Every finding on record at Beachwood Post-Acute & Rehab

Based on observation, interview, and record review, the facility staff failed to maintain respect and dignity of one of three sampled residents Resident 1 by: 1.Failing to ensure Resident 1 was transferred to another facility dressed in personal clothes, resulted in Resident 1 being transferred wearing only a hospital gown. 2.Failing to ensure document itemized list of personal property and belongings accompany Resident 1 upon discharge. These deficient practice had the potential for loss or misappropriation of property and resulted in Resident 1's family member (FM) feeling humiliated and stressed. During a review of Resident 1's admission Records, the Records indicated Resident 1 was initially admitted on [DATE] and readmitted on [DATE] with a diagnoses including unspecified encephalopathy (a disease damaged the functions of the brain) unspecified sequelae of cerebral infarction ( a type of stroke caused by a blockage (like a blood clot) in a brain artery, cutting off oxygen and nutrients, which makes brain cells die, leading to damage, disability, with a long term or permanent effects), end stage renal disease (ESRD the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life). During a review of Resident 1's History and Physical (H&P) dated 6/11/2026, the H&P indicated, Resident 1 was assessed for decision making capacity and Resident 1 has decision making capacity. During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment tool), dated 7/27/2026, the MDS indicated, Resident is dependent on staff with substantial/maximal assistance (helper does less than half the effort, Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 1's discharge plan Physicians Progress Notes dated 8/7/2026, the Physicians Progress Notes indicated Destination: home health and transfer to Board and Care/Assisted Living. During a review of Resident 1's Progress Notes dated 8/10/2026, the Progress Notes indicated Resident 1 left the facility at 11:09 AM on 8/10/2026 to dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so). Resident 1 was discharged from the facility and belongings taken with him. After Dialysis Resident 1 will be transferred to board and care. During an interview on 8/14/2026 at 11 AM with Resident 1's FM, the FM stated Resident 1 was transferred to a dialysis center on 8/10/2026 and from a dialysis center to a board and care facility. The facility did not send Resident 1's personal possessions and Resident 1 was not dressed in his personal cloth, rather was wearing only hospital gowns. FM stated, this experience was humiliating and created stressful day. During a concurrent observation and interview on 8/14/2026 at 11:52 AM with the facility case manager (CM), a brown cartoon box with Resident 1's name was observed. CM stated Resident 1's personal belongings in the box were in the storage room. CM stated, a maintenance person brought the box containing Resident 1's belongings to CM office on 8/13/2026. Resident 1's belongings did not accompany during the resident's transfer to dialysis and board and care facility. During a concurrent interview and record review on 8/14/2026 at 12:25 PM with registered nurse (RN), Resident 1's late entry Progress Notes dated 8/10/2026 were reviewed. The Progress Notes indicated Resident 1 left the facility via gurney (a specialized wheeled cart to move patients around) at 11:09 in a stable condition. All personal belongings accounted for and transported with [Resident 1]. During an interview on 8/14/2026 at 12:25 PM with RN, the RN stated, I asked the certified nursing assistant (CNA) to do the inventory and made sure [Resident 1] had everything with him. RN stated, resident belonging inventory is done during admission and discharges, RN does not recall reviewing Resident 1's belongings inventory during discharge on [DATE]. During an interview on 8/20/2026 at 9:52 AM with licensed vocational nurse (LVN), the LVN stated, Resident 1 was transferred to a dialysis center and discharged to a board and care facility on 8/10/2026. LVN stated, Resident 1 was transferred from the facility wearing only a hospital gown. LVN stated, I accounted for everything he had in his [Resident 1's] room, not what was kept in the storage room. LVN stated, the facility staff does not inventory specific items during discharges, rather collect what is available at bedside and in the resident room. During a review of the facility's Policy and Procedures (P&P) titled Personal Property, revised January 2026, the P&P indicated Residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. During a review of the facility's P&P titled Resident Rights, revised January 2026, the P&P indicated, Our facility will make every effort to assist each resident in exercising his/her rights to ensure that the resident is always treated with respect, kindness, and dignity.

Based on interview and record review, the facility failed to ensure that to adhere to professional standards of practice when the facility staff failed to document services provided to one of four sampled residents (Resident 1) in the resident's chart according to the facility's policy and procedures (P&P) titled Charting and Documentation with revision date of 1/2026. This deficient had resulted in a failure to maintain regulatory compliance and had the potential to result in the delay of the appropriate instructions needed from the physician to prevent decline in Resident 1's health.Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 7/30/2025 and readmitted Resident 1 on 6/23/2026 with diagnoses Sequelae (residual damage) of cerebral infarction (when blood vessels [body's plumbing system] in the brain get blocked), cognitive communication deficit (having trouble communicating due to problems with thinking and brain processing), and anxiety disorder (a feeling of fear, dread, or unease causing worry about what might happen in the future). A review of Resident 1's Minimal Data Set (MDS -resident assessment tool) dated 4/28/2026, indicated Resident 1 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 required staff assistance with activities of daily living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. A review of Resident 1's change of condition (COC -when a patient or resident is no longer at their normal health baseline. It indicates an unexpected, sudden shift in a person's physical, mental, or emotional abilities, pointing to an improvement, worsening, or a new underlying medical issue) dated 6/27/2026, at 7:05 A.M., indicated. signs and symptoms identified: Falls. were the change in condition d and notifications reported to care clinician? . Recommendation of Primary Clinician(s): awaiting response. During a concurrent interview and record review, on 7/16/2026, at 1:29 P.M., with the Director of Nursing (DON), Resident 4's electronic medical chart was reviewed. The DON stated that facility communication with a medical doctor (MD) is documented as a new order or as a progress note. The DON stated that the facility process is to call the resident's MD, and if the facility cannot reach the MD, then a follow up call is made within the next 2-4 hours. The DON stated Resident 1's COC indicated that awaiting response means that the nurse was not yet successful in communicating with the MD. The DON stated that on the day of the fall incident on 6/27/2026, there is no documented evidence that the facility made a follow up call with the Resident 1's MD or that the facility was successful in communication with the MD which includes an order. A review of the facility's P&P, titled, titled Charting and Documentation with revision date of 1/2026, indicated,Policy StatementAll services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.Policy Interpretation and Implementation1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records.2. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/L VN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified Nursing Assistants may only make entries in the resident's medical chart as permitted by facility policy.3. All incidents, accidents, or changes in the resident's condition must be recorded and include follow up documentation entries if necessary.6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: e. Notification of family, physician or other staff, if indicated; A review of the facility's P&P, titled, titled Acute Condition Changes -Clinical Protocol with revision date of 1/2026, indicated, .5. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less).6. The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status.a. The staff will notify the Medical Director for additional guidance and consultation if a timely response is not received.

Based on observation, interview and record review, the facility failed to ensure an alternative accessible call light device was provided to one of three sampled residents (Resident 1), who was unable to operate the button-activated call light device provided. Resident 1 had impairment (is any loss or abnormality of anatomical, physiological, or psychological structure or function) on both sides to the upper extremities (shoulder, elbow, wrist, and hand).This failure resulted in Resident 1 making a lot of noise when calling for help, was unable to utilize the facility's call system, increasing the risk to not meet Resident 1's needs not being met, and placing Resident 1 at an increased risk for falls, injuries, hospitalization and death. Findings: During a review of Resident 1's admission Record, dated 7/15/2026, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnoses including sequelae of cerebral infarction (lingering physical, mental, and psychological deficits that remain after a stroke (when blood flow to the brain is blocked or a blood vessel bursts)), dysarthria (a motor speech disorder that weakens or paralyzes the muscles used for speech), and generalized muscle weakness (a total lack of physical strength where most areas of the body feel universally weak). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/28/2026, the MDS indicated Resident 1's cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions) was moderately impaired. The MDS also indicated Resident 1 had impairment on both sides of his upper extremities (shoulder, elbow, wrist, and hand) and lower extremities (hip, knee, ankle, and foot). During a review of Resident 1's fall risk care plan (CP), dated 1/30/2026, the fall risk care plan indicated Resident 1 was at risk for falls related to general weakness. The fall risk CP indicated interventions for Resident 1's fall risk included to remind Resident 1 to call for assistance with all transfers and to keep the call light within Resident 1's reach. During an observation on 7/15/2026 at 8:17 AM in the doorway of Resident 1's room, Resident 1 was observed lying in bed shouting incomprehensible words. During an interview on 7/15/2026 at 8:21 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated she is the morning CNA assigned to Resident 1. CNA 1 stated when Resident 1 is screaming, she knows he needs something such as repositioning or food. CNA 1 stated Resident 1 can say a few simple words to convey needs such as water, food, or call my family, but cannot speak full sentences for conversation. During a concurrent observation and interview on 7/15/2026 at 12:20 PM with Resident 1 in Resident 1's room, Resident 1 was lying in bed. Resident 1's fingers on bilateral hands, were stiff, straight and in extended position. Next to Resident 1's pillow was a hand-held call light device that required a button to be pressed to be activated. When the surveyor asked Resident 1 to demonstrate using the call light device. Resident 1 attempted to hold the call light device in the left hand. Resident 1 attempted to bend/flex the fingers to the left hand to press down on the call light button but was unable. Resident 1 stated that he could not press the call light button and could not use the current call light device. Resident 1 further stated he has never pushed the call light device button before, and if he needs the help of a nurse, he will make a lot of noise until they (facility staff) come to help him. During a concurrent observation and interview on 7/15/2026 at 12:44 PM with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1 was attempting to press down on his call light button but was unsuccessful. LVN 1 stated Resident 1 is unable to press his call light button and does not believe he is able to hold the device in his hand without the device falling. LVN 1 further stated Resident 1's call light device should be replaced with a different type that Resident 1 can use. LVN 1 stated it is not safe for residents to be unable to use their call light because they may not get the help they need and increases their risk for falls. During an interview on 7/16/2026 at 11:13 AM with CNA 4, CNA 4 stated CNA 4 has provided care of Resident 1 a few times in the past. CNA 4 stated Resident 1 is unable to use the call light because Resident 1's hands are not strong, so Resident 1 screams for help when he needs something. CNA 4 further stated if a resident is unable to use the call light, the resident is at risk for negative outcomes such as falls. During an interview on 7/16/2026 at 1:29 PM with the Director of Nursing (DON), the DON stated the facility has two different types of call light devices: the traditional call light device with a button to press for activation and a soft touch call light pad that requires a small amount pressure on the pad to activate. The DON stated residents that have limited mobility could benefit from a more appropriate form of call light device if they are unable to use the standard call light button. The DON further stated the purpose of the call light device is to give residents a way to call for help. The DON stated that if a resident is unable to use the call light, the resident is at risk for unfavorable outcomes such as any harm. During a review of the facility's policy and procedures (P&P) titled, Answering the Call Light, last reviewed 1/2026, the P&P indicated a general guideline to responding to resident's requests and needs includes to ensure the call light is within easy reach of the resident when they are in bed. The P&P further indicated the call light must be plugged in at all times and defective call lights must be reported to the nurse supervisor promptly.

Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services by failing to setup the mechanical ventilation (a type of therapy that helps you breathe or breathes for you when you can't breathe on your own) including the alarm settings for two out of four sampled residents (Resident 1 and Resident 2) as indicated in the facility's policy and procedure (P&P), titled, Ventilator Alarm Settings. This deficient practice had the potential to cause complications associated with respiratory treatment.Findings:1.During a review of the admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), persistent vegetative state (means someone with severe brain damage is in an awake but unaware state) and dependence on respirator status (means a person's body cannot breathe adequately on its own and requires a medical machine [a ventilator] to pump air in and out of their lungs). During a review of the Minimum Data Set (MDS -a resident assessment tool) dated 5/6/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Order Summary Report (OSR), dated 6/22/2026, the OSR indicated, physician ordered, Ventilator orders: AC (Assist-Control - is a breathing mode where the machine guarantees a set number of breaths, but also gives a full breath whenever it senses the patient trying to inhale) 12, VT (Tidal Volume - exact amount of air pushed into or drawn out of the lungs with a single, normal breath) 400, 5 LPM (Liters Per Minute - it is a measurement of flow speed-essentially, how fast the ventilator or oxygen machine is pushing a volume of air and oxygen into the patient's lungs every minute), PEEP (Positive End-Expiratory Pressure - is a setting that maintains gentle pressure in the lungs at the end of every breath) +5 every 6 hours. During a concurrent interview and record review of Resident 1's Ventilator Machine (VM) with Respiratory Therapist 1 (RT 1), on 6/29/2026 at 1:20 p.m., observed and reviewed Resident 1's VM Alarm/Event History with RT 1, the Alarm/Event Histories were dated 6/30/2026. Reviewed Resident 1's VM settings with RT 1 and the VM was dated 6/30/2026. RT 1 stated, Resident 1's VM was dated incorrectly which is why the Alarm/Event History showed dates in the future. RT 1 stated, the settings on Resident 1's VM should be the current date and time which is 6/29/2026.2.During a review of the admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), respiratory failure, and pneumonia (lung infection that inflames air sacs with fluid or pus). During a review of the MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 2 required total dependent from staff for ADLs. During a review of Resident 2's OSR, dated 6/22/2026, the OSR indicated, physician ordered, Ventilator orders: AC 12, VT 450, 3 LPM (Liters Per Minute - it is a measurement of flow speed-essentially, how fast the ventilator or oxygen machine is pushing a volume of air and oxygen into the patient's lungs every minute), PEEP +5 every 6 hours. During a concurrent interview and record review of Resident 2's VM with RT 1, on 6/29/2026 at 1:33 p.m., observed and reviewed Resident 2's VM Alarm/Event History with RT 1, the Alarm/Event Histories were dated 6/30/2026. Reviewed Resident 2's VM settings with RT 1 and the VM was dated 6/30/2026. RT 1 stated, Resident 2's VM was also dated incorrectly which is why the Alarm/Event History showed dates in the future. RT 1 stated, the settings on Resident 2's VM should be the current date and time which is 6/29/2026. RT 1 stated, if the date on the VM machine are incorrect, they will be unable to review the Events/Alarm History accurately. During an interview with Director of Nursing (DON) on 6/30/2026 at 3:59 p.m., DON stated, the RTs and Registered Nurses are responsible for tracheostomy care. DON stated, he is not familiar with VM but the settings of the date on the machines are to be set. DON stated, the dates on residents medical machine should represent the current date. During a review of the facility's P&P titled, Assessment of Resident on Mechanical Ventilation, reviewed on 3/20/2025, the P&P indicated that, In addition to patient assessments, evaluate ventilator operation and settings every one to two hours, or as needed, to assure that the patient receives therapy as req uired. Evaluation of the ventilator should include: Check ventilator mode and adjunct. Also check the tidal volume, respiratory rate (for example: ratio, FiO2, peak inspiratory pressure, sighs per minute, and temperature settings); Assess the patient's tidal volume, plateau pressure, and static compliance; Check all alarms to assure they are set; Check the airway pressure gauge; Monitor exhaled tidal volume; If the patient is on a ventilator with a heated airflow, the gauges should be maintained between 95 degree and 98.6 degrees Fahrenheit; maintain the water level marker on the humidifier at the fill line; assess for condensation in large-bore tubing; Assess all connections to assure they are secure. During a review of the facility's P&P titled, Ventilator Alarm Settings, dated 1/2026, the P&P indicated that, To provide for the safety of ventilator-dependent residents on the SNF (Skilled Nursing Facility)/Sub-Acute Unit. It is the policy of this facility to verify the operation of the low-pressure alarm on all ventilators in use on the SNF/Sub-acute unit daily.

Based on observation, interview, and record review, facility failed to: 1. Ensure one of four sampled residents (Resident 1)'s medications were not left at bedside after administering them according to facility's policy and procedures (P&P) titled, Administering Medications. 2. Ensure that one of four sampled residents (Resident 1 and Resident 2)'s medications were administered in accordance with the physician's orders, including any required time frame according to facility's P&P, titled, Administering MedicationsThis deficient practice increased the risk for accidents, unintended complications from receiving more or less than the required medications dose and jeopardized resident's health and safety by failing to administer necessary medications in accordance with the physician order.Findings:1. During a review of the admission Record, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure).During a review of the Minimum Data Set (MDS - resident assessment tool) dated 8/1/2025 indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required maximal assistant to total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a review of Resident 1's Medical Record, the facility did not do a Self-Administration of Medication Observation Assessment on Resident 1 upon readmission on [DATE].During a review of Resident 1's Order Summary Report (OSR), the OSR indicated the following medications:i. Sevelamer Carbonate (a medication that prevents increases in phosphates among people who are on dialysis due to chronic kidney disease) tablet 800 milligram (mg - unit of measurement) - give three tablets by mouth three times a day ii. Combigan opthlmalmic solution (a prescription eye drop medication that helps lower pressure inside the eye) 0.2-0.5 percent (% - unit of measurement) - Instill one drop in both eyes two times a day for glaucoma (a group of eye diseases that damage the optic nerve, which carries visual information from the eye to the brain)During a review of Resident 1's Medication Administration Audit Record (MAAR) on 9/5/2025, the MAAR indicated that the sevelamer carbonate tablets were scheduled to be administered at 9 a.m., but the record indicated, the medications were administered on 10:33 a.m. The MAAR also indicated that on 9/4/2025, the combigan eyedrops were scheduled to be administered at 9 a.m., but the record indicated, the combigan were administered at 3:38 p.m.During a concurrent observation and interview with Resident 1 on 9/5/2025 at 11:29 a.m., observed Resident 1 with a medication cup filled with three white tablets at her bedside table. Resident 1 stated she did not take the medications after they were given to her because she wanted to take them before eating lunch. Resident 1 stated that the nurse gave her the medication, and they don't observe when she takes the medication. Resident 1 further stated, sometimes, her medications were being administered late and they don't follow the physician's order for the time frame the medications were due.During a concurrent observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 9/5/2025 at 11:39 a.m., LVN 1 stated, he administered Resident 1's medications this morning but he left Resident 1's room without observing her taking the medications. LVN 1 stated, he was called and was in a hurry and did not watch Resident 1 taking the medication after giving it to her. LVN 1 stated, he also documented the medications as administered in the electronic medical record. LVN 1 compared the three white tablets with the medications in the bubble pack and stated, the three white tablets on Resident 1's medication cup were sevelamer carbonate.During an interview with the Director of Nursing (DON) on 9/5/2025 at 3:02 p.m., DON stated, medications should not be left at bedside, and nurses must witness residents taking the medications. DON stated, if a resident refuses to take the medication at the time when it was scheduled, nurses need to explain the risk and benefits of not taking the medication timely and document the refusal and notify the physician. DON stated that not giving the medication on time was a delay of patient's care that may interfere with residents' recovery process and plan of care. 2. During a review of the admission Record, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting left non-dominant side, acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and DM. During a review of the MDS dated [DATE], Resident 2's cognitive skills for daily decisions were intact. The MDS indicated Resident 1 required maximal assistant to total dependent from staff for ADLs.During a review of Resident 2's OSR, the OSR indicated the following medications were scheduled to be administered at 9 a.m.:i. Thiamine (a B-vitamin that helps your body turn food into energy and is essential for a healthy nervous system and heart) oral tablet 100 mg - give one tablet by mouth one time a day for supplementii. Lactobacillus (a probiotic supplement containing good or friendly bacteria that help restore a healthy balance of microbes in your body) capsule - give one tablet by mouth one time a dayiii. Modafinil (a prescription drug that promotes wakefulness) oral tablet 100 mg - give 100 mg by mouth one time a dayiv. Sertraline (a prescription antidepressant that works by adjusting your brain's chemistry to improve mood and reduce anxiety) oral tablet 25 mg - give 50 mg by mouth one time a dayv. Furosemide (a water pill that works by making your kidneys remove extra water and salt from your body) oral tablet 20 mg - give 20mg by mouth one time a dayvi. Midodrine (a medication used to treat very low blood pressure) oral tablet 5 mg - give 5 mg by mouth three times a dayvii. Multivitamin-minerals (contains a mix of different vitamins and minerals, which are essential nutrients your body needs to function properly) oral tablet - give one tablet by mouth one time a dayviii. Senna (a laxative that helps relieve occasional constipation by making your intestines more active) oral tablet 8.6 mg - give 8.6 mg by mouth two times a dayix. Ascorbic acid (a supplement form of Vitamin C, a nutrient your body needs to stay healthy) oral tablet 500 mg - give 500 mg tablet by mouth two times a dayx. Folic acid (a B-vitamin that helps your body create new, healthy cells) oral tablet 1 mg - give 1 mg by mouthy one time a day During a review of Resident 2's MAAR, dated 9/4/2025, the MAAR indicated that the medications that were scheduled to be administered at 9 a.m., were recorded as administered at 11:34 a.m.During a concurrent interview and record review with DON on 9/5/2025 at 3:10 p.m., DON reviewed Resident 2's MAAR and confirmed, Resident 2's medications were administered late. DON stated, medications must be administered timely per physician's order. DON further stated that not giving the medication on time was a delay of patient's care that may interfere with residents' recovery process and plan of care.During a review of the facility's policy and procedures (P&P) titled, Administering Medications, reviewed on 1/2025, the P&P indicated, Medications must be administered in accordance with the orders, including any required time frame. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on interview and record review, the facility failed to initiate and review a resident specific discharge planning during admissions and quarterly reviews for one of three sample residents (Resident 3). This deficient practice resulted in a lack of individualized discharge planning to ensure Resident 3 receive appropriate and timely planning during a transition of care. Findings: A review of Resident 3's admission record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of acute pulmonary edema (a condition where fluid builds up in the lungs, making it hard to breathe), muscle weakness (a lack of strength in the muscles), anxiety disorder (a person is often worried or anxious about many things and finds it hard to control), type 2 diabetes mellitus without complications (A long-term condition in which the body has trouble controlling blood sugar and using it for energy), bilateral primary osteoarthritis of knee (a degenerative joint disease where cartilages cushioning the bones wears down, leading to pain, stiffness, and limited mobility in both knees). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 3/26/2025 indicated partial/moderate assistance (helper does less than half the effort, lifts, holds, or supports trunk or limb) for toilet transfer, chair/bed-to-chair transfer. No active discharge planning already occurring for the resident to return to the community. During a review of Resident 3's MDS dated [DATE] indicated, set up or clean-up assistance for eating. Supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard to complete activity) to sit and stand, toilet transfer (the ability to get in and out of a toilet or commode). No active discharge planning already occurring for the resident to return to the community.During a review of Resident 3's admissions care plan initiated on 3/20/2025, discharge care plans were not documented. During a review of Resident 3's quarterly care plan revised on 6/23/2025, discharge care plans were not documented. During an interview on 8/16/2025 at 9:25 AM with Resident 3, Resident 3 stated, the facility staff has been discussing discharge planning but did not provide a specific discharge date . Resident 3 stated, Two weeks ago, if no longer they told me I am ready to discharge because I was asking for it.During an interview on 8/16/2025 at 10:07 AM, Licensed Vocational Nurse (LVN) 1 stated, Resident 3 has been wanting to go home, I don't believe she can maintain her activities of daily living (ADL) fully by herself. Resident 3 will need assistance to ambulate to the toilet, bathroom, and for cleaning. During a concurrent interview and record review on 8/18/2025 at 10:40 AM, with LVN 1, Resident 3's care plans during admissions and quarterly review were reviewed. The care plan for discharge planning was not documented. LVN stated, care plan is implemented by MDS coordinator and Social Services (SS) worker. Care plan for discharges can benefit Resident 3 with proper planning and accommodation after discharge. During an interview on 8/18/2025 at 11:01 AM with Social [NAME] assistant (SS), SS stated, discharge planning is initiated by admitting licensed person and social services during resident admissions. Resident 3's discharge care plan was not documented during admissions and quarterly review. SS stated, discharge planning has been discussed with Resident 3 at different occasions, but care plan is not documented. During a concurrent interview and record review on 8/18/2025 at 11:34 AM with MDS coordinator, Resident 3's MDS and care plans during admissions on 3/20/2025 and quarterly review on 6/23/2025 were reviewed. MDS stated, care plans are implemented based on MDS assessments and resident's individual care needs. Discharge care planning should be initiated during admissions regardless of a resident's status. MDS stated, It is a deficiency not to document required care plans because it potentially affects the resident's care delivery. During an interview with the Director of Nursing (DON), on 8/18/2025 at 12:34 PM, the DON stated, I am not sure if Resident 3 was supposed to have a discharge care plan during admission. Discharges are determined by residents' desire, physician's decision and care team evaluations. A review of the facility's Policy and Procedures (P&P) titled, Care Plans -Comprehensive revised January 2025, the P&P indicated, The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. The care planning/Interdisciplinary Team is responsible for the review and updating of care plans: when the resident has been readmitted to the facility from a hospital stay; and at least quarterly.

Based on interview and record review, the facility failed to honor one of the three sampled residents (Resident 2) rights by failing to administer her ordered topical medication Triamcinolone Acetonide External Cream 0.1 % (belongs to the class of medications that are synthetic steroids used to reduce inflammation and itching of the skin. It works by reducing swelling, redness, and itching associated with various skin conditions) to her right elbow.This deficient practice resulted in Resident 2 not being able to make her own decisions regarding her own medications.During a review of the admission record for Resident 3 indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure (ACRF-when the lungs can't adequately provide enough oxygen to the body or remove enough carbon dioxide, and this condition happens suddenly but also persists over an extended period), hypertension (HTN-high blood pressure), and Hyperlipidemia (HLD- a condition in which there are abnormally high levels of lipids [fats] in the blood)During a review of Resident 2's late entry nursing note dated 5/20/2025 at 10:41 am indicated, Seen by dermatologist during tx (treatment) rounds concerning the current right arm with non-descript. erythematous papules (small, raised, red bumps on the skin). Skin scrapping (a diagnostic procedure where a healthcare provider scrapes a small sample of skin cells from a lesion or affected area using a scalpel or similar blade. It is immensely useful in skin infections such as fungus, bacteria, or even scabies mite infections) result is negative (5/15/25). She recommends topical Clobetasol oint (ointment) but Rp (representative) refused to be applied. Respect the refusal. Will continue to monitor.During a review of Resident 2's physician notes with an effective date range of 7/7/2025 indicated, Resident 2 was alert and oriented x 4 (alert and oriented to person, place, time and event are evaluated and understood who they are, where they are, approximate date or part of the day, and what is happening).During a review of a physician's order dated 6/14/2025 indicated, Triamcinolone Acetonide External Cream 0.1 % (Triamcinolone Acetonide (Topical) Apply to Affected areas topically one time only for topical redness and itching for 1 Day right posterior elbow, LUA (left upper arm), anterior upper leg.During an observation and interview with Resident 2 on 7/22/2025 at 11:17 am, Resident 2 was observed to have approximately 1.5-inch circular cluster of a raised scaly rash which was light brown is color located just above her elbow. Resident 2 was unable to vocalize due to the tracheostomy (often referred to as a trach, is a surgically created opening in the windpipe (trachea) through the neck) but was able to move her lips for lip reading as well as nodding yes and no. Resident 2 stated that she did get itchy but got relief with the application of the ointment. During an interview with Treatment Nurse (TN) 2 on 7/22/2025 at 1:23 pm, TN 2 stated that Resident 2's rash was recurring (occurring often or repeatedly) in the same area. TN 2 stated that Resident 2 was seen by a dermatologist who diagnosed it as fungal dermatitis (a skin condition caused by fungi, often appearing as a red, itchy, and scaly rash) and was ordered Triamcinolone Acetonide External Cream 0.1 %. TN 2 stated that the facility staff did not regularly apply the ordered ointment because Resident 2's RP was refusing the treatment. TN stated that Resident 2 was alert, oriented, and able to understand and make her own decisions. TN2 stated that she as well as the other facility staff did not ask the Resident if she wanted the treatment but accepted and respected the decision of Resident 2's RP even though they are not the resident's decision maker. TN2 admitted that by not allowing Resident 2 to decide if she wanted to have the ointment administered or not was noy allowing her to exercise her rights.During an interview with the Assistant Director of Nursing (ADON) on 7/22/2025 at 2:51 pm, the ADON stated that residents who are able to make their own decisions must be involved in their planning and administration of their own medications because that is their right.During a review of the Policy and Procedure (P&P) titled Resident Rights, revised 1/2025, the P&P indicated: Federal and state laws guarantee certain basic rights to all residents of this facility. Theserights include the resident's right to:- Be informed about what rights and responsibilities he or she has.- Choose a physician and treatment and participate in decisions and care planning.- Privacy and confidentiality.- Self-administer medication, if the interdisciplinary care planning team determines it is safe; and Refuse a transfer from a distinct pa rt within the institution.

Based on observation, interview, and record review, the facility failed to create an individualized care for one of three sampled residents (Resident 3) with specific goals and interventions for Resident 3's right upper arm and right groin rash. This deficient practice had the potential to result in worsening of Resident 3's rashDuring a review of the admission record for Resident 3 indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Chronic Respiratory Failure (CRF-when the lungs can't adequately provide enough oxygen to the body or remove enough carbon dioxide, and this condition persists over an extended period), and Hyperlipidemia (HLD- a condition in which there are abnormally high levels of lipids [fats] in the blood) During a review of history and physical (H&P- is a thorough assessment a doctor does to understand a patient's health. It involves asking about the patient's past and current health problems [the history] and then examining the patient's body to look for signs of illness [the physical examination], dated 6/13/2025 at 2 pm, indicated Resident 3 did not have capacity (he ability to understand information, make decisions, and communicate those decisions). During a review of Resident 3's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/3/2025 at 2:52 pm, indicated, Noted rashes RT arm and RT upper leg scattered rashes Informed DR (Resident 3's physician}. During a review of Resident 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated 7/10/2025, indicated Resident 3 had severe cognitive impairment (a person has great difficulty with thinking, learning, remembering, and making decisions, to the point where they can't live independently). The same MDS indicated Resident 3 was dependent on staff for his Activities of Daily Living such as: (ADLs­ routine tasks/activities such as eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of a physician's order dated 7/10/2025 indicated, skin scraping (a diagnostic procedure where a healthcare provider scrapes a small sample of skin cells from a lesion or affected area using a scalpel or similar blade. It is immensely useful in skin infections such as fungus, bacteria, or even scabies mite infections) one time only for one day During a review of Resident 3's SBAR dated 7/11/2025 at 8:28 pm, indicated, A new skin finding was noted by CNA (Certified Nursing Assistant) staff during daily skin check. Patient's (Resident 3) skin was examined by Tx (treatment) staff noting discoloration of the left outer forearm, skin intact with no sign of infection. MD (medical doctor) ordered monitor for skin breakdown, infection, or increase in size. During a review of Resident 3's care plan initiated 7/3/2025 indicated a focus of Skin: Resident has a body rash located (RT UPPER ARM and is at risk for pain or discomfort, skin breakdown, spreading and worsening of the rash, the interventions/tasks included:-Administer anti-pruritic medication as ordered.-Administer treatments as ordered and monitor for effectiveness.-Avoid the use of harsh detergents, soaps, fragrances, or other irritating substances.-Encourage to avoid scratching. During a concurrent observation of Resident 3 and interview with CNA 1 on 7/22/2025 at 12:24 pm, Resident 3 was observed to have a scattered papule appearing rashes to his right upper arm that were red brownish in color. The resident was also noted to have a few rashes to the right side of his groin which was also scattered, papule appearing, red brownish in color. CNA stated that she noticed the rash about two weeks prior. During a concurrent interview with Treatment Nurse (TN) 1 and record review of Resident 3's medical records on 7/22/2025 at 12:40 pm, TN 1 confirmed that Resident 3's rashes (right upper arm and right groin area) was first observed on 7/3/2025 and that a skin scrape test was completed on 7/10/2025. During a review of the care plan initiated on 7/3/2025, TN 1 confirmed that the interventions which included administer anti-pruritic medications and treatments as ordered were not individualized and specific. TN 1 admitted that medications must be listed by name and ensure that the interventions are specific to each Resident. TN 1 stated that the potential of not individualizing an care plan could result in miscommunication or misinterpretation amongst Resident 3's healthcare providers and may impact care. during a review of the Policy and Procedure (P&P) titled Care Plans - Comprehensive, revised 1/2025, indicated the following policy statement, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The same P&P policy interpretation and implementations included:Each resident's comprehensive care plan is designed to:a. Incorporate identified problem areas.b. Incorporate risk factors associated with identified problems.c. Build on the resident's strengths.d. Reflect the resident's expressed wishes regarding care and treatment goals.e. Reflect treatment goals, timetables and objectives in measurable outcomes.f. Identify the professional services that are responsible for each element of care.g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels.h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; [NAME]. Reflect currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to implement infection control policies and procedures (P&P) for one out of three residents (Resident 3) by failing to ensure Resident 3 who had a rash and was ordered a scrape test on 7/10/2025 was placed on contact isolation ( a set of precautions used in health care to prevent the spread of infections that are transmitted through direct or indirect contact with a patient or their environment).This deficient practice potentially increased the risk of infection to other residents and facility staff.During a review of the admission record for Resident 3 indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Chronic Respiratory Failure (CRF-when the lungs can't adequately provide enough oxygen to the body or remove enough carbon dioxide, and this condition persists over an extended period), and Hyperlipidemia (HLD- a condition in which there are abnormally high levels of lipids [fats] in the blood) During a review of history and physical (H&P- is a thorough assessment a doctor does to understand a patient's health. It involves asking about the patient's past and current health problems [the history] and then examining the patient's body to look for signs of illness [the physical examination], dated 6/13/2025 at 2 pm, indicated Resident 3 did not have capacity (he ability to understand information, make decisions, and communicate those decisions). During a review of Resident 3's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/3/2025 at 2:52 pm, indicated, Noted rashes RT arm and RT upper leg scattered rashes Informed DR (Resident 3's physician}. During a review of Resident 3 ' s Minimum Data Set (MDS - a resident assessment tool) dated 7/10/2025, indicated Resident 3 had severe cognitive impairment (a person has great difficulty with thinking, learning, remembering, and making decisions, to the point where they can't live independently). The same MDS indicated Resident 3 was dependent on staff for his Activities of Daily Living such as: (ADLs­ routine tasks/activities such as eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of a physician's order dated 7/10/2025 indicated, skin scraping (a diagnostic procedure where a healthcare provider scrapes a small sample of skin cells from a lesion or affected area using a scalpel or similar blade. It is immensely useful in skin infections such as fungus, bacteria, or even scabies mite infections) one time only for one day During a review of Resident 3's SBAR dated 7/11/2025 at 8:28 pm, indicated, A new skin finding was noted by CNA (Certified Nursing Assistant) staff during daily skin check. Patient's (Resident 3) skin was examined by Tx (treatment) staff noting discoloration of the left outer forearm, skin intact with no sign of infection. MD (medical doctor) ordered monitor for skin breakdown, infection, or increase in size. During a concurrent observation of Resident 3 and interview with CNA 1 on 7/22/2025 at 12:24 pm, Resident 3's room entrance was observed to have a sign for Enhance Based Precautions (EBP- implemented in nursing homes to reduce the spread of multidrug-resistant organisms [MDROs]. Staff are required to use gowns and gloves during high contact activities with residents). Resident 3 was observed to have a scattered papule appearing rashes to his right upper arm that were red brownish in color. The resident was also noted to have a few rashes to the right side of his groin which was also scattered, papule appearing, red brownish in color. CNA stated that she noticed the rash about two weeks prior. During a concurrent interview with Treatment Nurse (TN) 1 and record review of Resident 3's medical records on 7/22/2025 at 12:40 pm, TN 1 confirmed that Resident 3's rashes (right upper arm and right groin area) was first observed on 7/3/2025 and that a skin scrape test was completed on 7/10/2025. TN 1 confirmed that a skin scrape test was ordered to rule out scabies. TN 2 confirmed that scabies are contagious and must be on contact precautions. TN 1 admitted that EBP precautions may not be enough tp prevent the spread of infection. During a concurrent interview and record review of Resident 3's records with the Assistant Director of Nursing (ADON) on 7/22/2025 at 2:51 pm, the ADON confirmed that a scrape skin test was completed for Resident 3 on 7/10/2025. ADON confirmed that Resident was in EBP even after the scare test was ordered and completed. The ADON was not aware about the procedures of placing residents on contact isolation when a scrape test was ordered, stating that the resident was already on EBP. The ADON confirmed that when a resident is on EPB the PPE (Personal Protective Equipment-gown, gloves) are donned during personal high contact activities, while in contact isolation the PPE is donned before entering the room. The ADON confirmed that the facility also follows CDC (Centers for Disease Control and Prevention) guidelines. During a review of the Policy and Procedure (P&P) titled Infection Control, effective date 4/1/2025, indicated, it is the policy of this facility to prevent the spread of infection. Standard Precautions will be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others.

Based on interview and record review, the facility failed to provide a copy of the records upon request for one of four sampled residents (Resident 1).This deficient practice violated the rights of Resident 1's legal representative to obtain a copy of the medical records.Findings:During a review of the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical dated 7/30/2022 indicated, Resident 1 can make needs known but cannot make medical decisions. During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/1/2023, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required maximal assistance to dependent from staffs for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Limited Durable Power of Attorney (POA - authorizes someone else to handle certain matters, such as finances or health care, on someone's behalf. If the power of attorney is durable, it remains in effect if the person becomes incapacitated for any reason, including illness and accidents) for healthcare indicated, Resident 1's family member 1 (FM 1) was Resident's 1 appointed POA, signed and dated on 4/29/2025. During a review of Resident 1's Attestation Regarding a Requested Use of Disclosure of Protected Health Information Potentially Related to Reproductive Health Care (a signed document where someone requesting health information), dated 5/2/2025, indicated that a request for release of medical records form was faxed to the facility on 5/2/2025 and a follow-up request was sent to the facility via mail on 2/6/2025. During an interview with Family Member 1 Legal Representative (FMLR 1) on 7/14/2025 at 11:08 a.m., FM 1 stated, he requested Resident 1's medical record on behalf of Resident 1's Family Member back in May 2025 but had not received any medical records from the facility up to this date, 7/14/2025. During an interview with the Medical Record Director (MRD) on 7/14/2025 at 12:39 p.m., the MRD stated, a request for release of medical records was sent via email to the facility for Resident 1. MRD stated they have not sent these medical records as she is waiting for approval. The MRD further stated that the release of medical records must be sent timely within 5-7 business days. During a review of facility's policy and procedure (P&P) titled, Release of Information, revised on 1/2025, the P&P indicated, The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes. Such requests will be honored only upon receipt of a written, signed, and dated request from the resident or representative (sponsor). A resident may have access to his or her records within five days (excluding weekend or holidays) of the resident's written or oral request.

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 3 and Resident 4) who are fed by enteral received appropriate treatment and services by failing to elevate the head of the bed while receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach).This deficient practice had the potential to cause aspiration (inhalation of foreign materials) and can lead to pneumonia (a lung infection) for Resident 3 and Resident 4.Findings:1. During a review of the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), dysphagia (difficulty swallowing) and shortness of breath (an intense tightening in the chest, air hunger, difficulty breathing, breathlessness or a feeling of suffocation). During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 6/20/2025, indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 3 required total dependence from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 3's Order Summary Report (OSR), dated 4/10/2025, indicated physician ordered, Enteral Feed Order every shift Enteral - elevate head of head (HOB) 30 - 40 degrees (unit of measurement) at all times during feedings and for 30 minutes post-administration of feedings. During a review of Resident 3's Care Plan, date initiated on 3/29/2024, indicated an intervention of, The resident needs the HOB elevated 45 degrees during and thirty minutes after tube feed. During an observation of Resident 3 on 7/14/2025 at 11:19 a.m., Resident 3 was in bed, receiving feeding via GT with a HOB at about 15 degrees up. During a concurrent observation and interview with Registered Nurse 1 (RN 1) on 7/14/2025 at 11:31 a.m., RN 1 observed Resident 3's HOB and stated and confirmed, Resident 3's HOB needs to be elevated as the HOB is very low. RN 1 stated, the HOB needs to be elevated at least 30-40 degrees while receiving TF. 2. 2. During a review of the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), respiratory failure, and dysphagia. During a review of the MDS dated [DATE], Resident 4's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 3 required total dependence from staff for ADLs. During a review of Resident 4's OSR, dated 7/4/2025, indicated physician ordered, Enteral Feed Order every shift, Enteral - elevate HOB 30 - 40 degrees at all times during feedings and for 30 minutes post-administration of feedings. During an observation of Resident 4 on 7/14/2025 at 11:26 a.m., Resident 4 was in bed lying on his left sideways, receiving feeding via GT with a HOB at less than 30 degrees, the HOB was almost in a flat position. During a concurrent observation and interview with RN 1 on 7/14/2025 at 11:36 a.m., RN 1 observed Resident 4's HOB and stated and confirmed, Resident 4's HOB is at about 20 degrees up and definitely needs to be higher. RN 1 stated, the HOB needs to be elevated at least 30-40 degrees while receiving TF as this put residents at risk of aspiration, choking, and emesis, among other complications. During an interview with Director of Nursing (DON) on 7/15/2025 at 12:30 p.m., DON stated, residents' HOB must be elevated to semi-Fowlers position (when a person is lying on their back with their upper body slightly raised. The head of the bed is lifted to an angle between 30 and 45 degrees) while receiving TF to prevent risk of aspiration. During a review of the facility's policy and procedures (P&P) titled, Enteral Feedings - Safety Precautions, revised on 1/2025, the P&P indicated, Elevate the head of bed (HOB) at least 30 degrees during tube feedings and at least one hours after feeding.

Based on observation, interview, and record review the facility failed to ensure that the facility staff did not refer to residents needing assistnace [NAME] feeding as Feeders for seven of seven sampled residents (37, 97, 94, 95, 165, 188, and 454). This deficient had the potential to result in lowered self esteem for the residents needing assistnace with feeding. Findings: During a record review, Resident 37's admission record, indicated Resident 37 was admitted to the facility (skilled nursing facility [SNF]) on 3/31/25, with diagnoses that included, muscle weakness (a lack of physical or muscle strength, throughout the body), diabetes Type 2 (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). During a record review, Resident 37's Minimum Data Set (MDS - a resident assessment tool), dated 4/24/25, indicated Resident 37's cognition (the mental ability to make decisions of daily living) was moderately impaired. Resident 37 required substantial/maximal assistance with all activities of daily living (ADL- bed mobility, transfer, eating, toilet use and personal hygiene). During a record review, Resident 94's admission record, indicated Resident 94 was admitted to the facility on [DATE], with diagnoses that included, chronic obstructive pulmonary disease (COPD - a lung disease that damages the lungs and makes breathing difficult), and muscle weakness (a lack of physical or muscle strength, throughout the body). During a record review, Resident 94's MDS dated [DATE], indicated Resident 94's cognition was severely impaired. Resident 94 required substantial/maximal assistance with all ADL. During a record review of Resident 95's admission record, indicated Resident 95 was admitted to the facility on [DATE], with diagnoses that included, hypertension (Also known as high or raised blood pressure, a condition in which the blood vessels have persistently raised pressure causing a high blood pressure reading), and muscle weakness. During a record review, Resident 95's MDS dated [DATE], indicated Resident 95's cognition was severely impaired. Resident 95 required substantial/maximal assistance with all ADL. During a record review, Resident 97's admission record, indicated Resident 97 was admitted to the facility on [DATE], with diagnoses that included, muscle weakness, and anxiety disorder (restlessness, worried, tense, or afraid of what may happen in the future). During a record review, Resident 97's MDS dated [DATE], indicated Resident 97's cognition was severely impaired. Resident 97 required substantial/maximal assistance with all ADL. During a record review, Resident 165's admission record, indicated Resident 165 was admitted to the facility on [DATE], with diagnoses that included, pressure ulcer (also known as bedsore or pressure sore, is damage to the skin and underlying tissue caused by prolonged pressure, due to lying or sitting in one position for too long), of sacral region (the area between the lower back and the tailbone), and diabetes Type 2. During a record review, Resident 165's MDS dated [DATE], indicated Resident 165's cognition was moderately impaired. Resident 165 required substantial/maximal assistance with all ADL. During a record review, Resident 188's admission record, indicated Resident 188 was admitted to the facility on [DATE], with diagnoses that included, depression, (a constant feeling of sadness and loss of interest), and diabetes Type 2. During a record review, Resident 188's MDS dated [DATE], indicated Resident 188's cognition was moderately impaired. Resident 188 required substantial/maximal assistance with all ADL. During a record review, Resident 454's admission record, indicated Resident 454 was admitted to the facility on [DATE], with diagnoses that included, hypertension, muscle weakness, and diabetes Type 2. During a record review, Resident 454's MDS dated [DATE], indicated Resident 454's cognition was intact. Resident required substantial/maximal assistance with all ADLs. During an interview and concurrent record review on 6/24/25 at 1:10 PM with Certified Nursing Assistant (CNA) 6, the facility document titled Feeders was reviewed. CNA 6 stated staff have a list of feeders ssigned to Restorative Nurse Assistants (RNAs - CNAs with specialized training in restorative care, focusing on helping patients regain or maintain their physical function and independence) and CNAs. CNA 6 stated while pointing on the document, that Resident 165, and all the people (Residents 37, 97, 94, 95, 165, 188, and 454) on the list are feeders. During an interview on 6/24/25 at 2:38 PM the Director of Staff Developement (DSD) stated the residents who need assistance with feeding have a specific staff (RNAs and CNAS) assigned to feeds them (residents). The DSD stated that residents that are fed or need assistance with feeding are called the feeders. During an interview on 6/24/25 at 2:48 PM, the Interim Director of Nursing (IDON) stated, it is a matter of respect and dignity that the residents are addressed by their name, even if they do not understand what you are saying to them. During a record record review, the facility policy and procedures (P&P) titled Assistance with Meals revised 1/2025, indicated Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation. 1. Facility Staff will serve resident trays and will help residents who require assistance with eating. 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: A. Not standing over residents while assisting them with meals. B. Keeping interactions with other staff to a minimum while assisting residents with meals; C. Avoiding the use of labels when referring to residents (e.g., feeders).

Based observation, interview, and record review, the facility failed to: 1. Complete annual performances evaluations and annual skills competencies for eight of eight employees. This deficeint practice had the potential to cause harm to the residents. 2. Licensed nurses did not identify discrepancy (difference) between the medication on hand and what the medical doctor (MD) ordered for Resident 9. 3. Three of Three sampled Licensed Vocational Nurses (LVNs- 9, 11, and 13) were not able to correctly identify basic nursing dosage calculation conversions including the conversions from one ounce (oz - standard unit of weight) to milliliters (ml - a unit of volume) and from a tablespoon (tbsp - a common prescription used to dose liquid medications) to milliliters. 4. One of nine licensed nurses did not use proper dosing measurement tools to accurately measure the medication for Resident 157 as ordered by the MD. These deficient practices of failing to identify the discrepancy between the medication on hand and what the MD ordered, basic nursing dosage calculation conversions, and accurately measuring medications using proper dosing tools had the potential to cause physical and psychological harm to Residents 9 and 157. Cross Reference F759 and F760 Findings: During an interview and concurrent record review on 6/24/2025 from 2:45 PM, eight of eight employee files were reviewed with Director of Staff Development (DSD) and the following were noted: 1. House Keeping Supervisor-no annual tuberculosis (TB, is caused by bacteria that are spread through the air from person to person) skin test, last background check was 2017, last sexual harassment prevention completion was 3/7/2017, there was no annual physical and competencies. 2. LVN 9-TB Skin Test Report 1st step dated 4/2 (no year indicated), no date of skin test reading. The employee health examination was incomplete, Personal protective equipment (PPE, is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) competency was incomplete, the room cleaning check list incomplete, and the terminal room cleaning check list incomplete. 3.LVN 10 with hire date of 9/3/2020 there was no current TB skin test, no current elder abuse screening, last annual employee health questionnaire/physical 9/3/2020, there were no annual skills competencies. 4. RN 3 with date of hire of 5/7/2023, the last elder abuse training was completed on 5/7/2023, and the last background check 6/12/2023. 5. LVN 16 with hire date of 4/29/2016, the last annual physical was dated 12/28/2018, last TB skin test was dated 2/2/2018, BLS/CPR (BLS [Basic Life Support] and CPR [Cardiopulmonary Resuscitation] are medical procedures used to save lives in emergency situations) card with expiration date of 5/2025, and a background check dated 12/22/2015. 6. Respiratory Therapist (RT - ) is a healthcare professional specializing in the diagnosis, treatment, and the last competency 10/13/2021, 7. RT 2 with hire date of hire 5/31/2018, there was no current abuse training, annual skills, current physical, and no TB skin test, 8. RT Lead with hire date of 9/20/2022, the last background check was completed on 5/15/2025, there was no annual skills competency, no TB skin test, no background check, no abuse training, and no annual physical. During the same interview and concurrent record review with the DSD, the DSD stated sexual harassment training is renewed every two years. The DSD stated that the staff physicals and TB skin test are supposed to be completed yearly, the fire safety and CPR cards are supposed to be renewed every two years. The DSD further stated that the abuse training was supposed to be completed quarterly and as needed. The DSD stated performance evaluations annual skills competencies are to be completed by the DSD. The DSD stated if annual skills competencies are not completed annually, the staff can forget how to care for the residents competently in which it could cause harm to the residents. The DSD further stated all employee documents should be kept in the employee files and readily accessible. During a review of the facility's policy and procedures (P&P) titled Competency of nursing Staff with a revised date of 1/2025, the P&P indicated, Policy Interpretation and implementation: 3. The facility assessment includes an evaluation of the staff competencies annually that are necessary to provide the level and types of care specific to the resident population. 2. During a review of Resident 9's admission Record (face sheet - a document containing demographic and diagnostic information) indicated Resident 9 was admitted on [DATE] and was readmitted on [DATE] with the following diagnoses: neuromuscular dysfunction of the bladder (neuromuscular dysfunction of the bladder), peptic ulcer (a condition that causes ulcers (open sores) to develop in the lining of your digestive tract), gastroesophageal reflux (GERD - digestive disorder where stomach acid flows back into the esophagus), tracheostomy (a surgical procedure that creates an opening in the neck, directly into the windpipe, to assist breathing), contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), dependence on supplemental (extra) oxygen, gastrointestinal hemorrhage (a type of bleeding in the gut), and persistent vegetative state (a severe neurological condition characterized by a lack of awareness of oneself and the environment, despite the presence of sleep-wake cycles and basic reflexes). During a review of Resident 9's History and Physical (H&P - a physician's complete patient examination) dated 1/04/2025 indicated, Resident 9 did not have capacity to understand and make medical decisions. During a review of Resident 9's MDS dated [DATE], indicated, Resident 9 had severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 157 was completely dependent on staff for all self-care (the act of attending to one's physical or mental health) needs. During a review of Resident 9's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for June 2025 indicated, an MD ordered to give Resident 9 Polyethylene Glycol 1450 powder 17 milligram (mg - unit of measure) with 8 oz of water and stir with disposable spoon via gastrostomy tube (G-Tube - a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and meds) two times a day for constipation. During a review of Resident 157's admission Record indicated Resident 157 was admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses: atherosclerotic heart disease (damage or disease in the heart's major blood vessels), idiopathic hypotension (low blood pressure that develops without a known, identifiable cause), benign prostatic hyperplasia with lower urinary tract symptoms (frequent urination, a sudden urge to urinate, waking up at night to urinate), resistance (the act or power of resisting, opposing, or withstanding to multiple antibiotics), and history of other infectious and parasitic diseases (previously experienced infections or parasitic infestations that are not specified elsewhere in their medical history). During a review of Resident 157's H&P dated 5/27/2025 indicated, Resident 157 did not have capacity to make medical decisions. During review of Resident 157's Minimum Data Set (MDS - a resident assessment tool) dated 5/27/2025, indicated that Resident 157 had severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 157 was completely dependent on staff for all self-care (the act of attending to one's physical or mental health) needs. During review of Resident 157's MAR for June 2025 indicated, an MD ordered to give Resident 157 Psyllium Husk Powder (psyllium husk bulk - a dietary fiber supplement in a powder form helps with constipation) to give 1 tablespoon (tbsp) via gastrostomy tube (G-Tube - a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and meds) one time a day for bowel management, hold if loose stool, add 8 oz of fluid, stir well . During a review of Resident 157's MD Progress Notes (a doctor's written record that documents a patient's health status, treatment, and care plan) dated 6/24/2025, indicated Resident 157 did not have capacity to make medical decisions. 3. During a concurrent medication pass observation and interview on 6/25/2025 at 8:27 AM with Licensed Vocational Nurse (LVN) 11, LVN 11 was observed using a white plastic spoon to scoop out fiber powder (psyllium husk) medication from the medication container then placed the fiber powder in a 30 mL measuring cup. LVN 11 was then observed transferring the fiber powder into a 9 oz clear cup then added water without measuring 1 tbsp of fiber powder and 8 oz water as ordered by the MD. Just before LVN 11 was about to enter resident's room to gown up then pass the medications to Resident 157, the writer asked LVN 11 to demonstrate how LVN 11 measured 1 tbsp of fiber powder. LVN 11 observed take a white plastic spoon from the medication cart, placed the spoon about 6 inches Infront of LVN 11's face while frowning. When asked if the spoon is what LVN 11 uses to measure 1 tbsp of fiber powder, LVN 11 stated, Ahhh .yeah, this is a tablespoon while rolling her eyes. When LVN 11 was asked why LVN 11 did not use any measuring tools to measure 1 tbsp of fiber powder and 8 oz of water as ordered by the MD, LVN 11 was very quiet and did not answer. the writer. When asked how many mL was in a tbsp (correct answer 15 mL), LVN 11 she was very quiet .then shook her head, stated I don't know. When asked how many mL was in an ounce (correct answer 30 mL), LVN 11 stated, I don't know. LVN 11 it is important to follow MD's order by measuring 1 tbsp of fiber powder and 8 oz of water prior to administering the medication to Resident 157 for accuracy because too much fiber can cause Resident 157 to have diarrhea (loose stools), dehydration, tiredness, and stomach pain. During a concurrent observation, interview, and record review on 6/25/2025 at 8:27 AM with LVN 11 and LVN 13, Resident 9's MAR for 6/2025 was reviewed and a bottle of Polyethylene Glycol 3350 was inspected. LVN 11 did not read the bottle of Polyethylene Glycol 3350 on hand to compare with the MD's orders. LVN 11 stated the MAR indicated Polyethylene Glycol 1450 while the bottle indicated Polyethylene Glycol 3350. When asked LVN 11 if LVN 11 prepared the correct dose of Polyethylene Glycol for Resident 9, LVN 11 did not answer and remained quiet. LVN 11 then asked LVN 13 to check the medication room for Polyethylene Glycol 1450. LVN 13 returned and stated, we don't have that on stock, our house stock is always the 3350 (Polyethylene Glycol) . We never had (Polyethylene Glycol) 1450. During an interview on 6/25/2025 at 11:35 AM with LVN 13, LVN 13 was asked for a basic nursing dosage calculation of how much mL was in a tbsp, LVN 13 answered 16 mL (correct answer 15 mL). LVN 13 was asked for a basic nursing dosage calculation of how much mL was in an oz, LVN 13 was not able to provide any answers (correct answer 30 mL). During an interview with LVN 9, on 6/25/2025 at 12 PM, LVN 9 was asked for a basic nursing dosage calculation of how much mL was in a tbsp, LVN 9 answered 2.5 mL (correct answer 15 mL). During an interview with the Interim Director of Nursing (IDON), on 6/25/2025 at 2:58 PM, the IDON stated licensed nurses who administer medications to residents were expected to follow MD orders as written and to use their resources they have to measure properly. During an interview with the IDON, on 6/25/2025 at 3:42 PM, the IDON stated, if the nurse staff notices the MAR is different from what they have on hand, then they need to reach out to the MD for clarification. IDON also stated IDON expected the licensed nurses should reach out to MD to clarify and state what we have on hand and what we have as an order and to clarify with the MD how [MD] would like us to proceed. During a review of the facility's P&P titled Administering Medications with a revision date of January 2025, indicated, medications shall be administered .as prescribed and medications must be administered in accordance with the orders.

Based on interview and record review, the facility failed to ensure three of nine sampled residents (Residents 9, 37, and 157) were free from significant medication errors (an error in medication preparation or administration that can cause the resident discomfort or jeopardizes his or her health and safety) according to professional standards of practice by failing to: 1. Ensure Resident 37's Insulin Lispro (man-made version of human insulin used to manage blood sugar levels in people with diabetes [DM: a chronic condition where the body does not produce or use insulin properly, leading to high blood sugar levels]) Injection Solution 100 Unit/mL (milliliters) Inject 18 units subcutaneously (beneath the skin) before meals for DM 2 Rotate site. Hold for blood sugar (BS) less than (<) 100 and notify medical doctor (MD) if BS<80 or greater than (>) 400 was administered before dinner on 6/23/2025. 2. Ensure Licensed Vocational Nurse (LVN) 11 identified the discrepancy (differences) between the medication on hand and what the medical doctor (MD) ordered for Resident 9. 3. Ensure LVN 11 used the correct dosing tools to accurately measure Psyllium Husk Powder (psyllium husk bulk - a dietary fiber supplement in a powder form that helps with constipation) for Resident 157. 4. Three of three sampled Licensed Vocational Nurses (LVNs- 9, 11, and 13) were not able to correctly identify basic nursing dosage calculation conversions including the conversions from one ounce (oz - standard unit of weight) to milliliters (ml - a unit of volume) and from a tablespoon (tbsp - a common prescription used to dose liquid medications) to milliliters. 5. One of nine licensed nurses did not use proper dosing measurement tools to accurately measure the medication for Resident 157 as ordered by the MD. These deficient practices had the potential to result in: 1. Resident 37 suffering from complications caused by uncontrolled blood sugar, organ failure, and death. 2. The facility residents being underdosed or overdosed with medications, which could result in serious injury, harm, or death. 3. Resident 157 experiencing stomach issues, electrolyte loss, dehydration, organ failure, and death. Cross Reference: F726, F759 Findings: 1. During a review of Resident 37's admission record, the admission record indicated the facility admitted the resident on 3/31/2025, with diagnoses that included DM, muscle weakness (a lack of physical or muscle strength, throughout the body), and Alzheimer's disease (progressive mental decline due to generalized breakdown of the brain). During a review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/24/2025, the MDS indicated Resident 37's cognition (the mental ability to make decisions of daily living) was moderately impaired. The MDS indicated Resident 37 required substantial/maximal assistance with all activities of daily living (ADL's: activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), bed mobility, transfer, eating, toilet use and personal hygiene. During a review of Resident 37's physician's order dated from 3/31/2025 to 4/1/2025, the orders indicated an active order of Insulin Lispro Injection Solution 100 Unit/ML Inject 18 unit subcutaneously before meals for DM 2 Rotate site. Hold for BS<100 and notify MD if BS< (less than) 80 or > (greater than) 400. During an interview on 06/24/2025 at 11:27 AM, Resident 37 stated she did not get her insulin before dinner time on 6/23/2025 when the Resident's blood sugar was 140. Resident 37 stated the nurse just left after checking the blood sugar and did not come back to administer the insulin shot before dinner that evening. During a concurrent interview and record review on 6/24/2025 at 11:31 AM, LVN 1 reviewed Resident 37's record for diabetic medication administration record dated 6/23/2025 at 5:45 PM and stated LVN 2 did not administer Resident 37's Insulin Lispro Injection before dinner on 6/23/2025 when the resident's blood sugar was 141 grams per deciliter (g/dl). During a concurrent interview and record review on 06/26/25 at 02:40 PM, the Interim Director of Nursing (IDON) reviewed Resident 37's diabetic medication administration record and stated that nursing staff were required to follow doctor's orders regarding Resident care. The IDON stated LVN 2 did not administer Resident 37's Insulin Lispro Injection before dinner time on 6/23/2025. During a review of the facility's policies and procedures (P&P) titled Insulin Administration revised 1/2025, the P&P indicated the purpose of the policy was to provide guidelines for the safe administration of insulin to residents with diabetes. Steps in the Procedure (Insulin Injections via Syringe) 2. Check blood glucose per physician order or facility protocol. 7. Check and re-check that the type of insulin on the vial matches the type of insulin ordered. 8. Check the order for the amount of insulin. 11. Double check the order for the amount of insulin. 14. Re-check that the amount of insulin drawn into the syringe matches the amount of insulin order. 2. During a review of Resident 9's admission Record, the admission record indicated the facility admitted the resident on 3/03/2014 and readmitted the resident on 1/03/2025 with diagnoses that included neuromuscular dysfunction of the bladder (the nerves controlling the bladder are not working properly), peptic ulcer (a condition that causes ulcers (open sores) to develop in the lining of your digestive tract), gastroesophageal reflux (GERD - digestive disorder where stomach acid flows back into the esophagus), tracheostomy (a surgical procedure that creates an opening in the neck, directly into the windpipe, to assist breathing), contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), dependence on supplemental (extra) oxygen, gastrointestinal hemorrhage (a type of bleeding in the gut), and persistent vegetative state (a severe neurological condition characterized by a lack of awareness of oneself and the environment, despite the presence of sleep-wake cycles and basic reflexes). During a review of Resident 9's History and Physical (H&P - a physician's complete examination) dated 1/04/2025, the H&P indicated Resident 9 did not have capacity to understand or make medical decisions. During a review of Resident 9's MDS dated [DATE], the MDS indicated Resident 9 had severely impaired cognition. The MDS indicated Resident 157 was completely dependent on facility staff for all self-care (the act of attending to one's physical or mental health) needs. During a review of Resident 9's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for June 2025, the MAR indicated an MD ordered to give Resident 9 Polyethylene Glycol 1450 (laxative) powder 17 milligram (mg - unit of measure) with 8 oz of water and stir with disposable spoon via gastrostomy tube (G-Tube - a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and meds) two times a day for constipation. 3. During a review of Resident 157's admission Record, the admission record indicated Resident 157 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis that included atherosclerotic heart disease (damage or disease in the heart's major blood vessels), idiopathic hypotension (low blood pressure that develops without a known, identifiable cause), benign prostatic hyperplasia with lower urinary tract symptoms (frequent urination, a sudden urge to urinate, waking up at night to urinate), resistance (the act or power of resisting, opposing, or withstanding to multiple antibiotics), and history of other infectious and parasitic diseases (previously experienced infections or parasitic infestations that are not specified elsewhere in their medical history). During a review of Resident 157's H&P dated 5/27/2025, the H&P indicated Resident 157 did not have the capacity to make medical decisions. During a review of Resident 157's MDS dated [DATE], the MDS indicated Resident 157 had severely impaired cognition. The MDS indicated Resident 157 was completely dependent on staff for all self-care needs. During a review of Resident 157's MAR for June 2025, the MAR indicated an MD ordered to give Resident 157 Psyllium Husk Powder to give 1 tablespoon (tbsp) via gastrostomy tube one time a day for bowel management, hold if loose stool, add 8 oz of fluid, and stir well. During a review of Resident 157's MD Progress Notes dated 6/24/2025, the notes indicated Resident 157 did not have the capacity to make medical decisions. During a concurrent medication preparation observation and interview on 6/25/2025 at 8:27 AM with LVN 11, LVN 11 was observed using a white plastic spoon to scoop out fiber powder (psyllium husk) medication from the medication container then placed the fiber powder in a 30 mL measuring cup. LVN 11 was then observed transferring the fiber powder into a 9 oz clear cup then added water without using any measuring tools to accurately measure 1 tbsp of fiber powder and 8 oz of water as ordered by the MD. When LVN 11 was asked why LVN 11 did not use any measuring tools to measure 1 tbsp of fiber powder and 8 oz of water as ordered by the MD, LVN 11 was quiet and did not provide any answers. When LVN 11 was asked how much mL was in a tbsp (correct answer 15 mL), LVN stated I don't know. When LVN 11 was asked how many mL was in an ounce (correct answer 30 mL), LVN 11 continued to be quiet. LVN 11 never provided the surveyor with any answers. LVN 11 was asked why it was important to follow MD's order by measuring 1 tbsp of fiber powder and 8 oz of water prior to administering the medication to Resident 157, LVN 11 stated for accuracy. During a concurrent observation and interview on 6/25/2025 at 8:27 AM with LVN 11 and LVN 13, LVN 11 was observed not comparing the medication on hand to what the MD ordered for Resident 9, which was as written on the MAR. LVN 11 was asked what the medication on hand indicated, LVN 11 stated Polyethylene Glycol 1450 and what MD order indicated on the MAR, LVN stated Polyethylene Glycol 3350. The surveyor asked LVN 11 if the medication LVN 11 prepared for Resident 9 was the correct medication, LVN 11 remained quiet. LVN 13 stated the went to check if the facility had Polyethylene Glycol 1450 in stock and returned and stated we don't have that in stock, our house stock is always the 3350 . we never had [1450]. During an interview on 6/25/2025 at 11:35 AM with LVN 13, LVN 13 was asked how many mL was in a tbsp, LVN 13 answered 16 mL (correct answer 15 mL). LVN 13 was asked how much mL was in an oz, LVN 13 was not able to provide any answers (correct answer 30 mL). During an interview on 6/25/2025 at 12 PM with LVN 9, LVN 9 was asked for a how much mL was in a tbsp, LVN 9 answered 2.5 mL (correct answer 15 mL). During an interview on 6/25/2025 at 2:58 PM with Interim (temporary) Director of Nursing (IDON), the IDON stated licensed nurses who administered medications to residents were expected to follow MD orders as written and to use their resources they have to measure properly. During a follow up interview on 6/25/2025 at 3:42 PM with the IDON, the IDON stated if the nurse staff notices the MAR is different from what they have on hand, then they need to reach out to the MD for clarification. The IDON stated licensed nurses should reach out to MD to clarify and state what we have on hand and what we have as an order and to clarify with the MD how [MD] would like us to proceed. During a review of the facility policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Administering Medications with a revision date of January 2025, indicated, medications shall be administered .as prescribed and medications must be administered in accordance with the orders.

Based on observation, interview, and record review, the facility facility failed to ensure the kitchen staff stored food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food), as well as toxins when: 1. a. Food was not appropraitely stored b. Food was not labeled c. Prepared leftover tuna was not stored in the refrigerator d. Dietary staff did not follow cool down method e. Multiple food items were not labeled with expiration dates f. The ice machine and the kitchen stove were dirty with old, dried food, and debris. g. Clean water pitchers for the residents were stored on a cart with dirty dishes stored on the bottom of the cart. h. Employee water bottle sitting next to the clean cups on the counter top. 2. The walk in freezer floor in the kitchen had brown/blackish stains 3. The dish washing sink had a leaking pipe and green corrosion. 4. Four of Four residents outside food storage refrigerators had multiple food items not labeled properly, had no thermometer in the refrigerator freezers, and with expired dates. 5. A container of strawberry yogurt & granola parfait (written keep refrigerated observed at bedside) for one of one residents (Resident 73). These deficient practices had the potential to result to expose Resident 73 and all residents at increased risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and unnecessary hospitalization. Findings: During an observation on 24/25 at 8:31 a.m., of the refrigerator in the kitchen with Dietary Supervisor (DS), there was no label: On the brown box or the bag containing corn tortillas On broccoli covered with a plastic wrap on a tray On pieces of bread in a tray On meat in a pan; and On cold cooked sliced cut turkey. During an interview on 6/24/25 at 8:49 a.m., DS stated that food must be labeled with the food item, delivery date, best by or expiration date to make sure that the food being used is not expired. DS stated not labeling food can place the resident's health in danger by vomiting, indigestion, possibly food poisoning. During an observation and concurrent interview with License Vocational Nurse (LVN) 10 on 6/24/2025 at 9:03 a.m., the residents refrigerator for outside food storage on the 5th floor, the following were observed: -A clear food storage container with cooked food in it without a name received date, or expiration date or used by date -A brown paper container with no resident name or used by date -A plastic container with open cheese without a used by date or resident name -A container of whole milk without a residents name or expiration date -A bag of assorted candies without a residents name or expiration date -A bottle of grape juice without a residents name -A bottle open bottle of health aide kombucha without a residents name or expiration date -2 containers of activia yogurt without a residents name on the container. LVN 10 stated it is the license nurse's responsibility to label and store the resident's food in the residents outside food storage refrigerator. LVN 10 stated the housekeeper is responsible to discard food that have expired, are not labeled, or have been in the refrigerator no longer than 3 days. LVN 10 stated if the residents consume expired foods, they can become very sick and can become septic (is a life-threatening medical emergency where the body's response to an infection spirals out of control, damaging its own tissues and organs). During an observation and concurrent interview with Registered Nurse Supervisor (RNS) 3 on 6/24/2025 at 9:33 a.m., the residents refrigerator for outside food storage on the 4th floor, the following were observed: - No thermometer in the freezer. - Vanilla ice cream without a name or expiration date - A container of sour cream container with no open date or resident name - A container of sour cream with expiration date of 5/14/2025. RNS 3 stated it is the license nurse's responsibility to properly store, date, and label all the resident's food that is brought in from the outside. RNS 3 stated if any of the residents consume expired foods, they can acquire food borne illness, have vomiting, stomach aches, and become very ill. RNS 3 stated it is the duty of the housekeeper to clean and discard old foods from the residents outside food storage refrigerators. During an observation and concurrent interview with LVN 16 on 6/24/2025 at 10:13 a.m., the residents refrigerator for outside food storage on the 3rd floor, observed three clear containers not labeled or dated. LVN 16 stated that it is the license nurse's responsibility to store, date, and label all foods brought in from the outside and stored in the resident refrigerator. LVN 16 stated if the residents consume expired foods, they can become very ill. During an observation and concurrent interview with Maintenance Supervisor on 6/24/2025 at 12:26 p.m., the residents refrigerator for outside food storage on the 2nd floor, the following were observed: -A container of caviar with no residents name and date -CMAK drink with no resident's name or open date -ABC/[NAME] drink without resident's name or open date. Maintenance Supervisor stated if the residents consume expired foods the residents could get food poisoning, severe stomachache, and vomiting. During a followup observation of the kitchen with the DS on 6/25/2025 at 8:04 a.m., a large amount of water in the dish washing area was observed on the floor. A pipe under the kitchen sink was covered in a green substance/corrosion and was also leaking water. The DS stated it is the responsibility of the Maintenance Supervisor to monitor and repair the leaking pipes in the kitchen. DS stated the maintenance Supervisor is aware of the leaking pipe in the kitchen. During an observation and concurrent interview on 6/25/2025 at 8:24 a.m., Dietary [NAME] was noted preparing raw fish and cooking bacon, onions, chicken broth using the same gloves. Dietary [NAME] stated he is not supposed to use the same gloves to cook food and prepare raw fish. Dietary [NAME] stated it is important to change gloves and wash my hands after preparing raw fish. The Dietary cook stated he caused cross contamination by not changing gloves and not washing hands after preparing raw fish and it could make the residents very sick and the residents could get an infection. During an observation and concurrent interview on 6/25/2025 at 8:55 a.m., with the Dietary Supervisor state the cooks are not supposed to use the same golves to prepare raw foods and cook hot foods because the practice will cause cross contamination and can make the residents very sick. During an observation of the kitchen stove noted to be dirty, old, dried food and debris. An employee personal water bottle was also observed located next to the juice machine and clean cups. The Dietary Supervisor stated staff are not supposed to have their personal water bottles in the kitchen or in the work area due to infection control. The Dietary Supervisor stated employee personal water bottles should be kept in the employee lounge. During an observation and concurrent interview on 6/25/25 at 9:46 a.m., with the Maintenance Supervisor, a large amount of water was observed on the kitchen floor. Also observed was water leaking from the pipe under the kitchen sink for washing dishes, and a large orange industrial fan in the kitchen that was blowing air on high speed. Maintenance Supervisor stated he fixed the leaking pipe one year ago and that he had sanded the green corrosion from the pipe under the sink in the kitchen. Maintenace Supervisor stated none of the kitchen staff notified him that the pipe was leaking water. During a record review, the facility policy and procedures (P&P) titled Outside food Storage and Refrigerator Policy with a revised date of 1/2025, indicated: Purpose: To provide a safe and sanitary process for the storage, labeling, and monitoring of outside food items brought into the facility by family, friends, or residents themselves, in accordance with federal (42 CFR §483.60) and California Title 22 requirements for food safety in Skilled Nursing Facilities. Policy Statement: Beachwood Post-Acute & Rehab supports residents' rights to receive and consume food from outside sources. However, for the health, safety, and infection control of all residents, any outside food stored in the facility must be handled, labeled, and stored appropriately in designated food-safe conditions. 2. Labeling Requirements: All outside food must be clearly labeled with Residents full name, Date received, and Use-by date. Unlabeled or improperly stored food will be discarded. 3. Refrigeration and storage Guidelines: Perishable food must be refrigerated within 2 hours of arrival. Items stored in the resident refrigerator must be: -Kept in sealed leak proof containers -Labeled as described above -Discarded after 3 days, unless otherwise specified by nursing or dietary. During a record review, the facility P&P titled Ice Machines and Ice Storage Chest revised on 1/2025, indicated: Policy Statement: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. During a record review, the facility P&P titled Maintenance Service revised on 1/2025 indicated: Policy Statement: Maintenance services shall be provided to all areas of the building, grounds, and equipment. b. During a record review, Resident 73's admission record indicated Resident 73 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included heart failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), pneumonia (an infection that affects one or both lungs), dysphagia (difficulty swallowing), tracheostomy status (a surgical procedure to create an opening through the neck into the trachea (windpipe) to help with breathing), lack of coordination (muscle control problem that causes an inability to coordinate movements ), type 2 diabetes mellitus (a disease in which your blood glucose, or blood sugar, levels are too high) and morbid obesity (chronic disease in which you have a body mass index [BMI-ratio of your height to your weight] of 40 or higher). During a record review, Resident 73's Minimum Data Set (MDS - a resident assessment tool) dated 3/24/2025, indicated Resident 73's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 73's ability to eat was not attempted and Resident 73 did not perform this activity prior to the current illness, exacerbation, or injury, Resident 73 required partial to moderate assistance with oral hygiene. During a record review of Resident 73's Order Summary dated 6/27/2025, indicated Resident 73 was on a regular diet, dysphagia mechanical soft texture, thin liquid consistency. During a tour observation of Resident 73's room on 6/25/25 at 10:18 AM, Resident 73 was observed asleep in bed. A container of strawberry yogurt & granola parfait (written keep refrigerated) was also observed at the resident's bedside table. During an interview on 06/25/25 at 10:22 AM Respiratory Therapist (RT) 2 stated Yogurt is not supposed to be at bedside, it should be kept refrigerated. During an interview with Director of Nursing (DON), DON stated Yogurt should not be left at bedside because yogurt is a dairy product and is at high risk for spoilage and/or contamination from pathogens that cause food borne illnesses such as stomach infection, which if consumed can lead to food borne illness, leading to unnecessary hospitalization, poor outcomes and even death. During a record review, the facility policy and procedures titled Food Receiving and Storage dated 01/2025, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices, Refrigerated foods must be stored below 41 degrees Fahrenheit unless otherwise specified by law, Food items and snacks kept on the nursing units must be maintained as indicated below, All food items to be kept below 41 degrees Fahrenheit must be placed in the refrigerator located at the nurses' station and labeled with a use by date.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment by failing to implement standard precautions (a set of infection control practices used to prevent the transmission of diseases) in the provision of care for two of two sampled residents (Residents 10 and 131). This deficient practice placed residents at a higher risk of acquiring and transmitting infections to other residents, staff and visitors in the facility. Findings: During a review of Resident 131's admission Record, the admission Record indicated Resident 131 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included asthma (a chronic [long-term] condition that affects the airways in the lungs), epilepsy (a condition that affects your brain and causes seizures [abnormal electrical activity in your brain that temporarily affects your consciousness, muscle control and behavior]), pneumonia (an infection/inflammation in the lungs) chronic pulmonary obstructive disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included malignant neoplasm of larynx (a cancerous tumor that develops in the larynx [voice box]), Malignant neoplasm of the esophagus (a cancerous tumor that develops in the esophagus, the tube connecting the throat to the stomach), gastrostomy status (presence of a gastrostomy tube surgically placed into the stomach for feeding or medication administration), pneumonitis (inflammation of the lung tissue, often triggered by inhaled irritants) due to inhalation of food and vomit, lack of coordination (lack of voluntary muscle coordination) and chronic respiratory failure (when the lungs are unable to adequately exchange gases). During a review of Resident 131's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 05/27/2025, the MDS indicated Resident 131's cognition (the mental ability to make decisions of daily living) was intact. Resident 131's could not ingest food orally and required supervision or touching assistance with oral hygiene. During a review of Resident 131's history and physical (H&P) dated, 6/11/2025, the H&P indicated Resident 131 had the capacity to understand and make decisions. During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10's cognition was intact. Resident 10's could not ingest food orally and required supervision, or touching assistance with oral hygiene. During a facility tour on 6/24/2025 at 10:10 AM, a partially used sterile saline solution for nebulizer (a device that turns the liquid medicine into a mist) inhalation vial was observed at Resident 131's bedside. During an interview on 06/24/25 10:16 AM, Respiratory Therapist (RT1) stated the partially used saline inhalation vial was not supposed to be at bedside. RT1 stated that once the saline solution is open and used, any unused residual saline solution left in the vial must be discarded to prevent re-use and respiratory infections. During a facility tour on 6/25/2025 at 8:34 AM, the following items were observed in Resident 10's bedside drawer: a. an open water pitcher with Jevity (a medical product, specifically a tube feeding formula used for nutritional support in individuals who cannot eat or have difficulty eating). b. piston syringe (a medical device used for injecting fluids into or withdrawing fluids from the body) inside the water pitcher. c. urinal (a portable container used for urination, typically by individuals who have difficulty accessing traditional toilet facilities) with urine (the yellowish liquid waste that is released from the body when you urinate). e. an open can of soft drink. f. drinking cup with soft drink. g. and a bottle of sterile water. During an interview on 6/25/2025 at 8:43 AM, Licensed Vocational Nurse (LVN 14) stated the Jevity bolus in an open water pitcher cup, the carbonated soft drink and saline bottle should not be placed next to a urinal with urine. LVN 14 further stated there is a risk of contamination from bodily fluid that could cause infection. During an interview on 06/27/25 04:15 PM, Respiratory Therapist (RT 2) Lead stated once a saline inhalation vial is open and used, residual saline liquids must be discarded; residual saline inhalation vials with liquids should not be left at bedside because it is considered contaminated and must be discarded; leaving a saline inhalation vial with residual saline at bedside places resident at risk of infection if residual saline is used on a resident. During an interview on 6/27/2025 at 5:02 PM, Acting Director of Nursing (ADON) stated Residents are only allowed to self-administer g-tube feeding at bedside if they have been assessed to have cognition and [residents] physically demonstrated they can safely be able to do so and have a physician approval. The ADON stated self-administering without a physician's order and/or assessment and education can lead to negative outcomes from food inhalation leading to adverse reactions, unnecessary hospitalization and possible poor outcomes. During a review of facility policy and procedures (P&P) titled, Infection Control, dated 05/2025 indicated, it is the policy of this facility to prevent the spread of infection. Standard Precautions will be used when always caring for residents regardless of their suspected or confirmed infection status. During a review of facility policy and procedure (P&P) titled, Food Receiving and Storage, dated 01/2025, the P&P indicated, foods shall be received and stored in a manner that complies with safe food handling practices. Food items kept on the nursing units must be maintained as indicated below: All food belonging to residents must be labeled with the resident's name, the item and the Use by date. Beverages must be dated when opened . Other opened containers must be dated and sealed or covered during storage.

Based on observation, interview, and record review, the facility failed to maintain the shared shower room on the 5th floor east in a safe and operating condition This deficient practice had the potential to result in resident injury and/or fall due to pieces of broken safety handles on the left side of the shower wall and a loose safety handle on the right side of the shower wall. Findings: During an observation on 6/24/2025 at 10:05 AM, of the East side shower room on the 5th floor in the facility, the safety hand railing on the left side in the shower was broken and the handrail to the right side of the same shower was loose. During a concurrent interview and observation on 06/24/25 10:19 AM, certified nursing assistant (CNA 1) stated the left side handrail was problematic because residents complained about it being in the way when they took showers. Residents primarily use the handrail to the right and in front, not the one to the left. CNA 1 also stated the handrail to the left had been broken for about two months. CNA 1 stated she was not sure how long the handrail on the right of the shower had been loose. During an interview on 6/24/2025 at 11:20 AM, Maintenance supervisor (MS) stated he was not aware of the broken handrail on the left, or the loose handrail on the right in shower room East. The MS stated now that he is aware of the problem which needs to be fixed right away. The MS stated he will have someone remove the remaining pieces of what the handrail was to the left. In addition, he will have someone tighten the siderail to the right. During an interview on 6/24/2025 at 12:22 PM, the Administrator (ADM) stated he has been made aware that the shower room on the fifth floor was fixed. The ADM stated maintenance staff keep a log of items and places in the facility that need to be repaired, and the staff prioritize repairs as they are made aware or as they are discovered upon inspection. The ADM further stated the handrails are very important for resident safety, and they (the handrails) have been fixed promptly. During a review of the facility's Policy and Procedure (P&P) titled Maintenance Service dated revised January 2025, the P&P indicated Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards . f. Establishing priorities in providing repair service. 3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on observation, interview, and record review, the facility failed to ensure the call light was answered in a timely manner for three of three residents (Residents 23, 62, and 92) when the residents needed assistance with care including personal hygiene. This failure resulted in the residents becoming very upset, angry, and embarrassed. This deficient practice also had the potential for falls, injuries, and accidents. Findings: During a record review, Resident 62's admission record indicated Resident 62 was re-admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnoses of Heart Failure, and lack of coordination. During a record review, Resident 62's Minimum Data Set (MDS- a resident assessment tool) dated 5/13/2025, indicated Resident 62's cognitive skills [the core skills your brain uses to think, read, learn, remember, reason, and pay attention] for daily decision making was intact. The MDS further indicated Resident 62 needed minimal assistance with Activity of Dailly Living (ADL- fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). During a record review, Resident 62's care plan revised on 6/3/2025, indicated; Focus: 8/22/24 (Resident 62) readmitted with a diagnosis of generalized weakness. During a record review of Resident 92's admission record indicated Resident 92 was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnoses of muscle weakness, and Hemiplegia (paralysis that affects only one side of your body) and hemiparesis (is a mild or partial weakness on one side of the body). During a record review, Resident 92's History and Physical dated 2/17/2025, indicated Resident 92 has the capacity to make medical decision. During a record review Resident 92's MDS dated [DATE], indicated Resident 92's cognitive skills for daily decision making is intact. The MDS further indicated Resident 92 needed maximal assistance with ADL (toileting, personal hygiene, bathing, and mobility). During a record review of Resident 92's care plan revised on 6/3/2025, indicated; Focus: Resident 92 has an ADL self-care performance deficit r/t (related to) limited mobility. During a record review, Resident 23's admission record indicated Resident 23 was admitted to the facility on [DATE] and re-admitted on [DATE] muscle weakness, and colostomy status. During a record review, Resident 23's History and Physical dated 5/29/2025, indicated Resident 23 has the capacity to make medical decision. During a record review Resident 23's MDS dated [DATE], indicated Resident 23's cognitive skills for daily decision making is intact. The MDS further indicated Resident 23 needed maximal assistance with ADL such as toileting, personal hygiene, bathing, and mobility. During a record review, Resident 23's care plan revised on 6/1/25, indicated; Focus: Resident 23 has an ADL self-care performance deficit. During the Resident Council Meeting an interview on 6/25/25 at 11:03 a.m., Resident 23 stated on multiple occasions there was a delay of more than 30 minutes to 1 hour with the nurses answering the call light on the 11PM to 7AM shift. Resident 23 stated at times his call light was on so long that he fell asleep and never received colostomy (a surgical procedure that creates an opening [stoma] in the abdominal wall, connecting the colon [large intestine] to the outside of the body) care from the nurse. Resident 23 stated he would have to get out of bed into his wheelchair and go to the nurses station to get assistance from the nurses. Resident 23 stated this made him very angry and embarrassed because sometimes the colostomy bag would leak due to a delay in changing it. During the Residents Council Meeting on 6/25/25 at 11:28 a.m., Resident 62 stated during the 11PM to 7AM shift, the facility staff delay for more than 1 hour to answer his call light. Resident 62 stated he needed the nurses to empty his full urinal (a receptacle used for collecting urine, typically for patients who are unable to use a regular toilet) and almost urinated (passed urine) on himself due to the nurses not emptying his urinal. Resident 62 stated not answering the call lights makes him very upset to have to try to hold his urine until the nurse empties his urinal. During the Residents Couincil Meeting on 6/25/2025 at 12:03 p.m., Resident 92 stated on multiple occasions there is a delay in answering his call light on the 3PM to 11PM and 11PM to 7 AM shift. Resident 92 stated he experienced anger with the nurses due to being left soiled for more than 4 hours at times. Resident 92 stated he has reported the delay in answering the calls and to the Charge Nurses, but nothing is being done about it. During an interview on 6/25/25 at 2:36 p.m., the Director of Nursing (DON) stated the residents' call lights should be answered immediately to prevent the residents from falling, prevention of pressure ulcers from being left soiled. The DON stated the DON reminds staff daily of the importance of answering the residents call lights in a timely manner. During an interview on 6/25/25 at 3:03 p.m., License Vocational Nurse (LVN) 1 stated the residents call lights should be answered within 3 minutes or immediately to prevent falls, change in condition, pressure injuries, and for dignity. During a record review, the facility's policy and procedures titled Answering the Call Light with a date of 1/2025, indicated: Purpose: The purpose of this procedure is to respond to the resident's request and needs. General Guidelines: 7. Answer the resident's call as soon as possible.

Based on observation, interview and record review, the facility's staff failed to ensure for One of one sampled resident (Resident 10): 1. Had a physician's order to self-administer a medical nutritional supplement/tube feeding formula via bolus feeding (a method of enteral tube feeding where a large dose of formula is administered into the stomach or small intestine over a short period of time, typically 15-20 minutes, several times a day) 2. Was assessed, educated and determined to have cognitive and physically demonstrated capability to safely self-administer a bolus feeding. These deficient practice had the potential to result in negative outcomes from food inhalation which could lead to adverse reactions, unnecessary hospitalization and possible poor outcomes for Resident 10. Cross reference F693 Findings: During a review of Resident 10's admission record indicated Resident 10 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that include malignant neoplasm of larynx (a cancerous tumor that develops in the larynx (voice box)), Malignant neoplasm of the esophagus (a cancerous tumor that develops in the esophagus, the tube connecting the throat to the stomach), gastrostomy status (presence of a gastrostomy tube surgically placed into the stomach for feeding or medication administration), pneumonitis (inflammation of the lung tissue, often triggered by inhaled irritants) due to inhalation of food and vomit, lack of coordination (lack of voluntary muscle coordination) and, chronic respiratory failure (when the lungs are unable to adequately exchange gases) During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool) dated 05/27/2025 indicated the resident 10's cognition (The mental ability to make decisions of daily living) was intact, Resident 10's could not ingest food orally, and required supervision, or touching assistance with oral hygiene. During a facility tour on 6/25/2025 at 8:34 AM, Resident 10's bedside drawer was observed to have an open water pitcher (a container designed for serving water to patients) that had brown/tan liquid inside and a piston syringe (a medical device used for injecting fluids into or withdrawing fluids from the body) inside the water pitcher. During an interview on 6/25/2025, at 8:43 AM, Licensed Vocational Nurse (LVN) 14 was unable to state the name of the liquid inside the open water pitcher at Resident's 10's bedside. LVN 14 stated I don't know what that is. During an interview on 6/25/2025, at 8:57 AM, Resident 10 stated the tan/brown liquid in the water open water pitcher was Jevity (a medical product, specifically a tube feeding formula used for nutritional support in individuals who cannot eat or have difficulty eating), During an interview on 6/25/2025, at 9:00 AM Registered Nurse (RN) 6 stated Resident 10 self-boluses the feeding and has a physician's orders and has been care-planned to self-administer the Jevity independently. During a review of Resident 10's physician order summary dated 6/27/2025 indicated Resident 10 had an order for Jevity 1.5 viat gravity (Bolus) 237 ml, 5 times per day (1185ml/1778kcal) give water 50ml before and after each bolus feeding. During a review of Resident 10's physician order summary dated 6/27/2025 indicated there was not order for Resident 10 to self-administer/bolus his g-tube feeding. During an interview on 6/27/2025 at 5:02 PM Acting Director of Nursing (DON) stated Residents are only allowed to self-administer g-tube feeding at bedside if they have been assessed to have cognitive and physically demonstrated they can safely able to do so and have a physician approval, DON stated self-administering without a physicians order and/or assessment and education can lead to negative outcomes from food inhalation which could lead to an adverse reactions, unnecessary hospitalization and possible poor outcomes, During a review of the facility policy and procedures (P&P) titled, Self-Administering of Drugs dated 01/2025, the P&P indicated: 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications. 2. In addition to the general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels. b. Comprehension of the purpose and proper dosage and administration time for his or her medications. c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) them; and d. Ability to recognize risks and major adverse consequences of his or her medications.

Based on observation, interview, and record review, the facility failed to ensure to provide a Notice of Medicare Non-Coverage (NOMNC, is a document used in Medicare [a Federal health insurance program] to inform beneficiaries when their Medicare-covered services are ending, and to explain their appeal rights) to one of three sampled resident ' s (Resident 254), representative (responsible party). This failure had the potential to result in Resident 254's representative not being able to exercise their right to file an appeal. Findings: During a review of Resident 254's admission Record, the admission Record indicated the facility admitted Resident 254 on 6/9/2025, with diagnoses including unspecified heart failure heart does not pump as well as it should), unspecified dementia(a progressive state of decline in mental abilities), unspecified edema (swelling caused by an abnormal accumulation of fluids in the body ' s tissues), hypertension(high blood pressure), dysphagia(difficulty swallowing), generalized muscle weakness, unsteadiness on feet, malaise(overall weakness or discomfort), and unspecified disorientation(a state of being confused). During a review of Resident 254's History and Physical (H&P) dated 6/9/2025, the H&P indicated the resident had limited decision-making capacity. During a review of Resident 254's Minimum Data Set (MDS- a resident assessment tool) dated 6/19/2025, the MDS indicated Resident 254 was dependent (helper does all of the effort) from the staff for toileting, and tub/shower transfer, required substantial/maximal assistance (helper does more than half the effort) from the staff with bathing/shower self, had frequent urinary incontinence(involuntary leakage of urine) and always incontinent of bowel(losing control of bowel movements). During a concurrent interview and record review on 6/25/2025 at 3:12p.m., with the Infection Preventionist/Case Management (IPC, nurse who helps prevent and identify the spread of infectious agents like bacteria and viruses in a healthcare environment), Resident 254's Case Management Notes, dated 6/17/2025 were reviewed. The IPC stated Resident 254 was discharged home with family. The Case Management Notes indicated, informed Resident 254's Family Member (FM)1 of the discharge for 6/19/2025, and the financial responsibility beginning on 6/20/2025, should the resident remain in facility. The Case Management Notes indicated FM1 stated Resident 254 was unable to return home in Resident 254's current condition. During a concurrent interview and record review on 6/26/2025 at 2:25p.m., with Registered Nurse (RN)2, Resident 254's NOMNC form dated 6/16/2025 was reviewed. The NOMNC indicated a voicemail was left on 6/16/2025 at 11:24a.m. The NOMNC indicated information on how the responsible party could file an appeal and notification by certified mailed to representative and return receipt requested if direct phone contact could not be made. RN 2 stated she (RN2) did not speak with FAM1. RN2 stated she (RN2) only left a message once and did not attempt another phone call. RN2 stated she (RN2) did not send the NOMNC notice by certified mail according to the form's instructions. During a concurrent interview and record review on 6/27/2025 at 9:49a.m. with the Interim Director of Nursing (IDON), Resident 254's NOMNC form was reviewed. The IDON stated the NOMNOC form was incomplete, it was not completed according to the instructions. The IDON stated the importance of the beneficiary notification was to be completed so the resident or the resident's family or representative had enough time to make an informed decision about their care and have enough time to plan their care and aware of their resources or even appeal if they choose to. During a review of the document provided by the facility titled Notice of Medicare Non-Coverage (NOMNC), the document indicated, How to contact your Beneficiary and Family Centered Care Quality Improvement Organization to ask for a fast appeal . How to appeal if the resident or representative believes the services are ending too soon. During a review of the facility's job description titled Case Manager, undated, the job description indicated, Coordinate care with resident, care providers, facilities financial services . During a review of the facility's policy and procedure(P&P) titled, Resident ' s Rights, dated January 2025, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents in this facility. These rights include the resident ' s right to be informed what rights . he or she has .

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to: 1. Ensure LVN 3 notified a physician and handed over to a licensed nurse that Resident 1 did not pass urine and urine was not collected for urinalysis (UA- is a medical test that analyzes a urine sample. It involves examining the appearance, chemical composition, and microscopic components of the urine to detect potential health issue) on [DATE] from 7 a.m. to 3 p.m. 2. Ensure Resident 1's vital signs (VS- Temperature [Temp], blood pressure [BP], pulse rate [PR-heart rate], respirations [RR], and oxygen saturation [O2sat- a measurement of how much oxygen the blood is carrying as a percentage] were monitored and recorded every four hours according to a physician's order dated [DATE] when Resident 1 experienced a change in condition (COC- a deterioration in health, mental, or psychosocial status in either life-threatening circumstances or clinical complications). 3. Ensure Registered Nurse (RN) and or the Assistant Director of Nursing (ADON) assessed Resident 1 when Resident 1 developed difficulty in breathing twice on [DATE] between 8 p.m. and 8.30 p.m. and again on [DATE] at 9 p.m. 4. LVN 2 immediately called 911 (a phone number used to contact the emergency services) and transfer Resident 1 to a GACH when Resident 1 developed difficulty in breathing on [DATE] between 8 p.m. and 8.30 p.m. and again on [DATE] at 9 p.m. These deficient practices resulted in Resident 1 was found 1 not breathing well On [DATE] at 10.08 p.m., the paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) arrived at Resident 1's bedside and attempted to resuscitate (to revive a person from a state of apparent death or unconsciousness, often due to a cardiac or respiratory arrest) Resident 1. The paramedics pronounced Resident 1 dead in the facility on [DATE] at 10.35 p.m. Cross Reference F760 Findings: During a record review, Resident 1's admission record indicated the facility originally admitted Resident 1 on [DATE] and most recently on [DATE] with diagnoses including, acute respiratory failure with hypoxia (condition where the lungs are unable to deliver enough oxygen to the blood), severe sepsis with septic shock (a life-threatening blood infection), pneumonia (an infection/inflammation in the lungs) due to methicillin resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics), urinary tract infection (UTI- an infection in the bladder/urinary tract), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysarthria and anarthria (difficulty and lost ability to speak), and pleural effusion (an abnormal buildup of fluid in the space between the thin layers of the lungs and the wall of the chest cavity). During a record review, Resident 1's Admission/Re-admission Summary Note dated [DATE] at 5:12 p.m., indicated Resident 1 was a Full Code (refers to a patient's status indicating they want all possible measures taken to resuscitate them if they stop breathing or their heart stops beating). During a record review, Resident 1's Care Plan (CP) on Respiratory . At Risk for Complications . initiated [DATE], indicated the CP goal included Resident 1 will have unlabored respirations . Will not exhibit respiratory distress such as wheezing . and report abnormal findings to physician promptly. The CP interventions indicated that Resident 1 will be assessed for hypoxia (a deficiency of oxygen reaching the tissues of the body), altered level of consciousness, irritability, restlessness, and cyanosis (a bluish or purplish discoloration of the skin and mucous membranes, primarily due to a decrease in oxygen saturation in the blood). The CP interventions also included to monitor Resident 1 for shortness of breath, irregular respirations, . decreased energy, rapid breathing, . and inform physician promptly. During a record review, the facility In-service Lesson Plan on Change of Condition dated [DATE], indicated the topic of In-service for nursing included: 1. Assessment of patient (resident). 2. Obtaining vital signs, reporting vital signs and change of condition (COC) to medical doctor (MD). 3. Worsening/deterioration of residents condition; following emergency procedures. 4. Transferring of residents via paramedics. During a record review, the facility In-service Staff Attendance on Change of Condition dated [DATE], indicated Topic . Charge nurse will continue to monitor resident. If condition deteriorates and resident has no restrictions to transfer out, charge nurse/nurse sup (supervisor) will transfer patient (pt-resident) via paramedics, after transfer, charge nurse will notify MD and family/responsible party.' During a record review, Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE] indicated Resident1's cognition (mental ability to make decisions for daily living) was not intact. The MDS indicated Resident 1 was dependent (helper does all the effort) for dressing, bathing, and toileting) The MDS indicated Resident 1 transfers (moving between surfaces) from bed to chair were not attempted due to medical condition or safety concerns. The MDS indicated Resident 1 was not on oxygen. During a record review, Resident 1's Nurse's Note dated [DATE] at 11:15 a.m., indicated that on [DATE] at around 9:30 a.m., the charge nurse (unidentified) noted Resident 1's BP ,d+[DATE] millimeters of mercury (mmHg- unit of measurement), PR (pulse rate-71 per minute), RR 20, O2 sat 95% on room air (RA- Normal O2 sat range is between 90%-100%), and elevated temp of 100.2 degrees F with yellow emesis (vomit). Resident 1 was provided with cold packs and administered PRN (as necessary) Acetaminophen to reduce the fever. The Nurse's Note indicated MD was notified of Resident 1's condition who ordered to transfer Resident 1 to non-emergent to GACH 1 related to (r/t) elevated temp and emesis, notified Resident 1's responsible party (RP) and family (unspecified). The Nurse's Note indicated that family (unspecified) requested to transfer Resident 1 to GACH 2 and that family was notified of MD's order to transfer Resident 1 to GACH 1. The Nurse's Note indicated family (unspecified) requested not to transfer Resident 1 to GACH and keep the resident in the facility. The Nurse's Note indicated MD ordered the following for Resident 1: -VS every (Q) 4 hours (Hrs) for 72 Hrs -Stat (now) CBC and CMP -Start Augmentin 875 mg PO BID x 10 days - UA with culture. During a record review, Resident 1's History and Physical (H&P- the attending physician assessment and plan of care) dated [DATE], indicated nursing concerns about Resident 1 having increased shortness of breath today and a mild fever of 100.2 F. The H&P plan indicated to continue Augmentin every 12 hours (started today), monitor vital signs closely, obtain CBC (complete blood count-measures the numbers and types of cells in the blood), CMP (comprehensive metabolic panel-14 blood tests that provide information about the functions of the liver, kidneys, blood sugar levels, electrolyte [mineral] and fluid balance), UA with culture (a laboratory procedure used to identify microorganisms/bacteria etc) and assess the need for respiratory support. During a record review, Resident 1's Physician Order dated [DATE] at 11.14 a.m., indicated Resident 1 to receive Amoxicillin-Pot Clavulanate (Augmentin) tablet ,d+[DATE] mg, give 1 tablet by mouth every 12 hours for possible UTI for 10 days. During a record review, Resident 1's Physician Order dated [DATE] at 11.14 a.m., indicated to check vital signs every 4 hours x 72 hours for 3 days. During a record review, Resident 1's Weight and Vital Summary record effective [DATE] - [DATE], indicated the following: O2 sats Summary. [DATE] at 9.34 a.m. - 95% (Room Air) [DATE] at 1.32 p.m. - 97% (Room Air) Pulse Summary. [DATE] at 9.34 a.m. - 71 beats per minute (bpm) (Regular) [DATE] at 1.32 p.m. - 100 beats bpm (Regular). Respiration Summary. [DATE] at 9.34 a.m. - 20 breaths per minute (/min) [DATE] at 1.32 p.m. - 19 bpm Temperature Summary. [DATE] at 9.34 a.m. - 97.8 degrees F (Forehead non-contact). [DATE] at 9.49 a.m. - 100.2 degrees F (Forehead noon-contact). [DATE] at 1.32 p.m. - 98.6 degrees f (Forehead non-contact). The same Weight and Vital Summary record indicated no vital signs were entered/recorded after 1.32 p.m. on [DATE]. During a record review, Resident 1's Change in Condition Evaluation form dated [DATE] timed 11:21 a.m. indicated Resident 1 was noted with a fever of 100.2 F (checked on the forehead) and had color yellow emesis. The COC indicated a medical doctor (MD) was notified who ordered to monitor vital signs every 4 hours, stat (now) CBC and CMP, UA with culture and to start Augmentin twice a day. The COC Evaluation form indicated the order was carried out and the family/RP notified. The COC Evaluation form indicated that on [DATE] at 9:34 a.m., Resident 1's BP was ,d+[DATE] mm/Hg, PR 71 beats per minute, RR 20 per minute, and O2 sat was 95% on RA. During a record review, the facility undated document titled Inventory Item (E-KIT), indicated Amoxicillin 500 mg-potassium clavulanate 125 mg tablet (Amox TR-K ,d+[DATE] mg TA) is amongst medications included in the E-Kit. During a record review, the facility pharmacy document E-Rx New Prescription for Resident 1, indicated Amoxicillin-Pot Clavulanate tablet ,d+[DATE] mg was received by the pharmacy on [DATE] at 1:47 p.m. During a record review, Resident 1's Medication Administration Record (MAR) for the month of ,d+[DATE], indicated effective [DATE] at 6:50 p.m., Acetaminophen (Tylenol- medication for pain and raised temperature) tablet 325 mg, give 2 tablets . every 6 hours as needed for elevated temperature (degree of temperature not indicated) and pain, and do not exceed 4 grams (G-unit of measurement) in 24 hours (hrs). The same MAR did not indicate Resident 1 was administered Acetaminophen on [DATE]. During a record review, Resident 1's Change in Condition Evaluation form dated [DATE] timed 10:50 p.m. LVN 2 documented that while making rounds, certified nursing assistant (CNA) asked LVN 2 to check on Resident 1. LVN 2 documented that Resident 1's O2 sat was low at 78% at room air (RA-without extra oxygen) and Resident 1 was placed on oxygen and saturation improved (the amount of oxygen administered, and saturation not indicated). LVN 2 documented that while monitoring Resident 1, the resident desaturated gain (level not indicated) and that the paramedics were called. LVN 2 documented that the paramedics were unsuccessful at resuscitation attempts and that Resident 1 expired (date and time not indicated). During a record review, the Paramedic Run Sheet (a printable EMS (Emergency Medical Service) run report is a document that contains important information about a medical response or transport provided by EMS personnel) dated [DATE], indicated the paramedics arrived on [DATE] at 10:08 p.m. and found Resident 1 in supine (on the back) position . with a chief complaint of cardiac arrest for unknown amount of time. Staff called for a low O2 sat. Upon assessment, [Resident 1] was found to be in cardiac arrest (no heartbeat). Resuscitation was immediately started. Initial rhythm (heart rate pattern) was asystole (no heartbeat). The Paramedic -resident remained in asystole throughout resuscitation efforts. The paramedic run sheet indicated Resident 1 received epinephrine (a stimulant medication administered during cardiac arrest to stimulate the heart and help restore the heartbeat) on [DATE] at I mg at 10:10 p.m., 10:15 p.m., and 10:20 p.m. The paramedic run sheet indicated the time on scene to pronouncement (dead) was 27 minutes. During a record review, Resident 1's Late Entry Communication note dated [DATE] at 1:30 p.m., indicated the facility conducted a conference call Resident 1's family member (FM), MD, and the ADON. The communication note indicated that on [DATE] at around 11 p.m., the nurses were completing their rounds and noted that Resident 1 with a decrease in oxygen saturation. After the RT interventions proved ineffective (duration not specified), 911 was called. 911 arrived and implemented their (911) interventions which eventually led them to call the time of death. During an interview and concurrent record review on [DATE] at 12:26 p.m. with Licensed Vocational Nurse (LVN) 1. Resident 1's COC form dated [DATE] and physician's order for Augmentin dated [DATE] were reviewed. LVN 1 stated that while LVN1 was rounding on [DATE] at 7 a.m., LVN 1 touched Resident 1 and the resident felt warm to touch, checked Resident 1's temperature, and the resident's temperature was elevated at 100.2 Degrees F. LVN 1 stated Resident 1 vomited yellow fluid and informed MD (time not specified nor stated) who gave an order to transfer Resident 1 to GACH 1. LVN 1 stated LVN 1 then notified Resident 1's FM and the FM requested to transfer Resident 1 to GACH 2. LVN 1 stated LVN 1 then informed the MD of the FM request. LVN 1 stated the MD cancelled the transfer to GACH altogether and decided to treat/manage the resident in the facility. LVN 1 stated I remember her (MD) saying something like he (Resident 1) wasn't stable enough but I am not sure for what but I don't remember exactly LVN 1 stated LVN 1 was not sure why the MD cancelled the transfer to GACH and was not comfortable with the decision to not transfer Resident 1 to GACH and treat the resident in the facility. LVN 1 stated LVN 1 checked the facility Ekit for the Augmentin but there was no Augmentin in the Ekit and so LVN 1 ordered the Augmentin from pharmacy. LVN 1 stated that on [DATE] before 3 p.m., LVN 1 rechecked Resident 1's Temp and the Temp came down (LVN 1 unable recall the exact temperature recording). LVN 1 stated, I gave him (Resident 1) Tylenol thru the g tube and placed ice packs. The Augmentin did not arrive during my shift, so I endorsed it to the next shift at 3 p.m. LVN 1 stated LVN 3 tried to get the UA via straight catheter multiple times with no success. During a telephone interview on [DATE] at 12:58 p.m., LVN 3 stated that on [DATE], Resident 1 had an order for UA. LVN 3 stated Resident 1 had a urinary indwelling catheter and there was no urine output it was dry so initially I thought it was plugged so I irrigated it and it was not plugged, then after that I changed the indwelling catheter bag and checked for leaking and there was no leaking. It was dry and still no output. LVN 3 stated that after about 1 (one) and half hours later LVN 3 came back and still had no output in the dwelling catheter bag and informed LVN 1. LVN 3 stated, we need endorse to the next shift. LVN 3 stated, I did not inform the doctor there was no urine output because I thought someone else would report that. There was no urine when I left at 3pm so it was endorsed to the next shift. During a concurrent interview and record review on [DATE] at 2 p.m. with LVN 2, Resident 1's MAR for ,d+[DATE] was reviewed. The MAR indicated that on [DATE], Resident 1's MAR indicated number 10 (patient [Resident 1] unavailable) next to the Augmentin dose. LVN 2 stated LVN 2 did not recall what happened to the Augmentin and could not explain why the number 10 was documented on the MAR. LVN 2 stated LVN 2 did not recall administering any medication including Augmentin to Resident 1. LVN 2 stated LVN 2 worked on [DATE] from 3 p.m. to 11 p.m. LVN 2 stated that on [DATE] (time not specified), LVN 2 called RT to come and assist and the RT put Resident 1 on 15 liters of oxygen to increase the resident's 02 sat. LVN 2 stated LVN 2 then called 911 because the resident's O2 sat was not increasing. LVN 2 stated 911 came, stayed with [Resident 1] for about 30 minutes and started CPR. LVN 2 stated, I was not in the room when that happened. LVN 2 stated LVN 2 called 911 because Resident 1 desaturated below 90% and checked the vital sign machine and Resident 1 had a pulse. LVN 2 stated LVN 2 did not recall getting any endorsement for Resident 1 during report about monitoring the resident's vital signs every four hours. LVN 2 stated LVN 2 could not remember what happened with the order to administer Augmentin to Resident 1 and LVN 2 was very quiet on the phone. LVN 2 stated LVN 2 could not remember administering Augmentin to Resident 1 on [DATE]. During an interview on [DATE] at 2:30 p.m., CNA stated that CNA worked on [DATE] on the 3 p.m. to 11p.m. shift and was assigned Resident 1. CNA stated that on [DATE] during CNA's rounds at 3 pm Resident 1 was okay. CNA stated that on [DATE] at around 8 p.m. and 8.30 p.m., Resident 1 was not breathing well so I let the charge nurse (LVN 2) know to come and check on him. CNA stated LVN 2 went to Resident 1's, and I went to take care of my other patients (residents). CNA stated Resident 1 was wearing an oxygen cannula at the time LVN 2 called respiratory therapist (RT - a healthcare professional who specializes in diagnosing, treating, and managing breathing problems and disorders of the cardiopulmonary system) and the supervisor and the resident seemed to get better a few minutes later. CNA stated that on [DATE] at about 9 p.m. something, I passed back by the room to see [Resident 1] and [Resident 1] was not breathing well again, CNA called LVN 2 who then called 911. CNA stated that LVN 2 checked Resident 1's VS but could not remember the VS numbers. CNA stated CNA did not take Resident 1's VS on [DATE]. During an interview on [DATE] at 2 p.m. LVN 2 stated, I did not know [Resident 1] had a change in condition earlier that day ([DATE]) and was on vital sign monitoring every four hours. During an interview on [DATE] at 2:30 p.m. with the certified nursing assistant (CNA). The CNA stated, I worked from 3 p.m. to 11 p.m. on [DATE] and was assigned to [Resident 1]. Sometimes we do the vital signs and sometimes the nurses will do the vital signs. That day ([DATE]), I did not take any vital signs for [Resident 1] and I did not know about him having a fever earlier in the day. During a concurrent interview and record review on [DATE] at 11 a.m. with the Assistant Director of Nursing (ADON), Resident 1's vital sign summary document dated [DATE] was reviewed. Resident 1's vital sign summary indicated vital sign entries at 9:34 a.m. and at 1:32 p.m. and no other vital sign entries were made. The ADON stated Resident 1 was noted with a temperature of 102 degrees F and emesis, MD was notified who ordered to monitor Resident 1's vital sign every 4 hours and to start Resident 1 on Augmentin BID (twice a day). The ADON stated, I would start the Augmentin as soon as it is available. Normally we would have it in the Ekit. Resident 1's COC dated [DATE] at 10:50 p.m. was also reviewed. The ADON stated to assess a resident every four hours means to see if there is any change from the initial COC and continue to monitor and comment on what is observed and measured for four hours. The ADON stated a CNA was rounding and noticed that it looked like Resident 1 was having trouble breathing. The CNA called the charge nurse to assess Resident 1 and the charge nurse called RT to assist. Resident 1's O2 sat was 78%, was placed oxygen (O2) and the O2 sats went up, and then resident started to desaturate (desat- occurs when the amount of oxygen in the blood falls below the normal level) again and called 911 who came and were unsuccessful in resuscitating Resident 1. The ADON stated, It's hard to say if [Resident 1's] vital signs were monitored every four hours because there are no vital signs [documented]. We should see the vital signs documented every four hours after they are ordered. The Augmentin should have been given as [to Resident 1] soon as it was available. ADON stated, I don't see any notes from RT. On [DATE] a 12 p.m., the writer contacted MD and no answer. A voicemail was left for MD to call back the writer. During a record review, the facility Policy and Procedures (P&P) titled, Vital Signs revised ,d+[DATE], indicated, Vital signs shall be monitored according to the following guidelines: Upon Admission - All residents shall have baseline vital signs recorded upon admission to the facility. Routine Monitoring- Vital signs shall be taken as ordered by the physician or per the resident's care plan. Change in Condition - Vital signs shall be taken immediately when a resident exhibits signs of distress, deterioration, or any significant change in condition. Post-Procedure/Medication Administration- Vital signs shall be monitored as required after certain medical procedures or medication administration, especially for high-risk drugs (e.g., antihypertensives [medications to treat/control] high blood pressure), opioids [controlled prescription medications used to treat pain]). As Needed (PRN) - Vital signs shall be taken when requested by a physician, resident, or per nursing judgment. During a record review, the facility P&P titled Acute Condition Changes -Clinical Protocols revised ,d+[DATE], indicated: Assessment and Recognition: 1. As part of the initial assessment, the licensed nurses will help identify individuals with significant risk for having acute changes of condition during their stay; for example, an individual with an indwelling urinary catheter who has recurrent urinary tract infections . 2. The nurse shall assess and document/report the following . a. Vital signs g. Onset, duration severity . 5. The nursing staff will contact the physician based on the urgency of the situation. Monitoring and Follow-Up: 1. The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly. During a record review, the facility Policy and Procedures (P&P) titled Administering Medications revised ,d+[DATE], indicated, Policy Statement: Medication shall be administered in a safe and timely manner and as prescribed. 3. Medication must be administered in accordance with the orders, including any required time frame. During a record review, the facility P&P titled Identifying and Managing Medication Errors and Adverse Consequences revised ,d+[DATE], indicated, Policy Statement: The Staff and practitioner shall try to prevent medication errors . and shall strive to identify and manage them appropriately when they occur.

Based on interview, and record review, facility failed to provide one of three residents (Resident 1) supervision, by failing to ensure that Resident 1 who is a high fall risk was not left unattended in the common area near the nursing station. on 12/18/2024 at 3:30 PM. This deficient practice resulted in Resident 1 had an unwitnessed fall from the wheelchair on 12/18/2024 and sustaining a nasal (nose) fracture. Findings: A review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included dementia (loss of cognitive functioning, thinking, remembering, and reasoning), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), diabetes mellitus type II (lifelong (chronic) disease in which there is a high level of sugar (glucose) in the blood), spinal stenosis (a condition in which the spinal canal is too small for the spinal cord and nerve roots.), abnormalities of the gait (balance), and difficulty walking. A review of Resident 1s Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 10/21/2024, indicated Resident 1's cognition (the mental ability to understand and make decisions of daily living) was severely impaired and the resident required partial/moderate (helper does less than half the effort) assistance from staff with eating, substantial maximum assistance (helper does more than half the effort) with oral hygiene, upper body dressing and personal hygiene, was totally dependent on facility staff for toileting hygiene, shower/bathing, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 1 was non-ambulatory (unable to walk). A review of Resident 1's history and physical dated 12/28/2024, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Nursing - Fall Risk Observation/assessment dated [DATE], indicated Resident 1 was at high risk for falls. A review of Resident 1's care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for At Risk for Falls dated 5/26/2022, indicated interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) to prevent falls included bed in low position, call light within reach, keep call light within reach, explain all procedures and purpose prior to starting, and close observation. The care plan indicated a revised date of 12/19/2024, however the interventions all were dated 5/26/2022. A review of Resident 1's Change in condition evaluation note dated 12/18/2024 at 4:14 PM, indicated the resident had a fall that was associated with no or minor injury. The note indicated the resident's physician was notified and the resident was to be sent to the local hospital for evaluation. A review of Resident 1's acute care emergency service report dated 12/18/2024, indicated Resident 1 arrived in the emergency room at 5:44PM on 12/18/2024 from facility where he (Resident 1) reportedly had an unwitnessed fall from the wheelchair, and resident was found lying face down next to the wheelchair. A review of Resident 1's computerized tomography scan (CT: a type of imaging that uses X-ray techniques to create detailed images) of the face dated 12/18/2024 at 11:11pm, indicated an impression of comminuted (shattered) and displaced (out of place) nasal fractures. During an interview on 1/6/2025 at 11:13 am Resident 3 (roommate of Resident 1) stated Resident 1 was alert but could be confused at times. Resident 3 stated Resident 1 understood little English. Resident 3 stated he (Resident 3) had tried to get out of bed several times in the past (unable to recall dates and times During an interview on 1/7/2025 at 11:30AM, Licensed Vocational Nurse 1 (LVN1) stated Resident 1 was difficult to understand because he (Resident 1) spoke and understood minimal English. LVN 1 stated Resident 1 was not alert and oriented and was to never be left in a wheelchair unattended because the resident was non-ambulatory and had been assessed to be at high fall risk for falls. During an interview on 1/7/2024 at 11:50AM, the Director of Staff Development (DSD) stated Resident 1's family hired a companion (CP1) who spoke Resident 1's native language. The DSD stated the companion had been going to the facility for a long time (unable to state how long). The DSD stated the Resident's companion would at times wheel Resident 1 to and from his (Resident 1's) room on the 3rd floor to the 2nd floor open air patio for fresh air, to the Rehabilitation room for physical, and occupational therapy services. During an interview on 1/7/2025 at 12:50PM, the Director of Nursing (DON) stated on 12/18/2024 at 3:45 PM, Resident 1 was found on the floor by 3rd floor nursing station in prone position (lying face down on one's stomach). The DON stated upon assessment Resident 1's nose was noted slightly deviated (shifted out of place) to the right with a small cut on the bridge with scant amount of blood. The DON stated Resident 1 was assessed and deemed to be stable, and first aid was immediately rendered. The DON stated Resident 1 was transferred to the hospital for evaluation and higher level of care. The DON stated prior to Resident 1's fall, the resident was with CP1, whose job was to provide social stimulation to the Resident 1 in the resident's native language. The DON stated the Resident 1's companion (CP1) had been spending time with Resident 1 and would wheel the resident to the common dining and activity area to watch movies, outdoor patio on the 2nd floor and to the 6th floor for rehab services. The DON stated on 12/28/2024 at 1 PM, LVN2 observed CP1 wheeling Resident 1 to the open-air patio on the 2nd floor, and the resident was seated calmly in his wheelchair. The DON stated around 12/28/2024 at 3:30 PM, CP 1 left the Resident in the common area near the nursing station and did not notify the staff that she was leaving. A review of the facility's policy and procedures (P&P) titled Safety and Supervision of Resident dated 1/2024 indicated, facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. A review of the facility's P&P titled Safety and Supervision of Residents with a revision date of January 2024, indicated systems approach to safety included 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors. and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on interview and record review the facility failed to implement fall precautions to prevent falls for one of three sampled residents (Resident 1) by failing to: 1. Provide two-person assist when turning and repositioning for Resident 1 who was identified as high risk for fall. 2. Implement the risk for fall care plan for Resident 1 to provide fall mats (a floor pad designed to help prevent injury should a person fall). As a result, on 11/4/2024 at 6:40 a.m., Resident 1 fell from the bed and hit head on the floor when Certified Nursing Assistant (CNA) 1 was providing care to the resident. Resident 1 was transferred to a general acute care hospital (GACH) and diagnosed with a 1 centimeter (cm-unit of measurement) thick right parietal subdural hematoma (SDH-a collection of blood outside of a blood vessel caused by a broken blood vessel between the brain and the skull). Resident 1 was subsequently admitted to the GACH intensive care unit (ICU - a department in a hospital where critically ill patients who are cared for constantly observed) for further care and management. Findings: A review of Resident 1's Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cerebral vascular accident (CVA-stroke, loss of blood flow to a part of the brain), multiple fractures of left ribs, cerebral edema (swelling in the brain), respiratory failure, essential hypertension (high blood pressure), tracheostomy(surgical opening in the neck for breathing) and long term mechanical ventilator (a medical device to help support or replace breathing) dependence. A review of Resident 1's Nursing-Admission/Readmission Evaluation/assessment dated [DATE] at 6:40 p.m., indicated the following: Resident 1 had limited range of movement (ROM- a joint or body part cannot move through its normal range of motion); required assistance with transfer; and required assistance with eating, bathing, dressing, grooming, toileting, and bed mobility. A review of Resident 1's Fall Risk assessment dated [DATE] indicated the following: Resident 1 had 1-2 falls in the last 90 days; The fall risk score was 26 (a score of 16 to 42 is considered a high risk for fall); Resident 1's vision was moderately impaired (limited vision but can identify objects). Resident 1 was non-ambulatory (unable to walk). A review of Resident 1's care plan titled, Resident 1 is at risk for falls, dated 9/7/2024, indicated the goal included to minimize complications related to falls risks for falls and the resident will not have any major injuries related to falls. The care plan interventions included to keep bed in low position, side rails up (1/4 bed mobility bars) while in bed to aid in mobility and repositioning, and place safety devices as ordered fall mats (a floor pad designed to help prevent injury should a person fall). A review of Resident 1's Minimum Data Set (MDS- resident assessment tool) dated 9/9/2024, indicated Resident 1's cognition (mental ability to make decisions for daily living) was not intact. The MDS indicated Resident 1 had impairment to both upper extremities (shoulder, elbow, wrists, hand) and both lower extremities (hip, knee, ankle, foot). The MDS indicated Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with rolling left to right, toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. A review of the Facility In-service lesson plan titled, Taking care of total dependent residents, dated 10/14/2024 and 10/15/2024 indicated use two-person assist when turning and repositioning. A review of Resident 1's Progress Notes date range of 11/1/2024 to 11/4/2024, indicated, CNA reported that while changing patient, patient rolled over to the opposite side of the bed and had a witness fall . Notified MD, awaiting further orders at this time. A review of Resident 1's Change in Condition Evaluation form dated 11/4/2024 timed at 7:09 a.m., Licensed Vocational Nurse (LVN) 1 documented that Resident 1 had a fall and that Certified Nursing Assistant (CNA) 1 reported that while CNA 1 was changing (providing care) Resident 1, Resident 1 rolled over to the opposite side of the bed and fell on the floor; No obvious injury was noted; Resident 1 was placed back into bed and the attending physician was notified, awaiting further orders. A review of Resident 1's Nurse's Note dated 11/4/2024 at 7:15 a.m., RN 2 documented that on 11/4/2024 at 6:40 a.m., CNA (CNA 1) reported to writer (RN 2) and Charge Nurse (LVN 1) regarding a witnessed fall involving the patient (Resident 1). Per CNA, the patient fell from the bed during patient care and that the bed was above the knee level. The writer and additional Nurses assisted in assessing the patient, finding no visible injuries at the time of assessment. The patient was safely placed back in bed . A review of Resident 1's note titled Communication with Family dated 11/4/2024 at 9:25 a.m., Registered Nurse (RN) documented that on 11/4/2024 at 6:40 a.m., CNA (unidentified) reported to Registered Nurse Supervisor (RNS) and Charge Nurse (LVN) of a witnessed fall involving the patient (Resident 1). Per the CNA, the patient fell from the bed during patient care. A full head to toe assessment completed, finding no visible injuries and the patient was safely placed in bed. Vital signs were as follows: Blood Pressure (BP) 152/73 milliliters of mercury (mmHg-Unit of measurement), Heart Rate (HR-Pulse) 87 (beats per minute, Temperature (T) 98.9, RR (Respirations) 18, SpO2 (amount of oxygen in the blood) 99 percent (%-normal range is 96% to 99%). The Communication with Family note indicated Medical Doctor (MD) 1 and MD 1's Nurse Practitioner (NP) were informed that Resident 1 fell . RN supervisor recommended to transfer the resident to general acute care hospital (GACH) for further evaluation. The NP approved and ordered a transfer Resident 1 to GACH for further evaluation via ambulance. LVN 1 and CNA 1 were not assigned to care for the resident in the future. A review of CNA 1's statement dated 11/4/2024 indicated while changing Resident 1, CNA 1 turned Resident 1 on the side and before turning back Resident 1, Resident 1 rolled over the other side and fell . The bed was above knee level and slightly below the waist. Licensed Vocational Nurse (LVN) 1 was immediately made aware of the resident's fall. A review of Resident 1's Nursing Progress Note dated 11/4/2024 timed 11:12 a.m. indicated Resident 1 was transferred to the GACH for evaluation post (after) the fall. A review of Resident 1's GACH Neurocritical Care Note dated 11/4/2024 indicated Resident 1 had a computed tomography (cat- is a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) scan of the head that indicated a 1cm thick acute right parieto-occipital SDH. Resident 1 was admitted to neuro ICU for blood pressure monitor and repeat cat scan to monitor the size of the SDH. A review of Resident 1's Interdisciplinary Team (IDT - a group of professional and direct care staff that have primary responsibility for the development of a Service Plan for an individual receiving services) dated 11/5/2024 indicated that CNA reported to RN supervisor and charge nurse of a witnessed fall involving Resident 1 from bed during care. Per CNA the resident fell to the floor from bed as she (CNA) was adjusting the pad and the sheets under the resident . A review of Resident 1's Nursing-Admission/Readmission Evaluation/assessment dated [DATE] at 7:43 p.m., indicated the following: Resident 1 was in coma/vegetative state; confused; had short-term and long-term memory loss; was on oxygen; had a tracheostomy; and was on a ventilator/respirator. Resident 1 had left side craniotomy stiches/scar. During an interview on 12/16/2024 at 1:58 p.m. LVN 1 stated that on 11/4/2024 CNA 1 informed LVN 1 that Resident 1 fell on the floor during morning care. LVN 1 stated upon entering the room Resident 1 was observed lying on the floor, next to the bed in supine position (on the back) looking up at the ceiling. LVN 1 stated, I am not sure what fall precautions were in place prior to the fall but I did not see any fall mats on the floor underneath Resident 1. LVN 1 stated that it took four staff members to pick up and place Resident 1 back into the bed. During an interview on 12/16/2024 at 2:24 p.m. the Director of Nursing (DON) stated Resident 1 was identified as high risk for fall upon admission. DON stated, On 11/4/2024, I was here that morning but when I went to the room Resident 1 was already back in the bed. I don't recall seeing the fall mats on the floor. On that floor (where Resident 1 was located) we train everyone to provide two-person assist because all the residents are totally dependent and CNA 1 did not ask for help and that is why Resident 1 fell , it is our fault. We fired CNA 1 after the incident. A review of the facility policy and procedures titled, Falls and Fall Risk Managing revised 1/2024 indicated: 1. The licensed staff will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 2. Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture. If a medication is suspected as a possible cause of a resident's falling, the initial intervention might be to ta per or stop that medication. 3. In conjunction with the Consultant Pharmacist and nursing staff, the Attending Physician will identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even for a trial period. 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling.

Based on observation, interview, and record review, the facility failed to: A. 1. Ensure the staff did not leave a hot cup of coffee at Resident 108's bedside table. 2. Ensure Certified Nursing Assistant 7 (CNA7) did not prepare hot liquid in an electric water kettle on the resident's bedside table, serve, and leave a cup of hot coffee unattended and within the resident's reach. 3. Ensure a licensed nurse assessed and measured Resident 108's skin immediately after the resident was burnt with the hot coffee. As a result, on 4/2/2024, Resident 108 reached, grabbed, and spilled the hot cup of coffee onto the resident's right upper lateral (side) hip resulting in a 2nd degree burn (involving the two layers of the skin) injury and pain, and treatment with Lidocaine (medication for pain) and Silvadene 1% (medication used to treat and prevent wound infections in people with severe burns) on the resident's right upper lateral hip. B. Implement accident prevention protocols and interventions for one of 13 sampled residents (Resident 428). As a result, Resident 428 suffered a skin tear to the forehead and a deviated (a departure from the normal) nose. C.1 Ensure an oscillating pedestal electric fan was not placed and left standing in the middle of a high-traffic walkway in one of 13 residents room (Resident 137). C.2 Ensure CNA 2 locked the wheels of a wheelchair when one of 13 residents (Resident 103) was sitting in the wheelchair. These failures had the potential for physical harm related to fall for Resident 137 and Resident 103. Findings A. A review of Resident 108's admission record indicated Resident 108 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes mellitus type II (DM- high blood sugar), chronic (on-going) obstructive pulmonary disease (COPD- a lung disease causing restricted airflow and breathing problems), congestive heart failure (CHF- a weak heart), peripheral vascular disease (the narrowing of blood vessels) cervical spinal stenosis (narrowing of the spinal canal), abnormalities of the gait and mobility and generalized muscle weakness. A review of Resident 108's medical record titled, Change in Condition (CIC- a deterioration in health, mental, or psychosocial status in either life-threatening circumstances or clinical complication), dated 4/2/2024, indicated, Resident's care provider (Medical Doctor -MD) was notified of coffee burn on 4/2/2024 at 7:30am. The MD ordered to apply Lidocaine (dose not indicated) for pain not on the blister and Silvadene 1% to Resident 108's right hip 2nd degree burn. A review of Resident 108's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 5/29/2024, indicated Resident 108's cognition (the mental ability to understand and make decisions of daily living) was intact, required partial/moderate assistance with eating and upper body dressing. The MDS indicated Resident 108 was dependent on staff for dressing. The MDS indicated Resident 108 was non-ambulatory. A review of Resident 108's medical record on 6/27/2024 with MDS coordinator medical record titled, Progress Note dated 4/27/2024-6/27/2024 were reviewed. The progress notes dated 4/2/2024, indicated the facility did not take the initial/progress pictures of the burn injury, did not conduct/complete burn injury evaluation assessment, did not perform/complete burn injury measurement and/or did not document the degree level of the burn injury. During initial tour observation and concurrent interview with Resident 108 on 6/25/24 at 9:50 AM, Resident 108 was observed in bed with both hands covered with a towel. Resident 108 did not move either hands. Resident 108 stated that on 4/2/2024 during early hours of the morning on the 11PM-7 AM shift, Resident 108 requested CNA7 to heat up some hot water using Resident 108's electric hot water kettle on the resident's bedside table and make a cup of coffee for the resident. Resident 108 stated CNA7 heated water in an electric hot water kettle owned by the resident and made a cup of coffee for the resident. Resident 108 stated CNA7 placed the cup with hot coffee on the resident's bedside table and told Resident 108 to wait a few minutes because the coffee was still hot. Resident 108 stated Resident 108 waited for few minutes (unable to recall the wait time) then grabbed the coffee cup from the resident's bedside table, tried to bring the cup of hot coffee close to the resident's mouth, and the resident spilled the coffee on herself. The resident states she has hand tremors (shaking or trembling movements). Resident 108 stated she sustained burns to the right hip as a result. During an interview with the Director of nursing (DON) on 6/25/2024 at 3:19 PM, the DON stated the DON could not recall the exact date Resident 108 sustained the 2nd degree burn. The DON stated the DON did not investigate how Resident 108 sustained the 2nd degree burn to the right upper lateral hip. A review of Resident 108's Summary Report with active orders from 6/27/2024, indicated the change the treatment orders for Resident 108 as follows: 1. Right Hip fragile (delicate) scar: Cleanse (wash) with Normal Saline (NS- Solution for wound care), pat dry, apply triple antibiotic (medication to prevent/treat infection) and cover with dry dressing (DD) daily (QD) and as necessary (PRN) x 14 days . 2. Right hip reddened area/peeled area: Cleanse with NS, pat dry, apply xeroform (non-stick wound care material) and cover with foam dressing (a bandage that cushions a wound) QD and PRN x 14 days . During an observation of treatment and measurement of Resident 108's right hip burn injury by Treatment Nurse 1 (TX1) on 6/27/2024 from 11:13 AM, Resident 108's right hip burn injury was measured by the TX1. The burn injury measured 13 centimeters (cm- unit of measurement) x 12cm, pink in color with some bleeding observed. TX1 cleansed the burn injury with NS, patted the wound dry, applied triple antibiotic then applied xeroform dressing and covered the wound with foam dressing. During a concurrent interview and record review, TX1 stated that on 4/2/2024 at 7:00AM change of condition evaluation regarding Resident 108's burn was documented, Resident 108's care provider (MD) was notified at 7:30AM, a treatment order for Lidocaine for pain, not on the blisters and Silvadene 1 % was given and carried out. Resident TX1 stated she did not assess, measure and document Resident 108's 2nd degree burn injury because the burn injury was red and blistered (a fluid filled sac). TX1 stated Resident 108 sustained the burn injury from hot coffee prepared and provided by CNA7. TX1 stated CNA7 boiled water and made the coffee for Resident 108 using Resident 108's personal hot water kettle. During an interview with CNA7 on 6/27/2024 at 4:11 PM, CNA7 stated that on 4/2/2024 at about 7 AM, CNA7 used Resident 108's personal electric hot water kettle to boil water and made coffee for the resident. CNA7 stated the electric hot water kettle was on top of Resident 108's bedside table. CNA7 stated CNA7 left the cup of hot coffee at Resident 108's bedside and instructed the resident not to touch the coffee, and to let the coffee cool down because the coffee was hot. CNA7 stated that on 4/2/2024 during 11 PM - 7 AM shift, CNA7 found out that Resident 108 had accidentally spilled the very hot coffee on herself [Resident 108], sustained a burn on the right hip, and a bandage/dressing was applied. A review of the facility's policy and procedures (P&P) titled Safety and Supervision of Resident, revised 1/2024 indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The risk factors and environmental hazards include Electrical safety and water temperatures. A review of facility's P&P titled, Assistance with Meals, dated 1/2024, indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each Resident. Facility will serve .and will help residents who require assistance with eating. 48903 B. A review of Resident 428's face sheet indicated Resident 428 was admitted to the facility, on 6/11/24, with diagnoses including tracheostomy (a surgically created hole in your windpipe that provides an alternative airway for breathing), transient cerebral ischemic attack (a temporary blockage of blood flow to the brain) and cardiomyopathy (a condition that makes it hard for the heart to deliver blood to the body). A review of Resident 428's History and Physical (H&P) dated 6/13/24, indicated Resident 428 did not have the capacity to understand and make decisions. A review of Resident 428's MDS dated [DATE], indicated Resident 428 did not have intact cognition and was dependent on staff for oral hygiene, toileting, showering, dressing and personal hygiene. A review of Resident 428's Care Plan (CP) dated 6/23/24, indicated Resident 428 had impaired skin integrity as evidenced by a skin tear to his forehead. The CP interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) indicated that facility staff to identify potential causative factors of the skin tear and eliminate when possible, educate resident on avoiding skin injuries, and administer treatments as ordered. A review of Resident 428's CP dated 6/23/24, indicated Resident 428 was at risk for falls related to cognitive impairment and impaired mobility (refers to conditions that limit a person's coordination or ability to move). The CP interventions indicated that staff anticipate and meet the needs for Resident 428, educate the resident to call for assistance, keep the call light within reach, monitor for changes in condition and notify doctor, and safety devices as ordered. A review of Resident 428's Progress Notes dated 6/23/24 at 7:50 AM, indicated, a clip board accidentally fell on Resident 428's head resulting in a small cut to the resident's forehead with minimal bleeding. The MD was notified who recommended to continue monitoring Resident 428's skin breakdown and mental status. A review of Resident 428's Progress Notes dated 6/23/24 at 8:15 AM, indicated, open blister on forehead was cleaned and antibiotic (unspecified) applied. A review of Resident 428's Treatment Administration Record (TAR) dated 6/1/24 to 6/30/24, indicated, cleanse skin tear on the forehead with normal saline, pat dry and cover with dry dressing daily for 14 days every shift. Start date: 6/25/24. There is no order for antibiotic. A review of Resident 428's Progress Notes dated 6/23/24 at 1:05 PM, indicated, Resident 428's family member 1 (FM 1) noticed that Resident 428's nose looked deviated towards the left. A review of the facility's Inservice Lesson Plan dated 6/24/24, indicated, Program Outline: 2) Make rounds, remove possible hazardous items which may fall on patients 3) Report accidents to MD/family accurately, describe facts to MD/family. During an interview on 6/28/24 at 11:18 AM with Resident 428's FM 2, FM 2 stated, the nurse that took care of [Resident 428] overnight told me the cut on Resident 428's head was a water blister that it had had burst. [Resident 428's] nose looked bent. It looked like someone punched [Resident 428] in the face. The charge nurse told me that the cut was from a clipboard that fell on [Resident 428's] head. During an interview on 6/26/24 at 5:38 PM with the Director of Nursing (DON), the DON stated, the overnight nurse told [Resident 428's] family that the cut on [Resident 428's] head was a burst water blister. I don't know why she [nurse] didn't tell the family the truth but she [nurse] was suspended. A review of the facility's P&P titled, Accidents and Incidents: Investigating and Reporting dated 1/24, indicated, All accidents or incidents involving residents occurring on our premises shall be investigated and reported to the Administrator. A review of the facility's P&P titled, Safety and Supervision of Residents dated 1/24, indicated, Our facility strives to make the environment as free from accident hazards as possible. When accident hazards are identified, the Safety Committee shall evaluate and analyze the cause of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. 48026 C.1. A review of Resident 137's admission record indicated, Resident 137 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralysis [complete or partial loss of muscle strength] that affects all four limbs and body from the neck down), type 2 diabetes mellitus (a long-lasting condition when the pancreas does not produce enough insulin or when body cannot effectively use the insulin it produces causing blood glucose [sugar] to go high), abnormal posture (rigid body movements and chronic abnormal positions of the body), and muscle weakness (when muscles are weak causing difficulty performing normal activities that require strength). A review of Resident 137's MDS dated [DATE], indicated, Resident 137 was cognitively intact. A review of Resident 137's CP did not include Resident 137 brought her own electric fan to the facility for personal use. The CP did not include Resident 137's risk and environmental hazards to minimize the likelihood of accidents. During an interview on 6/25/2024 at 9:59 AM with Resident 137, Resident 137 stated she owns the oscillating pedestal electric fan found in her room. Resident 137 stated she liked where the electric fan was placed exactly where it is because the fan provided her with the cooling relief she needed. During an interview on 6/27/2024 at 3:56 PM with LVN 7, LVN 7 stated it was not safe to have the fan in the middle of the walkway because someone may trip on the cord causing an accident. During an interview on 6/27/2024 at 5:57 PM with DON, DON stated, the staff can accidentally trip on the cord when the pedestal electric fan was left standing in the middle of high-traffic walkway. A review of the facility's P&P titled Falls - Clinical Protocol revised on 1/2024, indicated, facility staff will document risk factors for falling which included musculoskeletal abnormalities, gait and balance disorders, cognitive impairment, weakness, environmental hazards, and illnesses affecting the central nervous system. C.2. A review of Resident 103's admission record indicated, Resident 103 was admitted to the facility on [DATE] with the following diagnoses: chronic respiratory failure with hypoxia (the respiratory system cannot adequately provide oxygen to the body leading to insufficient amount of oxygen at the tissue level), chronic multifocal osteomyelitis of the right ankle and foot (a disease that causes pain and damage in the right ankle and foot bones due to inflammation [a normal part of the body's response to injuries and invaders like germs]), paralytic syndrome following other cerebrovascular disease, bilateral (paralysis affecting both sides of the body), acquired absence of left leg below knee (below the knee amputation), unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and muscle weakness (when muscles are weak causing difficulty performing normal activities that require strength). A review of Resident 103's care plan with an initiated date of 3/25/2024, revised on 4/16/2024, and a target date of 7/25/2024 indicated, Resident 103 was at risk for falls with or without injury related to impaired mobility and left below the knee amputation (BKA). A review of Resident 103's H&P dated 3/27/2024, indicated, Resident 103 was able to make needs known but cannot make medical decisions. The H&P indicated Resident 103 was a high risk for fall. A record review of Resident 103's MDS dated [DATE] indicated, Resident 103's cognitive skills for daily decision making was severely impaired. During an observation and interview with CNA 2 on 6/26/2024 at 9:05 AM, CNA 2 was observed walking away from Resident 103 who was sitting in an unlocked wheelchair unattended. CNA 2 later returned to Resident 103 accompanied by CNA 3. CNA 2 stated, Yes when asked if CNA 2 had locked the wheelchair before walking away from Resident 103. The surveyor and CNA 2 inspected the wheelchair and observed that the wheelchair wheels were unlocked. CNA 2 stated it is important to always lock the wheelchair heelsfor Resident 103's safety. During an interview on 6/27/2024 at 4:15 PM with LVN 7, LVN 7 stated wheelchairs must be in a locked position when resident is in sitting in one because the resident may fall and get hurt. A review of the facility's policy and procedures (P&P) titled Falls - Clinical Protocol with a revision date of 1/2024, indicated, facility staff will document risk factors for falling which included musculoskeletal abnormalities, gait and balance disorders, cognitive impairment, weakness, environmental hazards, and illnesses affecting the central nervous system (made up of the brain and spinal cord that controls how we think, learn, move, and feel).

Based on interview, and record review the facility failed to implement measures to prevent falls and injuries for one of three sampled residents (Resident 1). For Resident 1, who was confused, was a high fall risk, and attempted to get up without assistance, the facility failed to prevent repeated falls by not: 1. Supervising and monitoring Resident 1. 2. Identify interventions related to Resident 1's specific risks and contributing factors to prevent repeated falls and minimize complications from falling. 3. Ensure Resident 1's care plan interventions were effective and appropriate to the resident's safety needs. 4. Implement its policies and procedures (P&P) on Safety and Supervision of Residents and Falls-Clinical Protocol The staff will monitor and document the individual's response to interventions intended to reduce falling As a result, Resident 1 suffered four falls within one month since initially admitted to the facility and on the 4th fall, on 9/26/2023, Resident 1 required transfer to a General Acute Care Hospital (GACH) and he underwent on 9/29/2023 a total hip replacement (the hip joint is replaced by a prosthetic implant [replace missing body parts]) to correct a dislocated (occurs when there is an abnormal separation in the joint) of the right hip hemiarthroplasty (the prosthetic hip implant joint was moved out of the socket by a traumatic force). Findings: A review of Resident 1's Admission Record indicated the facility initially admitted Resident 1 on 9/2/2023 from a GACH with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (a group of thinking and social symptoms that interferes with daily functioning), difficulty walking, and age-related osteoporosis (bone disease causing brittle bones). A review of Resident 1' GACH Discharge Summary Report, dated 9/2/2023, indicated Resident 1 had three falls before admission with the last fall resulting in a right femoral (thigh bone) neck (upper part of the thigh bone) fracture (break in a bone). The Discharge Summary Report indicated that on 8/29/2023, Resident 1 underwent a right hip hemiarthroplasty (replacement to the ball portion of the hip joint, not the socket portion). A review of Resident 1's Fall Risk Observation/Assessment for, dated 9/2/2023, indicated Resident 1 had one to two falls prior to admission, was unable to walk, required wheelchair for mobility, was incontinent (little or no control over urge to urinate and have bowel movements), and was taking one to two medications that could cause dizziness. The Fall Risk Observation/Assessment form indicated Resident 1 scored 18 which was a high fall risk (above 16 was high risk for falls). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/8/2023, indicated Resident 1 had impaired cognition (ability to comprehend, think, solve problem, process information, and make decisions). Resident 1 was dependent (full staff performance) on staff for activities of daily living (ADLs, such as bed mobility, dressing, toilet use, personal hygiene, and dressing. Resident 1 required two-person assist for surface transfers (from or to bed or chair). The MDS also indicated Resident 1 was not steady and was only able to stabilize with staff assistance during balance transitions and walking. Resident 1 used a wheelchair for mobility. A review of Resident 1's Nursing Progress Notes, dated 9/9/2023 timed at 4:49 a.m., indicated that Family Member 1 (FM 1) informed Licensed Vocational Nurse 1 (LVN 1) that Resident 1 rolled out of bed and fell on the floor (1st fall). LVN 1 observed Resident 1 lying on the back with no injuries found. A review of Resident 1's Change in Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Evaluation form, dated 9/9/2023 timed at 6:30 a.m. indicated Resident 1 fell on [DATE] at 4:49 a.m. A review of Resident 1's Nursing Progress Notes, dated 9/9/2023 timed at 6:50 a.m., indicated a message was left for the physician and was endorsed to morning shift for follow up. A review of Resident 1's Care Plan developed om 9/9/2023 for Resident 1's unwitnessed fall, included in interventions anticipating Resident 1's needs, educating to call for assistance, encouraging activities as tolerated, evaluating medications, keeping Resident 1's bed low, the call light within reach, obtaining physical therapy (PT, the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) consult, and monitoring for complications for Resident 1. A review of Resident 1's Nursing Progress Notes, dated 9/9/2023 timed at 3:26 p.m., indicated FM 1 informed LVN 6 of Resident 1's unwitnessed fall earlier in the morning and was waiting for someone to check on Resident 1. The Nursing Progress Note indicated the morning Charge Nurse informed the doctor who ordered transfer to a hospital. The Nursing Progress Note indicated bilateral (by both side of the bed) floor mats (to cushion falls when rolling out of bed) were placed after the fall. Resident 1 was transferred to a GACH for further evaluation. A review of Resident 1's Nursing Progress Notes, dated 9/11/2023 timed at 3:20 p.m., indicated Resident 1 returned to the facility. Resident 1 did not have injuries (from the fall). A review of Resident 1's Nursing Progress Notes, dated 9/12/2023 and timed at 11:27 a.m., indicated Resident 1 had an unwitnessed fall from bed (2nd fall) and the care plan was updated to include bilateral mats on both sides of the bed. Resident 1 did not sustain injuries from the fall. A review of Resident 1's Nursing Progress Notes, dated 9/25/2023 timed at 3:12 p.m., indicated Resident 1 fell out of a wheelchair while sitting at the Nursing Station (3rd fall). Resident 1 was helped back into the wheelchair and then back into bed. Resident 1 noted with redness on the right side of head. Resident 1 was confused, denied pain, and refused ice packs when offered. Resident 1 was sent to a GACH. A review of Resident 1's Care Plan developed on 9/25/2023 for Resident 1's unwitnessed fall, included in the interventions anticipating Resident 1's needs, educating the resident to call for assistance, encouraging activity as tolerated, evaluating medications, keeping the bed low with call light within reach, obtaining PT consult, and monitoring Resident 1 for complications related to the fall (injury, loss of range of motion, pain). A review of Resident 1's Nursing Progress Notes, dated 9/25/2023 and timed at 3:53 p.m., indicated Resident 1 returned from the GACH with order for oral antibiotic (medication to treat infection). A review of Resident 1's Nursing Progress Notes, date 9/26/2023 timed at 3:10 p.m., indicated, Resident 1 was found on floor lying on floor mat (at bedside) close to the door (4th fall). Resident 1 sustained an abrasion (superficial scrape of the skin) on the forehead and the top of the right eyebrow. Resident 1's physician was notified, and order was moved to a room close to the Nursing Station to avoid more falls. A review of Resident 1's Nursing Progress Notes, dated 9/27/2023 timed at 3:48 a.m., indicated that results of X-rays showed right hip dislocation from the fall the prior day. Resident1 's physician ordered transfer to a GACH. A review of Resident 1's GACH Orthopedic (medical specialty that focuses on treating injuries and diseases of the muscles and bones) H&P, dated 9/27/2023, indicated Resident 1 arrived after a fall the day before, on 9/26/2023. The H&P indicated Resident 1 had had multiple falls since SNF admission, along with multiple emergency department (ED) visits. The H&P indicated Resident 1 had prominence (body part that is visibly larger or more pronounced than usual) on the right hip with leg shortened and internally rotated. The H&P recommended closed reduction of dislocated right hip in the operating room. A review of Resident 1's GACH right hip X-rays result, dated 9/27/2023, indicated a closed right hip hemiarthroplasty dislocation. A review of Resident 1's GACH Orthopedic Consult note dated 9/29/2023, indicated Resident 1's family member agreed to the surgical option and that Resident 1 was taken to the operating room for a right hip hemiarthroplasty revision to a total hip replacement. Resident 1 tolerated the surgery well with no complications. On 3/26/2024 at 2:30 p.m., during a concurrent interview and record review with LVN 3, Resident 1's COC form dated 9/25/2023 timed at 3:12 p.m., was reviewed. The COC form indicated Resident 1 fell in the morning on 9/25/2023, no change in mental status, no bruising was noted, Resident 1 moved all extremities, and the doctor was informed. The COC form did not include a narrative description about Resident 1's fall. LVN 3 stated been informed by a staff (unable to recall who) that Resident 1 was found on the floor. LVN 3 stated Resident 1 fell at change of shift and that she had just clocked in and was about to start rounding to check on residents. On 3/26/2024 at 3:02 p.m., during an interview LVN 2 stated Resident 1 was very confused, always wanted to get out of bed, throwing the covers off like he was going to get up. On 3/26/2024 at 3:30 p.m., during an interview, LVN 5 stated FM 1 was always at Resident 1's bedside. LVN 5 also stated Resident 1 was very confused. On 3/27/2024 at 10:54 a.m., a concurrent interview and review of the PT notes for 9/27/2024 with the Director of Nursing (DON) was conducted. The DON stated that Resident 1 was a high fall risk and whoever was around, was responsible to watch Resident 1. The DON stated the ward clerk (WC) knew Resident 1 needed to be watched and distract residents with an activity or by talking to them. The DON stated she got an order for X-rays after PT evaluated and documented that Resident 1 demonstrated significant pain upon palpation (touching) and when attempting range of motion (movement of the joint) of the right hip. The DON stated PT documented the right hip was significantly rotated internally (inwards) and adducted (movement of a limb toward the midline of the body) and when attempted to correct position of the leg to neutral and Resident 1 verbalized pain. The DON stated the X-rays confirmed Resident 1's right hip joint was dislocated, and the facility transferred Resident 1 GACH on 9/27/2024. The DON further stated the licensed nurses should have assessed Resident 1's mobility on all the extremities (arms/legs) after the fall on 9/26/2024. On 3/27/2024 at 12:37 p.m., during a concurrent interview with the DON and review of Resident 1's care plans for fall risk, the DON could not explain why supervision of Resident 1 was not included in any of the care plans for fall prevention. The DON was unable to provide evidence the interdisciplinary team (IDT, group of health care professionals from different disciplines who work together for the care of the resident) attempted to identify effective interventions related to Resident1's specific risks, safety needs, and contributing factors, to prevent repeated falls and minimize complications from falling. The DON could not provide evidence of a thorough assessment of Resident 1 after each fall to identify causal factors and prevent further falls and injuries. During an interview with DON on 3/27/2023 at 4:25 p.m., the DON stated residents are placed at the Nursing Station for close monitoring if the residents are at risk for fall. The DON stated the resident should be within arm's reach of the person watching/monitoring. The DON stated, I do think the fall from the wheelchair could have been avoided if we assigned a specific person for direct supervision. A review of the facility P&P titled, Safety and Supervision of Residents, revised 1/2024, indicated: Facility-Oriented Approach to Safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QA&A reviews of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization. 3. The IDT and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary. Resident-Oriented Approach to Safety 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents. 2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS. 3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff. b. assigning responsibility for carrying out interventions. c. ensuring that interventions are implemented; and d. documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. ensuring that interventions are implemented correctly and consistently. b. modifying or replacing interventions as needed; and c. evaluating the effectiveness of new or revised interventions. Systems Approach to Safety 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. The type and frequency of resident supervision may vary among residents and over time for the same resident. Resident Risks and Environmental hazards: 1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: a. Bed Safety b. Safe Lifting and Movement of Residents c. Falls d. Smoking e. Unsafe Wandering f. Poison Control g. Electrical Safety h. Water Temperatures 2. Other topics related to resident risk and environmental hazards may be addressed within related policies and procedures (for example, adequate lighting is addressed under the topic of falls). A review of the facility P&P titled, Falls-Clinical Protocol revised 5/2023 indicated: Monitoring and follow up: 1. The staff with the physician's guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. 2. The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious consequences can sometimes be minimized even if falls cannot be prevented. 3. If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention (for example: dizziness, or musculoskeletal pain) has resolved. 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. 5. As needed, the physician will document the presence of uncorrectable risk factors including reasons why any additional search for causes is unlikely to be helpful.

Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had a history of falls, and was assessed as a high risk for falls, received care and services to prevent falls and injuries. The facility failed to: 1. Implement the facility's policy and procedure to promptly initiate and document investigation of the unwitnessed falls on 11/11/2022 and 11/20/2022. 2. Ensure to revise the Fall Risk care plan after the unwitnessed fall on 11/11/2022. 3. Identify hazards and risks of Resident 1 unwitnessed falls on 11/11/2022 and 11/20/2022. 4. Identify and develop new interventions related to the resident's specific risks and causes to try to prevent further falls after each unwitnessed falls on 11/11/2022 and 11/20/2022 5. Implement the facility's policy and procedure titled, Falls - Clinical Protocol to evaluate for possible injuries (after Resident 1's fall on 11/20/2022), the staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture (a break in the bone) have been ruled out (to eliminate or exclude something from consideration). These deficient practices resulted in Resident 1's on 11/25/2022 sustained a distal (situated away from the point of attachment or origin) left femoral (thigh bone just above the knee) fracture (broken bone) requiring transfer to General Acute Care Hospital 1 (GACH 1) on 11/26/2022 and on 12/1/2022, Resident 1 underwent open reduction and internal fixation (ORIF - a type of surgery used to stabilize and heal a broken bone) surgery of the left knee. Findings: A review of Resident 1's Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), type II diabetes (a chronic condition that affects the way the body processes blood sugar), chronic respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and dependent on tracheostomy and ventilator (the reliance of an individual on either of the preceding devices to support body function). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 9/19/2022, indicated Resident 1's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were severely impaired and required total dependence from staff with two person-assists for activities of daily living (ADL-bed mobility, dressing, toilet use, eating and personal hygiene). A review of Resident 1's Fall Risk Observation/Assessment, dated 10/25/2022, indicated Resident 1 was non-ambulatory (Not able to walk around), highly or severely impaired with vision and dependent on staffs with mobility. The same fall risk assessment further indicated Resident 1 scored 22 (16 or higher was considered high risk for potential falls) for fall risk. A review of Resident 1's Risk of Fall Care Plan developed upon admission on 10/25/2022, had a goal to be free from fall or injury. The interventions included to keep environment free of hazards, side rails up and notify medical doctor (MD) and Responsible party (RP) promptly for all fall incidents. A review of Resident 1's Nursing Notes late entry dated 11/11/2022, indicated Resident 1 was found on the floor at bedside with a bump on the left side of the head and a skin tear on the back of the right hand on 11/11/2022 at around 11 pm. Head to toe assessment was done. During an interview with Certified Nursing Assistant 1 (CNA 1), on 12/12/2022 at 1:23 p.m., CNA 1 stated, Resident 1 was non-verbal and dependent on staff with mobility. CNA 1 stated, Resident 1's fall on 11/11/2022 at around 11pm was an unusual occurrence for Resident 1 to fall from the bed since she can barely move and needed at least two-persons assist for bed mobility and ADLs. During a concurrent interview with Registered Nurse 2 (RN 2) and Resident 1's Medical Records review, on 12/12/2022 at 2:15 p.m., RN 2 stated Resident 1 was non-verbal and bedridden. RN 2 stated, she did not know how Resident would have fallen from the bed on 11/11/2022. RN 2 further stated Resident 1 was totally dependency on staff with ADLs. RN 2 further stated, it was an unusual occurrence for Resident 1 to fall out from the bed. RN 2 further stated, if a resident was found on the floor with a bump on the head and a skin tear, she would recommend a test like an X-ray (use of invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film or digital media) to rule out injury. RN 2 stated, no X-ray was done after the fall on 11/11/2022 found in Resident 1's Medical Records. RN 2 further stated, she was not sure why there was no X-ray done after Resident 1 had a fall incident on 11/11/2022. RN 2 stated, when X-rays are not performed after a resident fall could put the resident at risk for undiagnosed fracture or any other further injury. During the same concurrent interview with RN 2 and Resident 1's Medical Records review on 12/12/2022 at 2:15 p.m., RN 2 stated there are no revised fall risk care plan or fall care plan found in Resident 1's Medical Records. RN 2 stated the care plan for Resident 1 should have been revised or develop a fall care plan after the unwitnessed fall incident on 11/11/2022. RN 2 further stated without the revised fall risk care plan puts Resident 1 at risk of further fall and injury. During an interview and a concurrent record review with the Administrator (ADM), on 12/28/2022 at 5:09 p.m., Resident 1's Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations) Form, dated 11/12/2022 was reviewed. Resident 1's SBAR indicated a change of condition (COC) was reported due to fall, with recommendations to do an X-ray upon fall. Upon review of Resident 1's documentation with ADM, the ADM stated there was no X-ray done after incident of fall on 11/11/2022. The ADM further stated he's not sure why X-ray was not done and why MD did not order x-ray. A review of Resident 1's Physician Progress Notes, with date of visit of 11/14/2022, indicated, there was no summary noted regarding Resident 1's incident of fall on 11/11/2022 and no follow-up or changes made to his order to rule out Resident 1's injury of the bump of the head and skin tear sustained after the fall incident. A review of Resident 1's Nursing Notes dated 11/20/2022, indicated Resident 1 was found lying on the floor on her left side on 11/20/2022 at 9:45 pm. The same nursing notes indicated Resident 1 was transferred on the bed from the floor with a three-person assistance. Visual assessment done and no visual injury noted. A review of Resident 1's Nursing Notes dated 11/25/2022, indicated, Resident 1 have a discoloration, edema, redness, and warmth on left knee. Physician ordered for left knee X-ray. A review of Resident 1's Left Knee X-ray Result dated 11/26/2022 at 1 am indicated on a single image there is a fracture with separation and angulation (the presence of angular deformity to a fractured bone) of the distal femoral diaphysis (central part of the long bone) . A review of Resident 1's Nursing Notes dated 11/26/2022 at 7 am indicated Resident 1's Physician order to transfer Resident 1 to GACH 1. A review of Resident 1's Nursing Notes dated 11/26/2022 at 4:22 pm indicated Resident 1 was transferred to GACH 1. During an interview with the ADM on 12/28/2022 at 5:15 p.m., the ADM stated, he was not sure what happened or what Resident 1's physician ordered for Resident 1 after the fall incident on 11/11/2022. The ADM further stated the fall on 11/11/2022 should have been investigated by the RN why the resident fell and identify the possible cause of fall. ADM further stated investigation should be conducted to rule out the injury sustained since she was found with a bump on the head and skin tear. The ADM further stated a revised fall risk care plan should have been completed to prevent future fall incidents. During an interview with Resident 1's Physician (MD), on 12/29/2022 at 11:15 p.m., the MD stated Resident 1 was nonverbal, dependent on tracheostomy and ventilator and comatose (of or in a state of deep unconsciousness for a prolonged or indefinite period, especially because of severe injury or illness). The MD further stated, he was surprised as to how Resident 1 could have fallen which caused him to order the transfer of Resident 1 to GACH on 11/26/2022 due to the result of the x-ray. The MD stated when he visited Resident 1 on 11/14/2022, he does not remember why he did not document anything about Resident 1's fall incident on 11/11/2022. The MD further stated, he should have ordered an X-ray to rule out the injury Resident 1 sustained on 11/11/2022 since she was found on the floor with a bump on the head and a skin tear. A review of Resident 1's Medical Records from the GACH 1 indicated the following: a. The X-ray of Resident 1's left knee, femur (thigh long bone), pelvis, and ankle taken on 11/26/2022 at 6:24 p.m. showed displaced (bones are out of alignment) and angulated (the presence of angular deformity to a fractured bone) left distal femur fracture which looks to extend through the skin surface along the distal anterior thigh. b. On 11/28/2022, Resident 1's hemoglobin (red blood cell) level was 6.5 (grams per deciliter-gm/dl, normal reference range is 12 gm/dl to 15.5 gm/dl.) and received one unit of red blood cells. c. On 12/1/2022, Resident 1 underwent surgery of the left knee. d. During ORIF surgery, Resident 1 had an acute blood loss and was transferred to Intensive Care Unit (ICU) for monitoring after surgery due to blood loss, new vasopressors (is a drug that healthcare providers use to make blood vessels constrict or become narrow in people with low blood pressure) requirement and acidotic (blood has too much acid) on venous blood gas analysis (VBG - a laboratory and point-of-care test routinely used to assess acid-base status along with adequacy of ventilation and oxygenation). e. On 12/4/2022 after ORIF surgery, Resident 1's hemoglobin level dropped to 6.6 gm/dl and received another one unit of red blood cells. A review of the facility's policy and procedures (P&P) titled, Falls and Fall Risk, Managing , with revised date of December 2021, indicated, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The same P&P indicated, if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . The staff will monitor and document each resident's response to interventions intended to reduce falling of the risks of falling . If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. A review of the facility's P&P titled, Falls - Clinical Protocol , with revised date of May 2022, indicated, for the individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall; causes refer to factors that are associated with or that directly result in a fall . After more than one fall, the physician should review the resident's gait, balance, and current medications that may be associate with dizziness or falling . the staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture has been ruled out or resolved, delayed complications such as late fractures and major bruising may occur several hours or several days after a fall. A review of the facility's P&P titled, Accidents and Incidents - Investigating and Reporting , with revised date of December 2021, indicated, all accidents or incidents involving a resident, employees, visitors, vendors, etc. occurring on our premises shall be investigated and reported to the Administrator . the nurse supervisor/charge nurse and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who require [MEDICAL TREATMENT] services (a life-support treatment that uses a special machine to filter harmful wastes, salt, and excess fluid from your blood) and was diagnosed with [REDACTED]. As a result, on 5/14/2020, after missing three [MEDICAL TREATMENT] treatments, Resident 1 was transferred to the General Acute Care Hospital (GACH) for emergency [MEDICAL TREATMENT]. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the care plan initiated 3/28/2020, indicated Resident 1 had a concern with [MEDICAL TREATMENT] (use of a machine to clean your blood) related to [MEDICAL CONDITION]. The care plan indicated Resident 1 recieved [MEDICAL TREATMENT] on Monday, Wednesday, and Friday, with interventions of fluid restriction as ordered, intake and output as indicated, and notify physician of [MEDICAL CONDITION]. A review of the physician's orders [REDACTED]. A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 5/14/2020 indicated Resident 1 was cognitively intact (capable of understanding and making decisions), and had total dependence with two people assist for activities of daily living. The MDS, under section Special Treatments, Procedures, and Programs indicated Resident 1 receied [MEDICAL TREATMENT]. Resident 1's [MEDICAL TREATMENT] Communication Forms was requested for review. No Forms were available on 5/8/2020, 5/11/2020, and 5/13/2020 to indicate Resident 1 had received [MEDICAL TREATMENT] services. A review of Resident 1's Nursing Progress Notes dated 5/14/2020 indicated, received report from morning shift charge nurse that Resident 1 missed one-week session of [MEDICAL TREATMENT]. The progress note indicated Resident 1 was going to emergency room (ER) for emergency [MEDICAL TREATMENT] by regular ambulance. A review of the physician's orders [REDACTED]. During an interview, on 11/19/2020 at 12:11 PM , Licensed Vocational Nurse (LVN )1 stated Resident 1 missed [MEDICAL TREATMENT] twice, on 5/8/2020 and 5/11/2020. LVN 1 stated the Physician was notified of the missed [MEDICAL TREATMENT] on 5/14/2020. LVN 1 further stated the facility failed to ensure Resident 1 received [MEDICAL TREATMENT] treatments per the physician's orders [REDACTED]. During an interview with the Admininstrator (Admin, who was also a registered nurse) on 11/23/2020 at 12:15 PM, when asked why Resident 1 did not receive [MEDICAL TREATMENT] per the physicina's order, he stated the [MEDICAL TREATMENT] facility required Resident 1 to have a Hep B panel prior to recieving [MEDICAL TREATMENT]. The Admin stated he tried to arrange for Resident 1 to receive services at a different [MEDICAL TREATMENT] facility. During an interview with Administrator (Admin), on 11/23/2020 at 12:22 PM, the Admin stated Resident 1 did not receive [MEDICAL TREATMENT] from 5/7/2020 to 5/14/2020. The Admin stated Resident 1 was transferred to the GACH emergency room (ER) for emergency [MEDICAL TREATMENT] on 5/14/2020. The Admin stated the facility failed to ensure Resident 1 received [MEDICAL TREATMENT] treatment timely and per the physician's orders [REDACTED].>Attempts were made to interview the Director of Nursing (DON) on 11/19/2020 and 12/23/2020, but she was unavailable for interview. During an interview with Assistant Director of Nursing (ADON), on 12/23/2020 at 11:29 AM, the ADON stated it was the facility's responsibility to ensure residents received [MEDICAL TREATMENT] treatments. The ADON stated and confirmed the facility failed to provide appropriate [MEDICAL TREATMENT] care for Resident 1 and the potential outcome was risk for infection or death. A review of the GACH Discharge Summary, dated 6/3/2020, indicated Resident 1 received [MEDICAL TREATMENT] and the problem was resolved. A review of the facility's policy and procedures titled, End Stage [MEDICAL CONDITION], Care of a Resident, revised October 2009, indicated residents with end stage disease will be cared for according to recognized standards of care. Residents will receive [MEDICAL TREATMENT] care outside the facility.

Based on observations, interviews, record reviews, and policy review it was determined the facility failed to assure infection control policies and procedures related to the prevention of COVID-19 were written and implemented according to Centers for Disease Control and Prevention (CDC) guidelines, for 7 of 10 sampled residents (Resident (R)2, R3, R4, R5, R6, R9, and R10) identified by the facility's undated Isolation Color Coding chart for the yellow Person Under Investigation (PUI) quarantine status. The facility implemented policies and procedures that allowed residents admitted from acute care settings, with a negative test and requiring 14-day quarantine, to share a room with already established residents working on their own 14-day quarantine, likely exposing both residents to unknown [MEDICAL CONDITION] contact and precluding any tracing attempts. The facility also allowed residents in quarantine status to leave the isolation of their rooms to go to different floors for therapy and/or smoking without appropriate personal protective equipment (PPE) in use by staff. The facility further failed to assure PUI residents received care according to infection control policies and procedures developed to prevent contamination or infection for 2 of 10 sampled residents (R5 and R6). A Certified Nurse Aide (CNA) 1, observed during R6's incontinent care, allowed contaminated resident items to be touched and placed on the floor during care. The CNA further failed to perform hand hygiene after removing soiled gloves and re-applying (donning) new ones. The CNA touched R6's skin and percutaneous endoscopic gastrostomy (peg) tube with soiled gloved hands and then contacted the roommate's furniture and a clean gown with the same gloves on. The facility Administrator and Director of Nursing were notified on 11/12/20 at 4:30 PM of concerns rising to the level of immediate jeopardy at F880 infection control. This was related to a failure to follow CDC recommendations in the area of cohorting new admissions or readmission residents from acute care settings. The facility was also informed of their failure to assure rooms containing PUI residents were cohorted on a designated unit or area for residents with the same PUI status and/or possible COVID contact. The immediate jeopardy further identified a failure to consistently isolate PUI residents in their rooms during their 14-day quarantine. They allowed PUI residents to be transported, via elevators, to the therapy gyms, located on a different floor, and those who were smokers, to be transported via elevators to the floor with a smoking area, without appropriate PPE in use. The facility provided an acceptable plan for removal of the immediate jeopardy on 11/13/20 at 2:07 PM. Validation of the plan for removal was accomplished by observations of room changes to go along with the CDC guidelines and the cohorting of like transmission-based precaution rooms and residents. In addition, changes to the facility policy and procedures were reviewed, including PPE requirements during therapy of PUI residents. The facility provided evidence of ongoing staff training related to the changes to COVID related infection control policies and procedures and provided sign-in sheets containing staff signatures. The Administrator was notified the immediate jeopardy was removed on 11/13/20 at 2:45 PM. Findings include: 1. During the initial tour of the facility on 11/09/20 at approximately 10:00 AM, a number of resident rooms were identified with yellow stickers, indicating the residents, according to the DON, were PUI residents for new or re-admissions, [MEDICAL TREATMENT], and/or frequent outside appointments. Observations on 11/09/20 at around 11:00 AM, of a room on the fifth floor, shared by R3 and R4, displayed a yellow sticker on the door, indicating the residents were PUI's. According to the DON, at that time, R3 was a new admission resident on PUI for 14 days. She said R4 was a [MEDICAL TREATMENT] resident, who left the facility three times per week to go to the [MEDICAL TREATMENT] center in the community. She said they were roommates because they were both PUI's. Record review of R3's electronic medical record (EMR), under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's roommate, R4, according to a review of his resident Face Sheet, retrieved from the EMR, under the Face Sheet tab and provided by facility, was admitted at least 24 days before R3, on 09/24/20. R4's face sheet indicated the resident had [DIAGNOSES REDACTED]. According to R4's current Physician order [REDACTED]. 2. On 11/11/20 at 11:00 AM, R6 and R5 were observed sharing a room. During record review of R6's undated Face Sheet, provided by the facility, it was determined the resident was last admitted to the facility on [DATE], after a discharge from an acute care setting. R6's roommate, R5, according to her undated Face Sheet, was admitted to the facility, after a hospital discharge, on 10/24/20, into the room with R6. R6 was on her third day of quarantine when R5 was admitted into her room. In addition, R5 continued with a PUI status after a 14-day quarantine because of her weekly [MEDICAL TREATMENT] treatments. According to her current Physician Orders, located under the Orders tab of the EMR, dated 11/10/20, R5's orders included [MEDICAL TREATMENT] three times per week. Although R5 remained in a PUI quarantine status, her roommate had completed her quarantine, but continued in the room with R6, who could likely make contact with people with unknown COVID status during weekly trips to the [MEDICAL TREATMENT] center. On 11/09/20, around 3:30 PM, an interview with the Administrator revealed R4 was a PUI resident because the resident left the facility to receive [MEDICAL TREATMENT] three times per week. He revealed R3, R4's roommate, was also a PUI because he was a new admit on the 14-day quarantine. He said they were roommates because they were both PUI status. The Administrator said most of the facility PUI residents did not complete their 14-day quarantine before they were discharged after short therapy stays. The Administrator said quarantine did not mean isolate but that the person was being monitored in a controlled environment. 3. Record review of R2's undated resident Face Sheet, revealed the resident was readmitted from acute care to the facility on [DATE] into a room on the fifth floor. According to the facility's undated Isolation Color Coding chart of residents in the yellow PUI status, R2 was in quarantine because of frequent outside of facility appointments. An interview with the Activity Assistant on 11/11/20, around 9:00 AM, indicated PUI residents, in the yellow zone, were allowed to go to the second floor outside patio to smoke. She said she sometimes took the yellow residents by themselves. A review of the facility's Smoking Residents, list, dated 11/03/20, revealed R2, was a PUI resident because of continuous appointments, and was listed as a resident who could smoke without supervision. 4. Record review of R9's undated resident Face Sheet, provided by the facility, revealed the resident was admitted to the facility on [DATE]. According to R9's Care Plan History, with a date range of 10/12/20 through 11/12/20, provided by the facility, R9 had an approach to maintain isolation in addition to keeping the door closed and privacy curtain pulled. The approach was documented as created on 11/09/20. Despite R9's admission to the facility and start of quarantine on 11/07/20, the resident was placed in a room with R10. R10, according to her undated resident Face Sheet, was admitted to the facility on [DATE], two days after her roommate, R9. Both residents were listed on the facility's Isolation Color Coding chart as new admissions with a yellow (PUI) status. However, R9 was two days into her 14-day quarantine when R10 arrived to start her 14-day quarantine. Review of the facility's undated policy, titled Beachwood Post-Acute and Rehab COVID-19 Cohorting Protocol, yellow zone (PUI) residents .admitted from the acute hospital for therapy services with no known COVID exposure, a negative COVID test, and no signs/symptoms of COVID can be taken to medical appointments and therapy sessions with proper PPE. Residents can be cohorted for therapy services in the therapy gyms up to 2 residents per gym. Proper cleaning of equipment and space must occur after the therapy session. The policy did not provide criteria for cohorting residents, with the same color status and different admitted s, into the same room. Observations on 11/11/20 at 11:40 AM, in one of the therapy gyms, revealed R9, a PUI resident, receiving therapy from Physical Therapy Assistant (PTA) 1, as two other staff (Physical Therapy (PT2 and PT3) were busy sanitizing equipment used earlier. The three staff and R9 were wearing face masks. The staff also were wearing gloves. No other PPE was in use. PTA1 providing hands on care was not wearing a face shield or goggles or a gown while providing care. According to the facility's undated policy titled, Beachwood Post-Acute and Rehab COVID-19 Cohorting Protocol, PPE required for staff caring for PUI residents were isolation gown, eye protection, and KN95 mask. A review of the facility's 10/01/20 COVID 19 Mitigation Plan, under the section titled Procedures: COVID-19 Confirmed Cases; Symptomatic and Suspected: COVID Unit, revealed Cohorting of residents will be identified by three units: Green, Yellow, Red. According to the facility's plan, Green represented residents who had no COVID exposure and cleared their 14-day quarantine period .from prior exposure of positive results. Those residents required standard precautions. Residents designated with the color status of Yellow, were . residents who are newly admitted from the hospital and are not positive . Yellow zone residents: who are admitted from the acute hospital for therapy services with no known COVID exposure, a negative COVID test, and no signs/symptoms of COVID can be taken to medical appointments and therapy sessions with proper PPE. Residents can be cohorted for therapy services in the therapy gyms up to (two) residents per gym . However, observations throughout the survey from 11/09/20 to11/13/20 revealed color status zones were mixed on floors 2, 3, 4, and 5. Rounds on the second floor east wing, on 11/10/20 at around 1:05 PM revealed seven yellow rooms (PUI) cohorted with six orange rooms (Contact Isolation). On the west side there was one orange room surrounded by green rooms. Observations on the fourth-floor east wing, on 11/20/20 around 1:05 PM, revealed there was one yellow room surrounded by 11 green rooms. According to CDC recommendations, in regard to new and/or re-admissions to facilities, the facility should .Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19 . https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html 5. Observations on 11/10/20 at 11:00 AM, in R6's room, revealed PT1 and CNA1 providing incontinent care. R6, a PUI resident, was observed lying in bed with her lower body exposed for care. Her roommate, R5, was lying in her bed, behind the privacy curtain. CNA1, while wearing PPE, gown, gloves, face shield, and mask, proceeded to clean the resident of bowel incontinence. Three opened plastic trash bags were observed sitting on the resident's floor. Two bags contained trash, including disposable briefs and wipes soiled with feces. Another bag contained soiled linens. CNA1 stepped away from R6 after cleaning the resident's buttocks and while wearing the same gloves worn during care, retrieved a clean sheet to use as a pad and a brief from a closet. She returned and proceeded to pull the soiled pad from under the resident and threw it to the floor. CNA1, while continuing to complete the resident's care with PT1 assisting with positioning, stepped on the soiled pad on the floor as she moved around the room. CNA1 did not change her gloves between clean and dirty care. With her soiled gloves on, CNA1 patted R6 on her bare legs and hips, then positioned a towel under the resident's peg tube, extending from her abdomen. When asked to retrieve the towel from the tube for the surveyor to view it, CNA1 presented the towel. The towel was soiled with a dark brown substance, which had the same coloring and appearance as the feces on the soiled wipes and brief. Prior to leaving R6's room to retrieve additional trash bags, CNA1 removed her old gloves and applied clean ones, without sanitizing or handwashing her hands. She touched the door handle to open the door and stepped out of the room. On 11/11/20 at 12:55 PM an interview with CNA1 about the care observations above, the aide said she had only worked for the facility for six days. She confirmed she had been trained and knew she was supposed to remove soiled gloves and sanitize before putting on clean ones. CNA1 said she had to remove her PPE before leaving the room and because there was no sanitizer in the room, she could not clean her hands. However, observations in R6's room on 11/10/20 at 11:00 AM, after incontinent care was completed, revealed there was soap, water, and paper towels available at the resident's hand sink. Review of the facility's undated policy titled, Laundry and Bedding, Soiled, revealed soiled laundry and bedding should be . contaminated with blood or other potentially infectious materials is handled as little as possible and with a minimum of agitation .b. Laundry that is contaminated with blood or body substances is placed in leak-proof bags or containers. C. Contaminated laundry is placed in a bag or container at the location where it is used and not sorted or rinsed at the location . The facility's undated Handwashing/Hand Hygiene policy documented, . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . c. Before and after direct contact with residents. Before donning sterile gloves . j. After contact with a resident's intact skin . n. After removing gloves . 8. Hand hygiene is the final step after removing and disposing of personal protective equipment . On 11/11/20 at 12:13 PM, an interview was conducted with the Infection Control Preventionist (ICP), who was also the Director of Staff Development (DSD). Observations of R6's incontinent care provided by CNA1 was shared with the ICP/DSD and later with the Director of Nursing (DON) who joined the interview. The ICP/DSD reported that CNA1 had successfully completed her skills competencies. She confirmed that staff must successfully complete their skills competencies before they are released to work independently.

Based on observation, interview and record review, the facility staff failed to promote healing of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for seven of 35 sampled residents (Residents 251, 7, 56, 93, 112, 134, and 147) including not limited to: 1. Failure to follow Resident 251's Clinitron Bed Air Fluidized Therapy Unit (a specialty bed) manufacturers' recommendations to not use plastic ((backed of the chux was plastic) plastic does not allow for airflow through the pad) on the bed. 2. Failure to ensure Resident 251's pressure ulcer dressing was free of fecal matter to prevent cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). 3. Failure to use a DryFlow chux (an incontinence protection pad that allows air to flow through the pad while acting as a barrier to to moisture) underneath Resident 251, while on a Clinitron bed to avoid - moisture, skin breakdown, and maintain a pressure relief to get the full effect of the Clinitron bed, instead of a [MEDICATION NAME] (plastic) chux. 4. Failure to ensure Resident 251's care plan addressed the resident's stage 4 pressure ulcer and develop interventions necessary to promote healing of a stage 4 pressure ulcer. 5. Failure to implement Resident 251's care plan to ensure the Skin Condition Report indicating the resident had a stage 4 pressure ulcer (a wound that is caused by constant pressure and a wound that has spread to the underlying bone or muscle) on the sacrococcyx area, included a date, size of the pressure ulcer, and the skin description. 6. Failure to ensure Residents 56, 93 and 147's low air loss mattress (LAL- a device used in the prevention, treatment and management of pressure ulcers), pressure setting was maintained based on residents' weight. 7. Failure to measure accurately Resident 134's wound depth. 8. Failure to follow nursing standards of practice by reverse staging Resident 134's wound that had been classified by a wound consult as a stage 4 wound (full thickness skin loss with extensive destruction, tissue necrosis (death) or damage to muscle, bone, or supporting structure (such as tendon)). 9. Avoid the use of multiple layers of bed sheets over a low-air -loss mattress (LAL - a medical device used to relief pressure on the skin) that compromised the full effect of the pressure relieving device for Resident 7 and 112. 10. Ensure the treatment nurse conducted accurate assessment and to request for wound consult specialist when treatment was not effective for Resident 7. 11. Ensure the weekly wound assessment was conducted to identify the progression of pressure ulcer for Residents 112 and 251. These deficient practices resulted in Resident 251 at risk for worsening of a stage 4 pressure ulcer, worsening of the pressure ulcer infection, which can lead [MEDICAL CONDITION] (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death). Also, a potential for delayed identification of worsening pressure ulcers, delayed wound healing, a potential to result in a reoccurrence of a pressure ulcer and the potential for the development of new pressure ulcers. Findings: a. A review of Resident 251's skilled nursing facility (SNF) admission record indicated Resident 251 was originally admitted to the facility on (MONTH) 23, (YEAR), discharged from the facility on (MONTH) 19, (YEAR), and readmitted to the facility on (MONTH) 31, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 251's Admission Minimum Data Set (MDS a resident assessment and care screening tool) dated, (MONTH) 30, (YEAR), indicated Resident 251 had a total BIMS (Brief Interview for Mental Status), score of 13. A BIMS score of 13 indicates Resident 251 was cognitively intact. The MDS indicated the resident required extensive assistance from the staff with activities of daily living (ADL's), such as bed mobility (how resident moves from side to side in bed) toileting and personal hygiene, had a urinary catheter and was always incontinent of bowel. The Active [DIAGNOSES REDACTED]. The skin and ulcer treatments indicated: Pressure reducing device for bed, pressure ulcer care, application of non-surgical dressings and applications of ointments/medications. A review of Resident 251's Admission Minimum Data Set (MDS) dated (MONTH) 19, (YEAR), indicated Resident 251, had a BIMS Score of 10. A BIMS score of 10 indicates Resident 251 had moderately impaired cognition. The MDS indicated the resident was totally dependent on staff support for physical help with ADLs. The Active [DIAGNOSES REDACTED]. A review of Resident 251's medical record indicated the resident was discharged home on (MONTH) 19, (YEAR). A review of Resident 251's GACH History and Physical (H and P) date of service (MONTH) 28, (YEAR), indicated Resident 251 was at home bedbound, and was sent to the GACH Emergency Department (ED), for initial workup, and evaluation of worsening pain in his sacrum (buttock) secondary to his sacral decubitus (stage 2). According to the H and P, Resident 251, was previously admitted to the SNF (skilled nursing facility) on (MONTH) 23, (YEAR) to (MONTH) 19, (YEAR). The ED's H and P indicated on (MONTH) 28, (YEAR), Resident 251 had a 9 inch length (22.86 centimeters-cm), by 6 inch width (15.24 cm), sacral decubitus ulcer that appeared deep with surrounding redness. A wound culture was done in the ED. According to the ED H and P, Resident 251's sacral decubitus ulcer was noted to have a foul odor. A review of the GACH General Surgery Consult dated (MONTH) 28, (YEAR), indicated the resident had large decubitus ulcer approximately 12 cm by 20 cm and had a sharp (scalpel-a knife with a small, sharp, sometimes detachable blade) abridgement (the removal of damaged tissue or foreign objects from a wound) performed down to bleeding tissue. A review of (GACH) referral to the skilled nursing facility dated (MONTH) 31, (YEAR) at 10:15 a.m., indicated Resident 251 had a stage 4 decubitus ulcer, requiring daily care and intravenous antibiotics for 31 days. A review of Resident 251's Initial Admission Licensed Nurses Assessment Note dated (MONTH) 31, (YEAR) at 9:31 p.m., (readmission) indicated Resident 251 had a stage 4 decubitus sacral ulcer and was incontinent of bowel. A review of the Braden Scale assessment dated (MONTH) 31, (YEAR), (used to predict pressure sore risk) indicated the resident had a total score of 11.0 (high risk) due to the resident's complete immobility, being bedfast and being exposed to having very moist skin most always and requiring an extra linen change approximately once per shift. A review of Resident 251's care plan dated (MONTH) 31, (YEAR), indicated the resident has a Pressure Ulcer of the sacrococcyx and was at risk for further breakdown and or slow/delayed healing related to decrease mobility, co-morbidities (is the presence of one or more additional diseases or disorders co-occurring with a primary disease or disorder). The approaches indicated the resident was to have a pressure reduction mattress to the bed as indicated, to turn and reposition the resident frequently as indicated, to assess the pressure ulcer for stage, size, (length, width, and depth), and condition of surrounding skin. Resident 251's care plan did not include the following: 1. The resident had a stage 4 pressure ulcer of the sacrococcyx area 2. Interventions necessary to promote healing of a stage 4 pressure ulcer 3. The specific treatment to provide as the physician ordered including, a. The use of a Low Air Loss or Clinitron Bed (specialized bed used for pressure ulcer healing). b. The application of Santyl dressings. 4. Include provision care related to the resident's Santyl dressing, if soiled 5. Include methods to ensure the effectiveness of the Clinitron bed or Low Air Loss mattress including, a. The use of bed linens with chux b. The use of specific protection pads (chux) that allows air to flow through the pad while acting as a barrier to to moisture. 6. The frequency of when to turn and reposition the resident A review of a physician's orders [REDACTED]. re-evaluate in 14 days, once a day; 7 a.m. to 3 p.m. and to provide a LAL mattress. A review of Resident 251's Wound Management Information dated (MONTH) 1, (YEAR) at 2:19 p.m., indicated Observation History: Stage 4 pressure ulcer. Length: 14 cm's (5.5 inches), Width: 10 cm's (3.9 inches) Depth: 3 cms (1.1 inches). Exudates (pus) amount: moderate. Exudates color and consistency: Serosanguineous (pale red to pink, thin and watery the liquid part of blood). Undermining (extend under the skin) 12 o'clock 4 cms (1.5 inches), 3 o'clock 1 cm (.393 inch) 9 0clock 3 cm (1.1 inches). Percent (%) of wound covered by slough (dead skin or tissue that has fallen off of decubital ulcers) tissue: 30%. Comments: LAL mattress. Tissue type: necrotic (lack of blood supply) tissue: Skin surrounding wound: dark purple or rust discoloration. Wound edges: macerated (to soften tissue by steeping or soaking)/soft, and wound healing status: Declining, this wound has not been healed. A review of Resident 251's physician's orders [REDACTED]. On (MONTH) 9, (YEAR) at 10 a.m., during an observation of Resident 251's sacral wound dressing change with Licensed Vocational Nurse 10 (LVN 10) the treatment nurse, and Certified Nursing Assistant 7 (CNA 7), Resident 251 had blood and feces covering his sacral dressing, and there was yellow slough with undermining of the sacral pressure area and a foul smell was noted. The resident was lying in a Clinitron Bed and there was a chux (a protection pad) that had a blue plastic backsheet underneath Resident 251's buttock, and beneath the chux was a full bed sheet. On (MONTH) 9, (YEAR) at 10 a.m., in a concurrent interview with the observation, LVN 10 stated she instructed CNA 8, to place the blue chux (with a plastic backsheet) on the resident's bed and a sheet underneath Resident 251, thirty (30) minutes ago. On (MONTH) 10, (YEAR) at 7:54 a.m. in an interview, CNA 8 stated on (MONTH) 9, (YEAR), at 9:30 a.m., before Resident 251's sacrococcyx dressing change by the treatment nurse, she observed Resident 251 had loose bowel movement and there was bowel movement on the outside and on the top of Resident 251's pressure ulcer dressing. (The resident was receiving intravenous antibiotics for the stage 4 decubitus ulcer, but the resident's soiled pressure ulcer dressing was changed 30 minutes later on (MONTH) 9, (YEAR) at 10 a.m.). On (MONTH) 10, (YEAR) at 8:42 a.m., during a second, subsequent wound observation and interview with LVN 10, at Resident 251's bedside, a blue chux (with a plastic backsheet) and one full sheet was noted beneath Resident 251's buttock on the Clinitron Bed. LVN 10, stated the resident poops in the bed, and that is why we have the blue chux. LVN 10, stated the blue chux (with a plastic backsheet) was placed to prevent fecal matter soiling the resident's Clinitron Bed. On (MONTH) 10, (YEAR) at 9 a.m., during an interview, the DON stated Resident 251 should not have two layers (a sheet and a blue plastic backsheet chux) on his Clinitron Bed, because the fluidized air bed company makes a special chux to use on their beds. The DON stated the chux with plastic should not used because it defeats the purpose of the bed. When asked the DON stated when Resident 251's dressing is soiled with bowel movement, the dressing should be changed immediately, due to contamination of the resident's stage 4 pressure ulcer. The DON stated the resident should be changed immediately to prevent infection. On (MONTH) 10, (YEAR) at 11:29 a.m. a review of Resident 251's Skin Condition Report did not include a date, size of the pressure ulcer, and the skin description as the care plan indicated (the last wound description was dated (MONTH) 1, (YEAR)) to determine the healing status of the pressure ulcer. In a concurrent interview with the record review, the DON stated the resident's report was incomplete because there was no documentation of the date on the report. The DON stated the resident's care plan did not include the pressure ulcer stages because the Quality Assurance and Performance Improvement (QAPI) Committee instructed to not indicate the stage of pressure ulcer on the care plan. A review of the Clinitron Bed's manufactures' Air Fluidized Therapy Unit Quick Reference Guide, dated (MONTH) 2005, indicated the following: 1. We recommend one full flat sheet under the patient. 2. Do not use plastic. A review of the facility's policy and procedure titled, Pressure Ulcer Treatment, dated (MONTH) (YEAR), indicated the purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the pressure ulcer(s). b. Managing tissue loads. c. Pressure ulcer care. d. Managing bacterial colonization and infection. e. Operative repair of the pressure ulcer(s). f. Education and quality improvement. A review of the facility's policy and procedure titled Comprehensive Assessments and the Care Delivery Process dated (MONTH) (YEAR), indicated, Monitoring results and adjusting interventions include: Periodically reviewing progress and adjusting treatments as well as overall care and services. Continue to define or refine objectives of specific treatments as well as overall care and services. Completed assessments (baseline, comprehensive, MDS, etc. are maintained in the resident's active record for a minimum of 15 months. These assessments are used to develop, review, and revise the resident's comprehensive care plan. b. During the initial tour observation and interview on (MONTH) 7, (YEAR) at 11:06 a.m., in the presence of Licensed Vocational Nurse 8 (LVN 8), the LAL mattress of Resident 147 was observed. The mattress dial was set to a dial stop that was indicative of a person of 315 pounds (lbs. - a unit of measure). LVN 8 stated she did not think this was the right setting because the resident did not weigh that much. LVN 8 stated she goes by the Air Mattress Pressure Adjustable Dial chart and showed the form. Then the LVN treatment nurse, LVN 9 entered Resident 147's room and stated that the LAL dial is to be set to the resident's comfort. LVN 9 stated that he does not use the Air Mattress Pressure Adjustable Dial chart. LVN 9 stated he was not familiar with the LAL for Resident 147 and left the room to obtain the manual. A review of the Admission Record of Resident 147 indicated the resident was admitted to the facility on (MONTH) 8, 2013 and readmitted on (MONTH) 20, (YEAR) with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool), dated (MONTH) 18, (YEAR), indicated Resident 147 was cognitively intact (a process of acquiring knowledge and understanding through the use of thought, experience and the senses) in activities of daily living. Resident 147 needed one-person extensive assistance with bed mobility, dressing, and personal hygiene. Resident 147 did not have any pressure ulcer but was at risk of acquiring a pressure ulcer. Resident 147, according to the section K - Height and Weight section, weighed 198 pounds (lbs. - a unit of measure). A review of Resident 147's Braden Scale (The purpose of the scale is to help nurses assess a patient's risk of developing a pressure ulcer) score, dated (MONTH) 11, (YEAR), was 14 which indicated Resident 56 was at moderate risk for developing a pressure ulcer. c. During another observation of Resident 56's LAL mattress on (MONTH) 7, (YEAR) at 1:00 p.m. in the presence of LVN 9, the LAL mattress setting was set to static and not circulating. LVN 9 stated the mattress is set to static only when staff provide care to the resident. During that observation, Resident 56 was sleeping and staff was not providing care. LVN 9 provided a manual for the LAL mattress but the manual appeared to be for a different manufacturing company than Resident 56's actual physical LAL mattress. A review of the Admission Record indicated Resident 56 was admitted to the facility on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. A review of the MDS, dated (MONTH) 6, (YEAR), indicated Resident 56 was severely impaired in cognitive skills in daily decision-making. Resident 56 was totally dependent on staff for transfer, dressing, and personal hygiene. Resident 56 did not have any pressure ulcer but was at risk of acquiring a pressure ulcer. A review of Resident 56's Braden Scale score, dated (MONTH) 6, (YEAR), was 14 which indicated Resident 56 was at moderate risk for developing a pressure ulcer. During an interview with the Administrator (ADM) (who is also a registered nurse), on (MONTH) 8, (YEAR) at 10:00 a.m., he stated the pressure dials should be set according to a resident's weight and that the resident's weights were checked and the dial setting indicating what the pressure mattress should be set at was now taped to each residents' LAL mattress so that staff would know which was the correct setting for the LAL mattress. During a sacral (a portion in the lower back situated between the two hipbones of the pelvis) wound treatment observation of Resident 134 on (MONTH) 9, (YEAR) at 10:05 a.m., LVN 9 conducted the dressing change. After the old dressing was removed, the wound was measured which included the dimensions: length, width, and depth. The length and width were measured with a paper ruler. For the measurement of the depth, LVN 9 placed the same ruler inside the wound, not completely touching the wound base to measure the depth. When asked about this, LVN 9 stated for the resident's comfort, he used the paper ruler instead of using the customary Q-tip (cotton swab) which touches the base of the wound. The wound measurements were: 3.4 cm in length, 1.8 cm. in width, and 0.3 cm. in depth. During an interview with the Director of Nurses (DON) on (MONTH) 9, (YEAR) at 11:15 a.m., she stated LVN 9 should have used a cotton swab to measure accurately the depth of the wound. The DON stated the wound consult notes should be kept in a resident's physical chart. d. A review of the Admission Record indicated Resident 134 was admitted to the facility on (MONTH) 7, 2014 and readmitted on (MONTH) 29, (YEAR) with [DIAGNOSES REDACTED]. A review of the MDS, dated (MONTH) 5, (YEAR), indicated Resident 134 was moderately impaired in cognitive skills in daily decision making. Resident 134 required extensive assistance in bed mobility and was totally dependent on one-person staff for toileting, and personal hygiene. Resident 56 was indicated to have an unstageable ulcer. However, according to the Wound Consult Notes, dated (MONTH) 25, (YEAR) indicated Resident 56 had a stage 4 pressure ulcer. A review of Resident 134's Wound Consult Notes, dated (MONTH) 25, (YEAR), indicated Resident 134 had a stage 4 sacral pressure ulcer. The measurements were the following: 1.2 cm. in length, 2.3 cm. in width, and 0.7 cm. in depth after a debridement was completed with 20% slough (yellow tissue, that can be stringy or thick on the tissue bed) present. A review of Resident 134's Braden Scale score, dated (MONTH) 29, (YEAR), indicated 15 a mild risk for developing a pressure ulcer. However, according to Wound Consult Notes, dated (MONTH) 25, (YEAR), Resident 134 already had a stage 4 pressure ulcer which should indicate the resident is at high risk. A review of the Weekly Wound Management Notes, dated (MONTH) 7, (YEAR), completed by LVN 9, indicated Resident 134 had an unstageable would due to 60% covered by slough tissue. A review of the document titled, Pressure Ulcers: A Patient Issue (Lyder, C., Ayello, E. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, [NAME]land, Agency for Healthcare Research and Quality) indicated an unstageable wound is full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough in the wound bed. A review of the document titled, Pressure Ulcer Staging, (Ayello, E. (May 2014). Pressure Ulcer Staging. Retrived from (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/IRF-QRP-Training-%E2%80%93-PrU-Staging-May-12-2014-.pdf), indicated that according to the National Pressure Ulcer Advisory Panel (NPUAP), a wound is not to be reverse staged. (For example, once a pressure sore is a stage IV ulcer, if it improves it is still considered a stage IV wound). A review of the article titled, Measuring Wounds, (Morgan, Nancy. (2017, August). Measuring Wounds. Retrieved from https://woundcareadvisor.com/measuring-wounds/), indicated to measure the depth of a wound to place a cotton-tip applicator into the deepest part of the wound bed and grasp the applicator by the wound margin and place it against a ruler. A review of the facility's policy and procedure titled, Pressure Ulcer Treatment, did not address any of the issues brought to the facility by the survey team. e. According to the admission record, Resident 112 was admitted to the facility on (MONTH) 6, (YEAR) and readmitted on (MONTH) 25, (YEAR) with [DIAGNOSES REDACTED]. electrical activity in the brain). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated (MONTH) 1, (YEAR) indicated, Resident 112 had severely impaired cognitive skills for daily decision making and was dependent on staff for toilet use, personal hygiene and bathing. On (MONTH) 7, (YEAR) at 9:40 a.m., Resident 112 was observed sleeping on a LAL mattress that had a setting of firm. Resident 112 also was lying on three layers of linen that included an incontinent brief, a thin blue chux, and a full sheet while on the LAL mattress. A review of the Air Mattress Pressure Adjustable Dial indicated that at the firm setting the weight should be at 350 pounds. On (MONTH) 7, (YEAR) at 10:08 a.m., during an interview, the Licensed Vocational Nurse 11 (LVN 11) stated that the setting on the LAL mattress is based on the resident's weight. Resident 112 weight was 155 pounds on (MONTH) 4, (YEAR). LVN 11 further stated that the setting was not correct and then adjusted the dial that correlated with the resident's weight. LVN 11 stated the layers of linens placed on the bed was depending on if the resident have a lot of bowel movement or if the resident was incontinent. A review of the Wound Management dated (MONTH) 26, (YEAR) indicated Resident 112 was readmitted to the facility with pressure ulcer on the left heel. On (MONTH) 7, (YEAR) at 10:30 a.m., a follow up interview, LVN 11 stated the weekly skin assessment for (MONTH) 2, (YEAR) was not conducted by the treatment nurse. On (MONTH) 8, (YEAR) at 2:25 p.m., during an interview, the Director of Nursing (DON) stated there should be either a thin blue chux with a full sheet or an incontinent brief with a full sheet. f. According to the admission record, Resident 7 was admitted to the facility on (MONTH) 3, 2014 and was readmitted on (MONTH) 31, (YEAR) with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated (MONTH) 26, (YEAR) indicated, Resident 7 had severely impaired cognitive skills for daily decision making and was dependent on staff for transfer, bed mobility, dressing, toilet use, personal hygiene and bathing. On (MONTH) 7, (YEAR) at 10:48 a.m., Resident 7 was observed sleeping on a LAL mattress that had five layers of linen under the resident that included an incontinent brief, two blue chux, one fabric pad, and a full sheet. During a concurrent interview, Certified Nursing Assistant 6 (CNA 6) stated that the resident should have one full sheet and either an incontinent brief or a blue chux. A review of Wound Management indicated the following: 1. (MONTH) 3, (YEAR) - Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence) wound on the coccyx that measured 2 cm x 2 cm. 2. (MONTH) 23, (YEAR) - Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) wound on the coccyx that measured 1.5 cm x 1.5 cm and a depth of 0.2 cm. 3. (MONTH) 7, (YEAR) - Stage 2 wound on coccyx that measured 1.4 cm x 1.2 cm and a depth of 0.2 cm. A review of the physician's orders [REDACTED]. 1. (MONTH) 23, (YEAR)-February 10, (YEAR) - an order to cleanse the coccyx area with normal saline, pat dry, then apply hydrogel, cover with dressing daily. 2. (MONTH) 24, (YEAR)-March 1, (YEAR) - an order to cleanse the coccyx area with normal saline, pat dry, then apply hydrogel, cover with dressing daily. 3. (MONTH) 12, (YEAR)-July 6, (YEAR) - an order to cleanse the coccyx area with normal saline, pat dry, then apply hydrogel, cover with dressing daily. 4. (MONTH) 8, (YEAR) - an order to cleanse the coccyx area with normal saline, pat dry, then apply hydrogel and paint periwound area with [MEDICATION NAME] solution then cover with dressing daily. On (MONTH) 8, (YEAR) at 11:07 a.m., during a wound observation, the Licensed Vocational Nurse 11 (LVN 11) treatment nurse stated the wound was a Stage 2 on the coccyx area and a depth of 0.2 centimeters (cm). During the wound treatment, LVN 11 stated the wound measured was 1 cm x 0.8 cm and the depth was 0.5 cm, no undermining and no tunneling and that the wound should be a stage 3 now because of the depth. LVN 11 further stated that he did not see the maceration yesterday when he did the wound assessment. Maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) of the wound was not identified by LVN 11. On (MONTH) 8, (YEAR) at 2:25 p.m., during an interview, the Director of Nursing (DON) stated she reassessed the wound and stated the wound measured 1.4 cm x 1.2 cm and had a depth of 0.4 cm and did not have maceration. DON stated there was no maceration and only light pink color around the periwound (wound edges). DON also stated that there should not have five layers of linen. A review of the Surgical Consult notes dated (MONTH) 31, (YEAR) indicated that this was the first visit to evaluate the wound on the coccyx area. On (MONTH) 10, (YEAR) at 12:05 p.m., during an interview, the Administrator spoke with LVN 11 and LVN 11 stated that the wound is changing in size, getting smaller then bigger. Administrator further stated that there was not much difference in the size of the wound and from now on to call for the surgical wound consult after 2 weeks when there was no physical improvement in the size of the wound. A review of the facility's revised policy and procedure dated (MONTH) 2007 and titled, Pressure Ulcer Treatment, indicated the purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. The pressure ulcer treatment program should focus on the following strategies that included assessing the resident and the pressure ulcer(s), managing tissue loads, and pressure ulcer care. g. A review of the admission record indicated Resident 93 was initially admitted into the facility on (MONTH) 15, (YEAR) and readmitted on (MONTH) 18, (YEAR) with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS- a comprehensive assessment tool dated (MONTH) 22, (YEAR), indicated Resident 93 had severe impairment of cognitive skills for daily decision making. The MDS also indicated Resident 93 had stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). A review of Resident 93's Braden scale indicated a total score of 11. According to the assessment tool, Resident 93 was at high risk for pressure ulcer. Interventions included pressure reducing device/mattress for bed, pain management, and redistributing pressure. A review of physician order [REDACTED]. A review of the care plan dated (MONTH) 21, (YEAR), indicated Resident 93 had pressure ulcer at the sacrococcyx are. The goal indicated the pressure ulcer will decrease in size and heal without complication. The care plan interventions included pressure reduction mattress to bed as indicated, assess for pain related to pressure ulcer or treatment, and report any signs of any further skin breakdown. A review of the weight record dated (MONTH) 4, (YEAR), indicated Resident 93 weighed 160 pounds. On (MONTH) 7, (YEAR) at 9:32 a.m., during an observation in the presence of Licensed Vocational Nurse 6 (LVN 6), Resident 93 was lying in bed. The LAL mattress was set at 350 pounds (firm). During a concurrent interview, LVN 6 stated that the LAL pressure setting was to be based on Resident 93's weight and should not have been set on firm. On (MONTH) 10, (YEAR) at 9:51 a.m., during a wound care observation, Resident 93 had a pressure ulcer on the sacrococcyx area measuring 4 centimeters (cm) in length by 4.5 cm width by 1.5 cm depth. The wound had granulation tissue and undermining (a pocket beneath the skin at the wound edge).

Based on observation, interview, and record review, the facility failed to implement thier abuse policy and procedures to prevent and protect two of 27 sampled residents (Resident 13 and Resident 17) from physical, verbal psychological, abuse, mental anguish and neglect by five of five facility staff by failing to: 1. Ensure Certified Nursing Assistant (CNA) 1 did not physically abuse Resident 13 by scratching her left arm causing her to bleed. 2. Ensure CNA 2 did not physically abuse Resident 13 by hitting her between her eyes with an open hand. 3. Ensure LVN 11 reported Resident 13's allegation of being physically abused (hit) by CNA 2 to the DON and administrator. 4. Implement interventions to immediately suspend and or reassign CNA 1 and CNA 2, after Resident 13 had voiced allegation's of physical, psychological, mental and verbal abuse by CNA 1 and CNA 2 to the DON and Administrator. This resulted in Resident 2 experiencing intense fear for her life and anxiety, which had the potential to cause an exacerbation of the resident's [MEDICAL CONDITION] (A mental health issue triggered by a terrifying event). 5. Ensure Licensed Vocational Nurse (LVN) 6 did not verbally abuse Resident 13 by speaking to her in a rude harsh manner, calling her a liar and retaliating against the resident by shoving paper in her face because she shared her concerns in front of the surveyor. This resulted in Resident 13 feeling neglected and uncared for. 6. Ensure CNA 3 did not intimidate Resident 17 which resulted in the resident feeling fearful and helpless. These deficient practices resulted in Resident 13 feeling fearful, afraid, and neglected, and Resident 17 feeling fearful and helpless and had the potential to place other residents at risk for ongoing physical, verbal, and psychological abuse. Findings: A. During an initial tour of the facility on August 16, 2016, at 2:45 p.m., Resident 13 stated in the presence of licensed vocational nurse (LVN 3) that she was afraid of CNA 1 and CNA 2. She was afraid because CNA 1 told her he would kill her and scratched her on the left arm a few weeks prior causing her to bleed. CNA 2 hit her between her eyes the previous day with an open hand. Resident 13's admission record indicated Resident 13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 13's Minimum Data Set (MDS - a standardized resident assessment and care screening tool), dated February 17, 2016, indicated the resident was cognitively intact but required total assistance from facility staff in all activities of daily living such as eating, bathing, toileting, and transferring. A review of Resident 13's History and Physical dated April 4, 2016 indicated the resident had the capacity to understand and make decisions. During an observation, on August 16, 2016 at 2:47 p.m., Resident 13 showed the surveyor a reddish-brown discoloration measuring half an inch to the left upper arm. During an interview, on August 16, 2016, at 3:03 p.m. accompanied by the the administrator and the DON, in the presence of the surveyor, Resident 13 stated CNA 1 scratched her left arm causing her to bleed. CNA 2 hit her between the eyes with an open hand and called her a white [***] . Resident 13 stated she informed LVN 11 that she was hit by CNA 2 on August 15, 2016. Resident 13 further stated she feels scared because her life was threatened by CNA 1. CNA 1 also waved his closed fist in her face and forced her to watch Spanish television (Resident 13 speaks english) He also told the resident she was cuckoo and no one would believe her. During the interview, the administrator and DON assured Resident 13 both CNA 1 and CNA 2 would not take care of her any longer. During the interview on August 16, 2016, at 3:06 p.m., The surveyor observed the DON assess Resident 13's left upper arm and confirmed the resident had a purple mark the size of a penny. The facility did not assess the residents bruises prior to the survey. On August 17, 2016, at 11:21 a.m., during an inteview Resident 13 stated CNA 2 came into her room, that morning, after being told she would not be there anymore by administration on August 16, 2016, yesterday. The resident stated that she started screaming for help because she was scared and feared for her life. During an interview on August 17, 2016, at 12:00 p.m., the surveyor alerted the administrator that CNA 2 had contact with Resident 13 this morning. The administrator stated the facility could not get a hold of CNA 2 via telephone the previous day August 16, 2016, to inform her of her suspension. During an interview, on August 17, 2016, at 12:05 p.m., with the registered nurse (RN) consultant he stated he suspended and sent CNA 2 home at the start of the shift, sometime around 7 a.m., on August 17, 2016, at which time, he informed CNA 2 not to return until the completion of the ongoing abuse investigation. During an interview, on August 17, 2016, at 12:07 p.m., the DON stated the plan was to ask the RN consultant to intercept CNA 2 before the start of the shift to inform her of the investigation and suspension. The DON stated, I was here all night until 4 a.m., perhaps I should have been here until 7 a.m. to intercept CNA 2. The RN consultant then stated CNA 2 was sent home around 8:15 a.m. During an interview, on August 17, 2016, at 12:55 p.m., RN supervisor 1 stated CNA 2 arrived to the floor at 7 a.m. and saw her near Resident 13's room between 7:45 a.m. and 8 a.m., but no later than 9 a.m. RN supervisor 1 stated LVN 3 made the assignment in the morning. A review of the CNA work assignment for the 7-3 shift on August 17, 2016 indicated CNA 2 was assigned to Resident that morning. During an interview, on August 22, 2016, at 3:11 p.m., LVN 3 stated she made the assignment on August 17, 2016. CNA 2 was scheduled for the day and was not happy about her assignment. LVN 3 stated CNA 2 was assigned to Resident 13 that morning but was unsure if she went inside the resident's room. LVN 3 was unaware of CNA 2's pending suspension. During an interview, on August 19, 2016, at 9:21 a.m., RSR 35 stated CNA 2 had a short temper, had called the resident a liar, and she was scared of CNA 2 because of her short temper. RSR 35 recalled a time in which CNA 2 called her roommate a liar and stated to her roommate, You are not blind, you are not fooling anybody, and you are a liar. RSR 35 stated she went without pooping for two days because she is afraid of having CNA 2 assigned as her nurse. RSR 35's roommate was hospitalized at the time of the interview. A review of the facility's Resident Abuse Investigation Report Form indicated the CNA 1 and 2 were terminated on August 19, 2016 after further investigation for a lack of remorse, dishonesty, and attitude It further indicated LVN 11 received oral counseling and a written warning on August 18, 2016 for failure to report abuse. A review of the facility's Corrective/Disciplinary Action Form dated August 18, 2016, indicated LVN 11 was informed by Resident 13 on August 15, 2016 that CNA 2 hit her in the nose. LVN 11 assessed the resident and did not see any signs or symptoms of injury and did not report it to the administrator. A review of the facility's revised December 2006 policy and procedure titled Resident Behavior and Facility Practices - Abuse Prevention indicated the following: a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed. b. Should the employee(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building, which the resident frequents. c. Should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of unknown source), the nurse supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record. d. Employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incident of abuse to the DON. In absence of the DON such reports may be made to the nurse supervisor on duty. B. During an observation, on August 17, 2016, at 4:25 p.m., LVN 6 returned to Resident 13's room with a full water pitcher. After giving Resident 13 a sip of water, the resident asked again the name of her assigned nurse. LVN 6 grabbed the Nurse Assignment Sheet from the medication cart and returned to the room. Resident 13 then stated her nails were too long and asked LVN 6 when he was going to clip her nails. Resident 13 continued, stating that she had asked LVN 6 last week and he told her he did not have time to trim her nails. LVN 6 replied to Resident 13 that she was making up stories and that the trimming of her nails was news to him. During an observation, on August 17, 2016, at 4:28 p.m., LVN 6 the surveyor observed LVN 6 shoving the Nurse Assignment Sheet back and forth inches away from Resident 13's face while stating, Have I been bad to you, say it now, I'm confronting you in front of the surveyor. LVN 6 swiftly walked out of the room. During an interview, on August 17, 2016, at 4:30 p.m., LVN 6 stated Resident 13 was the only resident lying to the surveyors by telling all kinds of stories about the nurses. LVN 6 stated because the surveyor asked for his name when he returned to the room that Resident 13 might have said something behind his back when he left the room to refill the resident's water pitcher. During an interview with the DON on August 17, 2016, at 4:44 p.m., the DON was informed of the encounter between LVN 6 and Resident 13. The DON stated he would take disciplinary action because LVN 6 has had attitude issues before. There were no prior written disciplinary notices regarding LVN 6 in his employee file. During an interview with Resident 13 on August 17, 2016, at 5:56 p.m., the resident stated LVN 6 was rude to her and called her a liar. Resident 13 stated LVN 6 does not pay much attention to her and does not like to do anything when asked making her feel neglected. A review of the facility's Licensed Vocational Nurse Job Description indicated nurses must demonstrate knowledge of, and respect for, the rights, dignity and individuality of each resident in all interactions. A review of the facility's Corrective/Disciplinary Action Form dated August 17, 2016 indicated LVN 6 was terminated from the facility because the incident happened in the presence of a surveyor. A review of the facility's revised December 2006 policy and procedure titled Abuse Prevention Program indicated the facility's residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. C. A review of Resident 17's Admission Record indicated the resident was admitted to the facility on [DATE]. Resident 17's [DIAGNOSES REDACTED]. A review of the Minimum Data Sheet ((MDS)-a comprehensive assessment and care screening tool) dated August 8, 2016 , indicated Resident 17 was cognitively intact without no behavioral symptoms. According to the MDS Resident 17 was totally dependent with bed mobility, transfers, toileting, personal hygiene and dressing that required a one person physical assist. A review of the physician's progress notes dated August 6, 2016, indicated Resident 17 psychiatric orientation was within normal limits and the resident's behavior management was evaluated and adequate. A review of the physician's progress notes dated August 10, 2016, indicated Resident 17's behavior management was evaluated and adequate. The physician's progress note dated August 16, 2016 indicated Resident 17's behavior management was evaluated and adequate. According to the physician's orders [REDACTED]. A review of the nurses notes dated August 14, 2016, indicated Resident 17 stated it is hard to lay in the bed and wait on people. On August 15, 2016 Resident 17 became agitated and stated that he was sick of lying in the bed informed the staff that he would call 911. During an interview on August 23, 2016 at 10:45 a.m., Resident 17 stated he was upset because he had asked CNA 3 for assistance. The resident further stated that the CNA ignored him. Resident 17 stated when CNA 3 returned to his room the resident expressed his frustration to the CNA. Resident 17 stated the CNA stated You cannot do anything to me; you are lying in the bed while pointing his finger. The facility's charge nurse instructed CNA 3 to leave the room. CNA told the nurse that he was not going anywhere. Resident 17 stated that CNA 3 was moved to another floor but continues to walk pass the room intimidating the resident. Resident 17 further stated that he was afraid and fear for his life. During an interview on August 24, 2016, at 4:50 p.m., the Administrator stated she had no knowledge of an abuse allegation regarding Resident 17 and CNA 3. The administrator further stated that the charge nurse did not report this incident. During a telephone interview on August 28, 2016, at 11:20 a.m., the Director of Nurses in training stated CNA 3 remains on suspension since August 24, 2016, from working at the facility. She further stated CNA 3 was not currently working in the facility. During a telephone interview on August 30, 2016 at 10:20 a.m., CNA 3 stated that he could not recall the exact day in question, yet on this day Resident 17 wanted his back to be scratched. CNA 3 stated that he told the resident to wait for a few minutes because the lunch trays were coming out. at that time between 11:00 a.m. to 11:15 a.m. and he needed to pass the lunch trays. CNA 3 stated after the lunch trays were passed, he decided to take a lunch break. CNA 3 stated Resident 17 was very upset and cursed him out because he did not scratch his back. CNA 3 was asked if the resident could have received a back scratch prior to the lunch trays being passed, CNA 3 stated that it was not because he did not want to scratch the resident's back; he stated that he had something else to do. CNA 3 stated that he was instructed by LVN 7 not to return to Resident 17's room and the assignment was changed. LVN 7 stated Resident 17 was in room During a telephone interview on August 30, 2016, at 2:30 p.m., LVN 7 stated Resident 17 informed her that a male Hispanic CNA with tattoos was very rude to him. According to LVN 7 she was unable to recall the day in question. On the following day CNA 3 was on the floor and Resident 17 pointed the CNA out and confirmed that CNA 3 was rude to him. According to LVN 7, CNA 3's assignment was changed and she had informed the Director of nurses (DON) that Resident 17 had complained about CNA 3. According to LVN 7, the facility was aware that CNA 3's rudeness and inability to take instruction from authority. LVN 7 further stated when CNA 3 is given instruction he will brush you off. A review of the facility's CNA daily assignments, revealed that CNA 3 was assigned to Resident 17 on August 03, 2016, August 06, 2016, August 07, 2016, August 08, 2016 and August 09, 2016. During a telephone interview on August 30, 2016 at 10:55 a.m., the DON stated that the facility conducted an investigation after 48 hours and allowed CNA 3 to return to work on Saturday August 27, 2016 at 7:00 a.m. However, the facility failed to send a report to DPH.

Based on observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services as indicated in the residents' plan of care for three of 30 sampled residents (13, 16, 18) by failing to: Resident 16, who had signs and symptoms of pain during wound treatment observation was not assessed, not monitored and the pain medication was not administered as ordered by the physician 1/2 hour prior to wound treatment. The deficient practice resulted in unrecognized and untreated pain daily for Resident 16. Resident 18 was observed with +2 - +3 [MEDICAL CONDITION] (swelling of body tissue due to fluid accumulation) to lower extremities, the resident's legs were not elevated as indicated in the resident's care plan to decrease the swelling. Resident 13, who had signs and symptoms of pain during range of motion exercises (ROM (the distance and direction a joint can move to its full potential)), the restorative nursing assistant did not stop to report the resident response, signs and symptoms of pain during the ROM exercises. As a result, Resident 13 experienced pain daily during ROM exercises. Findings: a. On May 21, 2015 at 10 a.m., Resident 16 was observed during morning care which consisted of bed bath and wound treatment. While being provided care the resident was turned and repositioned approximately four times. Each time Resident 16 was placed on his side and/or repositioned onto his back he had facial grimacing and would say ouch. At one point, while being repositioned onto his back, Resident 16 had facial grimacing, grabbed and guarded his right hip and again said ouch. A review of the admission record indicated Resident 16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A resident care plan dated May 6, 2015, addressed Resident 16 having self-care deficits and debility requiring assistance with his activities of living. Factors contributing to the debility included multiple falls and pain to his right hip and shoulder. There was another care plan dated May 6, 2015, for potential for alteration in comfort/pain related to [MEDICAL CONDITION], and chronic pain. The goals were for the resident to be free of pain daily, pain and discomfort will be gradually relieved one hour after nursing intervention. The interventions included assess the resident for non-verbal signs of pain such as moaning, facial grimacing, irritability, restlessness, and yelling and/or screaming, to find out the reason for pain and intervene, and to observe for patterns of pain and provide routine pain medication as needed. A physician's orders [REDACTED]. Resident 16 also had an order dated May 7, 2015, for Tylenol 325 mg two tablets as needed every four hours for mild pain. A Minimum Data Set (MDS, an assessment care screening tool) dated May 13, 2015, indicated Resident 16 had clear speech, usually understood others and was usually able to make himself understood. The MDS indicated Resident 16 had pain occasionally, but not within the last five days of the assessment period. The MDS indicated a staff assessment for pain, including indicators (moaning/groaning), vocal complaints, facial expressions, protective body movements and frequency of pain/possible pain should not be conducted due to Resident 16 not having any complaints of pain within the last five days. However, the MDS included Resident 16's chronic pain as an additional active diagnosis. A review of the Licensed Progress Notes dated May 18, 2015, indicated Resident 16 had chronic pain; however, there were no further details of the type, frequency or location of the pain. The Licensed Progress Notes dated May 19, 20 and 21, 2015, did not provide any documentation regarding Resident 16 experiencing pain at any time. The Medication Record and Profile for May 2015, indicated Resident 16 was to receive [MEDICATION NAME] 5/325 mg one tablet orally every four hours as needed for moderate pain. However, the physician's orders [REDACTED]. The Medication Record and Profile indicated Resident 16 received [MEDICATION NAME] 5/325 mg on May 7, 12, and 15, 2015 at 9 a.m. and on May 22, 2015 at 10 a.m., for complaint of lower back pain. The documentation indicated the resident's pain level was six to seven over ten (ten being the worst pain a person could experience). There was no documented evidence the [MEDICATION NAME] was administered daily, 1/2 hour prior to the wound treatment as prescribed by the physician. A review of the Treatment Record for May 2015, with registered nurse (RN 39), there was no documentation which included the order and/or instructions to pre-medicate Resident 16 1/2 hour prior to the wound treatment. On May 26, 2015 at 10:50 am, the licensed vocational nurse (LVN 12) stated she had not given Resident 16 any pain medication. LVN 12 stated the medication was to be given as needed and Resident 16 had not asked for any. On May 26, 2015 at 9:55 am, the certified nursing assistant (CNA 30) stated Resident 16 says ouch when he was turned and repositioned. On May 26, 2015 at 11:50 am, LVN 12 stated she reevaluated Resident 16 and the resident complained of having a lot of pain. LVN 12 stated she considered Resident 16's pain as severe. Concurrently, the registered nurse supervisor stated Resident 16's pain management program was not effective and needed to be reevaluated. RN 38 and LVN 12 agreed Resident 16 had not been properly assessed for pain upon admission. RN 38 nor LVN 12 could explain why Resident 16's pain was not being monitored and/or communicated by the CNAs or licensed staff on a daily basis. On May 26, 2015 at 12:30 pm, with the assistance of a translator, Resident 16 was interviewed in his room while lying in the bed. Resident 16 stated he has pain in his legs and arms. He stated when he is just lying down in the bed his pain feels worse. Resident 16 stated he believes when he is up in the wheelchair he feels better. Resident 16 stated on average his pain is a 7 or an 8 on a scale of one to ten, ten being the worst. Resident 16 stated he has pain daily, but it is less when he receives medication. A facility policy and procedure on Administering Pain Medication (2012) indicated the pain assessment consist of gathering subjective and objective data (pain location, type, intensity, facial grimacing, moaning, guarding). The policy indicated to administer pain medication as ordered. b. On May 18, 20, 21 and 22, throughout each day, Resident 18 was observed sitting at the bedside with her feet directly on the floor. Resident 18 had +2 - +3 pitting (an indentation that persists for some time after the release of the pressure) [MEDICAL CONDITION] in both of her lower extremities. A review of the admission record indicated Resident 18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Physicians Progress Notes for October 10 and 26, 2014, identified Resident 18 as having +3 [MEDICAL CONDITION] of her lower extremities. A resident care plan dated November 4, 2014, addressed Resident 18's [MEDICAL CONDITION]. The nursing interventions included monitoring for [MEDICAL CONDITION] and elevating the affected areas with pillows as much as possible. The Minimum Data Set (an assessment care screening tool) dated November 28, 2014, indicated Resident 18 usually understood others and had no behaviors of refusing/rejecting care. The Medication Administration Record [REDACTED]. Reviewing the sheet with LVN 12 indicated Resident 18 had +1 [MEDICAL CONDITION] daily and no change of condition. However, on May 18, 20, 21 and 22, throughout each day, Resident 18 was observed with +2 - +3 [MEDICAL CONDITION]. On May 22 at 4:50 p.m., LVN 12 stated Resident 18 currently had +1 - +2 (the seconds it takes an [MEDICAL CONDITION] area to return to normal after pushing down on it) of the right lower extremity and +2 - +3 [MEDICAL CONDITION] of the left lower extremity. LVN 12 stated the resident usually has + 2 - +3 [MEDICAL CONDITION] and should have her legs elevated on pillows rather than hanging down to the floor. A facility policy and procedure on Change of Condition or Status (2012) indicated the nurse supervisor or charge nurse will record the information relative to changes in the medical record. c. On May 26, 2015 at 10:30 a.m., Resident 13 was observed during range of motion (ROM) exercises performed by restorative nursing assistant (RNA 5). RNA 5 stated the resident was medicated for pain because the resident screams during the exercises. RNA 5 raised the resident's left arm and moved the resident's arm in an extension and flexion motion. The resident yelled oh, oh with facial grimacing. RNA 5 told the resident to take a deep breath. RNA 5 continued to do the exercise, again the resident yelled oh, oh, oh with facial grimacing. Again, RNA 5 told the resident to take a deep breath. RNA 5 stated she was going to perform passive range of motion (PROM (performed by health professionals, who move the resident's joint through range of motion) to the left lower extremity. The resident's left lower extremity was observed contracted lying on top of a pillow. RNA 5 pulled on the pillow to remove the pillow away from the resident's left lower extremity. Then RNA 5 slightly moved the left lower extremity up and off the pillow. The resident yelled oh, oh with facial grimacing. RNA 5 told the resident to take a deep breath and continued to lift the left lower extremity off the pillow. The resident yelled oh, oh. RNA 5 stopped and asked the resident are you in pain. During an interview on May 26, 2015 at 11 a.m., RNA 5 was asked why the PROM exercises were not stopped when the resident yelled oh, oh with facial grimacing. RNA 5 stated the resident was medicated and the charge nurse was aware. RNA 5 stated the resident had to be medicated before his exercises, because the resident screams during PROM exercises. RNA 5 did not respond, when asked if the resident required reassessment by the licensed nurse to ensure the pain medication was effective. On May 26, 2015 at 1 p.m., during an interview with licensed vocational nurse (LVN 20), she stated RNA 5 did not report to her that the resident yelled or made facial grimaces during his PROM exercises. LVN 20 stated the resident is not on the Pain Management Program. According to the admission record Resident 13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment care screening tool) dated January 21, 2015, indicated the resident's speech was clear, sometimes understands others and able to make self-understood. The resident's cognitive skills for daily decision-making were severely impaired and the resident was totally dependent from staff for transferring and bed mobility. The resident was assessed with [REDACTED]. The resident had a physician's orders [REDACTED]. On the same date, an order for [REDACTED]. The physician's orders [REDACTED]. On the same date an order was received for RNA to apply left resting hand and hand roll for 4 - 6 hours five times a week as tolerated. The plan of care, dated October 24, 2014, for potential for alteration in comfort/pain related to history [MEDICAL CONDITIONS], multiple joint contractures and the aging process, and the goal indicated the resident will verbalize relief of pain within 30 minutes of pain medication administration. The intervention included to assess intensity of pain using the pain scale, to monitor for any non-verbal communication of pain example facial grimacing, moaning or crying. On November 22, 2014, an order was received for RNA to perform PROM to left lower extremity five times a week to tolerance and to monitor the resident for pain. On the same date, an order was received for left knee splint three times per week for four hours as tolerated, and to monitor for pain and skin breakdown. A review of the Medication sheet for month of May 2015, indicated the resident did not receive pain medication except on May 26, 2015. The documentation indicated the resident received Tylenol 325 mg two tablets every four hours as needed. There was no documented evidence what time the Tylenol was given, assessment, and the reason why it was administered to the resident. The facility's policy titled, Pain Assessment, (not dated), indicated the purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team.