wound to the tip of his first finger left hand. With the wound we did take off the fingernail the wound should go onto heel [sic] just fine.non-pressure wound of the left, first finger full thickness (a wound that extends through all layers of the skin).trauma/injury.wound size (L (length) x W (width) x D (depth)) 2 x 2 x 0.2 cm (centimeters-unit of measurement)During a review of Resident 81's Progress Note (PN) dated 11/20/25, the PN indicated, Patient has a history of neuropathy to his hands and feet. He noted that he dipped his index finger left hand into a cup of hot soup, he didn't notice that he had dipped it in there. Subsequently he developed a 2nd degree burn/deep 2nd with blistering around his fingernail, at the time we saw the patient we debrided (remove damaged tissue) the blister as the fingernail leaving am [sic] area to the lateral (side) aspect of his finger which still showed evidence of deep tissue injury.During an interview on 12/2/25 at 10:55 a.m. with Administrator, Administrator stated Resident 81 received a burn to his left-hand pointer finger when Certified Nursing Assistant 7 heated up his instant cup of noodle soup in the microwave and Resident 81 stuck his finger in the soup. Administrator stated per facility policy the temperature should have been taken before it was served to Resident 81 and it was not.During a concurrent observation and interview on 12/2/25 at 11:45 a.m. with Resident 81, in Resident 81's room, Resident 81 had Band-Aids wrapped around his left pointer finger. Resident 81 stated when staff heated up his instant cup of noodle soup, the cup was filled up above the water line and he stuck his finger in it and it burned his finger. Resident 81 stated the soup was heated up in the microwave. During an interview on 12/2/25 at 6:32 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she was assigned to Resident 81 when PT reported that Resident 81's finger was red. LVN 5 stated CNA 7 heated up Resident 81's instant cup of noodle soup in the microwave and Resident 81 stuck his finger in the cup and burned his finger. LVN 5 stated CNA 7 did not take the temperature of the soup prior to giving it to Resident 81.During an interview on 12/2/25 at 6:45 p.m. with CNA 7, CNA 7 stated she heated up Resident 81's instant cup of noodle soup in the microwave for 1 1/2 minutes. CNA 7 stated she did not take the temperature of the soup prior to giving it to Resident 81. During an interview on 12/3/25 at 4:23 p.m. with Physical Therapist (PT), PT stated when he entered Resident 81's room on 11/15/25, Resident 81 was biting on his left pointer finger and covering up blood that was on his finger. PT stated from the top knuckle to the fingertip Resident 81's finger was red. PT stated Resident 81 was burned by a cup of hot noodles and was not aware of the burn due to decreased sensation in his fingertips. During an interview on 12/3/25 at 4:47 p.m. with Registered Dietician (RD), RD stated when heating up the instant cup of noodle soup for Resident 81 the CNA heated up the soup in the microwave and did not take the temperature prior to serving it to Resident 81. RD stated the CNAs were allowed to heat up the resident's food in the microwave at the time of the incident but had not received training on taking the temperatures prior to serving. RD stated Resident 81 wanted to test the temperature of the soup himself and used his finger like a stir stick and did not feel the burning. RD stated the temperature should have been taken prior to serving the soup to Resident 81 for safe consumption.During a review of the facility's policy and procedure (P&P) titled, Safety of Hot Liquids dated 02/2020, the P&P indicated, The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition (mental action of acquiring knowledge and understanding through thought, experience, and the senses) and nerve or musculoskeletal conditions.Food service associates shall monitor and maintain foods temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding.During a review of the facility's policy and procedure (P&P) titled, Food and Beverage Temperature Control dated 12/24, the P&P indicated, To ensure the safety of resident and associates, it is critical that all potentially hazardous food and beverages be prepared and maintained at safe temperatures.All foods should be cooked to the minimum safe internal cooking temperatures as outlined.Use the food and beverage temperature log to ensure all food and beverage holding temperatures are monitored and recorded.Food temperature chart.soups.140-165 F (Fahrenheit-unit of measurement used to measure temperature).Food code temperatures.food cooked in microwave oven.temperature 165 F. hold covered for 2 minutes after removing.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals (a therapeutic substance, such as a vaccine or drug, derived from biological sources) were stored appropriately when: 1. Vaccines were not labeled after opening. 2. Expired medications were not disposed.These failures had the potential to result in residents being administered vaccines and medications that were expired and not receiving the intended therapeutic effect.Findings:1. During a concurrent observation and interview on 12/2/25, at 11:39 a.m. with Licensed Vocational Nurse (LVN) 1, in Medication Room (2), a vial of (Tubersol (TB) is an infection that usually affects the lungs) for (Tuberculin skin tests (TST) are administered to detect the presence of Mycobacterium (type of germs) tuberculosis, the bacterium that causes TB) was opened with no open date. LVN 1 stated the vial should have been dated when opened.During a review of the facilities Immunization Report (IR) (undated), the IR indicated, the following TST's were administered to residents on 11/4/25, 11/8/25, 11/12/25, 11/13/25, 11/14/25, 11/16/25, 11/17/25, 11/18/25, 11/20/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/25/25, 11/26/25, 11/28/25, and 11/30/25.2. During a concurrent observation and interview on 12/3/25, at 10:22 a.m. with LVN 2, at Medication Cart 2, Lispro Insulin (fast acting insulin for high blood sugars within the blood) was opened and was not labeled with a residents name and opened date. LVN 2 stated the medication should have been removed from the cart and discarded.During a concurrent observation and interview on 12/3/25, at 10:23 a.m. with LVN 2, at Medication Cart 2, a bottle of zinc (mineral) 50 mg (milligrams) expired on 11/2025. LVN 2 stated the bottle of Zinc should have been removed and discarded.During a review of the facility's policy and procedure (P&P) titled, Storage and Expiration Dating of Medications and Biologicals, dated 12/1/07, the P&P indicated, 10. Facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacture or supplier guidelines . 11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medications. Facility staff should record the date opened on the primary medication container . once opened. 11.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days.

Based on observation, interview, and record review, the facility failed to ensure professional standards for food service safety and sanitary kitchen conditions were followed when: 1a. Dry food items were not stored in airtight sealed containers.1b. Vegetables were retained that were not safe for consumption.1c. Cold food items were not covered to prevent spillage and cross-contamination.2a. Clean dishware was not covered to prevent debris contamination.2b. Clean Utensils were not covered to prevent contamination.3a. Pasta was not labeled with an opened date.3b. Dairy Creamer was not labeled with an opened date.3c. Individually pre-dished, cut-up fruit, vegetables, and baked desserts were not labeled with prepared and use-by dates.These failures had the potential to cause foodborne illnesses (illness caused by the ingestion of contaminated food or beverages) for residents.Findings:1a. During a concurrent observation and interview on 12/1/25 at 9:21 a.m. with Certified Dietary Manager (CDM), in the dry storage room the following was found:An opened 25-pound (measurement of weight) bag of long-grain brown rice.An opened 5-pound bag of macaroni pasta.An opened 10-pound bag of penne pasta.An opened 5-pound bag of curly medium egg noodle pasta.CDM stated the long-grain brown rice, macaroni, penne, and egg noodle pastas should be stored in containers with lids and sealed to prevent debris and bugs potentially getting in.1b. During a concurrent observation and interview on 12/1/25 at 9:42 a.m. with CDM, in the refrigerated storage room, the following was found:Two cucumbers with diffuse, dark, black, and fuzzy white spots were inside a vegetable produce box. CDM stated the cucumbers were moldy, should not have been retained, and needed to be discarded.One tomato had the stem and core removed was inside a vegetable produce box. CDM stated when tomatoes are prepped for use, they are washed and cored. CDM stated the cored tomato should not have been placed back into the vegetable produce box with unwashed produce.During an interview on 12/2/25 at 10:30 a.m. with Server, Server stated produce like vegetables and fruits were to be checked for freshness. Server stated when a tomato is prepared, it is washed and cored before use. Server stated a prepared cored tomato should not be placed back into the produce storage box with unwashed produce.1c. During a concurrent observation and interview on 12/1/25 at 9:39 a.m. with CDM, in the refrigerated storage room, the snack, drinks, and refreshment cart had applesauce with an open lid that spilled contents onto other items on the cart. CDM stated there were 15 juices, 4 milks, 6 fruit cups, 4 yogurts, and 3 apple sauce containers. CDM stated there was an open applesauce container that had spilled onto other drink and snack items. CDM stated the drink and refreshments were contaminated and should have been discarded.During a review of the facility's policy and procedure (P&P) titled, FOOD STORAGE, dated 9/14/2018, the P&P indicated, POLICY. Food items should be stored . in accordance with good sanitary practice. PROCEDURE. Remember to cover, label and date. Dry Storage. 7. Any opened products should be placed in seamless plastic or glass containers with tight-fitting lids. Fresh Vegetables 1. Fresh vegetables should be checked and sorted for ripeness. 3. Unwashed produce should not be placed in the refrigerator with or near prepared foods due to high levels of competing organisms [germs].During a review of the facility's P&P titled, Storage of Perishable Food, dated 5/10, the P&P indicated, Perishable food must be refrigerated in a manner to optimize food safety, nutrient retention and aesthetic quality. Perishable foods include: fruits, vegetables, meats, dairy etc. 5. All pre-dished items must be covered, labeled, and dated to prevent off-flavors, drying, or cross-contamination while refrigerated.2a. During a concurrent observation and interview on 12/1/25 at 9:28 a.m. with CDM, in the dry storage room, glass dishware bowls were stored uncovered and inside surface area upright with debris. CDM stated she did not know what the debris was inside the glass bowl dishware. CDM stated the glass bowl dishware should be covered and stored with the inside surface area faced down.During a review of the facility's P&P titled, DISH AND UTENSIL PROCEDURE, dated 3/3/20, the P&P indicated, 2. Cups, glasses, bowls, and plates shall be handled without contact with inside surfaces or surfaces that contact the user's mouth . 9. Any dish, tray or utensil with debris should not be used.2b. During a concurrent observation and interview on 12/1/25 at 9:30 a.m. with CDM, in the dry storage room, adaptive (built-up silverware for residents, such as larger handles and gripping) utensils were inside an uncovered bin. CDM stated the bin should have a lid to prevent debris and bugs from contaminating the clean utensils. CDM stated when the container lid is opened, there was a chance of contamination and was an infection control concern.During a review of the facility's P&P titled, DRY STORAGE - DISHES AND UTENSILS, dated 2/1/12, the P&P indicated, Enclosed storage should be provided for clean and sanitized dishes and utensils. PROCEDURE 1. Spoon, knives, and forks shall be stored in containers with the handles upward or shall be covered.3a. During a concurrent observation and interview on 12/1/25 at 9:21 a.m. with CDM, in the dry storage room, the following was found:An opened 25-pound (measurement of weight) bag of long-grain brown rice.An opened 5-pound bag of macaroni pasta.An opened 10-pound bag of penne pasta.An opened 5-pound bag of curly medium egg noodle pasta.CDM stated the long-grain brown rice, macaroni, penne, and egg noodle pasta should have been labeled with open dates.3b. During a concurrent observation and interview on 12/1/25 at 9:34 a.m. with CDM, in the refrigerated storage room, an opened two-quart (unit of measurement) container of dairy creamer did not have an opened date label. CDM stated the dairy creamer should be labeled with an opened date to ensure food quality and safety.3c. During a concurrent observation and interview on 12/1/25 at 9:48 a.m. with CDM, in the refrigerated storage room, two trays of 4-ounce pre-dished, cut-up fruit, vegetables, and baked dessert were not labeled with prepared and use-by dates. CDM stated the two trays of pre-dished desserts, which included watermelon (quantity 7), sugar-free pound cake (quantity 6), and cucumber salad (quantity 9), were expected to be labeled with preparation and use-by dates.During a review of the facility's P&P titled, USE-BY DATES ON REFRIGERATED ITEMS, dated 10/17/22, the P&P indicated, Labeling & Dating Standards. All products should be dated upon receipt. All items should be dated when opened. Enter Use-By dates on all food once opened and stored under refrigeration.During a review of the facility's P&P titled, Labeling, dated 9/24, the P&P indicated, All food items must be labeled and dated before storing. Policy Detail 1. Upon receipt from vendors, all non-perishable food items must be labeled with the received date (month and year) before putting in dry storage. 2. All prepared items must have a label with the name of item, date and time prepared, by whom, and discard/use by date. Discard/use by dates should be no more than 3 days for leftovers/hazardous foods and 7 days for all other prepared food.

Based on observation, interview, and record review, the facility failed to implement effective infection control practices when the facility failed to:1) Follow their policy and procedure (P&P) on Infection Prevention and Surveillance when the facility's Infection Control Surveillance (ICS) binder did not contain information on infection trend tracker, changes and resolution, analyzation of trends identified, and educational program based on prevention.2) Ensure three of three dirty linen containers were in good repair.3) Ensure floors were disinfected (cleaned with chemical to destroy bacteria which causes diseases).4) Follow their P&P titled, ISOLATION TRAYS for one of five sampled residents (Resident 128).5) Assist two of five sampled residents (Resident 37 and Resident 84) with hand hygiene.These failures had the potential to spread infection to residents, staff, and visitors.Findings: 1) During a concurrent interview and record review on 12/3/25 at 10:26 a.m. with Infection Prevention Nurse (IPN), the facility's ICS binder dated August 2025, September 2025, and October 2025 were reviewed. The facility's ICS binder did not contain information on infection trend tracker which included changes and resolutions and no analyzation of trends identified, educational programs based on prevention, trends and outcomes. IPN stated the tracking and trending was not in the infection surveillance binder. During a review of the facility P&P titled, Infection Prevention and Surveillance dated 1/2020, the P&P indicated, The Nurse Leader designee shall track, trend and monitor infections in an ongoing basis to assist with the prevention, development and transmission of disease and infection. Policy Details: A. Each resident shall be reviewed for infectious diseases upon admission and on an ongoing basis. B. Nurse Leader Designee: 1. Shall apply scientific principles and methods to determine if the infection meets the criteria. 2. Shall data enter infections into the Infection Trend Tracker. 3. Shall provide updates in the Infection Trend Tracker including changes and resolution. 4. Shall analyze trends identified, investigate outbreaks of infection and implement infection preventions. 6. Plans and coordinates educational programs and based on prevention, trends and outcomes, including benefits of immunization. C. Infection Prevention Risk Assessment: 2. Infection Prevention Risk Assessment spreadsheet to be completed at a minimum of annually and/or when there is a significant change in resident population. 2) During a concurrent observation and interview on 12/3/25 at 11:10 a.m. in the laundry room, with Housekeeping Lead (HL), there were three large yellow containers of dirty linens. The three yellow containers had rips on all edges, exposing the metal frames. HL stated the dirty linen containers needed to be replaced. During a review of the facility's P&P titled, Laundry and Bedding dated 9/2019, the P&P indicated, Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items. 3) During a concurrent observation and interview on 12/3/25 at 10:53 a.m. with Housekeeper (HK) 1, in the hallway, HK 1 was mopping the floor. There was a yellow bucket with liquid in it where she was rinsing her mop. When asked what was in the yellow bucket, HK 1 stated, It's [liquid] just plain water. When asked if the water contained disinfectants (a chemical liquid that destroys bacteria that can cause and spread of diseases), HK 1 stated no. HK 1 stated she used the same water to rinse the mop for three to four rooms before replacing the water. During an interview on 12/3/25 at 11:05 a.m. with HL, HL stated she was told by the management not to put any disinfectant into the water to mop the floors. HL stated, We don't disinfect the floors, we just mop with hot water. During an interview on 12/3/25 at 3:34 p.m. with Administrator, Administrator stated the water for mopping needs to be mixed with disinfecting liquid. During a review of the facility's P&P, titled Cleaning and Disinfection of Environmental Surfaces & Common Areas dated 7/2019, the P&P indicated, Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical environmental surfaces include bed rails, some food utensils, bedside tables, furniture and floors. Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions. 4) During a concurrent observation and interview on 12/1/25 at 12:53 p.m. with Certified Nursing Assistant (CNA) 1, in the doorway of Resident 128's room, CNA 1 gathered Resident 128's dining plate warmer, cover, and a drinking cup partially filled with milk. CNA 1 stated she needed assistance removing Resident 128's dining tray contents because he was in contact isolation (transmission-based precaution, wearing personal protective equipment (PPE) gloves and a gown). During an observation on 12/1/25 at 12:59 p.m. in the doorway of Resident 128's room, CNA 1 was wearing soiled gloves, then handed CNA 2 Resident 128's meal tray's contents; plate warmer/cover, and a drinking cup partially filled with milk without changing her gloves or placing the meal tray contents inside of a plastic bag (barrier). CNA 2 was not wearing gloves, and there was no barrier between the contact isolation meal tray items and CNA 2's hands or body. During an interview on 12/1/25 at 1:02 p.m. with CNA 2, CNA 2 stated, We are not allowed to wear gloves in the hallway. CNA 2 stated she was unable to identify infection control prevention measures that could have prevented cross-contamination while she assisted in the removal of Resident 128's meal tray contents. During a review of Resident 128's Order Summary Report (OSR), dated 12/4/25, the OSR indicated, Contact isolation d/t [due to] ESBL [Extended Spectrum Beta Lactamase- bacteria (germs) infection]. During a concurrent observation and interview on 12/2/25 at 9:11 a.m. with CNA 3, in Resident 128's room, CNA 3 placed Resident 128's meal tray inside of a plastic bag. CNA 3 then handed the meal tray inside of the plastic bag to CNA 4 that was standing outside the room. CNA 3 stated the facility's process for removing meal trays and their contents from a contact isolation room included placing the items in a plastic bag, which served as a barrier between the contaminated items and the environment. CNA 3 stated this was an infection prevention measure to prevent cross-contamination. During an interview on 12/3/25 at 3:33 p.m. with IPN, IPN stated the facility's process of removing a meal tray from an isolation room was to place the tray in a plastic bag that serves as a barrier to prevent cross-contamination. IPN stated the facility staff were expected to maintain a barrier between themselves and items removed from a contact isolation room. IPN stated there was no P&P to provide for staff not to wear gloves in the hallway. IPN stated she was unaware of a P&P for the removal of meal trays from an isolation room. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 10/2025, the P&P indicated, G. CDC recommends using Alcohol Based Hand Sanitizer. Unless hands are visibly soiled. 12. After contact with objects. in the immediate vicinity of the resident.J. Single-use disposable gloves should be used. 3. When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. During a concurrent interview and record review on 12/4/25 with IPN, the facility's P&P titled, ISOLATION TRAYS, dated 8/31/18 was reviewed. The P&P indicated, b) No special precautions are indicated unless these items are visibly contaminated with infective material (example: blood, drainage, secretions). c) If visibly contaminated with infective material, reusable dishes, utensils, and trays should be bagged and labeled before being returned to the food service department. IPN stated when Resident 128's meal tray items were removed from his room they should have been placed inside a plastic bag for transport back to the kitchen. IPN stated, There was a breach in the infection control process. 5) During a concurrent observation and interview on 12/1/25 at 12:55 p.m. with Resident 37 in Resident 37's room. CNA 2 placed the lunch tray on Resident 37's bedside table. Resident 37 was asked if she had been offered to have her hands washed or had been given a towelette to wipe her hands before she received her meal tray. Resident 37 stated she had not been offered to wash her hands before her tray was given. During an interview on 12/1/25 at 1:17 pm with Family Member (FM) 1, FM 1 stated she comes all week and she has not seen or heard of the staff offering to wash the residents hands. During a concurrent observation and interview on 12/1/25 at 1:18 p.m. with Resident 84, in Resident 84's room. CNA 2 placed the lunch tray on Resident 84's bedside table. Resident 84 was asked if she had been offered to have her hands washed or had been given a towelette to wipe her hands before she received her meal tray. Resident 84 stated she had not been offered to wash her hands before her tray was given. During an interview on 12/1/25 at 1:19 p.m. with CNA 2. CNA 2 stated she had given Resident 37 and Resident 84 their meal tray and had not offered them hand hygiene and stated she should have. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 10/25, the P&P indicated, This community considers hand hygiene the primary means to prevent the spread of infections.E. Residents, family members and/or visitors will be encouraged to practice hand hygiene. F. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations 1. When hands are visibly soiled. 2. Before eating.

Based on interview and record review, the facility failed to implement an effective antibiotic stewardship program (a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antibiotics/antimicrobials) for four of four sampled residents (Resident 10, Resident 134, Resident 135, and Resident 3). This failure had the potential for residents developing antibiotic resistance (bacteria evolve defenses, allowing them to survive drugs meant to kill them, making infections harder to treat, this happens when bacteria change due to antibiotic use, creating superbugs, leading to longer illnesses, higher costs, and increased mortality) with the use antibiotic and experiencing adverse health outcomes. Findings:During a concurrent interview and record review on 12/3/25 at 9:03 a.m. with Infection Prevention Nurse (IPN) and Interim Director of Nursing (IDON), the facility's Infection Control Surveillance (ICS) binder dated August 2025, September 2025, and October 2025 were reviewed. The ICS indicated Resident 10 had Vancomycin (strong antibiotic medication) 750 mg (milligram) for cellulitis (bacterial infection of skin, tissues, and muscles) on 3/15/25 and 3/19/25. IPN and IDON stated the ICS did not indicate Resident 10's laboratory results for the use of Vancomycin. ICS indicated Resident 134 had Zosyn (strong antibiotic medication) discontinued on 9/6/25. IPN and IDON were unable to provide information and documentation if Zosyn was appropriate for Resident 134. ICS indicated Resident 135 had Levaquin (antibiotic) for infection of the glut (muscles in the buttocks). IDON was unable to provide information and documentation for Resident 135's use of Levaquin. ICS indicated Resident 3 had Cipro (antibiotic for bladder infection) for Urinary Tract Infection (infection of the bladder). IDON stated the ICS did not have documented laboratory results of urinalysis (analysis of urine to test for the presence of disease) for Resident 3. There was no available information and infection trend tracker provided for Resident 10, Resident 134, Resident 135, and Resident 3's use of antibiotics. During a concurrent interview and record review on 12/3/25 at 10:26 a.m. with IPN, the facility's ICS binder dated August 2025, September 2025, and October 2025 was reviewed. There were no infection trend tracker which included changes and resolutions and no analyzation of trends identified. There were no educational programs based on prevention, trends and outcomes included in the binder. IPN stated the tracking and trending documentation was not in the infection surveillance binder.During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship dated 9/2025, the P&P indicated, The Antibiotic Stewardship Program is a collaborative effort of community leadership, nursing associates, physicians and pharmacists focused on continuous improvement in the use of antibiotic agents in an effort to combat the emergence of resistant organisms. This community realizes the importance of this program as a necessary component of an overall patient/resident infection prevention program. Policy Detail: c) Document monthly infections and antibiotic usage utilizing the Infection Trend tracker. During a review of the facility's P&P titled, Infection Prevention and Surveillance dated 1/2020, the P&P indicated, Each resident shall be reviewed for infectious diseases upon admission and on an on-going basis. B. Nurse Leader Designee: 1. Shall apply scientific principles and methods to determine if the infection meets the criteria.

Based on observation, interview, and record review, the facility failed to ensure the call light was easily accessible for three of 46 sampled residents (Resident 12, Resident 102, and Resident 62). This failure resulted in Resident 12, Resident 102, and Resident 62 being unable to call staff and to have unmet care needs.Findings:During an interview on 12/1/25 at 9:29 a.m. with Resident 12, Resident 12 stated his call light was not within reach. Resident 12 stated this made him feel very frustrated.During an interview on 12/1/25 at 9:30 a.m. with Resident 12's Family Members (FM) 3 and FM 4 at bedside, FM 3 and FM 4 had watery and teary eyes. FM 4 stated, When we get here, his [Resident 12] head is away from the bed and he [Resident 12] can't reach the call light, and he [Resident 12] doesn't have his phone near him, it makes me sad.During a review of Resident 12's Care Plan (CP), dated 11/10/25, the CP indicated, Be sure [Resident 12] call light is within reach.During a concurrent observation and interview on 12/1/25 at 10:08 a.m. with Certified Nursing Assistant (CNA) 6, in Resident 102's room, Resident 102 was laying in his bed with the call light hanging on the side of the bed, not within reach. CNA 6 stated the call light should not be hanging and should be within reach.During a review of Resident 102's CP, dated 7/2/25, the CP indicated, Encourage the resident to use call bell for assistance.During an observation and interview on 12/1/25 at 12:37 p.m. with Resident 62, in Resident 62's room, a Licensed Vocational Nurse (LVN) 3 connected Resident 62 with feeding tube (delivers nutrition (food, water, medicine) through a flexible tube directly into the stomach or small intestine for people who can't eat enough by mouth). When LVN 3 was done with the care, she left the room without providing Resident 62's call light within reach. Resident 62 stated, When the nurses leave they forget to give me the call light. I am waiting for hours for them to come in to assist me because I can not tell them I need help. When asked where his call light was, Resident 62 stated, I don't know. The call light was on his left side not within Resident 62's reach.During an observation and interview on 12/1/25 at 12:46 p.m. with LVN 3, in Resident 62's room, the call light was not within reach. LVN 3 stated Resident 62 required assistance with call light. LVN 3 stated the call light was not within reach.During a review of Resident 62's Minimum Data Set (MDS-assessment tool), dated 11/14/25, the MDS indicated Resident 62 had a Brief Interview for Mental Status (BIMS) score of 15 (score of 13-15 means cognitive intact).During a review of the facility's policy and procedure (P&P) titled, Resident Call System and Door Alarm, dated 10/2022, the P&P indicated, Call system should be accessible to residents.During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Accommodation of Needs, dated 10/2025, the P&P indicated, assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being.During a review of the facility's policy and procedure (P&P) titled, Supporting Activities of Daily Living (ADL), dated 9/2025, the P&P indicated, Residents should be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 133) right to refuse was respected. This failure resulted in a violation of Resident 133's right to be treated with respect and dignity.Findings:During an interview on 12/1/25 at 7:54 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 133 had dried poop all over her bottom. CNA 5 stated Resident 133 did not want her brief changed; CNA 5 stated she could not leave Resident 133 in her brief because there was a lot of poop and Resident 133 was unstable. CNA 5 stated she cleaned and changed Resident 133's brief and Resident 133 was screaming during the brief change. CNA 5 stated, I should have left (Resident 133) because (Resident 133) was screaming. During an interview on 12/2/25 at 11:14 a.m. with the Administrator, Administrator stated during an interview with CNA 5, CNA 5 stated she was assisting Resident 133 in the restroom; Resident 133 was standing up and had a large bowel movement and CNA 5 was able to undo the brief and put a new one on but the whole time Resident 133 was standing up saying no. During a review of the facility's policy and procedure (P&P) titled, Quality of Life -Dignity, last revised 10/2025, the P&P indicated, Residents should be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents should be treated with dignity and respect. 2. The community culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's community stay.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan (CP) for one of 46 sampled residents (Resident 12). This failure had the potential to result in Resident 12 having an unrecognized change in condition and adverse health outcomes. Findings:During an observation on 12/1/25 at 9:29 a.m. with Resident 12, in Resident 12's room. Resident 12 was receiving intravenous (into the vein) Total Parenteral Nutrition (TPN - a method of delivering complete nutrition directly into the blood stream via an intravenous when the person's digestive system can not absorb nutrients from food).During a review of Resident 12's CP, dated 11/25/25, the CP indicated, [Resident 12] with TPN orders with oral gratification.During a concurrent interview and record review on 12/4/25 at 11:56 a.m. with Registered Nurse (RN) 2, Resident 12's clinical records was reviewed. Resident 12's clinical record indicated there was no record of monitoring Resident 12 receiving TPN. RN 2 stated they (staff) were not checking Resident 12's blood sugar and had no other monitoring. RN 2 stated Resident 12's CP was not comprehensive and not implemented to reflect the Policy and Procedure (P&P) on CP.During a review of the facility P&P, Comprehensive Care Plan, dated 11/2017, the P&P indicated, A comprehensive person centered care plan will be developed for each resident that includes measurable objects and time frames to meet the residents medical, nursing, mental and psychosocial needs that I have been identified through a comprehensive assessment. The comprehensive care plan will describe treatments and services to assist a resident to attain or maintain the highest level of physical mental and psychosocial well-being.

Based on interview and record review, the facility failed follow their policy and procedure (P&P) titled, Abuse, Neglect & Exploitation Policy, when the facility failed to investigate and protect one of three sampled residents (Resident 133) when allegations of physical abuse were made. These failures had the potential for Resident 133's allegation not to be investigated timely and Resident 133 not to be protected from further abuse. Findings: During a review of the facility provided document titled, Re: Allegations of Abuse, dated 11/13/25, the document indicated, 11/06/2025 1500 (3 p.m.) - The [Certified Nursing Assistant (CNA) 5] . assist [Resident 133] to the restroom. [CNA 5] enters restroom with [Resident 133]. [Resident 133] pulls down her pants and brief to urinate and [CNA 5] noticed [Resident 133] had a bowel movement. [CNA 5] attempts to change [Resident 133's] brief and [Resident 133] does not want to change brief. [Resident 133] exited the restroom and asks [Visitor] to take her to talk to someone. [Visitor] brings [Resident 133] to the [DCS]. [DCS] speaks with [Resident 133] and [CNA 5] (DCS) explains to (Resident 133) that [CNA 5] was providing care. 11/07/25 - [Resident 133] calls her daughter . and tells her a CNA hit her. 11/08/25 1000 [10 a.m.] [Family Member (FM 2]) calls the facility and speaks with Receptionist . [FM 2] tells [Receptionist] her [Resident 133] called her yesterday and told her a CNA hit her .During an interview on 12/1/25 at 7:54 a.m. with CNA 5, CNA 5 stated she assisted Resident 133 in the restroom Resident 133 did not want her brief changed. CNA 5 stated Resident 133 was screaming during the brief change. CNA 5 stated that day she witnessed Resident 133 making allegations of physical abuse to the DCS. CNA 5 stated she told the DCS she was assigned to Resident 133, and no one hit or beat Resident 133 that she (Resident 133) was just confused. CNA 5 stated the DCS told her to go and continue working.During a review of CNA 5's timecard dated 11/6/25, the time card indicated CNA 5 worked from 1:57 p.m. to 9:57 p.m. During an interview on 12/2/25 at 11:14 a.m. with Administrator, Administrator stated during the investigation of Resident 133's allegations on abuse on 11/8/25, she discovered that Resident 133 made allegations of physical abuse against CNA 5 on 11/6/25 to the DCS. Administrator stated there was no physical assessment of Resident 133 regarding the allegations of abuse completed on 11/6/25, and there was no investigation into the allegations of abuse initiated on 11/6/25. Administrator stated CNA 5 was not removed from Resident 133's care immediately after allegations were made on 11/6/25. Administrator stated CNA 5 continued to provide care to Resident 133 (approximately 6 hours) after the allegations were made.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect & Exploitation Policy, revised 10/22, the P&P indicated, [Facility's name] is committed to maintaining a safe environment for residents, visitors and associates. 1. Protection of Resident. Upon learning of alleged abuse . the Administrator or supervisor on duty should attempt to take necessary steps to verify residents are protected from subsequent episodes of abuse . If an allegation of abuse .is made against an associate or associates, the accused individuals should be suspended until the matter has been investigated and determination made as to the underlying allegation. ii. Follow up with reporting of the incident to the supervisor/manager on duty or Executive Director as soon as possible. 2. Provision of Medical Attention. Persons who are harmed during an incident should be provided medical attention, as appropriate. F. Investigation of Potential Abuse . 1. Internal Investigation. Upon receipt of resident abuse . the Administrator or designee should conduct a confidential internal investigation of the incident. a. The investigation should include interviews with potential witnesses, which may include the alleged perpetrator, the alleged victim, associates, other residents and visitors to the community. 3. Timing of Investigation. The investigation should be initiated as soon as practicable upon becoming aware of an incident. H. Internal Reporting . 2. Upon receiving reports of physical or sexual abuse, a licensed nurse or physician should immediately examine the resident. Findings of the examination should be recorded in the resident's medical record.

Based on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Abuse, Neglect & Exploitation Policy when allegations of abuse were not reported within 24 hours to the California Department of Public Health (CDPH-local state agency) and local ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) for one of three sampled residents (Resident 133). This failure resulted in Resident 133's allegation of abuse not being reported to CDPH and the local ombudsman timely. Findings:During a review of the facility provided document titled, Re: Allegations of Abuse, dated 11/13/25, the document indicated, 11/06/2025 1500 [3 p.m.] - The [Certified Nursing Assistant (CNA) 5] . assist [Resident 133] to the restroom. [CNA 5] enters restroom with [Resident 133]. [Resident 133] pulls down her pants and brief to urinate and [CNA 5] noticed [Resident 133] had a bowel movement. [CNA 5] attempts to change [Resident 133's] brief and [Resident 133] does not want to change brief. [Resident 133] exited the restroom and asks [Visitor] to take her to talk to someone. [Visitor] brings [Resident 133] to the Director of Clinical Services, [DCS]. [DCS] speaks with [Resident 133] and [CNA 5] [DCS] explains to [Resident 133] that [CNA 5] was providing care. 11/07/25 - [Resident 133] calls her daughter . and tells her a CNA hit her. 11/08/25 1000 [10 a.m.] [Family Member (FM) 2] calls the facility and speaks with Receptionist . [FM 2] tells [Receptionist] her [Resident 133] called her yesterday and told her a CNA hit her.During an interview on 12/1/25 at 7:54 a.m. with CNA 5, CNA 5 stated she witnessed Resident 133 making allegations of physical abuse to the DCS (approximately 11/5/25 or 11/6/25). During an interview on 12/2/25 at 11:14 a.m. with Administrator, Administrator stated during the investigation Resident 133's allegations of physical abuse made on 11/8/25, the DCS stated on 11/6/25, Resident 133 informed her that CNA 5 was rough with her during care. Administrator stated when she interviewed CNA 5, CNA 5 stated she witnessed Resident 133 making allegations of physical abuse by CNA 5 to the DCS. Administrator stated the abuse allegation was not reported to her, CDPH, or the local ombudsman until 11/8/25 (two days later). During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect & Exploitation Policy, revised 10/22, the P&P indicated, Instances or allegations of abuse, neglect, mistreatment or exploitation should be treated seriously and reported to the administrator or the supervisor on duty for investigation and appropriate follow-up. G. External Reporting 1. Alleged violations involving abuse, neglect, exploitation or mistreatment . should be reported: a. As soon as practical, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or . b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. c. Such alleged violation shall be reported to: i. The State Survey Agency .3. Refer to the reporting Suspected Crimes under the Elder Justice Act policy for additional External Reporting requirements.

Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 47 and Resident 101) were provided with 72 hour written notification prior to receiving a new roommate. These failures resulted in a violation of residents' rights.Findings:During a review of Resident 37's Progress Note (PN) dated 11/9/25 at 10:32 a.m., the PN indicated, Room change update: Resident [37] was temporarily moved from 103-A to 107-A the evening of 11/8/25 due to incompatible roommate. Resident [37] will be moved to 121-B.During a review of the Action Summary (AR-report used to identify room changes that have been made) dated 12/2/25 at 1:16 p.m., the AR indicated (Resident 37) was moved from 103-A to 107-A on 11/8/25 and moved from 107-A to 121-B on 11/9/25.During an interview on 12/3/25 at 8:40 a.m. with Social Service Director (SSD), SSD stated when a new roommate was to be received, the notification was done informally, and nothing was documented.During an interview on 12/3/25 at 8:48 a.m. with admission Coordinator (AC), AC stated when a new roommate was to be received, the resident was informed verbally and nothing was documented.During an interview on 12/3/25 at 3:52 p.m. with Administrator, Administrator stated when a resident receives a new roommate, the receiving roommate should have advanced notice, and it should be documented.During a concurrent interview and record review, on 12/4/25 at 9:24 a.m. with SSD, Resident 47 and Resident 101's clinical records were reviewed. SSD stated Resident 37 was moved into a room with Resident 47 on 11/8/25 and moved into a room with Resident 101 on 11/9/25. SSD was unable to provide evidence of Resident 47 and Resident 101 being notified of receiving a roommate prior to the move.During a review of the facility's policy and procedure (P&P) titled, Room Change/Roommate Assignment dated 10/2021, the P&P indicated, Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives) are given a 72 hour/day [sic] advance written notice of such change. A. Advance written notice of a roommate change includes why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan for falls within 48 hours of admission for one of three sampled residents (Resident 1) with a history of falls that included the necessary information for staff to ensure the safety and well-being of Resident 1. This failure resulted in Resident 1 falling, breaking her right hip and transfer to a local hospital for surgical repair. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, the facility admitted Resident 1 on 10/23/22. Resident 1's diagnoses included: urinary tract infection (UTI, infection of the urinary pathway), vascular dementia (changes to memory, thinking, and behavior due to decreased blood flow to the brain) and a history of falling. During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool), dated 10/26/22, Resident 1's MDS indicated, Resident 1 had significant cognitive impairment with a Brief Interview for Mental Status (BIMS, assesses mental processes) score of 5 (score of: 13-15 cognitively intact, 8-12 moderate impairment, 0-7 significant impairment). During a concurrent interview and record review on 11/2/22, at 4:20 PM with Director of Nursing (DON) and Administrator, Resident 1's Nursing Admission Data Collection, dated 10/23/22, was reviewed. Resident 1's Nursing Admission Data Collection indicated the following: Resident 1 had one or two falls during the last 90 days; Required assistance with going to the bathroom; Confined to a chair; not able to maintain balance when changing from sitting to standing without physical assistance; was unable to stand. Resident 1's Nursing Admission Data Collection indicated, Resident 1 was at risk for falls. Resident 1's Nursing Admission Data Collection indicated, If resident's total score is 10 or more, initiate fall risk interventions and document on Interim Care Plan. Administrator stated, Resident 1's fall risk score was 18, and any score above 10 identified the resident as at risk for falls. During a concurrent observation and interview on 11/2/22, at 10:31 AM, with Interim Assistant Director of Nursing (ADON), outside Resident 1's room, ADON stated, Normally a star sticker is placed on the name plate to indicate the resident is at risk for falls. ADON stated No, it [the star sticker] is not there. During a concurrent observation and interview on 11/2/22, at 10:36 AM, with DON, outside of Resident 1's room, DON stated, No, there is no star [on Resident 1's name plate]. During an interview on 11/2/22, at 1:46 PM, with Certified Nurse Assistant (CNA) 2, CNA 2 stated, residents at risk for falls have a star sticker on the door. During an interview on 11/2/22, at 2:05 PM, with LVN 3, LVN 3 stated, a star will be placed on the name plate outside the door of a resident's room, when a resident is identified at risk for falls. During an interview on 11/2/22, at 2:14 PM, with LVN 2, LVN 2 stated, she was familiar with and provided care to Resident 1. LVN 2 stated, Resident 1 needed a lot of assistance. LVN 2 stated, upon admission, if the resident was identified as risk for falls, they qualified for the Falling Star Program. During an interview on 11/2/22, at 2:40 PM, with CNA 1, CNA 1 stated, she cared for Resident 1. CNA 1 stated, I did not know anything about the Resident being a fall risk. CNA 1 stated, I do not recall seeing a star sticker on the door and [I] did not receive report [that Resident 1 was a fall risk]. During an interview on 11/3/22, at 2:48 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she first cared for Resident 1 on 10/26/22. LVN 1 stated, Resident 1 was fairly new to the facility. LVN 1 stated, she was one door down from Resident 1's room, when a person from the dietary department came out of Resident 1's room and asked if Resident 1 was allowed to get up out of bed on her own. LVN 1 stated, she rushed to Resident 1's room and found Resident 1 on the floor, on her back, at the foot of her bed. During an interview on 1/10/23, at 10:45 AM, with Registered Dietitian (RD), RD stated, she visited Resident 1's room on 10/26/22 to interview Resident 1. RD stated, Resident 1 was confused and not able to answer the questions. RD stated, Resident 1 was sitting on the side of the bed and started to get up. RD stated, she told Resident 1 to hold on, wait, while she got someone to help. RD stated, she left the room to find a nurse. RD stated, she told the nurse I don't know this resident [Resident 1] well, is she [Resident 1] ok to get out of bed? During a review of Resident 1's Collaborative Care Review signed by Administrator on 11/2/22 [date of inspection], Administrator entered a summary that indicated, 10/25/22 [sic, actual date of fall 10/26/22] - Nurse informed by RD resident trying to get up on her own. Nurse immediately responded and found resident on the floor at the foot of the bed lying on her back. Resident complained of right hip pain. Noted large skin tear to right elbow scant bleeding. Recommend STAT [immediately] x-ray of hip and elbow. Clean skin tear and cover with sterile dressing. Send to [local hospital] ER for evaluation. MD [Medical Doctor] and RP [Responsible Party] notified. Add to falling star program upon return. During a concurrent interview and record review on 11/2/22, at 4:20 PM with DON, Resident 1's Care Plan titled The resident is at risk for falls, dated 10/23/22, was reviewed. Resident 1's Care Plan indicated, the facility initiated the Falling Star Program for Resident 1 on 10/27/22 (the day after Resident 1 fell and broke her hip). DON stated, the facility initiated the Falling Star Program [for Resident 1] on 10/27/22, the day after Resident 1's fall, four days after the facility admitted Resident 1 and four days after the facility assessed Resident 1 as a high fall risk. Resident 1's Care Plan did not indicate the following: Resident should not sit on the side of the bed. Additional lighting or night light. Place resident close to nursing station. Ensure consistent toileting schedule. Keep room free of clutter. Maintain safe environment. During a review of Resident 1's Progress Notes, dated 10/26/22, at 3:47 PM, the Progress Notes indicated, Resident [1] had unwitnessed fall at end of shift. Dr. [Doctor] transferred resident [Resident 1] to ER [emergency room ] for evaluation. She [Resident 1] c/o [complains of] right hip pain also sustained [acquired a] large skin tear to right elbow. During a review of Resident 1's Result Type: Hip Rt [Right] 2-3 Vw [View] Report, (X-Ray report), dated 10/26/22, the Hip Rt 2-3 Vw Report indicated, Resident 1 had a Slightly displaced intertrochanteric fracture (broken hip bone). Orthopedic [doctor who specializes in treatment of muscle/bone injuries] consult recommended. During a review of Resident 1's Progress Notes, dated 10/28/22, at 19:52 [7:52 PM], the Progress Notes indicated, This is a nursing admission note for [Resident 1]: 10/28/22 @ [at] 17:00 [5 PM], [AGE] years old from [hospital]. s/p [status post, after] ORIF [Open Reduction Internal Fixation - surgery to repair the broken hip bone] . During a review of the facility's policy and procedure (P&P) titled, Falling Star Program, revised 10/2016, the P&P indicated, Policy Overview .The Falling Star Program is designed to facilitate recognition of residents who are at risk for falls. When residents are determined to be at risk of falls, they will be referred to the Falling Star Program. A star will be placed next to the nameplate outside his or her room and on adaptive devices the resident uses outside of their room, to indicate to care providers that this resident is at risk for falls. During a review of the facility's P&P titled, Falls Prevention, revised 10/21, the P&P indicated, A. Fall Risk Data Collection .c) If the resident scores above a 10 in Fall Risk Data Collection, he/she shall be placed on the Falling Star Program. Resident's Care Plan shall reflect that he/she is at a higher risk for falls and identifies approaches that are to be taken. During a concurrent interview and review of facility's P&P on 1/10/23, at 10:40 AM, with Administrator, Administrator reviewed P&P titled Falls Prevention revised 10/21, P&P indicated, B. Falling Star Program 1. The Falling Star Program shall be initiated at the time the increased risk for falling is identified and approaches shall be outlined on the care plan for all disciplines. Administrator stated all disciplines is the same as the Interdisciplinary Team (IDT). Administrator stated RD would be included on the team and are expected to identify residents at risk for falls by the falling star sticker on the resident's name plate outside the door.

Based on observation, interview, and record review, the facility failed to maintain a safe environment for one of four sampled residents ' (Resident 1) when: 1. Resident 1 ' s left wheelchair brake would not lock. 2. A care plan (helps nurses and other care team members organize aspects of resident care according to a timeline) for transfer and toileting was not followed and a non-compliance care plan was not initiated. 3. The policy and procedure for Falling Star Program (a star is placed at the entrance of the door and/or over the resident ' s bed indicating the resident is at risk for falls) was not implemented. 4. The staff were not educated on the policy and procedure for Falling Star Program. These failures resulted in Resident 1 sustaining a fall with fracture (break in the bone) on the medial malleolus (the bony bump on the inner side of the ankle) extending to the tibial plafond (bottom of one of two long bone that support the ankle) and acute transverse distal fibular shaft fracture (the end of one of two long bones in the leg that support the ankle) resulting in Resident 1 experienced severe pain (1-3 = mild pain, 4-6 = moderate, 7-10 = severe) and needing transfer to the acute hospital for treatment. Findings: 1. During a review of Resident 1 ' s Admission Record, (AR) the AR indicated, Resident 1 was admitted on [DATE], with diagnoses included history of falls, fracture to left tibia (main bone of the lower leg), and difficulty walking. During a review of Resident 1 ' s Minimum Data Set, (MDS - an assessment tool) dated 4/7/22, the MDS indicated, Resident 1 ' s BIMS (Brief Interview for Mental Status) score was 15 (a score of 13 to 15 suggests the resident is cognitively intact. During an interview on 7/6/22, at 10:57 AM, with Resident 1, Resident 1 stated when the fall incident happened (7/3/22) she was getting up to use the restroom and she reached for the wheelchair, the wheelchair turned, and then she fell . She stated she heard a crack that made her nauseous and the pain was excruciating then I broke my [left] ankle. Resident 1 stated she was admitted (3/31/22) to the facility because she fell at home and broke her tibia and fibula (calf bone). Resident 1 stated she also fell at the facility (7/3/22) because her left wheelchair brake would not lock. Resident 1 stated prior to her fall on 7/3/22, she informed the Physical Therapy Assistant (PTA - works under the supervision of Physical Therapist) on 7/2/22, at around 10 AM, and Licensed Vocational Nurse (LVN) 3 at around 4 PM, regarding her left wheelchair brake that would not lock. Resident 1 stated the PTA and LVN 3 told her they would call for the Maintenance staff to have the wheelchair brake fixed. During a review of Resident 1 ' s Change in Condition Evaluation, (COCE) dated 7/3/22, the COCE indicated, fell from the wheelchair when going to restroom [Resident 1] complained of ten out of ten [scale of 7-10 = severe pain] pain to left ankle. During a review of Resident 1 ' s Radiology Report (RR) dated 7/3/22, the RR indicated, Acute medial malleolus [the bony bump on the inner side of the ankle] fracture extending to the tibial plafond [bottom of one of two long bone that support the ankle] and acute transverse distal fibular shaft fracture [the end of one of two long bones in the leg that support the ankle]. During a review of Resident 1 ' s Nursing Progress Note (NPN) dated 7/3/22, at 9:05 AM, the NPN indicated, Resident 1 was sent to the acute hospital for evaluation and treatment for the left ankle fracture. During an interview on 7/6/22, at 2:46 PM, with Certified Nursing Assistant (CNA) 3, CNA 3 stated she worked with Resident 1 on the day of the fall incident (7/3/22), one of the brakes [left] on her [Resident 1] wheelchair was not working that day, she may have not locked the other one [right]. During a concurrent interview and record review on 7/6/22, at 3:27 PM, with Maintenance Supervisor (MS), MS stated, The turnaround time on wheelchairs or equipment the resident uses are critical and are to be dealt with immediately because they are a safety issue for the residents. MS also stated, For critical issues if we are not on site or it is after hours the nurse or receptionist places a work order and calls the on-call maintenance staff. We come to the facility and repair or replace the item right away. Maintenance Technician (MT) was on call last week. MS reviewed the work order titled, Wheelchair and Brake Broken for Resident 1 created on 7/2/22, at 12:52 PM, MS stated, I know the problem, it was coded as high and not critical. During an interview on 7/6/22, at 3:58 PM, with MT, MT stated critical items are beds, bed remotes, wheelchairs, air mattress, and plumbing (apparatus concerned in the distribution of water in the building). MT stated critical items must be fixed as soon as possible (ASAP), ASAP means immediately and critical items were always considered a safety issue and should be fixed ASAP. He stated he did not get any calls (7/2/22) for wheelchairs. During an interview on 7/7/22, at 6:12 PM, with Receptionist 1, Receptionist 1 stated the nurses will call and request a work order be placed, I ask them specifically how they would like me to rate it. Receptionist 1 stated, If urgent it is rated as critical and critical are anything that would cause a fall or injury to residents, it could be a wheelchair with no breaks, wheelchairs are extremely important and would be critical. If the work order is rated critical, we take the initiative to give Maintenance staff a call immediately and they do respond quickly. During an interview on 7/8/22, at 11:22 AM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the CNA called her on 7/3/22, at around 12:50 AM, in the resident ' s room and Resident 1 was noted on the floor in front of her wheelchair by her bed. Resident 1 complained of ten out of ten [scale of 7-10 = severe pain] pain in her left ankle. LVN 2 stated Resident 1 was trying to transfer and go to the restroom and was unable to lock the left wheelchair brake. LVN 2 stated upon inspection of the wheelchair, the left wheelchair brake was not locking. LVN 2 stated she was not aware Resident 1 ' s left wheelchair brake was not locking prior to the fall on 7/3/22. LVN 2 stated, When a resident ' s wheelchair brakes are not working, we inform the supervisor, remove the wheelchair, and call Maintenance immediately to get it fixed because it could cause injury. During an interview on 7/10/22, at 2:31 PM, with LVN 3, LVN 3 stated he worked with Resident 1 on 7/2/22, prior to her fall on 7/3/22. LVN 3 stated Resident 1 reported her left wheelchair brake was not locking and he called the receptionist and reported it as a critical item. He did not remove the wheelchair because Resident 1 was sitting on it when the resident reported it to him in the hallway. LVN 3 stated he could not remember the name of the Receptionist who he reported Resident 1 ' s left wheelchair brake was not locking, we are responsible for the residents ' , I feel like we (nurses) should have a direct contact with Maintenance staff, so we know what was reported and the issue is going to be taken care of. During an interview on 7/21/22, at 11:14 AM, with Director of Nursing (DON), DON stated broken wheelchairs and broken equipment, should be removed from the resident ' s room, and labeled that it is broken, it is defective and will not serve the purpose. During an interview on 7/12/22, at 2 PM, with Resident Program Assistant (RPA), RPA stated, I received a call from [LVN 3] the nurse on Saturday [7/2/22], he said a work order needed to be place for a wheelchair for [Resident 1's] room. RPA stated, If I did not put critical or ASAP it was not communicated to me. RPA stated, If I ' m in the room I would leave the resident and place the work order. I would move the wheelchair away, inform the resident so that they could not use it. RPA stated, If residents are using items that are not working properly, they could fall, it is their safety. During an interview on 7/21/22, at 2:55 PM, with Human Resource Assistant (HRA) and Quality Improvement Nurse ([NAME]), HRA stated if the brakes on the resident ' s wheelchair were not locking, the staff should remove the wheelchair and get a replacement from the Maintenance staff. [NAME] stated, It is a safety issue, and that has always been the standard. The Policy and procedure for the Maintenance of Equipment was requested and none were provided. During a review of the facility ' s policy and procedure (P&P) titled, Falls Prevention-CS-40-2, revised 10/21, the P&P indicated, A. Fall Risk Data Collection: .Maintain safe environment (dry floors, properly maintained resident equipment). 2. During a review of Resident 1's care plan dated 4/1/22, the care plan indicated The resident has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) altered activity tolerance r/t h/o (history of) Fall, s/p (status post) left tibial fx (fracture).Interventions/Tasks.The resident requires ext (extensive assistance [resident involved in activity, staff provide weight-bearing support] staff assistance to use toilet. Date Initiated 06/27/22.The resident requires ext assistance with transfers. Date Initiated 06/27/22. During an interview on 7/6/22, at 10:36 AM, with CNA 1, CNA 1 stated Resident 1 was transferring and toileting independently and not using her call light. During an interview on 7/6/22, at 2:46 PM, with CNA 3, CNA 3 stated Resident 1 was not calling for help because she wanted to be independent and transferring and toileting independently. During an interview on 7/10/22, at 2:31 PM, with LVN 3, LVN 3 stated he was not aware Resident 1 was transferring and toileting independently. During a concurrent interview and record review on 7/21/22, at 11:14 AM, with DON, DON was informed the CNAs were aware Resident 1 was transferring and toileting independently and the care plan was not followed since the care plan (4/1/22) indicated Resident 1 needed extensive assistance with transferring and toileting. DON stated she was not aware Resident 1 was transferring and toileting independently and confirmed the findings. DON stated regarding Resident 1 transferring and toileting independently, We would create a non-compliance care plan, for non-compliance care plan, we educate the resident of risk of their non-compliance and the benefits of compliance. DON reviewed Resident 1 ' s care plans and confirmed Resident 1 did not have a non-compliance care plan for transferring and toileting independently. During a review of the facility ' s P&P titled, Comprehensive Care Plan- SOM [State Operation Manual], effective date 11/2017, the P&P indicated, A. A person centered, comprehensive care plan will be developed and implemented in accordance with the following: 1. The Comprehensive Care Plan will describe treatments and services to assist the resident to attain or maintain the highest level of physical, mental and psychosocial wellbeing. 2. The comprehensive care plan is based on a comprehensive assessment which includes, but is not limited to the MDS, Care Area Assessment, clinical assessments, and data collection forms, .5. The Care Plan process assesses and is developed to meet the resident ' s medical, nursing, mental and psychosocial needs.9. Care plans will be revised as information about the resident and resident ' s condition changes. 10. The Interdisciplinary Team is responsible for the review and updating of care plans. This can be triggered by significant change in condition, a condition or outcome not being met or re-admission after a hospitalization and as needed with any changes. 3. During a review of Resident 1 ' s Fall Risk Data Collection, (FRDC) dated 7/3/22, the FRDC indicated, Resident 1 scored 14 (high risk for falls), and one of the interventions were Resident 1 was a Falling star participant. During a concurrent observation and interview on 7/6/22, at 10:36 AM, with CNA 1, outside Resident 1 ' s room. CNA 1 confirmed there was no star sticker on Resident 1 ' s nameplate. CNA 1 stated Resident 1 is at risk for falls. During a concurrent observation and interview on 7/6/22, at 10:55 AM, with DON, outside of Resident 1 ' s room. DON was observed placing a star sticker on Resident 1 ' s nameplate. DON stated she just placed a star sticker on Resident 1 ' s nameplate. During an interview on 7/21/22, at 11:14 AM, with DON, DON stated the expectation is the star sticker is placed on the resident ' s nameplate when a resident was identified as a fall risk. During a review of the facility ' s P&P titled, Falling Star Program-CS-40-1, revised 10/2016, the P&P indicated, 5. A resident who is identified as being at risk for falls (score of 10 or more on the Fall Risk Data Collection form in PCC [point click care]) or who has had two or more falls, will be referred to the Falling Star Program. A star will be placed next to the nameplate outside his or her room and on adaptive devices the resident uses outside of their rooms, to indicate to care providers that this resident is at risk for falls. During a review of the facility ' s P&P titled, Falls Prevention-CS-40-2, revised 10/21, the P&P indicated, 1. The Falling Star Program shall be initiated at the time the increased risk for falling is identified and approaches shall be outlined on the care plan for all disciplines. 2. A distinction will be made to alert care providers to observe safety precautions by placing a star on the resident ' s nameplate outside his/her door. 4. During an interview on 7/6/22, at 10:46 AM, with CNA 2, CNA 2 stated she was not sure what the stars (sticker) on the nameplates of some residents meant, almost everyone has them (stars) not sure if they mean risk for falls or not. During an interview on 7/6/22, at 2:39 PM, with LVN 1, LVN 1 stated she believes the facility had signs indicating residents were at risks for falls. LVN 1 stated she was not sure what the star sticker on the nameplates meant. During an interview on 7/21/22, at 11:14 AM, with DON, DON stated, The expectation for staff is they should be aware of what the star on the nameplate means, that resident is high risk for falls. During a review of the facility ' s P&P titled, Falling Star Program-CS-40-1, revised 10/2016, the P&P indicated, The Falling Star Program is designed to facilitate recognition of residents who are at risk for falls.

Based on interview and record review, the facility failed to ensure the physician was notified of a change of condition in one of three sampled residents (Resident 1) when Resident 1 was noted with a bruise to her right calf. This failure resulted in Resident 1 experiencing a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: During a review of Resident 1's Progress Notes (PN), dated 12/1/21 at 10:03 PM, the PN indicated, Family found a bruise on right calf. Ice pack placed. Routine pain meds given. Will continue to monitor. No further c/o (complaint of) pain. During a review of Resident 1's PN, dated 12/2/21, at 7:06 PM [approximately 21 hours after the bruise was initially discovered], the PN indicated, Situation: The Change in Condition/s reported on this CIC [Change in Condition] are/were.Outcomes of Physical Assessment.Pain Status Evaluation: Does the resident/patient have pain? Yes.Resident's daughter reported this nurse that resident has skin discoloration to her right inner leg. upon skin assessment, skin discoloration, purple in color, warm to touch also soft area noted below the knee inner side of right leg, resident c/on [sic] pain also. Upon asking resident denied any recent fall or hitting of her lower leg. Pain pill was offered and given with positive outcome. vitals are normal.Primary Care Provider Feedback.stat [immediately] xray of right lower leg below the knee two views. During a review of Resident 1's Radiology Report (RR), dated 12/2/21, the RR indicated, 1. Acute proximal tibial metadiaphyseal (at the growth plate of a long bone) fracture which may extend to the joint space. 2. Possible fibular neck fracture. During a review of Resident 1's (PN) completed by the physician, dated 12/3/21, the PN indicated, right lower ext [extremity] - below right knee medial (middle) area with large green ecchymosis (bruising) extending to proximal (near the center) third of right leg, mild swelling. During an interview on 12/21/21, at 2:39 PM, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, she discovered Resident 1's bruise during the evening shift of 12/3 while Resident 1 was sitting in her wheelchair. LVN 3 stated, the bruise was soft fluid filled, blue purplish in color with a yellow outline, and extended from her knee to her ankle. LVN 3 stated, the bruise had been discovered on 12/2 [the day prior] but the physician was not notified and there was no ongoing monitoring. LVN 3 stated, the physician should have been notified of the bruise when it was discovered and monitoring should have been implemented. During a concurrent interview and record review, on 12/21/21, at 4:12 PM, with Director of Nursing (DON), Resident 1's record was reviewed. DON was unable to provide documentation that the physician was notified of the bruise when it was discovered and ongoing monitoring. DON stated, the physician should have been notified of a change of condition when the bruise was discovered and monitoring should have been implemented. During a review of the facility's policy and procedure (P&P) titled, Change of Condition for Skilled Nursing, dated 9/19, the P&P indicated, When a resident is evaluated or assessed as having a change of condition, the charge nurse will follow through in documenting notification to family/legal representative, the health care provider and other licensed nurses in order to facilitate the appropriate plan of care. As indicated based on the comprehensive evaluation or assessment will document the current situation, background, assessment (RN) or appearance (LPN/LVN) and requested for the Health Care Provider on the eInteract Change of Condition Evaluation form including pertinent labs, tests, recent medication changes, and advanced directives.Call the appropriate Health Care Provider to communicate the eInteract Change of Condition Evaluation information and any needed treatment orders. A resident Change of Condition may include but is not limited to.Pain (new or uncontrolled).Skin/wound/ulcer.Following completion of the above process, the nurse shall then implement the spot the Dot program. Place an ORANGE sticker dot on the medical record.The ORANGE dot shall then serve as a cue or reminder that each record marked must have documentation on the change of condition. This documentation shall be specific to the change of condition and must be completed every shift for a minimum of seventy-two (72) hours or until the change of condition is evaluated as being resolved.

Based on observation, interview, and record review, the facility failed to implement it's pain control policy and procedure for one of one sampled resident (1) which resulted in Resident 1 experiencing uncontrolled pain. Findings: During an interview with Resident 1 on 3/23/16 at 2:20 PM, Resident 1 stated because of her diagnoses, she was in constant pain. Resident 1 stated the doctor had ordered [MEDICATION NAME] (medication used for severe pain) in addition to [MEDICATION NAME] (medication used for moderate pain) for her extreme pain but she did not like taking the [MEDICATION NAME] because it made her very sleepy. She stated, They tell me I'm dying. I will be going on hospice soon. I want to spend my last days with my family and not be too sleepy to be aware they are here. She stated the [MEDICATION NAME] was given to her every four hours but it only lowered her pain for about 30 minutes of those four hours. Resident 1 stated the facility staff had not told her of any other options for pain control except for the [MEDICATION NAME]. During this interview, Resident 1 was observed constantly shaking, she was very anxious while rubbing her stomach which was where she stated she had the most pain. Resident 1 stated she has been telling all the nursing staff that her pain was not controlled by the [MEDICATION NAME] alone. The electronic clinical record for Resident 1 was reviewed with the Director of Staff Development (DSD) on 3/23/16 at 2:48 PM. The Minimum Data Set (MDS-an assessment tool) dated 3/16/16, indicated Resident 1 had a score of 15 out of 15 which meant she was cognitively intact. The MDS pain assessment interview indicated Resident 1 had frequent pain that made it hard for her to sleep at night, limited her day-to-day activities, and was usually a 7 out of a possible 10 on the pain scale. A pain scale is a numeric rating scale from 0 through 10 for patients to self-report their level of pain. Zero means no pain, 1-3 means mild pain, 4-6 means moderate pain, and 7-10 means severe pain that is often disabling and patients are unable to perform activities of daily living (ADLs). The physician's orders [REDACTED]. No other pain medication was ordered for Resident 1. Resident 1's care plan for her chronic pain indicated staff was to observe and report changes in usual routine, sleep patterns, decrease in function abilities, decrease ROM (range of motion), withdrawal or resistance to care. Resident 1's care plan for pain medication indicated the staff was to monitor the efficacy of the pain medication and notify the attending doctor if the pain medication was not effective. The Medication Administration Record [REDACTED]. The progress notes for Resident 1 were reviewed from 3/12/16 through 3/23/16. There was no progress notes indicating the attending doctor was notified concerning Resident 1's continued uncontrolled pain. The DSD verified the above findings during the record review. During an interview with the Licensed Nurse (LN) on 3/23/16 at 3:25 PM, she stated Resident 1 often complained to her about the pain medication decreasing the pain for about 30 minutes before the pain would increase back to a high level. The LN stated Resident 1 was always anxious and shaky. The LN stated Resident 1 had refused the [MEDICATION NAME] because it made her lethargic and she wanted to be awake to spend time with her family. The LN stated she had never called the attending doctor, notified other licensed nurses, or charted in the clinical record about Resident 1's continued unrelieved pain and refusal of the [MEDICATION NAME]. During an interview with the Assistant Director of Nursing on 3/23/16, at 3:30 PM, she stated she was unaware of Resident 1's pain issues and that licensed staff should call the attending doctor when Resident 1's pain was not controlled. The facility policy and procedure titled Pain Management dated 11/2007, indicated The purpose of the policy is to identify, treat, and manage the resident's pain levels . Pain management needs will be addressed on the resident's care plan and monitored by Interdisciplinary Team (IDT) . New or worsening pain will be identified as a Change of Condition. The facility policy and procedure titled Clinical Status Change dated 11/2007, indicated When a resident is assessed as having a clinical status change, the licensed nurse will follow through in documenting notification to family/responsible party, the physician and other licensed nurses in order to facilitate the appropriate plan of care.

Based on interview and record review, the facility failed to provide adequate hydration (supplying fluid into the body) per Physician's order for one of one sampled resident (1) who was dependent on gastrostomy tube (tube inserted on the belly to provide nutrition for people who cannot obtain nutrition by mouth) which resulted in dehydration for Resident 1. Findings: During a review of the clinical record for Resident 1, the Admission Record indicated in the [DIAGNOSES REDACTED]. (A gastrostomy includes a small, flexible tube inserted into the stomach from the outside of the skin and is required when nutrition and hydration is insufficient based on clinical signs and documented laboratory values. Water and liquid feeding are administered into the stomach for hydration and nutrition. The water helps to maintain body functions, as well as, relieve constipation, maintain bladder function and to help the lungs clear of infection. Both liquid feeding and water can support hydration). The Order Summary Report, indicated in the physician diet order dated [DATE], NPO (nothing by mouth) and Flush with water 50 ml/hr (milliliter per hour) x (for) 20 hours (1000 milliliter per day). The physician order dated [DATE] and renewed on [DATE], indicated Resident 1 was to receive liquid feeding 20 hours a day at the rate of 70 ml per hour for a total of 1400 ml per day. During a concurrent interview and record review with the Director of Nursing (DON), the Input and Output Record, dated [DATE] to [DATE], indicated Resident 1's gastrostomy tube was not provided with the daily 1000 milliliter of water and the 1400 ml of liquid feeding on the following days: Amounts of Water given each day: [DATE], 400; [DATE], 900 ml; [DATE], 800 ml; [DATE], 400 ml; [DATE], 900 ml; [DATE], 600 ml, [DATE], 600 ml; [DATE], 400 ml; [DATE], 400 ml; [DATE], 400 ml; [DATE], 960 ml; [DATE], 700 ml, [DATE], 960 ml; [DATE], 800 ml; [DATE], none; [DATE], none; [DATE], 380 ml. Amounts of Liquid Feeding given each day: [DATE], none; [DATE], 1120 mil; [DATE], 1120 ml, [DATE], 560 ml; [DATE], 1120 ml; [DATE], 1400 ml; [DATE], 840 ml; [DATE], none; [DATE], 560 ml; [DATE], 560 ml; [DATE], 400 ml; [DATE], 840 ml; [DATE], 560 ml; [DATE], 280 ml; [DATE], none; [DATE], none; [DATE], none. During the above 17 days, Resident 1 should have received with the combination of water and liquid feeding, 40,800 ml of fluid. Per the above totals, Resident 1 received 19,060 ml of fluid, a deficit of 21,740 ml of fluid. The DON verified and confirmed the findings. During an interview with Licensed Vocational Nurse (LVN) 1, on [DATE], at 3:05 PM, she stated on [DATE], Resident (1) was lethargic and unresponsive. When asked about Resident 1's input and output record, she stated, We have a protocol that if a resident has gastrostomy tube, we have to record the input and output. When asked if she monitored and documented the input and output, she stated, I don't remember doing the input and output. When asked how often they have to monitor and document the input and output, she stated, We have to do it every shift. During a review of the clinical record for Resident 1, the Nursing Progress Note, dated [DATE], at 10:15 AM, indicated, Try to wake patient (Resident 1) noted patient is lethargic, O2 (oxygen) sat (saturation-level of oxygen in the blood) 84% (normal range is ,[DATE]%), heart rate elevated to 130 (normal heart rate is ,[DATE] beats per minute), Temperature 97.9 (degrees Fahrenheit), respiration 22 (normal breathing rate is ,[DATE] breaths per minute). Assessed patient by RN (Registered Nurse) Supervisor. Place phone call to MD (doctor) and notified wife. (Resident 1 was transferred to the hospital). The hospital History and Physical, dated [DATE], indicated, The patient arrived at the emergency room at 11:10 today morning with blood pressure (pressure exerted by circulating blood upon the walls of blood vessels) of ,[DATE] (normal adult blood pressure is ,[DATE]) with DNR/DNI (Do Not Resuscitate/Do Not Intubate - Do not revive) status. The patient was given boluses of fluid, although patient was DNR/DNI. Laboratory Studies: BUN (Blood Urea Nitrogen-blood test indicating kidney health) 48 (normal adult BUN in the blood is between 6 to 20 milligram of urea nitrogen per 100 milliliter of blood), Creatinine (blood test that measures kidney function) 2.6 (normal creatinine in blood is 0.7 to 1.2 milligram per deciliter for men).(Elevated BUN and creatinine can indicate kidney disease and dehydration). The x-ray report for Resident 1, completed while he was at the facility, dated [DATE], indicated he had a small amount of fluid in the lower portion of his right lung. The x-ray report for Resident 1 completed while he was at the facility, dated [DATE], one day before he was admitted to the hospital, indicated he had pneumonia (inflammation of the lungs) in the left lower part and the right upper part of his lungs. The hospital emergency department physician's notes dated [DATE], read Diagnoses: [REDACTED]. The hospital Discharge Summary, dated [DATE], indicated, The patient was in septic shock (a potentially lethal drop in blood pressure due to the presence of bacteria in the blood and part of the treatment is to administer fluids into the blood stream via a catheter.) when evaluated in the emergency room . Patient was almost dead, but the family chose to continue with fluid resuscitation. The patient expired on [DATE] peacefully. The facility policy and procedure titled, Intake Measuring and Recording, dated ,[DATE], indicated, General Guidelines: 5. At the end of your shift, total the amounts of all liquids the resident consumed. Documentation: The following information should be recorded in the resident's medical record, per facility guidelines: 3. The amount (in mls) of liquid consumed. Report other information in accordance with facility policy and professional standards of practice. The nursing manual titled Lippincott Manual of Nursing Practice ninth edition dated 2010, indicated the nurse was to administer the prescribed amount of enteral feeding (gastrostomy feeding) and water flushes. This manual read Document type and amount of feeding, amount of water given, and patient tolerance of procedure. Monitor breath sounds, gastric distention, diarrhea or constipation, intake and output, daily weight, and serum chemistry results.

Based on observation, interview, and record review, the facility failed to provide a Pressure Alarm Pad (pressure-sensitive pads placed on the seat of a wheelchair and/or the surface of a bed which sets off a loud sound as the resident attempts to get up from the wheelchair or bed) on Resident 1's wheelchair as ordered by the physician and as indicated in the plan of care. This failure resulted in Resident 1's un-witnessed fall which caused a skin laceration to the head, subdural hematomas, and subsequently, Resident 1's death. Findings: During an interview with Certified Nurse Assistant (CNA) 1, on [DATE], at 9:53 AM, she stated on [DATE], before 11 AM, she had noticed Resident 1 sitting in her wheelchair in front of the nurse's station. CNA 1 stated the call light of another resident was activated and she responded to that call light and remained with the resident until she was done assisting. At 11 AM, after CNA 1 had finished helping the other resident, she saw the bathroom call light was activated for Resident 1. She stated as she approached Resident 1's bathroom, the resident was calling for help, while knocking on the bathroom door. When CNA 1 entered the bathroom, she found the resident lying on the floor. CNA 1 stated she asked Resident 1 why she did not call for help, Resident 1 stated, "I don't know." When CNA 1 was asked if an alarm was in use during this time, CNA 1 stated she clipped a personal tab alarm (an alarm box that hangs at the back of the wheelchair and sounds a loud alarm when the clip hooked to the resident detaches from the box when the resident attempts to get up) to Resident 1's sleeve earlier that morning after she changed her briefs. CNA 1 verified after the fall, the alarm was not clipped to Resident 1's sleeve and was still attached to the alarm box. During the interview with CNA 1, there was no mention of a pressure alarm pad that was in use on Resident 1's wheelchair seat. During a concurrent observation of Resident 1's bathroom and interview with Licensed Nurse (LN) 1, on [DATE], at 3:06 PM, LN 1 stated she was one of the staff who assisted when Resident 1 fell in her bathroom on [DATE]. LN 1 described how the resident was lying on the bathroom floor, her feet were by the toilet bowl, her head was against the bathroom wall across from the toilet bowl, and her wheelchair was in front of the sink by the door. On the floor, under the toilet bowl, were a few drops of urine. LN 1 stated Resident 1 had placed the detachable seat cushion of the wheelchair between her head and the wall. LN 1 stated she felt a lump on the area of the resident's head which was in contact with the wall and "it was bleeding". LN 1 stated she was alternating with another nurse applying pressure to the resident's head to stop the bleeding. When asked if an alarm was in use at that time, LN 1 stated she saw a tab alarm hanging on the wheelchair. She stated the alarm did not sound off because it was not clipped to Resident 1. During the interview with LN 1, there was no mention of a pressure alarm pad in use on Resident 1's wheelchair seat. A review of the Nurse's Notes, dated [DATE], at 12:50 PM, written by LN 2 indicated she was notified of Resident 1's fall and also assisted the resident during this incident. LN 2 indicated in her notes the resident's brief was "halfway down" her legs, the resident's hands were noted with blood, and Resident 1 was frequently touching her head. When the resident was asked by LN 2 what she had wanted to do, the resident stated, "I just needed to go to the bathroom." LN 2 documented Resident 1 had a personal (tab) alarm at the back of the wheelchair that was not sounding an alarm because it was "unhooked" from the patient. The notes also indicated the resident was alert and oriented enough to unclip the personal tab alarm. A review of the Quality of Care Progress Notes, dated [DATE], was written after the fall had occurred on [DATE], and it indicated the resident removes her personal tab alarm and was noted several times attempting to transfer by herself from the wheelchair to the bed. She was also noted to be transferring herself to the toilet unassisted. During a review of the current physician's orders [REDACTED]. During a review of the Care Plan Report dated [DATE], one of the interventions indicated "Use pressure alarm in bed and w/c (wheelchair) to monitor attempts to rise". A handwritten note by an unknown staff at an unknown date was added to this intervention to also use a personal tab alarm in addition to the pressure alarm. During an interview with the Director of Nursing (DON) on [DATE], at 1:23 PM, she clarified the above physician's orders [REDACTED]. The DON stated the nursing staff was instructed by her to sign and date new information added to a care plan. The DON stated, she was unable to verify who added the handwritten notes to add the use of a personal tab alarm. When the DON was asked, what the nursing staff had done after learning Resident 1 knew how to remove the clip of the personal tab alarm from her sleeve and if any of the records indicated the pressure alarm pad was in use on the wheelchair seat during the time of the fall on [DATE], the DON responded she would have to review Resident 1's chart. No confirmation was received from the DON in response to these questions. During a review of Resident 1's records, it indicated she was transported to Hospital 1 via an ambulance on [DATE], at 12:45 PM, and was noted to be alert and verbally responsive upon transport. A review of the Emergency Department Report for Hospital 1 dictated by Physician 1 on [DATE], at 3:31 PM and 3:30 PM, indicated she had a laceration (tear) to the occipital scalp (skin on the back and lower part of the head) and was complaining of a mild headache. Her vital signs included a temperature of 98 degrees Fahrenheit, pulse at 66 beats per minute, respirations at 16 breaths per minute, blood pressure at ,[DATE] (normal blood pressure is below ,[DATE]) mm Hg (millimeter per Mercury), oxygen saturation level (amount of oxygen in the blood) of 92 percent (normal oxygen saturation is between ,[DATE] percent), and a 2 out of 10 level on the pain scale (0- no pain, 10- worst pain). The scalp laceration measured "approximately 5 cm" (centimeter) and she had a GCS (Glasgow Coma Scale) of 15 (GCS is a scoring system used to describe the level of consciousness in a person to assess the severity of a traumatic brain injury- 3 being the worst and 15 being the best). Physician 1 also indicated she was alert and oriented with her pupils at an equal size and reacting to light. A CT Scan (Computerized Tomography scan showing detailed images of internal organs using a sophisticated X-ray device) of the brain showed a significant left subdural (area between the layers of tissue that surround the brain) hematoma (bleeding) with blood present in the frontal cortex area (front part of the brain), left falx (membrane that separates the brain hemispheres), left middle cerebral fossa (cavity in the middle part of the brain), and cranial fossa (one of the cavities in the brain- unknown area). There was also a small amount of blood in the right frontal sulcus (groove on the right and frontal area of the brain) possibly indicating a subarachnoid (area between the brain and the thin tissues that cover the brain) hemorrhage. Also found was a 5 mm (millimeter) shift of the brain from the left to the right side with some effacement (disappearance) of the brain on the left side. Physician 1's notes dictated on [DATE], at 4:09 PM, indicated the resident's scalp laceration was closed with staples to control further bleeding. Also, at the request of the Consulting Neurosurgeon 1, the resident was transferred in stabilized critical condition to the Intensive Care Unit at Hospital 2. On [DATE], at 5:35 PM, Hospital 2's Emergency Department (ED) report indicated Resident 1 was received from Hospital 1 by ambulance for definitive care (for completion of recommended treatment) at the request of Neurosurgeon 1. A review of Physician 2's notes dictated on [DATE], at 6:29 PM, indicated the resident was received unresponsive with a GCS of 5, body temperature at 97.8 degrees Fahrenheit, pulse at 80 beats per minute, respirations at 16 breaths per minute, and blood pressure of ,[DATE] mmHg. The right pupil measured 3 mm (millimeters) and the left pupil measured 5 mm (unequal pupil sizes after trauma to the head are indicative of severe brain injury). She had no response to any type of stimulation other than she was withdrawing from pain stimulation. Hospital 2 performed a repeat CT scan of the brain and results relayed to the ED physician by the Radiologist at 6:20 PM showed significant worsening of the subdural hematoma with "impending uncal herniation" (part of the brain is threatening to get displaced as a result of increasing pressure inside the head). Neurosurgeon 1's notes dictated on [DATE], at 8:06 AM, indicated the resident's hematoma had multiple components: 1 component was on the brain's left frontal area which was classified as chronic (an older hematoma), 1 component was located posterior (further to the back of the head) to the left frontal area which was classified as acute (a newer hematoma), and 1 component was located on the left occipital area (back and lower part) of the brain which was described as having the most dramatic abnormality where there was a large parafalcine subdural hematoma formation (large bleeding that starts from the front to the back of the head). The physical examination performed by Neurosurgeon 1 revealed the resident's left pupil had become smaller at about 2 or 3 mm and the right pupil pinpoint. The resident was prepared for a decompressive craniotomy procedure (a procedure to surgically open the head to release pressure) and removal of the subdural hematoma, with a likely poor prognosis (outcome) and a low likelihood of improvement. A review of Neurosurgeon 1's Operation Report dictated on [DATE], at 8:11 AM, indicated the resident was found to have a 1 centimeter tear in the superior sagittal sinus (a hollow area within the brain that allows for the drainage of blood to the rest of the body) which was the source of the hemorrhage (bleeding). This operation report also indicated there was evidence found of different ages of subdural hematoma- chronic, acute, and sub-acute (acute and sub-acute being new and chronic being old) measuring about an inch-thick. A review of the Neurologic evaluation by Neurologist 1 dictated on [DATE], at 8:55 PM, indicated the resident had undergone a craniectomy procedure (part of the skull bone was opened to allow the swelling brain to expand) on the left side with the bone flap removed. The resident was "comatose" (a state of unconsciousness and extreme unresponsiveness wherein even painful stimuli are unable to affect any response from a person) with very sluggish reactivity noted on the left pupil and an unreactive right pupil. She also did not respond to noxious (painful) stimuli. The notes further indicated that she had deteriorated rapidly since the start of the hemorrhage, and that her prognosis was very grave. A review of Physician 3's Discharge Summary dictated on [DATE], at 12:08 AM, indicated Resident 1's condition did not improve after coming out of surgery, was extubated (breathing tubes were removed), placed on a DNR (Do Not Resuscitate) status, and she subsequently died . The Certificate of Death indicated the resident's immediate cause of death was "Cardiorespiratory Failure" (inability of the heart and lungs to continue functioning) as preceded by "Intracranial Hemorrhage (bleeding inside the head) of Unknown Etiology".

Based on interview and record review, the facility failed to ensure Resident 1 was free of unnecessary drugs when physician orders [REDACTED]. These failures caused Resident 1 to continue to receive [MEDICATION NAME] and [MEDICATION NAME] (blood thinning medications), which caused the resident to be admitted to an acute care hospital with severe [MEDICAL CONDITION] and [MEDICATION NAME] Toxicity. Findings: During a review of the clinical record for Resident 1, Discharge Orders from the acute care hospital, dated 3/8/13, indicated Resident 1 was to receive [MEDICATION NAME] 5 milligrams (mg unit of measure) daily for five days. The physician had also ordered daily laboratory testing to monitor Resident 1's bleeding time. The orders, which were transcribed by the facility staff on 3/10/13, stated the resident's [MEDICATION NAME] was to be held if her INR (International Normalized Ratio is a laboratory test to check a patient's bleeding time) was greater than 3.0. Resident 1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident 1's laboratory results indicated staff had not followed the physician's orders [REDACTED]. The results of the 3/18/13 INR test was 11.7 (8.7 greater then ordered by the physician). The results were faxed to the physician, and on 3/19/13, he ordered to hold the [MEDICATION NAME]. On 3/21/13 the resident's INR was 15.8 (4.1 higher than the INR on 3/18/13), and the physician ordered to continue to hold the [MEDICATION NAME] and to check the INR the next day. No INR for 3/22/13 could be found in the record. The next INR completed was on 3/27/13 (five days after 3/22/13) the INR on that day was 12.6. During an interview with the Director of Nurses (DON), on 4/16/13, she reviewed the clinical record for Resident 1, and was unable to find any laboratory results monitoring the bleeding time as ordered by the physician. There were no bleeding time results in the record from admission on 3/10/3 until 3/16/13 when the physician wrote new laboratories and medication orders. The DON stated the admission laboratory draw orders had not been followed, and the nurse did not follow facility policy regarding monitoring laboratory results of residents receiving blood thinning medications. The facility policy and procedure titled "Orders for Anticoagulants" dated 2007, indicated, "Orders for anti-coagulants shall be prescribed only with the proper clinical and laboratory monitoring." Nurses notes dated 3/25/13 indicated Resident 1 had a nose bleed. Further review of the notes did not indicate staff had reviewed the INR results to rule out bleeding caused by the [MEDICATION NAME]. Review of the acute care hospital summary dated 3/30/13, at 2:21 PM, indicated Resident 1 was admitted to the acute care hospital on [DATE] with the [DIAGNOSES REDACTED]. Lexicomp an online medication resource indicated under the subtopic "Nursing Physical Assessment/ Monitoring", "Drugs which are therapeutic anti-coagulants such as [MEDICATION NAME] and therapeutic anti-platelet agents such as [MEDICATION NAME]. have a potential adverse effect of bleeding and should be monitored closely with lab work and assessment for potential bleeding problems." 2. Resident 1's discharge orders dated 3/8/13 stated the resident was to receive a daily PT ([MEDICATION NAME] Time test to check patient's bleeding time) and INR daily. During the review of the clinical record for Resident 1, the admitting physician orders [REDACTED]. On 3/16/13 the physician ordered to hold the [MEDICATION NAME] if the INR was greater the 1.8. Review of the laboratory results revealed on 3/18/13 Resident 1's INR was 11.7. Upon reviewing the MAR indicated [REDACTED].

Based on interview and record review, the facility failed to ensure one resident's (1) critical laboratory results were reported to the physician. This failure resulted in Resident 1's physician not being aware of dangerous laboratory results, which delayed treatment and ultimately required Resident 1 to be transferred to an acute care hospital. This failure had the potential to put all residents who receive laboratory testing at risk of having abnormal and critical laboratory results to go un-noted and not acted upon. Such systemic failure constituted an Immediate Jeopardy (IJ) situation. The IJ was called on [DATE], at 2 PM by the survey team. In addition to the survey team members, the following facility staff were present at the time the IJ was called: the Administrator and the Director of Nursing. Findings: On [DATE], Resident 1's clinical record was reviewed. Resident 1's physician, on [DATE], ordered a Complete Blood Count (CBC, a blood test that indicates [MEDICAL CONDITION] and infection) and a Basic Metabolic Panel (BMP, a test that indicates the status of the kidneys) to be done on the following day, [DATE]. These laboratory test results were faxed to the facility on [DATE], at 2:58 PM. The results showed several critical laboratory values requiring immediate attention. These critical results included a white blood cell count (indicates infection) of 24.9 (normal range 4XXX,[DATE].5), hemoglobin (part of red blood cells) of 6.9 (normal range 13XXX,[DATE].0, a low value means [MEDICAL CONDITION], a condition in which red blood cells are deficient), and hematocrit (used to measure the number of red blood cells in whole blood) of 22.2 (normal range ,[DATE], a low value could mean [MEDICAL CONDITION]). During a concurrent interview and record review with the Director of Nurses (DON) on [DATE], at 2 PM, she stated a Registered Nurse (RN) is responsible for reviewing all residents' laboratory results and immediately notifying the resident's physician of critical results. The DON stated RN 1 gave all the residents' laboratory results for [DATE] to Licensed Vocational Nurse (LVN) 1 to review and notify their physicians. The DON added, LVN 1 did not review the laboratory results, instead he placed the abnormal laboratory results on a clip board for the physician to review during his routine visit. The DON explained the licensed staff was not even aware of these critical laboratory results until Resident 1's physician came to the facility after his death, [DATE], to review the resident's records. Resident 1's physician took the critical laboratory results off the clip board and showed it to the DON. The facility staff had not reviewed these results until then. The facility policy and procedure for "Lab (laboratory) and Diagnostic Test Results - Clinical Protocol" was reviewed on [DATE]. It is read, under "Review by Nursing Staff," "A nurse will review all results." This policy and procedure was not followed by the facility staff. During further review of Resident 1's "ED (emergency department) Physician Notes" on [DATE], a complete blood cell count was done as soon as the resident arrived to the emergency department. The results showed his white blood cell count was 49.1, hemoglobin was 5.8, and hematocrit was 19.3. Resident 1's [DIAGNOSES REDACTED]. Resident 1 was unresponsive and had low blood pressure on arrival to the emergency department on [DATE], at 6:54 AM. He died in the emergency department within a few hours. During an interview with Resident 1's physician on [DATE] at 9:25 AM, he stated he had a meeting on [DATE] with the DON and nurses on duty that day to call him or the physician on call for all laboratory results because there had been problems with the facility not notifying the physicians of laboratory results. The physician stated, "I told them you guys are going to kill somebody." He verified he was the one who reviewed the laboratory results on the clip board and notified the facility of Resident 1's abnormal laboratory results the day after the resident died .

Based on interview and records review, the facility failed to ensure critical laboratory results for one resident (1) were reported to the physician. This failure resulted in Resident 1's physician not being aware of Resident 1's critical condition, and therefore the physician was unable to render treatment to the resident. Findings: On [DATE], Resident 1's clinical record was reviewed. Resident 1's physician, on [DATE], ordered a Complete Blood Count (CBC, a blood test that indicates [MEDICAL CONDITION] and infection) and a Basic Metabolic Panel (BMP, a test that indicates the status of the kidneys) to be done on the following day, [DATE]. These laboratory test results were faxed to the facility on [DATE], at 2:58 PM. The results showed several critical laboratory values requiring immediate attention. These critical results included a white blood cell count (indicates infection) of 24.9 (normal range 4XXX,[DATE].5), hemoglobin (part of red blood cells) of 6.9 (normal range 13XXX,[DATE].0, a low value means [MEDICAL CONDITION], a condition in which red blood cells are deficient), and hematocrit (used to measure the number of red blood cells in whole blood) of 22.2 (normal range ,[DATE], a low value could mean [MEDICAL CONDITION]). During a concurrent interview and record review with the Director of Nurses (DON), on [DATE], at 2 PM, she stated the Registered Nurse (RN) is responsible for reviewing all residents' laboratory results and immediately notifying the residents' physician of critical results. The DON was unable to find documentation the physician had been notified of these abnormal laboratory results. The DON stated a RN 1 gave all residents' laboratory results, including Resident 1's, on [DATE] to Licensed Vocational Nurse (LVN) 1 to review and notify their physicians. The DON stated, LVN 1 did not review any laboratory results nor did she notify physicians of critical results. The DON stated Resident 1's physician was the one who brought the problem to her attention. The facility policy and procedure for "Lab (laboratory) and Diagnostic Test Results - Clinical Protocol" was reviewed on [DATE]. It is read, under "Review by Nursing Staff," "A nurse will review all results." The facility licensed staff failed to review Resident 1's laboratory results. During an interview with Resident 1's physician on [DATE], at 9:25 AM, he stated he was not notified of Resident 1's critical laboratory values on [DATE]. The day after the resident died , [DATE], he went to the facility to review the resident's records. He found the critical laboratory values were still clipped on a clip board. He immediately notified the DON that no one had notified him of Resident 1's laboratory results. That was when Resident 1's laboratory values were first reviewed by the facility staff.