Every finding on record at Bell Convalescent Hospital

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan with interventions addressing a resident's identified risk for falls for one of one sampled resident (Resident 1).This failure had the potential to place Resident 1 at an increased risk for falls, injury, and failure to receive necessary care and services.FindingsDuring a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included dementia (a progressive state of decline in mental abilities), history of falling, and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left hand.During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/1/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (process of thinking) was severely impaired. The MDS indicated Resident 1 was dependent on staff for eating, toileting, bathing, and putting on/taking off footwear During a review of Resident 1's History and Physical (H&P), dated 4/4/2026, the H&P indicated Resident 1 did not have the capacity to understand or make decisions. During a review of Resident 1's Fall Risk Annual Evaluation, dated 3/3/2026, the Fall Risk Evaluation indicated, Resident 1 was at risk for falls.During a concurrent interview and record review on 6/16/2026 at 3:35 p.m. with Registered Nurse (RN) 2, Resident 1's Fall Risk Evaluation, dated 3/2/2026 was reviewed. The Fall Risk Evaluation did not indicate a care plan was developed addressing Resident 1's risk for falls. RN 2 stated Resident 1 was admitted with a history of falls and was identified as being at risk for falls and a care plan should be comprehensive. RN 2 stated failure to develop an at risk for falls care plan placed Resident 1 at risk for recurrent falls, fractures (broken bones), and loss of independence (a person no longer able to do things on their own and needs help from others). During an interview on 6/16/2026 at 4:35 p.m. with the Director of Nursing (DON), the DON stated care plans should be comprehensive and specific to resident needs. The DON stated residents who completed an annual fall risk evaluation should have a comprehensive care plan that addresses fall risk scoring to meet their medical needs. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Plan of Care, dated 12/2016, the P&P indicated, a comprehensive plan of care developed includes goals, measurable objectives and timetable to meet physical, psychosocial, and functional needs is developed and implemented for each resident. During a review of the facility's P&P titled, Fall Prevention Program, dated 12/2016, the P&P indicated, all residents will be assessed following incident of fall, if resident is at risk for falls, it will be added on their care plan.

Based on observation, interview, and record review, the facility failed to ensure the ice machine was cleaned and sanitized properly. This deficient practice had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 91 of 91 medically compromised residents who received food from the kitchen.Findings: During a concurrent observation and interview on 1/20/2026 at 11:15 a.m., with the Dietary Services Supervisor (DSS), observed a combination of dark black/grey dots along with a pink colored slime on a paper towel that was used to wipe underneath where the ice machine dispenses ice cubes. The DSS stated, I don't know what that is. It's the first time I'm seeing it. The DSS stated that she was not aware of the deep cleaning procedures as the Maintenance Department was responsible for deep cleaning. The DSS stated she had emergency ice to use for the remainder of the day. During a concurrent observation and interview on 1/20/2026 at 12:15 p.m. with the Maintenance Staff (MS), the MS was asked to demonstrate the deep cleaning procedure where he removed three screws from the ice maker housing. The MS leaned back the cover approximately 20 degrees. The MS stated, I take a clean rag and wipe it with sanitizer like I was told by my supervisor (Maintenance Supervisor). Observed on the cover were clusters of black dots with a web-like substance spanning 4.0 x 0.5 centimeters. Upon request, the MS removed the cover completely for a more thorough inspection where a steel plate fixed to the base of the ice maker located directly above the container where ice is dispensed and held, a substance was observed. The MS could not identify the substance. The MS stated, I don't know. Something dirty, like a stain. The MS wiped the area with a paper towel which resulted in a combination of dark black/grey dots along with a pink colored slime. During a concurrent interview and record review on 1/20/2026 at 11:15 a.m., with the DSS, of the Ice Machine Daily Cleaning log, the log indicated deep cleaning was signed off once per month, including 1/9/2026. The DSS stated cleaning and disinfection was performed on the ice container and signed off daily, whereas deep cleaning was performed monthly. During a review of the facility policy and procedure (P&P) titled Sanitation, undated, the P&P indicated, Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanity manner. During a review of the facility P&P titled Ice Machine, dated 4/2017, the P&P indicated, Maintenance staff will clean the ice making mechanism per manufacturer's guidelines. The P&P indicated Manufacturer guidelines to be followed for cleaning and sanitizing the ice making system. During a review of the manufacturer guidelines for the Ice Machine, undated, the manufacturer guidelines indicated to remove the evaporator cover, remove the water pipe retaining cover and water pipe, and use a brush to clean the inside of water pipe.

Based on observation, interview, and record review, the facility failed to dispose of garbage properly when the dumpster lid was overflowing with bags of waste on two consecutive days. This deficient practice had the potential to increase the likelihood of pest and vermin infestation contributing to unsanitary conditions on the facility premises.Findings: During a concurrent observation and interview on 1/20/2026 at 9:30 a.m., with the Administrator, observed the trash dumpster and several smaller bins labeled Soiled Linen located near the parking lot of the facility were filled beyond capacity and overflowing with bags of waste. The trash dumpster was located within a wooden shed which was disheveled with broken roofing. The Administrator stated that trash was not picked up the day prior due to a national holiday and the trash company would dispose of all waste tomorrow (1/21/2026). During a review of the trash pickup schedule, posted on the company's website, the schedule indicated, If your service falls on or after the holiday, your pickup will be delayed by one day. During a review of the monthly pest control reports, the reports indicated recommendations were made to keep the trash can lids closed on 2/25/2025, 3/21/2025, and 5/22/2025 in order to reduce pest attraction and source for pest breeding. During an observation on 1/21/2026 at 10:30 a.m., observed both nursing and kitchen staff taking out trash to the dumpster and bins outside. During a concurrent observation and interview on 1/21/2026 at 11:23 a.m., with the Administrator, the dumpster was observed filled with black trash bags beyond capacity. The lids were propped open. Next to the dumpster, a bin on wheels labeled Trash, contained bags protruding beyond the capacity of the bin and the lid rested on top, unclosed. The Administrator stated he confirmed that the daily trash production of the facility exceeded the current capacity available. The Administrator stated the trash could be a vector for pests. The Administrator stated they may require a second bin despite obstacles with physical space and access.

Based on observation, interview, and record review, the facility failed to develop a care plan with interventions for three of eight sampled residents (Resident 18, Resident 36, and Resident 48), addressing the use and refusal of dentures and hand tremors (involuntary, rhythmic, and alternating muscle contractions causing shaking in the hands or fingers). These deficient practices ha the potential to negatively affect Resident 18 and 36's mental, physical, and psychosocial well-being and had the potential to delay the delivery of necessary care and services. These deficient practice also had the potential for Resident 48 to exhibit impaired oral intake, aspiration (choking) and poor hygiene. Findings: a. During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 18's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN- high blood pressure). During a review of Resident 18's Minimum Data Set (MDS – a resident assessment tool), dated 10/21/2025, the MDS indicated Resident 18's cognition (the ability to think and process information) was intact. The MDS indicated Resident 18 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 18 was assessed as not having any oral and/or dental issues including denture. During a review of Resident 18's History and Physical (H&P), dated 11/13/2025, the H&P indicated Resident 18 had the capacity to understand and make decisions. During a concurrent observation and interview on 1/20/2026 at 9:02 a.m., in Resident 18's room, Resident 18 was observed eating breakfast. Resident 18's dentures were placed on the top of the resident's bedside table. Resident 18 stated it was difficult to chew because she did not have any teeth. Resident 18 stated she had dentures but was not using them because they were too big. During a concurrent observation and interview on 1/22/2026 at 8:30 a.m., with the Minimum Data Set Nurse (MDSN) and Resident 18, in Resident 18's room, Resident 18 was observed with no upper and bottom teeth. The MDSN stated Resident 59's dentures were placed on the top of resident's bedside table, indicating that the resident had dentures. Resident 18 stated she was not using her dentures because they were too big and felt loose. During a concurrent interview and record review on 1/22/2026 at 8:45 a.m., with the MDSN, Resident 18's care plans were reviewed. The care plans did not indicate there was a care plan addressing Resident 18's use of dentures. The MDSN stated there should have been a care plan initiated upon Resident 18's admission to the facility since the resident had ill-fitting dentures. The MDSN stated care planning serves as a communication tool among facility staff responsible for the resident's care. The MDSN stated if there was no care plan, the staff would not be able to provide quality and coordinated care to residents. During an interview on 1/22/2026 at 3:55 p.m., with the Director of Nursing (DON), the DON stated it was important to develop a comprehensive care plan for each resident for continuity of care and services, based on resident needs and interventions. b. During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included lack of coordination (inability to produce smooth, accurate, and voluntary muscle movements, resulting in jerky, unsteady, and clumsy motions) and diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 36's H&P, dated 12/5/2025, the H&P indicated Resident 36 was oriented to person, place and time. During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 36 required set up or clean up assistance for eating. The MDS indicated Resident 36 required supervision for oral hygiene, toileting hygiene, upper body dressing and putting on and taking off shoes. The MDS indicated Resident 36 required moderate assistance (helper does less than half the effort) for lower body dressing and personal hygiene. During a review of Resident 36's Psychiatric evaluation, dated 12/5/2026, the psychiatric evaluation indicated Resident 36 was alert and oriented to [NAME] and place. The psychiatric evaluation indicated Resident 36 was noted to have extrapyramidal symptoms ([EPS] drug-induced movement disorders, that result in involuntary movements, muscle stiffness, tremors, and restlessness). During a review of Resident 36's electronic medical record, the electronic medical record did not indicated a care plan addressing Resident 36's hand tremors. During an observation on 1/20/2026 at 9:51 a.m., in Resident 36's room, Resident 36 was observed sitting on her bed. Resident 36's hands were shaking. During an observation on 1/21/2026 at 12:32 p.m., in the dining room, Resident 36 was observed seated at a table. Resident 36's hands were shaking. During an interview on 1/22/2026 at 10:57 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 36 suffered from hand tremors and she recently noticed the tremors have gotten worse. LVN 1 stated Resident 36 received medication for EPS. LVN 1 stated a care plan should be developed for Resident 36's EPS because it would serve as a guideline for Resident 36's care. During a concurrent interview and record review on 1/22/2026 at 11:12 a.m. with LVN 1, Resident 36's electronic medical record was reviewed. The records did not indicate a care plan was developed for Resident 36' hand tremors. LVN 1 stated Resident 36 needed a care plan for her hand tremors. LVN 1stated if there was no care plan, staff would not monitor Resident 36 symptoms and goals would not be set for her. LVN 1 stated Resident 36's care plan should have interventions to assist Resident 36 with mobility, monitor for progression of tremors, monitor during activities of daily living and assist Resident 36 with eating. During an interview on 1/23/2026 at 2:02 p.m. with the Director of Nursing (DON), the DON stated Resident 36's hand tremors should have been care planned. The DON stated a care plan serves as a plan for Residents care and set goals for the residents to get better. The DON stated if there was no care plans, nursing staff would not know what interventions to follow for Residents 36's hand tremors. The DON stated if there was no care plan there was a potential for Resident 36 to suffer an injury or not receive quality care. c. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 48's diagnoses included dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), and abnormalities of gait and mobility. During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 48 required supervision for eating and required partial assistance (helper does less than half of the effort) for oral hygiene, toileting and putting on footwear. During a review of Resident 48's H&P, dated 12/7/2025, the H&P indicated Resident 48 had fluctuating capacity to understand and make decisions. During an interview on 1/20/2026 at 3:09 p.m. with the MDSN, the MDSN stated she knew Resident 48 refused to wear her dentures. During a concurrent observation and interview on 1/21/2026 at 12:18 p.m. with Resident 48's family member (FM) 1, Resident 48 was observed eating food without dentures. FM 1 stated Resident 48 had trouble eating because she did not have her dentures. During a concurrent record review and interview on 1/22/2026 at 1:41 p.m. with the MDSN, all of Resident 48's care plans were reviewed. There were no care plan in place for Resident 48's refusal to wear her dentures. The MDSN stated Resident 48 should have had a care plan in place to address her refusal to use dentures to ensure appropriate care was provided. The MDSN stated if Resident 48 did not have a care plan, Resident 48 was placed at risk for poor oral care, poor oral intake, and choking. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person Centered, revised 12/2016, the P&P indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was to be developed and implemented for each resident. During a review of the facility's P&P titled Care Plans, Comprehensive Person- Centered, revised 2016, the P&P indicated the facility would develop and implement a comprehensive person-centered care plan for each resident that would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a review of facility's P&P titled Care Plans, Comprehensive Person-Centered, dated 12/2026, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional need is developed and implemented for each resident. The P&P indicated care plan would describe services that would be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure all Restorative Nursing Aides (RNA) received training and demonstrated competency in performing Range of Motion (ROM) exercises for one of three sampled residents (Resident 38). This failure had the potential to place Resident 38 at risk for inconsistent or improper restorative care leading to decline in ROM.Findings:During an interview on 1/22/2026 at 9:34 a.m. with RNA 4, RNA 4 stated she receives in-service with new orders and residents with special concerns.During an interview on 1/22/2026 at 2:19 p.m. with the Director of Rehabilitation (DOR), the DOR stated RNA in-service included review of the RNA referral form which includes RNA order, instructions, and training for activity to be completed by the RNA. The DOR stated the form was for new orders and began on 12/05/2025. The DOR stated, regular RNA competency in-service and checklist and keeping record were important because RNAs needed to understand the orders, how to carry out the orders, and how the order impacts the resident's ROM. The DOR stated, lack of in-service and competency checklist could hinder resident's maintenance and lead to ROM decline.During an interview on 1/23/2026 at 9:20 a.m., with the DON, the DON stated the importance of ROM training and competency was to monitor RNA's skills and their need for education that effects resident's care. The DON stated lack of competency effects care and can lead to decline in ROM and quality of care. The DON verbalized the importance of keeping record of trainings to monitor RNA education needs and to keep skills updated to support resident's needs and prevent decline in ROM.During an interview on 1/22/2026 at 2:43 p.m., with the DSD, the DSD stated ROM training was not included in list of trainings. The DSD stated it was important to include ROM exercises as part of the CNA/RNA mandatory training to support resident ROM and well-being. The DSD stated without the training, the RNA could provide the wrong treatment which could result in the resident's ROM declining.During a review of facilities' In-service Training Program for CNA/RNA training log, dated 12/2019, CNA in-service training program did not include ROM training and competency checklist.During a review of the facility's Restorative Range of Motion policy, dated 2/2017, the P&P indicated The Physical Therapist (PT) or Physical Therapist Assistant (PTA) will review the program with the RNA at least every other month and advise on technique and documentation.

Based on observation, interview, and record review, the facility failed to ensure safe medication administration and accurate accountability of all controlled medications (medications with a high potential for abuse) for three of three residents (Resident 89, Resident 12, and Resident 27) by failing to: 1. Notify Resident 89's doctor as ordered when the resident's blood sugar was 436 milligrams per deciliter (mg/dL, which measures the amount of sugar in a specific amount of blood) on 1/22/2026, which was over the parameter of 400 mg/dL requiring doctor notification.This failure increased the risk of Resident 89 experiencing harmful effects from high blood sugar, which could lead to nerve damage, kidney disease, heart disease, stroke (a sudden loss of brain function due to a blocked or burst blood vessel), and vision loss. 2. Remove a discontinued controlled medication, lorazepam (a medication used to treat anxiety), 0.5 mg, for Resident 27 from the medication cart and not document the administration of lorazepam 0.5 mg incorrectly as lorazepam 1 mg on 1/18/2026. 3. Document Resident 12's controlled medication, hydrocodone-acetaminophen 10 mg/325 mg (a pain-relief medicine that combines a strong painkiller called hydrocodone and a milder pain reliever called acetaminophen), on the resident's Medication Administration Record (MAR, a record of each medication given, dosage, time, and person administering) on 1/21/2026 during morning medication administration before going to the next resident. These deficient practices created the potential for unsafe care, treatment, and medication administration for Resident 89, Resident 12, and Resident 27. The deficient practice increased the risk of not being able to readily identify controlled medication loss, drug diversion (illegal distribution or use of prescription drugs), or medication errors, which resulted in Resident 27 being administered a wrong dose of lorazepam on 1/18/2026.Findings: 1. During a review of Resident 89's admission Record, the admission record indicated Resident 89 was admitted to the facility on [DATE], and readmitted on 1/17/ 2026 with diagnoses that included, Type 2 diabetes mellitus (Type 2 DM, a condition where the body cannot properly use sugar for energy), heart failure (the heart cannot pump enough blood and oxygen to the body's organs), and hypertension (high blood pressure). During a review of Resident 89's Minimum Data Set (MDS - a resident assessment tool), dated 11/17/2025, the MDS indicated Resident 89's cognition (ability to learn reason, remember, understand, and make decisions) was intact. During a review of Resident 89's Physician Order Summary, the Order Summary indicated an order dated 1/18/2026, with instructions to administer Insulin Lispro Injection Solution 100 UNIT/ML (a fast-acting insulin used to control blood sugar levels in diabetes) per the following sliding scale (a method for adjusting the dose of insulin based on blood sugar levels). The Order Summary indicated inject as per sliding scale: if blood glucose (BG) is 61 - 150 = 0 units (no insulin). The Order Summary indicated if BG was less than (<) 70 give glucose gel (a fast-acting sugar) 1 tube by mouth (PO) or Glucagon (a hormone that raises blood sugar levels) 1 milligram (mg, unit of measurement), then call to doctor (MD). The Order Summary indicated the following sliding scale:BG 151 - 200 = 3 units;BG 201 - 250 = 5 units;BG 251 - 300 = 8 units;BG 301 - 350 = 10 units;BG 351 - 400 = 12 units;if BG > (is greater than) 400, give 15 units, then call to MD,Inject subcutaneously (under the skin) four times a day for Type 2 DM before meals and at bedtime. During a review of Resident 89's undated care plans titled Resident has Hyperglycemia (high blood sugar) and Resident has Diabetes Mellitus,, the care plans indicated the resident has hyperglycemia and Type 2 Diabetes Mellitus. The interventions indicated to give medication as ordered, monitor compliance with diet and document any problems, monitor blood sugar as ordered, monitor for signs and symptoms of high or low blood sugar, and notify MD as needed. During a concurrent medication pass observation and interview on 1/21/2026 between 11:30 AM to 11:40 a.m., with Licensed Vocational Nurse (LVN) 1, at Medication Cart (MedCart) B, observed LVN 1 enter Resident 89's room. LVN 1 pricked the resident's finger on the right hand to check the resident's BG. LVN 1 stated that Resident 89's BG read 436. LVN 1 was observed preparing and administering Insulin Lispro to Resident 89. LVN 1 stated 15 units of Insulin Lispro was administered to Resident 89 based on the sliding scale parameters for BG greater than 400 (mg/dL). During an interview on 1/21/2026 at 2:26 p.m. with LVN 1, LVN 1 stated that Resident 89's physician had not been notified of the resident's BG being over 400 during the BG check earlier on 1/21/2026 during the scheduled 11:30 AM medication pass. LVN 1 stated the physician should have been notified right away when the BG was over 400 as ordered. LVN 1 stated the facility's protocol was to inform the doctor and to recheck the BG after the insulin administration. LVN 1 stated that she will recheck Resident 89's BG now and then call the physician. During a concurrent interview and record review on 1/22/2026 with the Director of Nursing (DON), Resident 89's Order Summary, Nursing Progress Notes, and BG results were reviewed. The DON stated Resident 89'a nursing progress note dated 1/21/2026 at 11:34 a.m., documented a BG of 436 and licensed nurse documented, Will advise MD. The DON stated there was no documentation that indicated Resident 89's physician was notified of the resident's BG being over 400 as ordered on 1/21/2026. The DON stated there was a progress note dated 1/19/2026 for Resident 89's BG of 524 which indicated, MD notified. The DON stated there was no documentation of when the physician was notified or response or what instructions were given. The DON stated the licensed nurses have to document in the nursing progress notes the time the physician was notified, the instructions given by the physician, and follow any orders given by the physician for the resident. During a concurrent interview and record review on 1/22/2026 at 2:00 p.m., with Resident 89's Primary Care Physician (PCP) 1, Resident 89's BG results were reviewed. PCP 1 checked and stated, he did not see a message from the facility's nurse about Resident 89's BG of 436 on 1/21/2026. PCP 1 stated he was able to see a message on 1/18/2026 when Resident 89's BS read 448, and made an insulin dose adjustment, but was unable to see any other messages from the facility when Resident 89's BS was over 400. PCP 1 stated the expectation is to be informed by the facility about abnormal BG readings and abnormal laboratory results. During a review of Resident 89's BG readings between December 2025 to January 2026, the BG readings indicated the following:On 1/21/2026 at 9:05 p.m. (21:05) - 400.0 mg/dL On 1/21/2026 4:40 p.m. (16:40) - 400.0 mg/dL On 1/21/2026 at 11:34 a.m. - 436.0 mg/dL On 1/19/2026 at 11:12 a.m. - 524.0 mg/dL On 1/18/2026 at 5:08 p.m. (17:08) - 448.0 mg/dL On 1/17/2026 at 9:40 p.m. (21:40) - 498.0 mg/dL On 1/14/2026 at 8:56 p.m. (20:56) - 500.0 mg/dL On 1/13/2026 at 4:47 p.m. (16:47) - 412.0 mg/dL On 1/10/2026 at 4:08 p.m. (16:08) - 497.0 mg/dL On 1/8/2026 at 9:38 p.m. (21:38) - 411.0 mg/dL On 1/8/2026 at 9:36 p.m. (21:36) - 411.0 mg/dL On 1/8/2026 at 4:18 p.m. (16:18) - 441.0 mg/dL On 1/8/2026 at 11:19 a.m.- 452.0 mg/dL On 1/7/2026 at 11:30 a.m. - 458.0 mg/dL On 1/4/2026 at 5:09 p.m. (17:09) - 453.0 mg/dL On 1/4/2026 at 11:06 a.m. - 401.0 mg/dL On 1/3/2026 at 4:07 p.m. (16:07) - 500.0 mg/dL On 1/2/2026 at 11:19 a.m. - 424.0 mg/dL On 1/1/2026 at 11:04 a.m.- 491.0 mg/dL On 12/31/2025 at 8: 14 p.m. (20:14) - 500.0 mg/dL On 12/31/2025 at 11:32 a.m. - 434.0 mg/dL On 12/30/2025 at 11:19 a.m. - 449.0 mg/dL On 12/28/2025 at 5:32 p.m. (17:32) - 499.0 mg/dL On 12/26/2025 at 11:36 a.m. - 421.0 mg/dL On 12/25/2025 at 8:40 p.m. (20:40) - 496.0 mg/dL On 12/22/2025 at 11:23 a.m. - 454.0 mg/dL On 12/21/2025 at 6:06 p.m. (18:06) - 456.0 mg/dL On 12/21/2025 at 11:46 a.m. - 500.0 mg/dL On 12/19/2025 at 4:51 p.m. (16:51) - 411.0 mg/dL On 12/17/2025 at 9:20 p.m. (21:20) - 500.0 mg/dL On 12/14/2025 at 11:35 a.m. - 431.0 mg/dL On 12/13/2025 at 8:16 p.m. (20:16) - 447.0 mg/dL On 12/13/2025 at 11:21 a.m. - 439.0 mg/dL On 12/12/2025 at 8:47 p.m. (20:47) - 477.0 mg/dL On 12/12/2025 at 4:06 p.m. (16:06) - 429.0 mg/dL On 12/11/2025 at 4:32 p.m. (16:32) - 463.0 mg/dL On 12/10/2025 at 4:36 p.m. (16:36) - 434.0 mg/dL On 12/3/2025 at 3:30 p.m. (15:30) - 457.0 mg/dL On 12/2/2025 at 4:22 p.m. (16:22) - 405.0 mg/dL On 12/2/2025 at 11:13 a.m. - 401.0 mg/dL On 12/1/2025 at 10:50 a.m. - 441.0 mg/dL During an interview on 1/22/2026, at 2:15 p.m. with Primary Care Provider (PCP) 1, PCP 1 stated that acute (sudden and severe) complications from high blood glucose may include diabetic ketoacidosis (a dangerous condition where the body makes high levels of acids [ketones]) and confusion. PCP 1 stated chronic (persistent and long-lasting) complications may include kidney injury, neuropathy (nerve damage), increased risk of stroke, and heart disease are common with high blood glucose levels. During a review of the facility's policy and procedures (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, Medications are administered in accordance with prescriber orders. During a review of the facility's P&P titled, Diabetic Management, dated 1/2021, the P&P indicated, Hyperglycemia - High blood sugar [typically above 200 mg/dL].The licensed nurse assesses the resident for any hyper/hypoglycemic episodes and intervenes as necessary by documenting, communicating findings to the physician and implementing appropriate interventions.Managing Diabetes, checking blood sugar.Request the registered dietitian to develop a diet plan that will help the resident get better blood sugar control if needed. Request the consulting pharmacist to assess possible causes of glucose changes.Document doctor's order in the physician orders and nurses' notes. During a review of the facility's undated P&P titled, Policy and Procedures on Licensed Nurse Progress Notes, the P&P indicated, Evaluation and assessment of a resident's status & condition shall include, at a minimum.Any recent change of conditions including interventions done to address problem and meet resident's needs.It is the responsibility of the licensed nurse to ensure accuracy in reporting resident's status & condition. 2. During a review of Resident 27's admission Record, the admission record indicated Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anxiety disorder (a mental health condition characterized by excessive worry or fear). During a review of Resident 27's MDS dated [DATE], the MDS indicated Resident 27's cognition was severely impaired. During a review of Resident 27's physician orders dated 10/21/2025, the order indicated lorazepam 0.5 mg, to give one tablet by mouth every 6 (six) hours as needed for anxiety manifested by (m/b) sudden striking out for 90 days. The order was discontinued on 1/16/2026. During a review of Resident 27's physician orders dated 1/16/2026, the order indicated lorazepam 1 (one) mg, to give 1 mg by mouth every 4 hours as needed for anxiety m/b restless and agitation. The order was discontinued 1/18/2028. During a review of Resident 27's physician orders dated 1/19/2026, the order indicated lorazepam 1 mg, to give 1 (one) tablet by mouth every 4 hours as needed for anxiety m/b restless and agitation. The order indicated the lorazepam 1 mg order was placed on hold on 1/20/2026 for Resident 27's 911 transfer to hospital. During a concurrent observation and interview on 1/21/2026 at 2:49 p.m., with LVN 3, at MedCart A, observed inside of MedCart A was a medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication) labeled to contain lorazepam 0.5 mg for Resident 27. LVN 3 stated Resident 27 do not have a current order for lorazepam 0.5 mg. During a concurrent interview and record review on 1/21/2026 at 2:50 p.m., LVN 3, Resident 27's Controlled Drug Record (CDR, a continuous log that tracks the inventory of controlled substances to prevent misuse) ) and MAR for the month of January 2026 were reviewed. Resident 27's CDR for lorazepam 0.5 mg indicated by documentation and licensed nurse's initials that one dose was marked as removed on 1/18/2026 at 8 a.m Resident 27's January 2026 MAR indicated by documentation and licensed nurse's initials the resident was administered one dose of lorazepam 1 mg on 1/18/2026 at 7:12 AM. LVN 3 stated Resident 27's lorazepam 0.5 mg was discontinued on 1/16/2026 and the resident's CDR was marked to indicate a dose of lorazepam 0.5 mg was removed on 1/18/2026, and marked on the resident's MAR as if resident was administered lorazepam 1 mg. LVN 3 looked through MedCart A and stated there was no lorazepam 1 mg for Resident 27 in stock. LVN 3 reviewed Resident 27's lorazepam 1 mg order, that indicated, need to be ordered. LVN 3 stated when Resident 27's lorazepam 0.5 mg order changed to lorazepam 1 mg, the discontinued medication should have been removed from the medication cart and not available for use. During a telephone interview on 1/21/2026 at 3:43 p.m.with the facility's dispensing pharmacy technician (PharmTech) 1 in the presence of LVN 3, PharmTech 1 stated lorazepam 1 mg was not sent to the facility for Resident 27 as they were waiting for the physician to approve the controlled medication order. PharmTech 1 stated for Resident 27, lorazepam 0.5 mg was last sent to the facility on [DATE]. During an interview on 1/22/2026 at 12:44 p.m. with the DON, the DON stated there should be no discontinued controlled medications stored in the medication cart. DON stated the licensed nurse should bring the discontinued controlled medication to the DON right away. DON stated if the controlled medication is discontinued at night or during the weekend the discontinued controlled medication should be given to the DON the next day or on Monday if occurs over the weekend. During a concurrent interview and record review on 1/22/2026 at 1:36 PM with the DON, Resident 27's physician orders, transfer records, and January MAR were reviewed. The DON stated Resident 27 was transferred to the hospital on 1/12/2026 and returned to the facility on 1/16/2026 with a new order for lorazepam 1 mg which was not communicated to the charge nurses. DON stated on 1/18/2026 Resident 27's order was for lorazepam 1 mg and the charge nurse did not match the order and accidentally gave lorazepam 0.5 mg. DON stated administering lorazepam 0.5 mg to Resident 27 on 1/18/2026 was a medication error as the facility did not have lorazepam 1 mg in stock for the resident on 1/18/2026. During a review of the facility's P&P titled, Disposal of Medications, dated 7/2022, the P&P indicated, Discontinued medication and/or medications left in the nursing care center after a resident's discharge, which do not qualify for return to the pharmacy, are identified and removed from current medication supply in a timely manner for disposition.The Director of Nurses (DON) and/or its designee shall be responsible for implementation and enforcement of this policy.Controlled Substances listed in Schedules II, III, IV, and V remaining in the facility after the order has been discontinued are retained in the facility in a securely double locked area with restricted access until destroyed. During a review of the facility's P&P titled, Medication Administration-General Guidelines, dated 1/2022, the P&P indicated the following:a. Five Rights - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away.b. The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule .c. Medications are administered in accordance with written orders of the prescriber. 3. During a review of Resident 12's admission Record, the admission record indicated Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 DM, disorder of muscle, gout (a common, treatable form of inflammatory arthritis caused by high levels of uric acid in the blood forming crystals in joints), and polyneuropathy (a condition where many nerves in the body are damaged). During a review of Resident 12's MDS dated [DATE], the MDS indicated Resident 12's cognition was intact. During a review of Resident 12's Physician Order Summary, the Order Summary included an order dated 11/6/2025, for hydrocodone-acetaminophen 10 mg/325 mg, with instructions to give one tablet by mouth every eight hours as needed (PRN) for severe pain of seven (7) to 10 (the severity of pain is assessed on a scale of zero [no pain] to ten [worst possible pain], with seven (7) to ten (10) indicating severe pain). During a concurrent interview and record review on 1/21/2026 at 3:06 p.m. with RN 1, at MedCart C, Resident 12's Controlled Drug Record (CDR, a continuous log that tracks the inventory of controlled substances to prevent misuse) for hydrocodone-acetaminophen and the MAR, printed on 1/21/2026 at 3:31 p.m. was reviewed. Resident 12's MAR indicated the last dose of hydrocodone-acetaminophen was given on 1/20/2026 at 11:06 p.m. Resident 12's CDR indicated a dose of hydrocodone-acetaminophen was removed from the medication card on 1/21/2026 at 9:48 a.m. RN 1 stated she forgot to document the administration of Resident 12's hydrocodone-acetaminophen on the MAR on 1/21/2026 at 9:48 a.m. During an interview on 1/21/2026 at 3:38 p.m. with RN 1, RN 1 stated that she should have documented on Resident's 12's MAR the administration of hydrocodone-acetaminophen 10 mg/ 325 mg immediately after administration on 1/21/2026 at 9:48 a.m. RN 1 stated not documenting the administration of a controlled medication had the risk for Resident 12 to receive duplication of medication, experience adverse reactions (harmful effects), or lack of pain control. During a review of Resident 12's progress notes, dated 1/21/2026 at 9:48 a.m., the progress note indicated hydrocodone/acetaminophen was given at 9:48 am but was not documented until 4:27 p.m. on 1/21/2026, almost seven hours after administration. During an interview on 1/22/2026 at 1:24 p.m., with the DON, the DON stated licensed nurses must follow the one by one administration and documentation. The DON stated the facility's licensed nurses must document the administration of all medications on the MAR on time especially for PRN controlled medications for pain and before going to the next resident. During a review of the facility's P&P titled, Medication Administration-General Guidelines, dated 1/2022, the P&P indicated, The individual who administers the medication dose records the administration on the resident's MAR/eMAR directly after the medication is given. During a review of the facility's P&P titled, Controlled Substances, dated 4/2019, the P&P indicated, Upon Administration: The nurse administering the medication is responsible for recording.signature of nurse administering medication

Based on observation and interview, the facility failed to dispose of non-controlled medications in the presence of a witness in accordance with the facility's policy titled, Disposal of Medications. This deficient practice increased the risk for lack of accountability for disposal of non-controlled medications throughout the facility.Findings: During a concurrent medication storage inspection and interview on 1/22/2026 at 12:32 p.m. with the Director of Nursing (DON), inside of the DON's office, the non-controlled medication disposal logs documentation between 11/26/2025 through 1/15/2026 was reviewed. The logs indicated one licensed nurse's initials were on the forms. The DON stated the non-controlled disposal log was used by both nursing stations (Station A and Station B). The DON stated non-controlled drug disposal was done by one person, either by the DON or the Registered Nurse (RN) Supervisor and did not require a witness. During an interview with the DON on 1/23/2026 at 11:25 a.m., the DON provided a copy of the facility's policy titled, Disposal of Medications. The DON stated that the facility's policy indicated, non-controlled medication disposal requires disposal in the presence of a pharmacist or nurse and one witness. During a review of the facility's policy and procedures (P&P) titled, Disposal of Medications, dated 7/2022, the P&P indicated, Medications not listed in Schedules II, III, IV and V (non-controlled medications) shall be destroyed by the facility in the presence of a pharmacist or nurse and one other witness. Medications may not be left in the original vials or container for disposal.

Based on observation, interview, and record review, the facility failed to ensure the cook (Cook 1) followed the Korean menu recipes and failed to ensure the zucchini recipe ingredients were not altered. These deficient practices had the potential to alter nutrition, provide the appropriate therapeutic texture, and introduce allergens to resident meal trays.Findings: During a concurrent observation, interview, and record review on 1/20/2026 at 12:05 p.m., with the Dietary Services Supervisor (DSS), the Weekly Korean Menu and Recipe titled Korean Pot Stickers were reviewed. The menu indicated Korean Pot Stickers and Dipping Sauce. The recipe indicated procedures to wrap meat mixture into pot sticker or won ton wraps. Observed a pan of chunky meat with cabbage and peppers being served for lunch service. The DSS stated the chunky meat with cabbage and peppers were being served, from the Korean Menu, at lunch. The DSS stated that [NAME] 1 may have followed Monday's menu mistakenly. The DSS stated that the food being served on 1/20/2026 was also not aligned with Monday's menu and corresponding recipe. During a concurrent observation, interview, and record review, on 1/20/2026 at 12:10 p.m., with the DSS and [NAME] 1, the facility's Weekly Menu was reviewed. The weekly menu indicated Seasoned Zucchini. [NAME] 1 was observed serving a vegetable dish which contained a combination of zucchini, carrots, red peppers, and corn. During lunch service [NAME] 1 added boiled cauliflower to a pan on the steam table toward the end of lunch service. The DSS stated, I don't know why she (Cook 1) added that. [NAME] 1 stated the facility was out of zucchini and she chose to add cauliflower. During a concurrent observation, interview, and record review, on 1/21/2026 at 11:50 p.m., with the DSS and [NAME] 1, the Weekly Korean menu and recipe titled Fish Stew was reviewed. The menu indicated Fish Stew. The recipe indicated to make a soup using the fish. [NAME] 1 was observed serving whole filets of fish for the Korean menu. The DSS stated [NAME] 1 baked it instead of making a stew and [NAME] 1 did not check the menu. The DSS stated, It's different from what the menu says. It changes nutrient and changes everything. Changes resident expectation. The DSS was not able to present a substitution log denoting any menu changes that were documented or revised and approved by a Registered Dietitian. During an interview with the DSS on 1/21/2026 at 1:45 p.m., the DSS stated this practice is a risk for changing nutritive value, decreasing meal satisfaction by introducing disliked items, and potentially exposing residents to allergens.

Based on observation, interview and record review, the facility failed to provide the correct food texture-modified diet (alters the consistency of food and liquids to make swallowing safer and easier for people with chewing or swallowing difficulties) for two of eight sampled residents (Resident 44 and 77). This deficient practice has the potential for Resident 44 and 77 to have problems chewing and swallowing and increased the risk for Residents to choke while eating.Findings:During an observation on 1/20/2026 at 12:30 p.m., in the dining room, Resident 44 was eating lunch. Resident 44's food plate had one toasted garlic bread and chopped chicken with vegetables. Resident 44's diet card indicated Resident 44 had a mechanical soft texture diet (foods that are physically altered-chopped, ground, mashed, or pureed-to be easy to chew and swallow, reducing choking risks).During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 44's diagnoses included dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities).During a review of Resident 44's History and Physical (H&P), dated 6/29/2025, the H&P indicated Resident 44 did not have the capacity to understand and make decisions.During a review of Resident 44's Minimum Data Set ([MDS] a resident assessment tool), dated 12/18/2025, the MDS indicated Resident 44's cognitive skills for daily decision making was severely impaired (ability to think and reason). The MDS indicated Resident 44 required maximum assistance (helper does more than half the effort) for eating.During a review of Resident 44's Dietary Profile dated 12/19/2025, the dietary profile indicated Resident 44's food texture diet was L5 minced and moist (a texture-modified diet designed for individuals with chewing or swallowing difficulties, food that is soft, moist, and cut into small pieces). The dietary profile indicated Resident 44 had a history of dysphagia.During a review of Resident 44's Order Summary Report, dated 12/29/2025, the Order Summary Report indicated Resident 44 had an order for an L5 minced and moist texture diet.During an interview on 1/20/2026 at 12:36 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 44's food had to be cut into smaller pieces because chunks of chicken are too big for her to chew and swallow. CNA 4 stated it was not the first time Resident 77 received food that size and she usually cut the food to a smaller size before feeding it to Resident 44.During an interview on 1/23/2026 at 10:10 a.m. with CNA 4, CNA 4 stated a mechanical soft diet was food texture that was cut into small pieces. CNA 4 stated on 1/20/2026 for lunch Resident 44 did not receive the correct food texture because she had to cut the food into smaller pieces. CNA 4 stated the edges of the bread were hard to cut down with a fork. During an observation on 1/20/2026 at 12:47 p.m., in the dining room, Resident 77 was eating lunch. Resident 77's food plate had one toasted garlic bread, chicken with vegetables and a full quesadilla. Resident 77's diet card indicated Resident 77 had a mechanical soft texture dietDuring a review of Resident 77's admission Record, the admission Record indicated Resident 77 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) affecting left non dominant side of body.During a review of Resident 77's H&P, dated 12/10/2025, the H&P indicated Resident 77 had the capacity to understand and make decisions.During a review of Resident 77's MDS, dated [DATE], the MDS indicated Resident 77's cognitive skill for daily decision making was moderately impaired. The MDS indicated Resident 77 required supervision for eating.During a review of Resident 77's Order Summary Report, dated 12/9/2025, the Order Summary Report indicated Resident 77 had an order for an L6 soft and bite sized texture diet. During a review of Resident 77's Dietary Profile dated 12/25/2025, the dietary profile indicated Resident 77's food texture diet was L6 soft and bite sized texture diet (therapeutic diet consisting of moist, tender food, cut into pieces).During an interview on 1/20/2026 at 12:49 p.m. with the Dietary Supervisor (DS), the DS stated the food that Resident 77 had on her plate was for a regular food texture diet and not for a mechanical soft diet. The DS stated Resident 77's quesadilla should not be served in full and that it should be served in smaller pieces.During an interview on 1/23/2026 at 1:17 p.m. with the DS, the DS stated residents that have swallowing or chewing problems get an order for mechanical soft texture diet order. The DS stated if a resident did not receive the correct food texture they were at risk for choking. The DS stated a mechanical soft diet was a chopped or soft and bite size food. The DS stated Resident 77 did not receive the correct food texture because the bread should have been soaked to make it soft and the chicken should have been cut into smaller pieces.During an interview on 1/23/2026 at 2:40 p.m. with Director of Nursing (DON) the DON stated residents with chewing and swallowing problems had food texture diets as a precaution and safety measure to prevent choking. The DON stated it was not acceptable for a resident to receive food texture that was not ordered for them. The DON stated it was the dietary department's responsibility to check food before it left the kitchen and it was the licensed nurses' responsibility to check food before it is given to the residents. During a review of facility's menu for 1/20/2026 lunch meal, the menu indicated for L6 and L5 food texture, the chicken had to be minced. The menu indicated the garlic bread for L6 texture had to be chopped, soaked and drained. The menu indicated the garlic bread for L5 texture had to be minced and moist.During a review of facility's Policy and Procedure (P&P) titled Mechanical or Dental Soft dated 2018, the P&P indicated a mechanically altered diet provided food that was easily chewed. The P&P indicated the diet was for individuals who have chewing problems, and swallowing problems. The P&P indicated food was modified in texture by chopping, dicing, and grinding. The P&P indicated food must be served moist to facilitate chewing and swallowing.

Based on observation, interview, and record review the facility failed to ensure a resident's personal belongings were inventoried and tracked upon discharge and readmission for one out of one sampled residents (Resident 48). This deficient practice resulted in the facility's inability to account for Resident 48's hearing aids and dentures.Findings: During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 48's diagnoses included dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), and abnormalities of gait (manner of walking) and mobility. During a review of Resident 48's Minimum Data Set ([MDS], a resident assessment tool), dated 11/27/2025, the MDS indicated Resident 48's cognitive skills (ability to think and reason) for daily decision making were moderately impaired. The MDS indicated Resident 48 required supervision for eating and required partial assistance (helper does less than half of the effort) for oral hygiene, toileting and putting on footwear. During a review of Resident 48's History and Physical (H&P), dated 12/7/2025, the H&P indicated Resident 48 had fluctuating capacity to understand and make decisions. During a review of Resident 48's Theft and Loss Form dated 10/1/2025, the Form indicated Resident 48 reported her dentures were missing and was unable to recall where they were. During a review of Resident 48's Inventory Lists, dated from 2021 through 2026, there was only one inventory list dated 5/30/2021. The Inventory list indicated Resident 48 had a right and left hearing aid. During a concurrent observation and interview on 1/21/2026 at 12:18 p.m. with Resident 48's Family Member (FM) 1, Resident 48 was observed eating her food without her dentures. FM 1 stated he had known Resident 48 to have dentures and believed the dentures were missing. During an interview on 1/22/2025 at 8:58 a.m. with the Director of Staff Development (DSD), the DSD stated the certified nursing assistants (CNAs) were responsible for completing the resident inventory lists. During an interview on 1/22/2026 at 9:00 a.m. with Restorative Nurse Aide (RNA) 1, RNA 1 stated CNAs were to complete the resident's inventory lists upon discharge and readmission to the facility. RNA 1 stated she was responsible for completing Resident 48's inventory list upon the resident's readmission on [DATE]. RNA 1 stated she did not complete the inventory list because she knew Resident 48 had a locked closet and also kept belongings at her bedside. RNA 1 stated she did not try to locate or obtain the key so she could complete Resident 48's inventory list. RNA 1 stated all residents had the right to keep their belongings safe while residing in the facility. RNA 1 stated not having an inventory list resulted in the facility's inability to account for Resident 48's belongings. During a concurrent interview and record review on 1/23/2026 at 9:46 a.m. with the Director of Nursing (DON), Resident 48's Census (admission and readmission Dates), and all of Resident 48's Inventory Lists, dated in 2025, were reviewed. The Census indicated Resident 48 was discharged and readmitted to the facility five times between 10/2025 through 1/2026. The DON stated there should have been at least one to two inventory lists completed within that timeframe to account for Resident 48's valuable belongings, like her hearing aids and dentures. During a review of the facility's Policy and Procedure (P&P) titled, Resident's Personal Property, dated 12/2016, the P&P indicated residents were permitted to retain personal possession and any personal clothing or possessions retained by the facility for the resident during his or her stay would be identified and inventoried upon admission and the copy of inventory provided to the resident. The P&P indicated documentation of inventoried personal effects was to be completed.

Based on interview and record review, the facility failed to ensure a PRN (as needed) order for Lorazepam (psychotropic medication- drug that affects mental processes, moods, and behaviors) indicated a stop date for one of six sampled residents (Resident 16). This deficient practice placed Resident 16 at risk for continued use of unnecessary psychotropic medication without timely physician reassessment and had the potential for Resident 16 to be chemically restrained by the administration of unnecessary psychotropic medication, and/or suffer extrapyramidal symptoms (a group of movement disorders that can occur because of certain medications, particularly antipsychotics) due to prolonged use. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 16's diagnosis included depression (a mental disorder that affects how person thinks, feels, and acts), anxiety (a feeling of fear, and dread), and epilepsy (a brain disorder), During a review of Resident 16's Minimum Data Set (MDS- a resident assessment tool), dated 12/11/2025, the MDS indicated Resident 16's cognition (the ability to think and process information) was intact. The MDS indicated Resident 16 was dependent (helper does all the effort) on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 16's order summary report, dated 1/5/2026, the order summary report indicated Resident 16 was to receive Lorazepam (a psychotropic medication) 0.5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount), one (1) tablet by mouth every eight (8) hours as needed for anxiety. The order did not indicate a stop date for the administration of Lorazepam. During a concurrent interview and record review on 1/23/2026 at 1:25 p.m., with the Director of Nursing (DON), Resident 16's physician order for Lorazepam 0.5 mg, dated 1/5/2025, and the facility's policy and procedure (P&P) titled Psychoactive Medication Physician's Order, dated 7/2017, were reviewed. The DON stated the physician order did not indicate a stop date for the administration of Lorazepam. The DON stated the P&P indicated the resident's psychotropic medication order was to be written by a physician for specific time period. The DON stated the P&P indicated PRN orders for psychotropic medications were limited to 14 days. The DON stated Resident 16's Lorazepam order was not in alignment with the facility's P&P. The DON stated the purpose of the 14-day limit was to ensure the continued need for the psychotropic medication was clinically justified to prevent unnecessary use of such medications.

Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS, a resident assessment tool) assessment for one of six sampled residents' (Resident 18) oral and/or dental status. This deficient practice resulted in incorrect data transmitted to the Centers for Medicare and Medicaid Services (CMS) regarding Resident 18's missing natural teeth and had the potential to negatively affect the resident care plan and delivery of necessary care and services. Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 18's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN- high blood pressure). During a review of Resident 18's MDS, dated [DATE], the MDS indicated Resident 18's cognition (the ability to think and process information) was intact. The MDS indicated Resident 18 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 18 was assessed as not having any oral and/or dental issues. During a review of Resident 18's History and Physical (H&P), dated 11/13/2025, the H&P indicated Resident 18 had the capacity to understand and make decisions. During a concurrent observation and interview on 1/20/2026 at 9:02 a.m., in Resident 18's room, Resident 18 was observed eating breakfast. Resident 18 stated it was difficult to chew the food because she did not have any teeth. Resident 18 stated I have dentures, but they don't fit, they're too big. During a concurrent interview and record review on 1/22/2026 at 8:45 a.m., with the Minimum Data Set Nurse (MDSN), Resident 18's MDS, dated [DATE], section oral/dental status were reviewed. The MDS indicated Resident 18 was assessed as not having any oral and/or dental issues. The MDSN stated Resident 18's MDS oral/dental status assessment was coded incorrectly, as it did not reflect the resident's actual oral and/or dental status. The MDSN stated that because Resident 18 did not have her natural teeth, the MDS should have been coded to reflect that the resident was edentulous (toothless). The MDSN stated accuracy of the MDS assessment was important not only for outcome measures and quality indicators, but also for developing and individualizing the care plan based on the resident's actual needs. The MDSN stated inaccuracy of the MDS assessment had the potential to negatively impact the care provided, leading to inappropriate care planning and not meeting the residents' needs and services. During a review of the facility's policy and procedures (P&P) titled Minimum Data Set (MDS) Accuracy, dated 10/2023, the P&P indicated the facility would ensure MDS accuracy for each resident's status, needs, and strengths. The P&P indicated MDS data element set was reviewed for accuracy of coding.

Based on observation, interview, and record review, the facility failed to ensure services met professional standards when a medication for one of five sampled residents (Resident 63) was not handled according to instructions. This deficient practice had the potential to result in adverse side effects, absorption of medication, and birth defects for the nurse. Findings: During a review of Resident 63's admission Record, the admission record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses that included but not limited to, benign prostatic hyperplasia (BPH- a noncancerous enlargement of the prostate gland), retention of urine, and chronic kidney disease (a long-term condition where the kidneys gradually lose their ability to filter waste and excess fluids from the blood effectively). During a review of Resident 63's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 12/19/2025, the MDS indicated Resident 63 cognitive skills (ability to think and reason) for daily decision making was moderately impaired. The MDS indicated Resident 63 required setup or clean-up assistance for eating, oral and personal hygiene, and upper body dressing. The MDS indicated Resident 63 required moderate staff assistance for shower/bathing and lower body dressing. During an observation on 1/21/2026 at 9:12 a.m., at Resident 63's room, with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed not wearing gloves while handling and preparing finasteride (a prescription medication used for BPH) for administration to the resident. During a concurrent interview and record review on 1/21/2026 at 9:16 a.m. with LVN 1, Resident 63's physician's order dated 12/12/2025 was reviewed. The physician's order indicated finasteride oral tablet 5 milligrams (mg, unit of measurement by weight), to give 5 mg by mouth in the morning for BPH, wear gloves when handling/administering medication. LVN 1 stated she did not wear gloves when administering medications but should have read the order and followed the instructions when administering finasteride to prevent the risk of absorption of the medication through the skin. During a review of Resident 63's Consultant Pharmacist's Medication Regimen Review (MRR), dated 12/20/2025, the MRR indicated gloves should be worn when handling or administering finasteride. During an interview on 1/22/2026 at 1:00 p.m. with the Director of Nursing (DON), the DON stated, gloves must be worn when giving finasteride to avoid absorption of the medication through the skin and the nurse being exposed to the medication. The nurses should be following pharmacy recommendations and doctor's orders for each medication ordered, including finasteride. During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines, dated 1/2022, the P&P indicated, examination gloves are worn during medication administration when ordered by the prescriber.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 36), who had hand tremors, was assisted during mealtimes. This deficient practice had the potential to cause a negative impact on Resident 36's overall health status. Findings: During an observation on 1/21/2026 at 12:30 p.m., in the dining room, Resident 36 was observed seated at a table. A cup of coffee and food tray was placed on top of the table. Resident 36 was observed not eating. Resident 36's hands were shaking. Resident 36 grabbed the cup of coffee and brought it toward her face. Resident 36 began to spill coffee over herself and she returned the cup coffee back to the table. During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included lack of coordination (inability to produce smooth, accurate, and voluntary muscle movements, resulting in jerky, unsteady, and clumsy motions) and diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 36's History and Physical (H&P), dated 12/5/2025, the H&P indicated Resident 36 was oriented to person, place and time. During a review of Resident 36's Psychiatric evaluation, dated 12/5/2026, the psychiatric evaluation indicated Resident 36 was alert and oriented to person and place. The psychiatric evaluation indicated Resident 36 was noted to have extrapyramidal symptoms ([EPS] drug-induced movement disorders, that result in involuntary movements, muscle stiffness, tremors, and restlessness). During a review of Resident 36's Minimum Data Set ([MDS] a resident assessment tool), dated 12/4/2025, the MDS indicated Resident 36's cognitive skills for daily decision making was moderately impaired (ability to think and reason). The MDS indicated Resident 36 required set up or clean up assistance for eating. The MDS indicated Resident 36 required supervision for oral hygiene, toileting hygiene, upper body dressing and putting on and taking off shoes. The MDS indicated Resident 36 required moderate assistance (helper does less than half the effort) for lower body dressing and personal hygiene. During an interview on 1/21/2026 at 12:35 p.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 36 had hand tremors but did not require assistance to eat and could eat on her own. During a concurrent observation and interview on 1/21/2026 at 12:42 p.m., in the dining room, with CNA 5, observed CNA 5 ask Resident 36 if she needed help with eating. Resident 36 replied yes. CNA 5 set up Resident 36's food and fed the resident. CNA 5 stated she assisted Resident 36 with eating because she observed her hands were aggressively shaking and knew she would not be able to feed herself. During an interview on 1/22/2026 at 10:57 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 36 had hand tremors but has always been able to feed herself. LVN 1 stated Resident 36 would benefit from feeding assistance when her tremors were more aggressive. LVN 1 stated Resident 36 needed assistance to eat to ensure adequate nourishment and to avoid food and drink spillage. LVN 1 stated Resident 36 should receive assistance. During an interview on 1/23/2026 at 2:02 p.m. with the Director of Nursing (DON), the DON stated Resident 36 was independent and did not require assistance for eating. The DON stated a resident with hand tremors would not be able to feed themselves and would require staff's assistance to eat. During a review of the facility's P&P titled Quality of Life dated 11/2019, the P&P indicated it was the facility's policy to ensure that residents received treatment and care in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs.

Based on observation, interview, and record review, the facility failed to maintain good grooming and personal hygiene for two of 12 sampled residents (Resident 33 and Resident 3) by failing to keep their nails clean and neat. This deficient practice had the potential to result in a negative impact on Residents 33 and 3's quality of life and self-esteem and had the potential for development of infection. Findings: a. During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 33's diagnoses included enterocolitis (an infection causing inflammation of the small intestine and colon), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN- high blood pressure). During a review of Resident 33's Minimum Data Set (MDS- a resident assessment tool), dated 11/19/2025, the MDS indicated Resident 33's cognition (ability to think and process information) was intact. The MDS indicated Resident 33 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 1/20/2026 at 9:30 a.m., with Resident 33, in Resident 33's room, observed Resident 33's fingernails long with black substance underneath her nails. Resident 33 stated her fingernails looked long and that she would like to have her fingernails cut and cleaned. During an observation on 1/21/2026 at 1:13 p.m., in Resident 33's room, Resident 33 was observed to have long fingernails with a black substance underneath all ten fingernails. During an interview on 1/21/2026 at 2:13 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated nail care was a part of the CNA's duties, which include clipping, trimming, and cleaning the resident's nails. CNA 1 stated residents' nails should be monitored daily to ensure they remain clean and neat. CNA 1 stated that residents may scratch themselves, and if their fingernails were dirty, this could lead to open wounds and increased risk for infection. CNA 1 stated dirty fingernails were unsanitary, especially when residents use their hands to eat, as bacteria under the nails could be transferred to food or utensils and then injected. CNA 1 stated having dirty fingernails also placed other residents at risk, as bacteria from one resident's hands could be transferred to share surfaces or objects, potentially spreading germs and increasing the risk of illness among residents. During an interview on 1/23/2026 at 2:15 p.m., with the Director of Nursing (DON), the DON stated it was the facility's expectation for nursing staff, including CNAs, to monitor and assist residents with nail hygiene as a part of their routine care. The DON stated dirty overgrown fingernails could pose health and infection control concerns. The DON stated staff were expected to trim or report unclean fingernails promptly and to document any refusal or limitations. b. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included diabetes mellitus and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's History and Physical (H&P), dated 10/7/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 3 was dependent on staff for all ADL's. During a review of Resident 3's Order Summary Report, dated 1/10/2026, the Order Summary Report indicated podiatry (treatment of the feet and their ailments) consult as needed. During a review of Resident 3's care plan titled ADLs, dated 7/23/2025, the care plan indicated interventions were during baths/showers staff would check nail length, trim, and clean nails on bath days and as necessary. During a concurrent observation and interview on 1/23/2026 at 9:40 a.m. with CNA 2, in Resident 3's room, observed Resident 3's toenails were long, yellow, thick and digging into adjoining toes. CNA 2 stated he reported the nails to the charge nurse and to social services director (SSD). CNA 2 stated he informed the SSD that Resident 3 needed to get her nails cut and the SSD stated Resident 3 had issues with insurance and could not receive that service at that moment. CNA 2 stated he spoke to the facility's podiatrist (a person who treats the feet and their ailments) when he came to cut Resident 3's roommate's toenails and asked if he was going to cut Resident 3's nails. CNA 2 stated the podiatrist replied no because Resident 3 was not on his list of residents to be seen. During an interview on 1/23/2026 at 1:40 p.m. with the SSD, the SSD stated all residents were seen by the podiatrist on admission and every two months after. The SSD stated if residents' nails got too long it could be uncomfortable and non-hygienic. The SSD stated residents were not seen by the podiatrist when they refused or when they have billing issues. The SSD stated Resident 3 was last seen by the podiatrist on 7/19/2025. The SSD stated Resident 3 was not seen since the last visit because Resident 3 had insurance issues. The SSD stated Resident 3 should have been seen by podiatry even though she was having insurance issues because the facility offered that service without charge. The SSD stated she did not put Resident 3 on the list to be seen by the podiatrist since 7/19/2025. The SSD stated she should have followed up to prevent any injuries or complications due to Resident 3's long nails. During an interview on 1/23/2026 at 2:36 p.m. with the DON, the DON stated all residents must be seen by podiatry once a month. The DON stated residents must see a podiatrist for infection control and for hygiene purposes. The DON stated if residents do not see a podiatrist routinely, they have a risk of infection and could potentially miss skin injuries around toenails. During a review of the facility's policy and procedure (P&P) titled Fingernails/Toenails, Care of, revised 2/2018, the P&P indicated the facility would provide daily nail care including cleaning and regular trimming, to prevent the resident from accidentally scratching, injuring his or her skin, and to prevent infections. During a review of the facility's Job Description for Social Services Designee, dated 5/2017, the job description indicated the Social Services Designee would work cooperatively with resident/family, administration, and facility staff to assure that the physiological and concrete needs are maintained for their well-being of the resident (i.e. optical, dental, audiological, clothing, etc.).

Based on interview and record review, the facility failed to follow physician's orders, ensure medication parameters were followed, and orthostatic hypotension (sudden, sustained drop in blood pressure that occurs when standing up from a sitting or lying position) monitoring was performed for three of 12 sampled residents (Resident 84, Resident 2, and Resident 6). These deficient practices placed Residents 84 and 2 at risk for serious medication related complications, including potential overdose, underdose, or adverse effects due to unmonitored response to treatment, and placed Resident 6 at risk for undetected episodes of hypotension, falls, and injury for not being monitored. Findings: a. During a review of Resident 84's admission Record, the admission Record indicated Resident 84 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 84's diagnoses included hypertension (HTN- high blood pressure), dementia (a progressive state of decline in mental abilities) and epilepsy (a chronic brain disorder). During a review of Resident 84's Minimum Data Set (MDS – a resident assessment tool), dated 10/13/2025, the MDS indicated Resident 84's cognition (ability to think and process information) was moderately impaired. The MDS indicated Resident 84 required moderate (helper does less than half the effort) assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 84's History and Physical (H&P), dated 11/7/2025, the H&P indicated Resident 84 did not have the capacity to make medical decisions. During a review of Resident 84's physician's order, dated 11/4/2025, the order indicated to monitor Resident 84's weight weekly for four weeks. During a review of Resident 84's Order Summary Report, dated 12/9/2025, the order summary report indicated on 11/5/2025, Resident 84's attending physician prescribed Lisinopril (medication used to treat hypertension) 10 milligrams ([mg]- metric unit of measurement, used for medication dosage and/or amount) by mouth daily in the morning for hypertension. The order included a clinical hold parameter, which directed nursing staff to withhold Lisinopril dose if the resident's systolic blood pressure (SBP) was below 110 millimeters of mercury ([mm/Hg] measure blood pressure), or the heart rate (HR) below 60 beats per minute (bpm) at the time of administration. During a concurrent interview and record reviewed on 1/22/2026 at 3:50 p.m., with the Director of Nursing (DON), Resident 84's physician's order, dated 11/5/2025, and Medication Administration Record (MAR), dated 11/2025 through 1/2026, and weights and vitals summary, dated 1/23/2026, were reviewed. The physician order indicated Resident 84 was to receive Lisinopril 10 mg by mouth daily in the morning, with parameters to hold medication if SBP below 110 mm/Hg or HR below 60 bpm. The DON stated the MAR indicated The DON stated the MAR indicated Resident 84 received Lisinopril 10 mg daily from 11/9/2025 through 1/22/2026. The DON stated Resident 84's BP was recorded as ordered; however, the HR was not recorded prior to medication administration. The DON stated there were no HR readings documented from 11/5//2025 to 1//22/2026. The DON stated there was no documented evidence explaining missed Lisinopril doses from 11/5/2025 to 11/7/2025. Upon further review of Resident 84's weights and vitals summary, dated 1/23/2026, the DON stated the last weight recorded for Resident 84 was on 1/28/2025, even though a physician order dated 11/4/2025 indicated staff to monitor weight weekly for four weeks. The DON stated the facility did not implement the weight monitoring order as written. The DON stated the HR and weight monitoring had not been completed as ordered. The DON stated the facility's expectation was for all physician orders to be reviewed and implemented as written. The DON stated failure to follow the physician order for HR monitoring placed Resident 84 at risk for medication side effects and worsening heart function, such as hypotension (low blood pressure), and bradycardia (abnormal heart rate below 60 bpm). The DON stated that without accurate and timely HR monitoring could result in delayed recognition of Resident 84's changes in condition, inappropriate continuation of antihypertension medication, and health decline. The DON stated failure to implement physician order for weight monitoring timely placed Resident 84 at risk for potential unavoidable weight loss or gain. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure) and heart failure (progressive heart disease that affects pumping action of the heart muscles, causes fatigue and shortness of breath). During a review of Resident 2's H&P, dated 10/26/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 2 required supervision for eating and oral hygiene. The MDS indicated Resident 2 required moderate assistance (helper does less than half the effort) for upper body dressing and personal hygiene. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) for toileting hygiene, lower body dressing, and putting on and taking off shoes. During a review of Resident 2's Order Summary Report, dated 10/27/2025, the Order Summary Report indicated Resident 2 had an order for diltiazem (used to treat high blood pressure) oral tablet 60 mg, one tablet by mouth three times a day for atrial fibrillation ([Afib], irregular heart rhythm) hold if SBP was less than 110. During a review of Resident 2's MAR, dated 1/1/2026 – 1/31/2026, the MAR indicated on 1/3/3036, 1/9/2026 and 1/10/2026 at 9:00 p.m., on 1/18/2026 at 9:00 a.m., and on 1/22/2026 at 5:00 p.m., Resident 2 was administered diltiazem. The MAR indicated Resident 2's SBP was less than 110. During an interview on 1/23/2026 at 11:02 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated blood pressure parameters were used to prevent blood pressures to drop. LVN 3 stated a resident with a systolic blood pressure less than 110 should not receive diltiazem medication because it could potentially lower blood pressure to an unsafe level. LVN 3 stated licensed nurse should hold medication and inform the doctor the resident did not receive mediation. During a concurrent interview and record review on 1/23/2026 at 11:25 a.m. with LVN 3, Resident 2's MAR, dated 1/1/1016 – 1/31/2026 was reviewed. The MAR indicated Resident 2 received diltiazem medication on days where the SBP was less than 110. LVN 3 stated it was an unsafe practice to administer this medication when the resident's SBP was already low. LVN 3 stated the medication would lower Resident 2's blood pressure more. During an interview on 1/23/2026 at 2:40 p.m. with the DON, the DON stated nursing staff must follow all medication parameters. The DON stated it would be harmful to administer medication if Resident 2's SBP was lower than 110. The DON stated she expected nursing staff to retake the blood pressure. The DON stated if the blood pressure was still low to hold the medication and document why the medication was not administered. c. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included hypertension and end stage of renal disease ([ESRD], irreversible kidney failure). During a review of Resident 6's H&P, dated 11/11/2025, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 6 required set up and clean up assistance for eating. The MDS indicated Resident 6 required supervision for eating and upper body dressing. The MDS indicated Resident 6 required moderate assistance for toileting hygiene, lower body dressing and personal hygiene. During a review of Resident Order Summary Report, dated 12/24/2025, the Order Summary Report indicated to check Resident 6's orthostatic hypotension every Sunday. During a review of Resident 6's MAR, dated 1/1/2026 – 1/31/2026, the MAR did indicate Resident 6's orthostatic blood pressure was documented for sitting, lying and standing positions on Sundays. During an interview on 1/23/2026 at 11:38 a.m. with LVN 3, LVN 3 stated orthostatic blood pressure was monitored to find out if there was a sudden drop of blood pressure when changing positions from lying, sitting and standing. During a concurrent interview and record review on 1/24/2026 at 11:47 a.m. with LVN 3, Resident 6's MAR, dated 1/1/2026 - 1/31/2022 was reviewed. The MAR indicated Resident 6's orthostatic blood pressure for lying, sitting and standing was not monitored. LVN 3 stated she monitored Resident 6's blood pressure in the lying and sitting position but it did not show in the MAR. LVN 3 stated she did not monitor Resident 6's orthostatic blood pressure when standing. LVN 3 stated she was supposed to monitor the orthostatic blood pressure when standing but did not. LVN 3 stated the blood pressure monitoring was inaccurate and there was no way of knowing if there was a difference in Resident 6's blood pressures when in different positions. During an interview on 1/23/2026 at 2:28 p.m. with the DON, the DON stated orthostatic blood pressures were monitored for any changes in blood pressure when the residents change positions. The DON stated if the orthostatic blood pressures were not monitored there would be a risk of injury for residents. The DON stated if orthostatic blood pressures were not monitored, the doctor's orders were not followed and the residents' doctor had to be notified. During a review of the facility's Policy and Procedure (P&P) titled Medication Administration, dated 12/2019, the P&P indicated medications would be administered in accordance with written orders of the prescriber. During a review of the facility's P&P titled Medication Administration- General Guidelines, revised 12/2019, the P&P indicated the facility should follow specific procedures for medication administration, including, but not limited to, documentation of medication refusal, holding of doses, and monitoring vital signs. During a review of the facility's P&P titled Physician's Order Clarification, dated 11/2021, the P&P indicated all physician orders must be clear, complete, and accurately transcribed into the resident's medical record. The P&P indicated the order would be communicated to all relevant staff, would be promptly implemented and caried out. During a review of facility's LVN Job Description, dated 5/2017, the Job Description indicated LVN's would follow through resident care services needed to meet the individualized needs of each resident. The job description indicated LVN's would administer medications in a proficient manner. The job description indicated LVN's would correctly differentiate between normal and abnormal clinical findings and intervene in accordance with clinical standards of practice and per physician orders.

Based on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 38) was provided active-assist range of motion [(AAROM), a physical therapy term for exercises where the patient moves a body part independently but a therapist or device assists further] as indicated in the physician's (MD, medical doctor) order.This failure had the potential for Resident 38 to exhibit range of motion (ROM, full movement potential of a joint) decline. Findings: During a review of Resident 38's admission Record, the admission Record indicated the facility admitted Resident 38 on 6/26/2025 with diagnoses including cerebral ischemia (reduced or blocked blood flow to the brain), hypertension (HTN-high blood pressure), dysphagia (difficulty swallowing), and lack of coordination. During a review of Resident 38's Minimum Data Set (MDS, a resident assessment tool) dated 1/02/2026, the MDS indicated Resident 38 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 38 was dependent on staff for Activities of Daily Living (ADLs) such as bathing, dressing and toileting.During a review of Resident 38's history and physical (H&P), dated 6/29/2025, the H&P indicated Resident 38 did not have capacity to understand and make medical decisions.During a review of Resident 38's physician (MD, medical doctor) order, dated 12/1/2025, the order indicated Resident 38 was to receive restorative nursing aide [(RNA), a certified nursing assistant (CNA) with specialized training in therapeutic rehabilitation, focused on helping patients maintain or improve functional mobility and independence] services for AAROM to bilateral (both) upper extremities (BUE)/bilateral lower extremities (BLE) as tolerated daily 5 times a week. During a review of resident 38's care plan dated 1/15/2026, the care plan indicated Resident 38 needed assistance with Activity of Daily Living (ADL). Resident 38 had an ADL self-care performance deficit and needed assistance from staff with interventions that included encouraging the resident independence, restorative nursing program as ordered, notifying the charge nurse or rehabilitation MD of any decline, and providing RNA for AAROM to BUE/BLE as tolerated daily 5 times a week as ordered. During an observation on 1/21/2026 at 1:56 p.m., at Resident 38's bedside, Resident 38 was observed receiving Passive Range of Motion [(PROM), moving of joints through their full range without muscle effort from the patient] exercises by Restorative Nursing Aide (RNA) 2. During an observation on 1/21/2026 at 3:17 p.m., at Resident 38's bedside, Resident 38 was observed receiving PROM and AAROM exercises to BUE and BLE by Physical Therapist (PT). During interviews on 1/21/2026 at 1:56 p.m. and 1/22/2026 at 9:25 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 38 cannot do AAROM on the right side of the body. CNA 2 stated she was performing PROM exercises on Resident 38. CNA 2 stated Resident 38's order indicated Resident 38 should receive AAROM to BUE and BLE. CNA 2 stated it was important to follow the MD order to identify changes that may need to be reported. During an interview on 1/21/2026 at 3:17 p.m., with the PT, the PT stated Resident 38's order indicated Resident 38 should receive AAROM to BUE and BLE. During an interview on 1/22/2026 at 8:35 a.m., with RNA 3, RNA 3 stated Resident 38's order indicated Resident 38 should receive AAROM to BUE and BLE. RNA 3 stated if the resident cannot participate independently, the RNA does PROM. RNA 3 stated it was important to follow orders so the residents' ROM can improve. During an interview on 1/22/2026 at 9:50 a.m., with the Director of Staff Development (DSD), the DSD stated Resident 38 receives AAROM because the resident can initiate movement of BUE and BLE and staff will assist with AAROM. DSD 1, stated it was important to follow the physician's order so the resident will benefit and not decline in ROM. During an interview on 1/23/2026 at 9:20 a.m., with the Director of Nursing (DON), the DON stated not following the order could result in decreased mobility. DON stated the importance of following RNA orders to prevent contractures and improve quality of care. During an interview on 1/23/2026 at 10:35 a.m., with the Director of Rehabilitation (DOR), the DOR stated, AAROM exercises will allow resident to activate muscles themselves. The DOR stated not following the order could lead to increased tension in the muscle resulting in decreased ROM.During a review of the facility's Restorative Range of Motion policy, dated 2/2017, the P&P indicated Restorative ROM should be conducted as directed by the physician's order.

Based on observation, interview, and record review, the facility failed to ensure care and services related to urinary Foley catheter (a flexible tube inserted through the urethra [a hollow tube that lets urine leave the body] into the bladder to drain urine into a collection bag) management were provided for one of two sampled residents (Resident 11) by failing to:a. Irrigate (wash out) Resident 11's Foley catheter as needed as indicated by the physician orders.b. To Notify the Resident 11's physician of urine sediment (matter that settles to the bottom of a liquid), cloudiness and urinary pain.These deficient practices resulted in urinary catheter obstruction, and had the potential for increased infection, discomfort and decline in Resident 11's health status.Findings:During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE]. Resident 11's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), neuromuscular dysfunction of bladder (a dysfunction of the bladder caused by nerve damage, resulting in loss of bladder control, urinary incontinence, or retention), chronic kidney disease (long-term, irreversible loss of kidney function), hearth failure (a condition where the heart muscle doesn't pump blood as well as it should), and epilepsy (a chronic brain disorder causing recurring seizures due to abnormal electrical activity among brain cells).During a review of Resident 11's History and Physical (H&P), dated 1/22/2026, the H&P indicated Resident 11 did not have the capacity to understand and make decisions.During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool), dated 12/9/2025, the MDS indicated Resident 11 had severe cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 11 required substantial/maximal assistance (helper does more than half the effort). Substantial/maximal assistance for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a concurrent observation and interview on 1/20/2026 at 9:40 a.m., with Resident 11, Resident 11's Foley catheter was observed to be cloudy and clogged with sediment. Resident 11 stated, I don't think the Foley catheter has ever been flushed. Resident 11 stated he had on and off urinary pain and burning when urinating. Resident 11 stated the nurses were aware, but nothing had been done.During a concurrent interview and record review on 1/21/2026 at 2:03 p.m., with Registered Nurse (RN) 2, Resident 11's nursing progress notes for the months of 11/2025, 12/2025 and 1/2026 were reviewed. RN 2 stated the last time Resident 11's Foley catheter was flushed was 11/15/2025. RN 2 stated that he was not aware as to why the Foley catheter had not been irrigated, changed or reinserted recently as per the physician orders. RN 2 stated he was unable to locate any progress notes or change in condition notes regarding physician notification of the urine sediment, cloudiness and reports of urinary pain and burning for Resident 11.During a concurrent interview and record review on 1/21/2026 at 2:15 p.m., with the Infection Preventionist (IP), Resident 11's physician orders dated 12/04/2025 were reviewed. The physician orders indicated:1. May irrigate with 100 cc (cubic centimeters - measurement of volume) normal saline as needed for tube clogging or maintain patency.2. Change catheter bag as needed when bag is soiled or catheter dislodged as needed.3. May reinsert Foley catheter as needed for malfunction or dislodgment.During a concurrent observation and interview on 1/21/2026 at 2:33 p.m., with the IP, and Resident 11, Resident 11's indwelling Foley catheter was observed with visible sediment and cloudy urine. The IP asked Resident 11 if he had pain. Resident 11 replied, I have on and off urinary pain and burning. The IP stated that urine from a Foley catheter should be clear and free of sediment. The IP stated that the presence of sediment and cloudiness indicated an abnormal finding. The IP stated that the physician's orders related to Foley catheter care had not been followed. The IP indicated that this represented a significant failure to provide appropriate care for Resident 11. The IP stated that failure to follow physician orders places the resident at increased risk for urinary tract infection, sepsis (a life-threatening blood infection) , and worsening of the resident's medical condition.During a review of the facility's policy and procedure (P&P) titled, Indwelling Catheter Care dated 2/2017, the P&P indicated To ensure the care of the urinary catheter is carried out in a manner that minimizes trauma and infection risk. Maintenance: change catheter and drainage bag as needed for any signs of infection and obstruction.During a review of the facility's P&P titled, Change of Condition dated 8/2017, the P&P indicated It is the facility's policy that it shall promptly notify resident's attending physician of changes in the resident's medical condition and/or status.During a review of the facility's P&P titled, Physician's Order Clarification dated 11/2021, the P&P indicated physician orders to ensure resident safety, regulatory compliance, and effective communication among healthcare providers in the facility.

Based on interview and record review, the facility failed to ensure a pain scale (an assessment tool used to rate pain level) was used when administering Tramadol (a narcotic medication used to treat moderate to severe pain) for one of one sample resident (Resident 33). This deficient practice had the potential to result in the resident having inadequate treatment, miscommunication between nurses and physicians, and poorly controlled pain. Findings: During a review of Resident 33's admission Record, the admission record indicated Resident 33 was admitted to the facility on [DATE] and was readmitted [DATE] with diagnoses that included but not limited to Type II diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), and low back pain. During a review of Resident 33's Minimum Data Set (MDS- a resident assessment tool) dated 11/19/2025, the MDS indicated Resident 33's cognitive skills (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 33 required set up or clean up assistance for eating. The MDS indicated Resident 33 required moderate assistance (helper does less than half the effort) for oral and personal hygiene, and upper body dressing. The MDS indicated that Resident 33 required maximal assistance (helper does more than half the effort) from staff for toileting, lower body dressing and dependent upon staff for shower/bathing. During a concurrent interview and record review on 1/21/2026 at 3:06 p.m. with Registered Nurse (RN) 1, Resident 33's Tramadol Administration details from the medication administration record (MAR) printed on 1/21/2026 at 3:31pm was reviewed. The tramadol administration detail did not indicate a pain rating for Resident 33. RN 1 stated that Tramadol was given for pain, but she did not document a pain rating. During an interview on 1/21/2026 at 3:06 p.m. with RN 1, RN 1 stated a pain rating was needed to determine the correct medication to give Resident 33. RN 1 stated, that not giving the correct medication could result in Resident 33's pain not being controlled. During a review of Resident 33's physician's order for Tramadol dated 1/12/2026 at 9:22 p.m., the physician's order indicated tramadol should be given as needed for moderate pain of four through six (4-6) (on a scale from 0 to 10, where 0 represents no pain and 10 represents the worst possible pain). During an interview on 1/22/2026 at 1:00 p.m. with the Director of Nursing (DON), the DON stated that pain rating must be documented when administering a pain medication. During a review of the facility's policy and procedure (P&P) titled, Pain, dated 2005, the P&P indicated staff should assess for pain using a tool such as a pain scale (an assessment tool residents can use to rate the intensity of pain). During a review of the facility's P&P titled, Ordering and Implementing PRN Medications and Treatments, dated 2005, the P&P indicated as needed (PRN) orders will clearly identify appropriate circumstances for a medication's use.

Based on observation, interview, and record review, the facility failed to follow physician orders for dialysis treatment (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) on Sundays, Tuesdays, and Fridays, and failed to ensure staff assessed the dialysisaccess site (surgically created access allowing blood removal and return during dialysis) each shift for two of two sampled residents (Residents 90 and 102). These deficient practices placed Resident 102 at risk for undetected dialysis access site complications, including swelling, pain, bleeding, bruising, and access malfunction, and placed Resident 90 at an increased risk of missed or delayed dialysis treatments, potentially resulting in serious adverse health outcomes.Findings: 1. During a review of Resident 102's admission Record, the admission Record indicated Resident 102 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 102's History and Physical (H&P), dated 1/22/2026, the H&P indicated Resident 102 had the capacity to understand and make decisions. During a review of Resident 102's Minimum Data Set ([MDS] a resident assessment tool), dated 12/2/2025, the MDS indicated Resident 102's cognitive skills for daily decision making was intact (ability to think and reason). The MDS indicated Resident 102 required set up or clean up assistance for eating. The MDS indicated Resident 102 required supervision for oral hygiene, toileting hygiene, upper body dressing, putting on and taking off shoes, and personal hygiene. The MDS indicated Resident 102 required maximal assistance (helper does more than half the effort) for shower/bathing. During a review of Resident 102's Order Summary Report, dated 1/12/2026, the Order Summary Report indicated to monitor Resident 102's dialysis access site, right upper chest for signs and symptoms of infection, bleeding, redness, swelling, and discharge every shift. During a review of Resident 2's Medication Administration Record (MAR), dated 1/1/2026 – 1/31/2026, the MAR indicated Resident 102's perma catheter (catheter placed inside a blood vessel in the neck or under collarbone and then threaded into the right side of heart, used for dialysis) would be monitored for signs and symptoms of infection such as redness, swelling, soreness, pain warmth and bleeding on every shift. The MAR indicated monitoring was discontinued on 1/12/2026. During an interview on 1/23/2026 at 10:40 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated dialysis access sites must be monitored every day and on every shift. LVN 1 stated dialysis access sites must be monitored for signs and symptoms of infection. LVN 1 stated if dialysis sites were not get monitored for signs and symptoms of infection or for bleeding there would be a risk of delayed care. During a concurrent interview and record review on 1/23/2026 at 10:50 a.m. with LVN 1, Resident 102's MAR, dated 1/1/1016 – 1/31/2026 was reviewed. The MAR indicated Resident 102 perma catheter would be monitored for signs and symptoms of infection such as redness, swelling, soreness, pain warmth and bleeding on every shift. The MAR indicated perma catheter monitoring was discontinued on 1/12/2026. LVN 1 stated she was not aware Resident 102's perma catheter monitoring order was not renewed after he returned to the facility. LVN 1 stated the MAR indicated Resident 102's perma catheter site was not monitored since he returned from the General Acute Care Hospital (GACH) on 1/12/2026. LVN 1 stated if Resident 102's perma catheter site was not monitored there would be no way of knowing if the site was bleeding or had signs of infection. During an interview on 1/23/2026 at 2:20 p.m. with the Director of Nursing (DON), the DON stated dialysis access sites have to be monitored to make sure they were in working condition. The DON stated if dialysis access sites were not monitored, there was a risk of not providing the care that residents needed. 2. During a review of Resident 90's admission Record, the admission Record indicated the facility admitted Resident 90 on 6/28/2024 with diagnoses including diabetes mellitus, hyperlipidemia (high cholesterol), and end stage renal disease (ESRD, the final, permanent stage of kidney failure) and dependent on renal dialysis. During a review of Resident 90's History and Physical (H&P), dated 9/26/2024, the H&P indicated Resident 90 had the capacity to understand and make decisions. During a review of Resident 90's MDS, dated [DATE], the MDS indicated Resident 90's was dependent (helper does all of the effort.). The MDS indicated Resident 90 was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs). During an interview on 1/20/2026 at 9 a.m., with Resident 90, Resident 90 stated that she attends dialysis on Monday, Wednesday, and Friday. During a concurrent interview and record review on 12/22/2026 at 2:51 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 90's physician orders for dialysis dated 12/22/2025 were reviewed. The physician order indicated: Hemodialysis every Sunday, Tuesday, Friday. LVN 2 stated Resident 90 was sent for dialysis every Monday, Wednesday and Friday which was not consistent with the physician's orders. LVN 2 stated the dialysis order was not being followed. LVN 2 stated that this failure could have placed Resident 90 at risk for fluid overload, electrolyte imbalance and demonstrate noncompliance with physician orders. During an interview on 1/23/2026 at 10:50 a.m., with the Director of Nursing (DON), the DON stated that all physician orders must be followed to provide proper care for all residents. The DON stated that not all residents have the same dialysis schedule and therefore their dialysis schedule must be followed to avoid potential schedule conflict with the dialysis center and/or transportation company. The DON stated that not following the physician orders for dialysis placed Resident 90 at risk for fluid overload, inadequate toxin removal and potential hospitalization. During a review of the facility's Policy and Procedure (P&P) titled Dialysis Care, undated, the P&P indicated it was the facility's policy to provide standards of care to residents receiving dialysis care. The P&P indicated shunt sites ([vascular access] a high flow, easily accessible pathway to the bloodstream for dialysis) would be checked every shift for condition and patency. During a review of the facility's P&P titled, Hemodialysis, Care of Residents dated 8/2017, the P&P indicated Review and ensure orders upon admission are received for follow-up dialysis center appointments, shunt care, diet and fluid restriction. The P&P indicated the facility would provide residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes. The P&P indicated facility would review and ensure orders upon admission are received for follow-up shunt care. The P&P indicated the facility would provide routine shunt care and monitoring per physician order.

Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 17 and Resident 44) were free from avoidable accidents and accident hazards when the facility: 1. Did not conduct an Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) assessment following Resident 17's fall on 6/14/2024. 2. Did not develop or implement person-centered interventions to prevent Resident 17 from having repeated falls on 6/21/2024 and 8/3/2024. 3. Did not conduct an IDT in a timely manner, after Resident 44 fell on [DATE], to prevent further falls. 4. Did not develop new, person-centered, fall prevention interventions following Resident 44's fall on 5/19/2024 and subsequent falls on 8/22/2024 and 9/14/2024. 5. Failed to conduct an accurate IDT assessment on 6/24/2024 and provide individualized recommendations to prevent Resident 44 from further falls. 6. Failed to provide padded siderails for Resident 44, Resident 6, and Resident 35 as ordered by the physician. These deficient practices resulted in Resident 17 having two falls on 6/21/2024 and 8/3/2024. On 8/3/2024, Resident 17 sustained a laceration (a cut, tear, or opening in the skin) to the back of her head, a right parietal scalp hematoma (a collection of blood between the skin and skull bone on the side of the head), and fractures (broken bones) to the sacral (area near the low back and upper buttocks) and lumbar (lower back) regions, which led to a hospitalization at a general acute care hospital (GACH) for evaluation and treatment. This deficient practice also resulted in Resident 44 falling on 8/22/2024, where he sustained a forehead abrasion (a partial thickness wound caused by damage to the skin). Resident 44 fell a third time on 9/14/2024 (within 23 days from the previous fall) and complained of moderate pain (pain that can't be ignored for more than a few minutes but can be managed with effort) to his head. This deficient practice also placed Residents 44, 6, and 35 at risk for injuries. Findings: 1. During a review of Resident 17's Admission Record, the Admission Record indicated Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 17's admitting diagnoses included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), dementia (a progressive state of decline in mental abilities), history of falling, lack of coordination, and abnormalities of gait (manner of walking) and mobility. During a review of Resident 17's History and Physical (H&P), dated 8/11/2024, the H&P indicated Resident 17 did not have the capacity to understand and make decisions. During a review of Resident 17's Minimum Data Set (MDS, a resident assessment tool), dated 10/29/2024, the MDS indicated Resident 17 had severe cognitive impairment (problems with the ability to think, learn, remember, and make decisions). The MDS indicated Resident 17 required partial to moderate assistance from staff to transition from a sitting to standing position, transferring from bed to chair or chair to bed, and to transfer on and off the toilet. The MDS indicated Resident 17 required partial to moderate assistance to walk 150 feet once standing. During a review of Resident 17's Fall Risk Evaluation, dated 1/30/2024, the assessment indicated Resident 17's score was 11 (a score of 11 or higher indicated a risk for falls). During a review of Resident 17's care plan titled At risk for fall related to history of fall, weakness, dementia, osteoarthritis, osteoporosis, created 2/15/2024, the care plan indicated staff were to encourage Resident 17 to call for assistance. During a review of Resident 17's Change of Condition (COC) assessment, dated 6/14/2024, the COC assessment indicated on 6/14/2024 Resident 17 was found on the floor in her room. The COC assessment indicated Resident 17 told staff she fell . The COC assessment indicated Resident 17 reported a pain score of 7 (scale of 1 to 10, with 10 being excruciating pain) to the right side of her head. The COC assessment indicated Resident 17 was transferred to the GACH following the fall. During a review of Resident 17's Fall Risk Evaluation, dated 6/17/2024, the evaluation indicated Resident 17's score was 13. During a review of Resident 17's COC assessment, dated 6/21/2024, the COC assessment indicated Resident 17 had a history of fall on 6/14/2024, and 6/21/2024 with minor injury (injury unspecified). The COC assessment did not indicate any new fall interventions. During a review of Resident 17's IDT Assessment, dated 7/29/2024, the IDT assessment indicated Resident 17 had a fall on 6/14/2024 requiring hospitalization , and another fall on 6/21/2024. The IDT assessment indicated Resident 17's medical diagnoses caused her to experience confusion and forgetfulness. The IDT assessment indicated the recommendations indicated staff would continue to educate Resident 17 to use her call light for assistance and to sit up slowly before walking. During a review of Resident 17's Fall Risk Evaluation, dated 7/30/2024, the evaluation indicated Resident 17's score was 13. During a review of Resident 17's COC assessment, dated 8/3/2024, the COC assessment indicated on 8/3/2024, Resident 17 was found on the floor, with a bleeding wound on the top of her head. The COC assessment indicated Resident 17 complained of moderate pain to her head and back. The COC assessment indicated Resident 17 was transferred to GACH 1 via emergency services. During a review of Resident 17's GACH 1 record titled Emergency Department Note, dated 8/3/2024, the record indicated Resident 17 was brought to GACH 1 by ambulance after she fell on the back of her head. The record indicated Resident 17 had a 0.5 inch laceration to the back of her head and complaints of pain to her head and lower back. During a review of Resident 17's GACH 1 computed tomography (CT) scan (a medical imaging procedure that uses X-rays and a computer to create detailed pictures of the inside of the body) report of her chest, abdomen, and pelvis, dated 8/3/2024, the report indicated Resident 17 had a compression fracture (a break in a bone that occurs when pressure causes the bone to collapse) at lumbar spine 1 (L1, the first bone of the spine in the lumbar region of the back), and broken bones to the resident's sacral region on both sides of the body. During a review of Resident 17's GACH 1 CT scan report of the head and brain, dated 8/3/2024, the report indicated Resident 17 had a moderate right parietal scalp hematoma (a collection of blood between the skin and skull bone on the side of the head). During a review of Resident 17's GACH 1 Discharge Summary Brief, dated 8/13/2024, the note indicated Resident 17 had diagnoses of bilateral (both sides of the body) sacral fractures and L1 compression fracture. The note indicated Resident 17's fractures were determined inoperable and the resident was recommended for higher level of care. During a concurrent interview and record review, on 12/3/2024 at 2:57 p.m., with Registered Nurse (RN) 1, Resident 17's COC assessments dated 6/14/2024, 6/21/2024, and 8/3/2024, and care plan titled At risk for fall related to history of fall, weakness, dementia, osteoarthritis, osteoporosis, dated 2/15/2024, were reviewed. RN 1 stated the COC assessments indicated Resident 17 had three falls after the initiation of her fall risk care plan on 2/15/2024. RN 1 stated the care plan and COC assessments did not indicate that new, resident-centered interventions to prevent further falls had been developed or implemented after Resident 17's falls on 6/14/2024 and 6/21/2024. RN 1 stated Resident 17 was confused and forgetful. RN 1 stated Resident 17 could have benefited from the implementation of staff supervision. RN 1 stated the implementation of resident-specific interventions could have prevented Resident 17 from falling and sustaining injuries on 8/3/2024. During a concurrent interview and record review on 12/4/2024 at 3:24 p.m., with the Director of Nursing (DON), Resident 17's IDT assessments dated 7/29/2024 and 10/28/2024 were reviewed. The DON stated the IDT assessment dated [DATE] indicated a fall prevention intervention of educating the resident to call for help and to sit up slowly before walking. The DON stated the IDT assessment should have been completed at the time of Resident 17's falls on 6/14/2024 and 6/21/2024. The DON stated the fall prevention intervention was not appropriate for Resident 17 because the resident was confused and forgetful. The DON stated it was not reasonable to expect Resident 17 to remember or follow staff's instructions. The DON stated the IDT should have implemented different, and/or additional, resident-specific fall prevention interventions after Resident 17's falls on 6/14/2024 and 6/21/2024. The DON stated the failure to implement new, resident-specific fall prevention measures placed Resident 17 at risk for repeated falls and injuries. 2. During a review of Resident 44's Admission Record, the Admission Record indicated Resident 44 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 44's admitting diagnoses included history of falling and anxiety disorder (a condition that causes excessive fear, worry, and feelings of dread or uneasiness). During a review of Resident 44's H&P, dated 3/25/2024, the H&P indicated Resident 44 did not have the capacity to understand and make decisions. During a review of Resident 44's MDS, dated [DATE], the MDS indicated Resident 44 had severe cognitive impairment, and inattention and disorganized thinking. The MDS indicated Resident 44 required substantial to maximal assistance from staff to transition from a sitting to standing position, transferring from bed to chair or chair to bed, and to transfer on and off the toilet. During a review of Resident 44's Fall Risk Evaluation, dated 3/21/2024, the evaluation indicated Resident 44's score was 14. During a review of Resident 44's care plan titled High risk for falls, initiated 3/26/2024, indicated a care goal that Resident 44 would not sustain serious injury. Staff interventions indicated to follow the facility fall protocol, review information on past falls, attempt to determine the cause of falls, and alter or remove potential causes of falls. During a review of Resident 44's COC assessment, dated 5/19/2024, the COC assessment indicated on 5/19/2024, Resident 44 had a fall. The COC did not indicate any new documented fall interventions. During a review of Resident 44's IDT Assessment, dated 6/24/2024, the IDT assessment indicated staff were required to indicate if Resident 44 had any safety issues or risks, including a history of falls in the previous 180 days. The IDT assessment did not indicate Resident 44's history of a fall on 5/19/2024. The IDT assessment did not indicate the cause of Resident 44's fall on 5/19/2024, or if staff altered or removed potential causes of falls, as indicated on Resident 44's care plan. During a review of Resident 44's Fall Risk Evaluation, dated 6/26/2024, the evaluation indicated Resident 44's score was 13. During a review of Resident 44's COC assessment, dated 8/22/2024, the COC assessment indicated on 8/22/2024, Resident 44 was found with his face down on the floor. The COC assessment indicated Resident 44 reported he fell from his bed. The COC assessment indicated Resident 44 sustained a forehead wound measuring 3.8 centimeters (cm, measurement of length) by 3.8 cm, with surrounding redness to the skin. The COC assessment did not indicate any new documented fall interventions. During a review of Resident 44's COC assessment, dated 9/14/2024, the COC assessment indicated on 9/14/2024, Resident 44 was found with his face down on the floor. The COC assessment indicated Resident 44 reported he fell from his bed. The COC assessment indicated Resident 44 complained of moderate pain to his head. The COC assessment did not indicate any new documented fall interventions. During a concurrent interview and record review, on 12/3/2024 at 2:57 p.m., with RN 1, Resident 44's COC assessments dated 5/19/2024, 8/22/2024, and 9/14/2024, care plan titled High risk for falls, initiated 3/26/2024, and IDT assessment, dated 6/24/24, were reviewed. RN 1 stated the COC assessments indicated Resident 44 had three falls following the initiation of his fall risk care plan on 3/26/2024. RN 1 stated the care plan did not indicate new fall prevention interventions were created after Resident 44 fell on [DATE]. RN 1 stated Resident 44's IDT assessment, was inaccurate because it did not address Resident 44's fall from 5/19/2024. RN 1 stated the IDT indicated Resident 44 was at risk for falls. RN 1 stated Resident 44's fall and IDT assessment were two opportunities for the IDT to assess Resident 44 and develop resident-centered interventions to prevent additional falls. RN 1 stated no interventions were developed based on Resident 44's needs. RN 1 stated Resident 44's falls on 8/22/2024 and 9/14/2024 could have been prevented. During a review of the facility's policy and procedure (P&P) titled Fall Risk and Prevention Assessment, updated 3/2018, the P&P indicated facility staff were to assess and identify residents who were at risk for falls and develop appropriate plans of care to prevent resident falls and/or further falls. The P&P indicated residents identified as high risk for falls were supposed to be referred to the IDT for further assessment, proper intervention, and care planning to prevent falls. 49900 3. During a review of Resident 44's Admission Record, the Admission Record indicated Resident 44's admitting diagnoses included epilepsy (a chronic brain disorder that causes seizures [episodes of abnormal electrical activity in the brain]). During a review of Resident 44's active physician orders, dated 10/2/2024, the orders indicated staff were to apply padded siderails to prevent injury related to diagnosis of epilepsy. During a review of Resident 44's care plan titled Has a seizure disorder, dated 4/10/2024, the care plan indicated Resident 44 was to have padded siderails on both sides of his bed to prevent injury. During an observation on 12/2/2024 at 10:00 a.m., at Resident 44's bedside, observed Resident 44 bed with quarter-length siderails on both sides. The siderails were not padded. During an observation on 12/2/2024 at 8:47 a.m., at Resident 44's bedside, observed Resident 44's bed with quarter-length siderails on both sides. The siderails were not padded. During a concurrent observation and interview, on 12/3/2024 at 2:53 p.m., at Resident 44's bedside, with Certified Nursing Assistant (CNA) 2, Resident 44's bed was observed. CNA 2 stated she did not know Resident 44 was at risk for seizures or had a history of seizures. CNA 2 stated Resident 44 did not have padded siderails. CNA 2 stated the purpose of padded siderails was to protect Resident 44 from injury. During a concurrent interview and record review, on 12/3/2024 at 2:57 p.m., with RN 1, Resident 44's physician orders were reviewed. RN 1 stated Resident 44 was supposed to have padded siderails. RN 1 stated Resident 44 did not have padded siderails, and stated the purpose of the siderails was to prevent injury. RN 1 stated the absence of padding on the siderails increased the potential for Resident 44 to sustain injury if he had a seizure. 4. During a review of Resident 6's Admission Record, the Admission Record indicated Resident 6 was originally admitted to facility on 5/2/2024 and readmitted on [DATE] with diagnoses of diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN, high blood pressure), history of falling, and seizure. During a review of Resident 6's H&P, dated 5/3/2024, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making was mildly impaired. The MDS indicated Resident 6 required supervision or touching assistance (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completed activity) with oral hygiene and upper body dressing; moderate assistance (helper did less than half the effort) for toileting hygiene, lower body dressing, and personal hygiene, and substantial/maximal assistance (helper did more than half the effort) for showering /bathing and putting on/ taking off footwear. During a review of Resident 6's Order Summary Report, dated 11/5/2024, the report indicated an order, dated 7/5/2024, to apply padded side rails while in bed to prevent injury related to diagnosis of seizure. During a review of Resident 6's care plan titled The resident has a seizure disorder, revised 5/23/2024, the care plan indicated the goal was for Resident 6 to be free from injury from seizure activity. The care plan indicated staff's interventions included to apply padded side rails while in bed to prevent injury. During an observation on 12/2/2024 at 10:14 a.m., in Resident 6's room, observed Resident 6 lying on the bed with no padded side rails. During an observation on 12/3/2024 at 3:09 p.m., in Resident 6's room, observed Resident 6 lying on the bed with no padded side rails. During a concurrent observation and interview on 12/3/2024 at 3:24 p.m. with Licensed Vocational Nurse (LVN) 3, in Resident 6's room, observed Resident 6 s lying on the bed with no padded side rails. LVN 3 stated Resident 6 should have padded side rails. 5. During a review of Resident 35's Admission Record, the Admission Record indicated Resident 35 was originally admitted to facility on 7/13/2024 and readmitted on [DATE] with diagnoses of DM, HTN, epilepsy, and dementia (a progressive state of decline in mental abilities). During a review of Resident 35's H&P, dated 10/3/2024, the H&P indicated Resident 35 did not have the capacity to understand and make decisions. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognitive skills for daily decision making was intact. The MDS indicated Resident 35 required substantial/maximal assistance with upper body dressing; and was dependent with eating, oral hygiene, toileting hygiene, showering /bathing self, lower body dressing, putting on/ taking off footwear, and personal hygiene. The MDS indicated Resident 35 required substantial/maximal assistance to roll left and right; and was dependent to sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, and tub/ shower transfers. The MDS indicated Resident 35 had impairment on the upper extremity (arm) and used a wheelchair for mobility. During a review of Resident 35's Order Summary Report, dated 10/5/2024, the report indicated an order, dated 10/1/2024, to apply padded side rails while in bed to prevent injury related to seizure. During a review of Resident 35's care plan titled The resident has a seizure disorder, revised 10/25/2024, the care plan indicated the goal was for Resident 35 to be free from injury related to seizure activity. The care plan indicated staff's intervention was to apply padded side rails. During an observation on 12/2/2024 at 11:38 a.m., in Resident 35's room, observed Resident 35 lying on the bed with no padded side rails. During an observation on 12/2/2024 at 3:04 p.m., in Resident 35's room, observed Resident 35 lying on the bed with no padded side rails. During an observation on 12/3/2024 at 8:50 a.m., in Resident 35's room, observed Resident 35 lying on the bed with no padded side rails. During a concurrent observation and interview on 12/3/2024 at 2:41 p.m. with LVN 3, in Resident 35's room, observed Resident 35 lying on the bed with no padded side rails. LVN 3 stated Resident 35 should have padded side rails to prevent head injury from seizure activities. LVN 3 stated the charge nurse was responsible for ensuring the presence of padded side rails. During a review of the facility's P&P titled Safety and Supervision of Residents, revised on 7/2017, the P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated to implement interventions to reduce accident risks and hazards shall include ensuring interventions were implemented. The P&P indicated staff shall ensure that interventions were implemented correctly and consistently to monitor the effectiveness of interventions.

Based on interview and record review, the facility failed to provide visual monitoring and prevent accident hazards, as indicated in the resident ' s care plan, for one of seven sampled residents (Resident 1), who had a high risk for fall. This deficient practice resulted in Resident 1 falling, sustaining facial trauma and a right arm fracture (broken bone) which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 1 ' s admission record (face sheet), dated 1/22/2024, the face sheet indicated Resident 1, was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included parkinsonism (a brain condition that causes slow movement, stiffness, and tremors), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and osteoarthritis (a wearing down of the protective tissue at the ends of bones, causing pain and stiffness). During a review of Resident 1 ' s History and Physical (H&P) dated 1/14/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 11/1/2023, the MDS indicated Resident 1 sometimes understood others and was usually understood. The MDS indicated Resident 1 required moderate assistance from staff for activities of daily living (ADL) such as eating, oral hygiene, and personal hygiene. The MDS indicated Resident 1 required maximum assistance from staff for lower body dressing. The MDS indicated Resident 1 was dependent on staff for toileting, and showering. The MDS indicated Resident 1 was dependent on staff for transferring from a chair to a bed, and to the toilet. The MDS indicated Resident 1 required staff ' s assistance in wheeling her wheelchair for 50 feet with two turns and wheeling 150 feet. During a review of Resident 1 ' s fall risk assessment dated [DATE], the fall risk assessment indicated Resident 1 was a high risk for falls. During a review of Resident 1 ' s fall risk evaluation, dated 11/6/2023, the fall risk evaluation indicated Resident 1 was at high risk for falls. During a review of Resident 1 ' s care plan titled, At risk for fall/injury, dated 11/2023, the intervention indicated staff will assist Resident 1 with transfer and ambulation as needed (PRN), and visual monitoring every hour. During a review of Resident 1 ' s care plan titled, The resident has impaired cognitive function, impaired thought process related to dementia, dated 12/10/2023, the care plan intervention indicated staff will supervise Resident 1 as needed. During a review of Resident 1 ' s visual check monitoring sheet dated 8/2022, the monitoring sheet did not indicate Resident 1 was monitored every hour in 2024, as indicated in Resident 1 ' s care plan intervention. During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR) Fall report, dated 1/7/2024, the SBAR indicated on 1/7/2024, Resident 1 was in the hallway outside her room, waiting to be transferred to bed. The SBAR indicated Resident 1 was found on the floor, face down, in front of the wheelchair. The SBAR indicated Resident 1 had a pain level of 6/10 (moderate pain) and swelling to her left elbow and forehead. The SBAR indicated Resident 1 ' s Physician ordered the resident to be transferred to an emergency room (ER) for further evaluation. During an interview with Registered Nurse (RN 1) on 1/22/2024 at 3:30 p.m., RN 1 stated on 1/7/2024, while at the nurses ' station, a Certified Nurse Assistant (CNA) notified him, Resident 1 fell . RN 1 stated it was an unwitnessed fall which occurred after a CNA (name unknown) left Resident 1 on his wheelchair, outside the resident ' s room, unattended. RN 1 stated the CNA should not have left Resident 1 in the hallway and unattended. RN 1 stated the CNA should have notified another staff to monitor Resident 1 for safety. During an interview with Licensed Vocational Nurse (LVN 1) on 1/23/2024 at 2:45 p.m., LVN 1 stated on 1/7/2024, she observed Resident 1 outside her room on her wheelchair when she fell . LVN 1 stated she was not sure who brought Resident 1 back outside her room since the residents had just finished eating lunch. LVN 1 stated Resident 1 was at risk for falls and should not have been left unsupervised. During a concurrent interview and record review with the Director of Nursing (DON) on 1/23/2024 at 3:55 p.m., Resident 1 ' s fall risk assessment was reviewed. The DON stated Resident 1 was at risk for falls. The DON stated Resident 1 ' s interventions included visual checks and monitoring. The DON stated, Resident 1 fell after a CNA left the resident in the wheelchair, unsupervised in the hallway. The DON stated there was no staff monitoring or supervising Resident at the time of the fall. During a phone interview with CNA 1 on 2/1/2024 at 12:19 p.m., CNA 1 stated she saw Resident 1 on the floor face down, when she was walking down the hall. CNA 1 stated there were no other CNAs around when Resident 1 fell because it happened after lunch time. CNA 1 stated CNAs were busy taking residents back to their rooms. CNA 1 stated staff were not supposed to leave any residents in the hallway. During an interview with LVN 1 on 2/1/2024 at 3:42 p.m., LVN 1 stated Resident 1 was in the hallway in front of her room when Resident 1 fell . LVN 1 stated it was hard to see the resident in the hallway if the staff were inside the nurse ' s station. LVN 1 stated if staff could not see Resident 1 in the hallway, the resident was not supervised and could fall. LVN 1 stated Resident 1 ' s fall could have been prevented if the resident was supervised and monitored. During a concurrent interview and record review on 2/1/2024 at 4:11 p.m., with RN 2, Resident 1 ' s fall risk care plan was reviewed. RN 2 stated interventions for the fall risk care plan included visual (seeing) monitoring every hour. RN 2 stated visual monitoring meant making rounds every hour and seeing where the residents were. RN 2 stated the facility had just switched from paper to electronic charting and she was not sure where the visual monitoring for Resident 1 was documented. During a concurrent interview and record review on 2/1/2024 at 4:40 p.m., of Resident 1 ' s Visual Checks Monitoring Sheet dated 8/2022, with the medical records (MR), the MR stated the last visual check monitoring sheet for Resident 1 was from 8/2022 and was unable to find documentation visual monitoring being done every hour on the electronic records. During a phone interview with LVN 1 on 2/2/2024 at 9:35 a.m., LVN 1 stated she saw a CNA push Resident 1 in her wheelchair while she was gathering resident supplies. LVN 1 stated, then she saw Resident 1 sitting in the hallway outside her room but did not see any staff with Resident 1. LVN 1 stated when Resident 1 fell in the hallway, and no one saw Resident 1 fell , no one must have been keeping an eye on Resident 1. LVN 1 stated she did not tell any other staff to keep an eye on Resident 1. LVN 1 stated if anyone was at the nurses ' station, it would have been difficult to see Resident 1. During a review of Resident 1 ' s physician ' s order dated 1/7/2024 at 1:32 p.m., the order indicated to transfer Resident 1 to the GACH ER. During a review of Resident 1 ' s GACH radiology (process of taking pictures to diagnose and treat diseases) report dated 1/7/2024, the report indicated multiple right rib fractures, most likely old, maxillofacial (jaw and face) with soft tissue swelling, left supracondylar (a round part at the end of a bone) fracture and dislocation (separation of bones). During a review of Resident 1 ' s GACH ' s, H &P, dated 1/8/2024, the H &P indicated Resident 1 fell from a wheelchair and sustained a left forehead, periorbital (surrounding the eye), left elbow bruising with deformity (abnormal shape). During a review of Resident 1 ' s GACH Discharge Summary, dated 1/11/2024, the discharge summary indicated Resident 1 ' s admitting diagnosis included a fall with facial trauma and bilateral orbital ecchymosis (bruises), left elbow fracture and multiple rib fractures (possibly old findings). The discharge summary indicated Resident 1 had a left shoulder brace in place and due to her age, the resident was not a candidate for surgery because the risks outweighed the benefits. During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated the facility ' s priority was to ensure resident safety, supervision, and assistance to prevent accidents. The P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P indicated implementing interventions to reduce accident risks and hazards shall include communicating specific interventions to relevant staff and assigning responsibility for carrying out interventions.

Based on observation, interview, and record review, the facility failed to provide care and services for four of 24 sampled residents (Resident 70, 9, 49, and 68) by failing to: 1a. Ensure the correct dose of Methadone (a powerful drug used for pain relief and treatment of drug addiction) 50 milligrams ([mg]- a unit of measurement) twice a day was transcribed (copy from one place to another) per physician order. 1b. Follow up on the delivery of the Methadone with the pharmacy on 11/8/2023 when ordered by the Physician. 1c. Ensure accurate and complete documentation of the medications administered on the Electronic Medication Administration Record (EMAR, an electronic record of medications administered to a resident) and the Controlled Drug Administration Record. 1d. Notify the physician that Resident 70 had been receiving the wrong dosage of Methadone 5mg twice a day for six days (9/8/2023-9/13/2023). 2. Ensure Resident 9's diaper change was performed in a timely manner. 3. Ensure Resident 49's antibiotic (medication that treat an infection) treatment was completed and was administered at the time the medication was scheduled. 4. Ensure Resident 68 was fed in a timely manner. These failures resulted in Resident 70 verbalizing symptoms of pain, inability to sleep, and anxiety (a feeling of fear, dread, and uneasiness) as evidenced by reporting a level of eight out of ten (severe) pain on a pain scale throughout his entire body, shortness of breath, and feelings of anger, and had the potential not to meet Resident 9, 49, and 68's physical, mental, psychosocial needs, and resident's well-being. Findings: 1. During a review of Resident 70's Admission Record, the Admission Record indicated Resident 70 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The Admission Record indicated Resident 70 was admitted with diagnoses that included but not limited to fibroblastic disorders (tumors that affect connective tissue of the body), heart failure (condition in which the heart cannot pump enough oxygen-rich blood to meet the body's needs), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems) and anxiety. During a review of Resident 70's Minimum Data Set ([MDS]- a comprehensive resident assessment and care-screening tool), dated 9/14/2023, the MDS indicated Resident 70's cognition (ability to think and reason) was intact and Resident 70 required extensive assistance for bed mobility, transfers, getting dressed, toileting and performing personal hygiene. During a review of Resident 70's Care Plan, titled, At risk for pain or discomfort related to diagnosis of necrotizing fasciitis (aggressive skin and soft tissue infections that cause death of the muscle and tissues of the body), osteomyelitis (inflammation or swelling that occurs in the bone), and polyneuropathy (simultaneous [at the same time] malfunction [not working] of the nerves throughout the body), dated 9/2/2023, and revised on 9/14/2023, the staff's interventions indicated to administer pain medications as ordered, observe for pain and provide comfort. During a review of Resident 70's History and Physical (H&P), dated 10/24/2023, the H&P indicated Resident 70 had a diagnosis of polysubstance abuse (the consumption of one or more illicit substances over a defined period or simultaneously) and on methadone. During a review of Resident 70's Physician's Orders, dated 11/8/2023, the Physician's Orders indicated Resident 70 was to receive Methadone 5mg ([mg]- unit of measurement) twice a day, for a total of 10 mg a day, for chronic pain; Hydrocodone- Acetaminophen (narcotic pain medicine) oral tablet 10-325 mg, every 6 hours, for severe pain; and Hydroxyzine (medication used to help control anxiety and tension caused by nervous and emotional conditions) oral tablet 25 mg by mouth, every six hours, as needed for anxiety manifested by inability to sleep. During a review of the Pharmacy Delivery Receipt, dated 11/14/2023 and timed 12:01 p.m., the Pharmacy Delivery Receipt indicated the facility received 14 tablets of Methadone 5mg. During an interview, on 11/14/2023, at 8:25 a.m., with Resident 70, Resident 70 stated, I feel anxious, and I did not sleep well. They (staff) gave me a pill. It did not work. If I don't have my Methadone, I will feel terrible. Makes me feel angry. During an interview, 11/15/2023, at 7:36 a.m., with Resident 70, Resident 70 stated he was experiencing an eight out of ten (severe) pain, on a pain scale of 1 to 10, all over his body, felt short of breath, could not sleep well, and felt anxious. During an interview on, 11/15/2023, at 9:28 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 70's dose of Methadone was not available on 11/15/2023 and 11/14/2023. During an interview, on 11/15/2023, at 9:55 a.m., with the Pharmacist in Charge (PIC), the PIC stated the last dose of Methadone 5 mg, was delivered 11/14/2023 at 6:22 p.m. and stated was the first dose of the Methadone 5 mg delivered to the facility in November 2023. The PIC stated Resident 70 had previously been on Methadone 50 mg twice a day. The PIC stated 70 tablets of Methadone 10mg was delivered on 10/31/2023 to the facility and there had been no doses taken from the facility's emergency medication kit. During a concurrent interview and record review, on 11/16/2023, at 11:30 a.m., with LVN 1, Resident 70's eMAR, dated, 11/2023, was reviewed. The eMAR indicated the facility had administered Methadone 5 mg twice a day, per physician's order, from 11/9/2023 to 11/13/2023 at 9:00 a.m. and 5 p.m. each day. The eMAR indicated LVN 1 administered the Methadone 5 mg dose on 11/9/2023 at 9:00 a.m. and 11/13/2023 at 9:00 a.m. LVN 1 stated the Methadone 5 mg was unavailable until 11/14/23 at 12:01 p.m. and she had documented the administration of Methadone 5 mg on 11/9/23 at 9:00 a.m. and 11/13/23 at 9:00 a.m. in error. LVN 1 stated she (LVN 1) should have followed up on the reason as to why the Methadone 5 mg dose was not delivered by the pharmacy and unavailable in the facility. LVN 1 stated the lack of follow up led to the unavailability of Methadone 5 mg for six days (11/8/2023- 11/13/2023) and the inaccuracy of the eMAR documentation led to the uncontrolled pain and discomfort for Resident 70 from 11/8/2023 through 11/13/2023. LVN 1 stated this was considered a medication error. During a concurrent interview and record review, on 11/16/2023, at 12:50 p.m., with LVN 2, Resident 70's eMAR, dated 11/10/2023, was reviewed. The eMAR indicated LVN 2 administered the 5 mg dose of Methadone on the morning of 11/10/2023. LVN 2 stated the Methadone dose was not available and she inaccurately documented the administration of Methadone 5 mg. LVN 2 stated she was assigned a lot of residents that day (11/10/2023). LVN 2 stated, if the eMAR was not accurate, and Resident 70 had not received his dose of Methadone, then the resident would be subjected to pain and the resident's quality of care would be affected. During an interview, on 11/16/2023, at 1:51 p.m. with Registered Nurse (RN) 1, RN 1 stated she made a mistake when transcribing the physician order for Methadone on 11/8/2023. RN 1 stated the physician ordered Methadone 50 mg twice a day and RN 1 transcribed the order as Methadone 5 mg twice a day in the eMAR. RN 1 stated RN 1 had another admission within the same hour of Resident 70's admission, felt rushed, and did not check if the eMAR had the correct order. RN 1 stated she did not notice the transcription error until 11/14/2023, six days after Resident 70 had been admitted to the facility on [DATE]. RN 1 stated due to this mistake, Resident 70 had the potential to exhibit symptoms of pain and withdrawal during the six days of the Methadone 5mg order. During a concurrent interview and record review, on 11/16/2023, at 2:54 p.m., with the Director of Nursing (DON), the Controlled Drug Administration Record, dated 11/2023, Resident 70's eMAR, dated 11/2023, and the Nursing Progress Notes, dated 11/2023 were reviewed. The Controlled Drug Administration Record indicated the facility withdrawn from the controlled rug supply 5 tablets of Methadone 10mg, for a total of 50 mg, on 11/8/2023 at 8:41 a.m. and on 11/9/2023 at 4:17 p.m. The Controlled Drug Administration Record indicated there was no preparation documented on 11/8/2023 for the 5 p.m. dose, and on 11/9/2023 for the 9 a.m. dose. There was no documentation indicating the 9 a.m. and 5 p.m. doses were withdrawn from the drug supply on 11/10/2023, 11/11/2023, 11/12/2023, and 11/13/2023 for the 9 a.m. and 5 p.m. doses. The eMAR indicated the following administrations of Methadone 5mg, 1 tablet, to Resident 70 on following dates/times: 11/8/2023, no administration at 9 a.m. 11/8/2023, 1 tablet at 5 p.m. 11/9/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/10/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/11/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/12/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/13/2023, 1 tablet at 9:00 a.m. and 5 p.m. 11/14/2023, no administration at 9 a.m. and 5 p.m. The Nursing Progress Notes lacked documentation to explain the reason as to why the Methadone 5 mg was not given on 11/14/2023. The Nursing Progress Notes, dated 11/8/2023, indicated Resident 70 was admitted to the facility around 11:00 a.m. The Nursing Progress Notes, dated 11/8/2023, indicated Resident 70 was admitted to the facility around 11:00 a.m. The eMAR indicated Resident 70 received three doses of Hydrocodone- Acetaminophen oral tablet 10-325 mg on 11/14/2023 at the following times: At 1:10 a.m., for severe pain At 7:43 a.m., for severe pain At 16:46 (4:46 p.m.), for severe pain The eMAR indicated Resident 70 received 1 dose of Hydroxyzine (medication used to help control anxiety and tension caused by nervous and emotional conditions) 25 mg on the following dates/ times: 11/12/2023, 1 tablet at 1:38 a.m. 11/13/2023, 1 tablet at 9:59 p.m. 11/15/2023, 1 tablet at 6 a.m. The DON stated several LVN's (LVN 1, 3, and 5) had possibly administered Methadone 10 mg tablets from Resident 70's previous supply prior to the resident's readmission on 11/8/2023. The DON stated RN 1 had transcribed Methadone 5 mg twice a day instead of Methadone 50 mg twice a day when Resident 70 was readmitted to the facility on [DATE]. The DON stated the licensed nurses administered the wrong dose of Methadone, the facility failed to provide Resident 70 Methadone 50 mg twice a day as ordered by the physician, and these failures led to significant medication errors for Resident 70. The DON stated, These practices have led to the resident (Resident 70) to exhibit pain, withdrawal, and anxiety as we (DON and facility's staff) have seen today. More training needs to be done for the nurses, the RNs, and some nurses are so new. All of this [these practices] can affect the quality of care for our residents During an interview on 11/16/2023, at 3:13 p.m., with the PIC, the PIC stated the pharmacy had not delivered the dose of Methadone 5 mg because the pharmacy was questioning the dose, made multiple attempts to reach the prescribing physician, and waited until a signature authorization was sent to them. The PIC stated the pharmacy finally received the authorization and proceeded to deliver the dose on 11/14/2023. During an interview on 11/16/2023, at 4:25 p.m., with the PIC, the PIC stated, the pharmacy questioned the medication order and held the medication because the dose was significantly lowered. The PIC stated with a medication like methadone, the dose was usually gradually lowered by the prescriber. The PIC stated that if a resident had been on a high dose of a narcotic for a length of time and had been given a significantly lowered dose of the medication, then that could possibly cause withdrawal symptoms for the resident. The PIC stated, If the resident received subtherapeutic doses of methadone, especially if it was prescribed for chronic pain, then the resident may have endured pain. During an in interview on 11/17/2023, at 11:24 a.m., with Resident 70's Physician's Assistant (PA) 1, PA 1 stated Resident 70 had the potential to experience withdrawal, agitation, night sweats, inability to sleep, and anxiety due to the subtherapeutic (less than the amount needed to be effective) doses of Methadone that was wrongfully prescribed. PA 1 stated he was not made aware that Resident 70 was given a lower dose of Methadone. PA 1 stated he was not made aware Resident 70 was experiencing, pain and anxiety. PA 1 stated Methadone 10 mg a day was a significantly lower dose compared to Resident 70's usual dose of Methadone 100 mg a day. PA 1 stated it was important that he (PA 1) knew about the dosage change and the symptoms Resident 70 had been experiencing so that he could further evaluate the resident. During a review of the facility's P&P titled, Physician Orders (undated), the P&P indicated the facility was to provide care and services to the resident in accordance with physician orders. During a review of the facility's P&P titled, Controlled Substances, dated 4/2019, the P&P indicated the facility was to ensure medication administration included the name, strength, and dose of the medication and the time of administration. During a review of the facility's P&P titled, Documentation Principles (undated), the P&P indicated the facility was to ensure the staff adhered to maintain clinical records in a manner that would comply with licensing and certification governmental agency requirements and professional standards. The P&P indicated clinical entries must be accurate, legible clear and timely (recorded within the required time period). 2. During a review of Resident 9's Admission Record, the admission record indicated Resident 9 was originally admitted to the facility on [DATE] with diagnosis that included pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (tailbone) and chronic pain (long standing pain that persists beyond the usual recovery period or occurs along with a chronic health condition). During a review of Resident 9's Care Plan titled, Activity of daily living (ADL, self-care activities performed daily such as bathing, grooming, and dressing), dated 10/11/2023, the care plan indicated the goal was for all ADLs needs to be met. The staff's interventions indicated to provide assistance as needed. During a review of Resident 9's Care Plan titled, Skin Integrity, dated 10/11/2023, the care plan indicated the goal was for Resident 9 not to have skin complications. The staff's interventions to provide incontinent care as needed and to keep the resident's skin clean and dry. During a review of Resident 9's H&P dated 10/12/2023, H&P indicated Resident 9 had the capacity to understand and make decisions. The H&P indicated Resident 9 had a history of hypertension (high blood pressure). During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decision making was intact. The MDS indicated Resident 9 was totally dependent on staff for toileting, hygiene, and shower/bathing. The MDS indicated Resident 9 had a diagnosis of pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid). During a concurrent observation and interview with Resident 9 on 11/14/2023 at 8:27 a.m., in Resident 9's room, Resident 9 stated she put her call light on and told CNA 3 to change her diaper at 7:30 a.m. Resident 9 stated CNA 3 told her she was busy and would return when she (CNA 9) was done. Resident 9 stated it she felt uncomfortable sitting on a soiled diaper for almost an hour. Observed CNA 3 enter resident 9's room at 8:25 a.m., then left and returned with linens. During a concurrent observation and interview with CNA 3, in Resident 9's room, CNA 3 stated she entered Resident 9's room to change the resident's diaper. Observed CNA 3 provide a diaper change to Resident 9. CNA 3 stated she did not change Resident 9's diaper earlier because she was busy with returning food trays and then went on her break. CNA 3 stated the time Resident 9 waited to get her diaper changed was acceptable. CNA 3 stated for a resident with a decubitus ulcer (skin and soft tissue injuries that form as a result of constant or prolonged pressure exerted on the skin) on her buttocks, sitting on a soiled diaper for almost one hour could cause further skin problems. Observed CNA 3 provide a wet washcloth to Resident 9 to wipe the resident's face. CNA 3 grabbed the wet washcloth and placed it in a wet basin and used that same washcloth to clean resident's perianal area (genital region). CNA 3 stated she used the same washcloth for Resident 9's face and perianal area because she did not grab more washcloths. CNA 3 stated she should have grabbed more washcloths because using one was not hygienic. CNA 3 stated that using one washcloth could possibly cause an infection in the resident's perianal area. Resident 9 had complaints of pain when was asked to move side to side during the diaper change. CNA 3 did not offer Resident 9 a break or question where the pain was located. CNA 3 stated Resident 9 had something wrong with her hip and that was why the resident was in pain. CNA 3 stated Resident 9 was usually in pain. CNA 3 stated she did not know she had to inform her charge nurse that Resident 9 was in pain. During an interview with the Director of Staff Development (DSD) on 11/15/2023 at 3:41 p.m., the DSD stated that she expects all staff to answer call light and assist the residents right away. The DSD stated a resident should not wait more than 10 to 15 minutes for care. The DSD stated it was unacceptable to have a resident wait for almost one (1) hour to change their diaper. The DSD stated for a resident that waited for almost an hour to get a diaper change, it was negligent and CNA 3 did not meet Resident 18's needs. The DSD stated for a resident that sat on a soiled diaper, it could increase the risk for skin breakdown. The DSD stated CNA 3 should have attended to Resident 18's needs first before taking a break and CNA 3 should have communicated to someone that she was busy and Resident 18 needed a diaper change. During a review of facility's P&P titled, Call Light, dated 4/4/2017, the P&P indicated staff must answer the call light, ask the resident what they need and to attend to resident's needs promptly. 3. During a review of Resident 49's Admission Record (Face Sheet), the Admission Record indicated Resident 49 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included urinary tract infection (UTI, infection in any part of the urinary system that includes the kidneys and bladder), extended spectrum beta lactamase resistance (ESBL, enzyme that makes bacteria difficult to treat with antibiotics), type 2 diabetes mellitus (high blood sugar), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49's cognition was moderately impaired. The MDS indicated Resident 49 was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. During a review of Resident 49's Order Summary Report, dated 11/8/2023, the Order Summary Report indicated to administer Piperacillin Sod-Tazobactam So Solution Reconstituted (also known as Zosyn, name of antibiotic) 3-0.375 gram (g, unit of measurement) intravenously (IV, into the vein), every 8 hours, at 7 a.m., 3 p.m., and 11 p.m. for UTI and ESBL in the urine for five days until 11/13/2023. During an interview on 11/1/5/2023 at 11:21 a.m., with RN 1, RN 1 stated the RNs were responsible for administering IV antibiotics. RN 1 stated when she administered antibiotics, she looked at the order from the physician and did not look back at the previous shift to see what time the antibiotics were last given. During a concurrent interview and record review on 11/15/2023 at 11:40 a.m., with the IPN, Resident 49's Medication Administration Record (MAR), dated 11/2023, was reviewed. The MAR indicated Resident 49 did not receive Zosyn on 11/9/2023 at 11 p.m., 11/10/2023 at 3 p.m., 11/10/2023 at 11 p.m., and 11/11/2023 at 11 p.m. The MAR indicated the scheduled time and the administered time for the dose of Zosyn were as follows: 1. Scheduled dose on 11/10/2023 at 7 a.m. was administered at 10:24 a.m. 2. Scheduled dose on 11/11/2023 at 7 a.m. was administered at 8:53 a.m. 3. Scheduled dose on 11/12/2023 at 7 a.m. was administered at 11:44 a.m. 4. Scheduled dose on 11/12/2023 at 3 p.m. was administered at 6:22 p.m. The IPN stated Resident 49 did not receive 4 doses of Zosyn. The IPN stated completing the full course of antibiotics was important to ensure the resident would be rid of the initial infection and to prevent the infection from reoccurring and making the resident sick again. The IPN stated if a dose of antibiotics was missed, the physician must be notified to see if an additional dose was to be administered. The IPN stated antibiotics were the most effective when given at the scheduled time. The IPN stated giving the antibiotics too late could cause the medication to not be as effective. The IPN stated administering the medication too close together could result in adverse (harmful) reactions such as an upset stomach or damage to other organs. The IPN stated since Resident 49 did not complete his course of antibiotics, there was the potential the resident still had the infection, and another course of antibiotics would be necessary. The IPN stated Resident 49's infection could become worse, or the infection would become even more resistant to antibiotics. During an interview on 11/15/2023 at 3:07 p.m., with the DON, the DON stated when a resident missed a dose of antibiotics, the nurse was responsible for notifying the physician to see if the physician wanted to extend the course of the antibiotics. The DON stated if the antibiotic course was not completed, there was the potential that the infection did not go away and if the infection were to worsen, the resident could become septic (life-threatening emergency where the body has an extreme response to an infection). During a review of the facility's P&P titled, Physician Orders, undated, the P&P indicated, It shall be this facility's policy to provide care and services to the resident in accordance with physician orders. During a review of the facility's P&P titled, Administering Medications, revised 4/2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame . Medications are administered within one hour of their prescribed time, unless otherwise specified. 4. During a review of Resident 68's Admission Record, the admission record indicated Resident 68 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included aphasia (language disorder that affects a person's ability to communicate) and dysphagia (difficulty or discomfort in swallowing). During a review of Resident 68's H&P dated 8/12/2023, the H&P indicated Resident 68 did not have the capacity to understand and make decisions due to history of dementia. The H&P indicated Resident 68 had a history of cerebrovascular accident (CVA, a loss of blood flow to part of the brain, which damages brain tissue). During a review of Resident 68's Minimum MDS, dated [DATE], the MDS indicated Resident 68's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 68 sometimes made herself understood and sometimes understood others. The MDS indicated Resident 68 was totally dependent on staff for all ADLs. The MDS indicated Resident 68 required extensive assistance for eating. The MDS indicated Resident 68 had a diagnosis of hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness, and lack of control in one side of the body). During a review of Resident 68's Care Plan titled, Swallowing, dated 8/24/2023, the care plan indicated the goal was for Resident 68 not to have an injury related to aspiration, and Resident 68 would not have choking episodes when eating. The staff's interventions indicated for Resident 68 to be on 1:1 feeding assistance. During a review of Resident 68's Order Summary Report dated 9/23/2023, the order summary report indicated Resident 68's enteral feeding was to start at 6:00 p.m., and to end at 6:00 a.m. The order summary report dated 10/17/2023 indicated Resident 68 required 1:1 feeding assistance. During an observation on 11/14/2023 at 12:45 p.m., in Resident 68's room, observed Resident 68's lunch tray on the bedside table. The food was uncovered, the utensils were clean, and the food was not touched. During an interview with CNA 2 on 11/14/2023 at 1:00 p.m., in the hallway, CNA 2 stated she was assigned to Resident 68 but did not know who was assigned to feed the resident. CNA 2 stated Resident 68 ate a little but needed to be fed by staff. CNA 2 stated she could not feed Resident 68 because she was busy answering call lights and had another resident in the restroom. During an interview with the Director of Staff Development (DSD) on 11/14/2023 at 1:16 p.m., in Resident 68's room, the DSD stated after staff passed out food trays, staff have to return to feed their residents. The DSD stated CNA 3 was supposed to feed Resident 68 but did not know why the resident was not fed. During an interview with CNA 3 on 11/14/2023 at 1:22 p.m., in Resident 68 room, CNA 3 stated she did not feed Resident 68 because she was busy passing out trays and feeding another resident. CNA 3 stated she did not inform anyone she was running behind and did not request for help. CNA 3 stated she had come to Resident 68's room to start feeding the resident now. CNA 3 stated she was not aware Resident 68's food had been uncovered and was sitting on the bedside table for 35 minutes. CNA 3 stated it was her practice to feed Resident 68 when she got a chance. CNA 3 stated staff uncovered the resident's food and left it at the bedside. CNA 3 stated a resident should not be eating cold food. During a concurrent observation and interview with the DSD and CNA 4 on 11/14/2023 at 1:25 p.m., in Resident 68's room, CNA 4 entered the room to remove Resident 68's food tray and return it to the food tray cart. CNA 4 saw the food was untouched and did not ask if Resident 68 was done eating. CNA 4 stated she took the tray because she thought Resident 68 was done eating. The DSD asked CNA 4 if she had asked anyone if Resident 68 was done eating and CNA 4 stated she did not. CNA 4 stated she was supposed to ask if Resident 68 was done eating before removing the food tray. During a review of the facility's policy and procedure (P&P) titled, Feeding the Resident, undated, the P&P indicated the food lid is to be removed prior to food preparation. The P&P indicated the nursing assistant will document the food intake percentage on the appropriate form. During a review of the facility's P&P titled, Activities of Daily Living, supporting, dated 2001, the P&P indicated residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal care and oral hygiene. The P&P indicated that staff would provide assistance with elimination (toileting) and dining (meals and snacks). The P&P indicated that care and services to prevent and/or minimize functional decline will include appropriate pain management.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant 3 (CNA 3) transferred one of 3 sampled residents (3) from bed to a shower chair in accordance with the comprehensive assessment and plan of care to prevent injury. The facility failed to: 1. Ensure CNA 3 used a mechanical lift (an assistive device/machine used by a caregiver to facilitate safe patient transfers. They are often used to transfer individuals who are unable to stand or bear their full weight between a bed and a chair or other similar resting places. It involves a pad that connects to the lift frame and a hydraulic or electric pump used to lift, and transfer the resident between surfaces), and utilized the assistance of another staff when transferring Resident 3 from bed to a shower chair. 2. Implement Resident 3's plan of care for the risk for injury by not using a mechanical lift and another staff's assistance when transferring Resident 3. As a result, on 10/17/18 at 8:45 a.m., Resident 3, while transferred by CNA 3 from bed to a shower chair, sustained a right shoulder fracture (broken bone) of the proximal (nearer to the center of the body or the point of attachment) humerus (the long bone in the upper arm), with skin discoloration (changes), swelling, and pain to the right arm. Findings: A review of Resident 3's Admission Record (Face Sheet) indicated Resident 3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to Resident 3's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 8/17/18, Resident 3 required two or more persons' physical assistance for transfers and one-person physical assistance with dressing, eating, toilet use and personal hygiene. The MDS assessment indicated the resident had an impairment upper extremity, including shoulder, elbow, wrist, and hand one one side of the body. The MDS assessment indicated there was functional limitations in range of motion (the full movement potential of a joint) on both lower extremities. The resident required a wheelchair and a mechanical lift as an assistive device for locomotion and transfers. A review of Resident 3's History and Physical exam, dated 12/24/17, indicated Resident 3 did not have the capacity to understand and make decisions. A review of Resident 3's Fall Risk Assessment form, dated 8/3/18, indicated Resident 3 had impaired gait (manner of walking) with the score of 14 or greater, representing a high risk for fall. A review of Resident 3's plan of care, developed on 11/2/16, for the Risk for Fall related to general weakness, poor safety awareness, unsteady gait, limited mobility, and impaired gait, indicated the goal was for Resident 3 to be free from falls or injury. The interventions included staff should provide visual check every two hours or as needed, educating staff of Resident 3's assistance with activities of daily living (ADLs), ensuring the wheelchair was locked during transfers, and using a mechanical lift during Resident 3's transfer with another staff assistance. A review of Resident 3's care plan, developed on 11/2/16, for the Self-Deficit in Activity related to dementia and impaired cognition indicated the resident's transfer had to be provided with the use of assistive device. A review of the licensed nurse's progress notes, dated 10/17/18, timed at 8:45 a.m., indicated while in the shower room, when Resident 3's gown was removed, the right upper arm was noted with skin discoloration, and it was swollen. On the same day at 12:30 p.m., the licensed nurses notes indicated Resident 3's attending physician was notified, and ordered an x-ray (a photographic image of the internal composition of a part of the body) of the right arm to rule out fracture. A review of the facility's Investigative Report notes dated 10/19/18, indicated the facility did not address the proper methods of transferring Resident 3 from a bed to a shower chair, although CNA 3 was supposed to use the mechanical lift with the help of another staff, as indicated in Resident 3's comprehensive assessment. The primary physician was notified and a stat (immediately) x-ray was done, which revealed Resident 3 had a fracture. The notes indicated the primary physician ordered Resident 3's transfer to the hospital for an evaluation and treatment. The notes indicated Resident 3's representative refused a transfer to the hospital. In connection to this statement Resident 3's Physician order [REDACTED]. A review of CNA 3's written statement, dated 10/17/19 at 1 p.m., indicated on 10/17/18 at 8:30 a.m., CNA 3 transferred Resident 3 from a bed to a shower chair by herself. While in the shower room, CNA 3 removed Resident 3's night gown and noticed Resident 3 had skin discoloration and swelling on her right arm. CNA 3 instructed CNA 7 to watch Resident 3, and left the shower room to notify the infection control nurse (INC), who came immediately. However, the written statement did not indicate the method and/or device Resident 3 was transferred with and what happened in the shower room. On 5/23/19 at 2:25 p.m., during a phone interview, CNA 3 stated she transferred Resident 3 by placing both of her arms under the resident's armpits, she then manually lifted, then pivoted, before placing the resident on the shower chair. A review of Resident 3's x-ray report dated 10/17/18, ordered due to skin discoloration and swelling of the right arm (10/17/18) revealed Resident 3 had a [MEDICAL CONDITION] shoulder involving the proximal humerus. A review of the nursing notes and physician order, dated 10/17/18 timed at 12:45 p.m., indicated the attending physician ordered to transfer Resident 3 to a General Acute Care Hospital (GACH 1). According to the licensed nurses notes, dated 10/17/18, timed at 12:45 p.m., Resident 3's representative (RR) was informed of the physician order [REDACTED]. According to these licensed nurses notes the attending physician was notified immediately regarding the RR request. A review of licensed nurses notes, dated 10/18/18 timed at 10 p.m., indicated Resident 3's fractured right shoulder was immobilized (device that keeps arm and shoulder in a fixed position). A review of Resident 3's Joint Mobility Assessment diagram, dated 2/2/18, indicated Resident 3 had right arm range of motion, including shoulder, elbow, wrist and hand, within functional limits. A review of Resident 3's Joint Mobility Assessment diagram, dated 2/1/19, indicated Resident 3 had severe functional limitation in the right arm including shoulder, elbow, wrist and hand, due to the right shoulder fracture. A review of the Physical Therapy (PT) notes, dated 10/19/18, indicated Resident 3 was evaluated due to the right shoulder discoloration and swelling. According to PT's notes Resident 3 had right shoulder pain level of eight out of ten (on a pain rating scale from zero to ten, zero meant no pain and ten was the worse pain possible). According to PT's notes, dated 11/09/18, Resident 3 had right shoulder pain of seven out of ten on a pain rating scale. On 05/23/19 at 1:53 p.m., during an interview, PT stated Resident 3 was evaluated on 10/17/18, because of skin discoloration and swelling of the right upper arm. PT stated, Resident 3 had a proximal [MEDICAL CONDITION] shoulder due to improper transferred from a bed to a shower chair by CNA 3. A review of the physician's orders [REDACTED]. A review of a letter, dated 10/18/18, addressed to the Department of Public Health, indicated on 10/17/18, CNA 3 reported to the licensed nurse in charge that Resident 3 had right upper arm discoloration, and swelling. On 5/10/19 at 9:46 a.m., Resident 3 was observed in bed with the immobilizer on her right upper arm. Concurrently, during an interview, Resident 3 was not able to be interviewed, and was nonverbal (unable to express self). On 5/20/19, at 3:33 p.m., during an interview, MDS nurse confirmed Resident 3 had skin discoloration and swelling on her right shoulder, when observed in the shower room. MDS nurse stated CNA 3, manually transferred the resident from a bed to a shower chair instead of using a mechanical lift, and another CNA for physical assistance. MDS nurse stated the proximal humerus fracture (right shoulder) could have happened, while CNA 3 manually transferred Resident 3 to the shower chair. On 5/21/19, at 11:59 a.m., during an interview, the director of nursing (DON), confirmed CNA 3 manually transferred Resident 3 from a bed a shower chair on 10/17/18. DON acknowledged Resident 3 had to be transferred with a mechanical lift (assistive device) and two persons (CNAs) physical assistance, as coded in Resident 3's comprehensive assessment to prevent fall and injury. DON confirmed Resident 3 had a right shoulder fracture on 10/17/18. On 5/21/19, at 12:59 p.m., during an interview, CNA 3 stated Resident 3 had to be transferred using mechanical lift with the physical assistance of another CNA. When asked how she transferred Resident 3 from a bed to a shower chair, CNA 3 stated she was facing the resident, while placing her arms underneath Resident 3's armpits, lifted, and pivoted the resident, before sitting her on a shower chair. During an interview, CNA 3 stated she always transferred Resident 3 manually by herself. CNA 3 acknowledged Resident 3 had functional limitations in her upper and lower extremities. On 5/21/19 at 01:19 p.m., during an interview, Director of Staff Development (DSD), stated CNA 3 was supposed to use a mechanical lift with the physical help of another CNA. DSD stated CNA 3 had been educated on methods of transferring Resident 3 using a mechanical lift machine. DSD acknowledged CNA 3 received in-services training on the use of mechanical lift for a residents transfer, however, CNA 3 choose not to use mechanical lift with Resident 3's transfer. DSD stated CNA 3 was not supposed to manually transfer Resident 3 from a bed to a shower chair for safety reasons, and to prevent fall and injury. On 5/21/19, at 01:38 p.m., during an interview, the registered nurse (RN 2) confirmed CNA 3 did not use the mechanical lift on 10/17/18, and Resident 3 sustained the right shoulder fracture. RN 2 stated, Resident 3 was nonverbal, bed ridden, was out of bed sometimes with physical assistance of two CNAs, and the use of mechanical lift. On 05/21/19 at 04:27 p.m., during an interview, the infection control nurse stated during a stand up meeting on 10/18/18, it was reported Resident 3 could not move her right shoulder an x-ray report, dated 10/17/18, indicated Resident 3 had right shoulder fracture due to improper transfer method by CNA 3. The infection control nurse stated Resident 3 had to be transferred from bed to a shower or a wheel chair with the use of mechanical lift, and the assistance of two CNAs to prevent fall and injury. On 05/21/19 at 04:37 p.m., during an interview, CNA 4 stated Resident 3 had to be transferred with the use of mechanical lift and two CNAs. On 05/23/19 at 11:06 a.m., during a telephone interview, RR confirmed the facility contacted her and informed regarding Resident 3's right shoulder fracture on 10/17/18. RR confirmed she refused Resident 3's transfer to the GACH 1.

Based on interview and record review, the facility's staff failed to follow its policy when there was an incident or a change in a resident's condition and report all findings for one of three sampled residents (Resident 1). Resident 1 slid down to the bathroom floor after being assisted by CNAs 1 and 2 to the toilet. The fall resulted in Resident 1 sustaining a bilateral (both sides) fixated (broken bone pieces that are out of alignment) [MEDICAL CONDITION] (broken bone) with suboptimal (less than the highest quality) left screw migration (movement from one part to another). These failures of CNAs 1 and 2 to report Resident 1's fall resulted in a delay in care, diagnosis, treatment, and pain to the pelvic area requiring a transfer to the general acute care hospital (GACH) and undergoing surgery (2 days after incident). Findings: A review of Resident 1's Face sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 9/25/18, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 3 (0-7= severely impaired (thought process) skills). The MDS indicated Resident 1 required an extensive assistance and was dependent in care of a one-person physical assist for toilet use and transfers between surfaces. The MDS indicated Resident 1 was impaired of one side of the lower extremities and was wheelchair dependent for mobility. A review of the Fall Risk Assessment, dated 9/25/18 indicated Resident 1 had a score of 16 (score of 10 or higher indicated high risk). A review of a plan of care, dated 9/25/18 and titled, Risk for Falls/Injury Related to General Weakness and unsteady Gait, indicated Resident 1 would remain free from falls or injuries. The staff's interventions included visual checks, assist resident with activities of daily living (ADL) as needed, and assist the resident to the toilet. A review of a Situation, Background, Assessment and Recommendation ((SBAR)-internal communication form), dated 10/24/18 and timed at 5:50 p.m., indicated Resident 1 had left lateral pelvic (lower part of the trunk of the body between the abdomen and the thighs) pain of 5 out of 10 (the pain scale of 0 to 10, (0 being the worse)), and the left lower extremity shorter than the right lower extremity. A review of the facility's investigation with a conclusion, dated 10/26/18 indicated that Resident 1 slipped from the toilet during adult diaper change. A review of the physician's orders [REDACTED]. A review of Resident 1's X-ray results, dated 10/24/18 and timed at 8:35 p.m ., indicated a fixated bilateral [MEDICAL CONDITION] with suboptimal left screw migration. A review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's physician's orders [REDACTED].# 3 (([MEDICATION NAME] with [MEDICATION NAME]) narcotic pain medication) every six (6) hours as needed (PRN) for pain management until 11/2/18. On 12/11/18 at 10:43 a.m., during a concurrent interview and review of the Medication Administration Sheet (MAR) for the month of 10/2018 (10/24/18 through 10/28/18), the Medical Records Director (MRD) stated and confirmed Resident 1 received four (4) doses of two tablets (8 tablets) of Tylenol 650 mg by mouth on 10/25/18 and 10/26/18 for pain 3 out of 10. On 10/26/18 and 10/27/18 the resident received one dose of Tylenol #3 for pain 5 out of 10. A review of the physician's orders [REDACTED]. A review of the GACH's report indicated Resident 1 was admitted on [DATE] with left hip pain, shortening of the left leg with swelling after a fall that occurred two days prior. The summary indicated Resident 1 underwent an open reduction and internal fixation ((ORIF) surgery used to stabilize and heal a broken bone by realigning the bone fracture into the normal position) surgery of the left hip and required a blood transfusion due to the blood loss during surgery. On 10/30/18 at 5:24 p.m., during an interview in the presence of Licensed Vocational Nurse 1 (LVN 1), Resident 1's roommate (Resident 2) stated that on 10/24/18, she witnessed CNAs 1 and 2 lift Resident 1 from the bathrooms floor and placed her in a wheelchair. Resident 2 stated that she saw one of the CNAs cleaning resident's stool from the bathroom floor after lifting Resident 1. Resident 2 stated that she heard Resident 1 crying in pain while she was on the bathroom floor and neither of the CNAs called the nurse for help, but transferred Resident 1 back to the bed with her pants down. Resident 2 stated that she asked the CNAs to lift the residents' pants up, but they just walked out of the room and ignored that Resident 1 was crying in pain. Resident 2 stated being afraid of CNAs 1 and 2 returning and hurting her too. A review of Resident 2's Face sheet (Admission Record) indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated the resident had a BIMS score of 9 (9-12= moderately impaired (thought process) skills). On 10/30/18, at 5:34 p.m., during an interview, LVN 1 stated that on 10/24/18, the day of the fall incident, she overheard Resident 1 crying . LVN 1 stated that upon entering the room, Resident 1 was in the bed uncovered and her vaginal area was exposed. LVN 1 stated Resident 1's left leg appeared shorter than the right leg . On 10/30/18, at 5:50 p.m., during an interview, CNA 3 stated on 10/24/18 she walked into Resident 1's room to pick up the dinner tray and saw CNAs 1 and 2 lifting Resident 1 from the floor. CNA 3 stated she did not report the incident to the charge nurse because she thought CNAs 1 and 2 were going to report it. On 10/30/18, at 6:02 p.m., during an interview, the Administrator (ADM) stated that CNAs 1 and 2 were placed on suspension until further review. On 11/1/18 at 2:50 p.m., during an interview, LVN 1 stated that CNAs 1 and 2 did not report Resident 1's fall incident to any of the change nurses. LVN 1 stated not knowing why the two CNAs left Resident 1's pants down and why both transfer the resident back into the bed. LVN 1 stated that when residents' have a fall or complain of pain, the CNA should notify the charge nurse. On 11/2/18 at 10:30 a.m., during a telephone interview, CNA 1 stated that she and CNA 2 assisted Resident 1 to the restroom, and after Resident 1 had a bowel movement, both she and CNA 2 lifted the resident from the toilet seat. CNA 1 stated that CNA 2 mentioned she did not like taking Resident 1 to the restroom because she was unable to stand on her own and that was when the resident started sliding down to the bathroom floor. CNA 1 stated she and CNA 2 tried to clean the resident, but they were unable because Resident 1 was slipping due to poor balance. CNA 1 stated, Resident 1 was like dead weight. CNA 1 stated that they placed the resident in the wheelchair and then transferred her to the bed. CNA 1 stated that she did not report the resident's fall to the charge nurse or the pain that the resident was experiencing. On 11/2/18 at 12:05 p.m., during a telephone interview, CNA 2 stated that Resident 1 was not able to stand on her own while she was being assisted in the restroom. CNA 2 stated that she did not report to the nurses that Resident 1 was complaining of pain or that the resident slipped to the floor while in the restroom. A review of the facility's undated policy and procedure (P/P) titled, Fall Prevention and Reduction Program, indicated that each staff must report all incidents he/she are involved in or witnessed to, to his/her immediate supervisor or to the licensed nurse in charge or a resident's care. Residents identified to be at greater risk for falls or further falls should be monitored closely to prevent further occurrences of fall incidents .CNAs should document account of the incident if they have witnessed the fall incident or found the resident after the fall.

Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to prevent a fall for one of three sampled residents (Resident 1). Resident 1, who had a high risk for falls, was not assessed upon admission to the facility, provided with floor mats, as indicated in the facility's policy and the resident's care plan to prevent injuries. Resident 1, who had dementia (decline in mental ability), fell out of the bed on 11/30/17 after being newly admitted to the facility (within two (2) hours), which involved hitting her hip during the fall. (Cross Reference F 689) These deficient practices resulted in Resident 1 falling, sustaining a fracture hip, requiring a transfer to the general acute care hospital (GACH), undergoing hip repair surgery and expiring five days later on 12/4/17. Findings: A review of GACH 1's document titled, Occupational Therapy Plan of Care, dated 11/21/17 and timed at 11:09 a.m., prior to Resident 1's admission to the facility, indicated that a Nursing Home referral was recommended for a short-term stay for the resident due to weakness, confusion, and lack of safety awareness. The note indicated Resident 1 required an increased assistance and supervision at home due to resident being a fall risk. A review of the Admission Record (face sheet) indicated that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 11/30/17, indicated Resident 1's cognitive skills (thought process) for daily decision making had modified independence with some difficulty in new situations. The MDS indicated Resident 1 walked in her room once or twice during the review period to use the toilet and to perform personal hygiene. A review of Resident 1's Fall Risk Assessment, dated 11/30/17, indicated the resident was a high risk for falls with a score of 10 (a total score of 10 or above represented high risk for falling). A review of the Nursing Admission Assessment, dated 11/30/17, indicated Resident 1 was forgetful and confused, had history of falls, poor safety judgement, required an extensive assistant for toileting. The admission assessment, also indicated the bed was placed in the lowest position for safety, extra mattress on the floor, and bed alarm. A review of Resident 1's record titled Licensed Nurses Progress Note, dated 11/30/17 and timed at 7:10 p.m., indicated Family Member (FM 2) went to the nurses' station to notify the staff that they were leaving the facility. The note indicated the bed was set to the lowest level. At 7:40 p.m., on 11/30/17, the note indicated Licensed Vocational Nurse 1 (LVN 1) reported to Registered Nurse 1 (RN 1) that Resident 1 was laying on the floor on her right side. The note indicated right leg shortening was noted and Resident complaint of pain on the right side hip. At 8 p.m., on 11/30/17, Resident 1 was transfer to the GACH via emergent transportation. A review of Resident 1's physician orders, dated 11/30/17 and timed at 7:40 p.m., indicated to transfer Resident 1 to the GACH for evaluation. A review of Resident 1's record titled, Medication Administration Record [REDACTED]. On 12/15/17 at 3:50 p.m., during a concurrent interview and record review of Resident 1's medical record , the Administrator (ADM) stated on 11/30/17 at 5:20 p.m., Resident 1 was admitted to the facility and the nurses' did not place the floor mats and the bed alarm on the bed because the family was in the room with the resident. The ADM stated before all the family left, FM 2 came and notified the staff they were leaving and remind them that Resident 1 had a high risk for falls. On 12/15/17 at 4:28 p.m., during a telephone interview, FM 1 stated that the facility was made aware that Resident 1 was at high risk for falls. A review of GACH 2's records titled, history and physical examination [REDACTED]. The report indicated Resident 1 had a [MEDICAL CONDITION] hip. A review of GACH 2's, Orthopedic Surgery Consultation (branch of surgery concerned with conditions involving the musculoskeletal system), dated 12/2/17, indicated Resident 1 presented to the hospital with an intertrochanteric (line located on the anterior side of the proximal end of the femur) femur (bone of the thigh or upper hind limb) fracture on the right side. The note indicated that the ability to ambulate and be mobilize was vital for life and the early demise (death) or increase morbidity (the rate of disease in a population) was increased with a [MEDICAL CONDITION]. The note indicated that the best outcome for Resident 1 was to immobilize the extremity to allow mobility and weight bearing. A review of GACH 2's, Consultation Report, dated 12/4/17, indicated Resident 1 underwent a total hip replacement on 12/3/17. A review of GACH 2's Death Summary for Resident 1, dated 12/4/17, indicated the resident presented to the GACH with a right [MEDICAL CONDITION] after sustaining a fall at the nursing home. A review of Resident 1's death certificate indicated: Immediate cause of death sequelae (condition that is the consequence of a previous disease or injury) and [MEDICATION NAME] force trauma. Other significant conditions contributing to death but not resulting in the underlying cause, Hypertension and Diabetes Mellitus (high blood sugar). The death certificate indicted Resident 1's death was caused by a fall from bed at the Skill Nursing Facility (SNF). On 1/16/18 at 9:30 a.m., during an interview, Admissions Coordinator (AC) stated that Resident 1 was admitted to the nursing facility due to history of falls at home. On 1/16/18 at 10:21 a.m., during an interview and record review, the current Director of Nursing (DON) stated that the facility was aware that Resident 1 was at risk for falls. The DON stated that when a resident was at risk for falls, the staff were responsible to place floor mats, alarms and place the resident near the station. On 2/16/18 at 2:24 p.m., during a telephone interview, FM 2 stated that Resident 1 needed to be supervised due to being a high risk for falls. FM 2 stated that on 11/30/17 a staff member gave Resident 1 her dinner tray but did not returned. FM 2 then informed a staff member that she was leaving. During the telephone interview FM 2 was heard crying and stated that she was aware that Resident 1 was of advanced age, but she was very sad because she was expecting Resident 1 would live for another five more years or so. FM 2 stated, I'm sad because of the way she (Resident 1) was taken away from me. On 2/22/18 at 3:28 p.m., during a telephone interview, Certified Nurse Assistant 1 (CNA 1) who was assigned to Resident 1, stated on 11/30/17 she went into Resident 1's room to perform gown and adult diaper change and she did not see any floor mats next to the bed. CNA 1 stated that she was on her break when the fall incident occurred and LVN 1 was in charge of Resident 1's care. On 2/22/18 at 3:53 p.m., during a telephone interview, RN 1 stated that LVN 1 found Resident 1 on the floor on 11/30/17 between the hours of 7:20-7:30 p.m. RN 1 stated when she went to into Resident 1's room, the resident was in the bed complaining of pain with facial grimacing. RN 1 stated that she was aware that the resident was a high risk for fall due to her advance age and her fall history. RN 1 stated, I did not place the floor mats on the floor because I was kind of busy with other residents. I had intentions on doing it but, I was not able too, it happened to quick. RN 1 stated that FM 2 notified her approximately at 7 p.m., on 11/30/17 she was leaving, but RN 1 stated she was not able to assess the resident or place the floor mats on the floor. RN 1 stated that the supervisor RN were responsible to do the initial assessments of residents upon admission. On 2/26/17 at 5:50 p.m., during a telephone interview, LVN 1 stated that while passing medications, she overheard Resident 1 saying, Help, Help. LVN 1 stated she saw Resident 1 on the floor on her right side and immediately called RN 1 to assess the resident. A review of the facility's undated policy and procedure titled, Nursing Admission Assessment, indicated that upon admission, licensed charge nurses are responsible for initial data collection and assessment of resident's immediate and long-term nursing needs. The policy also indicated to initiate plans of care to meet resident's immediate physical and nursing needs. A review of the facility's undated policy titled, Fall Risk and Prevention Assessment, indicated that it was the responsibility of the facility to assess and identify residents who are at risk for falls and develop appropriate plans of care to prevent falls and/or further falls, to the extent possible.

Based on interview and record review, the facility failed to ensure that registered nurse supervisor 1 (RNS 1) determined of whether the signs, symptoms, or general appearance exhibited by one of three sampled residents (Resident 1) was abnormal characteristics, and to implement based on observed abnormalities a standardized procedures such as notifying the physician, or the initiation of emergency procedures in accordance with professional standards of practice. The deficient practice resulted in Resident 1 not receiving immediate necessary care that led to deterioration in Resident 1. Resident 1 died in the facility. Cross-reference to F309 Findings: According to the Admission Record, Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE] indicated Resident 1 had the ability to understand others and make self-understood, The resident's cognitive skills for daily decision-making were moderately impaired and required extensive assistance to total dependence from the staff with activities of daily living. The MDS indicated Resident 1 required extensive assistance from the staff with eating. The Physician's Progress Notes dated, [DATE], [DATE], [DATE], [DATE], and [DATE] indicated that Resident 1 was a Full Code (meaning to do everything possible and necessary to save the life of the person). The Licensed Nurses Progress notes dated [DATE], at 11 a.m., indicated that Resident 1 had poor oral intake and refused breakfast. A subsequent licensed progress note entry dated [DATE] at 12:30 p.m., indicated that Resident 1 refused lunch. The licensed progress note entry timed at 5 p.m. on [DATE], documented that Resident 1 refused dinner. During an interview with registered nurse supervisor 1 (RNS 1) on [DATE], at 1 p.m., he stated Resident 1 refused breakfast, lunch, and dinner on [DATE]. RNS 1 stated, I just assumed the resident was dehydrated. RNS 1 stated that he gave the Resident 1 water but the water kept spilling out of the resident's mouth. RNS 1 stated at approximately 6:50 p.m., on [DATE], licensed vocational nurse 2 (LVN 2) found Resident 1 unresponsive. RNS 1 acknowledged that Resident 1 was a full code but he did not initiate CPR, because the resident was dead. During a follow-up interview with RNS 1 on [DATE], at 4:38 p.m., he stated that he called the administrator about Resident 1's condition because he was initially unable to contact the resident's attending physician. RNS 1 stated that he did not try to call an alternate physician. RNS 1 stated that the administrator coordinated Resident 1's transfer to the GACH. During an interview with the administrator on [DATE], at 6:19 p.m., she stated that the staff should have initiated CPR on Resident 1 because the resident was a full code. During an interview with Resident 1's attending physician on [DATE] at 3:10 p.m., he stated that he was not notified that Resident 1 refused all his meals on the day that Resident 1 died . He further stated, A prudent thing to do is try to find out what's going on with the resident and monitor the vital signs, and if a resident is full code and had no pulse and no blood pressure, you have to call 911. I guess the registered nurse took it on himself not to do CPR. According to the 2015 update of American Heart Association's Adult [MEDICAL CONDITION] Algorithm (Basic Life Support Healthcare Provider), the healthcare provider will begin CPR for a victim who is not breathing/only gasping and does not have a pulse. A review of the facility's undated Job Summary for a Nursing Supervisor, indicated that the person assigned would provide direction, supervision, and evaluation of all resident care. The performance standards of nursing supervisor indicated the following: - Implement established performance standards of nursing practice and facility policies and procedures. - Demonstrate consistent ability to manage nursing service concerns, emergencies, and immediately initiate lifesaving measures as necessary in the absence of a physician. - Perform nursing skills, demonstrating knowledge and competence. - Implement facility admission, discharge, and transfer procedures and supervises coordination with other departments, physicians, residents, families and community agencies. According to the undated Nursing Practice Act, Article 2. Scope of Regulation 2725. (b) The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following: (4) Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures. c) Standardized procedures, as used in this section, means either of the following: 1) Policies and protocols developed by a health facility licensed pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code through collaboration among administrators and health professionals including physicians and nurses.

Based on interview and record review, the facility failed to ensure a resident who had a significant change of condition manifested by weakness, refused to eat breakfast, lunch and dinner, and the water being given by a teaspoon was spilling from the resident's mouth received the necessary care and services for one of three sampled residents (Resident 1) by failing to: a. Identify the cause of Resident 1 weakness, refusal to eat and as to why the water being given was spilling from the resident's mouth. b. Implement the facility's policy and procedures to immediately consult with the primary care physician a lack of progress in the resident's condition after a nursing intervention. c. Transfer Resident 1 to a higher level of care in a timely manner. d. Initiate cardiopulmonary resuscitation (CPR, a life-sustaining emergency procedure for persons in [MEDICAL CONDITION]) as indicated in the physician's progress notes that Resident 1 was a Full Code (meaning to do everything possible and necessary to save the life of the person) when Resident 1 was found pulseless and not breathing on [DATE], at 6:50 p.m. These deficient practices resulted in Resident 1 not receiving immediate necessary medical intervention for acute [MEDICAL CONDITION] infarction (commonly known as a [MEDICAL CONDITION], occurs when blood flow stops to a part of the heart causing damage to the heart muscle) that lead to cardiopulmonary arrest. Resident 1 died at the facility on [DATE], at 6:55 p.m. Findings: According to the Admission Record, Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated [DATE] indicated the resident had the ability to understand others and make self-understood, cognitive skills for daily decision-making that were moderately impaired, required extensive assistance and was totally dependent on the staff for activities of daily living. The MDS indicated Resident 1 required extensive assistance from the staff with eating. The Physician's Progress Notes dated, [DATE], [DATE], [DATE], [DATE], and [DATE] indicated that Resident 1 was a Full Code. A review of the Licensed Nurses Progress Notes dated [DATE], at 11 a.m., indicated that Resident 1's blood pressure (BP is the pressure exerted by circulating blood upon the walls of blood vessels) reading was ,[DATE] millimeters of mercury or mmHg (reference range is ,[DATE] mmHg), pulse rate (PR is the speed of the heartbeat measured by the number of contractions of the heart per minute (bpm) was 83 bpm (reference range 60 to 100 bpm), respiratory rate 20 (resting respiratory rate,[DATE] breaths per minute), ,[DATE] (zero pain), and oxygen saturation (a measure of how much oxygen the blood is carrying) rate was 99 percent (%) (95 to 100 %), no documentation if the resident was receiving oxygen. There was no documented evidence Resident 1's body temperature was checked. The nurses' notes indicated the resident had poor oral (food) intake and refused breakfast. The documentation indicated the supervisor helped feeding the resident, and provided 60 cubic centimeters (cc) of thickened liquid. The Licensed Nurses Progress Notes dated [DATE] at 12:30 p.m., indicated that Resident 1's BP reading was ,[DATE], PR 86 bpm, RR 21 breaths per minute, and oxygen saturation reading was 98 %. There was no documented evidence Resident 1's body temperature was checked. The documentation indicated the resident refused lunch and was provided 150 cc of thickened liquid by teaspoon. The Licensed Nurses Progress Notes dated [DATE], at 5 p.m., indicated the resident BP reading was ,[DATE], PR 89 bpm, RR 21 breaths per minute, ,[DATE] (no pain) and oxygen saturation reading was 98 %. There was no documented evidence Resident 1's body temperature was checked. The documentation indicated that Resident 1 refused dinner and was provided 90 cc of thickened liquid. There was no evidence that licensed nurses identified the reason as to why Resident 1 refused to eat breakfast, lunch and dinner. There was no documented evidence the resident's primary care physician was notified of the resident's refusal to eat the whole day. The Licensed Nurses Progress Notes dated [DATE], at 5:50 p.m., indicated Resident 1's BP reading was ,[DATE], PR was 87 bpm, RR was 21 breaths per minute, ,[DATE] (no pain), and oxygen saturation reading was 96 %. The documentation indicated the resident had mild fever of 100 degrees Fahrenheit (Reference range 97.8 to 99 degrees Fahrenheit). The notes indicated the resident had gurgling sounds noted. There was no documentation that Resident 1's respiratory (lungs/throat) status was assessed. The notes indicated the physician was notified and had an order to transfer the resident to a general acute care hospital (GACH). The Licensed Nurses Progress Notes dated [DATE], at 6:10 p.m., indicated that staff arranged and prepared to transfer Resident 1 to a GACH via regular ambulance. The Licensed Nurses Progress Notes dated [DATE], at 6:50 p.m., indicated the supervisor was called by the charge nurse and reported that Resident 1's condition dramatically changed. The notes indicated a 911 (emergency number) was called. The notes indicated Resident 1 had no pulse, no heart rate, no breathing noted and the BP was not able to measure manually. The notes indicated the O2 saturation was also not able to be measured by oximetry (a device to check how much oxygen is in the blood). There was no documented evidence that cardiopulmonary resuscitation was initiated as per the physician progress notes [REDACTED]. During an interview and record review of Resident 1's clinical record with registered nurse supervisor 1 (RNS 1) on [DATE], at 1 p.m., he stated Resident 1 refused breakfast, lunch, and dinner on [DATE]. RNS 1 stated, I just assumed the resident was dehydrated. RNS 1 stated that he gave the resident water during the breakfast meal but the water kept spilling out of the resident's mouth. RNS 1 was unable to provide documentation that Resident 1's temperature was rechecked after 5:50 p.m. on [DATE]. RNS 1 stated at approximately 6:50 p.m., on [DATE], licensed vocational nurse 2 (LVN 2) found Resident 1 unresponsive. RNS 1 acknowledged that Resident 1 was a full code but he did not initiate CPR, because the resident was dead. During a follow-up interview with RNS 1 on [DATE], at 4:38 p.m., he stated that he called the administrator about Resident 1's condition because he was initially unable to contact medical Doctor 1. RNS 1 stated that he did not try to call an alternate physician. RNS 1 stated that the administrator coordinated Resident 1's transfer to the GACH. During an interview with LVN 1 on [DATE], at 9:55 a.m., she stated that she took care of Resident 1 in the morning shift (,[DATE] p.m.) on [DATE]. LVN 1 stated that she let Resident 1 stay in bed that morning because Resident 1 appeared weak and refused to eat breakfast. LVN 1 stated that Resident 1 did not eat lunch as well, He did not even open his mouth. LVN 1 indicated that she did not think Resident 1 was exhibiting a change in condition, I thought he was just having a bad day. LVN 1 stated that she reported the situation to RNS but she did not notify Resident 1's doctor. During a telephone interview with Doctor 1 on [DATE] at 3:10 p.m., he stated that he was notified that Resident 1 was weaker than usual and had a fever. When asked if he was aware that Resident 1 was unable to eat breakfast, lunch, and dinner that day, Doctor 1 stated, This is all unbeknownst to me. Doctor 1 stated, If a resident is not eating, try to find out what's going on and monitor the resident's vital signs. During an interview with LVN 2 on [DATE], at 10:30 a.m., LVN 2 stated that Resident 1 looked tired when she did her rounds at 3 p.m., the beginning of her shift on [DATE]. LVN 2 stated that she gave Resident 1 Tylenol by mouth at 5:30 p.m., for fever. LVN 2 stated that at 6:50 p.m., she noted that Resident 1's body was blue so she left Residents 1's room to call the other nurses. LVN 2 stated that it was her first time to see a resident who was unresponsive and no one directed her to begin CPR on Resident 1 during that time. LVN 2 stated that she and another licensed nurse checked the resident's breathing, pulse, oxygen saturation and the resident was completely dead, So we didn't do CPR. According to the Certificate of Death' the date of death was [DATE], at 6:55 p.m., indicated that Resident 1's immediate cause of death was cardiopulmonary arrest, and the secondary cause of death was acute (new) [MEDICAL CONDITION] infarction. A review of the facility's undated policy and procedures on Change of Condition Notification indicated that it is standard operating procedure to immediately consult with the primary care physician on drastic changes and/or lack of progress or improvement in the resident's condition. The procedures indicated that if a resident's primary care physician does not respond within a reasonable amount of time, it is the responsibility of the licensed nurse to notify alternate physician of resident's change in condition. According to the 2015 update of American Heart Association's Adult [MEDICAL CONDITION] Algorithm (Basic Life Support Healthcare Provider), the healthcare provider will begin CPR for a victim who is not breathing/only gasping and does not have a pulse. According to the 2007 Emergency Management Strategies for Acute [MEDICAL CONDITION] Infarction, indicated the time interval between the onset of acute [MEDICAL CONDITION] infarction and the initiation of reperfusion therapy (medical treatment that restores blood flow through blocked arteries) is a major determinant of patient (resident) outcome. An acute [MEDICAL CONDITION] infarction is a medical emergency requiring immediate intervention.

Based on observation, interview, and record review, the facility failed to follow its policy, regarding hydration, and implement a resident's plan of care to increase fiber and fluid intake, after the resident had the first fecal impaction (hard stool in colon unable to pass), and adequately assessing a resident's consistency of bowel movements, who had a history of [REDACTED]. Resident 7's bowel pattern was not monitored for amount and consistency of the stool and for the administration of a medication milk of magnesia ((MOM) a laxative), as prescribed by the physician, when the resident did not have a bowel movement for five days or when the resident was constipated (Cross Reference to F327). These failures resulted in Resident 7 complaining of abdominal tenderness/pain due to not having regular bowel movements and requiring two transfers to a general acute care hospital (GACH) and being diagnosed with [REDACTED]. Findings: A review of Resident 7's Face Sheet (admission record) indicated the resident was initially admitted to the facility on [DATE], and last readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 7's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/1/16, indicated Resident 7 had impaired communication skills and required extensive assistance (resident involved in activity, staff provide weight-bearing support) in bed mobility, and was totally dependent on staff with transferring. The Licensed Nurse Weekly Summary, dated from 12/1/15 to 3/14/16, indicated Resident 7 required extensive assistance in eating. On 3/17/16 at 7 p.m., during an observation, Resident 7 was lying on a low bed, sleeping, with two half side rails up. A water pitcher, dated 3/18/16, with NTL (nectar thick liquid) written on it. The pitcher was placed on a night stand located at the far left of the resident's head of the bed, while the bed was positioned in its lowest position making it difficult for Resident 7 to reach if the resident wanted a drink. On 3/18/16 at 8:30 p.m., during another observation, Resident 7 was lying on a low bed with two half-side rails up. There was a pitcher, dated 3/19/16, with NTL written on it, placed on the night stand at the far left of the resident's head of the bed. There was no cup near the pitcher. The bed remained at its lowest position making it difficult to reach if Resident 7 wanted to drink. Resident 7 was asked if he speaks English, and stated, Poquito (meaning a little in Spanish). Resident 7 was asked if he was thirsty, and he stated, Yes. A review of the Licensed Nurses Progress Notes indicated the following: On 5/30/15 at 2 p.m., the resident (Resident 7) had no bowel movement. Medication was provided. On 5/30/15 at 9:40 p.m., Resident 7 had no bowel movement. Encouraged resident to consume meal, but refused dinner. Provided oral fluid intake as tolerated. On 5/31/15 at 4 p.m., a new order for bowel management, was received and carried out. On 6/1/15 at 10:30 a.m., an ultrasound of the abdomen was done and reported to the physician with no new orders at 3:30 p.m. On 6/1/15 at 3:40 p.m., Resident 7 complained of mild nausea and ate 40 % of lunch. Abdominal distention noted but improved from a few days ago. No bowel movement during the day. On 6/3/15 at 4 p.m., laboratory result reported to the physician with no new orders. On 6/4/15 at 9 a.m., Resident 7 was lethargic (inactive; slow). Did not eat breakfast. Resident 7 complained of general weakness and a slight headache. Abdominal distention was continuously noted, but had a small amount of bowel movement three days in a row (but was not documented by the certified nurse assistants on the ADL form). The physician was notified and Resident 7 was transferred to the hospital. There was no documented evidence that the licensed nurses checked Resident 7 for a fecal impaction, after not having an adequate bowel movement and complaining of abdominal distention and being nausea (motion sickness; feeling sick or queasy) A review of Resident 7's physician's orders [REDACTED]. According to the physician's telephone orders, dated 6/9/15, Resident 7 was readmitted back to the facility on [DATE] (five days later) with [DIAGNOSES REDACTED]. A review of the GACH's history and physical (H/P), dictated 6/5/15, indicated Resident 7 was admitted for further care and treatment for [REDACTED]. Resident 7 received intravenous fluids, IV antibiotics (treatment of [REDACTED]. A review of another telephone physician's orders [REDACTED]. Resident 7 was readmitted back to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the GACH's abdominal CT Scan (computed tomography (X-ray CT) or computerized axial tomography scan (CAT scan)), performed on 11/19/15, indicated Resident 7 had a large amount of stool within the colon, particularly within the rectum (the concluding part of the large intestine that terminates in the anus) with distention (occurs when substances, such as stool, air (gas) or fluid, accumulate in the abdomen causing its outward expansion beyond the normal girth ( measurement around the middle of something, especially a person's waist)). A review of Resident 7's preprinted care plan, dated 11/29/15, and titled, Patient Care Plan Sheet. The care plan problem indicated Resident 7 was at risk for constipation related to medication, decreased physical activity, and had a history of [REDACTED]. patterns, and assessing for fecal impaction if no bowel movement in three days. The care plan did not specify how the facility's staff would assess Resident 7 for fecal impaction and constipation. There was no documented evidence the facility had a method on how to conduct an assessment for constipation, such as describing the consistency of the stool as hard or soft, and that the facility had offered foods high in fiber and incorporated it in the resident's diet. A review of an untitled facility form that certified nurse assistants (CNA) records residents' ADLs (activities of daily living) performance, for the month of 6/2015, indicated Resident 7 had no bowel movements recorded from 5/30/15 to 6/3/15. The form did not have a method for the CNAs to record and document a residents' stool consistency, to ensure a resident was having regular bowel movements. The CNAs only recorded the number of bowel movements per shift and if a resident was incontinent of bowel (inability to control bowel movement). There was no documented evidence that the licensed nurses monitored or recorded Resident 7's bowel patterns with regard to the amount and consistency. A review of Resident 7's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no documented evidence that Resident 7 was offered fluids at least once every two hours and how much fluids resident consumed. A review of the facility's interdisciplinary (IDT) Resident Care Conference Reviews, dated 6/8/15, 6/22/15, 9/4/15, 12/4/15, 1/15/16, and 3/4/16, indicated lack of attendance of the dietary supervisor (DS) and registered dietitian (RD) during some of the conferences. There was no documented evidence that an IDT approach was utilized to address Resident 7's clinical conditions to develop a plan of care for the resident, who had recurrent urinary tract infections, fecal impaction, and dehydration given the risk factors of poor oral intake, poor mobility, requiring extensive assistance in eating/drinking, refusal to drink, having dysphagia and receiving pureed diets with thickened liquids, weight loss, and [MEDICAL CONDITION]. On 3/20/16 at 3:30 p.m., during a telephone interview, the RD stated Resident 7's poor hydration status may lead to another urinary tract infection and fecal impaction. The RD was asked if the facility tried to incorporate fiber in Resident 7's diet as indicated in the resident's plan of care to offer foods high in fiber. The RD stated that it was hard to incorporate fiber in a pureed/renal diet, but offered no information about any attempts made or any alternatives. A review an online article by the National Center for Biotechnology Information (NCBI) titled, Fecal Impaction:A Cause for Concern?, indicated fecal impaction was a result of chronic or severe constipation, mostly found in the elderly population. The article indicated the three most important risk factors were bowel hypomotitlity (slow movement of bowels), inadequate dietary fiber and water intake. The treatment is aimed at relieving the major complaint and correcting the underlying fecal impaction to prevent reoccurrence. Also after removal of the impaction, the resident should be placed on additional stool softeners and laxatives for bowel management. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 34/ A review of an undated facility's policy and procedure titled, Policy and Procedures on Hydration, indicated that CNAs shall ensure provision of water pitchers by the residents' bedside, unless contraindicated, with a clean cup in reach for the resident's use. The policy stipulated the residents who were dependent on staff for performance of ADLs, fluid will be offered at least once every two hours. The policy also indicated residents at high risk for dehydration shall be placed on a 72 hour monitoring of intake and output to obtain baseline data of hydration status to identify any problems of poor hydration.

Based on observations, interviews, and record review, the facility failed to provide one of 18 sampled residents (Resident 7) with sufficient fluid intake, assess and document the actual amount of fluid intake and output, per the facility's policy, after Resident 7 was assessed as a high risk for dehydration (deficit of total body water) and urinary tract infections ([MEDICAL CONDITION] an infection in any part of your urinary system). Resident 7, who was at risk for dehydration and required an extensive assistance in eating and drinking, was not provided fluids and fluids were not accessible for the resident to drink to ensure hydration was maintained for fluid balance (cross referenced to F309). As a result of these deficient practices, Resident 7 required three transfers to a general acute care hospital (GACH) all related to hydration on 6/4/15, 11/19/15, and 12/12/15. Resident 7 was diagnosed with [REDACTED]. During the third transfer to the GACH, Resident 7 was diagnosed with [REDACTED]. Findings: A review of Resident 7's Face Sheet (admission record) indicated the resident was initially admitted to the facility on [DATE], and last readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 7's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 3/1/16, indicated Resident 7 had impaired communication skills and required extensive assistance (resident involved in activity, staff provide weight-bearing support) in bed mobility, and was totally dependent on staff with transferring. The Licensed Nurse Weekly Summary, dated from 12/1/15 to 3/14/16, indicated Resident 7 required extensive assistance in eating. On 3/17/16 at 7 p.m., during an observation, Resident 7 was lying on a low bed, sleeping, with two half side rails up. A water pitcher, dated 3/18/16, with NTL (nectar thick liquid) written on it, was observed on a night stand located at the far left of the resident's head of the bed, while the bed was positioned in its lowest position making it difficult for Resident 7 to reach. On 3/18/16 at 8:30 p.m., during another observation and a concurrent interview, Resident 7 was lying on a low bed with two half-side rails up. There was a pitcher, dated 3/19/16, with NTL written on it, placed on the night stand at the far left of the resident's head of the bed. There was no cup near the pitcher. The bed remained at its lowest position making it difficult to reach if Resident 7 wanted to drink. Resident 7 was asked if he speaks English, and stated, Poquito (meaning a little in Spanish). Resident 7 was asked if he was thirsty, and he stated, Yes. During the concurrent interview, the director of nurses (DON) stated Resident 7 did not like drinking the nectar thick liquids (liquids that have been thickened to a consistency that coats and drips off a spoon, similar to unset gelatin), but needed to be on nectar thick liquids because of swallowing difficulty. The DON further stated that nursing staff encourages the resident to drink and monitors Resident 7's fluid intake and output. On 3/18/16, at 9:10 p.m., during a concurrent interview and record review, Resident 7's Intake and Output Record, dated from 3/1/16 to 3/17/16, indicated documentation of Resident 7's fluid intake by mouth for all three shifts (7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m.). The total fluid intake for Resident 7 every 24 hours averaged between 500 to 700 cubic centimeters (cc). The DON stated the facility only monitors the fluids taken by resident during medication pass and fluids offered by nurses every time the resident was encouraged to drink. The DON further stated the facility monitors the fluid intake because Resident 7 has [MEDICAL CONDITION] (inability to urinate) and required in and out catheterizing (removal of urine from the bladder through the use of a rubber catheter) every shift if he does not urinate. The DON stated the facility did not monitor the fluids provided and taken by Resident 7 during meals (breakfast, lunch, and dinner). A review of Resident 7's physician's orders [REDACTED]. According to the physician's telephone orders, dated 6/9/15, Resident 7 was readmitted back to the facility on [DATE] (five days later) with [DIAGNOSES REDACTED]. A review of the GACH's history and physical (H/P), dictated 6/5/15, indicated Resident 7 was admitted for further care and treatment for [REDACTED]. Resident 7 received intravenous fluids, IV antibiotics (treatment of [REDACTED]. A review of another telephone physician's orders [REDACTED]. Resident 7 was readmitted back to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the GACH's abdominal CT Scan (computed tomography (X-ray CT) or computerized axial tomography scan (CAT scan), performed on 11/19/15, indicated Resident 7 had a large amount of stool within the colon, particularly within the rectum (the concluding part of the large intestine that terminates in the anus) with distention (occurs when substances, such as air (gas), stool, or fluid, accumulate in the abdomen causing its outward expansion beyond the normal girth ( measurement around the middle of something, especially a person's waist)). A review of another telephone physician's orders [REDACTED]. Resident 7's was readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the GACH's history and physical (H/P) for Resident 7, dated 12/13/15, indicated Resident 7 was admitted to the GACH with metabolic [MEDICAL CONDITION] (temporary or permanent damage to the brain that happens when the body's metabolic processes are seriously impaired), dehydration, urosepis, and acute [MEDICAL CONDITION]. A review of the GACH's physician's progress note, dated 12/15/15, indicated Resident 7 received intravenous fluids (IVF) because of [MEDICAL CONDITION] of 151 mEq/L ((milliequivalents per liter) an elevated sodium level in the blood, specifically a serum level above 145 mEq/L ( normal reference range 135-145)) consistent with free water deficiency. According to skilled nursing facility's Medication Administration Record [REDACTED]. A review of Resident 7's preprinted care plan, initiated on 11/28/15, and titled, At Risk for Dehydration, indicated Resident 7 was at risk for dehydration related to being dependent on staff for fluid intake, laxatives, and impaired cognition. The staff's approaches included monitoring intakes, weights, encouraging oral fluid intake, and offering fluids frequently. The care plan did not specify how the facility would monitor Resident 7's intake. There was no documented evidence the facility had a method on how to monitor intake from both nursing and dietary department to ensure Resident 7 was hydrated. A review of Resident 7's Hydration Assessment, dated 11/28/15, indicated the resident's medical factors and conditions did not have an impact on the resident's dehydration and fluid maintenance status. A handwritten entry, dated 11/28/15, indicated Resident 7 was able to reach fluid at bedside (sic). Another handwritten entry, dated 12/17/15, indicated a reevaluation of the resident's hydration assessment, which indicated the resident had no signs and symptoms of dehydration, but had a poor appetite and refused to drink water at times, despite constant recommendation for hydration (sic). There was no documented evidence that these concerns were included in the Resident 7's care plans. Another handwritten entry, dated 1/3/16, indicated Resident 7 continuously refused to eat or drink. The note indicated the facility will continue to offer extra fluids and monitor. A handwritten nurse's note, dated 3/4/16, indicated that Resident 7 had poor oral intake at times, but was still within the ideal body weight (IBW). The note further indicated Resident 7 had no signs and symptoms of dehydration at that time, but the nurse documented they would continue to monitor. There was no documented evidence that a care plan was developed for Resident 7's poor appetite and refusal to eat and drink water. There was also no documented evidence that Resident 7's plan of care was revised for the concerns of the resident's risk for dehydration. A review of the facility's interdisciplinary (IDT) Resident Care Conference Reviews, dated 6/8/15, 6/22/15, 9/4/15, 12/4/15, 1/15/16, and 3/4/16, indicated lack of attendance of the dietary supervisor (DS) and registered dietitian (RD) during some of the conferences. There was no documented evidence that an IDT approach was utilized to address Resident 7's clinical conditions to develop a plan of care for Resident 7, who had recurrent urinary tract infections, fecal impaction, and dehydration given the risk factors of poor oral intake, poor mobility, requiring extensive assistance in eating/drinking, refusal to drink, having dysphagia and receiving pureed diets with thickened liquids, weight loss, and [MEDICAL CONDITION]. On 3/19/16, at 10:20 a.m., during an interview, the DS stated she knew that she should have attended the facility's IDT Resident Care Conferences, but was just too busy to attend. The DS was asked if she had initiated a care plan for Resident 7's nutritional status and weight loss issues. The DS stated she does not create or read residents' care plans. The DS stated that when she writes her progress notes, she only reviews the resident's weight records, meal intakes, and physician's orders [REDACTED]. The DS could not answer when asked how the facility was ensuring that Resident 7 was receiving the daily fluid requirements. A review of an Initial Nutritional Assessment, dated 12/4/15, written by the facility's RD, indicated Resident 7's daily fluid requirements was 1,848 cubic centimeters (cc). A review of Resident 7's Nutritional Progress Note, dated 3/4/16, indicated the DS documented the resident had poor oral intake averaging between 30 to 60 percent (%) per meal with weight loss. The DS further documented that Resident 7 was receiving pureed diet with nectar thick liquids and had a recent urinary tract infection on 2/22/16. The DS written recommendations indicated the plan was to improve Resident 7's appetite and to continue with the same diet with good intake. A review of the Nutritional Progress Note, written by the RD, dated 3/17/16, indicated a high protein nourishment drink was ordered on [DATE] to be given twice daily. A review of an undated facility's policy and procedure titled, Policy and Procedures on Hydration, indicated that CNAs shall ensure provision of water pitchers by the residents' bedside, unless contraindicated, with a clean cup in reach for the resident's use. The policy stipulated the residents who were dependent on staff for performance of ADLs, fluid will be offered at least once every two hours. The policy also indicated residents at high risk for dehydration shall be placed on a 72 hour monitoring of intake and output to obtain baseline data of hydration status to identify any problems of poor hydration. There was no documented evidence that Resident 7 was offered fluids at least once every two hours and of how much fluids Resident 7 consumed. There was also no documented evidence that other recommendations were made by the RD, DS, or IDT, after Resident 7 continued to refuse to eat and drink. On 3/20/16 at 3:30 p.m., during a telephone interview, the facility's RD was asked what interventions were implemented to ensure that Resident 7 met his fluid requirements to maintain good hydration. The RD acknowledged that the fluids consumed by the resident from dietary were not included in the monitoring of Resident 7's intake to ensure the resident met the fluid requirements of 1,848 cc per day. The RD also agreed that the DS should have been present at all the facility's IDT Care Conferences, especially since Resident 7 had continuing problems with refusing to drink, eat, and had a high risk for dehydration. The RD stated Resident 7's poor hydration may lead to another urinary tract infection and fecal impaction. The RD further stated either she or the DS can develop care plans for the residents nutritional and hydration problems.