Every finding on record at Brookfield Healthcare Center

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 19) was free of significant medication errors, when:1. Resident 19's orders for Percocet (medication used to treat moderate or severe pain) and methocarbamol (a muscle relaxer used to relieve muscle, bone, and joint pain) were not clarified.2. Resident 19 was administered methocarbamol and Percocet together.These deficient practices had the potential to result in Resident 19 experiencing sedation (when given too much a medication that makes an individual sleepier or less conscious than intended) and respiratory arrest (when an individual stops breathing).Findings:During a review of Resident 19's admission Record (Face Sheet), the admission Record indicated Resident 19 was admitted to the facility on [DATE]. Resident 19's diagnoses included displaced fracture of the greater trochanter of the left femur (a break in the prominent, bony knob on the outer part of the left thigh bone and the broken pieces are moved out of their normal alignment), displaced fracture of the distal phalanx of the left index finger (a break in the tiny bone of the second finger on the left hand), scoliosis (an abnormal, sideways curvature of the spine that can appear as a C or S shape) and chronic pain syndrome (persistent pain lasting more than three to six months). During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 10/23/2025, the MDS indicated Resident 19's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 19 required maximal assistance (helper does more than half the effort) with toileting, bathing, lower body dressing, and personal hygiene. The MDS indicated Resident 19 was receiving a scheduled pain medication regimen. The MDS indicated Resident 19's pain occasionally affected her sleep, therapy activities, and day-to-day activities.During a review of Resident 19's History and Physical (H&P), dated 10/26/2025, the H&P indicated Resident 19 had the capacity to understand and make decisions.During a review of Resident 19's Physician Orders, dated 2/3/2025, the Physician Orders indicated the following:1. Methocarbamol (a muscle relaxer used to relieve muscle, bone, and joint pain) 750 milligrams (mg, a unit of measurement), by mouth three times a day for scoliosis and chronic pain, do not give with Percocet (medication used to treat moderate or severe pain) or temazepam (medication to treat insomnia, which is the trouble sleeping).2. Percocet 10-325 mg, by mouth every five hours as needed for moderate to severe pain. During an interview on 12/4/2025 at 8:35 a.m., with Pharmacist 1, Pharmacist 1 stated methocarbamol and Percocet had similar side effects such as sedation, drowsiness, and dizziness. Pharmacist 1 stated the side effects could potentially increase when methocarbamol and Percocet were administered together. Pharmacist 1 stated Resident 19's methocarbamol and Percocet should not be administered within an hour of each other due to Resident 19's physician order to not administer methocarbamol with Percocet.During an interview on 12/4/2025 at 12:51 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 19's methocarbamol was scheduled to administer three times a day and Percocet was administered in an as needed basis. LVN 1 stated according to Resident 19's methocarbamol order, the licensed nurses were not supposed to administer methocarbamol with Percocet or temazepam. LVN 1 stated she interpreted that order to give the medications at least an hour apart. LVN 1 stated Resident 19's methocarbamol order should have been more specific because do not give could be interpreted not to give both at the same time, within an hour, or a time frame less than an hour. LVN 1 stated Resident 19's methocarbamol should have specified not to give within an hour with Percocet. LVN 1 stated Resident 19's Percocet order does not specify whether to give with methocarbamol. LVN 1 stated Resident 19's Percocet order was an issue because the Percocet could be given as needed and the licensed nurse may not know the special instruction to avoid giving with methocarbamol. LVN 1 stated because methocarbamol and Percocet had sedative effects and if given together put Resident 19 at risk for oversedation (when given too much a medication that makes an individual sleepier or less conscious than intended) and respiratory arrest (when an individual stops breathing).During an interview on 12/4/2025 at 1:33 p.m., with Registered Nurse (RN) 1, RN 1 stated do not give with could be interpreted different ways. RN 1 stated Resident 19's methocarbamol and Percocet should not be given an hour or two hours within each other. RN 1 stated Resident 19's methocarbamol and Percocet orders should have been clarified to specify the administration time frame parameters (specific, measurable instructions that guide the safe and effective use of a medication). RN 1 stated with vague and nonspecific medication orders, Resident 19 was at risk of being administered methocarbamol and Percocet too close together which could lead to oversedation, respiratory distress, and increased risk for falls.During a concurrent interview and record review on 12/4/2025 at 1:39 p.m., with RN 1, Resident 19's Medication Administration Audit Report, dated 10/1/2025 through 10/31/2025 and 11/1/2025 through 11/30/2025, and Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 10/1/2025 through 10/31/2025 and 11/1/2025 through 11/30/2025, were reviewed. RN 1 stated Resident 19's Medication Administration Audit Report and MARs indicated methocarbamol and Percocet were administered 15 times either within an hour of each other or at the same time. RN 1 stated due to the sedative side effects of both methocarbamol and Percocet, Resident 19 was at risk of oversedation and respiratory distress. The Medication Administration Audit Reports and the MARs indicated methocarbamol and Percocet were given within an hour on the following dates and times:- 10/20/2025, methocarbamol administered at 12:49 p.m. and Percocet administered at 12:54 p.m.- 10/22/2025, methocarbamol administered at 10:26 a.m. and Percocet administered at 11:18 a.m.- 10/24/2025, methocarbamol administered at 1:42 p.m. and Percocet administered at 1:15 p.m.- 10/30/2025, methocarbamol administered at 9 a.m. and Percocet administered at 9 a.m.- 10/30/2025, methocarbamol administered at 6:58 p.m. and Percocet administered at 6:58 p.m.- 10/31/2025, methocarbamol administered at 10:27 a.m. and Percocet administered at 11:15 a.m.- 11/4/2025, methocarbamol administered at 6:19 p.m. and Percocet administered at 6 p.m.- 11/5/2025, methocarbamol administered at 9:45 a.m. and Percocet administered at 9:48 a.m.- 11/6/2025, methocarbamol administered at 5:40 p.m. and Percocet administered at 5:40 p.m.- 11/8/2025, methocarbamol administered at 9:21 a.m. and Percocet administered at 9:21 a.m.- 11/14/2025, methocarbamol administered at 5:22 p.m. and Percocet administered at 6:06 p.m.- 11/15/2025, methocarbamol administered at 6:08 p.m. and Percocet administered at 7:01 p.m.- 11/16/2025, methocarbamol administered at 2:57 p.m. and Percocet administered at 2:55 p.m.- 11/18/2025, methocarbamol administered at 1:39 p.m. and Percocet administered at 1:04 p.m.- 11/27/2025, methocarbamol administered at 2:02 p.m. and Percocet administered at 1:55 p.m.During an interview on 12/4/2025 at 2:33 p.m. with the Director of Nursing (DON), the DON stated medication orders should be specific and the licensed nurses were responsible for clarifying any vague orders with the physician. The DON stated Resident 19's methocarbamol order could have different interpretations since the order did not have specific administration time frame parameters. The DON stated Resident 19's order resulted in the licensed nurses administering methocarbamol and Percocet too close together which could lead to Resident 19 experiencing oversedation, respiratory distress, and altered consciousness. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration- General Guidelines, revised 11/2021, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices. The P&P indicated, Medications are administered in accordance with written orders of the attending physician.

Based on interview and record review, the facility failed to develop a comprehensive care plan with interventions for two of eight sampled residents (Resident 19 and 48) to address:1. Resident 19's use of methocarbamol (a muscle relaxer used to relieve muscle, bone, and joint pain).2. Resident 48's lack of dentures (a removable dental appliance that replaces missing teeth and surrounding tissues).This deficient practice had the potential to negatively affect Resident 19 and 48's mental, physical, and psychosocial well-being and had the potential to delay the delivery of necessary care and services.Findings:1. During a review of Resident 19's admission Record (Face Sheet), the admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses included displaced fracture of greater trochanter of the left femur (a break in the prominent, bony knob on the outer part of the left thigh bone and the broken pieces are moved out of their normal alignment), displaced fracture of distal phalanx of the left index finger (a break in the tiny bone of the second finger on the left hand), scoliosis (an abnormal, sideways curvature of the spine that can appear as a C or S shape) and chronic pain syndrome (persistent pain lasting more than three to six months). During a review of Resident 19's History and Physical (H&P), dated 10/26/2025, the H&P indicated Resident 19 had the capacity to understand and make decisions. During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool), dated 10/23/2025, the MDS indicated Resident 19's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 19 required maximal assistance (helper does more than half the effort) with toileting, bathing, lower body dressing, and personal hygiene. The MDS indicated Resident 19 received scheduled pain medication regimen. The MDS indicated Resident 19's pain occasionally affected her sleep, therapy activities, and day-to-day activities.During an interview on 12/4/2025 at 10:10 a.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated care plans were developed to address why the residents were in the facility, their medications, and any conditions that require specific care. The MDSC stated care plans were a communication tool to ensure all staff were aware of the residents' needs. The MDSC stated care plans should be developed to address medications the residents received to ensure the necessary monitoring for side effects were implemented.During a concurrent interview and record review on 12/4/2025 at 10:14 a.m., with the MDSC, Resident 19's Orders, dated 12/4/2025, and Care Plans, dated 10/19/2025 through 12/4/2025, were reviewed. The Orders indicated to give methocarbamol (a muscle relaxer used to relieve muscle, bone, and joint pain) 750 milligrams (mg, a unit of measurement), by mouth three times a day for scoliosis and chronic pain, do not give with Percocet (medication used to treat moderate or severe pain) or temazepam (medication to treat insomnia, which is the trouble sleeping). The Care Plans indicated were no Care Plans to address Resident 19's use of methocarbamol. The MDSC stated Resident 19 had an order to administer methocarbamol with specific instructions not to administer with Percocet or temazepam. The MDSC stated a Care Plan should have been developed with interventions to ensure those medications were not administered together and to include monitoring for sedation. The MDSC stated Care Plans were an additional tool to provide an overview of Resident 19's plan of care. The MDSC stated without a Care Plan addressing Resident 19's use of methocarbamol, Resident 19 was at risk of not receiving the necessary care.During an interview on 12/4/2025 at 2:23 p.m., with the Director of Nursing (DON), the DON stated Care Plans summarized everything regarding the resident's plan of care. The DON stated care plans developed for medications included interventions such as administering medications as ordered and monitoring as needed. The DON stated Resident 19 would have benefited from having a care plan for her methocarbamol's use to ensure the licensed nurses were aware to not to administer methocarbamol with Percocet and temazepam. The DON stated although there were orders in place, having a Care Plan would be a plus and without the necessary Care Plan, Resident 19's conditions and medications would not be accurately reflected. 2. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities).During a review of Resident 48's H&P, dated 8/26/2025, the H&P indicated Resident 48 was awake, oriented to self, followed simple commands. The H&P indicated Resident 48 had limited capacity to make decisions due to cognitive impairment. During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48's cognition was moderately impaired. The MDS indicated Resident 48 required moderate assistance (helper does less than half the effort) for eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 48 was dependent on staff for toileting hygiene, shower/bathing, lower body dressing and putting on/taking off footwear. During a review of Resident 48's electronic medical record, Resident 48's care plan for missing dentures was unable to be located.During an interview on 12/2/2025 at 11:02 a.m. with Resident 48, Resident 48 stated she lost her upper and lower dentures. Resident 48 stated she had informed the Social Services Director (SSD) she lost her dentures, and the SSD was assisting her in getting new ones.During an interview on 12/5/2025 at 9:48 a.m. with SSD, SSD stated Resident 48 had informed her she lost her dentures. SSD stated she did not develop a care plan for Resident 48 not having dentures. SSD stated Resident 48 did require a care plan for not having dentures. SSD stated Resident 48's care plan interventions should be to make sure Resident 48 had no problem chewing, ask if she had pain when chewing, make sure her food intake was good and to check if Resident 48 lost weight. SSD stated if Resident 48 did not have a plan of care for missing dentures, Resident 48 would be at risk of not receiving proper care.During an interview on 12/5/2025 at 1:56 p.m. with the DON, the DON stated a care plan was a map for resident's care and an overview of resident's health. The DON stated things got care planned to inform staff the plan of care for residents. The DON stated if something did not get care planned a resident may not receive the correct care. The DON stated Resident 48 required a care plan for missing dentures. The DON stated new interventions and goals should have been developed for missing dentures. The DON stated an intervention could be a dental consultation and diet modification.During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 12/2023, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to implement fall prevention interventions for one of three sampled residents (Resident 1) when staff failed to:1. Complete all sections of Resident 1's Fall Risk Evaluation, and develop a short-term fall care plan, following his fall on 11/13/2025.2. Conduct a Fall Risk Evaluation after Resident 1's fall on 11/21/2025.3. Revise Resident 1's fall risk care plan following his falls on 11/13/2025 and 11/21/2025.These deficient practices placed Resident 1 at risk for repeat falls and potential injury.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including reduced mobility, abnormal posture, limited ability or inability to move one side of the body following a stroke (loss of blood flow to a part of the brain) affecting his left side. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/21/2025, the MDS indicated Resident 1's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 1 was dependent on staff for all mobility while in and out of bed. During a review of Resident 1's Change of Condition Assessment (COC), dated 11/13/2025, the assessment indicated staff found Resident 1 on his back, next to his bedside table. During a review of Resident 1's Fall Risk Evaluation, dated 11/13/2025, the evaluation indicated two sections of the assessment that contributed to calculating Resident 1's risk for falls were not completed. The final evaluation indicated Resident 1 was not at risk for further falls. During a review of Resident 1's COC, dated 11/21/2025, the COC indicated staff found Resident 1 with his lower back and legs on the floor, and Resident 1 stated he slid off the bed. During a review of Resident 1's care plan titled At risk for falls, created 8/20/2025, the care plan indicated Resident 1 was at risk for falls. The care plan did not indicate it was revised following Resident 1's falls on 11/13/2025 or 11/21/2025. During an interview on 12/4/2025 at 2:41 p.m. with Registered Nurse (RN) 1, RN 1 stated after a fall, a Fall Risk Evaluation had to be completed immediately to identify further fall risk. RN 1 stated all sections of the evaluation had to be completed to ensure all potential risk factors were identified. RN 1 stated staff had to develop a short-term care plan to ensure all staff were aware of the required interventions to prevent further falls. During a concurrent interview and record review on 12/4/2025 at 2:46 p.m. with RN 1, Resident 1's care plan titled At risk for falls, created 8/20/2025, was reviewed. RN 1 stated Resident 1 did not have a short-term care plan developed after his fall on 11/13/2025. RN 1 stated that a short-term care plan should have been developed. During a concurrent interview and record review on 12/4/2025 at 2:48 p.m. with RN 1, Resident 1's Fall Risk Evaluation, dated 11/13/2025, was reviewed. RN 1 stated staff did not complete all sections of Resident 1's Fall Risk Evaluation and his fall risk would have been higher if it was completed. RN 1 stated all sections should be completed to get an accurate score and to identify the necessary interventions. RN 1 stated staff did not indicate Resident 1 was chairbound, did not walk, and was prescribed four different categories of high-risk medications. During an interview on 12/4/2025 at 2:55 p.m. with RN 1, RN 1 stated after Resident 1's fall on 11/21/2025, staff did not conduct a Fall Risk Evaluation. During a review of the facility's policy and procedure (P&P) titled Fall Management System, revised 12/2023, the P&P indicated that residents with high risk factors for falls were to have an individualized care plan developed. The P&P indicated that when a resident sustained a fall, a fall risk evaluation was to be completed and the care plan was to be updated.

Based on observation, interview, and record review, the facility failed to ensure oxygen therapy (a medical treatment that provides extra oxygen to breathe, typically prescribed for individuals with conditions causing low blood oxygen levels) was administered as ordered by the physician for two of 18 sampled residents (Residents 72 and 19). This deficient practice placed Resident 72 and Resident 19 at risk of sustaining complications of receiving too much supplemental oxygen.Findings: 1. During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 72's diagnoses included congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), upper respiratory infection, and asthma (a long-term condition that affects the airways in the lungs). During a review of Resident 72's Minimum Data Set (MDS, a resident assessment tool) dated 11/25/2025, the MDS indicated Resident 72's cognition (process of thinking) was moderately impaired. During a review of Resident 72's physician order, dated 11/21/2025, the physician order indicated Resident 72 was to receive oxygen therapy at two (2) liters per minute (L/min, a unit for measuring oxygen delivery rate). The physician order indicated staff could increase the delivery rate to three (3) L/min as needed. During observations on 12/2/2025 at 10:36 a.m., and 12/2/2025 at 2:50 p.m., at Resident 72's bedside, Resident 72 was receiving oxygen therapy at a rate of 3.5 L/min. During a concurrent interview and record review on 12/4/2025 at 2:38 p.m. with Registered Nurse (RN) 1, Resident 72's physician order, dated 11/21/2025 was reviewed. RN 1 stated Resident 72's orders indicated Resident 72 should not receive oxygen above 3 L/min. RN 1 stated Resident 72's oxygen should be administered as ordered. During a review of the facility's document titled Job Description - Registered Nurse, dated 12/2021, the document indicated the Registered Nurse was to administer services as appropriate and in accordance with applicable standards. 2. During a review of Resident 19's admission Record, the admission Record indicated the facility admitted Resident 19 on 10/19/2025. Resident 19's admitting diagnoses included chronic respiratory failure with hypoxia (long-term condition where the lungs consistently fail to get enough oxygen into the blood), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and hypertension (HTN-high blood pressure). During a review of Resident 19's Minimum Data Set (MDS - a resident assessment tool) dated 10/23/2025, the MDS indicated Resident 19 had moderate cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). During a review of Resident 19's physician order, dated 10/19/2025, the order indicated Resident 19 was to receive oxygen therapy at three (3) liters per minute (L/min, a unit for measuring oxygen delivery rate). The order did not indicate that oxygen delivery was titratable. During an observation on 12/3/2025 at 8:48 a.m., at Resident 19's bedside, Resident 19 was observed receiving oxygen therapy at a rate of 2.5 L/min. During an observation on 12/3/2025 at 3:16 p.m., at Resident 19's bedside, Resident 19 was observed receiving oxygen therapy at a rate of 2.5 L/min. During an interview on 12/3/2025 at 3:35 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 19's orders indicated Resident 19 should receive continuous oxygen at 3 L/min. LVN 2 stated Resident 19's oxygen should be administered as ordered. During an interview on 12/3/2025 at 3:45 p.m. with Registered Nurse (RN) 2, RN 2 stated Resident 19's orders indicated Resident 19 should receive continuous oxygen at 3 L/min. RN 2 stated Resident 19's oxygen should be administered as ordered. During a review of the facility's Licensed Vocational Nurse/Licensed Practical Nurse job description, dated 11/2021, the P&P indicated Licensed Vocational nurses were to provide services as appropriate and within standards of practice. During a review of the facility's Registered Nurse job description, dated 11/2021, the P&P indicated registered nurses were to provide services as appropriate and within standards of practice.

Based on observation, interview, and record review, the facility failed to provide a meal that was attractively appeasing and palatable for one of two sampled residents (Resident 71).This deficient practice had the potential for Resident 71's individual dietary and nutritional needs not being met, causing Resident 71 to not want to eat. Findings: During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was newly admitted to the facility on [DATE]. Resident 71's diagnoses included diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and congestive heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 71's History and Physical (H&P), dated 12/4/2025, the H&P indicated Resident 71 was awake, alert, and was able to answer questions appropriately. During a review of Resident 71's Order Summary Report, dated 12/2/2025, the Order Summary Report indicated an order for a consistent carbohydrate (essential macronutrients-sugars, starches, and fiber, they are the body's main fuel source) diet ([CCHO] a diabetes management plan focused on eating same amount of carbohydrates each meal daily), soft and bite sized. During a concurrent observation and interview on 12/3/2025 at 1:03 p.m. with Resident 71, observed Resident 71 eating lunch. The meal tray contained a green-colored pureed food item. Resident 71 stated she did not know what the green glob was. Resident 71 stated the food looked like baby food and did not want to taste it. Resident 71 then scooped some of the food onto a spoon and tasted it. Resident 1 stated it was not good and she was not going to eat it. Resident 71 stated her food was supposed to be cut into small pieces. During an interview on 12/5/2025 at 1:11 p.m. with the Dietary Supervisory (DS), the DS stated a soft and bite size diet was for residents that could tolerate chewing soft food but required dental work. The DS stated a resident prescribed a soft and bite size diet should have not received food that was pureed. The DS stated pureed food was meant for residents that could not chew. The DS stated it was important to serve food according to the resident's diet order and to offer a nutritional and palatable meal that residents will eat. During an interview on 12/5/2025 at 2:04 p.m. with the Director of Nursing (DON), the DON stated all residents must receive meals according to their prescribed diet. The DON stated it was important to provide palatable food to residents to promote food intake. During a review of the facility's policy and procedure (P&P) titled Level 6: Soft and Bite Sized, dated 2025, the P&P indicated a soft and bite sized diet was designed for residents who experience biting limitations but can chew food items for swallowing.

Based on observation, interview, and record review, the facility failed to maintain infection control measures for one of five sampled residents (Resident 61) when:1. Resident 61 was placed on contact precautions (using extra barriers, like gowns and gloves, to stop germs from spreading by touching a sick person or things in their room) with no visual signage to ensure hands were washed with soap and water. 2. Licensed Vocational Nurse (LVN) 2 performed hand hygiene with alcohol-based hand rub (ABHR- a liquid that is rubbed on the hands to quickly kill germs and stop their spread, without needing soap and water) instead of soap and water upon exiting Resident 61's room.These deficient practices had the potential to result in the spread of clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) to the residents and staff.Findings:During a review of Resident 61's admission Record (Face Sheet), the admission Record indicated Resident 61 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 61's diagnoses included type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), myocardial infarction (heart attack), and end stage renal disease (irreversible kidney failure).During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool), dated 10/10/2025, the MDS indicated Resident 61's cognition (process of thinking) was intact. The MDS indicated Resident 61 was dependent on staff's assistance with bathing, upper/lower body dressing, and putting on/taking off footwear.During a review of Resident 61's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/1/2025, the SBAR indicated on 12/1/2025, Resident 61 had three loose stools. The SBAR indicated Resident 61's physician ordered for a stool sample to rule out clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) and to place Resident 61 on contact isolation precautions (using extra barriers, like gowns and gloves, to stop germs from spreading by touching a sick person or things in their room). During a review of Resident 61's Order Summary Report, order dated 12/1/2025, the Order Summary Report indicated to place Resident 61 on contact precautions due to loose stool and pending C. diff results. During a review of Resident 61's Infection Surveillance, dated 12/2/2025, the Infection Surveillance indicated Resident 61 had three diarrhea episodes within a 24-hour period. The Infection Surveillance indicated the staff and Resident 61 were educated to increase hand hygiene with soap and water. The Infection Surveillance indicated Resident 61 was on contact and spore precautions (infection control measures for bacteria spread by touching a person or their environment that form hardy spores, requiring dedicated soap and water handwashing) due to loose stool.During a review of Resident 61's Test Results, dated 12/3/2025, the Test Results indicated Resident 61 was positive for C. diff.During a concurrent observation and interview on 12/3/2025 at 8:42 a.m., with Licensed Vocational Nurse (LVN) 2, outside of Resident 61's room, the sign outside of Resident 61's room indicated Resident 61 was on contact precautions and to clean hands when exiting the room. LVN 2 stated Resident 61 was on contact precaution because she had loose stools. LVN 2 stated Resident 61's C. diff results were pending. During an observation on 12/3/2025 at 8:43 a.m., with LVN 2, in Resident 61's room, observed LVN 2 put on a disposable gown and gloves prior to entering the room. LVN 2 asked for consent to check Resident 61's blood pressure (the force of the blood pushing against the artery walls as the heart pumps it through the body) before preparing Resident 61's medications. After LVN 2 checked Resident 61's blood pressure, she removed her gown and gloves and returned to the medication cart where she used the alcohol-based hand rub (ABHR- a liquid that is rubbed on the hands to quickly kill germs and stop their spread, without needing soap and water) to clean her hands. LVN 2 unlocked the medication cart, opened the medication drawer, and prepared to prepare Resident 61's medications.During a concurrent observation and interview on 12/3/2025 at 8:50 a.m., with LVN 2, in Resident 61's room, upon observing the State Surveyor washing her hands with soap and water upon exiting Resident 61's room, LVN 2 walked into the restroom and washed her hands with soap and water. LVN 2 stated although Resident 61's C. diff results were pending; she should have done all the precautions as if Resident 61 had a definitive result. LVN 2 stated after checking Resident 61's blood pressure and removing her gown and gloves, she was supposed to wash her hands with soap and water. LVN 2 stated C. diff spores were removed from the hands only by using soap and water and the ABHR was not strong enough. LVN 2 stated by using the wrong hand hygiene method, there was an increased risk of spreading C. diff to other residents and staff. During a concurrent observation and interview on 12/3/2025 at 8:54 a.m., with LVN 2, outside of Resident 61's room, the sign outside of Resident 61's room indicated Resident 61 was on contact precautions and to clean hands when exiting the room. The sign did not specify how to wash hands upon exiting. LVN 2 stated Resident 61 was on contact precaution but with additional spore prevention interventions such as washing hands with soap and water. LVN 2 stated the sign did not specify the hand washing method. During an observation on 12/3/2025 at 9:16 a.m., outside of Resident 61's room, observed the Director of Nursing (DON) passing through the hallway. The DON reminded LVN 2 to wash her hands with soap and water when exiting the room.During an interview on 12/3/2025 at 1:03 p.m., with Infection Preventionist Nurse (IPN) 2, IPN 2 stated Resident 61 was on transmission-based precautions (TBP- extra infection control steps used for residents with known or suspected infections that spread easily) due to the suspected C. diff infection. IPN 2 stated until Resident 61's results are finalized; the staff had to follow the guidelines to prevent the spread of C. diff in the facility. IPN 2 stated C. diff produced spores, which were easily spread, and hand washing with soap and water was a necessary way to ensure the spores were not left on the individual's hands. IPN 2 stated the ABHR was not strong enough to efficiently clean the hands. IPN 2 stated Resident 61 was placed on contact precautions, however, there was no specification to wash hands with soap and water. IPN 2 stated the staff were informed of Resident 61's status however, without the proper signage, the staff members could forget and not realize they needed to wash their hands with soap and water. IPN 2 stated by performing the incorrect hand washing method after attending to Resident 61, if spores were present on the hands, C. diff could easily be spread to other residents and staff members in the facility.During an interview on 12/4/2025 at 2:39 p.m., with the DON, the DON stated once Resident 61 experienced loose stool on 12/1/2025, Resident 61 was placed on contact precautions. The DON stated Resident 61 should have been placed on contact and spore precautions to specify the only appropriate hand washing method was with soap and water. The DON stated when LVN 2 did not wash their hands with soap and water after attending to Resident 61 and prior to returning to the medication cart, the risk of spreading C. diff in the facility increased. During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program Standard and Transmission-Based Precautions, revised 4/2025, the P&P indicated, It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions.During a review of the Centers for Disease Control and Prevention's (CDC- the national public health agency of the United States) webpage topic, link https://www.cdc.gov/c-diff/prevention/index.html, titled, Preventing C. diff, dated 12/18/2024, the webpage indicated, Washing your hands with soap and water is the best way to prevent the spread of C. diff from person to person.

Based on interview and record review, the facility failed to conduct an accurate fall reassessment for one of seventeen residents (Resident 3), after a fall.This deficient practice had the potential for Resident 3 not to receive the proper interventions to prevent further falls and injuries. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including muscle weakness and diabetes mellitus (DM- abnormal blood sugar level), hemiplegia (paralysis on one side of the body).During a review of Resident 3's History and Physical (H&P), dated 10/17/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Fall Risk Evaluation dated 10/15/2024, the evaluation did not indicate Resident 3 had a fall in the past 3 months. The evaluation indicated Resident 3 was incontinent, had balance problems with standing/walking and required use of assistive devices (i.e. cane, walker, wheelchair). The evaluation indicated Resident 3 had a score of 12, indicating a high risk of fall. During a review of Resident 3's SBAR Communication Form ([Situation, Background, Assessment, Recommendations] form that ensures all relevant information is conveyed in a structured manner) dated 10/29/2024, the SBAR indicated Resident 3 was found sitting on the floor in the room, on his bottom touching the ground and leaning on his shoulder against the glass sliding door. During a review of Resident 3's Fall Risk evaluation dated 10/29/2024 at 5:40 p.m., the evaluation did not indicate Resident 3's fall on 10/29/2024. The fall risk evaluation score was 7, indicating Resident 3 was a medium fall risk. The evaluation did not include Resident 3's incontinence, and the use of assistive device (wheelchair).During a review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 4/19/2025, the MDS indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required set up for eating and oral hygiene. The MDS indicated Resident 3 was dependent (helper does all the effort, resident does not) for toileting hygiene and maximal assistance (helper does more than half the effort to complete the activity, helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bath, dressing, upper/lower dressing, and putting on taking off footwear. The MDS indicated Resident 3 required moderate assistance (helper does less than half the effort, helper lifts, holds or supports trunk or limbs, but provides less than half the half the effort) to roll left and right side, sit to lying, and lying to sit on side of bed. The MDS indicated Resident 3 required maximal assistance with sitting to stand, chair/bed to chair transfer, tub/shower transfer, and with walking 10 feet. During a concurrent interview and record review on 7/24/2025 at 3:00 p.m. with the MDS Nurse, the MDS Nurse stated the fall risk evaluation was not done properly and did not include Resident 3's incontinence and the resident's use of wheelchair. The MDS Nurse stated the fall risk re-evaluation score of 7 indicating medium fall risk, after the fall was incorrect. The MDS Nurse stated not having a complete and correct assessment could lead to improper care planning and interventions for Resident 3. The MDS Nurse stated, it could also lead to recurrent fall. The MDS Nurse stated the nurse (unidentified) should have completed an accurate reassessment, by determining the correct score, to determine the resident's risk of falling. During a review of the facility's Policy and Procedures (P&P) titled, Fall Management System, dated 12/2023, the P&P indicated the facility should provide each resident appropriate assessment and interventions to prevent falls and to minimize complications, if a fall occurred.

Based on interview and record review, the facility failed to develop a resident-centered plan of care after one of three sampled residents (Resident 3), had a fall.This deficient practice resulted in the facility not having a care plan to implement for the resident's safety after the fall and had the potential to cause recurrent falls.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including muscle weakness and diabetes mellitus (DM- abnormal blood sugar level), hemiplegia (paralysis on one side of the body).During a review of Resident 3's History and Physical (H&P), dated 10/17/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's SBAR Communication Form ([Situation, Background, Assessment, Recommendations] form that ensures all relevant information is conveyed in a structured manner) dated 10/29/2024, the SBAR indicated Resident 3 was found sitting on the floor in his room, on his bottom touching the ground and leaning on his shoulder against the glass sliding door.During a review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 4/19/2025, the MDS indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required set up for eating and oral hygiene. The MDS indicated Resident 3 was dependent (helper does all the effort, resident does not) for toileting hygiene and maximal assistance (helper does more than half the effort to complete the activity, helper lifts or holds trunk or limbs and provides more than half the effort) shower/bath, dressing, upper/lower dressing, and putting on taking off footwear. The MDS indicated Resident 3 required moderate assistance (helper does less than half the effort, helper lifts, holds or supports trunk or limbs, but provides less than half the half the effort) to roll left and right, sit to lying, and lying to sit on side of bed. The MDS indicated Resident 3 required maximal assistance for sitting to stand, chair/bed to chair transfer, tub/shower transfer, tub/shower transfer, and walk 10 feet.During a concurrent interview and record review on 7/24/2025 at 3:00 p.m. with the MDS Nurse, the MDS Nurse stated there was no care plan initiated for Resident 3's fall on 10/29/2024. The MDS Nurse stated the facility should have initiated a care plan with specific interventions to address Resident 3's fall. The MDS Nurse stated that not having a care plan for Resident 3 could result in a recurrent fall and could lead to injury and hospitalization.During a review of the facility's Policy and Procedures (P&P) titled, Fall Management System, dated 12/2023, the P&P indicated the facility should develop care plan interventions to prevent falls by addressing the risk factors and should consider the particular elements of the evaluation that put the resident at risk and update the care plan after a fall.During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, dated 12/2023, the P&P indicated the interdisciplinary team (IDT) should develop a comprehensive person centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Residents 30) would not be administered any unnecessary medication in the form of duplicate drug therapy. (Cross Reference F756) The deficient practice created the risk for Resident 30 to receive excessive dosages of salmeterol (long-acting bcta2-adrcnergic agonist [[NAME]] medication, used to treat asthma - chronic inflammatory disease of the lungs) which are contained in both oral inhalers, Serevent Diskus (salmeterol) and Advair Diskus (a medication that contains both salmeterol and fluticasone propionate, an anti-inflammatory medicine, used to treat asthma and chronic obstructive pulmonary disease (COPD - lung disease that makes it difficult to breathe) which could lead to the resident experiencing serious side effects that include, high blood pressure, fast heart rate, irregular heart rhythm, which could result in an overdosage or hospitalization . Findings: During a review of Resident 30's Admission Record (document containing diagnostic and demographic information), the Admission Record indicated Resident 30 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included asthma and COPD. During a review of Resident 30's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/17/2024, the MDS indicated Resident 30 had intact cognition (ability to understand and process information). During a review of Resident 30's physician order, the physician order indicated the resident was prescribed: 1. Advair Diskus (fluticasone and salmeterol) 250 micrograms ([mcg] - unit of measure of weight)/ 50 mcg, instructions indicated, one inhalation by mouth every 12 hours for COPD (Rinse mouth with water after use), order date 9/13/2024. 2. Serevent Diskus (salmeterol) 50 mcg, instructions indicated, one inhalation by mouth every 12 hours for COPD, order date 9/13/2024. During a review of Resident 30's Medication Administration Records (MAR - a document that tracks medications given to a resident, including dosages, times, and the person administering them to ensure accurate and safe administration) for the months of 9/2024 and 10/2024. Resident 30's 9/2024 and 10/2024 MARs indicated the resident was administered both Advair and Serevent daily from 9/13/2024 through 10/15/2024. During a clinical record review on 10/16/2024 at 2:41 PM, Resident 30's physician orders and MARs between 9/13/2024 through 10/15/2024 were reviewed. Resident 30's MAR documentation, indicated by licensed nurses' initials that Resident 30 was administered both Advair and Serevent together for a total of 65 doses of Advair and 64 doses of Serevent for 33 days from 9/13/2024 through 10/15/2024. During a concurrent interview and record review on 11/17/2024 at 11:02 AM, with Registered Nurse (RN) 3, Resident 30's MARS for 9/2024 and 10/2024 were reviewed. RN 3 stated the initials on 9/20/2024 at 9 AM belonged to RN 3. RN 3 stated Resident 30 was administered Advair and Serevent inhalers at the same time. RN 3 acknowledged that Advair inhaler and Serevent inhaler both contain the same active ingredient salmeterol. RN 3 stated, I thought because they (Advair and Serevent) were scheduled at the same time that it was okay to give at the same time. RN 3 stated that she did not ask another nurse, a supervisor, call a pharmacist or use any drug reference to determine if the two inhalers, Advair and Serevent were okay to be administered together to Resident 30. During a concurrent interview and record review on 11/17/2024 at 11:22 AM, with Licensed Vocational Nurse (LVN) 2, Resident 30's MARs for 9/2024 and 10/2024 were reviewed. LVN 2 stated that she administered both inhalers, Advair and Serevent together to Resident 30 on 10/2/2024 and 10/4/2024, but did not recall which inhaler was administered first. During an interview on 10/17/2024 at 11:38 AM, with the Director of Nursing (DON), the DON stated once the surveyor identified there was no open date (the date the medication was first opened) on Resident 30's opened inhalers of Advair and Serevent, that was when the DON saw that the two inhalers contained the same active ingredient salmeterol. The DON stated she reached out to the pharmacist and the pharmacist informed her that one of the medications should be discontinued. The DON stated the facility's pharmacist missed the duplication in drug therapy when the Monthly Regimen Review (MRR - a regular assessment of a resident's medication and treatment plan every month to ensure it is effective, safe, and still necessary) was reviewed on 9/13/2024. The DON read the manufacturer's labeling for Serevent that indicated a warning of an increased risk for overdose when an active ingredient salmeterol was given together with another medication containing the same active ingredient. During an interview on 10/17/2024 at 1:11 PM, in the presence of the DON, with the facility's Consultant Pharmacist (Pharm 1) via telephone, Pharm 1 stated, he had not reviewed Resident 30's medications. Pharm 1 stated side effects of using both medications may include tachycardia (a fast heart rate), heart palpitations (fast or irregular heartbeat) or jitteriness (feeling of nervousness or shakiness). Pharm 1 stated his job included pointing out to the physician the overuse of salmeterol and medications that may cause increased risk of harm to the residents. During an interview on 10/17/2024 at 1:36 PM, in the presence of the DON, with the facility's dispensing pharmacist (Pharm 2) via telephone, Pharm 2 stated that giving Advair and Serevent together with both having salmeterol as the active ingredient was considered drug duplication and the resident (Resident 30) could experience an increase in side effects that include chest pain or chest palpitations. During a review of the facility's policy and procedure (P&P) titled, Administration Procedures for All Medications, dated 6/2021, the P&P indicated, To administer medications in a safe and effective manner .If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information . During a review of the facility's P&P titled, Medication (Drug) Regimen Review (MRR), dated 12/2023, the P&P indicated, Unnecessary drug is defined as medications ordered: o In excessive dosage (including duplicate drug therapy); or o For excessive duration; or o Without adequate monitoring; or o Without adequate indications for its use; or o In the presence of adverse consequences which indicate the dose should be reduced or discontinued . During a review of the manufacturer's labeling for Advair Diskus, dated 2/2019, the manufacturer's labeling indicated, ADVAIR DISK US is a combination product containing a corticosteroid and a long-acting bcta2-adrcnergic agonist ([NAME]) . ADVAIR DISKUS should not be used more often than recommended, at higher doses than recommended, or in conjunction with other medicines containing [NAME], as an overdose may result. Clinically significant cardiovascular effects and fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs. Patients using ADVAIR DISKUS should not use another medicine containing a [NAME] (e.g., salmeterol, formoterol fumarate, arformoterol tartrate, indacaterol) for any reason. During a review of the manufacturer's labeling for Serevent Diskus, dated 10/2022, the manufacturer's labeling indicated under Warnings and Precautions, indicated, Do not use in combination with an additional medicine containing a [NAME] because of risk of overdose . SEREVENT DISKUS should not be used more often than recommended, at higher doses than recommended, or in conjunction with other medicines containing [NAME], as an overdose may result. Clinically significant cardiovascular effects and fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs. 47858

Based on interview and record review, the facility failed to ensure a complete informed consent form (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) included the medication dosage, frequency, and behavioral manifestations prior to the administration of citalopram (medication used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest]) for one of five sampled residents (Resident 32). This deficient practice had the potential to result in Resident 32 and their Responsible Party (RP) being unaware of the medication treatment ordered, thus, being unable to make an informed decision regarding Resident 32's care. Findings: During a review of Resident 32's Admission Record (Face Sheet), indicated Resident 32 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 32's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and hypertension (elevated blood pressure). During a review of Resident 32's Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 9/20/2024, the MDS indicated Resident 32's cognition (process of thinking) was moderately impaired. The MDS indicated over a two-week period Resident 32 had felt down, depressed, or hopeless for half or more of the days (seven to eleven days). The MDS indicated Resident 32 was dependent on staff for oral hygiene, toileting, showering, and bathing. The MDS indicated Resident 32 received antidepressant medication while in the facility. During a review of Resident 32's History and Physical (H&P), dated 9/17/2024, the H&P indicated Resident 32 had the capacity to understand and make decisions. During a review of Resident 32's Psychiatric Follow-Up Note, dated 9/3/2024, the Psychiatric Follow-Up Note indicated Resident 32 was diagnosed with major depressive disorder. During a review of Resident 32's Order Summary Report, order date 10/3/2024, the Order Summary Report indicated to give citalopram 10 milligrams (mg, a unit of measurement) by mouth, one time a day, for depression as manifested by anxiety (feelings of fear, dread, and uneasiness) and loss of appetite. During a review of Resident 32's Medication Administration Record (MAR), dated 10/2024, the MAR indicated Resident 32 was administered citalopram 10 mg 10/4/2024 through 10/16/2024, with the exception of 10/10/2024 and 10/13/2024 when Resident 32 had refused the medication. During an interview on 10/17/2024 at 9:45 a.m., with Registered Nurse (RN) 4, RN 4 stated when a physician orders any kind of psychotropic medication (medication that affects the mind, emotions, and behavior), they physician would have to inform the resident and/or their RP of the medication being ordered, the indication of use, and the risks and benefits. RN 4 stated the licensed nurse was then responsible for verifying with the resident and/or their RP that they were fully informed of the mediation and agree with the plan of care. RN 4 stated the licensed nurse was responsible for completing the Facility Verification of Resident Informed Consent by indicating the medication name, dosage, frequency, indication, and behavioral manifestations. RN 4 stated it was important to indicate the full medication order to ensure the correct documentation because any changes in the medication would warrant a new informed consent process to occur, such as an increase in the medication's dosage or frequency. During a concurrent interview and record review on 10/17/2024 at 9:50 a.m., with RN 4, Resident 32's Facility Verification of Informed Consent, dated 10/4/2024 was reviewed. The Facility Verification of Informed Consent indicated the proposed treatment of psychotropic medication was citalopram for depression. RN 4 stated the Facility Verification of Informed Consent was incomplete because it did not indicate the dosage, frequency, and behavioral manifestations for the use of citalopram. RN 4 stated the verifying nurse should have documented everything that was verified to ensure clear documentation that Resident 32's RP understood the medication therapy Resident 32 was to receive. RN 4 stated without the complete documentation, Resident 32 and her RP could potentially not have been fully informed of the use of citalopram to treat Resident 32's depression and could not have made a fully informed decision regarding Resident 32's care. During an interview on 10/17/2024 at 2:10 p.m., with the Director of Nursing (DON), the DON stated when the licensed nurse verified with Resident 32 and their RP regarding the use of citalopram, they were responsible for verifying they understood and agreed to the medication use, the dosage, frequency, and behavioral manifestations. The DON stated without that verification, Resident 32 and RP would be misinformed and they could be agreeing to a treatment they were not fully aware of. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medications, revised 12/2023, the P&P indicated the facility's Interdisciplinary Team ([IDT], a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) would ensure informed consent was obtained prior to medication use.

Based on interview and record review, the facility failed to ensure the assessment entries on the Minimum Data Set ([MDS], a federally mandated resident assessment tool) were accurate for four of six sampled residents (Residents 3, 9, 32, and 253) when the facility failed to: 1. Include a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) per information in Resident 32 and Resident 3's medical record. 2. Include Resident 9's five (5) percent (%) weight loss in one month. 3. Include a diagnosis of seizure disorder (a disorder where a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) per information in Resident 253's medical record. These deficient practices had the potential to negative affect Residents 3, 9, 32, and 253's plan of care and delivery of necessary care and services. Findings: a. During a review of Resident 32's Admission Record (Face Sheet), the Admission Record indicated Resident 32 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 32's diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and hypertension (elevated blood pressure). During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32's cognition (process of thinking) was moderately impaired. The MDS indicated over a two-week period Resident 32 had felt down, depressed, or hopeless for half or more of the days (seven to eleven days). The MDS indicated Resident 32 was dependent on staff for oral hygiene, toileting, showering, and bathing. The MDS indicated Resident 32 received antidepressant medication while in the facility. During a review of Resident 32's History and Physical (H&P), dated 9/17/2024, the H&P indicated Resident 32 had the capacity to understand and make decisions. During a review of Resident 32's Psychiatric Follow-Up Note, dated 9/3/2024, the Psychiatric Follow-Up Note indicated Resident 32 was diagnosed with major depressive disorder. During a review of Resident 32's Order Summary Report, order date 10/3/2024, the Order Summary Report indicated to give citalopram (an antidepressant) 10 milligrams (mg, a unit of measurement) by mouth, one time a day, for depression as manifested by anxiety (feelings of fear, dread, and uneasiness) and loss of appetite. During a review of Resident 32's Order Summary Report, order date 10/8/2024, the Order Summary Report indicated to give mirtazapine (an antidepressant) 22.5 mg, by mouth, at bedtime for depression as manifested by decreased appetite and increased verbalization of sadness. During an interview on 10/17/2024 at 8:27 a.m., with the MDS Coordinator (MDSC), the MDSC stated she was responsible for conducting the MDS assessment for the residents on admission, quarterly, and annually and to transmit in a timely manner. The MDSC stated when she conducts her assessments she would do a physical assessment with the resident, speak with the family if she needed any clarification, and review the resident's hospital records and other medical records. The MDSC stated conducting an accurate assessment for the residents would allow for the development of a patient-centered care plan to provide the care and address the needs of each resident. During a concurrent interview and record review on 10/17/2024 at 8:29 a.m., with the MDSC, Resident 32's MDS, dated [DATE] was reviewed. The MDSC stated depression was not marked as one of Resident 32's diagnoses. The MDSC stated Resident 32 had been seen by a psychologist and psychiatrist and had indicated Resident 32 had been diagnosed with depression and had been treated with antidepressants. The MDSC stated depression should have been marked on Resident 32's MDS assessment to ensure the facility provides the necessary interventions to help treat Resident 32's depression. b. During a review of Resident 3's Admission Record (Face Sheet), the Admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 3's diagnoses included dementia (a progressive state of decline in mental abilities), cerebral infarction (stroke, loss of blood flow to a part of the brain), and osteoarthritis. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognition was severely impaired. The MDS indicated Resident 3 required setup or clean-up assistance with eating and moderate assistance (helper does less than half the effort) with toileting, dressing, and personal hygiene. The MDS indicated Resident 3 received antidepressant medication in the facility. During a review of Resident 3's H&P, dated 7/30/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Psychiatric Progress Note, dated 7/19/2024, the Psychiatric Progress Note indicated Resident 3's diagnosis of major depressive disorder. During a review of Resident 3's Order Summary Report, order date 10/20/2023, the Order Summary Report indicated to give Zoloft (an antidepressant) 25 mg, via gastrostomy tube (g-tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), one time a day for depression as manifested by self-report of feeling sadness. During a concurrent interview and record review on 10/17/2024 at 8:37 a.m., with the MDSC, Resident 3's MDS, dated [DATE] was reviewed. The MDSC stated depression was not marked as one of Resident 3's diagnoses. The MDS stated Resident 3 has had long-term depression and had been taking on antidepressants for a long period of time. The MDSC stated depression should have been marked on Resident 3's MDS assessment to ensure the facility provides the necessary interventions to help treat Resident 3's depression. c. During a review of Resident 9's Admission Record (Face Sheet), the Admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 9's diagnoses included end stage renal disease ([ESRD], irreversible kidney failure), congestive heart failure ([CHF], a chronic condition in which a weakness of the heart leads to a buildup of fluid in the lungs), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 was dependent on staff for oral hygiene, toileting, bathing, dressing, and personal hygiene. During a review of Resident 9's H&P, dated 9/19/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 9's Weights and Vitals Summary, dated 7/7/2023 through 10/9/2024, the Weights and Vitals Summary indicated on 8/7/2024, Resident 9 weighed 140 pounds (lbs, unit of measurement) and on 9/4/2024, Resident 9 weighed 133 lbs. Resident 9 had a 7 lbs weight loss which was a 5 percent (%) loss. During a concurrent interview and record review on 10/17/2024 at 8:49 am., with the MDSC, Resident 9's MDS, dated [DATE], was reviewed. The MDSC stated Resident 9's MDS was marked no for weight loss of 5% or more in the last month. The MDSC stated Resident 9 had an exact 5% weight loss from 8/7/2024 to 9/4/2024 and that weight loss should have been indicated on Resident 9's MDS so they could monitor Resident 9's nutritional status and provide the appropriate interventions to prevent further weight loss. d. During a review of Resident 253's Admission Record (Face Sheet), the Admission Record indicated Resident 253 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 253's diagnoses included hydrocephalus (condition where too much fluid builds up in and around the brain and spinal cord), myoclonus (a sudden, brief involuntary twitching or jerking of a muscle or group of muscles), and encephalopathy (damage or disease of the brain that changes how the brain functions). During a review of Resident 253's MDS, dated [DATE], the MDS indicated Resident 253's cognition was severely impaired. The MDS indicated Resident 253 was dependent on staff for eating, oral hygiene, toileting, bathing, and dressing. During a review of Resident 253's H&P, dated 8/13/2024, the H&P indicated Resident 253 did not have the capacity to understand and make decisions. During a review of Resident 253's general acute care hospital (GACH) Consultation Note, dated 8/7/2024, the Consultation Note indicated Resident 253 was admitted to the GACH with a diagnosis of seizures. During a review of Resident 253's Admission Note, dated 8/9/2024, the Admission Note indicated Resident 253 was admitted to the facility with the primary diagnosis of seizures. During a concurrent interview and record review on 10/17/2024 at 9 a.m., with the MDSC, Resident 253's MDS, dated [DATE] was reviewed. The MDSC stated seizure disorder was not marked as one of Resident 253's diagnoses. The MDSC stated Resident 253 was readmitted from the GACH for having seizures and seizure disorder should have been indicated on the MDS. The MDSC stated accurately indicating Resident 253's diagnosis of seizures would communicate Resident 253's medical condition to the rest of Resident 253's healthcare team to provide the necessary care. During an interview on 10/17/2024 at 2:13 p.m., with the Director of Nursing (DON), the DON stated having an accurate MDS was essential to provide the most appropriate patient centered care to each resident. The DON stated diagnoses, such as depression and seizures, and weight loss should be accurately indicated on the MDS so the facility could meet each residents' needs. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment and Associated Processes, revised 12/2023, the P&P indicated residents would be assessed comprehensively and accurately and would be made of the resident's needs, strengths, goals, life history and preferences and would include physical functioning, disease diagnosis, and health conditions.

Based on observation, interview, and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) in a timely manner for three out of six sampled residents (Resident 153, Resident 42, and Resident 21) when the facility failed to ensure the following: 1. Ensure a care plan was developed after the discovery of Resident 153's cancer of the left eye and skin. 2. Ensure a care plan was developed for Resident 42's use of a nicotine patch (a patch worn on the skin by a person trying to give up smoking). 3. Ensure care plan interventions were developed for the care of Resident 21's ileostomy (a surgical procedure that creates an opening in the abdominal wall to divert waste from the body through the small intestine instead of the anus), and stoma (a surgically created opening in the abdomen that allows waste to exit the body into a collection bag). These deficient practices had the potential to negatively affect the provision of care for Residents 153, 42, and 21. Findings: a. During a review of Resident 153's Admission Record, indicated Resident 153 was originally admitted to the facility on [DATE] with a diagnosis of kidney failure (occurs when kidneys suddenly become unable to filter waste products from the blood, kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and blood's chemical makeup may get out of balance) and congestive heart failure (heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 153's History and Physical (H&P) dated 9/12/2024, the H&P indicated Resident 153 had the capacity to understand and make decisions. During a review of Resident 153's Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 9/23/2024, the MDS indicated Resident 153's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 153 required maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathing, and putting on/taking off shoes. During a review of Resident 153's Electronic Medical Record (EMR), the EMR did not have a care plan developed for Resident 153's cancer of the skin and left eye. During an interview on 10/16/2024 at 8:22 a.m. with Resident 153, in Resident 153's room, Resident 153 stated she lost her vision to her left eye due to cancer. Resident 153 stated she had skin cancer and that her nurse was aware. Resident 153 stated she was told she had a dermatologist (a medical doctor who specializes in conditions that affect the skin, hair, and nails) appointment but was not sure when because staff did not inform her. Resident 153 stated the facility did not provide new treatments to her skin or asked her about her vision. Resident 153 stated she wanted to see a specialist for her skin and left eye because she wanted to get the care she needed. During an interview on 10/17/2024 at 12:49 p.m. with Registered Nurse (RN 4), RN 4 stated she was informed by Resident 153's family member (FM 1) the resident had skin cancer and needed to see a dermatologist. RN 4 stated a care plan should have been initiated for Resident 153's diagnosis of cancer but she did not initiate one. RN 4 stated it was important to develop a care plan for Resident 153's cancer diagnosis to have a proper plan of care and create goals and interventions for the resident's health. RN 4 stated if Resident 153 cancer diagnoses was not care planned there would not be any follow up of the resident's cancer and there would not be a plan of care for her diagnoses of cancer. During an interview on 10/18/2024 at 1:27 p.m. with the Director of Nursing (DON), the DON stated it was important to develop a care plan because it was the framework for a patients care. The DON stated staff developed interventions and a resident plan of care to direct care. The DON stated if something was not care planned the plan of care might not be followed. The DON stated when RN 4 was notified of Resident 153's cancer, RN 4 should have developed a care plan for continuity of care. 47679 b. During a review of Resident 42's Admission Record (Face Sheet), the admission record indicated Resident 42 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 42's diagnoses included peritonitis (redness and swelling of the lining of the abdomen), intestinal obstruction (blockage in the small or large intestine that prevents food, liquid, gas, and stool from passing though normally), and acute embolism and thrombosis of the deep veins of the lower extremity (a blood clot that forms in a vein deep in the body). During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42's cognition was intact. The MDS indicated Resident 42 required setup or clean-up assistance with eating and oral and personal hygiene. The MDS indicated Resident 42 required supervision with toileting and upper and lower dressing. During a review of Resident 42's Physician Admission Progress Note, dated 4/8/2024, the Progress Note indicated Resident 42 was alert (actively aware of the world, anticipating actions, and responding appropriately). During a review of Resident 42's Order Recap Report, dated 5/1/2024 through 10/31/2024, the Order Recap Report indicated: 1. Apply one nicotine patch 14 milligrams (mg, unit of measurement) per 24 hours (14 mg/24hr), transdermally (on the skin), one time a day for smoking cessation (process of stopping smoking tobacco) for six weeks and remove per schedule. Order date was 5/21/2024 and the duration of therapy was 5/22/2024 through 7/3/2024. 2. Apply one nicotine patch 7 mg/24 hr, transdermally, one time a day for smoking cessation for two weeks and remove per schedule. Order date was 5/21/2024 and the duration of therapy was 7/3/2024 through 7/17/2024. 3. Apply one nicotine patch 21 mg/24 hr, transdermally, one time a day for smoking cessation and remove per schedule. Order date was 8/9/2024 and the duration of therapy was 8/10/2024 through 8/13/2024. 4. Apply one nicotine patch 21 mg/24 hr, transdermally, one time a day for smoking cessation and remove per schedule. Order date was 8/13/2024 and the duration of therapy was 8/14/2024 through 9/21/2024. 5. Apply one nicotine patch 14 mg/24 hr, transdermally, one time a day for smoking cessation for two weeks and remove per schedule. Order date was 8/13/2024 and the duration of therapy was 9/21/2024 through 10/5/2024. 6. Apply one nicotine patch 7 mg/24 hr, transdermally, one time a day for smoking cessation for two weeks and remove per schedule. Order date was 8/13/2024 and the duration of therapy was 10/5/2024 through 10/16/2024. During an interview on 10/17/2024 at 8:12 a.m., with the MDS Coordinator (MDSC), the MDSC stated her role was to assess the residents upon admission and quarterly to complete the MDS and to develop patient-centered care plans. The MDSC stated care plans were used as a tool that would guide the staff to provide the necessary care to the residents. The MDSC stated care plans were developed based on the resident's assessment, medical diagnoses, and medications. The MDSC stated she based the planning and interventions on the resident's conditions and ensure the care plans were patient-centered to reach a goal. The MDSC stated care plans were developed for medications to ensure proper monitoring for any side effects and to evaluate if the medication was effective. The MDSC stated care plans should be developed as soon as possible so they could monitor the effectivity of the medication and the potential side effects. During a concurrent interview and record review on 10/17/2024 at 8:15 a.m., with the MDSC, Resident 42's Care Plan titled, Resident on nicotine patch for smoking cessation, initiated on 10/16/2024, was reviewed. The Care Plan indicated a goal for Resident 42 would refrain from smoking and interventions of the staff to ask resident about his tobacco use and to assess the resident's motivation to participate and continue with the smoking cessation plan. The MDSC stated she had initiated this care plan on 10/16/2024 because Resident 42 was seen that day in the smoking patio smoking a cigarette. The MDSC stated Resident 42 has had the nicotine patch applied on him daily starting in May 2024. The MDSC stated Resident 42's care plan for the use of the nicotine patch should have been developed at that time to help Resident 42 continue with his smoking cessation plan. The MDSC stated if the care plan had been developed earlier and the interventions had been implemented, the staff could have monitored Resident 42's desire to smoke closer. During an interview on 10/17/2024 at 2:15 p.m., with the DON, the DON stated Resident 42's care plan that addressed Resident 42's use of a nicotine patch should have been developed when it was initially ordered in May 2024. The DON stated Resident 42 wanted to stop smoking and was placed on the nicotine patch in hope he would not smoke again. The DON stated Resident 42 had smoked on 10/15/2024 for the first time and if Resident 42's care plan was developed and implemented earlier, that could have possibly prevented Resident 42 from smoking again. 47858 c. During a review of Resident 21's Admission Record, the admission record indicated Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 21's diagnoses included infection of the ileostomy surgical site and acute kidney failure. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21's cognition was intact. The MDS indicated Resident 21 was dependent on staff for toileting and showering, required supervision when eating, and required maximal assistance when dressing. During a review of Resident 21's Physician Orders, dated 9/23/2024, the Physician Orders indicated to change Resident 21's [ileostomy] bag (a bag connected to Resident 21's ileostomy to collect waste) when the bag was one-fourth or one-half full. The orders also indicated to wash [the ileostomy] with soap and water every shift and as needed. During a review of Resident 21's Care Plans dated 9/2024 to 10/2024, it was indicated there were no care plans initiated that identified specific interventions for the care and monitoring of Resident 21's stoma (a surgically created opening in the abdomen that allows waste to exit the body into a collection bag) or ileostomy bag. During a concurrent interview and record review, on 10/18/2024, at 8:44 a.m., with RN 2, all of Resident 21's care plans were reviewed. RN 2 stated there were no care plans specific to the care and assessment of Resident 21's ileostomy. RN 2 stated that care plans were important to be developed to guide the care of residents. RN 2 stated the care for Resident 21's ileostomy included monitoring and checking the stoma for any bleeding or infection, changing the bag, and cleaning the stoma and surrounding skin daily. RN 2 stated that without a care plan, there would not be a guide for the nurses to follow when care was provided for Resident 21's ileostomy and stoma. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised 12/2023, the P&P indicated, The interdisciplinary team ([IDT], a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs.

Based on interview and record review, the licensed nurses failed to review, update, and/or revise a care plan (written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) to reflect the attempts to prevent future falls for one out of one sampled resident (Resident 21). This deficient practice resulted in the facility having no interventions in the prevention for further falls for Resident 21 and could have potentially led to Resident 21's third fall. Findings: During a review of Resident 21's Admission Record, the admission record indicated Resident 21 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 21's diagnoses included history of falls and 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). During a review of Resident 21's History and Physical (H&P) dated 9/30/2024, the H&P indicated Resident 21 was alert and had appropriate mood, affect and insight. During a review of Resident 21's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/2/2024, the MDS indicatedResident 21's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 21 required moderate assistance (helper does less than half the effort) for toileting hygiene, upper body dressing and personal hygiene. During a review Resident 21's Care Plan dated 8/19/2021, the care plan indicated Resident 21 was at risk for falls due to generalized weakness, poor cognition, and history of falls. The care plan indicated Resident 21's goal was to minimize the risk of injuries and not to sustain a serious injury due to a fall. The staff's interventions indicated to anticipate Resident 21's needs, place the call light within reach and encourage the resident to use it, maintain Resident 21's bed in the lowest position, and encourage the resident to wear appropriate footwear when ambulating (walking) or wheeling in a wheelchair. The care plan indicated no revisions were made after Resident 21 had a fall on 8/9/2024 and 9/16/2024. During a review of Resident 21's Situation Background Assessment Recommendation (SBAR) Communication form, dated 8/9/2024 9/16/2024 and 10/4/2024, the SBAR indicated Resident 21 had a fall on 8/9/2024 9/16/2024 and 10/4/2024. During an interview on 10/17/2024 at 2:45 p.m. with Registered Nurse (RN 3), RN 3 stated after a resident has a fall their clan plan must be revised. RN 3 stated it was important to revise care plans to offer guidance in preventing future falls. RN 3 stated if a care plan was not revised it would delay treatment and the resident could fall again. During an interview on 10/18/2024 at 1:27 p.m. with the Director of Nursing (DON), the DON stated a care plan was an outline for a resident's care. The DON stated it was important to have care plans because it was a resident's framework to their care. The DON stated after Resident 21's falls the care plan should have been revised. The DON stated care plan revisions introduced new interventions to prevent further falls. During a review of the facility's Policy and Procedure (P&P) titled ,Fall Management System dated 12/2023, the P&P indicated it was the facility's policy to provide an environment that remains as free of accidents hazards as possible. The P&P indicated the facility would provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The P&P indicated the care plan must be updated after every fall.

Based on observation, interview, and record review the facility failed to ensure an interdisciplinary team (IDT, group of different disciplines working together towards a common goal of a resident) meeting was held after a resident fall on 9/16/2024 for one of one sampled resident (Resident 21). This deficient practice delayed the plan of care for reducing the risk of falls and could potentially have caused Resident 21 to sustain another subsequent fall. Findings: During a review of Resident 21's Admission Record, the Admission Record indicated Resident 21 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 21's diagnoses included history of falls and 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). During a review of Resident 21's History and Physical (H&P) dated 9/30/2024, the H&P indicated Resident 21 was alert and had appropriate mood, affect and insight. During a review of Resident 21's Minimum Data Set (MDS, a federally mandated assessment tool), dated 8/2/2024, the MDS indicated Resident 21's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 21 required moderate assistance (helper does less than half the effort) for toileting hygiene, upper body dressing and personal hygiene. During a review of Resident 21's Situation Background Assessment Recommendation (SBAR) Communication forms, dated 8/9/2024, 9/16/2024, and 10/4/2024, the SBARs indicated Resident 21 had falls on 8/9/2024, 9/16/2024, and 10/4/2024 . During a review of Resident 21's IDT notes, dated 8/9/2024 and 10/4/2024, the IDT notes indicated Resident 21 had a fall on those two dates. During a review of Resident 21's electronic medical record (EMR), the EMR indicated there were no IDT notes for Resident 21's fall on 9/16/2024. During an interview on 10/17/2024 at 1:10 p.m. with Registered Nurse (RN 4), RN 4 stated after every fall there must be an IDT meeting to plan the care for a resident. RN 4 stated a fall was a change of condition which should be documented and an IDT meeting done. RN 4 stated during an IDT meeting, staff develop a plan to prevent future falls. RN 4 stated if there was no IDT meeting done after a fall, there would be no interventions to follow and the resident could potentially fall again. During an interview on 10/18/2024 at 1:27 p.m. with the Director of Nursing (DON), the DON stated an IDT meeting was held after a resident had a fall to have a collaborated talk about the plan of care for the resident. The DON stated if an IDT was not done, fall interventions could be delayed and could potentially lead to another fall. The DON stated Resident 21 had a high risk for falls and an IDT meeting could develop interventions to reduce the risk for injury. The DON stated a fall was a change of condition and all change of conditions resulted in an IDT meeting. The DON stated Resident 21 should have had an IDT meeting after the resident's fall on 9/16/2024. During a review of the facility's Policy and Procedure (P&P) titled Significant change of conditions dated 12/2023, the P&P indicated when a fall or other related incidents occurred, the IDT shall collaborate with the attending physician, resident, and/or resident representatives to review risk indicators and the plan of care. The P&P indicated the IDT will document this collaboration in the EMR.

Based on observation, interview, and record review, the facility failed to ensure two of 12 sampled residents (Residents 253 and 21) were free of accidents and hazards by failing to: 1. Ensure floor mats (a cushioned floor pad designed to help prevent injury should a person fall) were utilized for Resident 253. 2. Ensure Resident 21 had an interdisciplinary team ([IDT], a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) review after a fall on 9/16/2024. These deficient practices had the potential to result in Resident 253 sustaining injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed) by potentially falling and hitting his head or other body parts on the bare floor. These deficient practices also resulted a delay in the plan of care for reducing the risk of falls and could have potentially caused Resident 21 to fall for a third time. Findings: a. During a review of Resident 253's Admission Record (Face Sheet), the Admission Record indicated Resident 253 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 253's diagnoses included hydrocephalus (condition where too much fluid builds up in and around the brain and spinal cord), myoclonus (a sudden, brief involuntary twitching or jerking of a muscle or group of muscles), and encephalopathy (damage or disease of the brain that changes how the brain functions). During a review of Resident 253's Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 8/12/2024, the MDS indicated Resident 253's cognition (process of thinking) was severely impaired. The MDS indicated Resident 253 was dependent on staff for eating, oral hygiene, toileting, bathing, and dressing. During a review of Resident 253's History and Physical (H&P), dated 8/13/2024, the H&P indicated Resident 253 did not have the capacity to understand and make decisions. During a review of Resident 253's Order Summary Report, dated 8/12/2024, the Order Summary Report indicated to place the floor mat adjacent (close or near) to the bed for safety and seizure precautions. During a review of Resident 253's Care Plan, dated 8/14/2024, the Care Plan indicated Resident 253 had the potential for injury and the potential for episodes of seizure activity. The staff's interventions indicated was to place the floor mat adjacent to the bed for safety and seizure precautions. During an observation on 10/15/2024 at 10:01 a.m. and 10/16/2024 at 9:02 a.m., in Resident 253's room, Resident 253 was observed lying in bed. One floor mat was observed on the right side of Resident 253's bed. No floor mat on the left side of Resident 253's bed was observed. During a concurrent observation and interview on 10/15/2024 at 2:30 p.m., with Licensed Vocational Nurse (LVN) 1, in Resident 253's room, Resident 253 was observed lying in bed and only one floor mat was observed on the right side of Resident 253's bed. LVN 1 stated Resident 253 only had a floor mat on the right side of his bed and did not have a floor mat on the left side of his bed. LVN 1 stated Resident 253's physician ordered a floor mat adjacent to Resident 253's bed for safety in the event Resident 253 had a seizure. LVN 1 stated if Resident 253 had a seizure, the resident potentially could move to his left or his right and could fall to the floor. LVN 1 stated there should have been a floor mat on both sides of Resident 253's bed because he could have a fall and have a serious injury such as a fracture (broken bone) or a head injury. During an interview on 10/17/2024 at 2:20 p.m., with the Director of Nursing (DON), the DON stated floor mats were utilized for Resident 253 as a seizure precaution. The DON stated Resident 253 should have had bilateral (both sides) floor mats. The DON stated Resident 253 was at risk for injury if he were to have a seizure and if he did not have bilateral floor mats, Resident 253 could fall to the ground and hit his head or sustain other injuries ranging from minor to major. During a review of the facility's policy and procedure (P&P) titled, Fall Management System, revised 12/2023, the P&P indicated the facility was to provide an environment that remains as free of accidents hazards as possible and to provide each resident with appropriate interventions to prevent falls and minimize complications. 45009 b. During a review of Resident 21's Admission Record, the Admission Record indicated Resident 21 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 21's diagnoses included history of falls and 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). During a review of Resident 21's History and Physical (H&P) dated 9/30/2024, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 21 required moderate assistance (helper does less than half the effort) for toileting hygiene, upper body dressing and personal hygiene. During a review of Resident 21's Situation Background Assessment Recommendation (SBAR) Communication form, dated 8/9/2024 9/16/2024 and 10/4/2024, the SBARs indicated Resident 21 had a fall. During a review of Resident 21's IDT notes, dated 8/9/2024 and 10/4/2024, the IDT notes indicated Resident 21 had a fall on 8/9/2024 and 10/4/2024. During a review of Resident 21's electronic medical record (EMR), the EMR indicated there were no IDT notes for Resident 21's fall on 9/16/2024. During an interview on 10/17/2024 at 1:10 p.m. with Registered Nurse (RN 4), RN 4 stated after every fall there must be an IDT meeting to plan the care for a resident. RN 4 stated a fall was a change of condition and should be documented and an IDT meeting should be done. RN 4 stated during an IDT meeting staff should develop a plan to prevent future falls. RN 4 stated if there was no IDT meeting done after a fall, there would be no interventions to follow and the resident could potentially fall again. During an interview on 10/18/2024 at 1:27 p.m. with the DON, the DON stated an IDT meeting was held after a resident had a fall to have a collaborated talk about plan of care for the resident. The DON stated if an IDT was not done, fall interventions could be delayed and could potentially lead to another fall. The DON stated Resident 21 was a high risk for falls and an IDT meeting could develop interventions to reduce the risk for injury. The DON stated a fall was a change of condition and all change of conditions resulted in an IDT meeting. The DON stated Resident 21 should have had an IDT meeting after his fall on 9/16/2024. During a review of the facility's P&P titled Significant change of conditions dated 12/2023, the P&P indicated when a fall or other related incidents occurred, the IDT shall collaborate with the attending physician, resident, and/or resident representatives to review risk indicators and the plan of care. The P&P indicated the IDT will document this collaboration in the EMR.

31333 Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff practiced safe and effective medication administration practices for four out of five sampled residents (Resident 19, 25, 48, and 49) when: 1. Registered Nurse (RN 2) did not administer medication to Resident 19 in a timely manner. 2. RN 3 left Resident 25's medications at the resident's bedside to self-administer. 3. Licensed Vocational Nurse (LVN) 2 did not administer medication to Resident 25 in a timely manner. 4. LVN 2 did not administer medication to Resident 48 in a timely manner. 5. LVN 1 signed the medication administration audit report for Resident 49 after another LVN administered pain medication. These deficient practices caused Resident 19, 25, 48, and 49 to have an interruption with their medication therapy and exposed the residents to a potential medication error and adverse effect to their medications. Findings: 1. During an observation on 10/17/2024 at 10:15 a.m., in Resident 19's room, Resident 19 was observed with a medicine cup containing five pills at her bedside. During a review of Resident 19's Admission Record, the Admission Record indicated Resident 19 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 19's diagnoses included diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension ([HTN] high blood pressure). During a review of Resident 19's History and Physical (H&P) dated 9/30/2024, the H&P indicated Resident 19 was able to make her own decisions and was alert and oriented. During a review of Resident 19's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/16/2024, the MDS indicated Resident 19's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 19 required maximal assistance (helper does more than half the effort) for oral hygiene, upper body dressing and personal hygiene. During a review of Resident 19's Medication Administration Audit Report dated 10/16/2024, the report indicated Resident 19 had an order to receive medications at 9:00 a.m. The report indicated Resident 19 received the following medications on 10/16/2024 at 11:36 a.m.: 1. Pro-Stat oral liquid, 30 milliliters by mouth, for supplement. 2. Enulose solution 10/15ml, 30 ml by mouth one time a day for bowel management. 3. Miralax oral powder 17gm/scoop, 1 scoop by mouth one time a day for bowel management. 4. Docusate sodium oral tablet 100 mg, 1 tablet by mouth two times a day for bowel management. 5. Oxybutynin chloride 5 mg, 1 tablet by mouth one time a day for overactive bladder. 6. Metformin 1000mg, give 1 tablet by mouth two times a day for DM. 7. Valsartan-hydrochlorothiazide tablet 320-12.5 mg, give 1 tablet by mouth one time a day for HTN. 8. Hydralazine 50 mg, give 1 tablet by mouth two times a day for HTN. 9. Jardiance 10 mg, give 1 tablet by mouth one time a day for DM. 10. Doxazosin mesylate 2 mg, give 1 tablet by mouth one time a day for HTN. 11. Aspirin 81 mg, give 1 tablet by mouth two times a day for deep vein thrombosis ([DVT] a condition where a blood clot forms in a large vein deep within the body). During an interview on 10/16/2024 at 10:55 a.m. with Resident 19, Resident 19 stated she was worried that she had not received her medications for that day (10/16/2024). Resident 19 stated she was worried she had not received her medication for her blood pressure and blood sugar. Resident 19 stated she had not seen her nurse yet. During an interview on 10/16/2024 at 11:15 a.m. with Registered Nurse (RN) 2, RN 2 stated he had not given Resident 19 medication yet because Resident 19 was in therapy and he (RN 2) was running a little behind on medication pass. RN 2 stated he was supposed to give Resident 19 her medications at 9:00 a.m. RN 2 stated he would give Resident 19 her medication after he was finished with his current task. During an interview on 10/17/2024 at 8:15 a.m. with Resident 19, Resident 19 stated RN 2 came to her room to give her the morning medications. Resident 19 stated she had not taken the medication yet because she was eating. Resident 19 stated RN 2 gave her a medicine cup that contained her medication and asked her to self-administer the medications when she was done eating. Resident 19 stated she had five pills in the medicine cup, two pills were for her blood pressure, one pill was for her blood sugar and she did not know wat the other two were. 2. During a review of Resident 25's Admission Record, the Admission Record indicated Resident 25 was admitted to the facility on [DATE]. Resident 25's diagnoses included diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should. Heart failure can occur if the heart cannot pump [systolic] or fill [diastolic] adequately). During a review of Resident 25's H&P dated 10/7/2024, the H&P indicated Resident 25 had good judgement and insight and was alert and oriented to person, place, time, and event. During a review of Resident 25's MDS, dated [DATE], the MDS indicated Resident 25's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 25 needed maximal assistance (helper does more than half the effort) for oral hygiene. The MDS indicated Resident 25 was dependent on staff for toileting hygiene, dressing, and shower/bathing. During a review of Resident 25's Medication Administration Audit Report dated 10/17/2024, the report indicated Resident 25 had an order to receive medications at 8:00 a.m. The report indicated the following medications were administered at on 10/17/2024 at 11:44 a.m.: 1. Ferrous Sulfate 325mg tablet,1 tablet by mouth three times a day for supplement. 2. Dextromethorphan oral syrup10-100mg/5ml, 5 ml by mouth every 4 hours for cough. 3. Calcium 250 mg, 2 tablets by mouth every 12 hours for supplement. 4. Lasix 40 mg oral tablet, 1 tablet by mouth one time a day for bilateral lower extremities edema (swelling). 5. [NAME]-Vite tablet, 1 tablet by mouth one time a day for supplement. 6. Cyanocobalamin tablet 100 micrograms ([mcg] metric unit of measurement, used for medication dosage and/or a mount), 1 tablet by mouth one time a day for supplement. 7. Docusate Sodium tablet 100mg, 1 tablet by mouth one time a day for bowel management. 8. Farxiga oral tablet 5 mg, 1 tablet by mouth one time a day for DM. During an interview on 10/17/2024 at 10:18 a.m. with Resident 25, Resident 25 stated she did not remember receiving her medications that day (10/17/2024). Resident 25 stated it was important for her to receive her medication on time to prevent getting sicker. During an interview on 10/17/2024 at 1058 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she had not given Resident 25's 9:00 a.m. medication because she was running late and got sidetracked. LVN 2 stated it was not acceptable to administer medications to residents two hours late because the residents need their medications. LVN 2 stated she was running late with her medication pass because she was new. During an interview on 10/17/2024 at 2:21 p.m. with RN 3, RN 3 stated it was acceptable to administer a medication 1 hour before the scheduled time and 1 hour after the scheduled time. RN 3 stated she provided a medicine cup with medications to Resident 25 to take after the resident finished eating. RN 3 stated it was not an acceptable practice to let Resident 25 self-administer medications because there was no way of knowing if the resident took the medications or if resident had a reaction to the medication. RN 3 stated she documented she administered medications to Resident 25 at on 10/16/2024 at 8:09 a.m., but she handed the medications to Resident 25 and did not know if Resident 25 took the medication. RN 3 stated it was not acceptable to document she administered the medication because she did not see Resident 25 take the medication. 3. During a review of Resident 48's Admission Record, the Admission Record indicated Resident 48 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 48's diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your own, lungs can't get enough oxygen into the blood) and kidney failure (occurs when kidneys suddenly become unable to filter waste products from the blood, kidneys lose their filtering ability). During a review of Resident 48's H&P dated 9/30/2024, the H&P indicated Resident 48 had fluctuating capacity to understand and make decisions. During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48's cognitive skills for daily decision making was intact. The MDS indicated Resident 48 required set up assistance for eating and oral hygiene. The MDS indicated Resident 48 was dependent on staff for toileting hygiene, dressing, and putting on/taking off shoes. During a review of Resident 48's Medication Administration Audit Report dated 10/17/2024, the report indicated Resident 48 had an order to receive medications at 9:00 a.m. The report indicated the following medications were administered on 10/17/2024 at 11:50 a.m.: 1. Cozaar oral tablet, 25 mg by mouth one time day for HTN. 2. Citalopram hydrobromide oral tablet 20 mg, 1 tablet by mouth one time a day for depression (feelings of sadness). 3. Carvedilol oral tablet 6.25 mg, 1 tablet by mouth two times a day for HTN. 4. Pro Stat oral liquid, 30 ml by mouth one time a day for skin management/wound healing. 5. Ferrous Sulfate tablet 325 mg, 1 tablet by mouth one time a day for supplement. 6. Zinc Sulfate capsule 220 mg, 1 capsule by mouth one time a day for skin management/wound healing. 7. LidoRx external gel 1%, apply to affected area topically three times a day for pain management. 8. Gabapentin oral capsule 30 mg, 1 capsule by mouth 3 times a day for neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). 9. Ascorbic acid tablet 500 mg, 1 tablet by mouth one time a day for skin management/wound healing. During an interview on 10/17/2024 at 10:28 a.m. with Resident 48, Resident 48 stated she had not received her morning medications. Resident 48 stated the nurses sometimes ran late giving her the medications. Resident 48 stated she knew the nurses sometimes got busy but it was important for her to get her medications. During an interview on 10/17/2024 at 1058 a.m. with LVN 2, LVN 2 stated she had not given Resident 48's 9:00 a.m. medication because she was running late and got sidetracked. LVN 2 stated it was not acceptable to administer medications to residents two hours late because the residents need their medications. LVN 2 stated she was running late with her medication pass because she was new. 4. During a review of Resident 49's Admission Record, the Admission Record indicated Resident 49 was admitted to the facility on [DATE]. Resident 49's diagnoses included diabetes mellitus and hypertension. During a review of Resident 49's H&P dated 9/24/2024, the H&P indicated Resident 49 was alert and oriented to person, place, time, and event. During a review of Resident 49's MDS, dated [DATE], the MDS indicated that Resident 49's cognitive skills for daily decision making was intact. The MDS indicated Resident 49 required maximal assistance for toileting hygiene, shower/bathing, lower body dressing and personal hygiene. During a review of Resident 49's Medication Administration Audit Report dated 10/15/2024, the report indicated Resident 49 had an order to receive oxycodone - acetaminophen (medication used to treat moderate to severe pain) oral tablet 325 mg, 1 tablet by mouth every 12 hours as needed for severe pain. The audit report indicated LVN 1 administered the medication to Resident 49. During an interview on 10/15/2024 at 12:22 p.m. with Resident 49, Resident 49 stated she was given her routine morning medications by a female nurse. Resident 49 stated she was confused when a male nurse came to give her pain medication and no one told her why the nurses were changed. Resident 49 stated she thought it was weird to send another nurse to give her pain medication. During a concurrent interview and record review on 10/15/2024 at 1:02 p.m. with LVN 1, Resident 49's Medication Administration Audit Report dated 10/15/2024 was reviewed. The audit report indicated LVN 1 administered oxycodone -acetaminophen 325 mg for pain control to Resident 49 at 10:57 a.m. LVN 1 stated Resident 49 received the pain medication when the resident requested it. LVN 1 stated she documented she administered the pain medication to Resident 49 but it was another nurse that actually gave it to the resident. LVN 1 stated she was not supposed to document she administered a medication when she did not do it because it was not a safe practice. During an interview on 10/18/2024 at 1:27 p.m. with the Director of Nursing (DON), the DON stated it was not acceptable for a nurse to leave medications at a resident's bedside for them to self-administer because the resident might not take medication. The DON stated it was important to give residents their medication at the scheduled time to avoid taking it close to their next dose of the same medication. The DON stated a nurse should not document that they administered a medication to a resident when they did not. The DON stated it was not an acceptable practice because the nurse could not confirm the resident actually received the medication. The DON stated the acceptable time for a resident to wait for their medication was one hour after their scheduled time. The DON stated if a resident did not receive their blood pressure medication on time, the resident's blood pressure would rise and it would not be controlled. The DON stated any late medication would not help the residents' health. The DON stated it was important for residents to receive their medications on time to avoid any negative effects from not getting the medications at their scheduled time. During a review of the facility's Policy and Procedure (P&P) titled, Administration Procedures for all Medications dated 6/2021, the P&P indicated it was the facility's policy to administer medications in a safe and effective matter. The P&P indicated after licensed nurse administered medication, the licensed nurse must document medication administration. The P&P indicated the licensed nurse should monitor for side effects or adverse drug reactions immediately after administration. During a review of facility's P&P titled, Medication Administration-General Guidelines dated 11/2021, the P&P indicated the facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The P&P indicated medications were to be administered within 60 minutes of the scheduled time. The P&P indicated the individual who administers the medication dose records the administration on the resident's medication administration record after the medication pass is complete.

Based on interview and record review, the facility failed to identify a drug irregularity (any deviation in the proper use, dosage, or administration of medication) during the Monthly Regimen Review (MRR - a regular assessment of a resident's medication and treatment plan every month to ensure it is effective, safe, and still necessary) for one of three residents (Resident 30) receiving duplicate drug therapy in the use of two orally inhaled medications, Serevent Diskus (salmeterol, a long-acting bronchodilator used to treat asthma by relaxing and opening air passages in the lungs, making it easier to breathe) and Advair Diskus (a medication that contains both salmeterol and fluticasone propionate, an anti-inflammatory medicine, used to treat asthma and chronic obstructive pulmonary disease (COPD - lung disease that makes it difficult to breathe) between 9/13/2024 through 10/15/2024. (Cross Reference F757) This deficient practice created the risk for Resident 30 to receive excessive dosages of salmeterol which are contained in both Advair and Serevent which could lead to the resident experiencing serious side effects that include, high blood pressure, fast heart rate, irregular heart rhythm, which could result in an overdosage or hospitalization . Findings: During a review of Resident 30's Admission Record (document containing diagnostic and demographic information), the Admission Record indicated Resident 30 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included asthma (chronic inflammatory disease of the lungs) and chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). During a review of Resident 30's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/17/2024, the MDS indicated Resident 30 had intact cognition (ability to understand and process information). During a review of Resident 30's physician order indicated, the physician order indicated the resident was prescribed: 1. Advair Diskus (fluticasone and salmeterol) 250 micrograms ([mcg] - unit of measure of weight)/ 50 mcg, instructions indicated, one inhalation by mouth every 12 hours for COPD (Rinse mouth with water after use), order date 9/13/2024. 2. Serevent Diskus (salmeterol) 50 mcg, instructions indicated, one inhalation by mouth every 12 hours for COPD, order date 9/13/2024. During a review Resident 30's MRR form titled, Clinically Significant Medication Regimen Review Communication Form, date 9/13/2024, the MRR form indicated, A drug regimen review was conducted to identify potential clinically significant medication issues, Upon completion of this review the following has been identified for your patient, a boxed was marked to indicated, No issues found during the drug regimen review. The spaces for Drug-Drug Interactions and Drug Duplications were both left blank, unmarked. During an interview on 10/17/2024 at 1:11 PM, in the presence of the Director of Nursing (DON), with the facility's Consultant Pharmacist (Pharm 1) via telephone, Pharm 1 stated, he had not reviewed Resident 30's medications. Pharm 1 stated had he seen the two medications (Advair and Serevent) he would have written a note to ask Resident 30's doctor if the doctor wanted the resident to be on both medications. Pharm 1 stated side effects of using both medications may include tachycardia (a fast heart rate), heart palpitations (fast or irregular heartbeat) or jitteriness (feeling of nervousness or shakiness). Pharm 1 stated his job included pointing out to the physician the overuse of salmeterol and medications that may cause increased risk of harm to the residents. During an interview on 10/17/2024 at 1:36 PM, in the presence of the DON, with the facility's dispensing Pharmacist (Pharm 2) via telephone, Pharm 2 reviewed Resident 30's medication orders and stated, that it did look like Serevent had salmeterol and Advair also have salmeterol and both medications were taken by the resident twice daily and that would be a duplicate therapy. Pharm 2 stated the duplicate therapy should have alerted when the dispensing pharmacist reviewed the orders for Serevent and Advair. Pharm 2 stated there was no documentation that Resident 30's doctor was called to clarify the order. Pharm 2 stated if there are any drug interactions it should be documented on the drug (medication) regimen review (MRR) when the resident was admitted to the facility. Pharm 2 stated that giving Advair and Serevent together with both having salmeterol as the active ingredient were considered drug duplication and the resident (Resident 30) could experience increase in side effects that include chest pain or chest palpitations. During a review of the facility's policy and procedure (P&P) titled, Medication (Drug) Regimen Review (MRR), dated 12/2023, the P&P indicated, A medication regimen review (MRR) includes a review of the resident's medical chart. Identified irregularities will be documented on a separate written report that includes the resident's name, the relevant drug, and the irregularity identified. The report will be sent to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) to be acted upon .The MRR includes identification of irregularities, medication-related errors, adverse consequences, and use of unnecessary drugs. Unnecessary drug is defined as medications ordered: 1. In excessive dosage (including duplicate drug therapy); or 2. For excessive duration; or 3. Without adequate monitoring; or 4. Without adequate indications for its use; or 5. In the presence of adverse consequences which indicate the dose should be reduced or discontinued . 47858

Based on observation and interview, the facility failed to ensure opened boxes of oral inhalation medications with a shortened expiration date once opened, had an open date (the date the medication was first opened) for three of three sampled residents (Resident 30, Resident 53, and Resident 54). The deficient practice of failing to label oral inhalation medications, per the manufacturers' requirements increased the risk that residents with asthma (chronic inflammatory disease of the lungs) or chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) could have received expired or ineffective medications which could result in health complications, difficulty breathing, or hospitalization . Findings: During a review of Resident 30's Admission Record (document containing diagnostic and demographic information), the Admission Record indicated Resident 30 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included asthma and COPD. During a review of Resident 30's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 30 had intact cognition (ability to understand and process information). During a review of Resident 53's Admission Record, the Admission Record indicated Resident 53 was admitted to the facility on [DATE]. Resident 53's diagnoses included COPD. During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53 had moderate impaired cognitive skills. During a review of Resident 54's Admission Record, the Admission Record indicated Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 54's diagnoses included pulmonary fibrosis (a lung disease that causes scarring in the lungs, making it difficult to breathe), pneumonia (an infection/inflammation in the lungs), and acute respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (a low level of oxygen in the blood), and COPD. During a review of Resident 54's MDS, dated [DATE], the MDS indicated Resident 54 had intact cognition. During an observation on [DATE] at 10:14 AM with Licensed Vocational Nurse (LVN) 1, on Nursing Station 1, the MedCart was inspected, and the following oral inhalers used to treat breathing difficulty was observed inside of the MedCart opened without an open date for: 1. Resident 30, two inhalers, one inhaler of Advair Diskus (a medication that contains both an anti-inflammatory medicine (fluticasone propionate) and a long-acting bronchodilator (salmeterol), used to treat asthma and COPD) 250 micrograms ([mcg] - unit of measure of weight)/ 50 mcg and one inhaler of Serevent (salmeterol) 50 mcg. 2. Resident 53, one inhaler of Arnuity Ellipta (fluticasone furoate, used to prevent and control symptoms of asthma for better breathing) 100 mcg. 3. Resident 54, one inhaler of Advair 250 mcg/50 mcg. During a concurrent observation and interview on [DATE] at 10:14 AM, with LVN 1, LVN 1 stated, the four inhalers (two Advair Diskus inhaler, one Serevent Diskus inhaler, and one Arnuity Ellipta inhaler) observed inside of Nursing Station 1 MedCart were open and did not have an open date. LVN 1 stated there should have been an open date indicated on the medication containers to ensure the inhalers would be good to use for the residents (Resident 30, Resident 53, and Resident 54) and to know when the medications should be discarded. LVN 1 stated if the inhalers were administered after expired, the medications may not be as effective for the residents and could lead to respiratory issues, that included shortness of breath or symptoms of oxygen desaturation (low levels of oxygen in the blood and symptoms include shortness of breath, rapid heart rate, rapid breathing, and confusion) During an interview on [DATE] at 3:24 PM with the Director of Nursing (DON), the DON stated the inhalers with shortened expiration dates, that include Advair Diskus, Serevent Diskus, and Arnuity Ellipta should have an open date. The DON stated expired inhalers may not be effective for the residents (Resident 30, Resident 53, and Resident 54) and residents could experience shortness of breath, respiratory concerns or result in an emergency transfer to the hospital. During a review of the facility's policy and procedures (P&P), titled, Administration Procedures For All Medications, dated ,d+[DATE], the P&P indicated, If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information .Check expiration date on package/container before administering any medication. When opening a multidose container, place the date on the container. During a review of the manufacturer's labeling for Advair Diskus, dated ,d+[DATE], the manufacturer's labeling indicated, Write the date you opened the foil pouch in the first blank line on the label .Write the use by date in the second blank line on the label .That date is 1 (one) month after the date you wrote in the first line. During a review of the manufacturer's labeling for Serevent Diskus, dated ,d+[DATE], the manufacturer's labeling indicated, Safely throw away SEREVENT DISKUS in the trash 6 weeks after you open the foil pouch or when the counter reads 0, whichever comes first. Write the date you open the pouch on the label on the inhaler. During a review of the manufacturer's labeling for Arnuity Ellipta, dated ,d+[DATE], the manufacturer's labeling indicated, Safely throw away ARNUITY ELLIPTA in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler. 47858

Based on interview and record review, the facility failed to ensure one of three residents' (Resident 1) itchy area was assessed, location/ site identified and ensure the physician's order contained the site of treatment order administration. This failure had the potential for Resident 1's skin itchiness not resolved. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including primary generalized (osteo) arthritis (a disease that worsens over time, caused by the breakdown of cartilage, a rubbery material that eases the friction in joints), other seizures (a sudden, uncontrolled burst of electrical activity in the brain), and acute (severe and sudden) 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). During a review of Resident 1's Minimum Data Set (Minimum Data Set [MDS] a standardized assessment and care screening tool), dated 6/18/2024, the MDS indicated Resident 1 had severe (intense) cognitive (the ability to think and reason) impairment (loss of part or all a physical or mental ability). Resident 1's MDS indicated Resident 1 required set up or clean-up assistance (staff sets up or cleans up prior to or following the activity) for Activities of Daily Living (ADLs) such as upper body dressing (ability to dress and undress about the waist) and personal hygiene (ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face, and hands). During a review of Resident 1's Medication Administration Record (MAR), dated May 2024, the MAR indicated Resident 1 had a physician's order of Triamnicolone Acetonide Ointment 0.1%, apply to area of itching topically two times a day for itching for 14 days. Apply 6 grams (a metric unit of mass equal to one thousandth of a kilogram) to all areas of itching x BID (two times a day). During a review of Resident 1's progress notes dated 6/1/2024, the progress notes did not indicate Resident 1's location of itching under the integumentary system (the system of the body that includes skin, hair, and fingernails) assessment. During an interview on 7/30/2024 at 1:40 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated they should have assessed Resident 1's skin or any resident who would report itching and would inform the doctor to ensure the resident is being monitored. During an interview on 7/30/2024 at 2:41 p.m., with Registered Nurse (RN) 1, RN1 stated RN 1 stated they were not sure why Resident 1 was itching. During an interview on 8/1/2024 at 2:29 p.m., with Director of Nursing (DON), the DON stated when receiving orders from a physician., the route, site, dosage, frequency and duration should be part of the physician's order. The DON stated, the MAR indicating to apply Triamnicolone Acetonide Ointment 0.1%, to area of itching is not complete. The DON stated the areas of itching, was not specific because it could not always be the same area and should have been further investigated or assessed. Without orders specific to area of itching, there was a chance that the medication could not be given correctly.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent a fall with injury for one of three residents (Resident 19) with history of falls by failing to: 1. Ensure Resident 19 performed toilet transfers toward the left, unaffected side and did not place weight onto the right leg after toileting. 2. Provide Resident 19 with two-persons assistance for toilet transfers and toilet hygiene (toileting, includes managing undergarments, clothing, and incontinence products and performing cleansing before or after voiding or having a bowel movement). 3. Provide Resident 19 with two-persons assistance for sit to stand transfers (transfers from a seated position to a standing position) after toileting. These failures resulted in Resident 19 falling from a standing position onto the floor in the restroom on 7/30/2023. On 7/31/2023, Resident 19 complained of right shoulder pain and received an X-ray (used to create images of the inside of the human body) which indicated Resident 19 had a right humeral (shoulder bone) fracture (break in the bone). The facility transferred Resident 19 to the general acute care hospital (GACH 2) on 8/1/2023 where Resident 19 underwent right shoulder surgery on 8/3/2023. Findings: During a review of Resident 19's Discharge Summary from the general acute care hospital (GACH) 1, dated 6/28/2023, the Discharge Summary indicated Resident 19 had a history of cerebral vascular accident (CVA or stroke, brain damage due to blocked blood flow) with right sided weakness and had worsening right knee pain after a fall onto the right knee at home. The Discharge Summary indicated Resident 19 had a distal femur (thigh bone close to the knee) fracture with hardware fracture (breaking of surgically placed pins, plates, or screws to help fix a broken bone). The Discharge Summary indicated Resident 19 underwent surgery on 6/26/2023 for rodding (operative insertion of a straight metal rod) with cement augmentation (injection of bone cement into a fracture) of the right leg and should maintain non-weight bearing (NWB, inability to place any weight through the limb, including an operated limb to allow healing) on the right leg for at least six weeks. During a review of Resident 19's Admission Record, the admission record indicated the facility admitted Resident 19 on 6/29/2023 with diagnoses including periprosthetic fracture around internal prosthetic right knee joint (fracture of the thigh bone occurring close to metal parts of a previous right knee surgery), encounter for other orthopedic aftercare, muscle weakness, difficulty walking, and hemiplegia and hemiparesis (weakness and paralysis [inability to move] to one side of the body) affecting the right dominant side. During a review of Resident 19's Physician's Order, dated 6/29/2023, the physician's order indicated Resident 19 was NWB on the right leg for six weeks. During a review of Resident 19's Fall Risk Evaluation, dated 6/29/2023, the fall risk evaluation indicated the facility assessed Resident 19 as a high risk for falls. During a review of Resident 19's care plan titled, At Risk For Falls, initiated on 7/11/2023, the interventions included placing the bed in the lowest position and maintain a clear pathway free of obstacles. During a review of Resident 19's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 6/29/23, the PT Evaluation indicated Resident 19's was NWB on the right leg for at least six weeks. The PT Evaluation indicated Resident 19 was dependent (required more than 75% physical assistance to perform the task) requiring the assistance of two-persons with bed mobility from lying to sitting on the side of the bed. The PT Evaluation indicated Resident 19 was unable to perform sit to stand transfers, bed-to-chair transfers, and toilet transfers due to medical conditions or safety concerns. The PT Plan of Treatment included therapeutic exercises (movement prescribed to correct impairments and restore muscle function), neuromuscular reeducation (technique used to restore movement patterns through repetitive motion to retrain the brain), gait (manner of walking) retraining therapy, therapeutic activities [tasks that improve the ability to perform activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility)], and wheelchair management training (training on proper positioning and ability to propel the wheelchair), five times per week for four weeks. During a review of Resident 19's Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 6/29/2023, the OT Evaluation indicated Resident 19 was NWB on the right leg for at least six weeks. The OT Evaluation indicated Resident 19 was dependent for toileting, showering, upper body dressing, and lower body dressing. The OT Evaluation indicated toilet transfers were not attempted with Resident 19 due to medical conditions or safety concerns. The OT Plan of Treatment included therapeutic exercises, neuromuscular reeducation, therapeutic activities, and self-care management training, five times per week for four weeks. During a review of Resident 19's Minimum Data Set (MDS, a comprehensive assessment and care planning tool), dated 7/3/2023, the MDS indicated Resident 19 had clear speech, clearly understood verbal content, and had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 19 was dependent for transfers (how resident moves between surfaces included to or from the bed, chair, wheelchair, and standing position) with at least two-persons physical assistance, dependent for dressing with one-person physical assistance, dependent for toilet use with one-person physical assistance, and bathing with one-person physical assistance. During a review of Resident 19's ADL flow sheet (record of nursing assistance provided) for 7/2023, the ADL flow sheet indicated Resident 19 received assistance with toilet use with one-person assistance on 7/25/2023, 7/26/2023, 7/27/2023, 7/28/2023, and 7/29/2023. During a review of Resident 19's PT Recert [sic] (Recert, re-evaluation documenting the need for continued therapy), Progress Report, and Updated Therapy Plan, dated 7/27/2023, the PT Recert indicated Resident 19 required maximum assistance with two-persons for sit to stand transfers and dependent with two-persons for functional transfers. During a review of Resident 19's OT Recert, Progress Report, and Updated Therapy Plan, dated 7/27/2023, the OT Recert indicated Resident 19 was dependent for toilet hygiene and dependent with two-persons for toilet transfers. During a review of Resident 19's Progress Note for eMAR-Medication Administration, dated 7/30/2023 at 9:57 AM, the progress note indicated Licensed Vocational Nurse (LVN) 3 administered one (1) Hydrocodone-Acetaminophen (pain medication) 5-325 milligrams (mg, unit of measurement) tablet to Resident 19 by mouth for severe pain. During a review of Resident 19's Progress Note for Nursing, dated 7/30/2023 at 12:00 PM, the nursing progress note indicated LVN 3 noted Resident 19 had an episode of weakness during transfers from wheelchair to toilet on 7/30/23 at approximately 10:20 AM that resulted in the Certified Nursing Assistant (CNA) slowly lowering Resident 19 to the ground in a sitting position. LVN 3's Nursing Progress Note further indicated Resident 19 stated she (Resident 19) felt weak upon transfer and both legs gave out. LVN 3's Nursing Progress Note indicated Resident 19 had no apparent injury, denied hitting head, and was assisted back to bed with three staff members. LVN 3's Progress Note also indicated Resident 19's physician and family members were notified. During a review of Resident 19's care plan titled, At risk for falls, initiated 7/31/2023, the care plan indicated the staff's interventions for fall included to increase staff assistance to two-persons assist during transfers as needed. During a review of Resident 19's Progress Note for Therapy, dated 7/31/2023 at 12:00 PM, the progress note indicated Physical Therapist (PT) 1 screened Resident 19 after the assisted fall on 7/30/23. PT 1's Therapy Progress Note indicated Resident 19 complained of right shoulder pain, right knee pain, and Resident 19 refused further assessment on the right shoulder and knee. PT 1's Progress Note for Therapy indicated nursing was aware and recommended an X-ray of the right shoulder and right knee. During a review of Resident 19's Radiology Results Report, dated 7/31/2023 at 9:41 PM, the right shoulder X-ray indicated Resident 19 had a comminuted fracture (broken bone in at least two places) of the right humeral neck (part of the upper arm just below the shoulder joint). During a review of Resident 19's Progress Note for Laboratory/Radiology, dated 7/31/2023 at 11:51 PM, the progress note indicated LVN 4 reported the X-ray results from 7/31/23 to Resident 19's physician (MD 1) without any new orders. During a review of Resident 19's Progress Note for eMAR-Medication Administration, dated 8/1/2023 at 8:57 AM, the progress note indicated LVN 5 administered one (1) Hydrocodone-Acetaminophen 5-325 mg tablet to Resident 19 by mouth for severe pain in the right shoulder. During a review of Resident 19's Progress Note for Transfer Out, dated 8/1/2023 at 11:11 AM, the progress note indicated Registered Nurse (RN) 2 noted Resident 19's X-ray results were received on 8:50 AM which had a significant finding of a right comminuted humeral neck fracture. RN 2's Progress Note indicated Resident 19 had sharp pain in the right shoulder which was swollen and warm to touch. RN 2's Progress Note indicated RN 2 placed a sling (bandage used to support an injured arm) on the right shoulder to ensure the right arm was NWB. RN 2's Progress Note indicated MD 1 was notified and provided orders to transfer Resident 19 to GACH 2 for further evaluation and treatment. During a review of GACH 2's Emergency Department Note, dated 8/1/2023 at 11:14 AM, the GACH 2 Emergency Department Note indicated GACH 2 admitted Resident 19 for right shoulder pain after a fall in the restroom. During a review of GACH 2's X-ray Report, dated 8/1/2023 at 12:46 PM, the GACH X-ray Report indicated Resident 19's right shoulder had diffuse osteopenia (bones weaker than normal) with a displaced (bone came out of alignment) and comminuted fracture through the right humeral head (shoulder joint) and neck. During a review of GACH 2's X-ray Report, dated 8/3/2023 at 6:00 PM, the GACH X-ray Report indicated Resident 19's right shoulder underwent an open reduction internal fixation (ORIF, surgical procedure where fractured bones are realigned and then stabilized in place with screws, plates, or rods) of the right humeral fracture. During a review of GACH 2's Progress Note, dated 8/4/2023 at 7:57 AM, the GACH Progress Note indicated Resident 19 had to be transferred to the Intensive Care Unit (ICU, department of the hospital for patients who are dangerously ill requiring constant observation) due to acute hemorrhagic shock (severe blood loss which leads to inadequate oxygen delivery) and required a blood transfusion (process of transferring blood into the veins of a patient). During a review of Resident 19's Physician's Orders, dated 8/7/2023, the physician's orders indicated the facility readmitted Resident 19 with diagnoses including displaced comminuted fracture of the right humerus and subsequent encounter for fracture with routine healing. During a concurrent observation and interview on 10/10/2023 at 10:01 AM with Resident 19, in the resident's room, Resident 19 was observed lying in bed with the head-of-bed elevated. Resident 19 appeared to understand questions but had limited ability to speak. Resident 19 stated she fell three months ago at home and broke the right leg. Resident 19 had difficulty lifting the right arm and raising the right leg. Resident 19 stated there was a problem with the right arm and the right leg but was unable to explain in further detail. During an observation on 10/10/2023 at 11:48 AM, in the Resident 19's room, Resident 19 was seated in a wheelchair and observed using the left arm to operate a touch screen tablet. During an interview on 10/11/2023 at 9:23 AM with Resident 19, in Resident 19's room, Resident 19 stated Resident 19 was assisted to the restroom with one staff member when Resident 19 fell (7/30/2023). Resident 19 was unable to explain the incident in further detail. Resident 19 stated having right arm pain after the fall and had surgery, which Resident 19 stated relieved the pain. During an observation on 10/11/2023 at 10:45 AM, in Resident 19's restroom, the small room contained a toilet on the right side and a sink on the left side, which was approximately two feet (unit of measure) immediately in front of the toilet. During a follow-up observation on 10/11/2023 at 12:51 PM, in the restroom, there was a vertical grab bar (safety devices a person can grab onto to maintain balance and hold some body weight while transferring) mounted to the wall on each side of the toilet. During an interview on 10/11/23 at 10:45 AM, in Resident 19's bathroom, LVN 3 recounted the events with Resident 19 on 7/30/2023. LVN 3 stated LVN 3 administered pain medication to Resident 19 in the morning due to right knee pain. LVN 3 stated Certified Nursing Assistant (CNA) 1 called LVN 3 through the facility's two-way radio earpiece for assistance in Resident 19's restroom. LVN 3 stated Resident 19 was already sitting on the floor with CNA 1 positioned behind Resident 19. LVN 3 stated CNA 1 reported Resident 19 stood at the sink after using the toilet. LVN 3 stated CNA 1 reported being positioned behind Resident 19 for toilet hygiene when Resident 19's knees gave out and CNA 1 reportedly lowered Resident 19 to the ground. LVN 3 stated Resident 19 denied any pain while seated on the floor during the assessment. LVN 3 stated CNA 1 and CNA 2 lifted Resident 19 back into the wheelchair, and all three staff members assisted Resident 19 from the wheelchair to the bed. LVN 3 stated Resident 19 did not complain of any pain throughout LVN 3's work shift. During a concurrent interview and record review with Physical Therapy Assistant (PTA) 2 on 10/11/2023 at 12:12 PM, PTA 2 reviewed Resident 19's PT Recert, dated 7/27/2023. PTA 2 stated Resident 19 was NWB on the right leg, required maximum assistance with two-persons for sit to stand transfers, and dependent with two-persons assistance for transfers. PTA 2 stated Resident 19 required the assistance of two-persons for safety and to maintain the NWB precautions on the right leg. During an interview on 10/11/2023 at 12:51 PM with CNA 1, in Resident 19's restroom, CNA 1 stated Resident 19 was sitting up in a wheelchair and requested to use the restroom on 7/30/2023. CNA 1 wheeled Resident 19 to the restroom, close to the toilet, and transferred Resident 19 from the wheelchair to the toilet toward the right side. CNA 1 stated Resident 19 used the grab bar on the right side of the toilet to assist with the transfer. CNA 1 stated CNA 1 assisted Resident 19 from sitting on the toilet to standing while CNA 1 stood on Resident 19's left side. CNA 1 stated Resident 19 took a step forward to hold onto the sink directly in front of the toilet. CNA 1 stated Resident 19 stood on both legs at the sink while CNA 1 was behind Resident 19 to clean and fasten Resident 19's incontinence brief. CNA 1 stated CNA 1 noticed Resident 19's right leg was getting weak and bent more. CNA 1 then grabbed the waist of Resident 19's pants to lower Resident 19 to the ground. CNA 1 stated CNA 1 called LVN 3 for assistance over the two-way radio, saw CNA 2 walk by Resident 19's room, and asked CNA 2 for assistance with Resident 19. During a concurrent interview and record review on 10/11/2023 at 1:35 PM with Occupational Therapist (OT) 1, OT 1 reviewed Resident 19's OT Recert, dated 7/27/2023. OT 1 stated Resident 19 was dependent with the assistance of two-persons for toilet transfers due to Resident 19's prior history of stroke affecting the right side and the NWB status on the right leg. OT 1 stated the transfer required two-persons since one person had to lift or support Resident 19's right leg during the transfer to ensure Resident 19 maintained NWB on the right leg. OT 1 stated a resident's level of assistance (in general) for transfers were communicated verbally to the nurses. OT 1 stated it would be unsafe for Resident 19 to transfer into the restroom's toilet toward right side due to Resident 19's NWB status on the right leg and weakness on the right side from the previous stroke. OT 1 stated Resident 19 was not allowed to place any weight on the right leg including standing on both legs. OT 1 stated placing any weight on Resident 19's right leg could result in pain, re-injury of the right leg, buckling (bending) of the right leg, or a fall. During an interview on 10/11/2023 at 2:05 PM with CNA 2, CNA 2 recounted the events with Resident 19 on 7/30/2023. CNA 2 stated CNA 2 looked into Resident 19's room and saw CNA 1 in the restroom asking for assistance. CNA 2 stated CNA 1 was behind Resident 19, who was already on the floor in a seated position, both legs were in front of Resident 19's body, and Resident 19's back was leaning against CNA 1. LVN 3 came into the restroom and assessed Resident 19. CNA 2 stated Resident 19 was anxious due to the fall but did not have any pain. CNA 2 stated LVN 3 was behind the wheelchair, holding it into place, while CNA 2 was positioned on the left side and CNA 1 was on the right side of Resident 19. CNA 2 demonstrated how CNA 1 and CNA 2 lifted Resident 19 from the floor and into the wheelchair. CNA 2 hooked CNA 2's elbow underneath the arm pit and stated using the other arm to grab behind Resident 19's waist pants to lift Resident 19 up into the wheelchair. During a concurrent interview and record review on 10/12/2023 at 10:30 AM with PT 1, PT 1 reviewed Resident 19's PT Evaluation dated 6/29/2023, PT Recert dated 7/27/2023, and Resident 19's Progress Note for Therapy dated 7/31/2023. PT 1 stated Resident 19 had NWB precautions on the right leg since the initial PT Evaluation on 6/29/2023. PT 1 reviewed the PT Recert, dated 7/27/2023, and stated Resident 19 required maximum assistance of two-persons for sit to stand transfers due to Resident 19's limited ability to perform the activity. PT 1 stated Resident 19 required two-persons assistance to ensure to not place any weight onto the right leg for safety since Resident 19 was placing all body weight onto the left leg. PT 1 stated Resident 19 did not stand on both legs during therapy sessions due to the NWB status on the right leg. PT 1 stated Resident 19's NWB status, need for two-persons during transfers, and need to transfer towards the left, strong side was verbally communicated to nursing staff (in general). Pt 1 stated nursing staff also observed Resident 19 perform two-person transfers with the therapists. PT 1 stated PT 1 performed the post-fall assessment on 7/31/2023. PT 1 stated Resident 19 usually had right knee pain after the surgery but complained of new right shoulder pain, which was a significant change. PT 1 stated Resident 19 did now allow PT 1 to assess the right shoulder because of the pain. PT 1 reported this finding to nursing and recommended an X-ray of the right shoulder and right knee. During a concurrent interview and record review on 10/12/2023 at 10:51 AM with Certified Occupational Therapy Assistant (COTA) 1, COTA 1 stated Resident 19 performed toilet transfers and toileting during OT treatment on 7/26/2023. COTA 1 stated Resident 19 was dependent with two-persons assistance for safety due to Resident 19's history of stroke and NWB precautions on the right leg. COTA 1 stated Resident 19 never stood on both legs during treatment since Resident 19's right leg was NWB. COTA 1 stated the therapy staff (in general) were in constant verbal communication with nursing staff regarding Resident 19's need for two-person assistance during toileting. During a telephone interview on 10/12/2023 at 12:24 PM with Resident 19's Family Member (FM) 1, FM1 stated the facility notified FM 1 immediately after Resident 19 fell on [DATE]. FM 1 stated Resident 19 understood everything but had difficulty speaking. FM 1 stated Resident 19 explained the fall to FM 1 as best as possible. FM 1 stated Resident 19 went to the bathroom toilet with CNA 1. FM 1 stated Resident 19 stood at the sink after using the toilet when Resident 19's right, surgical knee buckled. FM 1 stated Resident 19 had some pain on the right shoulder, and FM 1 asked for an ice pack for the right shoulder which relieved some pain. During a concurrent interview and record review on 10/12/2023 at 2:00 PM with the Director of Nursing (DON), the DON reviewed Resident 19's clinical record. The DON stated the facility admitted Resident 19 on 6/29/2023 after a fall at home, requiring surgery for the right distal femur fracture and was NWB on the right leg. The DON stated Resident 19 scored a 13 on the initial fall assessment, which indicated Resident 19 was a high risk for fall. The DON stated Resident 19's care plan for a high risk for fall included interventions to anticipate and meet needs, ensure the call light was in reach, encourage resident to use call light for assistance, and maintain a clear pathway free of obstacles. The DON stated Resident 19's LVN (in general) knew Resident 19's NWB status on the right leg since it was a physician's order. The DON stated the LVN should verbally communicate Resident 19's NWB status to the CNAs (in general) before each shift. The DON reviewed the PT Recert, dated 7/27/2023, and stated Resident 19 required maximum assistance with two-persons for sit to stand and functional transfers. The DON reviewed the OT Recert, dated 7/27/2023, and stated Resident 19 was dependent for toileting and dependent with two-persons assistance for toilet transfers. The DON stated the PT's and OT's assessments of Resident 19 requiring two-persons assistance with transfers were verbally communicated to the direct care CNA staff. The DON reviewed Resident 19's ADL Flow Sheet for 7/2023 and stated multiple CNAs, including CNA 1, had transferred Resident 19 onto the toilet and performed toileting successfully with one-person assistance. The DON stated Resident 19 did not have the assistance of two-persons during the fall on 7/30/2023. The DON stated Resident 19 had severe osteoporosis (medical condition in which bones become brittle and fragile) and believed Resident 19 fractured the right arm during the transfer from the floor into the wheelchair since CNA 1 and CNA 2 had an elbow under each of Resident 19's arm pits. The DON did not answer when asked whether Resident 19's fall was avoidable but stated Resident 19's right shoulder fracture was related to the fall. During a review of the facility's policy and procedure (P&P) titled, Fall Management System, revised on 1/2022, the P&P indicated the facility provided each resident an appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.