Every finding on record at Broadway Manor Care Center

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and care in accordance with professional standards of practice (established guidelines or requirements for safe and accountable practice, protecting both the public and the profession's reputation) for one of three sampled residents (Resident 1) by failing to assess the resident and notify the physician when the resident had a change of condition on 5/9/2026. Specifically, Resident 1 was noted with swelling and skin discoloration on right upper arm on 5/9/2026 however there was no documentation indicating that the attending physician was informed regarding the situation or discussion of possible cause of the condition change to further consideration of appropriate diagnostic test/treatment/intervention for Resident 1 until 5/13/2026, when the X-ray result indicated a displaced right humeral fracture and Resident 1 was transferred to general acute care hospital (GACH) for evaluation. This deficient practice had resulted in Resident 1's physician unaware of Resident 1's change of condition and therefore delayed necessary medical intervention including immobilization, and the facility continued to provide restorative nursing service (RNS) and assist Resident 1 out of bed via Hoyer lift transportation to shower on 5/11/2026 with the resident's displaced right humeral fracture. Findings: During a review of Resident 1's admission Record (AR), the AR indicated that Resident 1 was initially admitted to the facility on [DATE] and lately readmitted on [DATE] with diagnoses including displaced fracture of greater tuberosity of right humerus (the bony prominence at the top of the upper arm bone is broken and pulled out of position by the attached rotator cuff tendons [a group of muscles and tendons that surround the shoulder joint]), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimal Data Sheet (MDS- a federally mandated resident assessment tool) dated 4/24/2026, the MDS indicated that Resident 1 had functional limitation in range of motion (ROM- the extent of movement of a joint) in bilateral upper extremities (BUE) and bilateral lower extremities (BLE). The MDS also indicated that Resident 1 was dependent (helper does all of the effort) on shower/bath, upper/lower body dressing, and tub/shower transfer. During a review of the Resident 1's Licensed Nurses Note (LNN) Type Change of Condition dated 5/9/2026, the LNN indicated by the licensed vocational nurse (LVN) 1 that Resident 1 was on new monitoring for swelling on right anterior bicep (a large, thick muscle on the upper arm's front portion) with discoloration and no further change in skin integrity noted. The LNN also indicated that a voice message was left for Resident 1's attending physician (Physician 1). During a review of Resident 1's Hospice PRN (as needed) Visit Summary (HVS) dated 5/9/2026, the HVS indicated that facility for PRN visit due to Resident 1's right arm swelling with edema (swelling from fluid trapped in body's tissues). The HVS indicated normal temperature no redness noted. The HVS did not indicate specifically Physician 2 was made aware of and the physician's response. During a review of Resident 1's Care Plan Edema/Swelling Right Arm dated 5/12/2026, the Care Plan interventions indicated to assess and document color, odor, consistency, edema, and pain; to elevate affected extremity per MD (medical doctor) order; to handle affected extremity gently; to medicate as ordered; to monitor for pain and discomfort. During a review of Resident 1's LNN dated from 5/10/2026 to 5/11/2026, since after LVN 1 left voice message for Physician 1 on 5/9/2026, there was no documentation in the LNN indicating that Resident 1's physician responded or was contacted or notified regarding the swelling and skin discoloration on right upper arm. During a review of Resident 1's Restorative Nursing Orders (RNO) dated from 5/1/2026 to 5/31/2026, the RNO indicated PROM (passive range of motion) treatment BUE/BLE was provided 5/11/2026 and 5/12/2026. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 5/12/2026, timed 11AM, the SBAR indicated by the treatment nurse (TXN) 1 that Resident 1 was noted with increased discoloration and swelling to right arm. The SBAR further indicated that hospice was contacted and no new orders were received at this time. The SBAR indicated that physician was notified on 5/12/2026 at 11AM. During a review of Resident 1's Orders Summary Report (OSR) dated 5/14/2026, the OSR indicated to transfer to general acute care hospital (GACH) 1 for further evaluation and management of right humeral neck fracture (fx- break in the bone). The order did not indicate to hold providing PROM to REisdent 1's BUE and BLE. During a telephone interview on 5/22/2026 at 11:19 AM with the restorative nursing assistant (RNA) 1, RNA 1 stated that on 5/11/2026 she performed PROM for Resident 1's BUE and BLE and was not informed to hold off providing the PROM specifically Resident 1's right arm. During a concurrent record review and interview on 5/22/2026 at 11:59 AM with LVN 1, LNN was reviewed. LVN 1 stated that she paged Resident 1's attending physician and left a voice message regarding the change of condition on 5/9/2026 and endorsed to next shift. LVN 1 stated she did not perform mobility assessment on Resident 1 because Resident 1's skin discoloration and swelling were slight, and she was not endorsed for any incident that happened on Resident 1. LVN 1 also stated that she was not endorsed on 5/12/2026 regarding call back of Resident 1's physician and she did not clarify or make attempts to contact Resident 1's physician about the change of condition. During a telephone interview on 5/22/2025 at 12:25 PM with LVN 2, LVN 2 stated that she was assigned to Resident 1 on 5/11/2026 and 5/12/2026. LVN 2 stated she was endorsed for monitoring skin discoloration and swelling but she was not endorsed specifically for the size or measurements. LVN 2 stated she did not make attempt to call Resident 1's physician since she was not endorsed about it. LVN 2 further stated she notified her treatment nurse (TXN) 1 on 5/12/2026 as she noticed the swelling and discoloration on Resident 1's right upper arm appeared larger than the previous day. During an interview on 5/22/2026 at 2:29 PM with TXN 1, TXN 1 stated that she was notified about skin discoloration initially on 5/11/2026 and she was notified of it got bigger and a little more swollen on 5/12/2026. TXN 1 stated however her focus was about Resident 1's skin discoloration and did not assess Resident 1's pain and mobility. During a telephone interview on 5/22/2026 at 2:49 PM with the hospice home health aide (HHA) 1, HHA 1 stated that he visited Resident 1 on 5/8/2026 and used Hoyer Lift () to transport the resident to a shower chair with a male CNA. HHA 1 stated he did not remember the name of the male CNA. HHA 1 stated that he also visited Resident 1 and provided care and shower on 5/11/2026 and noticed the discoloration and swelling on her right upper arm. HHA 1 stated the staff did not inform him not to transfer Resident 1 out of bed for shower on 5/11/2026. During an interview on 5/22/2026 at 3:09 PM with the registered nurse supervisor (RNS) 1, RNS 1 stated she was informed about Resident 1's skin discoloration on 5/9/2026 during her shift and she noticed Resident 1's right upper arm appeared slightly edema (), and the discoloration was red-brown color like bruise. RNS 1 stated she assumed LVN 1 performed thorough assessment on Resident 1. RNS 1 stated she did not speak with the physician during her shift, and she did not work the next day. During an interview on 5/22/2026 at 3:40 PM with the director of nursing (DON), the DON stated there was no physician's order on 5/9/2026 in regard to what to specifically monitor on Resident 1 after the COC was noted. The DON stated there was no documentation in Resident 1's medical record dated from 5/9/2026 to 5/22/2026 from indicating the details on facility staff notified Resident 1's physician and the physician's response or any given order. During a telephone interview on 5/28/2026 at 10:35 AM with the Hospice Licensed Nurse (HLN), HLN stated during a visit to Resident 1 on 5/9/2026 she noted the resident's right upper arm with swollen and edema. HLN stated she also noticed light green discoloration around one centimeter by one centimeter on Resident 1's right upper arm. HLN stated there was no documentation about details that she informed Physician 2 on the phone. HLN stated she did not inform Physician 2 about the light green discoloration on Resident 1's right upper arm. HLN stated that there was no documentation of the time she made call and specific order she received from Physician 2. HLN stated she did not place a telephone order for monitoring for Resident 1. During a review of the facility's Policy and Procedures (P&P) Acute Condition Change-- Clinical Protocol revised in 3/2023, the P&P indicated the following: The nursing staff will contact the physician based on the urgency of the situation. The physician will respond in a timely manner to notification of problems or changes in condition and status. The nurse and physician will discuss and evaluate the situation. The staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, and if necessary, the physician will order diagnostic tests and evaluate the resident directly. During a review of the facility's P&P Hospice Program revised in 3/2023, the P&P indicated that it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that level of care provided is appropriately based on the individual resident's needs. The P&P also indicated responsibilities include to communicate with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day.

Based on observation, interview, and record review, the facility failed to develop a comprehensive resident specific care plan for three of eight sampled residents (Resident 4, 8 and 31) in accordance with the facility's policy and procedures. A care plan for Resident 4 and 31 was not developed for management of dementia ( a progressive brain disorder that affects memory and thought process). This failure had the potential to result in the resident not to receive the necessary care needs and psychosocial needs, increased behavioral escalation, resident distress, and risk of harm. 2. A care plan for Resident 8 was not developed for the management of self inflicted wound of both hands by picking at his nails and skin using fingers on both hands. This failure had the potential to result in worsened or delayed healing of Resident 8's wound. Findings: 1.During a review of Resident 4's Face sheet ( admission Record) indicated the resident was originally admitted to the facility on [DATE], with a diagnosis of but not limited to , dementia, psychotic disturbance ( trouble telling what is real from what is not) and anxiety ( a strong feeling of worry, nervousness, or fear). During a review of Resident 4's History and Physical ( H&P) , dated 3/14/2025, indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set ( MDS- a federally mandated resident assessment tool), dated 12/12/20225, indicated the resident has moderate cognitive impairment ( forgetful, confused, with unreliable judgment and decision – making) dependent on helper for all activities of daily living ( ADL's) such as eating, oral hygiene, toileting hygiene, showering, and dressing. During an interview on 2/12/2026 at 8:05 AM with Certified Nursing Assistant (CNA3) stated, Resident 4 has periods of confusion and forgetfulness, with episodes of irritability during which she may refuse assistance with activities of daily living (ADLs), including showering and eating. CNA 3 states that Resident 4 has safety concerns related to her cognitive impairment, requiring frequent reorientation and does not have the ability to use the call light. CNA 3 stated frequent rounding is provided for her behaviors. During a concurrent interview and record review on 2/12/2026 at 8:25AM with Registered Nurse Supervisor (RN1), Resident 1's care plans were reviewed. RN 1 stated, there was no care plan developed specific to the resident's diagnosis of dementia and associated behaviors. RN 1 stated that without a behavior – specific dementia care plan and care provided to the resident could be inconsistent. 2. During a review of Resident 31's admission record, the admission record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses but not limited to dementia, depression, anxiety, and bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 31's Minimum Data Set (MDS – a comprehensive resident assessment tool), dated 1/30/2026, the MDS indicated an active diagnosis of dementia. During an interview on 2/12/2026 at 8:40 AM with LVN (Licensed Vocational Nurse) 1, LVN 1 stated Resident 31 had a diagnosis of dementia and is sometimes confused and agitated. Resident 31's medical record was reviewed with LVN 1. Resident 31's medical record did not indicate a care plan for dementia. LVN 1 stated Resident 31 does not have a care plan for dementia. During an interview on 2/12/2026 at 9:01 AM with the Assistant Director of Nursing (ADON), the ADON stated Resident 31 should have a care plan for dementia. During an interview on 2/12/2026 at 9:25 AM with the MDS nurse, the MDS nurse stated it was important for residents to have dementia care plans to provide care for each resident to help with their cognitive impairment and safety. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2023, the P&P indicated the Interdisciplinary Team will develop and implement a comprehensive, person-centered care plan for each resident. 3. During a review of Resident 8's admission record indicated Resident 8 was had admitted to the facility on [DATE] and readmitted on [DATE] diagnoses of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest, chronic ataxia (neurological sign characterized by impaired muscle coordination that leads to unsteady movements) and type 2 diabetes mellitus ( disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool) dated 10/11/2025, the MDS indicated Resident 8 had moderately impaired cognition (ability to think and reason). During a review of Resident 8's Change of Condition /Interact Assessment, dated 12/21/2025, the assessment indicated Resident 8 had a self-inflicted wound with minimal bleeding from the nails and skin picking. During a review of all Resident 8's medical records, the medical records did not indicate a care plan to facilitate the treatment and monitoring of Resident 8's wound. During an observation on 2/9/2026 at 11:49 AM inside Resident 8's room, Resident 8 was picking at his nails and skin using fingers on both hands. During an interview on 2/11/2026 at 8:37 AM with Certified Nursing Assistant (CNA) 6, CNA 6 stated Resident 8 picks his skin with his nails and fingers causing them to bleed. During an interview on 2/12/2026 at 8:45 AM with Treatment Nurse (TN) 1, TN1 stated there was no care plan to care and treat for Resident 8's wound that TN1 also stated Resident 8's care plan should involve wound cleaning and monitoring for signs and symptoms of infection. During an interview on 2/12/2026 at 1:35PM with Assistant Director of Nursing (ADON), ADON stated the nurses didn't update Residents 8's care plan to include assessing and providing treatment for Resident 8's self-inflicted wound. During a review of the facility's policy and procedure ( P&P) titled, Care Plans, Comprehensive Person-Centered , revised March 2023, 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 care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person -centered care plan will include measurable objectives and timeframes, describes the services that are to furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and reflect current problem areas and conditions.

Based on observation, interview, and record review the facility failed to: 1.Reconcile (the process of comparing transactions and activity to supporting documentation) two medication emergency kitS ([eKIT] - kit containing medications needed to be used during emergencies) containing lorazepam (a controlled substance [CS - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication [CM] used for anxiety) for February 2026, in one of two Medication Rooms (Medication Room Station A) inspected. 2. Account for one dose of Modafinil (a CM used to sleep apnea [a disorder where breathing repeatedly stops and starts during sleep, preventing necessary oxygen flow and restful sleep]) for Resident 4 in one of two inspected medication carts (Medication Cart 1). 3.Include the verifying signatures of two licensed nurses on the Medication Disposition Record observed in Medication Room Station A for four of four sampled records. As a result, control and accountability of medication disposition (process of returning and/or destroying unused medications) did not follow state and federal regulations and facility policy and procedures. 4.Apply lidocaine (a medication used for relieving pain) patches (a medication delivery system) to one side of body to Resident 27, as ordered by the physician. These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and exposure of harmful medications to residents in the facility, that Resident 4 could have accidental overdose (administration of more than the prescribed dose) to CM possibly leading to physical and psychosocial harm, hospitalization and death and the potential to result in Resident 27's health and well-being to be negatively impacted. Findings: During an observation on 2/10/2026 at 10:10 A.M., Licensed Vocational Nurse (LVN) 4 was observed applying one lidocaine 4% patch to Resident 27's right flank (side of body below the ribs above the hips) area, and one lidocaine 4% patch to Resident 27's left flank area. During an observation and concurrent interview on 2/10/2026 at 1:10 P.M., with Registered Nurse (RN) 1, in Medication Room Station A, there was: One medication e-KIT stored in the refrigerator and labeled REF493, containing CSs without an accountability log for the reconciliation of CS inventory at every shift change for February 2026. One (1) medication e-KIT stored in the cabinet at room temperature and labeled 308, containing CSs without an accountability log for the reconciliation of CS inventory at every shift change for February 2026. Four (4) Medication Disposition Record logs, dated 1/19/2026, without witness initials for the destruction of the medications listed on the form. During a concurrent record review and interview on 1/19/2026, RN 1 reviewed four Medication Disposition Record logs and was unable to find signatures, initials, or witness names. RN 1 stated that licensed nurses did not comply with state requirements or facility policy, which indicated medication disposal entries be signed with a witness. During the same interview, RN 1 stated that all CSs, including medication e-KITs containing CSs must be reconciled every shift. RN 1 stated the e-KIT labeled REF493 and 308 in Medication Room Station A were not reconciled each shift in February 2026. RN 1 stated that consistent reconciliation is necessary to maintain accountability and prevent CS diversion. During a concurrent record review and interview, on 2/10/2026 at 3:35 P.M. with LVN 2, LVN 2 reviewed four (4) Medication Disposition Record logs dated 1/19/2026. LVN 2 stated she could not locate signatures, initials, or witness names on the records. LVN 2 stated failing to ensure that a licensed nurse initialed the log as a witness when disposing of medications on 1/19/2026. During an observation on 2/10/2026 at 1:33 P.M., with Licensed Vocational Nurse (LVN) 4, in Medication Cart 1, there was a discrepancy in the count between the Antibiotic or Controlled Drug Record accountability log and the amount of medication remaining in the medication cart or medication bubble pack (medication packaging system that contains individual doses of medication per bubble) for the following residents: Two (2) doses of Modafinil (a CM used to sleep apnea [a disorder where breathing repeatedly stops and starts during sleep, preventing necessary oxygen flow and restful sleep]) 100 milligram ([mg] - a unit of measure of mass) tablet was missing from the bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 4. The Antibiotic or Controlled Drug Record accountability log for Modafinil indicated the bubble pack should have contained a total of 28 Modafinil 100 mg tablets, however the bubble pack contained 26 Modafinil 100 mg tablets and no documentation of administrations. During a concurrent interview, LVN 4 stated LVN 4 administered two (2) Modafinil 100 mg tablets to Resident 4 that morning (2/10/2025) at 8:38 A.M. and forgot to sign the Antibiotic or Controlled Drug Record accountability log. LVN 4 stated LVN 4 failed to follow the facility's policy of signing each CM dose on the Antibiotic or Controlled Drug Record accountability log after preparing the dose for the resident. LVN 4 stated LVN 4 understood it was important to sign each dose once administered to ensure accountability, prevention of CM diversion, and accidental exposures of harmful substances to residents. LVN 4 stated if documentation was not accurate then it can lead to medication error if overdosed leading to stoppage of breathing, hospitalization and possibly death for Resident 4. During an interview on 2/10/2026 at 1:42 P.M., with LVN 4, LVN 4 stated during the medication administration that day (2/10/2026) at 10:10 A.M., LVN 4 applied one (1) Lidocaine 5% patch to Resident 27's right flank area, and one (1) lidocaine 5% patch to Resident 27's left flank area. LVN 4 acknowledged the physician's order specified to apply two (2) Lidocaine 4% patch to left flank area. LVN 4 stated that LVN 4 failed to follow 5 rights of medication administration and applied the lidocaine patches not according to physician orders. LVN 4 stated this was considered a medication error. During an interview on 2/10/2026 at 2 P.M., with the Director of Nursing (DON,) the DON stated that medication e-KITs containing CSs needed to be counted and reconciled at every shift change to ensure accountability and prevent CS diversion. The DON stated the e-KITs labeled REF493 and 308 containing CSs in Medication Room Station A were not reconciled at every shift in February 2026. The DON stated that the facility will immediately implement an accountability log for reconciliation of e-Kits containing CSs. During the same interview, the DON reviewed the four (4) Medication Disposition Record logs dated 1/19/2026. The DON stated the DON was unable to locate the witness initials on the logs. The DON stated licensed nurses failed to include the initials of witnesses when destroying medications. The DON stated it was important to verify and sign these logs with witnesses to prevent medication diversions and accidental exposure to residents. During the same interview, the DON stated that LVN 4 failed to follow facility policy of documenting the preparation of CM immediately on the Antibiotic or Controlled Drug Record accountability log for Resident 4. The DON stated not documenting the Antibiotic or Controlled Drug Record timely can lead to accountability failures, CM diversion, inaccurate clinical records, and accidental use and overdose of harmful substances for residents. The DON also stated that LVN 4 failed to follow five (5) rights of medication administration and facility medication administration guidelines to ensure physician orders were followed as prescribed and medications were administered correctly to Residents 27. The DON stated that LVN 4 did not administer both lidocaine patches to the left flank area of Resident 27. The DON stated not administering both patches on the left flank areas could harm Resident 27 by not reliving the pain. DON stated this was considered a medication error. During a review of Resident 4's admission Record (a document containing demographic and diagnostic information,) dated 2/10/2026, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] with diagnoses including respiratory (breathing) failure, Parkinson's disease (brain disorder that causes problems with movement, balance, and coordination,) epilepsy (brain disorder that causes recurring seizures,) psychosis (a mental health symptom where a person loses touch with reality,) dementia (a decline in mental ability such as memory, reasoning, and communication.) During a review of Resident 4's Medication Administration Record ([MAR - record of medications administered to a resident) for February 2026, the MAR indicated Resident 4 was prescribed Modafinil 200 mg for sleep apnea, starting 7/3/2025, to be given once a day at 9.a.m. During a review of Resident 27's admission Record dated 2/10/2026, the admission Record indicated Resident 27 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including abdominal (stomach) pain. During a review of Resident 27's MAR for February 2026, the MAR indicated Resident 27 was prescribed Lidocaine 4% patch apply two (2) patches at Left flank area for pain management, starting 11/10/2025, to be given once a day at 9 A.M. During a review of the Policy and Procedures (P&P) titled Controlled Medications, revised March 2023, the P&P indicated: When a CM is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: 1) date and time of administration 2) amount administered. 3) Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. During a review of the P&P, titled Controlled Medication Storage, revised March 2023, the P&P indicated: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substance are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. a.The DON and the consultant pharmacist maintain facility's compliance with federal and state laws and regulations in the handling of controlled medications. b. At each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. During a review of facility's P&P, titled Medication Destruction, last revised January 2025, the P&P indicated: a. Non-controlled medication destruction occurs in the presence of two licensed nurses. b. The nurse(s) and/or pharmacist witnessing the destruction ensure that the following information is entered on the medication disposition form signature of witnesses.

Based on observation, interview, and record review the facility failed to label, discard medications and stored safely, following manufacturer's recommendations and in accordance with the facility's Policy and Procedure (P&P) titled Medications and biologicals by failing to: 1.Label one (1) open Lantus (type of long-acting insulin [medication that lowers blood sugar]) in a Solostar pen (a type of prefilled syringe containing insulin) stored in Medication Cart 2 at room temperature for one of three sampled residents (Resident 83). 2. Remove from use and discard one (1) expired medication from facility stock, in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) inspected medication rooms (Medication Room Station A.) These deficient practices increased the risk that Resident 83 and other residents to receive medication that had become ineffective or toxic due to improper storage or labeling, experience medication adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) resulting in the negative impact to their health and well-being possibly leading to health complications, hospitalization, or death. Findings: During an observation and concurrent interview on 2/10/2026 at 1:10 P.M., in Medication Room Station A with Registered Nurse (RN) 1, an unopened box of Refresh (an eye drop medication used for dry eyes) eye drops was found stored at room temperature in the cabinet with other unexpired facility stock medications was labeled with an expiration date of 12/2025. According to the manufacturer's expiration date imprinted on the Refresh medication box, the medication should be used or discarded by December 2025. During a concurrent interview, RN 1 acknowledged the Refresh eye drops for facility stock expired in December 2025 and should had been removed from use and placed in the expired medication bin to be disposed and to prevent accidental use. RN 1 stated expired medications could have less or no potency (strength) and will not be effective when used in error for residents in the facility. RN 1 stating using expired Refresh eye drops will not be effective in treating residents with dry eyes. During an observation on 2/9/2026 at 1:45 P.M., the Medication Cart 2 in the presence of Licensed Vocational Nurse (LVN) 6, one open and used insulin Lantus belonging to Resident 83 was found stored at room temperature without a date indicating when storage or use at room temperature without label, an open date as required by their respective manufacturer's specifications or stored and labeled in a manner consistent with facility policies. LVN 6 stated according to the manufacturer's product labeling, open Lantus Solostar insulin pens should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening pen. During a concurrent interview on 2/9/2026 at 1:45 p.m. with LVN 6, LVN 6 stated insulin Lantus Solostar pen for Resident 83 was open, used, stored at room temperature, and not labeled with a date when use at room temperature began. LVN 6 stated insulin pen was considered a multi-dose (having more than one [1] dose) medication and according to manufacturer recommendation the Lantus pen needed to be discarded after 28 days of use, and after that day the insulin could lose potency (the strength of medication) and considered expired. LVN 6 stated that LVN 6 was unaware when the insulin Lantus Solostar pen for Resident 83 was opened or stored at room temperature therefore unknown when it would expire. LVN 6 stated administering expired insulin in error will not be effective in keeping the blood sugar stable and can harm Resident 83 by causing high blood sugar levels, leading to shock and coma (a state of deep unconsciousness caused by injury or illness), hospitalization or even death. During an interview on 2/10/2026 at 2 P.M., with the Director of Nursing (DON,) the DON stated the insulin Lantus Solostar pen for Resident 83 was not labeled with a date when the pen was first opened and used. The DON stated several LVN's failed to label the date the pen was opened and used. The DON stated without knowing when the Lantus Solostar pen was opened it was unknown when it would expire, increasing the risk of administration of expired insulin to Resident 83. The DON stated expired insulins have lost potency and effectiveness and when administered in error were not effective in controlling blood sugar levels leading to hyperglycemia (high blood sugar level) and potential hospitalization for Resident 83. During the same interview, the DON stated that expired medications are ineffective and may not work properly and need to be removed from use. The DON stated that several LVN's failed to remove expired Refresh eye drops from facility stock increasing the potential for use of expired medications and harming residents by not treating their condition. During a review of facility's Policy and Procedures (P&P) titled, Discontinued Medications, last revised January 2025, the P&P indicated that When medication are expired, discontinued by a prescriber, the resident is transferred or discharged .the medications are marked as discontinued or stored in a separate location and later destroyed. If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified or shall be stored in a separate location designated solely for this purpose. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up by pharmacy. Medications are removed from the medication cart or storage area prior to expiration, and immediately upon receipt of an order to discontinue. During a review of facility's P&P titled, Storage of Medications, last revised January 2025, the P&P indicated that Medications and biologicals are stored safely, and properly, following manufacturer's recommendations or those of the supplier the outdated, contaminated, or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. During a review of facility's P&P titled, Procedure for All Medications, revised March 2023, the P&P indicated: When opening a multi-dose container, place the date on the container. During a review of facility's P&P titled, Vials and Ampules of Injectable Medications, revised March 2023, the P&P indicated: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. The date opened and the initials of the first person to use the vial are recorded on multi-dose vials. Medication in multi-dose vials may be used until manufacturer's expiration date. During a review of manufacturer guideline, titled Highlights of Prescribing Information for Lantus, dated 6/2022, the guide indicated only use your pen for up to 28 days after its first use. Throw away the Lantus Solostar pen you are using after 28 days, even if it still has insulin left in it.

Based on observation, interview, and record review the facility failed to follow the facility's policy and procedure for Sanitation and Infection Control, to ensure the Dietary Aide (DA) followed infection control policies to ensure the department operated under sanitary condition to serve 70 of 70 residents. This deficient practice had the potential to cause food-borne illnesses caused by consuming contaminated foods or beverages. Findings: During an observation on 2/11/2026 at 11:40 AM, during a tray line observation, the Dietary [NAME] (DC) when serving food and was observed wearing gloves. The DC opened the refrigerator door, took out a box, set it on the counter, and proceeded to serve a bread roll with the same gloved hand. Registered Dietitian (RD) present during tray line was made aware of the observation and instructed the DC to wash his hands and change to new gloves. During an interview on 2/11/2026 at 3:18 PM with Dietary Supervisor Department (DSD) stated that the DC should have washed his hands and change gloves before proceeding to continue to serve food. DSD stated this deficient practice could have placed residents especially those that are immune compromised are at risk for food borne illness. During a review of the facility's policy and procedure titled, Sanitation and Infection Control, undated, indicated, disposable gloves are to be worn for single use and should be discarded after each use or when soiled.

Based on observation, interviews and record review, the facility failed to provide sufficient training program to ensure the continuing competence of certified nursing assistants. This deficient practice had the potential to negatively impact the competence and performance of certified nursing assistants in delivering safe and effective nursing care. Findings: During an interview on 2/12/2026 at 2:10 PM with Director of Staff Development (DSD), DSD stated that nursing assistants weigh the residents, but nursing assistants were not given a training on weight assessment and there was no competency tool checklist for weight assessment. During an interview on 2/12/2026 at 2:35 PM with Restorative Nursing Assistant (RNA)1, RNA 1 stated that they do weigh the residents but cannot remember the last time training on weighing residents was given by the facility. During an interview on 2/12/2026 at 2:55 PM with Registered Nurse (RN) 1, RN 1 stated Resident 8 was weighed monthly only and was not weighed every week for the first month of Resident 8's admission. During an interview on 2/12/2026 at 3:45 PM with Assistant Director of Nursing (ADON), ADON stated nursing assistants provide care to the residents and trainings should be provided for them to be competent on their job. ADON also stated one of the nursing assistants' main tasks is to weigh the residents upon admission, every week for first month of admission and monthly thereafter. During a review of the facility's annual education calendar for 2025, the calendar for the monthly topics provided by the DSD to the staff did not include topics on weight assessment. During a review of the Certified Nursing Assistant Competency Evaluation Checklist, dated 10/10/2025, the checklist indicated there is no evaluation for competency on weight assessment in the nursing assistant skills competency. During a review of the facility's policy and procedure (P&P) titled, In-service training , all staff, the P&P indicated, the primary objective of the in-service training is to ensure the staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. Training requirements are met prior to staff providing services to residents, annually and as necessary based on the facility assessment.

Based on interview and record review, the facility failed to ensure that 1 of 7 sampled residents (Resident 48) had a current and accessible copy of the Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) in the resident's electronic chart and physical clinical record. These failures had the potential to cause conflict with Resident 48's and their representative party's wishes regarding end-of-life treatment and care. Findings: During a review of Resident 48's admission Record (AR), the facility admitted Resident 48 to the facility on 6/4/2022 and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), and heart failure (chronic condition were the heart muscle cannot efficiently pump blood to the rest of the body). During a review of Resident 48's Advance Directive Acknowledgement document, dated 9/30/2022, the document indicated Resident 48 had an Advance Directive available and indicated that the terms of the Advance Directive will be followed by the healthcare facility and my caregivers to the extent permitted by law. During a review of Resident 48's Physician Orders for Life-Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life), prepared by the facility on 8/17/2023 and signed by Family Member (FM) 1 on 10/10/2024, the POLST indicated Resident 48 had an Advance Directive, dated 12/14/2020, that was available and reviewed by the facility. During a review of Resident 48's Minimal Data Set (MDS, a resident assessment tool), dated 1/1/2026, the MDS indicated that Resident 48 was unable to complete the Brief interview for Mental Status. The MDS indicated that there was a staff assessment of Resident 48's mental status, and the MDS indicated Resident 48's cognitive skills (a resident's thought process) for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 48's Advance Directive was not available. During an interview on 2/10/2026 at 11:45 AM with FM 1, FM 1 stated she had given the facility a copy of Resident 48's Advance Directive when Resident 48 was admitted to the facility initial admission into the facility. During a concurrent interview and record review on 2/10/2026 at 4:15 PM with the Assistant Director of Nursing (ADON), Resident 48's Advance Directive Acknowledgement form, dated 9/30/2022 and POLST, signed by FM 1 on 10/10/2024 were reviewed. The ADON stated that according to the Advance Directive Acknowledgement form and the POST, Resident 48 had an Advance Directive. During the same concurrent interview and record review on 2/10/2026 at 4:25 PM with the ADON, Resident 48's physical and electronic clinical chart were reviewed. The ADON stated, a copy of Resident 48's Advance Directive was not located in Resident 48's physical or electronic clinical chart and did not know why it was not in the resident's clinical records. During an interview on 2/11/2026 at 9:40 AM with the Social Services Director (SSD), the SSD stated, she was not aware that a copy of Resident 48's Advance Directive was not in the chart until it was mentioned to her during the recertification team's investigation on 2/10/2026. The SSD stated that it was important to have a copy of the resident's Advance Directive in the chart so the medical staff within the facility, the paramedics, and at the General Acute Care Hospital were aware of the resident's and their representative party's wishes in an event the resident is no longer cognitively intact and during an emergency situation. During a review of the facility's policy and procedure (P&P) titled Advance Directive, dated September 2022, the P&P indicated that if the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff.

Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards and facility policy and procedures (P&P) for one of six residents (Resident 55) observed for medication administration by failing to administer crushed medications separately. This deficient practice increased the risk that Residents 55 could experience medication adverse effects (unwanted, unintended result) such as drug (medication) - drug interactions and cross-contamination from combining and administering crushed medications together. Findings: During an observation on 2/10/2026 at 9:35 AM with Licensed Vocational Nurse (LVN) 6, LVN 6 was observed crushing and combing the following medications in a small plastic cup for Resident 55: Amlodipine (a medication used for high blood pressure) 5 milligram ([mg] - a unit of measure of mass) tablet. Benztropine (a mediation used for Parkinsons disease [a brain disorder that causes problems with movement, balance, and coordination]) 3 mg tablet. Docusate (a medication used for constipation) 100 mg tablet. LVN 6 was then observed opening Gabapentin (a medication used for neuropathy [pain caused by damaged nerves]) 100 mg capsule and pouring the contents on top of the other crushed medications in the small plastic cup. LVN 6 added applesauce to the plastic cup and mixed all the medications together. LVN 6 confirmed that LVN 6 prepared four (4) mediations for administration to Resident 55 and walked inside Resident 55's room. LVN 6 introduced herself to Resident 55 and prepared for the medication administration. LVN 6 was stopped by the surveyor before any medication was administered to Resident 55 and advised to discuss the medication preparation with the surveyor in the hallway. During an interview on 2/10/2026 at 9:40 AM, with LVN 6, LVN 6 stated that nurses should not combine crushed medications and to prepare each crushed medication separately for administration. LVN 6 acknowledged Resident 55's orders indicated may crush medications mixed with applesauce and administer as a single oral bolus starting that day. LVN 6 stated single oral bolus indicated to give each medication as a single administration. LVN 6 stated administering crushed medications combined and together could result in adverse reactions such as drug-drug interactions. LVN 6 stated that LVN 6 failed to follow standard of practice and facility P&P. During a concurrent record review and interview on 2/10/2026 at 2 P.M., with the Director of Nursing (DON,) the DON reviewed Resident 55's MAR and facility P&P titled Medication Administration - General Guidelines. The DON acknowledged Resident 55's orders indicated may crush medications mixed with applesauce and administer as a single oral bolus starting that day. The DON stated single oral bolus indicated to give each medication as a single administration. The DON stated as a standard of practice nurses should administer crushed medications separately and not combine together. The DON stated LVN 6 failed to prepare crushed medications separately for administration that day (2/9/2026) during morning medication administration, increasing the risk of medication adverse effects, and drug-drug interactions for Resident 55. During a review of Resident 55's admission Record (a document containing demographic and diagnostic information,) dated 2/10/2026, the admission Record indicated Resident 55 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including respiratory (breathing) failure, Parkinson's disease, neuropathy and hypertension (high blood pressure.) During a review of Resident 55's Medication Administration Record ([MAR] - record of medications administered to a resident) for February 2026, the MAR indicated the following for Resident: Amlodipine 5 mg tablet by mouth once a day for hypertension starting 11/14/2025, to be given at 9 A.M. Benztropine 3 mg tablet by mouth twice a day for Parkinsons disease starting 5/15/2023, to be given at 9 A.M. and 5 P.M. Docusate 100 mg tablet by mouth once a day for stool softener starting 10/2/2021, to be given at 9 A.M. Gabapentin 100 mg capsule by mouth three (3) times a day for neuropathy starting 12/7/2020, to be given at 9 A.M., 1 P.M. and 5 P.M. May crush medications mixed with applesauce or alternative and administer as a single oral bolus, starting 2/10/2026 at 9:33 A.M. Monitor side effect of adverse effect of oral bolus administration of crushed medications, starting 2/10/2026 at 9:33 A.M. During a review of the facility's P&P titled Medication Administration-General Guidelines, revised March 2023, the P&P indicated: crushed medications should not be combined and given all at once, either orally (e.g., in pudding or other similar food) or via feeding tube. During a review of the facility's P&P titled Crushing Medications, revised March 2023, the P&P indicated: Crushing each medication separately is considered best practice. However, separating and administering crushed medication is not appropriate for all residents. Issues related to safety, needs, preferences, medication schedule, and functional ability will determine the most resident-centered approach.

Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 7) with limited range of motion (ROM - the extent of movement of a joint) was assessed for refusal of care and provided alternative treatment and services when resident refused to receive ROM exercises, use of hand roll splints (rigid, or semi-rigid devices used to stabilize fractured bones, injured joints, or muscles) and no alternative measures provided to prevent decline in ROM. This deficient practice had the potential to place the resident at increased risk for ROM decline and development of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Findings: During a record review of Resident's 7 admission Record (AR), dated the AR indicated that Resident 7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with included diagnoses of rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a record review of Resident's 7 Minimum Data Set (MDS - a resident assessment tool) dated 12/21/2025. The MDS indicated Resident 7's had no cognitive (ability to think and reason) impairment. During a record review of Resident's 7 care plan Alteration in Joint Mobility dated 12/31/2025, indicated the goal was to minimize the risk for further loss of ROM daily. The care plan interventions included to monitor the resident for pain or stiffness, provide therapy intervention as needed, position resident to prevent further contractures with pillows or splints as needed. During a record review of Resident's 7 Joint Mobility Screen, dated 6/27/2025 a quarterly review indicated that Resident 7 continued to refuse bilateral upper extremities exercises despite education on purposes of joint mobility exercises and encouragements. During a record review of Resident 7 Joint Mobility Screening (OT) Upper Extremities, dated 11/7/2025, indicated, that splints were not recommended due to flexion contractures of joints and that Resident 7 was refusing to wear hand rolls and passive ROM and due to Resident 7 refusing to participate the RNA program was discontinued. During an interview on 2/11/2026 at 9:52 AM with the Physical Therapist (PT 1), PT 1 stated Resident 7 refused to have splints applied and to do ROM exercises with the RNA's therefore the RNA program was discontinued. During an interview on 2/11/2026 at 1:05 PM with PT 1and Resident 7, Resident 7 stated that she does not get out of bed because she cannot sit comfortably in the wheelchair or a decliner due to her poor back posture, Resident 7 stated that she is aware of her joint limitations but does have the ability to flex her elbows, move her arms up and down but can't move her fingers. Resident 7 also stated that she can lift her legs up and down but only with assistance. Resident 7 stated she would like to do simple preferred exercises. PT 1 acknowledged Resident 7 preferences and communicated to Resident 7 that PT 1 will work a plan of care customized to meet Resident 7 preferences. During an interview on 2/12/2026 at 2:08 PM with the Director of Nurses (DON), DON stated that the plan of care for any resident is to prevent further decline in the residents' condition. When a decline is not addressed this can worsen the overall health condition of the resident. The DON stated there was no alternative measures provided to the resident for the refusal of care or assessed for reason for refusal. During a review of the facility's Policy and Procedures (P&P) [NAME] Resident Mobility and Range of Motion, dated 7/2017, indicated the rehab department will identify the residents current mobility status and the residents ability to move to and from lying position, turn and move side to side in bed, change body positions, transfer to and from bed or chair, walk limitations in movement or mobility opportunities for improvement and previous treatment and services for mobility. The policy also stated that the care plan will include measurable goals and objectives and that the resident and representative will be included in determining these goals and objectives.

Based on observation, interview, and record review, the facility failed to provide safe and hazard free environment in accordance with facility's policy and procedure titled Oxygen Administration by failing to display a Oxygen in Use precaution on the door for one of eight sample residents (Resident 5) who was receiving oxygen. This deficient practice had the potential to place residents at risk of injury due to accidental fire and hazard. Findings: During an observation on 2/9/2026 at 9:52 AM during the initial tour, Resident 5 was lying on the bed receiving oxygen at 4 liters delivered via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) there was no sign on the resident's door indicating that oxygen was in use in Resident 5's room or that smoking was prohibited. During a record review of Resident 5's, admission Record (AR), the AR indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), schizophrenia (a mental illness that is characterized by disturbances in thought). During a record review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/22/2026, indicated Resident 5 moderately impaired (Moderate problems with thinking and memory). During a record review of Resident 5's physician Orders dated 2/1/2026 indicated an order for oxygen to administer oxygen at 2 liters per minute via nasal cannula and to titrate up to 5 liters per minute for oxygen saturation of less than 90% as necessary for shortness of breath and low oxygen saturation, During an interview on 2/9/2026 with Licensed Vocational Nurse (LVN 1) stated that oxygen was on and at 4 liters and that there should have been a sign on the resident's door to communicate to everyone that oxygen was in use. During an interview on 2/12/2026 at 1:59 PM with the Director of Nurses (DON), stated that whenever there is oxygen in use for safety reasons there should be a sign posted at the entrance of the residents room to alert everyone that oxygen is in use and this is to prevent fire and or injury. During a record review of the facility's policy & procedure (P&P) titled Oxygen Administration, dated 10/2010, indicated that the purpose of this P&P is to provide safe oxygen administration. The facility must place an Oxygen in Use sign on the outside of the room entrance door.

Based on observation, interview, and record review, the facility failed to ensure that one of three sample residents (Resident 2, a resident who had kidney failure (failure of the kidney to filter toxins and remove extra fluid in the body) and receives hemodialysis (dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) fluid intake restriction was monitored properly and followed the Registered Dietitian's (RD) fluid restriction recommendation of 750 to 1500 milliliters (mL, unit of measure) as indicated in the Nutritional Assessment on 1/26/2026. These failures had the potential to place Resident 2 at risk for altered hydration status which may lead to severe dehydration or fluid overload which may result in a hypotensive (low blood pressure) or hypertensive (high blood pressure) blood pressure emergency, edema (swelling), shortness of breath, heart failure (heart cannot effectively pump blood to the rest of the body) and may ultimately lead to hospitalization. Findings: During a review of Resident 2's admission Record (AR), the facility admitted Resident 2 on 12/27/2023 and readmitted Resident 2 on 1/16/2026 with diagnoses that included Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), End Stage Renal Disease (ESRD, irreversible kidney failure), and dependence on renal dialysis. During a review of Resident 2's care plan, dated 1/24/2024, the care plan indicated that Resident 2 was at risk for chronic anemia (a condition where the body does not have enough healthy red blood cells) related to her ERSD and hemodialysis. The care plan's interventions included monitoring fluid balance and consulting a RD. During a review of Resident 2's care plan, dated 7/2/2025, the care plan indicated Resident 2 was at risk for altered fluid balance. The care plan's interventions included educating Resident 2 and representative party regarding her fluid and dietary restrictions, instructing Resident 2 regarding her fluid and dietary restrictions, and monitoring Resident 2's compliance with dietary and fluid restrictions. During a review of Resident 2's care plan, dated 11/14/2025, the care plan indicated Resident 2 may expect weight changes due to fluid retention secondary to ESRD and hemodialysis. The care plan's interventions included a registered dietitian's evaluation as needed and the staff will assess for signs and symptoms of edema or fluid overload. During a review of Resident 2's History and Physical (HP), dated 1/1/2026, the HP indicated that Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Order Summary Report, the order, dated 1/18/2026, indicated Resident 2 had a fluid restriction limited to no water pitcher at bedside. During a review of Resident 2's Minimal Data Set (MDS, a resident assessment), dated 1/20/2026, the MDS indicated that Resident 2's cognitive (a resident's thought process) skills were intact. The MDS indicated that Resident 2 needed assistance (helper sets up or cleans up) for meals. The MDS indicated that Resident 2 received hemodialysis. During a review of Resident 2's Nutritional Assessment - Registered Dietitian (RD), dated 8/6/2024, 7/9/2025, 9/29/2025, and 1/21/2026, the RD's Nutritional Assessment indicated Resident 2's fluid requirement was 750 - 1500 mL. During an observation on 2/10/2026 at 4:35 PM in Resident 2's room, Resident 2 was observed sleeping in bed with small plastic cup half filled with water was noted on the overbed bedside table (a small adjustable table designed to roll over a bed and provide a flat surface). During a concurrent observation and interview on 2/11/2026 at 8:28 AM with Certified Nurse Assistant (CNA) 4 in the hallway in front of Resident 2's room, Resident 2's breakfast tray was observed. CNA 4 stated Resident 2 did not eat her breakfast and did not know how much fluids Resident 2 drank with this meal. During a concurrent observation and interview on 2/11/2026 at 1:30 PM with Restorative Nurse Assistant (RNA) 1 in the hallway in front of Resident 2's room, Resident 2's lunch tray was observed. RNA 1 stated Resident 2 ate about 80% of her meal, drank about 3/4 of her cup of milk, but did not know how much water Resident 2 drank with this meal. During an interview on 2/12/2026 at 9:30 AM in Resident 2's room with Resident 2, Resident 2 stated she did not drink any fluids last night [2/11/2026]. Resident 2 stated, she drank all her hot tea this morning and half a small plastic cup of water. During an observation on 2/12/2026 at 10:20 AM in Resident 2's room, Resident 2 was observed sleeping in bed with two small plastic cups of water 3/4 full of water on the overbed bedside table. During an interview on 2/12/2026 at 10:25 AM with CNA 4, CNA 4 stated, she was unaware of any current residents who were on fluid restrictions. During an interview on 2/12/2026 at 10:30 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated it was important to monitor the fluid intake of a resident receiving hemodialysis to ensure the resident was drinking enough fluids to be within the fluid restriction range. LVN 1 stated that a dialysis resident had a fluid restriction order with the amount of fluids intake the resident was allowed. LVN 1 stated, the CNAs and the licensed nurses (LN) needed to be aware how which residents were on fluid restrictions. During the same concurrent interview and record review on 2/12/2026 at 10:32 AM with LVN 1, Resident 2's care plans titled Risk for Altered Fluid Balance, dated 7/2/2025, was reviewed. LVN 1 stated, Resident 2's care plan meant that she had a fluid restriction and needed to be monitored for fluid retention and fluid overload. During the same concurrent interview and record review on 2/12/2026 at 10:40 AM with LVN 1, Resident 2's Active Orders List were reviewed. LVN 1 stated, the only fluid restriction order for Resident 12 was to limit to no water pitcher at bedside. LVN 1 stated, there was no order with the specific amount of fluids Resident 2 needed to drink each shift to meet the fluid restrictions. LVN 1 stated, he did not know how much fluids Resident 2 drank this morning [2/11/2026]. During a concurrent interview and record review on 2/12/2026 at 10:55 AM with Registered Nurse (RN) 1, Resident 2's Active Orders List was reviewed. RN 1 stated, Resident 2's fluid restriction order was limited to no water pitcher at bedside. RN 1 stated, she had been looking for a fluid restriction range since last week but could not find the range. During the same concurrent interview and record review on 2/12/2026 at 10:55 AM with RN 1, Resident 2's Nutritional Assessment RD dated 1/21/2026 was reviewed. RN 1 stated, Resident 2's fluid requirement indicated fluid limit to 750 - 1500mL. RN 1 stated, the fluid requirement meant this was Resident 2's fluid restriction range in 24-hours. RN 1 stated, she did not know this was the RD's recommendation. During the same concurrent interview and record review on 2/12/2026 at 11:05 AM with RN 1, Resident 2's electronic medical records (EMR) were reviewed. RN 1 stated, there was no place in the EMR to document the amount of fluids Resident 2 drank throughout the day and there was no documented evidence of monitoring Resident 2's fluid intake. RN 1 stated, since Resident 2 was receiving dialysis, it was important to monitor Resident 2's fluid intake to ensure she does not drink more than the fluid restriction range of 750 -1500mL. RN 1 stated the failure of not monitoring Resident 2's fluid intake may her experiencing fluid overload (excess fluid build-up in the body) that may result in swelling, high blood pressure crisis, heart failure, and shortness of breath leading to hospitalization. During a review of the facility's policy and procedure (P&P) titled Nutritional Assessment and Resident Care Plan Documentation, date unknown, the P&P indicated the nutritional assessment and resident care plan documentation will be provided for all residents and entered into the medical records. The P&P indicated the RD will include the estimation of the resident's nutritional intake and adequacy of nutritional intake.

Based on observation, interview, and record review, the facility failed to ensure that Certified Nurse Assistant (CNA) 6 had the competency skill to accurately monitor and document one of one sampled residents (Resident 2) food intake who was receiving a renal diet (a specialized diet prescribed by the physicians for residents with kidney disorder) as indicated in the facility's policy and procedures. This failure had the potential to place Resident 2 at risk for unintended weight loss and fluid deficit or excess that could further decline in her nutritional management. Findings: During a review of Resident 2's admission Record (AR), the facility admitted Resident 2 on 12/27/2023 and readmitted Resident 2 on 1/16/2026 with diagnoses that included Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), End Stage Renal Disease (ESRD, irreversible kidney failure), and hypothyroidism (thyroid does not make enough thyroid hormone to meet the body's needs). During a review of Resident 2's History and Physical (HP), dated 1/1/2026, the HP indicated that Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimal Data Set (MDS, a resident assessment), dated 1/20/2026, the MDS indicated that Resident 2's cognitive (a resident's thought process) skills were intact. The MDS indicated that Resident needed assistance (helper sets up or cleans up) for meals. The MDs indicated that Resident 2 was always incontinent (loss of control) of bladder and bowel. The MDS indicated that Resident 2 received hemodialysis and was on a therapeutic diet (diet prescribed by the physician). During a review of Resident 2's care plan, revised on 10/29/2024, the care plan indicated Resident 2 was at risk for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) related to DM. The care plan's interventions to offer snacks at bedtime and to monitor food intake and record. During a review of Resident 2's care plan, dated 1/24/2024, the care plan indicated Resident 2 was at risk for excessive weakness, shortness of breath, pale skin, or fatigue related to hypothyroidism. The care plan's interventions included to provide rest periods in between activities, observe for signs and symptoms of weakness or fatigue, and to monitor the percentage of Resident 2's intake and appetite. During a review of Resident 2's Active Order List, the order, dated 1/17/2026, indicated Resident 2's diet was placed on Renal 90 grams, Consistent Carbohydrate diet (CCHO diet, therapeutic diet focused on eating the same carbohydrates every day), regular texture and thin consistency. During a review of Resident 2's Nutritional - Amount Eaten (%) POC Response History record, the record indicated that on 2/11/2026 at 11:13 AM Resident 2 ate 60% of her breakfast and at 12:28 PM Resident 2 ate 60% of her lunch. During a concurrent observation and interview on 2/11/2026 at 8:28 AM with Certified Nurse Assistant (CNA) 4 in the hallway in front of Resident 2's room, Resident 2's breakfast tray was observed. CNA 4 stated Resident 2 did not eat her breakfast today and did not know Resident 2's fluid intake for breakfast. During a concurrent observation and interview on 2/11/2026 at 1:30 PM with Restorative Nurse Assistant (RNA) 2 in the hallway in front of Resident 2's room, Resident 2's lunch tray was observed. RNA 2 stated Resident 2 ate about 80% of her meal which consisted of eating most of her meats, a little bit of vegetables, and her desert, and drank about 3/4 of her cup of milk. During an interview on 2/11/2026 at 2:48 PM with CNA 6, CNA 6 stated, she picked up Resident 2's tray for breakfast the resident less than 50% of her meal. During an interview on 2/11/2026 at 2:48 PM with CNA 6 stated. she picked up Resident 2's trays and stated Resident 2 ate less than 50% of her breakfast tray and ate 50% of her lunch tray. During an interview on 2/12/2026 at 3:30 PM with the Director of Staff Development (DSD), the DSD stated that inaccurate monitoring and documentation of a resident's food intake may lead to weight loss, which is especially important to monitor in resident receiving dialysis. During the same interview and record review on 2/12/2026 at 3:44 PM, the facility's in-service sheet with the topic Nutritional and Hydration Needs dated 4/15/2025, was reviewed. The DSD stated CNA 4 and CNA 6 were not present April 2025 when Inservice about food intake documentation was done because they are newly hired. During a review of the facility's policies and procedures (P&P) titled In-service Training, all Staff, dated August 2022, the P&P indicated that the objective of in-service training is to ensure that staff are able to interact in a manner than enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas.

Based on observation, interview, record review, the facility failed to provide care and services to one of one sampled resident (Resident 8) with loss of dentures in accordance with facility policy and procedure titled Dental Services. This deficient practice had resulted in the Resident 8's ability to chew his food that could lead to choking or pain with chewing potentially leading to weight loss. Findings: During a review of Resident 8' face sheet, the face sheet indicated Resident 8 had an initial admission on [DATE] with the diagnoses but not limited to; major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) , chronic ataxia (neurological sign characterized by impaired muscle coordination that leads to unsteady movements) and type 2 diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 10/11/2025, MDS indicated that Resident 8 needs supervision or touching assistance when performing oral hygiene and using dentures. During a review of Resident 8's inventory list of resident's clothing and possessions, dated 7/23/2025, the inventory list indicated that Resident 8 has upper and lower dentures signed and certified by the ADON. During an interview on 2/10/2026 at 11:28 AM with Resident 8's family member, family member stated that Resident 8 has no teeth and uses upper and lower dentures. During an interview on 2/11/2026 at 8:37 AM with Certified Nursing Assistant (CNA)6 in Resident 8's room, CNA 6 stated Resident 8's upper and lower dentures were not in his room and cannot find Resident 8's dentures. During an observation on 2/11/2026 at 12:30 PM in the dining room, Resident 8 was not using his upper and lower teeth denture while he was eating his lunch. During an interview on 2/12/2026 at 3:36 PM with the Assistant Director of Nursing (ADON), ADON stated Resident 8's inventory list, dated 7/23/2025 indicated that Resident 8 has upper and lower dentures. ADON stated that staff should have placed a resident identification label on Resident 8's dentures to help prevent from loss or misplacement. During a review of the facility's policy and procedure (P&P) titled, Dental Services, dated 3/2023 the P&P indicated, the facility will provide routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Dentures will be protected from loss or damage, to the extent practicable, while being stored. Lost or damaged dentures will be replaced at the resident's expense unless an employee or contractor of the facility is responsible for accidentally or intentionally damaging the dentures.

Based on observation, interview and record review, the facility failed to ensure complete and accurate medical records were complete and accurate for 2 of 8 sampled residents (Resident 64 and 42) by failure to ensure: Advance Directive (document used to verify and record that the resident or legal representative was informed of their rights to accept or refuse treatment) for Resident 64 was dated. Physician Orders for Life -Sustaining Treatment form (POLST- a physician's order that includes level of medical intervention) for Resident 42 contained required signature. This failure had the potential to result in confusion regarding the validity of resident's treatment preferences and delay or delivery of care that may not have been consistent with the residents wishes. Findings: During a review of Resident 64's admission Record indicated the facility admitted the resident originally on 09/07/2022, with a diagnosis of acute respiratory failure( lungs cannot get enough oxygen into the blood), kidney failure( kidneys cannot properly filter waste and excess fluid from the blood) and atrial fibrillation( an irregular fast heartbeat). During a review of Resident 64's History and Physical (H&P) dated 1/23/26, indicated Resident 64 has the capacity to understand and make decisions. During a review of Resident 64 Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 12/9/2025, indicated Resident 64 was cognitively (ability to think and reason). During a review of Resident 64's Advanced Directive Acknowledgement form dated 06/16/2025, the document lacked a date indicating resident is capable of making preferred intensity decisions. During a review of Resident 42's admission Record Indicated the facility admitted the resident on 1/28/2026, with a diagnosis of urinary tract infection (a bacteria in any part of the urinary system casing an infection) , adult failure to thrive(an adult becomes weak, loses weight, and declines physically and mentally without a single clear cause), and dysphagia( difficulty speaking or understanding language). During a review of Resident 42's History and physical (H&P) dated 1/30/2026, indicated this resident is able to make decisions for activities of daily living (ADL's). During a review of Resident 42's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 02/1/2026, indicated resident has moderate cognitive impairment (have difficulty recalling words, require cueing or reorientation and have impaired short - term memory). During a review of Resident 42's POLST dated 1/3/2025, the required signature of the resident of legally recognized decision - maker was not present. During a concurrent interview and record review on 2/10/2026 at 09:16AM with Director of Nursing (DON), Resident 64's Advance Directive Notification was reviewed. DON verified the Advance Directive Notification was incomplete and stated that a date should have been included to ensure the document was accurately completed. During a concurrent interview and record review on 2/10/2026 at 9:19AM with Registered Nurse (RN3), Resident 42's POST was reviewed. RN3 stated the POLST did not include a signature from the legally recognized decision maker. RN3 verified that the document was not signed and stated that the legal document should have been completed with the required signature to ensure it was valid. During a concurrent interview and record review on 2/11/2026 at 11:40AM with Social Service Director (SSD), Resident 64's Advance Directive Acknowledgment form and Resident 42's POLST were reviewed. The SSD confirmed that Resident 64's Advance Directive Acknowledgement Form did not include a date indication the resident' s decision - Making status at time of completion. Additionally, Resident 42's POLST was unsigned. The SSD stated it is her responsibility to ensure residents' POLST forms and advance directives are completed accurately and acknowledged that these findings were documentation errors. During a review of the facility's policy and procedures ( P&P) titled Quick Reference Guide on POLST in Nursing Homes dated 05, 2024, indicated A POLST isn't valid unless it is signed by (1) a physician, nurse practitioner ( NP) or physician's assistant ( PA) and ( 2) the resident or, if the resident lacks capacity, the resident's legally recognized healthcare decision -maker. The POLST compliments a resident' s Advance Directive. If a resident has a POLST and an Advance Directive, the two documents should be consistent. When filling out POLST, staff should confirm whether the resident has an Advance Directive and, if so, obtain a copy of the Advance Directive and review it. During a review of the facility's policy and procedures (P&P) titled Advance Directives undated, indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Advance Directive is written instruction, such as a living will or durable power of attorney for health care. Nursing staff are responsible for documentation in the medical record

Based on observation, interview, and record review, the facility failed to implement the facility's infection control program for one of eight sample residents (Resident 62) by failing to assess and document signs and symptoms of respiratory infection as indicated in the facility's policy and procedure titled Infection Control. This deficient practice placed other residents at risk of repiratory infection. Findings: During a record review of Resident 62's admission Record (AR) the AR indicated Resident 62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), encephalopathy (malfunction of the brain that alters its structure or function), respiratory syncytial virus (RSV - a common, contagious virus causing mild, cold-like symptoms in most people but it can lead to severe lung infections like bronchiolitis or pneumonia in older adults). During a record review of Resident 62's Minimum Data Set (MDS - a resident assessment tool) dated 1/19/2026, indicated Resident 62 had severe cognitive (ability to think and reason) During a record review of Resident 62's History & Physical (H & P) dated 10/16/2025, indicated Resident 62 does not have the capacity to understand and make decisions. During a record review of Resident 62's Order Summary Report dated 2/1/2026 indicated, to monitor for signs and symptoms of Corona Virus Disease (COVID - a highly contagious respiratory illness caused by the SARS-CoV-2 virus, spreading mainly through airborne droplets from coughs, sneezes, or conversation) such as cough, shortness of breath, or difficulty breathing, fatigue, chills, muscle or body ache, sore throat, new loss of taste or smell, headache, congestion or runny nose, diarrhea, nausea/vomiting, and to document temperature, pulse and pulse oximetry every day shift. During a record review of Resident 62's Change of Condition/Interact Assessment Form, dated 2/9/2026 6:00 AM indicated Resident 62 had a suspected respiratory infection with symptoms of cough with a documented temperature of 98.0 Fahrenheit (F - a scale of temperature) and 98.0 F, pulse oximetry (SpO2 - oxygen in your blood) 95% and a heart rate (number of times your heart beats in one minute) of 69%. During a record review of Resident 62's Change of Condition/Interact Assessment Form, dated 2/10/2026 at 8:00 AM indicated Resident 62 currently on monitoring for coughing and new medication Azithromycin (antibiotic that treats bacteria) medication order given by physician. During a record review of Resident 62's Medication Administration Record, dated 2/9/2025 - 2/11/2026 indicated that there were no documented episodes of coughing. During an interview on 2/11/2026 at 11:09 AM Infection preventionist (IP- a person designated to serve as a coordinator of the infection prevention and control program). IP stated Resident 62 should have had a complete set of vital signs including a temperature, heart rate, and pulse oximetry following the recognition of the detected change of condition of coughing with the goal to prevent a potential outbreak of exposing other residents and staff of any respiratory infection including COVID. IP stated that it is important for primary caregivers to assess residents for signs of infection to prevent outbreaks. During an interview on 2/12/2026 at 2:01 PM with the Director of Nurses (DON) stated that a temperature should have been obtained followed by a change of condition since fever is a sign of infection. DON stated it is important to obtain a temperature reading with a new onset of cough to ensure an accurate report to the attending physician to ensure proper orders and plan of care are given by the attending physician. During a review of the facility's policy and procedure (P&P) titled, Infection Control, undated, indicated, that the facility must have an infection control program to be able to investigate, control, and prevent infections in the facility. The P&P indicated that infection prevention and control program includes monitoring and documenting infections.

Based on observation, interview, and record review, the facility failed to ensure that resident's bedrooms measured at least 80 square feet (sq. ft) per resident for 30 of 31 rooms (Rooms 1-4, 6-12, 4-32) in the facility in accordance with the facility's policies and procedures (P&P) titled, Bedrooms, dated May 2017. This deficient practice had the potential to negatively impact the care and services of the facility's staff and to provide safe nursing care and privacy to the residents. Findings: During a review of the facility's request for an additional room size waiver, dated 2/9/2026, the room waiver indicated that each bathroom was easily accessible in the rooms, and there was sufficient room between beds and the foot of the beds to allow freedom of movement and transfers for wheelchair-bound residents. During a review of the Client Accommodation Analysis form, dated 2/9/2026, submitted by the facility on 2/9/2026, the form indicated that there were 31 rooms that did not measure 80 sq. feet per resident as listed below: room [ROOM NUMBER]: Required sq. ft = 160 sq. ft; Actual sq. ft = 151.2 square feet with 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft; Actual sq. ft = 144.88 sq.ft; 2 beds with 1 resident. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft; Actual sq. ft = 134.88 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft; Actual sq. ft = 156.76 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft; Actual sq. ft = 184.28 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft; Actual sq. ft = 159.18 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft; Actual sq. ft = 141.47 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft; Actual sq. ft = 149.54 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft; Actual sq. ft = 141.47 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 149.66 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 141.47 sq.ft; 2 beds with 1 resident. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 141.64 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 320 sq. ft: Actual sq. ft = 314.27 sq.ft; 4 beds with 4 residents. room [ROOM NUMBER]: Required sq. feet = 320 sq. ft: Actual sq. ft = 291.48 sq.ft; 4 beds with 4 residents. room [ROOM NUMBER]: Required sq. feet = 320 sq. ft: Actual sq. ft = 291.48 sq.ft; 4 beds with 3 residents. room [ROOM NUMBER]: Required sq. feet = 320 sq. ft: Actual sq. ft = 291.48 sq.ft; 4 beds with 4 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 144.42 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 144.51 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 320 sq. ft: Actual sq. ft = 291.48 sq.ft; 4 beds with 4 residents. room [ROOM NUMBER]: Required sq. feet = 320 sq. ft: Actual sq. ft = 291.48 sq.ft; 4 beds with 4 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 144.54 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 320 sq. ft: Actual sq. ft = 291.48 sq.ft; 4 beds with 4 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 144.58 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 320 sq. ft: Actual sq. ft = 291.48 sq.ft; 4 beds with 3 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 149.85 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 148.01 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 138.99 sq.ft; 2 beds with 1 resident. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 145.91 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 138.99 sq.ft; 2 beds with 2 residents. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 145.91 sq.ft; 2 beds with 1 resident. room [ROOM NUMBER]: Required sq. feet = 160 sq. ft: Actual sq. ft = 138.92 sq.ft; 2 beds with 2 residents. During the survey, multiple observations from 2/9/2026 to 2/12/2026 were conducted at random times from 8 AM to 5 PM. The residents in Rooms 1-4, 6-12, and 4-32 were observed to have adequate room for the operation and use of the wheelchairs (a chair fitted with wheels for use as a means of transport by a person who is unable to walk as a result of illness, injury, or disability), walkers (a device that provides additional support to maintain balance or stability while walking), or canes. The room variance did not affect the care and services provided to the residents when nursing staff were observed providing care for the residents. During an interview on 2/11/2026 at 3:55 PM in room [ROOM NUMBER], Residents 26, 53, 60 stated they were happy with the care at the facility, and they felt they had enough space in their rooms. Resident 26. 53, and 60 stated the nursing staff was able to provide care without difficulty. During an interview on 2/11/2026 at 4:01 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated that the space in resident rooms was adequate and denied that space was a barrier to resident care. CNA 1 stated there was enough room to provide activities of daily living (ADL, activities such as bathing, dressing, and toileting a person performs daily) care for the residents. CNA 1 stated, there has been no issue providing care in the rooms when there was an emergency or transferring the furthest resident from the door out of the room. During an interview on 2/11/2026 at 4:30 PM with Resident 58, Resident 58 stated the space of his room was not a barrier to the care provided by the facility. During an interview on 2/11/2026 at 4:05 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, there was no difficulty providing care to his residents in their rooms and if there was an emergency in the room, the trash cans and wheelchairs were moved out of the room and the residents' beds were shifted to the side to make room for the resident to be transferred out of the room. LVN 2 stated, once the resident has been transferred out of the room, the residents' beds, trash cans, and wheelchairs would be put back in place. During an interview on 2/11/2026 at 4:15 PM with CNA 2, CNA 2 stated there was adequate space to provide ADL cares to her residents in their rooms. During a review of the facility's policies and procedures (P&P) titled Bedrooms, dated May 2017, the P&P indicated that bedrooms measure at least 80 square feet of space per resident in double rooms.

Based on interviews and record reviews, the facility failed to ensure Licensed Vocational Nurse [LVN] 1 and Registered Nurse Supervisor (RNS) 1 consulted and notified the attending physician (Physician 1) and/or Physician Assistant (PA) 1 of a resident's significant change in condition (refers to a major decline in a resident's health status that requires a comprehensive reassessment that is not expected to resolve on its own or through standard medical interventions) for one of two sampled residents (Resident 1) in accordance with Resident 1's physician's order and care plan developed to monitor Resident 1 and notify the physician for adverse reaction (unwanted, unexpected, or harmful effect resulting from a medication or other treatment), while receiving Eliquis (a brand of anticoagulant [blood thinner] medication that prevents or reduces blood clots) from [DATE] to [DATE]. Facility licensed staff that included RNS 1 and LVN 1 failed to promptly notify Physician 1 or PA 1 for Resident 1's significant change in mental status, shortness of breath, vomiting and bleeding in resident's orifice (an opening through which something may pass) on [DATE], as indicated in the physician's order. On [DATE], Resident 1 experienced altered level of consciousness (ALOC - refers to a change in a person's mental status) and three episodes of coffee-ground (a vomit that contains bits of food of what looks like coffee grounds due to presence of old blood, that may be coming from the stomach and may be a sign of a serious problem) emesis (forceful expulsion of stomach contents through the mouth) at 9 AM, 11:30 AM, and 1:25 PM. As a result of this deficient practice, RNS 1 called [DATE] emergency medical services (EMS - a system that responds to emergencies in need of highly skilled pre-hospital clinicians) on [DATE] at 1:25 PM and Resident 1 was transferred to the General Acute Care Hospital (GACH 1), after developing shortness of breath, hypotension (abnormally low blood pressure [BP] level, below ,d+[DATE] millimeters of mercury [mm/Hg - a unit that measures pressure]) with a BP of ,d+[DATE] mm/Hg, oxygen saturation (amount of oxygen circulating in the blood; [normal levels between 95% to 100%]) of 86% in room air (the normal air a person breathes). Additionally, this failure resulted in a delay of Resident 1's diagnosis, care, and immediate/emergency interventions on [DATE] from 9 AM to 1:25 PM (4.25 hours), when EMS arrived at the facility around 1:38 PM. The EMS report indicated Resident 1 had coffee ground emesis prior to EMS arrival at the facility and was in respiratory failure (a serious condition that makes it difficult to breathe on your own) upon EMS arrival to the facility, suctioned multiple times and performed cardiopulmonary resuscitation (CPR- an emergency treatment that's done when someone's breathing or heartbeat has stopped) by EMS during transport to GACH 1. On [DATE], at 1:55 PM, upon EMS arrival at GACH 1, resuscitation efforts (procedures aimed at reviving someone after their heart and/or breathing has stopped) continued, but Resident 1 passed away and pronounced dead at GACH 1 on [DATE] at 2:44 PM. The EMS report indicated Presumed Etiology (the cause of a disease) of Resident 1's cardiac arrest (when heart stopped beating) was Respiratory/Asphyxia (a condition where the body doesn't get enough oxygen due to a problem with breathing or inhaling). On [DATE] at 5:33 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (ADM) and Director of Nursing (DON) regarding the facility's failure to notify Physician 1 or PA 1 of Resident 1's significant change of condition, in accordance with the facility's policy & procedure (P&P) on Change of Condition Notification and physician order to notify the physician for adverse reactions as a result from the use of Eliquis. The surveyor notified the ADM of the IJ situation on [DATE] at 5:33 PM, due to LVN 1 and RNS 1 failures to consult and notify Physician 1 or PA 1 of a resident's significant change in condition on [DATE]. On [DATE] at 1:49 PM, the ADM provided CDPH with an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On [DATE] at 3:18 PM, the surveyor notified the ADM and the DON that the IJ was removed based on onsite verification/confirmation of the facility's full implementation of the IJ Removal Plan (a detailed plan to address the IJ findings) through observations, interviews, and record reviews. Following the removal of the IJ, the facility's noncompliance remained at a scope (refers to how widespread a deficiency is) and severity (level of harm) of G (isolated [one or a very limited number of residents are affected], actual harm, that is not immediate jeopardy). The acceptable IJ Removal Plan included the following: 1. On [DATE], the DON and Assistant DON (ADON) notified the nursing staff (all licensed nurses) of findings outlined in the IJ dated [DATE] and conducted in-services for all nursing staff (21 licensed nurses and 42 certified nursing assistants (CNAs) regarding the Change of Condition policy. The training covered: a. Utilizing the Interact (electronic records software) early warning toll-stop and watch technique to report any possible resident's changes in condition. b. Utilizing the SBAR [Situation, Background, Assessment, Recommendation] form to record the change of condition to ensure accuracy and completeness that included current vital signs ((measurable indicators that reflect a person's basic physiological functions and overall health status), detailed description of the identified situation, any drainage observed, interventions provided including physician notification. c. The anticoagulant monitoring which includes but not limited to: discolored urine, black tarry stools (dark, sticky, and foul-smelling stools that are a result of digested blood in the digestive tract), nausea/vomiting or diarrhea, bruising/bleeding, abnormal vital signs, shortness of breath, and change in mental status. d. Timely physician notification for the onset of changes in condition, including the identified signs related to anticoagulant adverse reaction monitoring. During the in-service, the DON emphasized the importance of notifying the physician upon identification of the situation to avoid any possible delay. 2. On [DATE], the facility pharmacist was contacted and will complete in-service today to licensed nurses regarding black box warning. During the in-service, the pharmacist will educate the following areas: a. Following physician's orders/instructions for residents with medications labeled black box (most serious warning label, indicating a medication carries a serious risk of adverse effects, including death) warning, such as specific monitoring, laboratory tests, etc., b. Creating and implementing the care plan c. Notifying the physician if any identified signs of adverse reaction 3. On [DATE], the DON notified the staff who could not complete the in-services must receive an in-service upon their return before their shift. 4. On [DATE], the facility notified the facility Medical Director of the IJ and the IJ Removal Plan. The Medical Director reviewed and approved the IJ removal plan. 5. On [DATE], the ADM completed the Quality Assurance and Performance Improvement (QAPI -a structured framework that helps healthcare organizations continuously improve the quality of care and patient safety) Plan for identifying and notifying the physician of resident change of condition. The Medical Director will review the QAPI program for change of condition/physician notification every month and assist the facility in adjusting the measures as necessary. 6. On [DATE], LVN [1] assigned to Resident 1 received disciplinary action pending investigation. The DON provided one-to-one in-service with LVN 1 regarding physician notification prior to the suspension. 7. As of [DATE], a total of 28 current residents are receiving anticoagulant therapy. All 28 residents who have anticoagulant orders have monitoring for adverse reactions in the electronic medication administration record. 8. Effective [DATE], the DON will conduct a monthly in-service for nursing staff (licensed nurses and CNAS) regarding change in condition for three months. 9. Effective [DATE], the DON and/or ADON will review the change of condition daily, to ensure timely physician notification of any onset signs or symptoms. 10. On [DATE], the DON created a change of condition monitoring log, which includes the physician notification of any changes. The DON notified nursing staff of the monitoring process and will document the findings and corrective action in the monitoring log for three months. If any issues are identified, the DON will extend the monitoring period for an addition of three months. 11. The DON/RNS will make daily rounds (a planned visit by facility staff, to assess a resident's condition and check what type of care/assistance is needed) to ensure that any resident changes in condition is being reported and addressed. The DON/RNS would provide a one-to-one inservice if any issues identified. 12. On [DATE], the facility initiated a QAPI for physician notification of changes in condition to address the findings outlined in the IJ template. The facility will review the progress every month for 3 months and adjust the measures as needed to ensure an effective and consistent plan. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted the resident on [DATE], with diagnoses that included Parkinsonism (a term used to describe a collection of movement symptoms associated with several conditions), dysphagia (difficulty swallowing), and long-term use of anticoagulants (the ongoing and indefinite use of medication to prevent blood clots). During a review of Resident 1's History & Physical (H&P) assessment dated [DATE] signed by PA 1, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 had the following present illnesses: orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), hypertension (high blood pressure), chronic kidney disease (progressive damage and loss of function in the kidneys), and seizures (a sudden, temporary alteration of behavior, movement, or consciousness caused by abnormal electrical activity in the brain). During a review of Resident 1's Minimum Data Set (MDS, a federally required assessment and screening tool) dated [DATE], the MDS indicated Resident 1 had severely impaired (significantly limits one person's physical or mental ability to do basic work activities) cognition (thought process). The MDS indicated Resident 1 required substantial/maximal assistance (a helper provides more than half of the effort required for a patient or resident to complete an activity) for chair/bed-to-chair transfer, sit to stand position, and bathing. The MDS indicated Resident 1 required partial/moderate assistance for personal hygiene, eating, toileting hygiene, rolling left and right, and sit to lying position. During a review of Resident 1's care plan titled Apixaban (generic name for Eliquis): At risk for adverse effect from black box medication dated [DATE], the care plan indicated Resident 1's risk for the use of a black box medication and would be monitored/identified by the licensed nurse. The care plan indicated the physician would be notified promptly of any adverse reactions. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician orders: a. A physician's order dated [DATE], to administer Eliquis Oral Tablet 2.5 milligrams (mg, unit of measure) give 1 tablet by mouth two times a day for deep vein thrombosis (DVT -a condition where a blood clot forms in a deep vein, typically in the lower legs or thighs) prophylaxis (action taken to prevent disease). b. A physician's order dated [DATE], to monitor anticoagulation medication (Eliquis) for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy (lack of mental alertness, sleepy), bruising, sudden changes in mental status and/or vital signs, shortness of breath, bleeding in any orifice, and abnormal labs; to document 'N' (No), if monitored and none of the above observed. Document 'Y' (Yes), if monitored and any of the above observed. The order indicated to notify physician and document in nurses' progress notes, every shift. During a review of Resident 1's Change of Condition (COC) Form - Situation Background Assessment Recommendation (SBAR) dated [DATE] timed at 1:25 PM, written by LVN 1, the SBAR indicated on [DATE] at 7:10 AM, Resident 1 was seen in bed by LVN 1 with chest rising up and down, responsive to verbal and tactile stimuli (any form of touch or physical contact that is perceived by the skin), resident was provided breakfast and ate 20% of breakfast . The SBAR indicated at 8:42 AM, Resident 1's vital signs obtained during medication administration indicated a BP at ,d+[DATE], pulse at 76 beats per minute (normal rate between 60 to 100 beats per minute), respiratory rate (normal rate between 12 to 20 breaths per minute) of 18 breaths per minute, oxygen saturation of 97% on room air, no pain, temperature of 97.8 degrees Fahrenheit (F, unit of measurement - normal range of temperature between 96 to 99 degrees Fahrenheit). Resident 1 received all due medication administered as ordered by the physician with no ASE (adverse side effects) noted. The SBAR indicated that at 9 AM, Resident 1 remained in bed awake and was assisted with activities of daily living (ADLs - basic tasks individuals perform daily for self-care and personal independence, such as bathing, dressing, toileting, and eating) by the CNA. The SBAR indicated Resident 1 had one episode of emesis. The SBAR indicated that at 11 AM, Resident 1 was in bed with nonlabored (easy, effortless, and comfortable) breathing, awaken to administer due medication. No ASE noted. resident kept clean and dry and comfortable. The SBAR further indicated that at 11:30 AM, Resident 1 had another episode of emesis, no shortness of breath (SOB) or distress noted. The SBAR further indicated that at 12:40 AM, Resident 1 was in bed sitting up and awake, the CNA (unknown) tried to assist with lunch and Resident 1 did not eat. The SBAR noted Resident 1 was left in bed with the head of bed (HOB) elevated with bed in the lowest position, call light within reach. The SBAR further indicated that at 1 PM, During rounds, [Resident 1] was in bed, no SOB or pain or discomfort noted. The SBAR further indicated that at 1:25 PM, during [RNS 1] rounds, Resident 1 was noted with SOB and pale skin color. Vitals signs obtained with BP at ,d+[DATE] mm/Hg, pulse was 81 beats per minute, respiratory rate at 17 breaths per minute, oxygen saturation was 87% on room air and 92% with non-rebreather mask (an oxygen mask that delivers high concentrations of oxygen) at 15 liters (L, unit of measure) per minute . The SBAR indicated 911 emergency services was called due to Resident 1's desaturation (abnormal drop in blood oxygen levels) and hypotension. The SBAR further indicated that EMS arrived (no time indicated) and took over. The SBAR indicated, during EMS assessment the resident had one more episode of emesis. The SBAR Note indicated Resident 1's Physician Assistant (PA 1) was made aware and Family member (FM) 1 was notified. The SBAR indicated that at 1:36 PM, Resident 1 was transferred to GACH 1 via 911 EMS. During a review of Resident 1's Transfer Record dated [DATE] timed at 1:30 PM, handwritten by RNS 1, the Transfer Record indicated Resident 1's reason for transfer were ALOC, desaturation, and three episodes of emesis. The record indicated Resident 1's vital signs were temperature of 97.4 F, pulse 118 beats per minute, respiratory rate was at 17 breaths per minute, BP was at ,d+[DATE] mm/Hg, and oxygen saturation of 86%. The Transfer Record indicated Resident 1's additional reason for transfer was altered mental status (a general term referring to a change to your average mental function), weakness, and shortness of breath. During a review of Resident 1's EMS Report dated [DATE], the EMS Report indicated upon EMS arrival to the facility at 1:32 PM, Resident 1 was lying in bed. The EMS report indicated a facility staff (unknown staff) stated they contacted EMS due to resident being altered (any condition which is significantly different from a normal waking state) approximately one hour prior to EMS arrival. The EMS report indicated Resident 1 was found in respiratory failure and ventilated (to force air in and out of the lungs of a person who cannot breathe easily on their own), with bag-valve-mask (BVM, a medical device used to provide air and oxygen to person who are not breathing or breathing adequately). The EMS report indicated Resident 1 was hypotensive and apneic (breathing is interrupted by the airway blocking the flow of air) and lifted onto the gurney (wheeled stretcher) and loaded into the ambulance. The EMS report indicated [Resident 1] had coffee ground emesis prior to EMS arrival (at the facility) and was suctioned multiple times throughout treatment and transport. During a review of Resident 1's GACH 1 record titled Emergency Documentation dated [DATE] documented at 3:12 PM, the GACH 1 record indicated Resident 1 was presented in by EMS to GACH 1 for cardiac arrest. The GACH 1 record indicated that according to EMS verbal report, the facility reported to EMS that [Resident 1] was altered from this ([DATE]) morning and was also noted to have coffee-ground emesis around his mouth. The GACH 1 record indicated upon EMS arrival to GACH 1, [Resident 1] was found to be in respiratory arrest (a state in which a patient stops breathing but maintains a pulse) and shortly thereafter, went into cardiac arrest. During a telephone interview with Family (FM) 1 on [DATE] at 2:07 PM, Family 1 stated she received a call from RNS 1 on [DATE] at around 1:27 PM to inform FM 1 that EMS was called for Resident 1 due to low oxygen saturation and blood pressure. Family 1 stated she was informed by RNS 1 that Resident 1 was fine the morning of [DATE], until staff noticed Resident 1's BP and oxygen saturation were low. FM 1 stated RNS 1 did not mention any other symptoms from Resident 1. FM 1 stated she requested for a verbal report of what happened to Resident 1, from the facility and was told later by the former Director of Nursing (DON 2) that Resident 1 had vomited. FM 1 stated when FM 1 was cleaning out Resident 1's belongings, Resident 1's roommate at that time (on [DATE]) told FM 1 that the CNAs got Resident 1 out of bed to use the bathroom. Family 1 stated that facility staff have never taken Resident 1 to the bathroom. FM 1 stated she was unsure if the facility gave FM 1 a reliable report about what happened to Resident 1 on [DATE]. FM 1 stated she received a copy of Resident 1's EMS report and was questioning what really happened that day. Family 1 stated if the facility noticed the coffee ground emesis, why would the facility's licensed nurses not act upon Resident 1's change in condition right away? Family 1 stated she felt the facility's licensed nurses should have done something to help Resident 1 sooner. During a concurrent interview on [DATE] at 3:17 PM with LVN 1 and record review of Resident 1's COC and SBAR notes dated [DATE] documented at 1:25 PM, LVN 1 stated she documented Resident 1's SBAR on [DATE]. LVN 1 stated Resident 1 had an episode of emesis at 9 AM and 11:30 AM, however, LVN 1 stated she could not recall the color and consistency of Resident 1's emesis. LVN 1 stated after lunch on [DATE], RNS 1 was doing her rounds and saw Resident 1's oxygen saturation was under 90%. LVN 1 stated she could not recall the exact time RNS 1 found Resident 1 and stated Resident 1 was given oxygen supplement via non-rebreather mask and was effective because Resident 1's oxygen saturation level was going back up. LVN 1 stated she could not recall what Resident 1's vital signs were. LVN 1 stated she could not recall who called the EMS on [DATE]. LVN 1 stated Resident 1 was confused most of the time and was alert and oriented to only his name. LVN 1 stated she was in Resident 1's room when EMS arrived, and they took over care Resident 1. LVN 1 stated Resident 1 had vomited but could not recall what the vomit looked like, including the color of Resident 1's vomit. LVN 1 stated Resident 1's vomiting occurred during the time the EMS was in the facility and LVN 1 stated she could not recall if Resident 1 had any other episodes of emesis earlier that day. LVN 1 stated if a resident would have 2 to 3 episodes of emesis, the licensed staff would monitor the resident and report to the physician. LVN 1 stated she did not remember calling Resident 1's physician or PA 1. LVN 1 stated she could not recall much of what happen to Resident 1 on [DATE]. LVN 1 stated Resident 1 could not recall if Resident 1 had other symptoms earlier that morning of [DATE]. During an interview with RNS 1 on [DATE] at 3:31 PM, RNS 1 stated she arrived at the facility for work at 12:30 PM on [DATE]. RNS 1 stated she conducted her resident rounds and noticed Resident 1's skin was pale and had shortness of breath. RNS 1 stated she took Resident 1's vital signs and Resident 1's BP was low. RNS 1 stated Resident 1's systolic pressure (the top number in blood pressure) was below 90 mm/Hg and could not recall if she documented Resident 1's low BP in the resident's record. RNS 1 stated that on [DATE] when RNS 1 saw Resident 1, Resident 1 was not alert or talking. RNS 1 stated she placed Resident 1 on oxygen via a non-rebreather mask. RNS 1 stated when the EMS arrived at the facility, Resident 1 had an episode of emesis that appeared dark. RNS 1 stated she could not recall if Resident 1 had an episode of emesis earlier that day, on [DATE]. RNS 1 stated if resident had an episode of emesis, per protocol she would notify the physician. RNS 1 stated she remembered notifying Resident 1's family and PA 1 after 911 EMS took Resident 1 to GACH 1. During an interview with LVN 1 on [DATE] at 4:03 PM, LVN 1 stated she recalled seeing emesis on the gurney Resident 1 was transferred onto by EMS but could not recall what Resident 1's emesis looked like. LVN 1 stated she still could not recall Resident 1's episodes of emesis as documented in Resident 1's SBAR note on [DATE]. LVN 1 stated that if Resident 1 had episodes of emesis earlier that day, on [DATE], LVN 1 acknowledged that she would have notified the physician. LVN 1 stated Resident 1 could have an underlying condition, and she should have documented Resident 1's vital signs and a description of the emesis episodes at the time. During a telephone interview with CNA 1 on [DATE] at 5:48 PM, CNA 1 stated when he came to work during the morning shift (7AM to 3 PM) on [DATE] and conducted resident rounds he noticed Resident 1 looked off (something is not quite right or that someone is not functioning or appearing as expected). CNA 1 stated Resident 1 was looking off for a while during that morning ([DATE]). CNA 1 stated Resident 1 did not look too well, Resident 1 was pale in color, confused and not talking. CNA 1 stated that on the same day, he was instructed by LVN 1 to take Resident 1 to the bathroom. CNA 1 stated prior to taking Resident 1 to the bathroom, Resident 1 appeared pale and weak, but CNA 1 still assisted Resident 1 to the bathroom. CNA 1 stated he could not recall if Resident 1 had an episode of emesis that day, but CNA 1 was accompanied by CNA 2. CNA 1 stated after taking Resident 1 to the bathroom, that is when RNS 1 saw Resident 1's condition and called 911. CNA 1 stated EMS arrived and since there were so many staff he backed away. During a telephone interview with CNA 2 on [DATE] at 6 PM, CNA 2 stated he remembered Resident 1 did not have a bowel movement so together with CNA 1, they brought Resident 1 to the bathroom. CNA 2 stated after Resident 1 had a bowel movement, RNS 1 stated Resident 1 did not look well, so RNS 1 called 911. CNA 2 stated Resident 1 was puking (vomiting), but could not recall how many times Resident 1 puked. CNA 2 stated Resident 1's puking occurred before the 911 EMS arrived at the facility. CNA 2 stated when Resident 1 was brought back to bed he saw puke at the side of Resident 1's bed and it was Black, it was something dark. CNA 2 stated when CNAs see something unusual, CNAs would notify the nurse. CNA 2 stated he recalled They (licensed nurses) were saying he [Resident 1] was puking something dark during the day. CNA 2 stated [LVN 1] said he [Resident 1] was puking something like that (dark) during the day. During a telephone interview with PA 1 on [DATE] at 1:18 PM, PA 1 stated she manages Resident 1's care while residing at the facility. PA 1 stated she was notified by the facility of Resident 1 being transferred to GACH 1 via text message on [DATE], after 911 EMS took Resident 1. PA 1 stated she looked back at her text messages, but that was the only time she was notified what happened to Resident 1 on [DATE]. PA 1 stated she was not notified by LVN 1 or RNS 1 about any episodes of emesis prior to Resident 1 being transferred by 911 EMS to GACH 1. PA 1 stated if Resident 1 had any episodes of emesis earlier that day ([DATE]) PA 1 would have expected the licensed staff to notify her, and PA 1 would have ordered the licensed nurses to call 911 EMS immediately or earlier that day. PA 1 stated she spoke with Resident 1's family (FM 1) (unknown date) and FM 1 mentioned Resident 1 had vomited that day ([DATE]) prior to 911 arriving at the facility. PA 1 stated In hindsight (refers to the ability to understand or judge an event or situation only after it has happened), they did tell me the resident had coffee ground emesis earlier that day ([DATE]). PA 1 stated the licensed nurses were even pretty good at reporting when Resident 1 vomits once before. PA 1 stated Yes, I did not find out about [Resident 1's] coffee ground emesis until a week later. When asked, PA 1 stated it was the ADM that told her Resident 1 had coffee ground emesis. PA 1 stated having coffee ground emesis could mean something was obviously going on internally in Resident 1 like bleeding. During a review of the facility's policy and procedure (P&P) titled Anticoagulation-Clinical Protocol dated ,d+[DATE] indicated to assess for any signs or symptoms related to adverse drug reactions due to medication alone in combination with other medications. The P&P indicated the staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. The P&P indicated if an individual on anticoagulation therapy shows signs of excessive bruising hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. During a review of the facility's policy and procedure (P&P) titled First Aid Treatment-Crash Cart/Emergency Response dated ,d+[DATE], the P&P indicated to contact the EMS immediately for the following situations: unconsciousness or altered consciousness, difficulty or absence of breathing, severe bleeding, vomiting blood or blood in stool, condition is not clear or is worsening. The P&P indicated regardless of the nature or severity, any resident's injury/situation shall be reported to the resident's attending physician and family and documented in the resident's medical record. During a review of the facility's P&P titled Change in a Resident's Condition or Status dated ,d+[DATE], the P&P indicated the nurse will notify the resident's attending physician or physician on call when there has been a (an): significant change in the resident's physical/emotional/mental condition; need to transfer the resident to a hospital/treatment center; specific instruction to notify the physician of changes in the resident's condition. The P&P indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the SBAR Communication form.

Amended Copy - [DATE] Based on interview and record review the facility failed to assess, monitor for the signs and symptoms of Peripheral Arterial Disease (PAD- also known as peripheral vascular disease [PVD], a circulatory problem where narrowed arteries reduce blood flow to the legs, arms, or other parts of the body, often due to plaque buildup), and follow the general acute care hospital (GACH 1) physician and facility ' s attending physician ' s recommendations for one of three sampled residents (Resident 1), who was recently hospitalized for an acute cerebrovascular accident (CVA - a type of stroke [occurred when blood flow to the brain was interrupted], loss of blood flow to a part of the brain), right internal carotid artery stenosis ([NAME]- a condition that happens when the carotid artery, which is the large artery on either side of the neck, becomes blocked), and PAD, by failing to: Ensure the facility ' s licensed staff and the attending physician, identified and addressed Resident 1 ' s diagnoses of PAD and Atherosclerosis (the buildup of fats, cholesterol and other substances in and on the artery walls. This buildup is called plaque) and include in the resident ' s cumulative diagnoses list (a compilation of all diagnoses a patient has received, including past and present conditions, to provide a comprehensive overview of their medical history) upon readmission to the facility on [DATE], to establish the resident ' s diagnoses while in the facility to maximize the resident ' s treatment benefits and ensure resident outcome and safety. Ensure the facility ' s licensed staff referred Resident 1 for an elective (a procedure that was chosen [elected] by the patient or physician that was advantageous to the patient but was not urgent) bilateral lower extremity (legs) arteriogram (a medical imaging procedure to visualize and assess blood flow in the arteries [blood vessels] and detect blockages to plan for surgical interventions) and endovascular intervention (a surgical procedure used to treat a wide range of vascular conditions including PAD and stenosis [narrowing of a passageway in the body]), in accordance with the GACH 1 Discharge Summary orders made by the GACH 1 Physician on [DATE]. Ensure the facility ' s licensed staff develop a PAD/PVD and Atherosclerosis comprehensive and individualized care plans, in accordance with the facility ' s policy & procedures titled Care Area Assessments. Ensure the facility ' s licensed staff monitor Resident 1 ' s bilateral (both) pedal pulses (palpable pulse wave in the arteries of the foot. It is a clinical sign used to assess the circulation in the lower extremities) as indicated in the resident ' s Physician ' s Order dated [DATE]. The licensed nurses documented monitoring and assessment of Resident 1 ' s left pedal pulses from [DATE] to [DATE] and did not have documentation of monitoring and assessment of Resident 1 ' s right pedal pulses from [DATE] to [DATE]. The order for bilateral pedal pulses monitoring was discontinued without a reason on [DATE]. As a result of these deficient practices Resident 1 did not receive the care, services, and interventions to ensure the resident ' s PAD/PVD were addressed during the resident ' s stay in the facility from [DATE] to [DATE]. These deficient practices resulted in a change in Resident 1 ' s condition on [DATE], when Resident 1 developed altered level of consciousness (ALOC), and fluctuating oxygen saturation (indicated how much oxygen the blood was carrying, [normal ranges from 95% to 100%) of 86 to 90%. Resident 1 was transferred to GACH 2 via 911 emergency services on [DATE]. Resident 1 ' s GACH 2 physician notes indicated Resident 1 had a suspected right lower extremity superficial femoral artery occlusion (refers to a partial or complete blockage of the femoral artery [a large blood vessel located in the upper thigh], which can lead to reduced blood flow and oxygen supply to the lower leg and foot). Resident 1 died at GACH 2, two days after the GACH 2 admission, on [DATE], with diagnoses that included but not limited to cellulitis of the leg (a bacterial infection of the skin and the tissues beneath the skin), right lower extremity gangrenous (when lack of blood flow causes tissues in the body to die) changes, PAD and septic shock (a subset of sepsis [a serious condition in which the body responds improperly to an infection] in which particularly profound circulatory (the system that contains the heart and the blood vessels and moves blood throughout the body) and metabolic abnormalities [disruptions in the body's chemical processes that convert food into energy and building blocks] substantially increase death). Findings: During a review of Resident 1 ' s GACH 1 record, the resident ' s Duplex Ultrasound ([US] a test to see how blood moves/flows through the arteries and vein) dated [DATE] was reviewed. The US indicated that Resident 1 ' s Right Lower Extremity Arterial (a blood vessel that carried blood from the heart to the tissues and organs in the body) US indicated 50 to 75% stenosis in the mid superficial (on the surface) femoral artery (the main blood vessel that delivered oxygen-rich blood from the heart to your lower body, specifically the thigh and leg), 30 to 49% stenosis in the right external iliac artery (a major blood vessel that carried oxygenated blood from the pelvis [bone that connects spine to the legs] to the legs) . During a review of Resident 1 ' s GACH 1 Left Lower Extremity Arterial Duplex (sound waves used to create images of blood vessels and assess blood flow) dated [DATE], the Ultrasound indicated Severe diffuse calcific (buildup of calcium deposits that could lead to hardening of tissues, blood vessels, or organs) atherosclerotic disease identified throughout the left lower extremity with at least moderate stenosis left external iliac (brings blood to the legs) and common femoral arteries with severe stenosis within the proximal (center of the body) and mid superficial (located on or near the surface of the body) femoral artery of at least 50 to 75% narrowing . During a review of Resident 1 ' s GACH 1 Interventional Radiologist ' s (IR, a medical specialty that used imaging techniques to guide tiny instruments through the body to diagnose and treat diseases) Consultation dated [DATE], the IR Consultation indicated Resident 1 would benefit from an elective bilateral lower extremity arteriogram and endovascular intervention when the resident is stable . During a review of Resident 1 ' s GACH 1 DC Summary dated [DATE], authored by the GACH 1 physician, the DC Summary indicated one of Resident 1 ' s problems included PAD. The DC Summary indicated Resident 1 ' s reason for admission to GACH 1 was Left Upper Extremity and Left Lower Extremity (LLE) numbness and weakness. The DC Summary indicated Resident 1 was deemed stable for discharge back to the facility. The DC Summary included the following problems for Resident 1: 1. Acute CVA 2. Stenosis of right internal carotid artery ([NAME]). 3. PAD - Doppler Ultrasound (used sound waves to visualize and measure blood flow in vessels, arteries, and veins, helping doctors assess blood flow speed and direction, and detect conditions like clots or blockages) showed LLE arterial stenosis and bilateral AT/PT stenosis. IR consulted for further recommendation indicated elective bilateral lower extremity arteriogram and endovascular intervention when resident was stable. Any dual antiplatelet (medications that prevent platelets from clumping together and forming blood clots) therapy would be beneficial for the resident ' s PAD. 4. Diabetes . During a review of Resident 1 ' s Admission Record (AR), the AR indicated the resident was readmitted to the facility on [DATE], with diagnoses that included but not limited to the following: Atherosclerosis of native arteries (a natural, un-altered blood vessel that carried oxygen-rich blood from the heart to the body ' s tissues and organs) of extremities with intermittent claudication (most common symptom of PAD which is pain and numbness in the lower extremities) of bilateral legs. Type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). Cerebral Infarction (or CVA). During a review of a facility record titled Cumulative Diagnosis List dated [DATE], the Cumulative Diagnosis List indicated Resident ' s diagnoses in the facility as provided by the facility ' s Medical Records Director. The Cumulative Diagnosis List indicated Include active diagnoses and conditions that are part of the resident ' s current plan. Enter the date resolved/discontinued when the condition is no longer active. A physician is legally accountable for establishing resident ' s diagnosis. The Cumulative Diagnosis List indicated a column for the physician ' s signature designated next to each of the indicated resident ' s diagnosis. The column for the physician ' s signature indicated a handwritten signature of Physician 1 and was dated [DATE]. The Cumulative Diagnosis List indicated the following handwritten diagnoses for Resident 1: Cerebral Infarction. Carotid Artery Stenosis (a narrowing of the carotid arteries in the neck). Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing). Diabetes Mellitus Coronary Artery Disease (CAD, a condition where plaque builds up inside the arteries that supply blood to the heart, potentially leading to reduced blood flow and heart problems). Congestive Heart Failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). Anemia (a condition where the body did not have enough healthy red blood cells). Osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). Hypertension (HTN, high blood pressure). Hyperlipidemia (HLD, a condition characterized by abnormally high levels of fats [lipids] like cholesterol in the blood). Major Depressive Disorder (MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review Resident 1 ' s Telephone Physician ' s Order dated [DATE], the Physician's Order indicated to monitor Resident 1 ' s bilateral pedal pulses, every day shift. During a review of Resident 1 ' s Treatment Administration Record (TAR) for the month of [DATE], the TAR indicated from [DATE] to [DATE] the resident ' s left pedal pulse was documented and monitored in accordance with the resident ' s Physician ' s Order to monitor bilateral (both) pedal pulses every day shift, instead of both (right and left) pedal pulses. During a review of Resident 1 ' s Facility Active Order Summary Report signed by the physician and dated [DATE], the Summary Report did not include the resident ' s diagnosis of PAD in accordance with the GACH 1 DC summary. During a review of Resident 1 ' s History and Physical (H&P) dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated diagnoses including right carotid stenosis and CVA. During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) dated [DATE], the MDS indicated the resident had severe cognitive impairment (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions). The MDS did not indicate Resident 1 had PAD. The MDS indicated the resident had zero number of venous (relating to or involving veins, the blood vessels that carry blood back to the heart, and the blood into those vessels) and arterial (relating to an artery) ulcers present and had no other ulcers (a small open sore [a break in the skin where the skin ' s surface was damaged, missing, or exposing the tissues beneath] or wound generally found in the stomach or on the skin), wounds, and skin problems. During a review of Resident 1 ' s Telephone Physician ' s Order dated [DATE] at 4:18 PM, the Physician ' s Order indicated to discontinue Resident 1 ' s monitor bilateral pedal pulses, everyday shift on [DATE] at 11:17 PM. The Physician ' s Order did not indicate a discontinue reason. During a review of Resident 1 ' s Physician ' s Progress Note dated [DATE], the handwritten Progress Note indicated the attending physician (Physician 1) added a diagnosis of PAD in the resident ' s record. During a review of Resident 1 ' s Physician ' s Progress Note dated [DATE], the handwritten Progress Note continued to indicate the resident had a diagnosis of PAD. During a review of Resident 1 ' s Physician ' s Progress Note dated [DATE], the handwritten Progress Note continued to indicate the resident had a diagnosis of PAD. During a review of Resident 1 ' s TAR for the month of [DATE], the TAR indicated Resident 1 received treatments as ordered, to the right knee open scratch wound and right lateral knee extending to posterior aspect open scratch wound from [DATE] to [DATE]. During a review of Resident 1 ' s Physician ' s Order dated [DATE] at 8:55 AM, the Physician ' s Order indicated treatment - right knee open scratch wound - cleanse with normal saline (NS, a saltwater solution), pat dry, apply medihoney (a wound dressing containing 100% active Leptospermum honey [a type of honey produced by bees that feed on the nectar of the Manuka bush] that helps remove dead tissue, promotes wound healing, and could be used on various types of wounds) and cover with border gauze (a wound dressing with a soft, absorbent gauze pad and an adhesive border) every day (QD) for 14 days every day shift. During a review of Resident 1 ' s Physician ' s Order dated [DATE] at 8:55 AM, the Physician ' s Order indicated treatment - right lateral (to the side of, or away from, the middle of the body) knee extending to posterior (the backside or rear part of the body) aspect open scratch wound - cleansed with NS, pat dry, apply medihoney, cover with Abdominal [ABD] pad (a highly absorbent, sterile dressing used to absorb wound discharge, cushion the wound area, and protect against further harm) and wrap with roll gauze (a long, soft, absorbent, and usually non-sterile fabric that was rolled up and used to hold dressings in place) daily for 14 days every day shift. During a review of Resident 1 ' s Interdisciplinary Team (IDT) Wound Management Care Plan Note dated [DATE] timed at 10 AM, the Note indicated Resident noted with episodes of scratching skin leading to open wounds. re-oriented, re-direction, and frequent reminder to not scratch skin. The Note indicated the altered skin integrity was a right knee open scratch wound. During a review of Resident 1 ' s Change of Condition (COC) form dated [DATE] timed at 11:55 AM, the COC indicated the resident was noted with an open scratch wound on the right knee and right lateral knee extending to posterior area. The COC indicated Resident had periods of scratching skin resulting in an open wound. The COC indicated initial treatment included cleansing with NS, pat dry, apply medihoney, and cover with border gauze. The COC indicated the physician and responsible party (RP) were notified. During a review of Resident 1 ' s Skin Progress Report dated [DATE] timed at 3 PM, the Progress Report indicated the resident had a right lateral knee open wound measuring five (5) by six (6) centimeters (cm, used to measure the unit of length). The Progress Report indicated the wound bed description with epithelial tissue (the lining and covering tissue of your body, forming a protective barrier and performing functions) with tan and reddened areas. The Progress Note indicated there was no drainage or odor and the wound care specialist (WCS) was notified. During a review of the same Skin Progress Report dated [DATE] timed at 3 PM, the weekly progress report indicated Resident 1 had a right lateral knee vascular wound (a sore or ulcer that developed due to problems with blood circulation, particularly in the legs and feet) measuring eight (8) by 13 cm with epithelial tissue. The Progress Report indicated Resident 1 ' s wound increased in size and had areas of tan wound bed with dark discoloration around scratch marks. The Progress Report indicated the WCS was notified and WCS had clarified Resident 1 ' s wound from an open scratch wound to a PVD on [DATE]. The same Progress Report indicated a weekly progress report section with an added date of [DATE] that further indicated WCS recommended to do a doppler ultrasound on Resident 1. During a review of Resident 1 ' s Non-Pressure Sore Skin Problem Report dated [DATE] timed at 2:57 PM, the Skin Problem Report indicated the Resident 1 had a right knee open scratch wound measuring 3 x 3 cm. The Skin Problem Report indicated to keep the right knee open scratch wound clean and dry, handle gently and slow, and to remind the resident not to scratch. During a review of the same Non-Pressure Sore Skin Problem Report dated [DATE] timed at 2:57 PM, the Skin Problem Report also included a weekly progress report section dated [DATE]. The weekly progress report indicated the resident had a right knee open scratch wound that measured 3 x 3 cm. The weekly progress report indicated the wound bed was red in color, but no changes were identified and to continue with the current treatment. During a review of Resident 1 ' s Wound Care Note dated [DATE], and authored by WCS, the Wound Care Note indicated Resident 1 had a right knee extending to posterior knee (back of the knee joint) self-inflicted (caused by one ' s own actions) scratches and excoriations (a scrape or scratch to the skin). The Wound Care Note indicated the tissue was 100% superficial with scant (barely or scarcely enough) serosanguineous (a fluid, often from a wound that contains both blood and the clear, watery part of blood) drainage and did not have an odor, was not infected, and the resident was not in pain. The Wound Care Note indicated the wound was fragile (easily damaged), scar, and discolored. The Wound Care Note indicated to apply medihoney daily. During a review of Resident 1 ' s PVD Ulcer Behavior Problem Care Plan dated [DATE], the Behavior Care Plan indicated a goal for the resident ' s PVD Ulcer to decrease in size one cm per month, would heal without complications, and be free from infection. The Care Plan interventions indicated to keep skin clean, dry, and provide skin care maintenance, provide behavior management techniques, and report any unusual drainage or order to the physician. During a review of Resident 1 ' s Wound Care Note dated [DATE] (no time), authored by WCS, the Wound Care Note indicated The resident did have a history of peripheral vascular disease (PVD or PAD) and the resident was on a low air loss mattress (a medical-grade mattress designed to prevent and treat pressure sores by maintaining a cool, dry environment through constant airflow). The Wound Care Note indicated the resident had a right knee extending to posterior knee self-inflicted excoriations to right lower extremity peripheral vascular wound with multiple superficial openings. The Wound Care Note indicated the tissue was 100% superficial with scant serosanguineous drainage and did not have an odor, was not infected, and the resident was not in pain. The Wound Care Note indicated the wound was fragile, scar, and discolored and to apply medihoney daily. During a review of Resident 1 ' s Right Knee Open Scratch Wound Care Plan dated [DATE], the Care Plan indicated a goal for the resident ' s wound to decrease in size one (1) cm per month, would heal without complications, and be free from infection. The Care Plan interventions indicated to keep skin clean, dry, and provide skin maintenance, provide behavior management techniques, and provide treatment per physician order. During a review of Resident 1 ' s Right Lateral Knee Extending to Posterior PVD Ulcer Care Plan dated [DATE], the Care Plan indicated a goal for the resident ' s PVD ulcer to decrease in size one cm per month, would heal without complications, and be free from infection. The Care Plan interventions indicated to keep skin clean, dry, and provide skin care maintenance, provide behavior management techniques, and to report any unusual drainage or order to the physician. During a review of Resident 1 ' s COC dated [DATE] timed at 8 AM, the COC indicated the resident was noted to be weak in appearance with ALOC. oxygen saturation of 86 to 90% with oxygen at three liters per minute (LPM). The COC indicated the resident was also noted with an open scratch wound on the right knee and right lateral knee extending to posterior aspect. The COC indicated emergency services was requested and Resident 1 was transferred to the GACH 2 for further management and treatment. During a review of Resident 1 ' s Physician ' s Order dated [DATE] timed at 9:58 AM, the Physician ' s Order indicated to transfer Resident 1 via emergency services to the GACH 2 for further management and treatment of ALOC, decreased oxygen saturation, bradycardia (a heart rate that was slower than normal, generally under 60 beats per minute), and right lateral knee wound. During a review of Resident 1 ' s Nursing Note dated [DATE] timed at 10:42 AM, the Nursing Note indicated the resident was transferred via ambulance to GACH 2 for ALOC, oxygen desaturation, and hyperglycemia (a condition characterized by high blood sugar levels). During a review of Resident 1 ' s GACH 2 Emergency Department (ED) Department Summary dated [DATE] documented at 5:42 PM, the Report indicated Resident 1 arrived at the ED on [DATE] at 10:14 AM and admitted as inpatient on [DATE] at 5:42 PM. During a review of Resident 1 ' s GACH 2 ED Physician Notes dated [DATE], the Physician ' s Note indicated the resident presented with weakness and poor responsiveness. The Physician ' s Note indicated Likely severe sepsis (a life-threatening condition that occurred when your body ' s response to an infection damages vital organs, often leading to death) given additional lactate (a substance produced in the body during intense physical activity or when oxygen levels were low) of 3.1 (lactate level was high if between two and four millimoles per liter [mmol/L, a unit used to measure the concentration of a substance]) but unclear source at this time. The GACH 2 ED Physician Notes indicated Suspect right lower extremity healing pressure ulcer (a localized injury to the skin and underlying tissue caused by prolonged pressure, often over body areas, leading to reduced blood flow and potential tissue damage or death) given presence of granulation tissue (a type of new connective tissue that formed in response to an injury or wound) but with central scattered punctate (characterized by or marked with small, pinpoint dots or depressions, like small, scattered spots or lesions [an area of abnormal or damaged tissue caused by injury, infection, or disease]) black discoloration . During a review of Resident 1 ' s Blood Culture Final Report dated [DATE] timed at 12:06 PM, the Report indicated the Blood Culture was growing streptococcus pyogenes (Group A strep, a common bacterium that caused a range of infections including serious, potentially life-threatening illnesses). During a review of Resident 1 ' s GACH 2 Photo #1 image dated [DATE] timed at 5:29 PM, the resident ' s right lateral lower leg had bright red discoloration lining the wound with yellow and blackish discoloration inside the wound bed and burgundy discoloration surrounding the wound. During a review of Resident 1 ' s GACH 2 Photo #2 image dated [DATE] at 5:30 PM, the resident ' s posterior right calf had bright red discoloration lining the wound with yellow and blackish discoloration inside the wound bed and burgundy discoloration surrounding the wound. During a review of Resident 1 ' s GACH 2 Photo #5 image dated [DATE] at 5:35 PM, the resident ' s right knee had broken skin with burgundy discoloration surrounding the wound. During a review of Resident 1 ' s Bilateral Lower Extremity Arterial Duplex US dated [DATE] at 5:28 PM, the US indicated Suspicion for right superficial femoral artery occlusion with poor visualization of the distal vessels (tubes or canals that carried fluid, most commonly blood) . During a review of Resident 1 ' s GACH 2 Discharge (DC) Summaries Note with documentation date of [DATE], the DC Note indicated Resident 1 was admitted on [DATE] and died at GACH 2 on [DATE] timed at 1:03 PM. The DC Summaries Note indicated the following information as indicated for Resident 1 ' s GACH 2 Admission Diagnoses: 1. Acute Kidney Injury 2. Cellulitis of the leg 3. Hyperglycemia 4. Septic Shock 5. Right lower extremity gangrenous changes 6. PAD The DC Summaries Note further indicated Resident 1 ' s discharge diagnoses were consistent with admission diagnoses, in addition to failure of thrive (a syndrome of unexplained weight loss, malnutrition, and disability) and complication by death. During a review of Resident 1 ' s Certificate of Death, the Certificate indicated Resident 1 ' s date of death was [DATE] (two days after Resident 1 ' s transfer from the facility to GACH 2). The Certificate indicated Resident 1 ' s cause of death included cardiopulmonary failure (when the heart suddenly stops pumping blood, and the lungs stop breathing effectively, leading to a loss of consciousness and potentially death if not treated immediately), septic shock, and CVA. During a telephone interview on [DATE] at 2:06 PM, Resident 1 ' s responsible party (RP) stated the GACH 2 ED nurse called her and stated GACH 2 were going to admit Resident 1 on [DATE]. The GACH 2 ED nurse stated to the RP that Resident 1 was pointing to his leg and mentioned there was a bad wound on his leg. The ED nurse stated to the RP that the GACH 2 medical staff stated there was gangrene (a serious condition where tissues died due to a lack of blood supply) on the resident ' s legs and Resident 1 had sepsis. The RP stated the GACH 2 ED Nurse informed her that GACH 2 had to run more tests to confirm what was going on with Resident 1 on [DATE]. During an interview on [DATE] at 2:44 PM, the Treatment Nurse (TN) stated he did not observe any signs of gangrene on Resident 1's right leg prior to the resident transferring to GACH 2 on [DATE]. The TN stated there were bruised areas because of deep scratches to the right leg and the WCS ordered a doppler on [DATE], but Resident 1 was transferred to the GACH 2 before the doppler test could be performed. The TN stated on [DATE], Resident 1 ' s wound got bigger and that was the reason why she reported the change in the condition of the wounds to the WCS who came to re-assess the resident ' s wound. During a telephone interview on [DATE] at 12:29 PM, the WCS stated Resident 1 had self-inflicted scratches from [DATE] but did not have gangrene. The WCS stated the resident had PVD and had discolored skin because Resident 1 would keep scratching and agitating the leg wounds. The WCS stated the resident ' s wound was superficial and was not a deep wound. During an interview on [DATE] at 9:14 AM, the TN stated Resident 1 had a history of intermittent claudication on bilateral lower extremities and based off that, the resident had PVD which the WCS clarified her diagnosis of the wounds on [DATE], prior to Resident 1 ' s transfer to GACH 2. During a concurrent interview and record review of Resident 1 ' s PVD Ulcer Behavior Problem Care Plan dated [DATE], on [DATE] at 9:25 AM, the TN stated he knew Resident 1 had an issue with scratching and the facility treated the scratching as a behavioral problem because he would just do it (scratch). The TN stated the facility would offer the resident activities as a distraction to the behavior. The TN stated there was no other care plans developed for Resident 1 ' s PAD/PVD prior to [DATE]. During the same concurrent interview and record review of Resident 1 ' s Right Knee Open Scratch Wound Care Plan dated [DATE], on [DATE] at 9:25 AM, the TN stated the resident ' s right knee wound could have been prevented if the facility communicated better and if the facility asked Resident 1 why he was scratching, if something was bothering him, or if his knee was painful. The TN stated there was no documented evidence that the facility conducted a root cause analysis or IDT prior to the incident as to why the resident was scratching. The TN stated the resident would scratch his forehead, arms and legs, and Resident 1 ' s scratching went down to his lower extremities - knees. During a concurrent interview and record review of Resident 1 ' s PVD Ulcer Behavior Problem Care Plan dated [DATE], on [DATE] at 10:54 AM, the Assistant Director of Nursing (ADON) stated the resident ' s scratching could be a behavioral problem because he had a diagnosis of behavior issues prior to admission and was being followed by a psychiatrist (a medical doctor who specialized in mental health, trained to diagnose, treat, and prevent mental, emotional, and behavioral disorders, often prescribing medication and offering therapy). The ADON stated if the interventions were not documented, then the interventions were not done. The ADON stated if the interventions were not provided the facility was unable to address the resident ' s behavior properly which could lead to a change of condition and if the scratch were severe, Resident 1 could have an open wound or infection. The ADON stated there was no documented evidence that the facility conducted a root cause analysis or IDT prior to the incident as to why the resident was scratching. During an interview on [DATE] at 10:10 AM, the Assistant Director of Nursing (ADON) stated the facility checks the GACH 1 DC Summary and hospital records to determine the diagnoses for the facility. Once a list was generated the physician checks all the diagnoses, would co-sign the form, and help categorize the diagnoses on the facility ' s Cumulative Diagnoses List. During a concurrent interview with the ADON and record review of Resident 1 ' s GACH 1 DC Summary dated [DATE], on [DATE] at 10:15 AM, the GACH 1 DC Summary indicated one of the resident ' s problems included PAD. The ADON stated she was unsure why the facility ' s admission records and diagnoses did not include PAD. The ADON stated PAD should have been included as a diagnosis because PAD was written on the GACH 1 DC Summary. During a concurrent interview with the ADON, and record review of Resident 1 ' s facility Cumulative Diagnosis List dated [DATE], on [DATE] at 10:26 AM, the Cumulative Diagnosis List did not include PAD as one of the resident ' s diagnoses upon admission and while residing at the facility. The ADON stated the PAD diagnosis should have been on the Cumulative Diagnosis List to have a better understanding of the resident ' s background for the physicians and nurses to monitor and watch Resident 1 closely. The ADON stated if the resident ' s PAD diagnosis was unknown there could have been a delay in treatment or symptom management to Resident 1 and the resident could have a change in condition. During a concurrent interview and record review of Resident 1 ' s developed Comprehensive Care Plans from readmitted d [DATE] to [DATE], on [DATE] at 11:05 AM, the ADON stated Resident 1 did not have a care plan for PAD, that included the recommendations to refer for a lower extremity arteriogram and intervention and Atherosclerosis and was unsure if the facility missed these diagnoses. Dur [TRUNCATED]

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for 11 of 13 sampled residents (Resident 2, 14, 24, 25, 26, 48, 49, 61, 71 55 and 67). This deficient practice had the potential to result in confusion regarding the care and services provided to the residents, and a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient-centered, equitable (fair), and timely care. Findings: 1.During a review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 4/30/2024 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hyperlipidemia (a condition where there are high levels of fat in the blood). During a review of Resident 2's MDS summary indicated the Quarterly MDS with Assessment Reference Date (ARD) of 11/12/2024, was completed on 11/26/2024, was due for submission by 12/10/2024. During a review of Resident 2's MDS 3.0 Kardex (a form that indicated when the MDS was transmotetd to CMS), indicated the status for Quarterly Assessment, dated 11/12/2024, was ready to be exported but no indication that it was transmitted to the CMS system (nine days late for submission as 12/19/2024). 2. During a review of Resident 24's Admission Record indicated the facility admitted Resident 24 on 8/9/2021 and readmitted on [DATE] with diagnoses that included dementia and heart failure (a serious condition that occurs when the heart is unable to pump enough blood to meet the body's needs). During a review of resident 24's MDS Summary, indicated the Quarterly MDS with ARD date was 9/11/2024, was completed on 9/25/2024, and was submitted to CMS system on 11/6/2024 (28 days late for submission). 3. During a review of Resident 25's Admission Record indicated the facility admitted Resident 25 on 6/18/2019 and readmitted on [DATE] with diagnoses that included bipolar disorder (a mental illness that causes extreme mood shifts, affecting a person's energy, thinking, behavior, and sleep) and diabetes mellitus (a group of diseases that result in too much sugar in the blood). During a review of resident 25's MDS Summary, indicated the Quarterly MDS with ARD of 9/127/2024, which was completed on 10/11/2024, was accepted by CMS on 12/18/2024 (68 days late for submission). 4. During a review of Resident 26's Admission Record indicated the facility admitted Resident 26 on 5/1/2024 with diagnoses that included Parkinson's disease (a chronic brain disorder that causes movement problems, mental health issues, and other health concerns) and seizure (a temporary, abnormal burst of electrical activity in the brain that can cause a sudden change in behavior, movement, or consciousness). During a review of Resident 26's MDS Summary, indicated the Quarterly MDS with ARD of 11/13/2024, which was completed on 11/13/2024, was due for submission to CMS by 11/27/2024. During a review of Resident 26's MDS 3.0 Kardex, indicated the status for Quarterly Assessment, dated 11/12/2024, was ready to be exported but no indication that it was transmitted to CMS timely (22 days late for submission as 12/19/2024). 5. During a review of Resident 48's Admission Record indicated the facility admitted Resident 48 on 4/25/2022 with diagnoses that included dementia and seizure. During a review of Resident 48's MDS Summary, indicated the Quarterly MDS with ARD of 11/9/2024, which was completed on 11/23/2024, was due for submission by 12/7/2024. During a review of Resident 48's MDS 3.0 Kardex, indicated the status for Quarterly Assessment, dated 11/9/2024, was ready to be exported but no indication that it was transmitted to CMS timely (12 days late for submission as 12/19/2024). 6. During a review of Resident 61's Admission Record indicated the facility admitted Resident 61 on 1/29/2024 and readmitted on [DATE] with diagnoses that included dementia and heart failure. During a review of Resident 61's MDS Summary, indicated the Quarterly MDS with ARD of 11/12/2024, which was completed on 11/26/2024, was due for submission by 12/10/2024. During a review of Resident 61's MDS 3.0 Kardex, indicated the status for Quarterly Assessment, dated 11/12/2024, was ready to be exported but no indication that it was transmitted to CMS timely (nine days late for submission as 12/19/2024). 7. During a review of Resident 55's Admission Record indicated the facility admitted Resident 55 on 8/3/2024 with diagnoses that included dementia and diabetes mellitus. During a review of Resident 55's MDS Summary, indicated the Discharge-return not anticipated MDS with ARD of 9/4/2024, which was completed on 9/18/2024, was accepted by CMS 12/18/2024 (91 days late for submission). 8. During a review of Resident 67's Admission Record indicated the facility admitted Resident 67 on 7/17/2024 with diagnoses that included dementia and diabetes mellitus. During a review of Resident 67's MDS Summary, indicated the Discharge-return not anticipated MDS with ARD of 9/7/2024, which was completed on 9/21/2024, was accepted by CMS on 12/18/2024 (88 days late for submission). During an interview on 12/18/2024 at 11:16 AM with the MDS Nurse (MDSN), the MDSN stated she was responsible to make sure all the residents' MDS assessments were completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) system timely. The MDSN stated once the MDS assessment was completed, the facility has 14 days to transmit the MDS to the CMS system. The MDSN stated she was aware that the facility had not ensure all the MDS assessments were transmitted timely, even with the extra help of a part time MDSN who was hired in October this year. The MDSN stated she was busy with other tasks and did not have time to transmit the MDS timely and she was not 100 percent doing her job. The MDSN stated the late submission of the MDS would delay the accuracy of the resident's assessment and affect resident's care negatively. During an interview on 12/19/2024 at 2:35 PM, with the Administrator (ADM), the ADM stated she was aware that some of the MDS assessments were transmitted late to the CMS system. The ADM stated all the MDS assessment should be transmitted in a timely manner to ensure quality of care for the residents by conducting proper assessment on the resident was conducted and developing and implementing the plan of care accordingly. 47882 9. During a review of Resident 14's Admission Record indicated the facility originally admitted Resident 14 on 7/31/2024 and readmitted on [DATE] with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries that supply blood to the heart). During a concurrent interview and record review, on 12/18/2024, at 1 PM, with MDS Nurse (MDSN), indicated Resident 14's Electronic Health Records (EHR) of the Quarterly MDS was completed on 11/21/2024 and was transmitted to CMS by 12/5/2024. MDSN stated, the submission of the MDS was late, it should have been submitted 14 days after completion date on 11/21/2024. The MDSN stated, she was not able to submit the MDS timely, since she was just busy with my other responsibilities as an MDS Nurse. 10. During a review of Resident 49's Admission Record indicated the facility admitted Resident 49 on 4/29/2024 with diagnoses that included schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors), Chronic Obstructive Pulmonary Disease (COPD- a common lung disease that makes it difficult to breathe), and anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells). During a concurrent interview and record review, on 12/18/2024, at 1:30 PM with MDSN, Resident 49's EHR indicated, the Quarterly MDS was completed on 11/24/2024 and was transmitted to CMS on 12/18/2024. MDSN stated, the submission of the MDS was late, it should have been submitted by 12/8/2024, which was 14 days after completion date on 11/24/2024. 11. During a review of Resident 71's Admission Record indicated the facility admitted Resident 71 on 9/3/2024 with diagnoses that included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance), and gastroparesis (paralysis of the stomach). During a concurrent interview and record review, on 12/18/2024, at 3:47 PM with MDSN, Resident 71's EHR indicated the Admission MDS was completed on 9/16/2024, and was transmitted to CMS on 10/7/2024. MDSN stated, the submission of the MDS was late, it should have been submitted by 9/30/2024, which was 14 days after completion date. During an interview on 12/19/2024 at 2:30 PM with Director of Nurses (DON), DON stated, it was important to complete and transmit MDS timely so that the facility would know if the resident had any significant changes in condition that needed to be addressed and a plan of care that could be developed based on the residents' status. During a review of the facility's Policy and Procedure (P&P), titled Resident Assessment, dated 3/2022, indicated the facility to follow the RAI (Resident Assessment Instrument) User's Manual on timing and submission of assessments. During a review of CMS Long-Term Care Facility MDS 3.0 RAI User's Manual, updated 10/2024, indicated MDS assessment must be submitted to the CMS system within 14 days of the MDS completion date.

Based on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices in accordance with the facility ' s policy and procedure by failing to ensure the scoop was not left inside the thickener (products used to modify the consistency of drinks, helping people with dysphagia [difficulty swallowing to control the way they swallow]) container/bin after each use. This deficient practice had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated (transfer of disease-causing organism the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) food. Findings: During a kitchen observation on 12/17/24 12:30 PM, in the presence of the Dietary Supervisor (DS), a scoop was found inside the thickener container with its handle touching the contents. DS stated that the scoop should not have been left inside the container because the handle could introduce bacteria or other contaminants, leading to cross-contamination (transfer of disease-causing organism the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During a review of the facility's policy and procedure (P&P) titled, Storage of Canned and Dry Goods indicated food, and supplies will be stored properly in a safe manner. In addition, the scoops should not be left in the container and will be cleaned after each use.

Based on interview and record review, the facility failed to provide the necessary care and services for two of two sample residents (Residents 1 and 2). For Resident 1, the facility: 1. Failed to implement the care plan for Resident 1's risk for respiratory distress. On [DATE], at 11:30 p.m. Licensed Vocational Nurse 1 (LVN 1) failed to evaluate Resident 1's respiratory rate, shortness of breath (SOB), irregular respirations, and abnormal lung sounds, and to identify the emergent decline of Resident 1's condition promptly and notify the attending physician (MD 1). 2. Failed to implement its policy and procedures on change of condition (C[NAME] - clinically significant deviation from a resident's baseline in physical, cognitive (knowledge), behavioral or functional domains that, without intervention, may result in complications or death). On [DATE], at 11:30 p.m., LVN 1 did not promptly report Resident 1's C[NAME] to MD 1 for MD 1 to determine the course of treatment. 3. Failure to follow MD 1's order to transfer Resident 1 to GACH 1 immediately after MD 1 ordered the transfer via 911 (emergency services - paramedics) to General Acute Care Hospital 1 (GACH 1) for evaluation of shortness of breath and respiratory distress (a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood). As a result, on [DATE], at 4:44 a.m., Resident 1 was pronounced dead at GACH 1's Emergency Department. For Resident 2, the facility: 1. Failed to follow Resident 2's physician order [REDACTED]. 2. Failed to implement Resident 2's care plan for risk of [DIAGNOSES REDACTED] by not notifying the attending physician (MD 2) promptly and not administering the medications as ordered. 3. Failed to implement its policy on Resident Care Plan by not implementing the plan of care for risk of [DIAGNOSES REDACTED]. 4. Failed to implement its policy on [DIAGNOSES REDACTED] by not administering diabetic medications as ordered by the physician and not having a complete diabetic emergency kit. 5. Failed to have readily available [MEDICATION NAME] 1 milligram (mg) intramuscular (IM - injection of medicine given into a muscle) as ordered for Resident 2. As a result, on [DATE], Resident 2 was hypoglycemic, oral interventions did not help, the licensed nurse did not administer the ordered [MEDICATION NAME] and the blood sugar level was 47 milligrams per deciliters (mg/dl). The licensed nurse called 911 and upon arrival, at 12:28 a.m., paramedics administered Resident 2 intravenous (IV) [MEDICATION NAME] (a solution treatment for [REDACTED]. Paramedics transferred Resident 2 to GACH 2 where Resident 2 was diagnosed with [REDACTED]. *Cross References F580 and F842 Findings: a. A review of Resident 1's Admission Record indicated Resident 1's admission to the facility was on [DATE] and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. to perform everyday activities). Other [DIAGNOSES REDACTED]. A review of the History and Physical exam completed by the attending physician (MD 1) on [DATE], indicated Resident 1 could not understand and make decisions. A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated [DATE], indicated Resident 1 had modified independence (some difficulty in new situations only) in cognitive skills (ability to think, understand, and reason) for daily decision-making, required extensive assistance with bed mobility, toilet use, and personal hygiene, and needed two-person assist with transfers. A review of Resident 1's physician's orders [REDACTED]. The POLST ordered to use medication by any route as needed to relieve pain and suffering; use oxygen, suctioning, and manual treatment of [REDACTED]. A review of Resident 1's Care Plan dated [DATE], indicated Resident 1 was at risk for respiratory distress related to congestion (an abnormal or excessive accumulation of a body fluid), SOB, irregular respirations, wheezing (a high-pitched [MEDICATION NAME] sound made while breathing), crackles (abnormal lung sounds characterized by clicking or rattling sounds), and rhonchi (low pitched, rattling lung sounds that often resemble snoring). The care plan interventions included to assess for SOB, irregular respirations, wheezing, crackles, rhonchi, coughing, weakness, activity intolerance, excessive secretions, and to inform the physician promptly. A review of the Licensed Progress Notes dated [DATE], at 10:45 p.m., indicated Resident 1 had an episode of high blood pressure of ,[DATE] mmHg (normal blood pressure below ,[DATE]), was restless, flushed (red and hot), and clammy (sweaty). A review of the Licensed Progress Notes dated [DATE], at 11 p.m., indicated MD 1 was notified of the C[NAME] (high blood pressure) and MD 1 did not give new orders. The licensed nurse called FM 1 and informed We would continue to monitor the resident and will notify him of any other changes. A review of Resident 1's Multidisciplinary Progress Record form dated [DATE] (should be [DATE]), at 11:30 p.m., indicated Resident 1 was in bed with continuous oxygen, at five liters per minute (5 L/min). Resident 1's oxygen saturation (O2 sat - a measure of how much oxygen the blood is carrying) was 96% (normal pulse oximeter readings range from 95 to 100 %). Resident 1's blood pressure was ,[DATE] mmHg, the pulse (heart rate) was 95 beats per minute (resting heart rate for adults ranges from 60 to 100 beats per minute), and was, Breathing with crackles sounds on her lungs, responsive only with deep tissue stimuli and very lethargic (lack of awareness). A review of the Multidisciplinary Progress Record dated [DATE] at 12:30 a.m. indicated Resident 1's O2 sat was 62%, the blood pressure was ,[DATE] mmHg (high), the pulse at 117 beats per minute (high), the breathing pattern and the shortness of breath worsened. A review of the Multidisciplinary Progress Record form dated [DATE], at 12:40 a.m., indicated LVN 1 notified the physician about Resident 1's condition and the physician ordered to transfer Resident 1 to the hospital. A review of the Physician and Telephone Orders form dated [DATE] (no time specified), indicated to transfer Resident 1 via 911 (emergency responders - paramedics) for evaluation due to SOB/respiratory distress. Apply oxygen at 2 L/min via nasal cannula (flexible plastic tubing used to deliver oxygen through nostrils) and titrate (continuously measure and adjust the balance) oxygen to keep saturation above 93%. A review of Resident 1's Incident Information for (paramedics report) dated [DATE], indicated 911 received the call at 1:31 a.m. and paramedics arrived at the facility at 1:38 a.m. Upon arrival, Resident 1 had a Glasgow Coma Scale (GCS - a 15-point scoring system used to describe the initial level of consciousness or awareness) of 3, had altered level of consciousness, and audible rhonchi. Resident 1's blood pressure at ,[DATE] mmHg, the pulse was 109 beats per minute. Paramedics gave Resident 1 oxygen at 15 L/min and transported to GACH 1. A review of GACH 1's Emergency Department Report dated [DATE], at 2:10 a.m., indicated Resident 1 presented with difficulty in breathing, diminished breath sounds and was placed on a Bi-level Positive Airway Pressure, ([MEDICAL CONDITION] a type of ventilator) on arrival. The white blood cell count (WBC - a blood test to measure the number of WBCs in the blood and help fight infections) was 22.7 K/uL (thousand per microliter - normal range 3.8 to 10.2K/uL). Resident 1 was pronounced dead at 4:44 a.m. Resident 1's [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. A review of the Certificate of Death indicated Resident 1's date of death was on [DATE], at 4:44 a.m., Resident 1's immediate cause of death was non-ST-elevation [MEDICAL CONDITION] infarction with leading causes cardiopulmonary arrest, [MEDICAL CONDITION] with rapid ventricular rate, and pneumonia (an infection of the lungs). A review of the facility's Interview Log, dated [DATE] (29 days after Resident 1 died ), indicated that LVN 1 missed documenting that LVN 1 gave a breathing treatment to Resident 1 on [DATE], at 12:30 a.m. and Resident 1's condition slightly improved. Resident 1 still had crackle breath sounds, FM 1, Refused to transfer the resident to the hospital. LVN 1 called FM 1 again to let him know Resident 1's condition did not improve, and FM 1 finally agreed to transfer Resident 1 to the hospital. During a telephone interview on [DATE], at 4:08 p.m., Registered Nurse 2 (RN 2) stated on [DATE] during the 3 p.m. to 11 p.m. shift, Resident 1 became restless and had a high blood pressure. MD 1 and FM 1 were notified of Resident 1's high blood pressure. MD 1 did not give new orders, and Resident 1 was only, Comfort measures. During a telephone interview on [DATE], at 9:40 a.m., LVN 1 stated that on [DATE], Resident 1 was under his care and at the beginning of his shift (11 p.m. to 7 a.m.), (LVN 1) saw Resident 1 had difficulty in breathing and was in and out of consciousness. Resident 1 had crackle sounds, difficulty in breathing, and was not responding, and tried to manage Resident 1's condition on his own. LVN 1 stated he did not consult with the Director of Nursing (DON) for guidance and there was no RN during his shift. LVN 1 said he provided breathing treatment and oxygen, which were not effective, and he decided to notify the physician. During a telephone interview on [DATE], at 3:41 p.m., FM 1 stated RN 2 called him twice on [DATE], once to let him know about Resident 1's episode of high blood pressure, and the second call was to inform him the blood pressure went down and Resident 1 was stable. FM 1 stated on [DATE], LVN 1 called him once to let him know he (LVN 1) was going to call 911. FM 1 said he (FM 1) did not refuse to send Resident 1 to the hospital at any time on [DATE] or [DATE]. During a telephone interview on [DATE], at 1:16 p.m., LVN 1 stated, on [DATE] he called FM 1 once to notify FM 1 that he was going to call 911 because Resident 1's condition had gotten worse. LVN 1 stated that FM 1 did not refuse to send Resident 1 to the hospital. LVN 1 said he could not remember the reason he wrote on the Interview Log dated [DATE] (29 days after Resident 1 died ) that FM 1 refused to send Resident 1 to the hospital. During a telephone interview on [DATE], at 2:47 p.m., RN 2 stated FM 1 did not mention any refusal to send Resident 1 to the hospital on [DATE]. A review of FM 1 Declaration dated [DATE], indicated on [DATE] and [DATE], he (FM 1) did not refuse to send Resident 1 to the hospital. During an interview on [DATE], at 1:31 p.m., RN 1 stated LVN 1 was supposed to call MD 1 and FM 1 as soon as he (LVN 1) noted Resident 1 had a C[NAME] with respiratory distress to verify whether Resident 1 required a transfer to the hospital to prevent delay in care and services. During a telephone interview on [DATE], at 12:27 p.m., DON stated Resident 1's Multidisciplinary Progress Record dated as [DATE] timed at 11:30 p.m., should be dated as [DATE], not [DATE]. DON said Resident 1's Multidisciplinary Progress Record did not indicate Resident 1's respiration description and count, and LVN 1 did not document other interventions than oxygen. DON stated LVN 1 made an addendum (addition) in Resident 1's clinical record on [DATE] (29 days after) regarding Resident 1's condition on [DATE] after she (DON) questioned him (LVN 1). DON stated LVN 1 was supposed to monitor Resident 1's respiration, breathing, and document. During a telephone interview on [DATE], at 2:40 p.m., the Medical Director (MD 2), stated in general, he expected licensed nurses to notify residents' physicians and responsible parties of any drastic C[NAME] for the physician to make a decision to transfer or not as Resident 2 had an order of DNR with Comfort-Focused Treatment to the hospital. A review of the (undated) facility's policy and procedures titled, Change of Condition, indicated the purpose was to ensure proper assessment and follow-through for any resident with a change of condition. A change of condition is a sudden or marked difference in resident's vital signs such as blood pressure, irregular pulse, and shortness of breath and that all changes of condition in a resident should be handled promptly. The physician should be called promptly. A review of the undated facility's policy and procedures titled, The Resident Care Plan, indicated the resident care plan should be implemented for each resident, on admission, and developed throughout the assessment process. Healthcare professionals involved in the care of the resident should contribute to the resident's written care plan, and it was the responsibility of the licensed nurse to ensure that the plan of care was initiated and evaluated. b. A review of Resident 2's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the History and Physical, dated [DATE], indicated Resident 2 could understand and make decisions. A review of the MDS, dated [DATE], indicated Resident 2 was moderately impaired in cognitive skills and required extensive assistance for bed mobility, transfer, and personal hygiene with a one-person physical assist. A review of the Physician's Telephone Orders dated [DATE], at 3:10 p.m., indicated for Resident 2 to receive [MEDICATION NAME] 1 mg IM as needed (PRN) for blood sugar below 70, or if unable to tolerate by mouth (PO) and to notify the physician. A review of the Resident Care Plan, dated [DATE], indicated Resident 2 was at risk for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] (high blood sugar levels) related to diabetes mellitus and the plan was to initiate nursing measures for [DIAGNOSES REDACTED] and [MEDICAL CONDITION] immediately, notify the physician promptly, and to administer medications as ordered. A review of Resident 2's Licensed Progress Notes dated [DATE] and timed at 9:30 p.m. indicated that Resident 2 had fatigue, anxious, alert, and verbally responsive and with a blood sugar of 70 mg/dl. Resident 2 received 16 ounces of orange juice, and the blood sugar remained at 70 mg/dl. Resident 2 received a peanut butter and jelly sandwich and the blood sugar remained at 70 mg/dl. A review of the Licensed Progress Notes dated [DATE], at 11:30 p.m., indicated Resident 2's blood sugar was 53 mg/dl. Resident 2 received 8 ounces of orange juice, chocolate, glucose gel (medication to raise blood sugar levels), the physician was paged, and Resident 2's blood sugar remained at 53 mg/dl. A review of the Licensed Progress Notes dated [DATE], at midnight, Resident 2's blood sugar was 43 mg/dl. The physician was paged a second time. A review of the Licensed Progress Notes dated [DATE], at 12:30 a.m., indicated that Resident 2's blood sugar remained at 43 mg/dl and 911 s called. A review of the Licensed Progress Notes dated [DATE] at 12:45 a.m., indicated 911 arrived; Resident 2 was stabilized, and paramedics transferred Resident 2 to the GACH 2. A review of the Incident Information, dated [DATE], indicated 911 arrived at 12:28 a.m., to the facility, and Resident 2's blood sugar was 47 mg/dl. Resident 2 received intravenous (IV) [MEDICATION NAME] (a solution treatment for [REDACTED]. A review of the GACH 2's Discharge Summary records, signed date on [DATE], at 4:15 p.m., indicated Resident 2 was admitted to the hospital, on [DATE], and was discharged , on [DATE], with the [DIAGNOSES REDACTED].>During an interview on [DATE], at 2:41 p.m., DON stated LVN 2 was supposed to give [MEDICATION NAME] to Resident 2 to treat resident's hypoglycemic episode as indicated in the physician orders. DON said the risks of [DIAGNOSES REDACTED] could lead to a resident becoming nonresponsive and into a deep sleep. During an observation and concurrent interview on [DATE], at 1:36 p.m., LVN 6 stated Station A's diabetic kit (a container to store the necessary emergency supplies to treat a diabetic resident) did not have [MEDICATION NAME] vial for injection, oral glucose gel, sugar packs, and a can of orange juice. LVN 6 stated the diabetic kit should have [MEDICATION NAME] glucose gel, sugar packs, and orange juice in case of any hypoglycemic emergency. During an interview on [DATE], at 2:09 p.m., DON stated the diabetic kits should have all items listed in the facility's [DIAGNOSES REDACTED] policy and procedure such as orange juice, glucose gel, sugar packs, and [MEDICATION NAME] (medicine used to raise very low blood sugar) injection) to be readily accessible in case of residents' hypoglycemic episodes. A review of the undated facility's policy and procedures titled Change of Condition, indicated to ensure proper assessment and follow-through for any resident with a change of condition. A change of condition is a sudden or marked difference in resident's vital signs such as blood pressure, irregular pulse, and shortness of breath and that all changes of condition in a resident should be handled promptly. The policy indicated to call the physician promptly. A review of the undated facility's policy and procedures titled The Resident Care Plan, indicated the resident care plan should be implemented for each resident, on admission, and developed throughout the assessment process. The policy and procedure indicated that the healthcare professionals involved in the care of the resident should contribute to the resident's written care plan, and it was the responsibility of the licensed nurse to ensure that the plan of care is initiated and evaluated. A review of the facility's undated policy and procedures titled [DIAGNOSES REDACTED], indicated to manage residents who were at risks for [DIAGNOSES REDACTED], and the licensed nurses would administer diabetic medications as ordered by physician. The policy and procedure indicated to provide a diabetic kit at each station, and the kit would have orange juice, glucose gel, sugar packs, and [MEDICATION NAME] injection.

Based on record review and interview, the facility failed to ensure one of three sampled residents (Resident 1) was provided adequate assistance to prevent accidents and the facility did not update / revise the plan of care to prevent avoidable accidents. For Resident 1, who required extensive assistance during transfer, the facility did not provide a two - person assist for use of the stand up machine (different model of the Hoyer lift, used for residents that are able to place pressure on the feet, or able to stand) per policy, and did not update / revise Resident 1's self care deficit care plan in six months to reduce the risk of accidents. These deficient practices resulted in Resident 1 hitting her head on the back of the shower chair during transfer from the stand up machine, while in the resident's room. Resident 1 sustained swelling with discoloration on the dorsal parietal (right side of the back of the head). Findings: According to the admission record, Resident 1 was readmitted to the facility, on December 14, 2015, with [DIAGNOSES REDACTED]. The minimum data set (MDS - an assessment tool), dated December 17, 2015, indicated Resident 1 was able to express ideas and wants, and able to understand verbal communication from others. The MDS indicated Resident 1 required extensive assistance during transfer, and with activities of daily living (ADL - bed mobility, transfer, personal hygiene and bathing). Resident 1 had no limitation in range of motion. A review of the care plan, dated July 16, 2014, and revised on August 28, 2015, indicated Resident 1 had self care deficits, and required extensive assistance with ADL's. The interventions included to assist the resident with ADL's, allowing the resident to be active in decision making process involving care, and providing safe environment. The care plan did not indicate the use of the stand up machine / Hoyer lift during transfer of Resident 1. A review of the care plan indicated it had not been updated or revised for approximately six months. According to the situation background assessment (SBAR) form, completed by registered nurse (RN) 1, on February 25, 2016, at 10 a.m., Resident 1 was assessed with [REDACTED]. An ice pack was applied to the site and RN 1 called and left a message to the attending physician. A review of the clinical records indicated Resident 1 was placed on 72 hours neurology monitoring (level of consciousness, motor and sensory assessment) from February 25, 2016, until February 28, 2016, at 8:45 a.m., a total of three days. A review of the facility's investigation of the incident, dated February 25, 2016, indicated the certified nurse assistant (CNA 1) transferred Resident 1 from the stand up machine to the shower chair without assistance. According to the final investigation report, during the transfer, Resident 1's head bumped on the back of the shower chair. During an interview, on March 11, 2016, at 2:30 p.m., the morning shift registered nurse (RN) supervisor stated Resident 1 required total care and needed a two person assist when using the Hoyer lift / stand up machine, in accordance with their policy. During a telephone interview, on March 15, 2016, at 2:30 p.m., CNA 1 stated she used the stand up machine to transfer Resident 1 to the shower chair. CNA 1 stated during the transfer Resident 1 accidentally bump her head at the back of the shower chair. CNA 1 stated she discovered the swelling when she was combing the resident's hair after the shower. CNA 1 stated she should have called for help when she transferred the resident and that she was no longer assigned to Resident 1 after the incident. A review of the employee file indicated CNA 1 was suspended for five days starting February 25, 28, 29 and March 1 and 2, 2016, secondary to the incident with Resident 1. A review of the facility's policy titled, Resident Lifting/Assisting Transfer, updated on February 26, 2014, indicated no resident lift or assisted transfers would be attempted without using either a Vander Lift, an Invacare Lift, or Hoyer Lift. The policy indicated the use of mechanical lift required at least two persons.

Based on observation, interview and record review, the facility failed to: ensure one out of one sample resident's environment was free of accident hazards, including a removable Lap Tray (tray attached to the wheelchair to prevent the resident from leaning forward and/or falling) assistive device, and ensure that supervision was provided to prevent falls; implement procedures based on the comprehensive assessment and plan of care to meet the resident's specific needs to prevent falls for Resident 1 who had a high risk for falls; conduct assessment after a fall occurred and the resident continued to complain of left hip/leg pain to ensure timely treatment for [REDACTED]. Resident 1 was left unattended in her wheelchair that had a removable Lap Tray attached. The resident had a known habit of loosening the Lap Tray's Velcro straps from the wheelchair arms if left unattended in her room. On July 9, 2010, she was left unattended in her room, when she removed the Velcro straps from the wheelchair arms, and fell out of her wheelchair. Xrays were taken after the fall, indicating there was no fracture. However, the resident continued to complain of pain to her left leg, and she refused to walk with the Happy Feet Program (facility's group program to help resident's walk), daily from July 9, 2010 through July 23, 2010. On July 12, 2010, the Physical Therapist evaluated her with ten (10) out of ten (10) pain (a numeric pain rating scale with 0 being no pain and 10 being the worst pain), however she did not receive any pain medication, and the physician was not informed of the resident ' s continued complaints of pain or refusal to ambulate. On July 23, 2010, she was sent to the hospital and was diagnosed with [REDACTED]. On July 27, 2010, Resident 1 was readmitted to the facility. On September 9, 2010, the resident again fell from her wheelchair when she was left unattended and was able to remove the Velcro straps of the attached Lap Tray. According to documentation, Resident 1 had pain to her left elbow and left rib side area at a level of 5 out of 10. Pain medication was administered and the physician ordered an xray of her left ribs and left elbow. Findings: The following violations were a result of an unannounced complaint visit that was initiated on September 7, 2010, at 11a.m., alleging a resident (Resident 1) fell and sustained a left [MEDICAL CONDITION]. A review of the admission records for Resident 1 revealed she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had a gastrostomy tube (GT) inserted (a tube inserted through the abdominal wall which allows food/liquids/medications to be placed directly into the stomach). The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had short and long term memory problems, was moderately impaired in cognitive skills for daily decision making (poor decision making, requiring cues/supervision), and was totally dependent on staff with transfers (moving from one surface to another), requiring two persons for physical assist. The Fall Risk Assessments dated January 29, 2010, reviewed May 3, 2010, indicated the resident was a high risk for falls. The Physical Restraint Assessment to prevent falls from the wheelchair, dated January 29, 2010, reviewed May 3, 2010, indicated the resident was forgetful, confused, non-compliant, had poor safety awareness, and had poor trunk control (unsteady balance when sitting). It was noted that safety reminders were "ineffective" due to the resident's impaired cognition. A wheelchair alarm was attempted but was not implemented, with a reason noted that the resident " still tends to lean forward due to poor trunk control. " The current restraint implemented on January 29, 2010 was a removable lap tray to prevent the resident from leaning forward, accompanied by visual checks. The Resident Assessment Protocol Summary (RAPS) Narrative Report dated February 11, 2010, in the area of Cognitive Loss, indicated staff were to provide "frequent" visual checks to assure the resident's safety. The area of Falls indicated the resident was a high risk for falls and injury related to physical limitation and cognitive functioning, and poor safety awareness. Staff were to monitor her whereabouts at frequent intervals (no frequency given) with verbal instructions for safety, and to proceed with a care plan to monitor safety. The area of Physical Restraints indicated the use of a lap tray when the resident was in the wheelchair related to poor trunk control with a tendency to lean forward with a risk for self injury. The care plans dated January 29, 2010, and reviewed in April 2010, include the following: The care plan for Injury Potential Related to Weakness and Poor Safety Awareness included approaches to provide a physical restraint/postural support for proper positioning, safety, and balance. A care plan for Lap Tray Utilized For Safety From Falls/Injury While Up In a Chair Related To Poor Trunk Control, and Tendency to Lean Forward included approaches to apply a Lap Tray for the prevention of falls; to attempt less restrictive devices on an ongoing basis; and to refer to the Interdisciplinary Team (IDT) for an evaluation and recommendation of appropriate use of the correct restraint. The MDS assessment dated [DATE] indicated the resident sometimes understands, required one person to assist her with transfers, with moving on and off the unit once in her wheelchair, and to assist with walking. She required partial physical assistance for balance and/or trunk control while she was sitting or for positioning, and "did not" follow directions. The restraint area was marked indicating a trunk restraint was used daily. The MDS assessments dated January 29, 2010 and May 3, 2010 in the area of pain symptoms indicated the resident had no pain. The Pain Risk Assessments dated January 29, 2010, reviewed May 3, 2010, indicated the resident had a low risk for pain. A review of the physician's orders [REDACTED]. The resident had a physician's orders [REDACTED]. A review of the Happy Feet program record for the time period of May 11, 2010 through July 8, 2010 revealed Resident 1 had been ambulating using a front wheel walker (walking aid), with assistance from staff using a gait belt (used by staff to assist resident walk). Staff would follow the resident with the wheel chair in case the resident wanted to sit down. The distance the resident could ambulate varied from 200 to 300 feet, according to the documentation by the activity staff who was in charge of the Happy Feet program. From July 12, 2010, to July 23, 2010, it was documented that the resident refused to ambulate. A review of the Licensed Nurses Record dated July 9, 2010, at 12:00 p.m. revealed the resident was seen wheeling herself around the facility in her wheelchair, alert and responsive with episodes of confusion and disorientation. The record indicated she was assisted to the dining room for lunch. At 12:30 p.m., the resident was found lying on the floor in her room. According to the documentation staff members heard a banging noise that came from the resident's room. The occupational therapist (OT), who is no longer employed by the facility, and the restorative nursing assistant (RNA) went to the room and found the resident lying on the floor on her back. The resident complained of pain to the "left femur" (upper leg bone) when attempting to move all four extremities (both arms and legs). Three staff members assisted the resident back to bed. A Tylenol 650 milligram (mg) was given for pain to the "left femur" at 2 p.m. The documentation noted the physician was notified , however the notation did not indicate the physician was notified that the resident had fallen. The physician ordered an xray to be done of the left femur for " pain ". There was no documented indication the Xray was for a fall or for pain from a fall. During an interview with the Activity Director on September 7, 2010, at 2:55 p.m. she stated the resident used to walk on a daily basis with the use of a front wheel walker or with assistance from the staff until she fell on [DATE]. After the fall the resident refused to walk, complaining she didn't feel good and wanted to go to bed. The Activity Director stated that she informed the charge nurse that the resident refused to walk. There was no documented evidence that there was further assessment by licensed staff as to why the resident refused to walk after the July 9, 2010 fall, or that the physician had been informed that the resident refused to walk, daily. A review of the physician progress notes [REDACTED]. During an interview with Registered Nurse (RN 1) on September 7, 2010, at 12:50 p.m., he stated that after the fall on July 9, 2010, he assessed Resident 1 as being unable to move her left leg completely, and she had pain. He stated he called the physician and obtained an order for [REDACTED]. A review of the xray result of the left femur dated July 9, 2010, revealed there was no fracture (break), no bony destructive [MEDICAL CONDITION] (abnormal growth of the bone), or other abnormalities present. The resident's care plan was updated on July 9, 2010, for actual falls with a problem of spontaneous behavior of getting out of the wheelchair unassisted related to dementia. The goal was for the resident not to have any injuries related to falls for 90 days. The approaches included to supervise the resident's whereabouts, but how, when, and frequency the facility staff were to do this was not addressed. A clip-on wheelchair alarm to alert staff when the resident attempted to get out of the wheelchair unassisted was added; and to medicate the resident's pain as ordered by the physician to manage pain at an acceptable level (the acceptable level was not given), and, to monitor the effectiveness of pain medications and report to the physician for changes in condition. A review of the pain assessment flow sheet dated July 9, 2010, at 2 p.m., indicated that Tylenol 650 mg was given for left femur pain for a pain level of 4 out of 10. The Tylenol given was effective and the pain scale was 1 out of 10 at 2:30 p.m. after medicated, according to the documentation. A review of the Multidisciplinary Progress Record dated July 9, 2010 at 10:30 p.m., revealed that at 9 p.m. the resident again complained of left side hip pain. Tylenol 650 mg was given at 9 p.m. However a review of the Medication Record revealed there was no assessment documentation as to the effectiveness of the medication or level of pain before and/or after the administration of the Tylenol for the resident's complaint of left side hip pain. A review of the pain assessment flow sheet dated July 10, 2010, at 9 a.m., indicated the resident was given Tylenol 650 mg, for left femur pain for a pain level of 4 out of 10. The Tylenol was effective with a reduced pain scale of 1 out of 10 at 9:30 a.m. There was no assessment documentation including the facility's post fall assessment information. A review of the Licensed Nurse Record and the Multidisciplinary Progress Record for July 9, 2010, through July 12, 2010, revealed that the nursing staff did not perform neurological assessments for 72 hours as indicated in their Policy and Procedure: Fall Reduction (General). There was no documentation for all three shifts on July 10, 2010, there was no notes for July 11, 2010, and all three shifts on July 12, 2010 were not documented. A review of the Physical Therapy (PT) Initial Evaluation dated July 12, 2010, for the after fall assessment, revealed that the resident had gait difficulty and weakness to both lower extremities. She was unable to ambulate because of difficulty bearing weight on her left leg due to pain, and she refused to ambulate because of severe pain. When flexion of the left hip was attempted, the resident had a limited range of motion and severe pain at a pain level documented as ten out of ten. A review of the medical record revealed there was no documentation as to the reassessment of the resident's severe left hip and leg pain after the Physical Therapy evaluation, nor that the physician was notified with the results of the Physical Therapy evaluation. During an interview with the Physical therapist (PT) who is no longer employed by the faciliy, on September 28, 2010 at 1:30 p.m., he stated that after his evaluation on July 12, 2010, he reported Resident 1's complaint of severe pain to the left hip with a pain scale level of ten out of ten to the Registered Nurse Supervisor (RN 1). And he reported the results of his evaluation to the Director of Nursing (DON) on July 13, 2010. During interviews with RN 1 on September 2, 2010, at 2:30 p.m., September 28, 2010, at 2:10 p.m., and on December 7, 2010, at 12:00 p.m., he stated that he was aware of the Physical Therapy Evaluation dated July 12, 2010. In a review of the PT's evaluation form and nursing notes with RN 1 he stated there was no daily assessment to monitor the resident's left hip and/or leg pain after July 10, 2010, until July 23, 2010. A review of documentation on three different forms regarding the resident's pain, with RN1, the DON, and the Administrator, revealed that nurses were monitoring the resident's oral status because she had multiple tooth extractions on July 12, 2010, but did not monitor the left hip pain. During the December 7, 2010 at 12:00 interview, RN1 also stated that on July 12, 2010, at 10:00 a.m., the resident complained of pain to her lower left leg with a pain level of three out of ten. The physician was contacted, who ordered [MEDICATION NAME] 50 mg every six hours via the GT for "muscle pain to the resident's left lower extremity." RN1 stated that he failed to administer the [MEDICATION NAME] as ordered by the physician. RN 1 stated that the physician was aware of the fall, however could not provide documentation that the physician was notified specifically of Resident 1's fall that occurred on July 9, 2010. A review of the Medication Record (MR) for July 2010, with RN1 during the interview, revealed that the resident was not given Tylenol for her left hip/leg pain after July 10, 2010 at 9 a.m., even though she had complained of pain. And, she was never given the pain medication [MEDICATION NAME] (stronger than Tylenol) that was ordered on July 12, 2010 for her left hip pain. The MR documentation shows that Resident 1 was not given the [MEDICATION NAME] pain medication until July 23, 2010, the day she was transferred to the acute care hospital for severe pain and swelling to her left hip, leg, knee and ankle. A review of the License Nurses Record dated July 23, 2010, at 7:30 a.m., revealed the resident complained of pain to her left hip with a pain level of ten on a pain scale from zero to ten. The resident had pain upon initiating movement. A body assessment was done, and no skin discoloration or skin tear was observed. The pain assessment flow sheet dated July 23, 2010, at 8:30 a.m., [MEDICATION NAME] was given for pain in the left leg for a pain level of ten out of ten. At 8:45 a.m., the physician was notified and an order was received for a stat xray of the left hip with a [DIAGNOSES REDACTED]. A review of the xray result dated July 23, 2010, indicated the resident had an acute left subcapital fracture (a break at the point where the neck of the leg bone joins the ball of the leg bone) with slight displacement. The physician was notified of the results, and he ordered the resident to be transferred to the acute care hospital on July 23, 2010, at 2 p.m. A review of the physical examination conducted in the emergency room dated July 23, 2010, indicated the left lower extremities (left hip and leg) were shortened when held flexed (bent) at the hip, and pain with range of motion (moving) and mild left ankle swelling. The acute care hospital records indicated hemiarthroplasty (surgery that is used most commonly to treat a broken hip) was done on July 25, 2010. On December 7, 2010, at 1 p.m., during an interview with the certified nursing assistant (CNA), who was generally responsible for the daily care of Resident 1 on the 7 a.m. to 3 p.m. shift, he stated that he was assigned to the resident on the day she fell . At the time she fell , he was assisting other residents with eating. He was called to the resident's room over the load speaker. When he got to her room, the resident was on the floor. He said that the resident was in the activity room for lunch before she fell . Her general habit was to wheel herself from the dining room to her room after lunch. Once she gets to her room, if left unattended, she had a tendency to remove the Velcro straps for the Lap Tray from both arms of the wheelchair, and would move the Lap Tray up and down, even though it was still connected around the wheelchair. He stated that she did this " all the time " if she sat by herself, and that he had informed the Licensed Vocational Nurse (LVN) charge nurse about this. He stated that no one saw the resident fall, but he believed that she was able to loosen the Lap Tray and slide right out because she was so small. During the interview, he proceeded to provide the exact type of Lap Tray that was used on Resident 1, and demonstrated how the Lap Tray was applied to the resident, including the Velcro straps that attached around each arm of the wheelchair. According to the acute care hospital records, Resident 1 was discharged from the acute care hospital after her surgery on July 27, 2010. The facility again assessed the resident as a high risk for falls on the Fall Risk Assessment. They implemented the same Lap Tray, and visual checks (no time intervals mentioned), but now added a wheelchair alarm, according to The Physical Restraint assessment dated [DATE]. According to the facility's Rehab Fall Risk Assessment and Physical Restraint Assessment, both dated September 10, 2010 for a fall incident that occurred on September 9, 2010 at 6:05 p.m., the resident fell out of her wheelchair a second time. When the resident was again left unattended, she was able to remove the Velcro straps around the wheelchair arms and remove the Lap Tray. The documentation indicated that the Lap Tray was dangling on the wheelchair when staff found the resident on the floor. After the second fall, the facility Inter Disciplinary Team now recommended a wheelchair wedge cushion to prevent the resident from getting up unassisted and hip pads in addition to the wheelchair alarm and Lap Tray. The Pain Assessment/Management form dated September 10, 2010, indicated the resident had pain to her left elbow and left rib side area at a level of 5 out of 10. Pain medication was administered. After notification, the physician ordered an xray of the left ribs and left elbow at 9:30 a.m. Two attempts were made to contact the resident's physician via phone regarding the July 9, 2010, fall. Messages were left on December 8, 2010 at 8:50 a.m., and on December 13, 2010, at 4:25 p.m., however there was no response from the physician. A review of the undated facility's policy and procedure titled, "Fall Reduction (Ambulatory)" indicated to assess all residents on admission to determine the risk for falling based on each resident's clinical assessment, even if the resident can ambulate. Once a fall risk has been established for a resident, the resident will be placed in a :fall prevention program, and a comprehensive care plan will be developed to meet the resident's specific needs. The facility's policy and procedure titled, "Fall Reduction (General)" indicated after a fall neurological assessments shall be done for 72 hours. As soon as a fall occurs, the resident will be assessed for the need of a restraint/safety device to minimize recurrence of a fall such as alarms, self-releasing seat belt, lap buddy, posey vest, "etc." This procedure also indicated that as soon as an incident of fall occurs, the charge nurse shall carefully assess the resident and determine any change in the resident's range of motion and signs of pain. Of primary concern is the resident's comfort, and alleviation of pain and suffering. The resident shall be assessed by the physical therapist for any significant change and notify the charge nurse for prompt follow up by the "MD". Cross Refer to F323, failure to ensure the resident's environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Based on observation, interview and record review, the facility failed to ensure one out of one sample resident's (Resident 1) environment was free of accident hazards, including a removable Lap Tray (tray attached to the wheelchair to prevent the resident from leaning forward and/or falling, also known as an assistive device), failed to ensure that supervision was provided to prevent falls for a resident who had a high risk for falls, failed to implement their fall reduction policies to update the plan of care after a fall occurred and make changes to meet the resident's specific assistive device and/or supervision needs to prevent a second fall that occurred the same way as the first fall occurred. Resident 1, had a known habit of loosening her Lap Tray 's Velcro straps from the wheelchair arms if left unsupervised in her room. On July 9, 2010, when she was left unsupervised in her room, she removed the Velcro straps from the wheelchair arms, and fell out of her wheelchair. Xrays were taken after the fall, indicating there was no fracture. However, the resident continued to complain of pain to her left leg, was unable to participate in the walking program because of excruciating pain, and on July 23, 2010, she was admitted to the acute care hospital and diagnosed with [REDACTED]. On July 27, 2010, after hip surgery, Resident 1 was readmitted to the facility. The nursing staff did not implement their fall reduction policies, and change the resident's plan of care to prevent her from falling out of her wheelchair a second time. Instead, they implemented the same preventions that were implemented on July 9, 2010, after the first fall. On September 9, 2010, after surgery for [REDACTED]. After the second fall, she had pain to her left elbow and left rib side area at a level of 5 out of 10 (a numeric pain rating scale with 0 being no pain and 10 being the worst pain). Xrays of her left ribs and left elbow were required. Findings: The following violations were a result of an unannounced complaint visit that was initiated on September 7, 2010, at 11a.m., alleging a resident (Resident 1) fell and sustained a left hip fracture. A review of the admission records for Resident 1 revealed she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had short and long term memory problems, was moderately impaired in cognitive skills for daily decision making (poor decision making, requiring cues/supervision), and was totally dependent on staff with transfers, requiring two persons for physical assist. The Fall Risk Assessments dated January 29, 2010, reviewed May 3, 2010, indicated the resident was a high risk for falls. The Physical Restraint Assessment to prevent falls from the wheelchair, dated January 29, 2010, reviewed May 3, 2010, indicated the resident was forgetful, confused, non-compliant, had poor safety awareness, and had poor trunk control (unsteady balance when sitting). It was noted that safety reminders were "ineffective" due to the resident's impaired cognition. A wheelchair alarm was attempted but was not implemented, with a reason noted that the resident "still tends to lean forward due to poor trunk control. " The current restraint implemented on January 29, 2010 was a removable lap tray to prevent the resident from leaning forward, accompanied by visual checks. There was no indication of how frequent the visual checks were to be accomplished. The Resident Assessment Protocol Summary (RAPS) Narrative Report dated February 11, 2010, in the area of Cognitive Loss, indicated staff were to provide "frequent" visual checks to assure the resident's safety. The area of Falls indicated the resident was a high risk for falls and injury related to physical limitation and cognitive functioning, and poor safety awareness. Staff were to monitor her whereabouts at frequent intervals (no frequency given) with verbal instructions for safety, and to proceed with a care plan to monitor safety. The area of Physical Restraints indicated the use of a lap tray when the resident was in the wheelchair related to poor trunk control with a tendency to lean forward with a risk for self injury. The care plans dated January 29, 2010, and reviewed in April 2010, include the following: The care plan for Injury Potential Related to Weakness and Poor Safety Awareness included approaches to provide a physical restraint/postural support for proper positioning, safety, and balance. A care plan for Lap Tray Utilized For Safety From Falls/Injury While Up In a Chair Related To Poor Trunk Control, and Tendency to Lean Forward included approaches to apply a Lap Tray for the prevention of falls, attempt less restrictive devices on an "ongoing" basis, and to refer to the Interdisciplinary Team (IDT) for an evaluation and recommendation of appropriate use of the correct restraint. The MDS assessment dated [DATE] indicated the resident sometimes understands, required one person to assist her with transfers, with moving on and off the unit once in her wheelchair, and to assist with walking. She required partial physical assistance for balance and/or trunk control while she was sitting or for positioning, and "did not" follow directions. The restraint area was marked indicating a trunk restraint was used daily. A review of the Happy Feet (walking ) program record for the time period of May 11, 2010 through July 8, 2010, prior to the first fall, revealed Resident 1 had been ambulating using a front wheel walker (walking aid), with assistance from staff between 200 to 300 feet. From July 12, 2010, to July 23, 2010, it was documented that the resident refused to ambulate. First Fall A review of the Licensed Nurses Record dated July 9, 2010, at 12:00 p.m. revealed the resident was seen wheeling herself around the facility in her wheelchair, alert and responsive with episodes of confusion and disorientation. The record indicated she was assisted to the dining room for lunch, and at 12:30 p.m., the resident was found lying on the floor in her room. According to the documentation staff members heard a banging noise that came from the resident's room. The occupational therapist (OT), who is no longer employed by the facility, and the restorative nursing assistant (RNA) went to the room and found the resident lying on the floor on her back. The resident complained of pain to the "left femur" (upper leg bone) when attempting to move all four extremities (both arms and legs). The physician ordered Xrays to be done of the left femur. A review of the Xray result of the left femur dated July 9, 2010, revealed there was no fracture (break), no bony destructive lesions (abnormal growth of the bone), or other abnormalities present. The resident's care plan was updated on July 9, 2010, after the first fall, for actual falls with a problem of spontaneous behavior of getting out of the wheelchair unassisted related to dementia. The goal was for the resident not to have any injuries related to falls for 90 days. The approaches included to supervise the resident's whereabouts, however did not address how, when, and the frequency the facility staff were to supervise the resident. A clip-on wheelchair alarm to alert staff when the resident attempted to get out of the wheelchair unassisted was added. A review of the pain assessment flow sheet from July 9, 2010 at 2 p.m. to July 12, 2010 revealed the resident continued to have pain ranging from 5 out of 10 to 10 out of 10. A review of the Physical Therapy (PT) Initial Evaluation dated July 12, 2010, for the after fall assessment, revealed that the resident had gait difficulty and weakness to both lower extremities. She was unable to ambulate because of difficulty bearing weight on her left leg due to pain, and she refused to ambulate because of " severe pain " . When flexion of the left hip was attempted, the resident had a limited range of motion and severe pain at a pain level documented as 10 out of 10. A review of the License Nurses Record dated July 23, 2010, at 7:30 a.m., revealed the resident complained of pain to her left hip with a pain level of 10 out of 10 and upon initiating movement. The physician was notified and an Xray revealed the resident had an acute left subcapital fracture (a break at the point where the neck of the leg bone joins the ball of the leg bone) with slight displacement. The resident was transferred to the acute care hospital on July 23, 2010, at 2 p.m. The acute care hospital records indicated hemiarthroplasty (surgery that is used most commonly to treat a broken hip) was done on July 25, 2010. During an interview with Registered Nurse (RN 1) On September 7, 2010, at 12:50 p.m., he stated that after the fall on July 9, 2010, he assessed Resident 1 as being unable to move her left leg completely, and she had pain. He stated that the resident was not supervised when she fell . During an interview with the Activity Director on September 7, 2010, at 2:55 p.m. she stated the resident used to walk on a daily basis with the Happy Feet Program until she fell on [DATE]. After the fall the resident refused to walk, complaining she didn't feel good and wanted to go to bed. On December 7, 2010, at 1 p.m., during an interview with the certified nursing assistant (CNA), who was generally responsible for the daily care of Resident 1 on the 7 a.m. to 3 p.m. shift, he stated that he was assigned to the resident on July 9, 2010, the day she fell . At the time she fell , he was assisting other residents with eating. He said that the resident was in the activity room for lunch before she fell . Her general habit was to wheel herself from the dining room to her room after lunch. Once she gets to her room, if left unsupervised, she had a tendency to remove the Velcro straps of the Lap Tray from both arms of the wheelchair, and would move the Lap Tray up and down, even though it was still connected around the wheelchair. He stated that she did this " all the time " if she sat by herself, and that he had informed the Licensed Vocational Nurse (LVN) charge nurse about this. He stated that no one saw the resident fall, but he believed that she was able to loosen the Lap Tray and slide right out because she was so small. During the interview, he proceeded to provide the exact type of Lap Tray that was used on Resident 1, and demonstrated how the Lap Tray was applied to the resident, including the Velcro straps that attached around each arm of the wheelchair. Resident 1 was discharged from the acute care hospital after her surgery on July 27, 2010. The facility's July 9, 2010 Fall Risk Assessment was still active, indicating the resident was at a high risk for falls. To prevent falls, the assessment indicated the nursing staff implemented the same Lap Tray that they knew the resident could remove if left unattended. The plan again included visual checks (nonspecific), and a wheelchair alarm, according to The Physical Restraint assessment dated [DATE]. There were no new safety devices added to minimize or prevent the reoccurrence of falls such as a self-releasing seat belt, lap buddy, Posey vest, or " etc " , as indicated in the facility's fall reduction policy, Section F, specific to Resident 1's needs to prevent her from falling from her wheelchair. Second Fall According to the facility's Rehab Fall Risk Assessment and Physical Restraint Assessment, both dated September 10, 2010 for a fall incident that occurred on September 9, 2010 at 6:05 p.m., the resident fell out of her wheelchair a second time. When the resident was again left unsupervised she was able to remove the Velcro straps from the wheelchair arms and remove the Lap Tray. The documentation indicated that the Lap Tray was dangling on the wheelchair when staff found the resident on the floor. After the second fall, the facility Inter Disciplinary Team now recommended a wheelchair wedge cushion to prevent the resident from getting up unassisted and hip pads in addition to the wheelchair alarm and Lap Tray. The facility's Investigation Of Incident/Accident/Injury Of Known/Unknown Origin form initiated on September 9, 2010, indicated that nursing staff had responded to the sound of the wheelchair alarm, and the resident was found sitting on the floor. The resident had successfully removed the removable Lap Tray and it was dangling on the side of her wheelchair. After the second fall, the Pain Assessment/Management form dated September 10, 2010, indicated the resident had pain to her left elbow and left rib side area at a level of 5 out of 10. The physician ordered an Xray of the left ribs and left elbow at 9:30 a.m. During interviews with RN 1 on September 2, 2010, at 2:30 p.m., September 28, 2010, at 2:10 p.m., and on December 7, 2010, at 12:00 p.m. that included the Director of Nurses, they were not able to provide information as to why nursing staff did not provide other safety measures that were indicated in their policy for fall reduction to prevent the reoccurrence of Resident 1 falling from her wheelchair. It was also stated that neither the July 9, 2010 fall or the September 9, 2010 fall were witnessed. They could also not provide documentation to indicate that staff were supervising Resident 1's whereabouts to ensure she didn't have another fall injury, as indicated in the care plan. Neither staff were able to explain why the resident was left unsupervised in her wheelchair, especially after they were aware of the reason for her first fall from the wheelchair. A review of the undated facility's policy and procedure titled, "Fall Reduction (Ambulatory)" indicated once a fall risk has been established for a resident, the resident will be placed in a fall prevention program, and a comprehensive care plan will be developed to meet the resident's " specific needs " . The facility's policy and procedure titled, "Fall Reduction (General)" indicated as soon as a fall occurs, the resident will be assessed for the need of a restraint/safety device to minimize recurrence of a fall such as alarms, self-releasing seat belt, lap buddy, Posey vest, "etc." A comprehensive care plan shall be developed to prevent any recurrence. Cross Refer to F309, failure of the facility to provide care and services in accordance with the comprehensive assessment and plan of care.