Every finding on record at Bayshire Yorba Linda Post-Acute

Based on interview and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1's call light was within the resident's reach. This failure had the potential to delay care and interventions and could negatively impact on the health outcome and safety of the resident.Findings: Review of the facility's P&P titled Answering the Call Light revised 3/2021 showed when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Medical record review for Resident 1 was initiated on 7/9/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Physician's H&P evaluation dated 5/8/26, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's care plan for risk for falls related to generalized weakness, recent left hip intertrochanteric fracture status post-surgical repair, impaired gait and mobility initiated on 5/8/26, showed the interventions included to keep the call light within reach and encourage the resident to use it for assistance as applicable. On 7/9/26 at 1507 hours, an interview was conducted with Resident 1. Resident 1 stated he was once assisted to a wheelchair by a staff (unknown date) with door closed as requested but his call light was not placed within reach. Resident 1 stated he screamed for help for over an hour. On 7/14/26 at 1245 hours, a telephone interview was conducted with LVN 1. LVN 1 verified that she worked on 6/13/26, and attended Resident 1's call for help at around 1630 hours. LVN 1 stated Resident 1 was found sitting in his wheelchair next to his bed with the call light on the top of the bed and not within reach. LVN 1 stated Resident 1 should always have the call light within reach to allow him to call for help with basic needs or for medical attention and to prevent fall. On 7/14/26 at 1640 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate administration and documentation of the ordered medication for one of three sampled residents (Resident 1). * The facility failed to ensure the acetaminophen medication (analgesics/pain relievers and antipyretics) was administered to Resident 1 as ordered by the physician. In addition, the facility failed to document in the MAR when Resident 1 was administered with acetaminophen for pain. These failures posed the risk for the resident to receive medications not ordered by the physician and negatively affect the resident's well-being. Findings: Review of the facility's P&P titled Administering Medications revised on 4/2019 showed the following:- only persons licensed or permitted by the state to prepare, administer, and document the administration of medications may do so;- medications are administered in accordance with the prescriber orders, including any required time frame;- medications errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staff training;- the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication; and- as required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, the signature, and title of the person administering the drug. Review of the facility's P&P titled Charting and Documentation revised on 7/2017 showed the following:- documentation in the medical record may be electronic, manual, or a combination; and- documentation in the medical record will be objective, complete, and accurate. Review of the facility's P&P titled Physician Orders revised on 2/2014 showed the staff shall follow physician orders and authorized practitioner orders when providing resident care and services. Medical record review for Resident 1 was initiated on 6/15/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 6/4/26, showed Resident 1 had no capacity to understand and make decisions. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's BIMS score was 0, indicating severe cognitive impairment. On 6/15/26 at 0943 hours, an interview was conducted with LVN 2. LVN 2 stated she was assigned to Resident 1 on 5/24/26, when Resident 1 had a change of condition of chest pain at around 1800 hours. LVN 2 stated Resident 1's family were present at bedside and requested a nurse to check on Resident 1. LVN 1 checked Resident 1's vital signs and obtained an elevated heart rate; however, Resident 1 had no fever. In addition, LVN 1 stated she administered Tylenol (acetaminophen, a pain reliever or antipyretic) tablet 325 mg two tablets via Peg-tube for pain and the resident's family were present at bedside. LVN 1 stated she did not recall documenting the administration of the Tylenol medication. LVN 1 stated if not documented, it did not happen. Furthermore, LVN 1 stated following the physician's order despite being busy was very important and not following the physician's order was a medication error. Review of Resident 1's Order Summary Report dated 6/15/26, failed to show a physician's order for the acetaminophen medication. In addition, the MAR failed to show any documentation the acetaminophen medication was administered between 5/20 to 5/24/26. Review of Resident 1's MAR for May 2026 showed a physician's order started on 5/20/26, for acetaminophen oral liquid 650 mg per 20.3 ml, to give 20.3 ml via the Peg-tube every four hours as needed for fever. On 6/15/26 at 1425 hours, an interview and concurrent medical record review was conducted with RN 1. Resident 1's MAR for May 2026 was reviewed with RN 1, failed to show documentation of administration for the acetaminophen oral liquid 650 mg per 20.3 ml, give 20.3 ml via the Peg-tube every four hours as needed for fever on 5/24/26. Resident 1's SBAR dated 5/24/26 at 1800 hours, was reviewed with RN 1 showed a change of condition of chest pain, documented temperature of 97.9 Fahrenheit, and section nine for pain evaluation was marked not clinically applicable to the change in condition being reported. RN 1 verified the above findings. In addition, RN 1 stated the licensed nurse must follow the physician's order for the medication administration then document in the MAR after the administration. On 6/16/26 at 1253 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were accurate and complete for one of three sampled residents (Resident 2). * The facility failed to ensure the information in Resident 2's shower skin check form were accurate. This failure had the potential for the residents' health care needs not be met as the medical record was inaccurate. Findings: Review of the facility's P&P titled Charting and Documentation revised on 7/2017 showed the following:- documentation in the medical record may be electronic, manual, or a combination; and- documentation in the medical record will be objective, complete, and accurate. Medical record review for Resident 2 was initiated on 6/15/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/6/26, showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's Shower Skin check dated 6/10/26, showed redness on groin, perineal and buttocks area. In addition, the section for the CNA signature showed CNA 1's name and a charge nurse's signature. On 6/15/26 at 1531 hours, an interview and facility document review was conducted with CNA 1. CNA 1 stated she provided the assigned shower to Resident 2 on 6/10/26; however, she did not remember completing the shower skin check form. Review of Resident 2's shower skin check with CNA 1 showed redness on groin, perineal and buttocks area, CNA 1's name written and dated 6/10/26. CNA 1 stated she did not want to lie and further stated she did not fill up the shower skin check form or sign and write her name. In addition, CNA 1 stated Resident 1 did not have any redness on the perineal and buttocks area on 6/10/26. Furthermore, CNA 1 stated it was not her handwriting on the shower skin check form next to the CNA signature. On 6/15/26 at 1640 hours, an interview and facility document review was conducted with LVN 3. LVN 3 stated she was assigned to Resident 2 on 6/10/26; however, he did not receive the shower skin check form or report for any redness from any CNAs especially from CNA 1 or other licensed nurses. On 6/16/26 at 0912 hours, an interview and facility document review were conducted with the DSD. Reviewed Resident 2's shower skin check dated 6/10/26, showed Resident 1 had redness on the groin, perineal, and buttocks areas. The DSD verified the above findings and her signature as the charge nurse. On 6/16/26 at 1253 hours, an interview was conducted with the DON. The DON stated documentation must be complete, accurate, and timely by the licensed nurses or the nursing staff assigned/responsible to complete them. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and/or worsening of pressure ulcers for one of three sampled residents (Resident 2). * The facility failed to complete the skin assessment, change of condition, notification of the physician, provide wound treatment, and initiate care plan for pressure ulcers on the bilateral buttocks of Resident 2. These failures had the potential for the residents to develop pressure ulcers and/or worsening of the existing pressure ulcers.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status, revised on 5/2017 showed the following:- the nurse will notify the resident's Attending Physician pr physician on call when there has been a significant change in resident's physical/emotional/mental condition;- a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by a staff or by implementing standard disease related clinical interventions and requires interdisciplinary review and/or revision to the care plan;- prior to notifying the physician or healthcare provider, the nurse will make a detailed observation and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication form;- unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychological status; and- the nurse will record in the resident's medical record information relative to changes in the resident's [NAME]/mental condition or status. Review of the facility's P&P titled Wound Care revised on 10/2010 showed the following:- the purpose of this procedure is to provide guidelines for the care of wounds to promote healing;- verify that there is a physician's order for this procedure; and- review the resident's care plan to assess any special needs of the resident Medical record review for Resident 2 was initiated on 6/15/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/6/26, showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's MDS assessment dated [DATE], showed Resident 2's BIMS score was 14, indicating cognitively intact. On 6/11/26 at 0909 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed lying in bed awake, alert, and verbally responsive. Resident 2 stated he had a wound on his buttocks and it hurts. Review of Resident 2's Order Summary Report dated 6/11/26, failed to show treatment orders for the bilateral buttocks. On 6/11/26 at 0935 hours, an observation for Resident 2 and concurrent interview was conducted with LVN 1. LVN 1 repositioned Resident 2 on his right side and was observed with a non-blanchable redness and skin openings on bilateral buttocks and sacral area. LVN 1 verified the above findings and stated there were no treatment orders, notification of the resident's physician, change of condition, and care plan. On 6/11/26 at 1148 hours, an observation, interview and concurrent medical record review was conducted with the Case Manager. The Case Manager stated she also assesses residents' skin and administer wound treatments. The Case Manager assessed Resident 2's buttocks and observed a Stage 2 pressure ulcer on the left buttock and right buttock redness with DTI. The Case Manager verified the above findings. The Case Manager stated and verified Resident 2's pressure ulcers on the buttocks did not have a physician's orders for wound treatments. The Case Manager stated for any new redness or wounds observed, the licensed nurse must assess the skin, complete a change of condition, inform physician and responsible party, obtain order for treatment like triad cream, and developed a care plan. On 6/15/26 at 1425 hours, an interview and concurrent medical record review were conducted with RN 1. During the review of Resident 2's medical record, the skin assessment dated [DATE], showed no documented redness or open areas to the buttocks, sacral, or coccyx regions. RN 1 verified prior to 6/11/26, there were no skin assessments, no documented change of condition, no physician notification, no wound treatment orders, and no care plan developed for Resident 2's left buttock Stage 2 pressure ulcer and right buttock deep tissue injury (DTI). RN 1 stated this should have been identified as a change of condition and the pressure injuries were avoidable had prevention interventions been implemented. On 6/16/26 at 1253 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the heavy-duty blenders used for puree preparation, the clear rectangular plastic bucket containers used for marinating meats and food storage were air dried prior to storing and stacking and to ensure the blender was free of food residue prior to storing. * The facility failed to ensure the countertop mounted can opener was in sanitary condition and free of residue. * The facility failed to ensure the hair restraints was worn appropriately by the dietary aide. These failures had the potential for cross contamination and foodborne illnesses to the 41 of 41 residents consuming the foods prepared in the facility's kitchen.Findings: Review of the facility's Diet Type Report dated 4/12/26, showed 41 of 41 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Hoods and Filters date revised 8/31/18, showed the hoods must be kept free of grease and dust at all times. Because of a potentially high fire hazard, it is important that hood filters be part of a strictly enforced cleaning schedule and be free of grease and dust at all times. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention the dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 4/12/26 at 0752 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The kitchen hood over the stove had black, dirt residue. The [NAME] acknowledged the findings and stated the [NAME] cleaned the hood once a week and the hood was also cleaned by an outside company. The sticker on the hood showed it was last serviced on 1/16/26. 2. Review of the facility's P&P titled Sanitization date revised 10/2008 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Plastic ware, china and glassware that cannot be sanitized or are hazardous because of chips, cracks, or loss of glaze shall be discarded. Damaged or broken equipment that cannot be repaired shall be discarded. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 4/12/26 at 0752 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The following was observed and verified by the Cook:- One black rubber spatula with black handle had heat erosion and cracked at the edge.- One black rubber spatula with black handle had cracked at the edge.- One stainless steel spatula with black handle partially melted.- One white basting brush with bristles frayed and worn out.- Two large white rubber spatulas with red handles had chipped and cracked edges.- Five small white rubber spatulas with red handles had chipped, cracked edges and discolored.- One stainless steel whisk had shape deformity. 3. Review of the facility's P&P titled Sanitization date revised 10/2008 showed all the equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/ or chemical sanitizing solutions. Further review of the facility's P&P titled Trayline Setup and Service date revised 7/2/18, showed all the dishware and utensils utilized on trayline should not be soiled. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, 4-602.13, Nonfood- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 4/12/26 at 0752 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The following was observed and verified by the Cook:- Clear plastic container used for storage of utensils and kitchenware was observed dirty, fuzzy films with watermarks and had dry residue inside.- Two white plastic ketchup pumps were observed dirty and had dry, crusted residue.- Six stainless steel scoops with gray handles were observed dirty, had fuzzy films, watermarks and dry, crusted residue.- One stainless steel scoop with green handle had fuzzy films and watermarks.- Four stainless steel scoops with red handles had watermarks.- One stainless steel scoop with yellow handle had fuzzy films.- One stainless steel scoop with purple handle had dry, crusted residue.- One stainless steel scoop with white handle had fuzzy films and watermarks.- One white plastic serving spoon was observed dirty with dry, crusted residue.- Two stainless steel slotted spoons were observed dirty and had fuzzy films and dry, crusted residue.- One stainless steel spoon had fuzzy films and watermarks.- One stainless steel ladle was observed dirty and had fuzzy films and watermarks.- One black peeler was observed dirty and had dry residue.- One stainless steel knife with black handle had fuzzy films and dry watermarks. 4. Review of the facility's P&P titled Sanitization date revised 10/2008 showed the cutting boards (acrylic or hardwood) will be washed and sanitized between uses. According to the USDA Food Code 2022 Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 4/12/26 at 0838 hours, during the initial kitchen tour, a concurrent observation was conducted with the Culinary Director. The white, brown, green, blue and yellow cutting boards were observed fuzzy, heavily marred and had deep groves. The Culinary Director verified the findings and stated the cutting boards should have been replaced. In addition, the Culinary Director stated she conducts her kitchen walk through every Monday and all worn out kitchenware and utensils should have been discarded and replaced, all dirty kitchenware and equipment should have been rewashed for sanitation purposes. 5. Review of the facility's P&P titled Sanitization date revised 10/2008 showed the food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 4/13/26 at 0823 and 1058 hours, during the follow up kitchen visit, an observation and concurrent interview was conducted with the Cook. The following was observed and verified by the Cook:- One heavy-duty blender stored on the metal rack shelf was observed dirty, still wet with visible water and had white residue inside and on the lid.- Five rectangular clear bucket containers used for marinating meats and storage were observed wet with visible water inside and stacked on top of each other. The [NAME] verified the above findings and stated all the kitchen utensils and equipment should have been cleaned and air dried to prevent bacteria growth. 6. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 4/12/26 at 0838 hours, during the initial kitchen tour, a concurrent observation was conducted with the Culinary Director. The countertop mounted can opener was observed with dry, crusted black and white residue on the blade. The Culinary Director acknowledged the findings and verbalized it should have been washed and cleaned. 7. Review of the facility's P&P titled How Clean Is Your Uniform and Personal Hygiene date revised 1/11/19, showed all the staff in the Food and Nutrition Services department or staff coming into the department must wear hair restraints and should not be touching their hair and face while serving food. According to the USDA Food Code 2022, Section 2-402.11 Effectiveness (A), Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils . During the lunch meal tray line observation on 4/13/26 at 1123 hours, the Dietary Aide was serving lunch with facial hair not covered with a hair restraint. The RD verified the findings and beard guard was used. On 4/15/26 at 1202 hours, the DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility's Consultant Pharmacist failed to identify and make recommendation for drug irregularities for three of 15 residents (final sampled Resident 19 and nonsampled Residents 17 and 30) reviewed for the medication administration. * Resident 17's drug regimen review failed to identify drug irregularities with the administration of levothyroxine sodium and lansoprazole (PPI medication used to treat GERD) together. * Resident 19's drug regimen review failed to identify drug irregularities with the administration of levothyroxine and pantoprazole sodium delayed release together. * Resident 30's drug regiment review failed to identify the drug irregularities with the administration of pantoprazole sodium delayed release (PPI medication used to treat GERD) and levothyroxine sodium (medication to treat hypothyroidism) together. These failures had the potential for the residents to not effectively absorb the ordered medication and potentially affect the residents' health.Findings: Review of the facility's P&P titled Medication Regimen Review revised 2/2025 showed the Consultant Pharmacist conducts a MRR for every resident in the facility receiving medications to minimize adverse consequences and a potential risk associated with medications. The MMR includes a review of the resident's medical record to prevent, identify, report, and resolve medication related problems, or other irregularities. Review of Mayo Clinic's recommendations for proper use of levothyroxine showed: - If you are using stomach medicine (e.g., lansoprazole, omeprazole, pantoprazole), or any medicine that contains calcium or iron, take them at least four hours before or four hours after you take the levothyroxine as they may reduce the absorption of the levothyroxine. Review of Drugs.com (an online resource) article for levothyroxine and pantoprazole use showed combining these medications pantoprazole may interfere with the absorption of oral levothyroxine sodium and reduce levothyroxine sodium's effectiveness. 1. Medical record review for Resident 30 was initiated on 4/12/26. Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's Order Summary Report showed physician's order dated 3/25/26, for levothyroxine sodium 75 mcg by mouth daily before breakfast and pantoprazole sodium delayed release 40 mg by mouth daily before breakfast. Review of Resident 30's MAR for April 2026 showed the levothyroxine sodium and pantoprazole sodium delayed release medications were scheduled to be administered daily at 0630 hours. Review of the facility's Consultant Pharmacist Monthly MRR for April 2026 showed the Pharmacy Consultant conducted the MRR on 4/7/26. The MRR failed to identify the drug irregularities with the administration of Resident 30's pantoprazole sodium and levothyroxine sodium medications which were being administered at the same time. On 4/13/26 at 0559 hours, a medication administration observation for Resident 30 was conducted with LVN 1. LVN 1 administered the pantoprazole sodium delayed release 40 mg and levothyroxine sodium 75 mcg medications at the same time to Resident 30. 2. Medical record review for Resident 17 was initiated on 4/13/26. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Order Summary Report showed the following physician's orders dated 3/19/26, to administer levothyroxine sodium tablet 88 mcg by mouth in the morning on an empty stomach for low thyroid hormone and one delayed-release tablet of lansoprazole 30 mg by mouth one time a day before breakfast for GERD. Review of Resident 17's MAR for April 2026 showed the levothyroxine sodium and lansoprazole were scheduled to be administered daily at 0630 hours. Review of the facility's Consultant Pharmacist Monthly MRR for April 2026 showed the Pharmacy Consultant conducted the MRR on 4/7/26. The MRR failed to identify the drug irregularities with the administration of Resident 17's levothyroxine sodium and lansoprazole medications which were being administered at the same time. On 4/13/26 at 0527 hours, a medication administration observation for Resident 17 was conducted with LVN 5. LVN 5 administered the levothyroxine sodium 88 mcg and lansoprazole delayed release 30 mg medications at the same time to Resident 17. 3. Medical record review for Resident 19 was initiated on 4/13/26. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's Order Summary Report showed a physician's orders dated 3/19/26, to administer levothyroxine sodium tablet 100 mcg by mouth in the morning on an empty stomach for low thyroid hormone and one delayed-release tablet of pantoprazole sodium 40 mg by mouth two times a day before breakfast and dinner for GERD. Review of Resident 19's MAR for April 2026 showed the levothyroxine sodium and pantoprazole sodium medications were scheduled to be administered daily at 0630 hours. Review of the facility's Consultant Pharmacist Monthly MRR for April 2026 showed the Pharmacy Consultant conducted the MRR on 4/7/26. The MRR failed to identify the drug irregularities with the administration of Resident 19's levothyroxine sodium and lansoprazole medications which were being administered at the same time. On 4/13/26 at 0553 hours, a medication administration observation for Resident 19 was conducted with LVN 5. LVN 5 administered the levothyroxine sodium 100 mcg and pantoprazole sodium delayed release 40 mg medications at the same time to Resident 19. On 4/13/26 at 1202 hours, a telephone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated there was not a concern with levothyroxine sodium being administered together with lansoprazole or pantoprazole medication. When asked about the lansoprazole medication affecting the absorption of the levothyroxine sodium medication when administered together, the Pharmacy Consultant stated she was not aware of any concerns but will research it. On 4/13/26 at 1223 hours, a follow-up interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated she researched and stated the levothyroxine sodium medication should not be administered within four hours of any PPI, including the pantoprazole sodium and lansoprazole medications, and the order should be clarified by the physician to possibly change the administration times.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food items were served in the appetizing temperatures. * The food temperature was above the recommended temperature for cold beverages and below the recommended temperature for hot food. * Test tray temperatures were below the recommended temperature for hot meat and vegetables. These failures had the potential for the residents not to eat the food served and could affect the residents nutritional status for 41 of 41 residents who received food from the kitchen . Findings: Review of the facility's P&P titled Trayline Setup and Service date revised 7/2/18, showed food temperatures should be palatable for residents receiving room trays. Hot food should be 110-120 degrees Fahrenheit and cold food 45-50 degrees Fahrenheit. Review of the facility's Diet Type Report dated 4/12/26, showed 41 of 41 residents consumed the food prepared in the kitchen. Review of the facility's menu titled Week at a Glance dated 4/7/26, showed the lunch menu for 4/13/26, included mixed green salad with dressing, artichoke chicken, red bliss potatoes, seasoned green peas, bread or roll with margarine, chocolate cake with caramel icing, choice of beverage and herb roast beef for alternate. a. On 4/13/26 at 1123 hours, a tray line observation and concurrent interview was conducted with the RD and DSS. The RD and DSS checked and verified the mashed potatoes were at 100 degrees Fahrenheit, and the apple juice was at 54.8 degrees Fahrenheit. The RD acknowledged the apple juice temperature of 54.8 degrees Fahrenheit was above the recommended temperatures for cold beverage and the mashed potato temperature of 100 degrees Fahrenheit was below the recommended temperatures for hot food. b. On 4/13/26 at 1300 hours, a test tray observation of the regular lunch menu items and concurrent interview was conducted with the DSS and RD. The DSS checked and verified the roast beef was at 105.8 degrees Fahrenheit, and the green peas were at 94 degrees Fahrenheit. The DSS verified the roast beef and green peas temperatures were not hot and below the recommended temperatures for a hot meal tray. The DSS verified the findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for five of 12 final sampled residents (Residents 2, 4, 10, 15, and 26) were accurate and complete. * The facility failed to ensure the POLST and social services notes contained the same information regarding the advance directive for Residents 2, 4, and 26. * The facility failed to ensure the social services assessment was completed upon admission for Resident 10. * The facility failed to ensure the behavior monitoring documentation was accurate for Resident 15. These failures had the potential for the residents' care needs not being met as their medical information were inaccurate and/or incomplete.Findings: Review of the facility's P&P titled Social Services Department revised 3/2022 showed the social services assessments are conducted to identify psychosocial, emotional, social, and discharge planning needs. A social services assessment shall be initiated upon admission and completed within seven days, and the assessment/evaluations may include, as appropriate, adjustment to placement, family or support system, resident preferences, behavior or mood concerns, coping status, communication needs, financial concerns, end-of-life preferences, advance directives, and the need for community resources or services. Review of the facility's P&P titled Advance Directives date revised 9/2022 showed under the section for If the Resident Has an Advance Directive, showed if the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed all documentation shall be complete and accurate and the medical record should facilitate communication between the IDT regarding the resident's condition and response to care. 1. Medical record review for Resident 26 was initiated on 4/12/26. Resident 26 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 26's POLST dated 3/18/26, under Section D, showed Resident 26 had an advance directive. However, there was no copy of the advance directive in Resident 26's medical records. Review of Resident 26's H&P examination dated 3/20/26, showed Resident 26 had the capacity to understand and make decisions. Review of Resident 26's Social Services Progress notes dated 3/19 and 3/23/26, failed to show documentation if the information and formulation of an advance directive was offered to Resident 26. Review of Resident 26's Social Service Evaluation dated 3/20/26, showed Resident 26 had no advance directive. Review of Resident 26's admission MDS assessment dated [DATE], showed Resident 26 had a BIMS score of 15 (13-15 score suggests intact cognition). On 4/14/26 at 1434 hours, an interview and concurrent record review for Resident 26 was conducted with the SSD. The SSD acknowledged the above findings and stated Resident 26's POLST dated 3/18/26, and the Social Service Evaluation dated 3/20/26 did not match. Cross Reference to F578. 2. Medical record review for Resident 4 was initiated on 4/12/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's POLST dated 3/13/26, under Section D, showed Resident 4 had no advance directive. Review of Resident 4's admission MDS assessment dated [DATE], showed Resident 4 had a BIMS score of 12 (8-12 score suggest moderately impaired cognition). Review of Resident 4's Social Service Evaluation dated 3/17/26, showed Resident 4 had formulated an advance directive. However, Resident 4's medical record failed to show documentation if a copy of the advance directive had been requested. On 4/14/26 at 1629 hours, an interview and concurrent record review for Resident 4 was conducted with the SSD. The SSD acknowledged the above findings and stated the POLST dated 3/13/26 and Social Service Evaluation dated 3/17/26 did not match. On 4/15/26 at 1202 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 2 was initiated on 4/12/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's POLST dated 3/9/26, showed Resident 2 had no advance directive. Review of Resident 2's Social Service notes dated 3/10/26, showed Resident 2 had an advance directive in place, the type of advance directive was Healthcare Power of Attorney, and code status was DNR (Do Not Resuscitate). Review of Resident 2's Social Service notes dated 4/12/26 at 1308 hours, showed Resident 2 had no advance directives. On 4/14/26 at 1409 hours, an interview was conducted with the SSD. The SSD stated she documented Resident 2 as having an advanced directive; however, the SSD verified with the family that Resident 2 had no Advanced Directive. On 4/12/26 at 1509 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings. 4. Medical record review for Resident 10 was initiated on 4/12/26. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's medical record failed to show the social services assessment was completed upon admission. On 4/12/26 at 1600 hours, an interview and concurrent medical record review for Resident 10 was conducted with the SSD. The SSD stated she would try to complete the social services assessments within 72 hours after admission. The SSD reviewed Resident 10 medical records and verified a social services assessment was not completed after Resident 10 was admitted to the facility on [DATE]. 5. Medical record review for Resident 15 was initiated on 4/12/26. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's MAR for April 2026 showed a physician's order dated 4/12/26, to monitor Resident 15's mood, behavior, and emotional status every shift. Further review of Resident 15's MAR showed for the night shift on 4/12/26, Resident 15 did not exhibit any behaviors. On 4/13/26 at 0510 hours, an interview was conducted with LVN 1. LVN 1 stated he was Resident 15's nurse during the night shift on 4/12/26, and Resident 15 had a few episodes of screaming during his shift. During the interview with LVN 1, a resident yelled out Oh God, I got to get out of here. LVN 1 stated that it was Resident 15 who just yelled out. On 4/13/26 at 0528 hours, an observation was conducted with Resident 15. Resident 15 was heard yelling out Oh, God! repeatedly. On 4/13/26 at 0532 hours, another observation was conducted for Resident 15. Resident 15 was heard screaming out Oh, God! I can't get out of bed! How am I going to get out? On 4/13/26 at 0533 hours, a CNA was observed going into the resident's room and Resident 15 could be heard shouting I don't give a damn! On 4/13/26 at 0744 hours, an interview and concurrent medical record review for Resident 15 was conducted with LVN 1. LVN 1 stated he had completed his documentation for the night shift and was ready to leave the facility. LVN 1 stated last night for his shift, Resident 15 had five or six episodes of screaming out, which started briefly at around 0200 hours, then the behavior increased at around 0400-0500 hours. LVN 1 reviewed Resident 15's MAR for April 2026 and verified the MAR showed Resident 15 had no behaviors on his shift. LVN1 stated he incorrectly documented in the MAR.

Based on observation, interview, and facility P&P review, the facility failed to maintain the infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections. * LVN 5 failed to perform hand hygiene during the medication administration for 12 residents and blood glucose checks for seven residents. * LVN 5 failed to clean the glucometer between use for seven residents. * LVN 5 utilized an alcohol swab from the floor of an isolation room to wipe blood from the finger of Resident 35. These failures posed the risk for transmission of disease-causing microorganisms and infections to the resident, staff, and visitors.Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the following:- medications are administered in a safe and timely manner, and as prescribed; and- staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility's P&P titled Obtaining a Fingerstick Glucose Level revised 10/2011 showed the following:- the purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level;- equipment and supplies: disinfected blood glucose meter (glucometer) with sterile lancet; and- steps in the procedure: always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses .clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice.wash hands. On 4/13/26 at 0515 hours, a medication observation was conducted with LVN 5. The following was observed:- Before beginning the medication administration, LVN 5 requested to step away to get a drink of water. LVN 5 went outside and returned to his medication cart to begin medication administration. LVN 5 did not perform hand hygiene upon returning to begin medication administration;- at 0520 hours, LVN 5 began the medication administration process; and from 0520 hours and 0644 hours, LVN 5 administered medications to 12 separate residents, which included performing blood glucose checks on seven of the 12 residents. LVN 5 did not perform hand hygiene between administering the medications and blood glucose checks to the residents. Additionally, LVN 5 did not disinfect the glucometer in between checking the blood glucose levels for the seven residents.- at 0610 hours, LVN 5 was observed performing a blood glucose check on Resident 35 who was on EBP isolation. LVN 5 placed the necessary supplies on the bedside table and dropped an unopened alcohol swab on the floor. LVN 5 picked up the alcohol swab with gloved hands and placed the alcohol swab on Resident 35's bedside table and proceeded to perform the blood glucose check. LVN 5 poked Resident 35's finger and wiped the first drop of blood with his gloved finger. After obtaining the blood sample, LVN 5 picked up the contaminated alcohol swab and used it to clean Resident 35's finger. On 4/13/26 at 0644 hours, an interview was conducted with LVN 5. LVN 5 verified he did not perform hand hygiene during his medication administration and stated he should be performing hand hygiene before entering a resident's room, upon exiting, and anytime his hands were visibly soiled. LVN 5 verified a lack of hand hygiene increases the risk for cross contamination between residents. LVN 5 verified he was supposed to disinfect the glucometer after every use and did not clean it during the entirety of his medication administration. LVN 5 verified he should not have used the alcohol swab he dropped on the floor because of risk of contamination to Resident 35. On 4/14/26 at 1134 hours, an interview was conducted with the DON. The DON stated during medication administration, nurses should be performing hand hygiene at cart before medication preparation, anytime they touch anything, before going into the resident's room and upon exiting. The DON verified the alcohol swab dropped on Resident 35's floor should have been discarded. The DON stated the glucometer should be disinfected after each use.

Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 20%. Two of four licensed nurses (LVNs 1 and 5) who were observed during medication administration were found to have errors. * LVN 5 failed to ensure medications levothyroxine (medication to treat underactive thyroid) and pantoprazole/lansoprazole (medication to relieve stomach acids) were administered a minimum of four hours apart for Residents 17 and 19 * LVN 5 crushed a delayed release medication (pantoprazole) for Residents 2 and 46 * LVN 1 failed to ensure Resident 30's levothyroxine sodium and pantoprazole sodium medications were not administered together. These failures created the risk for the residents to have potential side effects or complications related to the medications.Findings: 1.a. Review of Mayo Clinic's online recommendations dated 3/31/26, for proper use of the levothyroxine medication showed: - If you are using stomach medicine (e.g., lansoprazole, omeprazole, pantoprazole), or any medicine that contains calcium or iron, take them at least four hours before or four hours after you take levothyroxine as they may reduce the absorption of the levothyroxine. On 4/13/26 at 0527 hours, a medication administration observation for Resident 17 was conducted with LVN 5. LVN 5 prepared and administered the following medications to Resident 17: - Xopenex (medication to treat wheezing and shortness of breath) 1.25 mg; - levothyroxine 88 mcg one tablet; and - lansoprazole delayed release 30 mg one capsule. Medical record review for Resident 17 was initiated on 4/13/26. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Order Summary Report showed the following physician's orders dated 3/19/26, for: - levothyroxine sodium tablet 88 mcg by mouth in the morning on an empty stomach for low thyroid hormone. - lansoprazole delayed release tablet 30 mg one tablet by mouth one time a day before breakfast for GERD (acid reflux condition). - Xopenex concentrate inhalation nebulizing solution 1.25 mg / 0.5 ml via nebulizer every six hours. b. On 4/13/26 at 0553 hours, a medication administration observation for Resident 19 was conducted with LVN 5. LVN 5 prepared and administered the following medications to Resident 19: - levothyroxine 100 mcg one tablet; and - pantoprazole 40 mg one tablet. Medical record review for Resident 19 was initiated on 4/13/26. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's Order Summary Report showed the following physician's orders dated 3/19/26, for: - levothyroxine sodium tablet 100 mcg by mouth in the morning on an empty stomach for low thyroid hormone. - pantoprazole sodium delayed release 40 mg one tablet by mouth two times a day before breakfast and dinner for GERD. 2. a. Review of Mayo Clinic's online recommendations dated 3/31/26, for crushing delayed-release, extended-release, or sustained-release medications showed: Mayo Clinic strongly advises against crushing these medications as it damages the mechanism designed to release medicine slowly, potentially causing an overdose or rapid, ineffective absorption. Always swallow these tablets or capsules whole. On 4/13/26 at 0635 hours, a medication administration observation for Resident 2 was conducted with LVN 5. LVN 5 prepared and administered the following medications to Resident 2: - pantoprazole delayed release 40 mg one tablet During the medication administration, Resident 2 requested for the pantoprazole medication to be crushed and mixed with applesauce. LVN 5 returned to his medication cart, crushed the pantoprazole medication, mixed it with applesauce, and administered the medication to Resident 2. Medical record review for Resident 2 was initiated on 4/13/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MAR for April 2026 showed the following physician's order dated 3/7/26, for: - pantoprazole sodium delayed release 40 mg by mouth one tablet in the morning for GERD. b. On 4/13/26 at 0600 hours, a medication administration observation for Resident 46 was conducted with LVN 5. LVN 5 prepared and administered the following medications to Resident 46: - pantoprazole delayed release 40 mg one tablet. During the medication administration, LVN 5 stated Resident 46 had trouble swallowing the medication. LVN 5 proceeded to crush the pantoprazole medication, mixed it with applesauce, and administered the medication to Resident 46. Medical record review for Resident 46 was initiated on 4/13/25. Resident 46 was admitted to the facility on [DATE]. Review of Resident 46's MAR for April 2026 showed the following physician's order dated 3/20/26, for: - pantoprazole sodium delayed release 40 mg by mouth one tablet in the morning for GERD. On 4/13/26 at 0644 hours, an interview was conducted with LVN 5. LVN 5 stated he did not have a physician's order to crush the pantoprazole medication for Residents 2 and 46. LVN 5 verified he should not be crushing delayed-release medications because it affected how the medication was released and should have called the physician to change the medication order. On 4/13/26 at 1201 hours, a telephone interview was conducted with the Consultant Pharmacist. The Pharmacy Consultant stated the facility should not be crushing delayed-release medications like the pantoprazole medication. The Pharmacy Consultant stated the facility should call the physician and have the order changed to the pantoprazole granules which can be mixed with applesauce. On 4/13/26 at 1225 hours, a follow up telephone call from the Consultant Pharmacist was received. The Pharmacy Consultant verified the administration of the pantoprazole and lansoprazole medications should be separated by a minimum of four hours. The Pharmacy Consultant stated the levothyroxine medication should be given on an empty stomach and the facility should call the physician to reschedule the pantoprazole and lansoprazole medications. On 4/14/26 at 1134 hours, an interview was conducted with the DON. The DON verified the above findings. 3. Medical record review for Resident 30 was initiated on 4/12/26. Resident 30 was admitted to the facility on [DATE]. Review of Resident 30's Order Summary Report showed a physician's order dated:- 3/25/26, for levothyroxine sodium 75 mcg by mouth daily before breakfast.- 3/25/26, for pantoprazole sodium delayed-release 40 mg by mouth daily before breakfast. Review of Drugs.com, an online resource, showed the pantoprazole sodium medication may interfere with the absorption of the levothyroxine sodium medication and reduce the medications effectiveness. On 4/13/26 at 0559 hours, a medication pass observation was conducted with LVN 1. LVN 1 administered the pantoprazole sodium delayed release 40 mg and levothyroxine sodium 75 mcg medications to Resident 30. On 4/13/26 at 1223 hours, a follow-up interview was conducted with the Consultant Pharmacist. The Consultant Pharmacist stated she researched it and stated the levothyroxine sodium medication should not be administered within four hours of any PPI, including the pantoprazole sodium medication, and the order should be clarified by the physician to possibly change the administration times.

Based on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directive to one of 12 final sampled residents (Resident 26). * The facility failed to ensure the information and formulation of an advance directive was offered to Resident 26. This failure had the potential to violate the resident's rights to decline or formulate an advanced directive and for the resident's healthcare preferences not honored.Findings: Review of the facility's P&P titled Advance Directives date revised 9/2022 showed the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with the state law and facility policy. In addition, under the section for If the Resident Does not have an Advance Directive showed, if the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Medical record review for Resident 26 was initiated on 4/12/26. Resident 26 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 26's H&P examination dated 3/20/26, showed Resident 26 had the capacity to understand and make decisions. Review of Resident 26's admission MDS assessment dated [DATE], showed Resident 26 had a BIMS score of 15 (13-15 suggests intact cognition). Review of Resident 26's POLST dated 3/18/26, showed under Section D, Resident 26 had an advanced directive. However, further review of Resident 26's medical records failed to show a copy of the advance directive in Resident 26's medical records. Review of Resident 26's Social Service Evaluation dated 3/20/26, showed Resident 26 had no advanced directive and information was only provided on his right to formulate an advance directive on 4/14/26. Further review of Resident 26's Social Services Progress notes dated 3/19 and 3/23/26, failed to show a documentation if the information and formulation of an advance directive was offered to Resident 26. On 4/14/26 at 1434 hours, an interview with concurrent medical record review was conducted with the SSD. The SSD verified the above findings and stated there was no documentation if an advance directive was offered to Resident 26. On 4/15/26 at 1202 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Cross Reference to F842 #1.

Based on interview, record review, and facility P&P review, the facility failed to ensure the prescriber documented an appropriate clinical rationale for the continued use of the psychotropic medication for one of five final sampled residents (Resident 15) reviewed for unnecessary medications. * The facility failed to ensure an appropriate clinical rationale for Resident 15's continued use of the PRN zolpidem (a psychotropic sedative used to treat insomnia) was documented. This failure had the potential for the Resident 15 to receive unnecessary psychotropic medication and could negatively impact the resident's health outcomes and well-being.Findings: Review of the facility's P&P titled Psychotropic Medication Use dated July 2022 showed PRN psychotropic medications are limited to 14 days. If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, the prescriber will document the rationale for extending the use. Medical record review for Resident 15 was initiated on 4/12/26. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's MAR for April 2026 showed the following physician's order:- dated 3/21/26, to administer zolpidem tartrate 5 mg by mouth at bedtime PRN for insomnia, with an order duration of 14 days; and- dated 4/7/26, to administer zolpidem tartrate 5 mg by mouth at bedtime PRN for insomnia, with an order duration of 14 days. Review of Resident 15's nursing Progress Notes dated 4/6/26 at 2350 hours, showed Resident 15's physician was notified of the resident's request to extend the PRN zolpidem tartrate medication, and the physician agreed to extend the medication for an additional 14 days. Further review of Resident 15's medical record failed to show an appropriate clinical rationale for continued use of the zolpidem tartrate medication. On 4/14/26 at 1342 hours, an interview and concurrent medical record review for Resident 15 was conducted with RN 1. RN 1 reviewed Resident 15's medical record and verified the record failed to show documentation for the continued use of zolpidem tartrate beyond the original order of 14 days.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the person-centered care plan for the use of the psychotropic medications were complete for one of 12 final sampled residents (Resident 15). * The facility failed to ensure the care plan included the specific targeted behavior monitoring for Resident 15's use of zolpidem tartrate (a psychotropic sedative used to treat insomnia) and buspirone HCl (antianxiety) medications. This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised December 2016 showed a comprehensive person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs will be developed for each resident. The care plan will incorporate identified problem areas and reflect treatment goals, timetables and objectives in measurable outcomes. Medical record review for Resident 15 was initiated on 4/12/26. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's MAR for April 2026 showed the following physician's orders:- dated 3/21/26, to administer zolpidem tartrate 5 mg by mouth at bedtime PRN for insomnia, with an order duration of 14 days and buspirone HCl 15 mg by mouth twice a day for anxiety; and- dated 4/7/26, to administer zolpidem tartrate 5 mg by mouth at bedtime PRN for insomnia, with an order duration of 14 days. Review of Resident 15's Behavior/Side Effects Monitoring Record for April 2026 showed the physician's orders dated 3/21/26, for the following:- to monitor anxiety as manifested by verbalization of feeling anxious every shift, for buspirone HCl use; and- to monitor for insomnia and the ability to fall asleep every evening and night shift, for zolpidem use. Review of Resident 15's Care Plan Report failed to address Resident 15's specific targeted behaviors of verbalization of feeling anxious for buspirone HCl medication use and insomnia and the ability to fall asleep for zolpidem tartrate medication use. On 4/13/26 at 0920 hours, an interview and concurrent medical record review for Resident 15 was conducted with the DON. The DON reviewed Resident 15's Care Plan Report and verified Resident 15's care plan failed to address the behavior monitoring for Resident 15's for specific targeted behaviors for the zolpidem tartrate and buspirone HCl medications use.

Based on observation, interviews, medical record review, and facility P&P review, the facility failed to ensure the proper IV care was provided for one of one final sampled residents (Resident 19) receiving IV infusions. * The facility failed to ensure Resident 19's PICC line dressing was changed every seven days and Resident 19's IV infusion tubing was labeled. These failures posed the risk for Resident 19 developing complications related to IV infusions.Findings: Review of the facility's P&P titled Central Venous Catheter Dressing Changes revised 4/2016 showed the following:- The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings; and- Change transparent semi-permeable membrane dressings at least every 5-7 (five to seven) days and PRN (when wet, soiled, or not intact). Review of the facility's P&P titled Administration Set/Tubing Changes revised 10/2024 showed the purpose of this procedure is to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV therapy equipment:- Label tubing with date, time, and initials.- Any tubing that is found not labeled must be changed and then labeled accordingly. On 4/12/26 at 0851 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 19. Resident 19 was sitting up in bed. Resident 19 was observed to have an IV pole at the bedside with two IV bags hanging from the pole. The first IV bag was labeled NS (normal saline) 0.9% 1000 mL IV solution dated 4/11, and the bag was connected to unlabeled IV tubing. The IV NS bag was not connected to Resident 19. The second IV bag was labeled cefepime-dextrose 2 gm/50 mL (antibiotic). The cefepime bag was connected to a tubing with a green label which showed the IV set was good for 24 hours, the RN initials, start date and time of 4/12 at 0700 hours, and a discard date and time of 4/13 at 0700 hours. The cefepime bag was connected to Resident 19; however, the infusion was completed. Resident 19 stated he was receiving IV antibiotics and IV hydration through a PICC line. An observation of the PICC line showed a dressing with a hand-written date of 4/2/26. Medical record review for Resident 19 was initiated on 4/12/26. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 3/21/26, showed Resident 19 had the capacity to understand and make decisions. Review of Resident 19's Order Summary Report dated 4/14/26, showed a physician's order - dated 3/18/26, Cefepime Hcl 2 gm per 100ml, intravenously two times a day and - dated 3/27/26, for PICC dressing change - site: right upper arm - use IV dressing kit, perform dressing site care and change cap every seven days and PRN. On 4/12/26 at 1559 hours, a follow up observation was conducted for Resident 19. Resident 19 was observed sitting up in bed. Resident 19 was connected to the IV NS bag with a set rate to infuse at 50 mL/hr. During this observation, the IV NS IV solution bag was dated 4/11 and now the IV tubing had a green label dated 4/12 at 0800 hours. On 4/12/26 at 1601 hours, an interview and concurrent record review for Resident 19 was conducted with RN 2 and the DON. RN 2 verified Resident 19 had an order for three liters of IV hydration of NS to be infused at 50 ml/hr. RN 2 stated the third liter of NS was started on 4/11/26, and would complete on 4/12/26. RN 2 stated Resident 19's medical record showed the PICC line dressing was changed on 4/9/26. The DON stated the process for dating the PICC line dressings was to date the dressing on the day it was changed. The DON also stated the IV lines should be labeled when they were changed or every 72 hours as per the facility policy. On 4/12/26 at 1615 hours, an observation for Resident 19 and concurrent interview was conducted with the DON. The DON verified the date of Resident 19's PICC line dressing was 4/2/26. The DON further stated if the PICC line dressing was dated 4/2/26, then the PICC line dressing was never changed. Further observation of Resident 19 was conducted with the DON. The DON verified the IV NS bag was dated 4/11 but the IV tubing had a green label dated 4/12 at 0800 hours. When asked how the IV NS line had a label date the day after the infusion was started, the DON stated she called RN 1 earlier that morning and instructed him to ensure all the IV lines were labeled; however, the DON refused to make any further comments regarding the label on the IV tubing and stated she should speak to RN 1 who was responsible for labeling the IV tubing. On 4/13/26 at 0837 hours, an interview was conducted with RN 1. RN 1 stated the purpose of labeling the IV tubing was to indicate when the IV tubing was changed and when it expires. RN 1 stated he conducted rounds the day prior and observed Resident 19's IV NS tubing was not labeled. RN 1 stated he added a label dated 4/12 to Resident 19's IV NS tubing and verified the IV NS bag was dated 4/11. RN 1 stated he did not replace the IV tubing, he just added a green label. RN 1 stated this was not following procedure because incorrectly dating the IV tubing can potentially cause the tubing to be used past the expiration date.

Based on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary respiratory care and services for two nonsampled residents (Residents 17 and 52) reviewed for respiratory care. * The facility failed to ensure Residents 17 and 52 were provided the humidifier attached to the concentrator for the use of continuous oxygen therapy. This failure posed the risk for the residents to have nasal dryness and throat irritation. Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed in part, the purpose of this procedure is to provide guidelines for safe oxygen administration. Under the section for Steps and Procedure, showed check the mask, tank, humidifying jar, etc to be sure they are in good working order and are secularly fastened. Periodically re-check water level in humidifying jar. 1. On 4/12/26 at 0918 hours, during the initial tour of facility, an observation was conducted for Resident 52. Resident 52 was observed on her bed receiving oxygen therapy at a rate of 2 liters per minute via nasal canula. The oxygen concentrator was observed with no humidifier bottle. On 4/13/26 at 0805 hours, follow up observation was conducted for Resident 52. Resident 52's oxygen administration showed no humidifier connecting the concentrator into the resident's nostrils. On 4/13/26 at 0903 hours, interview was conducted with the DON. The DON stated if the oxygen was being administered continuously, the residents would need a humidifier to prevent dryness of the nostrils, no matter what the concentration of the oxygen was. Medical record review for Resident 52 was initiated on 4/13/26. Resident 52 was admitted to the facility on [DATE], with diagnosis of Acute Respiratory failure with Hypoxia. Review of Resident 52's Order Summary Report dated 4/14/26, showed a physician's order dated 4/10/26, for oxygen therapy continuously at a rate of 2 liters per minute via nasal cannula/mask, to maintain O2 sats (saturations) > 90%, contact MD if the O2 sats < 90%, and monitor the oxygen humidifier bottle every shift, change when bottle is close to empty every shift. On 4/13/26 at 0917 hours, interview with LVN 3 was conducted. LVN 3 stated humidifier should be replaced when it was empty. LVN 3 verified Resident 52's oxygen concentrator had no humidifier. On 4/15/25 at 1130 hours, interview was conducted with the DON. The DON was made aware and acknowledged the findings. 2. On 4/12/26 at 0952 hours, during the initial tour of the facility, an observation was conducted for Resident 17. Resident 17 was observed in bed on oxygen therapy via nasal cannula. The oxygen was observed set at a rate of 2 liters per minute with no humidifier bottle present. Medical record review for Resident 17 was initiated on 4/12/26. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's POLST dated 3/20/26, showed Resident 17 had the capacity to understand and make decisions. On 4/13/26 at 0906 hours, a follow up observation was conducted for Resident 17. Resident 17 was observed sitting in her chair wearing a nasal cannula. The oxygen was observed to be set at a rate of 2 liters with no humidifier bottle present. Review of Resident 17's Order Summary Report dated 4/14/26, showed the following physician's orders: - dated 3/19/26, to monitor the oxygen humidifier bottle every shift and change when the bottle was close to empty; and - dated 3/23/26, to administer oxygen therapy continuously at a rate of 2 liters per minute via nasal cannula every shift. On 4/13/26 at 1508 hours, an observation and concurrent interview and record review for Resident 17 was conducted with RN 1. RN 1 verified Resident 17 did not have a humidifier connected to the continuous oxygen. RN 1 verified there was an order to monitor the oxygen humidifier, and nurses had been marking the monitoring as completed without a humidifier present. On 4/14/26 at 1134, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care of the dialysis access site was provided for one of 12 final sampled residents (Resident 4). * The facility failed to ensure Resident 4's dialysis access site was consistently and accurately assessed pre and post hemodialysis treatments. This failure had the potential for delay in identifying complications related to the resident's dialysis access site.Findings: Review of the facility's P&P titled Care of a Resident with End-Stage Renal Disease date revised 9/2010 showed the residents with End-Stage Renal Disease (ESRD) will be cared for according to currently recognized standards of care. Further review of the facility's P&P titled Access and Care of Hemodialysis Catheters revised 2/2023 showed to check for signs of infection (warmth, redness, tenderness or edema) at the access site when performing routine care and at regular intervals. Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals. Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access. Medical record review for Resident 4 was initiated on 4/12/26. Resident 4 was admitted to the facility on [DATE]. Resident 4 had a diagnosis of End Stage Renal Disease which required hemodialysis. Review of Resident 4's Order Summary Report showed a physician's order dated 3/13/26, to check AV shunt for presence of bruit and thrill every shift, if negative notify the physician. Review of Resident 4's admission MDS assessment dated [DATE], showed Resident 4 had a BIMS score of 12 (8-12 means moderately impaired cognition). Review of Resident 4's Care Plan Report showed a care plan focus problem addressing Resident 4's hemodialysis treatment and access site located on the left upper extremity AVF dated 3/13/26. The interventions included to keep the dialysis access site clean and dry, monitor for redness, poor circulation as evidenced by decrease in bruit and thrill or absent, swelling, or drainage and report the abnormalities to the physician. Review of Resident 4's Dialysis Communication Forms for March and April 2026 showed the following:- dated 3/20/26, the dialysis access at the left upper arm was assessed for bruit and thrill pre dialysis; however, the form failed to show if the site was assessed for warmth, edema, drainage and bleeding; - dated 3/20/26, the dialysis access at the left upper arm was not assessed for bruit and thrill and for color, warmth and drainage post dialysis; and - dated 4/10/26, the dialysis access at the left arm was not assessed for bruit and thrill and for color, warmth, drainage, bleeding and edema post dialysis. On 4/15/26 at 1023 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 stated the licensed nurses were responsible for the assessment and documentation in the Dialysis Communication Form. LVN 6 verified the above findings and stated the dialysis site should have been assessed pre and post dialysis to ensure AVF was working. On 4/15/26 at 1202 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, and medical record review, the facility failed to provide the pharmaceutical services to ensure for accurate reconciliation and administration of the medications for one of 12 final sampled residents (Resident 55). * The facility failed to ensure the Lasix (a diuretic medication) order for Resident 55 listed the appropriate indication for use. This failure had the potential for the resident's needs not being met as the indication of the medication use was incorrect.Findings: Medical record review for Resident 55 was initiated on 4/12/26. Resident 55 was admitted to the facility on [DATE]. Review of Resident 55's H&P examination dated 4/9/26, showed Resident 55 had the capacity to understand and make decisions. On 4/12/26 at 1119 hours, an observation and concurrent interview was conducted with Resident 55. Resident 55 stated she was having trouble sleeping due to the edema in her legs. Resident 55's lower legs were observed with edema was present. Review of Resident 55's Telephone Orders sheet showed a physician's order dated 4/10/26, for Lasix 20 mg one tablet by mouth daily, give first dose today for four days. Review of Resident 55's MAR for April 2026 showed the following orders and administration: - Lasix oral tablet 20 mg (furosemide), give one tablet by mouth one time only for pain during urination until 4/10/26 at 2359 hours, to give the first dose today (4/10/26). The MAR showed the Lasix medication was administered on 4/10/26 at 2154 hours; and- Lasix oral tablet 20 mg (furosemide), give one tablet by mouth one time a day for pain during urination for three days, to give the first dose today (4/11/26). The MAR showed the Lasix medication was administered on 4/11, 4/12, and 4/13/26 at 0900 hours by LVN 3. Further review of Resident 55's medical record showed the telephone order dated 4/10/26, did not have an indication for the use of the Lasix medication. On 4/14/26 at 1134 hours, an interview and concurrent record review for Resident 55 was conducted with the DON. The DON stated the indications for the Lasix medication was for a diuretic effect used for the residents with excess fluid and it was not indicated for urinary pain. The DON reviewed Resident 55's Lasix medication order and verified the indications were incorrect and stated the nurse should have called the physician to clarify the order. On 4/14/26 at 1435 hours, an interview and concurrent medical record review for Resident 55 was conducted with LVN 3. LVN 3 stated the Lasix medication was used as a diuretic and was not used for urinary pain. LVN 3 stated he should have questioned the indication on the order and contacted the physician to clarify the order prior to administering the Lasix medication.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were store in a safe manner for one of 12 final sampled residents (Resident 55), one nonsampled resident (Resident 56) and in one of two medication carts (Medication Cart B). * LVN 5 failed to ensure Residents 55 and 56's medications were safely stored during the medication administration. This failure posed the risk for unauthorized individuals to have access to the medication. * An open foil packet of Sorbalgon Ag (Ca Alginate Ag) wound dressing was stored in Medication Cart B. This failure had the potential for residents to receive medications that was contaminated and/or losing stability and effectiveness.Findings: 1. Review of the facility's P&P titled Administering Medications revised 4/2019 showed during administration of the medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. a. On 4/13/26 at 0540 hours, a medication administration observation for Resident 55 was conducted with LVN 5. LVN 5 was observed preparing a medication and entered Resident 55's room to administer a medication. LVN 5 left a vial of insulin on top of the medication cart unattended. The medication cart was in the hallway. b. On 4/13/26 at 0543 hours, a medication administration observation for Resident 56 was conducted with LVN 5. LVN 5 was observed preparing the medication and entered Resident 56's room to administer the linaclotide (medication to treat constipation) medication. LVN 5 left a bubble pack of the linaclotide medication on top of the medication cart unattended. Several staff members and residents were observed in the hallway, in addition to an outside maintenance vendor who was replacing the sink in the kitchen. On 4/13/26 at 0644 hours, an interview was conducted with LVN 5. When asked about the medications left on top of the medication cart, LVN 5 stated he was supposed to lock medications in the cart whenever he walked away from the medication cart. On 4/14/26 at 1134 hours, an interview was conducted with the DON. The DON stated medications should never be left unattended on top of a medication cart and should always be securely locked in the medication cart when the nurse walks away. 2. On 4/14/26 at 1450 hours, an inspection of Medication Cart B was conducted with LVN 2. Medication Cart B contained a box of Sorbalgon Ag (is a sterile, antimicrobial dressing used to manage moderate to heavily exuding, infected, or infection-prone wounds) with each dressing individually wrapped in foil pouches. However, one of the foil pouches was open with a dressing inside. LVN 2 verified the open foil pouch of Sorbalgon Ag dressing. LVN 2 stated the dressing should have been thrown away and not stored in the cart.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed for three of 41 residents that consumed the foods prepared in the kitchen. * The facility failed to provide bread or roll with margarine to Resident 30 as per her meal ticket. * The facility failed to provide bread or roll with margarine to Resident 36 as per his meal ticket. * The facility failed to provide mashed potatoes to Resident 33 as per her meal ticket. These failures had the potential for the residents to not receive adequate nutrition and appropriate servings to meet their individual needs.Findings: Review of the facility's Diet Type Report dated 4/12/26, showed 41 of 41 residents consumed the foods prepared in the kitchen. Review of the facility's menu titled Week at a Glance dated 4/7/26, showed the lunch menu for 4/12/26, included mixed green salad with dressing, bacon meatloaf, scalloped potatoes, sauteed broccoli florets, bread or roll with margarine, cherry cheesecake, and choice of beverage. Review of the facility's P&P titled Trayline Setup and Service date revised 7/2/18, showed according to the diet called, the main plate is served from the steam table and covered. The therapeutic spreadsheets are posted on trayline and are followed. Portions are adhered to by following scoop sizes noted on the menu. Bread, salads, desserts, and any special items are placed on the tray and sent down the trayline. The therapeutic spreadsheets are followed for these items. 1. On 4/12/26 at 1317 hours, during the dining observation, Resident 30 was observed eating her lunch in the dining room. Review of Resident 30's meal ticket showed her menu included mixed green salad with ranch dressing, bacon meatloaf, scalloped potatoes, sauteed broccoli florets, bread or roll with margarine, cherry cheesecake and diet cola. Resident 30 was served mixed green salad with ranch dressing, bacon meatloaf, scalloped potatoes, sauteed broccoli florets and diet cola; however, Resident 30 was not served the bread or roll with margarine from the menu. 2. On 4/12/26 at 1313 hours, during the dining observation, Resident 36 was observed eating his lunch in the dining room. Review of Resident 36's meal ticket showed his menu included mixed green salad, bacon meatloaf, scalloped potatoes, sauteed broccoli florets, bread or roll with margarine, cookie and lemon tea. Resident 36 was served mixed green salad, bacon meatloaf, scalloped potatoes, sauteed broccoli florets, water and tea; however, Resident 36 was not served the bread or roll with margarine from the menu. On 4/12/26 at 1317 hours, an observation and concurrent interview was conducted with the RD. The RD verified Residents 30 and 36 did not receive the bread or roll with margarine and stated it should have been provided to both residents. 3. On 4/12/26 at 1310 hours, a dining observation and concurrent interview was conducted with Resident 33. Resident 33 was observed eating her lunch in her room. Review of Resident 33's meal ticket showed she requested bacon meatloaf, soft sauteed broccoli florets, mashed potatoes, and diet cola. Resident 33 was served bacon meatloaf, soft sauteed broccoli florets, and diet cola. Resident 33 stated she did not receive the scalloped potatoes from the menu or the mashed potatoes she requested as a replacement. On 4/12/26 at 1322 hours, an interview and concurrent menu ticket observation was conducted with the RD. The RD verified Resident 33 requested mashed potatoes on the menu ticket and verified Resident 33 did not receive mashed potatoes.

Based on observation, interview, and facility P&P review, the facility failed to ensure the facility's garbage and refuse was properly disposed of in three of seven garbage dumpsters. * Three garbage dumpsters were observed with the lids partially propped open by the cardboard boxes and black trash bags, preventing the lids from closing. This failure had the potential to harbor pests and rodents and cause unsafe sanitary conditions.Findings: Review of the facility's P&P titled Garbage and Rubbish Disposal dated 2020 showed garbage and rubbish will be disposed of to ensure a clean and sanitary kitchen that does not encourage insects or rodents. All outside dumpsters will be maintained in clean and sanitary condition. All garbage or rubbish is to be put into waste containers which are emptied as often as necessary to prevent overfilling. This will assist in the prevention of odors, pests, and possible contamination. All containers will be provided with tight-fitting lids or covers and will be leak proof and waterproof. All garbage and rubbish containing food waste are covered when not in immediate use so as to be inaccessible to vermin. Outdoor trash receptacles will be kept covered and the surrounding area kept free of litter. According to the 2022 FDA Food Code, the outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. On 4/12/26 at 1328 hours, an observation and concurrent interview was conducted with the Plant Operations Director. Three of seven garbage dumpsters were observed with the lids partially propped open by cardboard boxes and black trash bags preventing the lids from fully closing. The Plant Operations Director verified the findings and stated the dumpster lids should be completely always closed for safety and infection control purposes.

Based on observation, interview, and medical record review, the facility failed to provide the services and necessary interventions to identify, treat, and prevent the development of pressure ulcers for one of 12 final sampled residents (Residents 39). Resident 39 was admitted to the facility at low risk for developing a pressure ulcer. * The facility failed to ensure Resident 39's sacral redness was assessed when it was reported by the acute care hospital during transfer. * The facility failed to ensure Resident 39's back and buttocks areas were assessed when he complained of pain. * The facility failed to ensure Resident 39 was provided a pressure relieving device in his wheelchair. * The facility failed to develop a plan of care to address Resident 39's risk for developing pressure ulcers. * The facility failed to ensure hand hygiene was performed when skin treatments were provided to Resident 39. This posed the risk for Resident 39 to develop a wound infection. A Stage 3 (Full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dead tissue) may be visible.) coccyx (tail bone) pressure ulcer was discovered 16 days from admission. Resident 39 experienced additional pain, surgical debridement and daily dressing changes. Findings: According to the 2014 Clinical Practice Guideline: Skin Assessment and Preventive Skin Care Extract by the National Pressure Ulcer Advisory Panel, under the section Interventions for Prevention of Pressure Ulcers, skin and tissue assessment was important in the prevention, classification, [DIAGNOSES REDACTED]. Under the section Conducting Skin and Tissue Assessment, a comprehensive skin assessment with a focus on bony prominences such as the sacrum (bone at the base of the spine) had to be conducted to individuals at risk for pressure ulcers. Accurate documentation of findings is essential for monitoring the progress of the individual. Inspect skin [DIAGNOSES REDACTED]. Skin redness and tissue [MEDICAL CONDITION] is a response to pressure, especially over bony prominences. Differentiate whether the skin redness was blanchable or nonblanchable. A blanchable [DIAGNOSES REDACTED] is visible skin redness that becomes white when pressure is applied and reddens when pressure is relieved. A nonblanchable [DIAGNOSES REDACTED] is visible skin redness that persists with the application of pressure. It indicates structural damage to the capillary microcirulation and is an indication for Category/Stage 1 pressure ulcer. Nonblanchable [DIAGNOSES REDACTED] is a predictor for Category/Stage II pressure ulcer development. Assess for localized pain as part of every skin assessment. Pain is a factor for patients with pressure ulcer. Pain over the site suggest tissue breakdown. Individuals have to be assessed for pain to identify areas of discomfort. a. Review of Resident 39's medical record was initiated on 6/19/19. Resident 39 was admitted to the facility on [DATE]. Review of the admission MDS dated [DATE], showed Resident 39 was cognitively intact. Resident 39 needed extensive assistance from one person for bed mobility. Resident 39 had frequent episodes of pain. Resident 39 had a [MEDICAL CONDITION] and was continent of urine. Resident 39 had no pressure ulcer on admission. Review of a facility transfer report document showed Resident 39 had mild sacral redness. Review of the Nursing Admission Data Collection dated 5/21/19, under the section Skin Integrity Review showed Resident 39 had a [MEDICAL CONDITION] on the left lower quadrant of the abdomen with a drain site incision on the right lower quadrant. Resident 39 had a surgical incision on the mid abdomen and multiple discolorations on the bilateral upper extremities. Under the section Braden Scale showed Resident 39 had no sensory and mobility impairment. Resident 39 was chair-fast (ability to walk is severely limited or non- existent). Resident 39 had adequate nutrition. Resident 39 had the potential problem for friction and shear. Resident 39's Braden Score was over 16. For a Braden Score of 16 or less, initiate skin integrity interventions and document on interim care plan. Under the section Narrative Summary, showed Resident 39 was continent of bladder and had a new [MEDICAL CONDITION]. Resident 39's skin had sacral redness. There was no response on the Interim Care Plan-skin. There was no interim care plan initiated to address Resident 39's sacral redness and skin findings. Review of the Braden Scale assessments dated 5/29/18, 6/4/19 and 6/11/19, showed Resident 39 had a Braden Score of 19. Review of the Weekly Wound Data Collection Flow Sheet dated 5/21/19, showed Resident 39 had a surgical wound on the abdomen. There was no mention about Resident 39's sacral redness. There was no documentation to show Resident 39's sacral redness was assessed. There was no care plan developed to address Resident 39's risk for pressure ulcer development. Review of the progress notes showed the following: - Resident 39 had complained of back pain on 5/22, 5/23, 5/24, 5/25, 5/26, 5/28, 5/29, 5/30, 5/31,6/1, and 6/5/19. - On 5/27/19 at 0043 hours, Resident 39 complained of generalized body pain and lower back pain on a scale of 6/10 (on a pain scale of 0-10, 0 = no pain, 10 = worst pain). - On 6/2/19 at 0245 hours, Resident 39 was given pain medication when the resident complained of pain of 8/10 to the neck, back, and buttocks area. There was no documentation showing Resident 39's back and buttocks were assessed. Review of SBAR communication Form and Progress dated 6/6/19, showed Resident 39 had a coccyx wound with 100% slough, linear in shape and painful to touch. Review of the Treatment Administration Record dated 6/1/19-6/30/19, showed an order dated 6/8/18, showing a coccyx pressure injury Stage 3 - cleanse with normal saline, pat dry, apply Santyl ointment (a debridement agent) and cover with dry dressing every day. Review of the Surgical Consult dated 6/13/19, showed Resident 39 had a coccyx pressure injury, which measured 3.2 cm x 0.8 cm x undetermined (UTD) depth. Resident 39 underwent muscle tissue debridement due to the presence of slough. Under the section Assessment and Plan, offloading pressure on the wound included the use of additional cushioning in the wheelchair. The physician documented he did a surgical excision of devitalized skin, subcutaneous, muscle, facia, and tendon tissue. Hwe Review of the Provide Communication Log for Daily Rounds dated 6/13/19, showed Resident 39 had a 3.2 cm x 0.8 cm x UTD depth with 100% slough, mild serosanguinous exudate (clear liquid mixed with red blood). The Provider Communication Log for Daily Rounds dated 6/20/19, showed Resident 39's Stage 3 pressure ulcer measured 2.3 cm x 0.3 cm x UTD depth with 90% slough and 10% granulation tissue. Resident 39 underwent debridement and the post debridement measurements were 2.4 cm x 0.4 cm x UTD depth. Review of the Nutrition Risk Review by the RD dated 5/28/19, showed Resident 39 was within normal body mass index. Resident 39 had 4.6 pounds weight loss (2.8%) since admission. Resident 39 had a reported decrease in appetite because of a mouth sore. The RD recommended to change the diet to a regular diet with snacks at 1400 and 2000 hours and Med Pass (a calorie and protein supplement) 120 ml three times a day. Review of the Progress Notes showed an entry dated 6/7/19, addressing a Weight Change Note. The entry showed Resident 39 had a 1.4 pounds (0.9%) weight loss for one week - not a significant change. The RD notes showed the weight loss may have been due to possible fluid shift from [MEDICATION NAME] (diuretic) therapy and decreased intake secondary to intake of antibiotics. Resident 39's BMI (body mass index) was normal. Resident 39 had developed a Stage 3 coccyx pressure ulcer. The RD recommendation was to start Resident 39 on multivitamins, zinc sulfate (supplement for wound healing) and vitamin C. Review of the Collaborative Care Review dated 6/6/19, showed Resident 39 had a change in condition. Resident 39 was identified with a coccyx wound on 6/6/19, and with a foul smelling drainage from the rectum on 6/10/19. The rest of Resident 39's Collaborative Care Review was not completed. Review of the Types of Bath showed Resident 39 preferred to bathe on Monday and Thursday mornings. Resident 39 was provided a shower on 5/27/19, and 6/3/19. Resident 39 refused to be bathed on 5/30/19. On 6/19/19 at 1110 hours, Resident 39 was observed awake, lying on his back. A low air loss mattress was observed on Resident 39's bed. Resident 39 was observed turning on his right side. Resident 39 stated he was able to reposition himself while in bed. Resident 39 stated he had a [MEDICAL CONDITION] and was continent of urine. A urinal was observed at Resident 39's bedside. Resident 39 stated he developed a bed sore on his back when he got admitted to the facility. Resident 39 stated the bed sore on his back was painful and he had to turn himself frequently to relieve pressure on the wound. Resident 39 stated he had complained of pain to the back and buttock areas a few days after he was admitted . Resident 39 stated the staff gave him pain medications to relieve the pain but did not take a look at his back crack nor provided treatment for [REDACTED]. Resident 39's wheelchair was observed at the bedside. No cushion was observed in the wheelchair. On 6/20/19 at 0850 hours, Resident 39 was observed lying on his back, awaiting his skin treatment. Resident 39's wheelchair and walker were at the bedside. No cushion was observed in the wheelchair. On 6/20/19 at 0857 hours, a concurrent treatment observation and interview was conducted with LVN 7. Resident 39 had a Stage 3 coccyx wound which measured 2.4 cm x 0.4 cm x ITD depth. Resident 39's wound was observed at midline and the wound bed was pinkish with minimal serousanguinous discharge. LVN 7 stated Resident 39's wound was a Stage 3 pressure ulcer since it had extended to the muscles. On 6/20/19 at 0919 hours, an interview was conducted with LVN 7. LVN 7 stated Resident 39 was admitted on [DATE], and had no pressure ulcer. On 6/6/19, Resident 39 complained of pain on the back area when the Stage 3 coccyx pressure ulcer was first discovered. LVN 7 stated he did not know what happened. LVN 7 stated he was informed about the wound and assessed it to be a Stage 3 pressure ulcer. LVN 7 stated Resident 39 was alert with no mobility issues, continent with the [MEDICAL CONDITION] and was at low risk for developing pressure ulcers. On 6/20/19 at 1100 hours, Resident 39 was observed lying in bed. Resident 39's pillows were observed in his wheelchair. On 6/20/19 at 1502 hours, an interview was conducted with Resident 39. Resident 39 was sitting his wheelchair. Resident 39 stated his mattress was changed to a special one when he developed the pressure ulcer. When asked why he had pillows in his wheelchair, Resident 39 stated he had to sit on the pillows to ease the pain when he used the wheelchair. Resident 39 stated he sat in his wheelchair during meals and when he needed to go out for his therapy and appointments. On 6/20/19 at 1530 hours, a concurrent observation and interview was conducted with CNA 7. CNA 7 stated Resident 39 was alert, oriented, and continent of urine, and had a [MEDICAL CONDITION]. CNA 7 stated Resident 39 was quite independent with his ADLs but needed assistance when he needed to get out of bed. Resident 39 used his wheelchair. CNA 7 verified Resident 39 had regular pillows in his wheelchair. On 6/21/19 at 0736 hours, a concurrent interview and medical record review was conducted with LVN 8. LVN 8 stated he worked the night shift on 6/2/19. LVN 8 stated Resident 39 was alert, oriented and able to move independently. LVN 8 stated he took his break when Resident 39 complained of buttocks pain. Resident 39 was given pain medication by RN 3. LVN 8 acknowledged RN 3 told him about Resident 39's buttocks pain. LVN 8 acknowledged he did not check Resident 39's buttocks when he complained of buttocks pain. On 6/21/19 at 0838 hours, a concurrent interview and medical record review was conducted with LVN 7. LVN 7 stated he performed the skin assessment when Resident 39 was admitted . LVN 7 stated he was not aware of a report from the hospital about Resident 39's sacral redness. When asked what sacral redness meant, LVN 7 stated there was redness on Resident 39's back area possibly from a pressure ulcer. LVN 7 stated Resident 39 had to be assessed to see if it was a Stage 1 pressure ulcer. When asked what needed to be done when there was a report of sacral redness, LVN 7 stated he had to assess if it was nonblanchable or blanchable. LVN 7 stated if Resident 39's area of redness was nonblanchable, it had to be classified as Stage 1. LVN 7 stated a Stage 1 pressure ulcer was to be monitored and provided treatment to prevent further skin deterioration. When asked if there was documentation in the medical record to show Resident 39's sacral redness was assessed, LVN 7 stated there was none. When asked about Resident 39's plan of care, LVN 7 stated Resident 39's Braden Score was more than 16, which meant he had a low risk for developing a pressure ulcer. LVN 7 stated Resident 39 was alert, able to move by himself, was continent and hardly moist and fell under the category of low risk on the Braden Scale. LVN 7 stated Resident 39 had remained low risk based on his Braden score of more than 16. LVN 7 stated, since he was not likely to develop a pressure ulcer, a care plan was not necessary. When asked what interventions were provided to prevent Resident 39 from developing a pressure ulcer, LVN 7 stated there was no care plan developed to show Resident 39 was at risk for developing a pressure ulcer. When asked how Resident 39 developed a Stage 3 pressure ulcer, LVN 7 stated he did not know. LVN 7 stated Resident 39's pressure ulcer should have been caught at an earlier stage to prevent it from getting worse. When asked about Resident 39's wheelchair, LVN 7 stated Resident 39 did not have his own wheelchair. LVN 7 stated he provided Resident 39 a cushion in his wheelchair but the staff may have given the wheelchair to another resident. LVN 7 acknowledged Resident 39 had no pressure relieving cushion in his wheelchair. LVN 7 stated Resident 39 needed to have a pressure relieving cushion in his wheelchair to prevent deterioration of the pressure ulcer, as recommended by the wound consultant. When asked if a skin assessment was performed when Resident 39 complained of buttocks pain of 8/10 on 6/2/19 at 0245 hours, LVN 7 stated he was not aware of Resident 39's buttocks pain. LVN 7 stated it was not usual for Resident 39 to complain of buttocks pain. LVN 7 acknowledged the buttocks area should have been assessed. LVN 7 verified there was no documented evidence Resident 39's skin to the buttocks area was assessed when he complained of pain On 6/21/19 at 0943 hours, a telephone interview was conducted with RN 3. RN 3 stated she remembered when Resident 39 complained of buttocks pain. RN 3 stated she gave Resident 39 his pain medication. RN 3 stated she told LVN 8, who was in charge for Resident 39, about the buttocks pain. When asked if she checked Resident 39's buttocks area, RN 3 stated she did not remember assessing Resident 39's buttocks. RN 3 acknowledged there was no documentation in the medical record to show Resident 39's buttocks were assessed. On 6/21/19 at 0948 hours, a concurrent interview and medical record review was conducted with the MDS Coordinator. The MDS Coordinator stated an interim care plan was not initiated because the area on skin issue was not answered on the Nursing Admission Data Collection dated 5/21/19. The MDS Coordinator stated the assessing nurse should have triggered skin impairments on the Admission Assessment since Resident 39 had skin impairments. The MDS Coordinator stated the assessment was not completed properly. The MDS Coordinator stated Resident 39 had mobility issues, with a recent surgery, which put him at risk for pressure ulcer development. The MDS Coordinator acknowledged a care plan was not developed to address Resident 39's risk for developing a pressure ulcer. The MDS Coordinator stated when care plans were not developed, the staff was not made aware of the care residents needed. The MDS Coordinator acknowledged Resident 39 had a Stage 3 pressure ulcer to the coccyx. The MDS Coordinator stated Resident 39's pressure ulcer could have been prevented if a care plan was developed and interventions were in place. On 6/21/19 at 1031 hours, a concurrent interview and medical record review was conducted with the ADON. The ADON stated the Collaborative Care Review dated 6/6/19, was created when the IDT had to address Resident 39's change in condition. The ADON stated Resident 39 was discovered to have a Stage 3 coccyx pressure ulcer. The ADON stated the IDT had discussed Resident 39's concern. When asked what the IDT's recommendation was for Resident 39, the ADON stated to heal the wound to at least a Stage 2. The ADON acknowledged the Collaborative Care Review was not completed. The ADON stated the Collaborative Care Review should have been completed to reflect a full assessment of Resident 39's situation and the IDT recommendations. On 6/21/19 at 1050 hours, an interview was conducted with the RD. The RD stated Resident 39's weight loss on 5/28/19, was not considered significant. The RD stated she recommended additional calorie/protein source to ensure Resident 39 was meeting his nutritional needs. The RD stated the weight loss on 6/7/19, may be considered significant since the resident had lost 5.8% in 11 days. The RD stated the weight loss must have been from his diuretic therapy and some decrease in his intake. The RD stated Resident 39's intake was at 57% and was accepting his snacks and Med Pass supplements. The RD stated she had recommended to start Resident 39 on multivitamins, zinc sulfate, and Vitamin C to aid in wound healing. The RD stated Resident 39 had the potential risk for developing a pressure ulcer considering his diagnoses. On 6/21/19 at 1135 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 verified she received Resident 39's transfer report from the acute care hospital and wrote it on a transfer report form. RN 1 stated she provided Resident 39's report to the admitting nurse. RN 1 stated the nurse from the acute care hospital reported Resident 39 had sacral redness. RN 1 stated Resident 39's sacral redness had to be assessed to make sure it was not a pressure ulcer. RN 1 stated the treatment nurse was in charge of checking the resident's skin. On 6/21/19 at 1143 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 acknowledged he had written sacral redness in Resident 39's admission notes. RN 2 stated the report from the hospital showed Resident 39 had sacral redness. RN 2 stated Resident 39's sacral redness had to be assessed to see if it was blanchable or nonblanchable. RN 2 stated Resident 39's sacral redness may have been a Stage 1 pressure ulcer and had to be treated. RN 2 stated the treatment nurse had to assess Resident 39's sacral area. On 6/25/19 at 0759 hours, an interview was conducted with CNA 8. CNA 8 stated Resident 39 needed assistance during showers. CNA 8 stated she did body checks on Resident 39 when he showered. CNA 8 stated she did not remember seeing any skin problems on Resident 39. CNA 8 stated she used to write her body check findings on a paper but it was not used anymore. CNA 8 stated she had to inform the nurse if there were any skin findings. CNA 8 stated Resident 39 had refused showers. When asked how Resident 39's body was checked when he refused showers, CNA 8 stated she had to do it when he needed to be changed. When asked if Resident 39 was incontinent, CNA 8 stated Resident 39 was continent and had a [MEDICAL CONDITION]. CNA 8 stated Resident 39 was using a urinal. When asked if Resident 39 was wearing incontinence briefs, CNA 8 stated no, and smiled. On 6/25/19 at 1207 hours, an interview was conducted with the DON. The DON stated the nurses receive a transfer report from the hospital. The DON acknowledged Resident 39 was reported by the acute care hospital to have sacral redness. The DON stated the admitting nurse or the treatment nurse had to assess the skin. The DON stated Resident 39's sacral area had to be checked to see if the redness was blanchable or nonblanchable. The DON verified there was no documentation to show Resident 39's sacral redness was assessed. The DON acknowledged a more thorough assessment should have been done to ensure Resident 39' s skin was checked for a pressure ulcer. The DON verified there was no documentation an assessment was performed when Resident 39 complained of buttock pain on 6/2/19, and back pain since (MONTH) 2019. The DON stated the nurses should have assessed Resident 39's back and buttocks to see what was going on. The DON stated it could have been part of the developing pressure ulcer. The DON stated she had talked to Resident 39 about the pressure ulcer and was told he had been complaining of back pain but the nurses did not check. The DON acknowledged Resident 39's pressure ulcer was discovered when it was already a Stage 3. The DON stated the pressure ulcer could have been prevented or discovered early. When asked about Resident 39's care plan, the DON stated Resident 39's Braden Score was above 16 and did not require a plan of care. The DON stated a score of 16 and below on the Braden Scale meant the resident was a high risk and a care plan was to be initiated, whereas a score of over 16 meant a low risk for pressure ulcer development. The DON stated a care plan to address Resident 39's low risk for pressure ulcer development was not developed. When asked if Resident 39's pressure ulcer was avoidable since he had a low risk score, the DON acknowledged Resident 39's pressure ulcer was avoidable. The DON acknowledged the lack of a thorough assessment by the nursing staff prevented the early identification and treatment of [REDACTED]. b. According to the CDC Guideline for Hand Hygiene in Health Care Settings in 2002, the practice of handwashing decreases the transmission of pathogenic microorganisms to patients and healthcare workers. Hand washing is recommended a) prior to direct contact with a patient, b) after contact with a patient's skin, c) after contact with patient's body fluids, excretions, non-intact skin and wound dressings, and d) after removal of gloves. On 6/20/19 at 0857 hours, a concurrent treatment observation and interview was conducted with LVN 7. A black plastic folder cover with a white towel was observed on top of LVN 7's treatment cart. LVN 7 prepared normal saline and Santyl ointment in two separate cups. LVN 7 took pieces of gauze and gloves and placed them on top of the white towel. LVN 7 put on clean gloves without performing hand hygiene. LVN 7 picked up his folder and went inside Resident 39's room. LVN 7 closed Resident 39's privacy curtain. LVN 7 asked Resident 39 to turn on his side. LVN 7 put down his folder at Resident 39's bedside. While using the same pair of gloves, LVN 7 removed the old dressing from Resident 39's wound. LVN 7 cleansed the wound with normal saline. LVN 7 removed his gloves and donned a new pair of gloves. LVN 7 did not perform hand hygiene prior to donning new gloves. Resident 39's wound measured 2.4 cm x 0.4 cm x UTD depth. LVN 7 stated Resident 39 had just underwent wound debridement. LVN 7 stated Resident 39 had a Stage 3 pressure ulcer. LVN 7 applied Santyl ointment to the wound and dressed the wound. LVN 7 told Resident 39 the treatment was over. LVN 7 threw the used dressings in a plastic bag, took off his gloves and went out of the room. LVN 7 stood in front of his treatment cart and stated the treatment was over. On 6/20/19 at 0919 hours, an interview was conducted with LVN 7. LVN 7 acknowledged he did not perform hand hygiene prior to preparing his equipment and prior to starting skin treatment. LVN 7 stated he did not know he had to wash his hands when he had to change gloves. LVN 7 acknowledged he had to perform hand hygiene when providing skin treatments.

Based on observation, interview and clinical record review, the facility failed to provide the appropriate treatment for one of 10 sampled residents (Resident 4) with pressure ulcers (localized injury to the skin and/or surrounding tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear). Resident 4 is cognitively impaired and dependent on staff for his ADLs. He was admitted to the facility with [DIAGNOSES REDACTED]. The facility failed to perform the prescribed treatment and interventions for prevention resulting to pressure ulcers to both heels. Upon admission, Resident 4's heels were assessed as having "blanchable redness" which is not a classification of a pressure ulcer. The physician ordered daily treatments to be performed for Resident 4's blanchable redness to both heels; however, documentation to show the treatment was performed as ordered was not found in the clinical record. The care plan problem to address Resident 4's pressure ulcers failed to include specific interventions to promote healing and prevent new ulcers from developing. One week after admission, Resident 4 was assessed as having an unstageable pressure ulcer to his left heel and a suspected deep tissue injury (DTI - purple or maroon localized area of injury of discolored intact skin due to underlying soft tissue injury from pressure and/or shear) to his right heel. Also, the facility failed to obtain a physician's orders [REDACTED]. During a wound treatment observation, LVN 1 was observed applying a topical ointment on the periwound (tissue surrounding the wound itself) and the surrounding skin area of the sacrum of Resident 4. The ointment which was applied was not ordered by the physician. This poses the risk of potential adverse effects of the medication. Findings: According to Lippincott's Nursing Center, an online drug resource for healthcare professionals, if clinicians wait to observe a nonblanchable lesion to call it a "true" Stage 1 pressure ulcer (nonblanchable redness of intact skin), they can miss the opportunity to prevent irreversible tissue damage. In other words, if a possible DTI [DIAGNOSES REDACTED]. For this reason, capillary refill should be assessed at least twice (preferably every 8 hours) during the first 24 hours after admission, to distinguish between a Stage 1 pressure ulcer and deep tissue injury, particularly for a patient with diabetes mellitus. When the reddened area maintains capillary perfusion, recovery can occur in the following 72 hours. In a DTI that presents as a demarcated red or purple area, clinicians can count back 7 days to pinpoint when the actual pressure damage occurred. According to National Pressure Ulcer Advisory Panel, an online drug resource for health care professionals, Pressure Ulcer Prevention Points include to inspect the skin at least daily and document assessment results, turn and reposition persons at least every two hours, use devices that totally relieve the pressure on the heels (off load) and to monitor and document interventions and outcomes. Clinical record review for Resident 4 was initiated on 7/7/14. Resident 4 was admitted to the facility on [DATE]. Resident 4's [DIAGNOSES REDACTED]. Review of the MDS (a standardized assessment tool) dated 7/1/14, shows Resident 4 is severely cognitively impaired, requires extensive assistance of two persons for bed mobility and transfers, and requires extensive assistance of one person for dressing, toileting, personal hygiene and bathing. Review of the Admission Assessment - Nursing form dated effective 6/22/14, shows Resident 4's sacrum was assessed as having an unstageable pressure ulcer measuring 3.5 cm x 1 cm open area surrounded by 4 cm x 7 cm of darkened area, and his left and right heels were assessed as having "blanchable redness" with no measurements of size. a. Review of physician's orders [REDACTED]. Further review shows on 6/30/14 (8 days after admission), a physician's orders [REDACTED].", cover with dry dressing and wrap with roll bandage daily for 14 days; and an order for [REDACTED]. Review of the Treatment Administration Record dated 6/1/14 through 6/30/14, failed to show daily treatments were performed to Resident 4's right and left heels as ordered from 6/22/14 through 6/29/14. Review of the care plans show a care plan problem created on 6/22/14, to address Resident 4's pressure ulcers on the sacral area and right and left heel related to immobility, poor nutritional status, incontinence and right great toe diabetic ulcer related to diabetes. The interventions show to keep Resident 4 clean and dry; lab work when needed and treatments; and to administer medications as ordered. The care plan failed to show specific interventions to promote healing and prevention of pressure ulcer development such as turning and repositioning, off loading of the heels, daily assessing the skin for changes and notifying the physician, and the use of a low air loss mattress for wound management as ordered by the physician on 6/30/14. Review of the physician's Initial H&P (history and physical) dated 6/23/14, shows Resident 4's lower extremities and heels were inspected and were normal. Review of the Weekly Wound Documentation Progress Sheet dated effective 6/29/14 (7 days after Resident 4 was admitted to the facility), shows Resident 4 has an unstageable pressure ulcer to the left heel described as a blood blister measuring 5 cm by 3 cm and a right heel suspected deep tissue injury measuring 4 cm by 4 cm. The documentation shows both heel pressure ulcers were present on admitted d 6/22/14. Review of the P&P dated 2010 titled Policy and Procedure for the Prevention and Treatment of Skin Breakdown shows if a resident is admitted with or there is a new development of a pressure ulcer or lower extremity ulcer, the following procedure is to be implemented: * Initiate wound care treatment as ordered. * Notify the physician and family. * Re-evaluate turning and reposition intervals. * Re-evaluate interventions per risk factors identified. * Update the care plan for skin integrity interventions as appropriate. * Initiate weekly wound documentation progress note. * When a pressure ulcer is present, daily wound monitoring should include an evaluation of the ulcer if no dressing present; an evaluation of the status of the dressing, if present; the presence of possible complications; whether the pain is being controlled; and document any changes or concerns in the nurse's notes. On 7/9/14 at 1115 hours, an interview and record review was conducted with RN 1. RN 1 was asked when Resident 4's right and left heel pressure ulcers were identified. RN 1 stated they were present upon admission to the facility. RN 1 was asked to explain why the Admission Assessment - Nursing documentation and the physician's admission orders [REDACTED]. RN 1 stated the documentation was not correct. RN 1 stated the assessment and orders should not show "blanchable redness" because the right heel had a deep tissue injury and the left heel has an unstageable pressure ulcer upon admission. RN 1 was unable to provide documentation to show Resident 4 had pressure ulcers to his heels upon admission. When asked how she knows Resident 4 had pressure ulcers on both heels upon admission, RN 1 stated the treatment orders on admission shows to apply [MEDICATION NAME] to both heels daily which indicates both heels had pressure ulcers. On 7/9/14 at 1145 hours, LVN 1 was observed performing the wound treatment for Resident 4's right and left heel pressure ulcers. Black rounded eschar tissue was observed on Resident 4's left heel and purple discoloration was observed on the right heel. On 7/10/14 at 1120 hours, an interview and record review was conducted with LVN 1. When asked if she documents the daily assessment for Resident 4's right and left heel pressure ulcers, LVN 1 stated she signs the treatment record when she completes the treatment. LVN 1 stated the treatment nurse does the measurements and assessments weekly. LVN 1 was asked to provide documentation of a daily assessment for Resident 4's pressure ulcers and was unable to provide documentation. On 7/10/14 at 1440 hours, an interview and record review was conducted with RN 1. RN 1 stated Resident 4 was in isolation and receiving antibiotics for an infection, and has pressure ulcers. RN 1 stated the charge nurse should document what the wounds looks like and the treatment nurse documents weekly. Review of the Progress Notes dated 6/22/14 through 7/9/14, failed to show documentation of Resident 4's pressure ulcers to the heels. RN 1 acknowledged there is no daily documentation of the charge nurse's description of the pressure ulcers. On 7/25/14 at 0900 hours, an interview was conducted with RN 2 via telephone. RN 2 was asked if she is able to provide the documentation of daily treatments to Resident 4's right and left heel blanchable redness from 6/22/14 through 6/29/14. RN 2 stated the documentation of any treatments or changes in treatment for the month of June 2014 should be on the Treatment Administration Record. On 7/25/14 at 1144 hours, a follow-up interview was conducted with RN 2 via telephone. RN 2 was again asked if she has the documentation of treatments performed to Resident 4's heels from 6/22/14 through 6/29/14. RN 2 stated they do not have any documentation for the treatment from 6/22/14 through 6/29/14. On 7/25/14 at 1330 hours, an interview was conducted with Physician 1 via telephone. Physician 1 was asked about the Initial H&P dated 6/23/14, which indicated the resident's legs and heels were inspected and were normal. Physician 1 stated there is a template for completion of the H&P which he used to complete the documentation. He stated he observed the legs as being normal. When asked if he identified Resident 4 as having pressure ulcers to his heels upon admission, Physician 1 stated he does not remember looking at Resident 4's heels, but he did assess the sacrum pressure ulcer. Physician 1 was not aware of Resident 4 being admitted with the pressure ulcers to the heels. When asked if the treatment order dated 6/22/14, to apply [MEDICATION NAME] daily to treat the resident's blanchable redness of the heels was appropriate, Physician 1 stated perhaps not. He stated the wound nurse called him and initiated the treatment. Physician 1 verified he approved the treatment without questioning the wound nurse regarding the heels. Physician 1 also explained when there are too many orders coming at the same time, it is hard to distinguish. He stated he saw and assessed Resident 4's pressure ulcers to both heels on 7/8/14. b. Review of the physician's treatment order for Resident 4's unstageable sacral coccyx pressure ulcer dated 6/23/14, shows to remove the dressing; cleanse it with normal saline; apply Santyl ointment (a [MEDICATION NAME] ointment); and cover it with a dry dressing every day shift. On 7/9/14 at 1145 hours, LVN 1 was observed performing wound treatment for Resident 4's sacral pressure ulcer. After cleansing the area with normal saline, LVN 1 applied the Santyl ointment to the wound and then applied Repara skin ointment with [MEDICATION NAME] and menthol to the periwound (tissue surrounding the wound itself) and the surrounding skin area of the sacrum. Documentation to show an order for [REDACTED]. According to Lexi-Comp Online, a drug resource for healthcare professionals, [MEDICATION NAME] topical has contraindications hypersensitivity reactions to any component of the formulation. Educate patient about signs of a significant reaction (e.g., wheezing; chest tightness; fever; itching; bad cough; blue skin color; [MEDICAL CONDITION]; or swelling of face, lips, tongue, or throat). Menthol and zinc oxide topical: Adverse Reactions can cause dermatological reaction such as itching, rash, stinging (temporarily on application) and hypersensitivity reactions. On 7/10/14 at 1120 hours, an interview and record review was conducted with LVN 1. LVN 1 was asked to show the [MEDICATION NAME] ointment which she used the previous day on Resident 4's sacrum. LVN 1 verified the skin ointment package label showed ingredients contain menthol 0.45 % as external [MEDICATION NAME] 2 %, and zinc oxide 18% as skin protectant. LVN 1 was asked if the physician ordered to applied the skin ointment with [MEDICATION NAME] and menthol. She verified she did not have a physician's orders [REDACTED]. She stated she applied it because earlier she saw Resident 4 had soft stool to the area so she just took liberty in administering the skin ointment. She stated in her nursing judgment, she does not want the area to get worse.

Based on interview, facility document review and closed clinical record review, the facility failed to provide adequate supervision to prevent a fall for one of two sampled residents (Resident 2). Resident 2 was assisted to the bathroom by two CNAs, and was left without supervision. Moments later, Resident 2 was found on the floor by CNA 1 who had assisted her to the bathroom. The resident was transferred to an emergency room and was diagnosed to have sustained a fractured left clavicle (broken collar bone). In addition, Resident 2 did not have a care plan problem for reducing the risk for falls. Failure to provide adequate supervision and implement a care plan problem to reduce the risk for falls resulted in avoidable harm. Findings: According to the facility's policy and procedure titled "Fall Management Program" revised 5/15/13, the IDT will develop a comprehensive plan of care to reduce the risk of falls or injury for each resident. Upon admission, a plan of care to reduce the risk for falls will be initiated at the time of admission. In addition, the licensed nurse will initiate a fall risk evaluation upon admission. Closed clinical record review was initiated for Resident 2 on 4/16/14. Resident 2 was admitted on [DATE]. Resident 2 was transferred to the emergency roiagnom on [DATE], and was re-admitted on [DATE], after an evaluation of a fall which resulted in a clavicle fracture. Resident 2 had sustained a fall at home and was hospitalized with a [DIAGNOSES REDACTED]. She was then transferred to the facility for rehabilitation, and fell while being assisted with a family member on 3/30/14. The resident sustained [REDACTED]. This resulted in a left clavicle fracture. Review of the facility's investigation dated 4/2/14, showed Resident 2 was assisted to the bathroom by two CNAs. One CNA left the room and CNA 1 stayed with the resident. CNA 1 stepped out from the bathroom and was standing at the entry to the resident's bedroom when he heard the resident call out. CNA 1 responded and found Resident 2 on the floor, lying on her left side. Resident 2 was transferred to the emergency room and was diagnosed to have sustained a fractured left clavicle. Review of the MDS (standardized assessment tool) dated 4/4/14, showed the resident had a change in condition and was discharged to an acute care hospital. It also showed the resident had memory problems, had impaired decision-making skills and required supervision. Resident 2 required extensive assistance for all activities of daily living, except for eating. Review of the Nursing Admission assessment dated [DATE], showed Resident 2's admitting [DIAGNOSES REDACTED]. It also showed Resident 2 was assessed to need extensive assistance for toileting and transfers. Review of the Fall Risk assessment dated [DATE], showed Resident 2 had fallen one to two times within the last six months. The assessment showed the resident was unable to independently come to a standing position, required hands-on assistance to move from place to place, and had a decrease in muscle coordination. It did not show a fall risk score had been determined. Review of a Care Plan Conference Summary (undated) showed the resident was admitted to the facility after a CVA with left-sided weakness. She was confused, required two-persons' extensive assistance for activities of daily living, was identified to be a fall risk, and had severe osteoarthritis in her left hip. Review of a Fall Incident Care Plan - Short Term Goal dated 3/30/14, showed the resident fell on [DATE], and was identified to be at risk for further falls because of left sided weakness. There were no approaches listed regarding how to assist the resident when she was out of bed. On 4/3/14, the care plan was updated to show another fall was sustained by the resident on 4/2/14. It, too, did not contain approaches how to safely assist the resident when she was out of bed. On 4/16/14 at 1415 hours, a concurrent interview and facility document review was conducted with the Administrator and DON. They stated the resident had previously sustained an assisted fall, when her family member was attempting to get her out of bed. The Administrator stated, during the fall investigation, CNA 1 was asked if he left the resident unattended. He stated, "No." Later, when the Administrator interviewed CNA 1, he admitted he did leave the resident unattended. CNA 1's written statement showed he stood at the doorway with his back to the resident. The DON was asked to locate the score for Resident 2's assessment for fall risk. She was unable to do so. The DON was asked to locate a care plan initiated for being at risk for falls when the resident was admitted , but she was unable to do so. The DON asked RN 2 to locate a care plan problem to address the risk for falls. RN 2 stated the admission care plan was done, but there wasn't a care plan problem to address the risk for falls. The DON was asked to locate any care plan which may show approaches for assisting the resident when she was out of bed, but she was unable to do so.

Based on interview and closed clinical record review, the facility failed to ensure clinical assessments were performed for one of two sampled residents (Resident 1) to identify symptoms indicating a serious medical condition. Resident 1 had a history of [REDACTED]. The facility failed to assess the underlying cause of Resident 1's pain, nausea and vomiting which could be a known complication of [MEDICAL CONDITION]. Failure to assess Resident 1's condition and his response to medication in a timely manner resulted in Resident 1 requiring an emergency transfer to treat a medical complication related to the resident's medical condition. The facility failed to have a system in place to ensure the resident's diet was adhered to to prevent complications related to his gastric by pass (cross reference to F367). Findings: Closed clinical record review was initiated for Resident 1 on 4/16/14. Resident 1 was admitted on [DATE]. [DIAGNOSES REDACTED]. The history and physical dated 3/20/14, showed the resident does not have the capacity to understand and make decisions. The following are recommendations for gastric diets from the Mayo Clinic: * Keep meals small; Each meal should include about a half-cup to a cup of food. Make sure you eat only the recommended amounts and stop eating before you feel full. * Drink liquids between meals. Drinking liquids with your meals can cause pain, nausea and vomiting. Expect to drink at least 6 to 8 cups (48 to 64 ounces or 1.4 to 1.9 liters) of fluids a day to prevent dehydration. * Eat and drink slowly; Eating or drinking too quickly may cause dumping syndrome - when foods and liquids enter your small intestine rapidly and in larger amounts than normal, causing nausea, vomiting, dizziness, sweating and, eventually, diarrhea. * Take at least 30 minutes to eat your meals and 30 to 60 minutes to drink 1 cup of liquid. * Chew food thoroughly; The new opening that leads from the stomach into the intestine is very small, and larger pieces of food can block the opening. Blockages prevent food from leaving the stomach and can cause vomiting, nausea and abdominal pain. * Take small bites of food and chew them to a pureed consistency before swallowing. If you can't chew the food thoroughly, don't swallow it. Review of the physician's order dated 3/17/14, showed, per the resident's and family's request, 1/4 portion sizes for all meal times with snacks in between; no lettuce, hard vegetables, or nuts. During a visit to the dietary department on 4/16/14, review of Resident 1's tray card system entry (system used in the kitchen) showed the diet as regular mechanical soft, regular portion. At the bottom of the tray ticket was a note showing 1/4 portion sizes on the tray, no lettuce or raw vegetables on the tray. On 4/16/14 at 1215 hours, FSW 1 stated a small portion diet would be 1/2 of all portions from the regular diet. She identified the regular portion of stuffing was 4 ounces (#8 scoop) and, to make a small portion, she filled the 4 ounce scoop less than full. She demonstrated a 1/4 portion (1 ounce) by filling the 4 ounce scoop less than full and placed it on a plate. The Senior Dining Services Director assisted in measuring the stuffing served as a 1/4 portion size. The portion measured 2 ounces. The FSW was not accurately measuring portions with measured serving equipment to ensure the physician's ordered diets are served correctly. Review of a physician's order dated 3/17/14, showed to administer [MEDICATION NAME] (a drug for nausea and vomiting) 4 mg, one tablet by mouth every 12 hours as needed for nausea and vomiting. Review of the Progress Note dated 3/18/14, showed Resident 1 "has a gastric problem when he eats too much." Review of the MAR for March 2014 showed Resident 1 received [MEDICATION NAME] (narcotic pain medication) for pain once on 3/18/14, two times on 3/19/14, once on 3/20/14, two times on 3/21/14, and once each day on 3/23, 24,25 and 26/14. The MAR also showed Resident 1 received [MEDICATION NAME] on March 27, 2014 at 0810 hours, and on March 28, 2014 at 0207 hours. Review of the Progress Notes from 3/18/14 through 3/28/14, failed to show documentation of an assessment for the pain; the location, the intensity, the characteristics of the pain or possible causative factors for the pain. Review of a Progress Note dated 3/27/14 at 1149 hours, showed Resident 1 complained of nausea. It showed the resident received a medication, and it "was effective." It did not show if it was given for nausea, vomiting or both. Review of a Progress Note dated 3/28/14 at 0731 hours, showed medication Resident 1 received "was effective." It did not show if it was given for nausea, vomiting or both. Review of a Progress Note dated 3/28/14 at 1305 hours, showed the resident "has been vomiting" and [MEDICATION NAME] was given for nausea. A family member wanted 911 to be called because of the the resident's vomiting. The physician was contacted and advised the family member wanted 911 called, but in the meantime, the family member called 911. At 1604 hours, the resident was transferred to an acute care hospital based on a 911 call made by a family member. On 4/16/14 at 1445 hours, a concurrent interview and closed clinical record review was conducted with RN 3 regarding Resident 1. RN 3 confirmed [MEDICATION NAME] was given on 3/27 and 3/28/14, as documented on the MAR. RN 3 was asked to locate documentation showing if the resident had nausea, vomiting or both when he was medicated with [MEDICATION NAME] at 0810 hours on 3/27/14, but she was unable to do so. RN 3 was asked "did the resident actually vomit?" She stated "It should be in the nurse's note, but the notes do not show if the resident had nausea, vomiting or both." RN 3 was asked to locate documentation showing if the resident had nausea, vomiting or both when he was medicated on 3/28/14 at 0207 hours, but she was unable to do so. She stated the note for 3/28/14 at 0730 hours, only shows the medication was effective. The note showed the resident received [MEDICATION NAME] at 0207 hours, but the effectiveness was not documented until 0730 hours. It did not describe if there was vomiting (how much or how often) and does not show when the actual evaluation of effectiveness was determined. RN 3 was asked about the Progress Note dated 3/28/14 at 1305 hours, which showed "the resident has been vomiting." RN 3 was unable to state if the reference to vomiting was a new incident for the day shift or if it was in reference to the night shift incident at 0207 hours. RN 3 was asked to describe the facility's policy regarding how to document when medications are given as needed. She stated the nurse documents the medication given, and then follows up with the resident to evaluate the effectiveness of the drug. RN 3 stated the resident should be re-evaluated 30 to 60 minutes after receiving the medication and the note should show if the resident got relief. RN 3 was asked to locate a care plan for the resident's nausea and vomiting, but she was unable to do so. She also confirmed there were no other approaches listed regarding nausea and vomiting in other care plan problems. RN 3 was asked to locate any other documentation regarding the resident's change in condition at the time 911 was called. She confirmed there was no other documentation. She was asked to locate a physician's discharge summary, an IDT note, or any other documentation to show what happened to Resident 1, but she was unable to do so. Review of the acute care hospital's discharge summary dated 3/30/14, showed Resident 1 had been admitted from the facility because of upper GI (upper gastrointestinal) bleeding (commonly found in the esophagus, where food passes from the mouth to the stomach). The note showed the bleeding was due to a tear in the esophagus secondary to recurrent vomiting.

Based on interview and clinical record review, the facility failed to provide finely chopped meat for Resident A, as ordered by her physician. The facility failed to provide Resident A with her dentures when her lunch was served. The facility failed to implement their plan of care by not providing supervision when Resident A was eating lunch. Resident A was found unattended, unresponsive and cyanotic (blue color from lack of oxygen), with a partially eaten sandwich in front of her. The Heimlich maneuver (an emergency technique used to prevent suffocation when a person is choking) was performed and was unsuccessful. Resident A was transferred to the acute hospital, where a large piece of meat was removed from her airway. Resident A was admitted to the intensive care unit, where she remained unconscious and died six days later from cardiac and respiratory arrest due to foreign body aspiration (choking). Findings: Review of the facility 's P&P (policy and procedure) titled "Therapeutic Diets" undated, showed the facility should provide each resident with a therapeutic diet as ordered by the physician to ensure each resident receives the correct prescribed diet. On [DATE], closed clinical record review for Resident A was initiated. Resident A had a history of [REDACTED]. The Minimum Data Set (an assessment tool) dated [DATE], showed Resident A had impaired cognition and required moderate assistance from staff for activities of daily living and supervision during meals. A physician's orders [REDACTED]. The Interdisciplinary Progress Notes dated [DATE], showed Resident A required a mechanical soft diet with finely chopped meats due to "chewing problem." A care plan problem titled "Dining" dated [DATE], showed Resident A required supervision for all meals. The facility's dietary spreadsheet menu dated [DATE] through [DATE], showed on [DATE] an alternate lunch provided was a ham sandwich. The facility's recipe for ham sandwich showed for residents receiving mechanical soft diet, the meat is to be ground or chopped. The Nurse's Notes dated [DATE] at 1240 hours, documented by RN (Registered Nurse) 1, showed CNA (Certified Nursing Assistant) 1 summoned LVN (Licensed Vocational Nurse) 1 because Resident A did not "look good" and was "turning blue or purple." LVN 1 noticed the resident's lunch tray on her bedside table and immediately checked the resident's airway but the resident's mouth was clenched shut. Resident A was "purple, cyanotic" and "nonresponsive" and oxygen was administered to the resident. The Heimlich maneuver was attempted by LVN 1 without success. LVN 1 then summoned RN 1. The Nurse's Notes showed at 1241 hours, Resident A's family member was notified by telephone and at 1242 hours, 911 was called. At 1247 hours, the emergency response team arrived. LVN 1 told them Resident A was turning purple and the resident's lunch tray was in front of her when she was found. The Heimlich maneuver was attempted. At 1300 hours, Resident A was transferred to the acute hospital. On [DATE] at 0745 hours, during an interview with LVN 1, the LVN stated CNA 1 called her for help and when she arrived to Resident A's room, the resident was in bed and looked blue. LVN 1 stated Resident A had eaten some of her sandwich and foam was coming out of the resident's mouth. LVN 1 stated the resident was unresponsive but had a pulse. LVN 1 stated CNA 1 told her the resident had been eating and maybe she was choking. The LVN stated the resident's jaw was clenched tightly and she could not perform a mouth check or sweep. The LVN stated she attempted "back blows" and the resident was limp. The LVN stated RN 1 came to the room and she asked the RN to check the resident's code status and to call the resident's family member. The LVN stated Resident A had a seizure that morning and they kept her in bed for lunch that day because she was usually weak after a seizure. LVN 1 stated she documented the incident in an "initial report." On [DATE] at 0830 hours, during an interview with DSS (Dietary Services Supervisor) 1, the DSS stated the ham used in a sandwich for a mechanical soft finely chopped diet would be prepared by chopping up the meat. On [DATE] at 0915 hours, during an interview with CNA 1, the CNA stated she dropped off the lunch tray at Resident A's bedside and then left the room to pass out other resident's trays. CNA 1 stated when she returned to Resident A's room, she noticed the resident's color was grey and purple and she had foam coming out of her mouth. The CNA stated Resident A was sitting up in bed with her tray in front of her. She stated Resident A was served a ham sandwich and a bite had been taken out of the sandwich. The CNA stated the ham was in the form of a slice, not chopped. The CNA stated Resident A had some bottom teeth but no top teeth and she wore an upper denture. The CNA stated she "forgot" to place the upper denture in Resident A's mouth before the lunch meal was served that day. The CNA stated they all thought she was "choking" and the ham sandwich was an "issue." On [DATE] at 1135 hours, during an interview with Resident A's family member, she stated on [DATE], she received a telephone call from RN 1. The RN told her Resident A was turning blue and asked her permission to send the resident to the acute hospital and she agreed to the transfer. She stated she was not told Resident A was possibly choking. The family member stated she went to the acute hospital's emergency room and spoke with the emergency room physician. However, she stated the emergency room physician talked to her about intubating (a flexible tube placed into the trachea to open and maintain an airway) Resident A to provide ventilation and to try and find out why the Resident was in respiratory distress. The family member stated when the emergency room physician was attempting to place the tube he pulled out a "wad of ham." She stated the emergency room physician told her it was a good decision to intubate because they now knew the cause of the respiratory distress. She stated Resident A was then admitted into the intensive care unit and never regained consciousness and died . The family member stated she had contacted the facility a day or two after the resident went to the hospital to express her concerns. The family member stated the DON (Director of Nursing) told her Resident A not having her dentures in at the time she ate lunch was a mishap. On [DATE] at 1545 hours, during an interview with Physician 1, the physician stated he received a phone call from the facility telling him Resident A was in respiratory distress. Physician 1 stated the resident was transferred to the acute hospital and he spoke with the emergency room physician. Physician 1 stated the emergency room physician told him slices of ham were removed from Resident A's airway. Physician 1 stated the resident was then transferred to the intensive care unit. On [DATE] at 1125 hours, during an interview with the DSS 2, the DSS stated the incident happened on the weekend and when she returned to work she heard Resident A had been sent to the hospital. The DSS stated she was unaware of the circumstances at the time but later found out Resident A had choked. The DSS stated the facility traced it back to a ham sandwich. The DSS stated they received a report from the acute hospital showing the patient had choked. On [DATE] at 1510 hours, during an interview with the ST (Speech Therapist), the ST stated if a resident was used to eating with dentures in, then she would expect the dentures to always be used when the resident was eating. The ST stated Resident A was encouraged to eat meals in the dining room because she would be sitting upright in a chair and staff would be supervising her. On [DATE] at 0945 hours, during an interview with RN 1, the RN stated she was called to help LVN 1 in Resident A's room. RN 1 stated she was asked to check Resident A's clinical record for her "code status" (a set of instructions outlining treatment to be given in the event of an emergency) and to call the resident's family member and 911. RN 1 stated the paramedics arrived and transferred the resident to the acute hospital. RN 1 stated she documented the account of the incident, including the Heimlich maneuver, in Resident A's clinical record for LVN 1. The RN stated she was helping LVN 1 by documenting the note because LVN 1 was "uneasy" and "distraught" about what happened. When asked if she was part of any facility investigation, the RN stated yes, she provided a written account the following day. When the RN was asked if the facility made any conclusions as a result from their investigation, the RN stated shortly after the incident they received a report showing the resident had choked. Review of the ambulance service's Patient Care Report dated [DATE], showed an emergency call was received at 1242 hours. The chief complaint was "unresponsive" and Resident A was found in bed and unresponsive. On [DATE] at 1605 hours, during an interview with EMT (Emergency Medical Technician) 1, the EMT stated he responded to an emergency call made at the facility. The EMT stated the call came in indicating a resident was in respiratory distress and he arrived just before the fire department. EMT 1 stated if he had known the resident was a possible choking victim, he would have noted that on his report. The EMT stated he later found out Resident A had a large chunk of meat cleared from her throat at the hospital from hospital staff. On [DATE] at 1020 hours, during an interview with Physician 2, the physician stated Resident A was brought into the emergency department in "extreme" respiratory distress. Physician 2 stated he removed a slice of ham from the resident's airway. He stated the ham was not chopped. Physician 2 stated the EMTs and the paramedics did not have any knowledge that Resident A may have been choking. Review of the acute hospital's emergency room physician's report dated [DATE], showed Resident A arrived in severe distress with severe labored breathing. The physician documented possible causes were "unknown." A piece of meat was then removed from the resident's throat. The acute hospital's pulmonary consultation dated [DATE], showed Resident A had a "large piece of meat lodged in her airway" and had subsequent respiratory failure. The acute hospital's neurological consultation dated [DATE], showed Resident A "had aspirated piece of meat" and required intubation and placed on a ventilator (a machine which mechanically moves air into and out of the lungs). Resident A did not regain consciousness. Review of the acute hospital's discharge summary dated [DATE], showed Physician 1 documented Resident A had a foreign body aspiration, which led to hypoxia (lack of oxygen) and respiratory failure. Physician 1 documented Resident A aspirated a "big chunk of ham." A computed tomography scan was negative for any acute neurological events. The resident's cause of death was cardiopulmonary arrest due to hypoxemia and respiratory failure. Review of the Certificate of Death showed Resident A's cause of death was cardiopulmonary arrest due to respiratory failure due to foreign body aspiration. Review of the Coroner's report dated [DATE], showed Resident A's cause of death was cardiopulmonary and respiratory arrest due to foreign body aspiration. The manner of death was an accident. Review of the Orange County Sheriff Coroner's Case Notes report dated [DATE], showed Resident A's death was reported to them by the acute hospital. The report showed the resident's family member stated there were times when the resident's food was not cut up and she was found unsupervised while eating. The family member spoke with the emergency room physician and was told he pulled a nearly intact slice of ham from the resident's throat which was blocking her airway. The family member found out from the facility that Resident A was not feeling well that day and stayed in bed. A whole ham sandwich was served to the resident, she was unsupervised and she did not have her dentures in place. The report showed Physician 1 spoke to the emergency room physician and was told a chunk of sliced ham was removed from the resident's airway. The incident happened on [DATE] while the resident was unsupervised and "per the doctor, that food should have never been on that plate." The facility failed to provide Resident A with her dentures, supervision and finely chopped meat as ordered, causing Resident A to choke to death. These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and were a direct proximate cause of death of the resident.

Based on observation, interview, and clinical record review, the facility failed to implement consistent of recommended approaches for five of 10 sampled residents (Residents 1, 3, 4, 6 and 8). Residents 1 and 6 were a fall risk and were to have floor pads on both side of the bed. However, observations found either no floor pad or only on one side of the bed. This poses the potential for recurrent falls, head injury, or fractures for the residents. Findings: 1. Review of Resident 3's clinical record was initiated on 7/26/11. Resident 3 was admitted to the facility on [DATE]. The resident had a history of [REDACTED]. Review of the MDS dated ,[DATE], showed the resident needs one person physical assistant for mobility, transferring and ambulating. The resident was alert with confusion and poor long and short-term memory. a. On 3/11/11 at 0025 hours, Resident 3 was found on the floor. A Interdisciplinary Progress Notes dated 3/11/11, showed the resident found lying on the floor on the right side of the bed sustaining multiple abrasions to both sides of her face. The IDT recommended to use mobility alarm while in bed and in wheelchair to alert staff when the resident attempted to get up unassisted. In addition, the IDT recommended to keep the bed in the lowest position; use pads on the floor and consult with the physician regarding medications. An Incident Screen form dated 3/11/11, showed physical therapy recommended the use of a personal alarm in bed and on the wheelchair. b. On 3/15/11, Resident 3 was found lying on the floor. The personal alarm sound and the resident was found lying on the floor next to her bed. Review of the Interdisciplinary Progress Notes dated 3/16/11, showed the resident's fell on [DATE]. Staff documented the resident attempted to transfer herself in the bed. She had an episode of agitation and restlessness and Ativan (a medication used for agitation or restlessness) was given prior to the incident. The IDT recommended to change personal alarm to a pad alarm, remove the wheelchair footrests, encourage naps after meals and toilet before naps. Review of the physical therapy assessment dated [DATE], identified the same recommendations. On 7/26/11 at 1030 hours, Resident 3 was observed in the activity room. The resident was sitting on her wheelchair with two footrests on her wheelchair. Observation of the resident's room found no pads on the floor. On 7/26/11 at 1430 hours, and 1610 hours, Resident 3 was observed sleeping on her bed. There was no pad on the floor during either observation. c. On 3/19/11 at 1830 hours, Resident 3 slid out of her wheelchair while in the activity room. Review of the nurse's notes dated 3/19/11 at 1830 hours, showed a CNA found Resident 3 sitting on the floor, assisted her back to wheelchair by two staff. The resident sustained [REDACTED]. Further review of the nurses' notes found no documentation the physician was notified of the fall and injuries. Review of the Post Fall Assessment form regarding the fall on 3/19/11, showed Resident 3 had self propelled her wheelchair into the activity room. She tried to stand up and slid off of her wheelchair before a staff member could reach her. The plan of care included to continue to utilize the pressure alarm in the wheelchair and visual checks every 30 minutes. Review of the Incident Screen dated 3/21/11, showed the resident was screened by the PT after the incident occurred on 3/19/11 at 1830 hours. The PT recommended to continue pad alarm and use a wedge cushion in the wheelchair. An Interdisciplinary Progress Notes dated 3/21/11, showed the IDT meet and review the incidents on 3/19/11. The IDT recommend to have wedge cushion on her wheelchair. Review of the plan of care found several care plan problems to address the resident's risk for falls and actual falls. For example, a care plan problem dated 12/30/10, identified the resident's risk for falls due unsteady gait, psychiatric medications and use of assistive devices. The interventions included to assist resident and provide cueing as needed. The care plan problem was updated on 3/11/11, to include interventions to keep the bed in the lowest position, apply a mobility alarm in bed and wheelchair and a pad on floor. In addition, on 3/16/11, staff added to remove the footrests from her wheelchair and toilet before nap time. An additional short-term care plan problem dated 3/19/11, addressed the resident' fall of sliding out of the wheelchair. The interventions included frequent visual check every 15 minutes. On 7/27/11 at 0620 hours and 0837 hours, Resident 3 was observed sitting in her wheelchair with two footrest applied to the chair. In addition, on 7/27/11 at 0837 hours, 0840 hours, and 0855 hours, while the resident was in the activity room, there was no staff in the room with the resident. On 7/27/11 at 0915 hours, an interview was conducted with RN 1. The RN was asked if Resident 3 had a pad on the floor. The RN stated the resident's room did have a pad on the floor. However, observation conducted with the RN revealed no pad were on the floor. The RN confirmed there was no pad or floor mat on the floor. On 7/27/11 at 0920 hours, an interview with CNA 1 was conducted. The CNA was observed assisting the resident to walk. The resident's wheelchair was noted to have two footrest applied. The CNA was asked about the use of the footrests. He stated when he assists out of the wheelchair, he moves the foot rest to the sides. He also stated when the resident the resident is sitting on her wheelchair, he places her foot on the footrests. During an interview and clinical record review with the DON on 7/27/11 at 1025 hours, the DON was asked if there was documented evidence the resident's physician was notified about the fall and injuries sustained on 3/19/11. The DON reviewed the resident's clinical record and verified there was no documentation to show the physician was notified about the resident's fall incident. 2a. Clinical record review was initiated for Resident 1 on 7/26/11. Review of Resident 1's MDS dated [DATE], showed the resident has severe cognitive impairment and has a history of falls. Review of an Incident Screen form dated 2/25/11, showed Resident 1 rolled out of bed. Recommended interventions included the use of pads on the floor next to the resident's bed. (The use of a floor pad helps lessen the severity of injury should a resident fall from bed). Review of Resident 1's comprehensive care plan showed a care plan problem to address the resident's risk for falls dated 1/10/11. Approaches to the care plan problem included, provide floor pad on both sides of the resident's bed. On 7/26/11 at 1100 hours, Resident 1 was observed in bed. There were no floor mats on either side of the resident's bed. On 7/27/11 at 0615, 0940, 1100 hours, Resident 1 was observed lying in bed. There were no floor mats on either side of the resident's bed. On 7/28/11 at 0920 hours, Resident 1 was observed in bed. A floor mat was observed on the right side of the resident's bed, but not on the left side. b. Review of Resident 1's MDS dated [DATE], showed the resident required assistance from at least two staff for transferring to/from a bed/chair. Review of Resident 1's comprehensive care plan showed a care plan problem to address the resident's ADL assistance needs dated 1/10/11. The care plan problem showed the resident needed assistance from two or more staff for transferring. On 7/27/11 at 0720 hours, CNA 4 was observed while providing the resident's ADL care. When the resident was ready to be transferred to her wheelchair, the CNA was observed to transfer the resident without obtaining assistance from another staff person. The CNA transferred the resident by hugging the resident to her and lifting the resident under the resident's arms. This has potential to cause skin tears and shear. 3. Clinical record review was initiated for Resident 6 on 7/26/11. Review of Resident 6's comprehensive care plan showed a care plan problem was developed to address the resident's risk for falls, dated 6/20/11. Approaches to the care plan problem included the use of floor pads on both sides of the resident's bed. Further review of the resident's comprehensive care plan showed the resident rolled from her low bed on 7/6/11, 7/7/11, 7/12/11, and 7/15/11. On 7/26/11 at 1500 and 1600 hours, Resident 6 was observed asleep in bed. A floor pad was observed on the right side of the resident's bed, but not on the left side of the resident's bed. On 7/27/11 at 0618 hours, Resident 6 was observed asleep in bed. A floor pad was observed on the right side of the resident's bed, but not on the left side of the resident's bed. 4. On 7/26/11, clinical record review was initiated for Resident 4 which showed the resident was admitted to the facility on [DATE], with right sided weakness secondary to a recent stroke. Staff identified the resident was alert, oriented and needed two person assistance for transfers and ambulation. A fall risk assessment dated [DATE], showed the resident scored 14. A score greater than 7 shows he is at high risk for falls. On 7/19/11 at 0400 hours, Resident 4 fell from bed and sustained abrasions. Review of the Interdisciplinary Progress Note dated 7/20/11, showed Resident 4 fell on [DATE], when he attempted to sit on the edge of the bed to use his urinal. Staff documented the resident has right sided hemiparesis/weakness. According to the resident he slid off the bed, hitting his head on the floor. He sustained an abrasion to his right knee and right hand (knuckle). The resident also complained of dizziness. The IDT identified to encourage the resident to use his call light for assistance and to monitor for orthostatic blood pressure (drop in blood pressure when sitting or standing). On 7/23/11, a licensed nurse heard someone shouting. Resident 4 was found lying on the floor in a fetal position, next to the wall. Review of the Interdisciplinary Progress Note dated 7/24/11, showed Resident 4 had fallen. The resident stated he was trying to use his urinal and slipped off the bed. He sustained an abrasion to his right middle finger. The IDT recommended to educate the resdient to use the call light and a low bed and pad on the floor. On 7/26/11 at 1115 hours, an interview was conducted with Resident 4. The resident was asked about his recent falls. He stated he fell the first night in the facility. He stated he was tying to use his urinal and he slid off the side of the bed onto the floor and sustained a "rug burn" to his left knee. Resident 4 stated he has problems with his balance since his stroke. Observation of the resdient's room found no pad or mat on the floor as recommended by the IDT. Observations conducted on 7/26/11 at 1500 hours, 7/27/11 at 0630 hours, 1410 hours, and on 7/28/11 at 0945 hours, found no floor pad or mat in Resident 4's room. On 7/26/11 at 1520 hours, and interview and clinical record review was conducted with RN 1. The RN verified the IDT recommended the use of floor mats due to the Resident 4's risk of falls. RN 1 stated floor mats should have been implemented on 7/24/11. 5. On 7/28/11, clinical record review was initiated for Resident 8 which showed the resident was admitted to the facility on ,[DATE]. A physician admission order dated 6/30/11, showed to apply a mobility alarm while in the resident is in bed and in the wheelchair to alert staff if the resident attempts to get up without assistance. The MDS dated [DATE], shows Resident 8 is at risk for falls and requires extensive assistance with one person physical assistance with transfers and ambulation. A care plan problem dated 6/30/11, identified the resident's risk for falls. The interventions included the use a mobility alarm while in bed and wheelchair. On 7/28/11 at 0930 hours, an interview was conducted with CNA 2. The CNA stated Resident 8 requires one person assistance with transfers. The CNA was asked if the resident had a mobility alarm when in bed or in the wheelchair. The CNA stated no. On 7/28/11 at 0945 hours, Resident 8 was observed sitting in his wheelchair in the activity room. There was no mobility alarm observed applied to the resident. On 7/28/11 at 1010 hours, an interview an clinical record review was conducted with the DON. The DON verified the physician's orders [REDACTED]. The DON confirmed with staff that Resident 8 did not have the alarm applied and stated it should have been implemented.