Every finding on record at Costa del Sol Healthcare

Based on interview and record review, the facility failed to ensure licensed nurses notified the physician of low blood pressure measurements for four of four sampled residents (Resident 57, Resident 2, Resident 12, and Resident 1). This deficient practice had the potential to result in Residents 57, 2, 12, and 1 experiencing adverse side effects of hypotension (low blood pressure), including dizziness, fainting, and falls.Findings:1. During a review of Resident 57's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 57 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 57's diagnoses included hypertension (high blood pressure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and history of falling.During a review of Resident 57's History and Physical (H&P), dated 2/16/2026, the H&P indicated Resident 57 had the capacity to understand and make decisions.During a review of Resident 57's Minimum Data Set (MDS- a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 57's cognitive skills for daily decision making (process of thinking) was intact. The MDS indicated Resident 57 required partial assistance (helper does less than half the effort) with toileting, bathing, lower body dressing, and putting on/taking off footwear.During a review of Resident 57's Care Plan titled, Medication- Anti-hypertensive (medication used to lower blood pressure), dated 2/5/2026, the care plan indicated to observe side effects of amiodarone (medication used to treat and prevent irregular heart rhythms) and carvedilol (an antihypertensive medication) such as hypotension (blood pressure below 90 over 60 [90/60] millimeters of mercury [mmHg, a unit of measuring blood pressure]) and notify the physician promptly.During a review of Resident 57's Vital Signs record, dated 6/1/2026 through 8/31/2026, the record indicated Resident 57's low blood pressure measurements on the following dates:a. 6/27/2025 - 84/47 mm Hgb. 6/29/2026 - 75/49mmHgc. 7/16/2026 - 62/47mmHgDuring an interview on 8/13/2026 at 8:22 a.m., with Registered Nurse (RN) 1, RN 1 stated many residents tend to have lower blood pressure readings due to low activity and administration of antihypertensive medications. RN 1 stated hypotension with a systolic blood pressure (SBP- top number of a blood pressure reading) below 90mmHg would be concerning. RN 1 stated low blood pressure readings should be rechecked for validity and the resident's physician should be notified. RN 1 stated the physician should be notified because the resident could have an underlying infection causing the hypotension or the physician could adjust the resident's antihypertensive medications. RN 1 stated physician notification would be documented in the resident's Progress Notes.During a concurrent interview and record review on 8/13/2026 at 8:28 a.m., with RN 1, Resident 57's Progress Notes, dated 6/27/2026, 6/29/2026, and 7/16/2026, were reviewed. The Progress Notes did not indicate Resident 57's physician was notified of Resident 57's hypotensive measurements. RN 1 stated Resident 57's physician should have been notified because Resident 57 was on antihypertensive medications and received dialysis. RN 1 stated Resident 57 was at risk of dizziness, falls, and complications from her dialysis treatment. RN 1 stated dialysis treatments had the potential to lower Resident 57's blood pressure further and low blood pressure could cause severe complications.2. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included hypertension and history of falling.During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 was dependent on staff with oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 2's H&P, dated 4/30/2026, the H&P indicated Resident 2 did not have the capacity to make medical decisions.During a review of Resident 2's Care Plan titled, Medication- Anti-hypertensive, dated 7/19/2025, the care plan indicated to observe side effects of metoprolol tartrate (an antihypertensive mediation) such as hypotension and notify the physician promptly.During a review of Resident 2's Vital Signs record, dated 6/1/2026 through 8/31/2026, the record indicated Resident 2's blood pressures on the following dates:a. 7/8/2026 - 71/49mmHgb. 7/29/2026 - 77/48mmHgc. 8/1/2026 - 83/42mmHgDuring a concurrent interview and record review on 8/13/2026 at 8:38 a.m., with RN 1, Resident 2's Progress Notes, dated 7/8/2026, 7/29/2026, and 8/1/2026, were reviewed. The Progress Notes did not indicate Resident 2's physician was notified of Resident 2's hypotensive measurements. RN 1 stated Resident 2's physician should have been notified because Resident 2 was on antihypertensive medications. RN 1 stated Resident 2 was at risk for falls and hypotensive episodes increased Resident 2's risk for falls.3. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included hypertension and history of falling. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 1 was dependent on staff's assistance with oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 1's H&P, dated 5/17/2026, the H&P indicated Resident 1 did not have the capacity to make medical decision.During a review of Resident 1's Care Plan titled, Medication- Anti-hypertensive, dated 5/16/2026, the care plan indicated to observe side effects of amlodipine (an antihypertensive mediation) and losartan potassium (an antihypertensive medication) such as hypotension and notify the physician promptly.During a review of Resident 1's Vital Signs record, dated 6/1/2026 through 8/31/2026, the record indicated Resident 1's blood pressures on the following dates:a. 6/10/2026 - 88/60mmHgb. 7/19/2026 - 82/59mmHgc. 7/28/2026 - 89/55mmHgDuring a concurrent interview and record review on 8/12/2026 at 3:52 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 1's Progress Notes, dated 7/28/2026, was reviewed. The Progress Notes did not indicate Resident 1's physician was notified of Resident 1's hypotensive measurements. LVN 2 stated, on 7/28/2026, she did not notify Resident 1's physician of Resident 1's blood pressure of 89/55mmHg. LVN 2 stated she should have notified Resident 1's physician because 89/55mmHg was not Resident 1's baseline and there could be an undetected underlying cause to the low blood pressure.During a concurrent interview and record review on 8/13/2026 at 8:36 a.m., with RN 1, Resident 1's Progress Notes, dated 6/10/2026 and 7/19/2026, were reviewed. The Progress Notes did not indicate Resident 1's physician was notified of Resident 1's hypotensive episodes. RN 1 stated Resident 1's physician should have been notified of Resident 1's hypotensive readings because Resident 1 was receiving antihypertensive medications. RN 1 stated Resident 1 was at risk for dizziness and fainting.4. During a review of Resident 12's admission Record (Face Sheet), the Face Sheet indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included hypertension and syncope (fainting).During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 12 required substantial assistance (helper does more than half the effort) with toileting, bathing, lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 12's H&P, dated 3/11/2026, the H&P indicated Resident 12 did not have the capacity to make medical decisions.During a review of Resident 12's Care Plan titled, Medication- Anti-hypertensive, dated 10/27/2024, the care plan indicated to observe side effects of amlodipine such as hypotension and notify the physician promptly.During a review of Resident 12's Vital Signs record, dated 7/25/2026, the record indicated, on 7/25/2026, Resident 12's blood pressure was 89/60.During a concurrent interview and record review on 8/13/2026 at 8:28 a.m., with RN 1, Resident 12's Progress Notes, dated 7/25/2026, was reviewed. The Progress Notes did not indicate Resident 12's physician was notified of Resident 12's hypotensive episode. RN 1 stated Resident 12's physician should have been notified because Resident 12 was receiving antihypertensive medications. RN 1 stated Resident 12 was at risk for dizziness and fainting.During an interview on 8/13/2026 at 10:08 a.m., with the Director of Nursing (DON), the DON stated physicians should be notified if a resident's SBP dropped below 90mmHg. The DON stated the blood pressure should be rechecked and then the physician should be notified. The DON stated the resident's medications may need adjusting or the resident may need an evaluation for an underlying cause. The DON stated the lack of physician notification could cause a delay in care and increase the risks for falls and accidents.During a review of the facility's policy and procedure (P&P) titled, Blood Pressure, Monitoring, reviewed 1/2026, the P&P indicated, Hypotension should be reported to the physician.

Based on interview and record review, the facility failed to ensure adequate monitoring of psychotropic medications (any drug that changes brain function resulting in alteration to mood, thoughts, feelings or behavior) for three of six sampled residents (Resident 29, Resident 6, and Resident 12) when the facility failed to:1. Ensure Resident 29's behavior of being uncooperative with care was being monitored.2. Ensure Resident 6's behavior of agitation (feeling of unease) was being monitored.3. Ensure Resident 12's hydroxyzine (medication primarily used to treat itching but can be used to treat anxiety [mental health condition involving excessive, ongoing fear, or worry ]) had a stop date from 12/2024 through 3/2026 and had documentation in the medical record for use beyond 14 days.These deficient practices had the potential to place Residents 29, 6, and 12 at risk for unnecessary psychotropic medication use and unidentified and unaddressed changes in behavior. 1. During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was admitted to the facility on [DATE]. Resident 29's diagnoses included depression (mental health condition that causes deep feelings of sadness and loss of interest in activities), encephalopathy (any disease or damage that disturbs the brain function) and dysphagia (difficulty swallowing). During a review of Resident 29's History and Physical (H&P) dated 5/26/2026, the H&P indicated Resident 29 had the capacity to understand and make decisions. During a review of Resident 29's Minimum Data Set (MDS-a resident assessment tool) dated 6/1/2026, the MDS indicated Resident 29 had severe cognitive (ability to think and understand) impairment. The MDS indicated Resident 29 was dependent on staff for toileting, bathing and eating. During a review of Resident 29's care plan titled, Uses antidepressant medication related to depression Mirtazapine (antidepressant medication) oral tablet 15 milligrams (mg, metric unit of measurement used for medication dosage and/or amount), dated 8/4/2026, the care plan indicated to monitor/document/report to MD (doctor of medicine), prn (given as needed or requested), on going signs and symptoms of depression unaltered by antidepressant meds: sad, irritable, anger. During a concurrent interview and record review on 8/11/2026 at 1:39 pm with Licensed Vocational Nurse (LVN) 1, Resident 29's medical record and physician orders dated 7/29/2026 were reviewed. The physician orders indicated to administer Mirtazapine oral tablet 15 mg, give 15 mg by mouth at bedtime for depression manifested by uncooperative with care. The medical records did not indicate there was a physician order for the behavior monitoring of Resident 29's depression, or being uncooperative with care. LVN 1 stated Resident 29's behavior of being uncooperative with care should have been monitored to ensure medication was effective and physician was notified if there were any changes in behavior. LVN 1 stated psychotropic medications (medications that affect the mind, emotions, and behavior) being administered without appropriate behavior monitoring placed resident at risk of unidentified and unaddressed changes in behavior. 2. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure) and depression (mental health condition that causes deep feelings of sadness and loss of interest in activities). During a review of Resident 6's H&P dated 7/17/2026, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had moderate cognitive impairment. The MDS indicated Resident 6 was dependent on staff for personal hygiene, toileting, and eating. During a review of Resident 6's care plan titled, Uses anti-anxiety medications related to anxiety disorder (condition where a person feels extreme, ongoing fear, worry or nervousness) Lorazepam (medication that works to relieve symptoms of anxiety) oral tablet 0.5 mg, dated 6/26/2026, the care plan indicated to monitor and record occurrence for target behavior symptoms and document per facility protocol. During a concurrent interview and record review on 8/11/2026 at 1:31 p.m. with LVN 1, Resident 6's medical record and physician order's dated 7/22/2026 were reviewed. The physician orders indicated, Lorazepam oral tablet 0.5 mg, Give 0.5 mg sublingually (administered under the tongue) every six hours as needed for anxiety manifested by agitation for 14 days. The medical records did not indicate there was a physician order for the behavior monitoring of Resident 6's agitation. LVN 1 stated there should have been an order to monitor Resident 6's agitation to ensure effectiveness of medication regimen and to determine the need of physician reassessment. LVN 1 stated not monitoring Resident 6's agitation placed the resident at risk of unidentified and unaddressed changes in behavior. During an interview on 8/12/2026 at 2:06 p.m. with the Director of Nursing (DON), the DON stated monitoring indicated behaviors for psychotropic medications was important to ensure medications were effective, and any changes in behavior were identified and addressed. 3. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included HTN, anxiety disorder, and syncope (fainting). During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 12 required substantial assistance (helper does more than half the effort) with toileting, bathing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 12's H&P, dated 3/11/2026, the H&P indicated Resident 12 did not have the capacity to make medical decisions. During an interview on 8/13/2026 at 10:13 a.m., with the DON, the DON stated medications given to treat anxiety manifested behaviors were considered a psychotropic medication and had to follow the same requirements. The DON stated as needed use psychotropic medications were limited to 14 days unless the resident's physician documented a rationale for longer use. The DON stated the psychotropic medication would first be ordered for 14 days and if the resident required the medication consistently, the physician would reevaluate and determine to order the medication for another 14 days or longer. During a concurrent interview and record review on 8/13/2026 at 10:18 a.m., with the DON, Resident 12's Physician Orders, dated 12/1/2024 through 8/31/2026, was reviewed. The Physician Orders indicated Resident 12's hydroxyzine (medication primarily used to treat itching but can be used to treat anxiety) order on the following dates:a. Give hydroxyzine 25 milligrams (mg, a unit of measurement) by mouth, every six hours, as needed for anxiety manifested by restlessness. This order was active from 12/13/2024 through 3/8/2026.b. Give hydroxyzine 25mg by mouth, twice a day, as needed for anxiety manifested by restlessness. This order was active 3/18/2026 through 5/26/2026.c. Give hydroxyzine 25mg, twice a day, as needed for anxiety manifested by the inability to sit still for three months. This order was ordered on 5/26/2026 with an end date of 8/26/2026. The DON stated when Resident 12's hydroxyzine was initially ordered; the order was active longer than 14 days. The DON stated Resident 12 never had a 14-day trial to see if the medication was necessary to treat Resident 12's anxiety behavior. The DON stated when a psychotropic medication order was active longer than 14 days, the physician had to document the rationale in Resident 12's medical record. During a concurrent interview and record review on 8/13/2026 at 10:24 a.m., with the DON, Resident 12's Psychiatric Evaluations, dated 12/2/2025, 3/10/2026, 4/8/2026, 5/8/2026, 6/5/2026, and 7/8/2026, were reviewed. The Psychiatric Evaluations did not indicate a rationale to use hydroxyzine beyond 14 days. The DON stated without a documented rationale, there was no justification for the long-term use of Resident 12's hydroxyzine and no proof an evaluation was done. The DON stated without a rationale, how would Resident 12's healthcare team know if the hydroxyzine was effective and necessary to treat Resident 12's anxiety behaviors. During a review of the facility's policy and procedure (P&P) titled, Psychoactive/Psychotropic Medication Use dated 4/2025, indicated, Monitoring of a resident receiving psychotropic medication will include evaluation of the effectiveness of the medication. The P&P indicated, behavioral symptoms are reevaluated periodically to determine the potential for reducing or discontinuing the drug based on therapeutic goals. The P&P indicated [As needed] Psychotropic drug orders are limited to 14 days. If it is appropriate to extend the order beyond 14 days, the Attending Physician or prescribing practitioner shall document the rationale in the medical record and indicate a duration for the [as needed] order.

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 5 was proficient in taking one of two sampled residents' (Resident 12) orthostatic blood pressure (a measurement of the change in blood pressure between lying down and standing up).This deficient practice resulted in Resident 12's orthostatic blood pressure readings being inaccurate and had the potential for Resident 12 to experience untreated orthostatic hypotension (sudden drop in blood pressure when changing from a lying to standing position) and delay in evaluation and treatment.Findings:During a review of Resident 12's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included hypertension (high blood pressure and syncope (fainting).During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's cognitive skills for daily decision making (process of thinking) was severely impaired. The MDS indicated Resident 12 required substantial assistance (helper does more than half the effort) with toileting, bathing, lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 12's History and Physical (H&P), dated 3/11/2026, the H&P indicated Resident 12 did not have the capacity to make medical decisions. During a review of Resident 12's Physician Order, dated 3/9/2026, the Physician Order indicated to monitor Resident 12's orthostatic blood pressure (a measurement of the change in blood pressure between lying down and standing up), every Saturday, in a lying, sitting, and standing position within three-minute intervals. Notify the physician for systolic blood pressure (SBP- top number of a blood pressure reading) difference of 20 millimeters of mercury (mmHg- a unit of blood pressure measurement) and diastolic blood pressure (DBP- bottom number of a blood pressure reading) difference of 10mmHg.During a review of Resident 12's Care Plan titled, [Resident] Has Hypertension, dated 1/1/2024, the care plan indicated to monitor Resident 12 for orthostatic hypotension.During a review of Resident 12's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/1/2026 through 6/30/2026, the MAR indicated the following orthostatic blood pressure readings on the following dates:a. On 6/20/2026- 128/66 mmHg for lying, sitting, and standing.b. On 6/27/2026- 101/65mmHg for lying, sitting, and standing.During an interview on 8/12/2026 at 10:38 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated orthostatic blood pressures were taken in a lying, sitting, and standing position to assess whether Resident 12 experienced orthostatic hypotension. LVN 5 stated once Resident 12 was in each position, she waited 15 minutes to take the blood pressure. LVN 5 stated Resident 12 was on medications with side effects of hypotension. LVN 5 stated she waited 15 minutes after changing Resident 12's position because changing positions could cause dizziness, which increased Resident 12's risk for falls. LVN 5 stated waiting 15 minutes would allow Resident 12's dizziness and other symptoms to resolve. LVN 5 stated waiting 15 minutes to check Resident 12's blood pressures were incorrect because by that time, Resident 12's blood pressure could stabilize. LVN 5 stated waiting 15 minutes was not the correct way to obtain an accurate blood pressure and she would miss the window of hypotension.During a concurrent interview and record review on 8/12/2026 at 12:38 p.m., with the Director of Staff Development (DSD), the facility's In-Service titled, Vital Signs and Orthostatic Blood Pressures, dated 8/18/2025, was reviewed. The Inservice indicated orthostatic blood pressures were assessed within three minutes after changing positions. The DSD stated orthostatic blood pressures were done within three minutes of position changes between lying, sitting, and standing. The DSD stated orthostatic hypotension occurred suddenly and checking blood pressure within the three-minute mark was necessary for accurate orthostatic blood pressure readings. The DSD stated waiting longer than three minutes to take the blood pressures had the potential to miss the window of hypotension.During an interview on 8/13/2026 at 10:30 a.m., with the Director of Nursing (DON), the DON stated orthostatic blood pressures were taken in a lying, sitting, and standing position within three-minutes of changing positions. The DON stated taking the blood pressures within the three-minute mark was necessary to identify the sudden drop in blood pressure, which could cause the resident to feel dizzy. The DON stated the licensed nurses were supposed to be competent in taking orthostatic blood pressures to identify and notify the physician, who would evaluate the resident's medication. During a review of the facility's LVN Job Description, dated 2/2024, the Job Description's nursing care functions indicated for the LVN to take and record blood pressures as necessary.

Based on interview and record review, the facility failed to ensure medications were administered as ordered by the physician for six of 18 sampled residents (Resident 19, Resident 12, Resident 57, Resident 1, Resident 2, and Resident 66). This deficient practice created the potential for to Residents 19, 12, 57, 1, 2, and 66 to experience complications related to hypotension (low blood pressure), including dizziness, falls, and increased heart rate. Findings: 1. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 19's diagnoses included hypertension (HTN- high blood pressure). During a review of Resident 19's Minimum Data Set (MDS, a resident assessment tool), dated 7/31/2026, the MDS indicated Resident 19 had no cognitive impairment (trouble with thinking, learning, remembering, and making choices). The MDS indicated Resident 19 was dependent on staff for personal hygiene and for transferring between surfaces. During a review of Resident 19's Care Plan titled Hypertension., initiated 8/5/2024, the care plan indicated goals of care included Resident 19 maintaining his blood pressure within normal parameters. The care plan indicated staff were to administer carvedilol (a blood pressure medication) and furosemide (a medication that causes the kidneys to make more urine) as ordered and monitor for side effects such as orthostatic hypotension and increased heart rate. During a review of Resident 19's physician order, dated 5/13/2026, the order indicated staff were to administer carvedilol every 12 hours. The order indicated to hold for systolic blood pressure (SBP, the maximum force your blood exerts against your artery walls each time your heart beats) less than 100 millimeters of mercury (mm Hg, a unit for measuring blood pressure), or for heart rate less than 55 beats per minute (bpm, a unit for measuring heart rate). During a review of Resident 19's physician order, dated 5/14/2026, the order indicated staff were to administer furosemide in the morning. The order indicated to hold the medication if Resident 19's SBP was less than 110 mm Hg. During a review of Resident 19's Electronic Medication Administration Record (EMAR), dated 8/2026, the EMAR indicated: a. On 8/4/2026, Resident 19 was administered carvedilol for a HR of 54 bpm. b. On 8/4/2026, Resident 19 was administered furosemide for a SBP of 96 mm Hg. c. On 8/10/2026, Resident 19 was administered furosemide for a SBP of 101 mm Hg. During an interview on 8/11/2026 at 2:15 p.m., with the Director of Nursing (DON), the DON stated it was important to administer medication as ordered by the physician, especially if there were holding parameters. The DON stated that licensed nursing staff should pay attention to holding parameters because administration of a medication outside of the parameters could negatively affect the resident. 2. During a review of Resident 2's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included hypertension and history of falling. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 was dependent on staff with oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 2's History and Physical (H&P), dated 4/30/2026, the H&P indicated Resident 2 did not have the capacity to make medical decisions. During a review of Resident 2's Physician Order, dated 10/13/2025, the Physician Order indicated to administer metoprolol (a hypertensive medication used to lower blood pressure) 25 milligrams (mg, a metric unit of measurement) twice a day. The Physician Order indicated to hold for SBP less than 110mmHg or for heart rate less than 60 bpm. During a review of Resident 2's Care Plan titled, Medication- Anti-Hypertensive, dated 7/19/2025, the care plan indicated to administer metoprolol as ordered and to follow the holding parameters. During an interview on 8/12/2026 at 9:12 a.m., with Registered Nurse (RN) 1, RN 1 stated holding parameters for antihypertensive medications were supposed to be followed because of the risk of hypotension and bradycardia (low heart rate). RN 1 stated administering antihypertensive medications when a resident's blood pressure and/or heart rate and lower than the holding parameter placed the resident at risk for dizziness and falls. During a concurrent interview and record review, on 8/12/2026 at 9:18 a.m., with RN 1, Resident 2's MAR, dated 6/2026, 7/2026, and 8/2026, were reviewed. The MAR indicated Resident 2 was administered metoprolol outside of the holding parameters. RN 1 stated licensed nurses should not have administered metoprolol on the following dates when Resident 2's SBP and heart rate were outside the holding parameters:a. 6/3/2026- 100mmHg.b. 6/5/2026- 108mmHg.c. 6/6/2026- 101mmHg d. 6/7/2026- 106mmHg.e. 6/11/2026- 105mmHg.f. 6/12/2026- 107mmHg.g. 6/14/2026- 108mmHg and 109mmHg.h. 6/25/2026- 56 bpm.i. 7/19/2026- 107mmHg.j. 7/28/2026- 96mmHg.k. 8/4/2026- 108mmHg.l. 8/7/2026- 99mmHg.m. 8/9/2026- 102mmHg.n. 8/10/2026- 102mmHg.o. 8/11/2026- 108mmHg. 3. During a review of Resident 12's Face Sheet, the Face Sheet indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included hypertension and syncope (fainting). During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 12 required substantial assistance (helper does more than half the effort) with toileting, bathing, lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 12's H&P, dated 3/11/2026, the H&P indicated Resident 12 did not have the capacity to make medical decisions. During a review of Resident 12's Physician Order, dated 3/9/2026, the Physician Order indicated to administer amlodipine (an antihypertensive medication) in the morning. The Physician Order indicated staff to hold if Resident 12's SBP was less than 110mmHg During a review of Resident 12's Care Plan titled, Medication- Anti-hypertensive, dated 10/27/2024, the care plan indicated to administer amlodipine as ordered and to follow the holding parameters. During a concurrent interview and record review on 8/12/2026 at 9:15 a.m., with RN 1, Resident 12's MAR, dated 6/2026 and 8/2026, were reviewed. The MAR indicated Resident 12 was administered amlodipine outside of the holding parameters. RN 1 stated the licensed nurses should not have administered Resident 12's amlodipine on the following dates when her SBP were outside the holding parameters:a. 6/11/2026- 100mmHg.b. 6/12/2026- 101mmHg.c. 6/14/2026- 94mmHg.d. 6/18/2026- 97mmHg.e. 8/7/2026- 105mmHg. 4. During a review of Resident 57's Face Sheet, the Face Sheet indicated Resident 57 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 57's diagnoses included hypertension dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and history of falling. During a review of Resident 57's H&P, dated 2/16/2026, the H&P indicated Resident 57 had the capacity to understand and make decisions. During a review of Resident 57's MDS, dated [DATE], the MDS indicated Resident 57's cognitive skills for daily decision making was intact. The MDS indicated Resident 57 required partial assistance (helper does less than half the effort) with toileting, bathing, lower body dressing, and putting on/taking off footwear. During a review of Resident 57's Physician Order, dated 2/28/2026 through 8/4/2026, the Physician Order indicated to administer carvedilol 12.5mg twice a day every Monday, Wednesday, Friday, and Sunday. The Physician Order indicated to hold if Resident 57's SBP was less than 110mmHg or if her heart rate was less than 60 bpm. During a review of Resident 57's Physician Order, dated 8/4/2026, the Physician order indicated to administer carvedilol 6.25mg twice a day every Monday, Wednesday, Friday, and Sunday. The Physician Order indicated staff to hold if Resident 57's SBP was less than 110mmHg or if her heart rate was less than 60 bpm. During a review of Resident 57's Care Plan titled, Medication- Anti-hypertensive, dated 2/5/2026, the care plan indicated to administer carvedilol as ordered and to follow the holding parameters. During a concurrent interview and record review on 8/12/2026 at 9:16 a.m., with RN 1, Resident 57's MAR, dated 6/2026 and 7/2026, were reviewed. The MAR indicated Resident 57 was administered carvedilol outside of the holding parameters. RN 1 stated the licensed nurses should not have administered carvedilol on the following dates when her SBP were outside the holding parameters:a. 6/7/2026- 100mmHg.b. 6/19/2026- 108mmHg.c. 7/15/2026- 109mmHg. 5. During a review of Resident 66's Face Sheet, the Face Sheet indicated Resident 66 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 66's diagnoses included hypertension and atrial fibrillation (an irregular and often very rapid heart rhythm). During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 66 was dependent on staff's assistance with oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 66's H&P, dated 8/6/2026, the H&P indicated Resident 66 did not have the capacity to make medical decisions. During a review of Resident 66's Physician Order, dated 5/7/2026 and 8/5/2026, the Physician Order indicated to administer metoprolol 12.5 mg twice a day. The Physician Order indicated staff to hold if Resident 66's SBP was less than 110mmHg or if her heart rate was less than 60 bpm. During a review of Resident 2's Care Plan titled, Medication- Anti-Hypertensive, dated 5/8/2026, the care plan indicated to administer metoprolol as ordered and to follow the holding parameters. During a concurrent interview and record review, on 8/12/2026 at 9:19 a.m., with RN 1, Resident 66's MAR, dated 6/2026 and 7/2026, were reviewed. The MAR indicated Resident 66 was administered metoprolol outside of the holding parameters. RN 1 stated the licensed nurses should not have administered metoprolol on the following dates when Resident 66's SBP was outside the holding parameters:a. 6/19/2026- 97mmHg.b. 7/13/2026- 109mmHg. 6. During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included hypertension and history of falling. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 1 was dependent on staff's assistance with oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 1's H&P, dated 5/17/2026, the H&P indicated Resident 1 did not have the capacity to make medical decisions. During a review of Resident 1's Physician Order, dated 5/16/2026, the Physician Order indicated to administer amlodipine in the morning. The Physician Order indicated to hold if Resident 1's SBP was less than 110mmHg. During a review of Resident 1's Care Plan titled, Medication- Anti-hypertensive, dated 5/16/2026, the care plan indicated to administer amlodipine as ordered and to follow the holding parameters. During a concurrent interview and record review on 8/12/2026 at 9:17 a.m., with RN 1, Resident 1's MAR, dated 8/2026, was reviewed. The MAR indicated, on 8/7/2026, Resident 1 was administered amlodipine outside of the holding parameters, with a SBP of 100mmHg. RN 1 stated, on 8/7/2026, the licensed nurse should not have administered Resident 1's amlodipine when her SBP was outside the holding parameter. During an interview on 8/13/2026 at 10:35 a.m., with the DON, the DON stated holding parameters were ordered with antihypertensive medications to ensure the residents' blood pressure did not drop too low and cause avoidable issues. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 2/2024, the P&P indicated medications were to be administered in accordance with prescriber orders. The P&P indicated the resident's vital signs were to be checked/verified, if necessary, prior to administering medications.

Based on observation, interview, and record review, the facility failed to develop a care plan for the use of bedrails (adjustable metal or rigid plastic bars that attach to the bed) for one of two sampled residents (Resident 1).This deficient practice had the potential to result in the inappropriate use of bedrails.Cross Reference F700.Findings:During a review of Resident 1's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included hypertension (high blood pressure) and history of falling. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/22/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (process of thinking) was moderately impaired. The MDS indicated Resident 1 was dependent on staff with oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 1 was dependent on staff's assistance with turning left and right.During a review of Resident 1's History and Physical (H&P), dated 5/17/2026, the H&P indicated Resident 1 did not have the capacity to make medical decisions.During a review of Resident 1's Physician Order, dated 6/25/2026, the Physician Order indicated to apply top half side rails (adjustable metal or rigid plastic bars that attach to the bed) on both sides of the bed to aid in bed mobility, turning, and repositioning.During an observation on 8/10/2026 at 9:22 a.m. and 8/11/2026 at 9:22 a.m., in Resident 1's room, Resident 1 was observed lying in bed. Bilateral (both sides) padded half side bed rails were in the up position.During an interview on 8/12/2026 at 1:06 p.m., with the MDS Nurse (MDSN), the MDSN stated residents with side rails installed had to be evaluated to ensure side rails were indicated and safe for use. The MDSN stated if the resident benefited from installed side rails, the side rails would be installed and a care plan would be developed.During a concurrent observation and interview on 8/12/2026 at 1:12 p.m., with the MDSN, in Resident 1's room, Resident 1 was observed lying in bed and had bilateral padded side rails in the up position. The MDSN stated Resident 1 had bilateral padded side rails, therefore Resident 1 should have a care plan indicating its use.During a concurrent interview and record review on 8/12/2026 at 1:18 a.m., with the MDSN, Resident 1's care plans, active on 8/12/2026, were reviewed. The care plan did not indicate the use of bilateral padded side rails. The MDSN stated a care plan was necessary to communicate Resident 1's plan of care and ensure proper monitoring was done.During an interview on 8/13/2026 at 10:30 a.m., with the Director of Nursing (DON), the DON stated when a resident had bilateral bed rails, a care plan had to be in place. The DON stated the care plan included interventions for staff to implement such as monitoring for safety and effectiveness.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/2024, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure one of two dependent sampled residents (Resident 9) fingernails were trimmed and maintained in a clean manner. This deficient practice had the potential to result in a negative impact on Resident 9's quality of life and self-esteem, and had the potential to result in sustaining skin injury from scratching and developing an infection.Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), sepsis (a life-threatening blood infection), and urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of Resident 9's Minimum Data Set (MDS- a resident assessment tool), dated 8/4/2026, the MDS indicated Resident 9's cognitive skills for daily decision making (process of thinking) was moderately impaired. The MDS indicated Resident 9 was dependent on staff with toileting, bathing, and lower body dressing. The MDS indicated Resident 9 had an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine).During a review of Resident 9's History and Physical (H&P), dated 2/10/2026, the H&P indicated Resident 9 had no capacity to understand and make decisions.During an observation on 8/10/2026 at 9:14 a.m., at Resident 9's bedside, Resident 9's fingernails were observed. Resident 9's fingernails were long and untrimmed with black debris underneath the nail bed.During a concurrent observation and interview on 8/12/2026 at 1:50 p.m., at Resident 9's bedside, with Certified Nursing Assistant (CNA) 2, Resident 9's fingernails were observed. Resident 9's fingernails were long and untrimmed. CNA 2 stated Resident 9's fingernails were sharp, long and required trimming. CNA 2 stated nail care was one of the responsibilities of the CNA which included trimming and cleaning the resident's fingernails when they become long and dirty. CNA 2 stated residents' nails should be checked daily to ensure the nails remained clean and neat. CNA 2 stated residents sometimes scratched their skin, and if they scratched hard enough, they could break the skin and create an open wound. CNA 2 stated if a resident had dirty fingernails and scratched themselves, this increased the risk of infection.During an interview with the Infection Preventionist Nurse (IPN) on 8/13/2026 at 8:27 a.m., the IPN stated nail care should be assessed daily. The IPN stated residents who required assistance with cleaning or trimming their nails should be assisted by the CNA's or licensed nurses. The IPN stated fingernails were a source of bacteria, and that dirty or untrimmed nails could contribute to the spread of infection, especially among residents who may not be able to maintain their own hygiene. The IPN stated routine nail care was an essential part of both personal hygiene and infection control.During an interview on 8/13/2026 at 9:05 a.m., with the Director of Nursing (DON), the DON stated fingernail care was a part of the resident's activities of daily living (ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) routine. The DON stated if a resident had long and dirty fingernails, CNAs were expected to clean and trim them. The DON stated dirty fingernails was not acceptable, as they increased the risk of infection.During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, revised 3/2024, the P&P indicated, staff-dependent residents will receive necessary grooming services. The P&P indicated care for residents unable to perform ADLs independently will be provided according to their plan, including support with bathing, dressing, grooming, and oral care.

Based on interview and record review, the facility failed to ensure quality of care was maintained for two of 18 sampled residents (Resident 33 and Resident 91) when: 1. On 10/10/2025, Resident 33's orders for a repeat basic metabolic panel (BMP, a routine blood test that measures eight specific substances in your body) was not performed, following a critically low serum sodium level (electrolyte that helps control fluid balance, blood pressure, and nerve and muscle function) of 125 millimoles per liter (mmol/l, scientific unit used to measure the concentration of a substance (like glucose) in a specific volume of fluid) (normal range: 135-145)(normal range: 135-145) on 10/9/2025. 2. On 5/18/2026, staff failed to notify emergency services in a timely manner after Resident 91 was found with an oxygen saturation (a measurement of how much oxygen the blood is carrying as a percentage) of 77 percent (%) (normal range: 95% to 100%) and blue-colored lips and fingertips. These deficient practices placed Resident 33 at risk for undetected abnormal sodium levels, increasing his risk for adverse neurological effects such as brain swelling, confusion, and seizures. These deficient practices also placed Resident 91 at risk of receiving delayed medical intervention and evaluation by a medical doctor. Findings: 1. During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was admitted to the facility on [DATE]. Resident 33's diagnoses included epilepsy with status epilepticus (a life-threatening medical emergency where a seizure [a sudden, uncontrolled burst of electrical activity in the brain] lasts longer than five minutes, or when a person has back-to-back seizures without fully waking up in between), metabolic encephalopathy (a brain function problem), and altered mental status. During a review of Resident 33's Minimum Data Set (MDS, a resident assessment tool), dated 6/5/2026, the MDS indicated Resident 33 had severe cognitive impairment (trouble with thinking, learning, remembering, and making choices). The MDS indicated Resident 33 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. During a review of Resident 33's lab report, dated 10/8/2025, the lab report indicated a blood sample was collected on 10/8/2025 and the results were reported to the facility on [DATE]. The lab report indicated Resident 33 had a critically low serum sodium level (electrolyte that helps control fluid balance, blood pressure, and nerve and muscle function) of 125 millimoles per liter (mmol/l, scientific unit used to measure the concentration of a substance (like glucose) in a specific volume of fluid)(normal range: 135-145). During a review of Resident 33's Change of Condition (COC), dated 10/9/2025, the COC indicated Resident 33 had an abnormal sodium level. Resident 33's Nurse Practitioner (NP) ordered for staff to administer fluids containing sodium on 10/9/2025 and collect a repeat basic metabolic panel (BMP) on 10/10/2025. During a review of Resident 33's physician order, dated 10/10/2025, the order indicated a BMP was to be collected on 10/10/2025. During a review of Resident 33's lab reports, the lab reports did not indicate a BMP was collected on 10/10/2025 as ordered by Resident 33's NP. During an interview on 8/11/2026 at 2:02 p.m., with the Director of Nursing (DON), the DON stated laboratory services were always available, and stated the licensed nurse needed to notify the laboratory of any new orders. The DON stated Resident 33's electronic medical record did not indicate Resident 33's BMP was collected as ordered on 10/10/2025. The DON stated low sodium levels could cause confusion and other neurological changes. The DON stated Resident 33's known history of falls, epilepsy, and metabolic encephalopathy made it important to address low sodium levels timely to prevent delays in treatment. During a review of the facility's policy and procedure (P&P) titled Availability of Services - Laboratory & Diagnostic, revised 1/2026, the P&P indicated clinical laboratory services to meet the needs of the facility's residents were provided by the facility. The P&P indicated biochemical services (laboratory and medical testing procedures that analyze blood, urine, and other bodily fluids to measure chemical components, enzymes, hormones, and metabolic processes) were available 24 hours a day, seven days a week, including holidays. 2. During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was admitted to the facility on [DATE]. Resident 91's diagnoses included metabolic encephalopathy, chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), asthma (a long-term lung disease that inflames and narrows the airways), cognitive communication deficit (trouble with communication), dysphagia (difficulty swallowing), weakness, and atelectasis (a partial or complete collapse of a lung or a small section of a lung [lobe]). During a review of Resident 91's MDS, dated [DATE], the MDS indicated Resident 91 had moderate cognitive skills for daily decision making. The MDS indicated Resident 91 had clear speech and was usually understood by others. The MDS indicated Resident 91 required partial to moderate assistance with eating. The MDS indicated Resident 91 was dependent on staff to transition from a seated to lying position, a lying to seated position, a seated to standing position, and transferring from a chair/wheelchair to a bed. During a review of Resident 91's progress note, dated 5/18/2026, the progress note indicated on 5/18/2026, Resident 91 was eating lunch in the dining room when an unspecified certified nursing assistant (CNA) informed Licensed Vocational Nurse (LVN) 3 that Resident 91 was unable to hold utensils. The progress note indicated LVN 3 immediately went to observe Resident 91 and noted that he had bluish discoloration to his lips and slurred speech. Resident 91 was brought back to his room for further observation. Resident 91's oxygen saturation was 77%. Resident 91's provider (a healthcare practitioner, health professional, or clinician) was notified and ordered for staff to call emergency services. The progress note indicated emergency services were contacted and Resident 91 was transferred to the general acute care hospital (GACH). During an interview on 8/12/2026 at 10:29 a.m., with LVN 3, LVN 3 stated that on 5/18/2026, a CNA approached her and told her Resident 91 was trying to eat but was unable to bring the utensil to his mouth. LVN 3 stated the CNA further reported Resident 91 appeared bluish. LVN 3 stated she rushed to the dining room and upon her arrival he was unable to say much. LVN 3 stated his speech was slurred. LVN 3 stated Resident 91's lips and fingertips were blue and stated he was not the color he should've been. LVN 3 stated she checked his oxygen saturation and she recalled it being low. LVN 3 stated there was emergency equipment, including oxygen and equipment to administer oxygen, suction equipment, and a machine to check vital signs, available in the dining room, but staff transported Resident 91 back to his room and assisted him into bed. LVN 3 stated it took a few staff to transfer Resident 91 back into his bed because he was unable to assist with any movement or transfers. LVN 3 stated after Resident 91 had been returned to his room and transferred to his bed, his provider was notified. LVN 3 stated the provider instructed staff to contact emergency services. LVN 3 did not state emergency services was contacted at any time prior to receiving instruction from the provider. During an interview on 8/12/2026 at 11:02 a.m., with the DON, the DON stated the incident involving Resident 91 was an emergency and stated staff could have called emergency services right away. The DON stated there was no need to delay contacting emergency services, and no need to transfer Resident 91 back to his room and into his bed from his wheelchair, after LVN 3's initial assessment of the resident in the dining room. During a review of the facility's job descriptions for Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs), both dated 2024, the LVNs prior job description indicated LVNs were to monitor seriously ill residents as necessary, and the RNs job description indicated RNs were to assist the LVNs in monitoring seriously ill residents, and transfer residents as necessary.

Based on observation, interview, and record review, the facility failed to ensure orders for floor mats and bed rail padding were implemented for three of four sampled residents (Resident 33, Resident 17, and Resident 3). This deficient practice placed Residents 33, 17, and 3 at risk for avoidable injuries resulting from falls and accidents.Findings: 1. During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was admitted to the facility on [DATE]. Resident 33's diagnoses included epilepsy with status epilepticus (a life-threatening medical emergency where a seizure [a sudden, uncontrolled burst of electrical activity in the brain] lasts longer than five minutes, or when a person has back-to-back seizures without fully waking up in between), metabolic encephalopathy (a brain function problem), and altered mental status. During a review of Resident 33's Minimum Data Set (MDS, a resident assessment tool), dated 6/5/2026, the MDS indicated Resident 33 had severe cognitive impairment (trouble with thinking, learning, remembering, and making choices). The MDS indicated Resident 33 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. During a review of Resident 33's physician order, dated 10/5/2025, the order indicated staff were to place landing pads on both sides of Resident 33's bed, every shift, as a cushion due to his diagnosis of epilepsy. During a review of Resident 33's physician order, dated 10/5/2025, the order indicated staff were to apply padding on the bed rails of Resident 33's bed, every shift, due to his diagnosis of epilepsy. During a review of Resident 33's Change of Condition (COC) Assessment, dated 12/14/2025, by Licensed Vocational Nurse (LVN) 1, the assessment indicated Resident 33 was found by staff crawling out of bed. The assessment indicated the physician ordered floor mats to be placed at Resident 33's bedside. During a review of Resident 33's physician order, dated 12/14/2025, the order indicated to place floor mats at Resident 33's bedside, every shift, for safety related to falls. During a review of Resident 33's COC Assessments, dated 1/15/2026 and 1/18/2026, the assessments indicated Resident 33 had two unwitnessed falls. During a review of Resident 33's Fall Risk Observation/Assessment, dated 6/4/2026, the assessment indicated Resident 33 was at high risk for repeat falls. During observations on 8/10/2026 at 11:36 a.m., on 8/11/2026 at 9:09 a.m., and on 8/11/2026 at 1:52 p.m., at Resident 33's bedside, there were no fall mats or landing pads observed to either side of Resident 33's bed. There was no padding observed on Resident 33's bed rails. During an interview on 8/11/2026 at 2:22 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 33 had physician orders for staff to pad Resident 33's bed rails and place floor mats at his bedside. LVN 1 stated these interventions were for Resident 33's safety. During a concurrent observation and interview, on 8/11/2026 at 2:28 p.m., at Resident 33's bedside, LVN 1 stated there were no fall mats or landing pads to either side of Resident 33's bed. LVN 1 stated there was no padding on Resident 33's bed rails. 2. During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 17's diagnoses included reduced mobility, generalized muscle weakness, paraplegia (loss of movement and/or sensation, to some degree, of the legs), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 had severe cognitive impairment. The MDS indicated Resident 17 had upper extremity (arm) impairments on both sides of his body. The MDS indicated Resident 17 required partial to moderate assistance from staff to roll left and right in bed. The MDS indicated Resident 17 was dependent on staff for all other mobility while in bed. During a review of Resident 17's care plan titled, High risk for falls., initiated 5/13/2023, the care plan indicated staff were to place floor mats to both sides of Resident 17's bed. During a review of Resident 17's COC Assessment, dated 11/7/2025, authored by LVN 1, the assessment indicated Resident 17 was calling out for help and was found on the floor to the left side of his bed. The assessment indicated Resident 17 was unable to state what happened. During a review of Resident 17's COC Assessment, dated 1/15/2026, by LVN 5, the assessment indicated Resident 17 had an unwitnessed fall. During a review of Resident 17's Fall Risk Observation/Assessment, dated 1/15/2026, the assessment indicated Resident 17 was at moderate risk for repeat falls. During a review of Resident 17's physician order, dated 8/6/2026, the order indicated to place landing pads to both sides of Resident 17's bed, every shift, to prevent fall related injuries. During observations on 8/10/2026 at 11:17 a.m., on 8/11/2026 at 9:09 a.m., and on 8/11/2026 at 1:53 p.m., at Resident 17's bedside, there were no landing pads observed to either side of Resident 17's bed. During an interview on 8/11/2026 at 2:24 p.m., with LVN 1, LVN 1 stated Resident 17 had a physician order for staff to place landing pads at both sides of Resident 17's bed. LVN 1 stated the landing pads were for Resident 17's safety related to falls. During a concurrent observation and interview, on 8/11/2026 at 2:28 p.m., at Resident 17's bedside, with LVN 1, LVN 1 stated Resident 17 did not have landing pads, as ordered, to either side of his bed. 3. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or reduced control on one side of the body) affecting the left side, broken bone in the left leg bone with left knee pain, morbid obesity (a serious health condition that results from an abnormally high body mass), generalized muscle weakness, reduced mobility, and scoliosis (a medical condition that causes an abnormal sideways curve of the spine). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had no cognitive impairment. The MDS indicated Resident 3 had impairments to the upper and lower (leg) extremities on one side of her body. The MDS indicated Resident 3 was dependent on staff for all mobility. During a review of Resident 3's care plan titled At risk for falls., dated 4/23/2026, the care plan indicated staff were to place floor mats to both sides of Resident 3's bed. During a review of Resident 3's Fall Risk Observation/Assessment, dated 8/3/2026, the assessment indicated Resident 3 was at high risk for falls. During an observation on 8/10/2026 at 9:10 a.m., at Resident 3's bedside, a fall mat was observed to the left side of Resident 3's bed. There were multiple belongings stored on top of the floor mat, including a chair, a pillow, and a small personal handbag. There was no floor mat observed to the right side of Resident 3's bed. During an observation on 8/11/2026 at 1:50 p.m., at Resident 3's bedside, no fall mats were observed to either side of Resident 3's bed. A chair and other personal belongings, observed on 8/10/2026, were stacked on top of each other and placed to the left side of Resident 3's bed. During a review of the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing, dated 2001, the P&P indicated staff were to identify intervention related to the resident's specific risks and causes to try and prevent the resident from falling, and to try to minimize complications from falling. The P&P indicated staff were to implement a resident-centered call prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. During a review of the facility's P&P titled Bed Safety and Bed Rails, dated 2022, the P&P indicated staff were to consider the resident's safety and medical conditions when using bed rails. During a review of the facility's P&P titled Accident Prevention Program Policy, dated 1/2026, the P&P indicated the facility was committed to providing a safe environment for residents. The P&P indicated residents identified as at risk for falls and accidents were to have individualized interventions, which could include environmental modifications.

Based on observation, interview, and record review, the facility failed to ensure that a resident with an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services that included anchoring (secure) the urinary catheter tubing and ensuring the indwelling catheter drainage bag was off of the floor for two of six sampled residents (Resident 6 and Resident 9). These deficient practices had the potential to lead to risk for cross contamination, recurrence of urinary tract infection (UTI-an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney), and had a potential to lead to urosepsis (a potentially life-threatening complication of urinary tract infection). Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), and depression (mental health condition that causes deep feelings of sadness and loss of interest in activities). During a review of Resident 6's History and Physical (H&P) dated 7/17/2026, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 7/2/2026, the MDS indicated Resident 6 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 6 was dependent on staff for personal hygiene, toileting, and eating. During a review of Resident 6's physician orders dated 7/10/2026, the physician orders indicated, Indwelling Urinary catheter (flexible plastic tube placed in your bladder to drain urine) size 16 french for diagnosis: Neurogenic Bladder (condition where a person lacks bladder control because of brain, spinal cord or nerve problems). During a concurrent observation and interview on 8/12/2026 at 11:53 am with Licensed Vocational Nurse (LVN) 5, in Resident 6's room, Resident 6's indwelling urinary catheter bag was observed on the floor and not anchored onto the bed. LVN 5 stated the indwelling catheter should have been anchored to Resident 6's bed and inside a basin to ensure it was not touching the floor. LVN 5 stated ensuring indwelling catheter bags did not touch the floor was important to prevent contamination and infection. During an interview with the Infection Prevention Nurse (IPN) on 8/13/2026 at 8:37 a.m., the IPN stated indwelling catheter bags should be hooked onto the residents bed, below the level of bladder and not touching the floor to ensure resident did not develop an infection. 2. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), sepsis (a life-threatening blood infection), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 9 was dependent on staff with toileting, bathing, and lower body dressing. The MDS indicated Resident 9 had an indwelling urinary catheter. During a review of Resident 9's H&P, dated 2/10/2026, the H&P indicated Resident 9 had no capacity to understand and make decisions. During a review of Resident 9's care plan titled, The bladder at risk for complications with urinary system., dated 7/24/2026, the care plan indicated to keep the catheter anchored for security and to prevent trauma. During an interview on 8/11/2026 at 1:48 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated the indwelling catheter drainage bag should be kept below bladder level, properly secured, and off the floor. CNA 1 stated allowing the drainage bag to touch the floor may cause urine backflow, and impaired urinary drainage. During an interview on 8/11/2026 at 2:27 p.m., with the Treatment Nurse (TN), the TN stated the indwelling catheter drainage bag should be kept below the bladder and off the floor to maintain proper drainage to prevent the risk of contamination (when something gets germs on it). The TN stated improper placement may place Resident 9 at risk for recurrent UTI. During an interview on 8/12/2026 at 2:35p.m., with the Director of Nursing (DON), the DON stated catheter related care should be monitored and documented each shift by nursing staff. The DON stated this placed Resident 9 at risk for infection, development of a catheter-associated UTI, and other preventable infection-related complications. During a review of the facility's policy and procedure (P&P) titled Catheter Care, Urinary, revised 5/2024, the P&P indicated to make sure the catheter tubing and drainage bag are kept off the floor.

Based on interview and record review, the facility failed to ensure urinary output was consistently monitored and documented each shift for one of two sampled residents (Resident 9). This deficient practice placed Resident 9 at increased risk for undetected changes in condition, inadequate fluid intake, dehydration, and overall clinical condition.Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), sepsis (a life-threatening blood infection), and urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of Resident 9's Minimum Data Set (MDS- a resident assessment tool), dated 8/4/2026, the MDS indicated Resident 9's cognitive skills for daily decision making (process of thinking) was moderately impaired. The MDS indicated Resident 9 was dependent on staff with toileting, bathing, and lower body dressing. The MDS indicated Resident 9 had an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine).During a review of Resident 9's History and Physical (H&P), dated 2/10/2026, the H&P indicated Resident 9 had no capacity to understand and make decisions.During a review of Resident 9's care plan, titled, Resident 9 has indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) related to obstructive uropathy (a blockage that prevents urine from flowing normally and can harm the kidney) and urinary retention (difficulty emptying the bladder), initiated 7/24/2026, the care plan indicated to provide catheter care, empty and record catheter output every shift and as needed.During a concurrent interview and record review on 8/13/2026 at 8:51 a.m., with Infectious Prevention Nurse (IPN), Resident 9's indwelling urinary catheter urine output monitoring, dated 8/10/2026 through 8/12/2026, was reviewed. The urine output record did not indicate urine output monitoring was performed each shift. The IPN stated the lack of consistent monitoring and documentation increased Resident 9's risk of infection.During an interview on 8/13/2026 at 9:11 a.m., with the Director of Nursing (DON), the DON stated indwelling catheter care should be monitored and documented each shift by nursing staff. The DON stated failure to monitor and document placed Resident 9 at risk for development of a catheter-associated UTI, and other preventable infection-related complications. During a review of the facility's policy and procedure (P&P) titled Catheter Care, Urinary, revised 5/2025, the P&P indicated to empty the collection bag, measure, and document output every shift.

Based on interview and record review, the facility failed to ensure a dialysis (treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) fluid restriction (limiting how much liquid a person can drink or received each day) order was documented and maintained for one of three sampled residents (Resident 4). This deficient practice placed Resident 4 at risk for fluid volume overload and serious harm.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD -irreversible kidney failure), dependence on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and muscle weakness.During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated, 7/23/2026, the MDS indicated Resident 4's cognitive skills (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 4 required partial assistant (helper does less than half the effort) with toileting, bathing, upper/lower body dressing, and putting on/taking off footwear.During a review of Resident 4's History and Physical (H&P), dated 7/18/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions.During a review of Resident 4's Physician Order Report, dated 7/17/2026, the report indicated the following:1. Starting 7/17/2026, hemodialysis Mondays, Wednesdays, and Fridays. 2. Starting 7/17/2026, total fluid restriction of 1500 milliliters in 24 hours/day. During an interview and record review on 8/12/2025 at 9:29 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 4's Progress Notes, dated 8/8/2026 to 8/12/2026 at 4:14 a.m., were reviewed. The Progress Notes did not indicate Resident 4's fluid restrictions of 1500 milliliters per day were documented from 8/8/2026, 8/9/2026, 8/10/2026, 8/11/2026, and 8/12/2026 at 4:14 a.m. LVN 3 stated fluid intake should be measured and documented each day to ensure the resident followed the ordered fluid restriction. Missing documentation may place the resident at risk for fluid overload.During an interview on 8/13/2026 at 9:37 a.m., with the Director of Nursing (DON), the DON stated nursing staff were expected to accurately monitor and document Resident 4's daily fluid intake to ensure compliance with the ordered fluid restriction. The DON stated failure to monitor and document fluid intake may place the resident at risk for fluid overload, swelling, shortness of breath, and dialysis-related complications.During a review of the facility's policy and procedure (P&P) titled, Dialysis Fluid Restriction Management revised 1/2026, the P&P indicated to ensure residents receiving dialysis were safe, effective, individualized fluid management. The P&P indicated fluid management should be measured, monitor and documented daily.

Based on observation, interview, and record review, the facility failed to ensure proper use of bedrails (adjustable metal or rigid plastic bars that attach to the bed) as indicated in the facility's policy and procedure for one of two sampled residents (Resident 1) by failing to:1. Evaluate Resident 1's need for bedrails.2. Obtain informed consent prior to installing Resident 1's bedrails.These deficient practices had the potential to result in the inappropriate use of side rails.Findings:During a review of Resident 1's admission Record (Face Sheet, front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included hypertension (high blood pressure) and history of falling. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/22/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (process of thinking) was moderately impaired. The MDS indicated Resident 1 was dependent on staff with oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 1 was dependent on staff assistance with turning left and right.During a review of Resident 1's History and Physical (H&P), dated 5/17/2026, the H&P indicated Resident 1 did not have the capacity to make medical decisions.During a review of Resident 1's Physician Order, dated 6/25/2026, the Physician Order indicated to apply top half side rails (adjustable metal or rigid plastic bars that attach to the bed) on both sides of the bed to aid in bed mobility, turning, and repositioning.During an observation on 8/10/2026 at 9:22 a.m. and 8/11/2026 at 9:22 a.m., in Resident 1's room, Resident 1 was observed lying in bed. Bilateral (both sides) padded half side bed rails were in the up position. During an interview on 8/12/2026 at 1:06 p.m., with the MDS Nurse (MDSN), the MDSN stated residents with side rails installed had to be evaluated to ensure side rails were indicated and safe for use. The MDSN stated if the resident benefited from installed side rails, the side rails would be installed and informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) would be obtained. During a concurrent interview and record review on 8/12/2026 at 1:08 p.m., with the MDSN, Resident 1's Bed Rail and Entrapment Risk Observation/Assessment, dated 5/21/2026, was reviewed. The Assessment indicated Resident 1 did not require side rails at the time of the assessment. The Assessment indicated Resident 1 was unable to grab the side rails and Resident 1 was dependent on staff with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The Assessment did not trigger the informed consent section due to side rails not being recommended. The MDSN stated according to Resident 1's Bed Rail and Entrapment Risk Observation/Assessment, Resident 1 should not have side rails due to Resident 1's inability to effectively use the side rails as a mobility aid. During a concurrent observation and interview on 8/12/2026 at 1:12 p.m., with the MDSN, in Resident 1's room, Resident 1 was observed lying in bed and had bilateral padded side rails in the up position. The MDSN stated Resident 1 should not have had side rails installed on her bed. During an interview on 8/12/2026 at 1:15 p.m., with the MDSN, the MDSN stated Resident 1 had a new order for bilateral side rails to be used as a mobility aid and a new Bed Rail and Entrapment Risk Observation/Assessment should have been completed to determine Resident 1's ability to utilize the side rails. During an interview on 8/12/2026 at 1:16 p.m., with the MDSN, the MDSN stated informed consent should have been obtained from Resident 1's responsible party (RP) prior to installing the side rails on Resident 1's bed. The MDSN stated informed consent was necessary to provide explanation on the risks and benefits to use the side rails as a mobility aid. The MDSN stated informed consent provided clarification that the side rails were used as an enabler instead of a restraint. During an interview on 8/13/2026 at 10:27 a.m., with the Director of Nursing (DON), the DON stated prior to installing side rails, the licensed nurses were responsible for evaluating the resident and determining if the resident could use the side rails as a mobility aid. The DON stated the evaluation was necessary to determine whether the side rails would be beneficial or harmful. The DON stated informed consent was obtained to explain the risks and benefits to the RP so they could have a thorough understanding of the side rail use. During a review of the facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, revised 8/2022, the P&P indicated, The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.

Based on observation, interview, and record review, the facility failed to ensure accurate medical records were maintained for two of 18 sampled residents (Resident 33 and Resident 91) when: 1. Resident 33's Electronic Medication Administration Record (EMAR) indicated the placement of floor mats and padding to Resident 33's bedrails. 2. Licensed Vocational Nurse (LVN) 2 and Certified Nursing Assistant (CNA) 3 documented vital signs and an assessment were conducted on 5/21/2026, despite Resident 91 being discharged to the hospital since 5/18/2026. These deficient practices resulted in Resident 33 and Resident 91 having inaccurate medical records that did not reflect the care provided.Findings: 1. During a review of Resident 33's admission Record, the admission Record indicated Resident 33 was admitted to the facility on [DATE]. Resident 33's diagnoses included epilepsy with status epilepticus (a life-threatening medical emergency where a seizure [a sudden, uncontrolled burst of electrical activity in the brain] lasts longer than five minutes, or when a person has back-to-back seizures without fully waking up in between), metabolic encephalopathy (a brain function problem), and altered mental status. During a review of Resident 33's Minimum Data Set (MDS, a resident assessment tool), dated 6/5/2026, the MDS indicated Resident 33 had severe cognitive impairment (trouble with thinking, learning, remembering, and making choices). The MDS indicated Resident 33 was dependent on staff for all activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed. During a review of Resident 33's physician order, dated 10/5/2025, the order indicated to place landing pads on both sides of Resident 33's bed, every shift, as a cushion due to his diagnosis of epilepsy. During a review of Resident 33's physician order, dated 10/5/2025, the order indicated to apply padding to Resident 33's bed rails, every shift, due to his diagnosis of epilepsy. During an observation on 8/10/2026 at 11:36 a.m., at Resident 33's bedside, there were no landing pads observed to either side of Resident 33's bed. There was no padding observed to Resident 33's bed rails. During an observation on 8/11/2026 at 9:09 a.m., at Resident 33's bedside, there were no landing pads observed to either side of Resident 33's bed. There was no padding observed to Resident 33's bed rails. During an observation on 8/11/2026 at 1:52 p.m., at Resident 33's bedside, there were no landing pads observed to either side of Resident 33's bed. There was no padding observed on Resident 33's bed rails. During a review of Resident 33's electronic medication administration record (EMAR), dated 8/2026, the EMAR indicated on 8/10/2026 and 8/11/2026, staff documented the placement of landing pads and padding to Resident 33's bed rails every shift. During an interview on 8/11/2026 at 2:02 p.m., with the Director of Nursing (DON), the DON stated documentation in the medical record should accurately reflect the care provided. The DON stated staff should not document care or interventions as provided if they were not. The DON stated inaccurate documentation could negatively impact delivery of care. The DON further stated the medical record was a legal document, and it should be accurate. 2. During a review of Resident 91's admission Record, the admission Record indicated Resident 91 was admitted to the facility on [DATE]. Resident 91's diagnoses included metabolic encephalopathy, chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), asthma (a long-term lung disease that inflames and narrows the airways), cognitive communication deficit (trouble with communication), dysphagia (difficulty swallowing), weakness, and atelectasis (a partial or complete collapse of a lung or a small section of a lung [lobe]). During a review of Resident 91's MDS, dated [DATE], the MDS indicated Resident 91 had clear speech and was usually understood by others. The MDS indicated Resident 91 had moderate cognitive impairment (a middle stage of mental decline that causes clear problems with memory, thinking, and reasoning). The MDS indicated Resident 91 partial to moderate assistance with eating. The MDS indicated Resident 91 was dependent on staff to transition from a seated to lying position, a lying to seated position, a seated to standing position, and transferring from a chair/wheelchair to a bed. During a review of Resident 91's progress note, dated 5/18/2026, the progress note indicated Resident 91 was noted with bluish discoloration to his lips and slurred speech. The progress note indicated Resident 91's oxygen saturation was 77%. The progress note indicated Resident 91's provider (a healthcare practitioner, health professional, or clinician) was notified and ordered for staff to call emergency services. The progress note indicated emergency services were contacted, and Resident 91 was transferred to the general acute care hospital. During a review of Resident 91's census, the census indicated Resident 91 was transferred to the general acute care hospital on 5/18/2026. During a review of Resident 91's documented vital signs, dated 5/21/2026, the vital signs indicated that on 5/21/2026 at 11:59 a.m., Certified Nursing Assistant (CNA) 3 obtained Resident 91's heart rate, blood pressure, respiratory rate. During a review of Resident 91's Nursing Weekly Summary, dated 5/21/2026, the record indicated Licensed Vocational Nurse (LVN) 2 completed Resident 91's assessment. The record included Resident 91's vital signs, collected by CNA 3 on 5/21/2026 at 11:59 a.m. The record further indicated LVN 2 indicated staff would continue with plan of care. The record did not indicate Resident 91 had a change of condition (COC) that resulted in a transfer to the hospital on 5/18/2026. During an interview on 8/12/2026 at 11:13 a.m., with the DON, the DON stated there should not be vital signs documented as obtained for Resident 91, on 5/21/2026, because the resident was transferred to the hospital on 5/18/2026. During an interview on 8/12/2026 at 3:53 p.m., with LVN 2, LVN 2 stated the Nursing Weekly Summary was an assessment that was only to be conducted while the resident was at the facility. LVN 2 stated the Nursing Weekly Summary she documented was likely a documentation error. LVN 2 stated Resident 91's medical record should be accurate. During a review of the facility's LVN Job Description, dated 2024, the job description indicated LVNs were to document in an informative and descriptive manner that reflected the care provided to the resident. The job description indicated LVNs were to perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. During a review of the facility's P&P titled Vital Signs and Weight, undated, the P&P indicated vital signs were to be documented in the resident's medical record when taken.

Based on observation, interview, and record review, the facility failed to implement an effective infection control program for four of four sampled residents (Resident 6, Resident 29, Resident 9, and Resident 2) when:1. Resident 6 did not have an enhanced barrier precaution (EBP- an infection control measure to protect residents at high risk for multidrug-resistant organisms [MDRO- bacteria resistant to multiple classes of antibacterial medication) sign displayed at the doorway of the resident's room.2. A nebulizer face mask (medical device used to deliver medication in the form of mist, which is inhaled into the lungs) belonging to another resident was observed at Resident 29's bedside. 3. Certified Nursing Assistant (CNA) 1 did not don (put on) the appropriate personal protective equipment (PPE- items healthcare workers to protect themselves and residents from germs, such as gloves, gown, mask and eye protection) when emptying Resident 9's indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag.4. Treatment Nurse (TN) 1 did not tie the back of her gown when performing Resident 2's wound treatment.These deficient practices had the potential to result in the avoidable spread of MDROs and increased the risk of the avoidable spread of bacteria and disease. Findings: 1. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure) and depression (mental health condition that causes deep feelings of sadness and loss of interest in activities). During a review of Resident 6's History and Physical (H&P) dated 7/17/2026, the H&P indicated Resident 6 had the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool), dated 7/2/2026, the MDS indicated Resident 6 had moderate cognitive (ability to think and understand) impairment. The MDS indicated Resident 6 was dependent on staff for personal hygiene, toileting, and eating. During a review of Resident 6's physician orders dated 7/15/2026, the physician order indicated, Enhanced barrier precaution (EBP- an infection control measure to protect residents at high risk for multidrug-resistant organisms [MDRO- bacteria resistant to multiple classes of antibacterial medication]) during high contact resident care activities secondary to enteral feeding (feeding tube used to supply nutrients and fluids to the body), Foley catheter (a thin, flexible plastic tube placed into the bladder to drain urine). During a review of Resident 6's care plan titled, Enhanced barrier precautions: Resident requires EBP during high-contact resident care activities dated 2/4/2026, the care plan indicated, Place EBP notification/signage near resident room doorway to alert staff/visitors of precautions. During a concurrent observation and interview on 8/10/2026 at 9:02 a.m. with Licensed Vocational Nurse (LVN) 1, observed Resident 6's room door without an EBP sign. LVN 1 stated Resident 6 was on enhanced barrier precautions and an EBP sign should have been displayed on the door to alert staff to use personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when providing resident care. LVN 1 stated lack of EBP signage placed residents at risk for infection. During an interview with the Director of Nursing (DON) on 8/12/2026 at 2:06 p.m., the DON stated EBP signage was important to ensure staff wore appropriate PPE when providing care to residents. The DON stated following EBP protocol, including posting EBP signage, protects residents and staff from infection. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions dated 2001, the P&P indicated, Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. 2. During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was admitted to the facility on [DATE]. Resident 29's diagnoses included depression (mental health condition that causes deep feelings of sadness and loss of interest in activities), encephalopathy (any disease or damage that disturbs the brain function), and dysphagia (difficulty swallowing). During a review of Resident 29's H&P dated 5/26/2026, the H&P indicated Resident 29 had the capacity to understand and make decisions. During a review of Resident 29's MDS dated [DATE], the MDS indicated Resident 29 had severe cognitive impairment. The MDS indicated Resident 29 was dependent on staff for toileting, bathing and eating. During a concurrent observation and interview on 8/10/2026 at 12:04 p.m. with LVN 1 in Resident 29's room, a plastic bag with a nebulizer face mask (medical device used to deliver medication in the form of mist, which is inhaled into the lungs) was observed on Resident 29's side table labeled with a different resident's name. LVN 1 stated the nebulizer mask did not belong to Resident 29 and should not have been at his bedside. LVN 1 stated all resident specific medical equipment, including nebulizer masks should be with the intended resident to prevent cross contamination and spread of infection. During an interview on 8/12/2026 at 1:57 p.m. with the Infection Prevention Nurse (IPN), the IPN stated another residents medical equipment should not have been in Resident 29's room, and placed him at risk for cross contamination and infection. During a review of the facility's P&P titled, Departmental (Respiratory Therapy)-Prevention of Infection last revised 11/2011, the P&P indicated nebulizer equipment should be stored in a plastic bag, marked with the date and resident's name. 3. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), sepsis (a life-threatening blood infection), and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 9 was dependent on staff with toileting, bathing, and lower body dressing. The MDS indicated Resident 9 had an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). During a review of Resident 9's H&P, dated 2/10/2026, the H&P indicated Resident 9 had no capacity to understand and make decisions. During a review of Resident 9's Physician Order, dated 8/9/2026, the Physician Order indicated to place Resident 9 on EBP due to Foley catheter, related to vancomycin-resistant enterococci (VRE- a bacteria that do not respond to vancomycin (an antibiotic used to treat bacterial infections) in the urine, and history of multidrug resistant organism (MDRO). During an observation on 8/11/2026 at 2:27 p.m., in Resident 9's room, observed Certified Nursing Assistant (CNA) 1 enter Resident 9's room to empty the Foley catheter drainage bag. CNA 1 donned gloves but did not don a gown. During an interview on 8/12/2026 at 10:06 a.m., with the IPN, the IPN stated EBP was indicated for residents colonized (bacteria is present but has not caused any illness) with an MDRO. The IPN stated all staff were required to don PPE when performing high-contact activities such as Foley catheter care, adult brief changes, wound care treatments, toileting, and hygiene care. The IPN stated the purpose of donning PPE was to prevent the possible transfer of bacteria from the staff member to the resident. The IPN stated staff members who did not don the proper PPE, such as a gown and gloves, increased the risk of spreading bacteria to high-risk residents. During an interview on 8/11/2026 at 2:35 p.m., with CNA 1, CNA 1 stated she forgot about the EBP sign outside Resident 9's room. CNA 1 stated she was supposed to don a gown and gloves during Foley catheter care. CNA 1 stated donning the appropriate PPE was necessary to protect Resident 9 from infection. During an interview on 8/13/2026 at 8:16a.m., with the DON, the DON stated that EBP and appropriate PPE was important to prevent the spread of germs and infection. The DON stated failure to follow EBP and use required PPE could place residents at risk for cross-contamination and infection. 4. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included presence of gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and hypertension (high blood pressure). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 was dependent on staff with oral hygiene, toileting, bathing, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 2's H&P, dated 4/30/2026, the H&P indicated Resident 2 did not have the capacity to make medical decisions. During a review of Resident 2's Physician Order, dated 5/29/2026, the Physician Order indicated to implement EBP during high contact resident care activities secondary to presence of wound, indwelling urinary catheter, and g-tube. During a review of Resident 2's Care Plan titled, Enhanced Barrier Precautions, dated 2/4/2026, the care plan indicated for staff to utilize PPE during high-contact resident care activities such as wound care. During an observation on 8/10/2026 at 9:59 a.m., outside of Resident 2's room, an EBP sign was posted next to the entrance of Resident 2's room. During an observation on 8/10/2026 at 11:42 a.m., in Resident 2's room, TN 1 donned a disposable gown and gloves. TN 1 did not tie the back of the disposable gown. TN 1 approached Resident 2 and performed Resident 2's wound treatment to her back side. During Resident 2's wound treatment, TN 1 turned multiple times to acquire her equipment from the bedside table. TN 1's disposable gown moved when TN 1 turned and TN 1's clothing touched Resident 2's bed. During an interview on 8/10/2026 at 11:47 a.m., with TN 1, TN 1 stated Resident 2 was on EBP which required her to appropriately don a disposable gown and gloves. TN 1 stated she did not tie the back of her disposable gown which increased the risk of infection to Resident 2. During an interview on 8/12/2026 at 12:42 p.m., with the IPN, the IPN stated EBP was used to protect high-risk residents from getting infection from the staff. The IPN stated the nurses' clothing touch many surfaces and other residents in the hospital. The IPN stated clothing could have bacteria which could make a resident on EBP sick. The IPN stated when donning a disposable gown, the individual was responsible for ensuring the back was tied and the gown covered the individual's clothing. The IPN stated when the gown was not secured, the individual's clothing could be exposed and transmit bacteria to the high-risk resident. During a review of the facility's P&P titled, Enhanced Barrier Precautions, revised 12/2024, the P&P indicated for residents on EBP, the use of gown and gloves were used during high-contact care activities, which provide opportunities for indirect transfer of MDRO's to staff hands and clothing then indirectly transfer to residents. During a review of the facility's document titled, Sequence for Putting on Personal Protective Equipment, undated, the document indicated to don the gown to fully cover the torso from neck to knees, arms to end of wrist, and wrap around the back. The document indicated to fasten in the back of neck and waist.

Based on observation, interview, and record review, the facility failed to ensure proper wound management and care planning for one of three sampled residents (Resident 1). These deficient practices placed Resident 1 at risk for delayed wound healing, dehiscence (the premature separation or reopening of the edges of a surgical wound), and infection.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included pneumonia (an infection/inflammation in the lungs), muscle weakness, and sepsis (infection in the blood). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 was independent for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's History and Physical (H&P), dated 1/22/2026, the H&P indicated Resident 1 could make needs known and make medical decisions. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents) Note, dated 4/23/2026, the note indicated Resident 1 arrived to the facility from her medical appointment with an incision (a deliberate cut or wound made into the body tissues using a sharp instrument) to her left elbow mass (any abnormal lump, swelling). The SBAR did not indicate orders for wound care and daily wound monitoring were obtained. During an interview on 5/20/2026 at 8:22 a.m. with Resident 1, Resident 1 stated she had surgery on her left elbow the previous month and was worried that the surgical wound would become infected because staff had not cleaned the wound. Resident 1 stated the nursing staff only wrapped the dressing with gauze. During a concurrent observation and interview on 5/20/2026 at 10:28 a.m. with Resident 1, in Resident 1's room, Resident 1's left elbow wound dressing and wound was observed. Resident 1's wound dressing was loose, saturated with a brown substance, and had dried blood. Resident 1 had one wound incision and sutures (specialized threads or strands used by healthcare professionals to stitch together tissues following an injury or surgical procedure). During a concurrent record interview and record review on 5/20/2026 at 12:12 p.m. with Treatment Nurse (TXN) 1, Resident 1's care plan titled, At Risk For Pain, Infection Due To Status Post Left Elbow Incision, initiated 4/23/2026, was reviewed. The care plan did not indicate interventions to address the care, assessment, and follow up of the left elbow wound. TXN 1 stated the lack of a Weekly Skin interdisciplinary team (IDT, group of different disciplines working together towards a common goal of a resident) paired with the lack of care plan interventions to address Resident 1's wound placed Resident 1 at risk for complications related to the wound, like dehiscence and infection. During an interview on 5/20/2026 at 2:21 p.m. with the Director of Nursing (DON), the DON stated appropriate wound care plan interventions were important to support wound healing and prevent infection. The DON stated the lack of a care plan placed Resident 1 at risk for delayed treatment, wound healing, and infection. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 2001, the P&P indicated the facility was to ensure a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. The P&P indicated interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure the following for one of three sampled residents (Resident 1):1. A follow up wound care appointment was scheduled after Resident 1's initial post procedure visit on 4/30/2026.2. Physician orders for daily wound monitoring, assessment, and treatment were obtained and clarified.3. Wound care was performed only with a valid physician order.4. Physician wound care orders were accurately transcribed and implemented. These deficient practices resulted in delayed wound treatment and placed Resident 1 at risk for wound dehiscence (the premature separation or reopening of the edges of a surgical wound) and infection. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included pneumonia (an infection/inflammation in the lungs), muscle weakness, and sepsis (infection in the blood). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 was independent for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's History and Physical (H&P), dated 1/22/2026, the H&P indicated Resident 1 could make needs known and make medical decisions. During a review of Resident 1's Change of Condition Note, dated 4/23/2026, the note indicated Resident 1 arrived to the facility from her medical appointment with an incision (a deliberate cut or wound made into the body tissues using a sharp instrument) to her left elbow mass (any abnormal lump, swelling). The note did not indicate orders for wound care and daily wound monitoring, of the left elbow incision, were obtained. During a review of Resident 1's Physician Orders, dated 4/23/2026 through 5/19/2026, the orders did not indicate daily wound care or assessment for Resident 1's left elbow surgical wound. During a review of Resident 1's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 5/1/2026 through 5/19/2026, the MAR and TAR did not indicate Resident 1's left elbow wound was assessed, monitored for infection, or treated. During an interview on 5/20/2026 at 8:22 a.m. with Resident 1, Resident 1 stated she had surgery on her left elbow the previous month and was worried that it would become infected because staff had not cleaned the wound. Resident 1 stated the nursing staff only wrapped the dressing with gauze. During an observation on 5/20/2026 at 10:28 a.m. with Resident 1, in Resident 1's room, Resident 1's left elbow wound dressing and wound was observed. Resident 1's wound dressing was loose, saturated with a brown substance, and had dried blood. Resident 1 had one wound incision and sutures (specialized threads or strands used by healthcare professionals to stitch together tissues following an injury or surgical procedure). 1. During an interview on 5/20/2026 at 11:23 am. with Registered Nurse (RN) 1, RN 1 stated on 4/23/2026, Resident 1 had an incision and drainage (I&D, a minor surgical procedure used to treat localized infections). RN 1 stated Resident 1 went to a follow up appointment 4/30/2026. RN 1 stated the expectation of the licensed staff was to check any post-procedure paperwork to verify wound care orders or obtain orders from the resident's attending physician to monitor, assess, and treat the wound. RN 1 stated there were no wound care orders or assessment orders obtained for Resident 1 and no documentation to indicate the licensed nurses attempted to clarify or obtain any orders from 4/23/2026 to 5/2/2026. RN 1 stated it was important to ensure wound care and daily assessment orders were in place to ensure the wound healed appropriately and to minimize the chance of infection, especially because Resident 1 had sutures (a sterile surgical thread and needle used to hold body tissues together after an injury or surgery). RN 1 stated the licensed nurses should have verified if a wound care follow-up appointment was needed after Resident 1's initial follow-up appointment on 4/30/2026. RN 1 stated the lack of daily assessment and monitoring, wound care orders, and a timely appointment follow up (after 4/30/2026) delayed care and treatment for Resident 1's wound and placed her at risk for infection and poor wound healing. 2. During a concurrent interview and record review on 5/20/2026 at 2:50 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's Change of Condition Note, dated 4/23/2026, readmission Note, dated 5/1/2026, and Physician Order, dated 5/1/2026, was reviewed. The Change of Condition Note and the readmission Note, both authored by LVN 2, did not indicate orders for treatment, assessment, and follow up. The Physician Order indicated left elbow incision site with dressing. LVN 2 stated there were no specific orders for wound care or shift to shift monitoring for Resident 1's wound. LVN 2 stated the admitting nurse, or the treatment nurse should have obtained orders for assessment, monitoring and follow-up wound care. 3. During an interview on 5/20/2026 at 12:33 p.m. with Treatment Nurse (TXN) 2, TXN 2 stated he recalled reinforcing Resident 1's dressing with rolled gauze before he ended his shift on Friday (5/15/2026). TXN 2 stated he had knowledge Resident 1 had an incision on her left elbow but did not verify the need for wound care orders or daily monitoring and assessment. TXN 2 stated it was important to obtain orders from the physician for monitoring, assessing, and wound treatment to prevent any complications and to minimize the chance of infection. TXN 2 stated that he should not have applied the rolled gauze without a physician order because it was not the facility's standard of practice. 4. During a concurrent interview and record review on 5/20/2026 at 11:23 am. with RN 1, Resident 1's Physician Orders, dated 4/23/2026 through 5/19/2026, and Skin Evaluation Assessment, dated 5/2/2026, were reviewed. The Skin Evaluation Assessment indicated orders for the left elbow wound to be cleansed with normal saline (a solution that safely cleans and flushes injuries, surgical sites, and burns without damaging surrounding tissue), dressed with xeroform (a type of wound dressing), an abdominal pad (a thick, highly absorbent medical dressing used to manage large, heavily draining wounds), gauze and rolled gauze. RN 1 stated there were no transcribed orders for wound care after 5/2/2026. RN 1 stated orders obtained by TXN 3 should have been transcribed (on 5/2/2026) and clarified to ensure Resident 1's wound was cleaned, treated, and monitored. During a phone interview on 5/20/2026 at 2:29 p.m. with TXN 3, TXN 3 stated the facility's standard practice was to conduct a full skin assessment upon admission and ensure any wound orders were obtained, if needed. TXN 3 stated she recalled that she obtained wound care orders from the physician for Resident 1 but did not remember to transcribe the orders. TXN 3 stated that it was important that the orders were transcribed for the treatment nurses could carry out the order. TXN 3 stated the lack of wound cleansing and dressing orders placed Resident 1 at risk for the development of an infection. During a review of the facility's policy and procedure (P&P) titled, Quality of Care (undated), the P&P indicated the facility was required to maintain quality of care to meet certain quality indicators and standards set by federal and state laws which include measures related to resident care, staffing levels, health and safety, infection control, and more. During a review of the facility's P&P titled, admission Assessment and Follow Up: Role of the Nurse, revised 2001, the P&P indicated the licensed nurse would ensure to contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. During a review of the facility's LVN Job Description, dated 2/2024, the job description indicated the LVN was to ensure the following:Transcribe the physician's order to resident charts, cardex medication cards, treatment care plans, as required.Consult with the resident's physician in providing the resident's care, treatment, rehabilitation etc. as required.Review the resident's chart for specific treatments, medication orders, diets, etc., as necessary.

Based on observation, interview, and record review, the facility failed to ensure medications were not stored at the bedside for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unauthorized medication use.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included pneumonia (an infection/inflammation in the lungs), muscle weakness, and sepsis (infection in the blood). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 1 was independent for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's History and Physical (H&P), dated 1/22/2026, the H&P indicated Resident 1 could make needs known and make medical decisions. During a review of Resident 1's Physician Orders, dated 5/1/2026, the orders indicated Artificial Tears Solution 1.4 percent (%) (Polyvinyl Alcohol), instill one drop in both eyes four times a day for dry eye, and Flonase Allergy Relief Suspension (Fluticasone Propionate), give one spray into both nostrils two times a day for allergies. During a concurrent observation and interview on 5/20/2026 at 10:28 a.m. with Resident 1, in Resident 1's room, one bottle of Artificial Tears Solution and one bottle of Flonase Allergy Relief Suspension were observed on Resident 1's bedside. Resident 1 stated the licensed nurses left the medications at her bedside. During a concurrent interview and record review on 5/20/2026 11:23 a.m. with Registered Nurse (RN) 1, Resident 1's Self-Administration of Medication Observation Form, dated 5/1/2026, was reviewed. The form indicated Resident 1 did not want to self-administer medications. RN 1 stated medications should not be left at Resident 1's bedside, especially because the form indicated she was not to self-administer medications. RN 1 stated if eye drops and a nasal spray were left at the bedside, there was potential Resident 1 could incorrectly self-administer her own medications and, or another resident could obtain possession of the medication and self-administer. During a review of the facility's policy and procedure (P&P) titled, Self Administration of Medications, revised 2001, the P&P indicated any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, revised 2001, the P&P indicated the nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and record review, the facility failed to ensure four of six sampled residents (Residents 1, 2, 5, and 6), had indwelling catheters (catheter drains urine from bladder into a bag outside the body) free of sediments (mineral deposits and bacterial biofilm, leading to potential complications such as blockage and urinary tract infections) and cloudiness (when particles or substances in the urine made it appear milky, hazy, or opaque) in the urine. This failure placed the residents at risk for delayed assessments, physician notification and implementation of necessary interventions. This failure had the potential that Residents 1, 2, 5, and 6 had developed urinary tract infection (UTI).Findings: a.) During an observation on 4/16/2026 at 11:29 a.m., in Resident 1's room, Resident 1 was observed in bed and was unable to answer questions. Resident 1 had a suprapubic catheter ([SC] a hollow, flexible tube inserted through the lower abdominal wall into the bladder to drain urine when normal urination is not possible, when urethral catheterization is unsafe, such as in cases of urethral injury, strictures, enlarged prostate, pelvic trauma, or long-term urinary retention) connected to a drainage bag. The catheter tubing had visible white sediments observed. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included presence of urogenital implants (artificial, mechanical, or prosthetic devices in the urinary or reproductive system) and neuromuscular dysfunction of bladder unspecified (a condition where nerve damage from diseases or injuries disrupts normal bladder control, leading to urinary incontinence, retention, frequency, or urgency). During a review of Resident 1's History and Physical (H&P) dated 3/11/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/24/2026, the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 was dependent on staff with the ADLs such as dressing, toilet use, transfer and mobility. Resident 1 was dependent on oral hygiene, toileting hygiene, shower/ bathing self, upper and lower body dressing and putting on footwear. During a review of Resident 1's Physicians Orders dated 4/20/2026, the order indicated to monitor changes in urine character, document cloudiness, sediments, foul smell, blood in urine, or concentrated urine output and notify the doctor for potential UTI, every shift. During review of Resident 1's care plan titled, Bladder: at risk for complications with urinary system related to neurogenic bladder (bladder dysfunction) and SC, dated 12/19/2025, the goals indicated Resident 1's signs and symptoms of UTI will be managed and treated. The interventions indicated to notify the physician for signs and symptoms of UTI such as foul smell urine, color changes in urine, hematuria (blood in urine) and sediments. b.) During an observation on 4/16/2026 at 11:40 a.m., in Resident 2's room, Resident 2 was observed laying on bed and was unable to answer questions. Resident 2 had a Foley Catheter ([FC] a thin, flexible tube inserted into the bladder to drain urine) with visible white sediments noted in the catheter tubing. During a concurrent observation and interview on 4/16/2026 at 12:04 p.m., with the Licensed Vocational Nurse (LVN) 1, LVN 1 observed Resident 2 who had a FC, had sediments in the catheter tubing. The urine appeared amber (honey yellow) in color and had sediments. LVN 1 stated that when sediments builds up in the urine or tubing, nurses must notify the physician. LVN 1 stated the FC should be assessed daily for sediments to help prevent the development of a UTI. LVN 1 stated the catheter was not assessed this morning for sediments while wound care was performed. LVN 1 stated it was important to monitor the catheter bag and tubing for sediments and inform the physician when present, and obtain an order, if needed, to flush the FC. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included quadriplegia unspecified (refers to the partial or complete paralysis of all four limbs (arms and legs) and the torso), genitourinary prosthetic device implants and grafts (medical devices used to support or replace the function of the urinary and reproductive systems, enhancing patient quality of life) and anoxic brain damage (a type of acquired brain injury caused by a total lack of oxygen reaching the brain). During a review of Resident 2's H&P dated 10/14/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Residents 2's MDS dated [DATE], the MDS indicated Resident 2 had severe cognitive impairment. The MDS indicated Resident 2 was dependent on staff with the ADLs. During a review of Resident 2's Physician Orders dated 1/21/2026, the order indicated to monitor changes in urine character, document for cloudiness, sediments, foul smell, blood in urine, or concentrated urine output and notify the doctor for potential UTI, every shift. During review of Resident 2's care plan titled, Bladder: at risk for complications with urinary system related to neurogenic bladder and indwelling catheter, dated 8/31/2025, the goals indicated Resident 2's signs and symptoms of UTI will be managed and treated. The interventions indicated to notify the physician for signs and symptoms of UTI such as foul smell urine, color changes in urine, hematuria, and sediments. c.) During a concurrent observation and interview on 4/17/2026 at 9:25 a.m., in Resident 5's room, Resident 5 was observed in bed covered with blankets and refused to answer questions. LVN 3 observed Resident 5's SC drainage bag and tubing and stated, I see cloudiness in the urine. LVN 3 stated that SC should be assessed daily for signs and symptoms of infections like presence of blood, cloudiness, sediments. LVN 3 stated presence of sediments in the tubing or allow the urine to remain cloudy is not acceptable as this can cause bacteria to grow and travel to the bladder, resulting in infection. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5's diagnoses included paraplegia, neuromuscular dysfunction of bladder unspecified and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 5's H&P dated 1/21/2026, the H&P indicated Resident 5 did not have the capacity to understand and make decisions. During a review of Residents 5's MDS dated [DATE], the MDS indicated Resident 5 was dependent on staff with the ADLs. During a review of Resident 5's Physician Orders dated 2/27/2026, the orders indicated to monitor for changes in urine character, document for cloudiness, sediments, foul smell, blood in urine, or concentrated urine output and notify the doctor for potential UTI, every shift. During review of Resident 5's care plan titled, Indwelling FC: Neurogenic Bladder, dated 2/27/2026, the goals indicated Resident 5 will show no signs or symptoms of UTI. The interventions indicated to notify the physician for signs and symptoms of UTI such as foul smell urine, color changes in urine, hematuria and sediments. d.) During a concurrent observation and interview on 4/17/2026 at 9:32 a.m., in Resident 6's room, Resident 6 was observed in bed and was unable to answer questions. LVN 3 observed Resident 6's FC drainage bag and tubing with the presence of sediments. LVN 3 stated, I usually assess FC before starting the shift and then again when I pass medications. LVN 3 stated, I did not see the sediments in the tubing, but I did not pick up the drainage bag or tubing to assess properly. LVN 3 stated, I should have picked up the drainage bag and checked it. LVN 3 stated, I will report it to the doctor and get an order for a urinalysis (a test to analyze urine's physical, chemical, and microscopic properties to detect conditions such as UTI). During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland), neuromuscular dysfunction of bladder unspecified and unspecified dementia. During a review of Resident 6's H&P dated 2/26/2026, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Residents 6's MDS dated [DATE], it indicated Resident 6 had severe cognitive impairment. The MDS indicated Resident 6 was dependent on staff with the ADLs. During a review of Resident 6's Physician Orders dated 1/21/2026, the orders indicated to monitor changes in urine character, document for cloudiness, sediments, foul smell, blood in urine, or concentrated urine output and notify the doctor for potential UTI, every shift. During review of Resident 6's care plan titled, Indwelling FC: Neurogenic Bladder, dated 5/7/2025, the interventions indicated to notify the physician for signs and symptoms of UTI such as foul smell urine, color changes in urine, hematuria and sediments. During an interview on 4/17/2026 at 1:10 p.m. with LVN 3, LVN 3 stated it was important to properly assess the catheter every morning for any changes in the urine, such as no urine output, sediments, cloudiness, or leaking. LVN 3 stated nurses need to inform the doctor and document a change of condition (COC) if there were any changes in the resident. During an interview on 4/17/2026 at 3:00 p.m., with the Director of Nursing (DON), the DON stated that it was the nurse's responsibility to assess the catheter every shift for its appearance of the urine, including sediments, hematuria, or any characteristics that may indicate abnormalities. The DON stated nurses are required to call the doctor and follow physician's orders. The DON stated nurses must continue monitoring residents' FC to prevent residents from developing infections. During a review of the facility's policy and procedures (P&P) titled, Catheter Care, Urinary, dated 5/2024, the P&P indicated the residents should be observed for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately if the urine had an unusual appearance (color, blood, etc.) and if signs and symptoms of urinary tract infection or urinary retention occur.

Based on observation, interview and record review, the facility failed to provide 1 of 4 residents (Resident 1) with meals that accommodated the resident's food preference. This failure had the potential to result in decreased meal intake and could lead to weight loss and malnutrition for Resident 1. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included End Stage Renal Disease (ESRD-Irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 03/11/2026, the MDS indicated Resident 1 had clear speech, the ability to express ideas and wants, and was able to understand others. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching) with personal hygiene and upper body dressing, and partial/moderate assistance (helper does less than half the effort) with toileting hygiene and lower body dressing.During a review of Resident 1's Care Plan titled, Resident has food preference dated 3/15/2026, the Care Plan goal indicated Resident 1 will receive meals that align food preference daily and will verbalize satisfaction at least 2-3 weeks per month. The Care Plan interventions indicated staff would review Resident 1's food preferences sheet upon admission, update them as needed and ensure Resident 1 received alternative meal choices if the main entree conflicted with preferences.During a review of Resident 1's Order Summary Report dated 03/16/2026, the Order Summary Report indicated to provide Resident 1 with a renal 80 grams (g- unit of measurement) protein, constant carbohydrate or controlled carbohydrate diet (CCHO-the focus of the diet is eating the same amount of carbohydrates every day), regular texture.During a review of Resident 1's lunch ticket (a system for resident meal tracking) dated 03/16/2026, the lunch ticket indicated Resident1 disliked sausage, ravioli, tuna, yellow cheese, egg salad sandwich, Brussel sprouts and pasta.During a concurrent dining observation, record review and interview on 03/16/2026 at 12:52 p.m., with the Dietary Manager (DM), in the activities room, Resident lunch ticket was reviewed. Resident 1's lunch plate was observed with penne pasta. The DM stated Resident 1 disliked pasta and may not eat the food served to the resident. The DM stated Licensed Vocational Nurses (LVNs) were responsible for comparing the lunch tickets with the lunch tray to ensure residents received the correct diet and preferences. During a review of the facility policy and procedure (P/P) titled, Resident Food Preferences dated 2001, the P/P indicated the food preferences will be assessed upon admission and communicated to the interdisciplinary team (IDT-a group of healthcare professional from different disciplines who work together to manage the resident's care). Upon the resident's admission (or within twenty-four hours after his/her admission) the dietitian or nursing staff will identify a resident's preferences. Nursing staff will document the residents' food and eating preferences in the care plan.

Based on interview and record review, the facility failed to reconcile (process of reviewing resident medications to identify the most accurate list of all medications and resolve any discrepancies) the medication list for 1 of 3 sampled residents (Resident 1) upon re-admission or transfer back to the facility from the General Acute Care Hospital (GACH) on 11/18/2025.This deficient practice resulted in Resident 1 receiving incorrect doses of Ibuprofen (medication used to reduce pain and inflammation) and Norco ([Hydrocodone and Acetaminophen], medication used to treat moderate to severe pain). The failures also had the potential for unrelieved pain and worsening of symptoms or condition for Resident 1. Findings:During a review of Resident 1 admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including Lupus (an autoimmune disease where the body's immune system mistakenly attacks its own tissues and organs, leading to inflammation and damage that can affect joints, skin, kidneys, blood cells, brain, heart, and lungs), Post traumatic stress disorder ([PTSD], a mental health condition that can develop after a person experiences or witnesses a traumatic event) and hypertension (high blood pressure).During a review of Resident's 1 Minimum Data Set ([MDS] a resident assessment tool) dated 11/17/2025, the MDS indicated Resident 1 had no cognitive (ability to think and reason) impairment and the ability to make her needs known.During a review of Resident 1 Change in Condition Evaluation (COC), dated 11/17/2025, the COC indicated Resident 1 complained of back pain radiating to the left side, dizziness, nausea and had an elevated blood pressure of 223/137 mmHg ([millimeters of mercury] standard unit of measuring blood pressure). The COC indicated Resident 1 was transferred to the GACH on 11/17/2025 at 5:54 p.m.During a review of Resident 1's GACH Discharge Medication Reconciliation Order Report dated 11/17/2025, the Report indicated Resident 1 was prescribed Ibuprofen 600 milligrams ([mg.] metric unit of measurement, used for medication dosage and/or amount) one tablet orally (by mouth) every 6 hours as needed for pain and Norco 5/325 mg. one tablet orally every 6 hours as needed for pain. During a review of Resident 1's GACH prescription Form dated 11/17/2025, the Form indicated Resident 1 had a prescription for Ibuprofen 600 mg. one tablet every 6-8 hours as needed (prn) for fever, pain and Norco 5/325 mg. one tablet every 6 hours prn for pain. During a review of Resident 1's Nurses' Notes dated 11/18/2025, the Notes indicated Resident 1 returned to the facility from the GACH on 11/18/2025 at 12:30 a.m. The Nurses' Notes did not indicate a Medication Reconciliation was completed upon transfer back to the facility. During a review of Resident 1's Medication Administration Record (MAR) dated November 2025, the MAR indicated: On 11/18/2025 and 11/20/2025 during the day shift, Resident 1 was given Ibuprofen 800 mg prn for moderate pain (pain rating reference 1-3 mild pain; 4-6 moderate pain; 7-10 severe pain). On 11/18/2025 during the day, evening and night shift, 11/19/2025 during the day and evening shift, and 11/20/2025 during the day and evening shift, Resident 1 was given Norco 10-325 mg prn for severe pain.During a review of Resident 1's Nurses' Notes dated 11/20/2025, the Notes indicated Resident 1 handed written prescriptions from the GACH visit on 11/17/2025 to the Assistant Director of Nursing (ADON). The Notes indicated the prescription was sent to the physician on 11/20/2025. During an interview on 11/21/2025 at 2:50 p.m., with the ADON, the ADON stated she was unaware Resident 1 returned from the ER visit with new prescriptions. The ADON stated Resident 1 provided her with the new prescriptions on 11/20/2025 and she contacted Resident 1's physician to reconcile the prescription (on 11/20/2025).During an interview on 11/24/2025 at 11 a.m., with Registered nurse (RN 1), RN 1 stated he forgot to ask Resident 1 about the discharged paper from the ER visit on 11/17/2025 because Resident 1 was very agitated, complaining and demanding for her pain medication. RN 1 stated that he should have gotten the discharged paper and the prescriptions from Resident 1, reconciled the new prescription with her physician before administering medication to the resident.During an interview on 11/24/25 at 2 p.m., with the Director of Nursing (DON), the DON stated, during a readmission or transfer back of residents from the GACH, the licensed nurse should obtain the discharged records from and reconcile any prescriptions with the primary care physician before administering medicationsDuring a review of the facility's Policy and Procedure (P&P) titled, Reconciliation of Medications on Admission, dated 7/2017, the P&P indicated that the purpose of the policy is to ensure medication safety by accurately accounting for the resident's medications, route and dosage upon admission or readmission to the facility.During a review of the facility's P&P titled, Medication Administration dated February 2024, the P&P indicated medications are administered in a safe, timely manner and as prescribed.

Based on interview and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) were prepared for a safe discharge from the facility when the following occurred: 1. On [DATE], facility staff discharged Resident 1, who required extensive assistance with activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility, without arrangements for home health services (a wide range of health care services that you can get in your home for an illness or injury), as ordered by the physician. 2. On [DATE], facility staff discharged Resident 2, who had physician orders for continuous oxygen therapy (a treatment that provides you with extra oxygen to breathe in), without ensuring Resident 2 had the required equipment and instructions for continuous oxygen therapy. These deficient practices resulted in Resident 1 confined in her wheelchair from [DATE] through [DATE], resulting in macerated (skin condition that occurs when skin is exposed to moisture for an extended period), red skin to her buttocks and perineum (tiny patch of sensitive skin between the genitals) from sitting in her stool and urine. Emergency services [NAME] Resident 1 general acute care hospital (GACH) 1 on [DATE] and diagnosed with bilateral lower extremity venous stasis rash (a skin condition where blood pools in the lower legs due to poor circulation causing the skin to become swollen, itchy, discolored, dry, cracked, and inflamed). These deficient practices also placed Resident 2 at risk for harm of low oxygen levels, respiratory distress, and death due to lack of education and preparation regarding her orders for continuous oxygen therapy. Findings: 1. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's admitting diagnoses included generalized muscle weakness, unsteadiness on feet, history of falling, lack of coordination, heart attack (life-threatening emergency where blood flow to the heart is blocked), chronic embolism and thrombosis (a condition where blood clots form in a vein, usually in the legs, potentially breaking off and traveling to the lungs) of the right lower extremity. During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's discharge Minimum Data Set (MDS, a resident assessment tool required by the federal government), dated [DATE], the MDS indicated Resident 1 did not have cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 required set-up and/or clean-up assistance for brushing her teeth, upper body dressing, and personal hygiene, and required supervision or touch assistance for toileting hygiene, showering or bathing, and lower body dressing. The MDS indicated Resident 1 required partial to moderate assistance to move 50 feet and 150 feet while in a manual wheelchair. The MDS also indicated Resident 1 was frequently incontinent (inability to control) of bowel and bladder function. During a review of Resident 1's Nurse Practitioner (NP, an Advanced Practice Registered Nurse with advanced clinical training) progress note, dated [DATE], written by NP 1, the progress note indicated Resident 1 was at high risk for health complications due to her comorbidities (simultaneous presence of two or more diseases or medical conditions), including her diagnoses of lack of coordination, obesity, chronic embolism and thrombosis, and activities of daily living (ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) dysfunction. The progress note indicated Resident 1 required frequent evaluation. The progress note indicated neglecting regular monitoring and management could result in an acute increase in severity of symptoms, complications, and possible rehospitalization . During a review of Resident 1's physician orders, dated [DATE], the orders indicated to discharge Resident 1 home with a Home Health Agency (HHA) 1. During a review of Resident 1's Discharge Summary, dated [DATE], the Discharge Summary indicated on [DATE] Resident 1 was discharged home with home health services through HHA 1. The Discharge Summary indicated Resident 1 required extensive assistance for ADLs and mobility and indicated Resident 1's skin was intact at the time of discharge. During a review of the email correspondence between HHA 1 and the Social Services Director (SSD), dated [DATE], the email correspondence indicated the SSD received the referral documents on [DATE] at 1:11 PM and sent the referral to HHA 1 on [DATE] at 1:47 PM. During a review of Resident 1's physician's order, dated [DATE] (4 days after being discharged home), the order indicated May [discharge] with [HHA 2] . The SSD entered the order. During a review of Resident 1's social services progress note, dated [DATE] at 4:24 PM, the note indicated Home health referral was sent to [HHA 3] . waiting for response . During an interview on [DATE] at 9:30 AM, with Resident 1, Resident 1 stated she was confined to her wheelchair in the entryway of her apartment since she was discharged home from the facility on [DATE]. Resident 1 stated she slept in the wheelchair and urinated and had bowel movements into the incontinence brief because she could not get up on her own. Resident 1 stated that prior to leaving the facility, the Social Services Director (SSD) informed her she would receive help from HHA 1. Resident 1 stated the SSD instructed her to contact HHA 1 upon discharge. Resident 1 stated that when she contacted HHA 1 at the number provided by the SSD, HHA 1 informed her they did not receive a referral or orders for her to receive home health services. During an interview on [DATE] at 10:19 AM, with Case Manager (CM) 1 from HHA 1, CM 1 stated that when a resident was referred for home health services, the discharging facility would send a referral along with information about the resident. CM 1 stated she never spoke with anyone from the facility regarding Resident 1, and HHA 1 never received any referrals or faxes from the facility for Resident 1. During an interview on [DATE] at 11:23 AM, with Resident 1, Resident 1 stated she had not showered or bathed since returning home on [DATE]. Resident 1 stated she had trouble walking and could not do anything for herself by herself. Resident 1 stated she was handicapped and could not stand. Resident 1 stated her Family Friend (FF 1) came to help her change her incontinence brief on [DATE], but FF 1 was not available all the time because she worked. Resident 1's speech was rapid and frantic during the interview. Resident 1 stated she had no family to help her because they were all deceased . Resident 1 stated she was all alone . During an interview on [DATE] at 12:30 PM, with FF 1, FF 1 stated she lived in the same apartment complex as Resident 1 and had been helping Resident 1 for a few years. FF 1 stated Resident 1 used to be able to walk with a walker, do her own laundry, and only needed help with errands requiring her to drive. FF 1 stated Resident 1 did not require a wheelchair before the resident's admission to the facility. FF 1 stated she was surprised the facility discharged Resident 1 in her current condition because Resident 1 could not care for herself and was not receiving help from anyone else. FF 1 stated Resident 1 had been confined to her wheelchair since arriving home, from the facility on [DATE]. FF 1 stated Resident 1 had not bathed or slept, and urinated, and had bowel movements in her wheelchair, because she was unable to get up on her own. FF 1 stated she had to help Resident 1 change her incontinence brief on [DATE] because Resident 1 was soiled and could not change the brief by herself. During an interview on [DATE] at 4:59 PM, with Resident 1, Resident 1 stated she was suffering from severe pain in her left leg, extending from her knee to her ankle. Resident 1 also stated her right ankle was swollen. Resident 1 stated she was supposed to elevate her legs, but she could not elevate them while in the wheelchair. During an interview on [DATE] at 5:31 PM, with FF 1, FF 1 stated she went to help Resident 1 change her incontinence brief and stated Resident 1's perineum and buttocks were red and raw . During an interview on [DATE] at 8:45 AM, with CM 1 from HHA 1, CM 1 stated she received a referral via email from the facility's SSD, around 2:00 PM on [DATE], for Resident 1 to receive home health services. CM 1 stated this was the first referral received for Resident 1, and stated the physician order for discharge and referral for home health services was dated [DATE]. CM 1 stated home health services were not provided due to the delayed receipt of the referral. During an interview on [DATE] at 9:17 AM, with the Administrator (ADM) for HHA 2, the ADM stated the SSD sent a referral via email on [DATE] requesting home health services for Resident 1. The ADM stated HHA 2 sent a Registered Nurse to see Resident 1 on [DATE], and the SSD called on [DATE] and informed HHA 2 that HHA 1 would be seeing Resident 1, and HHA 2's services were no longer needed. During a concurrent interview and record review, on [DATE] at 9:47 AM, with the SSD, Resident 1's physician orders, progress notes, and Discharge Summary dated [DATE], were reviewed. The SSD stated the Discharge Summary, dated [DATE], indicated Resident 1 was discharged home on [DATE] and Resident 1 was supposed to receive home health services through HHA 1. The SSD stated she did not confirm that HHA 1 would be providing services prior to discharging Resident 1 on [DATE]. The SSD stated the progress notes indicated from [DATE] to [DATE], Resident 1 had not received home health services as originally indicated in the physician order dated [DATE]. The SSD stated it was important for residents to have confirmed arrangements for home health services prior to discharge to ensure the residents received the care needed once they left the facility. The SSD stated it was not safe to discharge Resident 1 without ensuring home health services would be provided, as ordered by the physician. The SSD stated Resident 1 required extensive assistance with ADLs (routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) at the time of discharge and home health services were necessary to carry out those tasks. During a concurrent interview and record review, on [DATE] at 10:11 AM, with Licensed Vocational Nurse (LVN) 1, Resident 1's Discharge Summary, dated [DATE], was reviewed. LVN 1 stated Resident 1's Discharge Summary indicated Resident 1 required extensive assistance with ADLs and could not stand up or walk by herself. LVN 1 stated the Discharge Summary indicated Resident 1 was incontinent of bowel and bladder and Resident 1's skin was intact at time of discharge. LVN 1 stated it was not safe for Resident 1 to be discharged home without someone available to help her, or arrangements for home health services. LVN 1 stated Resident 1 was at risk for injury, skin breakdown and urinary tract infection (UTI, an infection in the bladder/urinary tract) from her incontinence and inability to perform hygiene tasks on her own, hospitalization , and death. During an interview on [DATE] at 12:32 PM, with FF 1, FF 1 stated Resident 1 called emergency personnel due to increasingly severe pain in her legs. FF 1 stated emergency personnel assessed Resident 1 took her to GACH 1 on [DATE]. During a concurrent interview and record review on [DATE] at 1:32 PM, with the Director of Nursing (DON), Resident 1's Admission Record and NP progress notes dated [DATE] were reviewed. The DON stated Resident 1's Admission Record indicated a diagnosis of a heart attack, chronic embolism, and thrombosis of the right lower extremity. The DON stated Resident 1's prolonged confinement to her wheelchair from [DATE] to [DATE] placed her at risk for repeat formation of a thrombosis, which could lead to another heart attack. The DON stated Resident 1 would also be unable to apply compression to her lower extremities or elevate her lower extremities due to obesity if she was confined to her wheelchair. During a review of Resident 1's GACH 1 records, dated [DATE], the records indicated Resident 1 was brought to the emergency department on [DATE] with complaints of severe lower extremity pain and injury. The records indicated Resident 2 had bilateral grade 4 pitting edema (the most severe type of swelling, where a deep indentation remains in the skin for more than 30 seconds after pressure is applied). The records indicated Resident 2 had an anxious affect (a feeling of fear, dread, and uneasiness) and weak strength in both legs. The records indicated Resident 2 was diagnosed with bilateral lower extremity venous stasis rash and the emergency department physician recommended hospitalization for further evaluation and management. 2. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted on [DATE]. Resident 2's admitting diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD, chronic lung disease causing difficulty in breathing), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently). During a review of Resident 2's H&P, dated [DATE], the H&P indicated Resident 2 had capacity for medical decision making. The H&P further indicated that prior to admission to the facility, Resident 2 had been hospitalized due to COPD exacerbation and difficulty breathing. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment (a stage of cognitive decline where a person has difficulty with complex tasks and navigating to new places), The MDS indicated Resident 2 required supervision and/or touching assistance for picking up small objects. During a review of Resident 2's physician's order, dated [DATE], the order indicated Resident 2 was to be discharged home with HHA 3. During a review of Resident 2's NP Progress Note, dated [DATE], the NP progress note indicated Resident 2's primary diagnosis was COPD, and Resident 2 was at high risk for complications, including increased likelihood of hospital readmission due to complications from pulmonary dysfunction (a general term for diseases that affect the lungs or respiratory system). During a review of Resident 2's physician orders, dated [DATE], the orders indicated Resident 2 was supposed to receive continuous oxygen therapy for desaturation (when blood oxygen levels drop below normal) related to her COPD diagnosis. The order did not specify an oxygen flow rate (the measurement of how much oxygen is delivered to a patient per minute). During a review of Resident 2's care plan titled, Altered Respiratory Status/Difficulty Breathing related to COPD , dated [DATE], the staff's interventions indicated to administer oxygen therapy as ordered to prevent complications related to difficulty breathing or poor oxygen absorption. During a review of Resident 2's Interdisciplinary (IDT, group of different disciplines working together towards a common goal of a resident) Conference Note, dated [DATE], the note indicated Resident 2 informed the SSD that she had a portable oxygen delivery device in her personal possession. The note indicated Resident 2's orders for oxygen therapy were not for continuous oxygen and only as needed. The IDT note did not indicate that any teaching was provided to Resident 2 about her orders for continuous oxygen therapy, or if the personal oxygen delivery device Resident 2 had in her possession was assessed for functionality or the resident's ability to self-administer oxygen. During a review of Resident 2's Discharge Summary, dated [DATE], the Discharge Summary indicated on [DATE], Resident 2 was discharged home from the facility with FF 2. The Discharge Summary indicated Resident 2 required oxygen equipment after her discharge from the facility. The Discharge Summary did not indicate that any instructions or teaching were provided to Resident 2 or FF 2 at the time of discharge related to her orders for continuous oxygen therapy. The Discharge Summary did not indicate Resident 2's portable oxygen delivery device was checked for functionality. During an interview on [DATE] at 1:01 PM, with FF 2, FF 2 stated on [DATE], he assisted Resident 2 with her discharge from the facility because Resident 2 did not have any living children. FF 2 stated at discharge, the facility informed Resident 2 that her oxygen equipment would not be delivered until Tuesday, [DATE], at the earliest. FF 2 stated Resident 2 informed staff that she had a portable oxygen delivery device in her possession at the facility she would be taking home. FF 2 stated the facility did not check the functionality of the portable oxygen delivery device in Resident 2's possession. FF 2 stated the facility did not provide any instructions or teaching about how much oxygen Resident 2 required, or whether the oxygen therapy was needed continuously. During a concurrent interview and record review, on [DATE] at 1:41 PM, with LVN 1, Resident 2's IDT Conference Note and Discharge Summary, both dated [DATE], were reviewed. LVN 1 stated the IDT Conference Note and the Discharge Summary did not indicate Resident 2 or FF 2 were provided any teaching related to the resident's orders for continuous oxygen therapy. LVN 1 further stated the IDT Conference Note and Discharge Summary did not indicate that Resident 2's portable oxygen delivery device was checked by facility's staff to ensure it was able to provide continuous oxygen as ordered. LVN 1 stated Resident 2 was at risk for difficulty breathing, desaturation, hospitalization , and death from not receiving teaching related to oxygen administration, and assessment of her portable oxygen delivery device to ensure it worked and could meet the resident's needs. During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan , dated ,d+[DATE], the P&P indicated the staff was supposed to ensure the post-discharge plan included arrangements that had been made for follow-up care and services. The P&P indicated the resident (or their representative) was supposed to be involved in the post-discharge planning process and informed of the final post-discharge plan.

Based on interview and record review, the facility failed to prevent weight loss and dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake) as per the resident ' s plan of care and the facility ' s policy and procedure (P&P) for one of four sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 ' s nutritional status was assessed and addressed by the licensed staff from [DATE] to [DATE] and implement interventions such as honoring the resident ' s food preferences and likes/dislikes when Resident 1 began to refuse to eat. 2. Ensure the Registered Dietician (RD, health professional who has special training in diet and nutrition) was notified of Resident 1 ' s continued decreased oral intake and implement resident specific interventions to prevent further weight loss from [DATE] to [DATE], a total of 13 pounds. 3. Ensure a resident centered care plan was updated and implemented to address Resident 1 ' s decreased fluid and food intake and the nutritional needs to address significant weight change for Resident 1. 4. Notify Resident 1 ' s physician of continued decrease in appetite and refusal to eat from [DATE] to [DATE]. As a result, Resident 1 had insidious (gradual unintended weight loss over time) weight loss leading to severe weight loss of 6.7 percent (%) in one month (September to October) due to lack of continuous monitoring and interventions. The resident lost a total of 13 pounds from [DATE] to [DATE]. On [DATE], Resident 1 was transferred to a general acute care hospital (GACH) and expired. Findings: During a review of Resident 1 ' s Admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body), dysphagia (difficulty in swallowing food or liquid), muscle weakness (a decrease in strength in one or more muscles), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinson ' s disease (a degenerative condition of the brain associated with motor symptoms [slow movement, tremor, rigidity and imbalance]), and anxiety disorder (a mental health condition with frequently intense, excessive and persistent worry and fear about everyday situations). During a review Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated [DATE], the MDS indicated Resident 1 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required extensive assistance from staff with bed mobility, dressing, supervision for eating, and was totally dependent on staff with toileting, personal hygiene, and bathing. The MDS indicated Resident 1 had no weight loss of 5 percent or more in the last month or loss of 10 percent or more in the last 6 months. During a review of Resident 1 ' s History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 was admitted for 24-hour nursing care. The H&P indicated Resident 1 ' s weight was stable. A review of Resident 1 ' s Weights and Vitals Summary, dated from [DATE] to [DATE], indicated the following: On [DATE] - 191 pounds (lbs) (2 days after admission) On [DATE] - 193 lbs On [DATE] - 193 lbs On [DATE] - 193 lbs On [DATE] - 189 lbs On [DATE] - 186 lbs On [DATE] - 184 lbs On [DATE] - 180 lbs On [DATE] - 180 lbs On [DATE] - 181 lbs On [DATE] - 180 lbs On [DATE] - 180 lbs (last recorded weight at the facility) During a review of Resident 1 ' s Physician Order Summary Report, the order summary report indicated the following orders: 1. [DATE] - weekly weights for 4 weeks was ordered. 2. [DATE] - NAS (no added salt) diet, chopped texture, thin liquids consistency for breakfast, lunch, and dinner. 3. [DATE] - monitor for side effects of Ativan (medication used to treat anxiety) use; drowsiness, dizziness, loss of coordination, headache, nausea, blurred vision, constipation, heartburn, and change of appetite. 4. [DATE] - fortified diet (foods that have nutrients added that the food would not naturally contain), mechanical soft (a diet designed for people who have trouble chewing and swallowing), chopped texture, thin liquids consistency for breakfast, lunch, and dinner. 5. [DATE] Megestrol Acetate Suspension (Megace, used to help raise feelings of hunger) 400 milligrams (mg, a unit of mass or weight), by mouth two times a day for poor appetite. During a review of Resident 1 ' s Nutrition (PO Intake) records, the records indicated from August to [DATE], the forms were incomplete. A review of Resident 1 ' s dietary records indicated there was no documentation that alternative foods, snacks, or supplements were offered or provided to Resident 1, from [DATE] (day after admission) to [DATE] (transfer to the GACH). During a review of Resident 1 ' s Weights and Vitals Summary, effective date range [DATE] to [DATE], the summary indicated Resident 1 lost 13 lbs, 6.7 percent (%) of her body weight within 27 days. Resident 1 ' s weight went from 193 lbs on [DATE] to 180 lbs on [DATE]. During a record review of Resident 1 ' s Nutritional Risk Assessment (Admission/ Annual), dated [DATE], the assessment indicated Resident 1 ' s diagnoses of depression and anxiety placed the resident at high risk for nutritional problems. The assessment indicated Resident 1 ' s weight was to not exceed more or less than 4% of her current body weight of 193 lbs. The assessment indicated Resident 1 ' s PO (oral) intake was consistently meeting greater than 75 % of needs and was on monitoring and evaluation of weight and oral (PO) intake changes. The assessment indicated the plan for Resident 1 was weight maintenance and not weight loss. The assessment also indicated for Resident 1 ' s food preferences (likes/dislikes), to refer to the Dietary Screening Report which identifies a resident ' s food preferences. A review of Resident 1 ' s clinical records indicated there was no Dietary Screening Report completed. During a review of Resident 1 ' s care plan titled, Hydration Risk: At risk for Fluid Volume deficit related to (R/T) advanced age, date initiated [DATE], the care plan indicated Resident 1 would be well hydrated as evidenced by no weight loss, moist mucous membranes, good skin turgor (ability of skin to change shape and return to normal) and laboratory (labs) results within normal limits. The staff ' s interventions indicated to monitor Resident 1 ' s labs, weights, promote good nutrition and promote good PO intake. During a review of Resident 1 ' s care plan titled, Noted Recent Weight Change of nine (9) lbs. Weight Loss in a Week, initiated [DATE] and revised on [DATE], the care plan indicated Resident 1 would eat at least 50 percent of meals and drink adequate fluids. The staff ' s interventions included to monitor and record Resident 1 ' s weight, refer to the IDT for review and additional interventions, monitor lab work and provide supplements as ordered. During a review of Resident 1 ' s, Lab Results Report, dated [DATE], the report indicated labs was completed and all results were in normal range including Albumin results (normal reference range [NRR] 3.0 to 5.0 grams per deciliter [(g/dL]) which is indicative of malnourishment. During a review of Resident 1 ' s Nutrition/Dietary Note dated [DATE], the note indicated Resident 1 experienced a significant undesired weight loss of four (4) lbs in one week. The note indicated on [DATE], Resident 1 ' s weight was 184 lbs and on [DATE], the weight dropped to 180 lbs. The record indicated Resident 1 ' s weight loss was related to variable PO intake, urinary tract infection (UTI, bladder infection), and psychotropic medications (medications used to treat mental disorders), which may decrease appetite. The record further indicated Resident 1 was receiving Megace to stimulate appetite and would be monitored for improvement in PO intake and weight changes with a re-evaluation in 7 days. A review of Resident 1 ' s medical records indicated there was no re-evaluation addressing the resident ' s PO intake and weight changes after 7 days. A review of Resident 1 ' s Order Summary Report dated [DATE], indicated there was a physician ' s order dated [DATE], to administer multivitamin-minerals tablet, by mouth one time a day. During a review of Resident 1 ' s Nutrition note, and Nurses Progress note dated [DATE], the notes indicated Resident 1 ate ,d+[DATE] % for breakfast and lunch. There was no documentation for dinner and no documented evidence a change of condition (COC) was initiated on this date regarding Resident 1 ' s poor PO intake. During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR, communication form) dated [DATE], the SBAR indicated on [DATE] at 3:15 p.m., Resident 1 was found unresponsive with no pulse, and no breathing noted. 911 was called and Resident 1 was transferred to a general acute care hospital (GACH). During a review of Resident 1 ' s GACH ' s Emergency Department (ED) Note, dated [DATE], the note indicated Resident 1 was transferred via emergency medical services (EMS) for unresponsiveness and cardiac arrest (when the heart stops beating suddenly). A review of Resident 1 ' s GACH ED laboratory results dated [DATE] indicated the following laboratory results: 1. Blood Urea Nitrogen (BUN, test to determine kidney function): elevated at a level of 49 milligrams (mg, unit of measurement) per (/) deciliter (dL, unit of measurement), indicative of dehydration. Normal Reference Range ([NRR] ,d+[DATE] mg/dL). 2. Creatinine (test to determine kidney function): elevated at a level of 5.3 mg/dL. NRR 0XXX,d+[DATE].30 mg/dL. 3. Sodium (electrolyte which plays a critical role in helping your cells maintain the right balance of fluid and used to help cells absorb nutrients in the body): elevated at a critically high level of 170 millimoles per liter (mmol/L). NRR ,d+[DATE] mmol/L. 4. Potassium (critical to your heart function, too much or too little can cause serious heart problems): elevated at a critically high level of 6.4 mmol/L. NRR 3XXX,d+[DATE].1 mmol/L. 5. Total Protein (test measures the amount of protein in your blood, which are important for the health and growth of the body's cells and tissues): low level of 3.1 grams (g)/dL. NRR 6XXX,d+[DATE].2 g/dL. 6. Albumin (responsible for transporting vitamins, enzymes (proteins that help speed up chemical reactions in our bodies), and hormones (substance made by glands in the body) throughout your body. Albumin makes up 50% of the proteins found in your plasma (fluid part of the blood that carries the blood cells). When your albumin levels are low, hormones and other important compounds are not able to get to where they need to go in your body to fulfill their duties): low level of 1.4 g/dL. NRR 3XXX,d+[DATE].0 g/dL. During a review of Resident 1 ' s GACH ED Note dated [DATE], the note indicated per the EMS report, Resident 1 received 36 minutes of cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when the heart stops beating) at bedside at the facility followed by 10 minutes of CPR in route to the GACH. The note indicated at presentation to the ED, Resident 1 was apneic (breathing repeatedly stops and starts) and pulseless with CPR in progress. CPR was continued for approximately 35 minutes in the ED. Resident 1 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and regained perfusing pulse for approximately 10 minutes. CPR was re-initiated and after 10 minutes, Resident 1 was pulseless and without respiratory effort nor heart sounds. Resident 1 was declared deceased on [DATE] at 5 p.m. During a telephone interview with RD 1 on [DATE] at 2:06 p.m., RD 1 stated there were no follow up notes after [DATE], because Resident 1 ' s weight was stable at 180 lbs. RD 1 stated she did not look into Resident 1 ' s poor PO intake because the resident ' s weight was okay. RD 1 stated there were no nutrition labs recommended to Resident 1 ' s physician for October and [DATE] because [DATE] ' s lab results were good despite the resident ' s poor PO intake. RD 1 stated she did not make additional recommendations to address Resident 1 ' s continued poor PO intake. During an interview with Certified Nursing Assistant (CNA) 2 on [DATE] at 1:05 p.m., CNA 2 stated Resident 1 was confused, needed help with eating, and was unable to eat on her own. During an interview with RD 1 on [DATE] at 1:07 p.m., RD 1 stated she was not notified Resident 1 had poor PO intake. RD 1 confirmed snacks were not offered. RD 1 stated if she knew Resident 1 was not eating well, she would have recommended to order supplements to prevent losing more weight. RD 1 confirmed Resident 1 had multiple episodes of three or more episodes of poor meal intake in a two-day period. RD 1 was unable to provide documentation of Resident 1 ' s calorie count and measurement of the resident ' s fluid intake and output. RD 1 verified Resident 1 was not weighed after [DATE], despite Resident 1 ' s continued poor PO intake. During an interview with Licensed Vocational Nurse (LVN) 7 on [DATE] at 1:24 p.m., LVN 7 stated Resident 1 was alert and confused, and always needed prompting and assistance with eating and drinking. LVN 7 stated Resident 1 had water at the bedside but would not take the initiative to eat or drink by herself. LVN 7 stated Resident 1 ' s highly anxious state did not make eating and drinking her priority. LVN 7 stated Resident 1 refused her meals a lot and staff would try to soothe and relax her so she could eat. LVN 7 stated [DATE] was the last documented date Resident 1 ' s physician was notified regarding the resident ' s poor oral intake. LVN 7 stated multivitamins (MVIs) were ordered. During a concurrent interview and record review on [DATE] at 1:30 p.m. with LVN 7, Resident 1 ' s Weights and Vitals Summary, from [DATE] to [DATE], were reviewed. LVN 7 stated Resident 1 refused to eat, continued to have lose weight, and ultimately had an 11 lbs weight loss from [DATE] to [DATE]. The weights reviewed were as follows: 1. [DATE] weight was 191 lbs on admission. 2. [DATE] weight was 186 lbs, a 5-lb weight loss since admission. 3. [DATE] weight was 184 lbs, a 7-lb weight loss since admission. 4. [DATE] weight was 180 lbs, an 11-lb weight loss since admission. During a subsequent interview, LVN 7 stated Resident 1 ' s care plan should have been updated to address the resident ' s unintended continuous weight loss from August to [DATE]. LVN 7 stated each weight loss documented should have had new meaningful interventions. LVN 7 stated multivitamins should have been ordered sooner and oral nutritional supplements would have been helpful. LVN 7 stated Resident 1 ' s physician should have been notified on the dates the weight loss was noted and the interdisciplinary team (IDT, group of different disciplines working together towards a common goal for a resident) could have been more aggressive with interventions to aid in Resident 1 ' s nutritional status. During a concurrent interview and record review on [DATE] at 2:03 p.m., with LVN 8, Resident 1 ' s clinical record was reviewed. LVN 8 stated when Resident 1 ' s health started to decline a change of condition (COC) was noted for a 4-lb weight loss on [DATE]. LVN 8 stated Resident 1 was confused and needed a lot of cues to drink water. LVN 8 stated there was no documented evidence Resident 1 was cued to drink water several times a day in the resident ' s clinical record. LVN 8 stated if staff knew what Resident 1 liked to eat, it would have helped encourage the resident to eat more. LVN 8 stated if snacks were also added in between meals, it could have helped prevent the decline of Resident 1 ' s health. LVN 8 stated there were multiple missed opportunities to intervene and help Resident 1 with increasing her PO intake more aggressively. During a subsequent concurrent interview and record review on [DATE] at 2:03 p.m. with LVN 8, Resident 1 ' s clinical record was reviewed, LVN 8 stated there was no evidence Resident 1 ' s fluid intake was being monitored, and no record indicating RD 1 was notified of the resident ' s poor PO intake and refusals to eat and drink. During an interview with the Director of Nursing (DON) and Registered Nurse (RN) 1 on [DATE] at 3 p.m., the DON and RN 1 stated the facility staff failed to notify Resident 1 ' s physician of the resident ' s continued poor PO intake, and refusal to eat and drink fluids from [DATE], to [DATE]. The DON and RN 1 stated no additional interventions were made to address Resident 1 ' s continued poor PO intake from the last time the physician was notified of the resident ' s weight loss on [DATE]. The DON and RN 1 stated staff should have been notifying and updating Resident 1 ' s physician of the resident ' s continued poor PO intake and sought further guidance and medical interventions to prevent Resident 1 ' s health from declining. During an interview with Registered Dietician (RD) 1 on [DATE] at 3:12 p.m., RD 1 stated Resident 1 ' s food preference assessment was not completed because the facility did not have a dietary staff supervisor (DSS) at the time. RD 1 stated a food preference assessment should have been completed upon Resident 1 ' s admission to the facility and when the resident began refusing to eat. RD 1 stated it was important to ask Resident 1 ' s food preferences and offer food the resident liked to help improve the resident ' s appetite and increase PO intake. During a telephone interview with Resident 1 ' s physician (Physician 1) on [DATE] at 2:04 p.m., Physician 1 stated, If a resident is not eating or has poor intake and is losing weight, my expectations are for the nursing staff to contact me for the change in condition so that I may make appropriate medical decisions and provide orders to address the resident ' s issue. Physician 1 further stated the facility staff did not contact him nor his nurse practitioner (NP 1) about Resident 1 ' s poor oral intake and weight loss from [DATE] to [DATE]. During a review of the facility ' s P&P titled, Calorie Counts, dated ,d+[DATE], the P&P indicated nursing staff will document poor intake in the progress notes. Three or more episodes of poor meal intake in a two-day period will be reported in writing to the Dietitian. The P&P indicated the Dietitian will assess intake patterns. If unexpected weight loss or perceived decline in food intake warrants further investigation, a calorie count may be requested. A physician order is not required for the initiation of a calorie count. The P&P indicated the Dietitian will document results and assess adequacy of caloric intake in the medical record. If necessary, interventions will be initiated in accordance with current Standards of Practice. During a review of the facility ' s Policy and Procedure (P&P), titled, Food and Nutrition Services, revised ,d+[DATE], the P&P indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The P&P indicated the multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident ' s nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on this assessment. During a review of the facility ' s P&P titled, Food and Nutrition Services, revised ,d+[DATE], the P&P indicated nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems. a. Variations from usual eating or intake patterns will be recorded in the resident ' s medical record and brought to the attention of the nurse. b. A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian. During a review of the facility ' s P&P titled, Weight Assessment and Intervention, revised ,d+[DATE], the P&P indicated resident weights are monitored for undesirable or unintended weight loss or gain. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The P&P indicated the threshold for significant unplanned and undesired weight loss will be based on 1 month - 5% weight loss is significant; greater than 5% is severe. The P&P further indicated interventions for undesirable weight loss are based on careful consideration of nutrition and hydration needs of the resident.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of the coronavirus disease ([COVID-19]) an illness caused by a virus that can easily spread from person to person) per the facility's mitigation plan (MP). The facility failed to: a. Perform Non-Oil N95 respirator (a type of mask worn over the face to cover the nose and mouth that provides respiratory protections against aerosols [a suspension of fine solid particles or liquid droplets in air] and prevent infections) fit testing (a method of ensuring the mask properly fits the face of the wearer to protect from inhaling infectious particles) with the new N95 brands ([NAME], Champak, 3M, and [NAME]) for fifty-two (52) out of seventy-four (74) staff members. b. Ensure Certified Nursing Assistant (CNA) 1 and CNA 2 wore properly fitted N95 mask, isolation gown (a garment worn to protect the body or clothing from transfer of infectious agents), and gloves while proving direct resident care to Resident 4 in the yellow zone (an area housing COVID-19 suspected, symptomatic or exposed residents). c. Screen eight (8) staff members (Certified Nurse Assistant 3, 4, 5, and 6 [CNA 3, CNA 4, CNA 5, and CNA 6], activities director [AD], restorative nurse assistant [RNA], licensed vocational nurse 3 and 2 [LVN 3 and LVN 2]) for COVID-19 sign and symptoms and risks, including temperature check, before the staff entered the facility. d. Ensure an unvaccinated resident (Resident 1) and partially vaccinated (received only one dose and needed another dose of the COVID-19 vaccine) resident (Resident 2) did not attend indoor group activities during a COVID-19 outbreak (presence of least one confirmed COVID-19 resident) in the facility. e. Screen Resident 3 in the green zone (a designated area for residents who did not have COVID-19) for signs and symptoms of COVID-19 and vital signs, such as heart rate, temperature, respiration rate, and oxygen saturation by pulse oximetry [a test to measure oxygen level in the blood]) and document the screening results and vital signs. These deficient practices placed sixty-eight (68) of total number of residents in the yellow and green zone residents (16 in the yellow zone and 52 in the green zone), seventy-four (74) staff, and the community at higher risk of COVID-19 infection. On 12/22/2021 at 4:15 p.m., during an unannounced visit, an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) was identified due to 52 staff members were not fit tested with the new N95 brands ([NAME], Champak, 3M, and [NAME]); CNA 1 and CNA 2 did not wear fitted N95 mask, gloves, and gown while providing direct care to Resident 4; eight staff members (CNA 3, CNA 4, CNA 5, CNA 6, LVN 2, LVN 3, RNA, and AD) were not screened for signs and symptoms of COVID-19 before entering the facility; the unvaccinated resident (Resident 1) and partially unvaccinated resident (Resident 2) attended the indoor group activities; and a resident (Resident 3) in the green zone was not screened for signs and symptoms of COVID-19, including obtaining the resident's vital signs. The IJ was called in the presence of the administrator (ADM) and the Infection Preventionist (IP). On 12/23/2021 at 2:59 p.m., the ADM submitted an acceptable Plan of Action ([POA] a plan with interventions to correct the deficient practices). The IJ was lifted at 12/23/2021 at 5:14 p.m., after verifying and confirming on-site the POA was implemented per observations, interviews, and record reviews. The acceptable POA included the following immediate corrections: 1. The staff fit testing was started. Current staff were fit tested on [DATE] in accordance with current guidelines by California Division of Occupational Safety and Health (Cal OSHA) dated 5/7/2021; staff not working will be fit tested prior to working on their shift. The IP will be responsible to ensure all staff is fit tested . The IP, Director of Staff Development (DSD), Director of Nursing (DON), and ADM will ensure all staff wear N95 in accordance with the current guidelines. 2. The IP and DSD will review all staff due for annual renewal of N95 mask fit test 3. All unvaccinated or partially vaccinated residents in the green zone will stop participating in indoor activities and communal dining. The Activities Director (AD) discussed plan for activities for all unvaccinated and partially vaccinated residents in the green zone. 4. The staff were educated on required personal protective equipment ([PPE] attire such as goggles, gowns, and masks, worn to prevent the spread of infections) in different zones (red [an area housing COVID-19 confirmed residents], yellow, and green). Any staff not working will have an in-service prior to working on their shift. 5. All residents' vital signs (medical signs that indicate the status of the body's vital function) and signs and symptoms of COVID-19 will be completed and documented daily. 6. The facility will identify all residents and staff who have suffered or are likely to suffer a serious adverse outcome as a result of the noncompliance (in mitigating COVID-19) including: a. All residents who were in the green zone and who participated in group activities were assessed for signs and symptoms of COVID-19 by the Registered Nurse (RN) Supervisor on 12/23/2021. All other residents were assessed by the ADM and DON. There were no signs and symptoms of COVID-19 identified on the residents. b. The staff who assisted the residents in the yellow zone hallway were assessed by the RN supervisor on 12/22/2021 and again on 12/23/2021. There were no signs and symptoms of COVID-19 identified. No other staff showed signs and symptoms of COVID-19. 7. The facility will continue the testing protocol for COVID-19 per order of the Health Officer for control of COVID-19 dated 12/3/2021, and screening for temperature and signs and symptoms of COVID-19 prior to starting work. The above findings will be reviewed and will be brought to Quality Assurance and Performance Improvement (QAPI, a program to improve the quality of life and quality of care and services delivered in nursing homes) committee monthly meetings by the ADM for recommendations and follow-up. Findings: a. During an interview on 12/22/2021 at 1:08 p.m., the IP stated CNA 7 and Licensed Vocational Nurse (LVN) 1 were both working in the yellow zone. The IP stated CNA 7 and LVN 1 were both using the [NAME] brand N95 in the yellow zone and had not been fit tested for this N95 brand prior to using it. During an interview and review of Certified Nurse Assistant staffing sheets with the DSD on 12/22/2021 at 1:20 p.m., the DSD stated, 1. CNA 7 worked: (a) in the red zone on 12/20/2021 during the 7 a.m. to 3 p.m. shift (morning [AM] shift), and (b) in the yellow zone on 12/21/2021 during the AM shift. 2. CNA 8 worked: (a) in the red zone on 12/20/2021 during the 3 p.m. to 11 p.m. shift (afternoon [PM] shift), and (b) in the red zone on 12/21/2021 and 12/22/2021 during the AM shift. 3. CNA 9 worked in the red zone on 12/21/2021 during PM shift. 4. CNA 10 worked: (a) in the red zone on 12/20/2021 during the 11 p.m. to 7 a.m. shift (night or NOC shift), and (b) in the red zone on 12/21/2021 during the night shift. During an interview and review of the Respirator Training Program Attendance Roster, dated 9/8/2021, 9/10/2021, 9/17/2021, 12/1/2021, and 12/16/2021, with the DSD on 12/22/2021 at 1:20 p.m., the DSD stated she had not been fit tested for over a year with any N95 mask. The DSD stated CNA 7, CNA 8, CNA 9, and CNA 10 had not also been fit tested . The DSD stated that these CNAs (CNA 7, CNA 8, CNA 9, and CNA 10) were not wearing properly fitted N95 masks while providing direct care to residents in the yellow and red zone as specified on the assignment sheets. During an interview and review of All Facilities Letter (AFL) 21-37 from the California Department of Public Health dated 9/22/2021, with the IP on 12/22/2021 3:10 p.m., the IP stated after receiving this AFL on 9/22/2021 which indicated the BYD Precision Manufacture Co., Ltd. (a mask manufacturer) N95 was defective, the facility decided to use new masks from the [NAME], [NAME], Champak, and 3M manufacturers. The IP stated all staff started using the masks from the new N95 brands ([NAME], [NAME], Champak, and 3M manufacturers) on 9/23/2021 and the BYD N95 masks were thrown away. The IP stated after receiving the N95 masks from the new brands, the staff were not fit-tested before they started using the masks. During an interview and review of the facility's Respirator Training Program Attendance Roster, dated 9/8/2021, 9/10/2021, 9/17/ 2021, and 12/1/2021, with the IP on 12/22/2021 at 3:10 p.m., the IP stated the rosters indicated only eighteen (18) staff out of 74 staff had been fit tested for N95 in 2021 (after 9/22/2021, when the facility started using the new brands of N95). The IP stated 56 staff (including CNA 1 and CNA 2) required N95 fit testing because they were never fit tested for the N95 masks they were using. IP also stated not fit testing the staff could lead to the spread of COVID-19 in the facility and community. The IP stated that the facility's COVID-19 mitigation plan dated 9/17/2021 indicated initial and annual N95 respiratory fit testing should be conducted for all staff per California Division of Occupational Safety and Health (Cal-OSHA). A review of the California Division of Occupational Safety and Health (Cal OSHA) Interim Guidance Interim Guidance for Protecting Workers of Skilled Nursing and Long-Term Care Facilities from Exposure to Coronavirus Disease (COVID-19), dated 5/7/2021, indicated employers must provide and ensure employees use appropriate personal protective equipment and respiratory protection when entering a room or area where a suspected or confirmed COVID-19 resident was located, if the resident was not wearing a mask. Employers would provide employees with a fit-tested N95 mask whenever the employee was in the area where COVID-19 residents were located and that the employer would implement a respiratory protection program to ensure employees were medically evaluated for respirator use, trained and fit-tested . b. During a review of Resident 4's admission record (face sheet), the face sheet indicated the facility admitted Resident 4 on 9/23/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/29/2021, the MDS indicated Resident 4 had severely impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. The MDS indicated Resident 4 was totally dependent on staff with eating, bed mobility, dressing, transfer, personal hygiene, and toilet use. During an interview and review of the facility census for 12/22/2021 with the ADM, on 12/22/2021 at 10:10 a.m., the ADM stated Resident 4 was among the sixteen residents in the yellow zone, who had a potential to be positive for COVID-19. During a concurrent observation and interview with CNA 1 on 12/22/2021 at 1 p.m., CNA 1 was sitting right next to Resident 4 in the yellow zone hallway and not wearing gloves and gown while feeding the resident. CNA 1 stated she was not wearing gloves or a gown because gown and gloves were not allowed in the hallway. CNA 1 stated that when providing direct care to residents in the yellow zone, the staff was supposed to wear full PPE including gown, mask, and gloves. During an interview with RN 1 on 12/22/2021 at 1:19 p.m., RN 1 stated CNA 1 was feeding Resident 4 in the yellow zone hallway. RN 1 stated CNA 1 should have worn full PPE including a gown and gloves while rendering direct resident care to prevent the spread of COVID-19 and other infections. During an observation and interview with CNA 2 on 12/22/2021 at 1:26 p.m., CNA 2 was sitting a few inches away from Resident 4. CNA 2 removed Resident 4's blanket, placed a surgical mask on the resident's face, and adjusted Resident 4's legs in the wheelchair without wearing gloves or an isolation gown. CNA 2 stated Resident 4 was in the yellow zone because the resident was exposed to another resident (not identified) who had COVID-19. CNA 2 stated she should have worn gloves and a gown before providing care to Resident 4 to be safe and to help prevent the spread of COVID-19. During an interview and review of the facility's COVID-19 mitigation plan dated 9/17/2021 with the IP, on 12/22/2021 at 1:56 p.m., the IP stated when providing direct care to residents in the yellow or red zones, staff must wear gowns and gloves to protect themselves and residents as well as prevent the spread of COVID-19 in accordance with the facility's COVID-19 mitigation plan. c. During a concurrent interview and review of the facility's Staff Weekly Time Sheet and the Healthcare Provider COVID-19 Screening log with the IP on 12/22/2021 at 1:15 p.m., the IP stated: 1. CNA 5 worked on 12/18/2021, 12/20/2021, and 12/21/2021 (3 opportunities to screen) and was not screened for COVID-19 symptoms prior to entering the facility. 2. AD worked on 12/16/2021 (1 opportunity to screen) and was not screened for COVID-19 symptoms prior to entering the facility. 3. RNA 1 worked on 12/16/2021 and 12/18/2021 (two opportunities to screen) and was not screened for COVID-19 symptoms prior to entering the facility. 4. LVN 2 and LVN 3 worked for four days from 12/16/2021 to 12/19/2021 (eight opportunities to screen) and they were not screened for COVID-19 symptoms prior to entering the facility on all four (4) days. 5. CNA 6 worked on 12/16/2021 (1 opportunity to screen) and was not screened for COVID-19 symptoms prior to entering the facility. 6. CNA 3 and CNA 4 worked three days from 12/17/221 to 12/19/2021 (6 opportunities to screen) and were not screened for COVID-19 symptoms prior to working those three days. The IP stated, during the interview on 12/22/2021 at 1:15 p.m., between the eight (8) staff members (CNA 2, CNA 3, CNA 4, CNA 5, CNA 6, RNA 1, LVN 2, LVN 3), there were a total of twenty-one (21) missed opportunities for COVID-19 screening prior to the staff entering the facility. The IP stated that the facility's failure to screen staff could lead to a facility-wide COVID-19 outbreak. During a concurrent interview and review of the facility's COVID-19 MP dated 9/17/2020 with the IP, on 12/22/2021 at 3:03 p.m., the IP stated the MP indicated that all staff should be screened for COVID-19 signs and symptoms prior to entering the facility regardless of vaccination status. d. During a review of Resident 1's face sheet, the face sheet indicated the facility admitted Resident 1 on 7/23/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 had intact cognitive skills for daily decision making and was independent in eating. The MDS indicated Resident 1 needed limited to extensive staff assistance with bed mobility, dressing, personal hygiene, transfer, toilet use, and bathing. During a review of Resident 2's face sheet, the face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 2 was totally dependent on staff for eating, bed mobility, dressing, personal hygiene, transfer, toilet use, and bathing. During an interview on 12/22/2021 at 10:05 a.m., with the ADM, the ADM stated the facility had a COVID-19 outbreak after a resident's COVID-19 lab test result (Resident 5's) was positive on 12/19/2021. During an interview and review of the facility's resident vaccination log on 12/22/2021 at 10:45 a.m., with the IP, the IP stated Resident 1 was not vaccinated and Resident 2 was only partially vaccinated against COVID-19. During a concurrent interview and review of facility's log of activities on 12/22/2021, at 11:06 a.m., with the AD, the AD stated Resident 1 attended a group activity on 12/21/2021 at 2:08 p.m., and Resident 2 attended a group activity on 12/20/2021 at 5:16 p.m. The AD stated on 12/21/221 at 1:54 p.m., Resident 2 attended a group activity. During an interview and review of the facility's mitigation plan dated 9/17/2021 with the IP, on 12/22/2021 at 3:20 p.m., the IP stated the facility's mitigation plan indicated the residents in the green zone who were not fully vaccinated could not participate in indoor communal dining and group activities while there was a COVID-19 outbreak in the facility. The IP stated Resident 1 and Resident 2 should not have participated in indoor group activities because they were not adequately vaccinated (did not receive 2 doses of a COVID-19 vaccine) against COVID-19. e. During a review of Resident 3's face sheet, the face sheet indicated the facility admitted Resident 3 on 12/2/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had intact cognitive skills for daily decision making, was independent in eating and bed mobility. The MDS indicated Resident 3 needed limited staff assistance with dressing, and extensive assistance with personal hygiene, transfer, and toilet use. During an interview and review of Resident 3's vital sign report dated 12/20/2021 to 6:07 a.m. to 12/22/2021 at 12:10 p.m. with the MDS Nurse (MDSN), on 12/22/2021 at 3:36 p.m., the MDSN stated there was no documented evidence that Resident 3 had been screened for COVID-19 symptoms including temperature and oxygen saturation checks. The MDSN stated there was no documented evidence of COVID-19 symptoms monitoring because Resident 3 was not in the yellow or red zones. The MDSN stated there was no documentation indicating residents in the green zone were monitored for COVID-19 symptoms. During an interview on 12/22/2021 at 3:50 p.m., with LVN 2, LVN 2 stated there was no documentation of COVID-19 symptoms (presence or absence) for residents in the green zone because these residents were not monitored for COVID-19 symptoms. During a concurrent interview and review of the facility's mitigation plan dated 9/17/2021 with the IP, on 12/22/2021 at 3:55 p.m., the IP stated the MP indicated the facility shall conduct symptoms and temperature screening for all residents. IP stated the MP indicated all asymptomatic (no signs and symptoms) residents will be assessed for symptoms and have their temperature checked at least every 24 hours.

Based on interview and record review, the facility failed to initiate cardio-pulmonary resuscitation (CPR - an emergency procedure performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing) immediately after the licensed staff realized the resident was not breathing, in accordance with the Physician order [REDACTED]. American Heart Association Adult Basic Life Support for Healthcare Providers for one of one sampled resident (Resident 1). The Licensed Personnel Weekly Progress Notes dated [DATE] at 6:45 p.m., indicated Resident 1 was found unresponsive to both verbal and tactile (touch) stimuli. Resident 1's vital signs were "hardly appreciated but with weak pulse". At 6:50 p.m., [DATE] and staff were called to the room for assistance. Resident 1 was placed on oxygen at 15 liters per minute and the head of the bed was elevated. At 6:55 p.m., paramedics arrived and CPR was started, a total delay of 10 minutes. At 7:15 p.m., Resident 1 was transferred to the hospital and was intubated (the insertion of a long breathing tube or artificial airway to assist in breathing). On [DATE], Resident 1 expired at the hospital with the cause of death listed as [MEDICAL CONDITIONS] (brain damage due to lack of oxygen). There was no documented evidence the facility staff opened Resident 1's airway, assessed for breathing, provided rescue breathing promptly using a bag-mask device (a bag attached to a face mask and connected to an oxygen source in order to ensure the oxygen is forced into the lungs), rechecked pulse every 2 minutes and provided cardiac compressions when there was no pulse. Failure to initiate CPR immediately after the licensed staff realized the resident was not breathing, resulted in lack of oxygen to Resident 1, sustaining a brain damage. Findings: A review of the clinical records indicated Resident 1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - standardized assessment and care planning tool) assessment dated [DATE], indicated Resident 1 had short term memory loss, was severely impaired in cognitive skills for daily decision making, needed extensive assistance (staff provide weight bearing support and at times requires full staff performance) from staff for bed mobility, transferring, dressing, eating, toilet use, personal hygiene, and was always incontinent (no control) of bowel and bladder functions. The POLST dated [DATE], indicated Resident 1's legal decision maker wanted a full CPR to be performed in case of an emergency. A review of the facility's policy and procedure titled, "Cardiopulmonary Resuscitation and Basic Life Support" revised [DATE], indicated to check the victim for pulse and respirations. If they are absent, attempt to arouse the individual. If the victim is unresponsive, activate the emergency response team, initiate CPR, and call a code as designated by facility protocol. Designate a staff person to call [DATE], open the airway, check breathing, administer rescue breaths, check for pulse, and give chest compressions. According to the American Heart Association Adult Basic Life Support for Healthcare Providers manual dated 2010 - 2011, indicated when the resident is unresponsive with no breathing or no normal breathing, the first thing is to activate emergency response system (call for help or send someone to get help). The second step is to check the pulse rate and if definite pulse within 5 - 10 seconds, give 1 breathe every 5 - 6 seconds, and recheck the pulse every 2 minutes. If there is no pulse, begin cycle of 30 compressions to 2 breaths and ensure the chest rises that would indicate the resident is receiving the oxygen. The manual also indicated a bag-mask device is the most common method of delivering rescue breaths versus only administering oxygen through a regular mask. A review of the Licensed Personnel Weekly Progress Notes dated [DATE] at 6:45 p.m., indicated the licensed vocational nurse (LVN 1) reported Resident 1 was unresponsive to both verbal and tactile (touch) stimuli. Assessment was done. The notes indicated Resident 1's vital signs were hardly appreciated but there was a weak pulse. At 6:50 p.m., [DATE] and staff were called to the room for assistance. Resident 1 was placed on oxygen at 15 liters per minute and the head of the bed was elevated. At 6:55 p.m., paramedics arrived and CPR was started. At 7:15 p.m., Resident 1 was transferred to the hospital for further evaluation. On [DATE] at 8 a.m., in an interview with LVN 1 as she was reading her notes, she stated on [DATE] at around 6:45 pm, she was in the room attending to Resident 1. LVN 1 stated before she repositioned Resident 1, she noticed half of the resident's face was on the pillow and the pillow was wet with saliva (watery liquid secreted into the mouth). LVN 1 stated almost at the same time Resident 1's visitors entered the room and told her the resident 'looked funny'. LVN 1 then asked Resident 1 if she was all right, but Resident 1 did not open her eyes or respond. LVN 1 stated she took Resident 1's pulse and it was weak. LVN 1 stated she went to the Nurse's Station in order to call the registered nurse (RN) 1 on the intercom for assistance. On [DATE] at 9:20 a.m., in a phone interview with RN 1, she stated LVN 1 paged her to Resident 1's room and when she got there, Resident 1 was unresponsive and her vital signs could not be obtained. RN 1 stated she left the room to check Resident 1's code status in the clinical record, which indicated full code (the provision of a full cardio-pulmonary resuscitation comprising of rescue breathing with chest compressions). RN 1 stated that was when she called [DATE] for assistance and began copying the papers for the paramedics. When RN 1 was asked how she assessed Resident 1 when she first saw her, she stated she just checked the resident's pulse but the resident did not open her eyes. When asked for how long she took Resident 1's pulse and what the rate was, she could not recall. RN 1 was asked if she could had just called other staff members for assistance to ensure timely initiation of CPR, she did not answer. RN 1 stated shortly after starting the CPR, the paramedics arrived and they took Resident 1 to the hospital. On [DATE] at 4:06 p.m., in an interview, LVN 1 stated she took Resident 1's pulse for about 45 seconds to a minute, which was weak. LVN 1 could not remember what the pulse rate was. When asked about the resident's breathing, LVN 1 stated she did not see the resident's chest rising. LVN 1 stated that when she came back to Resident 1's room after calling RN 1, she attempted to take Resident 1's pulse rate again but was unable to find it. LVN 1 stated when RN 1 came to the room; she brought the crash cart (a wheeled container sometimes carrying medicine and equipment for use in emergency resuscitations). They administered oxygen through a face mask at 15 liters per minute. LVN 1 stated RN 1 could not obtain any of the vital signs. LVN 1 stated that was when they started CPR. When LVN 1 was asked how she ensured Resident 1 was getting enough oxygen when using a face mask instead of a bag-mask device (a hand-held device commonly used to provide positive pressure ventilation (forcing the oxygen in to the lungs) to patients who are not breathing or not breathing adequately) commonly used when administering CPR, she did not answer. On [DATE] at 9:55 a.m., in an interview with the director of nursing (DON), she stated if the resident was found with a change of condition, the staff should check the vital signs. If the resident was not breathing, they should administer oxygen. On [DATE] at 2 p.m., a review of Resident 1's hospital History & Physicals dated [DATE] indicated Resident 1 was intubated in the field (on the way to the hospital). A review of the death certificate dated [DATE] indicated Resident 1 expired on [DATE] due to [MEDICAL CONDITIONS].