Every finding on record at Coronado at Stone Oak

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food service sanitation and safety, in that:During the initial tour on 7/14/26:---The facility failed to ensure 3 portion plates and 4 baking pans were not upside down with food contact surfaces exposed. ---The facility failed to ensure an open box of Cream of Wheat was not on top of a warm oven. ---The facility failed to ensure 2 containers of soup base were not opened and not refrigerated as recommended on the labels. ---The facility failed to ensure there was not an unsecured overhead cover in the pantry. ---The facility failed to ensure the walk-in-refrigerator did not have an opened bag of (1) ham and salad container with an expiration date of 7/12/26. ---The facility failed to ensure the dried storage room did not have an opened bag of (1) fettuccine and 1 bag spaghetti.On follow up visit on 7/15/26:---The facility failed to ensure the can opener was not dirty with a black substance on the blade. These failures could place residents who eat meals from the kitchen at risk for spread of infections, food contamination, and food borne illness.Findings included: Based on observation on 7/14/26 at 9:30 a.m. the kitchen revealed:---3 portion plates and 4 baking pans upside down with food contact surface exposed.---open box of Cream of W on top of a warm oven.---2 containers of soup base opened and not refrigerated as recommended on the labels.---unsecured overhead cover in the pantry.---in the walk-in-refrigerator: opened bag of (1) ham and salad container with an expiration date of 7/12/26.----the dried storage room: opened bag of (1) fettuccine, (1) spaghetti. Based on an observation on 7/15/26 at 2:45 p.m., the can opener was dirty with a black substance on the blade, and the rotation mechanism appeared with a black substance. During an interview on 7/14/26 at 10:25 a.m., the FSS stated plates and baking sheets did not need to be exposed to possible contamination. He stated bags needed to be labeled by date. He stated he had no explanation for the loose overhead light cover in the pantry. During an interview on 7/14/26 at 10:30 a.m., the dietitian stated the items noticed by the surveyor could lead to contamination due to improper labeling and sealing of bags. She stated that the loose overhead cover in the pantry could result in accidents and needed to be secured. During an interview on 7/14/26 at 10:40 a.m., the Administrator stated he had no explanation for the finding in the kitchen, but he would address and take corrective action. The Administrator stated all residents eat from the kitchen except for Resident #16 who had a PEG and Resident #142 who was NPO. During an interview on 7/15/26 at 2:50 p.m., the FSS stated the can opener blade was cleaned but it was old and substances could fall on the blade. The FSS stated that the can opener needed to be replaced because it was old. The FSS stated that dirty can opener can lead to cross contamination. The FSS stated that the cleaning schedule was posted as a daily activity. During a telephone interview on 7/15/26 at 2:55 p.m., the dietitian stated the can opener needed to be cleaned because it could lead to cross contamination. The dietitian stated that the can opener could not be used until it was cleaned or replaced. Record review of the facility's kitchen cleaning scheduled dated 7/14/26 revealed the can opener was cleaned sometime during the day. The cleaning schedule did not document the cleaning of the can opener after every meal use. Record review of the facility's 14-day menu Summer 2026 week 3 revealed on 7/15/26 for the breakfast meal the can opener was used to open can(s) for fresh fruit cups. Record review of facility's Food Storage policy, dated revised 3/2019, read: .Food is stored, prepared, and transported at appropriated temperature and by methods designed to prevent contamination.All containers must legible and accurately labeled, including the date the package was opened.Frozen Foods.should be covered, labeled and dated.All food items should be stored upon delivery and careful rotation procedures should be followed. Record review of the FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines, dated 2022, paragraph 3.304.11, read: .Food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to. contamination.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 8 residents (Resident #2) reviewed for sanitary environment, in that: The facility failed to ensure on 7/15/26 Resident #2's catheter bag was hanging on the bed rail and not attached to a waste basket. This failure could result in the spread of disease and expose residents with catheters to infections and a diminished quality of life. Record review of Resident #2's face sheet, dated 7/15/26, reflected a [AGE] year-old male, with an admission date of 6/16/26 with diagnoses that included urinary tract infection (primary) and type 2 diabetes mellitus. The RP was listed as self.Record review of Resident#2's admission MDS (minimum data set), dated 6/25/26 reflected:BIMS (brief interview of mental status) Score was 15. (Cognitively intact)ADLs (activities of daily living): Toileting was dependent. B/B (bowel and bladder) Bladder was listed as Suprapubic catheter. Bowel was frequently incontinent.Record review of Resident# 2's Care Plan was in progress as a new admission. On 7/11/26, Care Plan intervention: Position catheter bag and tubing below the level of the bladder and away from entrance room door.Record review of Resident# 2's TAR (treatment administration record), (dated July 2026), reflected the resident received suprapubic catheter change (anchor and drainage bag) on 7/4/26, with orders for change every 15 days. Care plan also included, Care every shift Suprapubic Catheter care every shift.Record review of Resident#2's Physician' Orders, dated 6/15/26, reflected: change catheter every 15 days. Observation on 07/15/2026 9:21 a.m., revealed the drainage bag for suprapubic catheter was not properly hung and was hanging on a waste basket. LVN F moved the bag that was found placed inside a waste basket and moved it to the bed frame During an interview on 7/15/26 at 9:23 a.m., Resident #2 stated he had catheter for 2 years and one UTI about one month ago. The resident stated he was not certain where the catheter bag was hanging and he assumed it was hanging properly.During an interview on 7/15/26 at 10:20 a.m., LVN F stated she observed the drainage bag hanging on a waste basket inside the empty trash liner, instead of on the bed frame. LVN F stated that the drainage bag needed to be hung on the bed frame to avoid contamination. LVN F stated she had no explanation for the reason the drainage bag was placed in the waste basket. During an interview on 7/15/26 at 11:00 a.m. the DON stated that Resident #2's drainage bag should not have been in the waste basket. She stated the drainage bag should have been placed on the bed frame. The DON stated the error of placement could have occurred during an ADL activity like a transfer. The DON stated she had no explanation for the inappropriate placement of the drainage bag which had the potential for contamination. Attempted telephone interview on 7/15/26 at 11:30 a.m., LVN G (night nurse on 7/14/26) to check on placement of catheter and drainage bag; message left for return call to surveyor. Record review of Resident #2 's TAR dated 7/4/26 revealed the last time the catheter and drainage bag was changed was 7/4/26. Further review revealed that the placement of the catheter and drainage bag was checked on 7/14/26 on night shift by LVN G. Record review of R#2's physician orders dated 6/18/26 read: check for Patency and Placement every shift . Record review of Resident #2's TAR order read: check for Patency and Placement every shift. Record review of facility Catheter Care policies, dated 10/1/25, read, Bag and gather all supplies used, discarding disposable items in the trash can.Record review of facility Infection Prevention and Control Program, dated 12/1/25, read, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on observations, interviews, and record reviews, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #130) reviewed for an indwelling catheter. The facility failed to ensure Resident #130's indwelling catheter was attached to prevent pulling or tugging on the perineal area. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections. Findings included: Record review of Resident #130's face sheet, dated 7/15/2026, revealed a [AGE] year-old female, admitted to the facility on [DATE] with the diagnoses of Parkinson's disease (progressive neurological disorder that primarily affects movement), hypertension ( is a common condition where the force of blood against the artery walls is consistently too high) and dementia(condition characterized by progressive or persistent loss of intellectual functioning). Record review of Resident #130's MDS, dated [DATE], revealed a BIMS score of 05, which indicated severe cognitive impairment. Record review of Resident#130's care plan initiated on 07/12/2026 revealed a care plan with interventions position the catheter bag and tubing below the level of the bladder . Record review of monthly physician orders for Resident #130 dated 7/14/2026 revealed a change to anchor every 15 days. Observation on 7/15/26 at 11:05 AM revealed that Resident #130's indwelling catheter lacked an anchor to secure the tubing in place. Interview with Resident RP revealed the anchor fell during a bed bath on an undetermined date and was never reapplied by the nurse. During an interview on 7/15/26 at 11:40 AM, LVN B confirmed Resident # 130 was not wearing an anchor to keep the Foley catheter from pulling. He stated he did not know why Resident #130 was not wearing an anchor, but would place one right away. LVN B stated that nurses were responsible for placing a Foley Stat-Lock anchor in residents. He said this is important because residents sometimes lie on the catheter, which can cause it to coil or be pulled. He stated the Stat-Lock anchor should be used to keep the Foley catheter stable and prevent tugging, as it would be painful for the resident if the balloon were to come out. LVN B stated that he had not yet seen Resident #130 that morning because he was still passing medications and had not reached the patient's room. Interview on 7/16/26 at 3:00 p.m., the DON stated residents who had indwelling urinary catheters needed to have a securing device so the catheter tubing was not pulled, which could cause irritation to the urethra. The DON stated that the nurse was responsible for ensuring the urinary catheter tubing was secured with a securing device, and that the ADONs would be monitoring compliance at random. Record review of Catheter Care policy dated 10/1/2025 revealed, Leg bags may be worn during the day, but needed to be removed and a bedside drainage bag placed on the catheter at night.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one of eight residents (Resident #90) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light in Resident #90's room was placed in a position accessible to the resident on 7/15/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.The findings included: Record review of Resident #90's admission Record, dated 7/16/2026, revealed an [AGE] year-old female admitted on [DATE] with Parkinson's disease (a movement disorder of the nervous system) without dyskinesia (uncontrolled, involuntary movement) without mention of fluctuations and atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart). Record review of Resident #90's Quarterly MDS, dated [DATE] reveals a BIMS score of 99 indicated the resident was unable to complete the interview and zeros for all questions reflecting severe cognitive impairment. She had a functional limitation in range of motion with impairment on both sides of her lower extremities, used a wheelchair, and was dependent or required substantial/maximal assistance for her self-care and was dependent on staff for her mobility needs. Record review of Resident #90's undated Care Plan reflected an ADL self-care performance deficit r/t generalized weakness with the intervention The resident requires assistance x1 or x2 staff to move between surfaces. This may fluctuate with weakness, fatigue, or weight bearing status and Encourage the resident to use bell to call for assistance. Additional focus areas include The resident has a communication problem r/t Spanish speaking only with the intervention Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. During an observation and attempted interview on 7/14/2026 at 4:39 PM, Resident #90 was observed in a single occupancy room, was lying in bed, and did not respond when asked a question. During an observation on 7/15/2026 at 11:45 AM, Resident #90 was observed sitting in a wheelchair on the left side of the bed near the foot of the bed. The call light was observed hanging on the right side of the bed hanging on the quarter rail out of reach for Resident #90. During an observation and interview on 7/15/2026 at 4:42 p.m., LVN E observed that Resident #90's call light was out of reach on the bed quarter rail and stated it was not in reach. She said Resident #90 did not ambulate on her own and that the facility staff who assisted her would need to place the call light so that it is accessible to the resident in case she remembered to push it. She stated Resident #90 was not impacted by the call light being out of reach because she never used it but that it should still be accessible in case the resident remembered to push it. She stated that staff kept the residents' door open and would do more frequent rounding for Resident #90. LVN E stated she would get a call light with a longer cord so that it could be placed near Resident #90 as the installed cord was too short. The longer corded call light was observed to be installed and LVN E informed Resident #90 of the call light location. During an interview on 7/16/2026 at 4:45 PM, the DON stated that the call light should be repositioned so that it was accessible to the resident if the facility transfers a resident that cannot transfer themselves without assistance. She said residents that move themselves would be able to move to the call light. The DON said the concern with an inaccessible call light for residents that require mobility assistance would be They might need something, try to get it themselves, possible fall, or just have needs unmet. Record review of facility policy, Call Lights: Accessibility and Time Response with an implementation date of 10/01/2025 and a reviewed/revised date of 12/1/2025, reflected: Policy:The purpose of this policy is to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Policy Explanation and Compliance Guidelines:5. Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observations, interviews, and record reviews, the facility failed to ensure the safe and sanitary storage of residents' food items in 2 of 5 (Resident #6 and #104) reviewed residents' refrigerators.The facility failed to ensure Resident #6 did not have an unlabeled, undated container of watermelon pieces in her personal refrigerator on 7/16/2026. The facility failed to ensure Resident #104 did not have unlabeled, undated, opened cheese dip container in her personal refrigerator on 7/14/2026. This deficient practice could put residents at risk of foodborne illness from consuming spoiled food. The findings were: Record review of Resident #6's admission record, dated 7/16/2026, revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included: protein-calorie malnutrition (occurs when the body does not receive enough protein and energy to meet its nutritional needs), vitamin deficiency (occurs when the body lacks sufficient amounts of essential vitamins), and dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). Record review of Resident #6's significant change in status MDS assessment, completed on 06/30/2026, reflected a BIMS score of 14 out of 15, indicating intact cognition. Record review of Resident #6's care plan, undated, reflected a focus The resident has impaired cognitive function/impaired thought processes r/t dementia, initiated 4/07/2026, with intervention Confused/Disoriented: Cue, reorient and supervise as needed., initiated 4/07/2026. During an interview and observation on 7/16/2026 at 01:03 PM, it was revealed that the personal refrigerator for Resident #6 contained an unlabeled, undated container of pieces of watermelon. Resident #6 revealed she received the watermelon 2 weeks ago and stopped eating it so she did not get sick. She revealed it would be helpful for someone to discard the watermelon. During an interview and observation on 7/16/2026 at 01:05 PM, RN C revealed the container of watermelon pieces in Resident #6's refrigerator was undated and unlabeled. He revealed it was every staff member's duty to check the residents' personal refrigerators to ensure items in their refrigerators was safe. He revealed this was important to ensure food was safe to eat in order to prevent food poisoning. During an interview on 7/16/2026 at 01:10 PM, CNA A revealed she was not aware of who was in charge of checking the items in residents' personal refrigerators and RN C would know. She revealed she was not aware that Resident #6 had a container of watermelon in her refrigerator. Record review of Resident #104's face sheet, dated 7/14/2026, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: hypertension( Condition where the force of your blood pushing against your artery walls is consistently too high), cerebral infarction(Occurs when a blood vessel in the brain becomes blocked or severely narrowed) and anemia ( Condition in which the body does not have enough healthy red blood cells to carry oxygen to the body's tissues). Record review of Resident #104's BIMS assessment, completed on 06/04/26, revealed a BIMS score of 99, indicating the Resident was unable to complete the interview. Observations on 7/14/2026 at 10:20 AM revealed that the personal refrigerator for Resident #103 contained an unlabeled, undated, opened cheese dip container with unidentified, fuzzy patches in shades of white. Interview with Resident #103 on 7/14/2026 at 11:01 AM revealed that she was unaware of the unlabeled cheese dip container in her personal refrigerator. Interview with LVN B on 7/14/2026 at 12:00 p.m. revealed he was the assigned nurse for resident 103 and confirmed there was an unlabeled/undated cheese dip storage container in the personal refrigerator for resident 103. He stated he did not know who was responsible for removing undated and unlabeled food items from residents' personal refrigerators daily, but Resident # 103 risked foodborne illness by possibly consuming unlabeled, undated food. During an interview with the DON on 7/14/26, at 3:30 p.m., the DON confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled food. The DON stated that all nursing staff were responsible for removing undated, unlabeled food items from residents' refrigerators daily, including assisting families in labeling and dating food items brought in. The DON stated that families sometimes bring food for residents without notifying the nursing staff. She added that her charge nurses were responsible for overseeing this task, and her ADONs would be monitored at random. Record review of the facility policy, Patient/Resident / Food from outside , dated November 2016, revealed: Food or beverages brought in from the outside will be dated.

Based on observation, interview, and record review, the facility failed to protect a resident's right to be treated with respect and dignity and to care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for 1 of 8 residents (Resident #12) reviewed for dignity. The facility failed to ensure Resident #12 was provided with his preference for grooming/shaving of his facial hair for a period of 6 days. This failure could result in residents experiencing a diminished quality of life.Findings were: Record review of Resident #12's face sheet and Health Record revealed: male resident aged 78 was readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (primary, low oxygen) and need for assistance with personal care. Record review of Resident #12's admission MDS, dated [DATE], revealed a BIMS score of 11 which indicated his cognition was moderately impaired. The MDS indicated the resident required supervision or touching assistance for personal hygiene under ADL section. Record review of Resident #12's CP, dated 6/30/26, revealed for ADL personal care was one person assistance for grooming which included shaving. Record review of POC from 7/9/26 revealed bathing schedule, Patient received Tuesday, Thursday, Saturday day shift and PRN. Record review of POC in the past 30 days for bathing revealed documentation for shower 7/16/2026 and bed bath 7/2/2026 only. Observation on 07/15/2026 at 9:56 a.m. of Resident #12, revealed facial hair growth appeared longer than one inch in length. During interview on 07/15/2026 at 9:57 a.m., Resident #12 stated he wanted to be shaven. Resident #12 had not been shaven for two weeks, and CNA's have never asked him as an ADL activity whether he wanted to be shaven. Resident stated, You get used to shaving every day. The resident repeated he could shave himself with assistance from staff. During an interview on 7/15/26 at 10:00 a.m., LVN F stated her assessment of the hair growth involving Resident #12 was about one inch in length. LVN F stated part of grooming involved inquiring about whether he wanted the facial hair removed. LVN F stated whether the resident expressed a need for facial hair removal the CNAs needed to explore with the resident and document any refusal of grooming. LVN F stated that the charge nurse was responsible for follow-up on the completion of ADLs to include shaving. LVN F stated she had no explanation for the resident not being shaved given he was given a daily bed bath. During an interview on 7/15/26 at 10:05 a.m., CNA H stated she had seen Resident #12's facial hair and intended on asking the resident during grooming whether he wanted to be shaved. CNA H stated that shaving was part of the ADL activity of grooming. CNA H stated she had no explanation why the resident went for a period without facial hair shaving. CNA H stated that lack of shaving of a resident could lead to skin issues and a diminished quality of life. During an interview on 7/15/26 at 11:00 a.m., The DON stated the activity of grooming also involved inquiring whether a resident wanted facial hair removed. The DON stated Resident #12 never complained or requested a shaving of his facial hair. The DON stated the resident had recently returned from a hospital [6/9/26] and had facial hair. The DON stated Resident #12 when admitted to facility presented with facial hair, and the staff may have assumed the resident did not want to be shaved. The DON stated the expectation was that during the activity of grooming, CNAs should inquire if a resident want a shave or not. The DON stated she could not give an explanation why refusal of shaving was not documented in the POC. Record review of facility's ADL policy, 12/1/25, read, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 3 residents (Resident #3) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #3 was prescribed a psychotropic drug for anxiety no longer than 14 days PRN . This deficient practice could place residents at risk of receiving unnecessary psychotropic medications. The findings were: Record review of Resident #3's face sheet dated 7/16/26, revealed a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis that included: Peripheral vascular disease(a slow, progressive blood circulation disorder that narrows or blocks vessels outside the heart and brain, primarily affecting the legs and feet), Hyperlipidemia(blood has too many lipids) and anxiety(feeling of fear, dread, and uneasiness). Record review of Resident #3's admission MDS assessment, dated 6/26/26, revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #3's care plan, dated 6/23/26, revealed, Uses anti-anxiety medication. Record review of Resident #3 's order summary, dated July 2026, revealed an order for Ativan oral tablet 0.5 mg, give one tablet by mouth every 12 hours as needed for anxiety indefinite. Interview with RN C on 7/16/2026 at 8:05 AM: she stated that a verbal order was transcribed, and the RN wrote the order but forgot to tell the provider to make it for only 14 days on Ativan, not indefinite. RN C stated the Ativan order needed to be clarified and rewritten to expire every 14 days so that a physician can reassess whether the medication is needed. Interview with Resident # 3 on 7/16/2026 at 9:30 AM: he said he suffered from anxiety and needed his Ativan medication. During an Interview with the DON on 7/17/26 at 9:25 a.m., the DON said that Resident # 3 had an order for Ativan 0.5 mg every 12 hours PRN indefinite, and the order should have only been for 14 days. She said she did not know why the order was written over 14 days, as overuse can place Resident # 3 at risk for respiratory depression. The DON said that ADON was responsible for overseeing this task daily, and she currently monitors this at random, which is why the deficient practice was an oversight. Record review of the facility's policy titled, Use Psychotropic Medication Policy, dated 12/1/2025, revealed, .PRN orders for psychotropic medication are limited to 14 days.

Based on observation, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 4 of 4 residents (Residents #1, #2, #3 and #4) reviewed for medical records. 1. The facility failed to ensure Resident #1's ADL-Bathing record recorded a bath or refusal for 1/19/2026, as noted on the electronic medical record. 2. The facility failed to ensure Resident #2's ADL-Bathing record recorded a bath or refusal for 1/2/2026 and 1/19/2026, as noted on the electronic medical record. 3. The facility failed to ensure Resident #3's ADL-Bathing record recorded a bath or refusal for 1/26/2026, as noted on the electronic medical record. 4. The facility failed to ensure Resident #4's ADL-Bathing record recorded a bath or refusal for 12/30/2026, 1/3/2026, 1/6/2026, 1/8/2026, 1/15/2026 and 1/24/2026, as noted on the electronic medical record. These failures could place residents at risk of not receiving necessary care and services to ensure a resident's abilities in ADLs did not deteriorate, promoted proper hygiene and a dignified existence.Findings include: 1. Record review of Resident #1's admission record, printed on 1/27/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's 30-day Task record for ADL-Bathing reflected a preference of Monday, Wednesday and Friday Evening. Based on an admission date of 1/15/2026, Resident #1 did not have a bath entry or refusal for a preferred date of 1/19/2026 (Monday). During an observation and interview on 1/27/2026 at 3:34 PM, Resident #1 was observed in her room laying on her bed. She revealed she was able to take showers on her scheduled days, which she did on her own and she had not missed any showers. 2. Record review of Resident #2's admission record, printed on 1/27/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #2's 30-day Task record for ADL-Bathing reflected a preference of Monday, Wednesday and Friday Evening. Based on an admissions date of 12/31/2026, Resident #2 did not have a bath entry or refusal for a preferred date of 1/2/2026 (Friday) and 1/19/2026 (Monday). During an observation and interview on 1/27/2026 at 4:30 PM, Resident #2 was observed in her room laying on her bed. She revealed she was able to take showers on her scheduled days and one staff member helped her. 3. Record review of Resident #3's admission record, printed on 1/27/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #3's 30-day Task record for ADL-Bathing reflected a preference of Monday, Wednesday, and Friday Days. Based on an admissions date of 1/21/2026, Resident #3 did not have a bath entry or refusal for a preferred date of Monday, 1/26/2026. During an observation and interview on 1/28/2026 at 3:25 PM, Resident #3 was observed in his room laying on the bed. His family member was also in the room. He and his family member revealed he had been at the facility for a short time. He originally stated he had not received a shower, but his family member corrected him stating he received a shower to which he agreed. He stated he was not sure if he had missed a shower. 4. Record review of Resident #4's admission record, printed on 1/27/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #4's 30-day Task record for ADL-Bathing reflected a preference of Tuesday. Thursday and Saturday Evening. Based on an admissions date of 12/10/2026, Resident #4 did not have a bath entry or refusal for a preferred date of Monday, 1/19/2026. During an observation and interview on 1/27/2026 at 4:15 PM, Resident #4 was observed in her room seated in a wheelchair watching television. She revealed she was able to take showers on her scheduled days and staff assisted her. She stated I pay for 3 times a week. I don't take bed baths, but I could. During an interview on 1/28/26 at 4:10 PM, CNA A revealed his responsibilities included assisting residents with showers and he was required to document showers on the POC chart. When a resident refused a shower, he revealed he would try to convince them but if they wouldn't, he would tell the nurse and document the refusal. During an interview on 1/28/26 at 3:55 PM, CNA B revealed her responsibilities included assisting residents with showers which she started after checking on every resident at the beginning of her shift. She revealed she was required to document showers and refusals. During an interview on 1/28/26 at 3:45 PM, CNA C revealed his responsibilities included providing residents with baths and she documented the task in EMR. When a resident refused a shower, she revealed she would document the refusal and tell the nurse after a number of refusals. During an interview on 1/28/26 at 4:30 PM, RN D revealed there should be a record for resident showers. She stated baths were documented in the POC, we have a schedule, and it should be documented. We try to accommodate PRN showers. During an interview on 1/28/26 at 4:20 PM, RN E revealed baths were documented every time. She stated, Families will sometimes ask if a resident looks un-showered or they are wearing the same clothes. Then we check EMR and if not documented, we have to ask the CNA. During an interview on 1/28/26 at 5:55 PM, the DON revealed reasons why a bath was not documented could be login issues, times of crisis like the recent freeze, and sometimes they didn't do it, but they should. During an interview on 1/28/26 at 5:45 PM, the ADMIN revealed 90% of entries that were not entered into the EMR were staff moving from task to task and losing track. He stated, in a perfect world, everything would be documented. Record review of the facility's Charting and Documentation policy reflected the following: Policy:Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Policy Explanation and Compliance Guidelines:1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.3. Documentation may be performed manually or as per the facility's specific electronic medical record software program.4. Principles of documentation include, but are not limited to:a. Documentation shall be factual, objective, and resident centered.i. False information shall not be documented.ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided.iii. Subjective information shall be recorded only as relevant, such as the resident's verbalizations, in quotation marks.b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.c. Documentation shall be timely and in chronological order.

Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #4) reviewed for quality of care. The facility failed to notify the physician when Resident #4 gained 3 pounds over night between the dates of 1/19/2026 and 1/20/2026) per the orders and facility policy. This failure could place residents at risk of harm, not receiving necessary medical care, and hospitalization.The findings include: Record review of Resident #2's admission Record, printed on 1/27/2026, reflected a [AGE] year-old female who was originally admitted on [DATE] and readmitted on [DATE]. Resident #2 had diagnoses which included heart failure (heart does not pump enough blood leading to fluid retention) and pneumonia (lung infection which may fill with fluid). Record review of Resident #2's Quarterly MDS Assessment, dated 12/19/2025, reflected the resident had a BIMS score of 8, which indicated she was moderately impaired. She had an active diagnosis of coronary artery disease (narrowing of the coronary arteries due to plaque build-up), heart failure, renal insufficiency (kidneys are not functioning properly to remove waste and maintain fluid balance) and pneumonia. Record review of Resident #2's Care Plan Report, dated as last care plan review initiated 12/10/2025, reflected the focus, Resident requests code status of DNR and intervention, Monitor for decrease in change of condition-report to MD and responsible party. The focus, The resident has altered cardiovascular status r/t CAD/HTN/Heart Failure and intervention, Weigh resident as order. Record review of Resident #2's Order Summary Report, printed on 1/28/2026 for Active Orders as of 1/28/2026, reflected Resident #4 had an order for Daily Weight one time a day related Heart Failure, Unspecified (150.9) Obtain weight every morning before breakfast. If the patient gains 3 lbs overnight or 5 lbs or more in one week, Notify the physician. Record review of Resident #2's Wts (Weights) Vitals tab in the EMR on 1/28/2026 at 19:28 (7:28 PM), reflected Resident #2 weighed 92.6 lbs. on 1/19/2026 and 96.6 lbs. on 1/20/2026 which resulted in a 4 lb. gain overnight. Record review of Resident #2's Progress Notes, dated 12/29/2026 to 1/29/2026 did not reveal a progress note related to the 3 lbs. or more weight gain overnight. A Nutrition Note with an effective date of 01/20/2026 at 13:21 (1:21 PM) reflected, Update-Weight and Wound. Current weight of 92.6# (01/19/2026). A Nursing-Skilled Note on 01/20/2026 at 14:02 (2:02 PM) stated . v/s (vitals) are wnl (within normal limits), no concerns noted at this time. During an observation and interview on 1/27/2026 at 4:15 PM, revealed Resident #4 was sitting in her wheelchair in front of the television with a bedside table in front of her. She was wearing clean clothes and appeared comfortable. Resident #4 stated the facility staff was able to care for her needs and did not really have any concerns about her stay. During an interview on 1/28/2026 at 6:00 PM, the DON stated Overall, the goal was for her to gain weight. We did not notify the MD when she had a 4 lb. gain. The congestive heart failure is the reason for the 3 lb. weight gain notification. She is going on hospice due to the weight loss she has experienced. Record review of the facility's Change of Condition Policy, with a date implemented of 10//2025, reflected: Policy:To identify and evaluate a change in condition and notify the Physician andResponsible Party when indicated.A significant change in Resident's status is any sign or symptom that is:Acute or sudden onsetA marked change (i.e., more severe) in relation to usual signs and symptomsNew or worsening symptomsExamples include but are not limited to the following: cardiovascular, respiratory,behavioral, fall with major injury, infection, dehydration, altered mental status,pressure injury and any other condition based on professional judgment.Procedure:When a change in condition occurs, the Licensed Nurse will:Evaluate the signs and symptoms the Resident is experiencing and collectpertinent information to report to the Physician on the Resident's status.A. Obtain vital signs, oxygen saturation and blood sugar, if indicated.B. Review recent labs, if indicated.C. Review Resident history and diagnosis, if indicated.D. Review list of medications the Resident has taken, if indicated.Notify the Physician of the change in condition and advanced directives.Document date, time Physician, Responsible Party was notified of findings from the evaluation and any new orders obtained.The Licensed Nurse will monitor and document the Resident's progress and response to orders given by Physician in the EMR.If it is determined that there is no improvement or resolution in the Resident's condition change, the nurse will notify the Physician for further guidance and document response in the EMR.If the Physician chooses to send the Resident to the hospital for further evaluation and treatment, the charge nurse will initiate the transfer process. Evaluation findings will be documented on the communication tool used to transition the Resident to the next level of care.The Resident's plan of care will be updated accordingly.

Based on observation, interview, and record review the facility failed to ensure correct use of bed rails and to assess the resident for risk of entrapment from bed rails for 3 of 6 Residents observed for the use of side rails (Resident #1, Resident #13 and Resident #340). 1. Nursing staff failed to obtain an informed consent and assess Resident's #1 for the use of 1/4 side rails. 2. Nursing staff failed to obtain an informed consent for Resident #13 for the use of 1/4 side rails. 3. Nursing staff failed to obtain an informed consent and to assess Resident #340 for the use of 1/4 side rails. These deficient practices could affect any resident with bed side rails and could cause avoidable accidents. The findings were: 1. Review of Resident #1's quarterly MDS assessment, dated 12/13/24 revealed he was admitted to the facility on [DATE] with diagnosis including non-traumatic brain dysfunction. His BIMS score was 12 of 15 reflective of moderate cognitive impairment and he required substantial to maximum assistance with bed mobility; roll left and right. Review of Resident #1's document for Assist Rail/Enabler Device: Informed Consent, dated 3/21/24 was not signed by either the Patient or Patient Representative. Review of Resident #1's physician orders for May 2025 revealed an order Quarter assist rails in place as an enabler as desired or needed. Alert MD of any noted complications of Quarter Assist Rail use. PR aware and in agreement with use. No directions specified for order. Other Active 3/20/2025. Review of Resident #1's Care Plan initiated 4/8/25 revealed Patient uses quarter assist rails(s)as enabler to assist with bed mobility and transfer. [Specify]: Assist Rail x 1 Left) Assist Rail x 1, (Right)Assist Rails x 2 Assist Rail(s) - Quarter Rail(s) required as enabler in order to promote as much independence as possible. Resident will be free of entrapment and injury while using quarter assist rail(s) as an enabler for the next 90 days. Complete Assist Rail/ Enabler Device assessment to determine appropriate use. Obtain Consent Assess prn with Change of Condition. Observation and interview on 05/08/25 at 02:15 PM revealed Resident #1 lying in bed on an air mattress. There were wedges between 1/4 SR and the mattress on both sides of the bed. Interview with Resident #1 revealed he was doing well. He stated the wedges between the mattress and SR were used to keep him upright. He stated he did not use the side rail and commented could put a rope through it. and then commented would both get tangled up. Resident #1 stated staff would get him up out of bed. Resident #1 presented as being pleasantly confused. Interview on 05/08/25 at 03:25 PM with LVN/Unit Manager D revealed Residents who used side ails required a consent and assessment for use of side rails. She stated Resident #1 used 1/4 side rails but had experienced a decline in mentation/overall condition in the last several months. She stated Resident #1 was able to hold on to the side rails but was not able to use them for bed mobility. He required total assistance for bed mobility and repositioning. The ADON stated at this point the side ails would not be beneficial for Resident #1. The ADON stated nursing staff should re-assess Residents every 3 months for the use of side rails to ensure they could use the side rails safely to avoid accidents. She commented, that's my fault because I haven't done it; reassessed Resident #1. Unit Manager D stated she was responsible for ensuring Residents were assessed every 3 months. Further interview revealed, upon reviewing Resident #1's informed consent, it was not signed it; therefore, the consent was not valid. She stated it had to be signed and in place prior to the use of side rails. 2. Review of Resident #13's face sheet, dated 5/9/25, revealed she was admitted to the facility on [DATE] with diagnosis including unspecified Dementia. Review of Resident #13's re-entry MDS, dated [DATE], revealed her BIMS score was 10 of 15 reflective of moderate cognitive impairment and she required she required partial to moderate assistance by staff for bed mobility; roll left and right. Review of Resident #13's Care Plan initiated 4/8/25 revealed Patient uses quarter assist rails(s)as enabler to assist with bed mobility and transfer. [Specify]: Assist Rail x 1 Left) Assist Rail x 1, (Right)Assist Rails x 2 Assist Rail(s) - Quarter Rail(s) required as enabler in order to promote as much independence as possible. Resident will be free of entrapment and injury while using quarter assist rail(s) as an enabler for the next 90 days. Complete Assist Rail/ Enabler Device assessment to determine appropriate use. Obtain Consent Assess prn with Change of Condition. Review of Resident #13's document for Assist Rail/Enabler Device: Informed Consent, dated 12/13/24 was not signed by either the Patient or Patient Representative. Interview on 05/08/25 at 03:25 PM with Unit Manager D revealed, upon reviewing Resident #13's informed consent, the family representative had not signed it; therefore, the consent was not valid. She stated it had to be signed and in place prior to the use of side ails. 3. Review of Resident #340's face sheet, dated 5/9/25, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified Dementia and Unspecified Fracture Of Left Femur, Subsequent Encounter for closed fracture with routine healing, Review of Resident #340's initial assessment, dated 5/3/25, revealed he required assistance with bed mobility: c. Limited to extensive assist- assist x1-2. Intervention: BED MOBILITY: The resident requires assistance x1 or x2 staff to turn and reposition in bed. This may fluctuate with weakness and fatigue.' Review of Resident #340's BIMS assessment, dated 5/7/25, revealed his score was 9 of 15 reflective of moderate cognitive impairment. Review of Resident #340 electronic health record revealed there was not a consent or assessment for the use of 1/4 side rails. Observation and interview on 05/06/25 at 11:37 AM revealed Resident #340 lying in bed watching TV. Noted 1/4 side rails were up on both sides of the bed. Resident #340 stated staff helped him reposition in bed and he would hold on to the side rails. Interview on 05/08/25 at 03:25 PM with Unit Manager D revealed an informed consent had not been obtained for the use of side rails for Resident #340. She stated nursing staff had also not assessed Resident #340 to ensure he was safe to use the side rails. Review of facility policy, Proper Use of Side Rails, undated, revealed Purpose: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility. b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet. c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan.

Based on observations, interviews, and record reviews the facility failed to provide an assessment that accurately reflected the resident's status for 1 (Resident #26) of 32 residents reviewed for assessment accuracy. The facility failed to reflect Resident #26 used a Bipap machine (bilevel positive airway pressure device or Type of respiratory support therapy that uses positive air pressure to help individuals breathe, especially individuals who have sleep apnea (a condition that affects breathing at night) or other respiratory conditions) machine on her admission MDS. This failure placed Residents at risk of having inaccurate assesments to include those who need a bipap machine at night, that could lead to Residents careplan not being correct and Resident not recieving care as needed. The findings included: Record review of Resident # 26's EMR and face sheet dated 05/07/2025 reflected she was admitted to the facility on [DATE]. Her diagnoses included: displaced bicondylar fracture of right tibia (the shinbone is broken in two parts affecting both the medial and lateral bumps and the fragments are out of alignment), diabetes (a chronic condition where the body either does not produce enough insulin or cannot use the insulin it produces), morbid obesity (a severe form of obesity defined by a body mass index of 40 or higher with related health complications), and shortness of breath (difficulty breathing or feeling of not getting enough air) Record review of Resident #26's admission MDS assessment dated [DATE] reflected she was admitted from a short-term general hospital. She could understand others and be understood. She scored a 15/15 on her BIMS which signified she was cognitively intact. She had impairment of her upper extremity but could ambulate with a walker. Resident #26 required moderate assistance from staff with her ADL's. She was continent of bowel and bladder. Resident #26's Bipap was not reflected. Record review of Resident #26's comprehensive care plan date initiated 04/23/2025 and revised on 05/02/2025 reflected Focus, resident has an ADL self-care performance deficit r/t GENERALIZED WEAKNESS. Record review of Resident #26's Order Summer Report, Active as of: 05/07/2025 did not reflect a physician's order for bipap. Record review of Resident #26's NURSING-Skilled Assessment-V2 dated 04/28/2025 reflected 4. Require use of CPAP, BIPAP or Trilogy? and Yes was checked. Record review of Resident #26's Skilled Nursing Note dated 04/27/2025 reflected Wears CPAP at bedtime. Observation on 05/06/2025 at 11:00 am revealed Resident #26 was in her room lying in bed with a Bipap machine on her bedside stand with the connected tubing and mask closed in the top drawer. Interview on 05/06/2025 at 11:02 am with Resident #26, she stated she used the Bipap at night and brought it with her from the hospital. She stated she needed the Bipap at night for extra oxygen and she used it every night. She stated she would put the Bipap mask on herself and the settings were preset so all she had to do was turn on the machine. Observation on 05/07/2025 at 10:00 am of Resident #26 in her room revealed lying on her bed and a Bipap machine was on her bedside stand. Observation on 5/08/2025 at 09:00 am of Resident #26 revealed she was in her room, lying on her bed and a Bipap machine was on her bedside stand. Interview on 05/07/2025 at 4:30 pm with the DON in her office, she stated Resident #26's Bipap was considered a treatment and she was not aware it was not reflected on her admission MDS. She stated without the accurate reflection of what Resident #26's needs were, she was at risk for inadequate care. Interview on 05/08/2025 at 12:10 pm with LVN A, who was the charge nurse on Resident #26's hall, she stated Resident #26 had a Bipap and used it every night. Interview on 05/09/2025 at 1:27 pm with the MDS nurse revealed, she was not aware Resident #26 had used Bipap and it was not reflected on her admission MDS assessment. She stated not having her needs reflected could result in missed care. Interview on 05/09/2025 at 2:00 pm with the ADM who was accountable for the MDS's, he stated he was not aware Resident #26's Bipap was not reflected on her admission MDS, and the MDS needed to accurately reflect the residents care and needs, or they could be missed, and the resident would not have her health needs met. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, October 2023 reflected The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status.

Based on observations, interviews and record reviews, the facility failed to ensure that the comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 (Resident #26) of 32 residents reviewed for comprehensive care plans. The facility failed to reflect Resident #26 used a Bipap machine (bilevel positive airway pressure device or Type of respiratory support therapy that uses positive air pressure to help individuals breathe, especially individuals who have sleep apnea (a condition that affects breathing at night) or other respiratory conditions) machine and Resident #26's shortness of breath diagnosis was not reflected on her comprehensive care plan. This failure affects residents who need a bipap machine at night and could result in lack of oxygen to the brain. The findings included: Record review of Resident # 26's EMR and face sheet dated 05/07/2025 reflected she was admitted to the facility on [DATE]. Her diagnoses included: displaced bicondylar fracture of right tibia (the shinbone is broken in two parts affecting both the medial and lateral bumps and the fragments are out of alignment), diabetes (a chronic condition where the body either does not produce enough insulin or cannot use the insulin it produces), morbid obesity (a severe form of obesity defined by a body mass index of 40 or higher with related health complications), and shortness of breath (difficulty breathing or feeling of not getting enough air) Record review of Resident #26's admission MDS assessment dated [DATE] reflected she was admitted from a short-term general hospital. She could understand others and be understood. She scored a 15/15 on her BIMS which signified she was cognitively intact. She had impairment of her upper extremity but could ambulate with a walker. Resident #26 required moderate assistance from staff with her ADL's, and she was continent of bowel and bladder. Resident #26's Bipap was not reflected on the MDS. Record review of Resident #26's comprehensive care plan date initiated 04/23/2025 and revised on 05/02/2025 reflected Focus, resident has an ADL self-care performance deficit r/t GENERALIZED WEAKNESS. Resident #26's Bipap was not reflected on the comprehensive care plan. Record review of Resident #26's Order Summer Report, Active as of: 05/07/2025 did not reflect a physician's order for bipap. Record review of Resident #26's NURSING-Skilled Assessment-V2 dated 04/28/2025 reflected 4. Require use of CPAP, BIPAP or Trilogy? and Yes was checked. Record review of Resident #26's Skilled Nursing Note dated 04/27/2025 reflected Wears CPAP at bedtime. Observation on 05/06/2025 at 11:00 am revealed Resident #26 was in her room lying in bed with a Bipap machine on her bedside stand with the connected tubing and mask closed in the top drawer. Interview on 05/06/2025 at 11:02 am with Resident #26, she stated she used the Bipap at night and brought it with her from the hospital. She stated she needed the Bipap at night for extra oxygen and she used it every night. She stated she would put the Bipap mask on herself and the settings were preset so all she had to do was turn on the machine. Observation on 05/07/2025 at 10:00 am of Resident #26 in her room revealed lying on her bed and a Bipap machine was on her bedside stand. Observation on 5/08/2025 at 09:00 am of Resident #26 revealed she was in her room, lying on her bed and a Bipap machine was on her bedside stand. Interview on 05/07/2025 at 4:30 pm with the DON in her office, she stated Resident #26's Bipap needed to be reflected on her care plan to show she needed the supplemental oxygen at night, or it could be missed and result in hypoxia (low oxygen levels). Interview on 05/08/2025 at 12:10 pm with LVN A, who was the charge nurse on Resident #26's hall, she stated Resident #26 had a Bipap and used it every night. Interview on 05/08/2025 at 2:45 pm with LVN B, who was the nurse who admitted Resident #26, she stated she did not know Resident #26 had a Bipap machine and thought someone may have brought it into the facility for her the next day. She stated she was aware Resident #26 used Bipap at night. She stated Resident #26's comprehensive care plan needed to reflect her needs or care could be missed. Interview on 05/09/2025 at 1:27 pm with the MDS nurse revealed, she was not aware Resident #26 had used Bipap and it was not reflected on her comprehensive care plan. She stated not having her needs reflected on her care plan could result in missed care. Record review of the facility policy and procedure titled Care Plans-Comprehensive revised dated September 2010 reflected An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.

Based on interviews and record reviews, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one Resident (Resident #294) of 4 Residents reviewed for pressure sore management. 1. LVN C failed to document an accurate skin assessment for Resident #294 on 05/08/2025. This failurecould place Resident at risk on not recieving appropriate care leading to worsening of skin condition. The findings included: 1. Record review of Resident #294's EMR, electronic face sheet dated 05/03/2025 reflected she was admitted to the facility on [DATE]. Her diagnoses included: fracture of upper end of right humerus (break or crack in the bone located at the upper part of the arm near the shoulder joint), fracture of lower end of left radius (bone in forearm breaks near the wrist joint), chronic kidney disease (moderate decrease in kidney function), diabetes mellitus (group of diseases that affect how the body uses blood sugar) and edema (swelling caused by excess fluid trapped in the body's tissues). Review of Resident #294's EMR revealed Resident #294 was not at the facility long enough for an admission MDS assessment. Record review of Resident #294's comprehensive care plan initiated on 05/03/2025 reflected Focus, resident has a pressure ulcer, Interventions, administer treatments as ordered and monitor for effectiveness. Record review of Resident #294's Active Orders As of: 05/09/2025 reflected Right Buttock (Stage 3))-cleanse with wound cleaner/Ns, pat dry. Apply triad (unique wound care product that combines the benefits of a protective ointment and a moisture barrier cream. This cream is zinc oxide based). to affected area, and cover with DD, day shift, Monday, Wednesday, and Friday for Sacrum (a triangular bone at the base of the spinal column that connects with or forms a part of the pelvis), The wound order was dated 05/05/2025. Record review of the facility pressure sore log dated 05/07/2025 reflected Resident #294 had a Stage 3 pressure sore to the sacrum and date of onset was 05/03/2025 her day of admission. Record review of Resident #294's TAR dated May 2025 reflected she received the ordered wound treatment for her sacrum on Monday, 05/05/2025 and Wednesday, 05/07/2025. Record review of an assessment for Resident #294 by LVN C, completed dated 05/08/2025 reflected SECTION 4. Integumentary/Infection Status under Skin, wounds present was marked a no. In an interview on 05/9/2025 at 1:10 pm with LVN C, she stated she made a mistake by marking no to wounds on Resident #294's nursing assessment. She stated proper documentation in resident records was important because the record was reviewed by other providers and could affect the resident's care negatively. She stated she knew Resident #294 had a wound. In an interview on 05/09/2025 at 1:20 pm with the DON, she stated documentation and assessments needed to be accurate and was a professional standard due to the importance of correct health information being passed between care providers and could result in a negative outcome such as a wound not being treated due to a documentation problem. Review of the facility policy and procedure titled Physician Orders revised January 2020 reflected Physician orders include b. Treatments, Medications, diets, therapy, or any treatment may not be administered to the patient without a written order from the attending physician.

Based on observation, interviews and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 resident (Resident #293) of 32 residents reviewed for safe environments. The facility failed to ensure Resident #293 did not have flammable materials near her oxygen. This deficient practice places residents on oxygen therapy at risk for burns. The findings included: Record review of Resident #293's EMR, electronic face sheet dated 05/08/2025 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hemiplegia and hemiparesis (neurological conditions resulting from stroke or other brain damage, affecting one side of body. Hemiplegia is complete paralysis, while hemiparesis is weakness or impaired movement.) following cerebral infarction, (a type of stroke where blood supply to the brain is disrupted) acute respiratory failure with hypoxia (a condition where the lungs fail to adequately transfer oxygen into the blood, leading to low oxygen levels and potentially tissue hypoxia), diabetes mellitus (a chronic metabolic disorder characterized by persistently high blood sugar levels), neuromuscular dysfunction of bladder (arises from damage or malformation of nerves controlling the bladder) and allergic rhinitis (an allergy that causes inflammation of the nose and nasal passages). Record review of Resident #293's admission MDS assessment dated [DATE] reflected she could understand others and be understood. She scored a 06/15 on her BIMS which signified she was severely cognitively impaired. She used a walker or manual wheelchair for locomotion. Resident #293 required extensive assistance with ADL's. She had shortness of breath and trouble breathing when lying flat. She received oxygen therapy while at the facility. Record review of Resident #293's comprehensive care plan initiated on 04/25/2025 and revised on 05/06/2025 reflected Focus, resident has oxygen therapy as needed, intervention, provide oxygen as ordered. Record review of Resident #293's Order Summer Report, Active as of: 05/08/2025 reflected Oxygen at 2L per nasal cannula as needed, order active as of 05/06/2025. Observation on 05/06/2025 at 11:10 am revealed Resident #293 in her room lying in bed. Oxygen was infusing at 2L/min via nasal cannula. A tube of Carmex lip balm was on her bedside table and the igredients listed for the Carmex lip balm included 45.3% of white petrolatum. In an interview on 05/06/2025 at 11:11 am with Resident #293, she stated she used the Carmex and lathered it onto her lips for moisture. In an interview on 05/07/2025 at 4:30 pm with the DON in her office, she stated Resident #293 should not have the Carmex while she was administered oxygen. She stated she did not know why someone had not checked the tube of lip balm. She stated oxygen can react with oily substances and could cause burns. In an interview on 05/08/2025 at 12:10 pm with LVN A revealed she had started work at the facility recently and was not aware Resident #293's lip balm was flammable, or she would have taken it out of the resident's room and found a non-flammable alternate. Record review of facility policy and procedure titled Oxygen Administration, revised October 2010 reflected 20. Instruct the resident, his/her family, visitors, and roommate (if any) of the oxygen safety precautions. Provide the resident with a written copy of the Oxygen Safety handout. Record review of the NFPA oxygen handout titled Medical Oxygen Safety dated 2016, reflected Safety Tips, Body oil, hand lotion and items containing oil and grease can easily ignite. Keep oil and grease away from oxygen in use.

Based on observation, interviews and record reviews the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 1 resident (Resident #26) out of 3 residents observed for respiratory therapy. The facility failed to obtain physician orders for Resident #26's Bipap she used each night at the facility since her admission on 04/23/2025. This failure place residents who reside at the facility at risk for inaccurate care and communication of health conditions to other providers. The findings included: Record review of Resident # 26's EMR and face sheet dated 05/07/2025 reflected she was admitted to the facility on [DATE]. Her diagnoses included: displaced bicondylar fracture of right tibia (the shinbone is broken in two parts affecting both the medial and lateral bumps and the fragments are out of alignment), diabetes (a chronic condition where the body either does not produce enough insulin or cannot use the insulin it produces), morbid obesity (a severe form of obesity defined by a body mass index of 40 or higher with related health complications), and shortness of breath (difficulty breathing or feeling of not getting enough air) Record review of Resident #26's admission MDS assessment dated [DATE] reflected she was admitted from a short-term general hospital. She could understand others and be understood. She scored a 15/15 on her BIMS which signified she was cognitively intact. She had impairment of her upper extremity but could ambulate with a walker. Resident #26 required moderate assistance from staff with her ADLs. She was continent of bowel and bladder. Resident #26's Bipap machine was not reflected. Record review of Resident #26's comprehensive care plan date initiated 04/23/2025 and revised on 05/02/2025 reflected Focus, resident has an ADL self-care performance deficit r/t GENERALIZED WEAKNESS. Record review of Resident #26's Order Summer Report, Active as of: 05/07/2025 did not reflect a physician's order for bipap. Record review of Resident #26's NURSING-Skilled Assessment-Version 2 dated 04/28/2025 reflected 4. Require use of CPAP, BIPAP or Trilogy? and Yes was checked. Record review of Resident #26's Skilled Nursing Note dated 04/27/2025 reflected Wears CPAP at bedtime. Observation on 05/06/2025 at 11:00 am revealed Resident #26 was in her room lying in bed with a Bipap machine on her bedside nightstand with the connected tubing and mask closed in the top drawer. Interview on 05/06/2025 at 11:02 am with Resident #26, she stated she used the Bipap at night and brought it with her from the hospital. She stated she needed the Bipap at night for extra oxygen and she used it every night. She stated she would put the Bipap mask on herself and the settings were preset so all she did was turn on the machine. Observation on 05/07/2025 at 10:00 am of Resident #26 in her room revealed her lying on her bed and a Bipap machine was on her bedside stand. Observation on 5/08/2025 at 09:00 am of Resident #26 revealed she was in her room, lying on her bed and a Bipap machine was on her bedside stand. In an interview on 05/07/2025 at 4:30 pm with the DON in her office, she stated Resident #26 needed a physician's order for her Bipap and she did not know why it was not obtained when she was admitted . She stated without a physician's order, the treatment could be given at the wrong setting or time and cause discomfort or hypoxia. She stated the Bipap needed to have a physician's order which was considered professional standards for any treatment. In an interview on 05/08/2025 at 12:10 pm with LVN A, who was the charge nurse on Resident #26's hall, she stated Resident #26 had a Bipap and used it every night. In an interview on 05/08/2025 at 2:45 pm with LVN B, who was the nurse who admitted Resident #26, she stated she did not know Resident #26 had a Bipap machine and thought someone may have brought it into the facility for her the next day. She stated she was aware Resident #26 used Bipap at night but was not aware there was not a physician's order. She did not know how it was missed. She stated nursing staff provided care IAW physician orders. She did not know how it was missed. She stated IAW professional standards of practice, a physician's order was required for treatments such as a Bipap. She stated the wrong settings could cause too little or too much supplemental oxygen and result in discomfort. Review of the facility policy and procedure titled Physician Orders revised January 2020 reflected Physician orders include b. Treatments, Medications, diets, therapy, or any treatment may not be administered to the patient without a written order from the attending physician.

Based on interview and record review the facility failed to ensure the residents were seen by a physician at least at least once every 60 days for 2 of 6 Residents (Resident #2 and Resident 92) whose records were reviewed for physician visits. 1. The facility failed to ensure Resident #2's primary care physician met with Resident #2 as required. 2. The facility failed to ensure Resident #92's primary care physician met with Resident #92 as required. This deficient practice could affect any resident and could contribute to the resident's medical needs not being addressed or met. The findings were: 1. Review of Resident #2's face sheet, dated 5/9/25, revealed he was admitted to the facility on [DATE] with diagnoses including Epilepsy and personal history of Traumatic Brain Injury. Review of Resident #2's quarterly MDS assessment, dated 4/14/25, revealed his BIMS was 11 of 15 reflective of moderate cognitive impairment. Review of Resident #2's electronic health record including physician progress notes from December 2024 to May 2025 revealed there was no documentation from the PCP that he had visited Resident #2 for the last 6 months. Review of Resident #2's last health visit, dated 2/26/25, revealed a FNP had seen him. Interview with the DON on 05/09/25 01:50 PM revealed she did not find documentation to support Resident #2's primary care physician had seen Resident #2 most recently. She provided a progress note from a FNP, dated 2/26/25, and stated it was the last heath visit for Resident #2. The DON stated she did not believe there was a potential for a negative outcome because the NP visited regularly, However, stated she understood the primary care physician was ultimately responsible for Resident #2 healthcare and had an obligation to see Resident #2 at least every 60 days. 2. Review of Resident #92's significant MDS assessment, dated 4/15/25, revealed she was admitted to the facility on [DATE] with diagnoses including, Cancer and CVA (Cerebral Vascular Accident), her BIMS was 15 of 15 reflective she did not have cognitive impairment. Review of Resident #92's electronic health record including physician progress notes from December 2024 to May 2025 revealed there was no documentation from the PCP that he had visited Resident #92 for the last 6 months. Review of Resident #92's last health visit, dated 2/26/25, revealed a FNP had seen her. Interview with the DON on 05/09/25 01:50 PM revealed she did not find documentation to support Resident #92's primary care physician had seen Resident #92 most recently. She provided a progress note from a FNP, dated 2/26/25, and stated it was the last heath visit for Resident #92. The DON stated she did not believe there was a potential for a negative outcome because the NP visited regularly, However, stated she understood the primary care physician was ultimately responsible for Resident #92 healthcare and had an obligation to see Resident #92 at least every 60 days. Review of facility policy, Physician Visits revised April 2013, revealed The attending physician must make visits in accordance with applicable state and federal regulations. 1. The attending physician [NAME] visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. 2. The attending physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter.

Based on observations, interview, and record reviews, the facility failed to provide pharmaceutical services to administer drugs and biologicals that meet the needs of each resident for 2 of 5 medication carts (Cart #1 and #2 on 800 hall) observed and for 1 of 2 medication rooms ([NAME] Hall) observed. 1.The facility failed to remove expired medications from medication cart #1 and medication cart #2 on the 800 hall. 2. The facility failed to remove expired medication from the medication room on the [NAME] hall. These failures could place residents at risk of decreased therapeutic response and illness from expired medications. The findings included: Observation of the medication rooms on 5/7/2025 at 9:45AM revealed the [NAME] Unit medication room had an open box of Preparation H with a label expiration date of 5/2024. Observation of medication carts on 5/7/2025 at 10:00AM revealed medication carts #1 had 5 over the counter medications that were opened and were used. Record review of the 5 labels revealed the dates were expired: 1. Geridryl 25mg had a label expiration date of 1/2025; 2. Meclizine 12.5mg had a label expiration date of 2/2025; 3. Glucosamine Relief 500mg had a label expiration date of 1/2025; 4. Heart Burn Relief (Famotidine 20mg) had a label expiration date of 11/2024 and; 5. Aspirin 325mg had a label expiration date of 2/2025. Observation of medication cart #2 revealed 1 over the counter expired medication- Sodium Bicarbonate had a label expiration date of 2/2025. Interview on 5/9/2025 at 1:04PM the DON said expired medications may not be effective, could interact with other medications in a negative way, and could cause residents to become ill if they took expired medications. She said expired medications should not be on the carts or in the medication room for administration. Record review of the facility policy statement titled Storage of Medications revised April 2007 stated, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observations, interviews and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 (Residents #26 and #293) of 32 residents observed for medication safety and security. 1. The facility failed to store Resident #26's Flonase (allergy nasal spray) in the medication cart and the medication was left on Resident #26's bedside table. 2. The facility failed to store Resident #293's Flonase (allergy nasal spray) in the medication cart and the medication was left on Resident #293's bedside table. These failures could result in , access to medications by unauthorized persons, and could result in decreased health response or misuse of medication. The findings included: 1. Record review of Resident # 26's EMR and face sheet dated 05/07/2025 reflected she was admitted to the facility on [DATE]. Her diagnoses included: displaced bicondylar fracture of right tibia (the shinbone is broken in two parts affecting both the medial and lateral bumps and the fragments are out of alignment), diabetes (a chronic condition where the body either does not produce enough insulin or cannot use the insulin it produces), morbid obesity (a severe form of obesity defined by a body mass index of 40 or higher with related health complications), allergic rhinitis (an allergic reaction that causes inflammation in the nasal passages and other symptoms like sneezing, runny nose, and itchy eyes) and shortness of breath (difficulty breathing or feeling of not getting enough air) Record review of Resident #26's admission MDS assessment dated [DATE] reflected she was admitted from a short-term general hospital. She could understand others and be understood. She scored a 15/15 on her BIMS which signified she was cognitively intact. She had impairment of her upper extremity but could ambulate with a walker. Resident #26 required moderate assistance from staff with her ADLs. She was continent of bowel and bladder. Record review of Resident #26's comprehensive care plan date initiated 04/23/2025 and revised on 05/02/2025 reflected Focus, resident has an ADL self-care performance deficit r/t GENERALIZED WEAKNESS. Record review of Resident #26's Order Summer Report, Active as of: 05/07/2025 reflected Flonase Allergy Relief Nasal Suspension 50 MCG/ACT, 2 sprays in both nostrils two times a day related to Allergic Rhinitis. The active date on the order was Resident #26's admitted [DATE]. Record review of Resident #26's MAR reflected Resident #26 received Flonase each day at 08:00 am. Observation on 05/06/2025 at 11:00 am revealed Resident #26 in her room lying in bed. A prescription bottle of Flonase was on her bedside table. In an interview on 05/06/2025 at 11:03 am with Resident #26, she stated the nurse left the Flonase at her bedside and then the nurse would place the Flonase in her top dresser drawer. She stated she gave herself the nasal spray with the nurse present. Observation on 05/07/2025 at 10:00 am of Resident #26 in her room revealed her lying on her bed. There was no Flonase on her bedside table. In an interview on 05/07/2025 at 4:15 pm with Resident #26, she stated her nurse placed the prescribed Flonase in her top dresser drawer. Observation on 05/07/2025 at 4:15 pm revealed a bottle of prescribed Flonase was inside of Resident #26's top dresser drawer. Record review of the prescribed Flonase bottle located in Resident #26's top dresser drawer reflected the medication was prescribed for Resident #26. In an interview on 05/07/2025 at 4:30 pm with the DON in her office, she stated Resident #26' s Flonase was supposed to be locked in the medication cart because she did not have an order to keep it in her room or to self-medicate. She stated she was accountable for the nursing care at the facility, and nurses are trained not to leave medications at the bedside or store them in a resident's room. She stated the resident could use too much of the medication and have health complications or someone else could have access to the medication. In an interview on 05/08/2025 at 12:10 pm with LVN A revealed Resident #26's Flonase was at the resident's bedside the whole week she had worked. She stated she assumed Resident #26 could self-medicate, but never checked the resident's records or physician orders. She stated she was trained not to leave medications at the bedside because they would be available to others, or the resident could use too much causing harm. She stated she placed Resident #26's Flonase in the top dresser drawer in her room to keep it out of sight of others, and so the resident could not get it. 2. Record review of Resident #293's EMR, electronic face sheet dated 05/08/2025 reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: hemiplegia and hemiparesis (neurological conditions resulting from stroke or other brain damage, affecting one side of body. Hemiplegia is complete paralysis, while hemiparesis is weakness or impaired movement.) following cerebral infarction, (a type of stroke where blood supply to the brain is disrupted) acute respiratory failure with hypoxia (a condition where the lungs fail to adequately transfer oxygen into the blood, leading to low oxygen levels and potentially tissue hypoxia), diabetes mellitus (a chronic metabolic disorder characterized by persistently high blood sugar levels), neuromuscular dysfunction of bladder (arises from damage or malformation of nerves controlling the bladder) and allergic rhinitis (an allergy that causes inflammation of the nose and nasal passages). Record review of Resident #293's admission MDS assessment dated [DATE] reflected she could understand others and be understood. She scored a 06/15 on her BIMS which signified she was severely cognitively impaired. She used a walker or manual wheelchair for locomotion. Resident #293 required extensive assistance with ADLs. She had shortness of breath and trouble breathing when lying flat. She received oxygen therapy while at the facility. Record review of Resident #293's comprehensive care plan initiated on 04/25/2025 and revised on 05/06/2025 reflected Focus, resident has an ADL, self-care performance deficit r/t GENERALIZED WEAKNESS. Record review of Resident #293's Order Summer Report, Active as of: 05/08/2025 reflected Fluticasone Propionate Suspension 50 MCG/ACT, 1 spray in both nostrils two times a day related to Allergic Rhinitis. The active date on the order was Resident #293's initial admitted [DATE]. Record review of Resident #293's MAR reflected Resident #293 received Flonase each day at 08:00 am. Observation on 05/06/2025 at 11:10 am revealed Resident #293 in her room lying in bed. Oxygen was infusing via nasal canula. A prescription bottle of Flonase was on her bedside table. Interview on 05/06/2025 at 11:11 am with Resident #293, she stated the nurse left the Flonase at her bedside and then the nurse would place the Flonase in her top dresser drawer. Observation on 05/07/2025 at 4:17 pm revealed a bottle of prescribed Flonase was inside Resident #293's top dresser drawer. Record review of the prescribed Flonase bottle located in Resident #293's top dresser drawer reflected the medication was prescribed for Resident #293. Interview on 05/07/2025 at 4:30 pm with the DON in her office, she stated Resident #293' s Flonase was supposed to be locked in the medication cart because she did not have an order to keep it in her room or to self-medicate. Interview on 05/08/2025 at 12:10 pm with LVN A revealed Resident #293's Flonase was at the resident's bedside the whole week she had worked. She stated she assumed Resident #293 could self-medicate, but never checked the resident's records or physician orders. She stated she placed Resident #293's Flonase in the top dresser drawer in her room to keep it out of sight of others. Record review of the facility policy statement titled Storage of Medications revised April 2007 reflected The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .the nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.

Based on observation, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #294) of 32 residents reviewed for EBP. The facility failed to establish EBP for Resident #294 when she had an open sacral wound with a dressing. This facility failure affects residents with open wounds, or other requirements for EBP, and could result in MDRO contamination. The findings included: Record review of Resident #294's EMR, electronic face sheet dated 05/03/2025 reflected she was admitted to the facility on [DATE]. Her diagnoses included: fracture of upper end of right humerus (break or crack in the bone located at the upper part of the arm near the shoulder joint), fracture of lower end of left radius (bone in forearm breaks near the wrist joint), chronic kidney disease (moderate decrease in kidney function), diabetes mellitus (group of diseases that affect how the body uses blood sugar) and edema (swelling caused by excess fluid trapped in the body's tissues). Record review of Resident #294's EMR revealed Resident #294 was not at the facility long enough for an admission MDS assessment. Record review of Resident #294's comprehensive care plan initiated on 05/03/2025 reflected Focus, resident has a pressure ulcer, Interventions, administer treatments as ordered and monitor for effectiveness. Record review of Resident #294's Active Orders As of: 05/09/2025 reflected Right Buttock, Stage 3, cleanse with wound cleaner/Ns, pat dry. Apply triad (unique wound care product that combines the benefits of a protective ointment and a moisture barrier cream. This cream is zinc oxide based). to affected area, and cover with DD, day shift, Monday, Wednesday, and Friday for Sacrum (a triangular bone at the base of the spinal column that connects with or forms a part of the pelvis), The wound order was dated 05/05/2025. Record review of the facility pressure sore log dated 05/07/2025 reflected Resident #294 had a Stage III pressure sore to the sacrum and date of onset was 05/03/2025 her day of admission. Record review of Resident #294's TAR dated May 2025 reflected she received the ordered wound treatment for her sacrum on Monday, 05/05/2025 and Wednesday, 05/07/2025. Observation on 05/09/2025 at 11:30 am of Resident #294's wound care to her sacrum provided by the Treatment Nurse. Prior to entering Resident #294's room, the surveyor questioned the TX nurse why Resident #294 did not have EBP in place because she had a wound with a dressing. No signage was seen on her door and no bin was present by her room with PPE. In an interview on 05/09/2025 at 11:32 am with the TX Nurse, she stated Resident #294's wound did not have drainage, and she did not know open wounds with dressings required EBP. Record review of an EBP sign on a door across the hall from Resident #294's room for a resident on EBP reflected: STOP, ENHANCED BARRIER PRECAUTIONS, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities .Wound Care any skin opening requiring a dressing. Interview on 05/09/2025 at 4:30 pm with the DON revealed she was not aware Resident #294 was not on EBP because of her open wound which required a dressing. She stated staff was trained and she felt the facility overall did a great job and recognized residents who needed to be on EBP. She stated EBP was important to prevent cross contamination or development of MDROs for susceptible residents with open skin areas. Record review of staff in-service on EBP dated 3/19/2025 reflected the Treatment Nurse received training that covered the need for signage and precautions. Record review of the facility policy statement titled Enhanced Barrier Precautions dated August 2022 reflected Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents,.EBPs are indicated with the following: Wound care (any skin opening requiring a dressing).

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 of 15 residents (Residents #1 and Resident #2) reviewed for medical records. 1. The facility failed to ensure Resident #1's physician's orders dated 02/27/25 were updated to include the resident no longer received wound treatment to a stage 2 wound to her sacrum (triangular bone on the lower back) to include LVN A signing off for completing these treatments from March 17th to the 19th 2025. 2. The facility failed to ensure Resident #2's physician's orders dated 01/24/25 were updated to include the resident no longer received wound treatment to DTI area to his left heel to include LVN A signing off for completing these treatments from March 17th to the 19th 2025. These deficient practices could place residents at risk of improper care due to inaccurate medical records. The findings included: 1. Record review of Resident #1's face sheet, dated 03/20/25 reflected a [AGE] year-old female with diagnoses to include need for assistance with personal care, limitation of activities due to disability, and unspecified lack of coordination. Record review of Resident #1's admission MDS assessment, dated 03/02/25, reflected a BIMS score of 12 out of 15, indicating moderately impaired cognition. Record review of Resident #1's March 2025 Physician Order Sheet, dated, 03/20/25, reflected Wound Treatment-Collagen, Notes: Cleanse Stage 2 wound to Sacrum with Normal Saline or Skin Cleanser. Pat Dry. Apply Collagen to wound bed. Cover with Dry Dressing . with order date 02/27/25. Record review of Resident #1's March 2025 Treatments Administration record, dated 03/19/25, reflected Wound Treatment-Collagen One Time Daily Starting 02/27/25 . Cleanse Stage 2 wound to Sacrum with Normal Saline or Skin Cleanser, Pat Dry. Apply Collagen to wound bed. Cover with Dry Dressing . with Day Treatments signed off by nurses from March 1st to March 19th to include LVN A signing off for completing these treatments from March 17th to the 19th. Interview and observation on 03/19/25 at 1:30 PM, Resident #1 revealed there was no treatment done to her lower back. Resident #1 showed this area and there was no wound nor bandages to this area. Interview on 03/20/25 at 11:15 AM, CNA E revealed she provided care to Resident #1 and Resident #1 did not have any wounds to her sacrum and there was no wound treatment done for this resident. Interview on 03/20/25 at 12:52 PM, LVN A revealed Resident #1 no longer had a stage 2 wound on her sacrum as it was healed and said the physician's order for wound treatment needed to be discontinued. She revealed it was important to follow physician's orders to provide appropriate resident care. She further revealed she did not know when Resident #1's wounds healed. 2. Record review of Resident #2's face sheet, dated 03/20/25 reflected a [AGE] year-old male with diagnoses to include need for assistance with personal care, limitation of activities due to disability, and cognitive communication deficit. Record review of Resident #2's admission MDS assessment, dated 03/02/25, reflected a BIMS score of 06 out of 15, indicating severely impaired cognition. Record review of Resident #2's March 2025 Physician Order Sheet, dated, 03/20/25, reflected Wound Treatment-Skin Prep, Notes: Cleanse DTI area to Left heel with Normal Saline or Skin Cleanser. Pat Dry. Apply Skin Prep to affected area. Cover with Dry Dressing . with order date 01/24/25. Record review of Resident #2's March 2025 Treatments Administration record, dated 03/19/25, reflected Wound Treatment-Skin Prep One Time Daily Starting 01/24/25 . Cleanse DTI area to Left heel with Normal Saline or Skin Cleanser, Pat Dry. Apply Skin Prep to affected area. Cover with Dry Dressing . with Day Treatments signed off by nurses from March 1st to March 19th to include LVN B signing off for completing these treatments on March 19, 2025. Resident #2 declined to participate in an interview on 03/19/25 at 2:53 PM. Interview on 03/20/25 at 12:30 PM, CNA D provided care to Resident #2 and revealed Resident #2 did not have a wound to his left heel so there was no wound treatment done for this resident. Interview on 03/20/25 at 12:50 PM, LVN B revealed Resident #2 did not have any wounds on his foot because it healed. She revealed sign off that wound care per doctor's orders were done, but they did not need to put a dressing on Resident #2's foot anymore because it was healed. She further revealed the wound treatment nurse oversaw discontinuing these orders when the wounds had improved, but he had left, and the staff were adjusting to his absence and taking over his duties slowly. She further revealed she did not know when Resident #2's wound healed. Interview on 03/20/25 at 2:08 PM, the wound treatment nurse revealed the doctor orders of Resident #1 and Resident #2's wound treatment should have been changed to monitor the wounds and not provide wound treatment to them, because they have healed. He revealed he may not have relayed that information or updated before he left. He revealed the wounds have all improved when he was doing wound treatment before he left. Interview on 03/20/25 at 3:39 PM, ADON C revealed the LVN A and LVN B were new nurses and needed extra training to include signing off on doctor's orders. She revealed if the nurses signed the MAR this meant they completed that doctor's orders. She further revealed the wound treatment nurse left recently and the facility was taking over the wound treatment nurse's duties like updated the doctor's orders for wound treatments. Interview on 03/20/25 at 5:20 PM, the DON revealed the wound treatment for Resident #1 and Resident #2 were marked completed. She revealed the wound treatment nurse oversaw the doctor's orders and would have discontinued the wound care treatment orders after the wounds were healed. The DON further revealed she expected the nurses to not sign off that these treatments were done per doctor's orders. She further revealed these nurses should have let the ADON and DON know so they could update these doctor's orders. Requested policy for following doctor's orders, specifically for treatments, and the DON revealed they did not have this policy on 03/21/25 at 11:45 AM. Requested policy for discontinuing orders and the DON revealed they did not have a policy for this on 03/21/25 at 1:46 PM.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the residents' clinical condition and the residents' choice for 1 of 4 Resident (Resident #1) reviewed for quality of care, in that: RN A and LVN B failed to properly assess and administer life-saving measures including CPR to Resident #1 who was full code status when he was found without respirations and unresponsive. RN A and LVN B performed outside of their nursing scope of practice by pronouncing death to Resident #1 without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] This failure resulted in identification of Immediate Jeopardy (IJ) on [DATE] at 11:47 a.m. While the immediacy was removed on [DATE], the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. This failure affected residents with full code status and placed them at risk for not receiving full life-saving efforts in the event of cessation of respirations and/or a heartbeat and would result in deterioration and cessation of brain activity and death. The findings were: Record review of Resident #1's face sheet, dated [DATE] revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Admission Report dated [DATE] given and written by an unknown staff member from a local hospital RN revealed: Resident #1 had an admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was a full code status (should receive CPR and lift saving measures in the event of cessation of respirations and/or heartbeat). Record review of Resident #1's [DATE] Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Clinical Notes (nurses' notes) revealed: -[DATE] 11:56 p.m.: [AGE] year-old male admitted at 8:40 p.m. from a local hospital post hospitalization for left femoral fracture post fall .[Respirations] even and unlabored on room air. Alert and oriented x 1 (alert to self only) .hospital discharge medication reviewed and reconciled with NP with authorization to continue all medications and draw admission labs CBC, BMP on [DATE]. Signed by LVN I. -[DATE] 7:20 a.m.: Initial round completed around 6:40 a.m., nursing staff found patient in bed, unresponsive, mouth wide open with oral [MEDICATION(S)] secretions, patient pale with no vital signs, patient is full code-CPR initiate[d], code blue called, RN pronounced patient time of death 06:47 a.m. Called 911, police officer and local fire department came out to assess situation, NP called, facility management called, RP on file left voicemail. Signed by LVN B. -[DATE] 1:14 p.m.: Late entry: at approximately 6:40 a.m. (unknown date) this nurse was called into patient room by charge nurse (unidentified). CPR was initiated by charge nurse. This nurse called 911 and code blue. 911 and local fire department arrived. NP was made aware. Resumed rounds. Signed by RN A. -[DATE] 5:35 p.m.: Spoke with Medical Director, he reviewed resident record and noted resident labs drawn at 4:21 a.m. on [DATE] .labs resulted after patient expired. Signed by the DON. Record review of a facility employee schedule and sign-in sheet dated [DATE] revealed LVN B was assigned as the Charge Nurse for the 800-hallway and RN A was assigned as the Charge Nurse for the 700-hallway. Record review of a facility Accident/Incident Report (undated) for Resident #1 revealed On [DATE] the patient coded and was discovered by CNA C, time undocumented. ADON B, the NP and RP were all notified, date and time undocumented. Investigation ongoing. Record review of Form 3612-A Provider Investigative Report dated [DATE] and signed by the DON revealed an incident on [DATE] at 6:47 a.m. The facility reported a death and neglect to Resident #1. The facility confirmed the allegations the investigative findings and noted Resident expired (died ) within 24 hours of admission, found unresponsive, questionable code response. Alleged perpetrators are listed as RN A and LVN B. Outcome: Confirmed-nurse statements changed multiple times and not consistent. Record review of an email from the NP to the DON, dated [DATE] revealed: On [DATE] approximately 7:07 a.m., I received a phone call from LVN B regarding Resident #1. LVN B stated upon rounds, found patient unresponsive, pulse less, CPR initiated, EMS contacted. States patient did not have return of pulse or respiration, so CPR was ceased. During an interview on [DATE] at 1:20 p.m., the DON stated the Administrator was out of the facility on FMLA which started on [DATE] The Executive Director (ED) was filling in until the Administrators return. The DON further revealed she was responsible for abuse investigations which were also reviewed by the Regional Clinical Director. The DON stated Resident #1's death occurred on [DATE] sometime between 6:10 a.m.-6:40 a.m. and she had been unable to narrow down the window at the present time. The DON stated Resident #1 was a new admission to the facility, but the NP was aware the resident was in the building and had written orders. A physician or NP had not physically assessed the resident prior to his death. Record review of a typed statement dated [DATE] of an interview by the DON with LVN B regarding Resident #1 on [DATE], revealed: -LVN B stated she was standing near the nurses' station getting ready for rounds when she saw CNA C and CNA D making rounds, she then heard the CNA's call out LVN B, I think he's gone. -LVN B stated she believed RN A also heard them call because she was right behind her as they both went into the room -LVN B stated she assessed for vital signs and a pulse, but all were absent, RN A checked immediately after, I told her to call a code after she confirmed the code status, she ran out and I started CPR -LVN B stated she started check compressions immediately and RN A was in the room during compressions. The CNA's were near the door. -LVN B confirmed she did not use the crash cart or AED while performing CPR and then responded it was in the room but it was not used because the patient was clearly dead - LVN B stated she knew Resident #1 was dead because He didn't have a pulse and he looked like he had been gone. -LVN B stated the decision to stop CPR was made by both herself and RN A and stated RN A pronounced Resident #1's death. -LVN B confirmed she did not suction Resident #1. She stated she did CPR for 15 minutes. LVN B stated the Code Blue was called at 6:40 a.m. and Resident #1 was pronounced at 6:47 a.m. When asked how she performed CPR for 15 minutes from 6:40 am-6:47 am, LVN gave no response. LVN B stated she never rotated CPR with another staff member. -LVN B confirmed she did not use the AED. -LVN B confirmed she did not check for a blood pressure and stated Resident #1 obviously had no chest rise or fall and he didn't respond after the sternal rub, he was pale, white and clammy. -LVN B stated, police arrived first and he went to see the body, then he got information he needed .the fire department arrived right after him and they went to see the patient, they asked for paperwork but they did not do CPR. LVN B stated only 2 guys (paramedics), no stretcher, no gear. -The DON asked LVN B if she thought it seemed strange that 911 was called by EMS did not respond. LVN replied, I thought it was probably because of the way the death was reported, he was already dead. Record review of a witness statement dated [DATE] and written by LVN B to the DON revealed: Initial round conducted at 6:40 a.m., found patient in bed, head of bed [elevated] at 30 degrees. Patient unresponsive, pale, no pulse, mouth wide open with oral [MEDICATION(S)] secretions around his mouth. Code Blue called, CPR initiated, called NP, 911 called, RN pronounced time of death at 6:47 a.m. Record review of a witness statement dated [DATE] and written by LVN B to the DON revealed: On [DATE], I LVN B came in at 6:00 a.m. for my 6 a.m.-2 p.m. shift, approximately 6:30 a.m. after report I was .near nurses station when I heard CNA D and CNA C scream/yelled for me .I immediately rushed to see patient, RN A overheard this and walked right behind me. Patient in bed, unresponsive, cold, pale, rigid, bloated, unable to obtain vital signs. RN A ran out to confirm [code status], once confirmed patient was full code, CPR was initiated. Crash cart and AED brought in by CNA C and CNA D. After approximately 15 minutes of CPR and no response from patient, RN A and I mutually decided to stop CPR. RN A called time of death. RN A called 911. During an interview on [DATE] at 3:57 p.m., LVN B stated at approximately 6:30 a.m., she heard CNA C say, LVN B, Resident #1 is gone, come here. LVN B stated she entered Resident #1's room with RN A right behind her. LVN B stated she was not able to obtain vital signs because Resident #1 did not have a pulse by palpation (feel) and confirmed she did not check for a pulse by auscultation. LVN B stated she initiated CPR but did not move the resident to the floor, did not suction the secretions from the resident's mouth, did not ventilate or provide respirations and did not auscultate the resident's chest for lung sounds or a heartbeat. LVN B stated she was unable to get a response from Resident #1 because he was cold and pale. LVN B stated It all happened so fast. RN A and I decided by mutual agreement that Resident #1 was dead, so we stopped CPR. LVN B stated paramedics never arrived on scene. LVN B stated she called the NP and told her Resident #1 was found unresponsive, assessed for vitals. The NP asked what had happened because Resident #1 was a new admit to the facility. LVN B stated she then notified ADON B at approximately 7:00 a.m. and informed her exactly what happened. LVN B confirmed she should not have stopped CPR until EMS arrived. LVN B stated she was trained, based on her nursing scope of practice as a LVN to have an RN assess what the residents code status is, if full code status, then call Code Blue, initiate CPR, utilize AED device, RN has to supervise code, document, call 911 and have someone wait outside for EMS to show them to the residents room. She was also trained to suction the resident and provide ventilation/respirations along with chest compressions. LVN B confirmed she was the Charge Nurse assigned to care for Resident #1 on [DATE] and stated, Resident #1 was flat in bed with a back board placed by me. No, I did not use an ambu bag and no I did not give respirations or suction the resident because the resident was dead. Record review of a witness statement dated [DATE], written by RN A to the DON revealed: During completion of my first round, approximately 6:40 [a.m.]. Nurse was called into room for anticipated code blue. Verified full code, code was called to all nurses, crash cart obtained. Sternal rub, pulseless. 911 called. Time of death 6:47 a.m. Record review typed statement dated [DATE] of a DON interview with RN A regarding the events involving Resident #1 on [DATE] revealed: -RN A stated, At about 6:40 a.m., I was at my cart. I overheard one of the CNA's tell LVN B they thought [Resident #1] was gone. I started to follow LVN B [into the room] where she was with the aides assessing the patient. -RN A stated, I checked pulse at carotid or jugular and I did a sternal rub. Resident #1's eyes were closed, his mouth was open with [MEDICATION(S)] discharge in his mouth, he was pale white, cold, maybe a little swollen but I had nothing to compare to because I had never seen him. -RN A stated she did not start CPR and went to call 911. RN A stated, I think I reported [to 911] the patient was gone, but I honestly don't remember exactly what I said. They asked do I need EMS/Fire. I think I said something like I don't know what I need but he is gone, as in dead. -RN A stated LVN B, CNA C, CNA D and another person (unidentified) were in the room with Resident #1 and indicated she didn't know if LVN B performed CPR. -RN A stated she checked for a carotid pulse and determined Resident #1 was dead by this assessment and figured he had probably been gone a few hours. -RN A confirmed she did not suction the secretions from Resident #1's mouth, did not check for respirations, blood pressure, chest rise or breath sounds and indicated It was a mutual decision to stop CPR. RN A stated she doesn't know if LVN B performed CPR, or for how long because she, RN A was the runner. -RN A stated, I am a RN and pronouncing death is within my scope. The DON corrected RN A to the scope of her practice, and she responded No, well I guess I don't know the scope of my practice then. -RN A stated, I felt CPR would not have benefited him because of the stage of the body. I felt CPR would have been harsh trauma to his deceased body. Honestly my mind was racing and that combined with inexperience with death. I have only participated in 4 codes and the guy is always the one to do compressions. When asked if it seemed strange that 911 was called but EMS did not respond, RN A stated, No, the man was dead. Record review of a typed witness statement written to the DON dated [DATE] regarding Resident #1 and signed by RN A revealed: .between 6:30 a.m.-6:40 a.m., I overheard CNA D and LVN B say that a patient had expired. I noted LVN B briskly walking to go and assess the situation .I ran behind her. Upon entering the room, patient noted in bed, head of bed elevated, pale in appearance, mouth wide open, pale oral mucosa, greenish secretions surrounding lips, eyes closed. This nurse palpated (felt) for a carotid pulse, performed firm sternal rub. Absent pulse noted without auscultation (listening with a stethoscope), only palpation. Patient noted cold to touch. This nurse exited room with patient still in bed, possibly stating he is gone. Determination of code status began by this nurse .code blue called to all available staff. I do not recall the AED being obtained .I do not recall when re-entering room seeing Resident #1 being performed compressions on. Patient remained in bed. I did not perform any other CPR action. I recall a mutual look between LVN B and I, and I determining the patient was too far gone. No further actions performed by either of us .911 was called by this nurse. Dispatcher asked EMS, Fire or Police?. This nurse froze and stated something of the sort, I don't know who I need .this man was found passed away. Record review of a witness statement dated [DATE] and written by RN A to the DON revealed: This was a tragic situation. I fully understand the mistake that was committed during this code. This is a lesson I will always carry with me and will make me into a better nurse. During an interview on [DATE] at 3:13 p.m., RN A stated on [DATE] between 6:30 a.m. to 6:40 a.m. she heard CNA C and CNA D tell LVN B something (unknown) that caught her attention about Resident #1. RN A stated she walked fast down the hall to Resident #1's room where she saw the resident who was pale, with his mouth open and green secretions, eyes closed and head of bed elevated. LVN B was performing her assessment and said RN. RN A stated she checked Resident #1 for a carotid pulse and said He's gone. LVN B asked if RN A could pronounce the death at 6:47 a.m., which she did. RN A stated she didn't know Resident #1's code status so she exited the resident room. RN A stated, I was looking for the resident's code status. I shouldn't have left the room. RN A stated she confirmed Full Code status for Resident #1 and informed CNA C the resident was a full code. RN A stated she did not re-enter the resident room, instead she called a Code Blue on the facility's overhead speakers and at some point, called 911 and said, I think this man is gone. RN A stated she told the 911 operator she didn't know what kind of help she needed. RN A confirmed she did not take charge of the code even though she was the only RN on that side of the building. She did not delegate any tasks to other staff members during the code. RN A confirmed she never performed CPR and did not remember any other staff member performing CPR. RN A stated she was trained to assess the resident for respirations, if not breathing, check for a pulse. RN A stated she was trained to check for a pulse for one full minute by auscultation, if no heartbeat, move the resident to the floor, perform chest compressions and set up AED. RN A confirmed she did not do any of these things that she was trained to do during a Code Blue situation because, I don't have a lot of power in my arms to do CPR. I just picked another task that seemed more doable to me which included running and calling 911. RN A confirmed the facility policy was to perform CPR on a full code resident and not quit until EMS arrived and took over the scene. RN A confirmed the facility policy was not followed for Resident #1. During an interview on [DATE] at 4:34 p.m., LVN G stated he was working on another unit when he heard Code Blue paged to the 800-hallway. LVN G stated while walking toward the hallway, RN F passed by on her way to the 800 unit. When he arrived on the hallway LVN G saw CNA C and a female CNA (unknown) in the hallway. CNA C stated, The Code is over. LVN G witnessed RN A and LVN B exit Resident #1's room and one of the two (unknown) stated The patient is already dead. During an interview on [DATE] at 5:15 p.m. CNA E stated on [DATE] at approximately 6:40 a.m., a male CNA (unknown) and CNA D yelled to LVN B and the male CNA made a motion with his hand across his neck indicating Resident #1 was dead. CNA E stated everyone (RN A, LVN B, CNA D, male CNA C) went into Resident #1's room. CNA C retrieved the crash cart, which was never used and never opened. RN A rubbed Resident #1's chest (sternal rub) no lightly, but not too hard and said, he's gone indicating Resident #1 was dead. Resident #1 had yellow/white liquid coming out of his mouth and dripping down his chin. The liquid secretions were thick and not watery. CNA E stated Resident #1 was in an upright position with his head of bed elevated. CNA E stated no one lowered the head of the bed, no one put a back board underneath the resident or moved the resident to the floor. CNA E confirmed she didn't see any nurse listen for a heartbeat, take the residents pulse or attempt to get vital signs. CNA E further confirmed no staff member administered respirations or performed chest compressions or CPR to Resident #1. CNA E stated she didn't think the way the nurses responded to the Code Blue was appropriate since the resident was a full code. CNA E stated, they should have performed CPR. CNA further stated, she didn't think anyone called an ambulance because EMS never came. CNA E stated she was trained to respond by helping with CPR if needed but no one asked her to help. She stated she was trained to do whatever the nurses asked her to do. During an interview on [DATE] at 5:57 p.m., the DON stated the incident regarding Resident #1 was originally reported to her by a nurse manager (unknown). She was told Resident #1 had expired and CPR was done. Later, (unknown date/time) RN G and ADON A brought to her some irregularities and concerns for CPR. The DON began investigating and requested statements from the nursing staff. On [DATE] she found irregularities in the nurses' statements and stated the investigation was still in progress. The DON stated she self-reported the incident and began in-service training which was still in progress. The DON stated she reviewed lab work drawn from Resident #1 on [DATE] at 4:21 a.m. which revealed a markedly elevated white blood cell count and elevated BUN. The lab results were not received from the lab until after the resident's death. Record review of typed interview between CNA C to the DON (undated) regarding events with Resident #1 on [DATE] revealed: -CNA C stated, at approximately 6:10 a.m.-6:40 a.m. while doing walking rounds with CNA D, they walked into Resident #1's room and he was deceased . CNA C stated he stepped out of the room and called LVN B and told her he thought Resident #1 was gone. -CNA C stated LVN B told RN A to check the resident's code status and then went into Resident #1's room. -CNA C stated he and CNA D were waiting at the end of Resident #1's bed for instructions but none were given to them. RN A called a Code Blue overhead. -CNA C stated Resident #1 was pale and had secretions coming out of his mouth and did not see any staff member perform CPR. -CNA C stated LVN B was standing over Resident #1 but she was not performing CPR. Resident #1 remained in his bed. -When asked what RN A was doing, CNA C stated, She was not doing CPR. Nobody started CPR. CNA C confirmed the AED was not brought into the room. -When asked if RN A, LVN B or anyone else had assessed Resident #1, CNA C stated, I do remember LVN B checking for a pulse, but I never saw RN A touch the patient. -CNA C stated, RN A and LVN B looked at him (Resident#1), then at each other and said he's been gone a while. Then LVN B said, 'What do we do when we find them like this?' Record review of a typed interview (undated) of CNA D by the DON regarding the events involving Resident #1 on [DATE] revealed: CNA D stated while making rounds with CNA C, they walked into Resident #1's room and noticed the resident looked like he was gone (dead) and had been for a little bit. He was cold, had [MEDICATION(S)] on his lip and was pale white. CNA D stated LVN B checked for a pulse but did not start CPR. RN A came into the room and said Resident #1 was full code, but nobody started CPR. The crash cart was brought into the room but remained covered. RN A performed a chest rub, but that's it. RN F and LVN G came to the code but RN A and LVN B told them the patient was dead and the code was over. CNA D stated she did not see any CPR, did not see EMS. I only saw the police come in and [they] got a report, then LVN B told me and CNA E to do post-mortem care. During an interview o [DATE] at 6:27 p.m., CNA D stated she had just clocked in to work the 6 a.m.-2 p.m. day shift on [DATE] when she began walking rounds with CNA C. At approximately 6:40 a.m., they found Resident #1 with mucous coming out of his mouth and a pale color. Resident #1 was sitting up with the head of the bed at approximately 30 degrees. The two CNA's looked toward the nurse's station and saw LVN B so they called to her and waved their hands to get her attention. LVN B came into Resident #1's room and stated, he isn't breathing. RN A entered the room at this time. LVN B checked for a pulse on Resident #1's neck. RN A gave the resident a big sternal rub and Resident #1 didn't respond. RN A ran out of the room, confirmed Resident #1 was full code status and called a Code Blue over the intercom. The crash cart was brought into the room but never used. The net cover was never removed from the cart. The AED was not brought in with the crash cart and was left in the closet. There were several staff members in the room or in the doorway to the room including CNA C, CNA E, RN A, LVN B. CPR was never administered to Resident #1 by any staff member. No chest compressions were given, no suction, no ventilations/respirations were administered. No nurse every listened to Resident #1's chest or heart with a stethoscope. LVN B just took her gloves off and stated, he's gone and then exited Resident #1's room. RN F came into the room as LVN B stated, he's gone and then left the room. LVN G didn't enter the room to assess the resident because LVN B said he was gone. CNA D stated someone called the police after the event took place, but no one called 911 because paramedics never arrived. CNA D stated she was trained to tell a nurse who is certified in CPR and wait for instructions when finding a resident unresponsive. During an interview on [DATE] at 7:11 p.m., LVN J stated she was the charge nurse assigned to care for Resident #1 during the night shift from 10 p.m. [DATE] to 6 a.m. [DATE]. LVN J stated on [DATE] she clocked out and left the building at 6:40 a.m. and was unaware a Code Blue had been called in the facility. LVN J stated between 11:00 p.m. to 12:00 p.m. on [DATE] she obtained a set of vitals from Resident #1 which were all normal. The resident had even, unlabored breathing and his cheeks were not flushed. LVN J stated she was told in report that Resident #1 was alert and oriented x 1 which meant he was only alert to self and not his surroundings. Most of the time a resident with this cognitive status is unable to make their needs known and is non-verbal. Resident #1 made vocalizations and grunting and did not use the call light during the night. LVN J stated the grunting was vocalizations and not grunting from labored breathing. She described it as grunting from not wanting to be bothered or disturbed. At approximately ,d+[DATE] a.m. Resident #1 had his legs out of bed and she had CNA C assist her with getting the resident back into bed and positioned. Between 4 a.m.- 4:20 a.m. as she finished her last rounds, she noted Resident #1 was sleeping and aroused the resident verbally and by lightly rubbing the resident until he awoke. LVN J stated Resident #1 grunted at her like he didn't want to be bothered, she offered him water which was refused. LVN J stated CNA C had not reported any change of condition for Resident #1 during the night and she had not noticed any changes. During an interview on [DATE] at 7:32 p.m., LVN I stated Resident #1 was admitted to the facility on [DATE] and he performed the initial assessment at 8:45 p.m. LVN I noted the resident had poor cognitive functioning upon his arrival and was alert to self only. LVN I stated this meant the staff would have to anticipate the residents needs as he would not be able to make his needs known. LVN I stated upon arrival Resident #1 appeared weak and tired and was not participating to verbal instruction but did respond to verbal and tactile stimulation. Resident #1 had unlabored breathing and was not in any respiratory distress with oxygen saturations at 94% on room air. Resident #1's vital signs were all stable. LVN I stated he auscultated his lung sounds and did not hear wheezing or chest congestion and did not hear the resident cough. LVN I stated the resident appeared calm and relaxed but did look tired. LVN I stated he called the NP and reconciled medication and obtained standing orders which included a early morning CBC and CMP. The next morning, on [DATE] LVN I learned Resident #1 had coded. During an interview on [DATE] at 7:54 p.m., CNA C stated he worked the night shift from 10:00 p.m. to 6:00 a.m. from [DATE] to [DATE]. CNA C stated Resident #1 was admitted to the facility on [DATE] on the 2:00 p.m. to 10:00 p.m. shift and was told during report the resident was a fresh hip (recent hip surgery). CNA C stated between 11:45 p.m. to midnight he changed Resident #1's brief. During the night Resident #1 was observed dangling his leg off the bed ,d+[DATE] times during the night and he or LVN J would assist the resident back to bed. CNA C stated at approximately 4:30 a.m. he checked on the Resident and he looked fine and was resting and again put his leg back in bed. CNA C stated the resident was not in any distress and was breathing fine. Resident #1 was sleeping and relaxed. CNA C stated at approximately 6:05 am he went with CNA D and flipped on the light and noticed Resident #1 had expired. Resident #1 was sitting at a 45 degree angle with thick mucous coming out of his mouth, eyes closed and he had a white and waxy looking appearance. CNA C stated Resident #1 was very sweaty and had a ring of sweat on his pillow. CNA C stated both CNA's stepped into the hallway and motioned to LVN B. CNA C stated both LVN B and RN A came into Resident #1's room and neither of the nurses knew the code status of Resident #1. RN A left the room to check the code status and LVN B checked for a pulse with two fingers on the side of Resident #1's neck then went and stood in the doorway and waited for RN A to indicate the residents code status. CNA C stated this took approximately 1 minute before learning Resident #1 was a full code. RN A brought the crash cart, but nobody did anything. LVN B and RN A just looked at each other like they were confused and didn't know what to do. The CNA's were all waiting but the nurses didn't tell us what to do. CNA C stated would could have done CPR if they had been instructed by the nurses. CNA C confirmed the nurses did not listen to Resident #1's chest with a stethoscope, no one took vital signs, no one lowered the head of the resident's bed, no one put a back board under the resident or moved him to the floor. No one did chest compressions. No one gave respirations/ventilations or used an ambu bag. CNA C stated, No one gave CPR. CNA C stated he was trained to notify the charge nurse immediately for any change of condition or no respirations and wait for instructions from the nurses. CNA C stated Resident #1 was not breathing. He was cold, clammy and sweaty and he was dead. During an interview on [DATE] at 8:15 p.m., the DON confirmed the Code Blue was not run properly and based on conflicting statements it was unclear whether CPR was done on a full code resident. The DON stated, there are no witnesses to CPR for Resident #1, no witnesses to say a backboard was used. The DON stated Resident #1 was on the bed and if CPR was started it was not done properly. The DON stated witnesses stated the crash cart was in the room but was not utilized. The DON stated, It does not appear CPR was done on this patient. She further stated there were no witnesses to EMS arriving in an emergency and I have not been able to determine if 911 was called as an active code or as a death. The DON further stated, chest compressions without respirations/ventilations would not be appropriate in this situation. Staff stated, Resident #1's mouth was full of mucous. The DON stated we have suction and ambu bags available. The DON stated her expectation for staff was to have a team response to a Code Blue where the nurse or RN take over the code and delegate tasks. Someone should take notes for accurate documentation. Staff should initiate CPR on a full code resident and continue to perform CPR even if they think the resident has been dead for a long time until EMS takes over, a physician gives an order to stop or the resident is confirmed DNR status. The DON stated, even if the physician gives an order and approval to discontinue CPR, Two RN's are required to pronounce death. The DON stated staff must exhaust all measures for a resident who is a full code status. During an interview on [DATE] at 8:35 a.m., ADON BB stated on [DATE] at approximately 7:30 a.m. she received a call from LVN B who stated Resident #1 had expired after the staff ran a full code and she had notified the NP and EMS had been called. ADON BB stated to my understanding at that point in time, I thought the staff had done what they were supposed to do. ADON BB stated later on in the morning she heard from the Staffing Coordinator that there were inconsistencies, so she informed the DON. ADON BB stated the Code Blue was not run properly and staff did not follow facility protocol. RN A should have taken charge of the code and should not have acted as a runner. Resident #1 should have been placed on the ground or at least have a back board placed. The staff should have initiated CPR and continued with CPR until EMS arrived. ADON BB confirmed none of these things were done. ADON BB stated CNA's are instructed to alert a nurse if a resident had a change of condition or is found unresponsive. ADON BB stated she monitors staff by auditing charts, initiating care plans, performing meet and greets [TRUNCATED]

Based on interview, and record review the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 4 residents (Residents #1) reviewed for a notification of a change of condition, in that; RN B did not notify Resident #1's physician of a critically high [MEDICATION NAME] trough level resulting in continued administration of medication. Resident #1 had increased [MEDICATION NAME] levels and was admitted to the hospital. This failure to consult with the physician regarding a change of condition could result in delay of medical treatment, [MEDICAL CONDITION], and hospitalization . The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's initial Care Plan revealed the resident was receiving [MEDICATION NAME] antibiotic therapy and was at risk for adverse reactions with interventions which included: give medication per (physician) order, monitor labs, and report abnormal (lab values) to MD. Monitor resident for adverse reactions specific to the medication. Record review of Resident #1's hospital discharge orders dated [DATE] revealed an order for [REDACTED]. Record review of Resident #1's consolidated physician orders [REDACTED].>- order start date [DATE]:[MEDICATION NAME] 1 gram/250 ml in 0.9% sodium chloride intravenous solution (IV) every 12 hours for 20 days - order start date [DATE]: [MEDICATION NAME] trough one time daily - order start date [DATE]: [MEDICATION NAME] trough by shift - order start date [DATE]: [MEDICATION NAME] trough three times weekly Record review of Resident #1's MAR's revealed an order for [REDACTED]. Record review of Resident #1's laboratory results revealed: reference range (normal trough levels) for [MEDICATION NAME] trough 5XXX,[DATE].0. [DATE] 10:22 p.m.: [MEDICATION NAME] trough 22.9 [DATE] 7:35 a.m.: [MEDICATION NAME] trough 43.8 Record review of RN B's handwritten Supervisor Report to Management dated [DATE] revealed under the section titled Change of Condition no notes were made on the report. Further review of the entire document revealed there was no documentation written about Resident #1's elevated [MEDICATION NAME] trough or Resident #1 on the report. Record review of a NP (Nurse Practitioner) progress note dated [DATE] revealed Resident #1 had an acute change in mentation (mental status). Resident #1 was not oriented to place or time and her thought process was slow. She had new symptoms to her left upper extremity strength and grasp .possibility of [MEDICATION NAME] toxicity as she is undergoing therapy of [MEDICATION NAME] . Record review of Resident #1's hospital records revealed the resident was admitted to the hospital on [DATE] and discharged on [DATE] with an assessment and [DIAGNOSES REDACTED].>1. Metabolic [MEDICAL CONDITION] 2. Adverse reaction to medication, [MEDICATION NAME] toxicity 3. Acute [MEDICAL CONDITION] secondary to above [MEDICATION NAME] trough level greater than 50. Discussed hendiadys with family, per patient wishes, they defer. Make patient comfort measures only. Arrange outpatient Hospice and discharge home. Record review of a NP progress note dated [DATE] revealed: When asked about the missed [MEDICATION NAME] levels, nursing reported that facility had been having issues with lab company about collecting scheduled labs as ordered. In addition, nurse was not able to report if lab results had been sent/faxed to physician's office for medication evaluation. During an interview on [DATE] at 10:31 a.m. the DON stated Resident #1 had an order for [REDACTED].#1's physician of the lab results. As a result, Resident #1 continued to received IV [MEDICATION NAME]. On [DATE], Resident #1 had a [MEDICATION NAME] trough level of 40 plus. Resident #1 was sent to the hospital with a [DIAGNOSES REDACTED]. During an interview on [DATE] at 11:42 a.m. Resident #1's family member stated that Resident #1 had neck surgery and developed a staph infection. The resident was sent to the nursing facility on [DATE] for 20 days to receive IV administration of antibiotics and rehabilitation services. The family member stated Resident #1 expired on [DATE] after she was [DIAGNOSES REDACTED]. During an interview on [DATE] at 12:10 p.m., LVN A confirmed he did not notify Resident #1's NP or MD of the [MEDICATION NAME] trough level of 22 on [DATE]. LVN A stated he does not remember RN B as being involved with the flow of data or test results from the lab. LVN A stated he had several conversations with RN C about whether or not to administer [MEDICATION NAME] to Resident #1 on [DATE] and [DATE] because Resident #1's trough levels had been running high. LVN A stated he attempted to contact a NP (unknown name at unknown date/time) by text but did not receive a response fromt he NP. LVN A stated he had erased the text conversation off his phone and it was not available for review. LVN A stated you will not find my initials on the MAR indicated [REDACTED]. During an interview on [DATE] at 1:46 p.m , Weekend Supervisor, RN B confirmed she answered the phone on [DATE] and received the results of Resident #1's [MEDICATION NAME] trough which were 22 (normal is less than 20). RN B confirmed she did not notify the resident's NP or MD of the critical lab results. During further interview, RN B revealed she was the weekend supervisor in charge of facility oversite on the weekends. RN B stated the facility was having issues with getting lab results from the lab and had assisted nursing staff throughout the weekend with obtaining lab draws and test results related to the administration of [MEDICATION NAME] for Resident #1. RN B stated LVN A was the charge nurse for Resident #1 and was in another resident room and not available to receive the lab results from the pharmacy. RN B stated when LVN A came out of the resident room she informed him (verbally) of the critical lab results and instructed him to call the NP. RN B confirmed she did not document in Resident #1's medical record the results of the [MEDICATION NAME] trough and she did not follow up with LVN A to ensure the NP or MD had been notified. RN B stated, the facility process for handling abnormal lab values included: notifying the NP of the critical lab value and documenting the lab value in the medical record. RN B stated she delegated the task of physician notification and documentation to LVN A to which he replied okay. RN B stated, I feel like all nurses should know this (process}. RN B further stated, I know I needed to make sure he {LVN A} followed thru with the instructions I gave him, but I had already left the building (weekend shift over} and I don't work on Mondays. RN B stated another reason she did not follow up with the abnormal lab value was because nurses usually do what they are told to do. During an interview on [DATE] at 3:15 p.m., RN C stated she did not receive Resident #1's critical lab results on [DATE]. RN C denied knowledge of when the critical lab results came in or who took the phone call from lab. RN C further denied having a conversation with LVN A or RN B about the [MEDICATION NAME] trough levels received on [DATE]. RC C stated on [DATE] night shift (unknown name) informed her that Resident #1's [MEDICATION NAME] trough levels were running high. On [DATE] a [MEDICATION NAME] trough was ordered and drawn. The [MEDICATION NAME] trough was within normal limits and the NP gave an order to administer the [MEDICATION NAME] and repeat the trough level before the next dose ([DATE] 10:00 p.m.). RN C stated she collected the blood sample but did not get the results. RN C stated she instructed the night nurse, LVN A to hold the 10:00 p.m. dose of [MEDICATION NAME] on [DATE] because the facility was still waiting on trough results. During an interview on [DATE] at 4:36 p.m., LVN D confirmed she had administered [MEDICATION NAME] to Resident #1 on [DATE] at 10:00 a.m. and [DATE] at 10:00 a.m. LVN D stated she was not aware of the elevated [MEDICATION NAME] trough. LVN D stated Resident #1 had an order for [REDACTED]. LVN D confirmed she did not review Resident #1's medical record or lab results for a [MEDICATION NAME] trough level prior to administering either dose. LVN D confirmed she did not review orders or [MEDICATION NAME] trough levels and relied on change of condition report to learn when the troughs had been scheduled. When reviewing the physician order [REDACTED]. During an interview on [DATE] at 2:05 p.m., LVN E confirmed she administered [MEDICATION NAME] to Resident #1 on [DATE] at 10:00 p.m., [DATE] at 10:00 p.m. and [DATE] at 10:00 p.m. LVN E stated she looked at Resident #1's previous trough levels but did not see the test result for [DATE] with the results of 22.9. LVN E stated the last trough level she saw was a previous result of 16 (date unknown). LVN E stated the morning nurse was responsible for inputting the [MEDICATION NAME] laboratory order in the computer and calling the lab 24 hours in advance. On [DATE] the morning nurse (unknown name) was not the usual nurse and the order didn't get placed for lab. LVN E stated she attempted to notify a NP but did not receive a call back. On [DATE] the lab drew the [MEDICATION NAME] trough on the wrong resident and a trough was never completed for Resident #1. The following day the lab stated the order had never been called in. LVN E stated she was never told she had to call the lab to get the lab drawn. LVN E confirmed she did not notify the ADON, DON, Administrator or any other member of management about the lab difficulties or inability to get the [MEDICATION NAME] trough level drawn. On [DATE] at 2:53 p.m., the resident physician was called and a request for a return call was left with the physician group. At the time of exit, a call back had not been received. During an interview on [DATE] at 2:55 p.m. the Medical Director (MD) stated he was not aware of the medication error or critical lab value with Resident #1. The MD stated the facility management and MD met for monthly QA (Quality Assurance) meetings in which medication errors and other facility concerns were discussed. The MD stated the Administrator of the facility was a contact person for questions. During an interview on [DATE] at 3:44 p.m., the DON confirmed the facility was responsible for a medication error when the staff continued to administer IV [MEDICATION NAME] to Resident #1 without notifying the physician of a critically high [MEDICATION NAME] trough level and without receiving further instructions/orders related to the [MEDICATION NAME] from the physician. The DON confirmed the error began upon admission to the facility when Resident #1's orders for [MEDICATION NAME] trough were not correctly transcribed into the computer. The DON stated RN B should have communicated the critical lab value to the physician and documented the outcome of the notification in Resident #1's medical record. The DON stated a RN could not delegate the task of physician notification unless the nurse also followed up to ensure the task had been completed. Interview on [DATE] at 4:01 p.m. with a physician at the local hospital where Resident #1 was transferred to revealed Resident #1 had a [DIAGNOSES REDACTED]. The physician confirmed the elevated [MEDICATION NAME] levels played a role in the kidney failure. The physician revealed Resident #1 developed significant [MEDICAL CONDITION] (brain condition that affects brain function) as a result. The physician stated Resident #1 needed [MEDICAL TREATMENT] treatment, but it was unknown whether the [MEDICAL TREATMENT] would have effectively treated the resident or if she would be able to be able to return to baseline function as a result. The physician stated Resident #1 had expressed to the family prior to the hospitalization that she did not want [MEDICAL TREATMENT] or other life prolonging measures. During further interview on [DATE] at 12:05 p.m the Medical Director (MD) stated he spoke with the DON on [DATE] about the medication error involving Resident #1. The MD indicated he still had some clinical questions to look into regarding the situation and wasn't sure whether [MEDICATION NAME] was the only contributing factor. The MD stated [MEDICATION NAME] trough was definitely missed and stated we acknowledge the problem. He further stated, it was a system failure with medications, monitoring, pharmacy, nurses and doctors. Review of a facility policy, titled Significant Change in Patients Status dated [DATE] and last revised [DATE] revealed: As a significant change in Patient condition occurs, the Charge Nurse will notify the physician, Patient representatives, consistent with his or her authority of the significant change immediately.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (Resident # 1) reviewed for significant medication errors, in that; The facility failed to monitor Resident #1's [MEDICATION NAME] trough levels as ordered by a physician prior to administering IV (intravenous) [MEDICATION NAME] which resulted in increased blood levels of the medication, hospitlization, [MEDICAL CONDITION]. This failure placed residents at risk for not receiving therapeutic dosages and placed them at risk for a decline in health. The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's initial Care Plan, dated [DATE] revealed the resident was receiving [MEDICATION NAME] antibiotic therapy and was at risk for adverse reactions with interventions which included: give medication per (physician) order, monitor labs, and report abnormal (lab values) to MD. Monitor resident for adverse reactions specific to the medication. Record review of Resident #1's hospital discharge orders dated [DATE] revealed an order for [REDACTED]. Record review of Resident #1's consolidated physician orders [REDACTED].>- order start date [DATE]:[MEDICATION NAME] 1 gram/250 ml in 0.9% sodium chloride intravenous solution (IV) every 12 hours for 20 days - order start date [DATE]: [MEDICATION NAME] trough one time daily - order start date [DATE]: [MEDICATION NAME] trough by shift - order start date [DATE]: [MEDICATION NAME] trough three times weekly (days to be drawn not documented) Record review of Resident #1's laboratory results revealed: reference range (normal trough levels) for [MEDICATION NAME] trough 5XXX,[DATE].0. [DATE] 10:22 p.m.: [MEDICATION NAME] trough 22.9 [DATE] 7:35 a.m.: [MEDICATION NAME] trough 43.8 Record review of Resident #1's MAR's revealed an order for [REDACTED]. Record review of Resident #1's hospital records revealed the resident was admitted to the hospital on [DATE] and discharged on [DATE] with an assessment and [DIAGNOSES REDACTED].>1. Metabolic [MEDICAL CONDITION] 2. Adverse reaction to medication, [MEDICATION NAME] toxicity 3. Acute [MEDICAL CONDITION] secondary to above [MEDICATION NAME] trough level greater than 50. Discussed hendiadys with family, per patient wishes, they defer. Make patient comfort measures only. Arrange outpatient Hospice and discharge home. Record review of a NP progress note dated [DATE] revealed: When asked about the missed [MEDICATION NAME] levels, nursing reported that facility had been having issues with lab company about collecting scheduled labs as ordered. In addition, nurse was not able to report if lab results had been sent/faxed to physician's office for medication evaluation. During an interview on [DATE] at 10:31 a.m. during the entrance conference, the DON stated Resident #1 had an order for [REDACTED].#1's physician of the lab results. As a result, Resident #1 continued to received IV [MEDICATION NAME]. On [DATE], Resident #1 had a [MEDICATION NAME] trough level of 40 plus. Resident #1 was sent to the hospital with a [DIAGNOSES REDACTED]. During an interview on [DATE] at 11:42 a.m. Resident #1's family member stated that Resident #1 expired on [DATE] after she was diagnosed with [REDACTED]. During an interview on [DATE] at 12:10 p.m., LVN A confirmed he did not notify Resident #1's NP or MD of the [MEDICATION NAME] trough level of 22 on [DATE]. LVN A stated he does not remember RN B as being involved with the flow of data or test results from the lab. LVN A stated there was a lot of confusion with the lab and with the physician order [REDACTED]. in the order to the laboratory ahead of time. LVN A stated [MEDICATION NAME] troughs should be drawn 1 hour before every 3rd dose and then based on the trough levels from the lab the NP/MD would determine whether the medication should be given or held. LVN A stated he had several conversations with RN C about whether or not to administer [MEDICATION NAME] to Resident #1 on [DATE] and [DATE]. LVN A stated you will not find my initials on the MAR indicated [REDACTED]. During an interview on [DATE] at 1:46 p.m , Weekend Supervisor, RN B confirmed she answered the phone on [DATE] and received the results of Resident #1's [MEDICATION NAME] trough which were 22 (normal is less than 20). RN B confirmed she did not notify the resident's NP or MD of the critical lab results. During further interview, RN B revealed she was the weekend supervisor in charge of facility oversite on the weekends. RN B stated the facility was having issues with getting lab results from the lab and had assisted nursing staff throughout the weekend with obtaining lab draws and test results related to the administration of [MEDICATION NAME] for Resident #1. RN B stated LVN A was the charge nurse for Resident #1 and was in another resident room and not available to receive the lab results from the pharmacy. RN B stated when LVN A came out of the resident room she informed him (verbally) of the critical lab results and instructed him to call the NP. RN B confirmed she did not document in Resident #1's medical record the results of the [MEDICATION NAME] trough and she did not follow up with LVN A to ensure the NP or MD had been notified. During an interview on [DATE] at 3:15 p.m., RN C stated she did not receive Resident #1's critical lab results on [DATE]. RN C denied knowledge of when the critical lab results came in or who took the phone call from lab. RN C further denied having a conversation with LVN A or RN B about the [MEDICATION NAME] trough levels received on [DATE]. RC C stated on [DATE] night shift had informed her that Resident #1's [MEDICATION NAME] trough levels were running high. On [DATE] a [MEDICATION NAME] trough was ordered and drawn. The [MEDICATION NAME] trough was within normal limits and the NP gave an order to administer the [MEDICATION NAME] and repeat the trough level before the next dose ([DATE] 10:00 p.m.). RN C stated she collected the blood sample but did not get the results. RN C stated she instructed the night nurse, LVN A to hold the 10:00 p.m. dose of [MEDICATION NAME] on [DATE] because the facility was still waiting on trough results. During an interview on [DATE] at 4:36 p.m., LVN D confirmed she had administered [MEDICATION NAME] to Resident #1 on [DATE] at 10:00 a.m. and [DATE] at 10:00 a.m. LVN D stated she was not aware of the elevated [MEDICATION NAME] trough. LVN D stated Resident #1 had an order for [REDACTED]. LVN D confirmed she did not review Resident #1's medical record or lab results for a [MEDICATION NAME] trough level prior to administering either dose. LVN D confirmed she did not review orders or [MEDICATION NAME] trough levels and relied on change of condition report to learn when the troughs had been scheduled. When reviewing the physician order [REDACTED]. During an interview on [DATE] at 4:19 p.m., the DON confirmed Resident #1's orders from the hospital were to draw a [MEDICATION NAME] trough once every 3rd dose of [MEDICATION NAME]. The DON further confirmed the orders put into the facility computer did not accurately represent the physician orders. The DON stated we had issued inputting the orders into the computer. During an interview on [DATE] at 10:20 a.m., the Laboratory Director (LD) confirmed [MEDICATION NAME] troughs are a timed laboratory draw requiring coordination between the facility and the lab. The LD stated the laboratory requires the facility to call the lab 24 hours in advance of the laboratory draw. If the facility fails to notify the laboratory in advance, then a STAT order can be placed. The LD stated, I would discourage the STAT order and ask if they could wait until tomorrow. The LD stated the laboratory performed a [MEDICATION NAME] trough on [DATE] and gave the results of 22.9 to RN B. No further orders were received from the facility for [MEDICATION NAME] troughs for Resident #1 until [DATE] when results came back at 43.8. The LD stated she would hope that if a facility was having difficulty with coordinating of laboratory services they would reach out to the company. The LD stated neither the Laboratory Director or VP of Operations had been contacted by the facility. During an interview on [DATE] at 2:05 p.m., LVN E confirmed she administered [MEDICATION NAME] to Resident #1 on [DATE] at 10:00 p.m., [DATE] at 10:00 p.m. and [DATE] at 10:00 p.m. LVN E stated she looked at Resident #1's previous trough levels but did not see the test result for [DATE] with the results of 22.9. LVN E stated the last trough level she saw was a previous result of 16 (date unknown). LVN E stated the morning nurse was responsible for inputting the [MEDICATION NAME] laboratory order in the computer and calling the lab 24 hours in advance. On [DATE] the morning nurse (unknown name) was not the usual nurse and the order didn't get placed for lab. LVN E stated she attempted to notify a NP (unknown name) but did not receive a call back. On [DATE] the lab drew the [MEDICATION NAME] trough on the wrong resident and a trough was never completed for Resident #1. The following day the lab stated the order had never been called in. LVN E stated she was never told she had to call the lab to get the lab drawn. LVN E confirmed she did not notify the ADON, DON, Administrator or any other member of management about the lab difficulties or inability to get the [MEDICATION NAME] trough level drawn. On [DATE] at 2:53 p.m., an the resident physician was called and a request for a return call was left with the physician group. At the time of exit, a call back had not been received. During an interview on [DATE] at 2:55 p.m. the Medical Director (MD) stated he was not aware of the medication error or critical lab value with Resident #1. The MD stated the facility management and MD met for monthly QA (Quality Assurance) meetings in which medication errors and other facility concerns were discussed. The MD stated the Administrator of the facility was a contact person for questions. During an interview on [DATE] at 3:44 p.m., the DON confirmed the facility was responsible for a medication error when the staff continued to administer IV [MEDICATION NAME] to Resident #1 without notifying the physician of a critically high [MEDICATION NAME] trough level and without receiving further instructions/orders related to the [MEDICATION NAME] from the physician. The DON confirmed the error began upon admission to the facility when Resident #1's orders for [MEDICATION NAME] trough were not correctly transcribed into the computer. The DON stated RN B should have communicated the critical lab value to the physician and documented the outcome of the notification in Resident #1's medical record. The DON stated a RN could not delegate the task of physician notification unless the nurse also followed up to ensure the task had been completed. Interview on [DATE] at 4:01 p.m. with a physician at the local hospital where the resident ws transferred to revealed Resident #1 had a [DIAGNOSES REDACTED]. The physician confirmed the elevated [MEDICATION NAME] levels played a role in the kidney failure. The physician revealed Resident #1 developed significant [MEDICAL CONDITION] (brain disease that affects brain function) as a result. During further interview on [DATE] at 12:05 p.m the Medical Director (MD) stated he spoke with the DON on [DATE] about the medication error involving Resident #1. The MD further indicated he still had some clinical questions to look into regarding the situation and wasn't sure whether [MEDICATION NAME] was the only contributing factor. The MD stated [MEDICATION NAME] trough was definitely missed and stated we acknowledge the problem. He further stated, it was a system failure with medications, monitoring, pharmacy, nurses and doctors. Review of a facility policy titled, Medications dated [DATE] revealed, 1. Upon admission (including readmission) of each Patient/Resident, the physicians' orders for the Patient/Resident must be reviewed and reconciled by the Charge Nurse and the Director of Nursing or his/her designee for accuracy in the Electronic Medical Record. During an interview on [DATE] at 10:31 a.m. the DON confirmed she first learned Resident #1 had a critical high [MEDICATION NAME] trough level that was greater than 40 when the physician's group providing care to Resident #1 called the Marketing Director and informed them Resident #1 was [DIAGNOSES REDACTED]. The DON stated she started an internal investigation and once she determined the incident was neglect she reported the incident to HHSC on [DATE]. The DON confirmed the facility policy stated the facility should report allegations of neglect within 24 hours of learning of the incident. Reports from the laboratory given by telephone should be documented by a nurse in the nurses notes. The prescribing physician is to be notified of the results of the laboratory tests ordered. Nursing staff is to review all laboratory reports and notify prescribing physician of any abnormal results. Review of a patient safety document titled Understanding [MEDICATION NAME] dated [DATE] revealed: [MEDICATION NAME] levels are used to optimize dosing to help prevent bacterial resistance, improve patient outcomes and avoid drug toxicity. [MEDICATION NAME] serum trough concentrations, levels drawn just before the next scheduled dose, are considered the most practical method for monitory efficacy when the pathogen is susceptible. Studies have suggested that higher doses and higher trough concentrations are associated with increased rates of nephrotoxicity. Record review of a facility policy, titled Tests-Laboratory revealed: Use the correct form or portal for the laboratory test ordered. Check physician's orders [REDACTED]. Physicians should specify each individual test. Review of an intake report in Tulip received on [DATE] at 6:34 p.m. revealed critical lab results for [MEDICATION NAME] were not reported to Resident #1's NP or MD. As a result, physician orders [REDACTED].#1 had a change of condition and was transported to the hospital ER. The intake report revealed the facility first learned of the incident on [DATE]. Review of a facility policy, titled Intravenous Therapy dated [DATE] and last revised [DATE] revealed: The delivery of IV therapy provides no margin for error, and one mistake may cause irreparable damage to the Patient. The crucial elements in IV therapy are education and training, responsibility and accountability. Nursing Role: Definition of a qualified IV Nurse: LVN's have completed an approved IV training course, and have provided the facility with appropriate paperwork. In addition, all licensed nurses will have an IV competency on hire and annually thereafter by a qualified IV Nurse.

Based on observation, interview and record review, the facility failed to implement written policies and procedures to prohibit neglect for 1 of 16 residents (Residents #18) reviewed for neglect, in that: Resident #18 required minimal assistance during ambulation with 1-2 staff. CNA K did not assist him to stand or walk and the resident fell and sustained a right humerus (upper arm bone) fracture, which resulted in a decline in mobility. Resident #18 became more anxious about walking. This deficient practice resulted in harm to Resident #18 who had sustained a fracture and a decline. The findings were: Record review of Resident #18's face sheet dated 10/22/14 revealed he was admitted on [DATE] with muscle weakness, diabetes, and hypertension. Record review of the MDS dated [DATE] revealed Resident #18 scored a 15 on his BIMS, indicating no cognitive impairment, was 78 inches (6 ft and 6 inches) tall, and required extensive assistance (staff doing most of the work) of one person for walking in room and locomotion on the unit. Record review of the Comprehensive Plan of Care updated 8/9/14 revealed Resident #18 needed assistance of 1-2 staff for transfers, and the resident was at risk for falls. Record review of the Daily Care Guide dated 8/12/14 revealed Resident #18 was assisted by 2 staff with transfers. The Care Guide did not specify how much assistance he needed with walking or standing. Record review of the PT Discharge Summary dated 8/30/14 revealed Resident #18 needed minimal assist (resident performed 75% of the work to move and the physical therapist provided about 25% of the work) for safe ambulation. During an interview on 10/31/14 at 10:45 a.m. with the Director of Physical Therapy, she said when a resident required minimal assistance to walk, the caregiver needed to use a gait belt wrapped around the resident, and the caregiver should hold the gait belt at all times while helping the resident walk. She said a caregiver should not let go of the gait belt if a resident needed minimum assistance. She said there were different levels of assistance provided, and the only level where the caregiver can let go of the gait belt was called "stand by" assistance (where the care giver was next to the resident but does not hold on to the resident). Record review of Resident #18's Fall Risk assessment dated [DATE] indicated Resident #18 had a balance problem while he was standing. The assessment indicated he was at high risk of falls with a score of 18 (a score of 10 or more indicated a resident was at high risk of falls). Record review of the Accident/Incident Report dated 8/31/14 revealed Resident #18 was standing with the walker; CNA K was positioning his recliner when the resident fell . The resident hurt his right shoulder and was sent to the hospital. Record review of CNA K's handwritten statement dated 9/4/14 revealed Resident #18 was walking with his walker toward the recliner. CNA K turned her back for a second to lower the recliner, and she turned around to check on the resident and he was already falling. Record review of the Hospital Discharge Summary dated 8/31/14 revealed the resident was seen in the emergency room with a fracture to his upper extremity (humerus). The resident was sent back to the facility on [DATE] with a shoulder immobilizer and pain medication. Record review of the OT Discharge Summary dated 9/2/14 revealed the resident should be supported to increase his ability to stand for 5 minutes with reduced risk for falls. Record review of the Daily Care Guide dated 9/4/14 revealed the resident needed a mechanical lift with two staff for transfers. Record review of the MDS dated [DATE] revealed: Walk in room: self-performance activity did not occur, walk in room: support provided did not occur, locomotion on unit: self-performance activity occurred only once or twice, support provided two person physical assist. Interview on 10/30/14 at 1:50 p.m. with Resident #18 ' s family member revealed Resident #18 had become more fearful since his fall on 8/31/14. The family member said she felt the staff did not transfer the resident correctly. She said she was told he needed two people to transfer him, but on that day there was only one person helping him. She said his discharge plans had changed. She said before the fall, he was progressing in therapy very quickly, but after the fall, he had needed more help from staff and needed to stay in the facility longer than planned. During an interview on 10/31/14 at 10:45 a.m. with the Director of Physical Therapy, who worked with Resident #18 regularly, she said she was very surprised when she heard Resident #18 had fallen. She said he was very tall and said staff needed to hold the gait belt at all times while the resident walked. She said she would hold the gait belt at all times, and not let it go. She said Resident #18 was very scared to perform therapy after his fall. She said he used to walk with a 4 wheeled walker with staff support but after his fall, he was fearful to stand in the parallel bars, which demonstrated a decline. She said he had become totally dependent on staff since the fall, with 2 people doing all the work. She said after the fall, nursing started to transfer him with a mechanical lift because he was so tall, was unable to bear weight with his arms, and he was so fearful of falling. She said the communication with nursing staff was done verbally. She said when the therapist had to communicate the level of help a resident required, they would tell the charge nurse or the CNA, but not write anything down. She said there had been no change in the communication system since Resident #18 ' s fall. During an interview on 10/30/14 at 6:00 p.m. with Resident #18, he said he did not feel the facility protected him from falling. He said the CNA went to the other said of the bed, and was not holding him. He confirmed he was scared to walk after the fall, and his rehabilitation was prolonged because of his fall. During an interview on 10/31/14 at 11:50 a.m. with CNA L he said when he assisted Resident #18 to stand and walk he used a gait belt, and never let go of the gait belt. He said a one person assist meant that the CNA should walk with the resident at all times. During an interview on 10/31/14 at 10:20 a.m. with ADON C she said after Resident #18 fell , there were no additional in-services provided to the staff, and she did not perform additional monitoring of the CNAs to ensure they were providing assistance and doing transfers appropriately. She said the staff was educated on all types of transfers and the use of a gait belt upon orientation and throughout the year. She said they reviewed what a standby assist, a one person assist, and a two person assist was and the CNA should have one hand behind the resident on the gait belt when walking. She said the nurses would put instructions for CNAs on the Daily Care Guide. She confirmed there was no special instructions on Resident #18's Daily Care Guide concerning ambulation. She said the resident needed two person assist to transfer. During an interview on 10/31/14 at 10:00 a.m. with the Administrator he said he was aware of the incident at the time and interviewed CNA K. He said after he spoke with CNA K and Resident #18, he felt that the incident was not caused by neglect and he did not report it to the state survey agency. He said he did not remember if he asked CNA K about whether the resident had a gait belt in place. He said he did not realize CNA K let go of the gait belt. He said he spoke with the resident and the resident told him he lost his balance. He said there was no further investigation done other than the one done by the DON on the incident report. He said he did not interview the PT or OT about the resident's abilities and the level of assistance the resident needed until surveyor intervention. He said that nursing and therapy have different definitions of assistance and help needed, and there was no formal system to communicate between the disciplines. During an interview on 11/4/14 at 1:32 p.m. with CNA K she said she got Resident #18 dressed and used a gait belt to stand him on 8/31/14. She said he got out of bed on the right side, and he walked with his walker around the bed towards his recliner. She said she walked with him part of the way, and left him to adjust his recliner. She confirmed she let go of the gait belt to adjust the recliner when he fell . She said the nurses would verbally tell her how much help a resident needed. She said she did not remember if she had been told how much help he needed. She said she should not have not let go of the gait belt, and that when a resident needed assistance from one person, it meant the resident needed someone to walk with him holding the gait belt. Record review of CNA K ' s Orientation Checklist dated 4/23/14 revealed she received training on gait belt transfer and return demonstration, safe patient handling and movement program. Record review of the Restorative Nursing Competency Checklist dated 4/26/14 revealed CNA K was competent in using gait belt appropriately, and providing appropriate resident guarding. Review of the facility Resident Abuse Policy revised August 2006 revealed "Residents have the right to be freed from ...neglect. Our abuse prevention programs provides policies and procedures that govern, as a minimum: Identification of occurrences and patterns of potential mistreatment/abuse ...Timely and thorough investigations of all reports and allegations of abuse ...The implementation of changes to prevent future occurrences of abuse. " Review of the Abuse Investigations policy revised December 2009 revealed " All reports of resident abuse, neglect, and injured of unknown source shall be promptly and thoroughly investigated by facility management ...The individual conducting the investigation will, as a minimum: Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, Interview other residents to whom the accused employee provides care or services and review all events leading up to the alleged incident. " Review of the facility Abuse Protocol dated March 2012 revealed " Abuse is defined as ...deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental and psychosocial well-being ...The Abuse Prevention Coordinator will ...report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to the Department of Aging and Disability Services (DADS) or other appropriate authorities as required under applicable regulations and regulatory guidance. " Information obtained from the facility on 10/31/14 revealed there was 1 resident with a fractured humerous on the 600 hall.

Based on observation, interview and record review, the facility failed to implement written policies and procedures to prohibit neglect to protect residents at risk injuries from falls for 1 of 16 resident (Residents #18) reviewed for neglect, in that: Resident #18 required minimal assistance during ambulation with 1-2 staff. CNA K did not assist him to stand or walk and the resident fell and sustained a right humerus (upper arm bone) fracture, which resulted in a decline in mobility. Resident #18 became more anxious about walking. This deficient practice resulted in harm to Resident #18 who had sustained a fracture and a decline. The findings were: Review of the facility Resident Abuse Policy revised August 2006 revealed "Residents have the right to be freed from ...neglect. Our abuse prevention programs provides policies and procedures that govern, as a minimum: Identification of occurrences and patterns of potential mistreatment/abuse ...Timely and thorough investigations of all reports and allegations of abuse ...The implementation of changes to prevent future occurrences of abuse. " Review of the Abuse Investigations policy revised December 2009 revealed " All reports of resident abuse, neglect, and injured of unknown source shall be promptly and thoroughly investigated by facility management ...The individual conducting the investigation will, as a minimum: Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, Interview other residents to whom the accused employee provides care or services and review all events leading up to the alleged incident. " Review of the facility Abuse Protocol dated March 2012 revealed " Abuse is defined as ...deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental and psychosocial well-being ...The Abuse Prevention Coordinator will ...report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to the Department of Aging and Disability Services (DADS) or other appropriate authorities as required under applicable regulations and regulatory guidance. " Record review of Resident #18's face sheet dated 10/22/14 revealed he was admitted on [DATE] with muscle weakness, diabetes, and hypertension. Record review of the MDS dated [DATE] revealed Resident #18 scored a 15 on his BIMS, indicating no cognitive impairment, was 78 inches (6 ft and 6 inches) tall, and required extensive assistance (staff doing most of the work) of one person for walking in room and locomotion on the unit. Record review of the Comprehensive Plan of Care updated 8/9/14 revealed Resident #18 needed assistance of 1-2 staff for transfers, and the resident was at risk for falls. Record review of the Daily Care Guide dated 8/12/14 revealed Resident #18 was assisted by 2 staff with transfers. The Care Guide did not specify how much assistance he needed with walking or standing. Record review of the PT Discharge Summary dated 8/30/14 revealed Resident #18 needed minimal assist (resident performed 75% of the work to move and the physical therapist provided about 25% of the work) for safe ambulation. During an interview on 10/31/14 at 10:45 a.m. with the Director of Physical Therapy, she said when a resident required minimal assistance to walk, the caregiver needed to use a gait belt wrapped around the resident, and the caregiver should hold the gait belt at all times while helping the resident walk. She said a caregiver should not let go of the gait belt if a resident needed minimum assistance. She said there were different levels of assistance provided, and the only level where the caregiver can let go of the gait belt was called "stand by" assistance (where the care giver was next to the resident but does not hold on to the resident). Record review of Resident #18's Fall Risk assessment dated [DATE] indicated Resident #18 had a balance problem while he was standing. The assessment indicated he was at high risk of falls with a score of 18 (a score of 10 or more indicated a resident was at high risk of falls). Record review of the Accident/Incident Report dated 8/31/14 revealed Resident #18 was standing with the walker; CNA K was positioning his recliner when the resident fell . The resident hurt his right shoulder and was sent to the hospital. Record review of CNA K's handwritten statement dated 9/4/14 revealed Resident #18 was walking with his walker toward the recliner. CNA K turned her back for a second to lower the recliner, and she turned around to check on the resident and he was already falling. Record review of the Hospital Discharge Summary dated 8/31/14 revealed the resident was seen in the emergency room with a fracture to his upper extremity (humerus). The resident was sent back to the facility on [DATE] with a shoulder immobilizer and pain medication. Record review of the OT Discharge Summary dated 9/2/14 revealed the resident should be supported to increase his ability to stand for 5 minutes with reduced risk for falls. Record review of the Daily Care Guide dated 9/4/14 revealed the resident needed a mechanical lift with two staff for transfers. Record review of the MDS dated [DATE] revealed: Walk in room: self-performance activity did not occur, walk in room: support provided did not occur, locomotion on unit: self-performance activity occurred only once or twice, support provided two person physical assist. Interview on 10/30/14 at 1:50 p.m. with Resident #18 ' s family member revealed Resident #18 had become more fearful since his fall on 8/31/14. The family member said she felt the staff did not transfer the resident correctly. She said she was told he needed two people to transfer him, but on that day there was only one person helping him. She said his discharge plans had changed. She said before the fall, he was progressing in therapy very quickly, but after the fall, he had needed more help from staff and needed to stay in the facility longer than planned. During an interview on 10/31/14 at 10:45 a.m. with the Director of Physical Therapy, who worked with Resident #18 regularly, she said she was very surprised when she heard Resident #18 had fallen. She said he was very tall and said staff needed to hold the gait belt at all times while the resident walked. She said she would hold the gait belt at all times, and not let it go. She said Resident #18 was very scared to perform therapy after his fall. She said he used to walk with a 4 wheeled walker with staff support but after his fall, he was fearful to stand in the parallel bars, which demonstrated a decline. She said he had become totally dependent on staff since the fall, with 2 people doing all the work. She said after the fall, nursing started to transfer him with a mechanical lift because he was so tall, was unable to bear weight with his arms, and he was so fearful of falling. She said the communication with nursing staff was done verbally. She said when the therapist had to communicate the level of help a resident required, they would tell the charge nurse or the CNA, but not write anything down. She said there had been no change in the communication system since Resident #18 ' s fall. During an interview on 10/30/14 at 6:00 p.m. with Resident #18, he said he did not feel the facility protected him from falling. He said the CNA went to the other said of the bed, and was not holding him. He confirmed he was scared to walk after the fall, and his rehabilitation was prolonged because of his fall. During an interview on 10/31/14 at 11:50 a.m. with CNA L he said when he assisted Resident #18 to stand and walk he used a gait belt, and never let go of the gait belt. He said a one person assist meant that the CNA should walk with the resident at all times. During an interview on 10/31/14 at 10:20 a.m. with ADON C she said after Resident #18 fell , there were no additional in-services provided to the staff, and she did not perform additional monitoring of the CNAs to ensure they were providing assistance and doing transfers appropriately. She said the staff was educated on all types of transfers and the use of a gait belt upon orientation and throughout the year. She said they reviewed what a standby assist, a one person assist, and a two person assist was and the CNA should have one hand behind the resident on the gait belt when walking. She said the nurses would put instructions for CNAs on the Daily Care Guide. She confirmed there was no special instructions on Resident #18's Daily Care Guide concerning ambulation. She said the resident needed two person assist to transfer. During an interview on 10/31/14 at 10:00 a.m. with the Administrator he said he was aware of the incident at the time and interviewed CNA K. He said after he spoke with CNA K and Resident #18, he felt that the incident was not caused by neglect and he did not report it to the state survey agency. He said he did not remember if he asked CNA K about whether the resident had a gait belt in place. He said he did not realize CNA K let go of the gait belt. He said he spoke with the resident and the resident told him he lost his balance. He said there was no further investigation done other than the one done by the DON on the incident report. He said he did not interview the PT or OT about the resident's abilities and the level of assistance the resident needed until surveyor intervention. He said that nursing and therapy have different definitions of assistance and help needed, and there was no formal system to communicate between the disciplines. During an interview on 11/4/14 at 1:32 p.m. with CNA K she said she got Resident #18 dressed and used a gait belt to stand him on 8/31/14. She said he got out of bed on the right side, and he walked with his walker around the bed towards his recliner. She said she walked with him part of the way, and left him to adjust his recliner. She confirmed she let go of the gait belt to adjust the recliner when he fell . She said the nurses would verbally tell her how much help a resident needed. She said she did not remember if she had been told how much help he needed. She said she should not have not let go of the gait belt, and that when a resident needed assistance from one person, it meant the resident needed someone to walk with him holding the gait belt. Record review of CNA K ' s Orientation Checklist dated 4/23/14 revealed she received training on gait belt transfer and return demonstration, safe patient handling and movement program. Record review of the Restorative Nursing Competency Checklist dated 4/26/14 revealed CNA K was competent in using gait belt appropriately, and providing appropriate resident guarding. Review of the facility Resident Abuse Policy revised August 2006 revealed "Residents have the right to be freed from ...neglect. Our abuse prevention programs provides policies and procedures that govern, as a minimum: Identification of occurrences and patterns of potential mistreatment/abuse ...Timely and thorough investigations of all reports and allegations of abuse ...The implementation of changes to prevent future occurrences of abuse. " Review of the Abuse Investigations policy revised December 2009 revealed " All reports of resident abuse, neglect, and injured of unknown source shall be promptly and thoroughly investigated by facility management ...The individual conducting the investigation will, as a minimum: Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, Interview other residents to whom the accused employee provides care or services and review all events leading up to the alleged incident. " Review of the facility Abuse Protocol dated March 2012 revealed " Abuse is defined as ...deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental and psychosocial well-being ...The Abuse Prevention Coordinator will ...report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to the Department of Aging and Disability Services (DADS) or other appropriate authorities as required under applicable regulations and regulatory guidance. " Information obtained from the facility on 10/31/14 revealed there was 1 resident with a fractured humerous on the 600 hall.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 10 residents (Resident #4, #18) reviewed for safety, in that: 1. Resident #18 required minimal assistance during ambulation with 1-2 staff. CNA K did not assist him to stand or walk and the resident fell and sustained a right humerous (upper arm bone) fracture, which resulted in a decline in mobility. Resident #18 became more anxious about walking. 2. Resident #4's bolster pads were not correctly positioned on her bed. This deficient practice led to Resident #18 falling and sustaining a fracture could affect 2 residents who had air mattress with bolster pads and could result in a fall. The findings were: 1. Record review of Resident #18's face sheet dated 10/22/14 revealed he was admitted on [DATE] with muscle weakness, diabetes, and hypertension. Record review of the MDS dated [DATE] revealed Resident #18 scored a 15 on his BIMS, indicating no cognitive impairment, was 78 inches (6 ft and 6 inches) tall, and required extensive assistance (staff doing most of the work) of one person for walking in room and locomotion on the unit. Record review of the Comprehensive Plan of Care updated 8/9/14 revealed Resident #18 needed assistance of 1-2 staff for transfers, and the resident was at risk for falls. Record review of the Daily Care Guide dated 8/12/14 revealed Resident #18 was assisted by 2 staff with transfers. The Care Guide did not specify how much assistance he needed with walking or standing. Record review of the PT Discharge Summary dated 8/30/14 revealed Resident #18 needed minimal assist (resident performed 75% of the work to move and the physical therapist provided about 25% of the work) for safe ambulation. During an interview on 10/31/14 at 10:45 a.m. with the Director of Physical Therapy, she said when a resident required minimal assistance to walk, the caregiver needed to use a gait belt wrapped around the resident, and the caregiver should hold the gait belt at all times while helping the resident walk. She said a caregiver should not let go of the gait belt if a resident needed minimum assistance. She said there were different levels of assistance provided, and the only level where the caregiver can let go of the gait belt was called "stand by" assistance (where the care giver was next to the resident but does not hold on to the resident). Record review of Resident #18's Fall Risk assessment dated [DATE] indicated Resident #18 had a balance problem while he was standing. The assessment indicated he was at high risk of falls with a score of 18 (a score of 10 or more indicated a resident was at high risk of falls). Record review of the Accident/Incident Report dated 8/31/14 revealed Resident #18 was standing with the walker; CNA K was positioning his recliner when the resident fell . The resident hurt his right shoulder and was sent to the hospital. Record review of CNA K's handwritten statement dated 9/4/14 revealed Resident #18 was walking with his walker toward the recliner. CNA K turned her back for a second to lower the recliner, and she turned around to check on the resident and he was already falling. Record review of the Hospital Discharge Summary dated 8/31/14 revealed the resident was seen in the emergency room with a fracture to his upper extremity (humerus). The resident was sent back to the facility on [DATE] with a shoulder immobilizer and pain medication. Record review of the OT Discharge Summary dated 9/2/14 revealed the resident should be supported to increase his ability to stand for 5 minutes with reduced risk for falls. Record review of the Daily Care Guide dated 9/4/14 revealed the resident needed a mechanical lift with two staff for transfers. Record review of the MDS dated [DATE] revealed: Walk in room: self-performance activity did not occur, walk in room: support provided did not occur, locomotion on unit: self-performance activity occurred only once or twice, support provided two person physical assist. Interview on 10/30/14 at 1:50 p.m. with Resident #18 ' s family member revealed Resident #18 had become more fearful since his fall on 8/31/14. The family member said she felt the staff did not transfer the resident correctly. She said she was told he needed two people to transfer him, but on that day there was only one person helping him. She said his discharge plans had changed. She said before the fall, he was progressing in therapy very quickly, but after the fall, he had needed more help from staff and needed to stay in the facility longer than planned. During an interview on 10/31/14 at 10:45 a.m. with the Director of Physical Therapy, who worked with Resident #18 regularly, she said she was very surprised when she heard Resident #18 had fallen. She said he was very tall and said staff needed to hold the gait belt at all times while the resident walked. She said she would hold the gait belt at all times, and not let it go. She said Resident #18 was very scared to perform therapy after his fall. She said he used to walk with a 4 wheeled walker with staff support but after his fall, he was fearful to stand in the parallel bars, which demonstrated a decline. She said he had become totally dependent on staff since the fall, with 2 people doing all the work. She said after the fall, nursing started to transfer him with a mechanical lift because he was so tall, was unable to bear weight with his arms, and he was so fearful of falling. She said the communication with nursing staff was done verbally. She said when the therapist had to communicate the level of help a resident required, they would tell the charge nurse or the CNA, but not write anything down. She said there had been no change in the communication system since Resident #18 ' s fall. During an interview on 10/30/14 at 6:00 p.m. with Resident #18, he said he did not feel the facility protected him from falling. He said the CNA went to the other said of the bed, and was not holding him. He confirmed he was scared to walk after the fall, and his rehabilitation was prolonged because of his fall. During an interview on 10/31/14 at 11:50 a.m. with CNA L he said when he assisted Resident #18 to stand and walk he used a gait belt, and never let go of the gait belt. He said a one person assist meant that the CNA should walk with the resident at all times. During an interview on 10/31/14 at 10:20 a.m. with ADON C she said after Resident #18 fell , there were no additional in-services provided to the staff, and she did not perform additional monitoring of the CNAs to ensure they were providing assistance and doing transfers appropriately. She said the staff was educated on all types of transfers and the use of a gait belt upon orientation and throughout the year. She said they reviewed what a standby assist, a one person assist, and a two person assist was and the CNA should have one hand behind the resident on the gait belt when walking. She said the nurses would put instructions for CNAs on the Daily Care Guide. She confirmed there was no special instructions on Resident #18's Daily Care Guide concerning ambulation. She said the resident needed two person assist to transfer. During an interview on 10/31/14 at 10:00 a.m. with the Administrator he said he was aware of the incident at the time and interviewed CNA K. He said he did not remember if he asked CNA K about whether the resident had a gait belt in place. He said he did not realize CNA K let go of the gait belt. He said he spoke with the resident and the resident told him he lost his balance. During an interview on 11/4/14 at 1:32 p.m. with CNA K she said she got Resident #18 dressed and used a gait belt to stand him on 8/31/14. She said he got out of bed on the right side, and he walked with his walker around the bed towards his recliner. She said she walked with him part of the way, and left him to adjust his recliner. She confirmed she let go of the gait belt to adjust the recliner when he fell . She said the nurses would verbally tell her how much help a resident needed. She said she did not remember if she had been told how much help he needed. She said she should not have not let go of the gait belt, and that when a resident needed assistance from one person, it meant the resident needed someone to walk with him holding the gait belt. Record review of CNA K ' s Orientation Checklist dated 4/23/14 revealed she received training on gait belt transfer and return demonstration, safe patient handling and movement program. Record review of the Restorative Nursing Competency Checklist dated 4/26/14 revealed CNA K was competent in using gait belt appropriately, and providing appropriate resident guarding. 2. Review of Resident #4's facesheet dated 8/4/14 revealed an admitted [DATE] and readmitted on [DATE]. Observation on 10/28/14 at 3:20 p.m. revealed Resident #4 was in bed. Further observation revealed the foam bolster pads on the left side of the bed were not in place. Observation on 10/29/14 at 3:16 p.m. revealed resident #4 was in bed. Further observation revealed the bolster pads on the bed were up on the right side, but the bolster pads were laying flat instead of up on the left side of the bed. During an interview on 10/29/14 at 3:16 p.m. with LVN I, she confirmed the bolster were up on the right side of Resident #4's bed and were laying flat on the left side of the bed. During an interview on 10/29/14 at 3:28 p.m. and on 10/30/14 at 11:09 a.m. with ADON H, she confirmed Resident #4's left side of the bed was flat. ADON H further indicated Resident #4 had the bolster overlays on her air mattress as a precaution. ADON H further indicated Resident #4 rolled a lot in bed. Review of information provided by the facility on 10/31/14 revealed there were 2 residents who had air mattresses with bolster pads.