Every finding on record at Canyon Springs Post-Acute

Based on interview and record review, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice for one of three residents (Resident 1), when a medication was ordered with no indication for use identified. This failure had the potential to compromise Resident 1's health and well-being.Findings:Review of Resident 1's physician order dated 6/24/25 indicated Ivermectin (medication that treats infections caused by roundworms, threadworms, and other parasites [an organism that lives on or in a host organism]) 3 milligrams (mg, a unit of measure) 4 tablets daily for 3 days. The physician order did not identify the indication for the use of the Ivermectin.Review of Resident 1's medication administration record (MAR) indicated Ivermectin Oral Tablet 3 mg. Directions indicated to give 4 tablets by mouth in the evening for parasite infection for 3 days.During an interview and concurrent record review with Licensed Vocational Nurse A on 7/18/25 at 3:15 p.m., she stated she received Resident 1's medication order for Ivermectin from the Nurse Practitioner (NP) on 6/24/25. LVN A stated there was no indication for the use of Ivermectin identified in the NP's order. LVN A further stated, I did not know what Ivermectin was used for, so I googled it. LVN A stated she carried out the Ivermectin order in the MAR and stated she added the words for parasite infection. When asked if Resident 1 had a parasitic infection, LVN stated she did not know. LVN A stated, I am sorry, I should not have done that.During an interview and concurrent record review with the Assistant Director of Nursing on 7/22/25 at 9:15 a.m., she reviewed Resident 1's nurse practitioner's order for Ivermectin dated 6/4/24. The ADON confirmed there was no indication for the use of the Ivermectin. When asked what the process is when a medication order does not have an indication for use, the ADON stated the licensed nurse should clarify the order with the author of the physician order. The DON further stated a medication order needs to have a specific diagnosis or indication for the use of the medication. When asked if a licensed vocational nurse could assign a diagnosis or identify the indication for the use of a medication, she stated diagnosing is not in the scope of practice for licensed vocational nurses. The ADON confirmed LVN A should not have added for parasite infection to Resident 1's medication order on the MAR.Review of the facility policy titled Medication and Treatment Orders, dated 2001, indicated orders for medications must include the clinical condition or symptoms for which the medication is prescribed.

Based on interview and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one of four residents (Resident 1) on oxygen therapy when Resident 1's BiPAP (a breathing support method that delivers positive pressure to the lungs through a mask) application was not documented by licensed nurses. This failure had the potential to result in inadequate monitoring of the resident's condition, and the potential to negatively affect the residents' health, safety and well-being. Findings: Review of Resident 1's clinical record indicated she was admitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia (inability to keep oxygen and carbon dioxide at normal levels), congestive heart failure (heart works less efficiently and can lead to buildup of fluid in the lungs and shortness of breath), chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe), obstructive sleep apnea (a sleep related breathing disorder that occurs when the upper airway becomes blocked during sleep), chronic pulmonary edema (excess fluid builds up in the lungs making breathing difficult), and dependence on supplemental oxygen. Review of Resident 1's physician order, dated 1/24/25, indicated to apply BiPAP full face large mask at bedtime for obstructive sleep apnea. Review of Resident 1's Respiratory Administration Record (RAR) indicated the licensed nurses applied the BiPAP at bedtime for Resident 1. Further review of the RAR indicated missing entries for the bedtime application of Resident 1's BiPAP on following dates: February 2025: No documentation on 2/5, 2/15, 2/22, 2/23, and 2/28; March 2025: No documentation on 3/3, 3/6, 3/7, 3/12, 3/19, 3/21, 3/23, 3/24, and 3/31; April 2025: No documentation on 4/5, 4/8, 4/12, 4/13, 4/18, 4/20, 4/23, 4/26, 4/29, and 4/30; May 2025: No documentation on 5/6, 5/8, 5/11, 5/15, 5/16, 5/21, 5/22, and 5/24. During an interview and concurrent record review with director of nursing (DON), on 5/3/25 at 1:50 p.m., she reviewed Resident 1's RAR and confirmed the application of the BiPAP was not documented as completed on the above dates. The DON confirmed if the nurses applied the BiPAP at bedtime, they should document in Resident 1's RAR. The DON acknowledged that if the applications of the BiPAP were not documented, they were not done. The DON confirmed the licensed nurses should initial that the BPAP is applied at bedtime as per the physician order. Review of the facility's policy titled BiPAP Support , revised March 2015, indicated to document the time the BiPAP was started and to notify the physician if the resident refuses the procedure.

Based on observation, interview, and record review, the facility failed to ensure staff implemented proper infection control practices when: 1. Staff did not use proper gloving technique during a wound dressing change when hand hygiene was not properly performed for Resident 13; 2. Resident 54's urine drainage bag was not covered with a protective bag and was not kept off the floor; 3. Residents' used basins, bed pans and a urinal were unlabeled and stored on top of residents' bathroom toilet tank and under the bathroom sink beside a garbage container; 4. Registered nurse Z (RN Z) used contaminated (something has become impure or unsuitable due to contact with something unclean, harmful, or undesirable) gloves to administer Resident 151's eye drops to both eyes; 5. Registered nurse J (RN J) placed Resident 192's antibiotic (a medication used to treat bacterial infections) bag, intravenous tubing (IV, a soft, flexible tube used to administer medication or fluids through the vein), alcohol swabs, and normal saline (solution of salt and water) in a syringe on top of Resident 192's overbed table with visible beverage and food stains without wiping the table or placement of a protective sheet; 6. Licensed vocational nurse I (LVN I) wiped the used glucometer (an electronic device which displays a reading of blood sugar level) with one micro-kill bleach cloth wipes (germicidal wipes), then used the same cloth wipes to wipe the glucose strip (a test strip to check blood sugar level) container and also wiped the medication cart with the same used, contaminated cloth wipes; 7. Licensed vocational nurse B (LVN B) donned (put on) and doffed (remove) gloves without hand hygiene (washing hands with soap and water or using an alcohol-based hand sanitizer) and wiped the used glucometer with one micro-kill bleach cloth wipes then used the same cloth wipes to wipe the unused glucometer; 8. Staff fed two Residents (Resident 71 and Resident 152) at the same time; 9a. Contact precaution (measures taken to prevent the spread of germs through direct or indirect contact with a patient or their environment) signage was not posted outside Resident 16's entrance door; and, 9b. A staff not wearing Personal Protective Equipment (PPE, refers to specialized clothing or equipment worn to protect nurses and other healthcare personnel from potential exposure to infectious diseases and other hazards.) when entering the room for resident on contact precaution. These failures had the potential for development and transmission of communicable diseases and infections in the facility. Findings: 1. Resident 13 was admitted with diagnoses which included non-pressure chronic ulcer of skin (a persistent open sore that doesn't heal, and isn't caused by pressure, but rather by other factors like poor circulation, trauma, or underlying medical conditions) and local infection of the skin and subcutaneous tissue (a bacterial infection that affects the skin's deeper layers and underlying tissues). During an observation of a wound dressing change, by two treatment nurses (registered nurse A (RN A) and licensed vocational nurse B (LVN B)) for Resident 13 on 5/08/25 at 1:10 p.m. During the procedure, RN A and LVN B both changed their gloves numerous times without using any hand hygiene (washing hands nor using alcohol based hand sanitizer) after taking off their gloves. During an interview with LVN B on 5/8/25 at 1:27 p.m., she stated she did not use hand hygiene between each glove change. LVN B stated she should have used hand hygiene between glove changes. During an interview with RN A on 5/8/25 at 1:29 p.m., she stated they only used hand hygiene when they started. They did not have to use hand hygiene with each glove change, because they sanitized at the beginning. They changed gloves so they don't contaminate the wound. They did not need to use hand hygiene with each glove change. During an interview with the infection preventionist (IP) on 5/09/25 at 11:16 a.m., the IP stated the nurses need to use hand hygiene after every time they take off their gloves, they should use the alcohol based sanitizer. During a review of the facility's policy and procedure (P&P), titled Personal Protective Equipment-Using Gloves, revised 09/2010, indicated .Miscellaneous .5. Wash hands after removing gloves. (Note: Gloves do not replace hand washing.) Removing Gloves 1. Using one hand, pull the cuff down over the opposite hand turning the glove inside out.4. discard the glove into the designated waste receptacle inside the room.6. Wash hands. During a review of the facility's policy and procedure (P&P), titled Handwashing/Hand Hygiene, revised 10/2023, indicated .Indications For Hand Hygiene 1. Hand hygiene is indicated: .g. immediately after glove removal.5. The use of gloves does not replace hand washing/hand hygiene.Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. [Apply gloves. Remove gloves] .5. Perform hand hygiene. 42819 2. A review of Resident 54's clinical record indicated that the resident had diagnoses including, but not limited to, infection and inflammatory reaction due to indwelling urethral catheter (an infection or immune response caused by a urinary catheter). A review of Resident 54's Order Summary Report, dated 5/2025, indicated Resident 54 had a Suprapubic Catheter (a urinary catheter inserted through the lower abdomen directly into the bladder) due to Obstructive Uropathy (a blockage that prevents normal urine flow). The Order Summary Report also indicated that Resident 54 may use low bed (a bed positioned close to the floor to reduce fall injury risk). A review of Resident 54's Minimum Data Set (MDS, a resident assessment and care screening) dated 3/5/25, indicated a Brief Interview for Mental Status (BIMS, a screening tool used to assess thinking and memory) score of 10. A BIMS score of 9-12 indicates moderate cognitive impairment (difficulty with thinking and reasoning). During a concurrent observation and interview with Licensed Vocational Nurse H (LVN H) on 5/8/25 at 12:50 p.m., in Resident 54's room. Resident 54 was sitting on the edge of the bed. The catheter drainage bag was hanging from the left side of the bed frame and was touching the floor. The bed was positioned low, and the catheter drainage bag was not enclosed in a protective cover. A privacy shield covered only the front of the catheter drainage bag, which did not prevent contact with the floor. LVN H confirmed that the catheter drainage bag was touching the floor and was not covered with a protective bag. LVN H acknowledged that the catheter bag should be kept off the floor and covered to reduce the risk of infection. During an interview with the Infection Preventionist (IP) on 5/8/25, at 1:45 p.m., the IP was informed of the observation. The IP stated that catheter drainage bags should not touch the floor because it can cause infection. The IP also stated that when a resident has a low bed, the catheter drainage bag should be secured with a protective cover to prevent from making contact with the floor. A review of the facility's undated policy titled Catheter Care, Urinary indicated Be sure the catheter tubing and drainage bag are kept off the floor. 44583 3a. During an observation on 5/5/2025 at 8:33 a.m., inside Room AA's bathroom, there were six used basins, and one used bed pan stacked up on top of the toilet's tank. The basins and bed pan did not have a label. 3b. During an observation on 5/5/2025 at 8:54 a.m., inside Room BB's bathroom, there were four used basins stacked up on top of the toilet's tank. Room BB's (with three residents) bathroom was also shared with residents in Room CC (with three residents). During a concurrent observation and interview with certified nursing assistant AA (CNA AA) on 5/5/2025 at 8:58 a.m., inside the shared bathroom of Rooms BB and CC, CNA AA confirmed the basins were used and one basin had an unreadable label, the other three did not have a label of resident's room number or resident's name. CNA AA stated they stacked them up on the toilet's tank because they did not have a space to store them. 3c. During another concurrent observation and interview with CNA AA on 5/5/2025 at 9:01 a.m., inside Room DD's bathroom, there were five used basins stacked up and placed under the sink beside a garbage container. The bathroom was shared by residents in Rooms DD (two residents) and EE (two residents). CNA AA confirmed the above observations and stated two had unreadable labels while the other three basins did not have a label. CNA AA stated, we don't have space to store them. 3d. During an observation on 5/5/2025 at 9:07 a.m., inside Room FF's bathroom, there were three basins stacked up on top of the toilet's tank. 3e. During another concurrent observation and interview with CNA AA on 5/5/2025 at 9:17 a.m., inside Room GG's bathroom, there was one unlabeled urinal, one unlabeled kidney basin, and two basins stacked up on top of the toilet's tank. CNA AA confirmed the above observations and stated the used residents' items should be labeled. CNA AA further stated, they did not have any space to store them. During an interview with the facility's infection preventionist (IP) on 5/6/2025 at 3:02 p.m., IP confirmed all used basins, kidney basins, and urinals should be labeled and stored under the resident's bedside drawer when not in use. During an interview with the director of nursing (DON) on 5/9/2025 at 1:07 p.m., DON stated staff should label the basins, bed pans, and urinals with resident's room number and initials of their name. DON further stated, staff should clean, dry and store the used items under the resident's bedside drawer or in the bathroom individually wrapped in a plastic. During a review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, date revised 9/2022, indicated, Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g. bedpans, urinals). 4. During a medication administration observation on 5/6/2025 at 5:38 p.m., RN Z donned a new pair of gloves while standing in front of the medication cart, touched the medication cart to lock it, walked across the room and went inside Resident 151's room. RN Z was observed to touch Resident 151's bed remote control to adjust the head of bed, touched the overbed table to move it out of the way and touched the chair to grab some tissues and used the same gloves to administer Resident 151's eye drops. RN Z pulled down Resident 151's lower eyelids to administer one drop of the medication in each eye and wiped Resident 151's eyes after. During an interview with RN Z on 5/6/2025 at 5:45 p.m., RN Z confirmed the above observations and stated she should have changed her gloves to a new one before she administered the eyedrops to Resident 151. 5. During a medication administration observation on 5/7/2025 at 9:20 a.m., RN J donned a new pair of gloves, placed Resident 192's antibiotic bag, IV tubing, alcohol swabs, and NS in a syringe on top of Resident 192's overbed table with visible beverage and food stains without wiping the table or a protective sheet underneath the IV items. RN J removed the NS syringe from the plastic wrap, touched the alcohol swab from the overbed table and wiped Resident 192's peripherally inserted central catheter (PICC, long slender, flexible tube inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in the chest near the heart to obtain venous access) hub and started to flush the PICC line with NS. RN J unwrapped the IV tubing from the package and started to set up the IV antibiotic and hooked the end of the tubing to Resident 192's PICC line. During a follow-up interview with RN J on 5/7/2025 at 9:49 a.m., RN J confirmed the above observation and stated he should have wiped the table first with the germicidal cloth wipes before he placed the IV materials (IV tubings, NS flush syringe, IV bag, and alcohol swabs) on the table. During an interview with DON on 5/8/2025 at 1:56 p.m., DON stated nurses should place the IV materials in a tray prior to entering the room, instead of placing them on resident's overbed table. During a review of the facility's policy and procedure titled, Administering Medications, date revised 4/2019, indicated, Staff follows established facility infection control procedures (e.g. handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 6. During an observation on 5/7/2025 at 11:19 a.m., inside Resident 158's room, LVN I checked Resident 158's blood sugar level with the use of a glucometer device. After LVN I had obtained Resident 158's blood sugar level, she went back to the medication cart, took one germicidal cloth wipe then wiped the used glucometer, the glucose strip container and the medication cart with the same germicidal cloth wipe. During an interview with LVN I on 5/7/2025 at 11:41 a.m., LVN I confirmed the above observation and stated she should have changed the germicidal wipes to a new one before she wiped the glucose strip container and the medication cart. LVN I confirmed the glucometer was contaminated with Resident 158's blood. 7. During an observation on 5/7/2025 at 11:53 a.m., inside Resident 191's room, LVN B donned a new pair of gloves without performing hand hygiene, helped to pull up Resident 191 in bed with another certified nursing assistant (CNA). At 11:55 a.m., LVN B checked Resident 191's blood sugar level with the use of a glucometer, she removed the used gloves and donned a new pair of gloves without hand hygiene and started to wipe the used glucometer with the germicidal cloth wipes. LVN B was observed to wipe the other unused glucometer with the same germicidal cloth wipes. During an interview with LVN B on 5/7/2025 at 11:58 a.m., LVN B confirmed the above observation and stated she should have performed hand hygiene every time she removed her gloves to don a new pair of gloves. LVN B confirmed the germicidal cloth wipe used to wipe the used glucometer was already contaminated with Resident 191's blood and she should have used a new germicidal wipe to wipe the unused glucometer. During an interview with DON on 5/8/2025 at 1:56 p.m., DON stated nurses should not use a contaminated germicidal wipe to wipe another surface, they should use a new germicidal wipe. During a review of the facility's policy and procedure titled, Personal Protective Equipment-Using Gloves, date revised 9/2010, indicated, Putting on Sterile Gloves 1. Wash hands. 2. Obtain gloves .Removing Gloves .4. Discard the glove into the designated receptacle inside the room .6. Wash hands. During a review of the Micro-Kill Germicidal Wipes manufacturer's guidelines, it indicated to remove any visible soil or debris from the surface to disinfect, use the wipe to thoroughly wet the surface, allow the surface to remain wet for the required contact time and discard the wipe once the contact time is complete. 49345 8. During dining observation on 5/5/25 at 12:55 p.m. in the Facility's Communal Dining Area, Certified Nurse Aide (CNA)L was in a round table seated in between Resident 71 and Resident 152. CNA L was feeding both residents at the same time. Hand hygiene was not done in between feeding residents. During an interview on 5/5/25 at 12:59 p.m. with CNA L and Director of Staff Development (DSD), CNA L stated she helped Resident 71 because the resident liked her. DSD stated it was not okay to feed two residents at the same time by a staff. During an interview on 5/8/25 at 3:34 p.m. with the Director of Nursing (DON), the DON stated residents were at risk for choking if staff fed two residents at the same time because they cannot focus. A review of Resident 71's clinical record indicated diagnoses of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side (complete paralysis and weakness on right side of the body after a stroke), and muscle weakness. A review of Resident 71's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 51's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 10 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). A review of Resident 152's clinical record indicated diagnoses of dysphagia, unspecified (difficulty in swallowing) and, muscle weakness. A review of Resident 152's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 51's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 6 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). A review of facility's policy and procedure (P&P) entitled, Handwashing/Hand Hygiene revised October 2023, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .Indications for Hand Hygiene 1. Hand hygiene is indicated: a. immediately before touching a resident; .d. after touching a resident . 50855 9.a During an observation on 5/5/25 at 11:34 a.m., outside Resident 16's room there were signs posted outside the door of instructions on how to wear PPE, but there was no signage posted what type of precautions Resident 16 is on. During an interview on 5/6/25 at 10:30 am with Registered Nurse D (RN D), RN D stated Resident 16 is on contact isolation. She stated staff need to wear PPE when touching the resident and no need to wear PPE if away from the resident. During a concurrent observation and interview on 5/6/25 at 1:34 p.m., with the infection prevention nurse (IP), the IP checked Resident 16's door and confirmed there was no contact isolation posted outside Resident 16's door. The IP stated there should be signage posted for contact isolation. She further stated that staff need to wear PPE when going inside Resident 16's room even without touching the resident. During a review of Resident 16's physician's order dated 4/10/25 indicated, Contact Isolation in Place: Dx: (diagnosis) Septic Knee(a serious infection in the knee joint, often caused by bacteria entering the joint through the bloodstream or direct injury )- VRE (Vancomycin Resistant Enterococci, a type of bacteria that has become resistant to vancomycin [a powerful antibiotic used to treat infections]) q shift (every shift). During a concurrent interview and record review on 5/9/25 at 8:52 a.m., with the IP, the IP reviewed Resident 16 physician's order and confirmed Resident has an order for contact Isolation for VRE. During a review of the facility's policy and procedures titled, Isolation - Categories of Transmission-Based Precautions, dated 3/28/2024, indicated, .6. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s). instructions for use of PPE, and/or instructions to see a nurse before entering the room . 9.b During an observation on 5/7/25 at 2:49 p.m., the Director of Staff Development Assistant (DSDA) was observed not wearing PPE inside Resident 16's room, the DSDA standing next to Resident 16's bed (foot board). During an interview shortly after the observation on 5/7/25 at 2:52 p.m., with the DSDA, the DSDA confirmed not wearing PPE inside Resident 16 room, the DSDA reviewed the contact isolation signage posted outside Resident 16's door. The DSDA stated that they need to wear gown when going inside Resident 16's room without touching the resident. During a concurrent interview and record review on 5/9/25 at 8:52 a.m., with the IP the IP reviewed Resident 16 physician's order and confirmed Resident 16 has an order for contact isolation for VRE. The IP further stated staff going inside Resident 16's room need to wear PPE. During a review of the facility's policy and procedures titled, Isolation - Categories of Transmission-Based Precautions, dated 3/28/2024, indicated, .Contact precautions .7. Staff and visitors wear gloves (clean, non-sterile) when entering the room .8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potential contaminated surfaces with clothing after gown is removed .

Based on observation, interview, and record review, the facility had a medication error rate of 9.68% when three medication errors were observed out of 31 opportunities during medication administration for three of 11 residents (Residents 9, 193, and 79) when: 1. Resident 9 received the second dose of albuterol sulfate (an inhaler used to treat or prevent bronchospasm, or narrowing of the airways in the lungs) inhalation (or puff, the act of taking a substance into the body by breathing) without having to wait for one minute for first inhalation to be fully absorbed by the lungs; 2. Resident 193 received three puffs of budesonide -formoterol fumarate dihydrate (it is a combination of medications used to treat asthma [inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath] and chronic obstructive pulmonary disease [COPD, a long-lasting lung disease]) inhalation instead of two puffs as ordered by the physician; and 3. Resident 79 received five different medications through his gastrostomy tube (or G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) without water flushes in between medications. These failures resulted in residents not receiving medications as prescribed and had the potential to result in residents not receiving the full therapeutic benefit of their medications or experiencing negative health outcomes. Findings: 1. During a medication administration observation on 5/7/2025 at 12:30 p.m., inside Resident 9's room, Resident 9 was seated on her wheelchair and licensed vocational nurse I (LVN I) instructed Resident 9 to take one puff of albuterol sulfate inhalation. Resident 9 took one puff of the medication and after 10 seconds, LVN I continued to administer one more puff of the medication. During an interview with LVN I on 5/7/2025 at 12:35 p.m., LVN I stated she could give the second puff once resident exhaled. LVN I asked, is there a time interval for the second puff? Review of Resident 9's medical record indicated a physician's order dated 6/24/2022 of albuterol sulfate, 2 puff inhale orally four times a day for SOB [shortness of breath] . During an interview with the director of nursing (DON) on 5/8/2025 at 1:56 p.m., DON stated she did not indicate the time interval in between two puffs of inhalers when she did her in-service with nurses. During a review of National Heart, Lung, and Blood Institute Publication Number 21-HL-8165 titled, HOW TO USE A METERED-DOSE INHALER, dated 10/2021, indicated, .If your plan says to take more than 1 puff of medicine, wait 1 minute between puffs . During a review of the facility's undated policy and procedure titled, Administering Medications through a Metered Dose Inhaler, indicated, Repeat inhalation, if ordered. Allow at least one (1) minute between inhalations of the same medication . 2. During a medication administration observation on 5/8/2025 at 8:36 a.m., inside Resident 193's room, registered nurse R (RN R) handed the budesonide -formoterol fumarate dihydrate inhaler to Resident 193 who was sitting at the edge of the bed. RN R did not provide instructions to Resident 193 on how to use the inhaler, and Resident 193 was observed to self-administer three puffs of the inhaler. During an interview with RN R on 5/8/2025 at 8:40 a.m., RN R confirmed the above observation and stated she should have given Resident 193 instructions first on how to use the inhaler and how much she needed to self-administer before she handed the inhaler to Resident 193. RN R confirmed Resident 193 had an extra dose of the inhaler. During an interview with DON on 5/8/2025 at 1:56 p.m., DON stated nurses should have to explain what they were giving and the dosage of the inhaler before they provide the inhaler to residents who could self-administer. Review of Resident 193's medical record indicated an order dated 4/29/2025 of budesonide-formoterol fumarate dihydride, 2 inhalation inhale orally one time a day for asthma. During a review of the facility's undated policy and procedure titled, Administering Medications through a Metered Dose Inhaler, indicated, The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications . Confirm the identity of the resident. Explain the procedure to the resident. During a review of the facility's policy and procedure titled, Administering Medications, date revised 4/2019, indicated, The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 3. During a medication administration observation on 5/8/2025 at 9:21 a.m., inside Resident 79's room, licensed vocational nurse S (LVN S) went inside the room with Resident 79's five different medications: Famotidine (a medication that reduces the amount of acid produced in the stomach) 20 milligram (mg, unit of measurement) one tablet, Aspirin (a drug that reduces pain, fever, inflammation and blood clotting) 81 mg one tablet, Senna (a laxative, derived from the Senna plant (a type of Cassia), used to relieve constipation) 8.6 mg two tablets, Doxepin HCl (a hydrochloride salt form of antidepressant [a drug that treats depression] medication, it can also be used to treat chronic hives) two capsules and levetiracetam (common brand: Keppra, anticonvulsant - it can treat seizures) oral solution 7.5 milliliter (ml, volume of measurement). LVN S prepared the medications for G-tube administration. Each medication was separated into five medication cups. LVN S checked the G-tube placement, flushed it with 30 ml of water, then LVN S started to pour each medication one at a time without flushing in between medications with water. During an interview with LVN S on 5/8/2025 at 9:57 a.m., LVN S confirmed the above observation and stated they were taught to just mix the diluted medication with extra five ml of water in order not to clog. LVN S further stated they never flushed the G-tube with water in between multiple medication administration. During an interview with DON on 5/8/2025 at 2:00 p.m., DON stated she was not sure if nurses had to flush the G-tube with water in between multiple medication administration. During a review of the facility's undated policy and procedure titled, Administering Medications through an Enteral Tube, indicated, The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . If administering more than one medication, flush with 15 ml warm purified water (or prescribed amount) between medications.

Based on interview and record review, the facility failed to ensure three out of 35 sampled residents (Residents 77, 175, and 57) were free from chemical restraints (the use of medications such as psychotropic medications [drugs that affects brain activities associated with mental processes and behaviors, example is antipsychotics, antidepressants, anti-anxiety, hypnotics] not for therapeutic reasons, but to restrict a person's freedom of movement or control their behavior) when: 1. Resident 77 continued to receive lorazepam (brand name: Ativan; anti-anxiety - medication to treat agitation and anxiety) and trazodone (antidepressant - a medication used to manage and treat depression [low mood or loss of pleasure or interest in activities for long periods of time]) without clinical documentation of non-pharmacological interventions (treatments or strategies that aim to improve health or manage conditions without using medications, focusing instead on physical, psychological, or behavioral approaches) were attempted or provided for Resident 77's use of anti-anxiety and antidepressant medications; 2. Resident 175 continued to receive sertraline hydrochloride (HCl) (brand name: Zoloft, antidepressant) and mirtazapine (brand name: Remeron, antidepressant) without clinical documentation of non-pharmacological interventions were attempted or provided for Resident 175's use of antidepressants; and, 3. Resident 57 received Quetiapine (an antipsychotic medication that helps treat several kinds of mental health conditions) without target behavior monitoring. These failures had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the residents' physical, mental and psychosocial well-being. Findings: 1. Review of Resident 77's clinical record titled, Admission Record, dated 5/9/2025, indicated Resident 77 was admitted to the facility with diagnoses including nontraumatic chronic subdural hemorrhage (a bleeding event within the brain where blood collects between the dura mater [the tough outer membrane covering the brain] and the brain tissue itself, but without an injury or trauma to the head), dementia (a progressive state of decline in mental abilities), anxiety disorder (a mental illness that causes constant fear) and history of falling. Review of Resident 77's clinical record titled, Order Summary Report, dated 5/9/2025, it indicated the following orders: a. Lorazepam 0.5 milligrams (mg - unit of measurement), Give 1 tablet by mouth in the evening for anxiety m/b [manifested by] repetitive physical movements (fidgeting and pacing), and b. Trazodone HCl 50 mg, Give 1 tablet by mouth at bedtime for Depression m/b difficulty sleeping. Review of Resident 77's nursing progress notes and medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 3/2025, 4/2025, and 5/1-5/8/2025, the documentation did not indicate non-pharmacological interventions were attempted or provided to Resident 77 for the use of lorazepam and trazodone. During a concurrent interview with director of nursing (DON) and record review of Resident 77's MAR dated 3/2025, 4/2025 and 5/1 - 5/8/2025 on 5/9/2025 at 8:29 a.m., DON confirmed there were no documentation which indicated non-pharmacological interventions were attempted or provided to Resident 77 for the use of both lorazepam and trazodone. DON stated the non-pharmacological interventions should be documented in Resident 77's MAR. 2. Review of Resident 175's clinical record titled, Admission Record, dated 5/9/2025, indicated, Resident 175 was admitted to the facility with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia, and depression. Review of Resident 175's clinical record titled, Order Summary Report, dated 5/9/2025, indicated the following orders: a. Mirtazapine 15 mg, Give 1 tablet by mouth at bedtime for Depression m/b difficulty falling asleep, and b. Sertraline HCl 100 mg, Give 1 tablet by mouth one time a day for Depression m/b verbalization of feeling sad. Review of Resident 175's nursing progress notes and MAR for the month of 3/2025, 4/2025, and 5/1-5/8/2025, the documentation did not indicate that non-pharmacological interventions were attempted or provided to Resident 175 for the use of antidepressants. During a concurrent interview with DON and record review of Resident 175's MAR dated 3/2025, 4/2025 and 5/1 - 5/8/2025 on 5/9/2025 at 8:06 a.m., DON confirmed there were no documentation which indicated non-pharmacological interventions were attempted or provided to Resident 175 for the use of both antidepressants. During a review of the facility's policy and procedure titled, Psychoactive/Psychotropic Medication Use, dated 4/2025, indicated, Psychoactive (also known as Psychotropic) medications may be administered following federal and state regulations if the medication is necessary to treat a specifically diagnosed condition and is appropriately documented in the medical record. Additionally, behavioral interventions, unless contraindicated, will be used to meet the individual needs of the resident. Psychotropic medication management for the resident will involve the facility interdisciplinary team consideration of the following indication and clinical need for medication . Management will also include preventing (where possible), identifying, and responding to adverse consequences; and identifying person-centered non-pharmacological interventions, unless contraindicated, to meet the individual needs of the resident, and minimize or discontinue the use of Psychotropic medication. 50855 3. During a review of Resident 57's clinical record indicated Resident 57 was admitted to the facility with diagnosis including Alzheimer's disease (a progressive disease that destroys memory and mental functions). During a review of Resident 57's physician's order indicated an order for Quetiapine 25 milligram (mg, unit of measure), give 1 tablet by mouth at bedtime for Psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) m/b (manifested by) paranoia (is excessive mistrust or suspicion of people), dated 3/19/2025. During a review of Resident 57's clinical record indicated there was no monitoring for the target behavior of Quetiapine for psychosis manifested by paranoia. During a concurrent interview and record review on 5/7/25 at 3:36 p.m., with the Director of Nursing (DON), the DON reviewed Resident 57's clinical record and she confirmed that there was no target behavior monitoring for Quetiapine. The DON stated Resident 57 should have behavior monitoring for Quetiapine. During a review of the facility's P&P titled Psychoactive/Psychotropic Medication Use, dated 4/2025, indicated, . e. Monitoring of a resident receiving Psychotropic medication will include evaluation of the effectiveness of the medication, as well as an assessment for possible adverse consequences. Behavioral symptoms are reevaluated periodically to determine the potential for reducing or discounting the drug based on the therapeutic goals and any adverse effect or possible functional impairment .

Based on interview and record review, the facility failed to ensure an account of all controlled drugs (medications with high potential for abuse and addiction) was maintained and reconciled for four of six randomly selected residents (Residents 137, 3, 135, and 16) when: 1. Nursing staff signed out the controlled drugs from the Controlled Substance Accountability Sheet (CSAS - an inventory sheet that keeps record of the usage of controlled medications) but did not document on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) to indicate the controlled medications were given to the resident (Residents 16). 2. Nursing staff documented in resident's MAR that indicated the controlled medications were given but did not document or sign out in resident's CSAS to indicate the controlled medications were taken out of the narcotic box (Residents 3, 135, and 137). These failures had the potential for misuse or diversion of controlled medications. Findings: 1. Review of Resident 16's order summary report, it indicated an order dated 3/10/2025, hydrocodone-acetaminophen [brand name: Norco, a potent controlled medication for pain] 10-325 milligram (mg - unit of measurement) to give one tablet by mouth every 4 hours as needed for pain scale of 6-10 (severe pain). Review of the CSAS for Resident 16's hydrocodone-acetaminophen 10-325 mg and April MAR, indicated on 4/20/2025 at 5:00 a.m., one tablet of hydrocodone-acetaminophen 10-325 mg was signed out by a nursing staff, but it was not documented on the MAR as given to Resident 16. During a concurrent interview and record review on 5/8/2025 at 1:05 p.m., with the director of nursing (DON), DON reviewed CSAS for Resident 16's hydrocodone-acetaminophen 10-325 mg and April MAR and confirmed one tablet of hydrocodone-acetaminophen 10-325 mg was not documented on the MAR around the time it was signed out on 4/20/2025 at 5:00 a.m. 2a. Review of Resident 3's order summary report, it indicated an order dated 3/28/2025, HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for moderate to severe pain. Review of Resident 3's MAR for April and May 2025 and CSAS for hydrocodone-acetaminophen 5-325 mg, indicated one tablet of hydrocodone-acetaminophen 5-325 mg was documented as given in MAR on 4/24/2025 at 4:26 p.m. and on 5/4/2025 at 9:38 a.m., but they were not signed out on Resident 3's CSAS. During a concurrent interview and record review on 5/8/2025 at 1:02 p.m., with the DON, DON reviewed Resident 3's MAR for April/May 2025 and CSAS for Resident 3's hydrocodone-acetaminophen 5-325 mg and confirmed one tablet of the controlled medication was documented as given in the MAR on 4/24/2025 at 4:26 p.m. and one tablet on 5/4/2025 at 9:38 a.m. but were not signed out in CSAS. DON stated resident's controlled medications were dispensed from their Automated Dispensing Unit (ADU - a medication packaging system that stores bulk oral solid medications in canisters and packages), and once nurses took out some controlled medications, they should document the quantity dispensed from ADU and the amount administered to residents on CSAS. DON confirmed there were no other CSAS found for Resident 3's hydrocodone-acetaminophen 5-325 mg. 2b. Review of Resident 135's order summary report, it indicated an order dated 2/20/2025, Tramadol Hydrochloride (HCl) (brand name: Ultram - a controlled medication used for short term relief of moderate to severe pain) 50 mg, Give 1 tablet by mouth every 6 hours as needed for moderate pain. Review of Resident 135's MAR for April 2025 and CSAS for Tramadol HCl 50 mg, indicated one tablet of Tramadol HCl 50 mg was documented as given in MAR on 4/1/2025 at 8:19 a.m. and one tablet at 6:04 p.m., but they were not signed out on Resident 135's CSAS. During a concurrent interview and record review on 5/8/2025 at 1:10 p.m., with the DON, DON reviewed Resident 135's MAR for April 2025 and CSAS for Resident 135's Tramadol HCl 50 mg and confirmed one tablet of the controlled medication were documented as given on 4/1/2025 at 8:19 a.m. and 1 tablet at 6:04 p.m. but were not signed out in CSAS. DON confirmed there were no other CSAS found for Resident 135's Tramadol HCl 50 mg. 2c. Review of Resident 137's order summary report, it indicated an order on 4/16/2025, hydrocodone-acetaminophen 5-325 mg, Give 1 tablet by mouth every 6 hours as needed for Severe pain . During a controlled substance count and interview with licensed vocational nurse Q (LVN Q) on 5/5/2025 at 3:12 p.m., LVN Q reviewed Resident 137's CSAS for hydrocodone-acetaminophen 5-325 mg and confirmed it indicated the quantity remaining was three of the hydrocodone-acetaminophen 5-325 mg tablets but the actual count of the controlled medication in the box was two tablets. LVN Q stated she took one tablet at around 1:30 p.m. for Resident 137's pain but forgot to sign it out in Resident 137's CSAS. LVN Q stated the controlled medication should be signed out from Resident 137's CSAS and signed as given in the MAR as soon as the resident took the medication. During a review of the facility's policy and procedure titled, Controlled Substances, date revised 11/2022, indicated, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of controlled medications .If the count is correct, an individual resident controlled substance record is made for each resident who will be receiving controlled substance .This record contains: a. name of the resident; b. name and strength of the medication; c. quantity received; d. number on hand; .i. time of administration; .k. signature of nurse administering medication. Dispensing and Reconciling Controlled Substances 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records .3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count.

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored and labeled in two of four medication rooms and in four of seven medication carts when: Multiple opened inhalers, medications, and nasal sprays did not have an appropriate label of resident's named in the bottle or inhaler; [NAME]-dose vials were not labeled with open dates, or with an accurate expiration date, or being used past their discard dates; Opened or used eyedrops did not have a readable resident's name or had an unreadable open and expiration date; Multiple expired home medications were still stored in residents' overflow bin together with other medications that were still within the used by date; An expired over the counter (OTC) medication was still stored with other new OTC medications; and discontinued controlled medications (medications that the use and possession of are controlled by the federal government) and antibiotics (medications that fight bacterial infections) were still stored in the narcotic (controlled medications) box inside the medication carts. Also, one of the two medication refrigerators had discontinued resident's eye drops. These failures had the potential for residents to receive outdated and/or ineffective medications which could result in the residents not receiving the full benefit of the medications and negative health outcomes. The deficient practice had the potential for possible diversion of controlled medications. Findings: 1. During an inspection of Station 3 Medication Room on 5/5/2025 at 10:37 a.m. with both assistant director of nursing T (ADON T) and licensed vocational nurse U (LVN U), the following were identified and confirmed with ADON T and LVN U: a. An eyedrop gentamicin sulfate (medication used to treat eye infections) for Resident 97 had a label indicated it was delivered on 12/9/2024 and confirmed discontinued on 12/19/2024 was still stored in the medication refrigerator. ADON T stated weekend nurses should check the medication rooms and medication refrigerators for any expired or discontinued medications. ADON T further stated discontinued medications should have been removed from the medication refrigerator and discarded. b. Resident 36's medication from home (26 bottles) were expired and still stored together with Resident 36's medications that were still within the used by date bin: * Clopidogrel bisulfate (common brand: Plavix), it can prevent stroke, heart attack, and other heart problems) 75 milligrams (mg, unit of measurement): 5 bottles. Each bottle had indicated an expiration (exp) dated 3/5/2025; 4/16/2025; 3/18/2025; 4/1/2025; and 4/16/2025. * Famotidine 40 mg tablets (medication used to treat ulcers of the stomach and intestines and to prevent intestinal ulcers): 3 bottles. Each bottle had indicated an exp dated 3/5/2025; 4/1/2025; and 4/16/2025. *FeroSul 325 mg (an iron supplement to treat or prevent low blood levels of iron) 4 bottles. Each bottle had indicated an exp dated 3/5/2025; 4/16/2025; 4/1/2025; and 4/16/2025. *Tamsulosin hydrochloride (medication used to treat men with symptoms of an enlarged prostate [a gland that produces some of the fluid that carries sperm]) 0.4 mg : 5 bottles Each bottle had indicated an exp dated 4/16/2025; 3/18/2025; 3/5/2025; 4/1/2025; and 4/16/2025. * Sodium chloride (used to prevent or treat sodium deficiency) 1 gram: 4 bottles. Each bottle had indicated an exp dated 4/16/2025; 3/5/2025; 4/1/2025; and 4/16/2025. * Sertraline hydrochloride (a type of antidepressant used to treat depression and sometimes panic attacks) 25 mg: 4 bottles. Each bottle indicated an exp dated 4/16/2025; 3/18/2025; 4/1/2025; and 4/16/2025. * Rosuvastatin calcium 10 mg (medication used to lower cholesterol): 1 bottle with exp dated 4/16/2025. LVN U stated Resident 36's expired medications should have been discarded in the expired or discontinued medication bin. 2. During an inspection of Station 1 Medication Room on 5/5/2025 at 11:38 a.m. with registered nurse D (RN D), an over OTC medication, Aspirin 325 mg with label indicated an expiration date of 4/2025 was observed stored together with the other new OTC medications. RN D confirmed the above observation and stated the expired OTC medication should have been discarded. RN D stated nurses should check the expiration date of medications stored inside the medication room every Saturday and Sunday. 3. During an inspection of Station 2 Medication Cart on 5/5/2025 at 2:41 p.m. with licensed vocational nurse Q (LVN Q), the following were identified and confirmed with LVN Q: a. A bottle of clotrimazole topical solution (used to treat fungal infection that causes red scaly rash on different parts of the body) for Resident 156 did not have a label in the the bottle indicated Resident 156's name and instruction on how to use the medication; b. Another antifungal medication for Resident 156, clotrimazole cream did not have a label on the tube to indicate the medication was for Resident 156; c. Resident 107's inhaler, Breo Ellipta inhalation (used to treat asthma [inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath] and chronic obstructive pulmonary disease [COPD - a long-lasting lung disease]) did not have a label of Resident 107's name taped in the inhaler itself; d. The narcotic box still stored discontinued medications: * Lacosamide (used to control seizures) 100 mg - 1 tablet * Resident 57's Norco (generic name: hydrocodone-acetaminophen, a potent controlled medication for pain) 5/325 mg - 1 tablet * Resident 16's linezolid (an antibiotic medication) 600 mg - 1 tablet * Norco 5/325 mg - 2 tablets * Buprenorphine-Naloxone (a combination medication used to treat opioid use disorder) sub 2-05 mg - 7 tablets * Resident 41's antibiotic, Cephalexin 500mg - 1 capsule All these medication had Controlled Substance Accountability Sheet (CSAS - an inventory sheet that keeps record of the usage of controlled medications) which indicated the last time the medications were signed out was 4/2025. LVN Q stated nurses should have given discharged controlled medications to the director of nursing (DON) and should not be stored in the narcotic box. 4. During an inspection of Medication Cart 4 for Station 3 on 5/5/2025 at 3:20 p.m. with licensed vocational nurse V (LVN V) and licensed vocational nurse W (LVN W), the following were identified and confirmed with both nurses: a. An azelastine eye drop (used to treat itchy eyes) had a label of unreadable open and expiration date; b. A bottle of Minoxidil external solution (topical medication used to treat hair loss) did not have a label of resident's name on the bottle; c. Systane lubricant eye drops did not have a readable label on the bottle; d. Opened or used insulin Lispro (a fast acting insulin used to lower blood sugar) injection did not have a label of date opened; e. Propionate nasal spray (used to relieve symptoms of allergies such as sneezing, runny nose, and itchy nose) had no label in the bottle of resident's name; f. 24-hour allergy nasal spray had no label on the bottle of resident's name; and g. The narcotic box still had tramadol (a synthetic opioid analgesic used to treat moderate to severe pain) 50 mg - 2 tablets of resident transferred to the hospital. Both LVN V and LVN W stated discontinued narcotics should have been given to the DON. 5. During an inspection of Medication Cart 6 for Station 4 on 5/5/2025 at 3:58 p.m., with licensed vocational nurse X (LVN X), the Ipatropium nasal solution (a medication used to relieve runny nose) had a label indicated the open date was 3/31/2025 and an expiration date of 4/31/2025 was still stored in Medication Cart 6. LVN X confirmed the nasal solution was expired and should have been discarded. LVN X stated the medication was a routine order and the resident was still getting it. 6. During an inspection of Medication Cart 1 for Station 1 on 5/5/2025 at 4:28 p.m., with licensed vocational nurse Y (LVN Y), the following were identified and confirmed with LVN Y: a. The Bisacodyl (a medication used to treat constipation)10 mg tablet indicated in the box an expiration date of 2/2025. LVN Y stated the expired Bisacodyl should not be stored in the medication cart and should have been discarded; b. Resident 100's Lantus insulin (long acting insulin, used to manage high blood sugar level in people with diabetes) in a vial was observed to have an open date label indicated 4/5 and exp date 5/4. LVN Y stated Lantus insulin was good for 28 days once opened. LVN Y confirmed the label was incorrect, the exp date should have been 5/3 and stated it should have been discarded; and c. Resident 181's Lantus insulin in a vial was observed to have an open date label indicated 4/2 and exp date 4/30. LVN Y stated it should have been discarded. During an interview with DON on 5/8/2025 at 1:37 p.m., DON stated the following : all discontinued and expired medications should have been placed in the discontinued or expired medication box inside the medication room; resident's overflow home medications should be checked by nurses; central supply staff should check the OTC medication for the expiration date; and for discontinued antibiotics, nurse should have placed them in the discontinued medication bin. DON confirmed she collected all discontinued controlled substances every Friday and she did not get the chance to collect them yet. DON stated all nurses should discard expired medications. During a review of the facility's undated policy and procedure titled, Medication Labeling and Storage, indicated, It the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes, at minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name . For over the counter (OYC) medications in bulk containers .the label contains: .expiration date. Mutidose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial . During a review of the facility's policy and procedure titled, Controlled Substances, date revised 11/2022, indicated, Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed.

Based on observation, interview and record review the facility failed to ensure clinical records were accurately and timely documented for two sampled residents (Resident 86 and Resident 595) when: 1. Resident 86's Discharge Order and Progress Notes were documented late. 2. Resident 595's Interdisciplinary Team Meeting (IDT, involves various healthcare professionals collaborating to plan and coordinate a resident's care) notes were documented late. These failures resulted in an inaccurate presentation of information. Findings: 1. A review of Resident 86's medical record indicated a discharge date of [DATE]. A review of Resident 86's progress notes indicated, Physician Notification of Discharge, Ombudsman Notification of Discharge and IDT Meeting notes were documented on 5/5/25. A review of Resident 86's Physician Orders indicated, order for discharge was created on 5/5/25. During a concurrent interview and record review on 5/6/25 at 3:50 p.m. with Case Manager (CM) O, CM O verified Resident 86 was discharged on [DATE]. CM O also verified the Notice of Proposed Discharge form was sent to the Ombudsman on 4/25/25 and IDT meeting was done on 4/23/25. CM O also verified Physician Order for discharge was given on 4/25/25. CM O stated she overlooked Physician's Order for discharge, and she was running behind on documentation. A review of facility's policy and procedure (P&P) entitled, Charting and Documentation revised July 2017 indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record . 2. A review of Resident 595's medical record indicated a discharge date of [DATE]. A review of Resident 595's Progress Notes indicated, IDT meeting notes were documented on 5/5/25. During a concurrent interview and record review on 5/6/25 at 3:50 p.m. with Case Manager (CM) O, CM O verified Resident 86 was discharged on [DATE]. CM O also verified Resident 595's IDT meeting was done on 1/23/25. During an interview on 5/8/25 at 4:17 p.m. with the Social Services Director (SSD), SSD stated IDT meeting documentation was usually done after the meeting. A review of facility's policy and procedure (P&P) entitled, Charting and Documentation revised July 2017 indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record .

Based on observation, interview, and record review, the facility failed to provide services according to professional standards for two 11 sampled residents for medication administration (Residents 88 and 192) when: 1. Licensed vocational nurse I (LVN I) provided the wrong nutritional supplement (Boost Plus - brand name of the nutritional supplement) to Resident 88; 2. Registered nurse J (RN J) did not perform a push-pause method (or pulsatile flushing technique is a method to flush IV [intravenous] and catheters, which involves rapidly injecting fluid into the line, pausing briefly, then repeating the process) when flushing Resident 192's peripherally inserted central catheter (PICC, long slender, flexible tube inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in the chest near the heart to obtain venous access) line with normal saline (NS). These failures had the potential to affect residents' care, health, and well-being. Findings: 1. During medication administration observation on 5/7/2025 at 8:50 a.m., LVN I prepared all the medications and the nutritional supplement for Resident 88. LVN I showed the carton of Boost Plus before she entered Resident 88's room. Additional observation at 8:55 a.m., LVN I poured the whole carton of Boost Plus in a cup and handed it to Resident 88. Resident 88 drank the supplement. During a review of Resident 88's clinical record titled, Order Summary Report, dated 5/7/2025, it indicated an order dated 4/10/2025, Ensure Plus two times a day for supplement. Further review indicated there was no order for Boost Plus. During a review of Resident 88's clinical record titled, Weight variance note, dated 4/6/2025, it indicated a note from the registered dietitian (RD) which revealed Resident 88 had weight loss, PO [by mouth] has been variable and not meeting needs. Would benefit from oral supplement to help meet needs. Hard to meet needs d/t [due to] advanced age, medical status and variable po intake. Recommend: .1 can ensure plus . During a concurrent interview with LVN I and review of Resident 88's order summary report, LVN I confirmed she gave Boost Plus to Resident 88 instead of Ensure Plus. LVN I stated the physician's order was Ensure Plus. During an interview with director of nursing (DON) on 5/9/2025 at 8:00 a.m., DON stated if the physician's order was Ensure Plus, the nurse should have given Ensure Plus to Resident 88 instead of Boost Plus. DON further stated, nurses should follow the physician's order. 2. During medication administration observation on 5/7/2025 at 9:37 a.m., inside Resident 192's room, RN J flushed Resident 192's PICC line with 10 milliliters (ml - volume of measurement) of NS quickly, without using the push-pause method on the syringe plunger. During a follow-up interview with RN J on 5/7/2025 at 9:49 a.m., RN J confirmed the above observation and stated he should have performed the push-pause method in flushing Resident 192's PICC line to prevent it from clogging. During an interview with DON on 5/9/2025 at 8:00 a.m., DON stated nurses should flush the PICC line with the use of a flush and pause motion, in order to maintain the patency of the line. During a review of an article titled, How to Flush a PICC Line or Tunneled Catheter, dated 5/2020, indicated, Unclamp catheter. Begin flushing using a push-pause method on the syringe plunger. Push the contents of the syringe into the catheter, leaving a small amount of fluid in the syringe.

Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated resident assessment tool) assessments for one of 35 sampled residents (Resident 158) when Resident 158's five MDS assessments did not reflect Resident 158's feeding tube (a medical device, a thin and flexible tube, used to deliver nutrition and fluids directly into the digestive system when a person cannot eat or drink safely by mouth) and the percentage of intakes by artificial route. These failures resulted in inaccurate MDS assessments and had the potential to affect the residents' care. Findings: Review of Resident 158's clinical record titled, Admission Record, dated 5/9/5025, indicated Resident 158 was admitted to the facility with diagnoses including aphasia (a disorder that makes it difficult to speak) following cerebral infarction (also known as an ischemic stroke, is a condition where blood flow to the brain is interrupted, causing brain tissue to die), dysphagia (difficulty swallowing) following cerebral infarction, and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status. Review of Resident 158's clinical record titled, Order Summary Report, dated 5/9/2025, it revealed an order, Formula: Glucerna 1.2 via enteral pump at 85cc/hr [cubic centimeter per hour] x 15 hours (off from 07:00AM to 04:00PM) . It indicated the feeding to start at 4:00 p.m. and to end at 7:00 a.m. During observations on 5/5/2025 at 8:27 a.m., and 5/6/2025 at 9:22 a.m., inside Resident 158's room, Resident 158 was in bed and a feeding pump was observed in a pole positioned at the left side of Resident 158's bed. During a concurrent interview with MDS nurse G (MDSN G) and record review of Resident 158's MDS assessment on 5/8/2025 at 3:48 p.m., Resident 158's Annual assessment dated [DATE]; Quarterly review assessment dated [DATE]; 5-day scheduled assessment dated [DATE]; Quarterly review assessment dated [DATE] and Quarterly review assessment dated [DATE], revealed the following: 1. Section K0520B Nutritional Approaches: Feeding tube like gastrostomy tube was not coded or left blank; 2. Section K0710A Proportion of total calories the resident received through parenteral (also known as intravenous [IV] nutrition, which refers to the delivery of nutrients intravenously, bypassing the digestive system) or tube feeding was not coded or left blank; and, 3. Section K0710B Average fluid intake per day by tube feeding was not coded or left blank. MDSN G confirmed the above coding assessments and stated the facility's registered dietitian (RD) was the one who coded the mentioned MDS sections. During an interview with the director of nursing (DON) on 5/9/2025 at 8:40 a.m., DON confirmed Resident 158 had been on tube feeding since admission. During an interview with the RD on 5/9/2025 at 9:32 a.m., RD confirmed she was the one who completed Resident 158's MDS assessments' Section K - Swallowing/Nutritional Status. RD stated it was her error not to code Resident 158's feeding tube, total calories received and the fluid intake. RD further stated the MDS sections related to Resident 158's feeding tube should have been coded. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI - a guide for facility staff to existing coding and transmission) 3.0 User's Manual Version 1.19.1, dated 10/2024, indicated, Coding Tip for K0520B * Only feeding tubes that are used to deliver nutritive substances and/or hydration during the assessment period are coded in K0520B. K0710: Percent Intake by Artificial Route. Item Rationale: Health-related Quality of Life *Nutritional approached that vary from the [NAME], such as parenteral/IV or feeding tubes, can diminish an individual's sense of dignity and self-worth as well as diminish pleasure from eating .K0710A, Proportion of Total Caloris the Resident Received through Parental or Tube Feeding: Steps for Assessment: 1. Review intake records within the last 7 days to determine actual intake through parenteral or tube feeding routes. 2. Calculate proportion of total calories received through these routes .Coding Instructions *Select the best response: 1. 25% or less 2. 26% to 50% 3. 51% or more .K0710B, Average Fluid Intake per Day by IV or Tube Feeding: Steps for Assessment 1. Review intake records from the last 7 days. 2. Add up the total amount of fluid received each day by IV and/or tube feedings only .Code for the average number of cc per day of fluid the resident received via IV or tube feeding. Record what was actually received by the resident, not what was ordered. Further review indicated, Item Rationale in Section Z0400: Signatures of Persons Completing the Assessment . * To obtain the signature of all persons who completed any part of the MDS. Legally, it is an attestation of accuracy with the primary responsibility for its accuracy with the person selecting the MDS item response. Each person completing a section or portion of a section of the MDS is required to sign the Attestation Statement. * Read the Attestation Statement carefully. You are certifying that the information you entered on the MDS, to the best of your knowledge, most accurately reflects the resident's status. Penalties may be applied for submitting false information.

Based on observation, interview, and record review, the facility failed to maintain respect, and dignity to two of three sampled residents (Residents 20 and 591) when: 1. Certified nursing assistant C (CNA C) was standing while feeding Resident 20; and, 2. Restorative Nurse Assistant (RNA) K was standing while feeding Resident 591. These failures had the potential to negatively affect resident's emotional and psychosocial well-being. Findings: 1. Review of Resident 20's clinical record titled, Admission Record, dated 5/7/2025, indicated Resident 20 was admitted to the facility with diagnoses including dementia (a progressive state of decline in mental abilities), dysphagia (difficulty in swallowing), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). Review of Resident 20's quarterly minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 20's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 05 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During a concurrent observation and interview with CNA C on 5/5/2025 at 8:46 a.m., inside Resident 20's room, Resident 20 was sitting up in bed being spoon-fed by CNA C with breakfast food while CNA C was standing, and the privacy curtain was not drawn. CNA C confirmed the above observation and stated she preferred to assist Resident 20 with meals while standing because she wanted to see Resident 20's face while being fed. CNA C further stated that Resident 20 had asked her to sit down but CNA C refused. After five minutes of observation, CNA C sat on Resident 20's bed and continued to spoon-fed Resident 20. CNA C stated they did not have any available chair to sit on. During an interview with the director of staff development (DSD) on 5/6/2025 at 3:13 p.m., DSD confirmed staff should be seated in front of the residents during meal assistance. DSD stated staff should grab a chair when there was no chair inside the resident's room. DSD further stated staff should not sit on resident's bed during meal assistance. During a review of the facility's policy and procedure titled, Dignity, date revised 2/2021, indicated, Residents are treated with dignity and respect at all times . When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. 49345 2. A review of Resident 591's medical record indicated an admitted [DATE]. Resident 591's diagnoses included cognitive communication deficit (trouble communicating because of problems with their thinking and processing abilities, not just their language skills), and dysphagia, oral phase (difficulty with the first stage of swallowing, which happens in the mouth). A review of Resident 591's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 591's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 13 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). During a concurrent observation and interview on 5/5/25 at 8:56 a.m. inside Resident 591's room, Restorative Nurse Assistant (RNA) K was standing at bedside while feeding Resident 591. Resident 591 was sitting on the bed. RNA K stated it was okay to stand while feeding a resident. During an interview on 5/6/25 at 3:14 p.m. with the Director of Staff Development (DSD), the DSD stated staff must sit while feeding a resident. During an interview on 5/8/25 at 3:34 p.m. with the Director of Nursing (DON), the DON stated staff needed to sit down while feeding residents. A review of the facility's policy and procedure titled, Dignity, date revised 2/2021, indicated, Residents are treated with dignity and respect at all times . When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience.

Based on interview and record review, the facility failed to develop and implement comprehensive care plans that included target symptoms, measurable objectives, and interventions for one of 35 sampled residents (Resident 16) when there were no care plan developed for schizophrenia (chronic brain disorder that affects how a person thinks, feels, and behaves). The failure had the potential for the residents not attaining their highest practicable physical, mental, and psychosocial well-being. Finding: During a review of Resident 16's clinical record indicated Resident 16 was admitted to the facility on [DATE] with diagnosis including schizophrenia. During a review of Resident 16's physician's order indicated an order dated 4/24/25 Aripiprazole (Antipsychotic It can treat schizophrenia) 15 mg (milligram, unit of measure) give one tablet by mouth in the morning for schizophrenia . During a review of Resident 16's clinical record indicated there was no comprehensive care plan developed for the resident's schizophrenia diagnosis. During a concurrent interview and record review on 5/07/25 at 3:45 p.m., with the Director of Nursing (DON), the DON reviewed Resident 16's care plan and she confirmed that there was no care plan developed for schizophrenia diagnosis. The DON further stated any active diagnosis should have a care plan. During a review of the facility's policy and procedures titled, Care Plans, Comprehensive Person-Centered, dated 2001, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to ensure administration of enteral feeding (the delivery of nutrients through a feeding tube directly into the stomach) was consistent with and followed Physician's Order for one (Resident 51) out of three sampled residents when insufficient amount was administered, and oral care was not done. These failures had the potential to put Resident 51 at risk for dehydration, weight loss and infection. Findings: A review of Resident 51's clinical record indicated diagnoses of dysphagia following nontraumatic intracerebral hemorrhage (difficulty of swallowing after a stroke), hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side (complete paralysis and weakness on right side of the body after a stroke), aphasia following nontraumatic intracerebral hemorrhage (difficulty to speak, understand and write language after a stroke), and type 2 diabetes mellitus without complications (high levels of blood sugar). A review of Resident 51's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 51's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 6 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). A review of Resident 51's Physician's Orders indicated, NPO [nothing by mouth] diet ordered on 8/29/23, Enteral Feed order every shift tube feeding formula: Jevity 1.2 @ 75 ml/hr [milliliter/hour, unit of measurement] via feeding pump continuous x 20 hours/day to provide 1500 ml, 1800 kcal [kilocalorie, unit of measurement] ordered on 10/23/23 and Enteral [pertaining to stomach]- License Nurse to ensure: oral care every shift ordered on 10/22/23. During a concurrent observation and interview on 5/7/25 at 9:10 a.m. with the Director of Nursing (DON) at Resident 51's bedside, the DON verified Resident 51 had whitish buildup in the inner corner of the mouth and the tongue. The DON also verified the presence of tartar (hardened dental plaque that can form on your teeth, both above and below the gum line) around Resident 51's teeth. The DON verified Resident 51's feeding tube set was disconnected, and the level of the feeding solution was 1200 ml. The label of the tube feeding set indicated it was started on 5/6/25 at 5:30 p.m. During a concurrent observation and interview on 5/7/25 at 9:24 a.m. with Certified Nurse Aide (CNA) M, CNA M verified there was no toothbrush for Resident 51 at bedside. CNA M showed lemon glycerin swab sticks (a medical swab with a lemon-flavored, glycerin-soaked tip, designed to help relieve dry mouth and provide temporary relief from minor oral discomfort) and foam-tipped swab sticks and stated those were used to clean Resident 51's mouth. CNA M stated she had not given oral care to Resident 51 yet that morning. During a concurrent observation and interview on 5/7/25 at 9:28 a.m. with Licensed Vocational Nurse (LVN) N, LVN N stated Resident 51's tube feeding was stopped at 7:30 a.m. LVN N verified Resident 51's whitish build up in the mouth. During a concurrent observation and interview on 5/7/25 at 3:44 p.m. at Resident 51's bedside with LVN P, LVN P stated she was Resident 51's nurse for the afternoon shift. LVN P verified Resident 51's feeding tube was disconnected and was turned off. LVN P also verified Resident 51's feeding solution level was a little under 1100 ml. During a concurrent interview and record review on 5/7/25 at 3:50 p.m. with LVN N, LVN N stated she ran Resident 51's enteral feeding for a total of four hours during her morning shift. LVN N verified Resident 51's Physician Order for enteral feeding was 75 ml/hr for 20 hours per day for a total of 1500 ml. LVN N stated there was no documentation for the specific amount of enteral feeding administered for Resident 51. During a concurrent interview and record review on 5/7/25 at 4:08 p.m. with Registered Nurse (RN) D and Assistant Director of Nursing (ADON) E, RN D and ADON E verified Resident 51's Physician's order for enteral feeding. RN D and ADON E verified there was no hourly, per shift or daily documentation and monitoring of Resident 51's enteral feeding intake amount. During a concurrent interview and record review on 5/8/25 at 3:18 p.m. with the DON, the DON verified Resident 51's Physician Order for Enteral Feeding and NPO. The DON stated nurses should have checked the level of remaining enteral feeding solution during their report at the change of shift. The DON verified there was no monitoring for the accurate amount of enteral feeding solution administered for Resident 51. The DON stated it should have been accurately documented. The DON also stated Resident 51 was at risk for dehydration, weight loss and any change of condition due to inadequate monitoring of enteral feeding. During a concurrent interview and record review on 5/9/25 at 9:54 a.m. with Registered Dietician (RD), RD verified Resident 51's Physician's Order for enteral feeding and NPO. RD also verified there was no accurate monitoring and documentation of the amount of enteral feeding solution in milliliter administered to Resident 51. RD stated Resident 51 did not receive sufficient amount of enteral feeding as ordered by physician on 5/7/25. A review of facility's undated policy and procedure (P&P) entitled Enteral Tube Feeding via Continuous Pump, the P&P indicated, .Documentation: The person performing this procedure should record the following information in the resident's medical record: .3. Amount and type of enteral feeding. 4. The average fluid intake per day . A review of facility's policy and procedure (P&P) entitled Enteral Tube Feeding via Continuous Pump revised November 2018, the P&P indicated, .3. The dietician, with input from the provider and nurse: .b. Determines whether the resident's current intake is adequate to meet his or her nutritional needs .9. The nursing staff and provider monitor the resident for signs and symptoms of inadequate nutrition .15. Staff caring for residents with feeding tubes are trained on how to recognize and report complications relating to the administration of enteral nutrition products, such as: .b. inadequate nutrition .

Based on observation, interview and record review, the facility failed to ensure that a proper treatment services for oxygen (O2, a colorless, odorless gas) therapy was provided for one of four sampled residents (residents on oxygen therapy) when Resident 139 did not receive the correct flow of oxygen administration. This deficient practice had the potential for Resident 139 to have complication related to improper treatment while receiving O2 therapy. Findings: During an observation on 5/5/2025 at 8:24 a.m., inside Resident 139's room, Resident 139 was observed having breakfast in bed and with O2 therapy at 1.5 liters per minute (lpm) thru (via) a nasal cannula (NC - a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). During a concurrent observation and interview with licensed vocational nurse B (LVN B) on 5/6/2025 at 3:57 p.m., inside Resident 139's room, Resident 139 was observed in bed with O2 therapy at 1.5 lpm via NC. LVN B confirmed the oxygen flow was at 1.5 lpm. During a concurrent interview with LVN B and record review of Resident 139's oxygen order on 5/6/2025 at 4:09 p.m., LVN B confirmed the oxygen flow rate for Resident 139 was supposed to be at 1 lpm as ordered. LVN B stated they should have followed the doctor's order for oxygen therapy which was at 1 lpm and not at 1.5 lpm. Review of Resident 139's clinical record titled, Admission Record, dated 5/7/2025, indicated Resident 139 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), other asthma (inflammatory disease of the airway that often causes wheezing, coughing, and shortness of breath), and unspecified diastolic (congestive) heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During an interview with the director of nursing (DON) on 5/9/2025 at 1:04 p.m., DON stated nurses should review the doctor's order first before they administer the oxygen to the resident. DON further stated nurses should follow the doctor's order related to oxygen therapy and they should sit down to see the oxygen regulator at an eye level to administer the correct oxygen flow rate. During a review of the facility's policy and procedure titled, Oxygen Administration, date revised 10/2010, indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for one of 35 sampled residents (Resident 57) resident who used side or bed rails when there was no physician's order for bilateral (both) quarter upper bed rails prior to installing the bed rails, the care plan for bilateral quarter upper bed rails was not developed in a timely manner, and the informed consent for bilateral quarter upper bed rails was not obtained prior to installing the bed rails. These failures had the potential risk for injuries to the Resident 57. During an observation in Resident 57's room on 5/5/25 at 9:44 a.m., Resident 57's bed observed with bilateral quarter upper bed rails were up. During a review of Resident 57's clinical record indicated Resident 57 was admitted to the facility on [DATE] with diagnosis including Alzheimer's disease (a progressive disease that destroys memory and mental functions). During a review of Resident 57's clinical record titled Bed Rail and Entrapment Risk observation/Assessment, effective date 3/5/25, indicated in A. section I bed Rail use 1. Are bed Rails currently in use? a. Yes. 2. If yes, Bed Rail type in use: d. Quarter Rail(s). 2.b Bed Rails Location a. Left Upper, c. Right upper. 2c. Bed Rail(s) are in use: a. At all times when resident is in bed to enhance mobility. 3. Are Bed Rails being considered for use? a. yes . During a review of Resident 57's order summary report dated 5/7/25 at 16:05:29 PT (Pacific Time Zone) indicated there were no orders for bilateral upper quarter bed rails. During a review of Resident 57's clinical record indicated there were no care plans developed for the use of bilateral quarter upper bed rails. During a concurrent observation and interview inside Resident 57's room on 5/9/25 at 2:43 p.m., with Assistant Director of Nursing E (ADON E), she confirmed Resident 57's has bilateral quarter upper bed rails in use, ADON E stated prior to installing bed rails they should have a consent, assessment, physician order, and care plan. During a concurrent interview and record review on 5/9/25 at 2:50 p.m., with ADON E, she reviewed Resident 57's physician order for bed rails, dated 5/9/25 and a care plan, dated 5/9/25. ADON E confirmed the order and care plan was just made today 5/9/25. ADON E further stated they must have physician order prior to installing the bed rails and right away after installing they have to develop a bed rails care plan. During a review of Resident 57's clinical record indicated consent for bilateral quarter upper bed rails, dated 5/9/25. During a concurrent interview and record review on 5/9/25 at 3:14 p.m., with the Director of Nursing (DON) the DON stated confirmed consent was just today 5/9/25 signed by Resident 57's husband. During a review of facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails dated 2001, the P&P indicated, .8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons . During a review of the facility's policy and procedures titled, Care Plans, Comprehensive Person-Centered, dated 2001, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure that one of 35 sampled residents (Resident 160) received the planned menu meal or the food alternative, as indicated on the posted menu and consistent with the resident's preferences. As a result, Resident 160 did not receive the correct food items on multiple occasions. Findings: A review of Resident 160's Minimum Data Set (MDS, a resident assessment and care screening) dated 4/2/25, indicated a Brief Interview for Mental Status (BIMS, a brief screening tool used to assess thinking and memory) score of 15. A BIMS score of 13-15 indicates intact cognition (suggests no significant impairment in thinking, reasoning, memory, and problem solving). During a dining observation and concurrent interview on 5/5/25 at 1:23 p.m. in Resident 160's room, the resident's meal tray contained a beef patty and salad. Resident 160 confirmed the food items and stated he had received the same meal the day before. Resident 160's tray ticket documented a dislike of all pork. Resident 160 also reported that, several days earlier, he had requested barbecue chicken from the alternative menu but instead received two chicken nuggets. Observation of other residents showed they were served soft tacos and salad. During a follow-up interview on 5/6/25 at 3:15 p.m., Resident 160 stated he had not requested an alternative for lunch on 5/5/25. Resident 160 reviewed the facility's weekly menu, which listed soft tacos and salad. Resident 160 stated he likes soft tacos and should have received that meal instead of the repeated patty from the previous day. During an interview and concurrent review of the posted Spring menu and alternative meal options, on 5/6/25 at 3:30 p.m., the dietary manager (DM) confirmed the soft tacos on 5/5/25 were made with beef, not pork. The DM acknowledged that Resident 160 received a vegetable patty, not the planned menu item, and confirmed that no alternative had been requested. The DM reviewed the posted alternatives and verified that barbecue chicken was listed, but chicken nuggets were not. The DM stated Resident 160 should have received the requested barbecue chicken. During a follow-up interview at 3:50 p.m., the DM said she spoke with Resident 160, confirmed it was a kitchen error, and stated she would conduct in-service training for dietary staff on following the planned menu and honoring resident preferences. A review of the facility's policy titled Menu, revised October 2008, indicated that menus shall: a) meet the nutritional needs of residents; b) be prepared in advance; and c) be followed.

Based on observation, interview, and record review, the facility failed to ensure the call light (a visible and audible alarm activated by a call button) for two of 35 sampled residents (Resident 55 and Resident 148) was within reach. This deficient practice had the potential to result in a delay in meeting Resident 55 and Resident 148's needs for toileting and activities of daily living. Findings: 1. During an observation inside Resident 55's room on 5/5/25 at 9:38 a.m., Resident 55 was observed lying in bed, the call light was not in Resident 55's bed. During a concurrent observation and interview inside Resident 55's room on 5/5/25 at 3:00 p.m., with Certified Nursing Assistant F (CNA F), CNA F looked for the call light button and found it hanging on the feeding tube pole (a device used to support and secure feeding bags or feeding pumps during tube feeding). CNA F confirmed the call light was not within the reach of Resident 55. CNA F further stated Resident 55's call light should not be hanging in the feeding tube pole. During a review of Resident 55's clinical record indicated Resident 55 was admitted to the facility with diagnosis including cerebral palsy (is a brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination). During a review of Resident 55's Brief Interview for Mental Status (BIMS, a short performance-based cognitive screener for nursing home (NH) residents.), dated 4/15/25 BIMS is 14 (the range of 13-15, which suggests that the person is cognitively intact.) During a review of Resident 55's Minimum Data Set (MDS- a federally mandated resident assessment tool) Functional Abilities, dated 3/13/25, indicated Resident 55 was dependent with eating, oral hygiene, toileting hygiene, and shower/bathing self, upper and lower body dressing, and personal hygiene. A further review of Resident 55's MDS Functional Abilities indicated Resident 55 was dependent with rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. During an interview on 5/7/25 at 4:01 p.m., with the Director of Nursing (DON), the DON stated Resident 55 is dependent on ADL's. She stated Resident 55 call light should always be in reach to call for help. 2. During an observation inside Resident 148's room on 5/5/25 at 2:48 p.m., Resident 148 was observed lying in bed, the call light was not on the bed, it was clipped onto the privacy curtains and not within the reach of Resident 148. During a concurrent observation and interview inside Resident 148's room on 5/5/25 at 2:51 p.m., with Registered Nurse D (RN D), RN D confirmed the call light was clipped on the privacy curtains away from Resident 148. RN D stated the call light should be in the reach of Resident 148 and not hanging on the privacy curtains. During a review of Resident 148's clinical records indicated Resident 55 was admitted to the facility with diagnoses including hemiplegia (a condition characterized by paralysis or weakness affecting one side of the body) and hemiparesis (a condition characterized by weakness on one side of the body). During a review of Resident 148's BIMS, dated 2/18/25, the BIMS was 9 (8-12 indicates moderate cognitive impairment). During a review of Resident 55's Minimum Data Set (MDS- a federally mandated resident assessment tool) Functional Abilities, dated 2/18/25, indicated Resident 148 was dependent with eating, oral hygiene, toileting hygiene, and shower/bathing self, upper and lower body dressing, and personal hygiene. A further review of Resident 148's MDS Functional Abilities indicated Resident 148 was dependent with rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. During an interview on 5/7/25 at 4:03 p.m., with the Director of Nursing (DON), the DON stated Resident 148's call light should be always in reach to call for help. During a review of the facility's policy and procedures titled, Call System, Residents, dated 2001, indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor .

Based on interview and record review, the facility failed to ensure lab results were communicated to the physician for one of three sampled residents (Resident 1). This failure had the potential to delay treatments and interventions that Resident 1 may have needed. Findings: Review of Resident 1's medical record indicated he was admitted on [DATE] and had a history of pneumonia (an infection of the lungs) and urinary tract infection. Review of Resident 1's situation, background, assessment, recommendation (SBAR, a communication tool), dated 4/12/25, indicated he had an episode of vomiting. The SBAR also indicated Resident 1 had decreased appetite, fluid intake, and urine output. Review of Resident 1's Order Summary Report indicated he had a physician's order, dated 4/12/25, for a repeat CBC (complete blood count, a blood test that evaluates the number and types of blood cells) and CMP (comprehensive metabolic panel, a blood test that provides an overview of the body's chemical balance). Review of Resident 1's Lab Results Report indicated his blood was collected for the CBC and CMP on 4/14/25 at 8:10 a.m. The report indicated the lab results were reported to the facility at 8:37 p.m. the same day. The report further indicated there were multiple results that were not within normal range. Further review of Resident 1's medical record indicated there was no documentation that the above lab results were communicated to Resident 1's physician. During an interview with registered nurse A (RN A) on 4/30/25, at 1:38 p.m., RN A explained that when the facility receives lab results, the nurses should communicate the results to the physician by way of fax and/or telephone call. RN A confirmed she reviewed Resident 1's medical record and there was no documentation that his lab results from 4/14/25 were communicated to the physician. The facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol, dated 2001, indicated, A physician can be notified by phone, fax, voicemail, e-mail, page, or a telephone message to another person acting as the physician's agent (for example, office staff). Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented in four out of six shower rooms when: 1. Shower room [ROOM NUMBER] had a brown substance on the floor; 2. Shower room [ROOM NUMBER] had cotton swabs and a shaver cover on the floor drain; 3. Shower room [ROOM NUMBER] had a used white towel on the shower handlebar, and 4. Shower room [ROOM NUMBER] had a used shaver, toilet tissue, wheelchair footrests, and socks in the bathtub. These failures could result in the spread of infection and cross-contamination that could affect staff, visitors, and the 194 residents who reside in the facility. Findings: 1. During a concurrent observation and interview on 12/4/2024 at 10:12 a.m., with the Maintenance Director (MD), there was a brown substance on the floor in shower room [ROOM NUMBER]. The MD confirmed the brown substance was feces (bodily waste discharged from the bowels after food has been digested). The MD further stated staff should clean and disinfect after they use the shower rooms. 2. During a concurrent observation and interview on 12/4/2024 at 10:16 a.m., with the MD, there were cotton swabs and a shaver cover on the floor drain in shower room [ROOM NUMBER]. The MD confirmed this observation and stated staff should throw away these items after they are used on the residents. 3. During a concurrent observation and interview on 12/4/2024 at 10:20 a.m., with the MD, there was a used white towel on the shower handlebar in shower room [ROOM NUMBER]. The MD confirmed this observation and stated the shower room should be left clean for the next resident to use. 4. During a concurrent observation and interview on 12/4/2024 at 10:22 a.m., with the MD, there was a used shaver, toilet tissue, wheelchair footrests, and socks in the bathtub in shower room [ROOM NUMBER]. The MD confirmed this observation and stated items should be removed and the shower room should be left clean for the next resident to use. During an interview with the Director of Nursing (DON) on 12/4/24 at 2:48 p.m., the DON acknowledged the above observations and stated the shower rooms should not be left dirty and should be cleaned after use for the next resident to prevent infection. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, revised 2022, the P&P indicated, Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA bloodborne Pathogens Standards. During a review of the facility's policy and procedure (P&P) titled, Bathrooms, revised 2020, the P&P indicated, 2. Bathroom, including showers, sink, commodes are cleaned and disinfected daily in accordance with our established procedures. During a review of the facility's policy and procedure (P&P) titled, Policies and Practices-Infection Control, revised 2018, the P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections. 2. the objective of our infection control policies and practices are to: b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

Based on interview and record review the facility failed to notify a responsible party (RP, person who makes healthcare decisions on behalf of a resident) regarding change in condition (clinically important change of a person's health status) when a resident sustained an injury to his left elbow for one of three sampled residents (Resident 1). This failure resulted in the RP not being informed. Findings: Review of Resident 1's clinical record indicated a physician's order was obtained on 1/20/23 at 3 p.m. to treat the resident's left elbow injury. The clinical record lacked documentation the RP was notified of the wound. During an interview on 6/4/24 at 1:38 p.m., the director of nurses (DON) reviewed Resident 1's clinical record and stated the elbow wound was a change in condition (new wound). The DON stated could not find documentation of RP notification in Resident 1's clinical record. Review of the facility's Change in a Resident's Condition or Status policy, dated February 2021, indicated a nurse was to notify the resident's representative when there was a significant change in the resident's status.

Based on interview and record review, the facility failed to ensure a safe discharge for one of three randomly selected discharged sample residents (Resident 14) when: 1. The facility did not initiate a discharge care plan for Resident 14; 2. The interdisciplinary team (IDT, leaders from different departments discuss the resident's care) did not assess the safety of Resident 14's discharge; Facility discharged Resident 14 to the street and left the resident alone in the street; alone; Facility did not know the Resident 14's whereabouts after the discharge; 3. IDT team members were not involved in the resident's discharge; 4. The facility did not provide Resident 14 the instruction and education for the after discharge care; 5. The facility did not involve the responsible party (RP, a person who is designated to make the care decisions for the resident) regarding the discharge; facility did not inform RP that Resident 14 was discharged to the street; 6. The facility did not follow the doctor orders regarding Resident 14's discharge; 7. Ombudsman (advocate and liaison between residents and the facility) was not aware that the facility discharged Resident 14 to the street. 8. The facility unsafely discharged Resident 14 to the street on 6/7/21. Resident 14 was admitted to the acute hospital due to the weakness and abdominal discomfort (medical condition of unpleasant or painful feeling at the belly area) on 6/8/21. These failures resulted in the facility unsafely discharging Resident 14 with a walker to a local street corner, at two streets on 6/7/21. The facility did not verify where the resident was discharged and left the resident alone on the street. One day after the facility discharged Resident 14 to the street on 6/8/21, Resident 14 was admitted to the acute hospital for further evaluation due to the weakness and abdominal discomfort. Findings: Review of Resident 14's face sheet (document that summarizes a resident's information) indicated Resident 14 was a [AGE] year old man who was admitted to the facility on [DATE]. Review of Resident 14's face sheet and the SNF (skilled nursing facility) admission note dated 3/7/21, indicated Resident 14 was admitted from a local hospital after an auto versus pedestrian accident on 2/4/21, in which he was the pedestrian and suffered injuries. Injuries from the accident included the following: a concussion (brain injury), a C4-C5 (Cervical; bones in neck) ligament sprain in the spine (injury to the soft tissue in the neck), T6-8 (Thoracic; bones in upper spine in middle of back) ligament injury, T6 fracture (broken bone in spine), and Lumbar L3 fracture (Lumbar; bones in lower spine in middle of back; broken bone in spine). These injuries resulted in Resident 14 having spinal surgery on 2/16/21. As a result of the accident, Resident 14 had a right lateral (side) knee degloving (when top layers of skin and tissue are ripped from muscle and bone) with a right knee PCL (ligament in knee) injury (stretched or torn tissue that connect bones together). Resident 14 sustained a right femur fracture (broken thigh bone) , a right clavicle fracture (collarbone), left third and fourth rib fractures, right first through fifth rib fractures, an manubrial fracture (broken sternal bone in middle of chest), and a scalp laceration (wound). Resident 14 also developed a [CONDITION(S)]-resistant staphylococcus aureus infection (MRSA) (a super bug infection, resistant to some antibiotics) which required ongoing antibiotic treatment (medication to get rid of the infection). Resident 14's history included [CONDITION(S)] (mental health disease when people see and/or hear things that are not there, have beliefs not based in reality, and/or disorganized thoughts), [CONDITION(S)] (mood swings from depressive lows to manic highs), [CONDITION(S)], hypertension (high blood pressure), muscle weakness (generalized), and type 2 diabetes mellitus (medical condition that can result in too much sugar in the blood). During an interview with licensed vocational nurse K (LVN K) on 6/11/21 at 12:56 p.m., LVN K stated Resident 14 had behavioral issues every day with nonstop yelling. LVN K stated Resident 14's behavior was the same up until discharge and stated Resident 14 was a more difficult resident. Review of Resident 14's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 14's Behavior Monitoring Administration History (BMAH) from March 21 to 6/7/21, indicated Resident 14 had 39 documented episodes of this behavior in March 21; 214 documented episodes of this behavior in April 21; 100 documented episodes of this behavior in May 21 and 20 documented episodes of this behavior from 6/1/21 to 6/7/21. Review of Resident 14's face sheet indicated Resident 14's responsible party (RP) was a family member. Review of Resident 14's Minimum Data Set (MDS, an assessment tool) dated 3/8/21 indicated Resident 14 had a BIMS (Brief Interview for Mental Status) score of 11 (BIMs score of 8-12 indicates moderate cognitive impairment). 1. During an interview and concurrent record review of Resident 14's care plan with the director of nursing (DON) on 6/17/21 at 8:20 a.m., the DON acknowledged the facility did not initiate a discharge care plan for Resident 14. The DON reviewed Resident 14's medical records and confirmed there was no document to indicate the facility discussed the safety of the discharge for Resident 14. Review of the facility's Policy and Procedure Discharge Summary and Plan, revised in November 2017, indicated .Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan .The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. 2. During an interview and concurrent record review with the Social Services Director (SSD) on 6/11/21 at 4:22 p.m., the SSD stated an IDT discharge meeting to discuss Resident 14's discharge and the safety of the discharge did not occur. The SSD stated the facility did not have an IDT discharge meeting for Resident 14 because we (the facility) were distracted because you (California Department of Public Health survey team entered the facility on 6/7/21 for the recertification survey) all were here. The SSD stated Resident 14 bugged her on 6/7/21 from 8:30 a.m. and on. SSD stated .he (Resident 14) was bugging me and he wanted to go to the street and instead of stepping back and thinking this is not safe. SSD stated there was no IDT meeting to discuss Resident 14's discharge because she did not have time and wanted to finish Resident 14's discharge task. SSD stated, .if I had time, I would have, but I wanted to get it done . The SSD acknowledged a note documented as an IDT for Resident 14's discharge date d 6/7/21 did not involve other departments' leaders from IDT team other than SSD herself. The SSD stated the IDT team members should include the DON, ADON (assistant DON), social worker (SW), Rehab Director, dietician, administrator (ADM), MDS Coordinator, and the Activities Director. During an interview and concurrent record review with the DON on 6/14/21 at 2:47 p.m., the DON confirmed other than asking family if they would take Resident 14 to home or a homeless shelter placement, there was no documentation to indicate the facility tried to plan or attempt other options for discharge instead of the street for Resident 14. The DON confirmed the physician discharge order dated 6/4/21 indicated to discharge Resident 14 to home. The DON confirmed the physician was unaware that the facility discharged Resident 14 to the street. During a telephone interview with family member A (FM A) on 6/11/21 at 3:25 p.m., FM A stated, He (Resident 14) was released in the condition he was in. He can barely walk and was mostly in a wheelchair. FM A stated the facility did not call her about the discharge planning and Resident 14 called FM A and informed FM A he would be discharged from the facility. FM A stated, The facility never asked me if I would take him into my house. I have not heard from him since he was discharged . I let them know he was too sick to go. I told them he can't even walk. There was no cooperation. Review of Resident 14's Progress Notes written by the SSD, dated 3/18/21, indicated Resident 14's RP stated she wanted the resident to be discharged to a safe environment and an appropriate living arrangement . During an interview with LVN K on 6/11/21 at 12:56 p.m., LVN K stated she did not know where Resident 14 was being discharged when she discharged him on 6/7/21, and stated she believed it to be a home as the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the facility administrator on 6/14/21 at 3:13 p.m., the ADM stated he was unaware that Resident 14 was discharged to the street and he thought Resident 14 was going to be discharged to a homeless shelter. The ADM stated the facility should have addressed Resident 14's discharge. The ADM confirmed there was no IDT meeting to discuss Resident 14's discharge. During an interview and concurrent record review with the Rehabilitation Director (RD), on 6/14/21 at 2:32 p.m., RD confirmed there was no documentation indicating the facility completed a safety assessment of the area in which Resident 14 was to be discharged . The RD confirmed there was no documentation indicating Resident 14 was assessed from lying on the ground to sitting and standing positions. The RD stated the intent of the rehabilitation therapy was not to discharge Resident 14 to the street. The RD stated Resident 14 was discharged from the rehabilitation services prior to discharge from the facility. The RD stated Resident 14 used the wheelchair frequently and indicated there was no order for a wheelchair on discharge. The RD stated roughly half of the time Resident 14 used a walker and half of the time Resident 14 used a wheelchair. Review of Resident 14's MDS assessment dated [DATE] (when Resident 14 was discharged from the facility) indicated Resident 14 required limited assistance (staff provide guided maneuvering of limbs or other non-weight-bearing assistance) on how the resident moved to and from lying position and turned side to side. Resident 14 required extensive assistance (staff provide weight-bearing support) for dressing (putting on clothing), toilet use, and personal hygiene (combing the hair, brushing teeth, shaving, washing/drying face and hands). Review of Resident 14's MDS assessment dated [DATE] (when Resident 14 was admitted to the facility) indicated Resident 14 required extensive assistance with one person physical assist for dressing, toilet use, and personal hygiene. Resident 14's MDS assessments indicated Resident 14 did not improve his activity daily living (ADL, like walking, eating, dressing, toileting and personal hygiene) level of dressing, toilet use and personal hygiene and still required extensive assistance when the facility discharged Resident 14 to the street on 6/7/21. Review of Resident 14's Progress Notes written by the SSD dated 6/11/21, indicated family members had not heard from or seen Resident 14 and the facility staff were unable to find the resident in the area where he was discharged . Review of the facility's Policy and Procedure Interdisciplinary Team Daily Clinical QA Process, dated 11/08/18, indicated the IDT team consists of the ADM, DON, Director of Staff Development (DSD), MDS Coordinator, Medical Records Director, Rehabilitation Department, Social Services, Food/Nutrition Services, and Activity staff. Review of the facility's Policy and Procedure Discharge Summary and Plan, revised in November 2017, indicated the resident/representative will be involved in the post-discharge planning process. Review of the facility's Policy and Procedure Discharge Summary and Plan, revised in November 2017, indicated .Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan .The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family and will include: .Where the individual plans to reside .Arrangements that have been made for follow-up care and services .How the IDT will support the resident or representative in the transition to post-discharge care . The policy also indicated .post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. 3. During an interview and concurrent record review with the DON on 6/14/21 at 2:47 p.m., the DON confirmed the physician was unaware that the facility discharged Resident 14 to the street. During a telephone interview with medical doctor U (MD U) on 6/11/21 at 1:28 p.m., MD U stated I do not know where he (Resident 14) was discharged to. 4. During an interview with the SSD on 6/11/21 at 10:34 a.m., the SSD stated Resident 14 was discharged to the street on 6/7/21 with three days' supply of medications. Review of Resident 14's Discharge Medication list indicated post discharge from the facility, Resident 14 needed to take [MEDICATION(S)] (medication to control blood pressure) 25 mg (milligrams, measuring unit) as needed every six hours when the systolic blood pressure (the force the heart beats) was above 180 and with no indication of how much could be taken in a day or the blood pressure monitoring needed. Review of Resident 14's Discharge Medication list indicated [MEDICATION(S)] (medication to control blood pressure) 25 mg was to be taken if the systolic blood pressure was above 160 or if the heart rate was above 100 every six hours as needed with no indication how much could be taken in a day or what monitoring would be needed. Review of Resident 14's Discharge Summary dated 6/7/21, indicated Resident 14 should continue with a controlled carbohydrate diet with two times the portion of protein. Review of Resident 14's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and concurrent record review with the DON on 6/14/21 at 2:47 p.m., the DON confirmed there was no documentation that facility provided the discharge education to Resident 14 regarding how to obtain medications, how to safely self-manage medications, and how to safely self-administer medications. The DON confirmed there was no documentation that the facility provided the discharge education or training to Resident 14 regarding the use of a glucometer (medical device to check blood sugar level) or use of a blood pressure machine (medical device to check the blood pressure level and heart rate). The DON further confirmed there was no documentation that the facility provided the discharge education to Resident 14 regarding diet management for diabetes and blood pressure. During an interview and concurrent record review with the DON on 6/14/21 at 2:47 p.m., the DON confirmed the Discharge Summary which Resident 14 signed on 6/7/21, indicated Resident 14 should follow up with a primary care physician/provider within seven days after discharge and that the RP would arrange an appointment for this follow up. The DON confirmed the RP was to arrange for follow up care for Resident 14. The DON was unable to provide an answer as to how the RP could do so if the RP could not reach or locate Resident 14 after the resident was discharged to the street on 6/7/21. During a telephone interview with the RP on 6/11/21 at 4:55 p.m., the RP stated the facility never asked her to arrange for follow up care with a primary care physician and stated she had no way to contact Resident 14 to make arrangements as he did not have a phone. The RP stated she informed the facility in the initial meetings dated 3/8/21 that she wanted Resident 14 to be discharged to a half-way home or some real housing and not the streets. The RP stated she spoke with the Social Services Assistant (SSA) on 6/4/21 to voice her concerns about Resident 14's ability to walk. The RP stated she was told that Resident 14 used the wheelchair a lot in the facility. The RP stated she was concerned how the resident would manage his newly diagnosed diabetes if Resident 14 was discharged to the street. During an interview with the DON on 6/14/21 at 2:47 p.m., the DON confirmed Resident 14 had no personal belongings on his inventory list (the list indicated what belongings the resident brought to the facility). The DON confirmed there was no documentation the facility provided Resident 14 a glucometer, blood pressure machine, clothing, hygiene products or personal care items, face masks, hand hygiene wipes or sanitizer, or a blanket upon discharge on 6/7/21. Review of the facility's job description for social services director, revised 3/1/14, indicated an essential job function of the SSD include .Make arrangements for obtaining needed adaptive equipment, clothing, personal items ., and to participate in IDT care plan conferences and develop a plan of care to ensure needs are met. 5. During a telphone interview with the RP on 6/11/21 at 4:50 p.m., the RP stated the facility did not inform the RP that Resident 14 was discharged to the street on 6/7/21. The RP stated the facility did not give any other options nor did they want the RP's input regarding Resident 14's discharge. The RP stated I wasn't included (in the resident's discharge) and there was no discharge planning for Resident 14. During an interview with the ADON on 06/11/21 at 4:09 p.m., the ADON confirmed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON acknowledged the facility discharged Resident 14 on 6/7/21. The ADON confirmed the nursing note dated 6/7/21, indicated Resident 14 was discharged from the facility and the RP was not present or part of this discharge process. Review of the facility's Policy and Procedure Discharge Summary and Plan, revised in November 2017, indicated the Resident/representative would be involved in the post-discharge planning process. 6. During an interview and concurrent record review with the SSD on 6/11/21 at 10:34 a.m., SSD confirmed Resident 14's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .resident is incapable of understanding rights, responsibilities, and informed consent. Review of the Physician's Progress note written by MD U dated 6/5/21, indicated Resident 14's capacity did not change. Review of Resident 14's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident 14's Progress Notes written by MD U dated 6/5/21, indicated .patient is in wheelchair going around the facility. MD U's progress note also indicated Resident 14 needed to follow up with the infection disease clinic in three to four weeks. During an interview and record review with the SSD on 6/11/21 at 10:34 a.m., the SSD stated Resident 14 was discharged on [DATE] to a local street corner at two streets with a walker. SSD stated Resident 14's discharge location area was on the street and not an actual home. SSD confirmed the facility did not discharge Resident 14 home per MD U's order. During an interview with the SSD on 6/14/21 at 12:16 p.m., SSD stated Resident 14 was taken to the corner of two streets by an Uber (driving service) without the facility staff accompanying the resident. Resident 14 was discharged to the street alone. The SSD confirmed the community is not a street or a homeless shelter. During an interview with the SSA (social services assistant) on 6/14/21 at 1:30 p.m., the SSA provided Google map images of the area where Resident 14 was discharged and circled the corner of the two streets next to the traffic light as the location where the resident was dropped off. During a telphone interview with MD U on 6/11/21 at 1:28 p.m., MD U stated he did not know where Resident 14 was discharged to and the facility did not inform him that Resident 14 was discharged to the street. MD U stated he was shocked and it was not acceptable that Resident 14 was discharged to the street. MD U further stated Resident 14 would ended up back in the hospital and the discharge was not safe . Review of the facility's undated Policy and Procedure physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. During a telephone interview and concurrent record review with the facility ombudsman representative on 6/14/21 at 10:47 a.m., the ombudsman representative stated she was unaware Resident 14 was discharged to the street when the facility notified her that Resident 14 would be discharged from the facility. The Ombudsman stated I assumed they (the facility) would follow rules. I would not have approved of this (if aware Resident 14 was discharged to the street). Review of the fax the facility social services sent to the ombudsman dated 6/7/21 at 6:00 p.m., indicated Resident 14 was discharged to the community on 6/7/21. 8. During a telephone interview with FM A on 6/16/21 at 1:01 p.m., FM A called this writer (surveyor) and informed this writer that Resident 14 was found passed out on the street within the first day (within 24 hours) of discharge from the facility on 6/7/21. FM A stated Resident 14 could not eat, could not walk, and was confused. FM A stated emergency services were contacted and Resident 14 was taken to a local acute hospital via an ambulance for further evaluation. FM A stated Resident 14 was discharged from the hospital to a different skilled nursing facility. FM A stated she visited Resident 14 at the new skilled nursing facility on 6/16/21. Review of the acute hospital admission note dated 6/8/21, indicated Resident 14 was admitted to the acute hospital on 6/8/21, which was the second day after Resident 14 was discharged to the street from the facility. The hospital admission note dated 6/8/21, indicated Resident 14 was admitted to the hospital due to weakness and abdominal discomfort. The admission note indicated Resident 14 was a poor historian (unable to give a clear history of medical health information), had the inability to walk, and the resident had a chest X-ray (machine that uses waves to create pictures of the inside of the body) for the chest pain. The hospital planned to discharge Resident 14 to another skilled nursing facility.

Based on observation, interview and record review, the facility failed to provide adequate assistance for one of three residents (20) when certified nurse assistant H (CNA H) transferred resident 20 from shower chair to bed by herself. This failure resulted in Resident 20's sustained ankle fracture (common injuries that are most often caused by the ankle rolling inward or outward). Findings: A review of Resident 20's clinical record indicated she was admitted on [DATE] with the [DIAGNOSES REDACTED]. weakness (is a decrease in the strength in one or more muscles or muscle group exclusively. A review of Resident 20's fall care plan dated 11/15/13 indicated at risk for falls related to altered mental status (changes in brain function), antidepressants (to treat depression), antipsychotic (to treat mental disorders), antihypertensive (to treat hypertension), cardiovascular disease [MEDICAL CONDITION] disorder (sudden, uncontrolled electrical disturbance in the brain), and poor trunk control (ability to hold the body upright when sitting or moving). Her contractures care plan dated 10/16/17 indicated loss of muscle tone to left lower extremity (LLE) related to disease process. A review of the physical therapist (PT, allied health professionals that, by using mechanical force and movements, remediates impairments and promotes mobility and function) evaluation and plan of treatment dated 10/16/17 indicated Resident 20's prior level of function (PLOF, status of functional abilities prior to the condition causing the need for rehabilitation services) for transfer was maximum assist and functional mobility assessment for transfer indicated total dependence without attempts to initiate and pivot (rotate or turn) indicated total dependence without attempts to initiate. A review of Resident 20's minimum data set (MDS, an assessment tool) dated 10/19/2017 Section G letter B. Transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position (excludes to/from bath/toilet) indicated 7 (activity occurred only once or twice) and support indicated 3 (two + person physical assist). A review of Resident 20's fall risk assessment dated [DATE], indicated fall risk summary score was 14 with predisposing factor including [MEDICAL CONDITION] (sudden attack of illness, especially a stroke or an epileptic fit) disorder. A review of the nurse's notes dated 12/4/17 indicated at 16:50 p.m., CNA H transferred Resident 20 from shower chair to bed with one person assist. Resident 20 accidentally slid down on her left side. Resident 20 was noted with skin redness on the left elbow. On the same date at 21:00 p.m., Resident 20 was noted with swelling and skin discoloration on left lower leg and foot and Resident 20 complained of pain. A review of the acute care hospital discharge document indicated Resident 20 was admitted and discharged on [DATE] with a tibia (larger bone of the lower leg, on the big toe side of the ankle, where injury often happened when the ankle was twisted strongly, which tears ankle ligaments) fracture (break in a bone) with non-weight bearing instruction for left ankle. A review of the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) post-fall assessment (Accident: Event-Fall) notes completed on 12/8/17 indicated CNA H performed a one-person assist transfer, lifted Resident 20 off the shower chair to do a pivot transfer (to move patients with decreased weight-bearing ability, despite its high risk causing injury to both patient and caregiver), to bed when Residents 20's foot got caught on one of the shower chair legs. CNA H lost her balance and fell along with Resident 20 who landed on the floor next to CNA H. A review of the physician's orders [REDACTED]. A review of the physician's orders [REDACTED]. Monitor left leg (distal tibia fracture,) for signs of skin breakdown every shift. During an interview with CNA H on 3/8/18 at 6:09 p.m., with the presence of the assistant director of nursing G (ADON G), she stated the fall happened on 12/4/17 when she transferred Resident 20 from shower chair to bed. CNA H stated she lifted Resident 20 off the shower chair to do a pivot transfer to bed. CNA H stated she suddenly lost balance and she really was not sure what happened. CNA H also stated Resident 20's left foot probably got caught at the shower chair leg. Although she stated Resident 20 needed extensive help with two-person assist (when more than one person is required for safe transfers) for transfer, CNA H stated she transferred Resident 20 by herself and did not call for assistance. During an interview on 3/7/18 at 9:58 a.m., Resident 20 stated in Spanish (interpreted by LVN J), she had a fall and staff now use a Hoyer lift (an assistive medical device) to transfer her. Resident 20 then showed her left arm with splint and her left foot with the CAM boot on. During an interview and record review on 3/8/18 at 8:43 a.m., ADON G stated the fall incident happened on 12/4/17 when CNA H transferred Resident 20 from shower chair to the bed with one-person assist (by herself). ADON G also stated on the MDS, Section G (Functional Status) under letter B (Transfer) dated 10/19/2017 indicated support was coded 3 (two +persons physical assist). In another interview on 3/9/18 at 2:03 p.m., LVN I stated Resident 20 needed two-person assist even prior to her fall on 12/4/17. LVN I stated after the fall, CNAs use a Hoyer lift due to Resident 20's NWB status until her orthopedics doctor follow-up. A review of the facility's revised 12/2007 policy, Falls and Fall Risk, Managing, indicated the staff will identify interventions related to resident's specific risks and causes and try to prevent the resident from falling and to try to minimize complications from falling.

Based on interview and record review the facility failed to provide adequate supervision to prevent an accident for one of 11 sampled residents (Resident 1) when facility staff were aware of Resident 1's unsafe behavior of smoking with oxygen in use. This failure resulted in a fire with Resident 1 sustaining extensive thermal (burn) injuries and death. Findings: Review of Resident 1's record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had a physician's orders [REDACTED]. Review of Resident 1's nursing progress notes dated [DATE] at 2:14 p.m. (documented a day after the incident) indicated a fire started in Resident 1's room (Room A) and Resident 1 was caught on fire. Before the fire, a certified nursing assistant (CNA A) saw Resident 1 standing in her room, not on oxygen, and she was fiddling with hands under the table but did not smell smoke. CNA A left the room to retrieve supplies and on the way back, a visitor and Resident 1 called for help. CNA A saw Resident 1 standing and the top of her pants was on fire. After grabbing a towel and wetting it in the bathroom, CNA A saw the resident was already covered in flames and she couldn't get close to the patient. During an interview on [DATE] at 2:45 p.m., CNA A stated she was assigned to provide care to Resident 1 on the evening of the fire. Resident 1 used oxygen constantly, she sometimes removed it and the oxygen in her room (Room A) was never turned off. She recalled about two weeks before the fire, she smelled cigarette smoke in Resident 1's room. CNA A went out of the room to get supplies and when returning heard a male visitor yelling she needs help. She saw two nurses run into the Room A to stop the fire. CNA A proceeded to evacuate other residents and when she did not see Resident 1 outside, she went back to a bathroom joining Room A, opened the door and saw Resident 1 standing and saying help me, help me in a weak voice. CNA A screamed for help, ran to restorative nurses assistant (RNA) B and told him Resident 1 was still in her room. RNA B went to Room A and took Resident 1 out of Room A. During an interview on [DATE] at 3:15 p.m., RNA B described Resident 1 as forgetful, frequently asking Where's my room. and she smoked every day. On the day of the fire, RNA B entered Room A, saw a flame on one spot of the floor and discharged the fire extinguisher and stated he did not know someone was inside the room. RNA B then went out of the room holding his breath and saw a female staff holding a fire extinguisher. RNA B took the extinguisher from the staff and used it in Room A. When he stepped inside the Room A, he heard someone moaning and saw someone standing, leaning on the bedside table, and he was presuming the person was Resident 1. No one else was in the room. He hooked his left arm around Resident 1 and led her out of the building. During an interview on [DATE] at 4:30 p.m., the Minimum Data Set coordinator (MDS-C) stated he heard there was a fire, he got a fire extinguisher and went to Room A. MDS-C saw CNA A went to the bathroom to wet a towel and Resident 1 was standing, holding onto the bedside table and her lower trunk was on fire. The fire suddenly traveled to the resident's body, arms and legs and he discharged the fire extinguisher. There was so much smoke he could not see anything and he stepped out to rescue residents in the hallway. During an interview on [DATE] at 10:30 a.m., the charge nurse (CN) stated Resident 1 was confused, needed constant reminding about smoking times and designated smoking area. Resident 1 sometimes sneaked outside and smoked and needed oxygen when she returned to her room. On the day of the fire, CN was clocking in to work at 4:03 p.m. and heard someone shouted she needs help and a staff member was pointing to Room A. She saw Resident 1 in flames to her lower abdomen and clothing. She noticed the oxygen concentrator was running and pulled out the plug. The room was full of smoke and she could not breathe so she ran out of the room thinking someone was still with Resident 1. CN saw Resident 1 being taken out of the building by RNA B. The CN stated she did not take Resident 1 out of the room because she could not breathe and if she touched the resident she would also be on fire . During an interview on [DATE] at 11:10 a.m., the director of staff development (DSD, staff who oversees training programs and works directly with employees to become knowledgeable and efficient) stated the facility used the RACE procedure for emergency response. RACE is an acronym where R represents rescue, A - alarm, C - confining the fire, and E - extinguishing and evacuation. The DSD stated she gave staff inservice training going over the RACE procedure before the fire. The DSD stated if a person was on fire, the correct procedure was to put the person on the ground and roll. She did not know Resident 1 was left alone in the fire. Review of the DISASTER PREPAREDNESS AND FIRE PREVENTION a PowerPoint inservice, dated [DATE], indicated the first two to three minutes of a fire emergency was the most crucial. Memorizing the acronym RACE could help you remember what to do if such an emergency occurred. R was for rescuing residents and the First priority must always be to rescue resident in immediate life threatening danger. Review of the RESPONDING TO A PERSON IN FIRE undated lesson plan indicated if a person catches fire, to wrap them with blanket, get them down on the ground and if necessary use a leg, sweep, roll them on the ground until the fire is out. Review of the Sign-In Sheet dated [DATE] for the Disaster Preparedness and Fire Prevention inservice showed the staff involved in Resident 1's fire incident (CNA A, RNA B, MDS-C, CN and RN) had signed the sheet indicating they had attended the inservice. During an interview on [DATE] at 3:40 p.m., a register nurse C (RN C) stated she attended to Resident 1 on the day of the fire. Resident 1 was always smoking and someone in the past had reported the resident smoked in her room. The oxygen in Resident 1's room was always running. On the day of the fire someone was saying ahhh, ahhh and RN C ran with another female staff into Resident 1's room and saw a Resident 1 on fire and she was trying to pull down her pants. The fire to her left hip was growing fast. In another second the fire blew and she could not extinguish the fire and she ran out of the room to find an extinguisher. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated [DATE], indicated she had severe impairment in memory and in daily decision-making skills. Resident 1 had a cognitive loss/dementia care plan dated [DATE], indicating she had changes in short and long term memory recall and was moderately impaired in daily decision making skills. Review of Resident 1's nurses progress notes dated [DATE] at 1:52 p.m. indicated a certified nurse assistant D (CNA D) reported Resident 1 was observed smoking a cigarette in her room. Review of Resident 1's Nursing Quarterly Annual - Safe Smoking Evaluation form dated [DATE] and [DATE], both indicated Resident 1 was a safe smoker. The [DATE] form indicated yes to the question, Are there any concerns about the Resident's ability to smoke independently? and had no explanation of the smoking concern. Review of Resident 1's social services notes dated [DATE] at 8:15 a.m. indicated the social services director (SSD) informed Resident 1 about the smoking policy and smoking was only allowed in the designated area (outside gazebo). It indicated Resident 1 was in agreement and signed the smoking contract. Review of a SMOKING CONTRACT, dated [DATE], indicated a verbal consent was obtained by Resident 1's responsible party (RP) on [DATE] and signed by the administrator on [DATE]. It indicated Resident 1 agreed to refrain from smoking in the bedroom or in the building at any time and understood smoking was a Clear and present danger. Review of Resident 1's quarterly interdisciplinary (IDT, team members from different departments involved in a resident's care) conference note dated [DATE] at 1:38 p.m. indicated there was a discussion with the RP and ombudsman (an advocate who listens to and addresses the concerns of nursing home residents) about the implementation of the smoking policy and nursing was to call the RP when Resident 1 was found with a lighter. Review of Resident 1's smoking care plan dated [DATE], identified problem episodes of smoking in the side patio and the entrance of the facility, non-compliance with the smoking schedule and policy. The behavioral symptoms care plan dated [DATE], [DATE], and [DATE] indicated problem behaviors such as refusing care. The behavioral and smoking care plans were not revised in identifying Resident 1's behavior of using oxygen and smoking in her room and not informing staff when given cigarettes and lighters, despite the facility staff being aware of her non-compliance. During an interview on ,[DATE] at 2:15 p.m., the assistant director of nurses D (ADON D) who reviewed the record stated when Resident 1 was found in her room smoking , there should have been a care plan identifying Resident 1's behavior with new approaches developed. ADON D confirmed there was no documentation supporting Resident 1 was monitored for smoking and having smoking paraphernalia (e.g. cigarettes and lighters). During an interview on [DATE] at 10 a.m., the administrator (ADM) described Resident 1 as forgetful and hard to redirect. In February 2017, he saw Resident 1 with an unsafe behavior of smoking outside and reconstructed the smoking policy. The assistant director of nurses reassessed and passed Resident 1 as a safe smoker and Resident 1 continued to have unsafe smoking behavior. Residents who were unsafe could not have smoking materials on them and needed supervision. During an interview on [DATE] at 12:50 p.m. the social services director (SSD) stated Resident 1 was very forgetful about everything, had a two-minute attention span, and smoked 10 to 15 cigarettes a day. The SSD stated Resident 1 would slowly walk outside towards the gazebo (designated smoking area), get tired halfway and smoke near a trash can. The SSD also stated friends gave Resident 1 cigarettes even though they knew they were not supposed to, they felt sorry for her. The SSD further stated when a family member did laundry, she found several lighters in the pockets of her clothing. The SSD stated after the fire incident, Resident 1's smoking assessment was reviewed and determined the safe smoking conclusion was a mistake. During an interview on [DATE] at 12:40 a.m., the ADON C who completed Resident 1's smoking assessment on [DATE] stated Resident 1 was assessed as a safe smoker. Her concern of Resident 1 smoking safely was her low BIMs score (Brief Interview for Mental Status, an MDS assessment tool to evaluate a resident's decision making skills) and stated she should have but did not document her concern on the form. ADON C stated she assumed her role in [DATE] and did not know Resident 1 had been noncompliant with smoking rules. Because the resident was assessed as a safe smoker she was allowed to smoke unsupervised. Review of an acute care hospital emergency department provider notes dated [DATE] at 5:34 p.m. indicated Resident 1 was brought in by ambulance as major trauma for estimated 80% burns. It documented Resident 1 was smoking cigarette and the oxygen tank flashed and caused fire at the skilled nursing facility. During transport from the skilled nursing facility to the emergency room , Residnt 1 coded (absence of pulse) and died in the emergency room . Under SECONDARY SURVERY section, it indicated Resident 1's head had desquamation (peeling skin) and burns across face and scalp, tympanic membranes (eardrum) with scarred EAC (external auditory canal, or outer ear), large tongue, burned labia (the inner and outer folds of the vagina), and thickened skin with burns and sloughing off (dead tissue separating from living tissue) when touched over forehead, cheeks, neck, chest, back, arms, thighs, and genitals. Review of the county MEDICAL EXAMINER-CORONER report dated [DATE], indicated the cause of Resident 1's death was extensive thermal (burn) injuries. The undated SMOKING POLICY, indicated smoking was not allowed inside the facility. Unsafe /dangerous behavior was defined as smoking in areas that were not designated, smoking with oxygen tank in close proximity, improper extinguishing and disposal of cigarette buds, etc. For residents who demonstrate unsafe/dangerous smoking behavior, smoking was only allowed in the Gazebo and only at the designated times under the supervision of a facility staff member.

Based on observation, interview, and record review, the facility failed to conduct Resident 10's quarterly fall risk assessment (a tool used to identify risk factors for fall and formulate action plan), and failed to implement the intervention of placing the bed in a low position for one of 27 sampled residents (Resident 10). These failures resulted in a fall and a right hip fracture. Findings: Review of Resident 10's facesheet on 2/28/17, indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Her minimum data set (MDS, an assessment tool) dated 6/10/16 indicated the resident had severe impaired cognition (the activities of thinking, understanding, learning, and remembering), required assistance in bed movements, transfers, walking, and toileting. Review of Resident 10's fall risk assessment dated [DATE], indicated under fall risk summary score Resident 10 had a score of 19 which indicated she was at risk for fall. There was no quarterly fall risk assessment done for 9/2016. During an interview and record review with the assistant director of nursing (ADON) on 3/1/17 at 11 a.m., he stated Resident 10 was at high risk for falls, and there should be a quarterly fall risk assessment in 9/2016. Review of Resident 10's care plan for fall risk dated 9/17/16, indicated to keep the bed in the lowest position with the brakes locked. Review of Resident 10's event report dated 11/22/16, indicated the resident had an unwitnessed fall at 3:30 p.m., and was found on the floor. Per the body assessment it was suspected there was a fracture or an actual fracture. Review of Resident 10's progress note dated 11/22/16 at 11 p.m., indicated at 3:30 p.m., a CNA assisting across the hall noted the resident was on the floor with the bed elevated, and was calling for help. (Resident 10) was unable to state what she was doing prior to fall. Review of Resident 10's progress note dated 11/23/16 at 8:19 a.m., indicated receipt of the results of the X-ray (an imaging test used to produced photograph of bones which can be checked for fractures). Results were acute right hip fracture. Resident 10 had an old fracture involving right rami (part of a pubic bone) with modest healing. Resident 10's primary physician was called to report the X-ray result, and he ordered to transfer Resident 10 to the acute hospital. Review of Resident 10's acute hospital discharge summary dated 12/1/16 and the admitted d 11/23/16, indicated Resident 10's discharge [DIAGNOSES REDACTED]. Review of Resident 10's care plan for falls dated 12/2/16, indicated to keep the bed in a low position with an alarm, landing pad, and hip protector. Review of Resident 10's event report dated 12/23/16, indicated the resident had an unwitnessed fall when she was found on the floor while she transferred from the wheelchair to her bed, and lost her balance. During an observation on 2/28/17 at 7:40 a.m. and 3/1/17 at 8:30 a.m., Resident 10 was lying in her bed with her eyes closed. The bed was elevated and was not in a low position. During an observation and interview with licensed vocational nurse C (LVN C) on 3/1/17 at 8:35 a.m., Resident 10 was lying in bed. The bed was not in a low position, and the bed alarm was turned off. LVN C confirmed the bed should have been in a low position and the bed alarm should not be turned off. A review of the facility's 2001 policy, Fall and Fall Risk, Managing, indicated the staff identify interventions and implement relevant interventions to try to minimize serious consequences of falling.

Based on interview and record review, the facility failed to ensure one of five residents (3) was provided with adequate supervision when Resident 3 used a bedside commode (a movable toilet which looks like a chair with a toilet seat with a bucket or container underneath). Resident 3 fell to the floor when a certified nurse assistant (CNA) left Resident 3 alone on the bedside commode and sustained an acute subdural hematoma (SDH, a collection of blood on the surface of the brain), intraventricular hemorrhage (IVH, bleeding inside or around the ventricle spaces in the brain) and subarachnoid hemorrhage (SAH, bleeding in the area between the brain and the thin tissues that cover the brain). Resident 3 required one staff member's physical assistance to use the toilet. This failure resulted in brain injuries to the resident and Resident 3 required more assistance with activities of daily living (ADL) after hospitalization . Findings: Resident 3's clinical record was reviewed. Resident 3's Minimum Data Set (MDS, an assessment tool) dated 11/5/14, indicated she had short and long term memory problems with [DIAGNOSES REDACTED]. She had hearing difficulty and her vision was listed as severely impaired. Resident 3 was a non-English speaker and she needed one staff member's physical assistance for ADL such as toileting. The assessment for the balance during moving on and off the toilet indicated Resident 3 was not steady and only able to stabilize with staff assistance. Review of Resident 3's Optometric Consultation dated 2/17/14, indicated Resident 3 was legally blind. (Legal blindness is defined as visual acuity (vision) of 20/200 or less in the better eye with best correction possible. This means a legally blind individual has to stand 20 feet from an object to see it with the same degree of clarity as could a normally sighted person from 200 feet.) Review of Resident 3's Fall Risk Evaluation dated 8/25/14, indicated Resident 3 was at risk of fall with highly or severely impaired vision status, elimination with assistance, ambulation with problems and unsteady balance while standing, sitting and during transitions. It further indicated Resident 3 was only able to stabilize with physical assistance for the balance. Review of Resident 3's Fall Prevention and Safety Care Plan initiated 11/23/12 and revised 8/25/14, indicated not to leave Resident 3 alone in the bathroom due to poor safety awareness, unsteady gait, impaired cognition/communication, visual impairment, attempts to stand/transfer without assistance, and fragile skin. Review of Resident 3's SBAR Communication Form (Situation-Background-Assessment-Request, a standardized nursing communication tool) dated 11/10/14, indicated Resident 3 was on her bedside commode and certified nurse assistant A (CNA A) was assisting Resident 3. CNA A heard an alarm sound outside the room and CNA A left the room to check from where the alarm sound came. Resident 3 was left alone on the bedside commode and when CNA A returned to her, Resident 3 was found lying on the floor. It further indicated Resident 3 sustained a cut and a bump on the left eyebrow with moderate amount of blood coming out continuously and Resident 3 was transferred to an emergency room in a general acute care hospital (GACH). Review of Resident 3's History and Physical Report from the GACH dated 11/11/14, indicated Resident 3 sustained an acute subdural hematoma, intraventricular hemorrhage, and subarachnoid hemorrhage from the fall incident. Resident 3 was admitted to an intensive care unit in the GACH. During an interview with the assistant director of nursing (ADON) on 11/24/14 at 1:40 p.m., he stated staff should stay with Resident 3 during her toileting. During a telephone interview with CNA A at 11/24/14 at 3:20 p.m., she stated she was aware Resident 3 was confused and required assistance with toileting because of fall risks. CNA A stated she heard an alarm while she was assisting Resident 3 and left Resident 3 alone on a bedside commode to check the alarm outside the room. When CNA A returned to the room, CNA A found Resident 3 on the floor. CNA A stated she should not have left Resident 3 alone on a bedside commode. CNA A further stated she should have called coworkers for help. During an interview with the director of staff development (DSD) on 11/24/14 at 2:10 p.m., she stated she instructed staff not to leave alone a resident on a toilet who required assistance during toileting. During an interview with restorative nursing assistant C (RNA C) on 11/25/14 at 3:35 p.m., he stated Resident 3 was able to walk with assistance and her gait was unstable. RNA C stated Resident 3 required one staff member's physical assistance for toileting. Review of Resident 3's Admission Evaluation dated 11/17/14, indicated Resident 3 was readmitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 3's Occupational Therapy (OT) Discharge Summary dated 11/19/14, indicated Resident 3's baseline was assessed on 11/18/14. It indicated Resident 3 was unable to stand during ADL (total dependence) and Resident 3 showed total dependence for toilet/commode transfers. Review of Resident 3's ADL Tracking Form dated 11/17/14, indicated Resident 3 was totally dependent with two staff members' physical assistance for most ADL functions and Resident 3 became always incontinent (a loss of control) of bladder. During an interview with the Minimum Data Set coordinator (MDSC) on 11/24/14 at 3 p.m., she reviewed Resident 3's ADL Tracking Form and stated Resident 3 had a decline in ADL functions after hospitalization , which was caused by the fall incident. Review of the undated manufacturer's instructions for the bedside commode indicated users with limited physical capabilities should be supervised or assisted when using the commode.