Every finding on record at Bel Vista Healthcare Center

Based on observation, interview, and record reviewa) The facility failed to ensure Licensed Vocational Nurse (LVN)1 administered one of one sampled residents (Resident 10) receiving eye drops as the physician ordered. This failure had the potential to result in reduced medical effects or treatment failure.b) The facility failed to ensure one on three hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) residents (Resident 3) received prescribed medications on dialysis days.These failures had the potential to result in Resident 3's worsening condition. Findings: a.) During a review of Resident 10's admission Record (face sheet), the admission Record indicated Resident 10 was admitted to the facility 12/30/2020 with diagnoses of glaucoma (a group of eye diseases that damage the optic nerve, often due to high fluid pressure inside the eye) and type 2 diabetes (a condition that causes high blood sugar). During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool) dated 6/29/2026, the MDS indicated Resident 10 was moderately impaired of cognitive skills for daily decision making (decisions poor; cues/ supervision required). During a review of Resident 10's Order Summary Report dated 8/2026, an order was placed 10/5/2024 for Timolol Maleate Ophthalmic Solution 0.5 % (prescription medication used to lower high fluid pressure inside the eye caused by open-angle glaucoma or ocular hypertension (high blood pressure)); Instill 1 drop in both eyes one time a day for glaucoma and pinch tear duct for 1 minute for prevention of potential systemic effect of medication (body wide effects such as slow heart rate, low blood pressure, irregular heartbeat, confusion, sleep changes, and shortness of breath). On 8/19/2029 at 9:39 a.m., during a concurrent observation, with LVN 1, LVN 1 administered Timolol Maleate ophthalmic 0.5% 1 drop into each of Resident 10's eyes. After administering the drop into each of Resident 10's eyes, LVN 1 used tissue to press on Resident 10's tear ducts and then let go. LVN 1 did not hold the tissue on the tear duct for 1 minute as ordered. After administering all Resident 10's medications, LVN 1 read the instructions on the Timolol Maleate ophthalmic drops and confirmed the instructions stated to pinch the tear ducts for 1 minute to prevent systemic effect of the medication and LVN 1 stated she did not hold the tear duct for 1 minute. During an interview on 8/21/2026 at 10:57 a.m., the Director of Nursing (DON) stated it was important to follow the physician's instructions for medications to prevent adverse things such as going other places in the body other than the eye (systemic effects). During a review of the facility's Policy and Procedure (P/P) titled Administering Medications dated 1/2026, the P/P indicated medications were to be administered in accordance with prescriber orders. b) During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 5/30/2026 with diagnoses including end stage renal disease (ESRD -irreversible kidney failure) and dependence on renal dialysis, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognition (ability to think) was intact. The MDS indicated Resident 3 needed set up assistance when eating, supervision with oral hygiene, and substantial assistance (helper does more than half the effort) with showering. During a review of Resident 3's Medication Administration Record (MAR), 7/ 2026 a, the MAR indicated Resident 3 did not receive the following medications on dialysis days Tuesday, Thursday, and Saturday: 1) Duloxetine HCl Oral Capsule Delayed Release Particles 30 milligrams, one capsule by mouth one time a day 2) Ferrous Sulfate Oral Tablet (medication for anemia) 325 milligrams, 1 tablet by mouth one time a day. 3) Pro-Stat Oral Liquid (supplement), Give 30 milliliters by mouth one time a day. 4) [NAME]-Vite Tablet (vitamin supplement) one tablet by mouth in the morning 5) Vitamin D3 Oral Tablet (supplement) 25 micrograms, two tablets by mouth one time a day. During a review of Resident 3's Medication Administration Record (MAR), 8/1/2026 to 8/17/2026, the MAR indicated Resident 3 did not receive the following medications on dialysis days Tuesday, Thursday, and Saturday: 1) Duloxetine HCl Oral Capsule Delayed Release Particles 30 milligrams, one capsule by mouth one time a day 2) Ferrous Sulfate Oral Tablet (medication for anemia) 325 milligrams, 1 tablet by mouth one time a day. 3) Pro-Stat Oral Liquid (supplement), Give 30 milliliters by mouth one time a day. 4) [NAME]-Vite Tablet (vitamin supplement) one tablet by mouth in the morning 5) Vitamin D3 Oral Tablet (supplement)25 micrograms, two tablets by mouth one time a day. On 8/19/2026 at 2:42 p.m. during a concurrent interview and record review, with the Director of Staff development (DSD), Resident 3's 7/2026 and 8/1/2026 to 8/17/2026 MARs were reviewed. The DSD stated Resident 3 did not receive Duloxetine, Ferrous sulfate, Pro-Stat, [NAME]-Vite, and Vitamin D3 daily during the days Resident 3 was in dialysis on Tuesday, Thursdays and Saturdays. The DSD stated the facility will review the medications to see which medications need to have medication times changed so Resident 3 can get treated for her medical conditions. During an interview on 8/21/2026 at 11:09 a.m., the Director of Nursing (DON) stated medications need to be administered as ordered to prevent negative effects of not getting prescribed medications. During a review of the facility's policy and procedure (P/P) titled, End-Stage Renal Disease, Care of a Resident with revised 1/2026, the P/P indicated Residents with ESRD will be cared for according to currently recognized standards of care. During a review of the facility's P/P titled, Administering Medications, revised 1/2026, medications are administered in accordance with prescriber orders.

Based on observation, interview, and record review the facility failed to ensure one of one sampled resident's (Resident 30) artificial tears (lubricating eye drops used to moisten dry, irritated eyes ) were not stored in medication cart #2 past the beyond use date (BUD, a date set by the pharmacy. It shows when an opened drug starts to break down or risk growing germs). As a result of this deficient practice there was a potential for Resident 30 to receive his artificial tears past the BUD. Findings:During a review of Resident 30's admission Record (face sheet), the admission Record indicated Resident 30 was admitted to the facility [DATE] with diagnoses of Parkinson's disease (a progressive brain disorder that affects movement and coordination) and allergic rhinitis (an immune system reaction to tiny airborne particles like pollen, dust mites, or pet dander. Common symptoms include itchy, red, or watery eyes). During a review of Resident 30's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 30 had moderate cognitive impairment (a noticeable decline in thinking and memory skills). During a review of Resident 30's Order Summary Report dated 8/2026, an order was placed [DATE] for Artificial Tears Solution 1.4%: instill one drop in both eyes every 6 hours as needed for dry eyes. On [DATE] at 10:47 a.m., during a concurrent observation and interview, with licensed vocational nurse (LVN) 2, a medication storage observation was done on medication cart #2. Resident 30's artificial tears were stored in medication cart # 2 with an open date of [DATE] and an expiration date (BUD) of [DATE]. LVN 2 stated artificial tears (eye drops) had a shelf life of 28 days after opening. During an interview on [DATE] at 10:57 a.m., the Director of Nursing (DON) stated it was important to not store any expired medication in the medication cart because the medication might not be as effective and eye drops were only good for 28 days. During a review of the facility's pharmacy Beyond Use Day (BUD) list undated, artificial tears were good for 28 days after the open date.

Based on observation, interview, and record review, the facility failed to offer one of three residents (Resident 10) alternative menu items when Resident 10's meal intake amount was inadequate.The deficient practice had the potential to result in loss of appetite and cause unplanned weight loss.Findings:During a review of Resident 10's admission Record, the admission Record indicated the facility admitted Resident 10 on 12/15/2022 with diagnoses including dementia (a progressive state of decline in mental abilities), protein calorie malnutrition (condition resulting from inadequate intake of food), and diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 10's Minimum Data Set ([MDS] a resident assessment tool), dated 6/29/2026, the MDS indicated Resident 10 had severely impaired cognitive decision-making skills. The MDS indicated Resident 10 was dependent (helper does all the effort) on staff for all activities of daily living (activities such as eating, dressing and toileting a person performs daily).During a review of Resident 10's Summary Report, 3/6/2026, the order indicated Fortified diet (foods that have extra vitamins and minerals added during processing to boost their nutritional value) Regular texture (food of any texture), ok for outside foods, and ok for bread.During a review of Resident 10's Point of Care Response History from 7/20/2026 to 8/18/2026, For the task: percentage of meal eaten, Resident 10's meal intake was less than 50% for 52 meals. For the task: 50% or less meal consumption and/or refusal: Alternate meals/nourishments offered, Alternate meals were not offered in the past thirty days reviewed.On 8/18/2026 at 12:30 p.m., during a concurrent observation and interview with Certified Nurse Assistant (CNA) 1, CNA 1 brought Resident 10's tray out of the resident's room and only 5-10% of the meal was consumed. CNA 1 stated Resident 10 tried every item on the plate and refused the menu items served. CNA 1 stated she did not offer him an alternative meal. CNA 1 stated has not offered alternative food items when Resident 10 refuses or dislikes the items.On 8/19/2026 at 2:41 p.m., during a concurrent interview and record review with the Director of Staff Development (DSD), Resident 10's Point of Care tasks (7/20/2026 to 8/18/2026) of percentage of meals consumed and times staff alternative menu items were reviewed. The DSD stated Resident 10 ate less than 50% numerous times and staff never offered alternative menu items. The DSD stated that when residents do not eat at least 50% of their meals, residents are offered alternative menu items. During an interview on 8/21/2026 at 11:04 a.m., the Director of Nursing (DON) stated residents need to be offered alternative menu items so the residents can get the nutrients they need. During a review of the facility's policy titled, Substitutions/ Menu Alternates, revised 1/2026, the policy indicated food substitutions will be made as appropriate or necessary. Residents' likes and dislikes will be considered when making substitutions. Nursing will notify the dietary department about residents who refuse food items or expresses dislike of specific food items served at mealtimes and substitutes will be provided.

Based on observation, interview, and record review the facility failed to ensure one of one sampled cups of strawberry ice cream wrapped in clear plastic inside the freezer was labeled and dated. As a result of this deficient practice there was potential the ice cream could be consumed after the use by date (tells you when the product is best to use) and cause food borne illness (commonly known as food poisoning). Findings: On 8/18/2026 at 8:33 a.m., during a concurrent interview and initial kitchen tour observation, with the Dietary Supervisor (DS), one strawberry ice cream scoop in a clear bowl wrapped in clear plastic was not labeled or dated. The DS stated the strawberry ice cream scoop was not labeled or dated so he removed it from the freezer. During an interview on 8/21/2026 at 10:57 a.m., the DS stated all food items stored in the kitchen needed to be labeled and dated to ensure it was used by the use by date and ice cream was dairy so there was a potential it could spoil fast.During a review of the facility's policy and procedure (P/P) titled Food Production and Storage undated indicated all food items that are out of the original container will be properly covered, labeled, and dated.

Based on observation, interviews, and record review the facility failed to ensure that advanced directives for one of one resident (Resident 13) were included in the electronic and physical medical records. This failure has the potential for Resident 13 to receive care that conflicted with Resident 13's expressed wishes.Findings:During a review of Resident 13's admission record, the admission Record indicated facility admitted Resident 13 on 6/4/2026 with the diagnoses metabolic encephalopathy (brain dysfunction) and dementia (a progressive state of decline in mental abilities). The admission Record indicated family member 1 (FM 1) as Resident 13's responsible party.During a review of Resident 13's Minimum data Set ([MDS] resident assessment tool), dated 6/10/2026, the MDS indicated Resident 13's cognitive skills (ability to think) for daily decision making was severely impaired. The MDS indicated Resident 13 was dependent (helper does all the effort to complete the task) with oral hygiene, personal hygiene and toileting hygiene.On 8/19/2026 at 8:32 a.m. during a concurrent interview and record review, with the Social Services Director (SSD), Resident 13's IDT Conference Notes, dated 6/16/2026 at 1:35 p.m., were reviewed. The SSD confirmed and stated FM 1 stated Resident 13 had an advance directive and FM 1 will bring a copy.On 8/19/2026 at 9:58 a.m. during a concurrent observation and interview, with the SSD, Resident 13's medical records were reviewed and there were no Advanced directives in Resident 13's medical records observed. The SSD stated that she should have followed up with FM 1 to obtain the advanced directives since Resident 13 had been here since June.During an interview on 8/21/2026 at 11 a.m., the Director of Nursing (DON) stated Advance directives need to be in the chart, because it entails the residents' wishes during end-of-life care.During a review of the facility's policy and procedure (P/P) titled, Advance Directives, revised 1/2026, the P/P indicated if an advance directive was executed copies will be obtained and maintained in the resident's health records.

Based on interview and record review, the facility failed to complete a competency (measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics an individual needs to perform work roles successfully) evaluation for one of five sampled facility staff (Registered Nurse [RN] 1). This deficient practice prevented the facility from determining RN 1's competency to provide resident care. Findings: During a review of RN 1's competency evaluation titled, R.N. Competency Skills Checklist, dated 4/8/2026, RN 1's Competency Skills Checklist indicated the following symbols would be used:P = Previous experienceD = Demonstrated and/or instructed by the Department Head, Supervisor or Mentor/PreceptorRD = Return demonstration by the orienteer and/or meets performance objectiveNE = Needs further experience with performance objectiveNA = Not applicable During further review of RN 1's Competency Skills Checklist, dated 4/8/2026, there were check marks under previous experience (P) throughout RN 1's Competency Skills Checklist including effective communication, hand washing, universal precautions, isolation techniques, provision of nursing care, ability to respond to a resident code (level of life-saving medical interventions), identifying and utilizing documentation tools for skin/wound care protocols, medication administration, and pain management. RN 1's Competency Skills Checklist indicated check marks under needs further experience (NE) for completing the admission process, formulating an interim plan of nursing care for the resident, evaluating the effectiveness of the care plan, revising the care plan based on continuous evaluation of the resident, and discussing the care plan as appropriate with the resident/family/staff. RN 1's Competency Skills Checklist did include evidence of RN 1 providing demonstration (D) or return demonstration (RD) of competency skills included in the checklist.During a concurrent interview and record review on 8/20/2026 at 10:30 a.m. with the Director of Staff Development (DSD), the DSD reviewed RN 1's Competency Skills Checklist, dated 4/8/2026. The DSD stated RN 1 was a licensed vocational nurse (LVN) at another facility prior to working at this facility as a RN. The DSD indicated the Competency Skills Checklist indicated RN 1 had previous experience in performing competency. During a concurrent interview and record review on 8/20/2026 at 11:14 a.m. with the Director of Nursing (DON), the DON reviewed RN 1's Competency Skills Checklist, dated 4/8/2026. The DON stated the purpose of competencies (in general) included verifying and assessing whether the staff member had the skills to perform the job duties or if they needed additional training. The DON stated RN 1's roles at the facility included the Assistant Director of Nursing (ADON) and the treatment nurse. The DON stated RN 1's Competency Skills Checklist was a self-assessment to determine which areas RN 1 needed more experience.During a follow-up interview with the DON on 8/20/2026 at 11:40 a.m., the DON stated RN 1's competency skills were not validated with demonstration or return demonstration. During a review of the facility's policy and procedure (P&P) titled, Staff, Sufficient and Competent Nursing, revised 1/2026, the P&P indicated licensed staff must demonstrate the skills and techniques necessary to care for resident needs including resident assessments and care planning, communication, nursing skills consistent with scope of practice, skin and wound care, medication management, pain management, infection prevention and control, and identifying and responding to changes in condition.

Based on interview and record review, the facility failed to ensure one of three hemodialysis ([HD]a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) residents (Resident 3) received Epoetin Alfa-epbx (biologic injection to teat anemia [a condition where the body does not have enough healthy red blood cells] at the dialysis center. The failure had the potential to result in Resident 3's worsening anemia.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 5/30/2026 with diagnoses including end stage renal disease (ESRD -irreversible kidney failure) and dependence on renal dialysis, and anemia.During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 6/2/2026, the MDS indicated Resident 3's cognition (ability to think) was intact. The MDS indicated Resident 3 needed set up assistance when eating, supervision with oral hygiene, and substantial assistance (helper does more than half the effort) with showering.During a review of Resident 3's Order Summary Report, the report indicated, 5/30/2026, Epoetin Alfa-epbx Injection Solution 10,000 Unit /milliliter, Inject 1 milliliter subcutaneously (fatty layer under the skin) to be given at the dialysisOn 8/19/2026 at 4 p.m. during a concurrent interview and record review, with the Director of Staff development (DSD), Resident 3's Order summary report was reviewed. The DSD stated Resident 3 should have been receiving Epoetin Alfa-epbx Injection in the dialysis center during dialysis days.On 8/19/2026 at 4 p.m. during a concurrent interview and record review, with the DSD, Resident 3's Dialysis Communication records in July and August were reviewed and the records did not indicate that Epoetin Alfa-epbx Injection was administered on dialysis days. The DSD stated Resident 3 have not received Epoetin Alfa-epbx Injection in the dialysis center during dialysis days in July and August. The DSD stated the facility should have followed up with the dialysis center to confirm. The DSD stated Epoetin Alfa-epbx Injection was important for anemia. During an interview on 8/21/2026 at 11:02 a.m., the Director of Nursing (DON) stated communication with the dialysis center was important to ensure proper care is given to the dialysis resident. The DON stated the Epoetin Alfa-epbx Injection was part of the medication ordered on admission and should have been verified that Resident 3 was receiving it as scheduled. During a review of the facility's policy and procedure (P/P) titled, End-Stage Renal Disease, Care of a Resident with revised 1/2026, the P/P indicated Residents with ESRD will be cared for according to currently recognized standards of care. The P/P indicated agreements between this facility and the contracted ESRD facility include all aspects of how the residents' care will be managed, including how the care plan will be developed and implemented and how information will be exchanged between the facilities. During a review of the facility's P/P titled, Administering Medications, revised 1/2026, medications are administered in accordance with prescriber orders.

During observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 20) with a urinary catheter's (a thin, flexible tube used to drain urine from the bladder when a person cannot urinate on their own), catheter bag (a medical device that connects to a urinary tube to collect pee from the bladder) was not dragging on the floor. As a result of this deficient practice had a potential for Resident 20's urinary catheter to be dislodge, cause unnecessary pain, or cause infection. Findings: During a review of Resident 20's admission Record (face sheet), the admission Record indicated Resident 20 was admitted to the facility 9/4/2023 with diagnoses of muscle weakness and obstructive and reflux uropathy (conditions where a blockage or backward flow of urine damages the kidneys). During a review of Resident 20's Minimum Data Set (MDS, a resident assessment tool) dated 8/10/2026, the MDS indicated Resident 20 was cognitively intact (a person has normal brain function). During a review of Resident 20's Order Summary report for 8/2026, the Order Summary Report indicated an order was placed 8/15/2026 for urinary catheter for obstructive uropathy. Check urinary catheter every shift to ensure it was intact and functioning. During an observation on 8/18/2026 at 10:38 a.m., Resident 20 was wheeling himself from his room to the facility patio in his wheelchair and his urinary catheter bag was observed being drug underneathhis wheelchair. During an interview on 8/18/2206 at 10:41 a.m., the Director of Staff Development/ Infection Prevention Nurse (DSD/ IPN) stated she went out to the patio to attach Resident 20's urinary catheter bag to his wheelchair so it would not continue to drag on the floor. During an interview on 8/21/2026 at 10:57 a.m., the director of nursing (DON) stated if urinary catheter bags were dragging on the floor there was risk for infection and a risk for the urinary catheter to be pulled out. During a review of the facility's policy and procedure (P/P) titled Catheter Care. Urinary dated 8/2022, the P/P indicated staff were to ensure the catheter tubing and drainage bag were kept off the floor.

Based on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 5) with limited range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) by failing to:1. Indicate the amount of weight to provide Resident 5 while performing resistive exercise to both arms and legs in the Restorative Nursing Program ([RNP] nursing aide program that helps residents to maintain their function and joint mobility) Referral, dated 6/16/2026.2. Include Resident 5's specific RNP program in the physician's orders, dated 6/16/2026.3. Provide Resident 5 with a restorative nursing program ([RNP] nursing aide program that helps residents to maintain their function and joint mobility) that was consistent with the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) and Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) recommendations on 8/18/2026.This deficient practice had the potential for Resident 5 to experience a decline in ROM and strength for activities of daily living ([ADLs] basic tasks that individuals perform to maintain their daily lives and independence) and mobility (ability to move). Findings:During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 5/8/2026 with diagnoses including bilateral (both) osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the hip, muscle weakness, type 2 diabetes mellitus ([DM] disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified dementia (progressive state of decline in mental abilities). During a review of Resident 5's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 8/11/2026, the MDS indicated Resident 5 had unclear speech, had difficulty communicating some words, usually understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 5 had ROM limitations in one arm and both legs. The MDS indicated Resident 5 required setup or clean-up assistance (helper sets up or cleans up while resident completes the activity, helper assists only prior to or following the activity) for eating and oral hygiene and partial/moderate assistance (helper does less than half the effort) for toileting, bathing, lower body dressing, transfers from lying on the back to sitting at the side of the bed, sit-to-stand transfers, toilet transfers, and chair/bed-to-chair transfers. During a review of Resident 5's care plan titled, Resident is at risk for decline in range of motion (ROM), initiated 5/15/2026, the care plan interventions included RNA program for resistive exercises in all planes of motion (joint motions that move forward and backward, side-to-side, and rotational) to both arms and legs. During a review of Resident 5's OT Discharge summary, dated [DATE], the OT Discharge Summary included recommendations for an RNP to perform resistive exercises to both arms in all planes of motion, five times per week as tolerated. During a review of Resident 5's PT Discharge summary, dated [DATE], the PT Discharge Summary included recommendations for an RNP to provide ambulation (the act of walking) using the front wheeled walker ([FWW] an assistive device with two front wheels used for stability when walking) for 100 feet (unit of measure) or as tolerated. The PT Discharge Summary also indicated Resident 5's RNP included resistive exercise to both legs in all planes of motion, five times per week as tolerated.During a review of Resident 5's RNP Referral, dated 6/16/2026, the RNP Referral indicated recommendations for an ambulation/mobility program and a ROM program. The RNP Referral indicated for the Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) to provide ambulation with the FWW for 100 feet, five times per week. The RNP Referral also indicated for the RNA to perform resistive exercises using weights (unspecified) for both arms and legs with three sets of 12 repetitions in all planes of motion, five times per week. During a review of Resident 5's physician's order, dated 6/16/2026, the physician's order indicated to provide the RNA program for ambulation with FWW for 100 feet, five times per week or as tolerated. Another physician's order, dated 6/16/2026, indicated RNA program for resistive exercises to both arms and legs in all planes, five times per week, or as tolerated. During an interview on 8/18/2026 at 9:13 a.m. with the Director of Rehabilitation (DOR), the DOR stated the RNA program (in general) was a nursing program to prevent a resident's decline in mobility. The DOR stated the process of transitioning a resident (in general) from therapy services to the RNA program included the therapist completing a referral to the RNA program and reviewing the resident's program with the RNA.During an interview on 8/18/2026 at 9:54 a.m. in Resident 5's room, Resident 5 stated the facility staff (unnamed) walked with the resident using the walker but stated Resident 5's leg muscles become tight, preventing Resident 5 from walking. During an observation on 8/18/2026 at 11:04 a.m., Restorative Nursing Aide 1 (RNA 1) wheeled Resident 5 in a wheelchair from the bedroom to the therapy room. The therapy room was observed with two stationary exercise bicycles for arm and leg exercises. Two residents were already using both stationary exercises bicycles. RNA 1 stated Resident 5 was going to perform exercises on the stationary exercise bicycle once available.During an observation on 8/18/2026 at 11:19 a.m. in the therapy room, Resident 5 was seated in the wheelchair while performing arm and leg exercises using the bicycle. Resident 5's arms had quicker, alternating arm movements than both legs. During an observation on 8/18/2026 at 11:25 a.m., RNA 1 wheeled Resident 5's wheelchair into the main hallway and placed a FWW in front of Resident 5. Resident 5 required physical assistance to transfer from sit-to-stand and then walked eight to ten feet (8-10 feet) prior to sitting down in the wheelchair. RNA 1 stated Resident 5 usually walked most of the hallway during RNA sessions.During an interview on 8/18/2026 at 11:38 a.m. with Resident 5, Resident 5 stated the bicycle exercises took all of Resident 5's energy, preventing the resident from walking further. During an interview on 8/18/2026 at 11:42 a.m. with RNA 1, RNA 1 stated Resident 5 received RNA for resistive exercises on the bicycle and ambulation for 8-10 feet. RNA 1 stated the RNA resistive exercises program could mean on the bicycle, weights, or therapy. RNA 1 stated the therapists would inform the RNA (in general) of the resident's RNA program prior to discharge from therapy services.During a concurrent interview and record review on 8/19/2026 at 12:26 p.m. with the DOR, Resident 5's OT Discharge summary, dated [DATE], and PT Discharge summary, dated [DATE], were reviewed. The DOR stated the OT and PT Discharge Summaries included recommendations for resistive exercises to both arms and legs. The DOR stated resistive exercises were exercises with the use of weights.During a concurrent interview and record review on 8/20/2026 at 8:39 a.m. with Occupational Therapist 1 (OT 1), Resident 5's RNP Referral, dated 6/16/2026, was reviewed. OT 1 stated an RNA program involving weights (in general) was recommended for a resident to maintain strength to perform self-care and functional mobility. OT 1 reviewed Resident 5's RNA Referral and stated the recommendation was to provide exercises to both arms using weights. OT 1 stated the RNA Referral should have also included the amount of weight to maintain Resident 5's strength. OT 1 stated Resident 5 could experience a decline in strength for mobility and self-care without the use of weights during RNA. During a concurrent interview and record review on 8/20/2026 at 10:04 a.m. with Physical Therapist 1 (PT 1), Resident 5's RNP Referral, dated 6/16/2026, was reviewed. PT 1 stated Resident 5's RNA program included the use of weights for exercises to both legs. PT 1 stated the RNP Referral did not include the amount of weight Resident 5 was supposed to use with the RNA. During a concurrent interview and record on 8/20/2026 at 1:20 p.m. with RNA 1, Resident 5's RNP Referral, dated 6/16/2026, was reviewed. RNA 1 stated Resident 5's preferred resistive exercise was the bicycle. RNA 1 stated the RNP Referral to perform 3 sets of 12 repetitions of resistive exercises using weights on both arms and legs was not included in RNA 1's task assignment. RNA 1 stated the RNP task assignment for Resident 5 indicated resistive exercises and verbally asked the therapist (unknown) which resistive exercises to perform. During a concurrent interview and record review on 8/20/2026 at 1:29 p.m. with the DOR, Resident 5's physician's order for RNA, dated 6/16/2026, was reviewed. The DOR stated the therapists (PT and OT) have specific training to determine the RNA maintenance program to prevent decline in mobility and ROM. The DOR stated Resident 5's RNA order for resistive exercises was not specific enough to provide the RNA with the specific program. The DOR stated Resident 5 may not achieve optimal function without a specific RNA program. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, revised 1/2026, the P&P indicated the care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.

Based on observation, interview, and record review, the facility failed to provide one of 12 sampled residents (Resident 13) with a call light appropriate for the resident's physical ability. This deficient practice had the potential to prevent Resident 13 from using the push-button call light (hand-held device with a button on top to trigger the call light for assistance) to alert the facility staff for assistance. Findings:During a review of Resident 13's admission Record, the admission Record indicated the facility admitted Resident 13 on 6/4/2026 with diagnoses including metabolic encephalopathy (disease that affects the brain, causing changes in its function), dysphagia (difficulty swallowing), muscle wasting and atrophy (loss of muscle mass and strength, and dementia (progressive state of decline in mental abilities). During a review of Resident 13's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 6/10/2026, the MDS indicated Resident 13 had unclear speech, rare/never expressed ideas and wants, rarely/never understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 13 had ROM limitations in both arms and legs and was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for oral hygiene, toileting, dressing, bathing, rolling from lying on the back to either side in ed, and transferring from lying in bed to sitting at the sit of the bed. During a review of Resident 13's care plan titled, ADL (activities of daily living - basic tasks that individuals perform to maintain their daily lives and independence)/Mobility, initiated 6/4/2026, the care plan interventions indicated to Encourage to use call light for assistance.During an observation on 8/18/2026 at 10:18 a.m. in the resident's room, Resident 13 was lying in bed with the head-of-bed elevated, had unclear speech, and did not understand verbal questions. Both of Resident 13's elbows were bent with the right hand resting on Resident 13's chest and the left hand resting on the abdomen. Resident 13 was observed with active movement in both shoulders and elbows. Resident 13 had a hand roll (soft roll positioned in the palm of the hand and fastened with a strap) in the right hand and a push-button call light on the right side of the bed. During an observation on 8/19/206 at 7:55 a.m. in the resident's room, Resident 13 was lying awake in bed with both elbows bent. Resident 13's right hand was observed resting on Resident 13's chest and the left hand resting on the abdomen. Resident 13 had hand rolls in both hands. During an observation on 8/19/2026 at 9:05 a.m. with Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) 1 (RNA 1) in the resident's room, Resident 13's RNA session was observed. RNA 1 extended all of Resident 13's right-hand fingers, which made Resident 13's body jolt and had a grimaced expression. RNA 1 then performed slow extension of each finger on Resident 13's right-hand. During an observation on 8/19/2026 at 10:20 a.m. with Certified Nursing Assistant 2 (CNA 2) in the resident's room, CNA 2 stated Resident 13 could not use either hand functionally, requiring total assistance for eating.During an interview on 8/20/2026 at 11:14 a.m. with the Director of Nursing (DON), the DON stated the purpose of the call light (in general) was to alert the staff when the residents needed assistance. During a concurrent observation and interview on 8/20/2026 at 11:28 a.m. with the DON in Resident 13's room, the DON stated Resident 13's call light required the resident to push the button to use the call light. The DON stated Resident 13 did not have use of the hands to use the call light and needed a more appropriate call light.During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, revise 1/2026, the P&P indicated Residents are provided with means to call staff for assistance through a communication system that directly calls a staff member. The P&P indicated an alternative means of communication that is usable for the resident is provided if the resident had a disability that prevents him/her from making use of the call system.

Based on interview and record review, the facility failed to determine the number of qualified staff needed to meet 40 out of 40 residents' day-to-day needs.The failure resulted in an incomplete Facility assessment (structured framework to evaluate the facility's resident population, operational resources, and overall care capabilities) which can result in poor healthcare outcomes. Findings: On 8/21/2026 at 10:54 a.m., during a concurrent interview and record review with the Director of Nursing (DON), the Facility Assessment, updated 3/12/2026, was reviewed. The DON confirmed and stated the Facility assessment did not indicate the number of staff needed in their day-to-day operations.During a review of the Facility Assessment, 3/12/2026, the Assessment indicated:a. the facility must have sufficient nursing staff to meet the residents' needs.b. the facility routinely assesses staffing levels needed for all shifts (day, evening, night), and including weekends and holidays.

Based on observation, interview, and record review, the facility failed to ensure four out of forty sampled residents (Resident 14, 47, 36, and 51) resided in bedrooms (room [ROOM NUMBER] and 6) that were at least 80 square feet for each resident.This failure had the potential to limit space to provide nursing care, and limit privacy for residents.Findings:During a review of Resident 14's admission Record, the admission Record indicated the facility admitted Resident 14 to room [ROOM NUMBER]-A on 6/1/2026 with a diagnosis including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness of one side of the body) following a cerebral infarction (when blood flow to a part of the brain is blocked). During a review of Resident 14's Minimum Data Set ([MDS] a resident assessment tool), 6/8/2026, the MDS indicated Resident 14 had some difficulty in new situations only when making decisions regarding tasks in daily life. The MDS indicated Resident 14 was able to independently perform sit to stand, chair to bed transfer, and toilet transfer.During a review of Resident 36's admission Record, the admission Record indicated the facility admitted Resident 36 to room [ROOM NUMBER]-B on 7/24/2026 with a diagnosis including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 36's MDS, 6/16/2026, the MDS indicated Resident 36 rarely/never made decisions regarding tasks in daily life. The MDS indicated Resident 36's was dependent (helper does all the task) on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 47's admission Record, the admission Record indicated the facility admitted Resident 47 to room [ROOM NUMBER]-B on 8/14/2026 with a diagnosis including polyneuropathy (a medical condition where multiple peripheral nerves throughout the body malfunction at the same time). During a review of Resident 47's MDS, 8/20/2026, the MDS indicated Resident 47's ability to think was moderately impaired. The MDS indicated Resident 14 depended on staff help when trying to stand from a sitting position and chair to bed transfers.During a review of Resident 51's Admission/ readmission Evaluation/Assessment, dated 8/20/2026 at 8:36 p.m., the assessment indicated Resident 51 was admitted to room [ROOM NUMBER]-A with pneumonia (infection/ inflammation in the lungs). The assessment indicated Resident 51 was alert and oriented to person and place. The assessment indicated Resident 51 needed assistance with all ADLs. During a review of the facility's Client Accommodations Analysis form, submitted 8/18/2026, the form indicated the following resident rooms measured:room [ROOM NUMBER] (2 beds) 141.4 square feet total, 70.7 square footage per residentroom [ROOM NUMBER] (2 beds) 149.8 square feet total, 74.9 square footage per resident During an interview on 8/21/2026 at 11:05 a.m., the Director of Nursing (DON) stated to accommodate residents need, the resident bedrooms need to be 80 square foot per resident.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was safely discharged to a lower level of care by failing to:1.Ensure Resident 1 was discharged to a Board and Care (a small, residential care setting providing housing, meals, and personal care assistance for adults and seniors who cannot live alone but do not require skilled nursing care) and not discharged to a Recuperative Care facility ( provides a temporary, post-hospital care setting who are recovering from an illness and experiencing homelessness) according to physician's order and resident's preference.This failure put Resident 1 at risk for avoidable physical and psychosocial harm and resulted in an inappropriate discharge.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including hypertension (HTN-high blood Pressure), glaucoma( eye condition that damages the optic nerve which can lead to vision loss or blindness), lack of coordination and protein-calorie malnutrition( condition that occurs when a person does not consume enough protein and calories to meet body's needs).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 8/28/2025, the MDS indicated the resident had an intact cognition (thought process) and required supervision or touching assistance ( helper provides verbal cues as resident completes the activity) with bathing, dressing, transferring to and from a bed to a chair , toilet transfer( ability to on and off a toilet or commode) and bed mobility.During a review of Resident 1's Order Summary Report dated 8/27/2025, the Order Summary Report indicated to discharge Resident 1 to a Board and Care, with Home Health for Physical Therapy (PT-treatment that restores movement, reduces pain, and improve quality of life) , Occupational Therapy (OT- provides services to increase and/or maintain a person's capability to participate in everyday life activities) for safety and a Registered Nurse (RN) for medication compliance on 8/28/2025.During a review of Resident 1's Quarterly Interdisciplinary Team (IDT- team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) Conference Notes dated 7/21/2025, the IDT Conference Notes indicated the facility would look for a board and care versus assisted living (residential senior that provides housing and personal care) for discharge planning( a coordinated effort by healthcare staff, the resident and their family to create a personalized plan for a safe and smooth transition when the resident leaves the facility).During a review of Resident 1's Care Plan titled Discharge/Transfer Planning Preference: Resident indicated a preference to be discharged to an assisted living or Board and Care, initiated 4/24/2025. The Care Plan goal indicated the facility would honor resident's preference for discharge. The Care Plan interventions indicated to assess resident needs for discharge, assisting resident 's preference regarding discharge preferences and appropriate post-acute care.During a review of Resident 1's Progress Notes dated 8/28/2025 at 10:01 a.m., the Progress Notes indicated Resident 1 was discharged to a Board and Care in a stable condition.During a telephone interview on 9/12/2025 at 1:51 p.m. with Resident 1, Resident 1 stated the Board and Care where he was discharged looked unsafe and the facility personnel looked suspicious. During a telephone interview on 9/16/2025, at 11:59 a.m. with the Director of Patient Care (DOPC- third party collaborating with facility's social worker to find a place for a resident who is going to get discharged ), the DOPC stated the facility where the resident was discharged was not a Board and Care. The DOPC stated it was a recuperative care facility which was transitional housing for homeless people, and people who came from jail. The DPOC stated residents should be independent and should not require medical services. The DOPC stated they received an online referral from the facility's social worker and had spoken to Resident 1 over the phone about the place. The DOPC stated Resident 1 agreed but she did not know if the resident knew the facility was not a board and care. The DOPC stated Resident 1 refused to stay as soon as he got to the facility because of his fear of gangs and the facility's location. The DOPC stated Resident 1 left the recuperative care facility on his own and went back to an undisclosed place at Long Beach.During a concurrent interview and record review on 9/15/2025, at 2:34 p.m. with Case Manager (CM) 1 of Resident 1's electronic medical, CM 1 stated Resident 1 was discharged to a board and care on 8/28/2025. CM 1 stated the Social Worker (SW) arranged for the board and care facility.During an interview on 9/16/2025, at 10:32 p.m. with CM1, CM 1 stated Resident 1 was discharged to a Recuperative Care Facility and not to a Board and Care. CM1 stated Recuperative Care Facility is a home for homeless people and not a licensed facility. CM1 stated a Board and Care are for residents that need more help with activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and help residents with their medications. CM 1 stated the facility should have screened the facility to ensure the place was safe and able to meet the needs of Resident 1.During an interview on 9/16/2025, at 11:17 a.m. with the Administrator (ADM), the ADM stated there was a miscommunication between the SW and the DPOC about Resident 1's discharge. The ADM stated he was disappointed about what happened to Resident 1 getting discharged to a Recuperative Care facility instead of Board and Care. The ADM stated it was the responsibility of the facility to screen the place where Resident 1 will be discharged to ensure safe discharge.During a concurrent interview and record review on 9/16/2025, at 2:58 p.m. with the Director of Nursing (DON), Resident 1's electronic medical record was reviewed. The DON stated the physician 's order indicated to discharge Resident 1 to a Board and Care, obtain Home Health for physical and occupational therapy for safety and Registered Nurse for medication compliance. The DON stated the SW was on vacation and did not know what happened to the discharge of Resident 1. The DON stated the facility should have followed the physicians' discharge order to a Board and Care. The DON stated the SW should have verified the placement and discussed with Resident 1 and the physician if the resident was going to a recuperative care facility instead of board and care. The DON stated Resident 1 being discharged to Recuperative Care instead of a Board and Care could have caused emotional distress and could result in an inappropriate discharge.During a review of facility's policy and procedure (P&P) titled, Transfer or Discharge, revised 3/2025, the P&P indicated discharges must meet specific criteria and require resident or representative notification, orientation and documentation in the medical record.

Based on interview and record review, the facility failed to provide the necessary care and service for one of three sampled residents (Resident 2) by failing to:1.Monitor Resident 2 for constipation (a condition in which stool becomes hard, dry, difficult to pass) daily.2.Provide necessary medications for constipation when the resident had no bowel movement for three days as ordered by the physician.These failures had the potential to put Resident 2 at risk for fecal impaction (hardened stool that's stuck in the rectum or lower colon) that could lead to a bowel obstruction (partial or complete blockage of small or large intestines which is life threatening), nausea or pain.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted on [DATE] and was readmitted on [DATE] with diagnoses including metabolic encephalopathy( condition where the brain is unable to function properly due to an imbalance of chemicals in the blood), atrial fibrillation( irregular heartbeat), hypertension(HTN- high blood pressure), and acute osteomyelitis of left ankle and foot(inflammation of bone or bone marrow, usually due to infection).During a review of Resident 2's Minimum Data Set ( MDS- a resident assessment tool) dated 8/7/2025, the MDS indicated the resident had moderately impaired cognitive skills ( a person is having trouble with thinking, remembering, and making decisions) and required substantial assistance (helper does more than half the effort to complete an activity) with dressing, bathing and bed mobility.During a review of Resident 2's Care Plan titled, At risk for complications with bowel regimen/constipation due to immobility, side effects of medication initiated on 9/11/2025, the Care Plan's interventions included to administer medications for constipation per physician order.During a review of Resident 2's Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) Task for Bowel Continence (ability to control the passage of stool from the rectum), the ADL Bowel Continence Task indicated Resident 2 did not have a bowel movement on 8/20/2025, 8/21/2025, and 8/22/2025.During a review of Resident 2's Order Summary Report dated 8/2/2025, the Order Summary Report indicated a physician order to give Milk of Magnesia ([MOM]-laxative) oral suspension 400 milligrams ([mg]- unit of measurement) to give 30 milliliters ([ml]- unit of measurement) by mouth prn (as needed) every 24 hours for constipation daily.During a review of Resident 2's Order Summary Report dated 8/2/2025, the Order Summary Report indicated a physician order to give Dulcolax (laxative Suppository 10 mg rectally (per rectum) prn for constipation daily if MOM is ineffective. During a review of Resident 2's Order Summary Report dated 8/2/2025 indicated a physician order to give Fleet Saline Enema (a liquid laxative rectally to relieve occasional constipation) rectally prn for constipation every three days if Dulcolax is ineffective.During a concurrent interview and record review of Resident 2 's ADL Task for Bowel Continence on 9/16/2025 at 9:34 a.m. with Certified Nursing Assistant (CNA)2, CNA 2 stated Resident 1 had no bowel movement on 8/20/2025, 8/21/2025 and 8/22/2025. CNA 2 stated she should have notified the charge nurse when Resident 2 did not have a bowel movement so the resident could receive medication for constipation. CNA 2 stated Resident 2 could get sick and increase his chance of hospitalization due to infection.During a concurrent interview and record review on 9/16/2025 at 11:30 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's ADL Task for Bowel Continence and Medication Administration (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) were reviewed. LVN 1 stated Resident 2 did not have bowel movement on 8/20/2025, 8/21/2025, and 8/22/2025. LVN 1 stated the electronic chart would alert the LVNs if a resident had no bowel movement within 24 to 48 hours. LVN 1 stated she could not recall if she received an alert for Resident 2 in the electronic chart and was not notified by the CNA regarding Resident 2's constipation. LVN 1 stated Resident 2 did not receive any medication for constipation, and she should have administered the prn laxatives to relieve constipation. LVN 1 stated if all the prn laxatives are ineffective, the physician will be notified because the resident could be at risk for fecal impaction. During a concurrent interview and record review on 9/16/2025, at 10:49 a.m. with the Director of Staff Development (DSD), Resident 2's MAR was reviewed. The DSD stated CNAs report to the charge nurse when a resident has no bowel movement and if a resident has no bowel movement for two days, the licensed nurse should administer medications for constipation. The DSD stated the staff should have monitored the frequency of Resident 2's bowel movement on the MAR and the CNAs should have notified the licensed nurse about Resident 2's constipation.During an interview on 9/16/2025, at 3:54 p.m. with the Director of Nursing (DON), the DON stated the charge nurse should have checked to see if Resident 2 had a bowel movement, administer the laxatives if needed and notified the physician if the prn laxatives were ineffective. The DON stated Resident 2 could have developed abdominal pain, nausea, vomiting and constipation if the resident was not monitored and prn laxatives not administered as ordered by the physician for constipation.During a review of facility's Job Description for Certified Nursing Assistant, the Job Description of Certified Nursing Assistant indicated the CNA will report all changes in the resident's condition to the Nurse Supervisor/ Charge Nurse as soon as practical and performed all assigned tasks as instructed by the supervisor and in accordance with facility's policies and procedures.During a review of the facility's Job Description of LVN, the Job Description of LVN indicated the LVN will review the resident's charts for specific medication orders as necessary and will make periodic checks to evaluate resident's physical and emotional condition.

Based on interview and record review, the facility failed to provide the proper notice for discharge for one of two sample residents (Resident 1) by failing to:1. Provide a written discharge notice (30-day notice of proposed discharge) at least 30 days prior to the transfer or discharge of the resident from the facility.This failure had the potential to put Resident 1 at risk for inappropriate and unsafe discharge.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses including hypertension (HTN-high blood Pressure), glaucoma( eye condition that damages the optic nerve which can lead to vision loss or blindness), lack of coordination and protein-calorie malnutrition( condition that occurs when a person does not consume enough protein and calories to meet body's needs).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 8/28/2025, the MDS indicated the resident had an intact cognition (thought process) and required supervision or touching assistance ( helper provides verbal cues as resident completes the activity) with bathing, dressing, transferring to and from a bed to a chair , toilet transfer ( ability to on and off a toilet or commode) bed mobility.During a review of Resident 1's Order Summary Report dated 8/27/2025, the Order Summary Report indicated to discharge the resident to Board and Care on 8/28/2025. During a review of Resident 1's Notice of Proposed Transfer/Discharge (formal, written notification from long term care facility to a resident and their representative about a planned move from the facility and must be provided at least 30 days in advance under federal law) dated 8/28/2025, the Notice of Proposed Transfer/ Discharge indicated the resident received and signed the form on 8/28/2025. The Notice of Proposed Transfer indicated the resident was discharged to a Board and Care (a small residential care setting providing housing, meals, and personal care assistance for adults and seniors who cannot live alone but do not require skilled nursing care) on 8/28/2025.During a review of Resident 1's Progress Notes dated 8/28/2025 at 10:01 a.m., the Progress Notes indicated the resident was discharged to a board and care in stable condition.During a concurrent interview and record review on 9/15/2025, at 3:06 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's Notice of Proposed Transfer/ Discharge was reviewed. LVN 2 stated the Notice of Proposed Transfer/Discharge was provided to Resident 1 on the day of discharge. LVN2 stated the Notice of Proposed Transfer/ Discharge is provided to residents upon their discharge.During an interview on 9/16/2025, at 2:58 p.m. with the Director of Nursing (DON), the DON stated the facility provides a Notice of Proposed Transfer /Discharge to the residents on the day that they are leaving the facility or the day they get discharged . The DON stated she was not aware the written notice for discharge should be provided to the residents at least 30 days before the discharge as indicated in the facility policy. The DON agreed that the Notice of Proposed Transfer/ Discharge should be given at least 30 days prior to the discharge of the residents to give ample time to decide and be informed about their discharge.During a review of facility's policy and procedure (P&P) titled, Transfer or Discharge Notices, revised 3/2025, the P&P indicated residents or resident representative are notified of an impending discharge at least 30 days prior to transfer or discharge. The P&P indicated the written notice should be in a language or manner that the residents can understand.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed at risk for falls and who had a previous unwitnessed fall, did not fall again. Resident 1 following her first unwitnessed fall on 6/20/2025 had recommendations from the Rehabilitation Department to use a bed alarm (sensors placed in a bed or chair that alarm and alerts staff when a resident stands up unassisted). The bed alarm was not used, per the Rehab Department's recommendation. This deficient practice resulted in Resident 1 having a second unwitnessed fall on 6/30/2025 and sustaining a mild to moderate left parietal (refers to the sides of the head) scalp hematoma (a collection of blood outside of a blood vessel caused by a blunt trauma)/contusion (a bruise). This deficient practice had the potential for Resident 1 to sustain greater injuries.Findings: Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed at risk for falls and who had a previous unwitnessed fall, did not fall again. Resident 1 following her first unwitnessed fall on 6/20/2025 had recommendations from the Rehabilitation Department to use a bed alarm (sensors placed in a bed or chair that alarm and alerts staff when a resident stands up unassisted). The bed alarm was not used, per the Rehab Department's recommendation. This deficient practice resulted in Resident 1 having a second unwitnessed fall on 6/30/2025 and sustaining a mild to moderate left parietal (refers to the sides of the head) scalp hematoma (a collection of blood outside of a blood vessel caused by a blunt trauma)/contusion (a bruise). This deficient practice had the potential for Resident 1 to sustain greater injuries. Findings: During a review of Resident 1' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with the diagnoses including metabolic encephalopathy (a brain disorder that occurs when an underlying condition causes a chemical imbalance in the blood that affects the brain), abnormalities of gait (a manner of walking or moving on foot) and mobility, lack of coordination, and seizures (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movement, and awareness). During a review of Resident 1' s Minimum Data Set ([MDS] a resident assessment tool) dated 6/8/2025, the MDS indicated Resident 1 had moderate cognitive (thought process) impairment. The MDS indicated Resident 1 had a functional limitation in range of motion to her bilateral (both) lower extremities ([BLE] legs) and used a wheelchair as her mobility device. The MDS indicated Resident 1 was dependent for toileting hygiene and was incontinent (involuntary voiding of urine and stool) in both her bowel and bladder functions and had a fall history of less than a month prior to admission. During a review of Resident 1' s History and Physical (H&P), dated 6/2/2025, the H&P indicated Resident 1 was unable to make her own medical decision at this time. During a review of Resident 1's admission Fall Risk Observation and assessment dated [DATE], the Fall Risk Observation and Assessment indicated Resident 1 scored 10, meaning she was a moderate risk for falls During a review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment dated 6/3/2025, The PT Evaluation and Plan of Treatment indicated Resident 1 was referred to PT for assessment of her BLE range of motion [(ROM] the direction a joint can move to its full potential), strength, balance, motor coordination, motor control, gait mechanics, functional mobility, safety awareness and risk for falls due to Resident 1's fall risk, seizures, altered mental status (AMS). During a review of Resident 1's Change of Condition (COC) Evaluation dated 6/20/2025, the COC Evaluation indicated Resident 1 had an unwitnessed fall and was found sitting on her bottom on the floor with her back facing the side of her bed, with her left leg folded under her, her right leg straight with her right foot flat on the floor. The COC Evaluation indicated Resident 1 reported to LVN 1 that she did not know what happened. During a review of Resident 1's Rehab Status Post-Fall Screen dated 6/20/2025, the Rehab Status Post-Fall Screen indicated Resident 1 was found in her room on the floor. The Rehab Status Post-Fall Screen indicated Resident 1 was unable to recall a what happened due to her impaired cognition, cognitive issues, and poor safety awareness with impulsive tendencies. The Rehab Status Post-Fall Screen indicated a recommendation for bed and chair alarms: (bed alarms and chair alarms are commonly used to alert staff if a patient is attempting to get up without assistance, especially if they have a high fall risk and can help prevent falls by providing early warning signals that prompt staff to assist the patient). During a review of Resident 1's COC Evaluation form dated 6/30/2025, the COC Evaluation form indicated Resident 1 had an unwitnessed fall where she was found in her bathroom lying on the floor using her arm to cushion her head. The COC Evaluation form indicated Resident 1 had a hematoma on the left side of her scalp. The COC Evaluation form indicated Resident 1's physician gave instructions to transfer Resident 1 to a General Aute Care Hospital (GACH) via 911 for further evaluation. During a review of Resident 1's SBAR ([situation, background, assessment, recommendation] a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form dated 6/30/2025, the SBAR indicated Resident 1 was transferred to a GACH via 911 for evaluation. During a review of the Emergency Department (ED) documents dated 6/30/2025, the ER documents indicated Resident 1 was transferred to the ED on 6/30/2025. During a review of the GACH's Discharge Instructions dated 6/30/2025, the Discharge Instructions indicated Resident 1 sustained a mild to moderate left parietal scalp hematoma/contusion, which could represent a small calcification (an abnormal buildup of calcium salts in body tissues, leading to hardening) or small acute intraparenchymal hemorrhage (bleeding from a damaged blood vessel). During an interview on 7/14/2025 at 11:51 a.m., Licensed Vocational Nurse (LVN) 1 stated on 6/30/2025 she went to Resident 1's room and noticed she was not in bed and that her bedside table was next to the bathroom, when she opened the bathroom door she found Resident 1 on the floor. LVN 1 stated she assessed Resident 1 and found a hematoma on the left side of Resident 1's head. LVN 1 stated Resident 1 should be assisted when she gets up from bed because she was unsteady when she walked. LVN 1 stated she was not aware of the recommendation for Resident 1 to use a bed alarm and using one could have prevented Resident 1 from falling because the alarm should have prompted staff to check on her. During an interview on 7/14/2025 at 1:18 p.m., the Assistant Director of Rehab (ADOR) stated on 6/3/2025 Resident 1 they assessed Resident 1 at high risk for falls. On 6/20/2025, Resident had an unwitnessed fall and was reassessed by the Rehab Depart post fall. The ADOR stated recommendations for Resident 1 included using a bed alarm and all departments were made aware of the recommendation via the facility's computer systems, and verbally during the IDT meeting. The ADOR stated with Resident 1's history of falls, anxiety, her impaired cognition, impulsive behavior and weakness to her BLEs, Resident 1 was at risk for falls and needed assistance walking and getting out of bed. During an interview with on 7/14/2025 at 3:20 p.m., Certified Nursing Assistant (CNA) 1 stated Resident 1 was identified as high risk for fall because Resident 1 had a previous unwitnessed fall on 6/20/2025. CNA 1 stated she went to Resident 1's room and on 6/30/2025 and found the resident sitting on the bathroom floor and noticed a bump on the left side of her head. CNA 1 stated no one told her about the recommended interventions to use a bed alarm and using the bed alarm might have helped prevent Resident 1's second unwitnessed fall (6/30/2025). During an interview on 7/15/2025 at 3:20 p.m., the Director of Nursing (DON) stated Resident 1 had two unwitnessed falls, since her admission on [DATE], one on 6/20/2025 and another one on 6/30/2025. The DON stated the rehabilitation department assessed Resident 1 after her first unwitnessed fall on 6/20/2025 and recommended that a bed alarm was to be used. The DON stated although the Rehab Depart made a recommendation for Resident 1 to use a bed alarm, it did not mean the intervention would be used. The DON acknowledged that using the bed alarm might have prevented Resident 1 from falling the second time (6/30/2025). During a review of the facility s Policy and Procedure (P/P) titled, Falls and Fall Risk, Managing revised 3/2018, the P/P indicated that based on previous evaluations and current data, 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. Resident conditions that may contribute to the risk of falls may include cognitive impairment, lower extremity weakness, functional impairment and incontinence. Medical factors that contribute to the risk of falls may include neurological disorders. The staff with the input of the attending physician will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. During a review of the facility's undated P/P titled, Fall Risk Assessment the P/P indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.

Based on interview and record review, the facility failed to treat one of four sampled residents (Resident 1) with respect and dignity by failing to ensure Resident 1 was assisted with getting dressed prior to him leaving for his appointment. This deficient practice resulted in Resident 1 to feel embarrassed because he had to wear a hospital gown (a loose-fitting garment, typically open in the back, that patients wear in medical facilities) to his appointment. This deficient practice had the potential for Resident 1 to be exposed causing unworthiness and psychosocial harm to Resident 1. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute kidney failure ([AKI] also called acute kidney injury - when the kidneys suddenly can't filter waste products from the blood), type 2 diabetes ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), and colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 5/30/2025, the MDS indicated Resident 1's cognition was intact. During a telephone interview on 6/17/2025 at 1:56 p.m., with Resident 1's Family Member (FM 1), FM 1 stated on 5/30/2025 at 7:30 a.m., she brought Resident 1 street clothes (ordinary clothes that people wear in public) to wear to his appointment. FM 1 stated when Resident 1 arrived at his appointment, he was still wearing a hospital gown and not the street clothes she brought for him to be changed into. FM 1 stated she was upset because Resident 1 expressed to her that he was embarrassed because he had to wear a hospital gown in public. During an interview on 6/18/2025 at 11:46 a.m., with the Case Manager (CM), the CM stated she received a phone call (after Resident 1's appointment on 5/30/2025) from Resident 1's FM 1 complaining that Resident 1 arrived at his appointment wearing a hospital gown. The CM stated CNA 1 reported to her that Resident 1 had refused to change into his clothes. During a concurrent interview and record review on 6/18/2025 at 3:26 p.m., with the Case Manager (CM), Resident 1's Clinical Records dated 5/2025 were reviewed. The Clinical Records indicated, there were no documentation indicating on 5/30/2025 that Resident 1 refused to change into his street clothes prior to him leaving for his appointment. The CM indicated she did not find any documentation on Resident 1's refusal to change into his street clothes nor that the facility staff notified his RP 1 of his refusal to change into his clothes. During a telephone interview on 6/18/2025 at 4:19 p.m., with CNA 1, CNA 1 stated on 5/30/2025, she offered Resident 1 only once if he wanted to change into his clothes prior to leaving to his appointment. CNA 1 stated Resident 1 refused to be changed because he was hot. CNA 1 admitted to not reporting Resident 1's refusal to change into his clothes. CNA 1 stated she should have offered Resident 1 to be changed at least three times and if he still refused, she would notify the charge nurse immediately. During an interview on 6/18/2025 at 4:51 p.m., with the Director of Nursing (DON), the DON stated CNA 1 should have changed Resident 1 into his clothes prior to leaving for his appointment. The DON stated if a resident refused to be changed into their clothes, it should be documented in the medical record and the licensed nurses should have notified of his refusal. During a review of the facility's policy and procedure (P&P) titled, Dignity, revised 2/2021, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their rights. For example, residents are encouraged to dress in clothing that they prefer. During a review of the facility's P&P titled Resident Rights, dated 2/2021, the P/P indicated employees shall treat all resident with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence and be treated with respect, kindness and dignity.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with physician orders for two of eight sampled residents (Resident 2 and 28) by: 1.Failing to follow up dermatology (branch of medicine that diagnosis and treats skin disorders) consult for Resident 2. 2.Failing to follow physician orders for dressing change for Resident 28's right above the knee amputation (AKA). These deficient practices resulted in Resident 2 not being seen by a dermatologist and had the potential for Resident 28's wound to become infected. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), and chronic kidney (bean shaped organ responsible for filtering blood and removing waste) disease (progressive condition where the kidneys become damaged and are unable to filer blood effectively). During a review of Resident 2's History and Physical (H&P), dated 5/17/2025, the H&P indicated Resident 2 was able to make her own medical decisions. During a review of Resident 2's Minimum Data Set [MDS] a resident assessment tool), dated 3/6/2025, the MDS indicated Resident 2 's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were intact. The MDS indicated Resident 2 required moderate assistance (provide less than half the effort) in bathing, toileting hygiene, and shower transfer, required supervision for chair/bed-to-chair transfer, lower body (waist below) dressing, putting/taking shoes off, and is independent in eating, oral hygiene, upper body (waist above) dressing, and personal hygiene. The MDS indicated Resident 2 utilizes a wheelchair and walker and has bilateral (both sides) impairments on the lower (hips/legs) extremities. During a review of Resident 2's Order Summary Report (physician orders) dated 5/18/2025, the order summary indicated dermatology consult and treatment as indicated for right hand lesions with an active date of 1/31/2025. During a review of Resident 2's progress notes dated 5/18/2025, the progress note dated 1/31/2025 at 11:57 a.m. indicated Dermatologist 1 (DERM 1) was called for a dermatology consult and treatment as indicated for right hand lesions. DERM 1 requested the face sheet and to take a photograph of lesions on Resident 2's right hand. During a review of Resident 2's physician order sheet from DERM 1 dated 3/26/2025, the physician order sheet indicated to fax a signed consent form to schedule a biopsy to rule out basal cell (most common type of skin cancer)/ squamous cell carcinoma (type of skin cancer that makes up the outermost layer of the skin). During a review of Resident 2's skin biopsy consent form, there are no dates and signature indicated on the consent form. During a concurrent observation and interview on 5/17/2025 at 10:43 a.m. with Resident 2, Resident 2 stated she has had this skin issue for about six months. Resident 2 stated the facility is aware, and she had not received any medication, and the facility has not done anything for her. It was observed Resident 2 had two raised bumps on her right hand. During a concurrent interview and record review on 5/18/2025 at 11:34 a.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated the order for Resident 2 indicated there was an order for a dermatology consult on 1/31/2025. RNS 1 stated when there is an order for a dermatology consult, they will schedule and make an appointment with dermatology. RNS 1 stated depending on the insurance the Case Manager (CM) or the Social Service Director (SSD) will get prior authorization for the referral and fax the documents to the clinic. RNS 1 stated per order, Resident 2 should have a dermatology consultation appointment. RNS 1 stated the progress note on 1/31/2025, indicated DERM 1 asked for Resident 2's face sheet to be faxed over. RNS 1 stated the DERM 1 physician order sheet indicated the informed consent to be faxed, but the informed consent was not signed. RNS 1 stated there are no notations in March, April, and May 2025 regarding the dermatology consultation and indicated it is not known if a signed consent form was faxed to the dermatology clinic. RNS 1 stated the informed consent should have been signed and sent out at that time. RNS 1 stated the nurses usually follow up with the documents and indicated this was communicated from the nurses to DERM 1 and DERM 1 requested the face sheet. RNS 1 stated it is known what happened afterwards and usually follow up within 72 hours (hr.). RNS 1 stated if the resident does not receive the intended consultation, their condition can get worse and affect the health of the resident. During an interview on 5/18/2025 at 6:57p.m. with the Administrator (ADM), the ADM stated the previous Director of Nursing (DON) was in charge of all ancillary services (services that support, or supplement primary care provided by doctors and nurses) and was aware that Resident 2 had an order summary by DERM 1 in March 2025 and was not followed up. The ADM stated at that time, it was DON's responsibility and indicated that the residents not receiving the intended consultation is a huge issue as it can potentially lead to a more serious issue, and this could have been easily preventable had they made an appointment, and they did not. During an interview on 5/18/2025 at 8:38p.m. with the DON, the DON stated it was important for residents to get consultations if needed, and if there is an order, the resident should get the consultation. 2.During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was initially admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (a condition where the body has trouble controlling blood sugar) with hyperglycemia (elevated sugar in the blood), type 2 diabetes mellitus with diabetic neuropathy arthropathy (nerve damage and joint disease), hypertension (high blood pressure) and acquired absence of right leg above knee. During a review of Resident 28's history and physical (H&P), dated 5/15/2025 the H&P indicated Resident 28 had the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS), a resident assessment tool dated 3 /31 /2025, the MDS indicated Resident 28 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity) with eating, and personal hygiene, substantial / maximal assistance (helper lifts and holds trunk or limbs, provides more than half the effort ) with lower body dressing, shower/bathe self and putting on /taking off footwear. During a record review of Resident 28's Treatment Administration Record (TAR) dated 5/16/2025 , the TAR indicated right AKA (surgical incision) cleanse with normal saline (sterile water), apply xeroform (wound dressing), ABD pad (a highly absorbent medical dressing used to manage heavily draining wounds)and wrap with kerlix (used to secure and protect wounds , injuries or surgical sites ) every day shift x 30 days . Another order with a start date of 5/15/2025 indicated to monitor surgical incision daily every day shift. And last order dated 5/15/2025 indicated to monitor dressing integrity daily every day shift. During an observation and interview on 5/18/2025 at 11:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 28 was in bed with his right AKA without a dressing . LVN 3 stated she was aware resident had no dressing . LVN 3 states it was important to keep Resident 28's surgical wound covered with dressing to prevent infection. During an interview on 5/18/2025 at 12:30 p.m., with Registered Nurse 1 (RN 1), RN 1 stated she was not aware Resident 28 had no dressing to his right AKA. RN 1 stated it was important to keep Resident 28's right AKA surgical site completely covered to prevent infection, and it to follow the doctor's order. During an interview on 5/18/2025 at 8:00 p.m. with the Director of Nursing (DON), the DON stated we must follow doctors order and keep the wound covered and provide a dressing to prevent infection. During a review of the facility's policies and Procedures (P&P), titled Resident Rights, revised date February 2021, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; communication with and access to people and services, both inside and outside the facility. During a review of the facility's P&P, titled Dignity, revised date February 2021, the P&P indicated each resident shall be cared for in a matter that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. Individual needs and preferences of the resident are identified through the assessment process. During a review of the facility's policy and procedure (P&P) titled Residents Rights indicates federal and state laws guarantees certain basic rights to all residents of this facility these rights include the residents right to : Equal access to quality care, regardless of source of payment.

Based on interview and record review, the facility failed to ensure two of ten sampled residents (Resident 21 and 28) had their admission/readmission assessments completed by Registered Nurses (RNs) This deficient practice had the potential for delay in care and services, due to missed or inaccurate identification of problems. a. During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified fracture (break in a bone) of unspecified lumbar vertebra (one of the bones that make up the spinal column in the lower back), spinal stenosis (space inside the backbone is too small putting pressure on the spinal cord), and obstructive (urine flow is blocked) and reflux uropathy (occurs when urine flows backward into the bladder often as a result of obstruction). During a review of Resident 21's History and Physical (H&P), dated 4/20/2025, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21 Minimum Data Set [MDS] a resident assessment tool), dated 4/24/2025, the MDS indicated Resident 21's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS indicated Resident 21 is dependent on chair/bed-to-chair transfer and toileting hygiene, required maximal assistance (provide more than half the effort) for bathing, dressing upper (above waist) and lower (waist below) body, required supervision on personal hygiene and oral hygiene, and required set up for eating. The MDS indicated Resident 21 utilizes a wheelchair and has bilateral (both sides) impairments on the upper (arms/shoulders) and lower (hips/legs) extremities. During a review of Resident 21's Change of Condition (COC) dated 5/13/2025 at 4:26p.m., the COC indicatred Resident 21 was sent to the hospital for further evaluation for a left elbow skin tear and right forearm skin tear. During an interview on 5/18/2025 at 5:41p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated upon admission, they get the paperwork, introduce the resident, review the resident, do skin assessments with the Certified Nursing Assistant (CNA), assess for smoking, check if they are a fall risk, and do the Braden Scale (tool used to assess a patient's risk for developing damaged skin and tissue). LVN 2 stated they do the head-to-toe assessment and indicated the RN does not do the admission assessments. LVN 2 stated the Licensed Vocational Nurses are the ones that do the skin assessment, and it was primarily their responsibility to do the admission assessments not the Registered Nurses. LVN 2 stated if there is a serious incident such as a fall or bleed, they will notify the RN so they can assess the resident. LVN 2 stated if they do not have an RN, they will notify the physician. During a concurrent interview and record review on 5/18/2025 at 5:49 p.m. with LVN 2, LVN 2 stated Resident 21 went and came back from the hospital and usually an LVN will not do a full readmission assessment if the resident comes back from the hospital in the same day. LVN 2 stated the progress note indicated on 5/14/2025 at 12:55a.m., there is documentation that the resident returned from the hospital. LVN 2 stated the skin and pain assessment needs to be completed. LVN 2 stated there was no reassessment done by an LVN or an RN when Resident 21 returned back from the hospital and was supposed to do an assessment. LVN 2 stated an assessment is supposed to be done as Resident 21 has been on a gurney in the emergency room and you want to assess to ensure theres no new issues, and ensure the resident is not in pain. LVN 2 stated if there are no readmission assessments done, the resident may have skin breakdown, so it is important to cover all the basis as they are there to take care of the residents and make sure they are okay. b. During a review of Resident 28's admission Record, the admission Record indicated Resident 28 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Type II Diabetes Mellitus (DM: a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 28's H&P, dated 5/15/2025, the H&P indicated Resident 28 had the capacity to understand and make decisions. During a review of Resident 28 MDS dated [DATE], the MDS indicated Resident 2's cognitive skills were severely impaired. The MDS indicated Resident 28 is dependent on chair/bed-to-chair transfer, toilet transfer, toileting hygiene, required maximal assistance for lower body dressing, bathing, required moderate assistance (provide less than half the effort) for oral hygiene and upper body dressing, and required supervision for eating and personal hygiene. The MDS indicated Resident 28 utilizes a wheelchair and has bilateral impairments on the lower extremities. During a review of Resident 28's Admission/readmission Evaluation/assessment dated [DATE], the admission/readmission evaluation indicated this assessment document was completed by Licensed Vocational Nurse 3 (LVN 3). During a concurrent interview and record review on 5/18/2025 at 3:54 p.m., with Infection Preventionist Nurse (IPN), the IPN stated the LVN's have been doing the admission assessments and Registered Nurse Supervisor 1 (RNS 1) helps and does the care plans. the IPN stated RNS 1 also does the admission assessments, but most of the time, the LVNs do the admission assessments. The IPN stated that when the resident is admitted , the admission assessments have to be documented right away. The IPN stated that when a resident goes to the hospital and comes right back to the facility, they have to do an admission/readmission evaluation assessment right away as the resident might have bruising, there may be new medication orders, and does not want the facility to be blamed. IPN stated they also have to do the skin check and is done by the LVNs. During an interview on 5/18/2025 at 4:01p.m., with RNS 1, RNS 1 stated for admission, transfer, and discharge assessments, the LVN does it and she helps. During an interview on 5/18/2025 at 8:31p.m. with Director of Nursing (DON), the DON stated the Registered Nurses (RN) does not usually do the admissions and indicated any licensed nurse can do the head-to-toe assessment. The DON stated if the LVN completes the head-to-toe assessment, the RN should verify the assessment themselves. The DON stated RN completes a comprehensive assessment of the resident because they oversee the plan of care, treatments, and ensure issues are not missed. During a review of the facility's policies and Procedures (P&P), titled Job Description: Registered Nurse (RN), dated 1/2025, the P&P indicated participate in the development of written preliminary and comprehensive assessments of the nursing needs of each resident as necessary. Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan. Review nurses' notes to determine if the care plan is being followed. Review resident's medical and nursing treatments to ensure that they are provided in accordance with the resident's care plan and wishes. During a review of the facility's P&P, titled Job Description: Director of Nursing revised 1/2025, the P&P indicated the DON is a registered nurse who oversees and supervises the care of all the residents. Essential Duties: Overall management of the entire nursing department and staffing levels. Responsible for ensuring resident safety and that all residents are treated with utmost respect. Liaison between the facility, physicians and family members. Work closely with all other departments to ensure excellent overall resident care. I know During a review of the facility's P&P, titled admission Assessment and Follow Up: Role of the Nurse revised September 2012, the P&P indicated the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including MDS. 7. Conduct an admission assessment (history and physical), including a. A summary of the individual's recent medical history, including hospitalizations, acute illnesses, and overall status prior to admission. b. Relevant medical, social, and family history

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, and administering drugs and biologicals per physician orders to meet the needs of each resident for two out of five sampled residents (Resident 1 and 21) by: 1.Failing to follow up with the Medication Regimen Review (MRR: comprehensive evaluation of resident's medication performed by a pharmacist to promote positive outcomes and minimize adverse consequences) recommendations for Resident 1. 2.Failing to communicate new medication order to the pharmacy for Resident 1. 3.Failing to follow doctors orders and remove Lidoderm External Patch five (5) percent (%) (Lidocaine: medication that numbs specific area of the body by blocking pain signals to the brain) for Resident 21. These deficient practices had the potential for Resident 1 to not receive medication to address pain appropriately and increased the risk for adverse reactions for Resident 21 by leaving the Lidocaine patch longer than 12 hours (hrs). 1. During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke - loss of blood flow to a part of the brain) and osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the right ankle and foot. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/9/2025, the MDS indicated Resident 1 had moderate cognition (ability to learn, reason, remember, understand, and make decisions) impairment with the ability to recall information, required supervision when eating, required maximal assistance (helper does more than half of the effort) for dressing, and was dependent (helper does all of the effort) for showering and bathing. During a review of Resident 1's Physician Order Summary, the Order Summary indicated Resident 1 had an order for: a.Hydrocodone-acetaminophen (strong pain medication) tablet 5-325 milligrams (MG-unit of measurement) give one tablet by mouth every six hours as needed for severe pain (6-10 pain level) with start date 4/3/2025 and an end date 4/20/2025. b.Hydrocodone-acetaminophen tablet 5-325 MG give one tablet by mouth every six hours as needed for moderate pain (4-6 pain level) with start date 4/20/2025. During an observation on 5/18/2025 at 8:30 a.m., in Resident 1's room, Resident 1 reported a pain level of 7 out of 10. Licensed vocational nurse (LVN) 4 administered one tablet of hydrocodone-acetaminophen tablet 5-325 MG to Resident 1. During a concurrent interview and record review on 5/18/2025 at 10:10 a.m. with Licensed vocational nurse (LVN) 4, Resident 1's order summary, medication blister pack (type of tamper evident packaging that separates medication by dose), and reconciliation count sheet were reviewed. LVN 4 stated Resident 1's order summary indicated hydrocodone-acetaminophen tablet 5-325 MG is to be given for moderate pain (4-6). LVN 4 stated the blister pack and the reconciliation count sheet indicated hydrocodone-acetaminophen 5-325 MG for severe pain (6-10). During a concurrent interview and record review on 5/18/2025 at 1:11 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 1's MRR for hydrocodone-acetaminophen 5-325 MG dated 4/29/2025 was reviewed. The MRR indicated pharmacist (PHARM) 1 recommended to the facility to ensure that the order on the pain assessment flow sheet (also known as the MAR-Medication administration record) matches with the reconciliation or count sheet (Paper documentation for narcotic and controlled substance medications). RNS 1 stated she reviewed Resident 1's MRR and left a message with the MD on 5/17/2025. RNS 1 stated they should have reviewed the pain assessments on the MAR and compared it to the reconciliation sheet . During an interview on 5/18/2025 at 2:52 p.m., with pharmacist (PHARM) 2, PHARM 2 stated when a medication order is changed or updated, the facility has to print and fax the new order to the pharmacy. PHARM 2 stated the pharmacy did not receive an updated order for Resident 1 which indicated hydrocodone-acetaminophen 5-325 MG for moderate pain (4-6). During an interview on 5/18/2025 at 7:27 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated if a medication order's parameters were changed, it should have been faxed to the pharmacy. LVN 2 stated it is the LVN's responsibility to ensure the medication blister pack has the correctly ordered dose and parameters. During an interview 5/18/2025 at 11:29 a.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated MRR recommendations should be followed up with or acted upon within 5 days. RNS 2 stated the pain medication order should have been clarified with the physician and addressed. RNS 2 stated Resident 1 was at risk for pain not being managed adequately. During an interview on 5/18/2025 at 8:08 p.m., with the Director of Nursing (DON), the DON stated it is important for medications to be administered within the ordered pain level parameters. The DON stated if there is a discrepancy, the nurse should have clarified the order with the physician. The DON stated if the blister pack does not match the order, it can potentially cause a medication error. The DON stated Resident 1 could be at risk for being under or over medicated. During a review of the facility's policies and Procedures (P&P), titled Medication Regimen Reviews, revised February 2025, the P&P indicated the MRR includes a review of the medical record to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities . irregularities may include incorrect medications, administration times, or dosage forms; or other medication errors, including those related to documentation. The P&P indicated upon receiving the MRR report from the pharmacist, the attending physician review and responds to the report .if the physician does not provide a timely or adequate response, or the consultant pharmacist identifies that no action has been taken, he/she contacts the medical director or the administrator. 3. During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including unspecified fracture (break in a bone) of unspecified lumbar vertebra (one of the bones that make up the spinal column in the lower back), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and spinal stenosis (space inside the backbone is too small putting pressure on the spinal cord). During a review of Resident 21's H&P, dated 4/20/2025, the H&P indicated Resident 21 has the capacity to understand and make decisions. During a review of Resident 21 MDS, dated [DATE], the MDS indicated Resident 21's cognitive skills were mildly impaired. The MDS indicated Resident 21 was dependent on chair/bed-to-chair transfer and toileting hygiene, required maximal assistance (provide more than half the effort) for bathing, dressing upper (above waist) and lower (waist below) body, required supervision on personal hygiene and oral hygiene, and required set up for eating. The MDS indicated Resident 21 utilizes a wheelchair and has bilateral (both sides) impairments on the upper (arms/shoulders) and lower (hips/legs) extremities. During a review of Resident 21's Order Summary Report (physician orders) dated 5/18/2025, the order summary indicated Lidoderm External Patch five (5) percent (%) (Lidocaine: medication that numbs specific area of the body by blocking pain signals to the brain): apply to low back topically (applied to the skin) in the morning for low back pain for 14 days. Apply in the morning and remove at bedtime for 14 days. The Lidoderm order was placed on 5/15/2025 and started on 5/16/2025. During a review of the Medication Administration Record (MAR: detailed record of medication administered to residents) dated 5/1/2025 - 5/31/2025, the MAR indicated Lidoderm External Patch 5% scheduled at 9:00a.m. was administered on 5/16/2025 and 5/17/2025. There is no indication that the Lidoderm External Patch 5% was removed at bedtime. During a review of the location of the administration report dated 5/1/2025 thru 5/31/2025, the administration report indicated the Lidoderm External Patch 5% was administered at the following times: 5/16/2025 administration time 10:21 a.m. and 5/17/2025 administration time 10:19 a.m. During an interview on 5/17/2025 at 9:32 a.m. with Resident 21, Resident 21 stated they had started putting the Lidocaine patch on 2 days ago and they have not removed the patch. During a concurrent observation and interview on 5/17/2025 at 9:46a.m. with Licensed Vocational Nurse 1 (LVN 1), the Lidocaine patch was observed on Resident 21's back with no date. LVN 1 stated he placed the Lidocaine patch on yesterday 5/16/2025. During an interview on 5/17/2025 at 1:54 p.m. with LVN 1, LVN 1 stated if medication is due at 9:00a.m., there is a 2-hour (hr.) time frame in which the medication can be administered 2 hrs before and after the medication due time. LVN 1 stated despite the 2-hr. time frame, the medication preferably should be given closer to 9:00 a.m. LVN 1 stated for Lidocaine patches, if the administration time is 9:00a.m., it should be administered closer to 9:00 a.m. and has to be on for 12 hrs and be off for 12 hrs as that is the usual order for Lidocaine patches. LVN 1 stated the Lidocaine patch observed on Resident 21 was supposed to be removed during the night shift per physician's orders. LVN 1 stated leaving the Lidocaine patch on longer than 12 hrs is not good for the skin as it can cause irritation. During a concurrent interview and record review on 5/18/2025 at 12:15p.m., with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated medication can be administered upto one hour before and upto one hour after the scheduled administration time. RNS 1 stated Lidocaine patches are on for 12 hrs and off for 12 hrs and indicated the Lidocaine patch would be administered at 9:00 a.m. and removed at 9:00p.m. RNS 1 stated leaving the Lidocaine patch on for longer than 12 hrs may irritate the skin and cause the skin to break down. RNS 1 stated the MAR dated 5/1/2025 - 5/31/2025 that indicated the Lidocaine patch to be applied to the low back topically in the morning and remove at bedtime should reflect the removal time of the Lidocaine patch and the way the MAR is documents needs to be clarified with the physician. During an interview on 5/18/2025 at 8:31p.m., with the DON, the DON stated medications are administered one hour before and after and Lidocaine patches are left on for 12 hrs and are off for 12 hrs. The DON stated the Lidocaine patch is removed after 12 hrs as that is the dosage for pharmacy. During a review of the facility's policies and Procedures (P&P), titled Administering Medications, revised dated April 2019, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

45028 Based on interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 38) who with diagnosis type 2 diabetes mellitus (abnormal blood sugar) and receiving Sitagliptin phosphate ( medication to lower blood sugar) received a weekly complete blood count ([CBC] a laboratory test which gives information about the production of all blood cells in the body) and comprehensive metabolic panel ([CMP] a group of blood tests which provide information about the body's metabolism [chemical reaction in the body's cells which change food into energy]) per physician order. 2. Ensure Resident 38's blood sugar was checked when Resident 38 had a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember), behavioral, or functional status which without immediate intervention, may result in complications or death) of increased confusion on 3/4/2024 , in and out of sleep throughout the night, moaning and calling for his family members on 3/7/2024 and slurred speech (slow speech that can be difficult to understand) on 3/10/2024. 3. Ensure interventions on Resident 38's care plan titled Diabetes Mellitus dated 1/31/2024, which indicated Licensed Vocational Nurses (LVN) and Registered Nurses (RN) will monitor Resident 38, for signs and symptoms of hyperglycemia (high blood sugar) such as increased thirst, dry skin, stupor (altered level of consciousness) , and coma, (a period of prolonged unconsciousness brought on by illness or injury) the results documented and the physician (medical doctor [MD])notified. These failures resulted in Resident 38 receiving a delay in diagnosis, care, and treatment. Resident 38 was transferred to a general acute care hospital (GACH) for evaluation and treatment for a critically high blood sugar of 728 milligrams per deciliter ([mg/dL-unit of measurement] blood sugar reference range was from 70-100 mg/dl), hypernatremia (high sodium [salt] level) and tachypnea (rapid breathing over 20 breaths per minute). On 3/10/2024, Resident 38 was admitted to the GACH's Intensive Care Unit ([ICU] a unit with specialized staff, equipment, and standards to handle severe, potentially life-threatening illnesses). Findings: A review of Resident 38's Admission Record (Face Sheet), indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, cancer of the kidney (abnormal growth of cells in your body tissue), and gastrostomy tube ([GT] soft flexible tube surgically placed into the stomach through the abdominal wall to provide nutrition and/or medication). A review of Resident 38's History and Physical (H&P), dated 3/14/2024, indicated Resident 38 did not have the capacity to understand and make decisions. A review of Resident 38's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/3/2024, indicated Resident 38 had moderate impairment in cognitive skills for daily decision-making. The MDS indicated Resident 38 had a diagnosis of diabetes mellitus (DM-abnormal blood sugar). A review of Resident 38's Care Plan titled Diabetes Mellitus, dated 1/31/2024, indicated Resident 38 will be free from any signs and symptoms of hyperglycemia (high blood sugar) and will have no complications related to diabetes. The Care Plan interventions indicated staff will monitor and document any signs and symptoms of hyperglycemia such as increased thirst, fatigue, dry skin, abdominal pain, stupor, and coma. A review of Resident 38's Physician Order Summary Report dated 1/30/2024, indicated Sitagliptin Phosphate 50 milligrams ([mg] unit of measurement) daily orally for diabetes, CBC, and CMP every Wednesday. During a concurrent interview and record review on 5/18/2024 at 2:20 p.m., with Registered Nurse (RN) 1, Resident 38's Situation, Background, Assessment, and Recommendation ([SBAR] a structured communication tool which enhances the communication between members of the healthcare team) dated 3/4/2024, was reviewed. The SBAR indicated Resident 38 had increased confusion on 3/4/2024 (unspecified time). The SBAR indicated Licensed Vocational Nurse (LVN) 2 notified Resident 38's Medical Doctor (MD) 1 on 3/4/2024 at 7:47 a.m. and received orders for CBC and CMP due to Resident 38's change of condition. RN 1 stated labs were not drawn until 3/6/2024, (2 days after the order was received), because it was not entered as a stat (immediately) order. RN 1 stated Resident 38's blood sugar level was not checked upon Resident 38's change of condition (increased confusion). A review of Resident 38's Nurse's Notes dated 3/4/2024 and timed at 6:10 p.m., indicated Resident 38 was disoriented. Nurse's Notes did not indicate Resident 38's blood sugar was checked, or that MD 1 was notified of Resident 38's status (disorientation). During a concurrent interview and record review on 5/18/2024 at 2:35 p.m., with RN 1 Resident 38's Weekly Summary Notes dated 3/5/2024 timed at 12:06 a.m., and 4:09 a.m., were reviewed. The Weekly Summary Notes indicated Resident 38 continued to moan and ask for past and present family members throughout the day and night hours. RN 1 stated Resident 38's blood sugar was not checked on 3/5/2024, and MD 1 was not notified of Resident 38's altered mental status. A review of Resident 38's Nurse's Notes dated 3/6/2024 timed at 4:40 a.m., indicated Resident 38 was in and out of sleep throughout the night, moaning and calling for his family members. The notes did not indicate Resident 38's blood sugar was checked, or MD 1 notified of Resident 38's status. During an interview on 5/18/2024 at 2:42 p.m., with LVN 2, LVN 2 stated when Resident 38 was found with slurred speech on 3/10/2024, he (LVN 2) did not check Resident 38's blood sugar. LVN 2 stated it was possible Resident 2 had hyperglycemia and dehydration because of Resident 38's altered mental status, increased confusion, and dry/cracked lips. LVN 2 stated he contacted the on-call MD 2 by phone on 3/10/2024 at an unknown time, but MD 2 did not respond. LVN 2 stated he should have notified the Director of Nursing (DON) and recommended Resident 38 be transferred to a GACH for further evaluation and treatment. During a concurrent interview and record review on 5/18/2024 at 5:35 p.m., with RN 1, Resident 38's SBAR and the Medication Administration Record (MAR) was reviewed. RN 1 stated prior to 3/4/2024, Resident 38 could verbalize his needs and communicate with staff, so the signs and symptom on 3/4/2024 through 3/7/2024 were a significant change in Resident 38's mental status. RN 1 stated prior to 3/4/2024 Resident 38 was able to verbalize if he was in pain to staff. RN 1 stated Resident 38's blood sugar was not checked during the change of condition (COC) on 3/4/2024 through 3/7/2024. RN 1 stated there was no documentation on Resident 38's progress notes or in the MAR to indicate the resident's blood sugar was checked. RN 1 stated license nurses did not check the resident's blood sugar, not even once. During a concurrent interview and record review on 5/18/2024 a 6:00 p.m., with RN 1, Resident 38's 72-hour Charting dated 3/6/2024 and timed at 2:47 p.m., was reviewed. The 72-hour Charting indicated Resident 38 was disoriented to situations. RN 1 stated Resident 38's blood sugar was not checked, and MD 1 was not notified of Resident 38's altered mental status. A review of Resident 38's Lab Results Report dated 3/6/2024 and reported via telephone to LVN 3 at 9:57 p.m., indicated Resident 38's glucose level was 217 mg/dL, with critical (such a difference from normal, as to be life-threatening unless something is done promptly and for which some corrective action could be taken) laboratory results as follows: 1. Blood Urea Nitrogen ([BUN] a blood test which measures the amount of urea nitrogen [waste product when the liver breaks down protein] in the blood which if elevated can be indicative of poor kidney function or damage) level of 81 mg/dL. The BUN reference range is between 7-25 milligrams per deciliter (mg/dL-measures fluid volume). 2. Sodium level to 160 milliequivalents per liter (mEq/L measures fluid volume). The sodium reference range is between 136-145 mEq/L. During a concurrent interview and record review on 5/18/2024 at 6:25 p.m., with RN 1 Resident 38's Nurse's Notes dated 3/6/2024 timed at 10:59 p.m., was reviewed. The Nurse's Notes indicated Resident 38 continued to have increased confusion and his lab results were faxed to MD 1 on 3/6/2024 at 10:59 p.m. RN 1 stated there was no documented evidence that MD 1 responded to Resident 38's laboratory results or Licensed Nurses followed up with MD 1 (who was also the Medical Director). A review of Resident 38's Nurse's Notes dated 3/7/2024 and timed at 2:55 p.m., indicated Resident 38 continued to have episodes of confusion. The Nurse's Notes did not indicate Resident 38's blood sugar was checked, and that MD 1 was notified of Resident 38's status (change in mental status) or critical lab results from 3/6/2024. During a concurrent interview and record review on 5/18/2024 at 6:46 p.m., with RN 1 Resident 38's Nurse's Notes dated 3/9/2024 timed at 3:55 p.m., was reviewed. The Nurse's Progress Notes indicated RN 1 notified MD 2 of Resident 38's BMP results. RN 1 stated that she did not inform MD 2 about Resident 38's diagnosis of diabetes. RN 1 stated she informed MD 2 only of the BUN results because RN 1 was concerned about signs and symptoms of dehydration for Resident 38. RN 1 stated other critical laboratory result (Sodium 161 mEq/L) was not relayed to MD 2 and clinical symptoms including increased confusion on 3/4/2024, in and out of sleep throughout the night moaning and calling for his family members on 3/7/2024. A review of Resident 38's COC dated 3/10/2024, timed at 11:56 a.m., indicated Resident 38's Family Member (FM) 1 informed LVN 4 that Resident 38 was not responsive as usual. A review of Resident 38's SBAR Communication Form dated 3/10/2024, indicated LVN 4 paged MD 2 at 12 p.m., to notify the MD of Resident 38's chapped lips, tear to his upper left lip, and decreased communication (not responding). There was no documentation to indicate Resident 38's blood sugar level was checked, and if MD 2 responded to the page. A review of Resident 38's Nurse's Notes dated 3/10/2024 timed at 3:11 p.m., indicated Resident 38 was noted with a slurred speech. The Nurse's Notes indicated MD 2 was called (time not indicated) and awaiting his response. There was no documentation to indicate Resident 38's blood sugar level was checked. A review of Resident 38's COC dated 3/10/2024 timed at 6:43 p.m., indicated Resident 38 was still noted with increased weakness and was less verbal. The COC indicated Resident 38's Family Member (FM) 1 requested Resident 38 to be transferred to a GACH for evaluation and treatment. The COC also indicated Resident 38 would be transferred to the GACH via a regular ambulance transport. A review of Resident 38's GACH H&P dated 3/10/2024 timed at 7:43 p.m., indicated Resident 38 presented to the Emergency Department (ED) with a respiratory rate ranging between 25 and 37 breaths per minute and increased confusion. The H&P indicated FM 1 stated Resident 38's altered mental status continued to worsen and the resident had labored breathing. The H&P indicated the following laboratory results: 1. Glucose level of 728 mg/dL. A normal blood glucose level is less than 149 mg/dL. 2. Sodium level of 146 millimoles per liter ([mmol/L] measures fluid volume. The normal range for blood sodium levels is between 134-145 mmol/L. 3. Potassium (type of electrolyte [regulate nerve and muscle function]) level of 6.4 mmol/L. The normal range for blood potassium levels is between 3.5-5.2 mmol/L. High levels can cause irregular heartbeat. 4. Chloride (type of electrolyte) level of 119 mmol/L. The normal range for blood chloride levels is between 101-111 mmol/L. High levels maybe a sign of dehydration. 5. Blood Urea Nitrogen level of 132 mg/dL. The normal range for BUN levels is between 8-20 mg/dL. 6. Creatinine (a blood test used to check how well the kidneys are) level of 3.39 mg/dL. The normal range for blood creatinine levels is between 0.44-1.03 mg/dL.) If elevated can be indicative of dehydration, kidney damage or kidney failure) The H&P dated 3/10/2024 indicated Resident 38 presented to the ED with high serum osmolality (less water in the blood), a blood pH (a measure of how acidic or basic a substance or solution is) of greater than 7.3. The GACH H&P indicated Resident 38 required subcutaneous (under the skin) insulin (medication to lower blood sugar) administration and calcium gluconate (medication used to lower the level of potassium in the blood) in the ED. The H&P indicated Resident 38 was later admitted to the ICU on 3/10/2024. During an interview on 5/18/2024 at 12:42 p.m., with LVN 2, LVN 2 stated on 3/10/2024, when Resident 38 was observed to have a slurred speech, altered mental status, increased confusion, and dry/cracked lips, he (LVN 2) did not check the resident's blood sugar. LVN 2 stated Resident 2 might have had hyperglycemia and dehydration. LVN 2 stated he paged MD 2, but he did not get a response. LVN 2 stated he notified the DON on 3/10/2024 but the DON did not give any recommendation for Resident 38 to be transferred to the GACH. During an interview on 5/19/2024 at 12:21 p.m., with LVN 4, LVN 4 stated if a resident had or continued to have an altered level of consciousness, a COC had to be completed to include a blood sugar check, especially if the resident was diagnosed with diabetes. LVN 4 stated when Resident 38 continued to have an altered mental status, she should have been transferred to the GACH immediately. LVN 4 stated she forgot to check Resident 38's blood sugar when Resident 38 had a COC on 3/10/2024. LVN 4 stated she did not notify MD 2, who was the on-call MD that weekend. LVN 4 stated on 3/10/2024 she (LVN 4) paged MD 2 but did not respond. LVN 4 stated she should have notified the DON when she did not get a response from MD 2. During an interview on 5/19/2024 at 1:30 p.m., with the DON, the DON stated upon admission of residents in the facility she thoroughly checked the admission orders and clarified medications that required monitoring with the MD the day after admission. The DON stated she continued to monitor new residents until a care planning and Interdisciplinary Team (IDT- different health care disciplines to help receive the care they need) met to make sure nothing was missed with the plan of care. The DON stated it was the responsibility of all licensed nurses to ensure laboratory tests (labs) ordered by the physician were carried out in a timely manner. The DON stated she was responsible to ensure ordered labs (CBC and CMP) were done weekly but she forgot to ensure Resident 38's labs were done, and the MD notified of the resident's four missed CBC and CMP tests in the month of February 2024. The DON stated it was the standard of practice (the usual thing done in a particular situation) to monitor (check blood sugar) a resident's blood glucose levels if the resident was a diabetic and had a COC of altered mental status. The DON stated Resident 38's hospitalization could have been prevented if the resident's weekly CBC and CMP was performed as ordered on 1/31/2024 and Resident 38's MDs notified of any abnormal results. The DON stated unknown and uncontrolled blood sugar levels placed Resident 38 at risk for kidney failure, comatose (a period of prolonged unconsciousness brought on by illness or injury), impaired cognition, and death. During a concurrent interview and record review on 5/19/2024 at 1:30 p.m., with the DON, Resident 38's Clinical Record was reviewed. The DON stated there were no CBC and CMP results for the month of February 2024. A review of Resident 38's Nutritional Narrative Note dated 3/7/2024 and timed at 1:02 p.m., indicated MD 1 had not placed an order for Resident 38's critical labs dated 3/6/2024. The note did not indicate if the Registered Dietician (RD) notified MD 1 of the critical labs. During a concurrent interview and record review on 5/20/2024 at 8:28 a.m., with the RD, Resident 38's Admission Nutritional Risk assessment dated [DATE], was reviewed. The RD stated she identified Resident 38 was receiving Sitagliptin but did not check if the licensed staff were monitoring Resident 38's blood sugar. The RD stated Resident 38's blood sugar should have been checked at least daily to monitor if it was stable or not. The RD stated she did not recommend checking Resident 38's blood sugar since his admission on 1/30/2024. During a concurrent interview and record review on 5/20/2024 at 11:17 a.m., with MD 1 Resident 38's Lab Results Report dated 3/6/2024, and 3/9/2024, and of Resident 38's Clinical Chart were reviewed. MD 1 stated he ordered weekly CBC and CMP for Resident 38 on 1/30/2024 to help determine Resident 38's fluctuating labs and to monitor the resident's blood glucose levels. MD 1 stated if there was an increase in the blood glucose levels results on the weekly labs, MD 1 could have determined how often Resident 38's blood sugar should have been monitored, whether on a daily, twice daily, or weekly basis. MD 1 stated he was not aware weekly CBC and CMP was not done for Resident 38 as ordered on 1/30/2024. MD 1 stated had the weekly labs been done as ordered, he could have detected a change or abnormal lab results which would correlate with Resident 38's change of condition on 3/4/2024-3/10/2024. MD 1 stated on 3/9/2024, Resident 38 should have been transferred to the GACH for further evaluation immediately after the resident continued to have confusion, altered level of consciousness and critical high lab values that were not improving after intravenous (IV-through the vein) hydration on 3/6/2024. A review of the facility's policies and procedures (P&P) titled, Lab and Diagnostic Test Results - Clinical Protocol, revised 11/2018, The staff will process test requisitions and arrange for tests. The P&P indicated Direct a voice communication with the physician was the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status was unstable. The P&P indicated a physician should respond within one hour regarding a lab test result requiring immediate notification. The P&P indicated if the attending or covering physician did not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. A review of the facility's P&P titled, Nursing Care of the Older Adult with Diabetes Mellitus, revised 11/2020, indicated symptoms associated with diabetes included hyperglycemia. The P&P indicated older adults with diabetes were at higher risk for functional impairment, cognitive decline, muscle loss than other older adults. The P&P indicated for a resident on an oral medication (s) who was well controlled, his/her blood glucose levels should be monitored at least twice weekly (or more frequently if there was a change in drugs or drug dosages). The P&P indicated for the resident receiving oral medication(s) who was poorly controlled, blood glucose levels should be monitored two to four times daily, as needed. A review of the facility's P&P titled Change in a Resident's Condition or Status, revised 2/2021, indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the SBAR Communication Form.

Based on observation, interview and record review, the facility failed to ensure the resident, who was awake and alert, continent (ability to control) of bowel and bladder and had a high risk for a pressure ulcer (an injury that breaks down the skin and underlying tissue) development, received care and services to maintain bowel and bladder continence for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure the nursing staff assisted Resident 1 timely to go to the bathroom to maintain the resident's continence of bowel/bladder. 2. Ensure Resident 1 had access to the hallway bathroom or a bedside commode when she needed to urinate and/or have a bowel movement. 3. Implement Resident 1's plan of care and the Interdisciplinary Team ([IDT] a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the resident) assessment for the staff to assist the resident with toileting to ensure the resident's needs are met. 4. Ensure Resident 1, who was continent of both bowel and bladder, dignity was maintained by not putting an adult brief (adult diapers with tabs designed to provide full incontinence protection) on the resident for staff's convenience due to shortage of staff (crossed referenced to F550). These failures resulted in Resident 1, who was continent of both bowel and bladder, being encouraged to use a diaper instead of using a bedside commode or being taken to the hallway bathroom outside the resident room to maintain the resident's continence. Resident 1 expressed feelings of lack of dignity and being embarrassed of using a diaper. Findings: During an initial tour of the facility on 2/1/2023 at 5:20 a.m., there was two certified nurse assistants (CNAs 1 and 2) and one licensed vocational nurse (LVN 1) on duty to care for 43 residents. During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including neuropathy with ataxia (lose muscle control in the arms and legs), Type 2 diabetes mellitus (disease that occurs when blood glucose [sugar in the blood] was too high) and muscle weakness. During a review of Resident 1's history and physical (H/P), dated 10/20/2022, the H/P indicated Resident 1 had the ability to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 1/18/2023, the MDS indicated Resident 1 could always understand and be understood by others. According to the MDS, Resident 1 was continent of bowel and bladder, required an extensive assistance (resident involved in activity, staff provide weight-bearing [body weight] support) with at least two-persons physical assistance during toilet use and transfers (how resident moves between surfaces such as bed, chair, wheelchair, standing position) between surfaces. The MDS indicated Resident 1 was at risk for developing pressure ulcers/injuries. During a review of Resident 1's Care Plan (C/P), initiated on 1/18/2023, the C/P indicated Resident 1 was aware she could urinate and have a bowel movement in the diaper. The C/P goals indicated Resident 1 would remain continent of bowel and bladder through the next review date and at all times [sic]. The staff's interventions included to assist the resident with toileting needs. During a review of Resident 1's IDT conference notes, dated 1/31/2023, the IDT notes indicated Resident 1 was at risk for skin breakdown due to resident needing extensive assist with bed mobility and transferring. The IDT notes indicated staff would assist the resident with bowel and bladder every two hours while awake. During an interview on 2/1/2023 at 5:45 a.m. with CNA 1, CNA 1 stated she, CNA 2 and one LVN were the only staff working on the night shift from 11 p.m. until 7 a.m. CNA 1 stated it was difficult to meet the toileting needs of the residents because many residents required a two-persons physical assistance and there were not enough staff at night to accommodate the residents' toileting needs. CNA 1 stated Resident 1 can tell when she needs to urinate or have a bowel movement. CNA 1 stated the staff at night was not always able to assist Resident 1 to the bathroom in time as she needs a two-persons physical assistance in getting her up into and from a wheelchair. CNA 1 stated Resident 1 agreed to wear a diaper to avoid sitting in a mess although Resident 1 has the capability of going and sitting on a toilet. During a review of the facility's nursing staffing and sign-in sheets (staffing sheets) dated 1/14/2023, 1/17/2023, 1/18/2023, 1/22/2023, 1/23/2023, 1/26/2023 and 1/31/2023, the staffing sheets indicated during the 11 p.m.-7 a.m. shift there were two CNAs and one LVN on duty. During an observation on 2/1/2023 at 9:30 a.m., while in Resident 1's room, Resident 1 was observed sitting up in bed eating breakfast. A wheelchair was at the resident's bedside and there was no bathroom observed in the resident's room. During an interview on 2/1/2023 at 9:35 a.m. with Resident 1, Resident 1 stated she does not have a bathroom in her room but there was a bathroom outside of her room in the hallway. Resident 1 stated when staff can assist her, she prefers to use the bathroom and not to wear a diaper. Resident 1 stated she does not need to wear a diaper, but the staff puts a diaper on her, especially at night because the staff cannot attend to her needs on time. Resident 1 stated she needs two people to help her into the wheelchair to get to the bathroom. Resident 1 stated, I feel embarrassed to wear a diaper and it was not dignified but I guess it is better than sitting in a mess. During an interview on 2/1/2023 at 2:20 p.m. with the MDS Coordinator, the MDS coordinator stated Resident 1 was continent of bowel and bladder and should be accommodated to get up to use the bathroom or use a bedside commode (a portable toilet). The MDS coordinator stated by not accommodating the resident's needs Resident 1 was at risk for urinary tract infections ([UTI] an infection in any part of the urinary system), skin irritation, loosing continence of bowel and bladder and embarrassment. During an interview on 2/1/2023 at 4 p.m. with the Director of Nursing (DON), the DON stated the facility must accommodate the toileting needs of the residents and provide staff to assist residents to the bathroom. The DON stated by not assisting the resident in time to get to the bathroom, the resident will continue to urinate in her diaper and be at risk for UTIs and skin breakdown and can cause embarrassment for a resident, which does not enhance the resident's dignity. The DON stated the 11 p.m.-7 a.m. shift was short-staffed, the DON stated they have been trying to get staff to come in and work at night and offer overtime, but it has still been a challenge. During an interview with Resident 1 on 2/17/2023 at 8:40 a.m., Resident 1 stated, I have not worn a diaper since I was a baby, and it makes me feel like a baby. Resident 1 stated she was embarrassed, frustrated, and angry that she had to be wet in a diaper. Resident 1 stated she urinates in the diaper and have had one bowel movement (BM) in the diaper since she has been admitted to the facility (10/2022). Resident 1 stated sometimes when she calls for help to go to the bathroom, the staff brings a bedpan (a receptacle used by a bedridden resident as a toilet) which was very uncomfortable on her buttocks. Resident 1 stated she would rather use the bathroom rather than urinate or have a BM in a diaper because sitting on a toilet feels more natural. During a review of the facility's policy and procedure (P/P) dated 8/2022 and titled, Urinary Continence and Incontinence-Assessment and Management, the P/P indicated as part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence. The P/P indicated relevant information related to urinary continence included functional and or cognitive or limitations that could affect continence, including impaired mobility , decreased upper and lower extremity muscle strength, additional information such as type of frequency of physical assistance necessary for the resident to access the toilet or commode and environmental factors that may restrict or facilitate resident's access to the toilet , including distance to the toilet or commode. The P/P indicated the nursing staff and physician will identify risk factors for becoming incontinent including environmental factors (immobility and lack of toilet).

Based on interview and record review, the facility failed to develop a resident-centered comprehensive care plan with documented staff interventions to prevent a fall incident as per its policy and procedure (P/P) for one of three sampled residents (Resident 1). Resident 1, who was assessed as high risk for falls, was admitted to the facility for rehabilitation status [REDACTED]. This deficient practice resulted in Resident 1 falling and sustaining a right shoulder fracture (broken bone) and required a transfer to a general acute care hospital (GACH). Findings: During a review of Resident 1's Admission Face Sheet, dated 9/11/19, indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. During a review of Resident 1's Fall Risk Observation/Assessment, dated 9/11/19, the Assessment indicated Resident 1 was a high risk for falls. During a review of Resident 1's Admission/Readmission Assessment, dated 9/11/19, the assessment indicated Resident 1 was admitted S/P fall with fractures and kyphoplasty. Resident 1's assessment was incomplete and did not include documented staff interventions for Resident 1's ambulation, transferring, and activities of daily living ((ADLs) everyday activities, such grooming, eating and toileting etc.). During a review of Resident 1's Baseline Care Plan Person-Centered Care, dated 9/11/19, the care plan indicated Resident 1 was a fall risk due to a history of falls. The goal for Resident 1 was to manage the resident's pain's S/P laminectomy surgery (a surgical removal of the bony arch of the spine which covers the nerve). The plan of care did not have any documented staff interventions to prevent Resident 1 from further falls. During a review of Resident 1's untimed Nursing Progress Note, dated 9/11/19 indicated Resident 1 used a wheelchair for mobility. During a review of Resident 1's History and Physical (H/P), dated 9/12/19, the H/P indicated Resident 1 was admitted to the facility following a fall with fractures with surgery. The H/P physical examination indicated Resident 1 was elderly and frail (weak), had resting tremors (shakiness) with generalized weakness. The H/P indicated Resident 1's [DIAGNOSES REDACTED]. During a review of Resident 1's Physical Therapy ((PT) treatment used to restore normal physical functioning) Progress Reports, dated from 9/12/19 to 9/18/19, the PT progress notes indicated Resident 1 was a fall risk and had spinal precautions (efforts to prevent movement of the spine in those with a risk of a spine injury). The PT reports indicated Resident 1 was receiving therapy due to a recent fall and hospitalization status [REDACTED]. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/18/19, the MDS indicated Resident 1 had the ability to understand others. The MDS indicated Resident 1 required an extensive assistance of a one-person physical assist with transferring between surfaces. The MDS indicated Resident 1's moving from a seated to standing position, walking, and turning around was not steady and could only stabilize with assistance. The MDS indicated Resident 1 had a fall within the last month and a fall within the last two to six months prior to her admission to the facility. According to the MDS, Resident 1 had a fracture related to her fall in the last six months and was receiving opioid medications (narcotic medication used to treat pain) seven days a week. During a review of Resident 1's Physician's Progress Record, dated 9/19/19, the physician progress record indicated Resident 1 had mild confusion. The record indicated Resident 1 had a fracture and generalized weakness. During a review of Resident 1's Nursing Progress Note (NPN), dated 9/27/19 and timed at 10:15 a.m., the NPN indicated Resident 1 had a fall and was unable to move her right arm and Resident 1 complained of pain. During a review of Resident 1's NPN, dated 9/27/19, the NPN indicated Resident 1's x-ray indicated there was a right humeral surgical neck (shoulder bone) fracture. During a review of Resident 1's physician's orders [REDACTED]. During a review of an NPN, dated 9/27/19 and timed at 6:50 p.m., the NPN indicated Resident 1 was transferred to the GACH for further evaluation of her right arm fracture. During a review of Resident 1's GACH Emergency Department (ED) note, dated 9/27/19, the ED note indicated Resident 1 complained of pain on the right upper arm. The ED note indicated Resident 1 reported she slipped and fell out of her wheelchair and hit her right shoulder during the fall. The ED note indicated Resident 1's x-ray revealed a right humeral surgical neck fracture and Resident 1 was discharged with a right shoulder immobilizer (medical device used to immobilize for healing). During a review of Resident 1's Licensed Nurse titled, Following a Fall Report, dated 9/30/19, the report indicated Resident 1 had a fractured arm, [MEDICAL CONDITION], and was forgetful at times. The report indicated Resident 1's fall was attributed to the following: wheelchair brakes not being locked; history of one to two falls within the last six months; and an unsteady gait. As a result of the fall with a fracture, Resident 1 had a reduced or loss of use in arms and legs with a decline in function. During an interview, on 10/10/19 at 4:05 p.m., Resident 1 stated she had a fall before she was admitted to the facility and had broken several bones. Resident 1 stated she had a fall in the facility and broke her arm because the wheelchair's brakes were not locked. During an interview, on 10/10/19 at 4:35 p.m., Certified Nurse Assistant 1 (CNA 1) stated Resident 1 can no longer participate in her care as she did prior to the fall incident on 9/27/19. During an interview, on 1/23/2020 at 7:45 a.m., Housekeeper 1 stated on 9/27/19, she entered Resident 1's room to clean and she saw Resident 1 sitting in the wheelchair. Housekeeping 1 stated she walked outside of the room to grab her cleaning supplies and heard a noise and saw Resident 1 sitting on the floor. During an interview, on 1/23/2020 at 8:15 a.m., CNA 2 stated the brakes on Resident 1's wheelchair had to be locked to prevent the resident from having a fall. CNA 2 stated she locked Resident 1's wheelchair ten minutes prior to the fall. CNA 2 stated on 9/27/19, when she arrived to Resident 1's room the resident was on the floor. CNA 2 stated she thought Resident 1 fell trying to go back to bed on her own. CNA 2 stated she saw Resident 1 on the floor with her legs in front of her body and her head towards the door. CNA 2 stated Resident 1 required a one-person assistance with all her ADLs before she fell and now required a two-person physical assist with her ADLs because she had an arm immobilizer. During an interview and a concurrent review, on 1/23/2020 at 8:28 a.m., Licensed Vocational Nurse 1 (LVN 1) of Resident 1's care plans, LVN 1 stated residents were assessed for fall risk upon admission and interventions were tailored to each resident's need. LVN 1 stated the facility developed a care plan upon admission for Resident 1 as being at risk for fall because residents who had a history of [REDACTED]. LVN 1 stated she was called to assess Resident 1 after she fell . LVN 1 stated when she entered Resident 1's room, Resident 1 was sitting on the floor holding her right arm and complaining of pain. LVN 1 stated Resident 1 told her she fell when she tried to move, and the wheelchair moved with her because the wheels were not locked. LVN 1 stated she noticed something was wrong with Resident 1's right arm. LVN 1 stated Resident 1's x-ray showed she had a [MEDICAL CONDITION] arm and was transferred to a GACH. LVN 1 stated Resident 1 returned from the GACH with orders for an arm immobilizer with limited right arm movement. LVN 1 reviewed the Fall Risk Observation/Assessment, dated 9/11/19 and stated Resident 1 had a score of 22 on the fall risk assessment which indicated the resident was a high risk for falls. During an interview and concurrent review, on 1/23/2020 at 9:50 a.m., of Resident 1's care plans with LVN 2 she stated Resident 1 should have had a plan of care with staff interventions to prevent falls. LVN 2 was unable to find any documentation of staff's fall interventions for Resident 1 prior to her fall. LVN 2 stated the comprehensive care plan was developed within 14 to 21 days from admission. LVN 2 reviewed Resident 1's care plan, dated 9/27/19 that indicated the resident had a fall. The care plan interventions indicated to continue the interventions on the at-risk care plan, but LVN 2 stated she was unable to find a At Risk Fall care plan with staff interventions for Resident 1. During an interview and a concurrent review on 1/23/2020 at 10:22 a.m., of Resident 1's care plans LVN 1 stated Resident 1's baseline care plan, dated 9/11/19, identified Resident 1 was at risk for falls with S/P laminectomy surgery. LVN 1 stated she was unable to find any documentation of staff interventions to prevent Resident 1 from falling. LVN 1 stated it was important to develop staff interventions for Resident 1 to prevent her from falling. During a subsequent interview and a review of Resident 1's care plans on 1/23/2020 at 10:50 a.m., the Director of Nurses (DON) stated Resident 1 was at risk for falls but there was no care plan with staff's interventions documented to prevent a fall prior to 9/27/19. During a review of the facility's P/P, revised on 12/2016 and titled, Care Plan Comprehensive Person-Centered, the P/P indicated a comprehensive, person-centered care plan would include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident, would be developed and implemented as a comprehensive person-centered care plan for each resident. The care plan process would include an assessment of the residents' strengths and needs. The comprehensive, person-centered care plan would include measurable objectives and timeframe's; describe services that were to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well being; incorporate identified problem area; incorporate risk factors associated with identified problems, aid in preventing or reducing decline in the resident's functional status and/or functional levels. During a review of the facility's P/P, revised in 12/2016 and titled, Care Plans-Baseline the P/P indicated a baseline plan of care would meet the residents' immediate needs. The policy interpretation and implementation indicated the care plan would assure that the resident's immediate care needs were met and maintained. The IDT team would review the health care practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs. The comprehensive, person-centered care plan was developed within seven days of the completion of the required comprehensive assessment (MDS).

Based on observation, interview, and record review, the facility failed to follow the resident's plan of care and its policy and procedures related to resident transfers for one of two sampled residents (Resident 1). Resident 1, who had a history of [REDACTED]. As a result of the staff not following the resident's plan of care and the facility's policy, Resident 1 sustained a fracture (broken bone) to the right leg/knee. Findings: On September 14, 2017 at 9:17 a.m., during an observation, Resident 1 was awake, lying in bed, with a green-brown discoloration to the left leg. A leg brace was observed on the resident's right leg. A review of Resident 1's Admission Face Sheet indicated the resident was initially admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. has a sideways curve), [DIAGNOSES REDACTED] (a hormonal condition that involves many areas of the body and causes symptoms such as thinning of the skin, weakness, bruising and thin weak bones). A review of Resident 1's Minimum Data Sheet (MDS), a standardized assessment and care screening tool, dated June 16, 2017, indicated Resident 1's cognition (thought process) was intact. The MDS indicated Resident 1 used a wheelchair, required a two-person physical assist for all transfers and was totally dependent on staff for locomotion inside and outside of the facility. A review of Resident 1's Care Plan, dated June 14, 2017, indicated the resident had a self-care performance deficit and required total assistance of a two-person physical assist when transferring. A review of Resident 1's Care Plan, dated August 14, 2017, indicated the resident had multiple rib fractures and was at risk for repeated fractures. The staff's interventions included handling the resident gently when moving or positioning and maintaining the resident's body alignment. A review of Resident 1's Physical Therapy ((PT) healthcare specialty that includes the evaluation, assessment, and treatment of [REDACTED]. A review of Resident 1's PT Note, dated August 22, 2017, indicated PT 1 accompanied the resident to an appointment. The note indicated the resident was totally dependent on staff and required a two-person assist with transferring from low to high surfaces. A review of Resident 1's Nurse Progress Note, dated August 23, 2017, and timed 8:34 p.m., indicated the resident was observed to have swelling and tenderness to the right knee. A review of Resident 1's Nurse Progress Note, dated August 30, 2017, and timed 6:40 p.m., indicated the resident's family member (FM 1) was upset and wanted the resident to be seen by the orthopedic doctor (a doctor specializing in bones and joints) sooner than the appointment that was scheduled for September 15, 2017. FM 1 wanted the resident to be transferred to a hospital's emergency room for evaluation of the resident's continued knee swelling. A review of Resident 1's Nurse Progress Notes, dated August 30, 2017, and timed 8:15 p.m., indicated the resident was transferred via ambulance to a General Acute Care Hospital (GACH) for further evaluation of the resident's right knee swelling and redness. A review of Resident 1's PT note, dated August 31, 2017, indicated the resident's progress was slow during the week of August 22, 2017 through August 28, 2017, due to the resident reporting increased right knee discomfort and [MEDICAL CONDITION]. A review of the GACH's Diagnostic Radiology Report, dated August 30, 2017, and timed 9:58 p.m., indicated the resident had a right knee X-ray (a test that produces images of the structures in the body, such as bone). The results of the X-ray indicated the resident had a non-displaced intra-articular [MEDICAL CONDITION] tibial plateau (a break in the upper part of the shinbone that involves the knee joint). A review of Resident 1's Nurse Progress Notes, dated August 31, 2017, and timed 7:52 a.m., indicated the resident was transferred from the GACH back to the facility at 2:20 a.m. on August 31, 2017. The resident was diagnosed with [REDACTED]. A review of Resident 1's Nurse Progress Note, dated August 31, 2017 and timed 10:01 a.m., indicated the facility received a call from the GACH and was informed that the resident had a right tibial plateau fracture and needed to be sent back to the GACH for a splint (a strip of rigid material used for supporting and immobilizing a broken bone) placement. A review of the facility's investigation report, dated August 31, 2017, and timed 11:58 a.m., indicated PT 1 reported that he blocked Resident 1's knee with his knee for leverage during transferring. The report indicated that the repetitive transfers from wheel chair to the van and to the bone scan table may have caused micro trauma to the resident's knee. On September 14, 2017 at 10 a.m., during an interview, PT 1 stated that he accompanied the resident to an appointment for a bone scan (a test used to diagnose and track several types of bone disease) on August 22, 2017 to assist the resident with transferring to and from the wheelchair. PT 1 stated that while transferring the resident, he blocked Resident 1's knee by placing his knee against the resident's right knee, and pivoted the resident from the wheelchair to the car. PT 1 stated that on August 22, 2017 this technique was used to transfer the resident about four to five times over the span of two hours. PT 1 stated that he always used the knee block technique to transfer the resident. At 10:37 a.m., on September 14, 2017, during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 always required a two- person assist for transferring with a Hoyer lift (mechanical lifting device). On September 14, 2017 at 3 p.m., during an interview, the Director of Nursing (DON) stated they work with PT to determine the type of precautions and transfers that a resident should have. Initially, Resident 1 was a two-person manual assist and after the resident sustained [REDACTED]. The DON stated that when transferring a resident, physical therapy might use other modalities such as manually transferring the resident. A review of a facsimile received from the DON on September 15, 2017, indicated the facility did not have a policy and procedure for the type of transfers used by PT that was not part of Resident 1's plan of care. On September 26, 2017 at 1:30 p.m., during a telephone interview, the physician (MD 1) stated that Resident 1 was very fragile and that the best way to transfer the resident would be using a Hoyer lift. A review of the facility's policy and procedure titled, Safe Lifting, Transfer, and Movement of Residents dated March 16, 2015, indicated nursing and physical therapy staff would assess the resident's needs for transfer assistance on an ongoing basis and staff would document the resident's needs in the care plan. The policy indicated mechanical lifting devices would be used for heavy lifting, including the lifting and transferring residents. A review of the facility's undated policy and procedure titled, Care Plans-Comprehensive, indicated the resident's care plan was based on a comprehensive assessment and was designed to assist in preventing declines in the resident's functional status and/or functional levels.