Every finding on record at Beachside Post Acute

Based on observation, interview and record review the facility failed to ensure seven out of 10 sampled residents, (Resident 1, 10, 45, 52, 54, 55 and 67), who were not able to carry out Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) to maintain good grooming by:Failing to ensure Residents 1,10,45,52 and 54 fingernails were not long with jagged (sharp, uneven) edges.Failing to ensure Residents 55 and 67 who had long, jagged mycotic (fungus) toenails were seen by a podiatrist (foot doctor).These failures had the potential to cause pain, inflict injury and spread infection by not ensuring the fingernails for Resident's 1, 10, 45, 52 and 54 were kept short and free from jagged edges and by not ensuring Resident's 55 and 67 were seen by a podiatrist for their long, jagged mycotic toenails. Findings: 1a.During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1 had a diagnosis including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, and dementia (a progressive state of decline in mental abilities) . During a review of Resident 1's Care Plan titled ADL Self-Care Deficit dated 2/23/2026, the Care Plan indicated Resident 1 was totally dependent on staff for personal hygiene. The Care Plan indicated Resident 1 was to receive a quality of life program that included hygiene and grooming. During a review of Resident 1's History & Physical (H&P) dated 2/24/26, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated 3/2/26, the MDS indicated, Resident 1 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 1 needed substantial/maximal assistance (helper does more than half the work) with activities of daily living (ADL's). During a concurrent observation and interview with Resident 1 on 5/26/26 at 9:26 a.m. in Resident 1's room, Resident 1 was observed to have long, jagged fingernails. Resident 1 stated he would really like to have his fingernails trimmed. 1b.During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10 had diagnosis including diabetes mellitus, muscle weakness and dementia. During a review of Resident 10's H&P, dated 1/27/26, the H&P indicated, Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's MDS dated [DATE], the MDS indicated, Resident 10 had severe cognitive impairment. The MDS indicated, Resident 10 was totally dependent ( helper does all the work), with ADL'S. During a review of Resident 10's Care Plan titled ADL Self-Care Deficit dated 1/22/26 the Care Plan indicated, Resident 10 was totally dependent with personal hygiene. The Care Plan indicated, Resident 10 was to be provided with a quality-of-life program which included hygiene and grooming. During an observation on 5/26/26 at 10:32 a.m., in Resident 10's room, Resident 10 was observed to have long, jagged fingernails. 1c.During a review of Resident 45's admission Record, the admission Record indicated, Resident 45 was admitted to the facility on [DATE] with the diagnosis including schizoaffective disorder(a mental illness that can affect thoughts, mood, and behavior), muscle weakness and anxiety (emotion characterized by feelings of tension, worried thoughts). During a review of Resident 45's Care Plan titled ADL Self-Care Deficit dated 9/04/25 the Care Plan indicated, Resident 45 needed moderate assistance ( helper does less than half the work) with personal hygiene. The Care Plan indicated, Resident 45 was to be provided with a quality-of-life program which included hygiene and grooming. During a review of Resident 45's H&P dated 1/27/26, the H&P indicated, Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 45's MDS dated [DATE], the MDS indicated, Resident 45 cognition was intact. The MDS indicated Resident 45 needed set up assistance, with ADL'S. During a concurrent observation and interview on 5/26/2026 at 11:54 a.m. with Resident 45, in Resident 45's room, Resident 45 was observed to have long, jagged fingernails. Resident 45 stated he would like to have his fingernails trimmed. 1d.During a review of Resident 52's admission Record, the admission Record indicated Resident 52 was admitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 52's MDS dated [DATE], the MDS indicated Resident 52's cognition was severely impaired. The MDS indicated Resident 52 required maximal assistance with ADLs. During a concurrent observation and interview on 5/26/2026 at 11:32 a.m. with Certified Nurse Assistant (CNA) 1 in Resident 52's room, Resident 52's fingernails were long and dirty and required trimming and cleaning. CNA 1 stated it was important for Resident 52's nails to be clean and trimmed because bacteria could collect under the nails and the resident could scratch herself. 1e.During a review of Resident 54's admission Record, the admission Record indicated, Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 54 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle weakness and lack of coordination. During a review of Resident 54's Care Plan titled ADL Self-Care Deficit dated 10/24/25 the Care Plan indicated, Resident 54 needed moderate assistance with personal hygiene. The care plan indicated, Resident 54 was to be provided with a quality-of-life program which included hygiene and grooming. During a review of Resident 54's H&P dated 10/26/25, the H&P indicated, Resident 54 did not have the capacity to understand and make decisions. During a review of Resident 54's MDS dated [DATE], the MDS indicated, Resident 54 had moderate cognitive impairment. The MDS indicated, Resident 54 needed substantial/maximal assistance with ADL'S. During a concurrent observation and interview on 5/26/2026 at 2:37 p.m. with Resident 54, in Resident 54's room, Resident 54 was observed to have long, jagged fingernails. Resident 54 stated he needed to have his fingernails trimmed because they were way too long. 2. During a review of Resident 55's admission Record, the admission Record indicated, Resident 55 was admitted to the facility on [DATE] with the diagnosis including Parkinson's disease, muscle weakness and diabetes mellitus. During a review of Resident 55's Care Plan titled ADL Self-Care Deficit dated 2/24/26 the Care Plan indicated, Resident 55 was totally dependent with personal hygiene. The Care Plan indicated, Resident 55 was to be provided with a quality-of-life program which included hygiene and grooming. During a review of Resident 55's H&P dated 2/25/26, the H&P indicated, Resident 55 had the capacity to understand and make decisions. During a review of Resident 55's MDS dated [DATE], the MDS indicated, Resident 55's cognition was intact. The MDS indicated, Resident 55 was totally dependent with ADL'S. During a review of Resident 55's Order Summary Report dated 5/01/26, the order summary report indicated, Resident 55 had a standing (permanent) order to see the podiatrist every two months and as needed for mycotic and /or other foot problems. During a concurrent observation and interview on 5/26/2026 at 2:37 p.m. with Resident 55, in Resident 55's room, Resident 55 was observed to have long, jagged mycotic toenails. Resident 55 stated he needed to have his toenails trimmed because they were too long. During a review of Resident 67's admission Record, the admission Record indicated, Resident 67 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 67 had a diagnosis including spinal stenosis (narrowing of the spaces in the spine [back] causing stiffness), muscle weakness and chronic kidney disease (kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood). During a review of Resident 67's Care Plan titled ADL Self-Care Deficit dated 9/26/25 the Care Plan indicated, Resident 67 needed moderate assistance with personal hygiene. The care plan indicated, Resident 67 was to be provided with a quality-of-life program which included hygiene and grooming. During a review of Resident 67's H&P dated 9/28/25, the H&P indicated, Resident 67 had the capacity to understand and make decisions. During a review of Resident 67's MDS dated [DATE], the MDS indicated, Resident 67's cognition was intact. The MDS indicated, Resident 67 needed substantial/maximal assistance with ADL'S. During a review of Resident 67's Order Summary Report dated 5/01/26, the Order Summary Report indicated, Resident 67 had a standing order to see the podiatrist every two months and as needed for mycotic toenails and /or other foot problems. During a concurrent interview and record review on 5/28/2026 at 11:28 a.m. with the Social Services Director (SSD), a list of residents seen by podiatry dated 4/28/2026 was reviewed. The list indicated Residents 55 and 67 were not seen by the podiatrist due to their insurance. The SSD stated it was her responsibility to ensure the residents were seen by the podiatrist. She stated the facility was responsible for the residents' care and should have paid for the residents to have their toenails trimmed on 4/28/2026 when the podiatrist last visited the facility. The SSD stated she had forgotten to schedule another podiatry appointment for Residents 55 and 67 to have their toenails trimmed. She stated when residents' toenails become too long, it can be very uncomfortable for them to wear shoes and socks. During a concurrent observation and interview on 5/29/26 at 7:14 a.m. with Resident 67, in Resident 67's room, Resident 67 was observed to have long, jagged mycotic toenails. Resident 67 stated he needed to have his toenails trimmed, they were too long and very uncomfortable when he wears socks. During an interview on 5/29/2026 at 9:53 a.m. with the Director of Staff Development (DSD), the DSD stated the CNAs and treatment nurses were responsible for trimming and cleaning the residents' nails. The DSD stated it was important for residents' nails to be kept clean and trimmed because long or dirty nails could cause pain and discomfort, could break the skin if the residents scratched themselves, and could curl into the skin. During an interview on 5/29/2026 at 10:56 a.m. with the Infection Prevention Nurse (IPN), the IPN stated long, unclean nails could lead to an infection if bacteria were present under the nails and the resident put their hands in their mouth, or if the resident scratched themselves and broke the skin, which could also result in an infection During an interview on 5/29/2026 at 11:03 a.m. with the Director of Nursing (DON), the DON stated dirty and long nails placed residents at risk for infection if they ate with their hands or scratched themselves, causing skin breakdown. During an interview on 5/29/2026 at 11:14 a.m. with the Administrator (ADM), the ADM stated the SSD was responsible for ensuring the residents were seen by the podiatrist. The ADM stated the facility was responsible for the residents' care and Residents 55 and 67 should have been seen by the podiatrist, and the facility should have paid the bill During a review of the facilities policy and procedure (P&P) titled, Activities of Daily Living, and Scope of Services, dated 6/2022, the P&P indicated, It is the policy of the facility that each resident receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care.Staff will ensure that Activities of Daily Living are monitored, assisted with, and provided for those residents who are unable to perform Activities of Daily Living. The P&P indicated, ensure that the following ADL functions are monitored, supervised, assisted with and or provided to the Resident population that the facility is servicing to included but not limited to: a. Bathing/ Showering and or personal hygiene b. Eating/Feeding c. Mouth Care d. Dressing e. Grooming f. Toileting g. Transferring bed/Chair h. Repositioning i. Walking/Ambulation

Based on observation, interview, and record review the facility failed to store food in a safe and sanitary manner. The facility had 69 residents receiving oral diet. The facility failed to:1. Ensure open bags of frozen pizza dough, corn, potato puffs and hotdogs were stored in an airtight container or bags.This failure had the potential to place residents at risk for developing food borne illnesses (any illness resulting from eating contaminated/spoiled foods) and could reduce the quality of food served in the facility.Findings:During a concurrent initial kitchen observation and interview on 5/26/2026 at 8:20 a.m. with the Dietary Supervisor (DS), an open plastic bag containing frozen pizza dough, an open blue bag containing frozen corn inside a brown box, an open bag of frozen potato puffs, and an open bag of frozen hotdogs were stored in the reach in freezer. Crystalized ice was observed on the potato puffs and hotdogs. The DS stated the kitchen staff should have tied open plastic bags of frozen food items or stored them in sealed plastic bags or containers. The DS stated freezer burn (food drying out and losing flavor due to exposure to cold, dry air) was present on the frozen hotdogs because staff left the bag open, and the food should have been stored in a sealed bag.During an interview on 5/28/2026 at 8:29 a.m. with Dietary Aide (DA) 2, DA 2 stated open frozen items should be stored in a Ziplock bag or the plastic bag should be tied with a knot so ice crystals would not form on the frozen food. DA 2 stated the formed ice crystals could contaminate frozen food and could lead to food borne illness.During an interview on 5/28/2026 at 1:23 p.m. with the Dietary Supervisor (DS), the DS stated open frozen items not stored in airtight, sealed container could cause food-borne illness and decrease the quality of food served to the residents.During an interview on 5/27/2026 at 1:54 p.m. with the Registered Dietitian (RD), the RD stated improper storage of frozen food items could decrease the flavor and quality of food.During a review of facility's policy and procedure(P&P) titled, Procedure for Freezer Storage, dated 2023, the P&P indicated frozen foods will be stored in airtight moisture -resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn.

Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices. The facility failed to:1. Ensure staff performed hand hygiene in between residents when passing lunch trays.2. Ensure Licensed Vocational Nurse (LVN) 1 performed hand hygiene before, and after medication administration on Resident 20.3.Observe Enhanced Barrier Precautions (EBP- infection control rules used in nursing homes to stop the spread of dangerous, hard-to-treat germs) before administering Resident 20's medication through gastrostomy tube (GT- a soft tube surgically inserted directly into the stomach to administer medication, fluids and nutrition).These failures had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection. Findings: 1. During a concurrent observation and interview on 5/26/2026 at 12:11 p.m. in the hallway with Certified Nurse Assistant (CNA) 2, CNA 2 was observed going room to room passing lunch trays without performing hand hygiene between residents. CNA 2 stated he was supposed to perform hand hygiene between each resident's tray because not doing so could spread bacteria between residents and could cause them to get sick. During an interview on 5/29/2026 at 10:56 a.m. with the Infection Control Nurse (IPN), the IPN stated staff should perform hand hygiene between residents when passing trays to prevent the spread of infection that could cause residents to become sick. During an interview on 5/29/2026 at 11:03 a.m. with the Director of Nursing (DON), the DON stated staff should perform hand hygiene before and after entering residents' rooms when passing meal trays. The DON stated when staff did not perform hand hygiene between residents, it could potentially cause cross contamination and lead to residents becoming sick with an infection. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene, revised 7/2019, the P&P indicated, It is the policy of the facility that all staff members perform hand hygiene before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of infection. The P&P indicated, Alcohol-based hand rub should be available inside and outside of all resident rooms in order to improve access and compliance with hand hygiene. 2. During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was originally admitted on [DATE] and was readmitted on [DATE]. Resident 20's diagnoses including hemiplegia affecting the right dominant side (total paralysis of the arm, leg, and trunk on the right side of the body), dysphagia (difficulty in swallowing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool) dated 3/18/2026, the MDS indicated Resident 20 had severely impaired cognitive (ability to think, understand, learn, and remember) skills. The MDS indicated Resident 20 required substantial/maximal assistance ( helper does more than half the effort) with toileting hygiene, dressing, oral hygiene, and dressing. The MDS indicated Resident 20 had a feeding tube (flexible plastic tube used to safely liquid food, fluids, and medications directly into the stomach or small intestines). During a review of Resident 20's History and Physical (H&P) dated 4/21/2026, the H&P indicated Resident 20 did not have the capacity to understand and make decisions. During a medication pass observation on 5/26/2026 at 4:00 p.m. with LVN 1, LVN 1 did not perform hand hygiene before taking Resident 20's vital signs (VS-measure the basic functions of the body which include temperature, blood pressure, pulse and respiratory [breathing] rate), before preparing and crushing medications, or before administering Resident 20's medications via the gastrostomy tube. LVN 1 did not wear gloves or a protective gown before taking Resident 20's vital signs or administering medications through the GT. After administering the medications, LVN 1 wiped his hands with Clorox wipes (pre moistened disposable wipes used to clean and kill germs on surfaces). During an interview on 5/26/2026 at 4:50 p.m. with LVN 1, LVN 1 stated he had forgotten to perform hand hygiene. He stated he had not practiced hand hygiene at the start of the medication pass, so he decided to continue not performing hand hygiene while administering medications to Resident 20. LVN 1 stated that not practicing hand hygiene could place residents at risk for contracting an infection due to contaminated staff hands. 3. During an interview on 5/28/2026 at 1:10 p.m. with LVN 3, LVN 3 stated licensed nurses should wear gloves, a mask, and a protective gown when a resident was on EBP. LVN 3 stated staff should not use Clorox wipes for hand hygiene because they could cause chemical burns and were intended only for use on surfaces. LVN 3 stated staff practiced hand hygiene by using alcohol based hand rub (ABHR-liquid, gel used to quickly kill microorganism on hands) or by washing their hands with soap and water. During an interview on 5/28/2026 at 11:27 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated licensed nurses were expected to perform hand hygiene before administering medications and when switching from one task to another during the medication pass. The IPN stated Resident 20 was on EBP because of the gastrostomy tube, and LVN 1 should have practiced hand hygiene and worn personal protective equipment (PPE) before administering medications to Resident 20. The IPN stated staff used ABHR or soap and water for hand hygiene. The IPN stated LVN 1 could spread infection among staff and residents by not practicing hand hygiene. During an interview on 5/28/2026 at 4:59 p.m. with the DON, the DON stated LVN 1's failure to perform hand hygiene and wear Personal Protective Equipment (PPE- equipment used to prevent or minimize exposure to hazards) during the medication pass could spread infection among residents and staff due to contamination from his hands. During a review of facility's P&P titled, Medication Administration via Enteral Tube, revised 4/2017, the P&P indicated the licensed nurse should wash hands and wear gloves, then check placement of GT and administer medications via GT. During a review of facility's P&P titled, Enhanced Standard Precautions, revised 5/2024, the P&P indicated, EBP is an approach of targeted gown and glove use during high contact resident care activities( hands-on task that involve close proximity to a resident) to reduce transmission of multidrug-resistant organism (MDRO- type of germ that can cause an infection that is hard to treat and had developed resistance to a lot of infection).

Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 33 and Resident 88) were appropriately notified regarding the changes in their Medicare coverage through provision of Notice of Medicare Non-Coverage (NOMNC-given by the facility to residents at least two days before the end of a Medicare covered Part A stay or when all of Part B therapies are ending) form.This deficient practice had the potential to result in the responsible parties not being able to exercise their right to file and appeal.Findings:During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN- high blood pressure) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 33's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2026, the MDS indicated Resident 33's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 33 required maximal (helper does more than half the effort) with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 33's History and Physical (H&P) dated 2/10/2026, the H&P indicated Resident 33 has the capacity to understand and make decisions. During a review of Resident 88's admission Record, the admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses including depression (a serious mood disorder that causes a persistent feeling of sadness and a loss of interest in activities) and severe chronic kidney disease (progressive damage and loss of kidney function in the kidneys).During a review of Resident 88's MDS dated [DATE], the MDS indicated Resident 88's cognition was intact. The MDS indicated Resident 88 required supervision (helper provides verbal cues or touching assistance) with ADLs.During a review of Resident 88's H&P dated 2/21/2026, the H&P indicated Resident 88 has the capacity to understand and make decisions.During an interview on 5/28/2026 at 7:27 a.m., with Resident 33, the NOMNC form was provided, and Resident 33 denied that the signature on the form was his and denied having seen or ever being presented with the NOMNC form.During a concurrent interview and record review on 5/28/2026 at 7:41 a.m. with the Business Office Manager (BOM), the NOMNC forms for Residents 33 and 88 were reviewed. The BOM stated she had signed the NOMNC forms for Residents 33 and 88, but she acknowledged she should not have signed them because she was not the resident or the resident representative. The BOM stated signing the forms without the residents' consent or knowledge could cause the residents to feel a loss of trust and would affect their rights.During an interview on 5/29/2026 at 11:03 a.m. with the Director of Nursing (DON), the DON stated the NOMNC forms should only be signed by the resident or the resident representative, not the BOM, because having the BOM sign them could result in a lack of trust in the staff.During a review of the facility's policy and procedure (P&P) titled, Medicare Beneficiary Notice, revised 8/2018, the P&P indicated, It is the facility's policy to adhere to Medicare guidelines and to provide proper and timely notices to Medicare Beneficiaries when skilled services will end. The P&P also indicated, It is the facility's responsibility to ensure forms are completed as per Medicare guidelines and given to the resident and/or representative timely.

Based on observation, interview and record review the facility failed to ensure the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) was notified for one of three sampled residents (Resident10) who was hospitalized on [DATE].This failure violated the rights of Resident 10 by not notifying the ombudsman to ensure Resident 10's discharge was safe and appropriate.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10 had a diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and dementia.During a review of Resident 10's H&P, dated 1/27/26, the H&P indicated, Resident 10 did not have the capacity to understand and make decisions.During a review of Resident 10's Minimum Data Set ( MDS-resident assessment tool) dated 5/4/26, the MDS indicated, Resident 10 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated, Resident 10 was totally dependent ( helper does all the work), with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily)During a review of Resident 10's Physicians Discharge summary dated [DATE], the Physicians Discharge Summary indicated, Resident 10 was discharged to the general acute care hospital (GACH) on 3/9/26 for a low hemoglobin ( when the body lacks healthy red blood cells).During a concurrent interview and record review on 5/28/2026 at 10:03 a.m. with the Assistant Director of Nursing (ADON), Resident 10's Notice of Transfer/discharge date d 3/9/2026 was reviewed. The Notice of Transfer/Discharge indicated the Ombudsman was notified of Resident 10's discharge on [DATE]. The ADON stated that when residents were transferred to the GACH, the Ombudsman should be notified the same day. The ADON stated the Ombudsman was informed so they were aware the resident was no longer in the care of the facility and to ensure the discharge was appropriate. The ADON stated the Ombudsman served as the residents' advocate.During an interview on 5/29/2026 at 1:03 p.m. with the Director of Nursing (DON), the DON stated the Ombudsman should be notified immediately after a resident was transferred to the GACH to inform the Ombudsman that the resident was no longer in the facility and to ensure the discharge was appropriate to meet the resident's needsDuring a review of the facility's policy and procedure (P&P) titled Discharge Process dated 10/2017, the P&P indicated, The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and record the reasons for the transfer or discharge in the resident's medical record will include the following, the reason for transfer or discharge, the effective date of transfer or discharge and the location to which the resident is to be transferred or discharged as soon as practicable when an immediate transfer or discharge is required by the resident's urgent medical needs.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 6) with a positive Preadmission Screening and Resident Review Level 1 screening ([PASRR] a federal requirement to identify individuals with serious mental illness ([SMI] a mental, behavioral, or emotional condition that interferes with or limits a person's ability to function in daily life ), and intellectual disability ([ID] when a person has significant limitations in their mental abilities), prior to admission to the facility received a required PASARR Level II evaluation to determine the need for specialized services and appropriate placement.This failure had the potential to result in the resident's serious mental illness not being comprehensively evaluated, the resident not receiving specialized services as needed, and placement decisions being made without a complete assessment of the resident's mental health needs.Findings:During a review of Resident 6's admission Record, the admission Record indicated Resident 61 was initially admitted to the facility on [DATE], with a diagnoses of Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), depression (persistent feelings of sadness, emptiness, and a loss of interest in activities), anxiety disorder (emotion characterized by feelings of tension, worried thoughts ) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 6's Medical Administration Record (MAR) dated 2/3/2025, the MAR indicated, Latuda (a prescription medication considered a antipsychotic (medications used to treat residents with mental disorder) oral tablet 20 milligram (mg-unit of measurement ) give one tablet by mouth in the evening for bipolar disorder manifested by (m/b) mood swings from being sociable to keeping to self.During a review of Resident 6's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 3/13/2025, the PASRR indicated, Result of Level I Screening: Level 1- Positive for SMI. During a review of Resident 6's Care Plan, dated 7/13/2025, the Care Plan indicated, Level II PASRR Recommendation; Related to Manifested by: Resident with positive Level I PASRR screening and followed by Level II PASRR evaluation on: 7/13/2026.The Care Plan indicated a goal to help resident/ responsible party to identify mental health conditions or developmental disability and to ensure proper placement, whether in the community or in a nursing facility based on a personalized recommended specialized services by PASRR Level II.During a review of Resident 6's Progress Notes, dated 1/29/2026, the Progress Notes indicated, the resident describes his mood as steady, with persistent but manageable depressive features such as low motivation and occasional feelings of emotional heaviness.During a review of Resident 6's History and Physical (H&P), dated 2/18/2026, the H&P indicated, Resident 6 had the capacity to understand and make decisions.During a review of Resident 6's Progress Notes, dated 5/5/2026, the Progress Notes indicated, the patient was medically fragile individual with severe cognitive impairment consistent with advanced neurocognitive decline, currently resident in a highly supervised care setting.During a concurrent interview and record review on 5/28/2026 at 1:23 p.m. with the Medical Data Set Nurse (MDSN), Resident 6's PASRR Level I dated 3/13/2025 was reviewed. The PASRR Level I indicated that Resident 6 had a serious mental illness and was receiving psychotropic medication. The MDSN stated that she was responsible for screening residents. She stated Resident 6's diagnoses were considered mental illnesses for PASRR purposes including anxiety disorder, bipolar disorder, depression, and schizophrenia. She stated Resident 6 had a diagnosis of anxiety disorder and had been prescribed Latuda 20 mg daily. She stated based on the positive PASRR Level I screening, a PASRR Level II evaluation should have been completed. The MDSN stated she did not know why a PASRR Level II evaluation had not been obtained. She further stated the purpose of a PASRR Level II evaluation was to assess a resident's mental health needs and determine whether specialized services were required. MDSN stated if a resident who screened positive on the PASRR Level I did not receive a Level II evaluation, the resident's mental health needs might not be fully assessed and recommendations for specialized services could be missed.During a review of the facility's policy and procedure (P&P) titled, PASRR (Preadmission Screening Resident Review), dated 2019, the P&P indicated, If the result of the Level I screening is positive due to a diagnosed or suspected mental illness identified, the Level I Screening will automatically be sent to the DHCS Contractor for a Level II prescreening call.

Based on observation, interview, and record review, the facility failed to provide appropriate care for one of ten sampled residents (Resident 20). The facility failed to:1.Ensure Licensed Vocational Nurse (LVN) 1 verified the placement of the gastrostomy tube (GT-a soft tube surgically inserted directly into the stomach to administer medications, fluids, and nutrition) and checked or assessed the gastric residual volume (GRV-the amount of fluid or tube feeding formula [liquid nutrition] remaining in the stomach at a specific point in time) of Resident 20's GT prior to administering medications.This failure had the potential to place Resident 20 at risk for aspiration pneumonia (a lung infection caused by stomach or oral contents entering the lungs), vomiting, and the possibility of medications entering the wrong tract if the feeding tube was not positioned correctly, which could lead to peritonitis (inflammation or infection of the lining of the abdomen).Findings:During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was originally admitted on [DATE] and was readmitted on [DATE]. Resident 20's diagnoses including hemiplegia affecting the right dominant side (total paralysis of the arm, leg, and trunk on the right side of the body), dysphagia (difficulty in swallowing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 20's Order Summary Report dated 11/9/2020, the Order Summary Report indicated checking GT placement and patency every shift.During a review of Resident 20's Order Summary Report dated 10/6/2023, the Order Summary Report indicated checking residuals of GT every shift.During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool) dated 3/18/2026, the MDS indicated Resident 20 had severely impaired cognitive (ability to think, understand, learn, and remember) skills. The MDS indicated Resident 20 required substantial/maximal assistance ( helper does more than half the effort) with toileting hygiene, dressing, oral hygiene, and dressing. The MDS indicated Resident 20 had a feeding tube (flexible plastic tube used to safely liquid food, fluids, and medications directly into the stomach or small intestines).During a review of Resident 20's History and Physical (H&P) dated 4/21/2026, the H&P indicated Resident 20 did not have the capacity to understand and make decisions.During an observation of medication administration on 5/26/2026 at 4:00 p.m. in Resident 20's room with LVN 1, LVN 1 did not verify or assess the placement of the GT. LVN 1 did not check the GRV of Resident 20's GT prior to administering medications.During an interview on 5/26/2026 at 4:50 p.m., with LVN 1, LVN 1 stated he forgot to check the placement of the GT and the gastric residual before administering Resident 20's medications. He stated he would check the GT placement and gastric residual in the future to ensure the GT was correctly positioned before giving medications. LVN 1 stated he should have verified Resident 20's GT placement and gastric residual. He stated failing to verify the GT placement could put Resident 20 at risk for aspiration pneumonia. He stated checking the gastric residual would help ensure the resident was not at risk for vomiting, and a high residual could put Resident 20 at risk for vomiting.During an interview on 5/28/2026 at 11:27 a.m., with the Infection Preventionist Nurse (IPN), IPN stated licensed nurses must verify GT placement and check the gastric residual before administering medications through the GT. The IPN stated if the GT was not in place, Resident 20 could aspirate, would not receive his medication, and could be at risk for infection due to possible GT dislodgement (medical device has accidentally moved or been forced out of its original, correct position).During an interview on 5/28/2026 at 4:59 p.m., with the Director of Nursing (DON), the DON stated licensed nurses should check and verify GT placement to ensure it is correct before administering medications. The DON explained that if the GT placement was not verified, the nurse would not know whether the medications administered through the GT entered the correct route, and Resident 20 could experience significant pain.During a review of facility's policy and procedure (P&P) titled, Medication Administration via Enteral tube, revised 4/2017, the P&P indicated the nurse will verify tube placement by forcefully injecting air into tube while listening with stethoscope to the abdomen for a loud bubbling sound. The P&P indicated to check the residual amounts of feeding once placement is verified, then administer the medications.

Based on interview and record review, the facility failed to ensure staff were informed of and individualized, trauma informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma for residents with Post-Traumatic Stress Disorder (PTSD a mental health condition that can develop after experiencing or witnessing a traumatic event) for two of three residents reviewed for PTSD (Residents 28 and 66).This failure resulted in staff not being aware of each resident's PTSD triggers and increased the risk of unnecessary stress or escalation for the residents.Findings:During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 28 with diagnoses including PTSD and dementia (a progressive state of decline in mental abilities).During a review of Resident 28's Care Plan titled, PTSD, dated 12/22/2025, the Care Plan interventions indicated to beware of the triggers that cause the resident to escalate and the triggers included being touched by male personnel.During a review of Resident 28's Minimum Data Set (MDS- a resident assessment tool) dated 3/23/2026, the MDS indicated Resident 28's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 28 required maximal (helper does more than half the effort) assistance with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was admitted to the facility on [DATE] with diagnoses including PTSD and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility).During a review of Resident 66's Care Plan titled, PTSD, dated 1/29/2026, the Care Plan interventions indicated to beware of the triggers that cause the resident to escalate and the triggers included loud noises and yelling.During a review of Resident 66's MDS dated [DATE], the MDS indicated Resident 66's cognition was intact. The MDS indicated Resident 66 required maximal (helper does more than half the effort) assistance with ADLs.During an interview on 5/28/2026 at 9:09 a.m., with Resident 66, Resident 66 stated he has been diagnosed with PTSD, and his triggers include loud noises and fighting people.During an interview on 5/28/2026 at 9:35 a.m. with Certified Nurse Assistant (CNA) 4, CNA 4 stated she had not been made aware of which residents had PTSD or what their triggers were unless the residents told her themselves. CNA 4 stated she knew about Resident 66's PTSD and triggers because he informed her when she cared for him. CNA 4 stated it was important for staff to be informed about residents with PTSD and their triggers so they could provide proper care.During an interview on 5/28/2026 at 10:18 a.m. with CNA 3, CNA 3 stated she had not been aware that Resident 28 had PTSD or what his triggers were. CNA 3 stated she should have been informed of Resident 28's PTSD and triggers so she could better care for him and know what to watch for in case something happened.During an interview on 5/28/2026 at 11:12 a.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated it was important for CNAs to be aware of residents with PTSD and their triggers so they would not trigger the residents and so the residents would feel safe and comfortable in the facility.During an interview on 5/29/2026 at 11:03 a.m., with the Director of Nursing (DON), the DON stated all staff needed to know which residents had PTSD and what their triggers were so they could avoid triggering the residents and causing them additional stressDuring a review of the facility's policy and procedure (P&P) titled, Treatment and Services for Mental Disorders, Psychosocial Adjustment Difficulty, Trauma, and/or Post-Traumatic Stress Disorder, revised 10/2017, the P&P indicated, Residents admitted with a mental or psychosocial adjustment difficulty, or who have a history of trauma and/or PTSD, will receive appropriate person-centered and individualized treatment and services to meet their assessed needs.

Based on observation, interview and record review the facility's Social Services Director (SSD) failed to ensure two out of 10 sampled residents (Resident's 55 and 67) were seen by a podiatrist (foot doctor) for treatment of their long, jagged (sharp, uneven) mycotic (fungal) toenails.This deficient practice resulted in a delay in necessary care and services for Resident 55 and Resident 67.Findings:During a review of Resident 55's admission Record, the admission Record indicated, Resident 55 was admitted to the facility on [DATE] with a diagnoses including Parkinson's disease(a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), muscle weakness and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 55's Care Plan titled ADL Self-Care Deficit dated 2/24/26 the Care Plan indicated, Resident 55 was totally dependent with personal hygiene. The Care Plan indicated, Resident 55 was to be provided with a quality-of-life program which included hygiene and grooming.During a review of Resident 55's History and Physical (H&P) dated 2/25/26, the H&P indicated, Resident 55 had the capacity to understand and make decisions.During a review of Resident 55's Minimum Data Set (MDS-resident assessment tool ) dated 3/03/26, the MDS indicated Resident 55's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated Resident 55 was totally dependent (helper does all the work) with Activities of Daily Living During a review of Resident 55's Order Summary Report dated 5/01/26, the order summary report indicated, Resident 55 had a standing (permanent) order to see the podiatrist every two months and as needed for mycotic and /or other foot problems.During a concurrent observation and interview on 5/26/2026 at 2:37 p.m. with Resident 55, in Resident 55's room, Resident 55 was observed to have long, jagged mycotic toenails. Resident 55 stated he needed to have his toenails trimmed because they were too long.During a review of Resident 67's admission Record, the admission Record indicated, Resident 67 was admitted to the facility on [DATE] and readmitted [DATE]. Resident 67 had a diagnosis including spinal stenosis (narrowing of the spaces in the spine [back] causing stiffness), muscle weakness and chronic kidney disease (kidneys are damaged and gradually lose their ability to filter waste and excess fluid from the blood).During a review of Resident 67's Care Plan titled ADL Self-Care Deficit dated 9/26/25 the Care Plan indicated, Resident 67 needed moderate assistance with personal hygiene. The care plan indicated, Resident 67 was to be provided with a quality-of-life program which included hygiene and grooming.During a review of Resident 67's H&P dated 9/28/25, the H&P indicated, Resident 67 had the capacity to understand and make decisions.During a review of Resident 67's MDS dated [DATE], the MDS indicated, Resident 67's cognition was intact. The MDS indicated Resident 67 needed substantial/maximal (helper does more than half the work) assistance with ADL'S.During a review of Resident 67's Order Summary Report dated 5/01/26, the Order Summary Report indicated, Resident 67 had a standing order to see the podiatrist every two months and as needed for mycotic toenails and /or other foot problems.During a concurrent interview and record review on 5/28/2026 at 11:28 a.m. with the Social Services Director (SSD), a list of residents seen by podiatry dated 4/28/2026 was reviewed. The list indicated Residents 55 and 67 were not seen by the podiatrist due to their insurance. The SSD stated it was her responsibility to ensure the residents were seen by the podiatrist. She stated the facility was responsible for the residents' care and should have paid for the residents to have their toenails trimmed on 4/28/2026 when the podiatrist last visited the facility. The SSD stated she had forgotten to schedule another podiatry appointment for Residents 55 and 67 to have their toenails trimmed. She stated when residents' toenails become too long, it can be very uncomfortable for them to wear shoes and socks.During a concurrent observation and interview on 5/29/26 at 7:14 a.m. with Resident 67, in Resident 67's room, Resident 67 was observed to have long, jagged mycotic toenails. Resident 67 stated he needed to have his toenails trimmed, they were too long and very uncomfortable when he wears socks.During an interview on 5/29/2026 at 9:53 a.m. with the Director of Staff Development (DSD), the DSD stated the CNAs and treatment nurses were responsible for trimming and cleaning the residents' nails. The DSD stated it was important for residents' nails to be kept clean and trimmed because long or dirty nails could cause pain and discomfort, could break the skin if the residents scratched themselves, and could curl into the skin.During an interview on 5/29/2026 at 11:03 a.m. with the Director of Nursing (DON), the DON stated regardless of the payor source, the facility was responsible for providing care to the residents. The DON stated it was the SSD's responsibility to inform administration that the facility needed to pay for Residents 55 and 67 to have their toenails trimmed. The DON stated there was a possibility that Residents 55 and 67 could scratch themselves and develop a skin tear that could lead to an infection.During an interview on 5/29/2026 at 11:14 a.m. with the Administrator (ADM), the ADM stated the SSD was responsible for ensuring residents were seen by podiatry. The ADM stated the facility was responsible for providing the care and services Residents 55 and 67 needed. The ADM stated Residents 55 and 67 should have been seen by podiatry on 4/28/2026.During a review of the facilities policy and procedure (P&P) titled, Social Services Program dated 1/2027, the P&P indicated, Social services is responsible for making referrals to community resources as necessary and appropriate and maintaining appropriate documentation of referrals, when needed.During a review of the facilities policy and procedure (P&P) titled, Activities of Daily Living, and Scope of Services, dated 6/2022, the P&P indicated, It is the policy of the facility that each resident receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care.Staff will ensure that Activities of Daily Living are monitored, assisted with, and provided for those residents who are unable to perform Activities of Daily Living.

Based on observation, interview and record review, the facility failed to ensure medications are administered safely and in accordance with accepted standards of practice on two of nine sampled residents (Resident 20 and Resident 50). The facility failed to:1.Ensure Licensed Vocational Nurse (LVN) 1 verified the placement of the gastrostomy tube (GT-a soft tube surgically inserted directly into the stomach to administer medications, fluids, and nutrition) and checked or assessed the gastric residual volume (GRV-the amount of fluid or tube feeding formula [liquid nutrition] remaining in the stomach at a specific point in time) of Resident 20's GT prior to administering medications. 2. Ensure LVN 3 assessed Resident 50's pulse rate before administering Metoprolol, (a medication used to treat high blood pressure by relaxing blood vessels and slowing the pulse rate) with a pulse based hold parameter (a physician ordered instruction that guides when the medication should or should not be given).These failures placed Resident 20 and Resident 50 at risk for ineffective medication administration, aspiration (accidental inhalation of foreign material into the lungs), adverse drug reactions (harmful or unintended effects caused by a medication), and avoidable decline in health status. Findings:During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was originally admitted on [DATE] and was readmitted on [DATE]. Resident 20's had diagnoses including hemiplegia affecting the right dominant side (total paralysis of the arm, leg, and trunk on the right side of the body), dysphagia (difficulty in swallowing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a review of Resident 20's Order Summary Report dated 11/9/2020, the Order Summary Report indicated checking GT placement and patency every shift.During a review of Resident 20's Order Summary Report dated 10/6/2023, the Order Summary Report indicated checking residuals of GT every shift.During a review of Resident 20's Minimum Data Set (MDS- a resident assessment tool) dated 3/18/2026, the MDS indicated Resident 20 had severely impaired cognitive (ability to think, understand, learn, and remember) skills. The MDS indicated Resident 20 required substantial/maximal assistance ( helper does more than half the effort) with toileting hygiene, dressing, oral hygiene, and dressing. The MDS indicated Resident 20 had a feeding tube (flexible plastic tube used to safely liquid food, fluids, and medications directly into the stomach or small intestines).During a review of Resident 20's History and Physical (H&P) dated 4/21/2026, the H&P indicated Resident 20 did not have the capacity to understand and make decisions.1. During an observation of medication administration on 5/26/2026 at 4:00 p.m. in Resident 20's room with LVN 1, LVN 1 did not verify or assess the placement of the GT. LVN 1 did not check the GRV of Resident 20's GT prior to administering medications.During an interview on 5/26/2026 at 4:50 p.m., with LVN 1, LVN 1 stated he forgot to check the placement of the GT and the gastric residual before administering Resident 20's medications. He stated he would check the GT placement and gastric residual in the future to ensure the GT was correctly positioned before giving medications. LVN 1 stated he should have verified Resident 20's GT placement and gastric residual. He stated failing to verify the GT placement could put Resident 20 at risk for aspiration pneumonia. He stated checking the gastric residual would help ensure the resident was not at risk for vomiting, and a high residual could put Resident 20 at risk for vomiting.During an interview on 5/28/2026 at 11:27 a.m., with the Infection Preventionist Nurse (IPN), IPN stated licensed nurses must verify GT placement and check the gastric residual before administering medications through the GT. The IPN stated if the GT was not in place, Resident 20 could aspirate, would not receive his medication, and could be at risk for infection due to possible GT dislodgement (medical device has accidentally moved or been forced out of its original, correct position).During an interview on 5/28/2026 at 4:59 p.m., with the Director of Nursing (DON), the DON stated licensed nurses should check and verify GT placement to ensure it is correct before administering medications. The DON explained that if the GT placement was not verified, the nurse would not know whether the medications administered through the GT entered the correct route, and Resident 20 could experience significant pain.During a review of facility's policy and procedure (P&P) titled, Medication Administration via Enteral tube, revised 4/2017, the P&P indicated the nurse will verify tube placement by forcefully injecting air into tube while listening with stethoscope to the abdomen for a loud bubbling sound. The P&P indicated to check the residual amounts of feeding once placement is verified, then administer the medications.2.During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including hypertension (HTN- high blood pressure), cardiac murmur (a whooshing sounds made by rapid, choppy blood flow through the heart), and muscle weakness.During a review of Resident 50's Order Summary Report dated 2/21/2025, the Order Summary Report indicated an order of metoprolol tartrate oral tablet , give one tablet by mouth two times a day for HTN , hold for systolic blood pressure (SBP- measures the pressure of the blood as it pushes against the artery walls when the heart beats) less than 110 millimeters of mercury ( mmHg-unit of measurement used to record blood pressure) and pulse rate less than 60 beats per minute ( bpm).During a review of Resident 50's MDS dated [DATE], the MDS indicated Resident 50 had an intact cognition and required set up or clean-up assistance (helper sets up or cleans up as resident completes the activity) with bathing, dressing, toileting hygiene and personal hygiene.During a concurrent medication pass observation and interview on 5/27/2026 at 9:20 a.m. with LVN 3 in Resident 50's room, LVN 3 obtained Resident 50's blood pressure. LVN 3 stated she only takes a resident's blood pressure. LVN 3 stated she will take the pulse rate only when required by the physician's medication parameters. LVN 3 then administered one tablet of metoprolol tartrate 50 milligram (mg unit of measurement) to Resident 50 without assessing Resident 50's pulse rate.During a concurrent interview and record review on 5/27/2026 at 9:28 a.m., with LVN 3, Resident 50's physician order for Metoprolol was reviewed. LVN 3 stated the order included a parameter to hold Metoprolol if the pulse rate was less than 60 beats per minute, and she acknowledged she did not check Resident 50's pulse rate. LVN 3 stated if Resident 50's pulse rate was already low, administering Metoprolol could slow it further and cause dizziness or fainting. She stated a low pulse rate meant a heart rate or pulse rate below 60 beats per minute.During an interview on 5/28/2026 at 1:10 p.m., with LVN 3, LVN 3 stated she should have taken the complete set of vital signs, which include body temperature, pulse rate, blood pressure, and respiratory rate (breaths per minute). She stated Metoprolol lowers the pulse rate and decreases the heart's pumping action. LVN 3 stated not assessing Resident 50's pulse rate before administering Metoprolol could cause Resident 50 to become dizzy, tired, faint, and possibly increase her risk of hospitalization.During an interview on 5/28/2026 at 4:59 p.m., with the Director of Nursing (DON), the DON stated the licensed nurse should check the medication instructions, including any hold parameters. The DON stated if Resident 50's pulse rate was not checked before administering Metoprolol, the resident's pulse could drop very low, which could cause dizziness, bradycardia (a heart rate below 60 beats per minute), and syncope (fainting due to a sudden drop in blood pressure or heart rate that temporarily reduces blood flow).During a review of facility's P&P titled, Medication Administration, revised 4/2025, the P&P indicated Medications must be administered in accordance with the physician orders and the licensed nurse should check vital signs if necessary.Cross reference F693

Based on observation, interview and record review, the facility failed to ensure medications were stored properly on one of two medication storage rooms. The facility failed to:1. Ensure Resident 40's discontinued Risperidone (antipsychotic -[a type of medication prescribed to treat mental health problem]) was disposed of and not kept in a box labeled extra medicines in the Medication Storage room.2. Ensure expired hemorrhoidal ointment (medicated jelly or paste used to soothe swollen, inflamed veins in the rectal area) was not stored in the medication storage room.These failures resulted in expired and discontinued medications being available in the medication storage area, increasing the risk of medication administration error and having the potential to unintentional dispensing of expired or discontinued medications to residents.Findings:1. During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder(a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) and depression (serious mood disorder that causes persistent feelings of sadness, emptiness, or a loss of interest in activities once enjoyed).During a review of Resident 40's History and Physical (H&P) dated 12/23/2025, the H&P indicated Resident 40 had the capacity to understand and make decisions.During a review of Resident 40's Physician Order dated 5/7/2026, the Physician Order indicated an order of Risperdal (Risperidone) 2 milligrams (mgs-unit of measurement) give one tablet by mouth two times a day for schizoaffective disorder manifested by physical aggression was discontinued on 5/7/2026 at 12:59 p.m.During a review of Resident 40's Physician Order dated 5/7/2026, the Physician Order indicated Risperdal (Risperidone) one mg. give two tablets by mouth at bedtime for schizoaffective disorder manifested by physical aggression that may lead to altercation, total of 2 mgs. was discontinued on 5/7/2026 at 12:41 p.m.During a concurrent observation and interview on 5/26/2026 at 10:37 a.m. with Licensed Vocational Nurse (LVN) 2 in the medication storage room, clear plastic box labeled extra medicines filled with residents' medicines and an empty clear plastic box labeled discontinued medicines were on a shelf. Observed an unopen medication bubble pack (blister pack or multi-dose card) labeled as Risperidone one milligram (mg.- unit of measurement) one time a day and give two tablets (20 mg) at bedtime for schizoaffective disorder for Resident 40 was inside the clear plastic box labeled extra medicines. LVN 2 stated the dose of Risperidone 1 mg for Resident 40 was discontinued and was increased to 2 mgs LVN 2 stated the bubble pack of Risperidone 1 mg should have been discarded and not kept inside the box labeled extra medicines.During a subsequent interview on 5/26/2026 at 2:48 p.m., with LVN 2, LVN 2 stated licensed nurses placed discontinued residents' medications in the box labeled for discontinued medications in the medication storage area. She stated she had placed Resident 40's Risperidone in the box intended for extra medications and should have placed it in the discontinued medications box so the Registered Nurse (RN) Supervisor could dispose of it. LVN 2 stated Resident 40's Risperidone could have been used for other residents by licensed nurses.During an interview on 5/26/2026 at 2:25 p.m., with the Director of Nursing (DON), the DON stated the facility stored medications received from the general acute care hospital (GACH) and then gave them to family members. The DON stated Risperidone came from the facility's own pharmacy. She stated Resident 40's Risperidone should have been destroyed because the dose had been changed and the medication was no longer being used by the resident. She stated Resident 40's Risperidone dose had been changed on 5/7/2026. The DON stated the discontinued dose of Risperidone should have been placed in the box labeled for discontinued medications. She stated the RN Supervisor and LVN performed destruction of residents' non controlled prescription (medications that requires a doctor's prescription) medications on 5/26/2026. The DON stated there was a risk the discontinued Risperidone from Resident 40 could have been given to another resident.2. During an observation on 5/26/2026 at 10:37 a.m. in the medication storage room with LVN 2, an expired hemorrhoidal ointment with an expiration date of 8/2025 was stored on the shelf.During an interview on 5/26/2026 at 11:09 a.m., with LVN 2, LVN 2 stated the expired hemorrhoidal ointment would not be effective because its potency decreased when used on residents.During an interview on 5/29/2026 at 11:09 a.m., with the DON, the DON stated storing an expired hemorrhoidal ointment created a risk it could be used on residents and would not be effective. The DON stated that using an expired hemorrhoidal ointment on a resident could cause side effects (any effect of medication or treatment that happens in addition to its main and intended goal), such as diarrhea (loose stool) or constipation (hard stool).During a review of facility's policy and procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, revised 1/2025, the P&P indicated discontinued medications not returned to the pharmacy are destroyed in accordance with Medication Destruction policy. The P&P indicated expired medications, and medications discontinued by a prescriber are marked as discontinued or stored in a separate location and later destroyed.

Based on observation, interview and record review, the facility failed to ensure food service staff were competent in reading test strips (a small, treated piece of paper or plastic designed to interact with a sample and reveal the presence, absence, or concentration of specific chemical substances) used for testing chlorine (deep cleaning and sanitizing agent) in the dishwashing machine.This failure had the potential to put residents at risk for food borne illness (any illness resulting from eating contaminated/spoiled foods) due to inability to read and interpret the test strips used for testing the correct range of sanitizer solutions for the dishwashing machine.Findings:During a concurrent observation and interview with Dietary Aide (DA)1, DA 1 demonstrated on how to check the amount of chlorine in the dishwashing machine after the final rinse by dipping a test strip in the water and comparing the test strip to the color chart of the test strip container. DA 1 stated the strip read 50 parts per million (PPM- unit of measurement) and the kitchen staff follows 50-200 PPM for chlorine test.During a review of kitchen's Dish Machine Temperature Log, (document that records the temperature of the dishwasher machine during wash and rinse cycle, and reading obtained from test strip used to check chlorine) dated 5/2026, the Dish Machine Temperature Log indicated the following readings ranging from 58, 59, 60, 68, 69 and 70 PPM on various dates taken during breakfast and lunch.During a concurrent interview and record review on 5/27/2026 at 1:43 p.m. with DA 1, the kitchen's Dish Machine Temperature Log dated 5/2026 was reviewed. DA 1 stated that readings of 58, 59, 60, 68, and 70 PPM were not correct interpretations because the chlorine color chart only indicated a range of 50-100 PPM. She stated she had estimated the readings of 58, 59, 60, and 70 PPM because someone had instructed her to read them that way. DA 1 stated the color chart did not provide readings between 50 and 100 PPM. She stated not reading the log according to the color chart could place residents at risk for food borne illness because chlorine was used to kill germs on dishes and pots.During a concurrent interview and record review on 5/28/2026 at 8:29 a.m. with DA 2, the kitchen's Dish Machine Temperature Log dated 5/2026 was reviewed. DA 2 stated she checked the chlorine level in the dishwashing machine before starting to wash dishes to ensure the proper amount of chlorine would sanitize and clean the dishes. She stated the kitchen did not have a device that provided a specific numerical chlorine reading. DA 2 stated she approximated the chlorine level based on how the test strip became darker or lighter when reading levels such as 70, 69, 60, and 58 ppm. She stated the normal chlorine range in the dish machine was 50-100 ppm. DA 2 stated she had not been reading the chlorine test strips correctly and that residents could get sick if the strips were not interpreted properly.During an interview on 5/28/2026 at 1:23 p.m., with the Dietary Supervisor (DS), DS stated someone had told DA 1 and DA 2 to interpret and read the test strips by estimating the readings. The DS stated reading and interpreting chlorine test strips incorrectly could pose a hazard to residents and could lead to food borne illness.During a review of facility's policy and procedure (P&P) titled, DishWashing, undated, the P&P indicated the chlorine should read 50-100 ppm on dish surface in final rinse.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions to prevent or reduce the risk of contracture (loss of motion of a joint associated with stiffness and joint deformity) development for two of seven sampled residents (Residents 14 and 33) who were identified as having range of motion (ROM, full movement potential of a joint) limitations and were at high risk for contracture development. These deficient practices had the potential to negatively affect the delivery of necessary care and services for Residents 14 and 33. Findings: During a review of Resident 14's Admission Record, the Admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of the foot and ankle joint), chronic ulcer (sore that forms on the skin or the lining of an organ typically caused by damage to the skin or lining and does not heal properly) of the right leg, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/11/2024, the MDS indicated Resident 14 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 14 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 14 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both legs. During a review of Resident 14's Annual Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 12/11/2024, the JMA indicated Resident 14 had moderate ROM limitations (50 to 75% motion) in both shoulders and minimal ROM limitations (75 to 100% motion) in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee joint). During a concurrent observation and interview on 4/8/2025 at 12:40 pm, Resident 14 was lying in bed. Resident 14's right leg was fully straight and wrapped with an elastic bandage from the ankle to the knee. Resident 14's left leg was amputated below the level of the knee. Resident 14 was able to actively bend both knees and the right ankle minimally. During a review of Resident 33's Admission Record, the Admission Record indicated Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including left hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following a cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) and gout (form of arthritis that occurs when uric acid builds up in the blood and causes joint inflammation). During a review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 33 had severely impaired cognition. The MDS indicated Resident 33 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 33 had functional limitations in ROM in both arms and one leg. During a concurrent observation and interview on 4/8/2025 at 9:54 am, Resident 33 was lying in bed with both legs elevated on pillows with the right ankle crossed over the left ankle. Resident 33 stated he used to receive therapy services at the facility but no longer received them and was unsure why. Resident 33 was unable to make a full fist with the left hand, bent the left elbow minimally, and was unable to move the left shoulder. During a concurrent interview and record review on 4/10/2025 at 5:06 pm, the Minimum Data Set Coordinator (MDSC) stated a comprehensive (inclusive, including everything necessary) and individualized care plan was developed for every resident and used as a guide to ensure proper care was provided for each resident. The MDSC reviewed Resident 14's MDS, dated [DATE], and JMA, dated 12/11/2024, and confirmed Resident 14 was identified as having ROM limitations in both legs. The MDSC reviewed Resident 33's MDS, dated [DATE], and confirmed Resident 33 was identified as having ROM limitations in both arms and one leg. The MDSC stated Resident 14 and Resident 33 were at high risk for contracture development since they had existing ROM limitations and had no services in place such as therapy and/or a Restorative Nursing Aide Program (RNA, nursing aide program that helps residents maintain their function and joint mobility). The MDSC reviewed Resident 14 and Resident 33's care plans and confirmed there were no care plans and interventions in place to address Resident 14 and Resident 33's ROM limitations and high risk for contracture development. The MDSC stated the facility had a care plan titled, Risk for Contractures and Resident 14 and Resident 33 should have had that specific care plan but did not. The MDSC stated it was important for care plans to be developed, implemented, and accurate to ensure the appropriate care was provided to each individual resident. The MDSC and Minimum Data Set Assistant (MDSA) stated residents may not receive the treatment and services they required if the appropriate care plans were not developed to address each area of concern. During an interview on 4/11/2025 at 10:17 am, the Director of Nursing (DON) stated comprehensive care plans were developed for every resident and were used as a guide and communication tool for staff to identify the type of care to provide the residents in the facility. The DON stated a care plan with goals and interventions should be developed for all residents who were identified as having ROM limitations upon assessment, screens, and/or by report from the resident or staff. The DON stated it was important for care plans to be developed, implemented, and accurate to ensure the appropriate care was provided to each individual resident. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plan, revised 3/2019, the P&P indicated a comprehensive, resident-centered care plan would be developed for each resident that included measurable objectives and timeframes to meet each resident medical, nursing, and mental and psychosocial needs. The P&P indicated the care plan must include the services that were to be furnished to assist the resident attain or maintain that level of physical, mental, and psychosocial well-being that the resident desired or that was possible.

Based on interview and record review, the facility failed to ensure three out of six sampled residents ( Resident 39, Resident 56 and Resident 57) were provided necessary care and services when: a. Resident 39 was not provided medications for constipation (a condition in which stool becomes hard, dry, difficult to pass and bowel movements become infrequent) when Resident 39 had no bowel movement (BM- movement of feces through the bowel and out the anus) for four days. b. Facility failed to initiate change in condition (a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional condition) assessment for Resident 56 and Resident 57. These failures had the potential to cause delay in provision of necessary care and treatment to Resident 39, Resident 56, and Resident 57. Findings: a. During a review of Resident 39's Admission Record, the Admission Record indicated Resident 39 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including irritable bowel syndrome ( common condition that affects the digestive system causing abdominal pain, bloating, and changes in bowel habits including diarrhea [loose stool] or constipation or both), hematemesis (vomiting of blood)sepsis (a life-threatening blood infection),and muscle weakness. During a review of Resident 39's Minimum Data Set (MDS- a resident assessment tool) dated 3/30/2025, the MDS indicated Resident 39 had intact cognition (ability to think, understand, learn, and remember). Resident 39 required substantial/ maximal assistance (helper does more than half the effort) with transfer to and from a bed to a chair (or wheelchair), bed mobility, lower body dressing, toileting hygiene and personal hygiene. During a review of Resident 39's Activities of Daily Living (ADL- activities such as bathing, dressing and toileting a person performs daily) Task Screen, the ADL Task Screen for bowel elimination indicated Resident 39 had not had a bowel movement from 4/7/2025 to 4/10/2025 (four days). During a review of Resident 39's Care Plan titled Constipation/ Impaction initiated 3/27/2025, the Care Plan goals indicated the resident will have a bowel movement at least every three days and will be free from fecal impaction (hardened stool that's stuck in the rectum or lower colon). The Care Plan interventions included monitoring of bowel movement every shift, observing closely for any signs and symptoms of fecal impaction and administration of milk of magnesia (MOM- medicine that treats constipation), Dulcolax suppository (medicine used to treat constipation) if MOM is not effective for constipation. During a review of Resident 39's Physician Order Summary Report dated 3/27/2025, the Physician Order Summary Report indicated a physician order of MOM 30 milliliter (ml- unit of measurement) by mouth as needed for bowel management daily as needed if no BM for 3 days and bisacodyl (Dulcolax) suppository 10 milligrams (mgs.- unit of measurement) per rectum( through the rectum) as needed for constipation once daily if MOM is ineffective after 8 hours of administration. During a review of Resident 39's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 4/1/2025 to 4/11/2025, the MAR indicated the resident did not receive MOM, or Dulcolax suppository as ordered by the physician to be given for no BM for three days. During an interview on 4/11/2025, at 11:00 a.m. with Certified Nursing Assistant (CNA1), CNA 1 stated she did not know how to check in the resident's electronic chart if the resident had no bowel movement for days but would report to the charge nurse if the resident had experienced stomach pain or passage of hard stool. CNA 1stated it was important to report any irregularities in residents' bowel movement because it could lead to hospitalization . During a concurrent interview and record review on 4/11/2025, at 10:36 a.m. with Licensed Vocational Nurse (LVN 3), reviewed Resident 39's ADL Task Screen for Bowel Elimination. LVN 3 confirmed Resident 39 had no BM on 4/7/2025, 4/8/2025, 4/9/2025, and 4/10/2025. LVN 3 stated the licensed nurses should have called the physician to obtain order or administer the MOM for constipation. LVN 3 stated the certified nursing assistants usually would notify him if the resident had no BM for three days so he could determine if the resident could be given medicine to treat the constipation or notify the physician. During a concurrent interview and record review on 4/11/2025 at 11:18 a.m. with Director of Staff Development (DSD), reviewed Resident 39's ADL Task Screen for Bowel Elimination at 11:18 a.m. the DSD stated the certified nursing assistants should notify the charge nurse if a resident had no BM for three days and should look back on Resident 39's health record on how long the resident had no bm. DSD stated the CNA should have reported resident's having no bowel movement for three days to the charge nurse because constipation could lead to fecal impaction and could increase the risk of hospitalization . During an interview on 4/11/2025, at 2:48 p.m. with the Director of Nursing (DON), the DON stated the CNAs should have notified the charge nurse when Resident 39 had no BM for three days because constipation could lead to bowel obstruction (partial or complete blockage of small or large intestines which is life threatening). During a review of facility's Job Description of a Charge Nurse, the Job Description of a Charge Nurse indicated the licensed nurse will perform treatments, administer medications, and implement other nursing interventions as indicated by the resident care plan or as ordered by the physician. During a review of facility's Job Description of Certified Nursing Assistant, the Job Description of CNA indicated the certified nursing assistant will check and report bowel movements, stool condition and report significant changes in the resident's condition to a LVN or RN as soon as practical. 49145 b. During a review of Resident 56's Admission Record, the Admission Record indicated Resident 56 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marker by tremor, muscular rigidity, and slow, imprecise movement) and dementia (a progressive state of decline in mental abilities). During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 had severe cognitive impairment and was dependent (helper does all the effort) with ADL's. During a review of Resident 57's Admission Record, the Admission Record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and a mood disorder like depression {mood disorder that causes persistent feelings of sadness and loss of interest} and mania {mental state of an extreme high or depressive lows} and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57 cognition was intact and required maximum assistance for Activities of Daily Living ({ADLs}- activities such as bathing, dressing, and toileting a person performs daily). During a concurrent interview and record review on 4/11/2025 at 10:48 a.m., with LVN 3, LVN 3 confirmed there was no COC completed for Resident 56's new lump (areas of abnormally raise skin) on his arm nor was there a COC completed for Resident 57's fall, urinary tract infection (infection of any part of the urinary system), or gastrostomy tube (GT a feeding tube surgically placed through the abdominal wall directly into the stomach) dislodgement (being removed). LVN 3 stated a COC was crucial and should have been done for Resident 56 and Resident 57 to ensure they are aware of what was going on with the resident and to prevent these incidents from occurring again. During an interview on 4/11/2025 at 2:47 a.m., with the DON, the DON stated COC's are important to do because it was used as a communication tool between the nurses. The DON stated if a COC was not completed the staff will be unaware of what was occurring with the resident and the resident may then not receive the proper care and services required. During a review of the facility's policy and procedure (P&P), titled, Change of Condition- SBAR-Assessment, dated 5/2016, the P&P indicated, If there is a significant change in a resident's physical or mental condition, a thorough assessment of the resident's condition must be done by a licensed nurse.

Based on observation, interview, and record review, the facility failed to provide treatments and services to one of seven sampled residents (Resident 14) to improve, prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) by failing to: 1.Ensure Resident 14's Joint Mobility Assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, 12/11/2024, and 3/13/2025, included the assessment of Resident 14's left knee ROM. 2.Ensure Resident 14's Quarterly JMA, dated 6/2024, was completed. These deficient practices had the potential to result in missed opportunities for identifications of ROM declines and cause Resident 14 to have a decline in overall physical functioning and ROM leading to contracture (loss of motion of a joint associated with stiffness and joint deformity) development. Findings: During a review of Resident 14's Admission Record, the Admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of the foot and ankle joint), chronic ulcer (sore that forms on the skin or the lining of an organ typically caused by damage to the skin or lining and does not heal properly) of the right leg, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 14's Quarterly Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, the JMA indicated Resident 14 had moderate ROM limitations (50 to 75% motion) in both shoulders and minimal ROM limitations (75 to 100% motion) in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee joint). The section titled, Problem Summary, indicated Resident 14 had a left AKA, ROM limitations on the right leg, and no ROM changes (compared to previous assessment). During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/11/2024, the MDS indicated Resident 14 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 14 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 14 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both legs. During a review of Resident 14's Annual JMA dated 12/11/2024, the JMA indicated Resident 14 had moderate ROM limitations in both shoulders and minimal ROM limitations in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left AKA. The section titled, Problem Summary, indicated Resident 14 had a left AKA and ROM limitations in both shoulders and the right leg. During a review of Resident 14's Quarterly JMA dated 3/13/2025, the JMA indicated Resident 14 had moderate ROM limitations in both shoulders and minimal ROM limitations in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left AKA. The section titled, Problem Summary, indicated Resident 14 had no ROM changes. During a concurrent observation and interview on 4/8/2025 at 12:40 pm, Resident 14 was lying in bed. Resident 14's right leg was fully straight and wrapped with an elastic bandage from the ankle to the knee. Resident 14's left leg was amputated below the level of the knee. Resident 14 was able to actively bend both knees and the left ankle minimally. During an interview on 4/8/2025 at 2:58 pm, the Director of Rehabilitation (DOR) stated the facility monitored for changes in a resident's joint ROM by JMAs performed by the Rehabilitation Department (Rehab) and nursing along with notification from nursing staff of any observable changes. The DOR stated Rehab performed a detailed JMA which included a ROM assessment of each resident's arms and both legs upon admission, annually, and upon a change of condition. The DOR stated nursing monitored for changes in a resident's ROM through the completion of the MDS and quarterly JMAs. The DOR stated it was important JMAs were completed accurately and timely to ensure staff identified any declines in a resident's ROM and proper treatments and services were provided to the residents. During a concurrent interview and record review on 4/10/2025 at 10:46 am, the Minimum Data Set Coordinator (MDSC) and Minimum Data Set Assistant (MDSA) stated the facility monitored for changes in joint ROM by annual JMAs completed by Rehab, quarterly JMAs completed by nursing, and by staff report. The MDSC stated the MDSC and MDSA performed the quarterly nursing JMAs. The MDSC and MDSA stated the JMA assessment involved a detailed assessment of each resident's joints of both arms and both legs and indicated any ROM limitations and recommendations for services as needed to address any declines. The MDSC and MDSA stated they compared a resident's ROM of each joint to the previous JMA and performed their own physical assessment of the resident's joints to check for any ROM changes. The MDSC and MDSA reviewed Resident 14's JMAs and clinical record. The MDSC and MDSA confirmed the quarterly JMA for 6/2024 was not done. The MDSC stated a quarterly JMA should have been done in 6/2024 since JMAs were supposed to be done quarterly along with the MDS but was not and was unsure why. The MDSC and MDSA confirmed the JMAs, dated 9/10/2024, 12/11/2024, and 3/13/2025, did not include an assessment of Resident 14's left knee. The MDSC and MDSA confirmed Resident 14 had a left BKA, not a left AKA as was incorrectly documented on the JMAs. The MDSC and MDSA stated Resident 19's left knee ROM should have been assessed but was not and was unsure why it was overlooked for multiple JMAs. The MDSC stated it may have been mistakenly overlooked since the diagrams of the left knee and left ankle assessments were crossed out and incorrectly indicated Resident 14 had a left AKA. The MDSC stated missed JMAs, and lack of ROM assessment of every joint could potentially result in missed opportunities to identify ROM declines, ROM decline, and contracture development. During an interview on 4/11/2025 at 10:17 am, the Director of Nursing (DON) stated the facility monitored for changes in joint ROM by annual JMAs completed by Rehab, quarterly JMAs completed by nursing, and by staff report. The DON stated it was important JMAs assessed the ROM of all resident's joints and were done routinely and timely as required to ensure the facility promptly identified any ROM changes and provided the appropriate services to address any declines and prevent contractures. During a review of the facility's Policy and Procedure (P&P) titled, Limitations in ROM and Mobility and Referrals for Therapy, revised 10/2017, the P&P indicated a resident with limited ROM would be assessed and provided appropriate treatment and services to increase ROM and/or prevent a further decrease in ROM. The P&P indicated the appropriate therapy department would screen residents upon admission and quarterly. The P&P indicated a resident's comprehensive assessment should include and measure a resident's current extent of movement and the identification of any limitations and opportunity for improvement. CROSS REFERENCE TO F726 amd F842.

Based on observation, interview, and record review, the facility failed to ensure the facility's Minimum Data Set Coordinator (MDSC) and Minimum Data Set Assistant (MDSA) were competent in providing quarterly Joint Mobility Assessments (JMA, brief assessment of a resident's range of motion in both arms and both legs) affecting one of seven sampled residents (Resident 14) with limited range of motion (ROM, full movement potential of a joint). This deficient practice resulted in multiple missed assessments of Resident 14's left knee, failure to identify inaccurate documentation and assessment of Resident 14's left leg, missed opportunities to identify and report ROM decline, and had the potential to lead to ROM decline and contracture (loss of motion of a joint associated with stiffness and joint deformity) development. Findings: During a review of Resident 14's Admission Record, the Admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of the foot and ankle joint), chronic ulcer (sore that forms on the skin or the lining of an organ typically caused by damage to the skin or lining and does not heal properly) of the right leg, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 14's Quarterly Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, the JMA indicated Resident 14 had moderate ROM limitations (50 to 75% motion) in both shoulders and minimal ROM limitations (75 to 100% motion) in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee joint). The section titled, Problem Summary, indicated Resident 14 had a left AKA, ROM limitations on the right leg, and no ROM changes (compared to previous assessment). During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/11/2024, the MDS indicated Resident 14 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 14 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 14 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both legs. During a review of Resident 14's Quarterly JMA dated 3/13/2025, the JMA indicated Resident 14 had moderate ROM limitations in both shoulders and minimal ROM limitations in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left AKA. The section titled, Problem Summary, indicated Resident 14 had no ROM changes. During a concurrent observation and interview on 4/8/2025 at 12:40 pm, Resident 14 was lying in bed. Resident 14's right leg was fully straight and wrapped with an elastic bandage from the ankle to the knee. Resident 14's left leg was amputated below the level of the knee. Resident 14 was able to actively bend both knees and the right ankle minimally. During an interview on 4/10/2025 at 10:46 am, the Minimum Data Set Coordinator (MDSC) and Minimum Data Set Assistant (MDSA) stated the facility monitored for changes in joint ROM by annual JMAs completed by Rehab, quarterly JMAs completed by nursing, and by staff report. The MDSC stated the MDSC and MDSA performed the quarterly nursing JMAs. The MDSC and MDSA stated the JMA assessment involved a detailed assessment of each resident's joints of both arms and both legs and indicated any ROM limitations and recommendations for services as needed to address any declines. The MDSC and MDSA stated they never received competencies or formal instruction on how to administer JMAs. During a review of the employee files for the Minimum Data Set Coordinator (MDSC) and Minimum Data Set Assistant (MDSA), the employee files did not include a performance competency for ROM or for performing the JMA. During an interview on 4/11/2025 at 8:50 am, the Director of Rehabilitation (DOR) stated changes in joint ROM were monitored by JMAs performed by the Rehabilitation Department (Rehab) and nursing along with notification from nursing staff of any observable changes. The DOR stated Rehab performed a detailed JMA which included a ROM assessment of each resident's arms and both legs upon admission, annually, and upon a change of condition. The DOR stated nursing monitored for changes in a resident's ROM through the completion of the quarterly JMAs and MDS. The DOR stated it was important staff were competent to perform JMAs to ensure the assessments were accurate and any changes or declines in ROM could be identified and reported. During an interview on 4/11/2025 at 10:17 am, the Director of Nursing (DON) stated the MDSC and MDSA were responsible for conducting the quarterly JMAs for the residents in the facility to monitor for changes in joint ROM. The DON stated there were no competencies and/or formal training given to the MDSC and MDSA on how to conduct the quarterly JMAs. The DON stated ROM was a part of nursing skills, but the MDSC and MDSA did not perform ROM daily as a part of nursing practice as their job duties did not require them to do so. The DON stated nursing generally assessed ROM differently from Rehab since nursing looked at ROM in terms of general activities of daily living (ADL, basic activities such as eating, dressing, toileting) function and Rehab assessed every joint individually and in detail. The DON stated the MDSC and MDSA should have had competencies and formal instruction on how to accurately perform JMAs but did not. The DON stated it was important staff were competent to ensure assessments were accurate and any declines in ROM were appropriately identified and reported. During a review of the facility's Policy and Procedure (P&P) titled, Staff Competencies, revised 1/2017, the P&P indicated each employee would receive periodic performance reviews to ensure staff competencies. The P&P indicated performance evaluations were to ensure staff had the appropriate competencies and skills to assure resident safety and to provide care which included assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. The P&P indicated all performance evaluations of staff would be completed during their orientation and annually. CROSS REFERENCE TO F688 and F842

Based on observation, interview and record review, the facility failed to: 1. Ensure open bag of frozen sausages was stored properly in the freezer. 2. Ensure freezer temperature was maintained at 0-degree Fahrenheit (F-unit of measurement) while frozen vegetables were stored. 3. Ensure gloves were used by kitchen staff when serving cooked food during tray line. 4. Ensure proper donning of glove and handwashing was observed when the [NAME] switched tasks from tray line to prepare food in the microwave. These failures had the potential to put residents at risk for food-borne illnesses ( any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites) and affect the quality of food. Findings: 1.During an initial kitchen observation and interview on 4/8/2025, at 8:01 a.m. with Dietary Manager (DM), an open bag of frozen sausages was inside an open box. Observed the frozen sausages had ice crystals on the surfaces.DM stated the open bag of frozen sausages should be stored in a sealed plastic bag. During an interview on 4/9/2025, at 1:30 p.m. with Registered Dietician (RD), RD stated open bag of frozen sausages not properly sealed can affect the quality of food. RD stated the kitchen staff should have transferred the frozen sausages in zip lock bag or tied the bag to preserve the moisture because the frozen food could dry out and can be exposed to bacteria. During a review of facility's policy and procedure (P&P) titled Procedure for Freezer Storage undated, the P&P indicated to store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn (is a result of moisture loss from frozen food due improper packaging or storage). 2. During an initial kitchen tour observation on 4/8/2025, at 8:01 a.m. with Dietary Manager (DM), DM verified the internal thermometer of the reach in freezer for frozen vegetables was reading at 10 degrees F and the reach in freezer for meat products was reading at 24 degrees F. DM stated the kitchen personnel just removed some food items from the freezers that's why the temperatures are not 0-degree F on both freezers. During an interview on 4/8/2025, 2:15 p.m. with an unnamed technician (UT) in the kitchen, the UT stated that they were called to fix the freezers around noontime today because the temperatures were high. Observed the freezer's temperature was 10 degrees F for frozen vegetables and freezer for frozen meat products was at18 degrees F. During an observation on 4/9/2025, at 12:05 p.m. with DM, reach in freezer temperature for frozen vegetables was 10 degrees F. During a review of facility's recipe of stir-fry vegetables, the recipe indicated ingredients included assorted vegetables such as cauliflower, broccoli, squash, onions, zucchini and carrots and can use frozen or fresh. During an interview on 4/9/2025, at 12:10 p.m. and subsequent interview on 4/9/2025, at 1:17 p.m. with DM, DM stated he was aware the temperature of the freezer for the frozen vegetables was not maintained at 0-degree F or below since yesterday (4/8/2025). DM stated he was monitoring the temperature of the freezer and was waiting for the temperature to go down to 0 degree but did not happen yesterday. DM stated the Registered Dietician (RD),and the Administrator (ADM) were aware to reach in freezer for vegetables was not maintaining its proper temperature. DM stated they threw away some of the frozen food items at around 9:00 a.m. today but the kitchen used the vegetables from the non-working freezer for the stir fry vegetables that was served for lunch. DM stated residents could be at risk for unsafe food because of the vegetables used for the stir fry vegetables were not properly stored in the freezer. During a review of facility's Freezer Temperature Log for vegetables, the A.M. Temperature log of the freezer indicated a temperature of 10 degrees F on 4/9/2025. During an interview on 4/9/2025, at 12:51 p.m. with Dietary Aide (DA 1), DA 1 stated the DM told him to throw away the vegetables , and some breads from the freezer around 9:00 a.m. today and at that time the temperature of the freezer was 10 degrees F. DA 1 stated the vegetables used for the stir fry for lunch came from the freezer that was reading 10 degrees F. DA 1 stated the proper temperature to store frozen vegetables is 0 degree F to ensure freshness of food and to prevent bacterial growth that could place resident at risk for food borne illness. During an interview on 4/9/2025, at 12:50 p.m. with [NAME] (CK1), CK 1 stated the temperature of the freezer for the vegetables at around 4:00 a.m. was 10 degrees F. CK 1 stated that he pulled out broccoli, carrots, zucchini and cauliflower from the non-working freezer to prepare for the day's meal. CK 1 stated all the vegetables that was served for lunch was from the non-working freezer. CK 1 stated residents could get sick from consuming the food if the vegetables were not stored properly in the freezer. During an interview on 4/9/2025, at 1:46 p.m. with RD, RD stated the temperature log of the freezer might not be reliable because it all indicated the temperatures are 0-degree F for several days and the situation could be going on for days. RD stated they should have discarded everything in the freezer because the facility does not know how long it had not been working. RD stated she was aware not all the food items stored in the non-working freezer was thrown away and was served for lunch today. During an interview on 4/9/2025, at 2:24 p.m. with Maintenance Supervisor, MS stated he was made aware yesterday by the DM about the non-working freezer. MS stated they started emptying the food items in the freezer this morning and placed some of the food items in the other freezer. He said he would call the technician if the freezer needed repair. During a telephone interview on 4/9/2025, at 2:14 p.m. with Administrator (ADM), ADM stated when the freezer's temperature was over zero despite maintenance, the kitchen personnel should have discarded the food items stored in the freezer. ADM stated residents could get food poisoning from consuming the food that came from the freezer. 3. During a tray line observation on 4/8/2025, at 11:40 a.m. in the kitchen, cooked food items in trays were on the steam table as the [NAME] (CK1) took temperatures of each cooked food items then proceeded to start preparing a plate for each resident. Observed CK 1 and another kitchen staff were scooping cooked food items from the trays to a plate without wearing gloves as another kitchen personnel called out the diet of a resident. During an interview on 4/9/2025, at 12:10 p.m. with CK 1, CK 1 stated kitchen personnel do not wear gloves when handling and serving cooked food during tray line. During an interview on 4/9/2025, at 1:30 p.m. with RD, RD stated the kitchen staff should wear gloves when handling ready to serve and cooked food to prevent the risk of cross contamination (unintentional transfer of harmful bacteria from one surface or object to another). 4.During an observation on 4/9/2025, at 12:00 p.m. with CK 1, CK 1 wore a glove on the right hand without practicing hand washing first and brought a plate in the storage area to use the microwave. Observed CK 1 still wearing the glove on his right and continued serving in the lunch tray line without washing hands and removal of glove. During an interview on 4/9/2025, at 12:10 p.m. with CK 1, CK 1 stated hand washing should be practiced every time he touched another food item and admitted he committed in not practicing hand washing when he switched tasks. CK 1 stated he should have removed his glove and washed hands before serving food in the tray line to prevent cross contamination which could cause food-borne illnesses to the residents. During an interview on 4/9/2025, at 1:46 p.m. with RD, RD stated the cook should have removed his glove and washed his hands in between tasks then put on new pair of gloves before returning to serve food in the tray line. RD stated handwashing should be performed because of the risk of cross contamination between different objects like the microwave. During an interview on 4/11/2025, at 2:48 p.m. with Director of Nursing (DON), DON stated not practicing handwashing in the kitchen could spread infection among the residents and staff. DON stated the facility had a policy to maintain and keep the temperature of the freezers zero or below zero to ensure the food that will be consumed by the residents are safe to eat. During a review of facility's P&P titled Food Handling undated, the P&P indicated the food will be prepared and served in a safe and sanitary manner. The P&P indicated Food and Nutrition Services personnel should never use bare hand contact with any foods , ready to eat or otherwise including food item preparation. During a review of Food Code 2022 U.S. Food and Drug Administration ( a model document published by U.S. Food and Drug Administration that provides guidance for regulating food safety in a retail setting such as restaurants, groceries and institutions like Nursing Homes), the Food Code 2022 U.S. FDA indicated food employees shall clean their hands immediately before engaging in FOOD preparation including before donning gloves to initiate a task that involves working with food and after engaging in other activities that contaminate the hands.

Based on observation, interview, and record review, the facility failed to ensure two of seven sampled resident's (Residents 14 and 19) medical records were accurately documented when: a.Resident 14's Joint Mobility Assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, 12/11/2024, and 3/13/2025, inaccurately indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee) instead of the correct diagnosis of a left below knee amputation (BKA, surgical removal of a limb below the level of the knee involving the removal of the foot and ankle joint). b.Resident 19's Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) physician's order inaccurately indicated for RNA to use a two-wheeled walker (mobility aid with wheels on the front two legs of the device) for walking exercises with Resident 19 instead of a platform walker (PFW, a type of walking assistive device with forearm supports to provide extra support during walking) as recommended by Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function). These deficient practices had the potential to negatively impact the provision of necessary care and services, cause miscommunication among staff, cause a decline in function and safety concerns due to inappropriate use of assistive devices for mobility, and result in missed ROM assessments and opportunities to detect declines in joint range of motion (ROM, full movement potential of a joint). Findings: a.During a review of Resident 14's Admission Record, the Admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of the foot and ankle joint), chronic ulcer (sore that forms on the skin or the lining of an organ typically caused by damage to the skin or lining and does not heal properly) of the right leg, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 14's Quarterly Joint Mobility Assessment (JMA, a brief assessment of a resident's ROM in both arms and both legs), dated 9/10/2024, the JMA indicated Resident 14 had moderate ROM limitations (50 to 75% motion) in both shoulders and minimal ROM limitations (75 to 100% motion) in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left above knee amputation (AKA, surgical removal of a limb above the level of the knee joint). The section titled, Problem Summary, indicated Resident 14 had a left AKA, ROM limitations on the right leg, and no ROM changes (compared to previous assessment). During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/11/2024, the MDS indicated Resident 14 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 14 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 14 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both legs. During a review of Resident 14's Annual JMA dated 12/11/2024, the JMA indicated Resident 14 had moderate ROM limitations in both shoulders and minimal ROM limitations in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left AKA. The section titled, Problem Summary, indicated Resident 14 had a left AKA and ROM limitations in both shoulders and the right leg. During a review of Resident 14's Quarterly JMA dated 3/13/2025, the JMA indicated Resident 14 had moderate ROM limitations in both shoulders and minimal ROM limitations in both hips and the right ankle. The JMA diagrams of the left knee assessment and left ankle assessment were crossed out and indicated Resident 14 had a left AKA. The section titled, Problem Summary, indicated Resident 14 had no ROM changes. During a concurrent observation and interview on 4/8/2025 at 12:40 pm, Resident 14 was lying in bed. Resident 14's right leg was fully straight and wrapped with an elastic bandage from the ankle to the knee. Resident 14's left leg was amputated below the level of the knee. Resident 14 was able to actively bend both knees and the right ankle minimally. During a concurrent interview and record review on 4/10/2025 at 10:46 am, the Minimum Data Set Coordinator (MDSC) and Minimum Data Set Assistant (MDSA) stated the facility monitored for changes in joint ROM by annual JMAs completed by Rehab, quarterly JMAs completed by nursing, and by staff report. The MDSC stated the MDSC and MDSA performed the quarterly nursing JMAs. The MDSC and MDSA stated the JMA assessment involved a detailed assessment of each resident's joints of both arms and both legs and indicated any ROM limitations and recommendations for services as needed to address any declines. The MDSC and MDSA reviewed Resident 14's JMAs and clinical record. The MDSC and MDSA confirmed the JMAs, dated 9/10/2024, 12/11/2024, and 3/13/2025, indicated Resident 14 had a left AKA and did not include assessments of Resident 14's left knee. The MDSC and MDSA confirmed Resident 14 had a left BKA, not a left AKA as was incorrectly documented on the JMAs. The MDSC and MDSA stated Resident 19's left knee ROM should have been assessed but was not and was unsure why it was overlooked for multiple JMAs. The MDSC stated it may have been mistakenly overlooked since the diagrams of the left knee and left ankle assessments were crossed out and incorrectly indicated Resident 14 had a left AKA. The MDSC stated inaccurate documentation could potentially result in missed opportunities to identify ROM declines, ROM decline, and inappropriate delivery of necessary care and services. During a concurrent observation, interview, and record review on 4/10/2025 at 2:24 pm, Physical Therapist 1 (PT 1) assessed Resident 14's left leg. PT 1 asked Resident 14 to bend the left knee. Resident 14 bent the left knee minimally. PT 1 reviewed Resident 14's JMAs, dated 9/10/2024, 12/11/2024, and 3/13/2025, and confirmed the JMAs incorrectly indicated Resident 14 had a left AKA, instead of the correct diagnosis of a left BKA. PT 1 stated it was important JMAs were completed accurately as incorrect documentation could affect future assessments and services provided, lead to missed opportunities to identify declines, and result in ROM decline. b. During a review of Resident 19's Admission Record, the Admission Record indicated Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a right hemiplegia (weakness to one side of the body) and difficulty walking. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 was cognitively intact. The MDS indicated Resident 19 required substantial/maximal assistance with eating, partial/moderate assistance with walking, and was dependent for hygiene, bathing, toileting, dressing, and rolling to both sides. The MDS indicated Resident 19 had functional limitations in ROM in both arms. During a review of Resident 19's RNA/Certified Nursing Assistant (CNA) Referral Form, dated 3/25/2025, the RNA/CNA Referral Form indicated for RNA to assist Resident 19 with walking exercises using a platform walker, every day, five times a week. During a review of Resident 19's Physician Order Summary Report, the Physician Order Summary Report indicated a order, dated 3/25/2025, for RNA to assist Resident 19 with walking exercises using a two-wheeled walker, every day, five times a week. During an observation on 4/8/2025 at 11:04 am, observed Resident 19 was seated in a power wheelchair in the hallway. Resident 19's right hand was positioned in a fist and was unable to fully open the hand. The fingers of Resident 19's left hand was positioned with the thumb in hyperextension (the extension of a body part beyond it's normal limits) and the middle finger, ring finger, and small fingers bent into a fist. During an observation of Resident 19's RNA session on 4/10/2025 at 8:45 am, in the hallway, Resident 19 was seated in a power wheelchair with a platform walker positioned in front of him. Resident 19 leaned forward, grabbed the handlebars of the platform walker, put his upper body weight onto the platform walker with both forearms, and stood up with Restorative Nursing Aide 1 (RNA 1) and Restorative Nursing Aide 2 (RNA 2)'s assistance. Resident 19 walked two laps around the facility with RNA 1 and RNA 2's assistance, sat down in power wheelchair, and remained seated in the hallway at the end of the session. During a concurrent interview and record review on 4/10/25 at 9:40 am, RNA 1 and RNA 2 reviewed Resident 19's RNA orders and RNA/CNA Referral Form. RNA 1 confirmed Resident 19's RNA orders and RNA/CNA Referral Form instructions did not match. RNA 1 stated PT instructed the RNAs to use a platform walker when performing walking exercises with Resident 19 during RNA training. RNA 1 and RNA 2 stated Resident 19 would be unable to grasp the handles of a two-wheeled walker because the ROM of both of his hands were very limited. RNA 1 and RNA 2 stated the RNA order was written incorrectly. During a concurrent interview and record review on 4/10/2025 at 10:01 am, the Director of Rehabilitation (DOR) stated a licensed therapist determined the type of exercises and assistive devices a resident used for RNA services and established an RNA program for the RNAs to carry out. The DOR stated the licensed therapist wrote the details of the RNA program on the RNA/CNA Referral Form and entered the RNA order into the electronic charting system. The DOR reviewed Resident 19's RNA order, dated 3/25/2025, and the RNA/CNA Referral Form, dated 3/25/2025, and confirmed Resident 19's RNA order was written incorrectly. The DOR stated the PT wrote for RNA to use a platform walker with Resident 19 for walking exercises on the RNA/CNA Referral Form and incorrectly wrote for RNA to use a two-wheeled walker for walking exercises on the RNA order. The DOR stated if documentation was inaccurate, it could lead to RNAs providing the incorrect type of service, using an incorrect or unsafe device, and could result in the resident not being able to safely perform the activity or exercises prescribed. During an interview on 4/11/2025 at 10:17 am, the Director of Nursing (DON) stated it was important documentation was accurate to ensure the staff had a correct assessment of a resident's status and provided the appropriate care and services. The DON stated if documentation was inaccurate, it could lead to inappropriate delivery of care and services, missed opportunities to identify declines or problem areas, safety concerns, and the development and implementation of an inaccurate care plan. During a review of the facility's Policy and Procedure (P&P) titled, Documentation Principles, revised 2/2018, the P&P indicated resident's clinical records shall be current and kept in detail consistent with good medical and professional practice based on the care provided for each resident. The P&P indicated entries must be accurate, timely, objective, specific, concise, legible, clear and descriptive. CROSS REFERENCE TO F688 and F726

Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices by failing to: a.Change and label tube feeding water bag for Resident 28. b.Perform hand hygiene during wound care dressing change for Resident 56. c.Ensure Physical Therapist 1 (PT 1) wore an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) while assessing Resident 14's left leg which required direct contact with Resident 14 who was on Enhanced Barrier Precautions (EBP, infection control intervention using gown and gloves during high contact resident care activities designed reduce the transmission of multi-drug-resistant organisms). d. Licensed Vocational Nurse (LVN) 5 failed to sanitize blood pressure cuff in between residents. e. Ensure sanitary handling and transport of soiled linens. These deficient practice had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection. Findings: a. During a review of Resident 28's Admission Record, the Admission Record indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including hypertension ([HTN]- high blood pressure) and hemiplegia (weakness on one side of the body). During a review of Resident 28's Minimum Data Set ([MDS]- a resident assessment tool) dated 3/18/2025, the MDS indicated Resident 28 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 28 required maximal assistant with Activities of Daily Living ([ADL]- activities such as bathing, dressing, and toileting a person performs daily). During a concurrent observation and interview on 4/8/2025 at 10:42 a.m., with Licensed Vocational Nurse (LVN) 1 in Resident 28's room, LVN 1 stated Resident 28's tube feeding water bag was not labeled of date change and was unable to determine when it was changed. LVN 1 stated it was important to change and label the tube feeding water bags daily for infection control. During an interview on 4/11/2025 at 1:55 p.m., with the Infection Prevention Nurse (IPN), the IPN stated tube feeding water bags should be changed and labeled with date change daily to prevent the growth of bacteria which can cause the resident to develop stomach issues. During an interview on 4/11/2025 at 2:47 p.m., with the Director of Nursing (DON), the DON stated tube feeding water bags should be changed and labeled with changed date every 24 hours to prevent spoilage, stomach issues, and infection. b. During a review of Resident 56's Admission Record, the Admission Record indicated Resident 56 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marker by tremor, muscular rigidity, and slow, imprecise movement) and dementia (a progressive state of decline in mental abilities). During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 had severe cognitive impairment and was dependent (helper does all the effort) with ADL's. During an observation on 4/10/2025 at 11:11 a.m., in Resident 56's room, LVN 1 was observed changing a wound dressing without performing hand hygiene after removing the soiled wound dressing and cleaning the site and before applying the clean wound dressing. During an interview on 4/10/2025 at 11:23 a.m., with LVN 1, LVN 1 stated he did not perform hand hygiene after handling the soiled dressing and before applying the clean dressing to Resident 56's wound. LVN 1 stated he should have performed hand hygiene for infection control and failure to perform hand hygiene had the potential for spread of infection. During a interview on 4/11/2025 at 2:01 p.m., with the IPN, the IPN stated hand hygiene should be performed in between removing the soiled dressing and applying the clean dressing when doing a wound care dressing change. LVN 1 stated hand hygiene was important to do to prevent infection and contamination of the wound which could potentially lead to an infection of the wound. During a continued interview on 4/11/2025 at 2:47 p.m., with the DON, the DON stated hand hygiene should be performed before, after removing the dirty dressing, and before applying the clean dressing to prevent contamination and infection. 45382 c. During a review of Resident 14's Admission Record, the Admission Record indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a left below knee amputation (BKA, surgical removal of a limb [extremities] below the level of the knee involving the removal of the foot and ankle joint), chronic ulcer (sore that forms on the skin or the lining of an organ typically caused by damage to the skin or lining and does not heal properly) of the right leg, and polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain). During a review of Resident 14's Minimum Data Set (MDS- resident assessment tool), dated 12/11/2024, the MDS indicated Resident 14 was cognitively (ability to think, understand, learn, and remember) intact. The MDS indicated Resident 14 required set-up or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial/moderate assistance with upper body dressing, personal hygiene, and rolling to both sides, and substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 14 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both legs. During a concurrent observation and interview on 4/10/2025 at 2:24 pm, with PT 1 in Resident 14's room, observed Resident 14 lying in bed. PT 1 entered Resident 14's room, put on gloves, and did not put on an isolation gown. PT 1 walked to Resident 14's bed, picked up Resident 14's left leg, asked Resident 14 to bend his left knee, and put Resident 14's leg back onto the bed. After completing assessment of Resident 14's left leg, PT 1 removed both gloves, exited the room, and used alcohol-based hand sanitizer. PT 1 stated he did not wear an isolation gown while providing direct care to Resident 14. PT 1 stated he should have worn an isolation gown while assessing Resident 14's left leg because he had direct contact with Resident 14 who was on EBP precautions. PT 1 stated it was important to follow infection control protocols to prevent the spread of infection. During an interview on 4/10/2025 at 3:04 pm, the IPN stated the purpose of EBP was to minimize the risk of infection for residents with invasive devices (medical tools that enter the body either through a break in the skin or an opening in the body) such as foley catheters (thin, flexible rube inserted into the bladder to drain urine), gastronomy tubes (a tube placed directly into the stomach for long-term feeding), and open, non-healing wounds. The IPN stated all staff providing direct patient care for residents on EBP precautions must wear the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause serious injuries and illnesses) which included an isolation gown and gloves to prevent the spread of infection. During an interview on 4/11/2025 at 10:17 am, the Director of Nursing (DON) stated it was important all facility staff followed the proper infection control protocols to prevent the spread of infection. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Standard Precautions (ESP), revised 1/2024, the P&P indicated the purpose of ESP was to prevent Multi-Drug-Resistant Organisms (MRDO, bacteria resistant to many antibiotics) in skilled nursing facilities. The P&P indicated ESP was an approach of targeted gown and glove use during high contact resident care activities. The P&P indicated gowns and gloves were to be worn while performing high contact tasks associated with the greatest risk for MRDO contamination of hands, clothes, and the environment, which included any care activity where close contact with the resident was expected to occur. The P/P indicated, Change gloves, as necessary during the care of a resident to prevent cross contamination from one body site to another (when moving from a dirty site to a clean one). 39028 d. During an observation on 04/10/2025 at 4:57 p.m., during medication pass, observed LVN 5 brought a rolling blood pressure machine to resident room. LVN 5 failed to sanitize the BP cuff before and between resident use. During a concurrent observation and interview on 4/10/25 at 5:10 p.m , with LVN 5, LVN 5 stated she should sanitize the blood pressure cuff before and between resident use for infection control. During an interview on 4/11/2025 at 1:28 p.m., with the IPN, IPN stated the staff are required to disinfect equipment's such as the BP cuff before and after use to prevent cross contamination. During a review of the facility's policy and procedure (P&P) titled, Infection Control-DME dated 10/2011, the P&P indicated It is the policy of the facility to properly and routinely sanitize durable medical equipment (DME). When available, the manufacturer's instructions will be followed for cleaning non-critical care items. In the absence of manufacturer's cleaning instructions, the following will be used to clean and disinfect these items between resident use: 1.Bleach wipes or germicidal wipes will be used for DME after each use. 2.If any equipment has been potentially exposed to C-difficile (stool infection), a 1:10 bleach and water solution will be used to clean and sanitize. This solution should be allowed to remain on the item for 5 minutes. 3.It is the responsibility of the nursing personnel to properly and routinely sanitize DME after each use. 45269 5.During a concurrent observation and interview on 4/10/2025, at 9:03 a.m. with Maintenance Supervisor (MS), observed one plastic bag containing clean linen was torn and was on top of an uncovered laundry bin intended for clean linens and clothes located outside the facility. Observed two bags of dirty linens were on the floor next to the large blue bins and cart where the clean linens were located. MS stated the staff should not leave the soiled bags on the floor next to clean laundry bins and laundry cart to prevent spread of infection. MS stated they used an outside company to do the laundry of the residents, and the clean laundry was placed on the large blue laundry bins outside the facility. MS stated the staff would empty the soiled linens in the storage area outside the facility across the clean area where the bags of clean linens are located. During an interview on 4/10/2025, at 10:10 a.m. with CNA 2, CNA 2 stated the staff should not leave bags of soiled linens near the clean area where the blue clean laundry bins were located because of the risk of cross contamination and infection control. During an interview on 4/11/2025, at 11:39 a.m. with the Director of Staff Development (DSD), the DSD stated the laundry bins for the soiled linens were in the left side and on the right side was the blue laundry bins containing the clean bags of linens outside the facility. The DSD stated the laundry blue bins store the clean linens and should be covered to prevent cross contamination that could lead to spread of infection. The DSD stated the two bags of soiled linens should not be placed or laid on the floor next to the clean laundry bin because they were soiled and can cause spread of infection. The staff should have placed the bags of soiled linen directly to the laundry bins intended for soiled linens. During an interview on 4/11/2025, at 1:56 p.m. with the IPN, the IPN stated failed to observed and practiced proper handling and transporting of soiled linens could make residents sick in the facility and had the potential to cause cross contamination. During an interview on 4/11/2025, at 2:48 p.m. with the DON, the DON stated that clean linens, and dirty linens should be separated when handling and transporting linens to prevent spread of infection among the residents and staff members. During a review of facility's policy and procedure (P&P) titled Infection Control-Laundry Services, revised 7/ 2019, the P&P indicated It is the responsibility of the facility to ensure all laundry was handled, stored, processed and transported in a safe and sanitary manner, regardless of where the laundry is processed. The P& P indicated Dirty linen should be clearly separated from areas where clean linen is handled, and workflow should prevent cross contamination.

Based on observation, interview and record review, the facility failed to ensure reach in freezer for frozen vegetables and freezer for frozen meat products in the kitchen were maintained and kept in a safe and operating condition by failing to: 1. Follow their policy and procedure titled Freezer Storage regarding maintaining a temperature of 0-degree Fahrenheit (F- unit of measurement) or lower . This failure had the potential to expose residents at risk for food-borne illness (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites). Findings: During an initial kitchen tour observation on 4/8/2025, at 8:01 a.m. with Dietary Manager (DM), DM verified the internal thermometer of the reach in freezer for frozen vegetables was reading at 10 degrees Fahrenheit (F- unit of measurement) and the reach in freezer for meat products was reading at 24 degrees F. DM stated the kitchen personnel just removed some food items from the freezers that was why the temperatures are not 0-degree F on both freezers. During an interview on 4/8/2025, 2:15 p.m. with an unnamed technician (UT), the UT stated that they were called to fix the freezers around noontime today because the temperatures were high. Observed the freezer's temperature was 10 degrees F for frozen vegetables and freezer for frozen meat products was 18 degrees F. During an observation on 4/9/2025, at 12:05 p.m. with DM, reach in freezer temperature for frozen vegetables was 10 degrees F. Observed the freezer was empty. During an interview on 4/9/2025, at 12:10 p.m. and subsequent interview on 4/9/2025, at 1:17 p.m. with DM, DM stated he was aware the temperature of the freezer for the frozen vegetables was not maintained at 0-degree F or below since yesterday. DM stated he was monitoring the temperature of the freezer and was waiting for the temperature to go down to 0 degree but did not happen. DM stated the Registered Dietician (RD),and the Administrator (ADM) were aware the reach in freezer for vegetables was not maintaining its proper temperature. DM stated they threw away some of the frozen food items at around 9:00 a.m. today but the kitchen used the vegetables from the non-working freezer for the stir fry vegetables for lunch. DM stated residents could be at risk for unsafe food because of the vegetables used for the stir fry vegetables were not properly stored in the freezer. During a review of facility's Freezer Temperature Log for vegetables, the A.M. Temperature log of the freezer indicated a temperature of 10 degrees F on 4/9/2025. During an interview on 4/9/2025, at 12:51 p.m. with Dietary Aide (DA 1), DA 1 stated the DM told him to throw away the vegetables , and some breads from the freezer around 9:00 a.m. today and at that time the temperature of the freezer was 10 degrees F. DA 1 stated the vegetables used for the stir fry for lunch came from the freezer that was reading 10 degrees F. DA 1 stated the proper temperature to store frozen vegetables is 0 degree F to ensure freshness of food and to prevent bacterial growth that could place resident at risk for food borne illness. During an interview on 4/9/2025, at 12:50 p.m. with [NAME] (CK1), CK 1 stated the temperature of the freezer for the vegetables at around 4:00 a.m. was 10 degrees F. CK 1 stated that he pulled out broccoli, carrots, zucchini and cauliflower from the non-working freezer to prepare for the day's meal. CK 1 stated all the vegetables that was served for lunch was from the non-working freezer. CK 1 stated residents could get sick from consuming the food if the vegetables were not stored properly in the freezer. During an interview on 4/9/2025, at 1:46 p.m. with RD, RD stated the temperature log of the freezer might not be reliable because it all indicated the temperatures are 0-degree F and the situation that could be going on for days. RD stated they should have discarded everything in the freezer because the facility does not know how long it had not been working. RD stated she is aware not all the food items stored in the non-working freezer was thrown away and was served for lunch today. During an interview on 4/9/2025, at 2:24 p.m. with Maintenance Supervisor, MS stated he was made aware yesterday by the DM about the non-working freezer. MS stated they started emptying the food items in the freezer this morning and placed some of the food items in the other freezer. He said he would call the technician if the freezer needs repair and he does not do maintenance of the freezers. During a telephone interview on 4/9/2025, at 2:14 p.m. with Administrator (ADM), ADM stated when the freezer's temperature was over zero despite maintenance, the kitchen personnel should have discarded the food items stored in the freezer. ADM stated residents could get food poisoning from consuming the food that came from the freezer. During a review of facility's policy and procedure (P&P) titled Preventive Maintenance Policy dated 07/2023, the P &P indicated the facility considers a Preventative Maintenance Program for all physical plant systems and equipment in all departments to eliminate and prevent unsafe environments. During a review of facility's P&P titled Freezer Storage, the P&P indicated the freezer should be maintained at a temperature of 0-degree F and freezer should be recorded twice daily.

Based on interview and record review, the facility failed to ensure staff detached the fourth hook from the sling of the mechanical lift, while transferring one of three residents (Resident 1) and failed to ensure all staff including (CNA3) was trained on how to detach and unhook the sling. This resulted in Resident 1 falling onto the floor, hitting his head, sustaining a forehead laceration and two vertebral (back) fractures. Resident 1 was transferred to the general acute hospital for evaluation and treatment. Findings: During a review of Resident 1's admission record Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included metabolic [CONDITION(S)] (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), [CONDITION(S)] (a life-threatening complication of an infection) and hypertension (high blood pressure). During a review of Resident 1's Care Plan, dated April 16, 2020, and reevaluated on August 2021, Resident 1 required assistance, was dependent in transfers and had a history of falls. The Care Plan indicated the facility will use a mechanical lift for transfers which required two-person physical assistance. The listed interventions included to: 1. Follow guidelines for safety with mechanical lift transfers. 2. Proper staff training with mechanical lift transfers. 3. Observe safety at all times. During a review of Resident 1's History and Physical (H&P) dated August 11, 2021, the H&P indicated Resident 1 was alert, oriented to person and place, and was moderately demented (affected by dementia) {a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities} with slow mentation (slow mental processing). During a review of Resident 1's Minimum Data Set (MDS-comprehensive screening tool), dated August 13, 2021, the MDS indicated Resident 1 usually made himself understood, sometimes understood others and was totally dependent on staff for transferring, toileting, and personal hygiene. During a review of Resident 1's Change of Condition SBAR {(situation, background, assessment and recommendation) a tool to aid in facilitating and effective communication between nurses and providers} - Actual or Suspected Fall note dated, October 11, 2021 the SBAR indicated Resident 1 had a witnessed fall with injury, involving the use of a mechanical lift. The narrative portion of the report indicated Resident 1 was being transferred with two CNA's using a mechanical lift, the sling remained partially attached to the lift causing Resident 1 to be dragged or rolled off the bed onto the floor and sustaining an approximate seven-centimeter (unit of measurement) laceration on the right side of his forehead that was actively bleeding. During a review of the Physician Orders dated October 11, 2021, the physician ordered to transfer Resident 1 to the General Acute Care Hospital (GACH) for evaluation post fall with injury to right side of forehead. During a review of the Emergency Department (ED) notes from the General Acute Care Center (GACH) dated October 11, 2021, the ED note indicated Resident 1 was brought into the ED by the paramedics after sustaining a fall and right-side head laceration at the facility while being transferred with an assistive device. Part of the device failed dropping Resident 1 approximately five feet to the ground. Resident 1 was monitored in the ED for 24 hours and was noted to be alert, nonverbal, and withdrew to pain. Resident 1 was given intravenous (administered through the vein) antibiotics, intravenous pain medication, and underwent several imaging studies. While in the ED the laceration to resident 1 right forehead was repaired with surgical glue. Resident 1 was diagnosed with having two acute vertebral fractures while in the ED that did not require surgical intervention. During a review of the ED Computed Tomography (CT) scan (medical imaging technique used to get detailed images) of the abdomen (tummy) and pelvis (located between the abdomen and the legs) dated October 11,2021, the CT scan results revealed Resident 1 had acute vertebral fractures of the Lumbar (L) Spine (lower back) and [MEDICATION(S)] (T) spine (runs from the base of the neck to the bottom of your rib cage) L1, T1, and T5 acute fractures. During a review of the ED CT Cervical Spine scan (neck) dated October 11, 2021, there was a T1 vertebral body compression fracture that was very likely acute (of short duration) or subacute (between acute and chronic [a conditions that last 1 year or more]. During an observation on October 22, 2021, at 1:40 p.m., in room 24, Resident 1 was lying in a low-profile bed with no side rails. Resident 1 was not responsive to the surveyor's greeting and appeared to be sleep with his eyes closed. There were four mechanical lifts stored outside the building, just beyond the south-west patio entrance (about 10 feet from room 24). During an interview on October 22, 2021, at 2:40 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on October 11, 2021 around 8 a.m., she was called to room 24 by a Certified Nursing Assistant (CNA) to check Resident 1. When she entered the room, the DON was present. LVN 1 stated the resident was on the floor laying on his left side and was bleeding from his forehead. LVN 1 stated she was informed CNA 2 and 3 were transferring Resident 1 to his bed using the mechanical lift. They unhooked three of the four sling hooks and one hook remained attached to the mechanical lift. When CNA 2 and CNA 3 tried to remove the mechanical lift, Resident 1 was dragged onto the floor and hit his head on the base of the mechanical lift. LVN 1 stated pressure was applied to the resident's forehead, 911 was called, and the doctor was notified. During an interview on October 22, 2021, at 3:05 p.m., with Maintenance Supervisor (MTSUP) MTSUP stated the mechanical lifts are inspected monthly. Maintenance staff check the wheels, motor, and check for loose screws and bolts. The mechanical lifts were working properly and are tagged every month after the lifts are checked. If staff report issues with the mechanical lifts, he removes the item, so it is not used for patient care. During an interview on November 29, 2021, at 11:54 a.m., with CNA2, CNA2 stated during a two-person transfer using the mechanical lift CNA2 and 3 forgot to remove the fourth hook from the lift which caused Resident to fall onto the floor hitting his head. CNA2 stated it was an accident and she knew she should have unhooked all four hooks from the lift. During an interview on November 30, 2021, at 2:20 p.m., with CNA3, CNA3 stated she was helping her coworker CNA2 transfer the resident using the mechanical lift and CNA2 and 3 forgot to remove one of the hooks causing the resident to fall onto the floor and hitting his head. During a review of the undated Preventative Maintenance Monthly Log, the mechanical lifts had been checked monthly from November 2019 thru September 2021, and indicated that the four mechanical lifts were okay, and checked, as evidenced by a check mark for all months in 2020 and 2021. During a review Resident 1's licensed nurse discharge progress note, dated October 11, 2021, Resident 1 was transferred to the GACH for a fall with injury (laceration on the right side of his forehead). During a review of the CNA2's Orientation Competency Evaluation and Mechanical Lift Competency Checklist both dated, September 2021, indicated CNA 2 was checked off as being competent in the use of a mechanical lift. During a review of the CNA3's Orientation Competency Evaluation dated, February 27, 2020, indicated CNA3 was not evaluated for the use of a mechanical lift upon hiring. During a review of the CNA3's Mechanical Lift Competency Checklist dated, September 15, 2021, indicated CNA3 was checked off as being competent in all areas of the mechanical lift except unhooking the sling. During an interview on December 1, 2021 at 9:48 a.m., with the Director of Nursing (DON), DON stated he was one of the first responders to room 24 after Resident 1 fell from the mechanical lift. CNA2 and CNA3 were transferring Resident 1 using the mechanical lift and CNA2 and 3 forgot to unhook the sling from the mechanical lift causing the resident to fall onto the floor. Resident 1 was transferred via paramedic to the ED for evaluation due to the head injury. DON stated he ensured staff was properly trained on how to use the mechanical lift. DON also stated he believed the accident was avoidable. During a review of the facilities undated policy and procedure (P&P) titled Using a Mechanical Lifting Machine, indicated staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. The P&P also indicated when the transfer destination is reached, the resident should be slowly lowered to the receiving surface and the staff should detach the sling from the lift.

Based on interview and record review, the facility failed to adhere to its policy and the resident's plan of care in prevention of falls by not providing a thorough assessment for one of three sampled residents (Resident 1), who had a high risk for falls with a history of multiple falls, had four falls within a 24-hour period. These deficient practices resulted in Resident 1 falling on multiple occasions, sustaining a lip laceration (deep cut) and fractures (broken bones) of the left fourth and fifth proximal phalanges (toes). Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 1/4/17, indicated Resident 1 had no cognitive (ability to think and reason) impairment, and was able to make needs known and understand others. According to the MDS, Resident 1 required extensive assistance with bed mobility, transferring, locomotion on and off the unit, as well extensive assistance with eating and personal hygiene. A review of Resident 1's Fall Assessment, dated 1/18/18, indicated Resident 1 had a score of 23 (total score of above 10 represents high risk for falls). The fall assessment indicated Resident 1 had a history of [REDACTED]. A review of Resident 1's care plan titled, At risk for Injuries from falls ., indicated the staff's interventions included to monitor Resident 1's environment for wet spots or items placed below field of vision, keep call light within reach and answer promptly, ensure lighting was adequate, monitor the resident for steadiness and balance, keep bed low with floor mat, and refer to rehab or physician if indicated. A review of the facility's incident report, dated 12/29/17, and timed at 2:30 p.m., indicated Resident 1 was heard yelling and the licensed nurse observed the resident on the floor beside the bed, with the call light within reach. The report indicated Resident 1 was returned back to bed with a Hoyer lift (mechanical lift). Upon assessment, Resident 1 was observed with an abrasion to left second and third toes, with no swelling. According to the report, Resident (Resident 1) had pre-existing left-sided [MEDICAL CONDITION] (paralysis), and the resident was educated to use the call light at all times for assistance. A review of the Licensed Personnel Progress Note, dated 12/30/17, and timed at 6:30 a.m., indicated Resident 1 was on frequent monitoring for safety for fall precautions. A review of the SBAR (Situation Background Assessment Recommendation) Communication form, dated 12/30/17, and timed at 3 p.m., indicated Resident 1 had an unwitnessed fall and was found lying on the floor next to the bed. The SBAR communication form indicated Resident 1 had an abrasion to the left foot with throbbing pain 4 out of 10 on a pain scale. The interventions included assisting Resident 1 back to bed with a Hoyer lift and neurological checks (detect the presence of [MEDICAL CONDITION]) with monitoring of its progression for 72 hours post fall. A review of the facility incident report, dated 1/7/18, and timed at 8:40 a.m., indicated Resident 1 was found on the floor by Certified Nursing Assistant 1 (CNA 1). The report indicated CNA 1 notified the on duty charge nurse and helped transferred Resident 1 back to bed. According to the report, Resident 1 had no visible injuries noted and no complaints of pain. A review of the SBAR Communication form, dated 1/7/18 and timed at 9:05 a.m., indicated Resident 1 had a second unwitnessed fall and was found lying on the floor on his right side next to the bed with no injury. The SBAR communication form also indicated Resident 1 had back pain 5 out of 10 on a pain scale. A review of the Licensed Personnel Progress Notes, dated 1/7/18, shift 3 p.m. to 11 p.m. indicated Resident 1 was on monitoring for status [REDACTED]. A review of the facility incident report dated 1/8/18 and timed at 10:45 a.m., indicated Resident 1 had a witnessed fall in front of the nursing station from his wheelchair and sustained a laceration to his upper lip with bleeding. A review of the Licensed Personnel Progress Note, dated 1/8/18, and timed at 10:45 a.m., indicated Resident 1 was in front of the nursing station and was seen leaning forward from his wheelchair. The note indicated Resident 1 loss his balance and fell to the floor in the prone (face down) position. Resident 1 sustained a cut to upper lip with bleeding, and complaints of pain 3 out of 10. The note indicated Resident 1 had history of multiple falls, the resident's physician was made aware, with an order for [REDACTED]. A review of a SBAR Communication form, dated 1/8/18, and timed at 10:45 a.m., indicated Resident 1 had a third witnessed fall from his wheelchair. The SBAR indicated Resident 1 sustained a laceration to the upper lip with swelling and bleeding. Resident 1 was administered pain medication and given a cold compress to apply to both lips. A review of the Licensed Personnel Progress Note, dated 1/8/18, and timed at 10:40 p.m., indicated Resident 1 was administered [MEDICATION NAME] (a narcotic used to help relieve moderate to severe pain) 4 milligrams (mg) at approximately 6:30 p.m. on 1/8/18, for complaints of body pain. The note indicated to continue to monitor Resident 1 for status [REDACTED]. A second facility incident report, dated 1/8/18, and timed at 11:05 p.m., indicated Resident 1 had an unwitnessed fall for the second time on the same day from his bed, sustaining an injury to the left second and third toes. According to the report, Resident 1 was assisted back to bed by the charge nurse and assigned CNA, and first aid was rendered to the resident's left toes. A review of the Licensed Personnel Progress Notes, dated 1/8/18, and timed at 11:05 p.m., indicated Resident 1 had another fall and sustained injury to the left second and third toes with active bleeding, and first aid was rendered. The note indicated Resident 1 was transferred back to bed with the Hoyer lift. Another SBAR Communication form, dated 1/8/18, and timed at 11:30 p.m., indicated Resident 1 had an unwitnessed fourth fall on the same day with injury to left second and third toes. The interventions included conducting neurological checks for 72 hours and to place the resident's bed in the low position. A review of the facility incident report, dated 1/19/18, and timed at 3:45 p.m., indicated Resident 1 was found on the floor in the prone position on the floor mat next to his bed. The report indicated Resident 1 was assessed immediately after the fall with no visible injury. A review of the Licensed Personnel Progress Note, dated 1/19/18, and timed at 3:45 p.m., indicated Resident 1 denied any pain or discomfort, was in no distress. The note indicated Resident 1 had pre-existing left-sided [MEDICAL CONDITION] secondary to stroke. According to the note, Resident 1 was returned back to bed with help from staff, with frequent visual checks provided and bed in the low position with floor mats properly placed. Another SBAR Communication form, dated 1/19/18, and timed at 3:45 p.m., indicated Resident 1 had a unwitnessed fall from his bed and was found in prone position beside his bed on the floor mat with call light nearby. The interventions included conducting neurological checks for 72 hours post fall. A review of the physician's telephone order, dated 2/2/18, and timed at 10 a.m., indicated a left foot x-ray for Resident 1 was ordered per the family's request. A review of the radiology report, dated 2/2/18, and timed at 4 p.m., indicated non-displaced fractures (broken bone) at the base of the fourth and fifth proximal phalanges (toes) of the left foot for Resident 1. A review of the physician's telephone order, dated 2/8/18, and timed at 9:30 a.m., indicated Resident 1 was to be transferred to the general acute care hospital (GACH) for further evaluation due to left foot fourth and fifth non-displaced toes fractures. A review of the physician's telephone order, dated 2/8/18, and timed at 8:10 p.m., indicated to resume all of Resident 1's orders, discontinue the orthopedic consultation, discontinue heel protectors and immobilize left fourth and fifth left toes with tape treatment as needed for Resident 1. On 2/22/18 at 10:44 a.m., during an interview, Resident 1's family member (FM 1) stated, When he (Resident 1) was admitted he fell out of his bed and hit his toes. He has left-sided paralysis and has no bedrails on his bed. The next day his toes were discolored, I was concerned because he complained of pain. It took six weeks for the facility to order an x-ray and he had left fractured (broken bones) toes. He was given a lot of pain medication but the facility did not look at his feet. On 2/26/18 at 11:40 a.m., during a phone interview, the Ombudsman (an official appointed to investigate individuals' complaints against maladministration, especially that of public authorities) stated, The family member for the resident (FM 1) contacted me because the resident's toes were discolored and the facility did not address the family member's (FM 1) concerns. I had a care plan meeting with the facility and the family member (FM 1). An x-ray was ordered and it was discovered that his toes were broken. On 2/26/18 at 1:28 p.m., during an interview, Resident 1 stated, I have fallen from my bed a few times, my foot was painful and bruised, and they never checked my foot. I could not stand during physical therapy because of the foot pain, so my therapy was canceled. On 2/26/18 at 3:51 p.m., during an interview, Registered Nurse 1 (RN 1) stated, When the resident (Resident 1) fell on (MONTH) 30th he was given pain medication; there was only an abrasion on his foot with pain. I did not see any bruising; he puts himself on the floor for attention. He does not use the call light for any help. He has left sided paralysis, but we do not place side rails because we do not want to restrain him. He has a mat next to his bed. On 2/28/18 at 8:59 a.m., during an interview, LVN 1 stated, The resident has had several falls; I cannot remember the exact number, less than 10 falls. He rolls out of bed intentionally, and falls on his side, he does not use the call light. He just yells nurse. I do not know if he fractured his toes the day he was complaining of throbbing pain on his left foot. The reason we got an x-ray was because his family member kept asking for an x-ray because of the discoloration, saying his toes were black. For residents who fall we move them close to the nursing station. He only complained of general body pain, no complaint of pain of the toes. On 2/28/18 at 10:13 a.m., during an interview, CNA 3 stated, The resident (Resident 1) has fallen out of the bed, I remember him breaking the bedside drawer. He likes attention, I do not remember his toes being bruised or dark or of him complaining of pain, but he fell a lot. On 2/28/18 at 11 a.m., during an interview, the Physical Therapy Director (PTD) stated, The resident (Resident 1) did have a fall after admission, I assessed him. We met with the family and he received therapy for three weeks before the orders were discontinued. The resident hit a plateau and was not progressing. On 2/28/18 at 11:49 a.m., during and interview, the Director of Nursing (DON) stated, This resident rolls himself out of bed, and is noncompliant with using the call light. We held a care plan meeting about the falls, but did not know about the toe fractures. We did not report the falls because he was found on the floor mat next to his bed. The care plans were updated and incident reports were completed for each fall. A review of the facility's policy titled, Incident Report, dated 1/2017, indicates incidents involving residents, visitors, or volunteers be recorded on an incident form. An incident was identified as an unusual event or happening with unintended, undesirable, and or unexpected results. According to the policy, when appropriate, the administrator would notify the Department of Public Health and/or Ombudsman by telephone and in writing of reportable incidents and unusual occurrences in a timely manner. A review of the facility's policy titled, Falls by A Resident, dated 7/2017, indicates if a resident sustains a fall, an incident report will be completed. The policy indicated to identify an action plan of approaches that may be taken in an attempt to prevent further falls based on any identified facts or risk factors. A post fall assessment is also completed to identify factors that may have contributed to the fall. According to the policy, the incident report and post fall assessment should be reviewed by the interdisciplinary team.

Based on observation, interview, and record review, the facility's staff failed to provide adequate supervision for one of three sampled residents (Resident 1). Resident 1, a newly admitted resident, who had a high risk for elopement (to flee or to run away secretly) and falls and was confused eloped from the facility unsupervised and was later found by the local Fire/Police Department, in the streets. Resident 1 fell sustaining facial injuries (Crossed referenced to F609). This deficient practice of the facility not providing Resident 1 adequate supervision, resulted in the resident leaving the facility sustaining a laceration (a deep cut or tear in skin or flesh) to the lip and an abrasion (an area damaged by scraping or wearing away: superficial) to the right eye after a fall. Resident 1 was admitted to the general acute care hospital (GACH) for 10 days. Findings: On 12/20/17 at 8:24 a.m., during a telephone interview, the complainant stated, The resident (Resident 1) was found in the community after a fall, with a lacerated lip and abrasion to the right eye. The facility did not have the correct telephone number for the resident's family members to inform them that the resident went missing. At 8:44 a.m., on 12/20/17, during a general tour of the facility in the presence of Licensed Vocational Nurse 1 (LVN 1) the back gate, leading to an alley way was observed open. LVN 1 verified that the gate was opened and stated, The gate should not be opened and the door doesn't have an alarm, and sometimes its left opened. A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Nursing Admission Assessment, dated 11/28/17, and timed at 4:30 p.m., written by Registered Nurse 1 (RN 1) indicated Resident 1 was disoriented (confused) to person, place, date and time. The Assessment also indicated Resident 1 had an unsteady gait (walking) and was a fall risk, as well as a risk for elopement. A review of Resident 1's elopement risk assessment indicated a score of 12. According to the assessment a total score of 10 or greater was considered a high risk for elopement and the prevention protocols should be documented on the resident's care plan. There was no plan of care to address Resident 1's elopement risk. A review of Resident 1's care plan titled, Risk for falls, initiated on 11/28/17, identified a problem with falls due to resident 1's poor safety awareness. The goal indicated that the resident would not have any fall incidents. The care plan did not have any staff interventions documented. On 12/20/17 at 10:27 a.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated, The resident (Resident 1) would wander around the facility pushing his wheelchair looking for his family member. The day he went missing I placed him in the dining room for breakfast. A review of a hand written declaration, written by CNA 1, indicated on 12/2/17 at 8:35 a.m., the resident was last seen in the hallway wandering confused looking for his family member. The declaration indicated the charge nurse notified CNA1 that Resident 1 was missing, and was found later by the police. On 12/20/17 at 11:43 a.m., during an interview, RN 1 stated, I assessed the resident during admission and he was very confused. His wife was here during the admission process. I completed the resident's elopement risk form, but I did not initiate a care plan for elopement. A review of Licensed Vocational Nurse 2 (LVN 2) nursing note, dated 12/2/17 and timed at 9:30 a.m., indicated during medication pass, resident (Resident 1) was nowhere to be found. The note indicated the facility's staff searched for the resident all around building and the vicinities outside. A review of a subsequent nursing note, written by LVN 2, dated 12/2/17 and timed at 9:55 a.m., indicated she received a call from the local Fire Department stating that they found Resident 1 at 9:45 a.m. on the same day (12/2/17) on neighboring streets. According to the note, Resident 1 sustained a facial abrasion on the right eye and cut on the lip from fall. On 12/20/17 at 12:04 p.m., during an interview, the Director of Medical Records (DRM) was asked if they had notified Resident 1's family when he went missing. The DRM stated, I looked for the emergency contact information for the resident (Resident 1), but the number listed was an incorrect number. The DRM stated someone from admissions was supposed to verify the telephone number. A review of the GACH's emergency room (ER) note, dated 12/2/17 and timed at 10:42 a.m., indicated the resident (Resident 1) was brought after a trauma team was activated due to the resident being found down in the streets after a mechanical trip and fall. The ER note indicated the resident left the skilled nursing facility (SNF) and was confused X 4 (person, place, time and situation) and very combative (ready or eager to fight). The resident sustained [REDACTED]. Resident 1 was admitted to the GACH's telemetry unit (electronically monitoring of heart rhythms and rate for 24 hours) for 10 days due to irregular cardiac rhythm. Resident 1 was discharged on [DATE] to another SNF, per the family. On 12/26/17 at 10:20 a.m., during an interview, the director of nursing (DON) stated, The incident happened on a weekend day, I was informed by the charge nurse and the resident was found by the police. We did not notify the Department of Health because the resident was found. On 12/26/17 at 10:36 a.m., during an interview, in the presence of the DON, the administrator stated, I did not know that we were supposed to notify the Department of Public Health about a missing resident. On 12/26/17 at 11:02 a.m., during a telephone interview, Resident 1's family member (FM1) stated, I received a call late from the facility and they told me about him being found on the street, I was upset because they should have called when they realized he was missing. The nurse who called blamed him for leaving, instead of taking the responsibility for not supervising him. He has dementia, and they never called the resident's responsible party. The family did not want him (Resident 1) readmitted back to the facility, because they did supervise him and keep him safe. A review of a policy titled, Missing resident revised in (MONTH) (YEAR), indicated at the time the resident was located, the following steps will be taken, document notification of physician and responsible party as well as State agency and police if applicable.

Based on observation, interview, and record review, the facility failed to ensure seven blood pressure cuffs (a device used to measure blood pressure) were maintained and functioning properly for three of three sampled residents (Residents 1, 2, and 4) and 74 other residents who resided in the facility and required blood pressure monitoring. As a result of this failure, after Resident 1 had a change in condition, the blood pressure was inaccurately checked at the facility, but once transferred to the hospital it was identified elevated. Residents 2 and 4, who were receiving antihypertension (a drug used to lower high blood pressure) medications, blood pressures were not being monitored as prescribed by the physician. This failure also had the potential to negatively affect 42 residents with a [DIAGNOSES REDACTED]. who had the potential to experience a sudden change in condition and required an accurate blood pressure reading for an accurate assessment. Findings: On 12/27/17 at 6:51 p.m., an Immediate Jeopardy (IJ) was declared under F 908. The facility's administrator was notified of the immediacy and seriousness of the residents' health and safety being threatened. The facility submitted a Plan of Action (POA) for the correction of the IJ which included the following: 1. Immediate purchase of four blood pressure machines. 2. Provide in service to all nursing staff regarding the malfunction of blood pressure machines to Director of nursing (DON) and Administrator. 3. The central supplies staff will be monitoring the blood pressure machines on a monthly basis for proper functioning. 4. The results of such monitoring will be documented on the blood pressure monitoring function log. The digital blood pressure machines will be calibrated by an authorized contracted service provider, should there be abnormality on the reading monitor. 5. The results of such monitoring will also be documented on the blood pressure monitoring log. 6. The log will be maintained on each nursing station for the staff to write any request for medical equipment that is not in good working condition. 7. The central supply staff will check the log daily. 8. Central supply staff will communicate with charge nurse and DON, and the administrator through the utilization of the blood pressure machine monitoring log, should there be any problems associated with the vital sign devices. 9. The Director of staff development (DSD) will be providing in-service for the staff of nursing personnel on an ongoing basis. Since the findings the facility has given an in-service for three shifts for the licensed nurses and certified nurse assistants (CNA) regarding the use of the manual blood pressure cuffs and how to disinfect the machine after each use. 10. The use of personal blood pressure cuffs from the staff are not allowed to be used at any time. On 12/28/17 at 3:05 p.m., the administrator was notified that the IJ was lifted, after the team verified that the POA was followed and implemented. On 12/27/17 at 12:20 p.m., during a telephone interview, Resident 1's family member (FM 1) stated, The nurses were incompetent, they never knew when there was a decline or change in condition for Resident 1. FM 1 stated Resident 1's vital sign were never accurate because the blood pressure machines in the facility did not work, and the nurse continued to give antihypertensive medication, but did not check blood pressure. FM 1 stated Resident 1 was transferred out to the general acute care hospital (GACH) on 12/7/17, after a change in condition and prior to transfer FM 1 was told the blood pressure was normal, but the blood pressure recorded elevated upon arrival to the GACH. On 12/27/17 at 4:06 p.m., during an observation, in the presence of the Assistant Director of Nursing (ADON), two standing automatic vital sign machines were observed broken and not working properly. In addition, there were two manual standing blood pressure machines that did not have an inflatable cuff attachments. The ADON stated, I'm not sure which one works. On 12/27/17, at 4:12 p.m., all the facility's blood pressure machines, seven in total, were assessed by the staff to verify if the machines were operable. During an interview and concurrent observation, a certified nursing assistant (CNA 1) was asked to demonstrate use of the blood pressure machines in the presence of the ADON and the Registered nursing supervisor (RN 1). CNA 1 attempted to demonstrate use of the blood pressure machines, which included two standing automatic blood pressure machines, two standing manual blood pressure machines and one manual blood pressure machine, all five machines malfunctioned. CNA 1 stated, I am not able to use these machines. I do not know how long the machines have not worked, maybe a few months. A high-pitched sound of leaking air was heard from the tubing of one of the machines. A hole was observed in the tubing that was attached to the blood pressure cuff for inflation, which was causing the air leakage. On 12/27/17 at 4:31 p.m., the staff presented another automatic machine. CNA 1 placed the blood pressure cuff on CNA 2. The screen indicated a malfunction. At 4:33 p.m., on 12/27/17, during an interview, RN 1 stated, Each medication cart should have a blood pressure machine, but they have been broken for a few months, there is only one that works. On 12/27/17 at 4:42 p.m., during a concurrent observation and interview, Licensed Vocational Nurse 1 (LVN 1) was observed using an automatic wrist cuff retrieved from the medication cart. LVN 1 stated, I am in training and this is my second week. I use this automatic cuff from this middle cart to take the residents' blood pressure. I am not sure how long the other machines haven't worked. During an interview, on 12/27/17 at 4:49 p.m., CNA 2 stated, When the vital signs are taken, I use the thermometer (used to measure internal body temperature) from the broken machine, and I take the blood pressure with the blood pressure cuff from the medication cart that belongs to another CNA (CNA 3). The blood pressure machines have been broken for at least three months. I told the central supply and the charge nurses that the machines did not work. It makes it difficult for me to do my job. On 12/27/17 at 4:54 p.m., during an interview, CNA 3 stated, I bring my own blood pressure cuff; it is for the wrist, because the facility's blood pressure machines have been broken since I started working here. I do not want to repeatedly ask the charge nurses to give me their cuff. If the machines were all working my job would be easier. At 5 p.m., on 12/27/17, during an observation and concurrent interview, CNA 2 attempted to use the blood pressure cuff to demonstrate to the facility's Administrator that the machines were not working in the presence of CNAs 1 and 3. The Administrator stated, I had no idea the blood pressure machines were not working. The central supply staff are responsible for making sure the machines work. On 12/27/17 at 6:20 p.m., during an interview, Resident 4 stated, It has been months that they have taken my blood pressure, neither yesterday nor today. A review of Resident 4's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/7/17, indicated Resident 4's brief interview for mental status (BIMS) score was a 15, which indicated Resident 4 had no cognitive impairment (thought process). A review of Resident 4's physician orders, dated 2/26/16, indicated for [MEDICATION NAME] ( for treatment of [REDACTED]. The order indicated to check the blood pressure daily, hold medication if systolic blood pressure ((top number of blood pressure) indicating the maximum arterial pressure occurring during contraction of the left ventricle of the heart) was lower than 100. A review of CNA 2's hand written declaration, dated 12/27/17, and timed at 6:56 p.m., indicated When I found out the blood pressure machines were not working I reported it to the charge nurse. I reported it three months ago that the machines did not work, and we used the personal machine belong to (stated name (CNA 3)). In the presence of CNA 1 and CNA 3 we attempted to take the administrator's blood pressure, but the machines did not work. On 12/27/17 at 7:26 p.m., during an observation and concurrent interview, LVN 2 was asked and demonstrated the use of the digital blood pressure machine, but machine displayed an error on screen. LVN 2 stated, I don't think it works, that's why I bring my own blood pressure machine. I have not used the facility's blood pressure machines since I started working last year. Am I in trouble? During an interview on 12/27/17 at 7:34 p.m., the Central Supply Director (CSD) stated, Yes I was aware that the blood pressure machines weren't working. I was told last week by a CNA, but I do not know the name. I was not aware the machines were not working prior to that. I called the manufacture company last week to have the equipment checked. I was going to order more machines, but my computer is down. On 12/24/17 at 9:16 p.m., during an interview, the ADON stated, I was not aware the staff brought their own blood pressure machines to take the residents vital signs. I am not sure what the infection control policy is on that. The staff should not use their own equipment because of an infection control issue, and we do not know if their machines are accurate. Not taking accurate vital signs can put the residents at risk and can have adverse effects on their health. On 12/27/17 at 9:41 p.m., the facility's Nurse Consultant (NC) stated, The staff cannot use personal blood pressure machines from home on the residents. The facility should have borrowed blood pressure machines from our sister facility. The charge nurses should have been aware that the blood pressure machines were not working because that is how they assess and provide medications according to physician orders. We will obtain the blood pressure for every resident with hypertension; we will get on it immediately. On 12/28/17 at 9:31 a.m., during an interview in the presence of the NC, the CSD stated, I am not sure who is responsible for the maintenance of the vital signs machines. No one told me until last week that the blood pressure machines did not work. I have never checked the blood pressure machines; I guess I will start checking them now. On 12/28/17 at 10:11 a.m., CNA 4 stated, Honestly the vital sign machines have not worked in three to four months. The thermometers work on the machine, but not the blood pressure part. At 11:20 a.m., on 12/28/17, during an interview Resident 2 stated, The staff do not take my blood pressure here; I cannot remember the last time it was taken. A review of Resident 2's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated Resident 2's brief interview for mental status (BIMS) score was 14, which indicated Resident 2 had no cognitive impairment. A review of Resident 2's physician order, dated 7/19/16, indicated for [MEDICATION NAME] oral tablet 5 mg daily, for high blood pressure, hold medication if systolic blood pressure is lower than 100. A review of Resident 2's physician order, dated 7/19/16, indicated to give Losartan (keeps blood vessels from narrowing and lowers the blood pressure and improves blood flow) oral tablet 50 mg at bedtime, hold medication if the systolic blood pressure was lower than 100 or heart Rate ((HR) the number of heart beats per minute) was lower than 60. On 12/28/17 at 11:50 a.m., during an interview, CNA 5 stated, The blood pressure machines have not been working for a long time, one machine from the South Station worked, but it eventually was broken too. I saw the nurses use an automatic cuff from the medication cart; I think it belongs to a CNA. On 12/28/17 at 12:10 p.m., during an interview, CNA 6 stated, I have worked here two months and the blood pressure machines never worked since I started. I went to an in-service this morning and we were taught to take the blood pressures manually. However, there was not return demonstration, and I have not done it manual blood pressures in a long time. I hope we can get automatic cuffs soon, because it will take too long to take each residents' blood pressure. On 12/28/17 at 1:43 p.m., Restorative Nurse Aide ((RNA 1) a certified nursing assistant who has specialized training in helping residents gain an improved quality of life by increasing their level of strength and mobility) was observed taking CNA 6's blood pressure incorrectly during a manual blood pressure demonstration. CNA 6 did not place the bell of the stethoscope (blood pressure apparatus) over the brachial artery (blood vessel of the upper arm) in the presence of FNC. RNA 1 stated, During the in-services today the DSD (Director of staff development) did not have return demonstrations; it has been a while for me. On 12/28/17 at 2:58 p.m., the Administrator was asked about a policy regarding maintenance of medical equipment and he stated, We do not have a policy for working equipment for resident safety.

Based on interview and record review, the facility failed to thoroughly assess and monitor the change of condition, call 9-1-1 (emergency dispatch) for assistance and transfer to the General Acute care Hospital (GACH), when not able to stabilize the condition of one of 18 sampled residents (Resident 290). Resident 290 lung assessment indicated clear but diminished (reduced) in the base of the lungs. The Nurse Practioner (NP 2) ordered chest x-ray which revealed left lower lob infiltrate (infection), start [MEDICATION NAME] (medicine to treat infection), [MEDICATION NAME] (remove extra fluids) and transfer to GACH. However, when the staff called basic life support transportation ((BLS) provide transport to patients who do not require extra support or cardiac monitoring), it was not available for another two hours. The staff did not thoroughly monitor the lung sounds, the level of consciousness ((L(NAME)) a measurement of a person's arousability and responsiveness to stimuli from the environment), vital signs and did not call 9-1-1 (used for emergency for when needing immediate assistance from paramedics) for immediate assistance. Only when Resident 290 became pale, weak and blood pressure (BP) dropped further, did the staff call 9-1-1, almost 20 hours and 45 minutes later after the resident was discovered with a change of condition. The resident was transferred to GACH for difficulty breathing and stabbing pain for three days. The resident was diagnosed with [REDACTED]. The resident was administered intravenous (in to the vein) antibiotics, medication to increase the blood pressure, fluids, bilevel positive airway pressure (a machine that forces high pressured air in to the lungs) for severe respiratory distress and thoracotomy tube (an artificial opening through the chest wall to drain fluid or release abnormal accumulation of air). The deficient practice resulted in altered mental status (abnormal state of alertness or awareness), hypotensive (low blood pressure), shortness of breath (difficulty breathing), [MEDICAL CONDITION](fast heart rate) with admission to Intensive Care Unit (ICU), intubated (tube placed into the lungs through the mouth) and placed on a ventilator (machine used to assist with breathing). Findings: During a review of clinical records, indicated Resident 290 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review of the facility document titled Physician order [REDACTED]. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/9/2017, indicated Resident 290 had severe cognitive (ability to reason, think, learn, judge, and remember) impairment. Record review of the facility's document titled Licensed Personnel Progress Notes indicated the following: 12/10/17 at 12:55 PM, Nurse Practitioner (NP 1) was informed Resident 290's blood sugar reading recorded high ((HI) when blood sugar machine is not able to record a number). The resident received 12 units of Insulin (medication to control high blood sugar). However, there was no other assessment about the resident's consciousness levels, vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) documented in the clinical records. 12/10/17 at 1:30 PM, NP 2 was informed Resident 290's repeat blood sugar still recorded HI. NP 2 ordered basic metabolic panel ((BMP) used to check the status of a person's kidneys and their electrolyte and acid/base balance, as well as their blood glucose level) and complete blood count ((CBC), blood test to test for low blood count and infection) to be done immediately (stat). Resident was on 5 liters (L) a minute of oxygen. Oxygen saturation ((O2 Sat) oxygen in the blood) was 92 percent (percentage) (normal ranges 95% to 100%). However, there was no other assessment about the resident's consciousness levels, vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) documented in the clinical records. https://www.mayoclinic.org/symptoms/hypoxemia/basics/definition/sym- 930. Temperature, pulse, and respirations note documented. 12/10/17 at 5:54 PM, Resident 290's laboratory results received by facility staff indicated white cell count ((WBC) cells that fight infection) was high at 24.8 (normal 4.0-10.8), blood urea (kidney function) was high at 46 (normal 10-20), and Creatinine (kidney function) was high at 2.62 (normal 0.57-1.25). However, there was no other assessment about the resident's consciousness levels, vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) documented in the clinical records. 12/10/17 at 7:45 PM, NP 2 was informed of the CBC and BMP results. NP 2 ordered fluid restriction, repeat CBC and BMP in three days, and urine analysis ((UA) various tests of urine for diagnostic purposes) on 12/11/2018. 12/10/17 at 8:20 PM, Resident 290's O2 Sat was at 85% to 86% on 2 L of oxygen a minute via nasal cannula ((NC) a tube that delivers oxygen through the nose). NP 2 ordered a stat chest X-ray (CXR), [MEDICATION NAME] inhalation (medicine to open up the airways for better breathing), and to increase oxygen to 5 L a minute via NC. 12/10/17 at 8:30 PM, Resident 290's lung assessment, which was done by Registered Nurse (RN 2), indicated breath sounds (BS) was clear but it had been diminished (reduced) at bases of the lungs. However, there was no assessment of vital signs documented to ensure the resident was responding to the treatment. 12/10/17 at 8:45 PM, Resident 290's oxygen was increased to 5 L a minute via NC and nurses continued to monitor. 12/10/17 at 9:45 PM, Resident 290's O2 Sat was at 87% to 89%, and 89% to 90% after [MEDICATION NAME] inhalation. However, there was no other assessment about the resident's consciousness levels, vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) documented in the clinical records. 12/10/17 at 10:00 PM, Resident 290's O2 Sat was at 87% to 89% even on continuous oxygen. There was no assessment of lung sound documented. 12/10/17 at 10:50 PM, Resident 290's CXR indicated left (L) lower lobe consolidating infiltrate (lung infection) with moderate (medium) pleural (space between lung tissue) effusion (fluid). RN 2 informed NP 2 of the CXR results. NP 2 ordered [MEDICATION NAME] (medicine to treat infection) 500 milligrams (mg) orally (PO), [MEDICATION NAME] (medicine to remove fluids) 20 mg PO, and transfer to GACH. However, there was no other assessment about the resident's consciousness levels, vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) documented in the clinical records. 12/10/17 at 11:30 PM, RN 2 documented even though BLS ambulance transportation was called to transfer Resident 290 a total of four times, it was not available for another two hours. The Licensed Vocational Nurse (LVN 7) documented the following: a. Blood sugar was 144 milligram (mg) per deciliter (dl), b. Temperature (T) was 100.4 degrees Fahrenheit (F) (normal range 97 to 99 degrees F), c. Blood pressure (BP) was 130/84 millimeters of mercury ((mm/Hg) normal ranges 120-129 mm/Hg over 80-84 ), d. Pulse rate ((HR) heart rate) was 100 beats per minute, and e. Respiratory rate (RR) was 22 breaths per minute. The notes indicated LVN 7 started Resident 290 on [MEDICATION NAME] 500 mg PO. However, there was no other assessments about the resident's consciousness levels, lung sounds and cooling measures (using alternatives to cool the body) to reduce the fever, was documented in the clinical records. https://emedicine.medscape.com/article/ 1-guidelines 12/11/17 at 00:15 AM, RN 2 informed NP 2 of Resident 290's T of 102 degrees F and O2 Sat of 92% on 5 L per minute of oxygen via NC. RN 2 also wrote NP 2 ordered [MEDICATION NAME] inhalation every (Q) 4 hours for two days, then as needed (PRN), and cancel the transfer of Resident 290 to GACH. 12/11/17 at 6:00 AM, LVN 7 documented Resident 290's blood sugar was 175 mg/dl. The resident was on 5 L of oxygen per minute via NC and O2 Sat was at 90 to 92%. LVN 7 also indicated the resident was not in pain and there was no signs or symptoms of [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar). The clinical records failed to show Resident 290 was assessment and monitored from 12/11/17 at 00:15 AM until 12/11/17 at 6:00 AM. There was no other assessments about the resident's consciousness levels, vital signs and lung sounds, documented in the clinical records. 12/11/17 at 7:30 AM, Resident 290 was having rapid (fast) breathing. The resident's vital signs was: BP was 108/65 mm/Hg, HR was 110 beats per minute (min), RR was 28 breaths per min, T was 98.3 degrees F, and O2 Sat was at 86% on 5 L of oxygen via NC. The notes indicated the oxygen was increased to 8 L min via a non-rebreather mask (allows for the delivery of higher concentrations of oxygen). The blood sugar was 213 mg/dl and the resident was on frequent visual (eye) checks and monitored. Even though the resident's blood pressure reading had declined from 130/84 mm/Hg to 108/65 mm/Hg, exhibited rapid breathing with respirations of 28 beats per minute and O2 Sat at 86%, 9-1-1 was never summoned. 12/11/17 at 8:30 AM, Resident 290 was responsive to verbal and tactile (touch) stimuli (arouses). The resident's vital signs was recorded as: T was recorded at 98.2 degrees F, HR was at 112 beats per minute, RR was 29/min, BP 110/68 mm/Hg, and the O2 Sat was 89 to 92% on 8 L/min via a non-rebreather mask. The notes indicated the resident denied pain or discomfort, and continue to monitor. 12/11/17 at 9:45 AM, the document also indicated Resident 290 still had shortness of breath (SOB). The notes indicated Resident 290's vital signs was: T was recorded at 98.5 degrees F, HR 120/min, RR 30/min, BP 91/50, O2 Sat 89% on 10 L a minute via a non-rebreather mask, and the blood sugar was at 237 mg/dl. The resident was noted to be very pale (light colored), and weak and 9-1-1 was finally contacted and paramedics requested. 12/11/17 at 9:50 AM, Resident 290's vital signs was: BP was 91/50 mm/Hg, T 98.8, HR 128-130/min, RR 30/min, O2 Sat 88-90% on 10 L non-rebreather oxygen. A review of the facility's document titled Diagnostic Laboratories and Radiology dated 12/11/17 CXR indicated Resident 290 had marked degree of consolidation infiltrate in left lower lobe and moderate left pleural effusion. 12/11/17 at 10:00 AM, Resident 290 was finally transferred to GACH due to [MEDICAL CONDITION] (low blood pressure), desaturation (reduction in blood oxygen levels), BP of 91/50 mm/Hg, and O2 Sat of 89% on 10 L/min of oxygen. A review of Resident 290's document titled Emergency Department Provider Notes obtained from GACH dated 12/11/17 at 12:00 PM, indicated the Resident 290 complained of difficulty breathing for three days with a sharp stabbing chest pain. The T recorded as 97.7 degrees F, HR 132/min, BP 91/36 mm/Hg, RR 36/min, and O2 Sat of 89%. The resident was hypoxic (lack of oxygen), tachypnic (fast breathing), severe respiratory distress (severe difficulty breathing), bilateral diminished breath sounds (reduced air in both lungs), and crackles (rattling). The resident was diagnosed with [REDACTED]. A review of GACH's document titled LAB Results dated 12/11/17 at 11:00 AM, indicated Resident 290 was experiencing lactic acid (acid build in the body from persistent lack of oxygen associated with severe infection) which was 7.7 (normal 0.5-2.0 millimoles per liter (mmol/L)), and WBC of 17.3. The resident received [MEDICATION NAME] (medication to treat bacteria) 1500 mg intravenously ((IV) into vein), along with [MEDICATION NAME] (medication to treat infection) 500 mg IV, and [MEDICATION NAME] 2 grams IV. The resident also received 4221 ml of 0.9% normal saline (to give back the fluid and electrolytes) IV fluid. The resident was placed on Bilevel Positive Airway Pressure (([MEDICAL CONDITION]) a machine that gives high-pressure air, allows a patient to breath easily, and prevents throat muscles from closing) for severe respiratory distress. The resident was admitted to Intensive Care Unit ((ICU) a unit for very sick patients). A review of GACH's document titled Cardiology Progress Notes dated 12/12/17 at 8:54 AM, indicated Resident 290 was on [MEDICATION NAME] (medication to increase blood pressure) overnight for [MEDICAL CONDITION]. The document also indicated to continue the pressor (medication to increase blood pressure). A review of Resident's 290 Emergency Department (ED) Provider Notes dated 12/11/2017, indicated the following: 11:44 AM, BP 95/76 mm/Hg, T 98.5 F, HR 125/min, and RR 45/min. 12:05 PM, BP 74/42 mm/Hg, HR 137/min, and RR 36/min. 12:16 PM, BP 90/49 mm/Hg, and HR 125/min. 1:04 PM, BP 115/51 mm/Hg, T 98.3, HR 132/min, and RR 30/min. 1:32 PM, BP 69/55 mm/Hg, T 98.5 F, HR 130/min, and RR 30/min. A review of GACH's document titled Imaging dated 12/12/17, indicated Resident 290 had right neck central line (IV placed in the big veins to deliver medications quickly for very sick patients) placed. A review of GACH's document titled Imaging Xr Chest 1 View Portable dated 12/12/2017, indicated Resident 290 had congestive changes present with left effusion post (after) placement left-sided Thoracostomy tube (an artificial opening through the chest wall to drain fluid or release abnormal accumulation of air). A review of GACH's document titled Progress Notes Dated 12/15/2017 at 5:16 PM, indicated Resident 290's Computerized Tomography (CT, special X-ray used to view inside the body) Chest results indicated multiple (many) cavitary (holes) in the lungs worrisome for cavitary pneumonia or septic emboli (blood clot). The document also indicated the resident had a new tracheosophageal fistula (hole between the wind pipe and food pipe) for easier breathing. A review of GACH's document titled Outcome Eval dated 12/15/17 at 6:15 PM, indicated Resident 290 had central line inserted for [MEDICATION NAME] infusion. A record review of GACH's document titled Noc Shift Outcome Evaluation dated 12/16/17 at 5:46 AM, indicated Resident 290 was lethargic (weak) and pupils sluggish (slow) to react to light (normal quick). The resident was on [MEDICATION NAME] to keep Mean Arterial Pressure (average BP) to more than 65 (normal 70 - 100 mm/Hg). The document also indicated the resident had respiratory distress (difficulty), was sedated (put to sleep) with Propofol (mediation that causes brief sleep) and [MEDICATION NAME] (strong pain medication), intubated (tube placed into the lungs through the mouth), and placed on a ventilator (breathing machine). During an interview on 1/25/18 at 3:17 PM, RN 2 stated she was on duty on 12/11/17, from 3:00 PM to 12/11/17 until 00:25 AM. RN 2 stated Resident 290 should had been transferred to GACH after NP 2 gave the order. RN 2 also stated the resident was very sick and the facility was not able to provide the care the resident needed. RN 2 stated the resident's BP, RR, and HR on 12/10/17 at 3:00 PM, until 00:25 AM on 12/11/17. During an interview on 1/25/18 at 4:22 PM, RN 1 stated Resident 290 was transferred to GACH for SOB and desaturation (low blood oxygen). RN 1 stated on 12/11/17 at 9:45 AM, the resident was difficult to wake up. RN 2 stated the resident had change of condition (C(NAME)) along with SOB on 12/10/17 during the 3 to 11 PM shift. RN 2 also stated the resident had indicated pneumonia. RN 2 stated residents with SOB, desaturation, abnormal vital signs (BP, HR, RR, T, abnormal O2 Sat, altered mental status (AL(NAME)), and uncontrolled pain even were transferred to GACH. RN 2 further stated pleural effusion would be managed at GACH because a resident may need a chest tube placement. RN 2 also stated the facility would not be able to place and manage a chest tube. During an interview and record review on 1/26/18 at 2:29 PM, about Resident 290 the Director of Nurses (DON) stated a resident who had C(NAME) would have BP, HR, RR, T, O2 Sat, and blood sugar assessed. The DON also states a resident with O2 Sat less than 90% would be started on oxygen and 9-1-1 would be called. The DON stated our protocol showed if oxygen saturation was below 90% room air to give oxygen and immediately call 9-1-1. The DON stated the resident's doctor and responsible party would also be informed, and C(NAME) documented. The DON was not able to explain why Resident 290 was not transferred to GACH when NP 2 ordered the transfer. After reading Resident 290's Licensed Nurses notes, dated 12/10/17 the DON stated they had to contact the resident's doctor or the Medical Director and insisted on transferring the resident to GACH. During a telephone interview on 1/26/18 at 3:04 PM, LVN 7 stated she had worked at the facility for [AGE] years. LVN 7 stated on 12/9/17 at night Resident 290 was alert (aware), verbally responsive, and made needs known. LVN 7 also stated on 12/10/17 at 11:00 PM, Resident 290 was on oxygen 5 at L/min via NC and the resident was sleepy, arousal when touched, but moaning. LVN 7 stated all night, the resident had trouble breathing and was SOB. LVN 7 stated the resident's CXR indicated pneumonia and that's it. LVN 7 stated the resident was not able to take her medication by mouth because she had a hard time swallowing. LVN 7 stated the resident remained very sleepy throughout the night. LVN 7 was not able to state why the resident was not transferred to GACH at night. During a telephone interview on 1/26/2018 at 4:00 PM, NP 1 stated there was a total of [AGE] years of experience as an NP. NP 1 stated she would never cancel Resident 290's transfer to GACH in a million years. NP 1 also stated Resident 290's CXR, CBC, and BMP, had indicated the resident was very sick and should had been transferred to GACH right away. During a telephone interview on 1/26/2018 at 4:20 PM, NP 2 stated an order to transfer Resident 290 to GACH was never canceled. When CXR and CBC results was read, NP 2 stated with those kind of symptoms and results Resident 290 was not stable. NP 2 stated Resident 290 should had been immediately transferred to GACH. NP 2 further stated she was on call during the night of 12/10/2017 up to the morning of 12/11/2017. During an interview on 1/29/18, at 8:54 AM, RN 2 stated she contacted NP 2 on 12/11/17 at 00:15 AM with Resident 290's conditions such as; T 102 degrees F and O2 Sat 92% on 5 L/min, but NP 2 canceled the resident's transfer to GACH. However, RN 2 stated NP 2 was not reminded of Resident 290's CXR and CBC results because it was assumed NP 2 remembered the resident's results. RN 2 stated she contacted BLS four times to transfer Resident 290 to GACH but the wait time was two hours. RN 2 stated that was a long time for the resident to wait and should have contacted Advance Cardiac (heart) Life Support to transfer the resident to GACH. RN 2 stated she could not remember any staff present at the nurses station when RN 2 spoke with NP 2 about the cancellation of Resident 290's transfer to GACH. RN 2 further stated she had recorded Residents 290's BP, HR, and RR, however, RN 2 was not able to show the documentation. During a telephone interview on 1/29/18, at 9:27 AM, Resident 290 stated she had SOB and was very sick during the stay at the facility. The resident stated I was out of it. Resident 290 stated GACH drained the lungs. The resident stated, That is all I can remember. I was out of it. During an interview on 1/29/18, at 10:12 AM, the Director of Nursing (DON) stated the facility would request for BLS transportation when a resident's T, BP, HR, RR, and O2 Sat were within normal and when there was an order to transfer to GACH. The DON also stated the facility would otherwise call ACLS. The DON stated the facility did not have a policy on requirement for BLS and ACLS transportation. During a telephone interview on 1/29/18 at 11:12 AM, Resident 290's responsible party (RRP 1) stated the resident had severe pneumonia from lack of proper care. RRP 1 also stated at GACH, the resident was diagnosed with [REDACTED]. RRP 1 stated the resident was on the ventilator and remained in ICU for three weeks. RRP 1 stated GACH put a needle and removed fluid from the resident and the fluid showed severe bacteria in the resident's lungs. RRP 1 stated the resident's throat and lungs was scoped (looked into with a camera) to see how the resident got the lung infection. RRP 1 stated the resident was talking crazy while at the facility. RRP 1 further stated the resident was coherent (easy to understand) after discharge from the GACH. A review of the facility's policy and procedures titled Change of Condition dated 5/16, indicated a thorough assessment would include all important information related to the resident such as: the onset of current symptoms, vital signs, oxygen saturation if there is respiratory problem, most current labs available, blood sugar if the resident is diabetic, mental status, diagnoses, and a brief history of the resident. According to the facility's policy and procedures titled Emergency Care, indicated the following; - The facility will provide emergency care to a resident in need of urgent services. - The policy indicated the licensed nurse should observe the condition of all the residents by making rounds as soon as nursing report is completed, if the resident's condition changed, the attending physician should be called and the changes that have been observed are to be reported. - The emergency care is to be provided as necessary. - If the attending physician is not available, the alternate physician should be notified. - If the attending physician is not available, call the emergency physician listed or the medical director. - Vital signs should always be taken with a change in the resident's condition and documented - Document details and the exact time the change of condition was noted, as well as initiation of emergency procedures and the resident's response to the emergency care. - Vital signs, assessment and all observations related to the resident's condition. - Observations of the resident at regular intervals. The facility did not have a policy on BLS and ACLS transportation.