Every finding on record at Covina Rehabilitation Center

Based on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for two of five sampled residents (Residents 76 and 82) by failing to: a. Ensure Registered Nurse 1 (RN 1) wore required personal protective equipment (PPE, equipment that protects people from injury or illness) while providing care to Resident 76 who was placed on Enhanced Barrier Precaution (EBP, precautions that involve using a glove and gown during high-contact resident care activity for residents colonized or infected with multidrug-resistant organisms [MDRO, bacteria that is resistant to many types of antibiotics] and those at a higher risk of developing MDRO, such as residents with wounds or indwelling medical devices). b. Ensure Resident 82 had a urinal holder to hang the used urinal. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for Residents 76 and 82. Findings: a. During a review of Resident 76's admission Record (AR), the AR indicated the facility admitted Resident 76 on 5/21/2024 and readmitted on [DATE] with diagnoses including encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support), dysphagia (difficulty in swallowing) and muscle weakness. During a review of Resident 76's untitled care plan (CP) revised on 7/13/2025, the CP indicated Resident 76 was on EBP and high risk for infection due to the presence of feeding tube. The CP indicated for nursing staff to post signage for EBP and provide EBP gloves, gown and mask. During a review of Resident 76's Order Summary Report (OSR) dated 5/31/2026, the OSR indicated continuous GT feeding for Resident 76 of Jevity 1.5 (formula) at 40 milliliters (ml, unit of measurement) per hour (hr.) for 20 hours via pump; Turn on at 2 pm and turn off 10 am or until the dose was met. During an observation on 6/16/2026 at 9:18 am inside Resident 76's room together with Registered Nurse 1 (RN 1), Resident 76 was lying in bed with ongoing GT feeding running at 40 ml/hr. During an observation on 6/16/2026 at 9:23 am inside Resident 76's room, together with Registered Nurse 1 (RN 1), RN 1 did not wear a protective gown while assessing Resident 76's GT site. RN 1's clothes touched Resident 76's bed and beddings while RN1 was assessing Resident 76's GT site. During an interview on 6/16/2026 at 9:25 am, RN 1 stated RN1 did not wear a protective gown while doing GT site assessment on Resident 76. RN 1 stated protective gown and gloves needed to be worn while assessing Resident 76 to prevent infection and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During an interview on 6/17/2026 at 11:52 am with the facility's Director of Nursing (DON), the DON stated, staff needed to wear gown, gloves and mask while assessing residents on EBP to prevent spread of infection from staff to residents. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 6/5/2024, the P&P indicated, EBPs' are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include device care or use (central line, urinary catheter and feeding tube). b. During a review of Resident 82's Face Sheet (FS), the FS indicated Resident 82 was admitted to the facility on [DATE] with diagnosis including dementia (a decline in mental ability severe enough to interfere with daily life), benign prostatic hyperplasia without lower urinary tract symptoms (prostate gland has enlarged but not experiencing urinary side effects like a weak stream, urgency, or frequent nighttime urination), and cardiomegaly (enlargement of the heart). During a review of Resident 82's History and Physical (H&P) dated 8/20/25, the H&P indicated Resident 82 did not have the capacity to understand and make medical decisions. During a review of Resident 82's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/22/26, the MDS indicated Resident 82 was dependent (helper does all of the effort) for toileting hygiene. Resident 82 required substantial/maximum assistance (helper does more than half the effort) for putting on and taking off footwear. The MDS indicated Resident 82 required partial/moderate assistance (helper does less than half the effort) for personal and oral hygiene and eating. During an observation inside Resident 82's room on 6/16/2026 at 9:44 AM, Resident 82 was lying in bed attempting to place a urinal containing yellow liquid (urine) on Resident 82's bed rail. Resident 82 did not have a urinal holder hanging from the bed rail to place the used urinal. During an interview with the Assistant Director of Nursing (ADON) on 6/17/2026 at 8:45 AM, the ADON stated facility provided urinals and urinal holders were provided to the residents. The ADON stated the urinal holder should be placed hanging on the bedrail within the residents' reach so the residents could hang the urinal after they use it. The ADON stated that the urinal holder was provided to the residents to prevent the urine from spilling on the residents or the residents' bed. The ADON stated that placing a dirty or used urinal on the bedrail instead of inside the urinal holder was an infection control issue. During a concurrent observation inside Resident 82's room on 6/17/26 at 9:00 AM, Resident 82's bedrail had a urinal containing yellow liquid (urine). Some of the yellow liquid was dripping on the outside of the urinal landing on Resident 82's bed rail. During a review of the facility's undated P&P titled, Infection Control, the P&P indicated, This facility has established and will maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on interview and record review, the facility failed to ensure the accuracy and completeness of an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for two of two sampled residents (Residents 8 and 74) by failing to:a. Ensure Resident 8's informed consent for the use of Ativan (medication to treat anxiety [feeling of worry, fear or nervousness]) was dated when the informed consent was obtained.b. Ensure Resident 74's informed consent for the use of Seroquel (medication to treat mental health condition) indicated the name of the person giving the consent. These failures had the potential for Residents 8 and 74 to not receive adequate information to make educated decisions on the use of psychotropic medications.Findings: a. During a review of Resident 8's Face Sheet (FS), the FS indicated the facility initially admitted Resident 8 on 5/26/2023 and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that is characterized by disturbances in thought), anxiety disorder and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 4/30/2026, the MDS indicated Resident 8 had intact cognition (ability to understand and process information). The MDS indicated Resident 8 required partial/moderate assistance (helper did less than half the effort) with eating, upper body dressing and personal hygiene. The MDS indicated Resident 8 was dependent (helper did all the effort) with oral hygiene, toileting, shower and lower body dressing. During a review of Resident 8's Order Summary Report (OSR) dated 5/21/2026, the OSR indicated Resident 8 had an order for Ativan 0.5 milligrams (mg - unit of measurement) tablet via (by way of) gastrostomy tube (GT, a medical device inserted through the abdomen directly into the stomach) every eight (8) hours as needed for anxiety manifested by excessive worrying about health concerns. During a review of Resident 8's undated Psychotherapeutic Drug Informed Consent Form (IC), the IC indicated a telephonic consent (verbal or documented agreement obtained over a phone call) for Ativan was obtained from Resident 8's representative. The telephonic IC did not indicate when the telephonic consent was obtained. During a concurrent interview and record review on 6/17/2026 at 11:28 am with Registered Nurse Supervisor 1 (RN 1), Resident 8's OSR dated 5/21/2026 and the undated IC were reviewed. RN 1 stated Resident 8 had an order for Ativan. RN 1 stated Resident 8's IC was obtained telephonically. RN 1 stated Resident 8's IC was not dated when the IC was obtained. RN 1 stated Resident 8's IC should have complete information and should have a date to determine when the IC was taken/obtained. RN 1 stated an IC with incomplete information was not valid. b. During a review of Resident 74's FS, the FS indicated the facility admitted Resident 74 on 9/10/2022 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness characterized by disturbances in thought), and schizoaffective disorder. During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had severely impaired cognition. The MDS indicated Resident 74 was independent with eating. The MDS indicated Resident 74 required substantial/maximal assistance (helper did more than half the effort) with oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. During a review of Resident 74's OSR dated 5/13/2026, the OSR indicated Resident 74 had an order for Seroquel 25 mg tablet by mouth at bedtime for schizoaffective disorder. During a concurrent interview and record review on 6/17/2026 at 12:28 pm with Licensed Vocational Nurse 1 (LVN 1), Resident 74's OSR dated 5/13/2026 and IC were reviewed. LVN 1 stated Resident 74 had an order for Seroquel. LVN 1 stated Resident 74's IC did not indicate whether the IC was obtained by phone or in-person (physically present in the same location). LVN 1 stated the IC did not indicate the name of the person giving the consent for the use of Seroquel on Resident 74. LVN 1 stated the IC should be accurate and complete for the safety of the residents. During an interview on 6/18/2026 at 11:08 am with the Director of Nursing (DON), the DON stated all IC should have the name of the person giving the consent and all IC should be dated when the IC was obtained to ensure the risks and benefits of the medications or procedures were explained and understood by the resident or responsible party. During a review of the facility's Policy and Procedures (P&P) titled, Informed Consent, revised December 2024, the P&P indicated the purpose of the P&P was To ensure that residents and/or their representatives are fully informed of the benefits, risks, frequency/duration, and alternatives before initiating the administration of psychotherapeutic drugs or physical restraints. A licensed nurse will verify the informed consent information and sign it to confirm its accuracy and completeness.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent skin breakdown, promote wound healing and skin maintenance for two of four sampled residents (Residents 7 and 45) by failing to:a. Ensure staff trimmed the fingernails and provided a pressure-relieving barrier between the fingers, contracted thumb, and palm of the right hand for Resident 7 who was assessed as high risk for pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) development. This deficient practice resulted in Resident 7 developing skin indentations (depression or dent on the skins surface) and discoloration in the palm of Resident 7's hand and placed Resident 7 at risk for development of right-hand pressure ulcers. b. Ensure Resident 45's Low Air Loss (LAL, a specialized medical support surface designed to prevent and treat skin ulcers by combining alternating pressure with a steady low-volume airflow) was set on alternating pressure (a system of interconnected air cells that inflate and deflate in cycles to continuously shift support and relieve pressure over bony prominence) and not on static pressure mode.This deficient practice had the potential to result in worsening of wounds or development of new skin breakdown for Resident 45. Findings: a.During a review of Resident 7's Face Sheet (FS), the FS indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including myelin oligodendrocyte glycoprotein antibody disease (rare disease where the body's immune system attacks the protective nerve coverings in the brain and spinal cord), chronic respiratory failure (long term condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate carbon dioxide from the body), and muscle spasms (involuntary contractions of the muscles). During a review of Resident 7's untitled Care Plan (CP) initiated on 7/12/2024, the CP indicated Resident 7 was at risk for pressure injury and skin breakdown. The CP indicated a goal to minimize the risk of skin breakdown and pressure sores daily with interventions to provide pressure relieving devices as needed. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool) dated 5/11/2026, the MDS indicated Resident 7 had severely impaired cognitive skills (mental processes involved in gaining knowledge and comprehension) for daily decision making. The MDS indicated Resident 7 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) of both arms and both legs. The MDS indicated Resident 7 was dependent (helper does all the effort) on staff with hygiene, bathing, dressing, rolling to both sides, and bed to chair transfers and was at risk for pressure ulcer development. During a review of Resident 7's Braden Scale ( BS - pressure ulcer risk assessment tool) dated 5/11/2026, the BS indicated Resident 7 was at very high risk for pressure ulcer development due to very limited sensory perception (unresponsive to painful stimuli due to diminished level of consciousness or sedation or limited ability to feel pain over most of the body), occasionally moist skin, very limited mobility(inability to move), bedfast activity (confined to the bed), and concerns for friction (force that resists or slows down movement when two surfaces rub against each other) and shearing (tissue damage that occurs when skin stays in one place while the underlying bone or tissues shift causing tissues to stretch, tear or slide in opposite directions). During an observation and interview on 6/17/2026 at 8:58 am with Restorative Nursing Aide 1 (RNA 1) and Registered Nurse 2 (RN 2) during an RNA session in Resident 7's room, Resident 7 was lying in bed with the right arm straight and hyperextended (the extension of a body part beyond its normal limits) at the elbow, wrist bent downwards, and the hand in a fist. Resident 7 did not have a splint or towel roll (rolled up hand towel) in the right hand. RNA 1 assisted with passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 7's right arm and was unable to bend the elbow, straighten the wrist, or straighten the thumb which was bent inwards and positioned across the palm of the hand. RNA 1 stated Resident 7 resisted with range of motion (ROM, full movement potential of a joint) exercises to the right arm and RNA 1 could not straighten or pull Resident 7's thumb away from the palm of the hand. RNA 1 opened the fingers of Resident 7's right hand. A pink indentation of the skin was observed in the middle crease on the right side of Resident 7's palm of the right hand, located beneath the ring finger and fifth digit (pinky finger). The fingernails of all of Resident 7's fingers were long with jagged edges. RNA 1 stated Resident 7's fingernails were long and were digging into Resident 7's palm because staff did not place a towel roll in Resident 7's palm when the right-hand splint was removed. RNA 1 stated staff should always place a towel roll in Resident 7's hand when the hand was not in a splint, because Resident 7 consistently held Resident 7's right hand in a fist and cannot control its movement. RNA 1 stated Resident 7 did not have a towel roll or splint in the right hand upon arrival to Resident 7's room for RNA but should have to prevent problems like this. RN 2 entered Resident 7's room and examined Resident 7's right hand. RN 2 confirmed Resident 7 had a pink indentation of the skin in the middle crease on the right side of Resident 7's palm of the right hand, located beneath the ring finger and the fifth digit. RN 2 confirmed the fingernails of all of Resident 7's fingers were long with jagged edges and should have been trimmed but were not. RN 2 stated Resident 7's indentation and skin discoloration of the palm appeared to be caused by Resident 7's long fingernails digging into the palm of the right hand and a lack of a barrier in between the fingers and the palm of the hand. RN 2 stated Resident 7 was at high risk for developing skin breakdown and pressure ulcers due to need for total care, inability to control right-hand movements, constant positioning of the right hand in a fist, long fingernails, and hand contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).RN 2 stated staff were required to regularly trim Resident 7's fingernails and place a barrier, such as a towel roll or a right-hand splint, between Resident 7's fingers and the palm of Resident 7's right hand to prevent pressure ulcers, open wounds, and infections. During an interview on 6/17/2026 at 11:14 am with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated CNAs (in general) were instructed to always place a towel roll in Resident 7's right hand whenever Resident 7 was not wearing a right-hand splint because Resident 7's right hand was always positioned in a fist and the fingers dug into the palm of Resident 7's hand. During an interview on 6/18/2026 at 2:03 pm with the Director of Nursing (DON), the DON stated prolonged areas of pressure, lack of repositioning, and immobility put residents at risk for skin breakdown (tissue damage caused by friction, shear, moisture, or pressure) and pressure ulcers. The DON stated if a resident positioned their hand in a fist and had hand contractures, staff needed to trim the resident's fingernails weekly and always place a barrier, such as a splint or towel roll in the hand, to prevent skin breakdown, pressure ulcers, punctures in the skin, skin discoloration and infection. During a review of the facility's Policy and Procedure (P&P) titled, Prevention of Pressure Injuries, revised 3/2023, the P&P indicated staff were to review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The P&P indicated staff were to inspect the skin daily when performing or assisting with personal care or activities of daily living (ADLs) which included the inspection of pressure points and repositioning the resident as indicated on the care plan. The P&P indicated staff were to review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device, monitor regularly for comfort and signs of pressure-related injury, and to consult with current clinical practice guidelines for prevention measures associated with specific devices. During a review of the facility's P&P titled, Fingernails/Toenails, Care of, revised 3/2023, the P&P indicated trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. b. During a review of Resident 45's FS, the FS indicated Resident 45 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), osteoporosis (weak and brittle bones) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 45's untitled Care Plan (CP) dated 3/17/2025, the CP indicated Resident 45 had a LAL mattress for wound and skin management. The CP interventions included for the LAL mattress to be set according to the resident's weight, comfort, and manufacture setting and to monitor the air pressure setting and functionality of the mattress. During a review of Resident 45's Order Summary Report (OSR) dated 7/25/2025, the OSR indicated Resident 45 had an order for LAL mattress for wound care and management. During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45 had severely impaired cognition. The MDS indicated Resident 45 was dependent (helper did all the effort) with eating, oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. During a concurrent observation inside Resident 45's room and interview on 6/16/2026 at 9:45 am with Licensed Vocational Nurse 2 (LVN 2), Resident 45 was in bed, sleeping on a LAL mattress, set at 73 and in static pressure mode. LVN 2 stated Resident 45's weight was 73 pounds (lbs.) During an interview on 6/18/2026 at 10:33 am with Treatment Nurse 2 (TN 2), TN 2 stated LAL mattress should be on alternating pressure when the resident was sleeping to relieve pressure on bony prominence. TN 2 stated static pressure mode was firmer and used during turning or repositioning and transfer of the resident. During an interview on 6/18/2026 at 11:16 am with the Director of Nursing (DON), the DON stated LAL mattress should be on alternating pressure to distribute pressure equally for skin maintenance, wound healing and prevent wound decline. During a review of the facility's undated LAL Mattress Operation Manual (OM), the OM indicated, A firm surface will make it easier for the patient to transfer or reposition. Make use of the static mode function for this feature. During a review of the facility's Policy and Procedure (P&P) titled, Support Surface Guidelines, revised on September 2013, the P&P indicated, Redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed.

Based on observation, interview and record review, the facility failed to ensure three of seven sampled residents (Residents 7, 9, and 12) received appropriate services to prevent a decline or maintain joint (where two bones meet) range of motion (ROM, full movement potential in a joint) and mobility (ability to move) by failing to: 1. For Resident 7, provide Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) evaluation and treatment to assess proper fit and wear time for Resident 7's right-hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) after Resident 7's custom right hand splint was lost. 2a. For Resident 9, provide a Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) as ordered for active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) to both arms and both legs, five times a week, from 5/1/2026 to 6/17/2026. 2b. For Resident 9, objectively (unbiased, based on facts) measure ROM impairments of both of Resident 9's hands during the OT evaluation, dated 1/16/2026. 3. For Resident 12, provide passive ROM (PROM, movement at a given joint with full assistance from another person) exercises to both of Resident 12's wrists and ankles during the RNA session on 6/18/2026, in accordance with physician's orders. These deficient practices had the potential to cause injury, pain, and pressure injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence) due to ill-fitting and prolonged wear time of Resident 7's right-hand splint to Resident 7 and an overall decline in ROM, mobility, and activities of daily living (ADLs, basic activities such as eating, dressing, and toileting) for Residents 9 and 12.Findings:1. During a review of Resident 7's Face Sheet (FS-admission record), the FS indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to myelin oligodendrocyte glycoprotein antibody disease (rare disease where the body's immune system accidentally attacks the protective nerve coverings in the brain and spinal cord), chronic (long term) respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate carbon dioxide from the body), and muscle spasms (involuntary contractions of the muscles).During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 5/11/2026, the MDS indicated Resident 7 had severely impaired cognitive skills (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) for daily decision making. The MDS indicated Resident 7 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) of both arms and both legs. The MDS indicated Resident 7 required dependent assistance (helper does all the effort) with hygiene, bathing, dressing, rolling to both sides, and bed to chair transfers.During a review of Resident 7's Order Summary Report (OSR), the OSR indicated a physician's order, dated 4/10/2026, for RNA to don (apply) and doff (remove) resting hand splints (RHS, splint secured from the hand to the forearm to position the hand in a functional position with the thumb positioned away from the palm and the knuckles of the hand slightly bent) to both of Resident 7's hands, for four to six hours, seven times a week.During a concurrent observation and interview on 6/17/2026 at 8:58 am with Restorative Nursing Assistant (RNA) 1 in Resident 7's room, Resident 7's RNA session was observed. Resident 7 was lying in bed with the right arm straight and hyperextended (the extension of a body part beyond its normal limits) at the elbow, wrist bent downwards, and the hand in a fist. Resident 7's left arm was bent at the elbow and wrist, and the hand was positioned in a fist. RNA 1 assisted with PROM exercises to Resident 7's left shoulder, elbow, wrist, and hand and applied a splint to Resident 7's left hand. RNA 1 assisted with PROM exercises to Resident 7's right arm and was unable to bend the elbow, straighten the wrist, or straighten the thumb which was bent inwards and positioned across the palm of the hand. RNA 1 stated Resident 7 resisted with ROM exercises to the right arm and RNA 1 could not straighten or pull Resident 7's thumb away from the palm of the right hand. RNA 1 placed a resting hand splint on Resident 7's right hand with the thumb tucked in across the palm and secured the splint to the hand with a strap over the knuckles of the hand and in the webspace between the thumb and pointer finger. During a concurrent observation and interview on 6/17/2026 at 9:31 am with Occupational Therapist 1 (OT 1), OT 1 observed Resident 7 wearing the resting hand splint RNA 1 applied to Resident 7's right hand during the RNA session. OT 1 stated Resident 7's right-hand splint did not fit properly because Resident 7's right thumb was positioned underneath the hand and across the palm instead of away from the palm. OT 1 stated it was important that RNA positioned Resident 7's thumb away from the palm of the hand because it placed the thumb in a functional position and prevented the thumb from digging into the palm of the hand which could cause pressure injuries. OT 1 stated OT previously evaluated and recommended a custom hand splint for Resident 7's right hand which was different than the current splint because it held the thumb away from the palm of the hand. OT 1 stated Resident 7's custom right-hand splint was lost about a month ago and had no idea where the splint was. OT 1 stated OT 1 was unsure where RNA 1 got the current resting hand splint from but stated RNA 1 and RNAs (in general) should not be applying the splint without a licensed OT first assessing and determining the appropriate type of splint and wear time for the splint because it could cause skin breakdown (tissue damage caused by friction, shear, moisture, or pressure) and injury. During a concurrent interview and record review on 6/17/2026 at 9:57 am with the Director of Rehabilitation (DOR) and OT 1, Resident 7's medical record was reviewed. The DOR stated the purpose of splints was to improve or maintain a resident's ROM and prevent contractures (loss of motion of a joint associated with stiffness and joint deformity). The DOR stated a licensed OT or Physical Therapist (PT, profession aimed in restoration, maintenance, and promotion of optimal physical function) must assess a resident's need for splints and determine the splint wear tolerance and schedule by periodically assessing the splint for safety, comfort or need for modification. The DOR stated after the therapist assessed a resident for the correct type of splint and established the wear tolerance, the therapist transitioned the splinting plan of care to nursing and the RNA program. The DOR and OT 1 confirmed the custom right hand- splint was lost approximately one month ago and stated RNA replaced Resident 7's right-hand custom splint with one of the resting hand splints Resident 7 either arrived to the facility with or family brought into the facility without an OT assessment. The DOR stated Resident 7 did not receive any OT evaluation or treatment after Resident 7's custom right hand splint was lost and prior to continuing with the RNA program to apply a right-hand splint for four to six hours. The DOR stated a licensed OT should have assessed Resident 7 for a right-hand splint to determine the appropriate type of splint and establish a safe wear time schedule for a new splint when the custom right hand splint was lost but did not. The DOR stated if RNAs (in general) applied splints to residents without an OT or PT assessment, it could result in injury, deformity (condition where a part of the body does not have its normal or expected shape), and skin breakdown. During a review of the facility's Policy and Procedure (P&P) titled, Splinting, dated 5/4/2023, the P&P indicated once the patient has been screened for the appropriateness of splinting, the charge nurse or therapist will contact the physician and secure an evaluation order and treatment sessions for splint application, monitoring of wear schedule, splint modifications as needed and instruction of the nursing staff. The P&P indicated the therapist will order the splint, apply the splint, make the necessary fitting adjustments, proceed with a two-hour trial wearing period to check for pressure points and to assess the patient's tolerance to the splint, increase the angle of the splint and the wear time throughout the course of treatment, and in-service the nursing staff on the proper application, precautions, and wearing schedule once the therapist determines the splints has reached the maximum benefit to the resident. 2a. During a review of Resident 9's FS, the FS indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including but not limited to Guillain-Barre Syndrome (condition where the immune system mistakenly attacks the body's own nerves), quadriplegia (weakness or paralysis to all four extremities), and acute (sudden) respiratory failure.During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 was cognitively intact. The MDS indicated Resident 9 had functional limitations in ROM of both arms. The MDS indicated Resident 9 required dependent assistance with eating, hygiene, bathing, dressing, and bed to chair transfers.During a review of Resident 9's Order Summary Report (OSR), the OSR indicated a physician's order, dated 4/24/2026, for RNA to provide active assistive ROM exercises to both of Resident 9's arms and legs, five times a week.During a review of Resident 9's RNA Medication Administration Record (RNA MAR, daily record of RNA services provided for each month) for May 2026 and June 2026, the RNA MAR indicated for the RNA to provide AAROM exercises to both of Resident 9's arms and legs, five times a week. The squares on the RNA MAR flowsheet were blank on the following days: 5/4/2026, 5/13/2026, 5/23/2026, 5/29/2026, 6/5/2026, 6/6/2026, 6/10/2026, 6/13/2026, and 6/15/2026.During an observation and interview on 6/18/2026 at 10:09 am with Resident 9 in Resident 9's room, Resident 9 was observed sitting upright in bed with the head of the bed elevated. Resident 9 bent the fingers of both hands minimally at the knuckle joints and could not make fists with both hands. Resident 9 stated Resident 9 was unable to move the left shoulder and partially bent and straightened the left elbow and wrist. Resident 9 stated Resident 9's legs felt very stiff and minimally moved both hips, knees, and ankles. Resident 9 stated staff did not come enough to assist with ROM exercises and needed more therapy or staff to help move Resident 9's arms and legs because they felt very stiff. During a concurrent interview and record review on 6/18/2026 at 12:05 pm with the Assistant Director of Nursing (ADON), Resident 9's RNA physician's orders, dated 4/24/2026, and RNA MAR records for May 2026 and June 2026 were reviewed. The ADON stated the RNA program helps residents in the facility maintain and regain their mobility and strength to prevent contractures and functional decline. The ADON confirmed Residents 9 had physician orders for RNA to provide AAROM to both of Resident 9's arms and legs, five times a week, for the months of May 2026 and June 2026. The ADON stated a blank square on the RNA MAR indicated the resident was not seen for RNA treatment that day. The ADON confirmed that Resident 9 did not receive RNA services as ordered for four days in May 2026 and for five days in June 2026. The DSD stated it was important for RNA to provide services as ordered because missed treatments could place residents at risk for contracture development and functional decline.During an interview on 6/18/2026 at 2:03 pm with the Director of Nursing (DON), the DON stated the purpose of the RNA program was to maintain a resident's current level of function after discharge from skilled therapy services (services that require specialized training and experience of a licensed therapist or therapy assistant) and to prevent contractures and any functional declines. The DON stated that missed RNA treatments could potentially cause a resident to experience a decline in overall function, mobility, and ADLs.2b. During a review of Resident 9's Occupational Therapy Evaluation and Plan of Treatment (OT Eval), dated 1/16/2026, the OT Eval indicated Resident 9's ROM of both hands, thumbs, index fingers (pointer fingers), middle fingers, ring fingers, and little fingers were impaired.During a concurrent interview and record review on 6/18/2026 at 11:06 am with the DOR, Resident 9's OT Eval, dated 1/16/2026 was reviewed. The DOR stated the facility monitored for changes in joint ROM by staff report and Joint Mobility Assessments (JMA, a brief assessment of a resident's ROM in both arms and both legs) conducted by the Rehab upon admission, re-admission, annually, and upon a change of condition. The DOR stated PTs and OTs used goniometers (instrument used for the precise measurement of angles) to measure joint mobility to objectively determine a resident's baseline ROM and detect changes in joint ROM. The DOR stated Resident 9's ROM of all the fingers of both hands should have been measured with a goniometer since they were impaired but were not. The DOR stated that OT did not establish Resident 9's baseline ROM for both hands. The DOR stated if staff did not objectively measure ROM impairments on the OT and PT evaluations, staff could not effectively monitor or detect changes in a resident's ROM to prevent decline and contractures. During an interview on 6/18/2026 at 2:03 pm with the DON, the DON stated the facility monitored for changes in ROM by staff report, weekly RNA meetings, and JMAs done annually by Rehab. The DON stated it was important for staff to objectively measure ROM during ROM evaluations to ensure the facility had an accurate assessment of a resident's joints since it affected their ability to effectively monitor changes and provide the appropriate services to address any declines.3. During a review of Resident 12's FS, the FS indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to acute respiratory failure, non-traumatic intracranial hemorrhage (spontaneous bleeding inside the skull that occurs without any injury, fall, or surgery), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 12 had functional limitations in ROM of both arms and both legs. The MDS indicated Resident 12 required dependent assistance with hygiene, bathing, dressing, and rolling to both sides.During a review of Resident 12's Order Summary Report (OSR), the OSR indicated a physician's order, dated 3/11/2026, for RNA to provide PROM exercises to both of Resident 12's arms and legs, seven times a week. The OSR indicated a physician's order, dated 4/23/2026, for RNA to apply hand splints, knee extension splints, and ankle foot orthoses (AFO, an orthotic device designed to correct or address problems with the ankle and foot) to both sides of the body for four to six hours a day, seven days a week. During an observation on 6/18/2026 at 10:25 am in Resident 12's room, Resident 12's RNA session was observed. Resident 12 was lying in bed with both legs bent at the hips and knees and rotated to the right side of the body with both feet pointing downwards. RNA assisted with PROM to both of Resident 12's shoulders, elbows, and fingers on both hands and applied splints to both hands. RNA 1 did not provide PROM exercises to either of Resident 12's wrists. RNA 1 provided PROM exercises to both of Resident 12's hips and knees and applied splints to both knees and feet. RNA 1 did not provide PROM to either of Resident 12's ankles. During a concurrent interview and record review on 6/18/2026 at 10:54 am with RNA 1, Resident 12's RNA orders, dated 3/11/2026 and 4/23/2026, were reviewed. RNA 1 stated the RNA order, dated 3/11/2026, indicated for RNA to provide PROM to both arms and both legs which meant that RNA 1 must assist with PROM exercises to Resident 12's entire arm-including the shoulder, elbow, wrist, and hand-and the entire leg-including the hips, knees, and ankles. RNA 1 confirmed RNA 1 did not assist with PROM exercises to both of Resident 12's wrists because RNA 1 forgot. RNA 1 confirmed RNA 1 did not provide PROM to both of Resident 12's ankles because they felt too stiff. RNA 1 stated ROM exercises should be done to all joints included in the splints before splint application because it helped loosen the joints. RNA 1 stated RNA 1 should have assisted with PROM exercises as ordered to both wrists and both ankles and before applying splints to both of Resident 12's hands and feet but did not. RNA 1 stated Resident 12 could have a decline in ROM if RNA exercises were not provided as ordered.During an interview on 6/18/2026 at 11:06 am with the DOR, the DOR stated the purpose of the RNA program was to maintain a resident's current level of function after discharge from skilled therapy services and to prevent contractures and any functional declines. The DOR stated Rehab determined the types of exercises RNAs were to perform when creating an RNA program. The DOR stated if an RNA order was written for RNA to provide ROM exercises to both arms, it was expected for the RNA to provide ROM to the entire arm, which included the shoulders, elbows, wrists, and hands. The DOR stated if an RNA order was written for RNA to provide ROM exercises to both legs, it was expected for the RNA to provide ROM to the entire leg, which included the hips, knees, and ankles. The DOR stated it was important for the RNA to provide ROM exercises to all joints prior to splint application to prepare the joints for splinting and to ensure the splint was fitting properly. The DOR stated if the RNA did not provide RNA services as ordered, it could potentially result in a decline in ROM and ADLs.During an interview on 6/18/2026 at 2:03 pm with the DON, the DON stated it was important for RNA to provide exercises as ordered to ensure the residents in the facility maintained their level of function and to prevent potential declines in mobility, ADLs, and contracture development.During a review of the facility's P&P titled Resident Mobility and ROM, revised July 2017, the P&P indicated resident would not experience an avoidable reduction in ROM and residents with limited ROM would receive treatment and services to increase and/or prevent a further decrease in ROM. The P&P indicated the care plan would include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. The P&P indicated the care plan would include the type, frequency, and duration of interventions as well as measurable goals and objectives. During a review of the facility's P&P, titled Restorative Nursing Services, revised July 2017, the P&P indicated the residents would receive restorative nursing care as needed to help promote optimal safety and independence

Based on observation, interview, and record review, the facility failed to ensure safe food storage practices in one of two residents' refrigerators (Refrigerator 1), by failing to:a. Discard a plate containing three (3) meat tacos with no expiration date.b. Discard a container with pizza that had no expiration date.c. Discard a container of watermelon dated 6/11/26.d. Discard a cup containing mango slices with no expiration date. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.During an observation and interview with the Dietary Supervisor (DS) on 6/16/26 at 8:44 AM, the DS stated the residents' refrigerator was located inside the activity room on the 2nd floor. The DS stated the nurses collected the food brought in for the residents by family members and placed it inside the residents' refrigerator. The DS stated there was no resident food brought in by the family members that was kept in the kitchen area. The DS stated inside the residents' refrigerator, there were a plate containing three meat tacos with no expiration date, a container with pizza that had no expiration date, a container of watermelon dated 6/11/26, and a cup containing mango slices with no expiration date. The DS stated the food should be labeled including the resident's name, room number and expiration date or date the food that were placed inside the refrigerator. The DS stated expired or non-labeled foods should be discarded. The DS stated nursing staff were responsible for checking and cleaning the residents' refrigerator. During an interview with the Assistant Director of Nursing (ADON) on 6/17/26 9:39 AM, the ADON stated the residents' refrigerator should be cleaned daily by housekeeping staff. The ADON also stated that the License Nurses would check the refrigerator's temperature and the food items that were placed inside of the refrigerator for expiration date. The ADON stated that if a food item had an open date, the expiration date for that food item would be 3 days after the open date. The ADON stated that food items needed to be removed from the residents' refrigerator within 72 hours of the open date and there should not be any expired food inside the residents' refrigerator. The ADON stated that if a resident ate expired food, it would make the resident get sick from food born illness and even cause hospitalization of the residents. During an interview with the Director of Nursing (DON) on 6/18/26 at 12:07 PM, the DON stated there was another residents' refrigerator located on the 3rd floor. The DON stated there was a sign posted outside of the residents' refrigerator indicating for staff to name and label the food stored inside of the residents' refrigerator. The DON stated all food items that were placed inside the residents' refrigerator needed to be labeled with a received date. The DON stated expired food should not be stored inside the residents' refrigerator to prevent getting the residents sick when they eat expired food. During a record review of the facilities undated Policies and Procedures (P&P) titled, Food From Outside Sources, the P&P indicated, Food brought to the facility by visitors and family members is permitted. The P&P indicated facility staff will assist residents with food brought in to ensure safe and sanitary storage of outside food. All outside food will be properly covered, dated, and labeled. The nursing staff will discard perishable foods on or before the use by date. Leftover food or unused portions of packaged foods should be discarded. No food will be stored beyond 72 hours from received date. Food items that are expired or beyond the best buy date are discarded.

Based on interview and record review, the facility failed to follow its Antibiotic stewardship program (a coordinated healthcare initiative designed to promote the most appropriate, safe, and effective use of antibiotics [medication that kills or stops bacteria [microscopic single-celled organisms, some can cause illness] from reproducing]) by failing to prescribe antibiotics appropriately for three (3) of five (5) sampled residents (Residents 2, 15, and 77). These deficient practices had the potential to result in unresolved infections (the invasion and growth of germs in the body) and physical declines due to the inappropriate use of antibiotics for Residents 2, 15, and 77. Findings: a. During a review of Resident 2's Face Sheet (FS, admission record), the FS indicated the facility admitted Resident 2 on 10/3/2025 and readmitted the resident on 5/30/2026 with diagnoses that included Extended Spectrum Beta Lactamase (ESBL -a group of enzymes [specialized biological molecule] produced by certain bacteria that make them resistant to antibiotics) resistance and urinary tract infection (UTI - an infection in the bladder/urinary tract). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 6/3/2026, the MDS indicated Resident 2 had severely impaired cognitive (the ability to think and process information) skills for daily decision making. The MDS indicated Resident 2 was dependent on activities of daily living. During a review of Resident 2's Order Summary Report (OSR), dated active as of 5/30/2026, the OSR indicated a physician order for Meropenem (a powerful antibiotic) one (1) gram (g, metric unit of mass) intravenously (IV - administering medication or fluids through a needle or catheter directly into the bloodstream) every eight (8) hours for UTI until 6/6/2026. During a review of Resident 2's Medication Administration Records (MAR), dated May and June 2026, the MARs indicated Resident 2 was administered Meropenem from 5/31/2026 to 6/6/2026. During a concurrent interview and record review on 6/18/2026 at 9:28 AM with the Assistant Director of Nursing (ADON), Resident 2's Surveillance Data Collection Form (SDCF) UTI with Indwelling [urinary] Catheter [a flexible tube that is inserted into the urinary bladder and remains in place for continuous drainage of urine]) was reviewed. The SDCF was completed and signed on 6/17/2026. The SDCF indicated meropenem IV 1 g antibiotic treatment was started on 5/30/2026 for Resident 2. The SDCF indicated for residents (in general) with indwelling catheters, both criteria 1 and criteria 2 must be present. The SDCF indicated Criteria 1 was checked and Criteria 2 (urinary catheter specimen culture with a least 10 colony forming unit [cfu] / milliliter [ml] of any organism) was left blank (unchecked). The SDCF indicated Resident 2 was hospitalized and readmitted on [DATE] with an order for meropenem for treatment of a UTI. The SDCF indicated there was no urine culture (a test that checks for bacteria in the urine) results were available from the hospital. During an interview on 6/18/2026 at 9:30 AM, the ADON stated the admitting nurse or the IPN should coordinate with the hospital immediately (upon readmission or on the next day after readmission) to obtain the resident's urine culture results. The ADON stated the urine culture and sensitivity results were used to determine whether the prescribed antibiotics were appropriate for the bacteria causing the UTI. The ADON stated the ADON completed and signed the SDCF on 6/17/2026 after Resident 2 had already completed the antibiotic (meropenem). The ADON stated the SDCFs review should have been completed 24 hours post order date (5/30/2026). During a review of Resident 2's Progress Notes (PN), dated 5/30/2026 to 6/7/2026, the PN did not have documented evidence that the PN reflected communication with the general acute care hospital (GACH) regarding a follow-up on Resident 2's urine culture results. b. During a review of Resident 15's FS, the FS indicated the facility admitted Resident 15 on 2/28/2026, with diagnoses that included UTI and ESBL resistance. During a review of Resident 15's MDS dated [DATE], the MDS indicated Resident 15 had intact cognitive skills for daily decision making. Resident 15 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) for toileting hygiene, rolling left and right, sit to lying and lying to sitting on side of the bed. During a review of Resident 15's OSR dated 5/1/2026 to 5/31/2026, the OSR indicated an order for Ciprofloxacin (antibiotics) 500 mg, 1 tablet by mouth two times a day for UTI symptoms for seven (7) days, with an order date of 5/7/2026. During a review of Resident 15's MAR, the MAR indicated Resident 15 received Ciprofloxacin (antibiotics) 500 mg, 1 tablet two times a day from 5/7/2026 to 5/14/2026. During a review of Resident 15's urine culture results dated 5/6/2026, the result indicated the culture was not processed and the culture did not meet the National Healthcare Safety Network (NHSN, the most widely used system for tracking healthcare associated infections [HAIs], allowing healthcare facilities, states, and the Centers for Disease Control and Prevention to collect and analyze data to identify problem areas, measure prevention efforts, and ultimately work toward eliminating HAIs) UTI criteria. During a concurrent interview with the ADON and review of Resident 15's SDCF for UTI without an Indwelling Catheter on 6/18/2026 at 10:55 AM, the ADON stated Resident 15 had an antibiotic order for Ciprofloxacin tablet 500 milligrams (mg, units of measurement). The SDCF indicated both Criteria 1 and Criteria 2 must be present. Criteria 1 was checked while Criteria 2 was blank. The SDCF indicated culture does not meet criteria for UTI surveillance due to mixed flora growth. ADON stated that the ADON completed and signed the SDCF on 6/17/2026, after Resident 15 had already completed the antibiotics. During a review of Resident 15's PN, the PN did not have documented evidence that reflected communication with the physician regarding the results of the urine culture. During an interview on 6/18/2026 at 10:55 AM, ADON stated Resident 15's SDCF should have been completed prior to administration of antibiotics. The ADON stated the antibiotics review was not timely. c. During a review of Resident 77's FS, the FS indicated the facility admitted Resident 77 on 5/19/2025, with diagnoses that included dementia (a progressive state of decline in mental abilities) and carrier (the bacteria lives on or in their body) or suspected carrier of methicillin resistant staphylococcus aureus (MRSA, a bacteria that is resistant to certain antibiotics). During a review of Resident 77's MDS, dated [DATE], the MDS indicated Resident 77's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 77 had impairment on both upper extremities (shoulder, elbow, wrist and hand). During a review of Resident 77's Physician Orders dated 4/1/2026- 4/30/2026, the Physician's Order indicated to collect urine for urinalysis (UA - a test that checks the urine for blood cells, proteins, and other substances) and culture and sensitivity (urine C&S - a test to identify and quantify the microorganisms present in a urine sample and determine their sensitivity to certain antibiotics). During a concurrent review of Resident 77's laboratory results dated [DATE], the Laboratory Results indicated a result for urinalysis but did not have results for urinary culture. During a review of Resident 77's Physician's Order dated 4/20/2026, the Physician's Order indicated to give Macrobid 100 mg 1 capsule by mouth two times a day for UTI for 7 days. During a review of Resident 77's SDCF for UTI without an indwelling catheter, the SDC indicated Macrobid (type of antibiotic) 100 mg as the antibiotic treatment to start on 4/20/2026. The SDCF indicated Criteria 1 and Criteria 2 (microbiologic sub criteria) must be present. The SDCF indicated Criteria 1 was checked while Criteria 2 was left blank. The SDCF was completed and signed on 5/12/2026. During a review of Resident 77's PN, dated 4/19/2026 to 4/30/2026, the PN did not have documented evidence reflecting any communication to the physician regarding absence of urine culture. During a review of Resident 77's MAR, dated 4/1/2026 to 4/30/2026, the MAR indicated Macrobid was administered on 4/20/2026 to 4/27/2026. During an interview on 6/18/2026 at 10:36 AM, the ADON stated that the ADON could not find Resident 77's urine C&S report or a notification to the physician that there was no urine C&S. ADON also stated the SDCF was completed and signed by the IPN on 5/12/2026, which was after Resident 77 completed the antibiotics. During a review of the facility's Policy and Procedure (P&P) titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, dated December 2016. The P&P indicated all clinical infections treated with antibiotics will undergo review by the infection preventionist, or designee. The IP or designee will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Therapy may require further review and possible changes if: The organism is not susceptible to antibiotics chosen; The organism is susceptible to narrower spectrum antibiotics Therapy was ordered for prolonged surgical prophylaxis; or Therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. At the conclusion of the review, the provider will be notified of the review findings.

Based on observation, interview and record review, the facility failed to ensure one of one sampled resident's (Resident 3) fluid intake was monitored as ordered and in accordance with facility's policy and procedure (P&P) titled Care of Resident Receiving Renal Dialysis. This failure had the potential for complications related to electrolyte (minerals in the body) imbalance for Resident 3.Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility initially admitted Resident 3 on 2/23/2025 and readmitted on [DATE] with diagnoses that included chronic kidney disease (CKD, a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood) and retention of urine. During a review of Resident 3's untitled Care Plan (CP) dated 3/27/2026, the CP indicated Resident 3 had acute kidney failure. The care plan interventions indicated for nursing staff to encourage and maintain adequate hydration according to provider (physician) orders while avoiding excess fluid. During a review of Resident 3's Order Summary Report (OSR) dated 5/11/2026, the OSR indicated Resident 3 had an order for fluid restriction (FR, limits the amount of fluids a person consumes each day) of 1,200 cubic centimeters/day (cc/day, measure of volume per day) , allotted for dietary to provide 240 cc for breakfast, 360 cc for lunch, 360 cc for dinner, and for nursing to provide 100 cc for 7 am to 3 pm shift, 100 cc for 3 pm to 11 pm shift and 40 cc for 11 pm to 7 am shift. During a review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/27/2026, the MDS indicated Resident 3 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 3 was dependent (helper does all of the effort) from staff with eating, oral hygiene, toileting hygiene, shower, upper/lower body dressing, putting on/off footwear and personal hygiene. During an observation on 6/16/2026 at 9:55 am inside Resident 3's room, Resident 3 was asleep lying in bed. During a concurrent interview and record review of Resident 3's medical record (PointClickCare - PCC, a cloud-based software) on 6/16/2026 at 2:51 pm with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated Resident 3 was on fluid restriction of 1,200 ml/day. LVN 3 stated LVN 3 did not monitor Resident 3's fluid intake since 5/11/2026. LVN 3 stated there was no clinical documentation that Resident 3's fluid intake was documented or monitored. LVN 3 stated Resident 3's fluid intake should have been monitored daily by licensed nurses to prevent water retention because Resident 3 was on hemodialysis (procedure to remove wastes or toxins from the blood and adjust fluid and electrolyte imbalances). During a concurrent interview and record review of Resident 3's PCC on 6/17/2026 at 11:48 am with the facility's Director of Nursing (DON), the DON stated Resident 3 was on fluid restriction of 1,200 cc/day. The DON stated Resident 3's fluid intake needed to be documented in the Medication Administration Record (MAR) every shift by licensed nurses. The DON stated there was no other clinical documentation that Resident 3's fluid intake was documented and monitored by licensed nurses since 5/11/2026. The DON stated Resident 3's fluid intake needed to be monitored to determine if Resident 3 reached the restricted amount of 1,200 ml/day as ordered by the physician to prevent fluid overload, respiratory distress, shortness of breath (SOB) and edema (swelling caused by fluid retention). During a review of the facility's undated P&P titled, Care of Resident Receiving Renal Dialysis, the P&P indicated fluid restrictions will be followed per physician's order for specific fluid allowed in 24 hours. Intake and output were measured and recorded each shift if ordered.

Based on observation, interview, and record review, the facility staff failed to elevate the resident's head of the bed (HOB) while receiving feeding (formula) through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) in accordance with the resident's care plan and physician's order for one of five sampled residents (Resident 76). This deficient practice had the potential to result in aspiration (inhalation of foreign materials) and pneumonia (a lung infection) for Resident 76. Findings: During a review of Resident 76's admission Record (AR), the AR indicated the facility admitted Resident 76 on 7/11/2025 with diagnoses including encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support), dysphagia (difficulty in swallowing) and muscle weakness. During a review of Resident 76's Order Summary Report (OSR) dated 7/11/2025, the OSR indicated for staff to elevate Resident 76's head of bed (HOB) at 30 to 45 degrees at all times during GT feeding every shift for aspiration precaution. During a review of Resident 76's untitled Care Plan (CP) revised 2/27/2026, the CP indicated Resident 76 was at risk for aspiration and dehydration, related to dysphagia. The care plan interventions indicated for nursing staff to elevate Resident 76's head of bed and assess for shortness of breath, fever, congestion and other symptoms of aspiration and notify as indicated. During a review of Resident 76's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/26/2026, the MDS indicated Resident 76 had severely impaired cognition (ability to understand) for daily decision making. The MDS indicated Resident 76 was dependent (helper did all the effort) on staff for oral hygiene, toileting, shower, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 76's OSR dated 5/31/2026, the OSR indicated Resident 76 had an order for continuous GT feeding of Jevity 1.5 (formula) at 40 milliliter (ml, unit of measurement) per hour (hr.) for 20 hours via pump; Turn on at 2 pm, turn off 10 am or until the dose was met. During an observation on 6/16/2026 at 9:18 am inside Resident 76's room together with Registered Nurse 1 (RN 1), Resident 76 was lying flat in bed, in supine position and receiving GT feeding formula running at 40 ml/hr. During a concurrent observation and interview on 6/16/2026 at 9:21 am, together with RN 1, Resident 76 was awake, lying in bed, in supine position and with ongoing GT feeding formula. RN 1 stated, Resident 76's HOB should have been elevated at 35 to 45 degrees while receiving GT feeding to prevent aspiration. During an interview on 6/17/2026, at 11:52 pm, with the Director of Nursing (DON), the DON stated Resident 76 should not be flat in bed while on GT feeding. The DON stated Resident 76's HOB needed to be elevated at 35 to 45 degrees while receiving GT feeding to prevent aspiration. During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precaution, revised 11/2028, the P&P indicated, Elevate the head of the bed (HOB) at least 30 degrees during tube feeding and at least l hour after feeding. If elevating the HOB is medically contraindicated, use the reverse Trendelenburg (lies flat on back, but the entire bed or table is tilted so their head is higher than the feet) position.

Based on observation, interview, and record review, the facility staff failed to ensure one of three sampled residents (Resident 47) received two liters of oxygen per minute continuously through nasal cannula according to the physician's order. This deficient practice had the potential to result in respiratory complications for Resident 47 associated with oxygen therapy. Findings: During a review of Resident 47's admission Record (AR), the AR indicated the facility admitted Resident 47 on 4/12/2024 and readmitted on [DATE] with diagnoses that included acute and chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (deprived of adequate oxygen supply) and hypercapnia (high levels of carbon dioxide [waste product that the body gets rid of ] in the blood) and dependence on supplemental oxygen. During a review of Resident 47's untitled Care Plan (CP) dated 5/5/2026, the CP indicated Resident 47 was receiving oxygen therapy due to respiratory failure. The CP interventions indicated for nursing staff to check the rate of oxygen flow every shift and provide oxygen as ordered. During a review of Resident 47's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/14/2026, the MDS indicated Resident 47 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 47 required maximum assistance (helper does more than half the effort) from staff for toileting hygiene and lower body dressing. The MDS indicated Resident 47 required moderate assistance (helper does less than half the effort) from staff for oral hygiene. During a review of Resident 47's Order Summary Report (OSR) dated 5/22/2026, the OSR indicated for licensed staff to administer oxygen at two (2) liters per minute (L/min) via nasal cannula to Resident 47, every shift. During a concurrent observation and interview on 6/16/2026 at 9:42 am with Registered Nurse 1 (RN 1) inside Resident 47's room, Resident 47 was asleep, lying in bed with ongoing oxygen at 3.5 L/min via nasal cannula. During an interview with the Assistant Director of Nursing (ADON) on 6/17/2026 at 11:54 am and concurrent record review of Resident 47's medical records (PointClickCare - PCC, a cloud-based software), the ADON stated Resident 47 had an order of continuous 2 LPM of oxygen via nasal cannula. The ADON stated Resident 47 should be on continuous oxygen at 2 LPM via nasal cannula at all times as ordered by the physician to prevent respiratory distress. During an interview on 6/17/2026 at 11:58 am with the Director of Nursing (DON), the DON stated Resident 47 should have been on oxygen at 2 L/min via nasal cannula as ordered to prevent respiratory distress and complications. During a review of the facility's P&P titled, Oxygen Administration, revised 10/2010, the P&P indicated Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Assistant 1 (RNA 1) (RNA, a Certified Nursing Assistant who is trained to assist residents with restorative care such as exercises, walking, and restorative equipment) was competent in providing RNA services to one of seven sampled residents (Resident 7) for splinting (applying and/or removing splint(s) [device used to immobilize a body part]) when RNA 1 did not apply Resident 7's custom right-hand splint as ordered by the physician. This deficient practice had the potential to cause Resident 7 and other residents receiving RNA services in the facility to experience pain, injury, and skin breakdown (tissue damage caused by friction, shear, moisture, or pressure). During a review of Resident 7's Face Sheet (FS, document that contains a patient's personal and contact information, diagnoses, and medical history), the FS indicated the facility initially admitted Resident 7 to the facility on 7/11/2024 and readmitted Resident 7 on 3/12/2026 with diagnoses which included myelin oligodendrocyte glycoprotein antibody disease (rare disease where the body's immune system accidentally attacks the protective nerve coverings in the brain and spinal cord), chronic respiratory failure (long term condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate carbon dioxide from the body), and muscle spasms (involuntary contractions of the muscles).During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 5/11/2026, the MDS indicated Resident 7 had severely impaired cognitive skills (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) for daily decision making. The MDS indicated Resident 7 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) of both arms and both legs. The MDS indicated Resident 7 required dependent assistance (helper does all the effort) from staff with hygiene, bathing, dressing, rolling to both sides, and bed to chair transfers. During a review of Resident 7's Order Summary Report (OSR), the OSR indicated a physician's order, dated 4/10/2026, for RNA to don (apply) and doff (remove) resting hand splints (RHS, splint secured from the hand to the forearm to position the hand in a functional position with the thumb positioned away from the palm and the knuckles of the hand slightly bent) to Resident 7's both hands, for four to six hours, seven times a week.During a concurrent observation and interview on 6/16/2026 at 8:58 am with RNA 1 in Resident 7's room, Resident 7's RNA session was observed. Resident 7 was lying in bed with the right arm straight and hyperextended (the extension of a body part beyond its normal limits) at the elbow, wrist bent downwards, and the hand in a fist. Resident 7's left arm was bent at the elbow and wrist, and the hand was positioned in a fist. RNA 1 assisted with Passive Range of Motion (PROM, moving a joint by external force such as a therapist, caregiver, or device, without muscle effort from the resident) exercises to Resident 7's left shoulder, elbow, wrist, and hand and applied a splint to Resident 7's left hand. RNA 1 assisted with PROM exercises to Resident 7's right arm and was unable to bend the elbow, straighten the wrist, or straighten the thumb which was bent inwards and positioned across the palm of the hand. RNA 1 stated Resident 7 resisted with PROM exercises to the right arm and RNA 1 could not straighten or pull Resident 7's thumb away from the palm of the hand. RNA 1 placed a resting hand splint on Resident 7's hand with the thumb tucked in across the palm and secured the splint to the hand with a strap over the knuckles of the hand and in the webspace between the thumb and pointer finger. RNA 1 stated Resident 7 used to have a different splint for the right hand, but it was lost about a month ago. RNA 1 stated RNA found the current right-hand splint at the bedside and applied the splint to Resident 7's right hand because the RNA order indicated to apply splints to Resident 7's both hands. RNA 1 stated the previous right-hand splint, which was lost, fit Resident 7's right hand much better because it separated the fingers of the hand and brought the thumb away from the palm of the hand. During a concurrent observation and interview on 6/17/2026 at 9:31 am with Occupational Therapist 1 (OT 1) (OT- a healthcare professional who helps individuals improve their ability to perform everyday activities), OT 1 observed Resident 7 wearing the resting hand splint RNA 1 applied to Resident 7's right hand during the RNA session. OT 1 stated Resident 7's right-hand splint did not fit properly because Resident 7's right thumb was positioned underneath the hand and across the palm instead of away from the palm. OT 1 stated it was important that RNA positioned Resident 7's thumb away from the palm of the hand because it placed the thumb in a functional position and prevented the thumb from digging into the palm of the hand which could cause pressure injuries. OT 1 stated OT previously evaluated and recommended a custom hand splint for Resident 7's right hand which was appropriate and different than the current splint because it held the thumb away from the palm of the hand. OT 1 stated Resident 7's custom right-hand splint was lost about a month ago and had no idea where the splint was. OT 1 stated OT 1 was unsure where RNA 1 got the current resting hand splint from. OT 1 stated RNA should not be applying a splint on a resident without a licensed OT first assessing and determining the appropriate type of splint and wear time (amount of time the resident will have the splint on) for the splint because it could cause skin breakdown (tissue damage caused by friction, shear, moisture, or pressure) and injury. During a concurrent interview and record review on 6/17/2026 at 9:57 am with the Director of Rehabilitation (DOR) and OT 1, the DOR stated the purpose of splints was to improve or maintain a resident's ROM and prevent contractures (loss of motion of a joint associated with stiffness and joint deformity). The DOR stated a licensed OT or Physical Therapist (PT, profession aimed in restoration, maintenance, and promotion of optimal physical function) must assess a resident's need for splints and determine the splint wear tolerance and schedule by periodically assessing the splint for safety, comfort or need for modification. The DOR stated that after the therapist assessed a resident for the correct type of splint and established the wear tolerance, the therapist transitioned the splinting plan of care to nursing and the RNA program. OT 1 stated OT evaluated Resident 7 and recommended and issued a custom right-hand splint to ensure Resident 7's right thumb was supported and did not dig into the palm of the hand. The DOR and OT 1 confirmed Resident 7's custom right hand-splint was lost approximately one month ago and stated RNA replaced Resident 7's right-hand custom splint with one of the resting hand splints Resident 7 either arrived in the facility with or family brought into the facility, without an OT assessment. The DOR stated RNA should not have applied any other splint other than the custom right-hand splint which was issued to Resident 7 without OT first evaluating Resident 7 to determine if the splint was appropriate and establishing a safe wear time because RNAs were not qualified to do so. The DOR stated if RNAs applied splints to residents without an OT or PT assessment, it could result in injury, deformity (condition where a part of the body does not have its normal or expected shape), and skin breakdown (tissue damage caused by friction, shear, moisture, or pressure) leading to pressure injuries. During an interview on 6/18/2026 at 2:03 pm with the Director of Nursing (DON), the DON stated the Rehabilitation Department (Rehab) was responsible for splint assessments, determining the correct type of splint to issue, and establishing the splint wear time for all residents in the facility. The DON stated Rehab must formally assess a resident for splints prior to issuing splints to the residents and transitioning the splints to the RNA program. The DON stated the RNA treatment plan was determined by the licensed therapists and implemented by the RNAs as prescribed on the RNA order. The DON stated RNA must follow the RNA orders as written and were not qualified to modify the RNA program. The DON stated if a resident's recommended and prescribed splint was lost; the RNA must notify Rehab who in turn would reassess the resident for the appropriate type of splint and wear time. The DON stated RNAs lack the required training and expertise to apply splints to residents without a formal Rehab assessment. The DON stated if RNAs applied splints without following orders or without proper assessment, it could result in resident injury, ineffective treatment, pain, and decline in the resident's ROM and function. During a review of the facility's Policy and Procedure (P&P) titled, Competency Assessments, dated May 2023, the P&P indicated each employee must demonstrate competency requirement related to skills, technique, and training necessary to providing nursing and related care and services for all residents in accordance with resident care plans.During a review of the facility's undated Policy and Procedure (P&P) titled, Splinting, the P&P indicated once the patient has been screened for the appropriateness of splinting, the charge nurse or therapist will contact the physician and secure an evaluation order and treatment sessions for splint application, monitoring of wear schedule, splint modifications as needed and instruction of the nursing staff. The P&P indicated the therapist will order the splint, apply the splint, make the necessary fitting adjustments, proceed with a two-hour trial wearing period to check for pressure points and to assess the patient's tolerance to the splint, increase the angle of the splint and the wear time throughout the course of treatment, and in-service the nursing staff on the proper application, precautions, and wearing schedule once the therapist determines the splints has reached the maximum benefit to the resident.

Based on observation, interview, and record review, the facility failed to ensure call light was within reach and appropriate to the resident's physical ability for one of three sampled residents (Resident 7).This failure had the potential for Resident 7 not to receive necessary care or receive delayed services to meet Resident 7's needs.During a review of Resident 7's Face Sheet (FS), the FS indicated the facility admitted Resident 7 on 3/12/2026 with diagnoses including chronic respiratory failure (CRF, a long-term condition where the lungs could not adequately pull oxygen into the blood or remove carbon dioxide from the body), gastrostomy (a surgical opening fitted with a device to allow feeding to be administered directly to the stomach common for people with swallowing problems), tracheostomy (a surgical opening through the neck into the windpipe), and dystonia (a neurological movement disorder that causes involuntary, sustained or intermittent muscle contractions). During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool), dated 5/11/2026, the MDS indicated Resident 7 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 7 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. During a concurrent observation inside Resident 7's room and interview on 6/16/2026 at 10:43 am with Treatment Nurse 1 (TN 1), Resident 7 was in bed with two splints (rigid or flexible device used to support, protect, or immobilize a part of the body) applied on bilateral (both) hands. Resident 7 had a pad sensor call light (flat call light activated by gross movement) on the upper right side of the bed. TN 1 stated Resident 7 could move Resident 7's left arm compared to Resident 7's right arm. TN 1 stated the pad sensor call light should be placed next to the resident's functional arm so Resident 7 would be able to call for help when needed. During an interview on 6/18/2026 at 11:07 am with the Director of Nursing (DON), the DON stated the push button or sensor pad call light should be placed next to Resident 7's functional extremity so Resident 7 would be able to reach and use the sensor pad call light to call for assistance and alert the staff to address the resident's needs. During a review of the facility's Policy and Procedures (P&P) titled, Call System, Resident, dated March 2023, the P&P indicated, Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. If the resident has a disability that prevents him/her from making the use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 4 provided care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of four sampled residents (Resident 1), according to the facility's policy and procedure (P&P) titled, Safe Lifting and Movement of Residents, and the Inservice on the use of Hoyer lift (mechanical [made or operated by a machine] lift - a device used by staff to lift and transfer residents from bed to a chair or one location to another), dated 2/19/2025 by failing to: Ensure CNA 4 provided two-person physical assistance (help from two persons) to transfer (moving a resident from one place to another) Resident 1 from Resident 1's bed to the shower gurney (mobile bed used to assist in bathing residents) when CNA 4 used the Hoyer lift. As a result of this failure, on 5/26/2025 at 9:45 am, Resident 1 fell to the floor from the Hoyer lift. Resident 1's back of head and neck hit the floor and Resident 1's right lower leg was pinned (trapped) between the shower gurney and Hoyer lift. Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 5/26/2025 at 12:14 pm for further evaluation and was monitored for a closed head injury (any injury to the head that do not break through the skull [bone of the head that surround the brain]), right lower leg swelling, and blunt trauma (injury caused by a forceful impact, usually with a dull object or surface, that does not pierce the skin) to the neck. Cross reference F725 and F726 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/11/2020, and readmitted Resident 1 on 12/28/2024, with diagnoses that included morbid obesity (chronic disease characterized by excessive fat accumulation) and acute respiratory failure (a serious condition that makes it difficult to breathe on one's own) with hypoxia (low level of oxygen in the body that causes confusion, restlessness, and difficulty breathing). During a review of Resident 1's Care Plan (CP) titled, Care Plan Report, revised 3/27/2023, the CP indicated Resident 1 had activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily)/self-care deficit due to requiring assistance with ADLs. The CP interventions included for staff to provide Resident 1 a safe environment and follow bed mobility (ability to move around in bed)/ADL standard of care. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2025, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, showering/bathing self, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. During a review of Resident 1's Change of Condition/Interact Assessment Form (COC [a change in the resident's health or functioning that requires further assessment and intervention] form) dated 5/26/2025, timed at 9:45 am, the COC form indicated on 5/26/2025 at 9:45 am, Resident 1 had an assisted fall due to weight shifted onto one side of the Hoyer lift. The COC form indicated CNA 4 called out for help from Resident 1's room and when Licensed Vocational Nurse (LVN) 2 arrived, Resident 1 was noted to be in the sling (a device which consists of cable, chain, rope, or webbing and placed under the resident and attached to the Hoyer lift to facilitate lifting) while the sling was still attached to the Hoyer lift, and the Hoyer lift was tilted on its right side. The COC form indicated the top of the Hoyer lift was caught by the shower gurney, and CNA 4's left arm was wedged between Resident 1 and the shower gurney in assist to the fall. The COC form indicated Resident 1's (right) leg was noted to be caught between the sides of the shower gurney. The COC form indicated Resident 1 had pain (pain level unrated) to Resident 1's right lower leg, bruising (skin discoloration from damaged, leaking blood vessels underneath the skin) to Resident 1's right lower leg and right finger (location unspecified), and lump (bump or a solid mass without a regular shape) on the back right side of Resident 1's head. The COC form indicated Nurse Practitioner (NP- a nurse with advanced clinical education and training) 1 was notified and ordered to transfer Resident 1 to GACH 1 for further evaluation. During a review of Resident 1's Order from NP 1, dated 5/26/2025, timed at 11:18 am, the order indicated to transfer Resident 1 to GACH 1 emergency room (ER) for a Computed Tomography (CT- medical imaging technique used to obtain detailed internal images of the body) Scan of Resident 1's head due to status post (S/P, after) fall. During a review of Resident 1's GACH 1 Emergency Department Note Physician (EDNP) dated 5/26/2025 at 12:14 pm, the EDNP indicated Resident 1 presented to GACH 1 for a mechanical fall (a type of fall that is caused by an external force or object) at the skilled nursing facility (SNF). The EDNP indicated the SNF staff was attempting to lift Resident 1 with a Hoyer lift, but Resident 1 fell causing Resident 1 to strike the back of Resident 1's head on Resident 1's bed and hit Resident 1's right shin (front lower leg below the knee) against Resident 1's bed. The EDNP indicated given Resident 1 being on blood thinners (medications that help prevent blood clots from forming), a comprehensive (a large scope; covering completely or broadly) workup was initiated for evaluation of possible brain bleed (bleeding within the skull, specifically the brain and its surrounding areas), fractures (a break or crack in a bone), spinal (backbone, the bone from the skull to the tailbone) injury, dislocation (a medical condition where the two bones forming a joint are no longer properly aligned), and neurovascular (involving both nerves and blood vessels) injury. The EDNP indicated Resident 1 was to be admitted to GACH 1's Trauma Intensive Care Unit (TICU- specialized unit within a hospital that provides critical care to patients with severe trauma injuries, requiring advanced monitoring) and started on Keppra (a medication used to treat certain types of seizures [a sudden burst of uncontrolled electrical activity in the brain]) intravenous (IV- soft, flexible tube inserted into a vein) drip (medical technique used to administer fluids, medication, or nutrients directly to the bloodstream). During a review of Resident 1's head CT Scan Report (CT Report), dated 5/26/2025, timed at 5:32 pm, the CT Report indicated there was no evidence of subarachnoid hemorrhage (SAH- serious condition where bleeding occurs in the space between the brain and the tissue covering it). During a review of Resident 1's GACH 1 EDNP Addendum dated 5/26/2025, timed at 6:44 pm, the EDNP Addendum indicated Resident 1 was cleared for discharge and was discharged in stable condition. During an interview on 5/29/2025 at 11:09 am with Resident 1, Resident 1 stated Resident 1's fall (on 5/26/2025 unable to remember exact time) was a very traumatic experience. Resident 1 stated CNA 4 prepped Resident 1 and put Resident 1 in the Hoyer lift. Resident 1 stated only CNA 4 was helping Resident 1 with the Hoyer lift the day of Resident 1's fall (5/26/2025). Resident 1 stated there were normally two staff assisting Resident 1 with the Hoyer lift, but it was just CNA 4 that day (5/26/2025). Resident 1 stated CNA 4 told Resident 1 that CNA 4 was busy because they (the facility) were short-staffed. Resident 1 stated CNA 4 suspended (hanging or being held in the air) Resident 1 in a lying position using the Hoyer lift. Resident 1 stated, All of a sudden, I felt myself falling and then I hit my head on something close to the floor. Resident 1 stated It felt metal, like maybe the foot of the bed. Resident 1 stated, My right knee was wedged (force into a narrow space) between the Hoyer lift and the shower gurney, and it (right knee) was very painful. Resident 1 stated it was a very slow process to get help into Resident 1's room, and it was, painful and frustrating. Resident 1 stated, The whole experience made me feel overwhelmed because I couldn't believe it (the fall) happened. Resident 1 stated, Usually once I'm in the (Hoyer) lift, someone comes to help CNA 4, but that day (5/26/2025) no one was helping CNA 4. Resident 1 stated Resident 1 was worried that Resident 1's (right) leg was broken. During a concurrent observation of Resident 1 inside Resident 1's room and interview on 5/29/2025 at 11:41 am with Licensed Vocational Nurse (LVN) 2, Resident 1 was lying on Resident 1's bed with noticeable injuries to Resident 1 right index (pointer) finger and right leg. LVN 2 stated Resident 1 had a bruise on the right index (pointer) finger and a bump on the back right side of Resident 1's head, near Resident 1's neck. LVN 2 stated Resident 1 had a raised bump on Resident 1's right shin that was approximately two (2) inches (in- unit of measurement) by one and a half (1.5) in with purple and yellowish tone around the bump's edges. LVN 2 stated Resident 1's (right) leg was swollen from the injury. LVN 2 stated the right outer side of Resident 1's foot was also bruised and slightly purple and greenish in color. During an interview on 5/29/2025 at 11:46 am with LVN 2, LVN 2 stated on 5/26/2024 during the morning shift (7 am to 3 pm), LVN 2 and CNA 4 were assigned to care for Resident 1. LVN 2 stated the facility was short-staffed on Station 3 (the station where Resident 1 resides) that day (5/26/2025). LVN 2 stated LVN 2 was two doors down from Resident 1's room when LVN 2 heard CNA 4 asking for help in Resident 1's room. LVN 2 stated when LVN 2 came into Resident 1's room, LVN 2 saw that the Hoyer lift was in between Resident 1's bed and Resident 1's roommate's bed, tilted over on its right side but was stopped by the shower gurney. LVN 2 stated LVN 2 found CNA 4 still assisting Resident 1 and trying to stop Resident 1 from falling by wedging CNA 4's left arm between Resident 1's right leg and the shower gurney. LVN 2 stated one of the bolts (a screw-like metal object without a point, used to fasten things together) on the Hoyer lift popped out. LVN 2 stated LVN 2 and other staff (unidentified) had to work to get the cuffs (the end part, usually thicker) off the sling to free Resident 1's (right) leg. LVN 2 stated after LVN 2 and other staff (unidentified) freed Resident 1's right leg, LVN 2 noticed Resident 1's right leg injury. LVN 2 stated Resident 1's right leg was instantly a goose egg (when blood collects between the skin and the muscle). LVN 2 stated less than 30 minutes after Resident 1 fell, Resident 1 complained of a bump on the back right side of Resident 1's head. LVN 2 stated the Treatment Nurse (TN) assessed Resident 1's head, while LVN 2 called 9-1-1 (phone number used to contact emergency services in the event of a medical emergency). During an interview with on 5/29/2025 at 1:14 pm with the TN, the TN stated on 5/26/2025 (unable to remember exact time), Registered Nurse (RN) 2 asked the TN to assess Resident 1 after, an incident with the Hoyer lift. The TN stated Resident 1 had swelling to the right shin that was mildly red and had mild redness to the right index finger. The TN stated the TN assessed Resident 1's head but did not feel anything (without abnormal findings). The TN stated about 30 to 40 minutes after the assessment was completed, Resident 1 asked the TN to assess Resident 1's head again because Resident 1 told the TN, I think I hit my head. The TN stated the TN assessed Resident 1's head again and felt a bump to the back right side of Resident 1's head. The TN stated the TN notified NP 1 and NP 1 ordered to transfer Resident 1 to ER for further evaluation. The TN stated two staff needed to operate the Hoyer lift for safety issues because it was a mechanical lift. The TN stated if two staff were operating the lift, it was possible that the resident (Resident 1) may not have fallen or gotten hurt. During a concurrent record review and telephone interview on 5/29/2025 at 3:48 pm with the Director of Staff Development (DSD), the facility's Record of In-Service Training ([NAME]) titled, Lifting/Transferring: Hoyer Lift, Slings and Gait Belts, dated 2/19/2025 was reviewed. The [NAME] indicated staff would Verbalize the understanding of facility policy requiring Two-Person Assist when using a (Hoyer) lift . Acknowledge that one-person lift will lead to suspension or possible termination. The [NAME] indicated CNA 4 signed the [NAME] to confirm CNA 4 attended the training dated 2/19/2025. The DSD stated CNA 4 needed to be operating the Hoyer lift with another staff member (two-person physical assistance) in case there was an issue with the Hoyer lift such as a malfunction. The DSD stated the second person could assist with the fall so, No one gets hurt. The DSD stated the facility provided an in-service (staff education) on Hoyer lifts around the end of 2/2025, and CNA 4 attended the in-service. The DSD stated it was possible that when two staff were operating the Hoyer lift then Resident 1's fall and injuries could have been prevented. During a telephone interview on 5/30/2025 at 12:54 pm with CNA 4, CNA 4 stated on 5/26/2025 (unable to remember exact time), CNA 4 was assigned to care for Resident 1. CNA 4 stated there were only five (5) CNAs working on Station 3 that day (5/26/2025). CNA 4 stated when CNA 4 transferred Resident 1 in the Hoyer lift, CNA 4 did not ask for a second staff to help because, Everyone was so busy and there weren't enough people on our station (Station 3). CNA 4 stated, I didn't really think to ask for help because of it (short-staffed). CNA 4 stated CNA 4 was getting Resident 1 ready for a shower and had hooked Resident 1 into the Hoyer lift sling and was using the Hoyer lift and, All of a sudden the (Hoyer) lift gave out. CNA 4 stated the Hoyer lift made a noise and CNA 4 saw the sling and Resident 1 tilting down toward the floor. CNA 4 stated, It's hard to describe the angle. CNA 4 stated Resident 1 and the Hoyer lift fell to the floor. CNA 4 stated, I was holding onto Resident 1 and got hurt myself. CNA 4 stated I'm not sure how it happened. CNA 4 stated there were supposed to be two staff operating the Hoyer lift for safety reasons. During an interview on 5/30/2025 at 1:05 pm with the Director of Nursing (DON), the DON stated two staff needed to operate the Hoyer lift for safety reasons and to avoid falls, accidents, and injuries. The DON stated the Hoyer lift was a machine so there should be at least two staff (in general) or more if needed operating the Hoyer lift. The DON stated the two staff allowed the resident (in general) to be comfortable in the Hoyer lift during transfers. The DON stated if two staff were operating the Hoyer lift when CNA 4 was transferring Resident 1, it was possible Resident 1's fall and injuries could have been prevented. The DON stated, When we don't follow our education and training, and there are not enough staff working, it can lead to consequences like injury and fall. During a review of the facility's most updated P&P titled, Safe Lifting and Movement of Residents, revised 7/2017, the P&P indicated, In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. The P&P indicated, Staff would be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding the use of equipment and safe lifting techniques. The P&P indicated only staff with documented training on the safe use and care of the machines and equipment (Hoyer lift) used in this facility will be allowed to lift or move residents. The P&P indicated, Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order.

Based on interview and record review, the facility failed to provide sufficient number of nursing staff according to the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent, and Facility Assessment Tool (FA Tool), by failing to: 1. Ensure certified nursing assistants (CNA) were not assigned more than 12 residents on 5/6/2025, 5/7/2025, 5/14/2025, 5/15/2025, and 5/18/2025 on the 11 pm to 7 am (noc) shift on Station 3. 2. Ensure there were seven assigned CNAs on the 7 am to 3 pm (morning) shift in Station 3 on 5/26/2025. As a result of these failures, on 5/6/2025, 5/7/2025, 5/14/2025, 5/15/2025, and 5/18/2025 CNAs working in Station 3 were assigned between 24 and 25 residents during the noc shift. On 5/26/2025, there were five CNAs working in Station 3 during the AM shift. Resident 1 had a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) while being transferred (moving a resident from one place to another) in a Hoyer lift (mechanical lift- a device used by staff to transfer residents from one location to another e.g., a bed to a chair) due to CNA 4 operating the lift without assistance. Resident 1 was sent to general acute care hospital (GACH) 1 for further evaluation. These failures have the potential to result in residents not receiving the appropriate care and services needed to treat their medical conditions. Cross Reference F689 Findings: 1. During an interview on 5/28/2025 at 2:56 pm, with CNA 3, CNA 3 generally worked the noc shift. CNA 3 stated it was, a common trend, where the facility is understaffed three days a week. CNA 3 stated CNA 3 was offered (by the facility) to work overtime (working outside of regular working hours) for the 3 pm to 11 pm (evening) shift because there were not enough CNAs scheduled. CNA 3 stated when the facility was short-staffed CNAs on noc shift, CNA 3 and one other CNA were generally assigned 24-25 residents on Station 3. CNA 3 stated when that happens, CNA 3 stated, I absolutely cannot provide safe and effective care to 24-25 residents. CNA 3 stated, I cannot ensure [residents] are repositioned every two hours, or make sure they are changed in a timely manner or ensure a safe environment for them. During a concurrent interview and record on 5/30/2025 at 12:07 pm, with the Director of Nursing (DON) and the Director of Staffing Development Assistant (DSDA), the Nursing Staffing Assignment and Sign-In Sheet (NSASS) for Station 3 noc shift dated 5/6/2025, 5/7/2025, 5/14/2025, 5/15/2025, and 5/18/2025 were reviewed. The DON stated on 5/6/2025, there were two CNAs working and each CNA had 24 residents. The DON stated on 5/7/2025, there were two CNAs working and each CNA had 24 residents. The DON stated on 5/14/2025 and 5/15/2025, there two CNAs working and each CNA had 24 and 25 residents both days. The DON stated on 5/18/2025, there were two CNAs working and each CNA had 24 residents. The DON stated CNAs were not supposed to be assigned 24 or 25 residents because, It's too much to take care of because it's a risk for patient care safety. 2. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/11/2020, and readmitted Resident 1 on 12/28/2024, with diagnoses that included morbid obesity (chronic disease characterized by excessive fat accumulation) and acute respiratory failure (a serious condition that makes it difficult to breathe on one's own) with hypoxia (low level of oxygen in the body that causes confusion, restlessness, and difficulty breathing). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2025, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, showering/bathing self, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. During a review of Resident 1's Change of Condition/Interact Assessment Form (COC [a change in the resident's health or functioning that requires further assessment and intervention] form) dated 5/26/2025, timed at 9:45 am, the COC form indicated on 5/26/2025 at 9:45 am, Resident 1 had an assisted fall due to weight shifted onto one side of the Hoyer lift. The COC form indicated CNA 4 called out for help from Resident 1's room and when Licensed Vocational Nurse (LVN) 2 arrived, Resident 1 was noted to be in the sling (a device which consists of cable, chain, rope, or webbing and placed under the resident and attached to the Hoyer lift to facilitate lifting) while the sling was still attached to the Hoyer lift, and the Hoyer lift was tilted on its right side. During a review of Resident 1's Order from NP 1, dated 5/26/2025, timed at 11:18 am, the order indicated to transfer Resident 1 to GACH 1 emergency room (ER) for a Computed Tomography (CT- medical imaging technique used to obtain detailed internal images of the body) Scan of Resident 1's head due to status post (S/P, after) fall. During a review of Resident 1's GACH 1 Emergency Department Note Physician (EDNP) dated 5/26/2025 at 12:14 pm, the EDNP indicated Resident 1 presented to GACH 1 for a mechanical fall (a type of fall that is caused by an external force or object) at the skilled nursing facility (SNF). The EDNP indicated the SNF staff was attempting to lift Resident 1 with a Hoyer lift, but Resident 1 fell causing Resident 1 to strike the back of Resident 1's head on Resident 1's bed and hit Resident 1's right shin (front lower leg below the knee) against Resident 1's bed. During an interview on 5/29/2025 at 11:09 am with Resident 1, Resident 1 stated Resident 1's fall (on 5/26/2025 unable to remember exact time) was a very traumatic experience. Resident 1 stated CNA 4 prepped Resident 1 and put Resident 1 in the Hoyer lift. Resident 1 stated only CNA 4 was helping Resident 1 with the Hoyer lift the day of Resident 1's fall (5/26/2025). Resident 1 stated there were normally two staff assisting Resident 1 with the Hoyer lift, but it was just CNA 4 that day (5/26/2025). Resident 1 stated CNA 4 told Resident 1 that CNA 4 was busy because they (the facility) were short-staffed. Resident 1 stated CNA 4 suspended (hanging or being held in the air) Resident 1 in a lying position using the Hoyer lift. Resident 1 stated, All of a sudden, I felt myself falling and then I hit my head on something close to the floor. Resident 1 stated It felt metal, like maybe the foot of the bed. Resident 1 stated, My right knee was wedged (force into a narrow space) between the Hoyer lift and the shower gurney, and it (right knee) was very painful. Resident 1 stated it was a very slow process to get help into Resident 1's room, and it was, painful and frustrating. Resident 1 stated, The whole experience made me feel overwhelmed because I couldn't believe it (the fall) happened. Resident 1 stated, Usually once I'm in the (Hoyer) lift, someone comes to help CNA 4, but that day (5/26/2025) no one was helping CNA 4. Resident 1 stated Resident 1 was worried that Resident 1's (right) leg was broken. During an interview on 5/29/2025 at 11:46 am with LVN 2, LVN 2 stated on 5/26/2024 during the morning shift (7 am to 3 pm), LVN 2 and CNA 4 were assigned to care for Resident 1. LVN 2 stated the facility was short-staffed on Station 3 (the station where Resident 1 resides) that day (5/26/2025). LVN 2 stated there were supposed to be seven (7) CNAs in Station 3 that day (5/26/2025) but there were only five (5) CNAs. During a telephone interview on 5/29/2025 at 3:48 pm with the Director of Staffing Development (DSD), the DSD stated in Station 3 there should be four CNAs scheduled on the noc shift and the CNAs should not have more than 12 residents assigned to them. DSD stated if the Facility Assessment indicated nine CNAs should be scheduled in the skilled nursing area during the AM shift, then nine CNAs should be scheduled to work in Station 3 so each CNA would have seven residents so the CNAs could provide adequate care to the residents, residents could be changed as needed, kept clean, dry and comfortable, get call lights answered on time, and receive snacks and meals when requested. The DSD stated it was not appropriate for CNAs to have 20-25 assigned residents during the noc shift because, It is a huge safety concern and is too much burden on staff and the residents. The DSD stated CNAs should not have that many residents in any capacity for any length of time. During a concurrent interview and record review on 5/30/2025 at 12:07 pm, with the Director of Nursing (DON) and Director of Staffing Development Assistant (DSDA), the facility's NSASS dated 5/26/2025, morning shift, was reviewed. The DSDA stated during the morning shift on Station 3, the facility needed six to seven CNAs depending on the census. The DON stated on 5/26/2025 the NSASS indicated there were five CNAs working in Station 3. The DON stated after CNA 4 left the facility (time unspecified) there four CNAs working in Station 3. The DON stated the NSASS was redone to indicate CNA 5 was added to the NSASS, indicating five CNAs worked in Station 3 during the morning shift. During a telephone interview on 5/30/2025 at 12:54 pm with CNA 4, CNA 4 stated on 5/26/2025 (unable to remember exact time), CNA 4 was assigned to care for Resident 1. CNA 4 stated there were only five (5) CNAs working on Station 3 that day (5/26/2025). CNA 4 stated when CNA 4 transferred Resident 1 in the Hoyer lift, CNA 4 did not ask for a second staff to help because, Everyone was so busy and there weren't enough people on our station (Station 3). CNA 4 stated, I didn't really think to ask for help because of it (short-staffed). CNA 4 stated CNA 4 was getting Resident 1 ready for a shower and had hooked Resident 1 into the Hoyer lift sling and was using the Hoyer lift and, All of a sudden the (Hoyer) lift gave out. CNA 4 stated the Hoyer lift made a noise and CNA 4 saw the sling and Resident 1 tilting down toward the floor. CNA 4 stated, It's hard to describe the angle. CNA 4 stated Resident 1 and the Hoyer lift fell to the floor. CNA 4 stated, I was holding onto Resident 1 and got hurt myself. CNA 4 stated I'm not sure how it happened. CNA 4 stated there were supposed to be two staff operating the Hoyer lift for safety reasons. During an interview on 5/30/2025 at 1:05 pm with the Director of Nursing (DON), the DON stated two staff needed to operate the Hoyer lift for safety reasons and to avoid falls, accidents, and injuries. The DON stated the Hoyer lift was a machine so there should be at least two staff (in general) or more if needed operating the Hoyer lift. The DON stated the two staff allowed the resident (in general) to be comfortable in the Hoyer lift during transfers. The DON stated it was important to have sufficient staffing to ensure resident safety. During a review of Facility Assessment Tool, the FA Tool indicated nine CNAs were recommended to be scheduled during the AM shift and five CNAs during the noc shift. During a review of the facility's P&P title, Staffing, Sufficient and Competent Nursing, revised 8/2022, the P&P indicated the facility provides sufficient number of nursing staff with the appropriate skills and competency necessary to provide related care and services for all residents in accordance with resident care plans and the facility assessment. The P&P indicated staffing numbers and the skill requirements of direct care staff are determined by the needs of the resident based on each resident's care plan, the resident assessments, and the facility assessments. The P&P indicated factors considered in determining appropriate staffing ratios and skills included evaluation of diseases, conditions, physical or cognitive limitations of the resident population, and acuity. The P&P indicated minimum staffing requirements imposed by the state nursing assistant staffing ration to meet resident needs must be at a minimum of 2.4 and overall, 3.5, if applicable, were adhered to when determining staff ratios, but are not necessarily considered a determination of sufficient and competent staffing.

Based on interview and record review, the facility failed to ensure nursing staff had the appropriate skills and competency necessary to provide nursing care and services to one of four sampled residents (Resident 1), according to the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Staffing, and the Inservice on the use of Hoyer lift (mechanical [made or operated by a machine] lift - a device used by staff to lift and transfer residents from bed to a chair or one location to another), dated 2/19/2025 by failing to: Ensure Certified Nursing Assistant (CNA) 4 provided two-person physical assistance (help from two persons) to transfer (moving a resident from one place to another) Resident 1 from Resident 1's bed to the shower gurney (mobile bed used to assist in bathing residents) when CNA 4 used the Hoyer lift. As a result of this failure, on 5/26/2025 at 9:45 am, Resident 1 fell (move downward, typically rapidly and freely without control, from a higher to a lower level) to the floor from the Hoyer lift. Resident 1's back of head and neck hit the floor and Resident 1's right lower leg was pinned (trapped) between the shower gurney and Hoyer lift. Resident 1 was transferred to General Acute Care Hospital (GACH) 1 on 5/26/2025 at 12:14 pm for further evaluation and was monitored for a closed head injury (any injury to the head that do not break through the skull [bone of the head that surround the brain]), right lower leg swelling, and blunt trauma (injury caused by a forceful impact, usually with a dull object or surface, that does not pierce the skin) to the neck. Cross reference F689 Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 9/11/2020, and readmitted Resident 1 on 12/28/2024, with diagnoses that included morbid obesity (chronic disease characterized by excessive fat accumulation) and acute respiratory failure (a serious condition that makes it difficult to breathe on one's own) with hypoxia (low level of oxygen in the body that causes confusion, restlessness, and difficulty breathing). During a review of Resident 1's Care Plan (CP) titled, Care Plan Report, revised 3/27/2023, the CP indicated Resident 1 had activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily)/self-care deficit due to requiring assistance with ADLs. The CP interventions included for staff to provide Resident 1 a safe environment and follow bed mobility (ability to move around in bed)/ADL standard of care. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 3/12/2025, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, showering/bathing self, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. During a review of Resident 1's Change of Condition/Interact Assessment Form (COC [a change in the resident's health or functioning that requires further assessment and intervention] form) dated 5/26/2025, timed at 9:45 am, the COC form indicated on 5/26/2025 at 9:45 am, Resident 1 had an assisted fall due to weight shifted onto one side of the Hoyer lift. The COC form indicated CNA 4 called out for help from Resident 1's room and when Licensed Vocational Nurse (LVN) 2 arrived, Resident 1 was noted to be in the sling (a device which consists of cable, chain, rope, or webbing and placed under the resident and attached to the Hoyer lift to facilitate lifting) while the sling was still attached to the Hoyer lift, and the Hoyer lift was tilted on its right side. The COC form indicated the top of the Hoyer lift was caught by the shower gurney, and CNA 4's left arm was wedged between Resident 1 and the shower gurney in assist to the fall. The COC form indicated Resident 1's (right) leg was noted to be caught between the sides of the shower gurney. The COC form indicated Resident 1 had pain (pain level unrated) to Resident 1's right lower leg, bruising (skin discoloration from damaged, leaking blood vessels underneath the skin) to Resident 1's right lower leg and right finger (location unspecified), and lump (bump or a solid mass without a regular shape) on the back right side of Resident 1's head. The COC form indicated Nurse Practitioner (NP- a nurse with advanced clinical education and training) 1 was notified and ordered to transfer Resident 1 to GACH 1 for further evaluation. During a review of Resident 1's Order from NP 1, dated 5/26/2025, timed at 11:18 am, the order indicated to transfer Resident 1 to GACH 1 emergency room (ER) for a Computed Tomography (CT- medical imaging technique used to obtain detailed internal images of the body) Scan of Resident 1's head due to status post (S/P, after) fall. During a review of Resident 1's GACH 1 Emergency Department Note Physician (EDNP) dated 5/26/2025 at 12:14 pm, the EDNP indicated Resident 1 presented to GACH 1 for a mechanical fall (a type of fall that is caused by an external force or object) at the skilled nursing facility (SNF). The EDNP indicated the SNF staff was attempting to lift Resident 1 with a Hoyer lift, but Resident 1 fell causing Resident 1 to strike the back of Resident 1's head on Resident 1's bed and hit Resident 1's right shin (front lower leg below the knee) against Resident 1's bed. During an interview on 5/29/2025 at 11:09 am with Resident 1, Resident 1 stated Resident 1's fall (on 5/26/2025 unable to remember exact time) was a very traumatic experience. Resident 1 stated CNA 4 prepped Resident 1 and put Resident 1 in the Hoyer lift. Resident 1 stated only CNA 4 was helping Resident 1 with the Hoyer lift the day of Resident 1's fall (5/26/2025). Resident 1 stated there were normally two staff assisting Resident 1 with the Hoyer lift, but it was just CNA 4 that day (5/26/2025). Resident 1 stated CNA 4 told Resident 1 that CNA 4 was busy because they (the facility) were short-staffed. Resident 1 stated CNA 4 suspended (hanging or being held in the air) Resident 1 in a lying position using the Hoyer lift. Resident 1 stated, All of a sudden, I felt myself falling and then I hit my head on something close to the floor. Resident 1 stated It felt metal, like maybe the foot of the bed. Resident 1 stated, My right knee was wedged (force into a narrow space) between the Hoyer lift and the shower gurney, and it (right knee) was very painful. Resident 1 stated it was a very slow process to get help into Resident 1's room, and it was, painful and frustrating. Resident 1 stated, The whole experience made me feel overwhelmed because I couldn't believe it (the fall) happened. Resident 1 stated, Usually once I'm in the (Hoyer) lift, someone comes to help CNA 4, but that day (5/26/2025) no one was helping CNA 4. Resident 1 stated Resident 1 was worried that Resident 1's (right) leg was broken. During an interview on 5/29/2025 at 11:46 am with Licensed Vocation Nurse (LVN) 2, LVN 2 stated on 5/26/2024 during the morning shift (7 am to 3 pm), LVN 2 and CNA 4 were assigned to care for Resident 1. LVN 2 stated LVN 2 was two doors down from Resident 1's room when LVN 2 heard CNA 4 asking for help in Resident 1's room. LVN 2 stated when LVN 2 came into Resident 1's room, LVN 2 saw that the Hoyer lift was in between Resident 1's bed and Resident 1's roommate's bed, tilted over on its right side but was stopped by the shower gurney. LVN 2 stated LVN 2 found CNA 4 still assisting Resident 1 and trying to stop Resident 1 from falling by wedging CNA 4's left arm between Resident 1's right leg and the shower gurney. LVN 2 stated one of the bolts (a screw-like metal object without a point, used to fasten things together) on the Hoyer lift popped out. LVN 2 stated LVN 2 and other staff (unidentified) had to work to get the cuffs (the end part, usually thicker) off the sling to free Resident 1's (right) leg. LVN 2 stated after LVN 2 and other staff (unidentified) freed Resident 1's right leg, LVN 2 noticed Resident 1's right leg injury. LVN 2 stated Resident 1's right leg was instantly a goose egg (when blood collects between the skin and the muscle). LVN 2 stated less than 30 minutes after Resident 1 fell, Resident 1 complained of a bump on the back right side of Resident 1's head. LVN 2 stated the Treatment Nurse (TN) assessed Resident 1's head, while LVN 2 called 9-1-1 (phone number used to contact emergency services in the event of a medical emergency). During a concurrent record review and telephone interview on 5/29/2025 at 3:48 pm with the Director of Staff Development (DSD), the facility's Record of In-Service Training ([NAME]) titled, Lifting/Transferring: Hoyer Lift, Slings and Gait Belts, dated 2/19/2025 was reviewed. The [NAME] indicated staff would Verbalize the understanding of facility policy requiring Two-Person Assist when using a (Hoyer) lift . Acknowledge that one-person lift will lead to suspension or possible termination. The [NAME] indicated CNA 4 signed the [NAME] to confirm CNA 4 attended the training dated 2/19/2025. The DSD stated CNA 4 needed to be operating the Hoyer lift with another staff member (two-person physical assistance) in case there was an issue with the Hoyer lift such as a malfunction. The DSD stated the second person could assist with the fall so, No one gets hurt. The DSD stated the facility provided an in-service (staff education) on Hoyer lifts around the end of 2/2025, and CNA 4 attended the in-service. The DSD stated it was possible that when two staff were operating the Hoyer lift then Resident 1's fall and injuries could have been prevented. During an interview on 5/30/2025 at 1:05 pm with the Director of Nursing (DON), the DON stated two staff needed to operate the Hoyer lift for safety reasons and to avoid falls, accidents, and injuries. The DON stated the Hoyer lift was a machine so there should be at least two staff (in general) or more if needed operating the Hoyer lift. The DON stated the two staff allowed the resident (in general) to be comfortable in the Hoyer lift during transfers. The DON stated if two staff were operating the Hoyer lift when CNA 4 was transferring Resident 1, it was possible Resident 1's fall and injuries could have been prevented. The DON stated, When we don't follow our education and training, and there are not enough staff working, it can lead to consequences like injury and fall. During a review of the facility's P&P titled, Staffing, Sufficient and Competent Nursing, revised 8/2022, the P&P indicated the facility provides sufficient numbers of nursing staff with the appropriate skills and competencies necessary to provide nursing and related care and services for all residents in accordance with the resident care plans and facility assessment. The P&P indicated staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) person centered care, basic nursing skills, and communication. The P&P indicated competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that programming for staff training results in nursing competency and that training includes critical thinking skills and managing care in a complex environment with multiple interruptions. During a review of the facility's Record of In-Service Training ([NAME]) titled, Lifting/Transferring: Hoyer Lift, Slings and Gait Belts, dated 2/19/2025, the [NAME] indicated staff would verbalize understanding of facility policy requiring two-person assist when using a lift. The [NAME] indicated CNA 4 attended the training.

Based on interview and record review, the facility failed to ensure two of three sampled residents (Residents 35 and 89) were not administered Epoetin Alfa-epbx (Epogen, a medication to treat anemia [a condition when the blood does not have enough red blood cells or reduced amount of hemoglobin [Hgb, a protein in red blood cells that carries oxygen throughout the body]) injections as indicated in Residents 35 and 89's physicians orders (PO) to hold Epogen injections when Residents 35 and 89's Hgb level was > (more than) 10 grams per deciliter (g/dl, unit of measurement for Hgb). As a result, Resident 35 received 19 unnecessary (extra/not needed) doses of Epogen injections from [DATE] to [DATE] ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]) when Resident 35's Hgb level was at 11.5 g/dl. Resident 89 received three unnecessary doses of Epogen injections from [DATE] to [DATE] ([DATE], [DATE] and [DATE]) when Resident 89's Hgb levels were at 12.3 g/dl and 12.9 g/dl. These deficient practices placed Residents 35 and 89 at risk to experience adverse side effects (unintended effects that occur when a medication was administered incorrectly) such as polycythemia (a medical condition where there is an abnormally high number of red blood cells in the blood) and hypercoagulability (increased tendency to form blood clot), stroke (a medical condition where blood flow to part of the brain is disrupted, causing brain damage), and heart attack (a serious medical emergency where a section of the heart muscle is damaged or dies due to a lack of blood flow) from receiving excessive doses (toxic amount/ when taking more than the recommended amount) of Epogen injections, and had the potential to result in serious harm, injury or death from these significant medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm). On [DATE] at 12:43 pm, the California Department of Public Health (CDPH, the Department) called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, impairment, or death to a resident) situation, in the presence of the Administrator (ADM), the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The ADM, DON, and ADON were informed of the facility's failure to have a system in place to ensure Residents 35 and 89 were not administered Epogen injections as ordered by Resident 35 and 89's Primary Care Physicians (PCP 1 and PCP 2). The ADM, DON, and ADON were aware that the deficient practices resulted in potential serious harm that threatened the health and safety of Residents 35 and 89, from receiving excessive doses of Epogen injections (significant medication errors). On [DATE] at 3:30 pm, the facility provided an acceptable IJ Removal Plan (IJRP, interventions to correct the deficient practice). While onsite at the facility, the survey team verified/confirmed implementation of the IJRP through observation, interview and record review, and determined the IJ situation regarding significant medication errors was no longer present. The survey team removed the IJ on [DATE] at 4:18 pm in the presence of the ADM, DON, ADON and the Clinical Nursing Consultant (CNC). The facility provided an acceptable IJRP as follows: A1. For Resident 35: 1. On [DATE], the DON notified the pharmacist regarding Resident 35 received 19 extra doses of Epogen injections from [DATE] to [DATE] when Resident 35's Hgb level was at 11.5 g/dl, which was outside of the prescribed parameter (specific instructions that can be measured), with no further recommendations. 2. On [DATE], the DON communicated with the Nephrologist (Neph 1, a medical doctor specializing in diagnosing and treating diseases and disorders of the kidneys), who recommended that the dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) center will administer Epogen injections based on Resident 35's lab work (medical test performed in a laboratory to analyze bodily samples, such as blood, urine, or tissue ) during dialysis treatments at the dialysis center. 3. On [DATE], the ADON followed up with Resident 35's Primary Physician (PCP 1), who agreed with Neph 1's recommendation and clarified the order as: Epogen to be given at the dialysis center. 4. On [DATE], the DON assessed Resident 35 for overall health condition and status. Resident 35 denied any distress, no pain or other symptoms suggesting adverse reaction. A2. For Resident 89: 1. On [DATE], the DON notified Resident 89's Primary Physician (PCP 2) regarding Resident 89 received three extra doses of Epogen injections on [DATE], [DATE] and [DATE] when Resident 89's Hgb was > 10 g/dl. 2. On [DATE], PCP 2 ordered to continue the Epogen order with the same parameter (hold Epogen injections when Resident 89's Hgb > 10 mg/dl), pending a complete blood count (CBC, a blood test that measures amounts and sizes of red blood cells, hemoglobin, white blood cells [part of the body's immune system] and platelets [small, colorless fragments in the blood that form clots and stop or prevent bleeding]) results on [DATE]. 3. On [DATE], the DON notified the pharmacist regarding Resident 89 received a total of three Epogen injections administered on [DATE], [DATE] and [DATE] when Resident 89's Hgb was above the prescribed parameter (Hgb > 10 mg/dl), without any further recommendations. 6. On [DATE], the DON assessed Resident 89 for overall health condition and status. Resident 89 denies any distress, no pain or other symptoms suggesting adverse reaction. B. On [DATE] and [DATE], the ADM and DON notified the Medical Director of the IJ outlined in the IJ template (a document issued to the provider/facility when an IJ is called) and the Medical Director assisted in developing the IJ removal plan. C. On [DATE], the DON notified the licensed nurses (all Licensed Vocational Nurses [LVNs] and Registered Nurses [RNs]) of the IJ findings outlined in the IJ template and provided in-services regarding the Medication Administration policy and procedure. The training covered the following topics: 1. To avoid medication error, the licensed nurse must check or verify the following information, but not limited to: resident name, medication name, dose, route time and special instruction such as parameters (guideline/measurable factor) as ordered by the physician. 2. Hold or discontinue the medication according to the specific parameter instructions. 3. Notify the physician if the resident has medication related issues e.g., signs or symptoms of medication reaction. D. On [DATE] and [DATE], the ADM and DON notified one RN (RN 1) and three LVNs (LVN 3, 6, 7) who were responsible for the identified findings in the IJ template and provided one-on-one in-services regarding medication administration policy, focusing on Epogen injection administration based on parameters, following disciplinary action. E. As of [DATE], There are a total of 48 licensed nurses, and 44 licensed nurses had completed the in-services regarding medication administration policy and procedure. Four licensed nurses could not attend the in-services due to medical and personal leave and these four licensed nurses will complete the in-services upon returning to work, before the start of their schedule shifts. F. On [DATE], the ADM and DON initiated a Quality Assurance and Performance Improvement (QAPI, a systematic approach to ensure and enhance the quality of care and services in healthcare settings) plan to address the findings outlined in the IJ template. G. On [DATE], the DON and ADON reviewed all current residents with the order of Epogen injections. Except Residents 35 and 89, the facility had one resident (Resident 244) with Epogen order, and no issues were identified with Resident 244. H. Effective [DATE], the DON would provide a monthly in-service regarding medication administration policy and procedure for all licensed nurses for three months. The training covered the following topics: 1. To avoid medication errors, the licensed nurses must check or verify the following information, but not limited to, resident name, medication name, dose, route, time and special instruction, such as parameters as ordered by the physician instructions. 2. Hold or discontinue the medication according to the specific parameter instructions. 3. Notify the physician if the resident has medication related issues e.g., signs or symptoms of medication reaction. I. Effective [DATE], the DON and/or ADON will review all residents with Epogen injection order, medication administration records, laboratory results (the outcomes of medical tests conducted in a laboratory to analyze samples of blood, urine, or other bodily fluids or tissues), after their admissions, then weekly and as needed to ensure compliance. J. On [DATE], the DON created an Epogen injection administration log which included resident name, Epogen injection order, medication administration following parameter and laboratory monitoring. K. The DON and/or ADON will review all residents with Epogen injection order, medication administration record, laboratory results, after their admissions then weekly and as needed for three months and document the findings with corrective action on the monitoring log. L. Effective [DATE], the facility will review the QAPI program every month for three months then annually thereafter or as needed. The facility will adjust the measures needed to ensure effective and ongoing compliance with the State and Federal regulations. Findings: 1. During a review of Resident 35's Admission Record (AR), the AR indicated the facility admitted Resident 35 on [DATE] and readmitted Resident 35 on [DATE] with diagnoses including End Stage Renal Disease (ESRD, irreversible kidney failure), dependence on renal dialysis and anemia. During a review of Resident 35's untitled Care Plan (CP, a comprehensive personalized document outlining a patient's specific healthcare needs, goals, and preferences) revised on [DATE], the CP indicated, for licensed nurses to administer Resident 35's medications as ordered. During a review of Resident 35's PO dated [DATE], the PO indicated for licensed nurses to Administer Epogen injection solution, 10000 units per millimeter (unit/ml, unit of measurement), to inject subcutaneously (administered under the skin) in the evening. every Tuesday, Thursday and Saturday for anemia, and hold if Resident 35's Hgb was > 10 g/dl. During a review of Resident 35's laboratory report (LR, result from the blood test) dated [DATE], the LR indicated Resident 35's Hgb level was 11.5 g/dl. During a concurrent review of Resident 35's Medication Administration Record (MAR, record used to document medications taken by each resident), dated from [DATE] to [DATE], and interview with Licensed Vocational Nurse 6 (LVN 6) on [DATE] at 4:39 pm, the MAR dated from [DATE] to [DATE] indicated to administer Epogen injection solution 10000 unit/ml, inject 10000unit subcutaneously in the evening on Tuesday, Thursday and Saturday for amenia, hold if Hgb above 10 mg/dl. The MAR indicated Resident 35 received a total of 19 doses of Epogen injection ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]). The MAR indicated Resident 35's Hgb level was 11.5 g/dl. LVN 6 stated, LVN 6 administered Epogem injection to Resident 35 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. LVN 6 stated, Resident 35's most recent CBC result was reported on [DATE] and Resident 35's Hgb level was 11.5 g/dl. LVN 6 stated 11.5 g/dl was above the physician's order to give Epogen injection to Resident 35. LVN 6 stated, Resident 35's PO was to hold Epogen injection when Resident 35's Hgb was > 10 g/dL. LVN 6 stated LVN 6 did not check Resident 35's PO before administering Epogen injections to Resident 35. LVN 6 stated, LVN 6 need to follow Resident 35's PO and hold Epogen injections when Resident 35's Hgb was at 11.5 g/dL. LVN 6 stated that administering excessive doses of Epogen injections would increase Resident 35's blood Hgb level that could cause headache, dizziness, elevated blood pressure and polycythemia. LVN 6 stated, before Epogen administration, LVN 6 needed to check the right patient, right medication, right dose, right route, right time and relevant special instructions of the medication. During a telephone interview with the facility's Medical Director on [DATE] at 10:36 am, the MD stated the facility had residents receiving Epogen injections (Residents 35, 89 and 244) with a standing order (a pre-approved, written protocol) to hold Epogen injection if the Residents' (Residents 35, 89 and 244's) Hgb level was more than 10 g/dl. The MD stated the risk for Resident 35 receiving excessive doses of Epogen was elevated blood Hgb level and could result in polycythemia and hypercoagulability. During a telephone interview with Neph 1 on [DATE] at 10:50 am, Neph 1 stated, Resident 35 was under Neph 1's care. Neph 1 stated, Resident 35's Epogen injections should be administered at Dialysis Center (DC) 1 during Resident 35's dialysis days instead of at the facility because there was a standing order for DC 1 to check Resident 35's Hgb twice a month. Neph 1 stated licensed nurses needed to stop giving Epogen injection when Resident 35's Hgb level was >10 g/dl. Neph 1 stated, when residents (in general) receive excessive doses of Epogen injections the Hgb level would elevate and could result in stroke and heart attack. During a concurrent review of Resident 35's MAR, dated from [DATE] to [DATE] and interview with LVN 7 on [DATE] at 1:24 pm, the MAR dated from [DATE] to [DATE] indicated to administer Epogen injection solution 10000 unit/ml, inject 10000unit subcutaneously in the evening on Tuesday, Thursday and Saturday for amenia, hold if Hgb above 10 mg/dl. The MAR indicated Resident 35 received a total of 19 doses of Epogen injection ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] [DATE], and [DATE]). The MAR indicated Resident 35's Hgb level was 11.5 g/dL. LVN 7 stated, LVN 7 administered Epoge injection to Resident 35 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] when Resident 35's Hgb level was 11.5 g/dl. LVN 7 stated Resident 35's PO was to hold Epogen injection when Resident 35's Hgb level was > 10 g/dl but LVN 7 did not read nor check Resident 35's PO prior to administrating Epogen injections to Resident 35. LVN 7 stated LVN 7 needed to hold Resident 35's Epogen injections when the resident's Hgb level was 11.5 g/dl. LVN 7 stated, these (mistakes) were considered medication errors. LVN 7 stated high Hgb level could cause Resident 35 to have blood clots and possible stroke. During a telephone interview with the Clinical Coordinator (CC) from DC 1 on [DATE] at 9:30 am, the CC stated possible risks for high Hgb included blood clot, heart attack and stroke. During a review of DC 1's laboratory results for Resident 35 from [DATE] to [DATE], the laboratory results indicated Resident 35's Hgb level was at 10.7 g/dl on [DATE]; 11.5 g/dl on [DATE]; 12.4 g/dl on [DATE], and 12.5 g/dl on [DATE]. 2. During a review of Resident 89's AR, the AR indicated the facility admitted Resident 89 on [DATE] and readmitted Resident 89 on [DATE], with diagnoses including kidney transplant (a surgical procedure where a healthy kidney from a living or deceased donor was placed into a recipient whose kidneys were failing or no longer functioning) and anemia. During a review of Resident 89's most current LR dated [DATE], the LR indicated Resident 89's Hgb level was 12.9 g/dl. During a review of Resident 89's PO dated [DATE], the PO indicated for licensed nurses to administer Epogen injection solution 10000 unit/ml, inject subcutaneously in the morning, every Monday, Wednesday and Friday for anemia, hold if Hgb > 10 g/dl. During a review of Resident 89's untitled CP dated [DATE], the CP indicated for licensed nurses to administer Resident 89's medications as ordered. During a concurrent interview with LVN 3 and review of Resident 89's MAR dated from [DATE] to [DATE], on [DATE] at 1:40 pm, the MAR dated from [DATE] to [DATE], indicated to administer Epogen injection solution 10000 unit/ml, inject 10000unit subcutaneously in the morning on Monday, Wednesday and Friday for amenia, hold if Hgb above 10 mg/dl. The MAR indicated Resident 89 received Epogen injections on [DATE], [DATE] and [DATE]. The MAR indicated Resident 89's Hgb level was 12.3 g/dL. LVN 3 stated, LVN 3 administered Epogen injections to Resident 89 on [DATE] without checking Resident 89's latest Hgb level. LVN 3 stated based on the result of Resident 89's Hgb on [DATE] (12.9 mg/dl), Resident 89 did not need the Epogen injection on [DATE]. LVN 3 stated Resident 89's Epogen injections should have been held. LVN 3 stated, LVN 3 also administered Epogen injection to Resident 89 on [DATE] when Resident 89's Hgb level was at 12.3 g/dl. LVN 3 stated LVN 3 did not read Resident 89's PO accurately before administering Epogen injections to Resident 89. LVN 3 stated, high Hgb level could result in blood clots, heart attack and strokes to Resident 89. During an interview on [DATE] at 9:48 am, with the DON, the DON stated, It was a medication error. The DON stated the facility did not follow the physicians' order and administered Epoetin injections to Residents 35 and 89 when Residents 35 and 89's Hgb level were above the prescribed parameter (specific instructions to hold when Hgb >10 mg/dl). The DON stated, licensed nurses needed to check Residents 35 and 89's most recent/current Hgb level before administering Epogen injections to Residents 35 and 89. The DON stated, when administering medication, licenses nurses needed to follow the principle of Five Rights including right patient, right drug, right dose, right route and right time. The DON stated licensed nurses needed to double check any medication ordered with a parameter to prevent medication errors. The DON stated that high levels of Hgb would cause serious side effects including blood clots, heart attack and stroke. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated ,d+[DATE], the P&P indicated Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. During a review of the facility's P&P titled, Adverse Consequences and Medication Errors, dated ,d+[DATE], the P&P indicated A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional providing services.

Based on observation, interview, and record review, the facility failed to ensure the pad sensor/call lights were within reach for three of three sampled residents (Residents 9, 14, and 34). These failures had the potential for the residents not to receive or receive delayed care that could result in a fall or accident. Findings: a. During a review of Resident 9's Admission Record (AR), the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), osteoporosis (weak and brittle bone due to lack of calcium and vitamin D) and traumatic fracture (a bone break caused by a sudden, strong force, like a fall or car accident). During a review of Resident 9's untitled Care Plan (CP) dated 6/14/2024, the CP indicated Resident 9 was at risk for falls/injury related to impaired mobility, use of psychotropic medications and unsteady gait. The CP interventions included staff to keep the resident's call light within easy reach and to encourage the resident to use it to get assistance. During a review of Resident 9's Fall Risk Assessment (FRA) dated 3/18/2025, the FRA indicated Resident 9 was assessed as high risk for fall. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool) dated 3/19/2025, the MDS indicated Resident 9 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 9 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with eating, oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene. During a concurrent observation inside Resident 9's room and interview on 4/15/2025 at 10:40 am with Certified Nurse Assistant 1 (CNA 1), Resident 9 was lying in bed, on her back with pad sensor hanging on the left siderail of the bed. CNA 1 stated Resident 9 could not reach and pull the pad sensor. CNA 1 stated Resident 9 was stronger on her right side. CNA 1 stated the pad sensor should be placed next to the strong arm and hand of Resident 9 where she could reach it and call when help was needed. b. During a review of Resident 14's AR, the AR indicated Resident 14 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), muscle weakness (decreased strength in the muscles) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting the left dominant side. During a review of Resident 14's untitled CP dated 9/14/2022, the CP indicated Resident 14 was at risk for falls/injury related to difficulty walking, generalized weakness and poor body balance control. The CP interventions included placing the call light within easy reach. During a review of Resident 14's FRA dated 3/27/2025, the FRA indicated Resident 14 was assessed as high risk for fall. During a review of Resident 14's MDS dated [DATE], the MDS indicated Resident 14 had severely impaired cognition. The MDS indicated Resident 14 was dependent (helper did all the effort, resident did none of the effort to complete the activity) with eating, oral hygiene, toileting, shower, upper and lower body dressing and personal hygiene. During a concurrent observation inside Resident 14's room and interview on 4/15/2025 at 10:57 am with Licensed Vocational Nurse 2 (LVN 2), Resident 14 was in bed, on her back with the call light on the floor on the left side of the bed. LVN 2 stated Resident 14 could not move her left arm and hand. LVN 2 stated the call light should be placed next to the strong arm and hand of Resident 14 for Resident 14 to call for assistance and staff could address her needs in a timely manner. During an interview on 4/16/2025 at 8:45 am with the Director of Nursing (DON), the DON stated the resident's call light should be placed next and close to the residents' strong arm and hand so the resident could call for help, communicate needs and for staff to assist the resident's needs promptly. 36924 c. During a review of Resident 34's AR, the AR indicated Resident 34 was readmitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (disease that affects the function or structure of the brain), Parkinson's disease (disease that affects the nerve cells in the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and gait) and muscle weakness (decreased strength in muscles). During a review of Resident 34's History & Physical (H&P) dated 10/27/2024, the H&P indicated Resident 34 had the capacity to make decisions for activities of daily living (ADLs- basic self-care tasks). During a review of Resident 34's Fall Risk CP revised 1/29/2025, the CP indicated to place Resident 34's call light within easy reach. During a review of Resident 34's MDS dated [DATE], the MDS indicated Resident 34 had severely impaired cognition (ability to understand and process thoughts), and required substantial/maximal assistance with sit to stand, toileting, shower and bathing, personal hygiene and walking 10 feet. During a review of Resident 34's FRA dated 3/3/2025, the FRA indicated Resident 34 was assessed as high fall risk. During an observation on 4/15/2025 at 10:50 a.m. in Resident 34's room, Resident 34's call light was on the floor and not within Resident 34's reach. During an observation and interview on 4/15/2025 at 11:00 a.m. with the Director of Rehabilitation (DOR), the DOR stated the DOR observed Resident 34's call light on the floor. During a concurrent observation and interview on 4/15/2025 at 11:27 a.m., with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated the call light should not be on the floor because the floor was dirty and for infection control. During an interview on 4/18/2025 at 10:53 a.m. with the facility's DON, the DON stated it was the facility's policy to keep the residents' call light within easy reach. The DON stated the importance of the call light being within easy reach was for the resident to access right away when the resident needed assistance and to prevent falls for residents who were assessed as high risk for fall. During an interview on 4/19/2025 at 10:34 a.m. with LVN 11, LVN 11 stated interventions for fall risk residents included low bed, frequent checks, call light within reach and floor mat. LVN 11 stated it was important that the resident's call light was within reach for access and to call for assistance and for the residents not to get up unsupervised. During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's P&P titled, Call System, Residents, dated 9/2022, the P&P indicated, Each resident is provided with a means to call staff directly for assistance from his/her bed. From toileting/bathing facilities and from the floor. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

Based on interview and record review, the facility failed to ensure two of three sampled residents' (Resident 16 and 23's) swallowing/nutritional status was accurately assessed and coded in Resident 16 and 23's Minimum Data Set (MDS- a resident assessment tool). This deficient practice resulted in inaccurate reporting to the Centers for Medicare and Medicaid Services (CMS, a federal agency that administers major healthcare programs in the United States) and had the potential for Residents 16 and 23 to not receive interventions to address specific care concerns. Findings: a. During a review of Resident 23's Admission Record (AR), the AR indicated Resident 23 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23 had severely impaired cognition (ability to think, learn, and remember) for daily decision making. The MDS indicated Resident 23 required partial/moderate assistance (helper does less than half the effort) with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 23 required substantial/maximal assistance with toileting hygiene, showering/bathing self, and upper and lower body dressing. The MDS indicated Resident 23 had a weight loss of five (5) percent (%) or more in the last month or 10% or more in last six (6) months of the assessment. The MDS indicated Resident 23 had no weight gain of 5% or more in the last month or gain weight of 10% or more in last 6 months of the assessment. During a review of Resident 23's Weights and Vitals Summary (WVS) from 1/1/2024 to 4/30/2025, the WVS indicated Resident 23 had a weight gain of eight (8) pounds (lbs.- unit of weight) from 79 lbs. on 8/5/2024 to 87 lbs. on 2/5/2025 (period of six month). The WVS indicated Resident 23 had a weight gain of seven (7) lbs. from 80 lbs. on 1/6/2025 to 87 lbs. on 2/5/2025 (period of one month). During a concurrent interview and record review on 4/16/2025 at 8:58 am with the MDS Nurse (MDSN), Resident 23's MDS dated [DATE] was reviewed. The MDSN stated Resident 23's MDS needed to be coded with no weight loss and with weight gain. The MDSN stated Resident 23 had a weight gain of 7 lbs. in a month from 1/6/2025 to 2/5/2025 with a significant weight gain of 7.5%. The MDSN stated Resident 23's MDS assessment needed to be coded accurately to give accurate information to CMS. During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, dated 11/2019, the P&P indicated any person completing a portion of the MDS must sign and certify the accuracy of that portion of the assessment. The P&P indicated the information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. 40037 b. During a review of Resident 16's AR, the AR indicated Resident 16 was readmitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and respiratory failure (lungs are unable to adequately exchange oxygen). During a review of Resident 16's Minimum Data Set (MDS, a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 16 had unclear speech, did not have the ability to understand others and to make self-understood. The MDS indicated Resident 16 was dependent (helper does all of the effort) for personal hygiene, upper and lower body dressing, and rolling left and right. The MDS indicated Resident 16 had a weight loss of 5% (percent) or more in the last month or weight loss of 10% or more in the last six months. During a review of Resident 16's Weight and Vitals Summary (WVS) from 8/1/1024 to 4/30/2025, the WVS indicated Resident 16's weight was 108 lbs. (pound) on 9/24/2024, 110 lbs. on 2/5/2025 and 115 lbs. on 3/5/2025. The WVS indicated Resident 16 had a weight gain of 5 lbs. from 2/5/2025 to 3/5/2025 and a weight gain of 7 lbs. from 9/24/2024 to 3/5/2025. During an interview and concurrent record review on 4/16/2025 at 10:05 am, with the MDS Coordinator (MDS C), the MDS C stated, Resident 16's MDS was coded incorrectly in Resident 16' MDS dated [DATE]. MDS C stated Resident 16 actually had a weight gain during the identified period of time. The MDS C stated, Resident 16 had weight gain of 5 lbs. from 2/5/2025 to 3/5/2025, a weight gain of 7 lbs. from 9/24/2024 to 3/5/2025, and there was no weight loss during the last month's review and last six month's review from the MDS dated [DATE]. The MDS C stated the MDS C did not check Resident 16's WVS to ensure the correct weight information before MDS C entered the data in the MDS dated [DATE]. The MDS C stated it was important to ensure accuracy of Resident 16's weight entered in the MDS because it could affect resident's quality of care.

Based on observation, interview, and record review, the facility failed to change the dressing (a clean or sterile covering) every seven (7) days for two of two sampled residents' (Resident 63's and 294's) central line (a flexible tube inserted into a vein in the neck, chest, arm or groin) and midline intravenous (IV- existing or taking place within a vein/s) catheter (a long, thin, flexible tube that is inserted in the upper arm with the tip located just below the axilla [armpit]) in accordance with Resident 63's and Resident 294's care plan and the facility's policies and procedures (P&P) titled, Midline Catheter Dressing Change, and Peripheral and Midline IV Dressing Changes. This failure had the potential to result in an infection for Resident 63 and 294 and worsen Resident 63's and 294's health condition. Findings: a. During a review of Resident 294's Admission Record (AR), the AR indicated Resident 294 was admitted to the facility on [DATE], with diagnoses that included other acute osteomyelitis (infection of the bone) and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control) with diabetic polyneuropathy (nerves in various part of the body are damaged by elevated blood sugar levels). During a review of Resident 294's Physicians Order (PO) dated 4/3/2025, the PO indicated for staff to change (Resident 294's) central line and midline (catheter) every day shift, every seven (7) days for site care, until 4/28/2025. The PO indicated for staff to change all central line, peripherally inserted central catheter (PICC- a type of central line inserted into a vein in the arm and threaded to a large vein near the heart) and midline transparent dressings per sterile (free from bacteria or living microorganism) technique (upon admission if not dated or site not visible for assessment). The PO indicated for staff to change injection cap to each lumen (passageway inside the catheter) and change securement device. During a review of Resident 294's Care Plan (CP) titled Care Plan Report, revised 4/3/2025, the CP indicated Resident 294 required IV therapy related to osteomyelitis and had the potential for infection and/or complications related to IV access and medication administration. The CP interventions included for the nursing staff to change the dressing, needleless access device and securement device every 7 days and as needed (PRN) using a transparent dressing for central line, PICC line, and/or midline. During a review of Resident 294's Minimum Data Set (MDS, a resident assessment tool), dated 4/8/2025, the MDS indicated Resident 294 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 294 needed substantial/maximal assistance (helper does more than half the effort) from staff for toileting hygiene, showering/bathing self, lower body dressing, and personal hygiene. During a concurrent observation and interview on 4/15/2025 at 9:55 a.m. with the Director of Staff Development (DSD), Resident 294 was awake, lying in bed, with a midline IV catheter on Resident 294's right arm. Resident 294's midline IV catheter dressing was observed with a date of 4/1/2025. The DSD stated Resident 294's midline IV catheter dressing was dated 4/1/2025. During an interview on 4/16/2025 at 8:48 a.m. with the Director of Nursing (DON), the DON stated the resident's (in general) midline IV transparent dressing and securement device needed to be changed every 7 days to prevent infection on the site. During a concurrent interview and record on 4/16/2025 at 9:04 am with Registered Nurse 1 (RN) 1, Resident 294's electronic medical record was reviewed. RN 1 stated RN 1 did not change Resident 294's midline IV catheter transparent dressing based on the PO since 4/1/2025. RN 1 stated Resident 294's midline IV site dressing needed to be changed every 7 days or PRN to prevent infection. During a review of the facility's P&P titled, Midline Catheter Dressing Change, revised 3/2023, the P&P indicated, dressing changes using transparent dressings are performed upon admission, at least weekly, and if the integrity of the dressing has been compromised (wet, loose or soiled). The P&P indicated to change catheter securement device every 7 days and as needed. The P&P indicated, to change antimicrobial disc every 7 days and PRN. The P&P indicated to label dressing with date, time, and nurse's initials. 40438 b. During a review of Resident 63's AR, the AR indicated, Resident 63 was initially admitted on [DATE], and readmitted on [DATE], with diagnoses that included diabetes mellitus, hemiplegia (complete paralysis [loss of the ability to move] on one side of the body) and hemiparesis (partial weakness on one side of the body). During a review of Resident 63's MDS, dated [DATE], the MDS indicated Resident 63 had an intact cognition. The MDS indicated Resident 63 required partial/moderate assistance (helper does less than half the effort) with oral hygiene, required substantial/maximal assistance with upper body dressing, and was dependent (helper does all of the effort) on staff for toileting hygiene, showering/bathing, lower body dressing, and personal hygiene. During a review of Resident 63's CP titled, Care Plan Report, dated 4/8/2025, the CP indicated Resident 63 had the potential for infection and/or complications related to IV access and medication administration. The CP interventions included for staff to change the dressing and securement device every 7 days and PRN using a transparent dressing or every 48 hours if using gauze (a very thin fabric with loose open weave) dressing. During a concurrent observation and interview on 4/15/2025 at 10:10 am with Licensed Vocational Nurse (LVN) 1, inside Resident 63's room, Resident 63 had a midline IV on Resident 63's right upper arm. LVN 1 stated the midline IV was covered with white gauze dressing. LVN 1 stated the midline IV site dressing was not labeled with the date when it was inserted or changed. LVN 1 stated the midline IV site dressing should be labeled with the date to know when it was started and the last time the dressing was changed to prevent infection to the site. During an interview on 4/16/2025 at 8:47 am with the DON, the DON stated midline dressing should be changed every 7 days and PRN. The DON stated IV site dressing should be labeled with the date of when it was inserted and the date when the dressing was changed to keep the IV site clean and for infection control. During a review of the facility's P&P titled, Peripheral and Midline IV Dressing Changes, revised March 2023, the P&P indicated, Place new dressing (TSM [transparent semi-permeable (allowing for moisture and gas exchange) membrane] or gauze) over insertions site. Label dressing with the date and time of dressing change, and initials.

The facility failed to provide a 24-hour sufficient nursing staffing on one of fourteen Saturdays and one of fourteen Sundays for Quarter 1 of 2024 (10/1/2024 to 12/31/2024) consistent with Payroll Based Journal (PBJ, a system for collecting and reporting staffing information from nursing homes and other long-term care facilities) Staffing Data Report. The facility did not meet the required 2.4 Certified Nursing Assistant (CNA) direct care hours per patient day on 12/1/2024 and 12/14/2024. These failures had the potential to affect the quality of care and negatively affect the resident's quality of life in the facility. Findings: During a review of the facility's PBJ Staffing Data Report for Quarter 1 for 2024, from 10/1/2024 to 12/31/2024, the PBJ staffing Data Report indicated the facility had an excessively low weekend staffing. During a concurrent interview and record review on 4/18/2025 at 2:18 pm with the Director of Staff Development (DSD), the Weekend Nursing Staffing Assignment and Sign in Sheet from 10/1/2024 to 12/31/2024, the weekend Direct Care Service Hours Per Patient Day (DHPPD, refers to the actual hours of work performed per patient day by a direct caregiver) from 10/1/2024 to 12/31/2024, and the Staffing Summary report from 10/1/2024 to 12/31/2024, were reviewed. The DSD stated the nursing staffing and sign in sheet and ending census were verified and calculated as actual DHPPD wherein 2.4 hours were actual CNA DHPPD. The DSD stated completed DHPPD form were transmitted to the California Department of Public Health (CDPH). The DSD stated the DHPPD on 12/1/2024 was 2.04 actual CNA hours and on 12/14/2024 was 2.15 actual CNA hours. The DSD stated the facility did not meet the required 2.4 CNA direct care hours per patient day on 12/1/2024 and 2/14/2024. During an interview on 4/19/2025 at 4:15 pm with the Director of Nursing (DON), the DON stated the quality of care could be compromised if there were fewer nursing staff working. The DON stated the facility was struggling with the CNA hours last October 2024 to December 2024. The facility DON stated facility should have sufficient staff for every shift to meet the resident's needs. During a review of the facility's Policy and Procedure (P&P) titled, Nurse/Patient Staffing Policy, undated, the P&P indicated, the facility will employ sufficient nursing staff to ensure that the following nursing staffing hours are met: minimum daily average of 2.4 actual CNA hours per patient day. During a review of the facility's P&P titled, Staffing, Sufficient and Competent Nursing, revised 8/2022, the P&P indicated, the staffing numbers and requirements of direct care staff will be in compliance with the 3.5 and 2.4 minimum standards.

Based on observation, interview, and record review, the facility failed to provide safe and sanitary environment to help prevent the development and transmission of communicable diseases for three of five sampled residents (Residents 5, 24, and 1) by failing to: a. Ensure staff implemented the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precaution (EBP, precautions that include the use of a gown and gloves during high contact resident care activities for residents), to prevent the spread of infections for Residents 5 and 24. b. Ensure Resident 1's oxygen tubing was not on the floor. These failures had the potential to result in transmission of multidrug-resistant organisms (MDRO, bacteria that is resistant to antibiotics (medicine used to stop or kill the growth of bacteria) to other residents in the facility. Findings: a1. During a review of Resident 5's Admission Records (AR), the AR indicated Resident 5 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included respiratory failure (occurs when the lungs could not suitably exchange gases, causing abnormal levels of carbon dioxide and/or oxygen in the arteries), dementia (a progressive state of decline in mental abilities), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 4/7/2025, the MDS indicated, Resident 5 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 5 was dependent (helper did all the effort, resident did none of the effort) on staff for oral hygiene, toileting, showering/bathing, upper and lower body dressing, and personal hygiene. During a review of Resident 5's Physician Order (PO), dated 11/13/2024, the PO indicated, Resident 5 had an order for EBP due to gastrostomy tube (GT, a feeding tube surgically inserted into the stomach through the abdominal wall). a2. During a review of Resident 24's AR, the AR indicated, Resident 24 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included stage 4 pressure ulcer (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (triangular bone at the base of the spine that forms part of the pelvis), obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed) and dementia (a progressive state of decline in mental abilities). During a review of Resident 24's MDS, dated [DATE], the MDS indicated, Resident 24 had severely impaired cognition. The MDS indicated Resident 24 required partial/moderate assistance (helper did less than half the effort) with eating, oral hygiene, and was dependent (helper did all the effort, resident did none of the effort to complete the activity) on staff for personal hygiene, showering/bathing, and lower body dressing. During a review of Resident 24's PO, dated 11/24/2024, the PO indicated, Resident 24 had an order EBP for sacrococcyx wound (a type of pressure injury that occurs in the sacrum and tailbone). During a concurrent observation and interview on 4/15/2025 at 10:54 am with Licensed Vocational Nurse (LVN) 1, inside Resident 5's room, LVN 1 was checking Resident 5's GT for placement and residuals. LVN 1 was wearing a yellow gown and gloves. During an observation on 4/15/2025 at 10:58 am with LVN 1, inside Resident 24's room, Resident 24 was in bed on her back with an indwelling Foley Catheter (FC, a flexible tube inserted into the bladder to drain urine). LVN 1 was checking Resident 24's FC tubing for the presence of white sediments in the tubing. LVN 1 did not change LVN 1's gown and gloves LVN 1 used while providing care for Resident 5 before proceeding to Resident 24. During an interview on 4/15/2025 at 11 am with LVN 1, LVN 1 stated Residents 5 and 24 were both on EBP precaution. LVN 1 stated LVN 1 needed to change LVN 1's gown and gloves for every encounter with residents on EBP to prevent the spread of infection. During an interview on 4/16/2025 at 8:50 am with the Director of Nursing (DON), the DON stated gown and gloves should be donned and changed when in close contact with EBP residents to prevent cross-contamination of infection between residents. During a review of the facility's &P titled, Enhanced Barrier Precaution, undated, the P&P indicated, Perform hand hygiene, wear gowns and gloves while performing the following tasks associated with residents who require Enhance Barrier precaution: Morning and evening care, device care, for example, urinary catheter, feeding tube, tracheostomy, vascular catheter, any care activity where close contact with the resident is expected to occur such as bathing, peri-care, assisting with toileting, changing incontinence briefs, transferring, respiratory care . In multi-bedrooms, consider each bed space as a separate room and change gowns and gloves and perform hand hygiene when moving from contact with one resident to contact with another resident. 36924 b. During a review of Resident 1's AR, the AR indicated the facility readmitted the resident on 12/19/24 with diagnoses that included acute respiratory failure (lungs cannot properly exchange gases), schizoaffective disorder (mental illness) and chronic obstructive pulmonary disease (COPD- lung diseases that block airflow). During a review of Resident 1's History & Physical (H&P) dated 7/26/24, the H&P indicated Resident 1 had the capacity to make medical decisions. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 was cognitively intact. The MDS indicated Resident 1 was on oxygen therapy. During an observation on 4/19/25 at 11:15 a.m., Resident 1's oxygen tubing was on the floor. During a concurrent observation and interview on 4/19/25 at 11:17 a.m., with Licensed Vocational Nurse 9 (LVN 9), LVN 9 stated Resident 1's oxygen tubing was not supposed to be on the floor. LVN 9 stated it was important to keep the oxygen tubing off the floor for infection control. During an interview on 4/19/25 at 4:00 p.m., with the DON, the DON stated it was important that oxygen tubing was not on the floor to deliver oxygen adequately to the resident and for infection control. During an interview on 4/19/25 at 4:07 p.m., with the Infection Preventionist (IP), the IP stated it was important to keep the oxygen tubing off the floor to prevent infection. IP stated oxygen tubing on the floor was a hazard for tripping over causing trauma to the resident/staff. During a review of the facility's undated Policy and Procedure (P&P) titled, Oxygen Administration, the P&P indicated oxygen tubing should be used in a manner that prevents it from touching the floor.

Based on interview and record review, the facility failed to provide nursing care and services for one of five sampled residents (Resident 1) by failing to: 1. Ensure Registered Nurse (RN) 2 reconciled (comparing a resident's medication orders to the medications he/she has been taking to avoid medication errors) Resident 1's insulin [medication used to help the body turn food into energy and control blood-sugar/glucose (BS) levels] per Resident 1's physician order for insulin aspart (rapid-acting insulin that helps lower mealtime blood-sugar spikes) per sliding scale (varies the dose of insulin based on the BS level prior to insulin administration, the higher the BS level, the higher the insulin dose) when Resident 1 was readmitted from General Acute Care Hospital (GACH) 1 to the facility on [DATE]. 2. Ensure RN 2 reconciled Resident 1's tacrolimus (medication used to prevent the body from rejection organ-transplant/replacement) when Resident 1 was readmitted from GACH 1 to the facility on [DATE]. 3. Ensure Resident 1's Primary Care Physician (MD) 1 and Nurse Practitioner (NP) 1 reviewed Resident 1's Discharge Summary for medications ordered from GACH 1 on 11/22/2023. As a result, Resident 1 did not receive insulin aspart per sliding scale nor tacrolimus from 11/22/2023 to 11/29/2023 (eight days). These failures also had the potential to result in Resident 1 being hospitalized for uncontrolled BS levels, kidney, and pancreas (a gland that secretes enzyme/substance into the intestine/gut to help with digestion) organ transplant rejection (happens when the body's immune system treats the transplanted organ like a foreign object and attacks it), and/or death. On 11/30/2023 at 1:15 pm, while onsite at the facility, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified. The surveyor notified the Administrator (ADM) and Director of Nursing (DON) regarding the facility's failure to enter Resident 1's medications from GACH 1's discharge medication orders upon Resident 1's readmission to the facility on [DATE]. The facility's ADM and DON were aware Resident 1 who had diagnoses of type 2 Diabetes Mellitus (DM 2, chronic condition that affects the way the body processes BS), and a history of kidney and pancreas transplant, had not received insulin nor tacrolimus for eight days. On 12/1/2023 at 3:40 pm, while onsite at the facility, the IJ was removed in the presence of the ADM, after the ADM and DON submitted an acceptable IJ Removal Plan (interventions and implementations to correct the deficient practices). The surveyor verified and confirmed the facility's implementations of the IJ Removal Plan through observation, interview, and record review. The IJ Removal Plan, dated 12/1/2023, indicated the following: I. On 11/29/2023, the DON and RN Supervisor (RNS) called MD 1 and reconciled Resident 1's medications and other orders. The facility obtained orders for STAT (immediate) blood work, insulin aspart U-100 (Novolog [brand name for aspart] per sliding scale: Inject as per sliding scale: 0 - 150 millimoles per liter (mmol/L) = 0 unit (no coverage), if BS is less than 70, give 8 ounces (OZ, unit of volume) of orange juice and notify the MD. 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. If BS is above 400, give 12 units and notify MD, subcutaneously (injection under the skin) after meals and at bedtime and tacrolimus [1 milligram (mg, unit of volume) daily and 2 mg at bedtime]. II. On 11/29/2023, Resident 1's BS was obtained as ordered and insulin was administered accordingly per sliding scale. III. On 11/30/2023, Resident 1 started receiving tacrolimus as ordered. IV. On 11/30/2023, the DON conducted a one-on-one (1:1) in-service with RN 2 regarding the facility's policy and procedure on medication therapy with emphasis in ensuring medications and monitoring orders were reconciled and validated with MD's (in general) and resident's Responsible Party (RP, a person responsible for paying resident's bills or making healthcare decisions) upon admission or readmission. V. On 11/30/2023, DON and RNS obtained an order to monitor Resident 1 for signs and symptoms of graft rejection (transplant recipient's immune system attacks the transplanted organ or tissue) every shift for 14 days. VI. On 11/30/2023, MD 1 assessed Resident 1 for any adverse consequences of missed insulin coverage and tacrolimus. VII. On 11/30/2023, the facility obtained referrals for Nephrology (physician who specializes in kidneys) and Endocrinology (physician who specializes in hormones) consultations. VIII. On 12/1/2023, the Quality Assurance Consultant (QAC) discussed the missed medications (insulin and tacrolimus) for Resident 1 with the facility's pharmacist (PHAM 1). PHAM 1 recommended to continue tacrolimus and obtain blood work as follows: Tacrolimus blood levels (blood test to monitor therapeutic levels for organ rejection medication, tacrolimus) and liver function test (blood tests that measure different substances made by the liver). VIIII. Daily, during clinical meetings, the DON and/or designee will review admissions and readmissions medication orders to ensure the medications from the hospitals and all medications necessary to treat resident's (in general) existing conditions were verified with MD 1 and resident and/or responsible party and transcribed into the resident's record. Any findings would be corrected immediately. X. During the MD (in general) visit, the MD (in general) would verify the accuracy of verbal and telephone orders of when the orders were given and would authenticate, co-sign, and date the orders in a timely manner. Findings: a. During a review of Resident 1 Admission Record, the Admission Record indicated the facility admitted Resident 1 on 3/28/2022 and readmitted on [DATE] with diagnoses that included DM 2, pancreas transplant status, and kidney transplant status. During a review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 9/26/2023, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 required supervision (oversight, encouragement, or cueing) with bed mobility, and eating. The MDS indicated Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) with transfers, locomotion (movement or the ability to move from one place to another), dressing, toilet use, and personal hygiene. During a review of Resident 1's telephone order, dated 11/16/2023 at 4:35 pm, the order indicated to transfer Resident 1 to GACH 1 for evaluation and treatment of back pain and burning upon urination (resident is kidney and pancreatic transplant). During a review of Resident 1's Patient Visit Information (Discharge Summary [D/C Summary, a clinical report prepared by a health professional at the conclusion of a hospital stay]) from GACH 1, dated 11/22/2023, the D/C Summary indicated Resident 1 was discharged from GACH 1 back to the facility on [DATE]) and the discharge action plan included to continue insulin aspart U-100 sliding scale , The D/C Summary indicated blood-sugar level would be obtained prior to insulin dose (if needed) by finger stick (prick on the side of the finger with a needle to test blood-sugar levels). The D/C Summary indicated insulin would be administered per the sliding scale based on Resident 1's BS level. The D/C Summary indicated the amount of insulin to be given to Resident 1 was based on Resident 1's BS at the time of finger stick. During a review of Resident 1's Admission Assessment (AA) dated 11/22/2023 at 11:58 pm, the AA indicated Resident 1 was admitted back to the facility on [DATE] at 8 pm. The AA indicated RN 2 signed the AA. During an interview on 11/29/2023 at 11:55 am, with Resident 1, Resident 1 stated Resident 1 had not received insulin medication for a week. Resident 1 stated it was possible Resident 1 had not received other medications. Resident 1 stated insulin had not been given to Resident 1 and Resident 1's BS had not been checked since Resident 1 was readmitted to the facility on [DATE]. Resident 1 stated Resident 1 asked nursing staff (unable to identify) about Resident 1's insulin but staff told Resident 1 the insulin order was discontinued. Resident 1 stated it was confusing because Resident 1 was receiving insulin before being hospitalized and Resident 1 had DM 2. Resident 1 stated Resident 1 got light-headed a few days prior to today (11/29/2023). Resident 1 stated staff gave Resident 1 juice but did not check Resident 1's BS level. Resident 1 stated Resident 1 felt brushed off by staff when asking about not receiving insulin or BS checks. Resident 1 stated it felt like staff were not taking Resident 1's concerns seriously. Resident 1 stated Resident 1 was worried something bad would happen to Resident 1 because Resident 1's BS was not being monitored. During a concurrent interview and record review on 11/29/2023 at 12:47 pm, with the MDS Nurse (MDSN), Resident 1's Order Summary Report OSR, dated 11/29/2023 was reviewed. MDSN stated Resident 1 did not have an active order for insulin per sliding scale. The MDSN stated Resident 1's insulin per sliding scale order was discontinued (unable to provide the MD order who discontinued the insulin per sliding scale order) on 11/22/2023. During a concurrent interview and record review on 11/29/2023 at 1 pm, with RN 1, Resident 1's D/C Summary, dated 11/22/2023 and the Medication Administration Record (MAR), dated November 2023 were reviewed. Resident 1's D/C Summary indicated for Resident 1 to continue to receive the insulin aspart per sliding scale: Inject as per sliding scale: 0 - 150 mmol/L= 0 unit (no coverage), if BS is less than 70, give 8 ounces (OZ, unit of volume) of orange juice and notify the MD. 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. If BS is above 400, give 12 units and notify MD and tacrolimus 1 mg daily and 2 mg at bedtime. RN 1 stated when Resident 1 was readmitted to the facility on [DATE] Resident 1's GACH 1 D/C Summary indicated to continue insulin aspart per sliding scale. RN 1 stated Resident 1's MAR did not indicate insulin aspart was administered per sliding scale to Resident 1 from 11/22/2023 to 11/29/2023 (eight days). RN 1 stated Resident 1 was currently not on any insulin medication since being readmitted to the facility on [DATE] as indicated by the x marks on Resident 1's MAR. RN 1 stated Resident 1 had not been monitored for Resident 1's BS since Resident 1 was readmitted to the facility on [DATE], as indicated by the x marks on Resident 1's MAR. RN 1 stated the purpose of administering Resident 1's insulin was to treat Resident 1's DM 2. RN 1 stated not receiving insulin could cause Resident 1's medical condition to decline and lead to hospitalization or death. During a concurrent telephone interview and record review on 11/29/2023 at 4:40 pm, with NP 1, NP 1 reviewed Resident 1's GACH 1 D/C Summary, dated 11/22/2023. NP 1 stated NP 1 took (accepted) Resident 1's admitting orders on 11/22/2023. NP 1 stated NP 1 was not aware Resident 1 was taking insulin. During a concurrent interview and record review on 11/29/2023 at 5:30 pm, with Medical Records Staff (MRS), MRS stated Resident 1 did not have any new orders for insulin aspart per sliding scale since Resident 1's readmission to the facility on [DATE]. During an interview on 11/29/2023 at 6:10 pm, with the Director of Nursing (DON), the DON stated when residents (in general) return from GACH (in general), the nurses (in general) need to look at the residents' (in general) D/C Summary. RN 1 stated Resident 1's nurse should have called MD 1 to reconcile medications that needed to be restarted based on the GACH 1's D/C summary list. The DON stated if medications are not reconciled with the MD 1, it was possible RN 2 missed the reconciliation. The DON stated, if residents (in general) were alert enough, the residents would tell what medication they need to take or not take. The DON stated Resident 1 was alert enough to tell staff if Resident 1 was missing medication. The DON stated if Resident 1 told Resident 1's nurses (in general) that Resident 1 did not receive certain medications, the nurse should have reviewed the D/C Summary and compared the D/C Summary to Resident 1's OSR, MAR, and call MD 1 to ask about the missing medication. During a telephone interview on 11/30/2023 at 9:02 am, with RN 2, RN 2 stated RN 2 readmitted Resident 1 back to the facility and completed the AA. RN 2 stated the MDSN assisted RN 2 with Resident 1's readmission by taking report from GACH 1. RN 2 stated RN 2 did not see sliding scale parameters for the insulin order. b. During a concurrent interview and record review on 11/29/2023 at 12:47 pm, with MDSN, Resident 1's OSR, dated 11/29/2023 was reviewed. The MDSN stated the MDSN received report from GACH 1's staff (unidentified) before Resident 1 was readmitted on [DATE]. The MDSN stated the MDSN did not remember receiving report regarding Resident 1 being on tacrolimus. The MDSN stated Resident 1's tacrolimus 1 mg daily and tacrolimus 2 mg at bedtime were discontinued (unable to provide the MD order to D/C the tacrolimus medication orders) on 11/22/2023. During a concurrent interview and record review on 11/29/23 at 1 pm, with RN 1, Resident 1's GACH 1 D/C Summary, dated 11/22/2023 and the MAR, dated November 2023 were reviewed. RN 1 stated when Resident 1 was readmitted to the facility on [DATE], the D/C Summary indicated to continue tacrolimus 1 mg (daily) and tacrolimus 2 mg (daily at bedtime). RN 1 stated tacrolimus was a transplant anti-rejection medication. RN 1 stated tacrolimus was a vital medication to Resident 1's medical conditions. RN 1 stated tacrolimus stopped Resident 1's body from rejecting Resident 1's transplanted organs. RN 1 stated without the medication (tacrolimus), Resident 1 could die. RN 1 stated Resident 1's MAR did not indicate tacrolimus was administered to Resident 1 from dates 11/22/2023 to 11/29/2023 (eight days). During a concurrent telephone interview and record review on 11/29/2023 at 4:40 pm, with NP 1, NP 1 reviewed Resident 1's GACH 1 D/C Summary, dated 11/22/2023. NP 1 stated NP 1 was not aware Resident 1 was taking tacrolimus. During a concurrent interview and record review on 11/29/2023 at 5:30 with MRS, the ORS, dated 11/29/23 was reviewed. The MRS stated Resident 1 did not have any new orders for tacrolimus 1 mg, daily nor 2 mg, at bedtime since Resident 1's readmission to the facility on [DATE]. During an interview 11/29/2023 at 6:10 pm, with the DON, the DON stated when residents (in general) return from GACH, the nurses (in general) had to look at the residents' D/C Summary. RN 1 stated Resident 1's nurse (RN 2) should have called Resident 1's MD to reconcile medications that needed to be restarted based on the D/C summary. During a telephone interview on 11/30/2023 at 9:02 am, with RN 2, RN 2 stated not receiving tacrolimus was life-threatening to Resident 1. c. During a review of Resident 1's AA, dated 11/22/2023 at 11:58 pm, the AA indicated RN 2 notified MD 1 at 9 pm that Resident 1 was readmitted back to the facility. The AA indicated RN 2 signed Resident 1's AA. During a concurrent telephone interview and record review on 11/29/2023 at 4:40 pm, with MD 1 and NP 1, MD 1 and NP 1 reviewed Resident 1's GACH 1 D/C Summary, dated 11/22/2023. NP 1 stated NP 1 was not aware Resident 1 was taking insulin and tacrolimus. NP 1 stated she informed the facility nurse (unable to identify) to resume all of Resident 1's previous medications.NP 1 stated there were communications with facility's nurses about tacrolimus and insulin, but NP 1 did not have evidence of such communications. NP 1 stated Resident 1 was assessed by NP 1 on 11/23/2023, but NP 1 did not review Resident 1's MAR nor GACH 1 D/C Summary. MD 1 stated MD 1 had too many patients to keep track of and expected the facility to continue all medications indicated in the hospital D/C Summary. During a review of the facility's policy and procedure (PP) titled, Reconciliation of Medications on Admission, revised 7/2017, the PP indicated the facility would ensure medication safety by accurately accounting for the resident's medications routes and dosages upon admission or readmission to the facility. The PP indicated to prepare by gathering the approved medication reconciliation form, D/C Summary from the referring hospital, and most recent MAR if the resident was being readmitted . The general guidelines in the PP indicated that medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care, and medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. The PP indicated to review the list carefully to determine if there were discrepancies/conflicts. The PP indicated if there was a discrepancy or conflict in medications to contact the nurse or physician from the referring facility, discuss with the resident or family, and contact the admitting physician. The PP indicated to document the medication discrepancy on the medication reconciliation form, document what actions were taken by the nurse to resolve the discrepancy and how the discrepancy was communicated to the charge nurse, physician, pharmacy and/or next shift. During a review of the facility's PP titled, Admission Assessment and Follow Up: Role of the Nurse, revised 9/2012, the PP indicated to reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution. During a review of the facility's PP titled, Admission Criteria, revised 3/2023, the PP indicated the facility admits residents who had medical and nursing care needs can be met. The PP indicated prior or at the time of admission, the resident's attending physician provide the facility with information needed for the immediate care of the resident, including orders covering medication orders.

Based on interview and record review, the facility failed to implement interventions to supervise and prevent the fall incident to one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 to sustain a facial and rib fracture (broken bone) during the fall incident. Findings: A review of the clinical record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the facility's census dated 10/7/2015 indicated Resident 1 was no longer at the facility since 9/17/2015. A review of the Multidisciplinary Record, dated 9/16/2015, indicated Resident 1's safety alarm went off at 4:05 a.m. License Vocational Nurse (LVN 1) went to the room and found Resident 1 on the floor lying down with a skin tear on the right thumb with slight bleeding, a laceration (a deep cut on the skin) on the right cheek, and swollen right eye. Resident 1 was transported to the acute hospital by ambulance on 9/17/2016, at 4:10 a.m During an interview with the Director of Nursing (DON) on 9/30/2015 at 2:20 p.m., stated Resident 1 had multiple fractures from a fall in 2014 before Resident 1's admission to the facility on [DATE]. DON also stated Resident 1 fell while put on one to one supervision by CNA 1. CNA 1 who was assigned to Resident 1 had gone to check another resident leaving Resident 1 unsupervised. When CNA 1 came back, Resident 1 was already on the floor. A review of facility's Fall Risk Assessment form dated 1/07/2015, 3/13/2015, 6/23/2015 and 9/17/2015, indicated a total score of 30-34 which identified Resident 1 was high risk for fall. Resident 1's Fall Risk Assessment included: fracture (broken bone) related to a fall in the past six (6) months prior to admission, disoriented time, place and person. Resident 1 was chair bound/required restraints/assistance with elimination, poor vision (with or without glasses), presence of contractures (chronic loss of joint motion due to structural changes in non-bony tissue), and unsteady gait (problem in walking). A review of Facility Daily Assignment dated 9/16/2015 11:00 p.m. to 07:00 a.m. shift indicated staffing consisted of four (4) licensed nurses and four (4) Certified Nursing Aides (CNA) for a census of 70 residents for both station 2 (second floor) and station 3 (third floor) skilled nursing. CNA staffing indicated one (1) CNA had a split assignment of five (5) residents in station 2 and 12 residents in station 3 (total of 17 residents) for CNA 1. Another CNA had fourteen (14) residents in station 2 (CNA 2). CNA 2 went on break from 3:30 a.m. to 4 a.m. and CNA 1 took over CNA 2's residents plus her own assignment with the total of 17 residents. On 5/25/2016 at 1:50 p.m., an interview and record review with the Minimum Data Set (MDS- and assessment and care planning tool) coordinator was conducted and stated Resident 1 was a fall risk. MDS coordinator stated care plans were done on a quarterly basis and confirmed there was no care plan developed for fall prevention for June 2015. A telephone interview was conducted on 5/26/2016 at 11:00 a.m., with CNA 1. CNA 1 stated on 9/16/2015, during the 11 p.m. to 7 a.m. shift, she was relieving CNA 2 who was on a break. CNA 1 stated, she was working and assigned also in station 3 (her regular floor) when the fall incident happened. CNA 1 stated she had just been in Resident 1's room and saw Resident 1 sleeping (unable to state the time). She had left Resident 1's room when she heard yelling for help in one of the rooms (she did not remember the time). CNA 1 also stated she went back to Resident 1's room when she found Resident 1 lying down on the floor then called for help. CNA 1 also stated Resident 1 did not have a floor mat. During an interview on 5/27/2016 at 09:00 a.m., DON stated Resident 1 had a (prior) fall on June 28, 2015 at 1:30 a.m., that was investigated. She stated that Resident 1 was transported to an acute hospital by ambulance for evaluation. DON stated Resident 1 did not sustain any fracture and the facility created a care plan after that incident. During a review of the Computerized Tomography Scan (CT Scan- is an x-ray equipment to make cross-sectional pictures of body parts) dated 6/28/2015 showed no intracranial hemorrhage (bleeding within the skull of the head) or acute abnormality in the brain. There were fractures in the anterior (front) and lateral (side) of the right maxilla (upper jawbone) with hemorrhagic (bleeding) fluid in the right maxillary sinus (space within a bone especially on the face). During the review of the Interact Assessment form dated 6/28/2015, the record indicated that Resident 1 was on his right side on the floor with redness on his right temple facial area, right shoulder and minimal bleeding coming from Resident 1's nares (nose orifices). A review of Physical Therapy assessment dated [DATE], recommended a bed and wheelchair alarm, floor mat, all bed rails up at all times and a head protection gear (helmet). Review of undated facility policies and procedure on Rehabilitation-Fall Assessment/Risk Assessment under Quarterly Review (2). Fall assessment form may be required and will be completed by the appropriate discipline (nursing and therapy). Policy also included when a fall occurs, the Therapist will re-screen resident using the fall assessment form. An investigation and Interdisciplinary Team (IDT) meeting should address all resident safety issues and a care plan developed to prevent occurrence. Under Assessment for the Resident Assessment Instrument (RAI-approach adopted to examine nursing home quality and to improve nursing home regulation), nursing home should evaluate the appropriateness of the care plan after each quarterly assessment and modify the care plan on an ongoing basis, if applicable.