Every finding on record at Claremont Manor Care Center

Based on observation, interview, and record review, the facility failed to have an effective medication reconciliation (systematic collection and verification of a resident's complete and accurate medications during transitions of care, aims to identify and resolve discrepancies and can result in preventable adverse drug events [SE, undesired harmful effect resulting from a medication] and helps to identify the loss or potential diversion [illegal distribution of prescription drugs or their use for unintended purposes] of controlled medications [medications with high potential for abuse]) system in place for controlled medications for 3 of 8 sampled residents (Resident 8, Resident 48, and Resident 49).This deficient practice resulted in unaccounted controlled medications for Resident 8, Resident 48, and Resident 49 and the potential for controlled medication diversion and misuse.Findings:During a review of Resident 8 admission Record (AR), the AR indicated the facility admitted Resident 8 on 4/19/2006 with diagnoses that included dementia (a progressive state of decline in mental abilities), adhesive capsulitis of the right shoulder (frozen shoulder causing stiffness and pain).During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 11/28/2025, the MDS indicated Resident 8's cognition (the ability to think and process information) was moderately impaired and Resident 8 had impaired range of motion (ROM, how far a person can move a joint or muscle in various directions) on the bilateral (both sides) upper and lower extremities (arms and legs). During a review of Resident 48's AR, the AR indicated the facility admitted Resident 48 on 12/23/2024 with diagnoses that included dementia, wedge compression fracture of the fourth lumbar vertebra (a fracture [broken bone] that usually occurs in front of the vertebra, collapsing the bone in the front of the spine).During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48 had a short-term memory problem and moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 48 was dependent with all activities of daily living (ADL).During a review of Resident 49's AR, the AR indicated the facility admitted Resident 49 on 9/19/2018, with diagnoses that included dementia and malignant neoplasm of the breast (breast cancer).During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49's cognition was moderately impaired. The MDS indicated Resident 49's range of motion, upper extremities had no impairment and Resident 49 had impairment on one lower extremity.During a concurrent review of Resident 8's Narcotic Record (NR), issue date 7/28/2025, and review of the Medication Administration Record (MAR), dated 7/2025, the NR indicated Lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations], insomnia [sleep disorder], seizures [sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness], and other conditions by calming the central nervous system) 1 milligram (mg, unit of measurement) was removed from the narcotic supply for administration on 7/28/2025. The MAR indicated Lorazepam 1mg, give 1 tablet by mouth every 8 hours as needed for anxiety manifested as unconsolable yelling out. The MAR indicated on 7/28/2025 the space representing the dose for Lorazepam 1 mg was not signed-marked as administered.During a concurrent review of Resident 48's NR, issue date 12/10/2025, and review of the MAR, dated 12/2025, the NR indicated 1 tablet of acetaminophen with codeine (medication used to treat mild to moderate pain) 300 - 30 mg was removed from the narcotic supply for administration on 12/15/2025. The MAR indicated 1 tablet acetaminophen with codeine 300 - 30 mg by mouth every 6 hours as needed for mild to moderate pain. The MAR indicated on 12/15/2025 the space representing the dose for acetaminophen with codeine 300 - 30 mg was not signed-marked as administered.During a concurrent review of Resident 49's NR, issue date 12/10/2025, and review of the MAR, dated 12/2025, the NR indicated alprazolam (medication used for short term relief of moderate to severe anxiety disorders, panic disorders, and anxiety associated with depression) 0.25 mg tablet was removed from narcotic supply for administration on 12/12/2025. The MAR indicated 1 tablet of 0.25 mg alprazolam by mouth every 8 hours as needed for anxiety manifested by inconsolable yelling. The MAR indicated on 12/12/2025 the space representing the dose for alprazolam 0.25 mg was not signed-marked as administered.During a review of Resident 8, Resident 48, and Resident 49's NRs and MARs and concurrent interview on 3/13/2026 at 12:26 PM with the Director of Nursing (DON), the DON was made aware 3 controlled medications were pulled out (documented on the NRs) and not marked as administered on the MARs for Residents 8, 48, and 49. The DON stated the facility did not have a system in place where the MARs were reconciled with the NRs. The DON stated the DON had not investigated the controlled medications that were not accounted for Residents 8, 48, and 49.During an interview on 3/13/2026 at 1:26 PM, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated LVN 3 remembered Resident 48 needed pain medication for chronic (long standing) back pain but LVN 3 could not recall the reason why LVN 3 did not mark the acetaminophen with codeine as completed on the MAR. LVN 3 stated it was hard to recall the month of December 2025 to remember if the acetaminophen with codeine removed from the narcotic supply was administered to Resident 48.During a telephone interview on 3/13/2026 at 1:41 PM, LVN 4 stated LVN 4 remembered Resident 49 needed Alprazolam for constantly yelling behavior but LVN 4 could not recall the reason why LVN 4 did not mark alprazolam, recorded as removed on the narcotic record, as administered on the MAR.During an interview on 3/13/2026 at 2:12 PM, the DON stated signing [marking] the MARs indicated residents received the medications [removed from the NR]. The DON stated the process for administration of controlled medications included licensed nurses taking out the medication, signing [the removal] the NR and signing the MAR once the medication was administered to the resident. The DON stated the shift-to-shift reconciliation of controlled medications involved the licensed nurses to reconcile the medications signed out on the NR and the physical count of the medications.During a review of the facility's policy and procedure (P&P), dated 11/2017, titled Controlled Substances, the P&P indicated the DON and the Consultant Pharmacist establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, and determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. The P&P indicated controlled medications are obtained from the locked cabinet or safe, or medication cart. The P&P indicated when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing the dose from controlled storage: date and time of administration, amount administered, and signature of the nurse administering the dose. The P&P indicated to administer the controlled medication and document the dose administration on the MAR. The P&P indicated when a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed according to policy and the disposal documented on the accountability record on the line representing that dose. The same process applies to the disposal of unused partial tablets and unused portions of single dose ampules.

Based on observation, interview, and record review, the facility's licensed staff failed to obtain informed consents (IC, the process, a form indicating a resident or responsible party voluntarily agrees to a medical treatment or procedure after understanding the risks, benefits, and alternatives) from two of two sampled resident's (Resident 35 and Resident 46) responsible parties by failing to:A. Obtain an IC from Resident 35 and/or the resident's responsible party prior to the administration of Mirtazapine 15 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount). Additionally, the facility failed to obtain an IC in a timely manner for the administration of Mirtazapine 30 mg when the dose was increased from 15 mg to 30 mg on 10/2/2025.B. Indicate the frequency (how often a drug should be given, times per day) for Mirtazapine (an antidepressant medication used mainly to treat major depression) 30 mg in Resident 35's IC dated 12/16/2025. C. Indicate in Resident 46's IC the reason for the use and benefits, probable side effects (SE, undesired harmful effect resulting from a medication) and significant risks of divalproex sodium (a medication used as a mood stabilizer) or the reasonable alternative modes of treatment including possible nonpharmacological (healthcare interventions that do not primarily rely on medications) approaches that could address Resident 46's needs.This deficient practice violated Resident 35's and Resident 46's right to be fully informed and to provide informed consents prior to the administration of psychotropic (group of drugs that change brain function: behavior, mood, thoughts, or perception, used to treat various mental health conditions) medications.Findings: A & B. During a review of Resident 35's admission Record (AR), the AR indicated the facility admitted Resident 35 on 6/16/2025, with diagnosis including, dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic kidney disease (when the kidneys are damaged and gradually lose their ability to filter waste and extra fluid from the blood over a long period, usually months or years). During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool), dated 12/23/2025, the MDS indicated Resident 35's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 35 was dependent (helper does all of the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and was dependent on mobility. During a review of Resident 35's Order Recap Report (ORR), dated 3/12/2026, the ORR indicated Resident 35 had a prior order for Mirtazapine 15 mg with a start date of 06/27/2025 for depression manifested by poor PO intake, this order was discontinued on 10/2/2025. The ORR indicated an active order for Mirtazapine 30 mg with a start date of 10/2/2025, the active order indicated one tablet by mouth at bedtime for depression manifested by inability to sleep at night. During a review of Resident 35's Informed Consent Verification Form (ICVF), dated 12/16/2026, the ICVF's medication, dose, and frequency indicated Mirtazapine 30 mg PO (oral). The ICVF did not indicate the frequency for the administration of Mirtazapine. During a review of Resident 35's Medication Administration Record (MAR), dated June to December 2025 and dated January to March 2026, the MARs indicated the following: Resident 35 received Mirtazapine 15 mg from 6/27/2025 through 6/30/2025. Resident 35 received Mirtazapine 15 mg from 7/1/2025 through 7/31/2025. Resident 35 received Mirtazapine 15 mg from 8/01/2025 through 8/31/2025. Resident 35 received Mirtazapine 15 mg from 9/1/2025 through 9/30/2025. Resident 35 received Mirtazapine 15 mg on 10/1/2025. Resident 35 received Mirtazapine 30 mg from 10/2/2025 through 10/31/2026. Resident 35 received Mirtazapine 30 mg from 11/1/2025 through 11/30/2025. Resident 35 received Mirtazapine 30 mg from 12/1/2025 through 12/31/2025. Resident 35 received Mirtazapine 30 mg from 1/1/2026 through 1/31/2026. Resident 35 received Mirtazapine 30 mg from 2/1/2026 through 2/28/2026. Resident 35 received Mirtazapine 30 mg from 3/01/2026 through 3/12/2026 (date of review). During an interview and concurrent record review on 3/12/2026 at 11 AM, Resident 35's ICVF, ORR, and MARs were reviewed with Registered Nurse (RN) 1. RN 1 stated based on the ORR and MARs, Resident 35 was administered Mirtazapine 15 mg from 6/27/2025 through 10/01/2025. RN 1 stated no IC was obtained for the administration of Mirtazapine 15 mg, and no IC was found in Resident 35's medical record. RN 1 stated a new order for Mirtazapine 30 mg was started on 10/2/2025 and administered to Resident 35. RN 1 stated the ICVF indicated an IC for Mirtazapine 30 mg PO was obtained on 12/16/2025. RN 1 stated an IC was not obtained in a timely manner for Mirtazapine 130 mg. RN 1 stated an IC should have been obtained prior to the initial administration of Mirtazapine 15 mg and when the medication was first ordered on 6/27/2025. RN 1 stated a new IC should have been obtained on 10/02/2025 when the order for 15 mg was discontinued and the dose increased to 30 mg. RN 1 stated the ICVF did not include the frequency for Mirtazapine 30 mg and the IC was not completed. RN 1 stated antidepressants fell under the psychotropic medication classification and required ICs prior to administration [of these medications]. RN 1 stated the IC for Mirtazapine must have included the medication name, dosage, frequency, diagnosis, and associated behaviors/manifestations to ensure Resident 35 and/or the responsible party was fully informed of the treatment, including risks, benefits, and alternatives. RN 1 stated failure to obtain, and failure to complete ICs resulted in the resident and/or responsible party not being fully informed of the medication regimen, potentially impacting decision-making and the resident's rights. During an interview on 3/13/2026 at 10:45 AM, with the Director of Nursing (DON), the DON stated antidepressants fell under the psychotropic medication classification and required ICs prior to medication administration. The DON stated it was essential to obtain ICs prior to the administration of these medications to ensure residents (in general) and/or their responsible parties were fully informed of the medication, including the risks, benefits, alternatives, and intended use. The DON stated IC forms should be completed accurately and thoroughly, at a minimum including the medication name, dosage, frequency, and indication. The DON stated the information in the ICVF reflected the information provided to the resident and/or responsible party regarding treatment (administration of Mirtazapine). The DON further stated that incomplete or delayed informed consent created risk that treatment would be initiated without clear understanding or agreement, which could lead to confusion regarding the plan of care and undermine the resident's ability to make informed choices. During a review of the facility's Policy and Procedure (P&P) titled, Psychotherapeutic Medication Use, revised 1/2025, the P&P indicated:1. The signed written consent must be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent with the required signatures. The resident has a right to decline or refuse treatment. For a prescription written prior to facility admission, the facility staff must verify that the resident or the resident's representative gave informed consent and make a notation in the resident's records. If they can't verify, a new consent needs to be in place.a. Community must renew the written informed consent every six months. At that time, the community must provide the resident with any recommended dosage adjustments and the option of revoking consent. If the resident decides to discontinue using the drug, the prescriber is responsible for planning any necessary, gradual dose reduction, as well as possible behavioral interventions. Copies of the signed written consent must be given to the resident and resident representative. C. During a review of Resident 46's AR, the AR indicated the facility originally admitted Resident 46 on 6/2/2025 and was readmitted on [DATE] and on 3/9/2026 with diagnoses including urinary tract infection (an infection that affects any part of the urinary system including the kidneys, ureters, bladder, and urethra) and dementia with other behavioral disturbance. During a review of Resident 46's History and Physical (H&P), dated 3/11/2026, the H&P indicated Resident 46 did not have the capacity to understand or make decisions. During a review of Resident 46's MDS, dated [DATE], the MDS indicated Resident 46's cognitive (the ability to think and process information) skills for daily decision making were severely impaired (never/rarely makes decisions). The MDS indicated Resident 46 required substantial to maximal assistance with toileting, showering, and dressing, partial to moderate assistance with personal hygiene, supervision or touching assistance with oral hygiene, and setup or clean-up assistance with eating. During a review of Resident 46's Order Summary Report (OSR), dated active as of 3/13/2026, the OSR indicated Resident 46 had an order for divalproex sodium 250 mg, dated 3/10/2026, for two times a day for poor impulse control manifested by verbal aggression such as cursing. During a review of Resident 46's Psychotherapeutic Drug Informed Consent Form, dated 3/10/2026, the IC form did not indicate the reason for the use and benefits, probable SEs and significant risks of divalproex sodium. The IC form did not indicate reasonable alternative modes of treatment or possible nonpharmacological approaches that could address Resident 46's needs. These areas were left blank in the IC form. During an interview on 3/12/2026 at 2:43 PM with the DON, the DON stated Resident 46's IC form was not filled out completely. The DON stated it was important to have the IC form filled out completely to ensure Resident 46 was informed of the specific medication and SEs involved in Resident 46's care. During a review of the facility's P&P titled, Psychotherapeutic Medication Use, revised 1/2025, the P&P's policy indicated, Each resident shall receive the necessary care and services to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being. The P&P's procedure indicated, The signed written consent must be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent with the required signatures. The resident has a right to decline or refuse treatment. For a prescription written prior to facility admission, the facility staff must verify that the resident or the resident's representative gave informed consent and make a notation in the resident's records.

Based on observation, interview, and record review, the facility failed to identify food preferences and offer food substitutes for one of three sampled residents (Resident 4).This failure had the potential to adversely affect Resident 4's nutritional intake, dining experience, and overall quality of life.During a review of Resident 4's face sheet, the face sheet indicated Resident 4 had an initial admission on [DATE] with the diagnoses but not limited to: wedge compression fracture (a break or discontinuity in bone tissue) of first lumbar vertebra( one of the bones that make up the spinal column), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic polyneuropathy (a common complication of long-term diabetes characterized by nerve damage affecting multiple peripheral nerves throughout the body),hypertensive (high blood pressure) heart, chronic kidney disease (a long-term condition in which the kidneys are damaged) and legal blindless.During a review of Resident 4's Minimum Data Set (MDS-a resident assessment tool) dated 2/25/2026, the MDS indicated Resident 4 needs partial/moderate assistance on eating. Resident 4 has an active diagnosis that includes cataract (a clouding of the eye's natural lens), glaucoma (a group of eye conditions that damage the optic nerve), macular degeneration (a progressive eye disease that primarily affects central vision)During a review of Resident 4's care plans dated 2/19/2026, the care plans indicated Resident 4 is at risk for nutritional deficit. The interventions in the care plan include offering substitutes for food not eaten and assessing food preferences.During a review of Resident 4's order summary dated 2/24/2026, the order summary indicated Resident 4 was on a consistent carbohydrate diet, regular texture, regular consistency with a dietary supplemental health shake two times a day.During an interview on 3/10/2026 at 9:52 AM, with Resident 4, Resident 4 stated no one asked about his daily preferences nor offer satisfying food substitutes such as finger foods that support a more comfortable eating experience, especially given that Resident 4 is blind.During a concurrent observation and interview conducted on 3/12/2026 at 9:05 AM, with Certified Nursing Assistant (CNA) 3 and Resident 4, inside Resident 4's room, Resident 4's breakfast tray had scrambled eggs, a bread roll and slices of oranges. Resident 4 refused to eat the scrambled egg and CNA 3 did not ask for his preferences or offer substitutes. CNA 3 stated Resident 4 should consume whatever is on the meal served.During an interview on 3/12/2026 at 10:55 AM with the Certified Dietary Manager (CDM), CDM stated residents' meals are based on the registered dietician's nutrition recommendations which include the diet, texture, allergies, and preferences. CDM stated that Resident 4's preferences were only gathered at admission and were not reassessed daily.During an interview on 3/12/2026 at 3:18 PM with the Registered Dietician (RD), RD stated it is important to understand each resident's choices and preferences to provide appropriate meal alternatives. RD stated the dietary aides along with the CDM identify residents' preferences during admission and as needed.During a review of the facility's policy and procedure (P&P) titled, Resident Food Services-Resident Dining Profile and Food preferences, the P&P indicated individual food and dining preferences incorporating religious, cultural, ethnic and portion sizes are obtained from residents on a regular basis. Food substitutions are provided when the resident chooses not to consume meal items served and should be of equal nutritional value to the planned menu. Update preferences on admission, annually, and/or as desired by resident.

During a concurrent observation and interview on 3/10/2026 at 9:20 AM with the Kitchen Cook, five half gallon containers of milk with a best used by date of 2/26/2026 were found in the kitchen refrigerator. The Kitchen [NAME] stated expired milk should not be kept in the refrigerator, as it could be mistakenly served to the residents and potentially cause illness.During an interview on 3/11/2026 at 9:15 AM with the Director of Dining Services (DDS), DDS stated expired food items, including milk, must be discarded because retaining them in the refrigerators poses a potential health hazard to the residents.During a review of the facility's policy and procedure (P&P) titled, Production, purchasing, storage, the P&P indicated all food and supplies used in food preparation shall be stored in such a manner as to prevent contamination and maintain safety of the food for human consumption. The refrigerated storage life of food uses manufacturers expiration date and or milk should be plus three days after opening or by expiration date, if sooner.

Based on observation, interview, and record review, the facility failed to ensure two pill crushers were cleaned and the medication rooms were maintained free of food items.These failure had the potential to contribute to cross contamination of the residents' medications During a review of the facility's map, the map indicated the facility has two medication rooms located in nurses' stations 1 and 2.During a concurrent observation and interview on 3/12/2026 at 8:35 AM with Licensed Vocational Nurse (LVN) 3, in the nurses' station 1, the pill crusher had a reddish-brown color on the hinges and unidentified orange , white and yellow colored powder residue. LVN 3 stated the pill crushers are required to be cleaned daily at the end of each shift to prevent cross contamination of medications and avoid potential unintended chemical interactions.During a concurrent observation and interview on 3/12/2026 at 12:45 PM with Licensed Vocational Nurse (LVN) 2 in the nurses' station 2, the pill crusher had a whitish powder residue. LVN 2 stated the pill crushers are to be cleaned daily at the end of each shift to maintain infection control standards.During a concurrent observation and interview on 3/12/2026 at 1:34 PM with Registered Nurse (RN) 1 in the nurses' station 1 medication room, a bag of chips and an empty beverage cup were inside one of the medication room drawers. RN 1 stated food items should not be kept in the medication rooms because they can attract bugs into those areas. In the nurses' station 2 medication room, an opened lunch bag was inside the cabinet used for medication storage.During an interview on 3/11/2026 at 2:20 PM, with the Infection Preventionist (IP), IP stated that the facility has an infection control program that includes compliance audits and monitoring of adherence to infection prevention standards, with a focus on safety and sanitation practices.During an interview on 3/12/2026 at 3:25 PM, with the Director of Nursing (DON), DON stated nurses are responsible for cleaning pill crushers to prevent medication cross contamination and food items are prohibited in the medication rooms.During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and control Program, dated 2/9/2026, the P&P indicated the facility's program includes monitoring of infection control practices, environmental cleaning, education and competency assessment.During a review of the facility's P&P titled, Medication Administration, dated 1/2023, the P&P indicated that medications are to be crushed within a plastic bag or pouch to prevent direct contact between the medication and the crushing device.

Based on observation, interview, and record review the facility failed to follow fall prevention interventions for one of two sampled residents (Resident 23) when on 3/12/2026, Resident 23 did not have bilateral fall mats (a specialized, thick cushion designed to be placed alongside a bed or chair to absorb the impact of falls and reduce the risk of serious injuries like fractures or head trauma) on the ground alongside Resident 23's bed and while Resident 23 was in bed.This deficient practice had the potential to result in falls and injury to Resident 23. Findings: During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including bilateral primary osteoarthritis of the knee (a long standing, degenerative disease where the protective cartilage in the knee joint gradually breaks down over time), restless leg syndrome (condition that causes a very strong urge to move the legs) and age-related osteoporosis (bone disease where bones become thin, brittle, fragile due to accelerated loss of density over time, making them highly susceptible to fractures).During a review of Resident 23's Minimum Data Set (MDS- a resident assessment tool), dated 10/6/2025, the MDS indicated Resident 23's cognition (ability to understand and process information) was moderately impaired and required substantial/ maximal assistance (helper does more than half the effort) for toileting and personal hygiene.During a review of Resident 23's Fall Risk Evaluation (FRE), dated 1/6/2026, the FRE indicated if the total score is 10 or greater, the resident should be considered at high risk for potential falls.During a review of Resident 23's Progress Notes (PN) dated 1/6/2026, timed at 11:09 AM, the PN indicated Resident 23 had intermittent confusion and had a fall risk score of 11.During a review of Resident 23's Care Plan (CP), initiated 1/7/2026, the CP's focus indicated Resident 23 was at risk for falls related to history of falls, impaired mobility, urinary incontinence (loss of bladder control), cognitive impairment with poor safety awareness such as taking self to the bathroom without calling for help. The CP indicated Resident 23 had an unwitnessed fall from bed transferring self without staff assistance on 2/5/2025 and had an unwitnessed fall on 1/7/2026. The CP's goal indicated for Resident 23 to not have injury related to falls over the next quarter with target date 4/25/2026. The CP's interventions indicated floor mat[s] on [the] sides of [the] bed to prevent injury from falls.During a concurrent observation and interview on 3/12/2026 at 3:45 PM in Resident 23's room with Licensed Vocational Nurse (LVN) 4, Resident 23's floor mats were observed propped up on the wall while Resident 23 was lying in bed. LVN 4 stated Resident 23 needed the fall mats on the ground while Resident 23 was in bed because Resident 23 got up unassisted (without calling for assistance from staff).During an interview on 3/12/2026 at 3:49 PM with Certified Nursing Assistant (CNA) 2, CNA 2 stated no [facility staff] one informed CNA 2 Resident 23's fall mats were not alongside Resident 23's bed and Resident 23 needed the fall mats while Resident 23 was in bed. CNA 2 stated Resident 23 was more confused in the evening, and Resident 23 had tried to get out of bed unassisted before. CNA 2 stated the fall mats were implemented for Resident 23 after Resident 23's last fall that occurred a couple months ago in January 2026. CNA 2 stated Resident 23 was a high fall risk and could fall very easily.During an interview on 3/13/2026 at 9:23 AM with the Physical Therapist (PT), the PT stated Resident 23 had been receiving physical therapy to improve mobility since Resident 23 fell on 1/7/2026. The PT stated Resident 23's mobility had improved and Resident 23 was able to walk with assistance and sit at the edge of Resident 23's bed independently. The PT stated when Resident 23 was in bed, fall preventions were implemented such as keeping the bed at the lowest position and placing mats on the sides (alongside) of Resident 23's bed so if there was a fall, Resident 23 was protected from injury.During an interview on 3/13/2026 at 9:54 AM with the Director of Nursing (DON), the DON stated residents (in general) at risk for falls were placed on the facility's fall prevention program which included interventions such as keeping the bed at the lowest position and using fall mats while the resident was in bed. The DON stated if the fall mats were not used, the resident was at increased risk of injury if a fall occurred. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention Program, dated 2/2009, the P&P indicated the purpose of the fall prevention program was to improve or maintain the quality of life for community residents by properly assessing their risk for falling, providing adequate interventions to minimize risk, and then evaluating the effectiveness of those interventions. The P&P indicated the nursing function in a fall prevention program includes recognizing that a fall prevention program functions around the clock, informing ancillary staff of interventions to be used and monitoring staff compliance, and providing timely intervention to minimize risk.

Based on observation, interview, and record review, the facility failed to follow pressure ulcer-injuries (PIs, lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) preventive interventions for one of one sampled resident (Resident 15) by failing to:Encourage and offer to turn and reposition Resident 15 who preferred lying in bed on Resident 15's back.Float (healthcare practice aimed at preventing PIs by suspending the heels off the bed surface, thereby reducing pressure and friction on the skin) Resident 15's heels when Resident 15 was lying in bed.Ensure Resident 15's low air loss mattress (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) was set at the appropriate setting per the physician's order and not set on static (holds all air cells at the same inflation level, providing a stable, firm, and evenly distributed support surface for the resident) mode.This deficient practice had the potential to result in the development of new PIs to Resident 15. Findings:During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was originally admitted to the facility 3/30/2022 and readmitted on [DATE]. The AR indicated Resident 15's diagnoses included heart disease with heart failure and arthritis (group of conditions that cause joint inflammation, pain, stiffness, and swelling affecting movement and quality of life).During a review of Resident 15's care plan (CP), initiated 1/17/2025, the CP indicated Resident 15 had potential for PI development related to decreased mobility and history of ulcers. The CPs interventions indicated alternating pressure mattress for skin integrity, to assist/encourage to turn/reposition every 2 hours as tolerated, more often as needed or requested, and to float heels.During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 15's cognition (the ability to think and process information) was intact.During a review of Resident 15's CP, revised 1/16/2026, the CP indicated Resident 15 was at risk for skin breakdown related to fragile skin/ right lateral leg trauma wound. The CP's interventions indicated assisting [Resident 15] with repositioning frequently for pressure prevention and resident comfort and to float heels while in bed.During a review of Resident 15's Braden Scale - for Predicting Pressure Ulcer Risk Evaluation, dated 1/16/2026, the evaluation indicated Resident 15's activity was bedfast and Resident 15 was confined to a bed. The evaluation indicated Resident 15's mobility was very limited. The evaluation's friction and shear indicated, problem: requires moderate to maximum assistance in moving. The evaluation indicated a total score of 12 or less represented a high risk for PI development.During a review of Resident 15's Braden Scale - Assessment Outcomes, dated 1/16/2026, the assessment indicated Resident 15's score was 13 and Resident 15 was at high risk for PI development.During a review of Resident 15's Order Recap Report (ORR), dated March 2026, the ORR indicated a physician's order indicating Resident 15 may have an alternating pressure mattress for skin integrity, dated 3/5/2026.During an observation and concurrent interview on 3/10/2026 at 11:06 AM with Licensed Vocational Nurse (LVN) 1. Resident 15's LAL mattress setting was in static mode. LVN 1 stated static mode needed to be on for Resident 15.During an observation on 3/11/2026 at 9:36 AM with LVN 1, LVN 1 applied a lidocaine patch (topical medication that numbs a specific area of the skin to relieve pain), Resident 15 turned and LVN 1 applied the patch on Resident 15's lower back. After the patch was applied, Resident 15 laid on Resident 15's back. There was a pillow lengthwise under Resident 15's right leg, the pillow was touching Resident 15's right heel and the heel was not floating.During a continuous observation on 3/11/2026 from 9:36 AM to 1:21 PM, Resident 15 was lying on resident 15's back, the following observations were conducted,At 10:47 AM, a housekeeping (unidentified) staff entered Resident 15's room and Resident 15's heels were on top of a pillow.At 11 AM, Certified Nursing Assistant 4 (CNA 4) entered Resident 15's room to answer Resident 15's roommate's call light, Resident 15's heels were on top of a pillow. CNA 4 did not offer to turn or reposition Resident 15.At 11:02 AM, Resident 15's heels were on top of a pillow.At 12:20 PM, Resident 15 was sleeping and laying on Resident 15' back. Resident 15's heels were positioned directly on top of a pillow.At 12:29 PM, Resident 15 was eating lunch and sitting up in bed and Resident 15's heels were on top of a pillow.At 12:45 PM, CNA 4 entered Resident 15's room and took Resident 15's lunch tray, Resident 15's heels were on top of a pillow. CNA 4 did not offer to turn or reposition Resident 15.During a concurrent observation and interview 3/11/2026 at 1:21 PM with the Minimum Data Set Nurse (MDS). Resident 15 was laying on Resident 15's bed on Resident 15's back. The MDS stated Resident 15's heels were not floating and Resident 15's heels had to be floating.During a concurrent interview and record review on 3/11/2026 at 1:35 PM, LVN 1 stated, during the lidocaine patch administration, LVN 1 did not offer to turn or reposition Resident 15 and LVN 1 did not float Resident 15's heels. During a review of Resident 15's Order Recap Report, dated March 2026 with LVN 1, the physician orders indicated an order for alternating pressure mattress for skin integrity. LVN 1 stated Resident 15's LAL static mode needed to be changed to alternating pressure (a system that uses air filled cells that inflate and deflate in a cyclical pattern and helps to prevent prolonged pressure on a single area of the body, reducing the risk of damage. The system is designed to shift pressure points throughout the day, ensuring that no single area of the body experiences uninterrupted pressure, helping maintain adequate blood flow and preventing the development of PIs).During an interview on 3/11/2026 at 1:50 PM, Resident 15 stated Resident 15 agreed to be turned and repositioned by staff.During an interview on 3/13/2026 at 10:59 AM, with CNA 4, CNA 4 stated CNA 4 was assigned to care for Resident 15 and CNA 4 turned and repositioned Resident 15 on 3/11/2026 at around 9 AM. CNA 4 stated CNA 4 did not turn or reposition Resident 15 every 2 hours on 3/11/2026 because there was another resident (unidentified) who was restless and anxious that day and CNA 4 was busy with that resident. During a review of the facility's Policy and Procedure titled Skin Care Preventative Methods dated May 2016, the P&P indicated residents assessed to be at risk for skin impairment will have preventative measures placed into effect as appropriate for the resident to prevent skin breakdown. The P&P indicated intervention guidelines included the following: repositioning [while] in bed, turning and reposition residents every 2 hours or less depending on resident needs, use of pillows and cushions to distribute pressure, floating the heels for those with decreased sensation, hip and knee replacement(s).

Based on observation, interview, and record review, the facility failed to ensure Labetalol Hydrochloride (medication used to treat high blood pressure [BP], HCL, unit of measurement) was held in accordance with holding parameters for one of three sampled residents (Resident 5). On 3/11/2026, Resident 5's BP was 117/58 millimeters of mercury [mm Hg, unit of pressure measurement]), Licensed Vocational Nurse (LVN) 1 did not hold the medication and administered 300 milligrams (mg, unit of measurement) of Labetalol Hydrochloride to Resident 5.This deficient practice had the potential to result in dizziness due to a further drop in BP and a physical decline to Resident 5.Findings:During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 8/23/2017 with diagnoses that included hypertensive heart disease with heart failure (when long-term high blood pressure [hypertension] makes it harder for the heart to pump blood making it more difficult for the heart muscle to relax) and cerebral infarction (stroke).During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 5 had intact cognition and was dependent on staff for showers/bathing self and toileting hygiene.During a review of Resident 5's Medication Administration Record (MAR), dated March 2026, the MAR indicated to hold Labetalol HCL for parameters of Systolic (S, pressure exerted by blood on artery walls when the heart contracts and pumps blood out into the body) BP below 110 or diastolic (D, the pressure in the arteries when the heart relaxes between beats) BP below 60 starting 11/11/2024.During an observation and concurrent interview on 3/11/2026 at 10:10 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 checked Resident 5's BP by placing the BP cuff on the right wrist. LVN 1 checked Resident 5's BP a second time on Resident 5's left wrist and Resident 5's BP was 117/58 mm Hg.During a medication administration observation on 3/11/2026 from 10:10 AM to 10:30 AM, LVN 1 administered 1 tablet of Labetalol Hydrochloride (HCL) 300 milligrams (mg) with other scheduled medications.During a concurrent review and interview on 3/11/2026 at 10:40 AM with LVN 1. Resident 5's MAR, dated March 2026. LVN 1 stated LVN 1 administered Labetalol outside the holding parameters and this administration could lead to lower DBP which could potentially cause Resident 5 to develop weakness and dizziness. LVN 1 stated LVN 1 would notify Resident 5's physician and would monitor Resident 5's BP because Labetalol HCL was administered in error.During an interview on 3/13/2026 at 1:50 PM, with the Director of Nursing (DON), the DON stated the facility did not have a Policy and Procedure on significant medication errors. The DON stated administering Labetalol outside of the parameters was a medication error and the error could lead to further drop in Resident 5's BP.During a review of the facility's Policy and Procedure (P&P) titled Medication Administration, General Guidelines, dated 1/2023, the P&P indicated medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices, and only by persons legally authorized to do so.

Based on interview and record review the facility failed to provide transfer and bed-hold notification documentation for one of one sampled resident (Resident 42) as indicated in the facility's Policy and Procedure (P&P) titled, Admission, Transfer, & Discharge Rules, when:Resident 42 did not receive a written notice of transfer-discharge (a document a nursing facility must give a resident and/or their representative before the resident is moved out of the facility, explaining why the resident is being transferred, where they are going, the effective date, their right to appeal, and how to contact the State Long Term Care Ombudsman [an advocate who helps protect the rights, safety, and well-being of residents in nursing homes and other long-term care facilities]) when Resident 42 was discharged on 2/15/2026.Resident 42 was not provided bed hold notification (a written notice a nursing facility gives a resident and/or their representative when the resident is sent to the hospital or leaves the facility, explaining whether the resident's bed will be held, for how long, and their right to return to that bed) upon Resident 42's discharge on [DATE].This failure had the potential to result in Resident 42 being uninformed of the right to appeal the hospital transfer and the right to return to the facility and had the potential to result in the State Long-Term Care Ombudsman being uninformed of Resident 42's hospital transfer.Findings:During a review of Resident 42's admission Record (AR), the AR indicated the facility admitted Resident 42 on 1/30/2026 with diagnoses including encounter for surgical aftercare following surgery on the digestive system (a medical visit where a patient is being seen to monitor healing, manage recovery, or address follow up needs after having surgery on any part of the digestive tract) and unspecified intestinal obstruction (a blockage in the intestines that prevents food, fluids, or gas from moving normally).During a review of Resident 42's Minimum Data Set (MDS- a resident assessment tool), dated 2/6/2026, the MDS indicated Resident 42's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 42 required set up or clean-up assistance with eating, supervision or touching assistance with oral hygiene, partial to moderate assistance with personal hygiene, and was dependent on toileting, showering, and dressing.During a review of Resident 42's Physician Discharge Summary, discharge date [DATE], the Discharge Summary indicated Resident 42 was discharged to the General Acute Care Hospital (GACH) 1 on 2/15/2026.During a review of Resident 42's admission Notification of Bed-Hold Option, dated 2/4/2026, the Bed Hold Notification indicated, To Be Completed Upon Transfer [discharge] was not completed and left blank.During a concurrent interview and record review on 3/11/2026 at 2:57 PM with Licensed Vocational Nurse (LVN) 1, Resident 42's medical record was reviewed. LVN 1 stated LVN 1 discharged Resident 42 on 2/15/2026 but did not complete a notice of proposed transfer or discharge. Additionally, LVN 1 stated Resident 42's medical record did not contain documentation indicating Resident 42 received a bed hold notification upon discharge. LVN 1 stated it was important to fill out the notice of proposed transfer because it was Resident 42's right to be informed and to have the ombudsman informed of Resident 42's transfer. LVN 1 stated it was important to inform (offer) Resident 42 of the bed hold because this ensured Resident 42 was aware of the right to return to the facility if Resident 42 desired.During an interview on 3/12/2026 at 2:43 PM with the Director of Nursing (DON), the DON stated Resident 42's medical record did not indicate Resident 42 or the ombudsman received a notice of proposed transfer-discharge. The DON stated it was important to give Resident 42 a notice of proposed transfer-discharge because it ensured the resident was informed of why Resident 42 was being discharged and [made Resident 42 aware of] the right to appeal the transfer-discharge process. Additionally, the DON stated Resident 42's medical record did not indicate Resident 42 received [was offered] a bed hold notification. The DON stated it was important to inform Resident 42 of the bed-hold to ensure Resident 42 was informed of the right to return to the facility.During a review of the facility's P&P titled, Admission, Transfer, & Discharge Rules, dated January 2018, the P&P's policy indicated the facility did not discriminate when making admission, transfer, and discharge decisions and would follow identical policies and practices for all residents regardless of their source of payment when providing services that are required to be provided under the law. The P&P's admission, transfer and discharge rules indicated before the transfer or discharge occurred, the facility would notify the resident and, if known, the resident's representative of the transfer, the reasons for the transfer, and record the reasons in the medical record. The facility's notice would include an explanation of the right to appeal the transfer to the State, how to obtain an appeal form and how to obtain assistance with completing the form, and the facility's notice would be sent to the State Long-Term Care Ombudsman. Additionally, the P&P's admission, transfer, and discharge rules indicated whenever a resident was transferred to a hospital the facility had to provide a second written notice to the resident of the seven-day bed hold policy which included the policy on permitting the resident to return.

Based on interview and record review, the facility staff failed to notify Physician 1 and the responsible party of a change of condition (COC, an alteration in a resident's physical health that differs from their previous baseline) for one of one sampled resident (Resident 17) when Resident 17 experienced a significant weight loss of 12 pounds (lbs., a unit of weight) within one week. This deficient practice had the potential to result in delated implementation of timely interventions and the potential to result in a physical decline to Resident 17.Findings:During a review of Resident 17's admission Record (AR), the AR indicated the facility admitted Resident 17 on 11/25/2025, and re-admitted the resident on 2/21/2026, with diagnosis including, chronic kidney disease (when the kidneys are damaged and gradually lose their ability to filter waste and extra fluid from the blood over a long period, usually months or years), acute kidney failure (the sudden and rapid loss of kidney function, typically occurring within a few days or hours), and urinary tract infection (UTI-an infection in the bladder/urinary tract)During a review of Resident 17's Minimum Data Set (MDS- a resident assessment tool), dated 2/28/2026, the MDS indicated Resident 17's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 17 required partial/moderate assistance (helper does less than half effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required substantial/maximal assistance (helper does more than half the effort) with mobility.During a review of Resident 17's Order Summary Report (OSR), dated active as of 3/12/26, the OSR indicated an order, dated 2/21/2026, indicating to obtain weights weekly on Sundays for a duration of four (4) weeks for weight management.During a review of Resident 17's Weights and Vitals Summary (WVS), dated 3/13/2026, the WVS indicated,On 3/1/2026, Resident 17 weighed 169 lbs. (Sitting)On 3/9/2026, Resident 17 weighed 157 lbs. (Sitting).During a review of Resident 17's Medication Administration Record (MAR), dated March 2026, the MAR indicated:Resident 17 was administered Lasix (a medication [diuretic] used to remove excess fluid) 20 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount), administered by mouth at bedtime (9 PM) for edema (swelling caused by excess fluid trapped in the body's tissues), with a start date of 3/3/2026 and an end date of 3/9/2026.Resident 17 received Lasix 40 mg, administered by mouth in the morning (9 AM) for lower extremity edema, with a start date of 03/4/2026 and an end date of 03/9/2026.During an interview and concurrent record review on 3/12/2026 at 11 AM, Resident 17's WVS and MAR were reviewed with Registered Nurse (RN) 1. RN 1 stated based on the WVS Resident 17 experienced a weight loss of 12 lbs. within one week. RN 1 stated the MAR indicated Resident 17 received Lasix for lower extremity edema during that same period. RN 1 stated this was significant weight loss and stated the decrease in weight was expected due to the therapeutic effect of diuresis (the body's process of making and passing more urine than usual) in managing the resident's fluid overload. RN 1 stated based on clinical judgment, a COC assessment (includes physician and responsible party notification) was not completed because the weight loss aligned with the intended treatment outcome. RN 1 stated Physician 1 (Resident 17's physician) and responsible party should have been notified of the significant weight change. RN 1 stated physician notification was essential to evaluate the resident's (in general) ongoing treatment plan, including determining whether to continue, adjust, or hold diuretic therapy, assess for potential complications such as dehydration or electrolyte imbalance, and determining if additional monitoring or laboratory testing was necessary. RN 1 stated notification of the responsible party was necessary to ensure they were informed of significant clinical changes impacting the resident's condition. RN 1 stated there was no documented evidence in Resident 17's medical record indicating Physician 1 or Resident 17's responsible party were notified. RN 1 stated standard nursing practice required that all communication [regarding Resident 17] be documented, and if it was not documented, it could not be verified as completed. RN 1 emphasized that accurate and timely communication with Physician 1 was necessary to reflect care provided and clinical decision-making.During an interview on 3/13/2026 at 10:45 AM, with the Director of Nursing (DON), the DON stated that in situations where a resident was undergoing diuretic therapy for fluid overload, a significant weight reduction may be anticipated as part of the treatment response, and a formal COC assessment may not always be required when the outcome is consistent with the care plan. The DON stated that significant weight changes, regardless of the cause, should be communicated to the physician (in general) to allow for ongoing clinical evaluation of the resident's status, including reassessment of medication effectiveness, risk for adverse effects (AE, undesired harmful effect resulting from a medication), and the need for further interventions or monitoring. The DON stated that notifying the responsible party was essential to maintain transparency and ensure they were aware of meaningful changes in the resident's health condition. The DON stated communication of these changes was critical and the medical record must clearly indicate the communication occurred. The DON stated that the absence of documentation created uncertainty and did not support continuity of care.During a review of the facility's policy and procedure (P&P) titled, Change in Resident Condition, revision dated 2/2009, the P&P indicated changes in resident condition will be communicated to the physician and responsible party timely. The P&P's routine Medical Change indicated document resident change of condition and response in the nursing progress notes, on 24-Hour report and update the resident care plan as indicated. The P&P indicated all attempts to reach the physician and responsible party will be documented in the nursing progress notes and the documentation will include the time and response.

Based on interview and record review, the facility failed to complete an advanced directive acknowledgement form (ADAF) for one of three sampled residents (Resident 1) as indicated in the facility's policy and procedure (P&P) titled, Advance Directives.This deficient practice had the potential to result in lack of knowledge regarding care and treatment decision making for Residents 1. Additionally, there was a potential to result in confusion among the healthcare providers in the event Residents 1 required immediate medical care and/treatment and the potential for Resident 1 to receive inadequate or medically unnecessary care and/or treatment or services regarding life-sustaining treatment.Findings:During a review of Resident 1's admission Record (AR), the AR, indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including osteoarthritis (a degenerative joint disease in which the tissues in the joint break down over time) and macular degeneration (eye disease that can blue your central vision.)During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 2/9/2026, the MDS indicated Resident 1 had intact cognition (ability to understand and process information) and was dependent (helper does all the effort) on staff for toileting and required substantial/ max assistance (helper does more than half the effort) for bathing.During a concurrent interview and record review on 3/12/2026 at 10 AM with Licensed Vocational Nurse (LVN) 3, Resident 1's medical record was reviewed. LVN 3 stated LVN 3 could not find Resident 1's ADAF in Resident 1's electronic medical record chart or in the physical medical record.During an interview on 3/12/2026 at 10:43 AM with the Social Services Director (SSD), the SSD stated the SSD could not find Resident 1's ADAF. The SSD stated the ADAF was important to ensure the facility knew who to give information to in the event Resident 1 was unable and to follow Resident 1's wishes for treatment including the code status (a medical order indicating a patient's preference for life-saving interventions).During a review of the facility's P&P titled, Advance Directives, dated 3/2024 the P&P's definition for advance directive indicated an advance directive is a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury. The P&P indicated upon admission to the community social services staff or designee will inform and provide written information to the resident concerning their right to formulate an advance directive. The P&P indicated an Acknowledgement for Advance Directive form will be completed, signed, and placed in the resident's medical record.

Based on observation, interview, and record review, the facility failed to follow infection control practices and ensure a safe, sanitary environment for two of two sampled residents (Resident 5 and Resident 15).This deficient practice had the potential to cause healthcare associated infections that can cause pain and discomfort for residents.Findings:1. During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 8/23/2017 with diagnoses that included hypertensive heart disease with heart failure (when long-term high blood pressure [hypertension] makes it harder for the heart to pump blood making it more difficult for the heart muscle to relax) and cerebral infarction (stroke).During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 12/3/2025, the MDS indicated Resident 5 had intact cognition and was dependent on staff for showers/bathing self and toileting hygiene.During an observation on 3/11/2026 at 9:37 AM, Licensed Vocational Nurse (LVN) 1 checked Resident 15's blood pressure (BP) then proceeded with medication administration. LVN 1 placed the BP cuff on top of the medication cart without cleaning or disinfecting the cuff.During an observation on 3/11/2026 at 10:09 AM, LVN 1 was preparing medications for Resident 5.During an observation on 3/11/2026 at 10:10 AM, LVN 1 checked Resident 5's BP on Resident 5's right wrist. LVN 1 did not clean or disinfect the BP cuff before using it on Resident 5.During an interview on 3/11/2026 at 10:40 AM, LVN 1 stated LVN 1 forgot to clean and disinfect the BP cuff after using it on Resident 15 and prior to using it on Resident 5.During a review of the facility's Policy and Procedure (P&P) titled Cleaning of Vital Sign Equipment dated May 2017, the P&P's policy indicated to clean and disinfect BP equipment which is used on multiple residents in order to prevent the spread of infections. The P&Ps procedure indicated the BP cuffs will be disinfected between residents.2. During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was originally admitted to the facility 3/30/2022 and readmitted on [DATE]. The AR indicated Resident 15's diagnoses included dementia (gradual decline in mental abilities), congestive heart failure (long standing progressive condition where the heart muscle cannot pump blood efficiently to meet the body's needs), and arthritis (group of conditions that cause joint inflammation, pain, stiffness, and swelling affecting movement and quality of life).During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool), dated 1/16/2026, the MDS indicated Resident 15's cognition (the ability to think and process information) was intact.During an observation on 3/11/2026 at 1:21 PM, LVN 1 was providing wound care to Resident 15. LVN 1 was not wearing personal protective equipment (PPE -equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while providing wound care and there was no sign at Resident 15's door indicating PPE was to be worn.During an interview on 3/13/2026 at 10 AM, Infection Preventionist (IP) 1 stated the facility did not put Resident 15 on 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 [wounds] 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]) because Resident 15 only had a skin tear which was not a major wound.During a telephone interview on 3/13/2026 at 1 PM, Resident 15's wound care physician (Physician 2) stated Resident 15's has a chronic (long standing) wound.During a review of Resident 15's Wound Assessment Report dated 6/25/2025, the report indicated Resident 15 had a reopened right lateral lower leg vascular wound that required daily would care.During a review of Resident 15's Progress Notes (PN) dated 10/24/2025, the PN indicated Resident 15 had a right posterior shin skin tear measuring 1.5 X 1 centimeter (cm, unit of measurement).During a review of Resident 15's PN, dated 3/11/2026, the PN indicated a right posterior shin skin tear measuring 1.5 cm X 1.8 cm and a depth of 0.1 cm. The PM indicated wound care.During a review of the facility's Policy and Procedure (P&P) titled Infection Prevention and Control Program dated 6/12/2025, the P&P indicated Enhanced Standard Precautions (ESP): A resident-centered and activity-based approach for preventing MDRO transmission through healthcare provider (HCP) use of gowns and gloves during high-contact resident care activities for those known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition, even if blood and body fluid exposure is not anticipated. The P&P indicated ESP are indicated for high-risk residents, those with infection or colonization with an MDRO when contact precautions do not otherwise apply and/or with wounds and/or indwelling medical devices (urinary catheter, feeding tube, endotracheal or tracheostomy tube, vascular catheters) and/or may be considered for residents with functional disability and total dependence. The P&P indicated ESP includes activities that have demonstrated transfer of MDRO to hands and or clothing of HCP (i.e., helping a resident out of bed). ESP allows high-risk SNF residents to participate in activities outside of the room under specified conditions.

Based on interview and record review, the facility failed to prevent one of three sampled residents (Resident 1) from being verbally abused when Resident 2 threatened, cursed, and yelled at Resident 1.This failure resulted in Resident 1 being scared and angry and had the potential to result in Resident 1 experiencing feelings of decreased self-worth.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 11/10/2023 with diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that cause long-term breathing problems) and muscle weakness (a reduced ability of one or more muscles to exert force).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/14/2025, the MDS indicated Resident1's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 1 was independent (the resident completes the activity by themselves with no assistance from a helper) with toileting hygiene, partial/moderate assistance (helper does less than half the effort) with shower/bathing, upper/lower body dressing, putting on/taking off footwear, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity) with personal hygiene, and set up or clean-up assistance (helper sets up or cleans up, resident completes activity) with eating and oral hygiene.During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 10/19/2023 with diagnoses including polyneuropathy (a condition where the nerves outside of the brain and spinal cord are damaged or diseased) and muscle weakness.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 2 required partial/moderate assistance with toileting hygiene, shower/bathing, lower body dressing and putting on/taking off footwear, set up or clean up assistance with eating, oral hygiene, and upper body dressing, and was independent with personal hygiene. During a review of Resident 2's Situation, Background, Assessment, Recommendation form (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 7/1/2025, the SBAR indicated Resident 2 displayed verbal aggression in an altercation with another resident (Resident 1). During an interview on 7/14/2025 at 10:25 am with Resident 1, Resident 1 stated Resident 1 was in the activities room with Resident 2 on 7/1/2025 when Resident 2 started yelling at Resident 1. Resident 1 stated Resident 2 wanted to fight Resident 1. Resident 1 stated Resident 1 became scared and upset after Resident 2 threatened Resident 1.During an interview on 7/14/2025 at 11 am with Resident 2, Resident 2 stated Resident 2 spoke in a raised voice to Resident 1 on 7/1/2025. During an interview on 7/14/2025 at 11:22 am with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 7/1/2025 LVN 1 heard yelling coming from the activities room. LVN 1 stated LVN 1 went into the activities room and observed Resident 2 yelling at Resident 1. LVN 1 stated after the incident LVN 1 observed Resident 1's behavior was quiet the rest of LVN 1's shift. LVN 1 stated this behavior was out of the ordinary for Resident 1. During an interview on 7/14/2025 at 11:36 am with the Activities Director (AD), the AD stated during a class in the activities room on 7/1/2025, Resident 2 became upset with Resident 1. The AD stated Resident 2 was screaming at Resident 1. During an interview on 7/14/2025 at 12:30 pm with the Director of Nursing (DON), the DON stated on 7/1/2025, the DON had observed Resident 2 yelling and cursing at Resident 1. The DON stated Resident 2 was trying to get out of Resident 2's wheelchair and threatening to hurt Resident 1. The DON stated Resident 1 appeared angry after the incident. The DON stated verbal abuse would be defined as yelling, cursing, and threatening another resident. During a review of the facility's Policy and Procedure (P&P) titled, Adult Abuse, dated April 2018, the P&P indicated, This community will enforce a non-tolerance of any form of behavior that might be construed as abuse by any individual, family member, staff member, visitor, volunteer, student, or other person, including resident to resident abuse of any type.Definitions of types of abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. It includes.verbal abuse.

Based on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1) to the California Department of Public Health (the Department) within two hours, in accordance with the facility's policy and procedure (P&P), titled Adult Abuse, revised April 2018. This failure resulted in the delay of notification to the Department and had the potential for Resident 1 to be subjected to abuse while at the facility. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/3/2025, with diagnoses including urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra), metabolic encephalopathy (brain disease that alters brain function or structure), and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/10/2025, the MDS indicated Resident 1 was severely impaired in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) from staff for lower body dressing and toileting hygiene. The MDS indicated Resident 1 required supervision (oversight, encouragement or cuing) from staff for eating, oral and personal hygiene, and upper body dressing. During an interview on 4/17/2025 at 8:43 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 made an allegation of sexual abuse to CNA 1 on 4/16/2025 at around 7 a.m. CNA 1 stated that Resident 1 had claimed that during the night (no time specified), Resident 1 had been raped. CNA 1 stated CNA 1 informed Licensed Vocational Nurse (LVN) 1 right away of Resident 1's allegation of sexual abuse. During an interview on 4/17/2025 at 8:56 a.m. with LVN 1, LVN 1 stated CNA 1 informed LVN 1 of Resident 1's allegation of sexual abuse on 4/16/2025 at around 7:25 a.m. LVN 1 stated LVN 1 informed the Director of Nursing (DON) of Resident 1's allegation of sexual abuse when the DON arrived at the facility at around 7:45 a.m. LVN 1 stated all allegations of abuse needed to be reported within 2 hours to the police, Ombudsman (an official appointed to investigate individuals' complaints against maladministration), and the Department. LVN 1 stated LVN 1 did not report the allegation of abuse to the police, Ombudsman, or the Department. LVN 1 stated the Administrator (ADM) reported it. During a concurrent interview and record review on 4/17/2025 at 9:20 a.m. with the ADM, the facility's Communication Result Report (fax transmission report), dated 4/16/2025 was reviewed. The Communication Result Report indicated a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) was faxed to the Department on 4/16/2025 at 10:37 a.m. The ADM confirmed the facility reported Resident 1's allegation of abuse to the Department via fax on 4/16/2025 at 10:37 a.m. The ADM stated the facility had reported Resident 1's allegation of abuse to the Ombudsman and police within 2 hours of Resident 1's allegation. The ADM stated the facility did not report Resident 1's allegation of abuse to the Department within 2 hours. During an interview on 4/17/2025 at 1:45 p.m. with the DON, the DON stated LVN 1 informed the DON of Resident 1's allegation of abuse on 4/16/2025 at around 8:30 a.m. The DON stated the DON informed the ADM immediately. The DON stated the ADM was responsible to report the allegation of abuse to the police, Ombudsman, and the Department. The DON stated allegations of abuse needed to be reported within 2 hours to the police, the Ombudsman, and the Department. During a review of the facility's P&P titled, Adult Abuse, revised April 2018, the P&P indicated, Anyone who is an owner, operator, employee, manager, agent or contractor of the facility who has observed, suspects or has knowledge of an allegation of abuse shall report to the Department of Public Health Licensing Division, the Ombudsman, law enforcement and the administrator immediately, but not later than 2 hours.

Based on interview and record review, the facility failed to ensure an alleged violation involving abuse, for one of four sampled residents (Resident 1), was reported immediately but no later than 2 hours after the allegation was made, to the facility's administrator (ADM) and other proper authorities as indicated in the facility's policy and procedure (P&P), titled, Adult Abuse. This deficient practice resulted in the delay of notification to the State Agency (CDPH, California Department of Public Health) and the Ombudsman (an official, public advocate, helps to resolve issues between parties through various types of informal mediation) and had the potential to result in compromised safety to Resident 1 due to the facility's failure to take corrective actions to prevent further potential abuse. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated, Resident 1was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), unspecified, and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/21/25, the MDS indicated, Resident 1's cognitive skills (ability to think and process information) for daily decision making were severely impaired. The MDS indicated, Resident 1 used a wheelchair. During a concurrent interview on 3/11/25 at 11:30 a.m. with the ADM and the Director of Nursing (DON), the ADM stated, an incident of abuse happened on 1/20/25. The ADM stated, the abuse allegation was not reported to the ADM on 1/20/25. During an interview on 3/11/25 at 1:22 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, while LVN 1 was counting narcotics (drugs used to treat moderate to severe pain and have numbing or paralyzing properties), Resident 1 was trying to get up, so I said please sit down. LVN 1 stated, LVN 1 was not yelling at Resident 1, cuz my tone of voice is high tone. LVN 1 stated, abuse allegations were to be reported as soon as possible, within 2 hours for the safety and protection of the residents. During an interview on 3/11/25 at 2:00 p.m. with LVN 2, LVN 2 stated, allegations of abuse must be reported within 2 hours, is the protocol to prevent the abuse from happening for the safety of the residents. During an interview on 3/11/25 at 3:30 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, Resident 1 was in the wheelchair by the nursing station and Resident 1 was trying to get up. CNA 2 stated, CNA 2 heard LVN 1 saying with a loud, strong voice sit down, sit down, you gonna fall to Resident 1. CNA 2 stated, CNA 2 could not remember the exact date of the incident, but CNA 2 stated, the incident happened on the same day Resident 1 fell . CNA 2 stated, abuse allegations should be reported within 2 hours so the facility could investigate. During a review of Resident 1's Change in Condition (COC), dated 1/20/25, timed at 4:30 p.m. documented in the Progress Notes, the COC indicated, Resident 1 was found on the floor next to Resident 1's bed in a prone position (face down) on Resident 1's right side. During an interview on 3/11/25 at 3:48 p.m. with the Director of Staff Development (DSD), the DSD stated, during the DSD's follow-up meeting on 1/21/25 with CNA 1 about Resident 1's fall incident that happened on 1/20/25, CNA 1stated, one of the LVNs was raising her voice at Resident 1. The DSD stated, raising the voice was inappropriate and unprofessional and could be a form of verbal abuse. The DSD stated, the DSD notified the ADM about the LVN's voice raising on the same day (1/21/25) of the follow-up meeting with CNA 1. During an interview on 3/11/25 at 3:55 p.m. with the ADM, the ADM stated, it was possible the DSD reported to the ADM on 1/21/25 but the ADM, just can't remember. The ADM stated, facility was mandated to report allegations of abuse immediately, within 2 hours for the safety of the residents. During a review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC 341), date completed 2/25/25, the SOC 341 indicated, the ADM was notified on 2/25/25 at 11:45 a.m., of an incident that occurred on 1/20/25 at approximately 4:00 p.m. about a CNA (unnamed), who overheard, LVN 1 repeatedly and loudly instructing Resident 1 to sit down in Resident 1's wheelchair. The SOC indicated, LVN 1 was suspended immediately upon notification, pending investigation. The SOC 341 was the facility's report submitted to the State Agency. During a review of the facility's Statement (ST - interview report), of CNA 1, dated 2/26/25, the ST indicated, CNA 1 stated, CNA 2 told CNA 1 that the charge nurse was yelling at the resident [Resident 1] on 1/20/25. The ST indicated, CNA 1 stated, CNA 1 felt that yelling at a resident (in general) was a form of abuse. During a review of the facility's ST, of CNA 2, dated 2/26/25, the ST indicated, CNA 2 stated, on 1/20/25, CNA 2 observed a resident (Resident 1) tried to stand up from the wheelchair and CNA 2 heard LVN 1 kept yelling at Resident 1 to sit down. During a review of the facility's latest in-service lesson plan (LP), titled, Types of Abuse, Reporting protocol & SOC 341, dated 2/26/25, the LP indicated, to immediately report to the Abuse Coordinator (the ADM) who would complete the SOC 341, report to the Ombudsman, and report to CDPH (the State Agency) within two hours. During a review of the facility's P&P, titled, Adult Abuse, date revised 4/2018, the P&P indicated, any person having information, either by direct observation or by report, of any act or suspected act that may be considered to be a form of abuse was responsible for reporting the information immediately to the individual's department head or Executive Director/ADM, or their designee, regardless of the time of day. The P&P indicated, anyone who was an owner, operator, employee, manager, agent of the facility who had observed, suspected, or had knowledge of an allegation of abuse should report to the Department of Public Health (CDPH) Licensing Division, the Ombudsman, law enforcement, and the ADM immediately, but not later than 2 hours.

Based on observation, interview, and record review, the facility failed to have an effective pest control program, to prevent cockroaches in one of one kitchen for a facility licensed for a 59-bed count. This deficient practice had the potential to expose 38 residents currently residing in the facility to foodborne illness. Findings During a concurrent observation and interview on 2/11/25 at 1:15 p.m. while in the kitchen with the head chef (HC), HC stated he has only been employed at the facility for a few weeks. HC stated he doesn't know the last time the kitchen had a deep cleaning for the floors and all areas of the kitchen. HC stated the kitchen crew does daily sweeping and mopping two times (once during the day and once in the evening after dinner). During the tour of the kitchen, in the back of the cooking areas, there was grease and dirt build up observed on the pipes. The kitchen exhaust hood was observed with grease and dirt build up on the overhead fire sprinklers. During an observation on 2/11/25 at 1:40 p.m. while in the kitchen near the dishwashing area, 4 gray colored plastic compartment cup racks were stacked upon each other on the floor under the stainless-steel table. When the trays were pulled aside from underneath the table, two cockroaches were observed crawling on the lower wall. The wall, pipes, baseboard and tile floor all had white and brown residue build up; the wall had black, brown and white residue/stains and the grout in the tile floor was black in color. During an interview on 2/11/25 at 2:10 p.m. with the Infection Preventionist (IP), the IP stated there were no reported instances of cockroaches in the resident's room or in the resident's food. IP stated she does a walk-through in the kitchen once a month. IP stated she was aware that the kitchen was closed for 48 hours due to cockroaches found in the kitchen. IP stated no food from the kitchen will be served to the residents after lunch time on 2/11/25, and the facility's administration is working on who will provide food to the residents for dinner on 2/11/25. During a concurrent interview on 2/11/25 at 2:22 p.m. with the Director of Environmental Services (DES) and the Housekeeping Supervisor (HKS), the DES stated a professional deep cleaning is performed by a contracted vendor twice a year in the kitchen. The DES stated the last cleaning was completed on 8/12/24. The HKS stated the housekeeping department does not clean the kitchen area; the kitchen/dinning staff clean the kitchen daily. HKS stated housekeeping cleans the common areas used by the residents: bathrooms, showers, hallways, and resident's rooms. HKS stated she completes a work order or sends a notification e-mail to the Maintenance Department for any facility repair needed. DES stated he will be coordinating the vendor repair work in the kitchen to ensure entry points for any pests are sealed. During an interview on 2/11/25 at 2:41 p.m. with the Lead/Supervisor Kitchen (LSK), LSK stated she was informed there is a 48-hour mandated kitchen closure. LSK stated, For today's dinner the facility contacted a licensed vendor, and they will prepare and bring the food, which will be served in the dinner area. LSK stated all food is being prepared offsite and will be served in disposable containers. During an interview on 2/11/25 at 3:46 p.m. with the Administrator (ADMIN), the ADMIN stated the facility does not have a pest control policy. The ADMIN stated he was new at the facility, and the ADMIN has only been at the facility since December 2024. The ADMIN stated he would provide vendor receipts for pest control services completed in 2024 and 2025. The ADMIN stated the facility follows the pest control company's recommendations. During a review of the facility's vendor receipts for pest control services, the Summary of Service (S0S) dated 2/4/25, indicated, Kitchen area, recommendation: debris collecting under (food prep tables). Please remove debris to prevent unsanitary conditions and attraction by pests. Severity = High; Status: Pending; Date: 9/13/24. The SOS further indicated, Kitchen area, recommendation: pipes extending through wall allowing pest access. Please fill in gaps between pipes and wall to prevent pest entry. Severity = High; Status: Pending; Date: 9/13/24. During a review of the facility's policy and procedure (P&P) titled, Cleaning Protocol, dated, January 2017, the P&P indicated, Policy: Housekeeping services will be routinely provided to provide a clean environment which prevents the spread of infection. The P&P did not indicate cleaning of the kitchen area. The P&P indicated the areas cleaned by housekeeping are resident's room (daily and terminal cleaning on discharge), bathroom, nursing stations, central bath/shower rooms, physical therapy room, office areas, public restrooms, storage rooms, and hallway areas. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention & Control Program, revised, January 2024, the P&P indicated, Overview: Each skilled nursing (SNF) observes its adopted and implemented Infection Prevention and Control Program (IPCP) with standard and transmission-based precautions to be followed to provide a safe, sanitary and comfortable environment that helps prevent the development, transmission and spread of communicable disease and infections. The P&P indicated, The IPCP includes the following: Reviewing, establishing and monitoring environmental infection control approaches in accordance with CDC/HIPAC/OSHA guidelines and local or state requirements to provide the community with a safe and sanitary environment. The P&P further indicated, The IPCP includes the following: Providing guidance for maintaining the community in a sanitary fashion: Reviewing food handling practices, laundry practices, pest control, traffic control, visiting rules for high-risk areas and sources of airborne infection. During a review of the U.S. Food & Drug Administration Food Code, dated 2017, the food code indicated under 6-501.111 Controlling Pests, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 92), who had a diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and history of falling, received care and services to prevent a fall ( move downward, typically rapidly and freely without control, from a higher to a lower level) by failing to: a. Ensure Registered Nurse 1 (RN 1) notified Resident 92's physician/medical doctor (MD 1) regarding Resident 92's increased agitation (unable to relax and be still) and confusion (unable to think clearly) when Resident 92 attempted to stand up unassisted from Resident 92's wheelchair (WC) multiple times on 1/20/2025 as indicated in the facility's policy and procedure (P&P) titled, Change in Resident Condition. b. Ensure Certified Nurse Assistant 5 (CNA 5) did not wheel/take Resident 92 to Resident 92's room, placed Resident 92 in bed and left Resident 92 in Resident 92's bed, unsupervised, on 1/20/2025, when Resident 92 was agitated (irritable/distressed) and confused (lost, losing sense of time, place, or identity). As a result, on 1/20/2025, at 4:30 PM, Resident 92 fell out of Resident 92's bed. Resident 92 sustained a laceration (deep cut or tear on the skin), bruising (kin discoloration from damaged, leaking blood vessels [channels that carry blood throughout your body] underneath the skin) on Resident 92's right eyebrow, and abrasions (a superficial rub or wearing off from the skin) on both knees. The facility transferred Resident 92 to the General Acute Care Hospital 1's (GACH 1) Emergency Department (ED) via emergency services by calling 911 (phone number used to contact emergency services in the event of a medical emergency). Cross reference F580 Findings: During a review of Resident 92's Admission Record (AR), the AR indicated the facility admitted Resident 92 on 1/16/2025 with diagnosis that included Alzheimer's Disease (AD, a progressive brain disorder that gradually destroys memory, thinking skills, and the ability to perform everyday tasks), and psychosis (a mental health condition characterized by a loss of contact with reality). During a review of Resident 92's Progress Notes (PN), dated 1/16/2025, timed at 3:10 PM, the PN indicated Resident 92 was alert (a state of careful watching and readiness) and had some forgetfulness. The PN indicated Resident 92's gait (manner of walking) was unsteady, and Resident 92 had poor balance. During a review of Resident 92's PN, dated 1/16/2025, timed at 9:34 PM, the PN indicated Resident 92 was confused, needed full assistance with activities of daily living (ADL, term used in healthcare that refers to self-care activities), and was at risk for falls (fall risk was not indicated). During a review of Resident 92's Baseline Care Plan (BCP), signed on 1/17/2025 by RN 1, the BCP indicated Resident 92 was unable to be oriented due to Dementia. During a review of Resident 92's CP for alteration in cognitive function related to AD and Dementia, initiated on 1/17/2025, the CP's interventions indicated to provide reorientation, and redirection as needed to Resident 92. During a review of Resident 92's CP for at risk for falls related to impaired cognition, lack of safety awareness, and poor communication/comprehension, initiated on 1/17/2025, the CP's goal indicated to decrease the risk of falls and minimize injuries from falls. The CP's interventions indicated to remind Resident 92 not to get up [from the bed or WC] without assistance [from staff]. During a review of Resident 92's PN, dated 1/20/2025, timed at 6:40 PM, the PN indicated on 1/20/2025 at 4 PM, Resident 1 was placed in Resident 92's bed. The PN indicated Resident 92 had episodes of getting out of bed unassisted. The PN indicated at 4:30 PM, Resident 1 was found on the floor next to Resident 92's bed in a prone (lying flat with chest and face down) position. The PN indicated Resident 1 was confused, disoriented, (losing sense of time, place, or identity), and had a laceration on Resident 1's right eyebrow that measured 5.2 centimeters (cm-unit of measurement) in length by 0.3 cm in width by 0.1 cm in depth, and abrasions on both knees. The PN indicated (on 1/20/2025), at 4:35 PM, 911 was called due to Resident 1 sustaining a head injury. During a review of Resident 92's Situation, Background, Assessment and Recommendation Communication Form (SBAR, a communication tool that helps teams share information about the condition of a resident), dated 1/20/2025, the SBAR indicated Resident 92 was found on the floor (inside Resident 92's room) and Resident 92 had a laceration on the right eyebrow and abrasions on both knees. During a review of Resident 92's GACH 1 History and Physical (H&P), dated 1/20/2025, timed at 6:40 PM, the H&P indicated Resident 92 had a history of Dementia. The H&P indicated Resident 92 presented to the ED due to an unwitnessed fall. The H&P indicated Resident 92 had a laceration on the right eye with contusions (bruising or skin discoloration), abrasions on both knees, and a contusion on the right knee. During an observation on 1/21/2025, at 12:10 PM, Resident 92 was sitting on a WC in the dining room and eating lunch. Resident 92's right eye had light gray skin discoloration around the eye. There was swelling under the right eye, and a laceration on the right side of the eye that measured 4 cm, three steri strips (adhesive strips used to close wounds) covered the laceration. During an interview with Certified Nursing Assistant (CNA) 3 on 1/22/2025 at 11:23 AM, CNA 3 stated CNA 3 was assigned to care for Resident 92 on 1/20/2025 during the AM shift (7 AM to 3 PM). CNA 3 stated, on 1/20/2025 during the AM shift (unable to remember exact time frame), Resident 92 was trying to get up from Resident 92's WC multiple times and was, more confused. CNA 3 stated when Resident 92 was left by herself, Resident 92 attempted to get up from the [WC]. CNA 3 stated, The moment you turn your back [on Resident 92] she [Resident 92] will get up. CNA 3 stated Resident 3 was at risk for falls. CNA 3 stated to ensure safety and constant (continuous) supervision for Resident 92, CNA 3 wheeled/took Resident 92 to the nurse's station and informed RN 1 and LVN 3 of Resident 92's increased confusion. During an interview with RN 1 on 1/22/2025 at 11:48 AM, RN 1 stated upon admission (1/16/2025), Resident 92 was non-verbal and did not attempt to get out of bed/WC. RN 1 stated on 1/20/2025, during the AM shift, Resident 92 was placed at the nurse's station for constant monitoring because Resident 92 consistently attempted to stand up, mumbled, and spoke to herself. RN 1 stated, She (Resident 92) would just stand up. RN 1 stated, she (RN 1) did not tell the physician (MD 1) about the changes in Resident 1's condition (COC, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains). RN 1 stated, on 1/20/2024, during shift change (changing from AM shift to PM shift), RN 1 endorsed to LVN 6 that Resident 92 attempted to stand up from the WC multiple times and was placed in the nurse's station for constant monitoring. RN 1 stated RN 1 would have continued to monitor Resident 92. RN 1 stated RN 1 would not have placed Resident 92 back in bed and left Resident 92 unsupervised. During a concurrent interview with LVN 3 on 1/23/2025, at 10:54 AM, LVN 3 stated (on 1/20/2025) during the AM shift, Resident 92 was placed in the nurse's station for constant monitoring due to Resident 92's constant attempts to stand up from the WC unassisted. LVN 3 stated during shift change report (on 1/20/2025), LVN 3 reported to LVN 6 that Resident 92 had attempted multiple times to get out of Resident 92's WC and reported Resident 92 needed constant supervision. During an interview with LVN 6, on 1/23/2025, at 3:12 PM, LVN 6 stated on 1/20/2025, at 3 PM [start of LVN 6's shift], LVN 6 stated while Resident 92 was sitting at the nursing station, Resident 92 attempted to get up from the WC. LVN 6 stated LVN 3 and RN 1 informed LVN 6 that Resident 92 attempted to get up from Resident 92's WC multiple times during the AM shift, and Resident 92 needed to be placed in the nurse's station for constant monitoring. LVN 6 stated after 3 PM (exact time unknown), CNA 5 wheeled/took Resident 92 to Resident 92's room located at the end of the hallway, five to six rooms [down the hall] away [not within eyesight] from the nursing station and CNA 5 placed Resident 92 in Resident 92's bed. LVN 6 stated, I thought CNA 5 was watching her [Resident 92]. LVN 6 stated at 4:30 PM, LVN 6 walked inside Resident 92's room and Resident 92's bed was empty. LVN 6 stated LVN 6 found Resident 92 on the floor, face toward the floor (no staff was inside Resident 92's room supervising the resident). LVN 6 stated LVN 6 saw blood on the floor and Resident 92 had a long and big laceration with active bleeding ((blood pumping out from a wound) on the right side of Resident 92's eye and abrasions on both knees. Resident 92 was very confused, disoriented, and unable to state any pain. LVN 6 stated, I needed to make sure there is visual checks on [Resident 92] at all times. LVN 6 stated, Resident 92 should have been constantly monitored for the Resident 92's safety. During an interview with Certified Nurse Assistant 5 (CNA 5) on 1/23/2025, at 3:53 PM, CNA 5 stated Resident 92's mind did not follow directions. CNA 5 stated during shift change (on 1/20/2024, at 3 PM), CNA 3 endorsed to CNA 5 that Resident 92 was placed at the nurse's station for constant monitoring due to Resident 92's agitation and confusion. CNA 5 stated from 3 PM to 4 PM, Resident 92 was at the nurse's station being monitored by LVN 6. CNA 5 stated at around 4 PM, CNA 5 informed LVN 6 that CNA 5 would take Resident 92 back to Resident 92's room and put her (Resident 92) back to bed, to rest before dinner. CNA 5 stated LVN 6 did not say to not take Resident 92 to Resident 92's room. CNA 5 stated CNA 5 placed Resident 92 in Resident 92's bed and CNA 5 left Resident 92's room to care for other residents [leaving Resident 92 unsupervised]. During an interview and concurrent record review with the Director of Nursing (DON) on 1/24/2025, at 8:55 AM, the DON stated on 1/20/2025, CNA 5 should not have taken Resident 92 back to Resident 92's room and left Resident 92 unsupervised when Resident 92 had an increase in confusion and was attempting to get up [from the bed/ WC] multiple times. The DON stated Resident 92 needed constant monitoring during the day shift and more than likely Resident 92 required constant monitoring during the evening shift (3 PM to 7 AM) because Resident 92 could fall. The DON stated RN 1 needed to call and notify MD 1 to make MD 1 aware when Resident 92 had a COC such as increased in confusion and started to get up, unassisted, from the WC. During a telephone interview with MD 1 on 1/24/2025, at 4:23 PM, MD 1 stated MD 1 was not aware of Resident 92's mentation change/COC or the fall that occurred on 1/20/2025. MD 1 stated MD 1 should have been made aware for MD 1 to give [appropriate] orders. MD 1 stated MD 1 should have been notified upon Resident 92's change in behavior, trying to get out of bed/WC [unassisted], for MD 1 to evaluate Resident 1 and write new order and for the facility to implement safety measures to prevent falls. MD 1 stated MD 1 would write an order for 1:1 supervision (one staff supervising one resident) as intervention for Resident 1's COC. During a review the facility's P&P titled, Dementia, Caring of Residents, revised 1/2015 (most updated), the P&P indicated Residents who exhibited new or worsening behavioral or psychological symptoms (affecting, or arising in the mind; related to the mental and emotional state of a person) of dementia (BPSD) should have an evaluation by the physician in order to identify and address treatable [conditions] that may be contributing to behaviors. The P&P indicated Individualized approaches to care utilizing a consistent process that focuses on a resident's individual needs and tries to understand behavior as a form of communication may help to reduce behavioral expressions of distress in some residents. During a review of the facility's P&P titled, Change in Resident Condition, revised 11/2016 (most updated), the P&P indicated Changes in a resident condition will be communicated to the physician timely. The P&P indicated Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior, will be communicated to the physician . The P&P indicated The nurse in charge is responsible for notification of physician prior to the end of the assigned shift when a change in a resident's condition is noted. During a review of the facility's P&P titled, Falls Prevention and Management Program, revised on 12/14/2022 (most updated), the P&P indicated Staff, in conjunction with the attending physician . will properly assess a resident's risk for falling, provide accurate interventions to minimize that risk and try to prevent a resident from falling. The P&P indicated Interventions for fall prevention included, frequent (often, occurring or done on many occasions) observation of the resident, especially following admission, to learn their habits and to accommodate needs: assign a resident's room near the nurse's station, strategies for residents with dementia and those who have recurrent falls.

Based on interview and record review, the facility failed to implement the facility's policy titled Ordering and Receiving Non-Controlled Medications for two of two sampled residents (Resident 27 and 28) by failing to: a. Document the correct drug allergies into Resident 28's electronic medical record (EMR) when Resident 28 had 12 drug allergies and received Ambien (medication used to treat insomnia [difficulty in falling asleep]) nine times in 12/2024 which was indicated as one of the 12 drug allergies. b. Document the correct drug allergies in Resident 27's EMR when Resident 27's EMR did not indicate Resident 27 was allergic to clindamycin (type of antibiotic) and Norco (prescription medication used to treat moderate to severe pain) and incorrectly indicated an allergy to prednisone and prednisolone (medications used to treat swelling, redness, itching, and allergic reactions). These failures had the potential to result in Resident 27 and Resident 28 to sustain an adverse reaction to medications, such as, an anaphylactic reaction (severe, life-threatening allergic reaction that affects the entire body) and sustain a serious injury. Findings A. During a review of Resident 28's Admission Record (AR), the AR indicated Resident 28 was originally admitted to the facility on [DATE] with diagnoses that included major depressive disorder (MDD, mood disorder that causes persistent feelings of sadness and loss of interest), muscle weakness, and atrial fibrillation (a-fib, an irregular heart rhythm). The AR indicated Resident 28 was allergic to C. Indicium extract (extract from chamomile plant) and C. Sinesis leaf extract (oil from the leaves of the Camellia sinensis plant). During a review of Resident 28's History and Physical (H&P, formal document of a medical provider's examination of a patient) dated 10/3/2024, the H&P indicated Resident 28 can make needs known but cannot make medical decisions. During a review of Resident 28's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 10/24/2024, the MDS indicated Resident 28's cognitive abilities (ability to think, learn, and process information) were intact. During a review of Resident 28's Medication Administration Record (MAR) dated 12/1/2024-12/31/2204, the MAR indicated Resident 28 received Ambien (Zolpidem Tartrate) 5 mg one tablet by mouth at bedtime for insomnia on the following days: 12/7/2024 12/8/2024 12/9/2024 12/14/2024 12/15/2024 12/18/2024 12/19/2024 12/20/2024 12/21/2024 During a review of Resident 28's Order Summary Report (OSR) dated 1/9/2025, the OSR indicated Resident 28 had a Medical Doctor (MD) order for Zolpidem Tartrate Tablet five milligrams (mg, unit of measurement) by mouth as needed for inability to sleep at night for 14 days. B. During a review of Resident 27's AR, the AR indicated Resident 27 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic systolic heart failure (heart cannot pump blood effectively in the body), a-fib, and hyperlipidemia (high levels of cholesterol in the body). The AR indicated Resident 27 was allergic to penicillin (type of antibiotic), prednisolone, prednisone, and sulfa (type of antibiotic). During a review of Resident 27's MDS dated [DATE], the MDS indicated Resident 27's cognitive abilities were intact. During an interview on 1/21/2025 at 3:25 PM with Resident 27 while in Resident 27's room, Resident 27 stated Resident 27 had an allergy to penicillin, sulfa, Norco, and some antibiotics and stated if Resident 27 received those medications it causes Resident 27 to stop breathing. During a concurrent interview and record review on 1/21/2025 at 3:43 PM with Licensed Vocational Nurse 1 (LVN 1), Resident 27's EMR was reviewed. LVN 1 stated there was no indication that Resident 27 was allergic to clindamycin or Norco in Resident 27's EMR. LVN 1 stated there should be an indication Resident 27 is allergic to those medications because it would put Resident 27 at risk for receiving those medications and having an allergic reaction. During an interview on 1/22/2025 at 10:11 AM with Resident 28, Resident 28 stated Resident 28 was allergic to a lot of different medications and was unsure of the names of the medications. Resident 28 stated if Resident 28 received medications Resident 28 was allergic to it would cause Resident 28 to throw up and make Resident 28's throat swell up. During a concurrent interview and record review on 1/22/2025 at 12:25 PM with the Director of Nursing (DON), Resident 27's General Acute Care Hospital (GACH) record titled History and Physical Reports (H&P) dated 12/18/2024, Resident 28's GACH record titled Clinics-Offsite (CO) dated 12/6/2024, and Resident 28's MAR dated 12/1/2024 to 12/31/2024 were reviewed. Resident 27's H&P indicated Resident 27 was allergic to Norco, clindamycin, penicillin, and sulfa drugs. Resident 28's CO indicated Resident 28 was allergic to the following medications: a. Ambien with a reaction of confusion. b. Compazine (medication used for nausea and vomiting) causing a reaction of hives (itchy, raised, red bumps or welts that appear on the skin caused by an allergic reaction) c. Darvocet-N 50 (mediation used to treat mild to moderate pain) causing an unknown reaction. d. Darvon (medication used to treat mild to moderate pain) causing a reaction of hives. e. Hydromorphone (medication used to treat moderate to severe pain) causing unknown reaction. f. Percocet (medication used to treat moderate to severe pain) causing a vomiting reaction. g. Codeine (medication used to treat moderate to severe pain) causing an unknown reaction. h. Droperidol (medication used to prevent nausea and vomiting) causing a reaction of hives. i. Fentanyl (medication used to treat chronic severe pain or pain following surgery) causing an anaphylactic reaction. j. Morphine (medication used to treat severe, acute pain) causing respiratory distress (life-threatening lung injury that causes fluid to leak into the lungs making breathing difficult and not allowing oxygen into the body). k. Prochlorperazine (medication used to treat nausea and vomiting and nervous, emotional, and mental conditions, such as, schizophrenia [serious mental disorder in which people interpret reality abnormally]) causing an anaphylactic reaction. l. Propoxyphene (medication used to treat mild to moderate pain) causing an anaphylactic reaction; and m. Zolpidem (Ambien) causing a reaction of anxiety. The DON stated if residents are coming from a GACH, allergies should be verified from the discharge paperwork from the hospital and the MD. The DON stated drug allergies are not the same for Resident 27 and 28's EMR when compared to Resident 27's H&P and Resident 28's CO. The DON stated the EMR was directly connected to pharmacy and stated if there were discrepancies in medication orders pharmacy would let staff know. The DON stated if staff entered a medication the resident was allergic to or the same class of medication, it wouldn't trigger a notification to pharmacy as a drug allergy in the resident's EMR because the drug allergy was not entered correctly. The DON stated the risk of not having the correct allergies in the resident's EMR was that it can interact with other medications and the resident could have an anaphylactic reaction and cause harm. The DON stated the pharmacy wouldn't know the correct drug allergies and put the resident at risk if there was a drug allergy in the same drug class and cause a reaction. During a review of the facility's undated policy and procedure (P&P) titled, Ordering and receiving non-controlled medication the P&P indicated for newly admitted residents the pharmacy should be given mediation allergies.

Based on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered care plan (CP), for four of four sampled residents (Resident 37, Resident 27, Resident 6, and Resident 5), as indicated in the the facility's policy and procedure (P&P), tilted, Care Plan, by failing to, a. Develop a care plan (CP) for Resident 37 when there was a change in skin condition on 1/11/2025. b. Develop a CP for Resident 27 for anticoagulant (class of medication that help prevent blood clots from forming in the heart and blood vessels) use when Resident 27 received Eliquis (medication used to prevent blood clots) tablet 2.5 milligrams (mg, unit of measurement) by mouth twice a day. c. Develop a CP for Resident 6 for antipsychotic (class of medications used to treat symptoms such as hearing voices and hallucinations) use when Resident 6 received Quetiapine (antipsychotic medication to that helps regulate mood, behavior, and thoughts) 25 mg by mouth at bedtime for poor impulse control manifested by yelling and screaming spells. d. Develop a CP that addressed Resident 5's diagnosis of Dementia (a decline in mental ability severe enough to interfere with daily life). These failures had the potential to result in unmet individual needs and incorrect care and services for Residents 37, 27, 6, and 5 to achieve optimal level of function and the potential to affect the resident's physical well-being. Cross reference F686 Findings: a. During a review of Resident 37's Admission Record (AR), the AR indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included anxiety, Raynaud's Syndrome (condition that causes blood vessels in the extremities to narrow), and dysphagia (difficulty swallowing). During a review of Resident 37's History and Physical (H&P), formal document of a medical provider's examination of a patient) dated 12/27/2024, the H&P indicated Resident 37 did not have the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set (MDS, a standardized comprehensive assessment of each resident's functional capabilities and identifies health problems) dated 1/2/2025, the MDS indicated Resident 37's cognitive abilities (ability to think, learn, and process information) were intact. The MDS indicated Resident 37 required maximal assistance with rolling left and right. During a review of Resident 37's Continuous Pressure Ulcer Prevention (CPUP) form dated 1/11/2025, the CPUP form indicated a skin change with a circle on the rear side of the anatomical diagram. b. During a review of Resident 27's AR, the AR indicated Resident 27 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic systolic heart failure (heart cannot pump blood effectively in the body), atrial fibrillation (a-fib, irregular heart rhythm), and hyperlipidemia (high levels of cholesterol in the body). During a review of Resident 27's MDS dated [DATE], the MDS indicated Resident 27's cognitive abilities were intact and indicated Resident 27 was taking an anticoagulant. During a review of Resident 27's Order Summary Report (OSR) dated 1/13/2025, the OSR indicated Resident 27 had a Medical Doctor (MD) order for Eliquis tablet 2.5 milligrams by mouth twice a day for a-fib. c. During a review of Resident 6's AR, the AR indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6's cognitive abilities were moderately impaired and indicated Resident 6 was taking an antipsychotic medication. During a review of Resident 6's H&P dated 1/9/2024, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's OSR dated 1/10/2025, the OSR indicated Resident 6 was receiving Quetiapine Fumarate 25 mg one tablet by mouth at bedtime for poor impulse control manifested by yelling/screaming spells. During an interview on 1/24/2025 at 8:48 AM with Registered Nurse 1 (RN 1), RN 1 stated Resident 27 was on Eliquis and stated there was no CP for Eliquis. RN 1 stated RN 1 was unsure if residents required a CP for anticoagulant therapy and stated the purpose of a CP was to ensure staff are meeting the needs of the resident and to guide staff in implementing interventions. RN 1 stated the risk of not having a CP for anticoagulant therapy was that there would be no identification resident was a high risk for bleeding or bruising. During an interview on 1/24/2025 at 8:53 AM with RN 1, RN 1 stated Resident 6 was on Quetiapine and stated there was no CP for antipsychotic use. RN 1 stated there should be a CP for antipsychotics for monitoring of the drug, goal of the drug usage, and specific interventions for staff to follow. RN 1 stated the risk of not having a CP for specific antipsychotic drug use was that staff could miss the specific interventions for the specific target behavior and put the resident at risk for unnecessary medication use. During a concurrent interview and record review on 1/24/2025 at 1:52 PM with RN 1, Resident 37's PN dated 1/11/2025 timed at 9:34 AM was reviewed. The PN indicated a new order for Optifoam (dressing used to treat pressure ulcers, lacerations, abrasions, skin tears, and first- and second-degree burns) for protection of bony prominence of bilateral heels and coccyx and indicated the CP was updated. RN 1 stated RN 1 was made aware by a CNA on 1/11/2025 of a skin change for Resident 37. RN 1 stated the skin on the coccyx area was an unstageable pressure injury (UPU, bed sore where the severity of the wound cannot be accurately determined because it is covered by thick layer of dead tissue) or deep tissue injury (DTI, damage to soft tissue underneath the skin). RN 1 stated RN 1 did not create a CP when the skin change was identified on 1/11/2025 and stated there should've been a CP indicating when the injury started to ensure it was not getting worse. RN 1 stated the risk of not creating a CP for the wound on the coccyx was that there would be no monitoring and implementation of specific interventions. 38108 d. During a review of Resident 5's AR, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnosis that included Dementia, depressive disorder (causes feelings of sadness and/or a loss of interest in activities once enjoyed), lack of coordination (inability to control the movement of one's body) and feeding difficulties. During a review of Resident 5's H&P, dated 8/3/2024, the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of a MDS, dated [DATE], the MDS indicated Resident 5's hearing and vision were highly impaired (absence of) and Resident 5 did not speak. The MDS indicated Resident 2 was dependent (helper does all the effort) on eating, personal hygiene, showering, dressing, and sit to lying position. During an interview with Licensed Vocational Nurse (LVN) 5 and concurrent record review of Resident 5's paper and electronic medical records, on 1/24/2025 at 9:46 AM, LVN 5 stated Resident 5 did not have a CP for Dementia. LVN 5 stated Resident 5 should have a CP for cognitive impairment related to Dementia to address Resident 5's specific behaviors. LVN 5 stated CPs were necessary to address resident needs and continuity of care, especially for residents with behavioral issues. During a review of the facility's P&P, titled Care Planning, revised on 2/2021, indicated a comprehensive written plan is developed based on the Minimum Data Set (assessment and care-screening tool), to meet the individual needs of the resident in 14 days with corrections or addition made within 21 days. Resident care plan will be written in black in and maintained as part of the resident's health record. The P&P indicated the CP will identify problems or needs and should indicate the date when the problem was identified and potential problems as identified by the MDS, such as, drug therapy. The P&P indicate the CP is to be updated quarterly and upon a change of condition.

Based on observation, interview and record review, the facility failed to ensure residents who were at risk for skin breakdown and pressure injuries (PIs, localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) received treatment and services to prevent skin breakdown for two of three sampled residents (Resident 32 and Resident 37) who had PIs by failing to ensure, A. Resident 32's LAL mattress (LAL Mattress -air filled mattress used to relieve pressure) was set according to Resident 32's weight of 138 pounds (lbs.). Resident 32's LAL mattress was set at 550 pounds (lbs.). B. For Resident 37, 1.The facility did not Provide documented evidence to show Resident 37 was repositioned every two hours during the night shift (10:30 PM to 6:30 AM) from 12/26/2024 to 1/24/2024. 2. Perform weekly skin assessments as indicated in Resident 37's care plan (CP), dated 1/2/2025, for two weeks. 3. Perform treatment for the unstageable PI (UPI, pressure ulcer [injuries to the skin and underlying tissue that are result of pressure on the skin for long periods of time] that is not stageable due to coverage of the wound by slough [white, yellow, tan, gray, or green in color that consist of dead tissue] and or eschar [thick, dry, black or brown scab like covering that forms over the wound] ) on the coccyx (small triangle shaped bone at the end of the vertebral [spine] column) for Resident 37 on 1/12/2025. 4. Initiate pressure relieving devices when the UPI on the coccyx was discovered on 1/11/2025. 5. Registered Nurse 1 (RN 1) created a change of condition (COC, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains, an initial assessment and used to monitor progress), when the UPI on Resident 37's coccyx was discovered on 1/11/2025. These deficient practices had the potential to result the development of new PIs and worsened existing PIs to Residents 32 and 37. Cross reference F656 Findings: A. During a review of Resident 32's Admission Record (AR), the AR indicated the facility admitted Resident 32 on 6/26/2024, and readmitted the resident on 10/30/2024, with diagnoses including hemiplegia/hemiparesis (paralysis [complete or partial loss of muscle function] on one side of the body), and hemiparesis, muscle weakness (generalized), and need for assistance with personal care. During a review of Resident 32's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/4/2024, the MDS indicated Resident 32 had severe cognitive (the ability to think and process information) impairment. The MDS indicated Resident 32 was dependent (helper does all the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and dependent with mobility. During a review of Resident 32's Pressure Sore Risk, dated-signed 11/6/2024, indicated Resident 32 was at high risk for pressure sores. During a review of Resident 32's Order Summary Report (OSR), dated 1/23/2025, the OSR indicated low air loss mattress (LAL Mattress) related to (R/T) wound management every day shift. During an observation on 1/21/2025 at 11:25 AM, Resident 32's LAL Mattress was set at 550lbs. During a review of Resident 32's Order Summary Report, dated 1/23/2025, indicated low air loss mattress (LAL Mattress) related to (R/T) wound management every day/shift. During a concurrent interview and record review on 1/22/2025 at 11:20 AM, with Licensed Vocational Nurse (LVN) 3, Resident 32' s Clinical Weights and Vitals, dated 1/20 /2025, was reviewed in the electronic medical record. The Clinical Weights and Vitals indicated Resident 32 was 138lbs. LVN 3 stated Resident 32's LAL mattress setting was set too high. LVN 3 stated the LAL Mattress was designed to help prevent and treat PIs by redistributing pressure on the body and promoting skin health. LVN 3 stated a LAL mattress was only effective when properly adjusted and setting the mattress too high reduced its ability to maintain proper pressure redistribution, airflow, and moisture management, which were critical to preventing skin damage and PIs. During an interview on 1/24/2025 at 11:41 AM, with the Director of Nursing (DON), the DON stated that the purpose of setting the LAL mattress to the patient's correct weight was to ensure that the mattress provided effective pressure relief, maximized comfort, and helped prevent skin damage, particularly for residents who were at risk of pressure ulcers. The DON stated that when the setting isn't accurately adjusted, it could lead to inadequate pressure relief, which defeated the purpose of using the LAL mattress intended to prevent or treat pressure ulcers. During a review of the facility's policy and procedure (P&P) titled, Mattress, Low Air Loss, revised 2/2009, the P&P indicated the purpose of the policy was to reduce the mechanical forces of pressure, shear, friction, and moisture, which contribute to skin breakdown and to promote wound healing. During a review of the LAL Mattress Operation Manual Protekt Aire 8000, the operation manual indicated the pump and mattress system is intended to reduce the incidence of pressure ulcers while optimizing patient comfort. The manual indicated the product function press pressure range was adjustable pressure range selected by the patient's weight guide listed on the panel providing pressure range options. The manual indicated, - Individual home care setting and long-term care. - Pain management as prescribed by a physician. The manual indicated it is recommended to press auto firm on the panel when the mattress is first inflated. Users can then easily adjust the air mattress to a desired firmness according to the patient's weight and comfort. 48905 B. During a review of Resident 37's AR, the AR indicated Resident 37 was admitted to the facility on [DATE] with diagnoses that included anxiety, Raynaud's Syndrome (condition that causes blood vessels in the extremities to narrow), and dysphagia (difficulty swallowing). During a review of Resident 37's Braden Scale for Predicting Pressure Ulcer Risk Evaluation form (BSPPURE) dated 12/26/2024 timed at 9:36 PM, the BSPPURE indicated Resident 37 was a moderate risk (13.0) for developing a PI. During a review of Resident 37's MDS, dated [DATE], the MDS indicated Resident 37's cognitive abilities (ability to think, learn, and process information) were intact. The MDS indicated Resident 37 needed maximal assistance with rolling left and right and indicated Resident 37 was admitted to the facility without PIs and was at risk for developing PIs. During a review of Resident 37's CP dated 1/2/2025, the CP indicated Resident 37 had the potential for PI development related to being admitted from a general acute care hospital (GACH) with redness on the peri area (the thin layer of skin between the genitals [outer sexual organs]) and the heels. The CP's interventions indicated to assist Resident 37 to turn and repositioning every two hours, to observe/document/report as needed any changes in skin status: appearance, color, wound healing any sign or symptoms of infection, wound size (length by width by depth), stage of wound, and for staff to do weekly skin evaluations. During a review of Resident 37's BSPPURE dated 1/8/2025 timed at 10:24 AM, the BSPPURE indicated Resident 37 was a high risk (15.0) for developing a PI. During a review of Resident 37's Continuous Pressure Ulcer Prevention (CPUP) form dated 1/11/2025, the CPUP indicated the buttock area circled on the anatomical figure and indicated Resident 37 had a skin change (two anatomical figures side by side, one with the buttock area circled). During a review of Resident 37's Progress Note (PN), dated 1/11/2025 timed at 9:34 AM, the PN indicated the Medical Doctor (MD) ordered Optifoam (adhesive foam island dressing that is waterproof and has a high fluid-handling capacity) to both heels and coccyx for protection of bony prominences. The PM indicated the CP was updated. During a review of Resident 37's Treatment Administration Record (TAR) dated 1/1/2025 to 1/31/2025, the TAR indicated a blank space on 1/12/2025 for the application of Optifoam to the coccyx and bilateral heels for protection of bony prominences one time a day for deep tissue injury (DTI, localized area of discolored skin or blood-filled blister). The TAR indicated to change as needed or if soiled. During a review of Resident 37's CPUP dated 1/13/2025, the CPUP indicated the buttock area circled on the anatomical figure and indicated Resident 37 had a small opening on the buttock area. During an interview on 1/24/2025 at 10:48 AM with the Infection Prevention Nurse (IPN), the IPN stated the facility did not have a designated Treatment Nurse, so staff take turns on doing wound treatments and care. The IPN stated there was no COC documented for the change in skin condition that occurred on 1/11/2025. The IPN stated the risk of not completing a COC was that the wound would not be monitored and would worsen. The IPN stated wound treatment was missed on 1/12/2025 and stated the risk of missing treatment was that the wound could worsen. The IPN stated the wound opened on 1/13/2025. The IPN stated weekly skin evaluations/assessments were not completed as indicated in Resident 37's CP and stated skin evaluations were completed on 12/26/2024, 1/15/2025, and 1/22/2025. The IPN stated weekly skin evaluations should've been completed weekly to follow the CP and stated the purpose of doing weekly skin evaluations was to ensure staff was not missing any new skin issues. The IPN stated the risk of not implementing the CP intervention was that staff would not be able to assess the skin for any new changes especially since Resident 37 was a high risk for skin breakdown. Concurrent interview and record review on 1/24/2025 at 1:49 PM with the Director of Staff Development (DSD), Resident 37's POC Response History dated 12/26/2024 to 1/24/2025 were reviewed. The DSD stated there was no documentation indicating Resident 37 was turned or repositioned every two hours during the night shift as the night shift documented once at the end of the shift. The DSD stated staff should be documenting turning and repositioning every two hours to follow the resident's CP. The DSD stated if there was no documentation indicating turning and repositioning, this indicated it was not done. During an interview on 1/24/2025 at 1:52 PM with RN 1, RN 1 stated RN 1 was made aware of the change in skin condition by staff on 1/11/2025. RN 1 stated the wound on Resident 37's coccyx was either an UPI or a DTI (deep tissue injury, damage to deeper underlying structures overlaid with intact or non-intact skin) with some slough (layer of soft, yellow, or white dead tissue in the wound bed) around it. RN 1 stated RN 1 did not complete a COC and stated the purpose of creating a COC was to notify the care team of the change, assess, and monitor the change. RN 1 stated the risk of not creating a COC was that there was no initial assessment completed which could put the UPI at risk of getting worse. RN 1 stated CNAs were responsible for turning and repositioning the residents every two hours and stated RN 1 did not see any documentation for turning and repositioning during the shift from 12/26/2024 to 1/24/2025. RN 1 stated no documentation indicated the task was not done and possibly could lead to skin breakdown. RN 1 stated weekly skin assessments were not done based on the CP's interventions and stated two weeks were missed. RN 1 stated the importance of doing weekly skin assessments was to monitor the progress of the wound and stated the risk of not doing skin assessments was that the wound could get worse. RN 1 stated treatment to the coccyx was missed on 1/12/2025 and stated the wound opened on 1/13/2025, one day after the missed treatment. RN 1 stated the importance of following treatment orders was to prevent the wound from getting worse. RN 1 stated a LAL mattress is initiated when residents have a wound and stated a LAL mattress should have been initiated on 1/11/2025 when the UPI was found. RN 1 stated the delay in implementing pressure relieving devices was that it could make the UPI worse. During an interview on 1/24/2025 at 2:58 PM with Resident 37 in Resident 37's room, Resident 37 was observed to be lying in bed on Resident 37's back. Resident 37 stated staff turn Resident 37 sometimes and stated Resident 37 was unsure how Resident 37 acquired the UPU on the coccyx. During an interview on 1/24/2025 at 4:49 PM with the Director of Nursing (DON), the DON stated staff were to call the physician, notify the responsible party (RP), create a COC and implement a CP when a PI was developing. The DON stated the purpose of creating a COC was to inform the care team of the new condition and if any interventions or orders were placed. The DON stated if turning and repositioning every two hours was indicated in Resident 37's CP, the task should be added to the medical record, if the task was not added it meant staff did not complete the task. The DON stated it was important the resident received treatment as ordered and stated that if treatment was missed there was a possibility the wound would not heal. The DON stated the risk of not doing skin assessments weekly per the CP was that staff could miss a new skin issue and stated once a change in skin condition was identified a LAL mattress should've been implemented to reduce pressure on the wound as soon as possible. During an interview on 1/24/2025 at 5:20 PM with the IPN, the IPN stated the order for the LAL mattress for Resident 37 was placed on 1/14/2025. The IPN stated, the facility received the mattress on the same day and the LAL was implemented on 1/14/2025. During a review of the facility's policy and procedure (P&P) titled Skin/Wound Assessment and Treatment revised 12/2013, the P&P indicated the first step was to complete a thorough assessment of the skin/wound which would include: a. Size of the wound: length, width, depth, undermining, and tunneling. b. Specific location of the wound. c. Type of wound: pressure, venous, arterial, diabetic, and or neuropathic. d. Stage of the wound: stage one to four, any presence of eschar or slough. e. Additional assessments: presence of exudate, edema, pain, condition of the wound bed, and signs and symptoms of infection. The P&P indicated to place adaptive equipment such as pressure reducing mattresses, pressure relieving cushions, positioning devices, etc. The P&P indicated a treatment sheet will be initiated to record each treatment site and will be signed by the nurse when the treatment is completed. The P&P indicated the CP will be updated to address the plan of care for each site along with preventative measures to prevent further breakdown. The P&P indicated nursing notes will include and initial nursing note describing the skin/wound and treatment ordered and ongoing wound assessment.