Every finding on record at Claremont Care Center

Based on interview and record review, the facility failed to ensure quality of care for three of three sampled residents (Residents 2, 66 and 35) by failing:A. To follow physician's order when the license nurses administered insulin (a medication that removes excess sugar from the blood.) on one of three sample residents (Resident 2)'s left arm with a shunt. (a surgically created access point on the body for dialysis [a treatment to clean your blood when your kidney can't do it well.]) B. To ensure a Change of Condition (COC, a major unplanned deviation from the most recent status, when the change is identified the resident is evaluated and the changes are reported to the physician) assessment was completed for Resident 66 after a surgical debridement (the medical process of cleaning a wound by removing dead, damaged, or infected tissue, as well as foreign debris, to promote faster healing and prevent infection) of a callus (a thickened, hardened patch of skin that forms to protect a specific area of the body from repeated rubbing, pressure, or irritation) revealed an open diabetic (difficulty in blood sugar control and poor wound healing) foot ulcer (an open sore or wound, usually on the bottom of the foot, that develops in people with diabetes due to a combination of numb feet, poor blood circulation, and skin breakdown from pressure) was found on [DATE]. Additionally, the facility failed to notify Medical Doctor (MD, Resident 66's primary care physician) 2 of Resident 66's COC.C. To obtain a physician order prior to performing a fingerstick (a procedure that uses a medical device [a lancet] to prick the skin to check blood sugar) for Resident 35.These failures placed Residents 2, 66 and 35 at risk for serious complications, including bleeding and compromise of dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) access, delayed treatment, infection, impaired wound healing, and further clinical deterioration and Resident 35 feeling bothered and receiving unnecessary treatment.Findings: A. During a review of Resident 2's Face Sheet (admission record), the face sheet indicated the facility initially admitted a [AGE] year-old female on [DATE] and re-admitted on [DATE], with the diagnoses that included but not limited to end stage renal disease (irreversible kidney failure) , dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control). During a review of Resident 2's minimum data set (MDS, a resident assessment tool), dated [DATE], indicated Resident 2 is getting dialysis. During a review of Resident 2's physician's order dated 2/2026. The physician's order indicated Resident 2 should not receive any needle stick on her left arm. During a review of Resident 2's Medication Administration Record (MAR), dated 2/2026. The MAR indicated license nurses used Resident 2' left arm to administered medication through needle injection on following dates and time: Insulin glargine (a long-acting insulin helps people with diabetes control their blood sugar.) Solution 100 unit/ml [DATE] 6:35 PM NovoLOG (a fast-acting insulin) Injection Solution 100 unit/ml [DATE] 11:42 AM [DATE] 11:48 AM [DATE] 6:37 AM [DATE] 6:32 PM [DATE] 6:23 AM [DATE] 10:00 PM [DATE] 6:02 AM [DATE] 10:06 PM During an interview on [DATE] at 8:47 AM with Licensed Vocational Nurse (LVN)6, LVN 6 stated all physician's order should be reviewed before administered medication to a resident. If a resident is on hemodialysis, she will try to avoid the arm having shunt because injection on the shunt arm could result trauma to the resident. During a concurrent interview and record review on [DATE] at 9:07 AM, with LVN 5, Resident 2's physician's order dated 2/2026 was reviewed. The physician's order indicated, no needle stick on Resident 2's left arm. LVN 5 stated she was not aware of the order and had administered insulin injection on Resident 2's left arm. LVN 5 stated using Resident 2's left arm for injection will increase the risk of bleeding and cause trauma. During an interview on [DATE] at 9:50 AM with the Director of Nursing (DON), the DON stated that for any hemodialysis resident who is also on insulin injection, it is important that nurse check physician's order and avoid the arm with the shunt. The DON also stated their nurses should follow physician's order and avoid any harm to any resident. During a review of the facility's Policy and Procedure (P&P) titled, Medication administration, not dated. The P&P indicated medication should be administered as prescribed by the physician. B. During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted Resident 66 on [DATE], with diagnoses including cellulitis (a skin infection that causes swelling and redness), pressure ulcer (a small open sore or wound generally found in the stomach or on the skin), the need for assistance with personal care, and Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66's cognition (the ability to think and process information) was intact. The MDS indicated Resident 66 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL-term used in healthcare that refers to self-care activities) and substantial/maximal assistance (helper does more than half the effort) with mobility. During a review of Resident 66's Nursing Order (NO), dated [DATE], the NO indicated a plan for debridement (the medical process of cleaning a wound by removing dead, damaged, or infected tissue, as well as foreign debris, to promote faster healing and prevent infection) to Resident 66's right heel. During a review of Resident 66's Progress Note (PN), dated [DATE], the PN documentation indicated Resident 66 was seen at bedside for debridement and treatment of a complex callus on Resident 66's right foot. The PN indicated will debride callus today. The PN indicated non-selective active wound care (methods used to clean a wound that remove both dead [necrotic] tissue and healthy, living tissue in the process) to be provided by facility staff between visits. The PN indicated skilled nursing team to continue care as ordered. During a review of Resident 66's Care Plan Report (CPR), initiated [DATE], the CPR's focus indicated a right heel ulcer and on [DATE] Resident 66's callus was debrided exposing a diabetic fool ulcer on Resident 66's right heel. The CPR's goal indicated Resident 66's skin issue would begin the healing process by the next review date. During an interview on [DATE] at 10:27 AM, with LVN/Treatment Nurse (LVN) 7, LVN 7 stated following the surgical debridement to the right heel, the removal of the callus revealed an open diabetic foot ulcer requiring ongoing wound care treatment. LVN 7 stated and confirmed that a COC assessment was not completed. LVN 7 stated a COC assessment was needed because Resident 66's skin integrity status changed from an intact callus to an open wound, representing an alteration in medical condition requiring assessment, monitoring, and [new] interventions. LVN 7 stated completion of a COC assessment was essential to evaluate the extent of the wound, identify risk factors including infection and impaired healing related to DM, and to notify the resident's physician. LVN 7 stated that failure to complete the assessment limited comprehensive clinical evaluation of the resident's altered status and placed the resident at risk for delayed identification of complications, and impaired wound healing. During an interview and concurrent record review on [DATE] at 11:49 AM, with Registered Nurse (RN) 1, Resident 66's medical records were reviewed with RN 1, RN 1 stated when a resident's condition changed from intact skin to an open wound, a COC assessment was required. RN 1 stated completion of a COC assessment ensured a comprehensive nursing evaluation was performed, physician notification occurred, appropriate monitoring and interventions were initiated, and promoted clear interdisciplinary team (IDT, a group of experts from different fields [e.g., doctors, nurses, social workers] who work closely together, sharing knowledge to solve complex problems or care for a patient) communication. RN 1 stated there was no documented evidence MD 2 was notified of Resident 66's COC that occurred on [DATE]. RN 1 stated when there was a resident COC, the physician should be notified of the changes. During a review of the facility's P&P titled, Change in Condition dated 4/2025, the P&P's policy indicated the facility is to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. The P&P indicated if, at any time, it is recognized by any one of the team members that the conditions or care needs of the residents have changed. the nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using SBAR [COC] or similar process to obtain new orders or interventions. The P&P indicated the nurse will communicate the change to other departments as appropriate and each department notified will perform their own evaluation and assessment to determine if the change requires further intervention and implement actions accordingly. The nurse will transcribe the treatment and plan of care relative to the change of condition on the resident Electronic Medical Record (EMR). The P&P indicated the IDT shall collaborate with the attending physician.to review risk indicators and the plan of care. The P&P indicated the nurse shall use his/ her clinical judgment and shall contact the physician based on the urgency of the situation. C. During a review of Resident 35's AR, the AR indicated Resident 35 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM – adult-onset disorder characterized by difficulty in blood sugar control and poor wound healing) with other specified complication, and heart failure. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognitive skills for daily decision making were intact. The MDS indicated Resident 35 was dependent to required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with ADL. During a review of Resident 35's Order Summary Report (OSR), active orders as of [DATE], the OSR indicated an active order dated [DATE], for Lantus SoloStar (a type of long-acting insulin) subcutaneous (under the skin) solution pen-injector 100 unit/millimeters (ml, unit of volume) two times a day for DM. The OSR, did not indicate an order to check Resident 35's blood sugar for the Lantus SoloStar insulin ordered two times a day for DM. During a review of Resident 35's Medication Administration Record (MAR), dated 2/2026, the MAR indicated Lantus SoloStar insulin was scheduled to be administered daily at 9 AM and at 5 PM. During a review of Resident 35's Weights and Vitals Summary (WVS), effective date range: [DATE] to [DATE], the WVS indicated a blood sugar level of 127 mg/dL (milligrams per deciliter - a unit of measurement representing the concentration of blood sugar in a specific volume of blood) on [DATE] at 9 AM. During an observation on [DATE] at 8:05 AM, during medication administration, LVN 3 was preparing Resident 35's 9 AM scheduled medications. Resident 35 was lying in bed having breakfast. LVN 3 performed a fingerstick on Resident 35's right ring finger. LVN 3 stated, LVN 3 liked checking Resident 35's blood sugar since Resident 35 was getting Lantus, it's (insulin) a long acting. During an interview on [DATE] at 11:31 AM with Resident 35, Resident 35 stated Resident 35 was getting fingersticks around 5 [to] 6 times total in a day, including at 9 AM performed only by LVN 3. Resident 35 stated, being poked (fingerstick and insulin injections) many times in a day bothered Resident 35. During a concurrent interview and record review on [DATE] at 11:46 AM with LVN 3, Resident 35's OSR was reviewed. LVN 3 stated there was no order to check Resident 35's blood sugar for the Lantus 9 AM dose. LVN 3 stated, checking Resident 35's blood sugar for the Lantus 9 AM dose was not necessary and would not be following doctor's order and, that would be a mistake. LVN 3 stated, unnecessary fingersticks were something that residents (in general) would not like or enjoy and would be uncomfortable. During a concurrent interview and record review on [DATE] at 3:35 PM with the DON, Resident 35's OSR focusing on the orders for insulin with blood sugar checks were reviewed. The DON stated Resident 35 would be getting blood sugar checks four (4) times at 6:30 AM, 11:30 AM, 4:30 PM and at 9 PM. The DON stated Resident 35 did not have an order to check blood sugar for Lantus 9 AM dose and it was not necessary for LVN 3 to check Resident 35's blood sugar for the Lantus 9 AM administration. The DON stated unnecessary fingersticks were uncomfortable for residents and staff should only check resident's blood sugar without [a physician's order] during [medical] emergencies. During a review of the facility's P&P titled, Diabetes Mellitus Resident, reviewed 10/2025, the P&P indicated, to monitor blood sugar as needed and as ordered by the physician for symptoms of hyper/hypoglycemia (glycemia - concentration of sugar in the blood). During a review of the facility's P&P titled, Physician's Orders, telephone orders, reviewed 12/2025, the P&P indicated, physician's orders should be obtained prior to the initiation of any medication or other treatment.

Based on interview and record review, the facility failed to ensure the clinical record was complete and accurate for three of three sampled residents (Resident 2, Resident 66, and Resident 113).This failure had the potential to result in inaccurate assessments, inconsistent and/or inaccurate treatments provided to the residents and negatively impact Resident 2 and 66, and Resident 113's physical well-being. Findings: 1a(i). During a review of Resident 2's Face Sheet (admission record), the face sheet indicated the facility initially admitted a [AGE] year-old female on 5/27/2023 and re-admitted on [DATE], with the diagnoses that included but not limited to end stage renal disease (irreversible kidney failure) , dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control). During a review of Resident 2's minimum data set (MDS, a resident assessment tool), dated 11/1/2025, indicated Resident 2 is getting dialysis. During a review of Resident 2's Medication Administration Record (MAR), dated 2/2026, the MAR indicated the following dates and time Resident 2's insulin administered site was documented as on her Deltoid (muscle in the shoulder): NovoLOG (fast-acting insulin, medicine used by people with diabetes to help control blood sugar.) Injection Solution 100 unit/ml 2/3/2026 5:04 PM Insulin Glargine (long-acting insulin, medicine that helps people with diabetes control their blood sugar.) Solution 100 unit/ml 2/4/2026 5:06 PM During an interview on 2/11/2026 at 9:13 AM with Licensed Vocational Nurse (LVN) 4, LVN 4 stated deltoid is not a proper site for insulin injections because deltoid is muscle and insulin shot should be subcutaneous (under the skin) on the back of the arms and on stomach. During a concurrent interview and record review on 2/11/2026 at 9:50 AM with the Director of Nursing (DON), Resident 2's MAR dated 2/2026 was reviewed. The DON stated the documentation on Resident 2's MAR indicated that insulin shot was given on deltoid was wrong documentation. During an interview and on 2/13/2026 at 10:11 AM with Registered Nurse (RN), RN stated Resident 2 MAR has discrepancies. RN also stated false documentation is unacceptable, all documentation should be complete and accurate to reflect patient assessment. False documentation could lead to problems like medication error. 1a(ii). During a review of Resident 113's Face Sheet, the face sheet indicated the facility admitted Resident 113, a [AGE] year-old male, admitted on [DATE], with diagnoses that included end stage renal disease (irreversible kidney failure) , dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control). During a review of Resident 113's MDS, dated [DATE], indicated Resident 113 is getting dialysis. During a review of Resident 113's Care Plan (CP), date initiated 2/6/2026, the CP indicated no needle stick on Resident 113's left arm. During a review of Resident 113's MAR dated 2/2026. The MAR indicated the following dates and time Resident 113's insulin administered site was documented as on his Deltoid: NovoLOG Injection Solution 100 unit/ml 2/5/2026 4:08 PM 2/6/2026 4:02 PM 2/9/2026 4:10 PM 2/10/2026 4:11 PM 2/10/2026 8:21 PM During a review of Resident 113's MAR dated 2/2026. The MAR indicated the following dates and time Resident 113's insulin administered site was documented as on his left arm: NovoLOG Injection Solution 100 unit/ml 2/7/2026 5:24 PM 2/8/2026 12;22 PM During a concurrent observation and interview on 2/11/2026 at 8:10 AM with Resident 113 in Resident 113's room. Resident 113 was observed lying on the bed with a dialysis shunt on his left arm. Resident 113 stated nurse had been given his insulin injection on his stomach and his right arm; they never use his left arm or his shoulder. During an interview on 2/11/2026 at 9:13 AM with LVN 4, LVN 4 stated deltoid is not a proper site for insulin injections because deltoid is muscle and insulin shot should be subcutaneous on the back of the arms and on stomach. During a concurrent interview and record review on 2/11/2026 at 9:50 AM with the DON, Resident 113's MAR dated 2/2026 was reviewed. The DON stated the documentation on Resident 113's MAR indicated that insulin shot was given on deltoid was wrong documentation. During an interview on 2/13/2026 at 10:11 AM with RN, RN stated Resident 113's MAR has discrepancies. RN also stated that false documentation is unacceptable, all documentation should be complete and accurate to reflect patient assessment. False documentation could lead to problems like medication error. During a concurrent interview and record review with LVN 3 on 2/13/2026 at 10:54 AM, Resident 113's CP initiated on 2/6/2026 and Resident 113's MAR dated 2/2026 were reviewed. The CP indicated no needle stick on Resident 113's left arm and MAR indicated Resident 113 was given medication through a needle injection on his left arm. LVN 3 stated, the documentation on the MAR was wrong, she did not use Resident 113's left arm for any medication injections. LVN 3 also stated she needs to be more careful when she does documentation. Wrong documentation could lead to medication errors, and poor resident outcomes. 1b. During a concurrent interview and record review on 2/13/2026 at 10:11 AM with RN, Resident 113's dialysis communication form. dated 2/12/2026 was reviewed. The dialysis communication form was not completed and missing the following information: Dialysis center name Covid-19 (a respiratory disease) confirm Case status Location of the dialysis Access site Level of consciousness status If the dialysis access site had dressing or not If the dialysis access site had Infection or not RN stated the dialysis communication form on 2/12/2026 was incomplete, and it should be complete. She also stated it is facility nurses' responsibility to make sure the dialysis communication form to be completed and accurate. RN also stated that incomplete documentation is unacceptable, all documentation should be complete and accurate to reflect resident's assessment. Incomplete documentation will affect communication between nurses and will increase the risk of medication error for residents. During a review of facility's policy and procedures (P&P) titled, Resident Assessment and Associated Process dated 4/2025, the P&P indicated resident assessment should be documented comprehensive and accurate. 2. During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted Resident 66 on 4/4/2025, with diagnoses including cellulitis (a skin infection that causes swelling and redness), pressure ulcer (a small open sore or wound generally found in the stomach or on the skin), and the need for assistance with personal care. During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66's cognition (the ability to think and process information) was intact. The MDS indicated Resident 66 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL-term used in healthcare that refers to self-care activities) and substantial/maximal assistance (helper does more than half the effort) with mobility. During a review of Resident 66's Progress Note (PN), dated 12/25/2025, the PN indicated Resident 66 underwent surgical debridement (removal of dead, damaged, or infected tissue and foreign debris from a wound using instruments like a scalpel or scissors) of an ulcer located on the right heel. The PN indicated: Surgical debridement performed to the ulcer site. Plan for debridement continue as needed. Non-selective active wound care (methods used to clean a wound that remove both dead [necrotic] tissue and healthy, living tissue in the process) to be provided by facility staff between visits. Skilled nursing team to continue care as ordered. During a review of Resident 66's Order Summary Report (OSR), dated active as of 1/1/2026, The OSR reflected an active order with a start date of 12/25/2025 for: Right Heel Diabetic Ulcer – cleanse with normal saline (NS- a sterile mixture of 0.9% salt [sodium chloride] in water, designed to match the natural salt concentration in human blood), pat dry, apply collagen (a protein in the body) powder to the wound bed (the surface of the wound itself, specifically the exposed tissue at the base of a cut, sore, or ulcer) followed by calcium alginate (a natural, biodegradable gel that can hold shape and moisture) and cover with dry dressing QD (QD-once daily). During a review of Resident 66's Treatment Administration Record (TAR), dated 1/2026, under the TAR's Weekly Assessment – No Skin Impairment, the following entries were documented: 1/3/2026: Skin documented as intact. 1/10/2026: Skin documented as intact. 1/17/2026: Skin documented as intact. 1/24/2026: Skin documented as intact. The TAR indicated the weekly skin assessments reflected intact skin status on the above dates. During a review of Resident 66's PNs, dated 1/7/2026, 1/14/2026, 1/21/2026, and 2/4/2026, the PNs indicated Resident 66's wound had not resolved and remained open. During an interview and concurrent record review on 2/13/2026 at 10:36 AM, Resident 66's Treatment Administration Record (TAR), dated 1/2026, was reviewed with Licensed Vocational Nurse 7/Treatment Nurse (LVN 7). LVN 7 stated the weekly skin assessments were inaccurate and improperly documented. LVN 7 confirmed Resident 66's skin had remained open since the debridement and had not resolved. LVN 7 stated the documentation should have reflected that the wound remained open. LVN 7 stated accurate wound documentation was essential to ensure the correct wound care orders were followed, changes in condition were promptly identified, appropriate precautions were implemented, and for all staff to be aware of the resident's current wound status to provide consistent care. During an interview on 2/13/2026 at 11:49 AM, with RN 1, RN1 stated documentation [in resident medical records] should be accurate, timely, and reflective of the resident's actual condition. RN 1 explained that for wounds, it was essential to clearly document whether the skin was intact or open, the status of healing, and any changes observed. RN 1 stated proper and accurate wound documentation was critical to ensure appropriate treatment interventions, prevent infection, support care planning, and maintain continuity of care among staff. During a review of the facility's Job Description titled, Licensed Vocational Nurse dated 12/17/2021, the LVN job description indicated: Chart [document] nurses' notes in professional and appropriate manner that timely, accurately, and thoroughly reflect the care provided to the residents, as well as the resident's response to the care. Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures and applicable state and federal regulations. During a review of the facility's Job Description titled, Registered Nurse Supervisor dated 12/17/2021, the RN supervisor job description indicated: Reviews nursing personnel medical record documentation to ensure that it is appropriately and accurately descriptive of the nursing care provided.

Based on observation, interview, and record review, the facility failed to ensure five of five sampled residents (Resident 21, 61, 116, 117, and 35), were treated with dignity when:a. Licensed Vocational Nurse (LVN) 2 failed to knock on Resident 21 and 61, 116 and 117's doors prior to entering the resident's rooms.b. LVN 3 failed to draw (close) Resident 35's privacy curtains completely around Resident 35's bed during insulin (a medication, hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration in Resident 35's abdomen (belly). This failure could potentially result in Residents 21, 61, 116, 117, and 35 feeling bothered or startled, in the residents feeling invaded and humiliated, and negatively impacting the resident's psychosocial [the emotional and social requirements that individuals must have to feel safe, supported, and capable of functioning well in their environment]) well-being.Findings:a. During a review of Resident 21's admission Record (AR), the AR indicated, Resident 21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually due to an infection) of vertebra (one of the bones that make up the spinal column), thoracic (relating to chest) region, and bacteremia (bacteria in your blood).During a review of Resident 21's History and Physical (H&P), dated 12/20/2025, the H&P indicated, Resident 21 was A & O x 4 (alert and oriented to person, place, time, and situation).During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 12/23/2025, the MDS indicated Resident 21's cognitive skills (ability to think and process information) for daily decision making were intact. The MDS indicated, Resident 21 was independent (resident completes the activity by themself with no assistance from a helper) and required partial/moderate assistance (helper does less than half of the effort) with ADL (activities of daily living).During a review of Resident 61's AR, the AR indicated, Resident 61 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a long standing group of lung disease that block airflow causing difficulty in breathing) with (acute, sudden) exacerbation (worsening), and urinary tract infection (UTI - an infection in the bladder/urinary tract), site not specified.During a review of Resident 61's History of Present Illness (H&P), dated 1/21/2026, the H&P indicated, Resident 61 had the capacity to understand and make decisions.During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61's cognitive skills for daily decision making were intact. The MDS indicated Resident 61 required substantial/maximal assistance (helper does more than half the effort) to supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with ADL.During a review of Resident 116's AR, the AR indicated, Resident 61 was admitted to the facility on [DATE] with multiple diagnoses including anxiety disorder (a mental health condition characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life), unspecified, and old myocardial infarction (MI - heart attack).During a review of Resident 116's H&P, dated 2/9/2026, the H&P indicated, Resident 116 was frail but responsive to name.During a review of Resident 116's MDS, dated [DATE], the MDS indicated Resident 116 was dependent (helper does all of the effort) and required partial/moderate assistance with ADL.During a review of Resident 117's AR, the AR indicated, Resident 117 was admitted to the facility on [DATE] with multiple diagnoses including need for assistance with personal care, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), unspecified.During a review of Resident 117's MDS, dated [DATE], the MDS indicated Resident 117's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 117 required substantial/maximal assistance to supervision or touching assistance with ADL.During an observation on 2/10/2026 between 10:00 AM and 10:55 AM, multiple staff (unidentified) were entering multiple resident's rooms without knocking [announcing themselves] on the doors.During an observation on 2/11/2026 at 7:46 AM, LVN 2 entered Resident 21 and 61's room without knocking on the door [or announcing self] to check on Resident 21 and 61's breakfast trays. LVN 2 exited the room and entered Resident 116 and 117's roomwithout knocking on the door, and collected Resident 116's breakfast tray. LVN 2 exited the room and put away the breakfast tray in a meal delivery cart. LVN 2 entered Resident 21 and Resident 61's room a second time without knocking on the door and collected Resident 61's breakfast tray.During an interview on 2/11/2026 at 7:52 AM with LVN 2, in the presence of Registered Nurse (RN) 1, LVN 2 stated staff (in general) should knock [on the doors] prior to entering resident rooms and knocking was important to protect the resident's privacy and dignity.During a concurrent interview on 2/12/2026 at 11:16 AM with Resident 61 and the Responsible Party (RP), Resident 61 stated, staff not knocking prior to entering Resident 61's room would scare the (expletive) out of Resident 61. The RP stated, staff (unidentified) sometimes knocked on the door and sometimes, they don't.During an interview on 2/12/2026 at 3:35 PM with the Director of Nursing (DON), the DON stated, knocking on a resident's door before entering their room was important to let the resident know staff was entering the room, for staff to ask permission to enter, and for dignity [purposes]. b. During a review of Resident 35's AR, the AR indicated, Resident 35 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus (DM - adult onset disorder characterized by difficulty in blood sugar control and poor wound healing) with other specified complication, and heart failure, unspecified.During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognitive skills for daily decision making were intact. The MDS indicated Resident 35 was dependent and required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with ADL.During a review of Resident 35's Order Summary Report (OSR), active orders as of 2/12/2026, the OSR indicated, an active order for Lantus SoloStar (a type of long-acting insulin) subcutaneous (administered under the skin) solution pen-injector 100 unit/millimeters (ml, volume of liquid) two times a day for DM, dated 12/17/2026.During a review of Resident 35's Medication Administration Record (MAR), dated 2/1/2026 to 2/28/2026, the MAR indicated Lantus insulin was scheduled to be administered daily at 9:00 AM and at 5:00 PM. During an observation on 2/12/2026 at 8:36 AM, LVN 3 administered Resident 35's insulin in Resident 35's right upper quadrant of Resident 35's abdomen with Resident 35's privacy curtain drawn from Resident 35's head of the bed to the right corner of the foot of bed, Resident 5's abdomen was exposed. LVN 3 stated, LVN 3 should have drawn Resident 35's drape all the way around Resident 35's bed for privacy and dignity. During a review of the facility's policy and procedure (P&P) titled, Resident Rights-Dignity and Respect, revised 10/2025, the P&P indicated, it was the policy of the facility forall residents to be treated with kindness, dignity, and respect. The P&P indicated, residents should be examined and treated in a manner that maintained the privacy of their bodies. The P&P indicated, a closed door or drawn curtain shielded the resident from passers-by. The P&P indicated, staff should knock before entering the resident's room.

Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal the need for assistance) system was within reach for two of two sampled residents (Resident 3 and Resident 115), as indicated on Resident 115's care plans (CP) and in accordance with the facility's policy and procedure (P&P) titled Call Light. This failure resulted in Resident 115 feeling discouraged and had the potential to result in unmet needs and inability to alert staff during an emergency for Residents 3 and115. Findings: A. During a review of the admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included heart failure (a long standing condition where the heart muscle is too weak or stiff to pump blood efficiently, failing to meet the body's oxygen [a colorless gas essential to living organisms] needs), dementia (a progressive state of decline in mental abilities), Type 2 diabetes mellitus (DM – a disorder characterized by difficulty in blood sugar control and poor wound healing), difficulty in walking, and need for assistance with personal care. During a review of Resident 3's Care Plan Report (CPR), dated [DATE], the CPR indicated Resident 3 was at risk for falls related to impaired balance and mobility. The CPR's interventions indicated to be sure Resident 3's call light was within reach and to encourage the use of the call light to call for assistance as needed. During a review of Resident 3's History and Physical (H&P), dated [DATE], the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS – a comprehensive assessment and screening tool), dated [DATE], the MDS indicated Resident 3's cognitive (the ability to think and process information) ability was moderately impaired. During a concurrent observation and interview on [DATE] at 2:45 PM with Resident 3 in the resident's room, Resident 3 was sitting on his wheelchair. Resident 3 stated Resident 3 wanted a nurse and when asked where Resident 3's call light was, Resident 3 was unable to find the call light to call for assistance. During an interview on [DATE] at 2:47 PM with the Director of Nursing (DON), the DON stated the importance of having a call light within [a resident's, in general] reach was for the residents to use it when they had a need and have their needs met. During a review of the facility's P&P titled, Call Light, dated February 2023, the P&P indicated to leave the resident comfortable, ensure the call device is within resident's reach before leaving [the] room, and if the resident is unable to reach the call light, don't leave the resident unattended. B. During a review of Resident 115's AR, the AR indicated, Resident 115 was admitted to the facility on [DATE] with multiple diagnoses including other reduced mobility (ability to move oneself - or body parts freely, easily, and purposefully), and need for assistance with personal care. During a review of Resident 115's CPR titled, At risk for falls r/t (related to) impaired balance . initiated [DATE], the CPR indicated, one of the interventions was to ensure the call light was within reach and encourage to use it for assistance as needed. During a review of Resident 115's H&P, dated [DATE], the H&P indicated, Resident 115 could make needs known but could not make medical decisions. During a review of Resident 115's OT [Occupational Therapy - treatment that helps you improve your ability to perform daily tasks] Evaluation & Plan of Treatment (OTE), dated [DATE], the OTE indicated, Resident 115 had impaired strength on both upper extremities (the upper arm, forearm, and hand). During a review of Resident 115's MDS, dated [DATE], the MDS indicated Resident 115's cognitive skills (ability to think and process information) for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated, Resident 115 was dependent (helper does all of the effort) with activities of daily living (ADL – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated, Resident 115 was always incontinent (no episodes of continent [ability to control] bowel movements). During a concurrent observation and interview on [DATE] at 11:42 AM, with Resident 115, Resident 115 was lying in bed. Resident 115 had moderate contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) on both upper extremities. Resident 115's touch call pad (a touch sensitive call light) was slightly tucked underneath a pillow on the left bed siderail by Resident 115's left shoulder. Resident 115 was asking, can you help me? Resident 115 stated, Resident 115 was not able to use and press the call light and would just yell, I try my best, when Resident 115 needed to call for help and Resident 115 felt, it's hard when Resident 115 was unable to use the call light. During a concurrent observation and interview on [DATE] at 11:48 AM with Licensed Vocational Nurse (LVN) 1, Resident 115's touch call pad was tucked underneath a pillow by the left bed siderail and Resident 115's left shoulder. LVN 1 stated Resident 115's call light was by Resident 115's left shoulder. LVN 1 stated Resident 115's call light should be within Resident 115's reach so Resident 115's needs could be answered promptly. During an interview on [DATE] at 3:35 PM with the DON, the DON stated, resident's (in general) call lights should be within resident's reach for residents to call when residents need assistance [from staff]. During a review of the facility's P&P titled, Call Light, date revised 2/2023, the P&P indicated, the facility had a policy to provide the resident a means of communication with nursing staff. The P&P indicated, to ensure the call device was within resident's reach before leaving room and if the resident was unable to reach the call light, don't leave the resident unattended.

Based on observation, interview, and record review, the facility failed to ensure the plastic strip air curtain leading to the walk-in refrigerator in one of one kitchen (Kitchen 1) did not have a missing strip.This deficient practice had the potential to result in foodborne illness (disease caused by consuming contaminated food or drinks), to the residents consuming the food from the walk-in refrigerator, due to not maintaining consistent temperatures or the entry of insects, dust, and pollutants.Findings:During an initial tour observation of Kitchen 1 and concurrent interview on 2/10/2026 at 9:05 AM with the Dietary Services Supervisor (DSS), the walk-in refrigerator door leading into the walk-in freezer was observed directly next to Kitchen 1's exit door and lead to the outside of the facility. There was a plastic air curtain hanging on the refrigerator door that had a missing strip, resulting in a six-to-eight-inch gap. The DSS stated the air curtain was missing a strip and needed to be repaired. The DSS stated the air curtain helped maintain the cold air inside the refrigerator and without the strip, the temperature inside the refrigerator could quickly rise and could cause the food inside to go bad.During an interview with the Registered Dietician (RD), on 2/12/2026 at 3:03 PM, the RD stated kitchen equipment (used or not) should be functioning and in working condition.During an interview with the Administrator (ADM) on 2/13/2026, at 10:20 AM, the ADM stated the walk-in refrigerator was old, older than 40 years, and the air curtain was up and being used. The ADM stated the facility did not have a copy of the air curtain's maintenance manual. During an interview with the Maintenance Director (MDR) on 2/13/2026 at 10:49 AM, the MDR stated the MDR was informed, on 2/12/2026, of a missing air curtain strip in Kitchen 1.During a review of the facility's policy and procedure (P&P) titled Physical Environment-Equipment Maintenance, revised on 10/2025, the P&P indicated it was the policy of the facility to establish procedures for routine and non-routine care of equipment and to ensure that the equipment remained in good working order for resident and staff safety. The P&P indicated equipment instructions and manuals would be kept in the Maintenance Supervisor's Office.During a review of the facility's P&P titled Environmental-Maintenance Policy, reviewed on 10/2025, the P&P indicated a maintenance policy for [the facility] ensures that the building, equipment, and overall environment remain safe, clean, and functional for residents, staff, and visitors.

Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 2)'s care plan (CP - provides direction on the type of nursing care an individual needs that includes goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan) was implemented when licensed nurses administered insulin (a medication that removes excess sugar from the blood.) on Resident 2's Left arm where Resident 2 had a shunt (a surgically created access point on the body for dialysis [a treatment to clean your blood when your kidney can't do it well.]) This failure had the potential to increase the risk of bleeding and cause trauma to Resident 2. Findings:During a review of Resident 2's Face Sheet, the face sheet indicated the facility initially admitted a [AGE] year-old female on 5/27/2023 and re-admitted on [DATE], with the diagnoses that included but not limited to end stage renal disease (irreversible kidney failure) , dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control). During a review of Resident 2's minimum data set (MDS, a resident assessment tool), dated 11/1/2025, indicated Resident 2 is getting dialysis. During a review of Resident 2's CP, date initiated 2/6/2026, the CP indicated no needle stick on Resident 2's left arm.During a review of Resident 2's Medication Administration Record (MAR), dated 2/2026. The MAR indicated license nurses used Resident 2' left arm to administered medication through a needle injection on following date and time: Insulin glargine (a long-acting insulin helps people with diabetes control their blood sugar.) Solution 100 unit/ml 2/6/2026 6:35 PM NovoLOG (a fast-acting insulin) Injection Solution 100 unit/ml 2/2/2026 11:42 AM 2/4/2026 11:48 AM 2/6/2026 6:37 AM 2/7/2026 6:32 PM 2/8/2026 6:23 AM 2/8/2026 10:00 PM 2/9/2026 6:02 AM 2/9/2026 10:06 PM During a concurrent interview and record review on 2/11/2026 at 9:07 am with LVN 5, Resident 2's CP dated 2/2026 was reviewed. the CP indicated, no needle stick on Resident 2's left arm. LVN 5 stated she was not aware of the CP and had administered insulin injection on Resident 2's left arm. LVN 5 stated using Resident 2's left arm for injection will increase the risk of bleeding and cause trauma. During an interview on 2/13/2026 at 8:00 am with the director of nursing (DON), the DON stated nurse should follow resident's care plan, if nurses fail to follow or implement resident's care plan, then resident will have a poor outcome.During an interview on 2/13/2026 at 8:50 am with Quality Assurance (QA), QA stated resident's care plan needs to be implemented. QA also stated that for Resident 2, using her left arm to do insulin injections will increase the risk of bleeding or could even cause trauma.During a review of the facility's policy and procedure (P&P) titled, comprehensive person-centered care planning dated 4/2025, the P&P indicated facility should develop and implement resident's care plan.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 43), who was unable to carry out activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) received the necessary services to maintain personal grooming as indicated in the facility's policy and procedure (P&P) titled, ADL, Services to carry out.This deficient practice had the potential to impact Resident 43's overall health and could socially and psychologically affect Resident 43. Findings:During a review of Resident 43's admission Record (AR), the AR indicated Resident 43 was admitted to the facility on [DATE] with multiple diagnoses including the need for assistance with personal care, unspecified dementia (a progressive state of decline in mental abilities), psychotic (relating to or affected with a psychosis, a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) disturbance, mood disturbance, and anxiety (intense, excessive, and persistent worry and fear about everyday situations).During a review of Resident 43's Care Plan (CP), initiated 1/14/2026, the CP indicated Resident 43 had an ADL self-care performance deficit and indicated Resident 43 had impaired mobility, activity intolerance, and impaired cognition related to dementia.During a review of Resident 43's CP, initiated 1/15/2026, for Rehab [rehabilitation occupational therapy] OT, the CP indicated, Resident 43 was observed with ADL self-care performance deficit.During a review of Resident 43's History and Physical Examination (H&P), dated 1/16/2026, the H&P indicated, Resident 43 did not have the capacity to understand and make decisions.During a review of Resident 43's Minimum Data Set (MDS - a resident assessment tool), dated 1/18/2026, the MDS indicated, Resident 43's cognitive skills (ability to think and process information) for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 43 was dependent (helper does all of the effort) and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with ADL.During a concurrent observation and interview on 2/10/2026 at 10:33 AM with Certified Nursing Assistant (CNA) 1, Resident 43 was lying in bed awake. Resident 43 was unkempt with greasy hair, had whitish flakes on Resident 43's head, and had chin whiskers. CNA 1 stated, Resident 43 had little whiskers and needed to be shaved and Resident 43's hair was a little oily and Resident 43's hair needed to be washed but Resident 43 was combative during care. CNA 1 stated, grooming was important for residents (in general) to look presentable and feel clean.During an interview on 2/12/2026 at 3:35 PM with the Director of Nursing (DON), the DON stated Resident 43 had oily hair and facial hair and Resident 43 needed grooming for health reasons and for dignity [purposes].During a review of the facility's P&P titled, ADL, Services to carry out, revised 10/2025, the P&P indicated, the facility had a policy that residents were given the appropriate treatment and services to maintain or improve his/her abilities. The P&P indicated residents who were unable to carry out ADL will receive necessary services to maintain including grooming.

Based on observation, interview, and record review, the facility failed to implement appropriate fall prevention interventions for one of two sampled residents (Resident 113), who was at high risk for falls and had a history of recent falls, when on [DATE], Resident 113 was observed leaning toward the left side of Resident 113's bed and Resident 113's mattress did not have equal sized side borders.This deficient practice had the potential to result in a recurrent fall and injury to Resident 113.Findings:During a review of the admission Record (AR), the AR indicated Resident 113 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (a type of stroke where blood flow to part of the brain is blocked, usually by a clot), difficulty with walking and, in need of assistance with personal care.During a review of Resident 113's History and Physical (H&P), dated [DATE], the H&P indicated Resident 113 had the capacity to understand and make decisions.During a review of Resident 113's Care Plan Report (CPR), initiated [DATE], the CPR indicated Resident 113 was at risk for falls related to [having an] actual fall [DATE] when Resident 113 slid slowly from the bed to [the floor]. The CPR did not indicate a goal for Resident 113. The CPR's interventions indicated Resident 113 needed a safe environment.During a review of Resident 113's Fall Risk Evaluation, dated [DATE], the fall risk evaluation indicated a fall risk score of 11 (a total score of 10 or greater indicates the resident is at high risk for falls).During a review of Resident 113's Situation, Background, Assessment, Recommendation [SBAR, a structured four-step communication framework used primarily in healthcare to quickly, clearly, and concisely convey critical resident information] Communication Form, dated [DATE] time at 12:17 AM, the SBAR indicated the resident was found on the floor next to his bed on his left side. The SBAR indicated Resident 113 verbalized that he was trying to turn to his side in bed but slid slowly to the ground.During a review of Resident 113's Change in Condition (CIC, an alteration in a resident's physical health that differs from their previous baseline) Follow Up Nurses Note, dated [DATE], the CIC's additional notes indicated the resident was found in [the] room on the floor next to his bed [on the] left side. Resident [113] was trying to turn to [the] side and slid down slowly. Body check was done noted no injury. MD [unidentified] was notified and fall management initiated using floor mat[s] at bedside.During a review of Resident 113's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated [DATE], the MDS indicated Resident 113 required partial to moderate assistance when lying, sitting, or transferring.During a concurrent observation and interview on [DATE] at 10:23 AM with Resident 113, in Resident 113's room, Resident 113 was leaning towards the left side of Resident 113's bed. Resident 113 stated Resident 113 had not been at the facility for too long and Resident 113 had already had a fall. Resident 113 stated Resident 113's mattress made Resident 113 lean to the left [side of the bed] and Resident 113 fell [to the floor]. There were no pillows on Resident 113's left side of the bed.During an interview on [DATE] at 11:30 AM with Resident 113, Resident 113 stated [on [DATE]] at 11PM Resident 113 was asleep and Resident 113 slid off the left side of Resident 113's bed. Resident 113 stated the left side of Resident 113's mattress had a border made of foam, but the border would not stay up, and the nursing staff placed pillows on that side so that when Resident 113 leaned toward the left, Resident 113 would not fall.During an interview and concurrent observation on [DATE] at 12:16 PM with LVN 7, in Resident 113's room, LVN 7 stated LVN 7 had not noticed Resident 113's mattress. Resident 113 pointed at the left side border of Resident 113's bed and stated, isn't up like on the right side. LVN 7 stated the left upper side of Resident 113's mattress did not have a border like the right side of the bed. LVN 7 stated LVN 7 would call the mattress company to check if the mattress needed to be repaired. LVN 7 [exited Resident 113's room and entered an unidentified resident's room who was lying on the same mattress type] the unidentified resident's mattress upper borders on both sides stayed up firm. LVN 7 stated LVN 7 did not know the importance [or purpose] of Resident 113's mattress borders because they were all soft but [if firm] LVN 7 could see the border's use to prevent falls. During a review of the facility's policy and procedure (P&P) titled, Nursing, Resident Assessment - Fall Management System, revised [DATE], the P&P indicated the facility is committed to promoting resident autonomy by providing an environment that remains free of accident hazards as possible. The P&P indicated it is the policy of the facility to provide each resident with an appropriate assessment and interventions to prevent falls. The P&P indicated a review of the fall incident will include an investigation to determine probable causal factors [of the fall].

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 25) oxygen humidifier (a medical device used to add moisture to the air or oxygen [a colorless gas essential to living organisms] that a resident breathes to prevent nasal irritation for residents on oxygen therapy) bottle was labeled with a date as indicated in the facility's policy and procedures (P&P), titled Infection Control Policy/Procedure, Resident Care - Oxygen, Use of This deficient practice had the potential to result in Resident 25's humidifier becoming contaminated with bacteria (microscopic organism that can cause disease) and result in an infection to Resident 25.Findings:During a review of the admission Record (AR), the AR indicated Resident 25 was admitted to the facility on [DATE], with diagnoses that included chronic (long term) respiratory failure (CRF) with hypoxia (a dangerous medical condition where body tissues do not receive enough oxygen to maintain normal function) and chronic obstructive pulmonary disease (COPD - a long term group of lung diseases that clock airflow).During a review of Resident 25's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 25's cognition (the ability to think and process information) was intact.During a review of Resident 25's Care Plan Report (CPR), initiated [DATE], the CPR indicated Resident 25 had oxygen therapy related to Congestive Heart Failure (CHF, a long term progressive condition where the heart muscle is too weak or stiff to pump blood efficiently, causing blood to back up and fluid to accumulate in the lungs, legs, and body) and respiratory illness. The CPR indicated Resident 25 was at risk for respiratory distress: change in respirations,During an observation on [DATE] at 11 AM, in Resident 25's room, Resident 25 was resting in bed, under the covers, and was receiving 2 liters (L, metric unit of volume) of oxygen via nasal cannula (NC, a lightweight, flexible, and non-invasive device used to deliver supplemental oxygen directly into a resident's nostrils via two small prongs) with a humidifier bottle. The humidifier bottle was not labeled with a date. During an interview on [DATE] at 11:26 AM with the License Vocational Nurse (LVN) 7, LVN 7 stated, the humidifier [disposable bottle] was changed weekly and as needed and the bottle should be labeled [with a date indicating the date it was changed]. LVN 7 stated the Director of Staff Development (DSD) changed [the humidifier bottles] and the NC [tubing] and the [licensed] nurses labeled [the humidifiers] with a date.During an interview on [DATE] at 11:32 AM with the DSD, the DSD stated the DSD and the RNs were responsible for changing the [resident's, in general] NC [tubing] and humidifier [bottles] every Thursday and as needed. The DSD stated Resident 25's NC [tubing] was dated [DATE]. The DSD stated the NC [tubing] and the humidifier [bottles] were changed (dated) together (at the same time) and Resident 25's humidifier was not labeled with a date (to indicate the date the humidifier was changed).During a review of the facility's P&P titled, Infection Control Policy/Procedure, Resident Care - Oxygen, Use of dated [DATE], the P&P indicated it is the policy of this facility to promote resident safety in administering oxygen. The P&P indicated the following guidelines will be observed in oxygen administration: If a reusable humidifier is used, it should be emptied, rinsed, dried, and refilled with sterile water daily. The person changing the water should label it [the humidifier] with a date (this P&P is followed by the facility for disposable humidifier bottles).

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for four of five sampled residents (Resident 66, Resident 120, Resident 21, and Resident 61) by failing to:a. Ensure a personal care toiletry item (shaving cream) located inside Resident 21 and Resident 61's shared restroom was labeled and stored properly.b. Implement a physician order for Enhanced Barrier Precautions (EBP- extra measures, like wearing gowns and gloves, used during high-contact care activities with residents who are at a higher risk of having or spreading germs that are hard to treat, like multidrug-resistant organisms [MDROs, bacteria that have become resistant to certain antibiotics [medication used to treat bacterial infections], and these antibiotics can no longer be used to control or kill the bacteria]) for Resident 66.This deficient practice had the potential to result in cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and the transmission of infectious microorganisms to Resident 66, Resident 120 (Resident 66's roommate), Resident 21, and Resident 61, the facility staff, and increased the risk of the spread of infection within the facility.Findings: a. During a review of Resident 21's admission Record (AR), the AR indicated Resident 21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including osteomyelitis (inflammation of bone or bone marrow, usually due to an infection) of vertebra (one of the bones that make up the spinal column), thoracic (relating to chest) region, and bacteremia (bacteria in your blood). During a review of Resident 21's History and Physical (H&P), dated 12/20/2025, the H&P indicated, Resident 21 was A&O x4 (alert and oriented to person, place, time and situation). During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool), dated 12/23/2025, the MDS indicated Resident 21's cognitive skills (ability to think and process information) for daily decision making were intact. The MDS indicated Resident 21 was independent with personal hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying make-up, washing/drying face and hands [excludes baths, showers, and oral hygiene). During a review of Resident 61's AR, the AR indicated, Resident 61 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD – a long standing lung disease causing difficulty in breathing) with (acute) exacerbation (sudden worsening or flare-up), and urinary tract infection (UTI – an infection in the bladder/urinary tract). During a review of Resident 61's H&P, dated 1/21/2026, the H&P indicated Resident 61 had the capacity to understand and make decisions. During a review of Resident 61's MDS, dated [DATE], the MDS indicated Resident 61's cognitive skills for daily decision making were intact. The MDS indicated Resident 61 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with personal hygiene. During an observation on 2/10/2026 at 10:16 AM, Resident 21 and Resident 61's room had EBP signage posted and a white colored trimmed 3-drawer personal protective equipment (PPE – clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) cart located outside of the shared room. During a concurrent observation and interview on 2/10/2026 at 10:21 AM with the Housekeeper (HK) inside Resident 21 and Resident 61's shared restroom, an unlabeled 1.5 oz (ounce – a unit of weight) can of [NAME] (brand name) shaving cream was on the sink. The HK stated the shaving cream was not labeled and the HK was going to throw away the shaving cream. During an interview on 2/10/2026 at 10:28 AM with Resident 61, Resident 61 stated Resident 61 used the restroom and the shaving cream, it's (shaving cream) been there a while. During an interview on 2/10/2026 at 10:33 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated, a shaving cream was a personal item and should be labeled with the resident's (in general) name and bed number and stored at the resident's bedside. CNA 1 stated, labeling personal care items was important not to get mixed up with other resident's belongings and for infection control, if not labeled, you don't know who it belongs to [purposes]. During an interview on 2/11/2026 at 7:30 AM with Resident 21, Resident 21 stated, Resident 21 could walk to the restroom and shaved, I can do everything for myself. During an interview on 2/13/2026 at 7:52 AM with the Infection Preventionist (IP), the IP stated, a shaving cream was a personal item and should be labeled with the resident's name and stored at the beside. The IP stated, labeling personal care items was important to know who the personal care item belonged to and personal care items should only be used for that person for their own use, to prevent any type of infection or cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another), for infection control [purposes]. During a review of the facility's policy and procedure (P&P) titled, Personal Care Items, reviewed 12/2025, the P&P indicated, the facility ensured proper hygiene, safety, and accountability regarding personal care items (such as shaving cream) provided to or brought in by individuals. The P&P indicated, personal care items must be labeled with residents' name and stored in designated personal storage areas. During a review of the facility's P&P titled, IPCP Standard and Transmission-Based Precautions, revised 12/2025, the P&P indicated, the facility implemented infection control measures to prevent the spread of communicable diseases and conditions. b. During a review of Resident 66's AR, the AR indicated the facility admitted Resident 66 on 4/4/2025, with diagnoses including cellulitis (a skin infection that causes swelling and redness), pressure ulcer (a small open sore or wound generally found in the stomach or on the skin), and the need for assistance with personal care. During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66's cognition (the ability to think and process information) was intact. The MDS indicated Resident 66 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL-term used in healthcare that refers to self-care activities) and substantial/maximal assistance (helper does more than half the effort) with mobility. During a review of Resident 120's AR, the AR indicated the facility admitted Resident 120 on 2/5/2026, with diagnoses including heart failure, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and the need for assistance with personal care. During a record review of Resident 66's Order Summary Report (OSR), dated active as of 2/12/2026, the OSR indicated Resident 66 had an active order, dated 12/25/2025, for EBP indicating PPE required for high resident contact care activities. The order's indicated was a diabetic wound (a slow-healing open sore, most common on the feet, caused by high blood sugar that damages nerves and reduces blood flow). During a review of Resident 66's Progress Note (PN), dated 2/4/2026, the PN indicated a diagnosis of diabetic foot ulcer (an open sore or wound, usually on the bottom of the foot, that develops in people with diabetes due to a combination of numb feet, poor blood circulation, and skin breakdown from pressure) on the right heel. The PN indicated the wound remained open. During a review of Resident 120's MDS, dated [DATE], the MDS indicated Resident 120's cognition was intact. The MDS indicated Resident 120 required partial/moderate assistance with ADL and partial/moderate assistance with mobility. During an observation on 2/10/2026 at 11:10 AM, Resident 66's shared room had no EBP signage posted at the entrance or on the door. No EBP or PPE cart was observed at the doorway/hallway, and there was no visible indication that EBP were in place. During an interview on 2/10/2026 at 11:15 AM, Resident 66 stated Resident 66 had recently undergone a procedure to remove a callus on Resident 66's right foot, at which time a diabetic foot ulcer was identified. Resident 66 stated that the nurses had been providing daily wound care. Resident 66 stated Resident 66 had not observed staff wearing gowns when assisting Resident 66 with personal care. During an interview on 2/13/2025 at 9:45 AM, with the IP, the IP stated residents (in general) who had open wounds automatically required EBP to prevent the spread of infections and [this practice] protected both staff and residents. The IP stated a diabetic foot ulcer was an open wound and EBP should have been implemented immediately upon discovery and following a debridement (a procedure for cleaning and removal of dead, damaged, or infected tissue from a wound to promote healing) for Resident 66. The IP stated the IP had not been made aware of Resident 66's open wound and stated, this breakdown in communication was problematic. The IP stated the facility did not implement EBP in a timely manner for Resident 66, as ordered, and stated such delays increased the risk for infection transmission to Resident 120, other residents, and the facility staff. During an interview and concurrent record review on 2/13/2025 at 10:36 AM, Resident 66's Treatment Administration Record (TAR), dated 2/2026, was reviewed with LVN 7. The TAR indicated an active order for: Right heel diabetic ulcer – cleanse with normal saline (NS- a sterile mixture of 0.9% salt [sodium chloride] in water, designed to match the natural salt concentration in human blood), pat dry, apply collagen (a protein in the body) powder to the wound bed (the surface of the wound itself, specifically the exposed tissue at the base of a cut, sore, or ulcer) followed by calcium alginate (a natural, biodegradable gel that can hold shape and moisture) and cover with dry dressing QD (once daily). LVN 7 stated Resident 66 continued to receive daily treatment for the right heel diabetic ulcer and stated the ulcer remained open and had not resolved. LVN 7 stated that based on the physician's order for EBP and the presence of an open wound, EBP should have been implemented and followed to prevent the spread of infection and to protect residents and [facility] staff. During an interview and concurrent record review on 2/13/2025 at 12:27 PM, Resident 66's PN, dated 12/25/2025, was reviewed with Licensed Vocational Nurse/Treatment Nurse (LVN) 7. The PN indicated Resident 66 was seen at bedside for debridement and treatment of complex callus [a thickened, hardened patch of skin that forms to protect a specific area of the body from repeated rubbing, pressure, or irritation] to [Resident 66's] right foot. The PN indicated, Surgical debridement was done to the ulcer site. LVN 7 stated that following the debridement, the ulcer was identified as an open wound requiring ongoing treatment. During a review of the facility's P&P titled, IPCP Standard and Transmission Based Precautions revised 12/2025, the P&P indicated: Enhanced Barrier Protection (EBP) was used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds. who were especially high risk of both acquisition of and colonization with MDROs. The P&P indicated wounds included, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.

Based on interview and record review, the facility failed to accurately administer medication for two of six sampled residents (Resident 2 and Resident 4) according to the facility's policy and procedure (P&P) titled, Medication Administration, by failing to: 1. Ensure Licensed Vocational Nurses (LVN) 1, 3, 4, 5, 6, 7, and 8 assessed and documented Resident 4's blood pressure (BP- the pressure circulating blood against the walls of blood vessels where low BP was less than 120/80 millimeters of mercury [mmHg- unit of measurement] and BP above 140/90 mmHg considered high blood pressure) just prior to administering carvedilol (medication used to treat hypertension [HTN- condition where the force of blood against artery walls is consistently too high and BP is consistently high]) on 10/10/2025 to 10/25/2025, 10/27/2025 to 11/6/2025 at 2 pm. 2. Ensure LVNs 2, 6, 9, 10 and the Infection Prevention Nurse (IPN) assessed and documented Resident 4's BP just prior to administering nifedipine (medication used to treat HTN) on 10/1/2025, 10/4/2025, 10/5/2025, 10/10/2025, 10/13/2025, 10/16/2025 to 10/19/2025, 10/22/2025 to 10/25/2025, 10/28/2025, 10/29/2025, 11/1/2025, and 11/5/2025. 3. Ensure LVN 4 Resident 2's isosorbide mononitrate (medication used to treat HTN) was held (not given) on 10/27/2025 at 0900 when Resident 2's BP was assessed as 92/54 mmHg. As a result of these failures, Resident 4's BP were not assessed just prior to administering carvedilol and nifedipine. Resident 2 was given isosorbide mononitrate despite the medication order indicating to hold if Resident 2's systolic (the top number in a blood pressure reading, representing the pressure in your arteries when your heart beats and pumps blood) BP (SBP) was less than 100. These failures had the potential to put Resident 2 and Resident 4 at risk for HTN, hypotension (occurs when blood pressure is less than 90-60 milliliters of mercury [mm Hg]), leading to other complications and hospitalization.Findings: a. During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 8/29/2024 and was readmitted on [DATE] with diagnoses that included hypertensive heart disease (chronic changes in the left ventricle and atrium, and coronary arteries as a result of chronic raised blood pressure) with heart failure (occurs when the heart can't pump enough blood to meet the body's needs, leading to symptoms like shortness of breath, fatigue, and swelling), chronic kidney disease (CKD- damage to the kidneys so they cannot filter blood the way they should) stage four (4) (severe), and hyperlipidemia (having too many lipids or fat in the blood). During a review of Resident 4's untitled Care Plan (CP), initiated 8/29/2024, the CP indicated Resident 4 had HTN related to congestive heart failure (CHF- a chronic condition where the heart muscle cannot pump blood efficiently). The CP indicated Resident 4 would remain free of complications related to HTN through the review date. The CP interventions indicated to give carvedilol and nifedipine as ordered. During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 9/2/2025, the MDS indicated Resident 4 had intact cognition (ability to think, reason, and function). The MDS indicated Resident 4 had HTN and heart failure. During a review of Resident 4's Order Summary Report (OSR), active for the month of October 2025, the OSR indicated Resident 4 had the following orders: 1. Carvedilol oral tablet, 12.5 milligrams (mg- unit of measurement), give 12.5 mg by mouth one time a day for HTN. Hold for SBP less than 100 or heart rate less than 60 (beats per minute [bpm]). The order date indicated 10/1/2024. 2. Nifedipine extended release (ER) oral tablet 24-hour, 90 mg, give one (1) tablet by mouth at bedtime for HTN. Hold for SBP less than 100; do not crush. The order date indicated 10/14/2024. During a review of Resident 4's medication administration record (MAR- a report that serves as a legal record of the medications administered to a resident) dated 10/2025, the MAR indicated Resident 4 received carvedilol at 2 pm and nifedipine at 9 pm from 10/1/2025 to 10/31/2025. During a review of Resident 4's MAR dated 11/2025, the MAR indicated Resident 4 received carvedilol at 2 pm and nifedipine at 9 pm from 11/1/2025 to 11/6/2025. During a review of Resident 4's Weights and Vitals Summary (WVS) dated 10/1/2025 to 11/7/2025, the WVS indicated Resident 4's BP was check on the following dates, at the following times, by the following nurses: 1. On 10/1/2025 at 10:54 pm, Resident 4's BP was 143/74, assessed by LVN 6. 2. On 10/4/2025 at 2:51 pm, Resident 4's BP was 150/70, assessed by LVN 7.3. On 10/5/2025 at 6:46 pm, Resident 4's BP was 116/78, assessed by LVN 10.4. On 10/10/2025 at 8:07 am, Resident 4's BP was 129/76, assessed by LVN 1, and was checked again at 6:09 pm as 122/65, assessed by LVN 2. 5. On 10/11/2025 at 9:43 am, Resident 4's BP was 144/78, assessed by LVN 4. 6. On 10/12/2025 at 8:52 am, Resident 4's BP was 133/78, assessed by LVN 6.7. On 10/13/2025 at 10:21 am, Resident 4's BP 152/80, assessed by LVN 3, and was checked again at 10:38 pm as 132/80, assessed by LVN 9.8. On 10/14/2025 at 10:34 am, Resident 4's BP was 150/70, assessed by LVN 7. 9. On 10/15/2025 at 10:56 am, Resident 4's BP was 142/78, assessed by LVN 8.10. On 10/16/2025 at 10:27 am, Resident 4's BP was 130/80, assessed by LVN 3, and was checked again at 10:28 pm as 136/82, assessed by LVN 9.11. On 10/17/2025 at 9:45 am, Resident 4's BP was 144/80, assessed by LVN 4, and was checked again at 11:41 pm as 130/78, assessed by LVN 9. 12. On 10/18/2025 at 11:36 and 11:51 am, Resident 4's BP was 132/72, assessed by LVN 4. 13. On 10/19/2025 at 8:18 am, Resident 4's BP was 138/74, assessed by LVN 8, and was checked again at 5:41pm as 113/76, assessed by LVN 2. 14. On 10/20/2025 at 10:05 am, Resident 4's BP was 126/70, assessed by LVN 8. 15. On 10/21/2025 at 8:16 am, Resident 4's BP was 130/64, assessed by LVN 4. 16. On 10/22/2025 at 10:36 am, Resident 4's BP was 112/62, assessed by LVN 7, and was checked again at 10:15 pm as 126/66, assessed by LVN 9. 17. On 10/23/2025 at 10:24 am, Resident 4's BP was 128/70, assessed by LVN 4, and was checked again at 5:05 pm as 132/73, assessed by LVN 2. 18. On 10/24/2025 at 9:17 am, Resident 4's BP was 122/66, assessed by LVN 5, and was checked again at 3:56 pm as 119/75, assessed by LVN 2. 19. On 10/25/2025 at 9:12 am, Resident 4's BP was 138/78, assessed by LVN 8, and was checked again at 4:49 pm as 118/76, assessed by LVN 2. 20. On 10/27/2025 at 10:26 am, Resident 4's BP was 134/80, assessed by LVN 4.21. On 10/28/2025 at 10:16 pm, Resident 4's BP was 128/78, assessed by the IPN. 22. On 10/29/2025 at 7:48 pm, Resident 4's BP was 126/72, assessed by LVN 9. 23. On 11/1/2025 at 4:30 pm, Resident 4's BP was 121/84, assessed by LVN 2. 24. On 11/5/2025 at 7:19 pm, Resident 4's BP was 132/80, assessed by LVN 10. 25. On 11/6/2024 at 8:21 am, Resident 4's BP was 136/78, assessed by LVN 5. During a concurrent interview and record review on 11/6/2025 at 4:16 pm, with LVN 2, Resident 2's MAR dated 10/2025 and 11/2025 and Resident 2's WVS dated 10/1/2025 to 11/6/2025 were reviewed. LVN 2 stated (in general), when giving BP (lowering) medications, LVN 2 was supposed to check the resident's BP just prior to giving the medication to ensure the resident did not develop hypotension or other cardiac (heart) - related problems such as dizziness. LVN 2 stated, It's a safety. LVN 2 stated on 10/10/2025 at 6:09 pm, LVN 2 assessed Resident 4 for COVID-19 (infectious disease caused by SARS-CoV-2 virus) by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (122/65 at 6:09 pm) in order to give Resident 4 nifedipine. LVN 2 stated on 10/19/2025 at 5:41 pm, LVN 2 assessed Resident 4 for COVID-19 by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (113/76 at 5:41pm) in order to give Resident 4 nifedipine. LVN 2 stated on 10/23/2025 at 5:05 pm, LVN 2 assessed Resident 4 for COVID-19 by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (132/72 at 5:05 pm) in order to give Resident 4 nifedipine. LVN 2 stated on 10/24/2025 at 3:56 pm, LVN 2 assessed Resident 4 for COVID-19 by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (119/75 at 3:56 pm) in order to give Resident 4 nifedipine. LVN 2 stated on 10/25/2025 at 4:49 pm, LVN 2 assessed Resident 4 for COVID-19 by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (118/76 at 4:49 pm) in order to give Resident 4 nifedipine. LVN 2 stated on 10/30/2025 at 11 pm, LVN 2 assessed Resident 4 for COVID-19 by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (117/76pm at 11 pm) in order to give Resident 4 nifedipine. LVN 2 stated on 11/1/2025 at 4:30 pm, LVN 2 assessed Resident 4 for COVID-19 by checking Resident 4's BP. LVN 2 stated LVN 2 used the last recorded BP (121/84 at 4:30 pm) in order to give Resident 4 nifedipine. LVN 2 stated the risk of using a BP from a few hours prior to Resident 4's scheduled nifedipine dose of 9 pm, was that the BP could change and if given the medication, could cause adverse reactions like hypotension. LVN 2 stated, I'm not going to use the last recorded BP next time. During an interview on 11/6/2025 at 4:31 pm, with the IPN, the IPN stated the IPN passed (administered) medications from time to time if needed. The IPN stated (in general) prior to giving BP medications, the IPN was supposed to check a resident's BP right before giving a BP medication to make sure the resident's BP was within the parameters of the medication. The IPN stated BP were supposed to be checked at the time licensed nurses gave the medication. The IPN stated if BP were checked at the time of medication administration, they risked residents developing hypotension or even bradycardia (slow heart rate, defined as a resting heart rate of less than 60 BPM). During a concurrent interview and record review on 11/7/2025 at 9:58 am, with LVN 1, Resident 2's MAR dated 10/2025 and 11/2025 and Resident 2's WVS dated 10/1/2025 to 11/6/2025 were reviewed. LVN 1 stated (in general). LVN 1 was supposed to check a resident's BP and HR when giving carvedilol. LVN 1 stated, LVN 1 had to check the resident's MAR to ensure the BP and HR were within the parameters to give the medication. LVN 1 stated, I am supposed to check the HR and BP when I am ready to give the medication, just prior to giving. I check the BP and HR to make sure the resident doesn't get hypotension or have adverse effects to the medication. LVN 1 stated on 10/10/2025 LVN 1 gave Resident 4 carvedilol at 2 pm. LVN 1 stated that Resident 4 had Lasix (medication used to treat fluid retention and high blood pressure) due at 8 am that day, so LVN 1 checked Resident 4's BP at that time. LVN 1 stated, I remember taking [Resident 4's] BP but I guess I didn't document it. During a concurrent interview and record review on 11/7/2025 at 10:14 am, with LVN 3, Resident 2's MAR dated 10/2025 and Resident 2's WVS dated 10/1/2025 to 10/31/2025 were reviewed. LVN 3 stated (in general) LVN 3 checked residents' BP and HR just prior to giving the BP medication when ready to give the medication to ensure the medication was safe to be administered based on the BP and HR. LVN 3 stated on 10/13/2025, 10/16/2025, and 10/31/2025, LVN 3 gave Resident 4 carvedilol at 2 pm. LVN 3 stated if there was a parameter for giving BP medications, LVN 3 had to check Resident 4's BP prior to giving the medication. b. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 8/11/2025 and was readmitted on [DATE] with diagnoses that included hypotension, hypertensive heart disease with heart failure, and end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life). During a review of Resident 2's untitled CP initiated 9/16/2025, the CP indicated Resident 2 had hypotension and was at risk for dizziness, fainting, and fatigue. The CP goals indicated Resident 2 would be free of signs and symptoms of hypotension through the review date. The CP interventions indicated to give Resident 2's medications as ordered, and to monitor side effects and effectiveness. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had moderately impaired cognition. The MDS indicated Resident 2 had hypertension and heart failure. During a review of Resident 2's OSR, dated 10/1/2025 to 10/31/2025, the OSR indicated Resident 2 had an order for Isosorbide Mononitrate Oral Extended Release 24-hour, 30 mg, give one (1) tablet by mouth one time a day for HTN. Hold for SBP less than 100 or HR less than 60 BPM. The OSR indicated the order date was 10/14/2025. The OSR indicated the order was discontinued. During a review of Resident 2's MAR dated 10/2025, the MAR indicated on 10/27/2025, Resident 2 received isosorbide mononitrate at 9 am. The MAR indicated Resident 2's BP was 92/54. The MAR indicated LVN 4 administered the medication. During a telephone interview on 11/7/2025 at 1:26 pm, with LVN 4, LVN 4 stated (in general) when giving BP medications, LVN 4 checked the BP and HR prior to administration to ensure that the parameters were met prior to giving. LVN 4 stated, If the medications need to be held, we can check that. LVN 4 stated in for BP medications, the general parameters were to hold the medication of the HR was less than 60 and/or the SBP was less than 100. LVN 4 stated, If a resident had a BP of 92/54 and the parameter was to hold for SBP less than 100, I would not give BP medication because we could slow down their (the resident's) HR and cause hypotension. LVN 4 stated this could lead to hospitalization. During an interview on 11/7/2025 at 11:37 am, with the Director of Nursing (DON), the DON stated the purpose of hold parameters was an order to hold BP medications if the SBP was less than 100 and sometimes if the HR was less than 60. The DON stated, if hold parameters were not followed then residents could develop and injury and need to be hospitalized . The DON stated, isosorbide mononitrate should not be given if a resident's BP was 92/54. The DON stated isosorbide mononitrate was used to treat HTN. The DON stated if there was a parameter in a BP medication order, then the BP needed to be checked prior to administration of the BP medication, within a couple minutes but not more than an hour before or after the medication was given to ensure the BP was within the parameters of the medication. The DON stated those orders were to ensure a resident's BP was not too low prior to medication administration and that the resident did not have hypotension. During a review of the facility's P&P titled, Medication Administration, revised 10/2025, the P&P indicated it was the policy of the facility to accurately prepare, administer, and document oral medications. The P&P indicated, when administering unit doses and previously prepared drugs to.take vital signs (VS- fundamental measurements of basic bodily functions, including temperature, pulse [heart rate], respiration [breathing rate], and blood pressure) and to hold drugs if indicated.

Based on interview and record review, the facility failed to develop an individualized person-centered plan of care that included measurable objectives, timeframes, and interventions to meet the needs of one of three sampled residents (Resident 1). Specifically, the facility did not develop an individualized care plan (CP) for Resident 1 in a timely manner to address Resident 1's past trauma after Resident 1 reported the trauma to the administrator (ADM).This deficient practice had the potential to result in unmet individualized needs and adversely affect the delivery of necessary care and services to Resident 1.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 8/29/2024, with diagnoses including, heart failure (HF-a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling), chronic (persistent or long-lasting) obstructive pulmonary disorder (COPD, , long standing group of diseases that cause airflow blockage and breathing-related problems, make it difficult to breathe), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/2/2025, the MDS indicated Resident 1's cognition (the ability to think and process information) was intact. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and mobility.During a review of Resident 1's CPs, a CP, dated 8/21/2025, indicated Resident 1's potential for emotional distress related to [an] abuse allegation. There was no individualized CP in place that addressed Resident 1's reported history of trauma related to a prior sexual assault.During an interview on 8/22/2025 at 12:41 PM, with the ADM, the ADM stated Resident 1 disclosed Resident 1 was a victim of rape several years ago. Resident 1 stated Resident 1 had never shared this information with the facility before, and it was not documented in Resident 1's medical history. Resident 1 stated Resident 1 made the facility aware on 8/21/2025 when the resident reported the abuse allegations regarding Certified Nursing Assistant (CNA) 1.During an interview on 8/22/2025 at 12:57 PM, with Resident 1, Resident 1 stated Resident 1 disclosed to the ADM Resident 1 was a victim of rape several years ago. Resident 1 stated Resident 1 had never felt comfortable sharing this information with the facility before because it was a very sensitive topic. Resident 1 stated, with the most recent abuse allegations regarding CNA 1, Resident 1 was able to disclose this information to the ADM.During an interview and a concurrent review of Resident 1's CPs on 8/26/2025 at 11:14 AM, with the Social Services Director (SSD), the SSD stated a CP was created for emotional distress related to the abuse allegations, but a trauma-related CP was not initiated the same day. The SSD explained that both CPs are equally important, as timely trauma-informed planning helped prevent re-traumatization and ensured Resident 1's emotional and psychological needs were fully addressed in Resident 1's care. The SSD emphasized this process is the responsibility of the entire Interdisciplinary Team (IDT, a team of health care professionals who work together to establish plans of care for residents), not just one individual, and must be approached as a collaborative effort to ensure comprehensive care.During an interview on 8/26/2025 at 11:48 AM, with the Director of Nursing (DON), the DON stated a CP addressing the abuse allegations was created; however, a trauma-informed CP specific to the resident's history of rape was not initiated on the same day. The DON stated timely care planning was critical, particularly with trauma-related concerns, because delays could leave gaps in addressing the residents' emotional safety and well-being. The DON stated immediate initiation and implementation of trauma-informed care helped guide staff in providing sensitive, appropriate interventions and ensured the resident's needs were fully supported without risk of further emotional harm.During a review of the facility's policy and procedure (P&P) titled, Comprehensive Resident Centered Care Plan, reviewed 12/2023, the P&P indicated it is the policy of this facility that the IDT shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care and treatment in accordance with the facility's policy and procedure (P&P) titled, Transportation to Doctors/Diagnostic Appointments, by failing to ensure staff was available to accompany Resident 1 to Resident 1's scheduled GI (gastrointestinal, refers collectively to the organs of the body that play a part in food digestion) consult (a process where a healthcare professional requests advice or expertise from another healthcare professional specialist or expert in a particular area regarding a patient's care) appointment on 6/25/2025.This failure resulted in Resident 1 missing Resident 1's scheduled GI consult appointment and had the potential to result in the delay in treatment for Resident 1 that could potentially lead to disease progression and complications to Resident 1.Findings:During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including vascular disorder of intestine (long tubed-shaped organ in the abdomen that completes the process of digestion [food breakdown], condition where blood flow to the intestines is reduced or blocked), unspecified, anemia (a condition where the body does not have enough healthy red blood cells), unspecified, and difficulty in walking, not elsewhere classified.During a review of Resident 1's History and Physical Reports (H&P), dated 6/13/2025, from the General Acute Care Hospital (GACH), the H&P indicated, Resident 1 was recently discharged , [from the GACH] after being diagnosed ischemic colitis (a condition where reduced blood flow to the colon [longest part of the large intestine] causes inflammation and injury), a few days ago. The H&P indicated Resident 1 recently presented to the GACH with diarrhea, abdominal pain, and bloody stools. During a review of Resident 1's Progress Notes (PN), dated 6/17/2025, timed at 2:28 PM, the PN indicated, ST (Speech Therapist) recommended ENT (Ear, Nose, Throat) and GI consultations to r/o (rule out) possible reflux (the backward flow of stomach contents into the esophagus [tubular elongated organ that connects the throat to the stomach]). During a review of Resident 1's undated Order Summary Report (OSR), the OSR indicated, a physician's order, dated 6/20/2025, for a GI consult with the gastroenterologist (MD, medical doctor who specializes in the diagnosis and treatment of diseases and conditions affecting the GI tract and liver) on 6/25/2025 at 2 PM for dx (diagnoses) of ischemic colitis and GI bleed. The OSR indicated an order, dated 6/25/2025, for a GI consult with the MD on 7/15/2025 at 2 PM for dx of ischemic colitis and GI bleed.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/22/2025, the MDS indicated, Resident 1's cognition (ability to understand and process information) was moderately impaired. The MDS indicated, Resident 1 required substantial/maximal assistance (helper does more than half the effort) to partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities).During a review of Resident 1's social services PN, dated 6/24/2025, timed at 11:08 AM, the PN indicated, the Social Services Assistant (SSA) scheduled a wheelchair transportation for GI appointment on 6/25/2025 at 2 PM. The PN indicated the transportation pick up time was at 1:10 PM and the return pick up time at 3:15 PM. The PN indicated, a staff member (unnamed) would accompany Resident 1 to the appointment.During a concurrent interview and record review on 7/11/2025 at 12:25 PM with Registered Nurse Supervisor (RNS) 1, Resident 1's medical records were reviewed. A PN dated 6/25/2025, timed at 2:21 PM documented by the Case Manager (CM), indicated, the GI appointment was rescheduled due to Resident 1's family unable to attend and no cg (care giver) was available. RNS 1 stated, the facility provided staff such as the SSA or a CNA (Certified Nursing Assistant) if a resident (in general) did not have a family member to accompany the resident during transport to a doctor's appointment. RNS 1 stated, it was important to accompany the resident for safety reasons and to assist the resident if the resident needed assistance. RNS 1 stated, Resident 1 missing Resident 1's GI consult appointment on 6/25/2025 could cause a delay in Resident 1's treatment. During a concurrent interview and record review on 7/11/2025 at 12:47 PM with the Director of Nursing (DON), the facility's P&P titled, Transportation to Doctors/Diagnostic Appointments, revised 10/2024 was reviewed. The P&P indicated, a member of the nursing staff, or social services, may accompany the resident as needed to the diagnostic center when the resident's family was not available. The DON stated, a responsible party or staff accompanied the resident during transport to doctor appointments, so the resident had a representative to assume responsibility of the resident's care and to make sure they're [the residents were] safe while out of the facility for their appointment. The DON stated the facility did not have a designated staff to accompany residents during transport. The DON stated, the staff could be an SSA, CNA, or RNA (Restorative Nursing Assistant), somebody must be there. The DON stated, Resident 1 missing Resident 1's scheduled GI consult appointment on 6/25/2025 could result in Resident 1 not receiving the necessary treatment as Resident 1, had a GI bleed before.During an interview on 7/11/2025 at 1:28 PM with the SSA, the SSA stated, Resident 1's GI consult appointment scheduled 6/25/2025 was rescheduled because the facility had no staff available to go with Resident 1 to the appointment.During an interview on 7/11/2025 at 3:34 PM with RNS 2, RNS 2 stated, the facility encouraged the responsible party to accompany the resident to the resident's appointment and if no responsible party was available, then the facility provides a staff companion for resident safety. During an interview on 7/11/2025 at 4:11 PM with the Case Manager (CM), the CM stated, Resident 1's scheduled GI consult appointment on 6/25/2025 was rescheduled due to the facility not having a staff available, we did not have an extra staff and the facility was not able to accommodate. The CM stated the facility did not have any issues with short staffing.During a review of the facility's staff Sign-In Sheet (SIS - a document used to record the presence of staff at work), dated 6/25/2025, the SIS indicated, there were eleven CNAs and two RNAs working during the day (7AM - 3PM) shift.During an interview on 7/11/2025 at 4:28 PM with the CNA, the CNA stated, Resident 1 needed two people to transfer, in general and was not ok for Resident 1 to leave the facility by himself for doctor appointments. The CNA stated, residents usually leave the facility with a staff member for their doctor appointments.During a review of the facility's Facility Assessment 2024 Guidelines (FA), the FA, indicated, Based on our resident population and their care needs, we have made a good faith effort and approach to ensure we have sufficient and qualified staff to meet the needs of the residents at any given time.During a review of the facility's P&P titled, Transportation to Doctors/Diagnostic Appointments, revised 10/2024. The P&P indicated it was the policy of the facility to assist residents in arranging transportation to/from diagnostic appointments when necessary. The P&P indicated, shall it become necessary for the facility to provide transportation, the social service designee will be responsible for arranging transportation through coordination with the business office. The P&P indicated a member of the nursing staff, or social services, may accompany the resident as needed to the diagnostic center when the resident's family is not available.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1) by failing to: 1. Ensure Physical Therapist (PT- a healthcare provider who helps improve how the body performs physical movements) 1 and PT 2 accurately documented Resident 1's pain location in Resident 1's Physical Therapy Encounter Notes (PT TEN) dated 4/7/2025 and 4/14/2025. 2. Ensure Licensed Vocational Nurse (LVN) 1 assessed and documented Resident 1's pain location in Resident 1's medical record. 3. Ensure staff documented the rationale for initiating a room transfer for Resident 1 on 4/7/2025 in Resident 1's medical record. These failures resulted in Resident 1's medical record to contain inaccurate and incomplete information and had the potential to affect Resident 1's care. Cross Reference F697 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of history of falling, right femur (thigh bone) fracture (break in the bone), and encounter for orthopedic (the branch of medicine dealing with the correction of deformities of bones or muscles) after care, dementia (progressive state of decline in mental abilities), osteoarthritis (OA- a progressive disorder of the joints caused by a gradual loss of cartilage [connective tissue that protects the joints/bones])abnormalities of gait (manner of walking) and mobility (ability to move freely), and generalized muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 4/1/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, remember and make decisions) for daily decision making. The MDS indicated Resident 1 required supervision (helper provides verbal cues and or touching as resident competes activity) for oral and personal hygiene, partial/moderate assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs) for upper body dressing, and substantial/maximal assistance (helper does more than half the effort to lift or hold trunk or limbs) for showering/bathing, rolling left and right, sitting to lying on the bed, lying to sitting on side of the bed, and toilet transfer. The MDS indicated Resident 1 had not attempted to transfer to and from a bed to a wheelchair, sit to stand, or walk ten feet due to medical condition or safety concerns. The MDS indicated Resident 1 had a fall in the last month prior to admission, surgical repair of the hip, required pain assessment interview, and had not had any pain in the last five days of the assessment. During a review of Resident 1's Physician Order (PO), dated 3/31/2025, the PO indicated Resident 1 had an order for Hydrocodone-Acetaminophen (medication to treat moderate to severe pain) oral tablet 5-325 milligram (mg- a unit of mass) give one (1) tablet by mouth every six hours as needed (PRN) for moderate to severe pain from all sources. During a review of Resident 1's PT TEN dated 4/7/2025, timed at 2:38 PM, completed by PT 1, the PT TEN indicated Resident 1 complained of discomfort on Resident 1's left lower extremity (LLE- left leg, including the thigh, knee, calf, ankle, and foot) despite being pre-medicated. The PT TEN indicated PT 1 informed the licensed nurse (LVN 4) and agreed to monitor Resident 1. During a review of Resident 1's Medication Administration Record (MAR) for April 2025, the MAR indicated no documented evidence Resident 1 received Hydrocodone-Acetaminophen before or after the therapy session on 4/7/2025. The MAR indicated no documentation the licensed nurse assessed Resident 1 having any pain on 4/7/2025. During a review of Resident 1's MAR for April 2025, the MAR indicated Resident 1 was administered Hydrocodone-Acetaminophen 5-325 mg for complaints of pain (pain location was not indicated) on the following dates and times: a. On 4/9/2025 at 10:32 AM for pain level of 8 out of 10. b. On 4/14/2025 at 8:56 AM for pain level of 8 out of 10. c. On 4/14/2025 at 8:09 PM for pain level of 7 out of 10. d. On 4/16/2025 at 8:20 AM for pain level of 7 out of 10. e. On 4/17/2025 at 8:18 AM for pain level of 7 out of 10. During a review of Resident 1's PT TEN dated 4/14/2025, timed at 3:12 PM, completed by PT 2, the PT TEN indicated Resident 1 was pre-medicated prior to the therapy session and Resident 1 continued to complain of pain on left hip and left lower extremity during bed mobility exercises. During a concurrent interview and record review on 5/6/2025 at 12:40 PM with the MDS Nurse, Resident 1's MAR for April 2025 was reviewed. The MDS Nurse stated the MAR did not indicate Resident 1's pain location when the licensed nurse (LVN 1) administered pain medication to treat Resident 1's complaint of moderate to severe pain on 4/9/2025, 4/14/2025, 4/16/2025, and 4/17/2025. The MDS Nurse stated it was important for licensed nurses to document thoroughly such as the location of resident's pain to provide appropriate care, treatment, and notify the doctor if necessary. During an interview on 5/6/2025 at 2:50 PM with the Social Services Director (SSD), the SSD stated the SSD had written down the date when Resident 1 was moved from Room A to Room B on 4/7/2025, but the SSD failed to document the reason for the room transfer. The SSD stated the SSD could not recall by memory why the facility decided to move Resident 1 to another room. During a concurrent interview and record review on 5/6/2025 at 3:19 PM with LVN 4, Resident 1's medical record and MAR for April 2025 were reviewed. LVN 4 stated LVN 4 was Resident 1's licensed nurse on 4/7/2025 during the 7 am to 3 pm shift. LVN 4 stated LVN 4 could not remember being informed by PT 1 about Resident 1 having pain and giving Resident 1 pain medication. LVN 4 stated there were no documented interventions, assessments, nor pain relief provided to Resident 1 on 4/7/2025. LVN 4 stated the MAR indicated the licensed nurse (LVN 1) administered Hydrocodone to Resident 1 on 4/9/2025 at 10:32 AM, 4/14/2025 at 8:56 AM and 8:09 PM, 4/16/2025 at 8:20 AM, and 4/17/2025 at 8:18 AM but there was documentation of Resident 1's pain location therefore the location of the pain was unknown. During an interview on 5/7/2025 at 10:09 AM with LVN 1, LVN 1 stated when a resident (in general) reported pain, LVN 1 should ask the location, intensity, and onset of the pain, and what triggered the resident's pain. LVN 1 stated when LVN 1 administered Hydrocodone to Resident 1 on 4/9/2025, 4/14/2025, 4/16/2025, and 4/17/2025, LVN 1 failed to document the location of Resident 1's pain which put Resident 1 at risk for missed or delayed diagnosis, inappropriate treatment, ineffective pain relief, and delay in timely interventions which can further worsen any injury residents may have. LVN 1 stated she could not recall by memory where Resident 1's pain was located. During an interview on 5/7/2025 at 11:59 AM with PT 1, PT 1 stated that she provided therapy to Resident 1 on 4/7/2025 which consisted of the right leg range of motion, as well as the left leg range of motion while Resident 1 laid down on Resident 1's bed. PT 1 stated during the session, Resident 1 refused to attempt standing or getting out of bed and began to exhibit agitation. PT 1 stated Resident 1 wanted to go back to bed as Resident 1 complained of discomfort on his left lower extremity despite being pre-medicated prior to therapy and was guarding his left leg due to complaints of persistent pain. PT 1 stated PT 1 walked over to the nurse's station to inform the licensed nurse (LVN 4) of Resident 1's discomfort to Resident 1's left lower extremity and LVN 4 agreed to monitor Resident 1. PT 1 stated there was a possibility PT 1 may have written the wrong laterality (preference for using one side of the body over the other) of Resident 1's pain location. During an interview on 5/7/2025 at 12:19 PM with Resident 1's Family Representative (FR), the FR stated that FR 1 agreed to the facility's recommendation to move Resident 1 from Room A to Room B due to Resident 1's roommate requiring to be isolated. The FR was not sure why the roommate required isolation. During an interview on 5/7/2025 at 2 PM with the Admissions Coordinator (AC), the AC stated the facility's process for initiating a room transfer for residents was to document the reason for the transfer and notify the family representative. The AC stated Resident 1's family had requested a room change; however, the facility failed to ask the family and document a rationale for the room transfer and neither the AC nor the SSD could remember why the facility moved Resident 1 from Room A to Room B. During an interview on 5/7/2025 at 2:04 PM with the Assistant Director of Nursing (ADON), the ADON stated it was important for licensed nurses to ensure any resident (in general) pain assessment was accurate, consistent, and thoroughly documented to ensure proper pain management and continuity of care by rating pain level, asking pain location, aggravating and relieving factors, onset of pain, duration, characteristics, and treatment. The ADON stated failure to properly assess and document the resident's complaints of pain could result in untreated pain, delayed or missed interventions, decline in physical function, and complications from over or under medication. During a review of an electronic mail (e-mail) titled, Documentation Clarification, dated 5/7/2025, timed at 3:01 PM, emailed by the facility, the e-mail indicated PT 1 provided a written statement to clarify Resident 1's PT TEN dated 4/7/2025 completed by PT 1. The e-mail indicated per PT 1, PT 1 made an incorrect entry when PT 1 incorrectly documented Resident 1 complained of persistent pain on Resident 1's LLE instead of right lower extremity (RLE- right leg, including the thigh, knee, calf, ankle, and foot). The e-mail indicated per PT 1, Resident 1's pain location on 4/7/2025 was on the RLE. During a review of an e-mail titled, Resident 1, dated 5/14/2025, timed at 8:21 PM, emailed by the facility, the e-mail indicated PT 2 provided a written statement to clarify Resident 1's PT TEN dated 4/14/2025 completed by PT 2. The e-mail indicated per PT 2, PT 2 made an error in PT 2's documentation of Resident 1's pain location. The e-mail indicated per PT 2, Resident 1's pain location on 4/14/2025 was on the RLE and not on the LLE. During a review of the facility's policy and procedure (P&P) titled, Social Services Program, revised October 2024, the P&P indicated, The Social Services staff is responsible for . Maintaining regular progress and follow up notes indicating the resident's response to the care plan and interventions . maintaining contact with resident's family members, significant others, or responsible party, and involving them in resident's care plan ., The P&P indicated, The Social Services staff provides .comprehensive documentation of social service assessment and intervention for each resident . During a review of the facility's P&P titled, Charting and Documentation, revised 10/2024, the P&P indicated, Disciplines contributing to the record includes but is not limited to . nursing . social service .physical therapy . The P&P indicated, The resident's clinical record is an account of treatment, care, response to care, signs, symptoms and progress of the residents' condition. It also includes data needed for identification and communication with family/responsible party.

Based on interview and record review, the facility failed to assess and manage reported pain for one of three residents (Resident 1) as indicated in Resident 1's care plan and the facility's policies and procedures titled, Pain Recognition and Management, and Pain Management, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 assessed and documented Resident 1's pain location. 2. Ensure Resident 1 received pain medication when Resident 1 complained of persistent pain to Resident 1's right lower extremity (RLE- right leg, including hip, thigh, knee, calf, and foot) on 4/7/2025. These deficient practices had the potential for Resident 1 to experience unrelieved/uncontrolled pain that could result in physical, mental, and emotional distress. Cross Reference F842 Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of history of falling, right femur (thigh bone) fracture (break in the bone), and encounter for orthopedic (the branch of medicine dealing with the correction of deformities of bones or muscles) after care, dementia (progressive state of decline in mental abilities), osteoarthritis (OA- a progressive disorder of the joints caused by a gradual loss of cartilage [connective tissue that protects the joints/bones])abnormalities of gait (manner of walking) and mobility (ability to move freely), and generalized muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 4/1/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, remember and make decisions) for daily decision making. The MDS indicated Resident 1 required supervision (helper provides verbal cues and or touching as resident competes activity) for oral and personal hygiene, partial/moderate assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs) for upper body dressing, and substantial/maximal assistance (helper does more than half the effort to lift or hold trunk or limbs) for showering/bathing, rolling left and right, sitting to lying on the bed, lying to sitting on side of the bed, and toilet transfer. The MDS indicated Resident 1 had not attempted to transfer to and from a bed to a wheelchair, sit to stand, or walk ten feet due to medical condition or safety concerns. The MDS indicated Resident 1 had a fall in the last month prior to admission, surgical repair of the hip, required pain assessment interview, and had not had any pain in the last five days of the assessment. During a review of Resident 1's Care Plan (CP) titled Care Plan Report, dated 3/28/2025, the CP indicated Resident 1 had pain of the right femur due to a recent right femur fracture and surgical intervention following a fall. The CP interventions indicated for staff to administer analgesia (absence of pain) medication as per physician orders and give one-half (1/2) hour before treatments or care, anticipate need for pain relief, and respond immediately to any complaint of pain. During a review of Resident 1's Physician Order (PO), dated 3/28/2025, the PO indicated Resident 1 had an order for licensed staff to monitor Resident 1's pain level using zero (0) to 10 pain scale (0 = no pain, 1 to 3 = mild pain, 4 to 6 = moderate pain, and 7 to 10 = severe pain) every shift. During a review of Resident 1's PO, dated 3/31/2025, the PO indicated Resident 1 had an order for Hydrocodone-Acetaminophen (medication to treat moderate to severe pain) oral tablet 5-325 milligram (mg- a unit of mass) give one (1) tablet by mouth every six hours as needed (PRN) for moderate to severe pain from all sources. During a review of another Resident 1's CP titled, Care Plan Report, dated 4/4/2025, the CP indicated Resident 1 was at risk for hip fracture complications due to impaired mobility. The CP interventions indicated for staff to monitor/document/report to the doctor signs and symptoms (s/sx) of hip fracture complications such as unrelieved pain, impaired mobility, and pain after exercise or weight bearing. During a review of Resident 1's Physical Therapy (PT- treatment that helps improve how the body performs physical movements) Treatment Encounter Notes (PT TEN) dated 4/7/2025, timed at 2:38 PM, completed by Physical Therapist 1 (PT 1- a healthcare provider who helps improve how the body performs physical movements), the PT TEN indicated Resident 1 complained of discomfort on Resident 1's left lower extremity despite being pre-medicated. The PT TEN indicated PT 1 informed LVN 4 and agreed to monitor Resident 1. During a review of Resident 1's Medication Administration Record (MAR) for April 2025, the MAR indicated no documented evidence Resident 1 received Hydrocodone-Acetaminophen before or after the therapy session on 4/7/2025. The MAR indicated no documentation the licensed nurse assessed Resident 1 having any pain on 4/7/2025. During a review of Resident 1's Medication Administration Record (MAR) for April 2025, the MAR indicated Resident 1 was administered Hydrocodone-Acetaminophen 5-325 mg for complaints of pain (pain location was not indicated) on the following dates and times: a. On 4/9/2025 at 10:32 AM for pain level of 8 out of 10. b. On 4/14/2025 at 8:56 AM for pain level of 8 out of 10. c. On 4/14/2025 at 8:09 PM for pain level of 7 out of 10. d. On 4/16/2025 at 8:20 AM for pain level of 7 out of 10. e. On 4/17/2025 at 8:18 AM for pain level of 7 out of 10. During a concurrent interview and record review on 5/6/2025 at 12:40 PM with the MDS Nurse, Resident 1's MAR for April 2025 was reviewed. The MDS Nurse stated the MAR did not indicate Resident 1's pain location when the licensed nurse (LVN 1) administered pain medication to treat Resident 1's complaint of moderate to severe pain on 4/9/2025, 4/14/2025, 4/16/2025, and 4/17/2025. The MDS Nurse stated it was important for licensed nurses to document thoroughly such as the location of resident's pain to provide appropriate care, treatment, and notify the doctor if necessary. During a concurrent interview and record review on 5/6/2025 at 3:19 PM with LVN 4, Resident 1's medical record and MAR for April 2025 were reviewed. LVN 4 stated LVN 4 was Resident 1's licensed nurse on 4/7/2025 during the 7 am to 3 pm shift. LVN 4 stated LVN 4 could not remember being informed by PT 1 about Resident 1 having pain and giving Resident 1 pain medication. LVN 4 stated there were no documented interventions, assessments, nor pain relief provided to Resident 1 on 4/7/2025. LVN 4 stated the MAR indicated the licensed nurse (LVN 1) administered Hydrocodone to Resident 1 on 4/9/2025 at 10:32 AM, 4/14/2025 at 8:56 AM and 8:09 PM, 4/16/2025 at 8:20 AM, and 4/17/2025 at 8:18 AM but there was documentation of Resident 1's pain location therefore the location of the pain was unknown. During an interview on 5/7/2025 at 10:09 AM with LVN 1, LVN 1 stated when a resident (in general) reported pain, LVN 1 should ask the location, intensity, and onset of the pain, and what triggered the resident's pain. LVN 1 stated when LVN 1 administered Hydrocodone to Resident 1 on 4/9/2025, 4/14/2025, 4/16/2025, and 4/17/2025, LVN 1 failed to document the location of Resident 1's pain which put Resident 1 at risk for missed or delayed diagnosis, inappropriate treatment, ineffective pain relief, and delay in timely interventions which can further worsen any injury residents may have. LVN 1 stated she could not recall by memory where Resident 1's pain was located. During an interview on 5/7/2025 at 11:59 AM with PT 1, PT 1 stated that she provided therapy to Resident 1 on 4/7/2025 which consisted of the right leg range of motion, as well as the left leg range of motion while Resident 1 laid down on Resident 1's bed. PT 1 stated PT 1 provided hip and knee flexion, with hip abduction (the movement of a limb away from the midline of the body) and adduction (the movement of a limb towards the midline) to the left leg/left hip. PT 1 stated PT 1 only took care of Resident 1 that day, and her memory was blurry regarding actual events which was why she relied heavily on her thorough documentation to recall events that day. PT 1 stated based on her assessment and documentation, Resident 1 was able to roll to his right side while lying in bed, and partially roll to his left side, progressing to sitting on edge of bed with assistance. PT 1 stated during the session, Resident 1 refused to attempt standing or getting out of bed and began to exhibit agitation. PT 1 stated Resident 1 wanted to go back to bed as Resident 1 complained of discomfort on his left lower extremity despite being pre-medicated prior to therapy and was guarding his left leg due to complaints of persistent pain. PT 1 stated Resident 1 was unable to describe or quantify Resident 1's pain level at that time. PT 1 stated PT 1 walked over to the nurse's station to inform the licensed nurse (LVN 4) of Resident 1's discomfort to Resident 1's left lower extremity and LVN 4 agreed to monitor Resident 1. PT 1 stated PT 1 could not recall how Resident 1 was showing agitation other than refusing to continue the therapy session. PT 1 stated there was a possibility PT 1 may have written the wrong laterality (preference for using one side of the body over the other) of Resident 1's pain location. During an interview on 5/7/2025 at 12:45 PM with LVN 2, LVN 2 stated when residents (in general) report pain, licensed nurses should assess origin of pain, when the pain started, and depending on the pain level should give pain medication as needed, reassess the resident for effectiveness of pain medication, and document findings on the MAR. LVN 2 stated if the interventions were not effective, licensed nurses should document the reason, notify the doctor and family, and ask for X-rays (type of medical imaging that creates pictures of bones and soft tissues) or any type of diagnostic testing to rule out any unknown injuries. During an interview on 5/7/2025 at 2:04 PM with the Assistant Director of Nursing (ADON), the ADON stated licensed nurses were to communicate with staff and respond to any complaints of pain by assessing the resident's pain level, location of pain, pain intensity, new onset of pain, determining if pain was long-term, and check the resident's physician orders for any medication and/or treatment available to treat the resident's pain. The ADON stated it was important to follow up on the resident's pain levels and reassess the pain to determine if the treatment was effective and to ensure the facility was meeting the resident's needs. The ADON stated failure to properly assess the resident's complaint of pain can result in untreated pain, delayed or missed interventions, decline in physical function, and complications from over or under medication. During a review of an electronic mail (e-mail) titled, Documentation Clarification, dated 5/7/2025, timed at 3:01 PM, emailed by PT 1, the e-mail indicated PT 1 provided a written statement to clarify Resident 1's PT TEN dated 4/7/2025. The e-mail indicated per PT 1, PT 1 made an incorrect entry when PT 1 incorrectly documented Resident 1 complained of persistent pain on Resident 1's left lower extremity (LLE) instead of RLE. The email indicated per PT 1, Resident 1's pain location on 4/7/2025 was on the RLE. During a review of the facility's P&P titled, Pain Recognition and Management, revised 1/2022, the P&P indicated, It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan . The P&P indicated the care plan will reflect the location and type of pain, pharmacological, and non-pharmacological interventions, with evaluation and revision as indicated. During a review of the facility's P&P titled Pain Management the P&P dated 10/2024, the P&P indicated, The resident will be assessed for pain . On admission with a pain-related diagnosis, or if pain in indicated through the Nursing Admission Assessment . Upon development of new symptoms of acute pain . Complete the Pain Management Review assessment . Complete appropriate physical assessment to determine any physical changes or manifestations as needed. The P&P indicated, Monitor pain status and treatment effects on a regular basis, e.g., during routine medication pass . Consult physician for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures. The Care Plan will include pharmacological and non-pharmacological interventions, with evaluation and revision as needed.

Based on interview and record review, the facility failed to revise the plan of care for one of three sampled residents (Resident 1), who was at high risk for falls, following episodes of getting up unassisted on 4/8/2025. This deficient practice had the potential to increase Resident 1's risk for falls and injury. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of history of falling, right femur (thigh bone) fracture (break in the bone), and encounter for orthopedic (the branch of medicine dealing with the correction of deformities of bones or muscles) after care, dementia (progressive state of decline in mental abilities), osteoarthritis (OA- a progressive disorder of the joints caused by a gradual loss of cartilage [connective tissue that protects the joints/bones])abnormalities of gait (manner of walking) and mobility (ability to move freely), and generalized muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- resident assessment tool), dated 4/1/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to think, remember and make decisions) for daily decision making. The MDS indicated Resident 1 required supervision (helper provides verbal cues and or touching as resident competes activity) for oral and personal hygiene, partial/moderate assistance (helper does less than half the effort to lift, hold, or support trunk or arms and legs) for upper body dressing, and substantial/maximal assistance (helper does more than half the effort to lift or hold trunk or limbs) for showering/bathing, rolling left and right, sitting to lying on the bed, lying to sitting on side of the bed, and toilet transfer. The MDS indicated Resident 1 had not attempted to transfer to and from a bed to a wheelchair, sit to stand, or walk ten feet due to medical condition or safety concerns. The MDS indicated Resident 1 had a fall in the last month prior to admission, surgical repair of the hip, required pain assessment interview, and had not had any pain in the last five days of the assessment. During a review of Resident 1's Care Plan (CP) titled, Care Plan Report, initiated 3/28/2025, the CP indicated Resident 1 was at risk for falls related to impaired balance and mobility and decreased endurance. The CP interventions indicated for staff to ensure Resident 1's call light was within reach, encourage Resident 1 to use the call light to call for assistance as needed, may have low bed with bilateral floor mats for safety precautions, and may have pressure pad alarm in wheelchair and bed to alert staff of resident attempting to get up unassisted. During a review of Resident 1's Medication Administration Record (MAR) for April 2025, the MAR indicated Resident 1 had two episodes of attempting to get up unassisted from Resident 1's wheelchair on 4/8/2025. During an interview on 5/6/2025 at 12:40 PM with the MDS Nurse, the MDS Nurse stated no CP had been updated since 4/4/2025 for Resident 1 getting up unassisted to ensure Resident 1's safety and apply new interventions. During an interview on 5/6/2025 at 1:36 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 1 had a Care Plan for falls which should have been updated to include more frequent monitoring such as every hour as opposed to two hours since Resident 1 was at high risk for falls and kept getting up unassisted on 4/8/2025. LVN 2 stated not having a CP and updated interventions would not allow nurses to meet resident's needs and could contribute to a decline in resident's health. LVN 2 stated Resident 1's CP should have updated interventions to the CP to avoid missed diagnosis and delayed treatment. During an interview on 5/7/2025 at 2:04 PM with the Assistant Director of Nursing (ADON), the ADON stated it was important for licensed nurses to update and create care plans to meet resident's needs by implementing interventions to each resident's care area, prevent further decline, missed diagnosis, delayed treatment, and identify any new issues that require intervention. During a review of the facility's policy and procedure (P&P) titled, Fall Management System, revised October 2024, the P&P indicated, 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 P&P indicated, Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. The P&P indicated, Resident's care plan will be updated.

Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and homelike environment for ten of ten sampled residents (Residents 13, 23, 30, 32, 44, 56, 61, 75, 298, and 299's) rooms. These deficient practices had the potential for Resident 13, 23, 30, 32, 44, 56, 61, 75, 298, and 299 to be exposed to dirt, mold, and drywall dust, which can lead to adverse health effects such as irritating eyes, skin, nose, throat, and lungs. Prolonged exposure can cause more serious problems such as acute respiratory illness, persistent coughing, and asthma. Findings: During an observation on 12/11/24 at 9:10 a.m. in Resident 61, 298, and299's bathroom, the bathroom sink was observed with peeling paint, cracked drywall, a loosely fitting pipe escutcheon (a type of plumbing supply typically made of metal that hides the unsightly hole in the wall that pipes come through) exposing the pipe and hole in the wall under the sink, and there were brown spots underneath the sink. During an observation on 12/11/24 at 9:21 a.m. in Residents 23 and 75's bathroom, the bathroom sink was observed with cracked caulking around the sink, and cracked drywall near the sink. The bathroom door was observed with chipped and peeling paint, and the wall adjacent to the bathroom door was observed with peeling paint. During an observation on 12/11/24 at 10 a.m. in Residents 13, 30, and 32's room, raised and cracked tile between the room and the entry to the bathroom was observed with chipped paint around the bathroom door casing (the trim around a door opening). During an observation on 12/11/24 at 10:18 a.m. in Residents 44 and 56's bathroom, the bathroom sink was observed with peeling caulking, which exposed unpainted and chipped drywall behind the caulking. There was a gap between the wall base tile next to the toilet, along with chipped paint and cracked drywall. During an interview with Housekeeper (HK) 2 on 12/11/24 at 9:45 a.m., HK 2 stated she reported the broken or items that need to be repaired to the Maintenance Director (MD). During a concurrent interview and observations of Residents 13, 23, 30, 32, 44, 56, 61, 75, 298, 299's rooms with the MD on 12/11/24 at 10:46 a.m., the MD stated, Everyone should be able to report broken or items that need repair. When I am not here there is a maintenance log at each nursing station. The MD stated all bathrooms in Residents 13, 23, 30, 32, 44, 56, 61, 75, 298, and 299's rooms need to be repaired due to cracking drywall/caulking, and peeling paint. The MD stated the door jambs and casing needed to be repaired because of chipped paint and dents in the wood. The MD stated the dust from compromised and cracked holes in the drywall can affect the residents' breathing, and the drywall should be repaired and painted. The MS stated the cracked floor tiles and base wall tile needed to be replaced because there was a potential risk for residents and visitors fall to fall from the cracked floor tiles. During a review of the facility's Maintenance Logs from 2023 to 2024, the logs indicated Residents 61, 298 and 299's room, did not have any log entries for bathroom repairs. During a review of the facility's Maintenance Logs from 2023 to 2024, the logs indicated Residents 23 and 75's room did not have any log entries for bathroom repairs. During a review of the facility's Maintenance Logs from 2023 to 2024, the logs indicated Residents 44 and 56's room did not have any log entries for bathroom repairs. During a review of the facility's Maintenance Logs from 2023 to 2024, the logs indicated no log entries for any needed repairs for Resident 13, 30, and 32's room. During a review of the facility's Policy and Procedure (P&P) titled, Physical Environment: Environmental Conditions/Environmental Rounds, dated 01/2024, the P&P indicated, Policy: It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public through monthly environmental rounds. The P&P further indicated, Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.

Based on interview and record review, the facility failed to administer insulin as ordered for one of one sampled resident (Resident 19) in a timely manner. This deficient practice had the potential to make Resident 19 become lethargic, experience an altered level of consciousness or unresponsive to external stimuli. Findings: During a review of Resident 19's Admission Record, (AR), the AR indicated Resident 19 was admitted on [DATE] with multiple diagnoses including type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities) and adult failure to thrive ( a state of decline that is manifested by weight loss, decreased appetite, poor nutrition and inactivity). During a review of Resident 19's Minimum Data Set (MDS - a resident assessment tool) dated 10/2/2024, indicated Resident 19 did not have intact cognition (ability to think and process information). The MDS indicated Resident 20 was dependent (helper does all of the effort) on staff for toileting, bathing and required supervision for eating. During a review of Resident 19's Medication Administration Record (MAR), dated with active orders from 11/1/2024 - 11/30/2024, the MAR indicated Resident 19 had a physician order with start date of 8/6/2024 to administer insulin Lispro injection solution 100 unit/milliliter (ml) based on a sliding scale, scheduled every day at 6:30 AM and 5:00 PM. The MAR indicated Resident 19's insulin was given past the scheduled times on the following days and times: 1. 11/1/2024 dose scheduled at 5:00 PM and given at 7:55 PM. 2. 11/2/2024 dose scheduled at 5:00 PM and given at 7:51 PM. 3. 11/6/2024 dose scheduled at 5:00 PM and given at 7:42 PM. 4. 11/9/2024 dose scheduled at 6:30 AM and given at 8:23 AM. 5. 11/12/2024 dose scheduled at 5:00 PM and given at 6:20 PM. 6. 11/17/2024 dose scheduled at 5:00 PM and given at 7:51 PM. 7. 11/18/2024 dose scheduled at 5:00 PM and given at 6:30 PM. 8. 11/20/2024 dose scheduled at 6:30 AM and given at 7:56 AM. 9. 11/21/2024 dose scheduled at 5:00 PM and given at 7:42 PM. 10. 11/22/2024 dose scheduled at 6:30 AM and given at 8:00 AM. 11. 11/22/2024 dose scheduled at 5:00 PM and given at 10:45 PM. 12. 11/24/2024 dose scheduled at 6:30 AM and given at 8:15 AM 13. 11/24/2024 dose scheduled at 5:00 PM and given at 9:47 PM. 14. 11/27/2024 dose scheduled at 6:30 AM and given at 9:15 AM. 15. 11/27/2024 dose scheduled at 5:00 PM and given at 7:43 PM. 16. 11/29/2024 dose scheduled at 5:00 PM and given at 6:51 PM. During a review of Resident 19's MAR, with active orders dated from 12/1/2024 - 12/31/2024, the MAR indicated Resident 19 had a physician order with start date of 8/6/2024 to administer insulin Lispro injection solution 100 unit/ml based on a sliding scale scheduled every day at 6:30 AM and 5:00 PM. The MAR indicated Resident 19's insulin was given prior to and past the scheduled times on the following days and times: 1. 12/1/2024 scheduled dose at 6:30 AM and given at 3:17 AM. 2. 12/4/2024 scheduled dose at 5:00 PM and given at 9:48 PM. 3. 12/9/2024 scheduled dose at 5:00 PM and given at 6:21 PM. During an interview on 12/12/2024 at 11:17 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated in general, staff administer medication an hour prior and up to an hour after the scheduled time on the Medication Administration Record (MAR). LVN 1 stated Resident 19's blood sugar is scheduled to be checked at 6:30 AM and 5:00 PM. LVN 1 further stated staff could check the blood sugar up until Resident 19 gets the resident's meal. LVN 1 stated blood sugar should be checked prior to Resident 19 eating to ensure accuracy. LVN 1 also stated if the blood sugar is checked after eating, a staff member could give more insulin than needed and the resident could become lethargic, sweaty, unresponsive or have an altered level of consciousness. LVN 1 stated Resident 19's doctor would also have an inaccurate trend of the resident's blood sugars potentially affecting Resident 19's perceived need for medication. During a concurrent interview and record review on 12/12/2024 at 11:50 AM with the Director of Nursing (DON), Resident 19's MAR dated 12/1/2024 - 12/31/2024 was reviewed. The MAR indicated the days and times Resident 19's insulin was not administered according to the schedule. The DON stated nurses should be documenting when they actually administer the insulin and the MAR currently appeared to indicate insulin was administered much past the dose schedule. The DON stated if a nurse was to give insulin at the indicated times past the dose schedule without a meal or snack, the resident could become hypoglycemic (have abnormally low level of sugar in the blood). During a review of the facility's policy and procedure (P&P) titled, Medication Administration, revised 11/2021 and reviewed 1/2024, the P&P indicated under Essential Points: 1. No medication is to be administered without a physician's order. Accurate and timely administration according to MD order is essential.

Based on observation, interview and record review, the facility failed to ensure foods are handled, prepared, and stored in a manner that prevents foodborne illness (food poisoning) in the facility for one of one kitchen when: 1. Eleven milk cartons were observed in the reach-in refrigerator with an expiration date of [DATE]. 2. Seven milk cartons with an expiration date of [DATE] were observed on a tray of drinks to be serve to residents. 3. One half empty milk carton with an expiration date of [DATE] on a resident's tray was observed being brought back to the kitchen by Certified Nursing Assistant (CNA) 4. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed the residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, and can lead to other serious medical complications and hospitalization . Findings: 1. On [DATE] at 7:45 a.m., during an initial Kitchen tour, eleven cartons of 2% fat milk were observed in the reach-in refrigerator with a manufacturer expiration date of [DATE]. During a concurrent interview and observation with the Dietetic Service Supervisor (DSS) on [DATE] at 8 a.m., the DSS acknowledged the eleven cartons of milk were expired and should be tossed in the trash. The DSS was observed throwing the milk cartons in the trash can. 2. On [DATE] at 11:56 a.m., during a tray line observation in the kitchen, seven cartons of 2% fat milk with a manufacturer expiration date of [DATE] were observed on a tray of drinks to be serve to residents. During a concurrent interview and observation with the DSS on [DATE] at 12 p.m., the DSS acknowledged the seven cartons of milk were expired. The DSS stated he did not know where the cartons came from because he had checked the tray in the reach-in refrigerator. The DSS was observed throwing the milk cartons in the trash can. 3. On [DATE] at 2:40 p.m., CNA 4 was observed walking to the kitchen with a food tray that had one half empty carton of 2% fat milk with a manufacturer expiration date of [DATE]. The lunch food slip indicated the milk was for Resident 40. During an interview with the DSS on [DATE] at 2:43 p.m., the DSS stated he did not know how the milk carton got to Resident 40. The DSS stated he checked all food trays before they went out to the residents for lunch. During a review of the facility's Policy and Procedure (P&P) titled, Labeling and Dating of Foods, dated 2023, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation (FIFO - First In - First Out). Some cultured dairy products such as milk, cream, yogurt, sour cream & buttermilk .shall be discarded following the manufacturer expiration date or seven days after opening whichever comes first. The P&P further indicated, Once daily, the PM [NAME] and/or PM Diet Aide will be responsible to inspect the refrigerators and discard perishable foods that are time/temperature control for food safety (TCS) in order to ensure food safety.

Based on observation, interview, and record review, the facility failed to follow its infection prevention and control program for two of six sampled residents (Residents 20 and 78) by failing to: a. [NAME] (put on) a gown before entering Resident 78's room which it was under contact precautions. b. Wear personal protective equipment (PPE, prefers to protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) when cleaning Resident 20's room which it was under enhanced barrier precautions. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for all the residents and staff in the facility. Findings a. During a review of Resident 78's Admission Record (AR), the AR indicated the facility admitted Resident 78 on 9/3/2024, and readmitted on [DATE], with diagnoses including pneumonia (an infection/inflammation in the lungs), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). During a review of Resident 78's Minimum Data Set (MDS, a resident assessment tool), dated 11/21/2024, the MDS indicated Resident 78's cognition (the ability to think and process information) was moderately intact. The MDS indicated Resident 78 was dependent (helper does all the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) such as toileting hygiene, shower/bathe self, lower body dressing and putting/on/taking off footwear. During a review of Resident 78's untitled Care Plan, date initiated 12/1/2024, the Care Plan indicated Resident 78 was on Bactrim (antibiotic medication) for urinary tract infection. The care plan intervention indicated Resident 78 was on contact isolation for Methicillin-Resistant Staphylococcus Aureus (MRSA, a staph germ (bacteria) that does not get better with the type of antibiotics that usually cure staph infections. When this occurs, the germ is said to be resistant to certain antibiotics) of the urine. During an observation on 12/9/2024 at 09:40 AM, Certified Nursing Assistant (CNA) 1 entered Resident 78's room which it was under contact isolation without donning a gown. During an interview on 12/9/2024 at 09:46 AM, with CNA 1, CNA 1 stated that staff should wear proper PPE, before entering a room under contact isolation, which includes donning gown and gloves. CNA 1 stated she should have donned a gown before entering resident 78's room. CNA 1 stated that wearing proper PPE could protect residents and staff from cross-contamination of infections and ensures everyone's safety. During an interview on 12/10/2024 at 1:56 PM, with the Infection Preventionist Nurse (IPN), the IPN stated the expectation of staff when entering a room under contact isolation was always don and doff (remove) appropriate PPE including gown and gloves. The IPN stated that PPE could protect residents and staff from the transmission of communicable diseases and prevents the spread of infections. During a review of Resident 78's Order Summary Report, dated 12/11/2024, the report indicated Resident 78 was on contact isolation for MRSA. During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program and Transmission-Based Precautions, revision dated 10/2024, the P&P indicated that it was the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. The P&P indicated: A. Contact Precautions (Transmission-Based Precautions or TBP) are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment. (e.g. MDROs, A multidrug resistant organism is a germ that is resistant to many antibiotics. If a germ is resistant to an antibiotic, it means that certain treatments will not work or may be less effective. MDROs can be difficult to treat since many antibiotics won't work to treat them). B. Personal protective equipment: i. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. ii. [NAME] PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogens. 48729 b. During a review of Resident 20's AR, the AR indicated Resident 20 was admitted on [DATE] and readmitted on [DATE]. The AR indicated Resident 20 was admitted with multiple diagnoses including type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (a disorder characterized by difficulty in blood sugar control and poor wound healing) and heart failure (condition when the heart muscle does not pump enough blood for the body's needs). During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20 had intact cognition. The MDS indicated Resident 20 was dependent on staff for toileting, and bathing. During a review of Resident 20's Order Summary Report (OSR) dated with active orders as of 12/12/2024, the OSR indicated a physician order with a start date on 11/30/2024 for Enhanced Barrier Precautions: PPE required for high resident contact care activities. During a concurrent observation and interview on 12/12/2024 at 10:22 AM with the Housekeeping Staff (HSK) 1 in Resident 20's room, the HSK 1 was mopping the floor while wearing a surgical mask and gloves without a protective gown. A sign posted outside the room from the Los Angeles County Department of Public Health dated 9/8/2021 indicated staff must perform hand hygiene and wear gloves and gown for cleaning the environment due to enhanced standard precautions. The HSK 1 stated the HSK 1 should have been wearing a gown to clean but had forgotten. During an interview on 12/12/2024 at 1:00 PM with the Maintenance Director (MD), the MD stated staff need to wear a gown when cleaning the resident rooms and providing patient care under enhanced standard precaution. The MD further stated it's not always known if the residents have an infection and what they've touched in the room so housekeeping staff should have extra protection and wear a gown, mask and gloves when cleaning the rooms. The MD sated germs could get on the housekeeper themselves or their clothes while cleaning and spread to other residents or rooms. During an interview on 12/12/2024 at 1:12 PM with the Infection Preventionist Nurse (IPN), The IPN stated housekeeping would need to wear a gown for cleaning resident rooms to prevent the spread of infection from room to room. During a review of the facility's P&P titled, IPCP Standard and Transmission-Based Precautions, revised 10/2024, the P&P indicated the use and type of PPE is based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated). The P&P further indicated under Implementation, ii. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves.

Based on interview and record review, the facility ' s Licensed Vocational Nurse 3 (LVN 3) failed to identify signs and symptoms of a change in condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains), and provide needed care and services for one of six sampled residents (Resident 3), as indicated in the facility ' s policy and procedure. On [DATE], at 5:03 am, Resident 3 complained she could not breathe, felt very tired, and anxious (experiencing worry). LVN 3 told Resident 3 to stay in bed, close her eyes, relax, and left Resident 3 ' s bedside. At 6:04 am, Resident 3 ' s Family Member 1 (FM 1) arrived at the facility because Resident 3 called her via video call saying she could not breathe, and FM 1 called 911 (emergency services). As a result, on [DATE], at 6:31 am, 911 services arrived and transferred Resident 1 to a general acute care hospital (GACH). Resident 3 was admitted to GACH with shortness of breath, [CONDITION(S)] (irregular heartbeat) with rapid ventricular response (RVR, rapid heart rate that can be life threatening), chest pain, acute (sudden onset) exacerbation (increase in severity) of congestive heart failure, and a heart attack requiring surgery. Findings: A review of Resident 3 ' s Admission Record indicated the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3 ' s Order Recap Report (physician orders) dated [DATE], indicated the resident was to receive [MEDICATION(S)] inhalation (HFA) aerosol solution (prescription inhaled medicine used to treat wheezing and shortness of breath caused by breathing problems) to open airways in lungs and treat asthma,) 2 puffs orally every 4 hours as needed for wheezing (a high-pitched whistling sound made while breathing). A review of Resident 3 ' s untiled Care Plan, dated [DATE], indicated Resident 3 had potential for altered respiratory status/difficulty breathing related to disease process, asthma, and history of wheezing. The care plan indicated the nursing interventions were to monitor and document changes in orientation, restlessness, anxiety, and air hunger (shortness of breath). The care plan indicated the nursing staff was to monitor for signs and symptoms of respiratory distress (having trouble breathing) which included increased respirations, increased heart rate, and restlessness, and report to the physician. A review of Resident 3 ' s Minimum Data Set (MDS, standardized assessment and care planning tool tool), dated [DATE], indicated the resident was cognitively intact (the resident was able to make decisions), and required extensive assistance (resident involved in activity, staff provide weight-bearing support from) from two persons or more for bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed). A review of Resident 3 ' s Medication Administration Note, dated [DATE] at 1:23 am, indicated the resident received [MEDICATION(S)] HFA aerosol solution 2 puffs for wheezing. A review of Resident 3 ' s Progress Notes dated [DATE], indicated at 1:23 am, the resident requested and received [MEDICATION(S)] HFA. The note indicated around 5:03 am, a Certified Nursing Assistant (CNA unidentified) reported to LVN 3 that the resident complained that she can ' t breathe. The note indicated LVN 3 assessed the resident, and the resident was not in distress and had an oxygen saturation (the measure of how much oxygen is traveling through your body in your red blood cells) rate of ,d+[DATE]% (a normal blood oxygen saturation level in the range of ,d+[DATE]%). The note indicated the resident reported feeling very very tired and anxious. The note indicated Resident 3 was afraid and could not get up in the wheelchair. The note indicated LVN 3 told Resident 1 to stay in bed, close her eyes, and relax. The note indicated Resident 3 informed LVN 3 she was going to call FM 1. The note indicated LVN 3 left the room to continue passing medications to other residents. The note indicated around 6:24 am, FM 1 arrived at the facility upset because Resident 1 was not able to breathe. The note indicated at 6:31 am, paramedics (emergency services) arrived at the facility, assessed the resident and transported the resident to the emergency room for evaluation of Resident 1 ' s [CONDITION(S)] and an elevated heart rate. A review of Resident 3 ' s Prehospital Report dated [DATE], indicated the emergency service unit was notified at 6:22 am. The report indicated at 6:34 am, the resident was found lying supine (facing up) and complained of shortness of breath since [DATE] at 11 pm, with abdominal discomfort that radiated (spread) to her lower chest. The report indicated the resident was found with [CONDITION(S)] and RVR. The report indicated the resident ' s vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) were blood pressure (the pressure of the blood in the circulatory system) ,d+[DATE] (high, normal less than 120 and less than 80, elevated 120 to 129 and less than 80), heart rate148 (normal 60 to 100 beats per minute), respirations 28 (normal range 12 to 20 breaths per minute), and oxygen saturation 93%. A review of Resident 3 ' s Emergency Department (ED) Physician Note dated [DATE] at 7:57 am, indicated the resident arrived at the ED with significantly short of breath. The resident required oxygen and complained of chest pain. The note indicated Resident 1 was diagnosed with [CONDITION(S)] with rapid ventricular Response, chest pain, shortness of breath, and acute exacerbation of congestive heart failure (CHF, heart disease that affects pumping action of the heart muscle). A review of Resident 3 ' s untimed GACH Cardiac Consultation Notes, dated [DATE], indicated the tests on admission to the hospital ([DATE]) indicated the resident had elevated troponin levels (lab test to check for a heart attack) and a high heart rate of 140 beats per minute (bpm) (normal ,d+[DATE] bpm). The note indicated the resident needed open heart surgery but due to the risks of surgery would be a better candidate for stent placement (wire tube-like structure used to keep heart vessels open allowing blood flow). A review of Resident 3 ' s GACH Operative Procedure Document, dated [DATE], indicated the resident had stents placed in her heart. During an interview on [DATE] at 5:45 pm, FM 1 stated on [DATE] at 6:09 am, Resident 3 video called FM 1 to complain of not breathing well and chest pain since [DATE] in the evening, and said the facility ' s staff (unidentified) were not taking the resident serious. FM 1 stated it was clear on the video Resident 3 was having difficulty breathing. FM 1 stated she attempted to call the facility but not one answered the phone, so she called 911 and rushed to the facility. FM 1 stated upon arrival to the facility, Resident 3 ' s call light (a device used by a patient to signal his or her need for assistance) was on, and LVN 3 was sitting at the Nurses ' Station. FM 1 stated she walked out of Resident 3 ' s room and asked LVN 3 to check on Resident 3. FM 1 stated LVN 3 repeated I already checked her, I already checked her, she ' s fine. FM 1 asked LVN 3 to check the resident again and LVN 3 walked in with a pulse oximeter (electronic device that may be used to see if there is enough oxygen in the blood) and walked out of the room and said, she ' s fine. FM 1 stated the paramedics arrived at the facility and immediately transported the resident to the emergency room with an elevated heart rate and on oxygen because of the shortness of breath. FM 1 stated Resident 3 was having a heart attack and LVN 3 kept saying she ' s fine, and only checked the resident ' s oxygen saturation. FM 1 stated LVN 3 ignored the signs of a heart attack and dismissed the resident ' s complaints. FM 1 stated Resident 3 had a heart attack and she could have died if FM 1 did not call 911 and went to the facility. During a telephone interview on [DATE] at 1:48 pm, Resident 3 stated she is happy to be home. Resident 3 stated LVN 3 ignored her complaints of difficulty breathing, nausea, and vomiting, and feeling something weird in my chest. Resident 3 stated I felt miserable. Resident 3 stated she let LVN 3 know that she was so scared and LVN 3 told her that symptom was due to the medication ([MEDICATION(S)]) and would make faces at her. Resident 3 began to cry during the interview and stated, she felt awful, miserable, and scared. Resident 3 stated what happened to her was awful, Resident 3 stated, I had a heart attack, I could have died . Resident 3 stated she called FM 1 because LVN 3 was not listening to her and FM 1 called 911. During an interview on [DATE] at 4:04 pm, LVN 3 stated on the morning of [DATE], at 1:23 am she administered the [MEDICATION(S)] inhaler to Resident 3 but she was not sure and could not remember the reason for administering the [MEDICATION(S)]. LVN 3 stated, I guess it was for shortness of breath. LVN 3 stated later that morning Resident 3 seemed anxious and wanted to go home and then complained of having a hard time breathing. LVN 3 stated she told FM 1 that was not true that Resident 3 had trouble breathing due to the resident ' s oxygen saturation was not low. LVN 3 stated she agreed to go check Resident 3 ' s oxygen saturation again due to FM 1 ' s request and the resident ' s oxygen saturation was in the high 90 ' s. LVN 3 stated she did not count the resident ' s heart rate (heartbeat) and respiratory rate (rate at breathing occurs) were not done and stated, she did not listen to Resident 1 ' s lung sounds. LVN 3 stated once the paramedics arrived and reassessed Resident 3, they decided to transport the resident to the hospital because of [CONDITION(S)] and high heart rate. During a concurrent review of Resident 1 ' s Progress Notes and Medication Administration Records, dated [DATE], and interview on [DATE] at 1:35 pm, the Director of Nursing (DON) stated on [DATE], in the morning (can ' t remember the time), LVN 3 called the DON and stated Resident 3 ' s daughter arrived at the facility and called 911 but the resident was fine, oxygen saturation and vital signs) were okay (not specified). The DON stated LVN 3 told her that Resident 1 was just anxious because the resident did not want to get out of bed. The DON reviewed Resident 3 ' s Progress Notes and Medication Administration Records and stated Resident 3 received [MEDICATION(S)] on [DATE] at 1:23 am, for wheezing but the respiratory assessment was not documented. The DON stated a respiratory assessment which included listening to the resident ' s lungs to confirm the presence of wheezing needed to be done and documented. The DON stated signs and symptoms of a heart attack included shortness of breath and chest pain and required immediate action. The DON stated when Resident 3 complaint of shortness of breath, LVN 3 needed to provide interventions such as check lung sounds, administered oxygen and call Resident 3 's Physician if the shortness of breath did not alleviate. A review of the facility ' s job description for Licensed Vocational Nurse/Licensed Practical Nurse, dated [DATE], indicated essential duties and responsibilities included: Examine the resident and his/her records and charts to distinguish between normal and abnormal findings in order to recognize early stages of serious physical, emotional or mental problems and Chart all changes in resident condition and the response to those changes. A review of the facility ' s policy, titled Respiratory Care, dated ,d+[DATE], indicated the equipment needed for a respiratory assessment was a pulse oximeter and a stethoscope (a medical instrument for listening to the action of someone's heart or breathing). The policy indicated the following needed to be followed with a change of condition, which included: Observe respiratory rate and rhythm, check Oxygen Saturation, inspect chest configuration and the work of breathing, and auscultate (listening to sounds of the heart, lungs, or other organs), lung sounds and listening for adventitious sound (respiratory noises beyond that of normal breath sounds. The policy indicated for staff to Provide adequate documentation, assessment and evaluation of care plan that is deem necessary with resident significant change. A review of the facility ' s policy, titled Significant change in Condition, dated ,d+[DATE], indicated There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his/her clinical judgment and shall contact the physician based on the urgency of the situation. The policy indicated, The nurse will transcribe (when a medical report is typed from a dictated audio file recorded by a physician, a nurse, or some other healthcare provider) the treatment and plan of care relative to the change of condition on the resident Electronic Medical Record (EMR). According to a report on Nursing Considerations for the use of [MEDICATION(S)], indicated to monitor the resident ' s respiratory rate, oxygen saturation, and lung sounds before and after administering [MEDICATION(S)]. The report indicated to observe any changes in heart rhythm, episodes of palpitations, chest pian, shortness of breath, fatigue, and weakness. Retrieved from https://nursestudy.net/[MEDICATION(S)]-nursing-considerations/?utm_source=rss&utm_medium=rss&utm_campaign=[MEDICATION(S)]-nursing-considerations

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received one on one supervision (1:1, one staff supervising 1 resident) to prevent fall (move downward, typically rapidly and freely without control, from a higher to a lower level) as indicated in Resident 1 ' s Fall Care Plan and the facility ' s policy on Fall Management System. On 7/20/2022 at 9 PM, Certified Nurse Assistant 3 (CNA 3) left Resident 1 unsupervised on the bed to go to the restroom. As a result, Resident 1 fell from her bed and sustained a refracture [a break along the line of a previous fracture (break in the continuity of a bone)] of a healing right hip fracture. The resident was transferred to a General Acute Care Hospital (GACH) and underwent a removal of right hip deep hardware (device used to hold broken bone), a deep bone biopsy (remove a bone sample), intramedullary nail fixation (long rod inserted inside the bone) of the right hip fracture, intertrochanteric (top end of the thigh bone) closed reduction (procedure to set a broken bone without cutting the skin open) and nailing of right femur shaft (long part of the thigh bone) fracture. Findings: A review of Resident 1 ' s Face Sheet indicated the facility admitted the resident on 7/11/2022 with diagnoses that included a fracture of the right femur (thigh bone) and dementia (loss of memory, language, and other thinking abilities). A review of Resident 1 ' s Fall Risk Evaluation on Admission, dated 7/11/2022, indicated the resident was assessed as high risk for falls. A review of Resident 1 ' s Comprehensive Care Plan, titled At Risk for Falls Related to a Past History of Falls Requiring Right Hip Open Reduction and Internal Fixation Surgery (ORIF, a type of surgery used to stabilize and heal a broken bone) dated 7/11/2022, indicated the interventions were for staff to provide a call light within reach, bed in low position, floor mats at the bedside, and to ensure the needed items were within the resident ' s reach. A review of Resident 1 ' s Licensed Nursing Admission Note, dated 7/11/2022, at 8:27 PM, indicated the resident was admitted to the facility after sustaining a fracture on the right hip from a fall from an assisted living facility (housing for elderly) where she lived. A review of Resident 1 ' s Licensed Nursing Note, dated 7/12/2022, at 7:54 AM, indicated the resident attempted to get out of bed twice and was reoriented and educated on the proper use of her call light. A review of Resident 1 ' s Licensed Nursing Note, dated 7/13/2022, at 2:51 PM, indicated the resident was confused, forgetful, and was found sitting on the edge of the bed with the bed alarm on. The note indicated the resident verbalized wanting to use the restroom. A review of Resident 1 ' s Social Services Note, dated 7/13/2022, at 5:34 PM indicated the resident lived in a memory care unit of the assisted living facility due to dementia. A review of Resident 1 ' s Change of Condition (COC, a sudden clinically important deviation from the resident's baseline in physical, cognitive, behavioral, or functional domains) note, dated 7/14/2022 at 2:45 AM, indicated the resident fell and complained of right rib pain. The COC indicated an x-ray (a photographic or digital image) of the right ribs and right hip were ordered, and no fracture was found. A review of Resident 1 ' s Licensed Nursing Note, dated 7/14/2022 at 2:58 AM, indicated an unidentified Certified Nursing Assistant (CNA) heard Resident 1 ' s bed alarm went off and found the resident sitting on the edge of the bed. The note indicated Resident 1 asked to be changed and the CNA went to get supplies, turned around and saw Resident 1 stood up, lost her balance, and fell . The note indicated Resident 1 was assessed by Charge Nurse 1 without injury. A review of Resident 1 ' s Licensed Nursing Note, dated 7/15/2022 at 1:13 AM, indicated on 7/14/2022 at 11:40 PM the resident ' s bed alarm sounded, and a loud thud was heard as Registered Nurse Supervisor 1 (RNS 1) entered the room. The note indicated the resident was found on the floor by the foot of the bed with both legs flexed towards the foot of the bed and head towards the wall. The note indicated the resident had a hematoma (pool of clotted blood in a body space) to the back, left side, of the head with minimal bleeding. The note indicated Resident 1 complained of pain on the right thigh. The note indicated the resident was transferred to the emergency room (ER) via 911 (an emergency number for police, fire, or medic). A review of Resident 1 ' s Licensed Nursing Note, dated 7/15/22, at 8:50 AM indicated the resident returned to the facility on [DATE] at 8:45 AM. A review of Resident 1 ' s Comprehensive Care Plan, titled At risk for falls related to an actual fall secondary to impulsive behavior, poor safety awareness and perceived independence, created on 7/15/2022, untimed, indicated two interventions to be implemented to prevent falls including assigning the resident a 1:1 sitter and 1:1 activity for social and sensory stimulation. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment tool) dated 7/17/2022, indicated the resident required extensive assistance (resident involved in activity, staff provide weight bearing support) with toileting, bathing, bed mobility, and transfers. The MDS indicated Resident 1 had moderately impaired cognitive skills (ability to understand and process information) for daily decision making. A review of Resident 1 ' s Fall Committee Interdisciplinary Team (IDT, a group of health care professionals who work together toward the goals of their patients) Note, dated 7/18/2022, at 1:14 PM, indicated the resident was to be placed on 1:1 supervision with 1:1 activity for social and sensory stimulation. A review of Resident 1 ' s Licensed Nursing Note, dated 7/20/2022, timed at 9:35 PM, indicated at 9 PM, RNS 1 heard Resident 1 ' s bed alarm went off and found the resident on the floor by the foot of the bed with the right leg inverted inward. The note indicated the resident tried to reach out for something and fell from the bed. The note indicated 911 was called and the resident was transferred to GACH. A review of Resident 1 ' s GACH ER Physician ' s Note, dated 7/20/2022, at 9:56 PM, indicated the resident was diagnosed with a new right hip fracture. A review of Resident 1 ' s GACH right hip x-ray, dated 7/20/2022, indicated the resident had a proximal right (next to the right) femoral shaft (long part of the thigh bone) completely displaced (gap between pieces of bone) fracture, with moderate angulation (bent at an angle as opposed to straight). A review of Resident 1 ' s GACH Operative Procedural Documentation, dated 7/21/2022, at 3:32 PM, indicated the resident underwent an intertrochanteric fix with a nail two weeks prior to repair of the right hip fracture and required another surgery to repair the second fracture. The documentation indicated the surgery was risky and no guarantee could be made about the outcome. The resident underwent removal of right hip deep hardware, a deep bone biopsy, intramedullary nail fixation of the right hip fracture, intertrochanteric closed reduction and nailing of right femur shaft fracture. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 8/1/2022, at 3:16 PM, she stated she was assigned to care for Resident 1 on 7/20/2022. LVN 1 stated CNA 3 was the assigned 1:1 sitter for Resident 1. LVN 1 stated a 1:1 sitter was assigned for Resident 1 due to the resident had fallen two times prior and was very impulsive and would try to get out of bed. LVN 1 stated on 7/20/2022 at around 9 PM, after Resident 1 fell , RNS 1 called LVN 1 to help RNS 1. LVN 1 stated she was instructed by RNS 1 to stay with Resident 1 and to immobilize the resident ' s leg. LVN 1 stated CNA 3 was not in Resident 1 ' s room at the time of the fall and had walked out into the facility hallway to find someone to relieve her for a restroom break. LVN 1 stated CNA 3 should not have left the resident unsupervised. LVN 1 stated CNA 3 should have asked for help, by sending a text message or pushing the call light in Resident 1 ' s room to ask for a staff member to relieve her and not leave the resident unsupervised. During an interview on 8/1/2022 at 4:30 PM, RNS 1 stated on 7/20/2022 at around 9 PM, RNS 1 walked towards the Nurse ' s Station and heard Resident 1 ' s bed alarm went off and then heard Resident 1 yell. RNS 1 entered Resident 1 ' s room and found the resident on the floor at the foot of the bed with the resident ' s leg twisted inward. RNS 1 stated, she immobilized the resident ' s leg and yelled out for LVN 1. RNS 1 stated Resident 1 had been assigned a 1:1 sitter due to two prior fall incidents. RNS 1 stated, CNA 3, the 1:1 sitter for Resident 1. was not in the room with the resident when Resident 1 fell . RNS 1 stated CNA 3 only showed up when RNS 1 called for help. RNS 1 stated CNA 3 had left Resident 1 unsupervised to go to the restroom. RNS 1 stated CNA 3 should have called and asked another staff to cover/relieve her. RNS 1 stated Resident 1 liked to get up and that was why we have a sitter there to make sure the resident did not get up by herself and fall. During an interview on 8/1/2022 at 6:03 PM, CNA 3 stated she was assigned as the 1:1 sitter for Resident 1 on 7/20/2022 from 3 PM to 11 PM. CNA 3 stated a 1:1 sitter was supposed to always stay with the resident and made sure the resident did not fall. CNA 3 stated the facility did not assign anyone to cover her for the 15-minute breaks and her lunch break. CNA 3 stated she asked RNS 1 who was going to cover for her breaks and RNS 1 told her I don ' t know. CNA 3 stated on 7/20/2022 at around 9 PM she left Resident 1 ' s room to look for a staff member to cover for a restroom break but no one was around. CNA 3 stated at that point, she decided to walk towards the restroom and then she heard RNS 1 called out for help. CNA 3 stated Resident 1 was found on the floor by the foot of the bed and 911 was called. During a concurrent interview and review of Resident 1 ' s Fall Care Plan, on 8/2/2022, at 1:35 PM, the Director of Nursing (DON) stated after Resident 1 fell twice on 7/14/2022, the facility implemented a 1:1 sitter for the resident. The DON stated a physician ' s order was not obtained for the 1:1 intervention because nursing interventions, do not need a physician order. The DON stated the 1:1 sitter was expected to always stay with the resident. The DON stated on 7/20/2022, CNA 3 left Resident 1 ' s room to use the restroom, the resident was left unattended and fell . The DON stated Resident 1 ' s fall could have been prevented. A review of the facility Policy and Procedure, titled Fall Management System, with a revised date of 2/2022, indicated Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision to prevent accidents. The policy indicated 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 indicated Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk.