Every finding on record at Catalina Post Acute and Rehabilitation

Based on clinical record review, interviews, facility documentation, and policy review, the facility failed to ensure one resident (Resident #3) was administered a blood pressure medication within the provider-ordered parameters. This deficient practice places residents at risk for severe cardiovascular symptoms.Findings include:Resident #3 was admitted on [DATE] with diagnosis including epilepsy, hypertensive heart disease with heart failure, tachycardia, mixed anxiety disorders, systolic congestive heart failure and atherosclerotic heart disease of native coronary artery with unstable angina.The minimum data set (MDS) dated [DATE] revealed that the resident had a brief interview of mental status (BIMS) score of 14 indicating that the resident was cognitively intact.The physician orders revealed an order for Metoprolol Tartrate Oral Tablet to give 50mg by mouth 2 times a day and to hold for systolic blood pressure (SBP) less than 90 or heart rate less than 50.The August 2026 Medication Administration Record (MAR) revealed:August 23, 2026 the evening dose of Metoprolol Tartrate was not administered and that the resident's systolic blood pressure reading was 102 and heart rate was 73.August 24 2026 the evening dose of Metoprolol Tartrate was not administered due to systolic blood pressure reading outside of physician ordered parameters. Systolic blood pressure reading on August 24, 2026 revealed reading of 105 at 7:02 PM, and pulse was 66.An interview was conducted on August 26, 2026 at 7:29 PM with resident #3 who stated that his Metoprolol was not being administered as ordered. He stated that his neurologist wanted him to take the medication twice a day and that on at least 2 occasions he had been denied the Metoprolol by staff stating that his blood pressure did not meet physician ordered parameters.An interview was conducted on August 26, 2026 at 8:03 PM with Licensed Practical Nurse (LPN/ staff #15) who stated that if Metoprolol had physician ordered parameters indicating to not administer if systolic blood pressure was below 90 then if the vitals taken indicated a systolic blood pressure below 90, she would not administer the medication. She stated that if the systolic blood pressure was above 90 then she would administer the medication. The LPN stated that if she had concerns regarding the physician ordered parameters, she would reach out directly to the physician. She stated that the risk for not administering Metoprolol within the ordered parameters could include hypotension or hypertension.An interview was conducted on August 26, 2026 at 8:11 PM with Registered Nurse (RN/ staff #41) and LPN/ staff #55. The LPN pulled up and reviewed the electronic health record for resident #3 and stated that on the evening of August 23 and August 24 Metoprolol should have been administered based on the physician ordered parameters. The RN stated that Metoprolol is a medication that also helps with the heart rate and that not administering the Metoprolol within ordered parameters could put the resident into serious problems, to include death.An interview was conducted on August 26, 2026 at 8:22 PM with the Director of Nursing (DON/ staff #99) who stated that her expectation was for staff to follow physician orders. She stated that if staff had concerns regarding any of the ordered parameters that they need to contact the physician for any clarifications. The DON reviewed the electronic health record for resident #3 and stated the resident's systolic blood pressure was not below 90 on either August 23, 2026 or August 24, 2026 and therefore the Metoprolol should have been administered. The DON further stated that there was no documentation that the physician had been contacted for clarification. The DON stated that the risk to the resident is that it could negatively impact the resident's blood pressure or heart rate.A review of the facility policy titled Medication Administration reviewed May of 2025 revealed that the focus of the policy is to accurately prepare, administer and document oral medications. The policy further revealed that vitals signs are taken if required and medications are held if indicated. The policy also revealed that any irregularity in pouring or administering a medication must be reported to the doctor.

Based on observations, resident interviews, staff interviews, and a review of policies and procedures, the facility failed to ensure that one resident, out of three sampled residents (#201), had access to personal belongings within the facility, in reasonable timeframe, to ensure a homelike environment. The deficient practice could impact the resident's psychosocial well-being, and adjustment to the facility.Findings include:Resident #201 was initially admitted on [DATE] and the most recent re-admission was on July 22, 2026 with diagnosis including toxic encephalopathy, chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, depression-unspecified, anxiety disorder, Parkinson's disease with dyskinesia, insomnia, hypertensive heart and chronic kidney disease with heart failure, atherosclerotic heart disease, chronic diastolic heart failure, localized edema, chronic pain, obesity, dependence on supplemental oxygen, osteoarthritis, and age-related osteoporosis.A review of the annual minimum data set (MDS) assessment dated [DATE] revealed no evidence of a BIMS (brief interview of mental status) score. A further review of the MDS revealed resident preferences that included: caring for personal belongings, use of phone in private, and a place to lock personal belongings.The Inventory of Personal Effect form dated July 4, 2026, revealed no personal belongings upon readmission.The physician orders revealed an order dated July 22, 2026 for non-pharmacological interventions which included to provide a quiet environment, to encourage the resident to express feelings, to talk to activities and to provide reassurance.The care plan revealed focus areas of COPD and oxygen therapy noting to monitor for breathing difficulty on exertion, respiratory distress and to remind the resident not to push beyond endurance. An additional focus area included that the resident was prescribed opioids for pain. The care plan also noted that the resident was at risk for impaired thought process and interventions included for social services to provide psychosocial support as needed. Furthermore, the resident was noted to be at risk for communication problems and interventions included to anticipate and meet the needs of the resident and to ensure/ provide a safe environment. The care plan also identified that the resident had self-care performance deficits due to weakness and impaired mobility, that the resident was at risk for falls and that the resident also was noted to have a potential for psychosocial well-being problem due to adjustment to a new environment. The care plan further identified that the resident was receiving both anti-anxiety and anti-depressant medications.An Inventory of Personal Effects form dated July 22, 2026 noted no evidence of new items or previously stored items by the facility.An observation was conducted on July 30, 2026 at approximately 8:43 AM. It was observed that plastic was wrapped around the room door handle and secured to the closet door, holding the door open. Behind the door, several plastic bags were observed to be stacked on top of one another. There was no evidence of personal items displayed in the resident's designated area.A telephonic interview was conducted on July 30, 2026 at 9:35 AM with the complainant. The complainant stated that every time the resident is admitted to the hospital from the facility, items either go missing or are broken.An interview was conducted on July 30, 2026 at 8:45 AM with resident #201. Resident #201 stated that when she has to go to the hospital from the facility, her personal items always go missing, most recently these included her phone, phone charger, cold cream, ball point pens, clothes and other items that she previously had in her room. She stated that because she didn't have her phone she wasn't able to call her daughter and let her know that she was back from the hospital. Resident #201 stated that she had asked several certified nursing assistants (CNA's) to assist her, since she was re-admitted on [DATE], with going through and unpacking her stored bags but stated that to date no one had helped her. She further stated her belongings were in plastic bags behind the room door but because of her mobility limitations, she was unable to access them. She stated that she had asked numerous CNA's (unable to recall any specific CNA's) for assistance, but stated that she was always told that they were busy. The resident further stated that it made her sad and uneasy since she did not know what belongings she still had and which might be missing. She stated that she thought the phone might still be in the bag, but was not certain and as a result had not been able to call anyone or receive calls from friends and family. The resident further stated she would like to see if anything has gone missing and would like to feel more settled and at home.An interview was conducted on July 30, 2026 at 9:00 AM with registered nurse (RN/ staff #9). The RN stated that when a resident is transferred from the facility to the hospital and the facility is uncertain whether or not the resident will return, the personal belongings are bagged up. The RN stated that housekeeping staff bag the belongings, label the bags and place them into storage. Staff #9 stated that when a resident returns from the hospital, the bags are returned to the resident by housekeeping staff. Staff #9 further stated that the CNA's would help the resident with unpacking the items and getting things 'back in order.' Staff #9 stated that returning and unpacking the items should not take more than a couple of days, but never as long as a week.An interview was conducted on July 30, 2026 at 9:06 AM with CNA, staff #115. Staff #115 stated that when a resident is transferred to the hospital, housekeeping is in charge of bagging up the belongings. Staff #115 further stated that when a resident returns from the hospital, housekeeping staff would assist with unpacking the stored items. The CNA stated that the delivery and unpacking of personal items should be done within a day or two. Staff #115 stated that the risk to the resident, if they do not receive or are not assisted with unpacking could include the resident not feeling secure or comfortable in their environment.An interview was conducted on July 30, 2026 at 9:10 AM with the social services supervisor, staff #101. Staff #101 stated that when a resident is transferred to the hospital, housekeeping staff would collect all their belongings and place them into storage at the facility. Staff #101 stated that she wasn't sure if inventory of the belongings was conducted when a resident is transferred to the hospital. When a resident is re-admitted , she stated that housekeeping would then take the items out of storage and deliver them to the resident either the same day or the next morning if the resident returned to the facility at night. She stated that it shouldn't take more than a couple of days.An interview was conducted on July 30, 2026 at 9:56 AM with licensed practical nurse (LPN/ staff #18). Staff #18 stated that when a resident goes to the hospital, housekeeping staff packs everything up in a plastic bag and places the items into storage. Staff #18 stated that an inventory sheet is done and it would be compared when the resident returns to ensure that they have all their items; however, the review of the facility inventory forms revealed no evidence of documentation of items when the resident left for the hospital or a reconciliation of items when the resident returned. Staff #18 further stated that often residents return from the hospital in the evenings and housekeeping staff do not work that late and given that they have the keys to the storage room the resident might not receive their belongings back until the following day, but that the expectation would be that staff, either CNA's or housekeeping assist the resident with unpacking. The LPN stated that it should never take a week to unpack the resident's belongings and stated that it is important for a resident to have their personal belongings so they can feel more at home. Staff #18 further stated that the risk to the resident could include the resident not feeling good about the circumstances, feeling frustrated and worried if their items may have gotten lost.An interview was conducted on July 30, 2026 at 10:13 AM with the food and environmental services director, staff #39. Staff #39 stated that when a resident goes into the hospital, the admission department tells housekeeping to bag the resident's personal belongings. Staff #39 stated that there is no inventory of items conducted when the resident leaves for the hospital. She stated that housekeeping staff bag the items and label them with the resident's room number and date prior to storing the items in the storage shed. Staff #39 stated that the admissions department also informs housekeeping if a resident returns from the hospital, but stated no inventory reconciliation is conducted when the resident returns. Staff #39 stated that housekeeping would deliver the bags to the resident's room and the CNA would help with unpacking the items. She further stated that it should never take more than 3 days to unpack the resident's items. Staff #39 stated that the risk could include an emotional impact on the resident if items of sentimental value were not returned timely or if a resident did not have access to their phone, they might not be able to contact their family.An interview was conducted on July 30, 2026 at 10:32 AM with housekeeper, staff #13. Staff #13 stated that if a resident is sent to the hospital, she is notified and would pack up the belongings. She stated that if they return during the day, she sometimes will help unpack the items. She stated that unpacking of the resident's belongings is a task that is shared between the housekeeping staff and CNA's.An interview was conducted on July 30, 2026 at 10:43 AM with the director of nursing (DON/ staff #94). Staff #94 stated that a homelike environment is one that is comfortable, pleasing to the resident and how they would like to have their environment at home to include use and access of personal items. Staff #94 stated that when a resident is discharged , housekeeping staff would pack up the belongings in bags, label the bags and place them in the storage shed. She further stated that when a resident returns from the hospital, housekeeping staff would retrieve the bags and place them in the resident's room and either housekeeping or CNA's would help the resident unpack and put the belongings away. She stated that it should not take more than a day or two to get the resident's belongings situated. The DON pulled up the discharge and admission documentation for resident #201 and stated that the resident's personal belonging should have been unpacked by now. Staff #94 stated that the risk to the resident could include the resident feeling uncomfortable, wanting access to their belongings and not feeling that it was a homelike environment.A follow-up interview was conducted on July 31, 2026 at approximately 11:19 AM with resident #201. The resident stated that housekeeping staff had finally assisted her with unpacking her items and her phone and charger were in one of the bags that were unpacked. She stated that as far as she could tell, all of her items were accounted for.A review of the facility policy titled Homelike Environment with a date of May, 2026 revealed that the purpose of the policy was to provide a homelike environment for residents and that this would include encouragement and providing opportunities for each resident to occupy an area reflecting his/ her interests, family, and /or is made personalized by bringing photos or items from home.A review of the facility policy titled Resident Rights, reviewed June 2025 revealed that resident rights included for residents to keep and use personal clothing and possessions in the Nursing Center as space permits.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 1 of 3 sampled residents (Resident #301) was free from neglect related to adequate hydration and access to fluids to meet the resident's needs. The deficient practice could result in dehydration and associated complications, including physical discomfort and decline in the resident's health status. Findings include:Resident #301 was admitted on [DATE] with diagnosis including urinary tract infection, altered mental status, epilepsy, metabolic encephalopathy, anemia in chronic kidney disease, end stage renal disease, dependence on renal dialysis, unspecified atrial fibrillation, chronic diastolic heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, hypertensive heart and chronic kidney disease with heart failure and stage 5 chronic kidney disease, cirrhosis of the liver, type 2 diabetes mellitus, orthostatic hypotension, depression and anxiety disorder.A review of the 5-day minimum data set (MDS) dated [DATE] revealed that the resident had a BIMS (brief interview of mental status) score of 00, indicating that the resident was severely cognitively impaired.A review of the physician orders revealed a change of condition for a change in elevation dated July 29, 2026 6:00 PM. An order for in-house dialysis for Tuesday, Thursday and Saturday was observed to have had a start date of July 6, 2026. There was no evidence in the physician orders that the resident had a fluid restriction in place.A review of the care plan revealed a focus area noting that the resident had a potential/ actual impairment to skin integrity due to fragile skin and interventions included to encourage good nutrition and hydration in order to promote healthier skin. The care plan further noted that the resident was at risk for falls due to weakness and that interventions included to keep needed items, such as water 'etc' within reach. Another focus area noted that the resident was at risk for malnutrition/ hydration and noted interventions included to offer and encourage snacks / fluids between meals.A review of the fluid intake documentation on the Plan of Care (POC) Response History in the electronic medical record revealed the following fluid intake:July 7, 2026 (Tuesday): 9:59 PM no documented fluid intake noted as 'not applicable'.July 10, 2026 (Friday): 1:00 AM no documented fluid intake noted as 'not applicable'.July 11, 2026 (Saturday): 5:59 AM no documented fluid intake, noted as 'not applicable'. A total of 740 cc were (cubic centimeters) documented for the dayJuly 12, 2026 (Sunday): 5:59 no documented fluid intake, noted as 'not applicable'. A total of 720 cc documented for the day.July 13, 2026 (Monday): A total of 700 cc's was documented for the day.July 14, 2026 (Tuesday): 1:23 AM no documented fluid intake, noted as 'not applicable'.July 22, 2026 (Wednesday): Fluid intake only documented twice, once at 12:30 PM and once at 7:35 PM for a total of 960 cc for the day.A review of the progress notes revealed no evidence that the resident was out of the facility on July 7, July 10, July 11, July 12 and July 14 of 2026.An observation was conducted on July 30, 2026 at 8:34 AM in the room of resident #301. The left side of resident's bed was situated closet to the window and had a fall mat positioned to the right side of the bed with a bedside tray table observed to the right of the fall mat and out of reach of the resident. No water pitcher or glass was observed on the bedside table or dresser in the resident's room. The resident was observed to have dry, and chapped lips.An observation was conducted on July 30, 2026 at 10:49 AM in the room of resident #301. Bedside tray table was observed to still be to the right side of the fall mat, outside of the resident's reach. No observed water pitcher or glass in the resident's room.An observation was conducted on July 30, 2026 at 11:17 AM in the room of resident #301. No water pitcher or glass was observed in the resident's room. The tray table was still located to the right of the fall mat and outside of the resident's reach.An interview was conducted on July 30, 2026 at 10:49 AM with resident #301. Resident #301 stated that she was thirsty. She stated that every time she wants water she would have to use the call light to ask for it; however, she was unable to locate the call light which had been tucked into the side of her bed. Once the resident did locate the call light, she activated it and requested water. An interview was conducted on July 30, 2026 at 8:47 AM with licensed practical nurse (LPN/ staff #31). Staff #31 stated that signs of dehydration could include a change in blood pressure or other vital signs, dry skin, dry / chapped lips, frequent urinary tract infections and dizziness. Staff #31 stated that there should be water pitchers in every room and that they are refreshed at least twice per shift or more if the resident requests it. The LPN stated that she usually likes to see her residents take in 1000 cc or more of fluids unless they are on fluid restriction. Staff #31 stated that if a certified nursing assistant (CNA) reported that a resident was not drinking a lot or refusing fluids, she would attempt to discuss it with the resident and if the issue did not resolve, she would elevate it to her director of nursing (DON).An interview was conducted on July 30, 2026 at 10:38 AM with CNA/ staff #7. Staff #7 stated that some of the signs of dehydration would include if a resident's skin looked dry, if they were going to the bathroom less frequently then they had been, if the color of their urine has suddenly become darker, if a resident appears more fatigued or if they experience dizziness. Staff #7 stated if she observed that the resident wasn't drinking a lot, she would encourage fluids and advise the nurse. Staff #7 stated that fluid intake is documented once per shift in the CNA POC section of the electronic health record. She further stated that 'not applicable' in the POC should only be sued if the resident was out of the facility or on an appointment.An interview was conducted on July 30, 2026 at 11:06 AM with LPN/ staff #18. Staff #18 stated that resident #301 had no fluid restrictions and should have a pitcher of water in her room that should be refreshed several times per shift or more if the resident requests it. Staff #18 entered the resident's room and confirmed that there was no water pitcher or glass in the resident's room and that the bedside table was not within reach of the resident. Staff #18 stated that the resident's lips did look a little dry. Staff #18 obtained water for the resident and moved the fall mat in order to position the bedside tray table closer to the bed and ensure that it was within reach of the resident. Staff #18 stated that the risk of not being able to access water readily could include dehydration.An interview was conducted on July 30, 2026 at 11:15 AM with CNA/ staff #21. The CNA stated that she always moves the tray table close to the resident, but stated that she had not seen that it was out of reach this morning. Staff #21 further stated that when dialysis comes in, they sometimes move the tray table back for easier access and then forget to move it back closer to the resident. The CNA stated that she goes into the resident's room at least every couple of hours to check on the resident, make sure the tray table is positioned close to the resident, offer water and ask if she needs anything; however, there was no water observed in the resident's room and the tray table was out of reach of the resident since 8:34 AM on July 30, 2026.An interview was conducted on July 30, 2026 at 11:38 AM with the director of nursing (DON/ staff #94). The DON defined neglect as not providing the care to someone of who needs it, which would include food, water and basic needs. Staff #94 stated that the expectation for hydration is that ice water is passed every shift, and that residents receive water during medication administration and meals. Staff #94 further stated that unless a resident was on fluid restrictions, she thought residents should be receiving between 1200 and 1500 cc of fluids daily. Staff #94 pulled up the POC documentation regarding fluid intake for resident #301. The DON stated that it appeared that the CNA's may have missed some documentation and that several days indicated that the resident had below 1000cc of fluids. She further stated that she would be most concerned with the entry selection in the POC indicating 'not applicable'. Staff #94 stated that if a resident is not eating or drinking for a day or two, she would expect staff to 'move it forward' and that a change of condition would be noted and this may result in the resident receiving supplements and or intravenous hydration. Staff #94 stated that the POC for fluid intake is not 100% accurate as it did not account for water given with medications or during snacks. Staff #94 further stated that water should be within reach of the resident and if there is a fall mat that there is a way to position the bedside table to ensure that the resident has access to the table. Staff #94 stated that the risk for not receiving enough fluids or having access to fluids could result in dehydration and psychological stress.A review of the facility policy titled Intake dated May of 2026 revealed that the purpose of the policy was to provide an accurate record of the resident's fluid intake. The policy further noted that nursing assistants will document fluids (in cc's) consumed and to monitor and record fluid intake from diet trays and from water pitchers at bedside.The policy titled Hydration dated January 2026 revealed that it is the policy of the facility to provide each resident with sufficient fluid intake to maintain proper hydration and health. The policy further noted that each resident is provided a container of fresh water, which is located on the resident's bedside stand, unless contraindicated.The policy titled Abuse: Prevention of and Prohibition Against revised December 2025 revealed that each resident has the right to be free from abuse, neglect, misappropriation, exploitation and mistreatment. The policy defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure one resident's (#91) assessment was accurate and reflective of the resident's status at the time of the assessment. The deficient practice could result in the resident not receiving appropriate care that is necessary for their wellbeing.Findings include:Resident #91 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, generalized muscle weakness, tracheostomy status, and dysphagia following cerebral infarction.Resident #91 was discharged from the facility on October 10, 2025.Review of the admission Minimum Data Set (MDS), dated [DATE] indicated Resident #91 completed a Brief Interview for Mental Status (BIMS) and scored a 00 which indicated she had severe cognitive impairment. The same MDS also indicated Resident #91 had no impairments in in the upper (shoulder, elbow, wrist, and hand) extremity.Review of the discharge record from the resident's previous facility indicated that Resident #91 had an x-ray of the left humerus on August 28, 2025 at 1:52 P.M. Findings for the x-ray indicated there was a severely angulated fracture of the proximal humeral shaft. Glenohumeral joint alignment appears to be preserved. No focal soft tissue abnormality. It was also noted that per family, she broke it approximately 2 years ago and ortho determined she was too high risk for surgical fixation, daughter will bring in brace.A review of the Initial admission Record, dated September 10, 2025 at 5:46 PM indicated Resident #91 was nonverbal and was not admitted with a sling device. It also noted that Resident #91 only moved her extremities with tactile stimuli.A review of Resident #91's Care Plan, initiated on September 11, 2025, revealed no goals or interventions related to her history of shoulder dislocation.A review of a Physical Therapy Evaluation and Plan of Treatment, dated September 11, 2025 indicated Resident #91 was referred to Physical Therapy (PT) for several conditions and one of them was identified as a chronic left humerus fracture. It was also noted that the fracture took place 2 years ago and the resident was too high of a risk for surgical fixation. The same evaluation identified several precautions for the resident and one of the precautions was using a sling for comfort due to a left humerus fracture.A review of an Occupational Therapy Evaluation and Plan of Treatment, dated September 11, 2025, indicated Resident #91's Range of Motion (ROM) was impaired in the Left Upper Extremity (LUE).Review of the Physician's Orders revealed an order, dated October 8, 2025 for an x-ray of the left humerus and left shoulder, stat, for left shoulder looks displaced.A second order, dated October 9, 2025, indicated that a sling was to be used on the left arm continuously for 8 weeks for a fracture of midshaft of the humerus.Review of the clinical chart revealed a Daily Skilled Note, dated October 8, 2025 at 5:14 P.M. The note indicated that Resident #91 was spontaneously moving her left arm this evening at (4:30 P.M.) when the wound team was changing (resident's) wounds. The note continued to explain that Registered Nurse (RN/Staff #84) observed Resident #91 moving her left arm and that it appeared, to Staff #91, that the left shoulder was not in place. The note continued to explain that Staff #84 spoke with Resident #91's daughter, who was outside of the room, informing her what happened and that she was going to request an x-ray of the shoulder. The note indicated that the daughter explained that the left shoulder had been broken twice and Resident #91 was not a surgical candidate. The note indicated the provider was notified about the shoulder and a stat x-ray had been ordered for the left upper arm and shoulder.Review of a Nursing Note, dated October 9, 2025 at 5:58 P.M. indicated that the results of the x-ray was reported to the provider.Review of a Daily Skilled Note, dated October 9, 2025 at 1:00 P.M., noted the Resident's condition being monitored was the fracture of the left humerus with sling on at all times.An interview was conducted on October 30, 2025 at 8:24 A.M. with Certified Nursing Assistant (CNA/Staff #4). Staff #4 recalled Resident #91 as not moving all 4 extremities when she provided cares to her. She also did not recall Resident #91 using a shoulder sling however, she did remember when Resident #91 was being turned, her left shoulder looked like it had popped out. Staff #4 indicated that she did not know if the shoulder was broken. She shared that she shared the information with the nurse on duty but was unable to remember the name of the nurse she reported it to.An interview was conducted on October 30, 2025 at 8:39 A.M. with CNA/Staff #77. Staff described Resident #91 as incontinent, not talkative, didn't really move around and sometimes would track, Staff #77, with her eyes. She also described the left arm always hanging when providing cares. Staff #77 added that she would change Resident #91, sit her up to eat, changed her every two hours and repositioned her. She would sometimes groan during cares and Staff #77 would communicate the groans to the nurse on duty because she was not sure if Resident #77 was in pain or not. Staff #77 also recalled Resident #91 not being mobile but her right arm was bent as if she had a contracture while the left arm would just lay any out, and they would put a pillow under the left arm to prevent swelling or skin damage as that arm would swell up. She also did not recall Resident #91 having a sling on her left arm.An interview was conducted on October 30, 2025 at 9:15 A.M. with Licensed Practical Nurse (LPN/Staff #22). Staff #22 explained that for new admissions she will assess the resident's mobility, continence status, skin, fall risk, wound care, mental health needs, medications, and etc. within a certain time period after admission. There were around 10 different assessments that needed to be completed and the initial assessment covers the whole person which is a review of systems. These assessments were documented under the assessments tab (in the electronic health record). However, if a resident was non-verbal then they would get the resident's history and health status from the family, their provider, and from the hospital notes. They also monitor the resident for 3 days post admission and it is documented via a change in condition note so they are able to get baseline vitals. Staff #22 explained that it was important for resident assessments to be accurate because if there are changes to the resident, they have accurate documentation to go off of. The risk of not having accurate assessments would be that critical information would be missing especially for a resident that is non-verbal. Staff #22 recalled Resident #91 and described her as having spontaneous eye movement, not responsive to verbal commands, appeared to track with her eyes, and not being able to move all four extremities. Staff #22 described her first assessment with Resident #91 being on September 11, 2025 which was the Weekly Skin Assessment. Staff #22 explained that she was working as a wound nurse at the time and was assessing Resident #91's skin. She had to ask a CNA to assist her with rolling the resident as she had no motor skills. At that time, she explained, she did not see anything off with Resident #91's arm. She added that she did not know the resident had a shoulder issue until she returned to work after her vacation, which ran through October 10, 2025. She shared that Staff #84 had told her that she had put a note into the resident's chart about the shoulder. When asked if she typically accesses therapy notes for residents and she shared that she only accessed it when residents are asking questions related to their therapy. The few notes that she had read are gibberish. They use abbreviations that I'm not familiar with. Staff #22 explained that the risk to the resident, for not having an accurate assessment completed upon admission, would be the resident having pain, further dislocation of the shoulder which could cause more damage.An interview was conducted on October 30, 2025 at 9:57 A.M. with LPN/Staff #1. Staff #1 explained that for new admissions, she would do a variety of assessments such as a baseline assessment, mobility, cognitive status, how much assistance they need with Activities of Daily Living (ADL), and skin assessments. She also explained that she gets historical information on a resident by reviewing a report from the admissions department which gives a brief update on the resident such as if they are alert and oriented, equipment they might need, what health conditions they previously had and what they needed to look out for. She added that sometimes they get new admissions with no information and she has to go with what little information she has but she is sometimes also to get information from family if a resident is not alert and oriented. Staff #1 explained that it was important to have accurate assessments because it gives the staff an idea of the residents' baseline and they can determine if something is off from their baseline. She shared that the risk of not having accurate assessment is they could miss something. She gave an example of a resident having slurred speech and they might think it's the resident's baseline but they are really having a stroke. Staff #1 recalled Resident #91 and described her as being on a vent, having a gastrotomy tube (g-tube), non-verbal, and limited mobility. She admitted that she only cared for Resident #91 once.An interview was conducted on October 30, 2025 at 10:12 A.M with the Assistant Director of Nursing (ADON/Staff #82). Staff #81 explained that new admissions are given a variety of assessments such as head to toe, neurological, elopement risk, skin, fall risk, and depending on the type of medications they receive they might trigger additional assessments. She also shared that historical information is received from the hospital which is then reviewed by the admissions department and then is put into the physical chart by a nurse supervisor. At that point the chart is reviewed and sent throughout the facility for different teams to review it. She added that nurses do have access to hospital records but it can be hard for them to review it because of time constraints. Staff #82 explained that it was important for these initial assessments to be as accurate as possible so that the facility doesn't miss anything. When asked if the nursing staff had access to residents' Therapy notes for physical and occupational therapy, she indicated that she didn't think they did as the therapy team used a different charting system. The only way the nurses knew what was being worked on was through direct communication with the therapist. When asked what the risk to the residents would be if assessments were not accurate, Staff #82 shared that the plan of care would not be accurate without the full story of the resident and it could also lead to missed treatment. Staff #82 shared that she was familiar with Resident #91 a little bit but she typically did not provide direct care to residents. She was aware that the resident was non-verbal and dependent with ADLs but did not know her cognition status. She was not sure if Resident #91 was able to move any of her extremities. After reviewing the Initial admission Record, she indicated that the assessment note Resident #91 was only able to move her extremities with tactile stimuli and all four extremities had limited ROM with contracture to the left arm. When asked to read the Daily Skilled Note dated October 8, 2025 at 5:14 P.M. After reading the note, Staff #82 shared that the note told her the wound team might not have been aware of the fracture and that the floor nurse was not aware of the injury as well. When asked what the risk to the resident would be if staff were not aware of the resident's history related to her shoulder dislocation, Staff #82 shared that the risk would be an increase of the injury and hurting the arm more. She shared that she did not know if it was care planned but using her clinical judgement, it should be care planned. After reviewing the care plan, she indicated that the shoulder injury was not in the resident's care plan. She added that she would expect to see information related to the history of the resident's shoulder dislocation under the resident's medical diagnosis and in the care plan.An interview was conducted on October 30, 2025 at 10:52 A.M. with the Director of Nursing (DON/Staff #28). Staff #28 explained that new admissions are given an initial assessment which includes the full body assessment, skin, neurological, and cardiopulmonary. Also, these initial assessments might trigger additional assessments such as pain management and psychotropics. The initial assessments are completed by the nurse working the floor. Staff #28 shared that it was important for these initial assessments to be as accurate as possible because they help the nurses know about the residents so they can treat the residents adequately. If the assessments were not accurate as possible then the risk to the residents would be dependent on what was missed. Staff #28 indicated that she was somewhat familiar with Resident #91 but knew she was not alert and oriented, did not respond well to staff, and was a two-person assist for cares. When asked to review the initial nursing assessment (Initial admission Record), written on September 10, 2025, Staff #28 shared that the assessment noted Resident #91 had a contracture to the left arm and had a ROM limitation on all sides. When asked why an x-ray was ordered, she explained that the wound care team and never seen her and moved her arm and they noticed the shoulder was separated as there was an indent so it looked like it was not in place. The nurse had spoken with the family and the provider and the family said it was an old fracture. The doctor wanted an x-ray to follow up and then the daughter brought in a sling for the resident to use. Staff #28 explained that Resident #91 did not have a sling with her when she was admitted . She also shared that when she spoke with the Staff #84, she was given the impression the she did not know about the shoulder fracture until she spoke with the provider. Staff #28 also shared that when the resident was admitted , the information about the fracture was not on the facesheet provided by the hospital and was not on the resident's diagnoses list. She added that after the resident was sent to the hospital, on October 10, 2025, they found information on the hospital discharge list about the fracture. She shared that this recent admission was the 2nd time Resident #91 was at the facility and they were unaware of her shoulder issue during the 1st admission period last year. Staff #28 explained that the resident's history of shoulder dislocation is important and if it was known earlier, she'd expect to see it on the care plan and assessments. She added that the risk to the resident for not having an accurate assessment is that nurses would not know what to look for and they did not protect the dislocated shoulder. She added that the resident should have had a sling on when she was admitted to the facility but the facility should have reviewed the admission paperwork more thoroughly. She stated that her expectation was for staff to read residents' history paperwork from the hospital more thoroughly. It was missed in multiple places and the facility was using float help at the time of the admission so she was not sure where the ball was dropped. When asked why the Therapy notes identified Resident #91's shoulder injury history and the facility's initial nursing assessment did not, Staff #28 was not able to identify the discrepancy and acknowledged that was something that needed to be addressed.Review of the facility's policy titled, Admission, indicates it was last reviewed in May 2025. The policy states that it was the policy of this facility to have well defined guidelines for processing the Resident's entry into the nursing facility and the resident's right guaranteed under federal and state law are protected. The procedure explained that the Licensed Nurse was to initiate the admission assessments.

Based on review of facility documentation, staff interviews and facility policy, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 99. The deficient practice has the potential to negatively affect resident care.Findings include:Review of the facility staff posting for February 8, 2025, revealed 12 hours for an RN on February 8, 2025. However, review of the facility labor punch details revealed that on February 8, 2025 there was no RN on duty for 8 consecutive hours.An interview was conducted on September 16, 2025 at 8:30 a.m. with the Director of Nursing (DON/staff #51). She stated that she was aware of the regulation requiring RN nursing coverage being 8 consecutive hours daily. The DON further stated Yep, none. There was no RN's on that day, I'm shocked by that. The DON concluded that it did not meet her expectations and stated that I never have no RN days. Review of the facility Staffing policy titled 'Sufficient staff revealed that it is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skillsets to provide nursing and related services to promote resident safety and attain or maintain the highest practicable mental, psychosocial well-being of each resident, as determined by resident assessment and individual plans of acre and considering the number, acuity, and diagnosis of the facility's resident population in accordance with the facility assessment.

Facility The facility failed to ensure that food is labeled and dated in accordance with food safety practices.Based on observations, staff interviews and policy review, the facility failed to ensure that food is labeled and dated in accordance with professional food safety standards.Findings include:An initial kitchen walk-through was conducted on September 14, 2025 at 9:00 AM. The cook, staff #55, was present during the walk-through, as the dietary manager was not on premises at the time. A bag of jalapenos, dated August 27, 2025, was observed in the cooling refrigerator. Staff #55 stated that the jalapenos should not be in the refrigerator more than 2 weeks. She removed the bag and stated that the risk for storing the jalapenos past the 2 week designated time frame could include foodborne illness. A further observation revealed a tomato, not bagged, with no indication of date or how long it had been there. A bag of lettuce was observed dated September 7, 2025 with no noted use-by date. Staff #55 stated that she was unsure how long these could be kept.During the same initial kitchen walk-through, a freezer observation was conducted at 9:05 AM. Staff #55 was present. Within the freezer, 2 bags of bountiful harvest brussel sprouts, an open bag of breadsticks as well as an open bag of Hawaiian rolls were observed without an open or use-by date. In the refrigerator, a box of bananas was observed with a received by date of September 9, 2025, discolored and large areas observed to be blackened. Staff #55 stated that these were to be used for pancakes.A follow-up interview was conducted on September 14, 2025 at 9:15 AM with staff #55 post initial kitchen walk-through. Staff #55 stated that all food products that are stored in the kitchen should be labeled and dated once taken out of a box and or opened. Staff #55 stated that the risk could include no knowing how long an item has been stored and a potential for foodborne illness.An interview was conducted on September 15, 2025 at 7:24 AM with the Dietary Supervisor, staff #101. Staff #101 stated that the expectation is that all food is labeled and dated and that this should always be done. Staff #101 stated that she is constantly reminding staff and checking to ensure that it is done. Staff #101 stated that if something is not labeled and dated then it needs to be thrown out and that the risk could include residents getting sick.An interview was conducted on September 15, 2025 at 8:57 AM with the administrator, staff #88. Staff #88 stated that the expectation is that all food products are properly labeled and dated upon delivery and storage, as well as thereafter once items have been opened. Staff #88 stated that the risk could include not knowing when the food was received, stored or opened. A review of the policy entitled Food Storage with a copyright date of 2014 revealed that food should be covered, labeled and dated if stored and not for immediate use. The policy further noted that all foods will be checked to assure that foods (including leftovers) would be consumed by their use by dates.

Based on a review of the clinical record, staff interviews, and the facility's policies and procedures, the facility failed to ensure that 1 out of 23 residents (Resident # 7) received pain medication as ordered by the physician.Findings include: Resident # 7 was admitted on [DATE], with diagnosis of morbid obesity, muscle weakness, cognitive communication deficit, bipolar disorder, and major depressive disorder. Review of Resident # 7's care plan dated March 18, 2024, revealed that Resident # 7 was currently on opioids for pain management, with interventions that include administering opioids as prescribed. A review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating that Resident # 7 is cognitively intact. Further review of the MDS revealed opioid usage. Review of Orders dated August 16, 2025, for Resident # 7 revealed an order for Oxycodone oral tablet 10 milligrams (mg) to be given by mouth every 4 hours as needed for pain rated as a 6-10. The Medical Administration Record (MAR) for the month of August 2025 revealed the following; August 26. 2025, at 10:03 p.m., Oxycodone was administered for a pain level of 8 out of 10.August 27, 2025, at 6:24 a.m., Oxycodone was administered for a pain level of 0 out of 10.August 27, 2025, at 10:29 a.m., Oxycodone was administered for a pain level of 9 out of 10. August 27, 2025, at 2:30 p.m., Oxycodone was administered for a pain level of 0 out of 10. Review of Resident # 7 MAR Administration notes revealed the following; August 27, 2025, at 6:28 a.m., the as needed (PRN) administration of Oxycodone on August 26, 2025, at 10:03 p.m. was effective and pain scale was a 0, even though the Oxycodone was administered again at 6:24 a.m. for a pain level 0. August 27, 2025, at 10:25 a.m., the PRN administration of Oxycodone at 6:24 a.m. was effective and the pain scale still remained 0, even though Oxycodone was administered again at 10:29 a.m. for a pain level of 9 out of 10. August 27, 2025, at 2:27 p.m. the PRN administration of Oxycodone at 10:29 a.m. was effective and the pain scale was a 0, even though Oxycodone was administered again at 2:30 p.m. for pain level 0.August 27, 2025, at 8:27 p.m. the PRN administration of Oxycodone at 2:30 p.m. was ineffective and the follow up pain scale was an 8. An interview conducted on September 16, 2025, at 8:38 a.m. with Licensed Practical Nurse (LPN/Staff #1) revealed that when Resident # 7 requested her pain medication, they would attempt non-pharmacological approaches to reduce the pain. If that did not work, they would obtain a current pain level and blood pressure to ensure that they were within parameters of giving the medication. Staff # 1 also revealed that the pain level and blood pressure are documented in the MAR, and the pain medication is administered. LPN Staff # 1 also revealed that she would wait roughly 30 minutes to an hour and check with Resident # 7 to see if the medication was effective, and this is documented as a MAR administration note. An interview conducted on September 16, 2025, at 9:11 a.m. with Director of Nursing (DON/Staff # 51) revealed that she expects medications to be administered within parameters that are set by the physician. Reviewing the medical administration record on August 27, 2025, DON # 51 revealed that the administration of oxycodone with pain level of 0/10 was outside the parameters set by the physician. The DON Staff # 51 revealed that giving medication outside of parameters has been an ongoing issue, and they have been working on correcting the issue, including having a Quality Assurance and Performance Improvement (QAPI) plan in place for medications outside of parameters. A Policy and Procedure titled; Physician Orders, dated May 2025. revealed that it is the policy of the facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure an oxygen order was in place for 1 of 27 sampled residents (#45) in accordance with professional standards of practice. The deficient practice could result in being oxygen administered when not needed, oxygen concentration levels not aligned with the resident's needs, as well as appropriate monitoring, changing of oxygen tubing and documentation.Based on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure an oxygen order was in place for one resident (#45) out of 21 The deficient practice could result in being oxygen administered when not needed, oxygen concentration levels not aligned with the resident's needs, as well as appropriate monitoring, changing of oxygen tubing and documentation.Findings include:Resident #45 was initially admitted on [DATE] with diagnosis including type II diabetes mellites with diabetic neuropathy, chronic obstructive pulmonary disease, insomnia, gastro-esophageal reflux disease without esophagitis, hypertension, heart failure, chronic kidney disease stage, chronic respiratory failure with hypoxia, muscle weakness, dysphagia, unspecified atrial fibrillation and cognitive communication deficit.The quarterly MDS (minimum data set) dated August 27, 2025 revealed a BIMS (brief interview of mental status) score of 13, which indicated that the resident was cognitively intact. The MDS further revealed that the resident was noted to be on oxygen therapy while residing at the facility.A review of the physician orders revealed no evidence of an order for oxygen; however, an order dated November 17, 2024 did reveal a pulmonary consult and treat as needed.A review of the care plan revealed that the resident had a focus area of emphysema/ chronic obstructive pulmonary disease with noted interventions including giving aerosol or bronchodilators, monitoring for breathing difficulty on exertion, monitoring for signs and symptoms of acute respiratory insufficiency, monitoring documenting and reporting to the medical doctor and signs and symptoms of respiratory infections use of enhanced barrier precautions and providing oxygen as ordered. However, review of facility documentation revealed no oxygen order.An observation on September 15, 2025 at 3:27 P.M. revealed resident #45 reclining in her hospital bed with the oxygen canula properly inserted and looped around her ears. It was observed that the oxygen concentrator was set at 2 liters per minute. No documentation noted on the tubing indicating when it had last been changed.An interview was conducted on September 15, 2025 at 9:10 A.M. with LPN (licensed practical nurse, staff #65). Staff #65 was asked if this resident and one other resident had orders in place for oxygen, staff #65 reviewed the electronic health record for resident #45 and stated that she did not see orders in point click care (PCC) for this resident, but stated that some residents are followed by the respiratory therapists and they may have the orders elsewhere.An interview was conducted on September 15, 2025 at 3:34 P.M. with resident #45. The resident stated that she is on 2 liters of oxygen and reported that she had been on oxygen since arriving at the facility. The resident stated that she sometimes feels out of breath.An interview was conducted on September 15, 2025 at 3:34 P.M. with the DRT (Director of Respiratory Therapy, staff #4). Staff #4 stated that respiratory therapy does not have the capacity to follow every resident in the building, but those that are followed by respiratory therapy would have the orders in place under assessments section in PCC as opposed to the physician orders section. Staff #4 further stated that all other residents not followed by respiratory therapy directly would be followed by nursing and would have orders in place under the physician order section of PCC. Staff #4 reviewed the electronic health record and master list and stated that resident #45 was not followed by the respiratory therapy team. Staff #4 reviewed the physician orders for resident #45 and stated that she did not see orders for oxygen for this resident.An interview was conducted on September 15, 2025 at 3:56 P.M. with the DON (director of nursing, staff #51). Staff #51 stated that her expectations are that when a doctor gives orders that these are documented and carried out as ordered. Staff #51 further stated that oxygen orders are to be in place and properly documented for residents not followed by respiratory therapy. Staff #51 reviewed the resident's medical record in PCC and stated that she did not see any indication that the resident was being followed by the respiratory therapy team and stated that the resident was being followed by nursing. Staff #51 reviewed the resident's physician orders and stated that she did not see orders for oxygen for resident #45. Staff #51 further stated that this did not meet her expectations. She stated that the risk would include staff not being aware and able to monitor the resident accordingly for oxygen, as well as not documenting the oxygen saturation levels and changing out the tubing as required.A review of the policy entitled Oxygen Administration reviewed July 2025 revealed that the resident's clinical record will include that oxygen is be administered, when and how often it is to be administered, the type of oxygen device to be used, charting and documentation related to oxygen use, oxygen concentrators to be maintained in the room when oxygen is ordered, and staff are to replace oxygen tubing as needed.A review of the policy entitled Physician Orders revised May 2025 revealed that it is the facility policy that drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs.

Based on a review of clinical records, staff interviews, and review of the facility's policies and procedures, the facility failed to ensure that one out of 12 dialysis residents (Resident # 96) was properly assessed as ordered by the physician.Findings include:Resident # 96 was admitted on [DATE], with diagnosis end-stage renal disease, dependence on renal dialysis, muscle weakness, and dementia. Review of the resident's care plan dated July 3, 2025, revealed that Resident # 96 needed hemodialysis due to end-stage renal disease via in-house dialysis on Mondays, Wednesdays, and Fridays, with interventions that include obtaining vital signs and weight, and to report significant changes in pulse, respirations, and blood pressure immediately. Review of Resident # 96's Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS also revealed that the resident does receive dialysis. Review of Resident # 96's orders revealed an order dated June 28, 2025, to complete vital signs pre- and post-dialysis every day and evening shift, al well as every Tuesdays, Thursdays, and Saturdays. The order start date was July 1, 2025, with no end date. Further review of Resident # 96's orders revealed an order dated July 8, 2025, for dialysis on Tuesdays, Thursdays, and Saturdays. The order start date was July 8, 2025, and was discontinued on August 22, 2025. On August 22, 2025, there was an order for dialysis on Mondays, Wednesdays, and Fridays. The order start date was August 25, 2025, and did not have an end date.Review of Resident # 96's Medical Administration Record (MAR) for the month of August 2025 revealed that pre- and post-vitals were not documented on August 25, 27, 29th and September 1, 3, 5, 8, 10, and 12th, 2025. Furthermore, pre- and post-vitals were taken on August 26, 28, 30th and September 2, 4, 6, 9. 11, and 13th, 2025, when dialysis was not performed. An interview conducted with Licensed Practical Nurse (LPN/ Staff # 1) on September 16, 2025, at 7:40 a.m. revealed that Resident # 96 had dialysis on Mondays, Wednesdays, and Fridays. LPN # 1 also revealed that right before a dialysis resident performs dialysis, vitals are taken before they leave and right when they return from dialysis. LPN # 1 reviewed the MAR for September 2025, and stated that the order date for pre- and post-vitals of dialysis contains the wrong dates and should be on Mondays, Wednesdays, and Fridays. LPN # 1 revealed that vitals were being taken on Tuesdays, Thursdays, and Saturdays as the order was written, even though Resident # 96 had not had dialysis performed. An interview conducted with the Director of Nursing (DON/ Staff # 51) on September 16, 2025, at 9:11 a.m. revealed that it is her expectation that pre- and post-dialysis vitals will be performed as ordered by the physician. DON # 51 revealed that Resident # 96's dialysis dates were changed on August 25, 2025, and the order for pre- and post-vitals was never updated, resulting in the pre- and post-vital checks being performed on the incorrect days of the week. DON # 51 revealed that the correct order has been obtained as of September 16, 2025 and the MAR has been corrected as well. A Policy and Procedure titled; Physician Orders, dated May 2025. revealed that it is the policy of the facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. A Policy and Procedure titled; Dialysis (Renal) Pre and Post Care, dated reviewed on August 2025, revealed that pre-dialysis care includes assessing resident's blood pressure (in non-shunt arm) prior to being transported to the dialysis unit.

Based on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#50) was provided care and services to meet professional standards regarding following physician orders for assessment of a resident post-fall. The deficient practice could lead to an injury being missed and a delay of care provided to a resident. -Findings include: Resident #50 was admitted to the facility July 21, 2022 and discharged on August 19, 2022, with diagnoses that included metabolic encephalopathy, unsteadiness on feet, need for assistance with personal care, cognitive communication deficit, altered mental status, unspecified psychosis not due to a substance or known physiological condition, and bipolar disorder. An admission MDS (minimum data set) assessment, dated January 16, 2025, revealed the resident had a brief interview for mental status (BIMS) score of 8, indicating the resident had moderately impaired cognition, with no indicators for mood or behaviors identified. A Care Plan, initiated July 19, 2022 included a focus for anticoagulant therapy (Lovenox) related to deep vein thrombosis (DVT). Interventions included monitor/document/report to medical doctor as needed for signs or symptoms of anticoagulant complications. Further review of the care plan revealed a focus of at risk for falls related to unsteadiness on feet, had fall July 21, 2022 with bruising to right eye. Interventions implemented were first aid applied to bruising to the right eye and the resident was sent to emergency room for evaluation for change of elevation on July 21, 2022. A progress note with an effective date of July 21, 2022 at 03:00 am, revealed that the patient got up to the bathroom, returning back to bed, fell and hit her forehead on the counter, refused to have vitals done, has long hair falling over her face and does not wish it tied back. Vital signs stable. 135/90. An eMar-Medication Administration note dated July 21, 2022 at 03:09 am, revealed Acetaminophen Tablet give 650mg by mouth every six (6) hours as needed for pain. 650mg administered. A progress note with an effective date of July 21, 2022 at 06:45 am, revealed the following: has a bruise below right eye, states left upper forehead above left eye hurts, area red, ice was applied to site. A progress note dated July 21, 2022 at 07:13 am, revealed the following: Notified by primary nurse that resident had an unwitnessed fall overnight and hit her head, reports no loss of consciousness. Upon assessment there was no visible injury. Resident recalls walking to restroom and losing balance, hitting her head on counter, then walking herself back to bed. Pupils round and reactive, vital signs stable. Resident alert and oriented x4, reports a headache, no pain otherwise. Resident asks that nursing not notify her son. Director of Nursing (DON) notified, AMR dispatched, ETA one hour. Report called to medical center. A physician order dated July 21, 2022, was written for a change of condition for hitting head while taking self to bathroom, document in progress notes every shift for three days. An additional order was also written for Enoxaparin Sodium Solution Prefilled Syringe 40MG/0.4ML Inject 40 mg subcutaneously one time a day for clotting prevention. Review of the neurological check document dated July 21, 2022, revealed that the neurological checks were implemented at 3:00 am and ended 08:45 am. The document further revealed that the resident refused neurological checks at 3:15 am, 3:30 am, 3:45 am, 4:15 am, 4:45 am, 5:15 am and 5:45 am, with the re-implementation of neurological checks at 7:45 and 8:45 am. No evidence was found to indicate that neurological checks were conducted after 8:45 am, as ordered by the provider. The document also revealed that the resident was sent to the hospital at 9:45 am. A progress note dated July 21, 2022 at 07:55 am, revealed the following:: After further evaluation, son notified at 07:50 am due to resident mentation and medical power of attorney status (MPOA) and a voicemail was left with name, title and brief description of events, call back number provided for any questions. A progress notes effective date July 21, 2022 at 09:36 am, revealed that the patient left via stretcher via EMR (emergency medical) with 2 attendants at 9:30 am. An IDT progress note effective date July 21, 2022 at 10:51 am, revealed a note text stating the resident had an unwitnessed fall the morning of July 21, 2022 at approx. 0300 am. The note indicated that the resident was returning from the restroom when she lost balance and hit her forehead on the bathroom counter. The note further revealed that the resident denied loss of consciousness and returned to bed. No visible injury assessed, pupils' equal round and reactive, orientation within baseline, AVSS (afebrile, vital signs stable), resident denied additional vital sign collection for neuro assessments. The provider was notified, received order to send the resident to the ER for evaluation, DON and MPOA notified. Interventions included: Bed in lowest position and non-skid socks and the care plan was updated. Review of the facility 5-day report noted the incident occurred on July 21, 2022, and included the certified nursing assistant (CNA/Staff #174) was making last round at 0500 and found the resident sitting on the side of bed. The resident informed the CNA that she had gone to the bathroom and lost her balance, striking her head on the counter. The report included that the nurse (RN/Staff #3) was notified and neuro checks were initiated, the resident complained of pain above the left eye, ice was applied, the provider notified, and orders received to send the resident to hospital for CT (computed tomography) scan. Review of the facility internal investigation report dated July 21, 2022 revealed no injuries at time of incident and ambulatory with assistance. Review of the emergency department (ER) pertinent report dated July 21, 2022 at 9:56 am, revealed that the patient was a [AGE] year-old woman with a history of TIAs, bipolar disorder. and other undefined encephalopathy who presented to the ER as a trauma yellow. The report incuded that the resident with questionable altered level of consciousness, reportedly had an unwitnessed fall at 3:30 AM this morning, and was taking prophylactic Lovenox. The report further revealed that per chart review, the resident had been seen at the hospital approximately 11 days ago for another fall and that imaging at that time was negative but she was sent to the care center for rehabilitation. The report revealed that history was somewhat limited as the patient had difficulty focusing, but she endorsed pain in her back but nowhere else, she did not remember the events of the fall, had difficulty following commands but per chart review, it is difficult to ascertain if this is chronic or new since her accident. An interview was conducted with a Registered Nurse (RN / Staff #142) on June 20, 2025, at 10:36 am who stated that the facility's process for assessing residents who sustain an unwitnessed fall on anticoagulants was to immediately conduct neuro checks, make sure the resident was at their baseline, and answered questions appropriately, asses for any head injuries, nausea, pain with movement, palpitations and vital signs. The RN also stated that the assessment would include immediately notifying the doctor, the DON, family member-leaving a message if no response and with any head injury will call 911. The RN also stated that she would educate the resident if they should refuse neuro checks of possible death and if they continued to refuse the neuro checks would notify the doctor, DON (Director of Nursing), and family immediately and document the refusal and notification. The RN further stated that the resident would be sent to the hospital for a CT scan, if the resident was taking any blood thinner, including aspirin, and that staff are always able to contact the DON or the Medical Director if the resident's provider would be unavailable. The RN stated if the doctor decided not to send the resident to the hospital, the order would be documented in progress notes. The RN also stated any resident with an observable head injury with complaints of pain and/or redness would need to be sent to the ER immediately. The RN further stated that the risks of not following the process for an unwitnessed fall with observable head injury, complaints of head pain and receiving anticoagulant therapy could result in possible death for the resident. An interview was conducted with the DON (Staff #15) on April 3, 2025, at 10:15 am, who stated that the resident should be assessed by a nurse if an unwitnessed fall occurs or if the resident may have hit their head, neuro checks should be started, and the provider notified. The DON stated if the resident is not their own responsible party, then the responsible party is notified and depending on what the doctor has ordered, the resident will be sent to the hospital for a CT scan. The DON further stated if a resident should refuse neuro checks staff would try again, educate about the risks and benefits and notify the doctor. The DON also stated that all documentation of contacts should be in the progress notes, and the doctor should be notified of the fall immediately. Review of the facility policy titled, Resident Assessment: Fall Management System, revised May 2021 revealed that it is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. When a resident sustains a fall, a physical assessment/evaluation will be completed by a licensed nurse, with results documented in the Nursing Progress Notes and the attending physician and family/ responsible party as applicable shall be notified of the fall and the resident status.

Based on resident interview, policy review, and staff interview, the facility failed to ensure a Registered Nurse (RN/Registry Staff # 467), who was from a staffing agency and not employed by the facility directly, had the specific competencies and skill sets necessary to care for residents' needs. This failure had the potential to affect all residents assigned to the RN's care during her shift. Findings include: Review of the facility 5-day report revealed alleged perpetrator RN (Registry/ Staff # 467) had been contracted through a nursing registry. Facility eMAR documents revealed that the RN (alleged perpetrator) worked at the facility as a registered nurse starting August 26, 2022 and no additional documentation for scheduled shifts worked in August 2022. Further review revealed the registry RN was scheduled to work the following days; September 2,3,4,9,10.11.16.17, 18, 23,24,25, and 30 for the 6PM-6AM shift. The facility became aware of the alleged perpetrator on September 19, 2022 when the Dietary Supervisor (Staff/#56) alerted the Director of Nursing (DON/Staff #147) of recognizing the alleged perpetrator registry Staff # 467 as a potential candidate, when applying for a position in dietary/housekeeping. The DON attempted to verify the Arizona license for the agency RN and was unable to find licensure. The facility contacted the head of the nursing agency who was unable to verify the RN's license or contact the RN. The facility investigation determined that the alleged perpetrator RN (Registry/Staff # 467) had impersonated a registered nurse using another individuals RN nursing license. The report revealed that the facility substantiated the allegation of other unlicensed nurse providing care in the facility. Review of the Registry Agreement effective date February 2, 2022 revealed that Registry shall provide temporary clinical staff. Staff shall be properly licensed and qualified healthcare professionals duly trained and certified for their profession. Registry shall be solely responsible for screening staff to ensure suitability to perform the assignments as requested by the facility Applicable eligibility documentation for each staff personnel assigned to facility shall be provided prior to any staff beginning a shift at the facility. An interview was conducted on June 19, 2025 at 2:10 PM with the Human Resources Manager (HR Manager/Staff #118) who stated her role is to assist with the hiring process for all staff, including registry staff. The HR Manager stated the process for registry staff is to have them sign an orientation packet, but agencies will hold their staff certifications. Staff #118 stated the facility will verify any registry staff license, depending on their position through the State Board of Nursing, verify fingerprint cards and Adult Protective Services. The HR Manager stated as an registry RN, alleged perpetrator Registry RN (Staff # 467) license would have been verified through the State Board of Nursing. The HR Manager stated that she did not know the complete process for registry staff during 2022 and 2023, but the facility used a contingency checklist during that time frame. The HR Manager explaind that the Contingent Worker Checklist included online verification for Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN) and Registered Nurse (RN), Tuberculin Test, Arizona Fingerprint Card (online verification), and Background and Drug Screen (run by the registry). Staff #118 stated she looked for the document, when state requested documentation but it appeared that one was not completed for registry staff #467. She also stated that there is no documentation that the process was completed for registry staff #467. The HR Manager stated it would be her assumption that the checklist for registry staff #467 should have been completed before working on the floor with any resident. She also stated the facility does employ agency staff and current practice is the same as in 2022 with the completion of the orientation packet for agency staff and oversees to ensure that any registry staff have their license that are verified and current and are registered with the State Board of Nursing. Staff #118 stated the risks of having unlicensed individuals working as nurse pose a harm to our patients. An interview was conducted on June 20, 2025 at 11:34 AM with the Director of Nursing (DON/Staff #147) who stated registry (staff #467) had worked at the facility without a verified license. The DON stated verified nursing licenses through the State Board of Nursing, unless they are with and agency then the agency provides their own file on their licensed staff. A request was made for a copy of the nursing license for registry staff #467. The DON stated when registry staff #467 worked for the facility, the facility did not have a cross check in place for verification of licenses. The DON stated it is her expectation that all licensed staff, both facility and agency have licensure that are active. The DON stated the risks of working as a nurse without a license can cause harm to a resident or provide the resident with the wrong medications. Review of the facility policy titled, Nursing Services: Sufficient Staff, revised May 2022 revealed that it is the policy of the facility to have sufficient nursing staff with the appropriate competencies and skillsets to provide nursing and related services to promote resident safety and attain or maintain the highest practicable mental, psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment.

Based on clinical record, resident and staff interviews and facility documents, the facility failed to ensure that two residents (#21, #52) received activities of daily living (ADL) care per facility policy. Failure to do so could result in psychosocial harm. Findings include: -Resident #52 was admitted [DATE] with diagnoses of sepsis and metabolic encephalopathy. A care plan dated July 2, 2024 included a self-care performance deficit related to weakness, and impaired mobility which included to encourage to participate to the fullest extent with each interaction. A Minimum Data Set (MDS) dated [DATE] included that this resident was moderately cognitively impaired and that showering was not attempted due to a medical condition or safety concern. A document titled [NAME] Showers included that resident #52's room was to be provided showers 2 times a week by the 2 PM to 10 PM shift and that any missed showers were to be caught up on Sundays. This document included that shower sheets need to be filled out and signed by the nurse. However, review of bathing/showering documentation included: 1 shower was provided on July 1 - 6, July 21 - 27, and July 28 - August 3, 2024 No showers were provided July 7 - 13, 2024. -Resident #21 was admitted [DATE] with diagnoses of morbid obesity, open wound of abdominal wall, and bipolar disorder. A quarterly MDS dated [DATE] included that this resident was not cognitively impaired and was dependent for showering/bathing. However, review of bathing/showering documentation included: 1 shower was provided on July 1 - 6, and July 21 - 27. No showers were provided July 28 - August 3, 2024. An interview conducted on August 8, 2024 at 3:43 P.M. with a Certified Nursing Assistant (CNA/staff #130) who said that CNA's look at the shower list. She said that showers are scheduled for both day and evening shift. This staff said that if the resident refused the staff offer alternatives to showers such as bed baths. This staff said that if CNA's manage their time right that they should be able to get showers. This CNA said that each resident gets 2 showers a week unless they need more. She said that if showers are missed then on Sundays, they will try to make it up. She said that resident #52 did not want showers. An interview conducted on August 8, 2024 at 3:28 P.M. with a Licensed Practical Nurse (LPN/staff #120) who said that CNA's have assignments based on which rooms have showers on that day, which is determined by the shower sheet. She said that she performs skin checks on shower days and signs off on the shower sheet. She said that the shower sheets are then filed with medical records. An interview was conducted on August 8, 2024 at 4:33 P.M. with the Director of Nursing (DON/staff #59) who said that her expectation is that staff follow the shower schedule and residents should be offered 2 showers a week. This staff included that staff should document showers on shower sheets and in the task list in the medical record. She said that it does not meet her expectations if the showers are not documented if they are refused. She stated that resident #52 frequently refuses care but that it was not documented. A policy titled ADL, Services to carry out reviewed on August, 2023, included if a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, toileting, and personal oral hygiene will be provided by qualified staff. This policy included that bathing will be offered twice weekly (unless resident requests more or less), and as needed per resident request and ADL care will be documented in the medical record accordingly.

Based on observations, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure room temperatures were within the safe temperature range. The deficient practice put the residents at increased risks for harm such as lack of sleep and heat stroke. Findings include: A TELS (Facility maintenance reporting) report for 6/1/2024 through 7/8/2024 did not include any requests for action regarding temperature. However, interviews with 8 residents included that they had been informing staff of the problems with temperatures. A document dated 6/26/2024 an order was placed for a new HVAC (Heating, Ventilation and Air Conditioning) unit on the south hallway, on 6/28/2024, 3 rental air condition units, 3 swamp coolers, and 5 portable fans were placed on the south hallway. A temperature logbook included that temperatures had been taken in 2 rooms in each hallway 2 times since the breakdown of the air conditioning unit, however documentation was requested but not provided for every 2 hour temperature check of the affected rooms. -Resident #5 was admitted [DATE] with diagnoses of unspecified fracture of sacrum and traumatic subdural hemorrhage without loss of consciousness. A discharge assessment Minimum Discharge Set (MDS) dated [DATE] included that her decisions regarding daily life were consistent/reasonable. An interview was conducted on 7/8/2023 at 5:09 P.M. with resident #5. Resident #5 stated she had been there since the previous Friday and that it was hot as hell the whole time. This resident said that she had not been able to sleep at night and had told the staff and called her mother who had told staff. An observation was conducted of temperatures taken by maintenance (staff #158) on 7/8/2023 at 4:10 P.M. included a high of 85 degrees Fahrenheit. -Resident #8 was admitted [DATE] with diagnoses of anxiety disorder, morbid obesity and chronic respiratory failure. A Quarterly MDS dated [DATE] included the resident was cognitively intact. An observation was conducted of temperatures taken by maintenance (staff #158) on 7/8/2023 at 4:10 P.M. included a high of 83 degrees Fahrenheit. -Resident #9 was admitted [DATE] with diagnoses of acute combined systolic and diastolic congestive heart failure. An Admission MDS dated [DATE] included that the resident was cognitively intact and required substantial/maximal assistance to move from lying on her back to sitting on the edge of the bed. An interview was conducted on 7/8/2023 at 5:09 P.M. with resident #9 who stated it's hot and it's been over a week, and included that her back has been sweaty. This resident said that she had told staff and informed Adult Protective Services -Resident #10 was admitted [DATE] with diagnoses of paraplegia, pulmonary embolism and hypertension. An admission MDS dated [DATE] included that this resident was cognitively intact and required substantial/maximal assist with chair to bed transfers. An observation was conducted of temperatures taken by maintenance (staff #158) on 7/8/2023 at 4:10 P.M. included a high of 85 degrees Fahrenheit. An interview was conducted on 7/8/2023 at 5:05 P.M. with resident #10 who said that it was hard to sleep because of the heat and that the temperatures have been like that for 2 weeks. This resident said that the staff know about the temperature. -Resident #26 was admitted [DATE] with diagnoses of acute osteomyelitis, cellulitis and dilated cardiomyopathy. An admission MDS dated [DATE] included that this resident was cognitively intact and required supervision or touching assistance with chair to bed transfers. An observation was conducted of temperatures taken by maintenance (staff #158) on 7/8/2023 at 4:10 P.M. included a high of 85 degrees Fahrenheit. -Resident #28 was admitted [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, asthma, and chronic kidney disease stage 3 A quarterly MDS dated [DATE] included that this resident was cognitively intact and was independent with chair to bed transfers. An observation was conducted of temperatures taken by maintenance (staff #158) on 7/8/2023 at 4:10 P.M. included a high of 85 degrees Fahrenheit. An interview was conducted on 7/8/2023 at 5:19 P.M. with resident #28 who stated the air conditioning has been out since the beginning of June and that she was not able to sleep at night. She said that sometimes it was awful and she would get headaches. This resident said that she did not take Tylenol unless she really really needed it but that Saturday evening she asked for Tylenol because of the heat. She said that the facility had brought in a portable swamp cooler but then they took it out and brought in 2 fans. This resident said that her roommate (resident #79) is heat intolerant and has difficulty communicating so she had 1 fan on her and that there was 1 fan oscillating she shared with resident #5. She said it was not adequate and that she had informed the staff. -Resident #52 was admitted [DATE] with diagnoses of open wound of abdominal wall, morbid obesity, and Major Depressive Disorder. A quarterly MDS dated [DATE] included that this resident was cognitively intact and chair to bed transfers were not attempted due to medical conditions or safety concerns. An observation was conducted of temperatures taken by maintenance (staff #158) on 7/8/2023 at 4:10 P.M. included a high of 83 degrees Fahrenheit. An interview was conducted on 7/8/2023 at 4:00 P.M. with resident #52 who said it's been hot for weeks, that she had been buying fans with her own money and that she had had trouble sleeping. She said that she was always telling the staff but they did not bring in fans, that she had to buy her own. -Resident #53 was admitted on [DATE] with diagnoses of acute respiratory failure with hypoxia, pressure induced deep tissue injury of right and left heels, and morbid obesity. A 5-day MDS dated [DATE] included that this resident was moderately cognitively impaired and required partial to moderate assistance for chair to bed transfers. An observation was conducted of temperatures taken by maintenance (staff #158) on 7/8/2023 at 4:10 P.M. included a high of 83 degrees Fahrenheit. -Resident #58 was admitted to 7/12/2023 with diagnoses of pressure ulcer of sacral region stage 4, obesity and borderline personality disorder. A quarterly MDS dated [DATE] included that this resident was not cognitively impaired and chair to bed transfers were not attempted due to medical conditions or safety concerns. An observation was conducted of temperatures taken by maintenance (staff #158) on 7/8/2023 at 4:10 P.M. included a high of 85 degrees Fahrenheit. -Resident #61 was admitted [DATE] with diagnoses of cellulitis, acute kidney failure and cardiomegaly. A 5-day MDS dated [DATE] included that this resident was moderately cognitively impaired and chair to bed transfers were not attempted due to medical conditions or safety concerns. An observation was conducted of temperatures taken by maintenance (staff #158) on 7/8/2023 at 4:10 P.M. included a high of 85 degrees Fahrenheit. An interview was conducted on 7/9/2023 at 12:25 P.M. with resident #61 included that this resident said that the temperature had been too warm to sleep. -Resident #77 was admitted [DATE] with diagnoses of dementia, and difficulty in walking. A quarterly MDS dated [DATE] included that this resident was cognitively intact and the resident requires substantial/maximal assistance with chair to bed transfers. An observation was conducted of temperatures taken by maintenance (staff #158) on 7/8/2023 at 4:10 P.M. included a high of 85 degrees Fahrenheit. -Resident #78 was admitted [DATE] with diagnoses of end stage renal disease, acute respiratory failure, and acute embolism and thrombosis of unspecified vein. A quarterly MDS dated [DATE] included that this resident was cognitively intact and the resident was independent with chair to bed transfers. An observation was conducted of temperatures taken by maintenance (staff #158) on 7/8/2023 at 4:10 P.M. included a high of 85 degrees Fahrenheit. -Resident #79 was admitted [DATE] with diagnoses of multiple sclerosis and multiple unstageable pressure ulcers. A quarterly MDS dated [DATE] included that this resident's short and long term memory were ok, the resident was independent for making decisions of daily life, and the resident was dependent with chair to bed transfers. An observation was conducted of temperatures taken by maintenance (staff #158) on 7/8/2023 at 4:10 P.M. included a high of 85 degrees Fahrenheit. -Resident #41 was admitted [DATE] with diagnoses of Chronic Obstructive Pulmonary Disorder, and Schizophrenia. A quarterly MDS dated [DATE] included that this resident was cognitively intact, and chair to bed transfers were not attempted due to medical conditions or safety concerns. An interview was conducted on 7/8/2023 at 5:06 P.M. with resident #41 who stated it's so hot and that the temperature never gets fixed. She said she complained many times. -Resident #86 was admitted [DATE] with diagnoses of Chronic Obstructive Pulmonary Disorder and hemiplegia and hemiparesis. A quarterly MDS dated [DATE] included that this resident was cognitively intact, and this resident required partial/moderate chair to bed transfers. An interview was conducted on 7/8/2023 at 5:05 P.M. with resident #86 who stated it's so hot and that it feels like it's been a month. This resident included that the facility took away the fan that she had and replaced it with one that did not work as well and she told them that. -Resident #60 was admitted [DATE] with diagnoses of osteomyelitis, pneumonia, and psychosis. A 5-day MDS dated [DATE] included that this resident was cognitively intact, and chair to bed transfers were not attempted due to medical conditions or safety concerns. An interview was conducted on 7/8/2023 at 5:19 P.M. with resident #60 who said it's been hot and had been uncomfortable for the 4 days the resident has been in the facility and that they have not been able to sleep. This resident included that they have had a fan for a couple days but that it was only helping a little. This resident said staff know. An interview was conducted on 7/8/2023 at 4:12P.M. with a maintenance staff (#158) who said that the air conditioning failed on June 27, 2024 and that the next day temporary units were placed in the hall. He said that he usually took the temperatures from the wall with the head of the bed, however this time he temperature checked all the walls. He said that the new air conditioning had been ordered and that they were awaiting delivery and installation, and that they had ordered temporary air conditioners, which were in the hallway. An interview conducted on 7/8/2024 at 5 P.M. with the Director of Nursing (DON/staff #34) said that the facility did have an emergency plan and asked what was meant by emergency measures. This DON did not answer if the emergency plan had been enacted, and when questioned about the measure taken to combat the heat, she stated that ice water was passed around when asked for and that rooms were not outside of an acceptable temperature range before this surveyor discovered them on 7/8/24 at 4 P.M. An interview was conducted on 7/9/2024 at 3:43 P.M. with a Certified Nursing Assistant (CNA/staff #117) who said that it had been hot in the hall and that she felt that it had been that way a few weeks. She said that the air condition was not working and that the holiday week did not help with getting a new one. She said that the residents had been complaining to her about the heat. An interview was conducted 7/9/2024 at 3:16 P.M. with a Maintenance supervisor (staff #3) who said they had an air conditioning contractor come out who found that one of the compressors was not working and that the contractor had performed a temporary fix and that the fix had failed as well. This staff said that he checks the temperatures every morning checks the temperature and does some adjustments and if it's warm in some areas that he will move the temporary air conditioners. He said that he does not perform the temperatures on a schedule, but will check the temperatures if he is in an area. He states that he picks random rooms to temperature check. However, he had not routinely checked the hottest rooms or at the hottest part of the day. An interview conducted on 7/9/2024 at 5 P.M. with the administrator (staff #89) included that the temperature in the resident's rooms should be under 80 degrees Fahrenheit. A follow up interview was conducted on 7/9/24 at 5:28 with the administrator who said that the emergency plan would be used for summer if the temperature eclipses a certain threshold and that prior to this surveyor's arrival, the temperatures had been within the threshold. He said that for the emergency plan, the temperatures should be taken every 2 hours. He said that the only temperatures that were elevated were on the wall with the window but that they used the temperatures on the wall with the head of the bed. A procedure titled Extreme Heat Procedures revised 1/2024 included to continue on-going facility rounds a minimum of every two (2) hours. A policy titled Temperature, Rise in Environment and in the Facility included revised 5/2024 revealed that It is the policy of this facility to initiate appropriate action, to ensure the safety and well being of its residents in the event of an extreme rise in facility temperature. (Acceptable environmental temperature ranges from 71 - 81 degrees)

Based on clinical records, staff interviews, and facility policy, the facility failed to ensure a resident's code status was honored. Findings include: Resident #5 was admitted on [DATE] with pneumonia, and acute respiratory failure with hypoxia. A 5 day Minimum Data Set (MDS) dated [DATE] included that this resident was severely impaired for daily decision making and had a long and short term memory problem. A Prehospital Medical Care Directive dated [DATE] included that In the event of cardiac or respiratory arrest, I refuse any resuscitation measures Including cardiac compression, endotracheal Intubation and other advanced airway management, artificial ventilation,defibrlllation, administration of advanced cardiac Iife support drugs and related emergency medical procedures. A physician's order dated [DATE] included Do Not Attempt Resuscitation (DNR). However, a progress note dated [DATE] included Please note, this writer was informed that patient was found unconscious without a pulse/respirations, at 1657 resuscitation protocol was started, and because it was started it continued until 1703 where she was pronounced w/ time of death. An interview was conducted on [DATE] at 2:13 p.m. with a Certified Nursing Assistant (CNA/staff #27) who said that she would need to check code status in the book or the computer if she found a resident who was not breathing. An interview was conducted on [DATE] at 2:48 p.m. with a Registered Nurse (RN/staff #85) who said that usually she knows the code status but sometimes the nurse needs to check. She said that the code status is on PointClickCare right below the resident's name. She said that if a resident has a code status of DNR that CardioPulmonary Resusitation (CPR) should not have happened. An interview was conducted on [DATE] at 3:25 p.m. with the Director of Nursing (DON/staff #65) who said that a resident was a full code upon admission and then could be DNR if their family and provider agree upon it and then the orders are updated accordingly. She said that the facility should respect the wishes and follow the order. She said that the fact that they started CPR in the first in the first place did not meet her expectations. A policy titled Advanced Directives revised ,d+[DATE] revealed that it wass the policy of this facility that a resident's choice about advance directives will be recognized and respected.

Based on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated when opened. The deficient practice could result in a potential for food borne illness. Findings include: A freezer observation on [DATE] at 7:15 a.m. revealed vegetable patties and raw chicken not covered, labeled or dated. A refrigerator observation on [DATE] at 7:20 a.m. revealed potatoes, lemons and oranges not labeled or dated. Additionally, 2 oranges were observed to exhibit a fuzzy, grayish substance on the outside of the orange. The discolored oranges were present in a box of oranges. The kitchen manager removed the two oranges and stated that she generally reviews refrigerator contents once a week after deliveries. A box of shredded carrots was observed to be stored in the refrigerator with a use-by date of [DATE]. The kitchen manager stated that these should have been removed but had been missed. An interview with the dietary supervisor, staff # 65 was conducted on [DATE] at 12:40 p.m. Staff # 65 stated that she reviewed refrigerator and freezer content once a week and that the food items noted as not labeled, discolored and expired had been missed upon review. She stated that the risk factor to the residents could include a resident becoming ill. An interview with the administrator, staff # 115 was conducted on [DATE] at 12:29 p.m. The administrator stated that the expectation was that all food was labeled and dated. The expectation was that no expired food was kept in the refrigerator and that no foods with negative outcomes, including discolored fruit were stored in the refrigerator. He stated that the risk was potentially adverse effects on residents and staff. A review of the food storage policy, with a review date of [DATE] noted that all products should be inspected for safety and quality and be dated upon receipt, when open and when prepared.

Based on observations, staff interviews, and policy review, the facility failed to ensure the area around the dumpsters was free of refuse/garbage. The deficient practice could result in an unsanitary condition and the harborage of pests and insects. Findings include: An observation on June 29, 2023, revealed trash strewn in front and to the side of both outside dumpsters. Meatballs and what appeared to be mashed noodles were observed directly in front of the first dumpster, as well as to the side of the first dumpster. Small milk cartons and sausages were observed to the immediate left of the second dumpster. Staff # 65 identified the milk cartons as facility milk cartons utilized for residents. An interview with the dietary supervisor, staff # 65 was conducted on June 28, 2023 at 12:40 p.m. Staff # 65 stated she inspects the outside garbage containers at least daily and also relies on kitchen staff to report any adverse refuse conditions. An interview with the administrator, staff # 115 was conducted on June 6, 2023 at 12:29 p.m. He stated that the expectation was that the outside garbage containers remain free of refuse outside of the container and remain sanitary. He stated that the risk is potentially adverse effects on residents and staff. A review of the waste disposal policy with a review date of July, 2023 revealed that each waste container shall be cleaned as needed.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure that medication was administered as ordered for one resident ( #140) and that a physician was notified. Findings include: Resident #140 was admitted on [DATE] with diagnoses of sepsis and Clostridium difficile. A physician order dated June 16, 2023 included the following: -Levofloxacin (antibiotic), 500 mg (milligrams) intravenous one time a day for sepsis until June 20, 2023; -Meropenem (antibiotic), use 1 gram intravenous every 8 hours for sepsis until June 26, 2023; and, -Vancomycin HCl Oral Capsule (antibiotic), give 125 mg by mouth one time a day for C-diff prophylaxis until July 11, 2023. A care plan dated June 20, 2023 included that the resident was on antibiotic therapy including intravenous Meropenem and Levaquin and oral Vancomycin related to severe sepsis and Clostridium difficile prophylaxis. Interventions included to administer medication as ordered. A list of medications available in the emergency medication supply included Vancomycin HCl Oral Capsule 125 mg, Levofloxacin Intravenous Solution (antibiotic) 500 mg bag, Meropenem Intravenous Solution (antibiotic) 500mg bag. A discharge assessment Minimum Data Set (MDS) dated [DATE] included the resident had received 4 days of antibiotics of the last 7 days. However, the Medication Administration Record (MAR) for June 2023 revealed the following: -Vancomycin was not administered until June 17 which was 1 missed administration, the Meropenem was not administered until 1500 on June 18 which was 6 missed administrations, and the Levofloxin was not administered until June 19 which was 1 missed administration. Review of the clinical record did not find that the physician was informed regarding the missing medication administrations or that an attempt was made to access the emergency medication supply. An interview was conducted June 30, 2023 at 2:28 PM with a Licensed Practical Nurse (LPN/staff #67) who said if a resident's medication was not in the cart, the facility had an emergency medication supply that can be used. She said that if it's an antibiotic, they definitely don't want the resident to miss a dose. She stated that if the medication was not in the emergency medical supply kit then she would contact the provider to see if it was appropriate to use an available alternative medication or to change the order. She stated that she would document that in the progress notes. She further stated that nurses should never hesitate to contact the doctor or to check the emergency supply of medication. She stated in some situations, nurses can contact the pharmacy to put a rush on the order and get an expedited delivery on the medication if needed. An interview was conducted June 30, 2023 at 3:27 PM with the Director of Nursing (DON/staff #20). The DON stated that before a resident comes in the building, admission receives the orders which are then sent to the pharmacy. She stated that usually the pharmacy can get the authorization to allow the staff to pull from the emergency medication supply if needed. She stated that it does not meet her expectation that the physician was not notified regarding unavailable medications. She further that it was a standard practice that staff sign off on the medication administration record(MAR) and in this case,the staff did not sign the MAR. She stated that this also does not meet her expectation. This DON stated that if it's not signed off then it's assumed that it was not done. The facility policy Medication administration(reviewed 9/22) revealed that if medication is withheld, refused or given other than at the scheduled time the documentation be reflected in the clinical record.

Based on clinical record review, staff interviews and facility policy, the facility failed to ensure one resident (#140) receive care and services to prevent/heal pressure ulcers. Findings include: Resident #140 was admitted on [DATE] with diagnoses of a stage 4 pressure ulcer of right buttock, abdominal surgical dehiscence. A physician's order dated June 17, 2023 included cleanse sacral wound with normal saline and pat dry, pack with gauze soaked in Dakins Quarter strength 0.125% and cover with dressing every day shift. A wound assessment details report dated June 19, 2023 included that the sacrum wound was a stage 4 pressure ulcer measuring 2.5cm long x 4.00cm wide x 3cm deep. A wound assessment details report dated June 19, 2023 included that the right buttocks/ischium wound was a stage 4 pressure ulcer measuring 19 cm long x 17.00cm wide x 3cm deep. A physician's order dated June 19, 2023 included cleanse wound to right buttock and ischium with normal saline, pat dry, apply medihoney with alginate, secure with ABD and retention tape one time a day every Wednesday, Saturday and Sunday. A discharge assessment Minimum Data Set (MDS) dated [DATE] included that this resident was admitted with 1 stage 4 and 1 unstageable pressure ulcer. This assessment included that the resident required extensive to total assistance for most activities of daily living. A care plan dated June 21, 2023 included that the resident has pressure ulcers on the sacralcocyx and right ischium with intervention of administering treatments as ordered. However, a review of the Treatment Administration Record and Wound Team Administration Record for June, 2023 revealed the order for treatment of the sacral wound was not administered on June 17, 18 or 21 and the order for treatment of the right buttock and ischium was not administered on the 21. An interview was conducted June 30, 2023 at 1:36 PM with a wound Registered Nurse (RN/staff #133). She stated that when a resident was admitted she completes a full skin assessment and notes her findings. The RN also would put in orders at that time. She stated that if there are not orders in place, she would send the provider a picture and then put orders in the clinical record. She stated that she would use the orders to treat the resident. She stated that the floor nurses would do treatments on Wednesday and on the weekends and she would do the more extensive treatments including wound vacuums. She reviewed this resident's clinical record and stated that it does not appear that all the resident's treatments were completed as ordered. She further stated that a entry left blank on the treatment record would indicate that the treatment was not done. An interview was conducted June 30, 2023 at 3:27 PM with the Director of Nursing (DON/staff #20) who said that it is standard practice that the staff should sign off on medication administration record (MAR) and treatment administration record (TAR)and the staff did not sign off on several entries for this resident. She stated that it did not meet her expectations that the MAR and TAR are both completed. The DON stated that if it's not signed off, it was assumed that it was not done. A policy titled Wound Management (reviewed 5/2023)revealed that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing.The policy further stated that once a wound has been identified, assessed, and documented, nursing shall administertreatment to each affected area as per the Physician's order.

Based on clinical record review, observation, staff interviews, and policies, the facility failed to ensure one sampled resident (#19) who had an enteral feeding tube received the appropriate treatment and services to prevent complications. The deficient practice could result in potential enteral feeding tube complications. Findings include: Resident #19 was admitted on [DATE] with diagnoses that included malignant neoplasm of the larynx, oropharyngeal phase dysphagia, and chronic respiratory failure with hypoxia. A nutrition/hydration care plan initiated on March 24, 2023 indicated resident was NPO and enteral feeding dependent. The interventions included to administer medications as ordered and to monitor/document for side effects and effectiveness. Review of the physician's orders revealed the following: -3/23/2023: May crush/combine medications for administration if not contraindicated and mix with 4 0z (ounces) of water. May use slow push to facilitate consumption. -3/23/2023: Check tube placement and patency prior to each feeding/flush/medication administration via air bolus auscultation or residual aspiration every shift. -3/24/2023: NPO (nothing by mouth) -3/28/2023: Flush peg tube with 100 cc water every shift every 3 hours. -6/5/2023 Jevity 1.5 per peg via enteral pump at 85 ml (milliliter) per hour for 16 hours to provide 1360 ml. Pump to run from 1600 (4:00 p.m.) to 8:00 a.m. or until volumetric dose is met. . Review of the quarterly MDS (minimum data set) dated June 30, 2023 revealed a BIMS (brief interview of mental status) of 15 which indicated the resident was cognitively intact. The assessment included nutrition approach via feeding tube and a proposed total caloric intake through parenteral nutrition of 51% or more. A medication administration observation was conducted on June 29, 2023 at 7:39 a.m. through 8:10 a.m. with a registered nurse (RN/staff #6). Prior to the medication administration, staff #6 provided a brief report regarding resident #19. Staff #6 stated the pump for the tube feeding and the water flush was already off when she took over the resident's care from the night shift. She stated the tube feeding pump was not supposed to be turned off until 8:00 a.m. and turned back on at 4:00 p.m. Staff #6 stated she doesn't know exactly when the resident's feeding tube pump was turned off by the night shift. Staff #6 stated the resident often request to turn off the tube feeding pump and it varies every day. Continued observation of the medication administration conducted on June 29, 2023 at 8:01 a.m., staff #6 crushed all the medications and mixed it in 4 ounces of water. Upon entrance to the resident's room, the tube feeding pump was off and a bag of formula and a bag of water for flushing were hanging on the pole. Staff #6 placed the medication cup at the bedside and she was observed attempting to aspirate the gastric stomach content of the resident using a 60 cc (cubic centimeter) syringe with no return. Immediately after, staff #6 dipped the syringe in the medication cup and obtained approximately one half of the medication into the 60 cc syringe. Staff #6 was observed slowly pushing the medications into the resident's peg tube in its entirety. Staff #6 repeated the procedure until she has administered all the medications in the cup. Staff #6 did not flush the resident's peg tube before and after medication administration. An immediate follow up interview was conducted with staff #6 in which she stated the water flush and the tube feeding formula will be turned on again at 4:00 p.m. An interview was conducted with a pharmacy consultant (staff #34) on June 29, 2023 at 1:33 p.m. Staff #34 stated it is recommended that the peg tube flush is flushed before and after administration of medication due to potential clogging in the medication coagulating in the tube. Staff #34 stated medication will not be entering the patient's system if the peg-tube is not flushed after medication administration. Staff #34 stated the more serious risk could include the medication not entering the patient's system. An interview was conducted with the director of nursing (DON/staff #20) on July 6, 2023 at 2:36 p.m. Staff #20 stated it is her expectation that when medications are administered via peg tube that the placement is confirmed via injecting air and listening in a stethoscope prior to medication administration. Staff #20 stated that the peg tube has to be flushed with 30 cc of water before and after the medication administration. Staff #20 stated that there is a risk that the tube will clog, or there could be something in the if something is administered later that can be contraindicated if the tube is not flushed appropriately. The facility policy, Professional Standards, revised in November 2022 revealed the facility's expectation is to provide services that meet the professional standards of quality provided by qualified persons in accordance with each resident's care plan. The policy further defined professional standards regarding quality of care practices may be published by a professional organization, licensing boards, accreditation body or other regulatory agency.

Based on clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure one resident (#11) did not receive unnecessary oxygen therapy. The deficient practice could result in high carbon dioxide content in the resident 's blood that can lead to respiratory acidosis and death. Findings include: Resident #11 was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, heart failure and chronic respiratory failure with hypoxia. A care plan initiated on April 6, 2020 revealed that the resident was receiving oxygen therapy related to the diagnosis of COPD. The interventions included monitoring for signs and symptoms of respiratory distress and reporting to the MD (medical doctor) pulse oximetry. Review of the physician order dated February 21, 2022 included an order to check pulse ox (oxygen) level on room air and document for oxygen weaning purposes every shift. A physician order dated March 10, 2022 ordered to check pulse ox every shift and oxygen may be applied at 2-4 liters per minute and may titrate to maintain oxygen saturation greater or equal to 88% for diagnosis of COPD (chronic obstructive pulmonary disease). The clinical record revealed that the MAR (medication administration record) dated August 2022 revealed the oxygen saturation ranged from 92-99% on room air. Review of the resident's annual MDS (minimum data set) dated April 11, 2023 revealed a BIMS (brief interview of mental status) of 10 which indicated the resident had moderately impaired cognition. Review of MAR dated June 2023 revealed the oxygen saturation ranged from 92-99% except on June 5, 7, 8, 13 and 25, 2023. Further record review of the MARs revealed a check mark in the box indicating the oxygen was administered on the dates when the resident 's oxygen saturation on room air was within normal limits. Continued record review revealed no evidence that an attempt was made to wean the resident from oxygen use and no evidence that the physician was notified of the oxygen saturation results to determine further treatment. An interview was conducted on July 6, 2023 at 1:35 p.m. with a licensed vocational nurse (LVN/staff #29). She stated oxygen administration required a parameter be included in the physician's order. She stated that when a physician writes an order to check a resident 's oxygen saturation every shift, that is for the purpose of weaning the resident from oxygen use. She stated the oxygen saturation must be checked on room air. She stated the physician should be called to report the oxygen saturation result on room air and the physician notification is charted in the resident's electronic health record (EHR). She stated that in her experience, a resident whom was diagnosed with COPD would have their oxygen use discontinued by the physician if the resident 's oxygen saturation was 88% (percent) and above. She stated that the risks for residents who have been diagnosed with COPD and have too much oxygen included oxygen retention and respiratory arrest. An interview was conducted with the director of nursing (staff #20) on July 6, 2023 at 2:21 p.m. She stated that the process of weaning a resident from using oxygen included removing the oxygen and checking the oxygen saturation to see if it can be discontinued. She stated that usually the doctors like to see at least 88% however, that depends on the doctor's order because everyone is different. She stated, generally the doctor reviewed the oxygen saturation (taken at room air) with the nurse or the nurse notified the doctor of the oxygen saturation results. She stated that if the resident was diagnosed with COPD and they receive too much oxygen it could be a concern because their body may not be able to regulate it. She stated that the resident would have to be sent to the hospital if this occurred. She stated it was her expectation that staff follow the professional standard of practice and notify the physician of the oxygen saturation results for the purpose of weaning the resident from oxygen use. The facility policy, Oxygen Administration, revised in July 2023 revealed that the facility ' s policy is that oxygen therapy is administered by a licensed nurse as ordered by the physician. The policy included the purpose of the oxygen therapy was to provide sufficient oxygen to the bloodstream and tissues. The policy stated the resident's clinical record would include charting and documentation related to oxygen use.

Based on clinical record review, review of facility records, staff interviews, and review of policies and procedures, the facility failed to ensure one resident (#1) was provided adequate supervision to prevent an unwitnessed fall with significant injuries that required hospitalization . The deficient practice could result in additional residents sustaining significant injuries from falls. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included acute [CONDITION(S)], [CONDITION(S)], dependence on respirator, dependence on supplemental oxygen, anxiety disorder, and acute embolism and [CONDITION(S)] in right lower extremity. An Initial Admission Record dated [DATE] at 8:51 p.m. included that resident #1 was alert and orientated and was able to follow simple commands. The record included that resident #1 was sometimes understood and able to understand others and that that resident #1 had no behaviors. An Elopement/Wandering evaluation dated [DATE] at 11:17 p.m. included that resident #1 was confined to bed or chair. A care plan initiated on [DATE] for falls included a goal that resident #1 would be free of falls. Interventions listed in the care plan included to avoid rearranging the resident's furniture, and reviewing past falls to determine causative factors. An x-ray/radiology report dated [DATE] at 9:38 a.m. included that findings that reflected CHF (congestive heart failure), pneumonia or both conditions, and cardiomegaly (enlarged heart). A Respiratory Flow Sheet dated [DATE] at 2:00 p.m. included that resident #1 had Rhonchi breath sounds, and was breathing 28 breaths per minute with a heart rate of 120 beats per minute, and a large amount of secretions were suctioned out of the resident's [CONDITION(S)]. The assessment included that resident #1 was found extremely diaphoretic and lethargic with a high respiration rate, and that the resident had a blood pressure of 229 over 97. The assessment included that the provider was notified, orders were obtained, medications were provided and that the resident appears to be more relaxed at this time. A physician's order dated [DATE] at 4:30 p.m. included to for resident #1 to have a (repeat) chest X-ray. A Nursing note dated [DATE] at 7:38 p.m. included that a diagnostic (X-ray) technician arrived at 6:15 p.m. and departed at 6:30 p.m. and that the when the technician exited, the RN asked a TNA (Temporary Nursing Assistant/staff #100) to reposition resident #1 post CXR (Chest X-ray). The note included that seconds later, when the TNA entered the resident's room, the resident was found face down on the floor, the TNA called for help and immediately multiple staff responded to help. The note included that Respiratory Therapy (RT) began to provide respirations manually to the resident, and that at 6:28 p.m. 911 was called, and emergency personnel arrived at 6:35 p.m. The note included that resident #1 was transported via stretcher with a pulse at 6:45 p.m. A Nursing note dated [DATE] at 8:17 p.m. included an RN (staff #17) was contacted by the County Coroner's office regarding contusions found on resident #1's face and forehead. The note included that the resident's initial admission record and wound/skin care record had no presence of contusions noted. The note included that there were no witnesses to resident's descent to the floor on left side of bed per colleagues. A respiratory therapy note dated [DATE] at 9:31 p.m. included that a staff #100 had called for assistance at 6:30 pm. and that when the therapist arrived, resident #1 was found face down on the floor. The note included that the resident was repositioned and the therapist began to manually ventilate the resident with an ambu-bag. However, the resident's oxygen saturation level did not become higher than 78% on 100% oxygen. An eMAR (electronic Medication Administration Note) dated [DATE] at 12:19 am. included that resident #1 was deceased per County Coroner's Office. An undated facility investigative record for resident #1's fall on [DATE] included that resident #1 was found on the floor on the left side of her bed, lying on her back, and had blood visible over her lips, the [CONDITION(S)] was still intact, and the resident's nasal gastric tube was out. The investigation included that the resident was incontinent of bowel and bladder and was unable to give a description of the fall, and that a CODE was called for emergent help. The investigation included that, a team of six staff lifted the resident from the floor, CPR (cardiopulmonary resuscitation) was initiated, and that resident #1 had an injuries to the face. Review of the facility investigative record for resident #1's fall revealed the following staff interviews that were conducted on [DATE]: -A diagnostic technician (staff #89) stated he had informed a nurse (staff #3) that resident #1 was trying to get up and needed help, and that staff #3, then instructed a TNA (staff #100) to go check on the resident. -A Respiratory Therapist/staff #63 stated that when he was leaving shift report he heard the diagnostic tech tell the nurse that resident #1 needed to be repositioned, staff were on the way to the resident's room the ventilator alarm activated and resident #1 was found face down on the floor. -An RN (staff #3) stated that when the diagnostic tech came to resident #1's room, she was notified that resident #1 needed to be repositioned and sent a TNA (staff #100) in to check on the resident (rather than staff #3 check on the resident who was experiencing symptoms of distress). -There was no documented evidence that staff #100 had been interviewed for this investigation. Attempts to contact staff #100 were attempted on [DATE] and [DATE] and were not successful. During an interview conducted on [DATE] at 8:59 a.m. with an X-Ray technician (staff #89), he stated that after completing the chest x-ray on resident #1 on [DATE], the resident was trying to get out of bed, and appeared to be restless and was pulling at her [CONDITION(S)] tube, and that he instructed resident #1 to stay in bed while he was exiting the room. Staff #89 stated he saw a Registered Nurse (RN/staff #3) at the nursing station, and informed the RN that the resident needed assistance. Staff #89 heard the nurse tell a TNA (staff #100) to go look at the resident. During an interview conducted on [DATE] at 10:46 a.m. with an RN (staff #3), she stated that the injuries to resident #1 were of an unknown origin because it is not known how they happened, and that the incident was reported to the Director of Nursing (DON/staff #84). Staff #3 stated that when the X-Ray technician came out of resident #1's room, the technician asked if someone could go into resident #1's room to help the resident, and staff #3 sent a TNA (staff #100) into the resident's room. Staff #3 stated she did not know exactly when the technician left the resident's room or when the TNA entered the room. Staff #3 stated the TNA found the resident on the floor, and that a number of staff members entered the room to assist. During an interview conducted on [DATE] at 1:29 p.m. with an RT (Respiratory Therapist/staff #63), he stated that when he heard a TNA (staff #100) calling for help from one of the rooms, he entered the room and saw the resident face down between the bed and the wall. Staff #63 stated that resident #1 had a [CONDITION(S)] that was still connected to the ventilator while lying face down, and that the ventilator was not alarming which indicated the resident was still ventilating while face down. Staff #63 stated that staff turned the resident over onto her back, and that the resident appeared beat up because her face was covered in blood and there was blood all over the floor. Staff #63 stated the resident's [CONDITION(S)] was in place and that he ventilated the resident manually. The RT stated that the resident was unresponsive and had a pulse. During an interview conducted on [DATE] at 10:41 a.m. with the DON (Director of Nursing/staff #84), she stated that an injury of unknown origin is one that shows up without any idea of how it happened, and is not of known origin. The DON stated that the incident on [DATE] with resident #1 was not considered an injury of unknown origin based on everyone's statements that the resident had a fall which explained the resident's injuries. The DON stated that no one saw the resident fall because it happened after the diagnostic technician left the room and prior to the clinical staff entering the room, and that staff have been asked to monitor residents having x-rays more closely but there were no specific causative factors identified in the incident. The DON stated it is the staff's responsibility to check the residents more frequently, and estimated the time from the diagnostic tech leaving the room and the staff entering the room to be a couple of minutes. A facility policy titled Fall Management System included that the facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents. It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The policy included that review of the fall incident will include investigation to determine probable causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical or assistive devices that may be implicated in the fall.

Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure one resident (#204) received adequate supervision during incontinent care to help prevent a fall with injury. Findings include: Resident #204 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE], indicated the resident was totally dependent with bed mobility and required the physical assistance of two people. The annual MDS assessment dated [DATE], indicated the resident had severe cognitive impairment and was totally dependent with bed mobility and required the physical assistance of two people. Review of a nursing progress note dated April 30, 2015 at 1:30 a.m., revealed that while a certified nursing assistant (CNA) was providing incontinence care, the CNA rolled the patient over, and the bed bolster fell to the side of the bed and the patient rolled out of the bed, landing face first on the floor. The resident sustained [REDACTED]. A physician's order dated April 30, 2015, included to send the resident to the emergency room for treatment. A nursing progress note written later that day, documented that the resident returned to the facility after receiving sutures to the facial laceration. Review of the April 2015 Care Tracker (a form that documents the care and assistance a resident needs) revealed the resident was totally dependent on staff for bed mobility and required two CNA's for assistance. A nursing progress note dated May 1, 2015, included that the CNA had provided incontinence care alone and was counseled by nursing administration staff to remember to have two CNA's deliver incontinence care for this resident. During an interview conducted on June 18, 2015 at 11:45 a.m., the CNA that performed the resident's care at the time of the incident stated that she had received information regarding the care that the resident needed from the Care Tracker, and also during a report from the CNA from the prior shift. When questioned if she had received the information that the resident required two people for incontinence care and bed changes, she replied yes. The CNA also stated that she should have had another CNA help with the resident's care. An interview was conducted with the Director of Nursing on June 22, 2015, who confirmed that if two MDS assessments, spanning a period of three months, assessed the resident to need the assistance of two people for bed mobility, she would expect that level of assistance be provided for the resident. A review of the facility policy titled, Fall Management System revealed that it is the policy of this facility to provide an environment that remains as free of accident hazards as possible. The policy included that each resident is assisted in attaining or maintaining their highest practicable level of function through providing adequate supervision, assistive devices and functional programs to prevent accidents. The policy also included to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to prevent the development of a pressure sore for one resident (#2). The sample size was three. Findings include: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed a Comprehensive Admission assessment dated [DATE], which revealed the resident's skin was intact on admission to the facility. A physician's orders [REDACTED]." A physician's orders [REDACTED]." Another physician's orders [REDACTED]." A care plan dated April 2, 2014, documented "Resident has potential for impairment to skin integrity related to contact [MEDICAL CONDITION], fragile skin, and urinary incontinence with frequency and urgency, diabetes. Due to above is at risk for skin issues/pressure ulcer, infection, pain." An intervention documented was "...Identify/document potential causative factors and eliminate/resolve where possible..." Another intervention was to "...educate resident/family/caregivers of causative factors and measures to prevent skin injury..." No specifics were addressed regarding the brace or turning and repositioning. A Braden Scale for Predicting Pressure Sore Risk dated April 3, 2014, revealed that the resident was at low risk for developing pressure sores. A Skin Wound Note dated April 3, 2014, revealed documentation "Sacrum intact...dry scab on coccyx of unknown origin...buttocks intact." Review of the clinical record revealed no evidence that additional monitoring was provided for the dry scab on the coccyx to prevent pressure sores. A review of the resident's admission MDS (Minimum Data Set) assessment dated [DATE], revealed that the resident did not have any pressure sores on admission, but was at risk for developing pressure sores. A Braden Scale for Predicting Pressure Sore Risk dated April 10, 2014 revealed that the resident was at a moderate risk for developing pressure sores. The resident's care plan was not updated to reflect that the resident was at a higher risk for developing pressure sores on this assessment than on the April 3, 2014 assessment. A Skin Assessment Evaluation dated April 10, 2014 documented "All skin intact." The Skin Assessment did not refer to the dry scab on the resident's coccyx. Another Skin Assessment Evaluation dated April 15, 2014 documented "Bottom less reddened." Again, the dry scab on the resident's coccyx was not mentioned. A Braden Scale for Predicting Pressure Sore Risk dated April 17, 2014 revealed that the resident was at a moderate risk for developing pressure sores. A Physician's Progress Note dated April 25, 2014, documented "Brace off while eating." A Braden Scale for Predicting Pressure Sore Risk dated April 25, 2014, revealed that the resident was at a low risk for developing pressure sores. A Skin Assessment Evaluation dated April 27, 2014, documented "All skin clean, dry, and intact." A Skin Wound Note dated April 29, 2014, documented "Skin assessment per CNA (certified nursing assistant) report regarding new open area on bottom...Per nurses and CNA reports, she likes to sit in chair or in bed with head of bed elevated at 80-90 degrees...Skin assessment revealed wound on right aspect of coccyx 1.8 x 0.5 x 0.1. Wound bed was filled with 75% of slough and 25% of pink granulation tissue. Wound margins were well defined. Surrounding skin is with narrow area of non-blanching redness and no infiltration. The wound was identified as unstageable pressure ulcer. On sacrum/coccyx midline was noted small wound 0.3 x 0.4 x 0.1. This area was noted with dry scab on admission. Wound bed covered with pink moist tissue. Wound margins are macerated." A physician's orders [REDACTED]. Diagnosis: [REDACTED]. A physician's orders [REDACTED]. Apply Santyl ointment to wound bed. Apply ointment to periwound. Cover wound with gauze moistened with Hydrogel. Secure with Stratosorb dressing. Change dressing daily one time a day." Another physician's orders [REDACTED]. Apply small amount of barrier paste to periwound skin and wound margins. Apply Therahoney to wound bed. Cover with gauze and Stratosorb dressing. Change daily one time a day." An interview was conducted with a RN (registered nurse) wound nurse on July 17, 2014. The RN stated that when she did the initial skin assessment on April 3, 2014, if the scab would have been 1 cm. (centimeter) x 1 cm. or larger she would have assessed the resident weekly. The RN stated that she did not remember the size of the scab that she observed but believed that it was 0.3 cm. x 0.3 cm. and stable. The RN stated that the scab should have been mentioned on the weekly skin assessments. The RN stated that it was possible that when the weekly skin assessments were completed, staff just checked for redness. The RN stated that she would have spread the skin when completing a wound assessment. The RN stated that the resident was a high risk for pressure sores. The RN stated that the resident was physically able to turn herself but because of her dementia did not turn herself. The RN stated that the resident liked to sit in a chair. The RN stated that the resident was not on a turning scheduled but that the CNAs are supposed to reposition residents every two hours. An interview was conducted with the ADON (assistant director of nursing) on July 17, 2014, regarding the skin assessments she completed on April 10 and April 27, 2014 documenting the resident's skin being intact. The ADON stated that she only documented what she saw. The ADON stated that the resident's skin color was dark and that she had excess skin. A review of the facility's policy Wound Management documented "It is the policy of this facility that: A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable." The policy also included "...the nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions: ...develop comprehensive care plan if indicated following the evaluation/assessment. Care plans must be individualized and designed to meet the needs of the particular resident for whom they are being developed...In order to prevent the development of skin breakdown...nursing staff shall implement the following approaches as appropriate and consistent with the resident's plan of care: stabilize, reduce or remove any existing underlying risks; monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition..."

Based on closed clinical record review, staff interviews and review of facility policy, the facility failed to ensure that one resident (#5) was provided adequate respiratory services. Findings include: Resident #5 was originally admitted on [DATE], and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The physician's admission orders [REDACTED]. The nursing admission assessment included that the resident arrived at the facility at approximately 7:20 p.m. on [DATE], and that she was alert and oriented to self and situation. The assessment also included that the resident was calm, denied pain, had no tremors and did not appear to be anxious or grabbing at the tubing or staff, as in her previous stay. A review of the respiratory flow sheet dated [DATE], revealed that at 7:20 p.m., according to the documentation, [MEDICAL CONDITION] was in place. The respiratory flow sheet also included that the resident was assessed for a total of 15 minutes. According to the nursing note entry at 8:22 p.m., the CNA (Certified Nursing Assistant) called for assistance to the resident's room. At this time, the resident was found with [MEDICAL CONDITION] over her head, was unresponsive, pale, cool to the touch, and without femoral pulses. The documentation also included that CPR was initiated and 911 was called. However, at 8:38 p.m., the resident expired. The next respiratory entry at 8:23 p.m. included that the resident had coded. No additional entries were included on this flow sheet. Despite the admission orders [REDACTED]. An interview was conducted on [DATE], with the Respiratory Therapy Director. At this time, he confirmed that according to the date/time stamp, the admission orders [REDACTED]. He also stated that he was very concerned that the resident had expired approximately one hour after admission to the facility and because of this concern, he met with the respiratory staff and instructed them that when a resident is admitted and there is a question as to the orders, put the resident on the ventilator. Another interview was conducted on [DATE], with the Director of Nursing, who stated that the nursing staff only verifies the nursing care orders and that the respiratory staff verifies all respiratory care orders. A second interview was conducted on [DATE], with the Respiratory Therapy Director. At this time, he stated that the respiratory department had standing orders that were able to be implemented, for example, to monitor oxygen saturation levels but that the specific respiratory care orders would be obtained and verified upon admission with the physician and then implemented by the respiratory staff. At this time, he stated that the respiratory staff would have been responsible to obtain the respiratory care orders from the physician. An interview was also conducted on [DATE] at 10:05 a.m., with the respiratory therapist, who was assigned to care for the resident. The respiratory therapist stated that she recalled the resident and the circumstances regarding the incident. She stated that she arrived for her shift at 6:00 p.m., and started her rounds. She stated that she received a shift to shift report and therefore, she knew she would be receiving an admission (resident #5), and that the resident was supposed to be [MEDICAL CONDITION] trials during the day and on the ventilator at night. According to the therapist she was behind and still in the middle of her rounds when this resident arrived at the facility. The respiratory therapist stated that when the resident arrived, she recalled that she had hooked the resident up to the oxygen supply in the wall, left [MEDICAL CONDITION] on the resident and conducted a brief assessment of the resident. She recalled that a CNA had gone into the resident's room to get the resident settled and ready for bed and that was when the resident coded. According to the therapist, she knew that the actual physician's orders [REDACTED]. At this time, the therapist stated that according to the physician's orders [REDACTED]. Per the therapist, the facility had provided her with 6 days of orientation but during that orientation she had not been assigned a new admission and that this resident was her first experience with an admission. She also stated that after the incident, the Respiratory Therapy Director came into the facility and told her that anytime a resident had any ventilator orders, to put them on the ventilator immediately upon admission. Following this interview, the in-service education that was provided on [DATE], was reviewed. The in-service was held with the respiratory staff at the facility and included that all residents arriving from the hospital with ventilator orders, arriving to the facility not on the ventilator, need to be place on the ventilator according to physician ventilator settings. A facility policy titled, Standard Protocol Orders, included the following indication: Residents admitted to facility with need for respiratory therapy services such as but not limited to: [MEDICAL CONDITION], ventilators, [MEDICAL CONDITIONS], chest physiotherapy, incentive spirometer, small volume nebulizer, oxygen therapy, or any resident requested by provider to be follow by the respiratory therapy department. The first step in the procedure is: 1. Review resident records for evaluation of respiratory therapy.

Based on observations, closed and current clinical record reviews, staff interviews, and review of facility policies and procedures, the facility failed to prevent the development of unavoidable pressure ulcers for two residents (#s 7 and 196) and failed to provide care and services for multiple pressure ulcers for one residents (#s 127). The sample size was five. Findings include: -Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a Comprehensive Resident Admission Evaluation dated October 21, 2012, which included the resident had skin grafts to his right lower extremity. There was no documentation of any pressure ulcers present. A Braden Scale - For Predicting Pressure Sore Risk dated October 21, 2012, documented the resident was at mild risk for developing pressure sores. A physician's order dated October 21, 2012 included for "Weekly skin check by licensed nurse." Review of a Skin Integrity care plan dated October 22, 2012, included to "...Report any skin problems to the charge nurse..." A Weekly/Monthly Skin Evaluation dated November 1, 2012, revealed the resident's skin was intact. Review of the 14 day MDS (Minimum Data Set) assessment dated [DATE], documented that the resident was at risk for developing pressure ulcers. Per the clinical record documentation, the resident was being seen by a wound physician at the wound clinic, regarding the skin grafts to his right leg. A physician's progress note from the wound clinic dated November 14, 2012 documented "...There is a red spot on his left posterior heel - please float this heel and reassess daily..." A Weekly/Monthly Skin Evaluation dated November 15, 2012, documented the resident's skin was intact, despite the red spot identified on the left posterior heel the previous day, per the wound physician. A Braden Scale - For Predicting Pressure Sore Risk was again completed on November 16, 2012, which identified the resident was still a mild risk for developing pressure sores. Continued review of the clinical record revealed there was no documentation that the resident's heels were being floated, nor that the left heel was being reassessed daily, as per the wound physician. According to the Pressure Ulcer Review dated November 20, 2012, the resident now had a suspected deep tissue injury to his left heel, with an onset date of November 19, 2012. Comments documented were "...Size in centimeters (Length by Width) 1.2 x 1.2...Dark purple blue red discolored spot with red skin around...Sureprep applications every shift started." A physician's order dated November 20, 2012, included for "Sureprep to left heel deep tissue injury every shift." Review of the November 2012 Treatment Sheet revealed that the Sureprep was not applied to the left heel on the day shift on November 20, 21, 24, 25, 27, and 28, 2012. There was no also no documentation that the Sureprep was applied on the afternoon shift on November 25 and 27, 2012. Review of the Pressure Ulcer Review dated November 27, 2012, revealed the size of the wound on the left heel was still 1.2 x 1.2 cm. Comments documented were "Dark brown discolored spot. No induration to periwound..." A physician's order dated November 28, 2012, documented "To left heel eschar: cleanse with normal saline pat dry, apply Medhoney patch, cover with gauze, wrap with Kerlix, change every Monday and Thursday." According to the Pressure Ulcer Review dated December 4, 2012, the size of the left heel wound remained at 1.2 x 1.2 cm. Comments documented were "...Black/Brown (Eschar)...treatment changed..." Clinical record documentation included that the resident was discharged on [DATE], with the pressure ulcer to the left heel. An interview was conducted with an RN (registered nurse) on February 15, 2013. The RN stated that she was unable to provide evidence that the Sureprep was applied to the resident's left heel on the days that it was not documented on the November 2012 Treatment Sheet. The RN stated that when the Sureprep was applied to the resident's heel, the resident's skin should have been assessed at that time. -Resident #196 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's clinical record revealed a Comprehensive Resident Admission Evaluation dated November 30, 2011, which documented concerns regarding the ankles and heels being dry with peeling skin, and that the resident's heels were mushy. There was no documentation regarding any skin concerns related to the resident's toes. A physician's order dated November 30, 2011 included, "Profo boots to bilateral feet secondary to foot drop as tolerated by patient." An Admission Wound/Skin Evaluation dated December 1, 2011, documented "...Heels boggy with blanchable [DIAGNOSES REDACTED]. Left heel tender to touch." There were no skin concerns documented related to the resident's toes. A Skin Integrity care plan dated December 1, 2011, identified the problems with the boggy heels and peeling skin, but there were no concerns documented regarding the resident's toes. The care plan did include the use of the Profo boots, however, the interventions did not address the need for frequent skin checks, despite the use of the Profo boots. Review of a Pressure Ulcer Site Sheet dated December 14, 2011, now documented an unstageable pressure ulcer, which measured 2.0 x 1.7 cm on the resident's left fifth metatarsal (toe). The documentation included the pressure ulcer was not present on readmission to the facility. A Pressure Ulcer Site Sheet dated December 14, 2011, also revealed a suspected deep tissue injury which measured 3.5 x 2.0 cm on the resident's right first metatarsal. The documentation included the pressure ulcer was not present on readmission to the facility. Also identified was an unstageable pressure ulcer which measured 4.0 x 2.0 cm on the resident's right fifth metatarsal. The documentation included the pressure ulcer was not present on readmission to the facility. Review of the Pressure Ulcer Site Sheet dated December 15, 2011, also revealed there was a stage 3 pressure ulcer which measured 4.0 x 2.0 x 0.2 cm on the resident's right fifth metatarsal. The documentation included the pressure ulcer was not present on readmission to the facility. A physician's progress note dated December 15, 2011, documented "Wounds on feet - boots discontinued-wound team monitoring." Further review of the clinical record revealed there was no physician's order written to discontinue the Profo boots. There was also no documentation of any increased skin monitoring that was done of the resident's feet, despite using the Profo boots. A physician's order for wound treatment was finally obtained on December 19, 2011. The resident was discharged on [DATE]. An interview was conducted with an RN on February 15, 2013. The RN stated that when a resident had an order for [REDACTED]. An interview was conducted with the interim DON (director of nursing) on February 15, 2013. The interim DON stated that the resident's order for the Profo boot was to wear as tolerated and that a CNA (certified nursing assistant) could put the boots on and take the boots off, and should look at the feet for changes in skin condition and notify the nurse. -Resident #127 was admitted to the facility August 14, 2012, with [DIAGNOSES REDACTED]. Regarding the coccyx pressure ulcer: Review of the clinical record revealed a Patient Discharge Instruction Plan and Transfer of Care dated August 14, 2012, that included the resident had a stage II right buttock/coccyx decubitus ulcer and to cleanse the wound and apply [MEDICATION NAME] daily. A Comprehensive Resident Admission Evaluation dated August 14, 2012, revealed that the resident had a 2 x 1 cm abrasion to the left buttock, however, there was no documentation regarding the stage II decubitus ulcer to the right buttock/coccyx area. Physician orders on admitted d August 14, 2012, included to cleanse the right buttock/coccyx decubitus ulcer with normal saline, pat dry, and apply [MEDICATION NAME] daily, and cover with a dry dressing everyday. admission orders [REDACTED]. A Braden Scale - For Predicting Pressure Sore Risk was completed on August 14, 2012, and revealed the resident was at severe risk for developing pressure sores. Review of the treatment record for August 2012 revealed no documented evidence that the treatment to the right buttock/coccyx area was provided, as ordered, from the time of admission through the end of August. Review of the September 2012 treatment record, revealed the wound treatment was only provided on September 1, and 2, and on September 3, it was discontinued. However, further review of the clinical record revealed there was no written order to discontinue the wound treatment. In addition, the next Braden Scale evaluation was not completed until September 3, 2012, more than two weeks after the one done upon admission. Continued review of the clinical record revealed pressure ulcer assessments were only completed upon admission and on September 22, 2012. On the September 22 Weekly/Monthly Skin Evaluation, the documentation included there were no open areas to the coccyx area and skin was intact. There was no documented evidence that the pressure ulcer to the coccyx area and been consistently monitored and thoroughly assessed. Regarding the right inner calf and right outer ankle pressure ulcers: A physician's order dated October 26, 2012, documented on the treatment record to apply skin prep every shift to the right inner calf stage II, and to the right outer ankle stage I. Review of the treatment record for October 26, 2012 through January 2013, revealed that on multiple dates there was no documentation the treatment to the right inner calf and right outer ankle were done. In addition, the treatment record for January 2013 documented the treatment to the ankle was discontinued on January 28. However, clinical record review revealed there was no physician's order to discontinue the treatment. Review of the treatment record for February 2013 revealed the order for the skin prep to the right inner calf every shift had not been transcribed over to the treatment record, and as a result, there was no evidence that the treatment had been provided. There was also no clinical record documentation of any order to discontinue this treatment. Regarding the right ear deep tissue injury: A physician's order dated January 8, 2013, included to apply [MEDICATION NAME] to the right ear deep tissue injury every shift. Review of the treatment record for January 2013, revealed this order was documented. Written on the treatment record was that it was discontinued on January 28, 2013. However, clinical record review revealed there was no documented evidence that a physician's order was obtained to discontinue the [MEDICATION NAME] treatment. During an interview conducted on February 14, 2013, licensed staff stated that the Braden Scale Evaluation for pressure ulcer risk should be conducted once on admission and then weekly three times for a total of four evaluations, and if the resident's condition worsened or a pressure ulcer developed, then the Braden Scale evaluation would be continued past the initial four weeks. Additionally, she stated that weekly skin assessments are conducted by licensed staff and documented on the treatment record. During an interview conducted on February 14, 2013, the interim director of nursing stated that the resident's treatment for [REDACTED]. ulcers. During an interview conducted on February 19, 2013 with the clinical nurse consultant, she stated that there were orders for treatments to all of the wounds, however, she could no locate physician's orders for discontinuation of the wound treatments. Review of the facility's policy regarding Wound Management included that it is the policy that "1. A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable." The policy further included that a resident with a pressure ulcer would receive necessary treatment and services to promote healing, and that once a wound had been identified, assessed, and documented, nursing would administer treatment to each affected area, as per the physician's order. The facility identified concerns with the development of pressure ulcers and began a Quality Improvement Program. Problems identified on the Quality Improvement Tracking Form dated December 3, 2012, included "Braden Scale not done consistently every week times four from date of admission. Committee meetings not consistently held as scheduled. Weekly skin check sheets not done consistently as scheduled. Inconsistent wound management and documentation specifically for new admits and newly identified wounds, in-house timeliness of interventions, care plans, flow sheets, physician and family notification. Identified multiple new in-house pressure ulcers." Causal Factors identified on the Quality Improvement Form dated December 3, 2012 were "Lack of education and understanding by the new wound nurses. Lack of monitoring system. Staff turnover. Director of nursing turnover. Lack of education and understanding by the nursing staff regarding weekly skin checks. Residents are debilitated with multiple co-morbidities. Residents are highly compromised nutritionally. Lack of education and understanding by the nursing staff regarding skin management program." Interventions identified on the Quality Improvement Form dated December 3, 2012 were "Review current policy and procedures and related forms and educate the nursing staff. Nursing staff and other members of the Skin Program will be in-serviced on the Skin Program. Weekly committee meeting is held every Thursday afternoon and attended by the interim director of nursing services, wound nurses, dietary. Inservice all nursing staff regarding hygiene and skin care. Charge Nurses to co-sign for completion of resident showers. Individual counseling and disciplinary action for nursing staff by director of nursing services. Skin sweep of the entire facility performed and completed on December 10, 2012. Director of nursing services/designee will monitor completion of weekly skin check daily during morning rounds until substantial compliance is attained. Inservice given to nursing staff on turning/repositioning/floating heels on December 22, 2012. Clinical Resource Nurse will monitor skin program as needed. Review current residents with skin breakdown and evaluate interventions."