Every finding on record at Crystal Creek Post-Acute

Based on interview and record review, the facility failed to ensure that clinical assessments and corresponding interventions were accurately documented for one out of three sampled residents (Resident 1) when staff administered a pain medication without documentation supporting the clinical indication or rationale for the intervention.This failure resulted in inaccurate and unreliable clinical documentation for Resident 1, compromised the integrity of the medical record, and impaired the facility's ability to evaluate the resident's condition, response to treatment, and ongoing care needs.FINDINGS:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with multiple diagnoses which included orthopedic aftercare (medical care after surgery on a bone), spinal stenosis (narrowing of the spine that can cause pain), and chronic pain syndrome (pain that lasts longer than 12 weeks).A review of facility document titled, Weights and Vitals Summary, effective date range 3/23/26 through 3/24/26, under the category titled, Pain Level Summary, indicated Resident 1's pain level assessments utilizing a numeric pain scale 0 through 10 (0 indicates no pain and 10 indicates the most severe or extreme pain):3/24/26 at 12:40 AM = 03/23/26 at 11:01 PM = 03/23/26 at 10:08 PM = 03/23/26 at 8:04 PM = 0A review of facility document titled, Medication Administration Record, (MAR - a legal document that lists the drugs given to a resident based off the physician's order) dated 3/1/26 through 3/31/26, indicated Resident 1 had a physician's order for two (2) acetaminophen 500 milligram (mg, unit of measurement) tablets to be given by mouth every eight hours as needed for mild pain (0 through 3 pain score). The MAR further indicated on 3/23/26 at 11:09 PM, Licensed Nurse (LN) 1 administered acetaminophen to Resident 1 despite there was not an updated pain assessment completed that supported the administration of the pain medication. During a concurrent interview and record review on 4/09/2026 at 5:42 PM with LN 1, Resident 1's MAR, dated 3/1/26 through 3/31/26 and Weights and Vitals Summary, effective date range 3/23/26 through 3/24/26, under the category titled, Pain Level Summary were reviewed. LN 1 confirmed Resident 1 had a documented pain level of 0 out of 10 on 3/23/26 at 11:01 PM and acknowledged she administered acetaminophen to Resident 1 on 3/23/26 at 11:09 PM with a pain level of 0 (no pain). LN 1 further stated she was overwhelmed while managing multiple tasks that evening and had not performed an updated pain assessment.During a concurrent telephone interview and record review on 4/15/26 at 12:31 PM with the Director of Nursing (DON), Resident 1's MAR, dated 3/1/26 through 3/31/26 and Weights and Vitals Summary, effective date range 3/23/26 through 3/24/26, under the category titled, Pain Level Summary were reviewed. The DON confirmed there was no documentation in the Resident 1's medical record that supported the clinical rationale for the administration of acetaminophen on 3/23/26 at 11:09 PM. The DON stated she expected the nursing staff would have assessed Resident 1's pain level, administered medications based on Resident 1's clinical needs and physician orders, and documented Resident 1's response to the effectiveness of the pain medication. The DON further confirmed the documentation did not support the administration of a pain medication when Resident 1's documented pain level was 0 out of 10 on 3/23/26 at 11:01 PM. The DON acknowledged the record lacked evidence of appropriate assessment, justification for the administration of acetaminophen, and a follow-up pain assessment related to the effectiveness of the medication.A review of facility policy titled, Pain Assessment and Management, revised March 2019, indicated, . 5. Implement the medication regimen as ordered, carefully documenting the results of the interventions. 1. Document the resident's reported level of pain with adequate detail.

Based on interview and record review, the facility failed to ensure that physician-ordered pain management interventions were implemented for one out of three sampled residents (Resident 1) when staff failed to administer ordered pain medication in response to the Resident 1's reported pain. This failure could have resulted in Resident 1 experiencing unrelieved pain, placing the resident at risk for deterioration in condition and significant adverse outcomes.FINDINGS:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with multiple diagnoses, including orthopedic aftercare (medical care after surgery on a bone), spinal stenosis (narrowing of the spine that can cause pain), and chronic pain syndrome (pain that lasts longer than 12 weeks).A review of facility document titled, Weights and Vitals Summary, effective date range 3/23/26 through 3/24/26, under the category titled, Pain Level Summary, indicated Resident 1 had a documented pain level of 4 out of 10 (a pain scale of 0 through 10 utilized; 0 indicates no pain; 1 through 3 indicates mild pain; 4 through 6 indicates moderate pain; and 7 through 10 indicates severe pain). On 3/23/26 at 8:04 p.m.; however, there was no documentation of any pain intervention or reassessment at or around that time.A review of facility document titled Narcotic Emergency Drug Kit, (eKIT - supply of medication kept at the facility for immediate use medication when the pharmacy medications are not yet available) dated 4/2/26, indicated the facility maintained an emergency medication supply containing controlled pain medications, including but not limited to:Hydromorphone (Dilaudid) - taken via tablet or injection (shot)Morphine sulfate - taken via oral solution or injection Oxycodone (Roxicodone) - taken via tabletHydrocodone/acetyl-p-aminophenol (Norco) - taken via tablet The document indicated that these medications were available for emergency use.A review of facility document titled, Order Summary Report, dated 3/23/26 through 4/10/26, indicated the following active PRN (as needed) pain medication orders for Resident 1:hydromorphone Oral Tablet 4 mg - Give 1.5 (one and a half) tablets by mouth every four (4) hours as needed for moderate to severe pain (pain rating of 4 through 10 out of 10).hydromorphone Oral Tablet 4 mg - Give 1 tablet by mouth every four (4) hours as needed for moderate to severe pain; Alternatives to be used prior to administering PRN (as needed) included repositioning, distraction, breathing techniques, gentle massage, relaxation techniques, music, and other non-pharmacological interventions.acetaminophen tablet 325 mg - Give 2 tablets by mouth every four (4) hours as needed for mild pain (1 through 3 out of 10), not to exceed 4 grams in 24 hours. Non-pharmacological interventions to be attempted included repositioning, dim lighting, quiet environment, snacks, therapeutic touch, redirection, music, guided imagery, distraction, exercise, deep breathing, socialization, and other measures.acetaminophen tablet 500 mg - Give 2 tablets by mouth every eight (8) hours as needed for pain; not to exceed 3 grams in 24 hours. Non-drug interventions to be attempted included repositioning, distraction, breathing techniques, and gentle massage.However, there was no documentation that any of the above PRN pain medications or non-pharmacological interventions were implemented when the resident reported a pain level of 4 on 3/23/26 at 8:04 PM.During a concurrent interview and record review on 4/9/26 at 5:42 PM with the Licensed Nurse (LN 1), Resident 1's Weights and Vitals Summary, effective date range 3/23/26 through 3/24/26, under the category titled, Pain Level Summary, was reviewed. LN 1 verified the document indicated Resident 1 had a reported pain level of 4 out of 10 (moderate pain) on 3/23/26 at 8:04 PM and stated the ordered pain medication was not available at the time of the pain assessment. LN 1 stated she had not considered calling the doctor or pharmacy to obtain medications available through the facilities eKIT. LN 1 further stated she attempted to administer acetaminophen (used for mild pain); however, Resident 1 refused. LN 1 confirmed she did not document Resident 1's refusal for the pain medication. During a telephone interview on 4/14/26 at 2:16 PM with the Pharmacy Operations Manager (POM), the POM stated resident prescriptions are transmitted electronically through the facility's electronic medication administration record (eMAR- a legal document that listed the drugs given to resident) system. The POM stated routine medication deliveries occurred prior to 10:00 PM and confirmed that staff had the ability to utilize medications available through the eKIT when ordered medications were not yet available or had run out. The POM further stated that facility staff were expected to follow established guidelines, including notifying the physician and the pharmacy when medications were not available.During a telephone interview on 4/14/26 at 2:43 PM with the Nurse Practitioner (NP), the NP stated the nursing staff should have notified him regarding the missing pain medications and that he could have provided additional orders, including authorizing the use of medications available through the eKIT. The NP stated the nursing staff could have contacted both the pharmacy and him directly and obtained orders and facilitated timely medication administration.During a concurrent telephone interview and record review on 4/15/26 at 12:31 PM with the Director of Nursing (DON), Resident 1's documents titled, Weights and Vitals Summary, effective date range 3/23/26 through 3/24/26, under the category titled, Pain Level Summary, Order Summary Report, dated 3/23/26 through 4/10/26, and the Medication Administration Record, (MAR) dated 3/1/26 through 3/31/26 were reviewed. The DON confirmed that although a physician's order for pain medication was placed, no pain medication was administered when Resident 1 reported pain on 3/23/26 at 8:04 PM. The DON further confirmed there was no documentation of any intervention or reassessment completed. The DON stated that staff were expected to administer medications as ordered and to reassess and document the resident's response to the interventions that were implemented.A review of the facility policy titled, Pain Assessment and Management, revised March 2020, indicated, . 2. Pain Management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Discuss with the resident (or legal representative) his or her goals for pain management and satisfaction with the current level of pain control.

Based on interview and record review, the facility failed to ensure that physician-ordered medications were administered as prescribed for one out of three sampled residents (Resident 1) when nursing staff omitted multiple scheduled medications. This failure resulted in Resident 1 not receiving essential prescribed medications, placing the resident at risk for worsening of underlying conditions, inadequate symptom control, and potential adverse outcomes.FINDINGS:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with multiple diagnoses, including orthopedic aftercare (medical care after surgery on a bone), spinal stenosis (narrowing of the spine that can cause pain), hyperlipidemia (elevated levels of fats like cholesterol and triglycerides in the blood), and chronic pain syndrome (pain that last longer than 12 weeks).Review of facility document titled, Medication Administration Record, (MAR- a legal document that listed the drugs given to resident) dated 3/1/26 through 3/31/26, indicated the following medications were scheduled for administration on 3/23/26 at 9 PM and were not administered as ordered: Amitriptyline (medication to treat depression) 50 milligrams (mg- unit of measurement) tablet - Give 1 tablet by mouth at bedtime. Gabapentin (medication to treat neuropathy) 600 mg tablet - Give 2 tablets by mouth at bedtime. Simvastatin (medication to treat hyperlipidemia) 20 mg tablet - Give 1 tablet by mouth at bedtime. Dicyclomine (medication to treatment irritable bowel syndrome) 10 mg capsule - Give 2 capsules by mouth four times daily. A review of Resident 1's document titled, Progress Notes, indicated that on 3/23/26 at 11:03 PM, the licensed nurse (LN) 1 documented that multiple prescribed medications (including those listed above) had not yet been delivered from the pharmacy.During a concurrent interview and record review on 4/9/26 at 5:42 PM with LN 1, Resident 1's MAR, dated 3/1/26 through 3/31/26 was reviewed. LN 1 confirmed that the prescribed medications scheduled for 9:00 PMN were not available at the time they were due. LN 1 acknowledged that no alternate measures were taken to obtain the medications and stated she did not notify the physician or the pharmacy regarding the unavailable medications. LN 1 further stated she was overwhelmed that evening while managing multiple tasks.During a telephone interview on 4/14/26 at 2:43 PM with the Nurse Practitioner (NP), the NP confirmed that he was not notified regarding the missed or unavailable medications. The NP stated that facility staff should have contacted him and reported the missing medications. The NP stated he could have provided an order to access medications through the Emergency Medication Kit (eKIT- medications stored at the facility for use until new ordered medications are available from the pharmacy).The NP further stated the nursing staff were expected to notify him of any missed medications and could have contacted the pharmacy and the provider and facilitated timely medication access. The NP reported he had not received any calls or text messages regarding the medication delay.During a concurrent telephone interview and record review on 04/15/2026 at 12:31 PM with the Director of Nursing (DON), Resident 1's MAR, dated 3/1/26 through 3/31/26 and Order Summary Report, dated March 2026 were reviewed. The DON confirmed that scheduled medications were not administered as ordered and that staff failed to notify the physician and pharmacy when medications were not available. The DON stated that staff were expected to administer medications as prescribed and to follow appropriate notification procedures when medications are unavailable.A review of facility policy titled, Administering Medications, revised 4/2019, indicated, Policy Statement - Medications are administer in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.

Based on observation, interview, and record review, the facility failed to ensure safety measures were in place while providing care for one of three sampled residents (Resident 2), when:1. During a change of bedding, without securing Resident 2's right side of the bed, Certified Nursing Assistant (CNA) 2 turned Resident 2 to her right side, away from the CNA.This deficient practice resulted in Resident 2 falling out of bed and onto the floor on 1/23/26. Resident 2 sustained injuries including a fracture (broken bone) to her right elbow.2. The staff did not implement interventions timely to prevent further falls and to reduce the impact of potential falls after Resident 2's fall incident on 1/23/26.This failure exposed Resident 2 to potential falls and associated injury.Findings:1. A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility in 2025 with diagnoses which included intervertebral disc degeneration lumbar region (wear and tear of the discs in the lower back which compress nerves and cause pain), closed fracture right patella (broken kneecap), infection (presence of germs) of internal fixator right ankle (surgically reconnecting broken bones with screws, plates, rods, or nails), and unspecified fall (accidental fall where the exact nature of incident was not specified).A review of Resident 2's Fall Risk Assessment, dated 10/18/25, indicated, .Score: 25.Category: Moderate Risk for Falling.A review of Resident 2's SBAR (a communication tool for sharing information with teams and stands for Situation, Background, Assessment, and Recommendation or Requests) Nurse Progress Notes, dated 1/23/26, at 9:30 a.m., indicated, .Fall Details.1. Describe the problem/symptom: Resident alert awake and verbally responsive CNA states During care she [CNA 2] turned resident to the opposite side because she needs to change everything but before turn [sic] her [Resident 2] she said she make [sic] sure there should be enough space on the other side so she [Resident 2] would not fall so she turn [sic] her [Resident 2] and pulled the old flat sheet but according to her she held her [Resident 2] tooo [sic]. But when she let her [Resident 2] go to hold the curtain during care so that she can take out the old flat sheet but suddenly she [Resident 2] fell on the floor on her right side.2. Was fall witnessed? Yes.3a. Location of fall: Resident Room.4. Date & Time of Fall: 01/23/2026 09:00 [9 a.m.].5. What was the resident doing prior to the fall? Resident laid on her right side with [sic] holding curtain with both hands.6. Does the resident exhibit or complain of pain related to the fall? Yes.7. Location of pain: right elbow.8. Most recent pain level.Pain Level: 7.Date 01/23/2026 14:47 [2:47 p.m.].Pain Scale.Numerical [a method of rating level of pain numerically with 0 meaning no pain and 10 meaning worst pain].Body Observation.Location of injury.right humerus [arm] elbow.redness.Describe Range of Motion [ROM].ROM painful/limited in upper extremity.Possible contributing factors.Orthopedic condition [a medical issue that affects the musculoskeletal system (consists of the body's bones, muscles, tendons, ligaments, joints, and cartilage)].Muscle weakness.Date and time physician notified.01/23/2026 0900.Date and time Resident/Resident Representative notified.01/23/2026 1000 [10 a.m.].A review of Resident 2's Transfer Record, dated 1/23/26, at 3:16 p.m., indicated that Resident 2 was transferred to an acute care facility's emergency department (ED) for treatment.A review of Resident 2's Acute Care emergency room Treatment Record, dated 1/23/26, at 3:57 p.m., indicated, .Chief Complaint.[Resident 2] from [facility] GLF [ground level fall] this AM [morning], positive right humerus fx [fracture] per x-ray done at facility.No LOC [loss of consciousness] No head strike [did not hit her head during fall].Physical Exam.right upper arm and elbow TTP [tender to touch and palpation (a method of feeling with the fingers or hands during a physical examination)].Diagnostic Results.XR [Xray] knee 3 view right [right knee x-ray] negative for fracture.XR Elbow 3+ Views Rt [x-ray of right elbow] horizontal distal humerus fracture without displacement [traumatic break in bone near the elbow where bones remain aligned].CT head WO Con [Computerized Tomography of head without contrast, uses many x-rays to create pictures of the skull bones, brain and eye sockets without dye that could affect kidney function].negative.long arm splint [support used to stabilize injury] to right arm.follow up in Ortho clinic in 1-3 days call to schedule.Plan: DC [discharge] back to facility.ice.elevation of right arm.pain medication as needed.keep splint in place until follow up appointment.A review of Resident 2's Nurse Progress Note, dated 1/24/26, at 2:06 a.m., indicated that Resident 2 was transferred back to the facility from the acute care ED.During a phone interview on 1/28/26, at 12:10 p.m., with Resident 2's Family Member (FM), the FM stated that on the morning of 1/23/26 she was at work and noticed a missed call from Resident 2. The FM further stated that she called Resident 2 back, and Resident 2 told her that earlier that morning during incontinence care (hygiene routine provided to individuals who cannot control their bladder or bowel movements), the CNA pulled the sheet, and she fell onto the garbage can near her bed then onto the floor. The FM stated that Resident 2 was sent to the ED later that day. The FM further stated that Resident 2 returned to the facility at 1 or 2 in the morning on 1/24/26. The FM stated that Resident 2 sustained a broken elbow from the fall. The FM further stated that Resident 2 said that she was in pain. The FM stated that Resident 2 was waiting to be scheduled for surgery.During a concurrent observation and interview on 1/28/26, at 2:15 p.m., with Resident 2 in her room, Resident 2 was noted to be resting in bed with her right arm in a splint and elevated on a pillow. Resident 2's bed was observed with side rails, was in low position with the wheel brakes locked. No fall mats were observed on the floor near Resident 2's bed. Resident 2 stated that she fell out of bed while a CNA provided care and her arm was broken as a result. Resident 2 further stated that the side rails were installed on her bed on 1/28/26. Resident 2 stated that she had pain, but staff gave pain medication that provided relief to her arm.During an interview on 1/28/26, at 2:32 p.m., with CNA 2, CNA 2 stated that she knew Resident 2. CNA 2 confirmed that she was the CNA providing care to Resident 2 when Resident 2 fell on 1/23/26. CNA 2 stated that she checked Resident 2 that morning, and Resident 2 was incontinent of stool (had an uncontrolled bowel movement in the bed). CNA 2 further stated that she changed the bed linens and rolled the soiled bed linens to tuck them under Resident 2. CNA 2 stated that she had one hand on Resident 2 to steady her and one hand on the tucked linen. CNA 2 further stated that she pulled the tucked linens with one hand and attempted to remove them from the bed, but she could not remove them with one hand. CNA 2 stated that she told Resident 2 to hold onto the cabinet near the bed or the bed frame so that she could pull the soiled linens off the bed with both hands. CNA 2 further stated that she did not know that Resident 2 held the privacy curtain. CNA 2 stated that she let Resident 2 know that she was about to remove the hand she used to support her so that she could use both hands to pull the soiled linen off the bed. CNA 2 further stated that Resident 2 said that it was okay, so she let go of Resident 2 and used both hands to pull the soiled linen off the bed. CNA 2 stated that Resident 2 fell off the bed when she pulled the soiled linen off the bed and landed on the floor on her right side. CNA 2 further stated that she went to tell the charge nurse what happened quickly. CNA 2 stated that her coworkers came to the room and helped her to get Resident 2 off the floor and back into bed. CNA 2 stated that Resident 2 complained that her right elbow hurt. CNA 2 further stated that she used folded blankets to support Resident 2's right arm and support her on her left side. CNA 2 further stated that the charge nurse and the supervisor came to the room to assist. CNA 2 stated that the charge nurse called Resident 2's family. CNA 2 acknowledged that Resident 2 did not have side rails on her bed or fall mats on the floor on either side of the bed at the time of the fall. CNA 2 confirmed that side rails were installed on Resident 2's bed on 1/28/26.During an interview on 1/28/26, at 2:38 p.m., with Licensed Nurse (LN) 1, LN 1 stated that he was on duty the day when Resident 2 fell (1/23/26). LN 1 further stated that Resident 2's family and physician were called. LN 1 stated that the physician ordered a stat (immediately, as soon as possible) x-ray for Resident 2's right arm. LN 1 further stated that the facility physicians highly encouraged the LNs to get the stat x-ray first before making a decision to send residents out to the emergency department (ED) for care. LN 1 stated that the x-ray results were reported to Resident 2's physician at 1:30 p.m., on 1/23/26, Norco (medication prescribed for pain) was given to Resident 2 for pain, and Resident 2 was sent to the ED per the physician's orders.During an interview on 1/28/26, at 3:16 p.m., with LN 2, LN 2 stated that she knew Resident 2. LN 2 further stated that she was the charge nurse on duty when Resident 2 fell out of bed and broke her arm (on 1/23/26). LN 2 stated that she was giving medications to a resident when CNA 2 provided incontinent care to Resident 2. LN 2 further stated that she heard a noise and went to Resident 2's room. LN 2 stated that Resident 2 was lying on the floor on her right side. LN 2 further stated that she notified the supervisor. LN 2 stated that the staff moved Resident 2 back to bed. LN 2 further stated that she did a head-to-toe assessment on Resident 2 and took vital signs (temperature, heart rate, and blood pressure). LN 2 stated that Resident 2 complained of pain in her right arm with movement. LN 2 further stated that she notified the physician and the physician ordered an x-ray stat. LN 2 stated that she gave Resident 2 medication for the pain. LN 2 further stated that the x-ray was completed at around 10 a.m. that day. LN 2 stated that after the x-ray results were phoned in to the physician, Resident 2 was sent to the ED. LN 2 stated that the bed rails were installed on the bed after consent was obtained from Resident 2's family, but she was not sure when the bed rails were installed. LN 2 stated that Resident 2 required maximum assistance with incontinence care. LN 2 confirmed that only one CNA assisted Resident 2 with incontinence care that day. LN 2 further stated that residents who required maximum assistance required two CNAs to assist with care.During an interview on 1/28/26, at 3:20 p.m., with CNA 2, CNA 2 stated that Resident 2 was able to move in bed, so only one CNA was needed for incontinent care.During a concurrent interview and record review on 1/29/26, at 2:10 p.m., with the MDS Coordinator (MDS Coordinator [MDS], a nurse that collects data related to residents in order to develop and evaluate a comprehensive care plan and to make sure the facility gets payment from Medicare and Medicaid), Resident 2's MDS (Minimum Data Set, a comprehensive care assessment tool) Section GG-Functional Abilities Assessment, dated 9/22/25 was reviewed. The MDS confirmed that Resident 2's MDS Section GG-Functional Abilities Assessment, indicated that Resident 2 needed substantial/maximum assistance (Helper does more than half the effort. Helper holds or lifts trunk [body] and limbs and provides more than half the effort) with toileting/hygiene. The MDS stated that the CNAs did most of the work for residents that needed maximum assistance with toileting/hygiene. The MDS stated that if a resident was incontinent, one CNA could provide the care.2. A review of Resident 2's Physician Order Summary, indicated, .Resident is capable of making his/her own health decisions.Active.Order Date.01/08/2026.A review of Resident 2's Physician Order Summary, indicated, .May have quarter siderails in bed for mobility and positioning (start when available).Active.Order Date.01/26/2026.A review of Resident 2's Physician Order Summary, indicated, .Apply landing mat on floor to reduce impact and injury of fall while in bed. Check placement QS [every shift]. every shift.Active.Order Date.01/29/2026.Start Date.01/29/2026.During a review of Resident 2's Interdisciplinary Team Falls Progress Notes (IDT, a team of professional staff or a care team consisting of different disciplines working together towards the goal of the residents), dated 1/25/26, 5:07 p.m., the IDT Falls Progress Notes, indicated, .Summary and Root Cause Analysis.Resident fell when [CNA 2] was turning her. Per resident statement, she was holding on to the side of the mattress while CNA was doing the care. She was leaning too much resulting to loss of balance and fell.PREDISPOSING/RISK FACTORS FOR FALLS.BIMS score 15 [Brief Interview for Mental Status- a tool to assess cognition (the mental processes involved in gaining knowledge and understanding). The total possible BIMS score ranges from 00 to 15. 13 - 15: cognitively intact; 08 - 12: moderately impaired; 00 - 07: severe impairment].History of Falls.Muscle Weakness.Gait/Balance Deficit.Poor Safety Awareness.Overestimates limits.Other predisposing risk factors.h/o [history of] falls prior to admission.PREVENTIVE MEASURE/S PRIOR TO FALL.ASSESSED FOR NEEDS: TOILETING, REPOSITIONING, FLUIDS, OR SNACK Q [every] 2 HOURS.BED IN LOW POSITION WHEN IN BED TO LESSEN IMPACT OF FALLS.KEPT BED LOCKED.LANDING MAT ON FLOOR TO REDUCE IMPACT AND INJURY OF FALL.NOTES.Interventions.pain management Xray right arm low bed landing mat frequent visual check sent to ER [emergency department] for further eval d/t [due to] Xray result of right humerus [long bone of upper arm extending from shoulder to elbow] f/u [follow up] with Ortho IDT Recommendations: Quarter side rail to bed to assist with mobility/positioning when available 2 person assist with ADLs [activities of daily living, tasks of everyday life including eating, dressing, bathing, or showering, and using the bathroom].During a concurrent observation and interview on 1/28/26, at 2:15 p.m., with Resident 2 in her room, Resident 2 was noted to be resting in bed with her right arm in a splint and elevated on a pillow. Resident 2's bed was observed with side rails, was in low position with the wheel brakes locked. No fall mats were observed on the floor near Resident 2's bed. Resident 2 stated that she fell out of bed while a CNA provided care and her arm was broken as a result. Resident 2 further stated that the side rails were installed on her bed on 1/28/26. Resident 2 stated that she had pain, but staff gave pain medication that provided relief to her arm.During an observation on 1/28/26, at 3:15 p.m., in Resident 2's room, a gray fall mat was placed on the floor on the right side of Resident 2's bed.During a concurrent interview and record review on 1/29/26, at 3:32 p.m., with the Director of Nursing (DON), Resident 2's Electronic Medical Record (EMR) was reviewed. The DON stated that residents were assessed for the use of side rails (bed rails) during admission, as needed, and at the request of a resident and/or responsible party (RP, the person designated to direct the care of a loved one admitted into a nursing facility). The DON further stated that staff documented bed rail risk assessments in the residents' EMR, staff obtained consent from the resident and/or RP for the use of bed rails, staff explained the risks and benefits of bed rails to the residents and/or RPs, and staff documented bed rail use on the residents' care plans. The DON stated that if a resident's physician gave an order for bed rails, the nursing staff or the physical therapist did an assessment of the resident. The DON further stated that once the assessment was completed and the use of bed rails was deemed to be beneficial to the resident, the care plan was updated, and the maintenance staff installed the bed rails on the resident's bed immediately as soon as the staff did the assessment if the resident was a fall risk. The DON acknowledged that Resident 2 had a physician order for bed rails dated 1/26/26. The DON confirmed that a bed rail assessment was completed for Resident 2 on 1/26/26, and that Resident 2 consented to the use of bed rails on 1/26/26. The DON further confirmed that Resident 2 was able to make her own healthcare decisions. The DON confirmed that the bed rails were installed on Resident 2's bed on 1/28/26 after obtaining consent from Resident 2's family member. The DON stated that the risk of delaying the installation of bed rails on Resident 2's bed was limited mobility or falling. The DON acknowledged that Resident 2's MDS Section GG-Functional Abilities Assessment, completed 9/22/25 indicated that Resident 2 needed substantial/maximal assistance with toileting/incontinence care. The DON stated that residents who needed substantial/maximal assistance with toileting/incontinence care required assistance of two CNAs if the resident needed to transfer from wheelchair to toilet, and only one CNA for incontinence care in bed unless the resident was dependent (staff did all the work and resident was unable to assist or move during care). The DON further stated that if a resident was at moderate to high risk for falls, care plan interventions for fall risk were individualized and documented on the care plan. The DON acknowledged that the IDT Falls Progress Note dated 1/25/26 indicated that a landing mat (fall mat) was implemented in Resident 2's room prior to the fall on 1/23/26. The DON confirmed that the fall mat was placed in Resident 2's room on 1/28/26 as an intervention after the fall on 1/23/26. The DON further confirmed the physician's order for a fall mat dated 1/29/26 in Resident 2's EMR. The DON acknowledged that once Resident 2 fell, the fall mat should have been placed immediately. The DON acknowledged that Resident 2's injury was preventable.During an interview on 1/29/26, at 4:06 p.m., with the Maintenance Director (MD), the MD stated that when a physician placed an order to install bed rails on a resident's bed, the staff notified Maintenance. The MD further stated that the facility had been low on bed rails. The MD stated that if the order for bed rails was for a resident at risk for falls, he borrowed the bed rails from a sister facility. The MD confirmed that the staff notified Maintenance of an order to place bed rails on Resident 2's bed on 1/26/26, so he reached out to a sister facility to get bed rails for Resident 2, and it took a day to get the bed rails. The MD further confirmed that the bed rails were installed on Resident 2's bed on 1/28/26. The MD stated that lots of residents requested bed rails for their beds and the facility did not have an issue with being low on supplies of bed rails.During a phone interview on 1/30/26, at 3:02 p.m., with Resident 2's treating physician at the facility (Physician 1), Physician 1 confirmed that he was Resident 2's treating physician at the facility. Physician 1 stated that he was not aware that only one CNA provided incontinent care to Resident 2 on the day when Resident 2 fell (1/23/26). Physician 1 further stated the facility CNAs needed training. Physician 1 stated that there should have been two CNAs providing incontinent care to Resident 2.A review of a facility P&P titled, Proper Use of Bed Rails, revised December 2016, indicated, .Purpose.The purpose of these guidelines are [sp] to ensure the safe use of bed rails as resident mobility aids.General Guidelines.2. Bed rails are only permissible if they are used.to assist with mobility and transfer of residents.3. An assessment will be made to determine.reason for using bed rails.9. Consent for bed rail use will be obtained from the resident.after presenting potential benefits and risks.A review of a facility P&P titled, Fall Risk Assessment, revised March 2018, indicated, .Policy Statement.The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.Policy Interpretation and Implementation.1. Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time.2. The nursing staff will ask the resident and/or his/her family about any history of the resident falling.7. The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including.mobility.activities of daily living (ADL) capabilities.continence.9. The staff and attending physician will collaborate to identify and address modifiable risk factors and interventions.A review of the facility P&P titled, Safe Lifting and Movement of Residents, revised July 2017, indicated, .1. Resident safety, dignity, comfort and medical condition will be incorporated into decisions regarding the safe lifting and moving of residents .

Based on observation, interview, and record review, the facility failed to ensure a care plan (a personalized document that outlines a person's health conditions, specific needs, goals, and the actions required to manage their well-being, ensuring consistent, coordinated, and effective support from caregivers or healthcare teams, helping everyone involved stay organized and focused on the individual's quality of life) was developed and revised for 2 of 35 sampled residents (Resident 9 and Resident 126), when: 1. A care plan was not developed for Resident 9 with a diagnosis of PTSD (Post-Traumatic Stress Disorder, is a mental health condition that can happen after someone experiences or witness a traumatic event such as violence, abuse war, serious accidents or disasters),2. A care plan was not developed for Resident 126's speech device (A battery-operated device held to the neck or placed in the mouth via a tube; it creates vibrations that are shaped into speech by the mouth, tongue, and lips).These failures had the potential for unmet care needs for Resident 9 and Resident 126. Findings: 1. During a concurrent interview and record review with the Director of Nursing (DON) on 12/18/25 at 7:40 AM, the DON reviewed Resident 9's undated admission RECORD, the EXT [external] REFERRAL SKILLED NURSING FACILITY, dated 10/26/22, and the resident's care plans. The DON confirmed that the physician order included PTSD on Resident 9's active problem list. The DON verified that the onset date of the resident's PTSD diagnosis was 10/26/22. The DON stated the facility did not have a care plan specific to PTSD until 12/17/25, thereby potentially delaying appropriate care for Resident 9 who lacked the capacity to make healthcare decisions. During an interview with the DON on 12/18/24 AT 4:15 PM, The DON stated the facility did not have Trauma Screening Tool when the facility was aware of Resident 9's PTSD diagnosis on 10/28/22. During an interview with the DON on 12/19/25 at 7:11 AM, the DON stated the facility did not have a comprehensive assessment for PTSD for Resident 9 since 10/28/22. A review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised on 3/22, the policy indicated .2. The comprehensive person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.3. The care plan intervention are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are.c. trauma-informed.11. Assessment of residents are ongoing, and care plans are revised as information about the resident and the residents' condition change. A review of the facility's policy titled Trauma Informed Care and Culturally Competent Care revised on 8/22, the policy indicated .To address the needs of trauma survivors by minimizing triggers and/or re-traumatization.3. For trauma survivors, the transition to living in an institutional setting.can trigger profound re-traumatization.Triggers are highly individualized.Organizational Strategies: Evaluate the need for trauma-informed practices as part of the facility assessment.Resident Assessment: Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. A review of Resident 126's admission Record indicated Resident 126 was admitted to the facility in 2025 with diagnoses which included major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities), muscle weakness, dysphagia (difficulty swallowing food or liquids, making it hard to move them from the mouth to the stomach), tracheostomy status (a person has a surgically created opening (stoma) in their windpipe (trachea) for breathing) and acquired absence of larynx (the voice box (larynx) has been surgically removed (laryngectomy) or lost due to trauma, leading to permanent changes in breathing and speech, requiring the creation of a neck stoma for breathing and often speech rehabilitation). Review of Resident 126's INVENTORY OF PERSONAL EFFECTS, dated 11/14/2025, indicated, ITEMS OF SPECIFIC VALUE Description: Speech device for communication. Review of Resident 126's PERSONAL HISTORY AND PHYSICAL EXAMINATION, dated 11/17/2025, indicated, .E.E.N. T Throat Stoma Open.Summary (MEDICAL DIAGNOSIS) .laryngeal cancer, laryngectomy, tracheostomy. Review of Resident 126's Discharge Summary, dated11/9/2025, indicated, .laryngectomy.Hospital Course: In summary, [Resident 126] .communicates using a speech device following his laryngectomy. Review of Resident 3's Care Plan, initiated on 12/17/2025, indicated, .Focus: [Resident 126] has alteration in communication as evidenced by impaired ability to make self understood related to history of laryngeal cancer with permanent tracheostomy.Communicates using a speech device.Goal: [Resident 126] will be able to communicate needs and desires using speech device.Interventions: Change battery per patient request. Keep speech device charged and ready. Keep speech device within reach. During an observation and interview on 12/17/25 at 8:50 A.M., in Resident 126 room, Resident 126 used his speech device to communicate. During an interview and concurrent record review on 12/17/25 at 3:44 P.M., Licensed Nurse (LN) 5 stated Resident 126 was admitted to the facility on [DATE] with his speech device and there was no care plan implemented for Resident 126's speech device until 12/17/25. LN 5 stated Resident 126 used his speech device on 11/19/25 when LN 5 did MDS assessment ((Minimum Data Set) assessment is a mandatory, standardized tool used in U.S. skilled nursing facilities to comprehensively evaluate residents' health, functional abilities, and needs for care planning, quality improvement) for Resident 126. LN 5 stated the risk of not having speech device care plan was that staff would not know how the speech device functioned and how to take care of the speech device. LN 5 further stated Resident 126 would not be able to communicate with staff if the speech device stopped functioning. LN 5 stated staff would not know whether Resident 126 could take the speech device inside shower room and how to safely handle the speech device. During an interview on 12/17/25 at 4:20 P.M., Certified Nursing Assistant (CNA) 7 stated Resident 126 used speech device for communication. CNA 7 stated she did not know how to care for the speech device. CNA 8 further stated she did not know if Resident 126 could take his speech device in the shower. During an interview on 12/17/25 at 4:24 P.M., CNA 8 stated she did not know how the speech device for Resident 126 functioned. CNA 8 stated Resident 126 had used his speech device from the time he was admitted to the facility. During an interview on 12/19/25 at 9:29 A.M., the Administrator (ADM) stated there should have been a care plan for Resident 126's speech device. The ADM stated speech device care plan would have helped staff properly communicate and care for the speech device for Resident 126. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022 indicated, .The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Admission, Annual or Significant Change in Status), and no more than 21 days after admission.The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to accommodate the needs of four out of 35 sampled residents (Resident 45, Resident 52, Resident 93 and Resident 149) when Resident 45, Resident 52, Resident 93 and Resident 149's call light (device used to contact staff for assistance) were not within their reach.This deficient practice placed Resident 45, Resident 52, Resident 93 and Resident 149 at increased risk for unmet care needs, delayed staff response, and potential for accidents or injury.Findings: Review of Resident 45's admission Record indicated, Resident 45 was admitted to the facility with a diagnosis including hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness on one side of the body caused by a stroke), atrial fibrillation (the most common type of irregular heartbeat (arrhythmia), where the heart's upper chambers quiver chaotically instead of beating effectively, causing an irregular, often rapid pulse. This poor coordination can lead to fatigue, palpitations, dizziness, shortness of breath, and chest pain, and significantly increases the risk of stroke, heart failure), aphasia (a language disorder from brain damage (often stroke/injury) that impairs speaking), and osteoarthritis (condition causing pain and stiffness within the joints) left wrist.During a concurrent observation and interview on 12/16/25 at 12:42 PM with Resident 45 in Resident 45's room, Resident 45 was sitting in her wheelchair and Resident 45's call light was observed hanging from the right-side bed rail down to the bed frame. Resident 45 stated the call light was not within reach and she could not call staff if she needed help.During a concurrent observation and interview on 12/16/25 at 12:45 PM with Certified Nursing Assistant (CNA) 5 in Resident 45's room, CNA 5 stated that Resident 45's call light was not within reach because it was on Resident 45's bed. CNA 5 stated call light should have been within reach of Resident 45. CNA 5 further stated that Resident 45 could have fallen when trying to reach for her call light to ask for help. Review of Resident 52's admission Record indicated, Resident 52 was admitted to the facility with a diagnosis including hemiplegia and hemiparesis following cerebral infarction, chronic obstructive pulmonary disease (chronic lung disease that causes breathing difficulty, shortness of breath, coughing, and reduced activity tolerance), congestive heart failure (chronic heart condition that causes shortness of breath, fatigue, and reduced activity tolerance), adult failure to thrive (unintentional weight loss with physical and functional decline), and unspecified mood disorder (mental health condition that affects a person's mood, emotions, and daily functioning).During a concurrent observation and interview on 12/16/25 at 2:49 PM with Resident 52 in Resident 52's room, Resident 52's call light was observed hanging from the right-side bed rail down to the bed frame. Resident 52 stated that if he needed help, staff could not come right away because he could not reach the call light to call for help.During a concurrent observation and interview on 12/16/25 at 2:54 PM with Licensed Nurse (LN) 2 in Resident 52's room, LN 2 stated that Resident 52's call light was not within reach because it was hanging from the bed rail down to the right side of the bed frame. LN 2 further stated that Resident 52 could be at risk for a fall if he could not use his call light to ask for help, as he might perform task without assistance. Review of Resident 93's admission Record indicated, Resident 93 was admitted to the facility with a diagnosis including early onset cerebellar ataxia (condition that begins at a young age and causes problems with balance, coordination, and movement), dysphagia (difficulty or trouble swallowing), glaucoma (eye disease that damages the nerve that helps you see and can slowly cause vision loss) , major depressive disorder, anxiety disorder, and palliative care (care that focuses on comfort and relief from symptoms during serious illness).During a concurrent observation and interview on 12/16/25 at 10:45 AM with Resident 93 in Resident 93's room, Resident 93's call light was observed not in bed and not within reach of Resident 93. Resident 93 stated that she could not find the call light, which she used to ask for help.During a concurrent observation and interview on 12/16/25 at 10:53 AM with LN 2 in Resident 93's room, LN 2 stated that Resident 93's call light was stuck on the bed frame between the headboards. LN2 stated that if residents could not reach or use the call light to ask for help, residents would be at risk for falls, injury, and unmet needs. LN 2 further stated that Resident 93 was on hospice care (care for people who are very sick and not expected to get better, with the goal of comfort rather than cure), and lack of access to call light could delay comfort measures for Resident 93. Review of Resident 149's admission Record indicated, Resident 149 was admitted to the facility with a diagnosis including, spinal stenosis (the narrowing of spaces within your spine, putting pressure on the spinal cord and nerves, causing pain, numbness, cramping, or weakness, often in the back, neck, arms, or legs), chronic obstructive pulmonary disease ((COPD) is an ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs. This limited airflow is known as obstruction. Symptoms include trouble breathing), atrial fibrillation, pain in left hip and pain in leg.During a concurrent observation and interview on 12/16/25 at 11:32 AM with Resident 149 in Resident 149's room, Resident 149 was sitting in his wheelchair and Resident 149's call light was observed hanging from the bedside top drawer. Resident 149 stated the call light was not within reach and he could not call staff if he needed help. Resident 149 further stated he would not be able to call for help if he was having problems and unable to breathe.During a concurrent observation and interview on 12/16/25 at 11:33 AM with CNA 4 in Resident 149's room, CNA 4 stated the call light for resident 149 was hanging from Resident 149's bedside top drawer. CNA 4 stated call light should be within reach of Resident 149. CNA 4 further stated Resident 149 could have fallen and hurt his arm when reaching for his call light to call for help. During an interview on 12/27/25 at 3:41 PM with LN 5, LN 5 stated all residents should have call light within reach. LN 5 stated when call light was within reach, residents could alert staff in case of an emergency. LN 5 stated the risk of not having call light within reach of resident was resident could have had a fall when trying to reach for a call light. During a record review of Resident 45's Care Plan, in the section titled focus initiated on 9/12/25, indicated, .ADL Self Care Performance Deficit. The section titled Interventions initiated on 9/13/25, indicated .Encourage [Resident 45] to use bell to call for assistance.During a record review of Resident 149's Care Plan, in the section titled focus initiated on 11/5/25, indicated [Resident 149] has Self Care Performance Deficit r/t muscle weakness, poor endurance, decline in balance/transfers/walking, pain. The section titled interventions initiated on 11/5/25, indicated . [Resident 149] requires weight bearing assistance.supervision/touching assistance.physical assistance. weight bearing assistance. During a concurrent interview and record review on 12/18/25 at 11:41 AM with the Assistant Director of Nursing (ADON), Resident 52's Care Plan, in the section titled Focus initiated on 12/3/25, indicated, . [Resident 52] found sitting on the floor, attempted to self-transfer. The section titled Interventions initiated on12/4/25, indicated .Keep [Resident 52's] call light within reach. was reviewed. Resident 93's Care Plan, in the section titled Focus initiated on 12/14/23, indicated Coordinate [Resident 93's] care with Bristol Hospice. The section titled Interventions initiated on 12/15/23, indicated, .Keep [Resident 93's] call light within reach. was also reviewed. Th ADON stated that the call light should always be within reach of the resident for safety. The ADON further stated that when a resident could not reach the call light, help from staff could be delayed and the risk of falls increased. During an interview on 12/18/25 at 1:16 PM with the Director of Nursing (DON), the DON stated that staff were expected to clip the call light near the resident to prevent it from falling out of bed and to ensure it remained within the resident's reach. The DON further stated that if the call light was not within reach, residents could experience delayed assistance, unmet needs, lack of care, and increased risk for accidents and skin issues. During an interview on 12/19/25 at 9:29 AM with the Administrator (ADM), the ADM stated all residents should have call light within reach to give the residents an opportunity to ask for assistance whenever needed. The ADM stated the risk of not having call light within reach of a resident was residents could not be able to alert staff for help in case of an emergency. The ADM further stated residents could sit in soiled brief for a long time when they are not able to call for help using call light. A review of facility's policy titled, Call System, Residents, dated September 2022, indicated, .Residents are provided with a means to call staff for assistance through a communication system that directly call a staff member or a centralized work station.Each resident is provided with a means to call staff directly for assistance.Call system communication may be audible or visible.The resident call system is routinely maintained.Calls for assistance are answered as soon as possible, but no later than 5 minutes .

Based on interview and record review, the facility failed to offer, obtain informed consent and provide education to a resident or resident's representative (RP) about influenza (or the flu, is a contagious viral infection of the respiratory system that can range from mild to severe, causing symptoms like fever, cough, sore throat, muscle aches, and fatigue) vaccine for three out of five sampled residents when Resident 159, Resident 8 and Resident 110 was not offered the flu vaccine during the flu season.These failures had the potential for the residents and resident's responsible parties to not be fully informed about the risks and benefits, and potential side-effects of the flu vaccine prior to receiving or declining the vaccination.Findings: During an interview on 12/16/25, at 9:25 AM, with Resident 159, Resident 159 stated she asked for the flu vaccine several times. Resident 159 stated she did not refuse shots (vaccines), and she always got her shots every year for flu and pneumonia. Resident 159 stated she did not get the flu, COVID19 and pneumonia vaccine but she had asked for it, and she was told that she needed to sign, and she asked for the document to sign but they still did not give her the vaccine. During a concurrent interview and record review on 12/18/25, at 10:48 AM, with the Infection Preventionist (IP), the IP stated they started the flu clinic last September. Resident 110's immunization record was reviewed with the IP, indicated Resident 110 signed the consent for the flu vaccine on 5/3/25 upon admission to the facility. The IP stated Resident 110 was signed up for clinic this year back in September but on the day of vaccination, the resident decided not to proceed with the vaccination. The IP stated she had not documented about holding off Resident 110's flu vaccine, but it was not a refusal. The IP stated if it was not documented it was not done. Resident 8's immunization record was reviewed with the IP, the record indicated Resident 8 received flu vaccine on 10/4/24. The IP stated she had not given the flu vaccine to Resident 8 and had not had asked for the consent. Resident 159's immunization record was reviewed with the IP, The IP stated Resident 159 refused all the vaccines and there was no history documented. The IP stated Resident 159 was admitted after flu season, but for this year's flu season, she was not given the flu vaccine yet. The IP stated that the importance getting the residents vaccinated was for preventive care. The IP stated that the facility wanted to make sure that the residents have the option to receive the vaccine especially at this time there was high incidence of respiratory viruses, and with the resident's age which put them in being high risk of getting infected by the viruses. During an interview on 12/19/25, at 12:30 PM, with the Director of Nursing (DON), the DON stated if it was flu season, she expected the nurses particularly the IP to make sure immunization was offered. The DON stated they offer the flu vaccine to the resident or the RP if the resident is not the RP. The DON stated that the resident or the RP's decision regarding the flu vaccine should be documented, whether they agree to receive it or not. The DON stated if the resident said to hold off the vaccine or if they could not decide yet, the IP or the nurse needs to tell the resident that they will document refused for now and to advised the resident to let the staff know if they already want the vaccine. The DON stated if the resident or RP refused the vaccine, they need to document the reason for refusal. The DON stated it should be offered to all residents. The DON stated if the vaccine was not offered to all residents, there was a possibility that the resident would acquire flu during flu season and if they get the flu vaccine, they can still get flu, but the risk is lesser. A review of the facility's policy and procedure (P&P) titled, Influenza Vaccine, revised March 2022, indicated, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza .A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine .

Based on observation, interview and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when:1. The can opener blade had shards of metal, layers of food residue, and metal chipped at the tip of the can opener,2. Several tray line pans (standard commercial-grade baking sheets or pans used in kitchens) were found stacked wet in the ready to use areas,3. One kitchen staff was observed washing dishes and going back and forth from the dirty dishes to the clean dishes without washing their hands or changing their apron, These failures had the potential to lead to cross contamination (when bacteria or germs spread from one place to another) and food borne illness (an illness that causes nausea, vomiting, and/or diarrhea) for the 149 residents who receive meals from the facility kitchen. Findings:Findings:1. During the initial kitchen tour on 12/16/25 at 8:17 AM with the Registered Dietician (RD, a health professional who has special training in diet and nutrition) in the cook's preparation area, the can opener was observed to have the chipped tip, missing metal pieces, and a dried layer of food residue. The surroundings of the can opener had metal shavings and a black oily substance. The RD confirmed these finding and stated the chips of metal had the potential to get into the food that was prepared for the residents.During an interview on 12/18/25 at 4:15 PM with the RD, the RD stated the condition of the can opener that was observed during the initial kitchen walk through with the Department, did not meet his expectations. The RD stated his expectation was for the blade of the can opener to be cleaned after each use, for the can opener blade to be intact, and for the can opener to be free from food debris. The RD stated the condition the can opener placed a risk for the residents' food to have bacteria cross contamination and physical contaminants (any foreign object, such as glass, metal, plastic, hair, or natural debris) to be present in the food and presented a food safety hazard. During a review of the facility's policy and procedure (P&P) titled, CAN OPENER AND BASE, dated 2023, the P&P indicated, Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade and worn out cogwheel [a rotating wheel] .The can opener should be thoroughly cleaned each work shift and, when necessary, more frequently.Replace the blade on the can opener, as needed.During a review of the facility's P&P titled, SANITATION, dated 2023, the P&P indicated, .The Food & [and] Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving and storing of food.All equipment shall be maintained as necessary and kept in working order.All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas.Employees are to alert the FNS [Food and Safety Director] immediately to any equipment needing repair.During a review of the 2022 Food Code U.S. [United States] Food and Drug Administration Section 4-601.11 on Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, the Food Code indicated, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The objective of cleaning focuses on the need . to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. https://www.fda.gov/food/fda-food-code/food-code-2022 2. During a joint initial kitchen tour observation and interview on 12/16/25 at 8:58 AM with the RD, seven of 18 large tray line pans were noted on a shelf with water collected on the inside and at the bottom rim of the pans. The RD confirmed the pans were wet and instructed his staff to re-wash the wet pans. During an interview on 12/18/25 at 4:15 PM with the RD, the RD stated his expectations were for all dishes in the kitchen to be stacked and stored dry. The RD stated the dishes were supposed to be washed, placed on a rack to air dry, and then stacked in the assigned area. The RD stated stacked wet trays did not meet his expectations and placed the residents at risk for developing a foodborne illness because the moisture in on the pans attracted harmful germs and placed the resident at risk for illness. During a review of the facility's P&P titled, 3-COMPARTMENT PROCEDURE FOR MANUAL DISHWASHING, dated 2023, indicated, .Clean and sanitize all work surfaces. Set up area for air drying.All items are air-dried, which means no water droplets are present.3. During an observation on 12/17/25 at 11:13 AM in the facility's dishwashing area of the kitchen, Dietary Aide (DA) 1 washed dishes and handled both clean and dirty dishes without removing and replacing his apron and gloves or washing his hands. During an interview on 12/19/25 at 1:36 PM with DA 1, DA 1 stated when he washed the dishes, there were supposed to be multiple dishwashers. DA 1 acknowledged that he was going back and forth from a dirty area to a clean area when he washed the dishes. DA 1 stated he was unsure why he did that but understood that he was supposed to wash his hands before going from the dirty dishes to the clean dishes. During an interview on 12/18/25 at 4:15 PM with the RD, the RD stated his expectation was for multiple kitchen staff to have washed the dishes; one kitchen staff for the clean side and the other kitchen staff for the dirty side. The RD stated if a kitchen staff went from the dirty to the clean side, his expectation was for them to remove their apron and wash their hands. The RD stated the residents in the facility were placed at risk for developing a food borne illness (nausea, vomiting, diarrhea) when safe dishwashing practices were not maintained. During a review of the facility's P&P titled, HANDWASHING, dated 2023, indicated, POLICY: All employees will be instructed in the proper procedure of hand washing.Employee hands must be washed frequently in the hand washing sink or designated sink for hand washing. During a review of the facility's P&P titled, 3-COMPARTMENT PROCEDURE FOR MANUAL DISHWASHING, dated 2020, indicated, . Pay close attention to prevent cross-contamination of workers going from handling dirty dishes and then clean, touching face, body, dropping items on the floor.Wash hand and change gloves whenever cross-contamination occurs.During a review of the facility's P&P titled, SANITATION, dated 2023, indicated, .A minimum of two employees will be used when dishes are machine washed. One will handle the soiled [dirty] area, and one will handle the clean side. If an employee does need to go from soiled end to clean end, a strict hand washing routine must be followed.During a review of the undated Job Description (JD): Dietary Aide, the JD indicated, .Safety and Sanitation.Follow established safety policies and Infection Control and Universal Precautions policies and procedures when performing daily tasks. Maintain proper personal hygiene and cleanliness, practicing proper hand washing, glove, hairnet and apron use.

Based on observation, interview, and record review the facility failed to ensure three of 35 sampled residents had water or fluids available when,Resident 52 did not have water or fluids available at the bedsideResident 87 did not have water or fluids available at the bedsideResident 99 did not have water or fluids available at the bedsideThese failures had the potential to place Resident 52, Resident 87, and Resident 99 at risk for dehydration (when the body does not get enough fluids to function properly), falls, and/or chocking.Findings: 1.During a review of Resident 52's admission Record, the record indicated Resident 52 was admitted to the facility with diagnoses that included adult failure to thrive (a decline in overall health due to poor nutrition or fluid intake) and tubule-interstitial nephritis (a kidney condition in which the kidneys become irritated and inflamed, making it harder to clean the blood and balance fluids.)During a concurrent observation and interview on 12/16/25 at 2:49 PM with Resident 52 in Resident 52's room, Resident 52 was lying in bed with a water pitcher placed on the nightstand table far from the resident and not within reach. Resident 52 stated that when he needed water, water was not readily available. During a concurrent observation and interview on 12/16/25 at 2:54 PM with the Licensed Nurse (LN) 2 in Resident 52's room, LN 2 checked Resident 52's water pitcher located on the nightstand table and found it empty. LN 2 stated that when water was not readily available, Resident 52 was at risk for dehydration. 2. During a review of Resident 87's admission Record, the record indicated Resident 87 was admitted to the facility with diagnoses that included chronic kidney disease (long term kidney damage that makes it difficult for the kidneys to clean the blood and balance fluids) and a history of falling. During a concurrent observation and interview on 12/16/25 at 11:20 AM with the Certified Nursing Assistant (CNA) 10 in Resident 87's room, Resident 87 was lying in bed without a water pitcher or fluids at the bedside. CNA 10 stated that Resident 87 did not have water readily available. CNA 10 stated that because Resident 87 was on thickened fluids (drinks that are made thicker, so they are easier and safer to swallow for people with swallowing problems), Resident 87 had to ask staff for water. CNA 10 stated that the CNAs had to ask nurses for thickening mixtures before they provided thicken fluids to residents on thickened fluids. CNA 10 further stated that this process delayed resident's access to water. During a concurrent observation and interview on 12/16/25 at 11:51 AM with Resident 87 in Resident 87's room, Resident 87 was lying in bed without water at the bedside. Resident 87 stated that each time he needed water to drink, it was not readily available because staff could not come right away to provide it.3. During a review of Resident 99's admission Record, the record indicated Resident 99 was admitted to the facility with diagnoses that included Alzheimer's disease (a brain condition that slowly affects memory, thinking, and the ability to care for oneself) and diverticulosis of large intestine (condition where small pouches form in the colon and are often prevented with adequate fiber and fluid intake). During a concurrent observation and interview on 12/16/25 at 10:58 AM with Resident 99 in Resident 99's room, Resident 99 was lying in bed without a water pitcher or fluids at the bedside. Resident 99 stated that water was not readily available and each time water was needed, Resident 99 had to ask staff and wait for it to be provided. During a concurrent observation and interview on 12/16/25 at 11:08 AM with Licensed Nurse (LN) 2 in Resident 99's room, LN 2 stated that there was no water at Resident 99's bedside. LN 2 further stated that when residents could not find water at the bedside, they attempted to get up on their own, placing them at risk for falls. During a concurrent interview and record review on 12/16/25 at 11:13 AM with LN 2, Resident 99's Care Plan, initiated on 11/18/22 was reviewed. In the section titled, Focus, the record indicated, The resident [Resident 99] has dehydration or potential fluid deficit. In the section titled, Interventions, the record Indicated, .Ensure the resident has access to.water.whenever possible. LN 2 stated that when water was not readily accessible to Resident 99, the resident was at risk for dehydration and choking. During an interview on 12/16/25 at 12:35 PM with LN 2, LN 2 stated that residents on thickened fluids should still have had water available at the bedside to prevent delays in providing fluids.During an interview on 12/18/25 at 10:01 AM with the Assistant Director of Nursing (ADON), the ADON stated the residents' water pitchers should have been available with fresh water. The ADON further stated that when water was not available at the bedside, residents lacked access to fluids, which could have increased the risk of dehydration. During an interview on 12/18/25 at 1:10 PM with the Director of Nursing (DON), the DON stated that fluids should have been accessible to the residents by always having [NAME] pitchers available at residents' bedsides. The DON further stated that when fluids were not available at the bedside, residents were at risk for dehydration.Review of facility policy and procedure (P&P) titled, Hydration - Clinical Protocol, revised 9/2017, the P&P indicated, . The staff will provide supporting measures such as supplemental fluids.

Based on observation, interview and record review the facility failed to ensure that staff utilized appropriate Personal Protective Equipment (PPE, special gear worn to protect themselves and others from germs) upon entering an isolation room for one of three sampled residents (Resident 37) when Licensed Nurse (LN) 3 was observed inside a contact isolation room (a room where a sick person is kept separate and staff use additional protective equipment, such as gloves and gowns, to prevent the spread of germs) checking Resident 37's pulse without wearing gloves or a gown.This failure increased the risk of spreading germs to staff, other residents and visitors in the facility.Findings:Review of Resident 37's admission RECORD, indicated that Resident 37 was admitted to the facility with the following diagnoses including, but not limited to, Acute Respiratory Failure with Hypoxia (lungs cannot get enough oxygen into the blood to meet the body's needs), and Pneumonia (lung infection that makes it hard to breathe).During a concurrent observation and interview with Resident 37 on 12/16/25 at 12 PM, it was noted that a contact isolation sign was posted outside the resident's room. Resident 37 stated that she had Pneumonia.During a concurrent observation and interview with LN 3 on 12/17/25 at 11:14 AM, it was observed that LN 3 was inside Resident 37's contact isolation room without wearing any PPE, including gloves or gown, while checking the resident's pulse. During the interview, LN 3 stated that he believed Resident 37 had pneumonia and that he entered the room to assess the resident's pulse. LN 3 acknowledged that he did not wear PPE. LN 3 stated that the risk of his actions was that he could become contaminated and potentially transmit bacteria to other residents. During a concurrent interview and record review with the Director of Nursing (DON) on 12/18/25 at 7:40 AM, the DON reviewed Resident 37's laboratory records and confirmed that the resident had ESBL (Extended-Spectrum Beta-Lactamase - is a hard-to-kill germ that spreads by contact from person to person, especially through hands, clothing, or shared equipment if proper protection was not used) detected in her urine. The DON stated that LN 3's provision of care to Resident 37 without wearing contact isolation PPE did not meet her expectations.During an interview with the Infection Preventionist (IP) on 12/19/25 AT 9:35 AM, the IP stated that LN 3 entering Resident 37's isolation room without PPE did not meet her expectations, as the room was designated for contact isolation and all staff were expected to adhere to PPE requirements.A review of the facility's policy titled Isolation - Categories of Transmission-Based Precautions revised 9/22, the policy indicated, .Transmission-based precautions are initiated when a resident.has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents.1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with resident or indirect contact with environmental surfaces.7. Staff and visitors wear gloves.8. Staff and visitors wear a disposable gown upon entering the room.A review of the facility's policy titled Personal Protective Equipment revised 10/18, the policy indicated, .The type of PPE required for a task is based on: a. the type of transmission-based precaution.Review of an online document published by the Centers for Disease Control and Prevention (CDC) titled Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), updated on 9/2024, the guideline indicated, .II.E.2.When Contact Precautions are used.donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces.III.b.1 Contact Precautions.Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens. https://www.cdc.gov/infection-control/media/pdfs/Guideline-Isolation-H.pdf

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to meet the dental health needs for one of thirty-five sampled residents (Resident 72), when Resident 72's mouth wash and dental consult ordered on 11/25/25 were not carried out timely. This deficient practice had the potential to negatively affect Resident 72's dental health needs and could contribute to unnecessary pain and suffering.Findings:Review of Resident 72's admission RECORD, indicated Resident 72 was initially admitted to the facility in the spring of 2025, with diagnosis including but not limited to acute and chronic respiratory failure (lung disease often requiring long-term oxygen therapy), chronic obstructive pulmonary disease (long-term lung condition that blocks airflow and can make it hard to breath), dependence on supplemental oxygen, depression (serious mood disorder causing persistent sadness, loss of interest in activities), and anxiety disorder (mental health condition marked by intense, persistent and excessive worry).Review of Resident 72's NURSES NOTES, dated 10/21/25, indicated, .Alert and orientated. On monitoring for immovable mass to center of abdomen and broken tooth to right lower side. No c/o [complain of] pain or discomfort to site. No s/sx [sign and symptoms] of worsening.POC [plan of care] ongoing.Review of Resident 72's SBAR [Situation, Background, Assessment, Recommendation, and is a structured communication tool in healthcare to convey critical information of patient's condition to healthcare team, including MD] & INITIAL COC /ALERT CHARTING & SKILLED DOCUMENTATION, dated 11/20/25, indicated, .SITUATION.Resident reports having sore gums and discomfort.Pain.Resident Reports Pain? .Yes.Most Recent Pain Level.4.Location.Sore gums.Notes.New onset of sore gums.Initial COC Alert Charting Notes.Resident complains of sore gums and discomfort, no active bleeding observed. Tylenol administered as ordered for pain, resident tolerated medication well, remains stable, no acute distress, denies other symptoms. MD [Medical Doctor] notified of the condition. Resident is self RP [Representative Party] and aware. Will continue to monitor.Review of Resident 72's Care Plan, initiated 11/20/25, indicated, .Resident has impaired oral/dental condition due to sore gums and discomfort.Resident will maintain oral mucosal integrity and decreased gum soreness.Assess gums for redness, swelling or bleeding.Monitor episodes of chewing problems.Notify provided if symptoms worsen or if infection is suspected.Perform oral assessment as needed.Review of Resident 72's Physician Progress Note, dated 11/25/25, written by Nurse Practitioner (NP) 1, indicated, .Asked to see pt [patient] for sore mouth. Pt stated needs to see dentist. Will write referral. Otherwise pt states all going well.Assessment.Mouth pain.Ventral hernia and lower and pain.PLAN.Dental referral. Magic Mouthwash. Continue current treatment plan and adjust care and medication as needed. Monitor neuro and mental status, pain control. Monitor ABD [abdomen] symptoms.Chart, medication, and labs reviewed.Review of Resident 72's Order Details, dated 11/25/25, written by Nurse Practitioner (NP) 1, indicated, .Order Summary.magic mouthwash.every 6 hours as needed for sore gums prior to meals.Review of Resident 72's Order Details, dated 11/25/25, written by Nurse Practitioner (NP) 1, indicated, .Order Summary.CONSULT.dental evaluation for worsening sore gums.Review of Resident 72's Medication Administration Record for the months of 11/2025 and 12/2025, did not indicate any mouth wash or Magic Mouthwash was ordered or administered.During a concurrent observation and interview on 12/17/25 at 2:00 p.m., Resident 72 stated about a month ago the facility sent her to the hospital and while she was there, she received a mouth wash called magic mouthwash that helped with numbing her gums so she could tolerate eating food. Resident 72 stated she was not receiving the mouthwash at the facility and she had asked several staff members about receiving the mouthwash and had told them it helped her with the pain in her mouth. Resident 72 further explained she still had not received the mouthwash and was in a lot of mouth pain. Resident 72 stated because of her missing teeth and her gums hurting she was only able to eat certain foods. Resident 72 explained because of her mouth pain she gets same food every day.During a concurrent interview and record review on 12/18/25 at 12:40 a.m., Licensed Nurse 4 stated she was aware Resident 72 was using mouthwash while she was recently in the hospital. LN 4 stated Resident 72 had asked her about the mouthwash, and she told her she would look into her orders but could not locate an order for a mouthwash. LN 4 stated Resident 72 had also inquired about the mouth wash with another nurse and LN 4 had thought that nurse would follow up. LN 4 stated she did not see anything in Resident 72's medical chart regarding new orders and acknowledged she did not call the doctor regarding the mouthwash. LN 4 stated she does not usually look at resident's progress notes in their medical record. During a record review of Resident 72's clinical record, LN 4 acknowledged there was a progress note written by the NP 1 regarding Resident 72's mouth pain and her order for magic mouthwash. LN 4 stated she was per diem [on call] and she would need to contact the doctor to get the order, and the NP could have placed the order for the mouthwash. LN 4 stated it had been at least a month since the progress note regarding the mouth wash. Through a record review of Resident 72's orders, LN 4 acknowledged the order for the magic mouthwash and stated she was not sure why it was not on Resident 72's MAR.During a concurrent interview and record review on 12/18/25 at 1:07 p.m., with the Social Services Director (SSD) and the Social Services Assistant (SSA), the SSD stated she was not familiar with Resident 72 and regarding scheduling consultation appointments the Social Service Scheduler usually makes the appointments, and she was not working that day. The SSD and SSA stated they both were not aware of the two consultation requests ordered for Resident 72 addressing a dental consult for mouth pain and abdominal surgeon consult. Through record review of Resident 72's clinical record, the SSD stated she could not locate a SS note regarding the scheduling of dental or abdominal surgeon consults. The SSD stated the expectation was there should be notes in electronic medical records from SS regarding receiving and scheduling of appointments. The SSA stated the dentist the facility uses had come to the facility for their monthly visit on 12/11/25 and had performed resident examinations. Through record review of the facility's Oral Health Care list, the SSA confirmed Resident 72 was not on the list of residents scheduled to be seen nor was she examined by the dentist that day. The SSA stated had they had the consultation request she would have been seen on 12/11/25. The SSD confirmed Resident 72's dental consult ordered by the MD on 11/25/25 due to mouth pain. The SSD stated her expectation was within a week for sure the appointment should have been followed up on and scheduled. The SSD stated she would send an email now to the dentist and this was important due to Resident 72's mouth pain. The SSD stated she would be calling the dentist Resident 72 had seen previously while in house (facility) for her progress notes as she was not sure what the treatment plan was.During an interview on 12/18/25 at 4:25 p.m., LN 7 stated she was familiar with Resident 72 and Resident 72 had lived in the facility for about a year. LN 7 stated Resident 72 had complained to her about her broken teeth, her tooth pain and her gum pain. LN 7 stated she was on hold earlier with the pharmacy regarding Resident 72's magic mouthwash. Resident 72 explained she was not able to speak with anyone from the pharmacy regarding what the holdup was on getting Resident 72 her mouth wash medication. LN 7 stated she had given the mouthwash to other residents, and the mouthwash would come from the pharmacy. LN 7 stated the mouthwash was for Resident 72's mouth sores and helps alleviate pain. LN 7 stated the risk to Resident 72 if she did not receive the ordered mouth wash medication would be worsening pain, her eating less, possible weight loss due to her nutritional value consumed being compromised. LN 7 stated regarding Resident 72 consult for the dentist, appointments were scheduled by Social Services (SS). LN 7 stated once the order was received from the doctor then the LN make SS aware through printing the order out and slipping the paper under the SS office door or they tell SS verballing. LN 7 stated that since she works the evening shift, she will also endorse the order to the next shift nurse for them to follow up. LN 7 stated there should be a progress note written in the resident's electronic clinical record of nursing staff informing SS of the ordered dental consult. Through a record review of Resident 72's progress notes, LN 7 acknowledged there was no communication note written of a dental consult being ordered. LN 7 stated the risk to Resident 7 for her abdominal surgeon and dental consult not being followed up on was Resident 72 experiencing worsening pain and symptoms.During a concurrent interview and record review on 12/18/25 at 5:04 p.m., the Director of Nurses (DON) reviewed Resident 72's clinical record, the DON acknowledged the order for a dental consult written by the NP and stated Resident 72 was most likely seen by the NP for her mouth pain but nursing missed the order for the consult. The DON stated her expectation was Resident 72's dental consult order be carried out timely. The DON stated the risk of Resident 72's order not being addressed was her mouth symptoms worsening and continued pain for the resident since the appointment had not been scheduled. The DON stated her expectation was Resident 72 should have been on dentist consult list for the dentist's visit to the facility that occurred on 12/11/25. The DON stated the nurse should have notified social services of the dental appointment order. The DON stated the process for new orders was that medical records audits for new orders and sends them to the nurses to review and they should have caught the new dental consult order. The DON stated her expectation was once the nurse receives the order and they then notify the appropriate department or person that will be taking care of scheduling the appointment and writes a note in the resident's chart document this. The DON stated the risk for the dental consultation not being scheduled timely and/or being missed was the resident could be in continuous pain and the issue not being addressed. During an interview on 12/19/25 at 9:33 a.m., Resident 72 stated social services had just come into to her room to tell her they have an appointment scheduled for her to see an outside dentist on 1/5/26. Resident 72 stated she needed the Magic Mouthwash for her mouth pain. Resident 72 stated she had swelling and blistering in her mouth which had happened while she was in the hospital. Resident 72 stated she was seen in October of 2025 by the dentist who comes to the facility and they cleaned her mouth. Resident 72 explained during that dental visit, the dentist told her she need upper dentures and needed her bottom teeth pulled. Resident 72 further explained there was no follow up with the dentist after that visit. Resident 72 stated she had asked the Certified Nurse Assistant (CNA) about her dental status a couple of times and did not receive any information. Resident 72 stated her teeth had broken off at the gumline. Resident 72 stated it was upsetting to her because she was now on a soft food diet and eating foods with pudding texture and the foods stick to her throat, were tasteless, and were a yucky texture. Resident 72 stated her preference was to eat a regular diet. Resident 72 stated she was emotional and upset because she wanted her mouth issues taken care of and was concerned that she could get mouth infections and be back in the hospital.Review of facility P & P titled, Medication and Treatment Orders, revised 7/2016, indicated, .Orders for medication and treatments will be consistent with principles of safe and effective order writing.Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.Review of facility P & P titled, Dental Services, revised 12/2016, indicated, .Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.Routine and 24-hour emergency dental services are provided to our residents through.a contract agreement with a licensed dentist that comes to the facility monthly.referral to the resident's personal dentist.referral to community dentists.referral to other health care organizations that provide dental services.Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the stated plan.Review of facility P & P titled, Resident Participation-Assessment/Care Plans, revised 2/2021, indicated, .The resident and his or her representative are encouraged to participate in the resident's assessment and in the development of and implementation of the resident's care plan.The resident/representative's right to participate in the development and implementation of his or her plan of care includes the right to.participate in establishing his or her goals and expected outcomes of care.receive services and/or items included in the plan of care.Review of facility provided document titled, Job Description: Licensed Vocational Nurse, undated, indicated, .The primary purpose of your job is to assist the RN's in giving services, organizing, developing and doing the day-today functions of the Nursing Service Department.Conducts initial and ongoing assessments of resident's health status.administers medications, and observes any changes in condition.Notifies the RN or healthcare provider of any significant changes or concerns.Administers medications as prescribed by the healthcare provider .Ensures accurate dosage, proper route, and timely administration.Monitors and records residents response to medications.Review of facility P & P titled, Dental Consultant, revised 4/2007, indicated, .Dental care shall be provided through the services of a Consultant Dentist.Our facility does not maintain a resident dentist on staff and therefore does not provide on premises dental services.A consultant dentist is retained by our facility and responsible for.providing consultation to physicians and providing other services relative to dental matters.assuring that emergency dental services are available.providing necessary information concerning other residents to appropriate staff, care planning conferences and/or committees.Review of facility policy and procedure (P & P) titled, Social Services, revised 10/2010, indicated, .Our facility provided medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being.The Director of Social Services is a qualified social worker and is responsible for.Consultation with other departments regarding program planning.priority setting of social services.Consultation of allied professional health personnel regarding provisions for the social and emotional needs of the resident and family.Medically related social services to maintain or improve each resident's ability to control everyday physical needs (e.g., appropriate adaptive equipment for eating.); and mental and psychosocial needs (.coping abilities.).Factors that have a potentially negative effect on psychosocial functioning include.Institutional attitudes a and practices which affect the resident's dignity and sense of control.Disability or loss of function.Maintaining regular progress and follow-up notes indicating the resident's response to the plan and adjustment to the institutional setting.Maintaining appropriate documentation of referrals.Making supportive visits to residents and performing needed services (.coordinating resources and services to meet the resident's needs.).

Based on observation, interview, and record review, the facility failed to ensure that informed consent (explaining the risks, benefits, and choices to the resident or their representative [someone authorized to act on behalf of a resident]) for the use of bed rails (adjustable metal or plastic bars along the sides of a hospital bed) was obtained from the appropriate resident representative for one of 35 sampled residents (Resident 107), when the informed consent was obtained from Resident 107, who lacked decision-making capacity.This failure resulted in Resident 107's representative not being able to make an informed choice regarding the use of bed rails and placed Resident 107 at risk of entrapment (when a resident gets caught, trapped, or entangled in the spaces within or around the bed rails, mattress, or the bed frame) injury, or restraint (something that keeps a resident from free movement).Findings: During a review of Resident 107's admission Record, the record indicated Resident 1 was admitted to the facility with diagnoses that included dementia, (condition that causes memory loss, confusion, and trouble thinking or making decisions) schizophrenia, (mental illness that can cause confusion, unusual thoughts, or seeing or hearing things that are not real) and major depressive disorder. Review of Resident 107's doctor's order titled, Order Details, dated 11/1/25, indicated, .Order Summary: Bedrail: Left Side Grab bar.During a concurrent observation and interview on 12/16/25 at 11:24 AM with Resident 107 in Resident 107's room, Resident 107 had a bed rail on the left side of the bed. Resident 107 stated that he could not remember if staff members explained the pros and cons of a bed rail.During a concurrent interview and record review on 12/17/25 at 2:21 PM with Licensed Nurse (LN) 6, Resident 107's informed consent for bed rails titled, BED RAIL OBSERVATION/ASSESSMENT (WGC)-V3, dated 11/1/25 and Resident 107' s doctor's order titled, Order Listing Report, dated 12/31/24 were reviewed. The BED RAIL OBSERVATION/ASSESSMENT (WGC)-V3 indicated that Resident 107 had signed the informed consent for the use of bed rails on 11/1/25. Resident 107's Order Listing Report indicated, MD [Medical Doctor] determines that [Resident 107] does NOT have the Mental Capacity to make Healthcare decisions. LN 6 stated that Resident 107's informed consent for bed rails was invalid because Resident 107 lacked decision-making capacity and was not fully alert to understand the safety issues related to bed rails. During a concurrent interview and record review on 12/18/25 at 11:45 AM with the Assistant Director of Nursing (ADON), Resident 107's BIMS [Brief Interview for Mental Status: an assessment of the resident's thinking and memory] TEMPORARY WORKSHEET., dated 11/26/25 was reviewed. The BIMS TEMPORARY WORKSHEET. indicated that Resident 107 BIMS score was 11 which indicated Resident 107 had moderately impaired cognition (13-15 = Intact, 8-12 = Moderate, 0-7 = Severe). The ADON stated that Resident 107 had a BIMS score of 11, which showed moderate cognitive impairment, and that Resident 107 did not have the capacity to make healthcare decisions. The ADON stated that Resident 107 could not understand the risks of using a bed rail. The ADON stated that informed consent should have been signed by the resident's representative, not the resident, and that the informed consent for the bed rail was not valid. ADON further stated that the use of a bed rail for Resident 107 was a safety concern and increased risk of entrapment.During an interview on 12/18/25 at 1:23 PM with the Director of Nursing (DON), the DON stated that an informed consent for bed rail use should have been signed by the family or resident's representative because Resident 107 lacked the capacity to make healthcare decisions and did not understand the risks of bedrails, including entrapment. The DON further stated that any consent signed by a resident without capacity was not valid. Review of Resident 107's Care Plan, initiated on 11/29/25, in the section titled, Focus, indicated, BED RAIL-Bed Rail: May have 1/4 bar side rail. In the section titled Interventions, indicated, .Educate the.resident and/or resident representative on the risks and benefits of bed rail use as noted on the informed consent.Review of facility policy and procedure (P&P) titled, Bed Safety and Bed Rails, revised 8/22, the P&P indicated, .For the purpose of this policy bed rails include:.grab/assist bars.The use of bed rails is prohibited unless criteria for use of bed rails have been met, including.informed consent.Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent.

Based on observation, interview, and record review, the facility failed to provide timely and proper pain relief for two of 35 sampled residents (Resident 72 and Resident 78), when:1.Resident 72 complained of sore gums and discomfort, and the ordered Magic Mouthwash [medicated liquid mouthwash mixture used to relieve pain from mouth and throat sores] and dental evaluation were not carried out and/or administered to Resident 72; and, 2. Resident 78 did not receive comfort measures or pain medication in a timely manner when Resident 78 reported moderate to severe (strong) pain. These failures resulted in Resident 72 and Resident 78 experiencing continued pain, which affected Resident 72's and Resident 78's comfort and emotional well-being (the resident's ability to feel calm, secure, and free from worry).Findings: 1.Review of Resident 72's admission RECORD, indicated Resident 72 was initially admitted to the facility in the spring of 2025, with diagnoses that included depression (serious mood disorder causing persistent sadness, loss of interest in activities), and anxiety disorder (mental health condition marked by intense, persistent and excessive worry). Review of Resident 72's NURSES NOTES, dated 10/21/25, indicated, .Alert and orientated. On monitoring for.broken tooth to right lower side. No c/o [complaints of] pain or discomfort to site. No s/sx [sign and symptoms] of worsening.POC [plan of care] ongoing. Review of Resident 72's NURSES NOTES, dated 10/22/25, indicated, .alert and responsive, continues monitoring.broken tooth, pain to mouth.managed with PRN [as needed] pain medication. Able to verbalize needs to staff. Continue with current POC. Review of facility provided document titled, Oral Health Care We Come To You dated 10/22/25, indicated, .[name redacted, Resident 72].Procedure.Full debridement [removal of plaque build-up].heavy plaque.heavy calcus [calculus means buildup of plaque on teeth].NV [next visit] Recommended.Recap [summary].#28 [tooth number]-sharp.wants it extracted [pulled out] ASAP [as soon as possible] . Review of Resident 72's SOCIAL SERVICES PROGRESS NOTES, dated 10/28/25, indicated, Resident was seen by oral health on 10/28/25. Resident received services. Review of Resident 72's SBAR [Situation, Background, Assessment, Recommendation, a structured communication tool in healthcare to convey critical information of resident's condition to healthcare team] & [and] INITIAL COC [change of condition]/ALERT CHARTING & SKILLED DOCUMENTATION, dated 11/20/25, indicated, .SITUATION.Resident reports having sore gums and discomfort.Pain.New onset of sore gums.Initial COC Alert Charting Notes.MD [Medical Doctor} notified of the condition. Review of Resident 72's Physician Progress Note, dated 11/25/25, written by Nurse Practitioner (NP) 1, indicated, .Asked to see pt [patient] for sore mouth. Pt stated needs to see dentist. Will write referral [referring a resident for consultation, review, or further action]. Otherwise pt states all going well.Assessment.Mouth pain. PLAN.Dental referral.Magic Mouthwash. Review of Resident 72's Order Details, dated 11/25/25, written by Nurse Practitioner (NP) 1, indicated, .Order Summary.magic mouthwash.every 6 hours as needed for sore gums prior to meals. Review of Resident 72's Order Details, dated 11/25/25, written by Nurse Practitioner (NP) 1, indicated, .Order Summary.CONSULT.dental evaluation for worsening sore gums. Review of Resident 72's Medication Administration Record for the month of 12/25, did not indicate any mouth wash or Magic Mouthwash was ordered or administered for Resident 72. During a concurrent observation and interview on 12/17/25 at 2:00 p.m., Resident 72 stated about a month ago the facility sent her to the hospital and while she was there, she received a mouth wash called, magic mouthwash, that helped numb her gums so she could tolerate eating food. Resident 72 stated she had not received the mouthwash at the facility and she had asked several staff members about the mouthwash and had verbalized to staff that the mouthwash helped her control the mouth pain. Resident 72 stated because she was missing teeth and her gums hurt, she was only able to eat certain foods. Resident 72 explained because of her mouth pain she received the same food every day. Resident 72 stated she wanted and needed new teeth because her teeth were missing or broken. Resident 72 stated she saw a dentist about a month ago in the facility and they told her they needed authorization from the insurance company to pull her teeth, and she had not received a status update. During a concurrent interview and record review on 12/18/25 at 12:40 a.m., with Licensed Nurse (LN) 4, Resident 72's clinical record titled, Physician Progress Note, dated 11/25/25, written by Nurse Practitioner (NP) 1 was reviewed. LN 4 stated she was aware Resident 72 had used mouthwash while she was recently in the hospital. LN 4 stated Resident 72 had asked her about the mouthwash, and she told her she would look into her orders but could not locate an order for a mouthwash. LN 4 stated Resident 72 had also inquired about the mouth wash with another nurse and LN 4 had thought that nurse would follow up. LN 4 stated she did not see anything in Resident 72's medical chart regarding new orders and acknowledged she had not called the doctor regarding the mouthwash. LN 4 stated she did not review Resident 72's progress notes in the medical record. During a record review of Resident 72's clinical record, LN 4 acknowledged there was a progress note written by the NP 1 regarding Resident 72's mouth pain and her order for magic mouthwash. LN 4 stated it had been at least a month since the progress note regarding the mouth wash was written. LN 4 acknowledged there was an order for the magic mouthwash and stated she was not sure why it was not on Resident 72's Medication Administration Record (MAR - a document that contains medications ordered, given or held). During a joint concurrent interview and record review on 12/18/25 at 1:07 p.m., with the Social Services Director (SSD) and the Social Services Assistant (SSA), the facility's Oral Health Care list, was reviewed. The SSD stated she was not familiar with Resident 72's plan of care and the Social Service Scheduler usually made the consultation appointments. The SSD and SSA stated they both were not aware of the consultation request ordered for Resident 72 that addressed a dental consultation for mouth pain. Through record review of Resident 72's clinical record, the SSD stated she could not locate a Social Services (SS) note regarding the scheduling of a dental consultation. The SSD stated the expectation was there should have been notes in the electronic medical records from SS regarding appointments that were received and scheduled. The SSA stated the dentist the facility used had come to the facility for their monthly visit on 12/11/25 and had performed resident examinations. Through record review of the facility's Oral Health Care list, the SSA confirmed Resident 72 was not on the list of residents scheduled to be seen nor was she examined by the dentist that day. The SSA stated had they had the consultation request she would have been seen on 12/11/25 for her dental needs. The SSD confirmed Resident 72's dental consultation ordered by the MD on 11/25/25 due to mouth pain. The SSD stated her expectation was the appointment should have been followed up on and scheduled within a week. The SSD stated follow up was important due to Resident 72's mouth pain. During an interview on 12/18/25 at 4:25 p.m., LN 7 stated she was familiar with Resident 72 and Resident 72 had lived in the facility for about a year. LN 7 stated Resident 72 had complained to her about her broken teeth, her tooth pain, and her gum pain. LN 7 stated she had given the magic mouthwash to other residents before, and the mouthwash came from the pharmacy. LN 7 stated the mouthwash was for Resident 72's mouth sores and helped alleviate pain. LN 7 stated the risk to Resident 72 that she did not receive the ordered mouth wash medication was worsening pain, eating less, and possible weight loss due to her nutritional intake being compromised. LN 7 stated regarding Resident 72 consult for the dentist, appointments were scheduled by Social Services (SS). LN 7 stated once the order was received from the doctor then the LN made SS aware through printing the order out and slipping the paper under the SS office door or they verbally told SS. LN 7 stated that since she worked the evening shift, she would also endorse the order to the next shift nurse for them to follow up. LN 7 stated there should have been a progress note written in the resident's electronic clinical record of nursing staff informing SS of the ordered dental consult. Through a record review of Resident 72's progress notes, LN 7 acknowledged there was no communication note written of a dental consult being ordered. LN 7 stated the risk to Resident 7 for her dental consultation not being followed up on was Resident 72 experiencing worsening pain and symptoms. During a concurrent interview and record review on 12/18/25 at 5:04 p.m., with the Director of Nurses (DON), Resident 72's clinical record was reviewed. The DON stated Resident 72's mouthwash order was dated 11/25/25 and the order required an LN to go into the electronic medical record and revise the order for it to appear on Resident 72's MAR. The DON explained since this was not completed the Magic Mouthwash order never went to the pharmacy to fill. The DON stated her expectation was once the doctor or nurse practitioner wrote a new order, the LN reviewed and updated the order, so it populated in the resident's MAR. The DON stated if a resident asked for medication and/or mouthwash for mouth pain, the nurse should have followed up with the doctor and/or checked the resident's orders. The DON stated the risk for the resident if this was not done was that the resident would not get medication and could have worsening pain and there was a risk of not eating or lack of nutrition due to the continued mouth pain. The DON acknowledged the order for a dental consult written by the NP and stated Resident 72 was most likely seen by the NP for her mouth pain, but nursing missed the order. The DON stated her expectation was Resident 72's order be carried out timely. The DON stated the risk of Resident 72's order not being addressed was her symptoms worsening and continued pain for the resident since the appointment had not been scheduled. The DON stated her expectation was Resident 72 should have been on the dentist consult list for the dentist's visit to the facility that occurred on 12/11/25. The DON stated the nurse should have notified social services of the dental appointment order. The DON stated the process for the new orders was that medical records would audit for new orders and send them to the nurses to review and they should have caught the new order. The DON stated her expectation was once the nurse received the order and they then notified the appropriate department or person that would be taking care of scheduling the appointment, it should have been documented in Resident 72's health record. The DON stated the risk for the consultation not being scheduled timely and/or being missed was the resident could have been in continuous pain, and the issue was not being addressed. During an interview on 12/19/25 at 9:33 a.m., Resident 72 stated her teeth had broken off at the gumline. Resident 72 stated it was upsetting to her because she was now on a soft food diet and eating foods with pudding texture and the foods stuck to her throat, were tasteless, and were not a pleasing texture. Resident 72 stated her preference was to eat a regular diet. Resident 72 stated she was emotional and upset because she wanted her mouth issues taken care of and was concerned that she could get mouth infections and be back in the hospital. During a concurrent interview and record review on 10/19/25 at 10:05 a.m., with the Assistant Director of Nursing (ADON), Resident 72's Pain Assessment, completed on 11/17/25; Resident 72's care plan, dated 11/20/25; and Resident 72's Change of Condition, dated 11/20/25 were reviewed. The ADON acknowledged Resident 72's pain assessment was marked as general pain and there was no mention of specific areas of pain including her mouth. The DON stated it was important for the nurse to document specific pain so they could have addressed issues and interventions. Review of facility policy and procedure (P & P) titled, Pain-Clinical Protocol, revised 3/18, indicated, .The Physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain; for example.oral or dental pathology.It also includes review for any treatments that the resident currently is receiving for pain, including complementary and non-pharmacological treatments.The nursing staff will assess each individual for pain upon admission to the facility.whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity.The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated.The physician will help identify causes of pain; for example, by examining the resident directly, reviewing the resident's history, and via discussion with the resident and staff.The physician will help identify the extent to which underlying causes of pain can be addressed or reversed.With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment; for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep.The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain.Pain medications should be selected based on pertinent treatment guidelines.If the resident's pain is complex or not responding to standard interventions, the Attending Physician may consider additional consultative support.If a consultant is involved in managing pain, the attending physician will maintain an active role by reviewing the consultant's recommendations, addressing medical issues that affect pain, monitoring for complications related to treatment, and evaluating subsequent progress Review of facility P & P titled, Administering Medications, revised 4/19, indicated, .Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber's orders, including any required time frame.Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include.Enhancing optimal therapeutic effect of the medication.Honoring resident choices and preferences, consistent with his or her care plan. Review of facility P & P titled, Dental Services, revised 12/16, indicated, .Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.Routine and 24-hour emergency dental services are provided to our residents through.a contract agreement with a licensed dentist that comes to the facility monthly.referral to the resident's personal dentist.referral to community dentists.referral to other health care organizations that provide dental services.Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the stated plan. Review of facility provided document titled, Job Description: Licensed Vocational Nurse, undated, indicated, .The primary purpose of your job is to assist the RN's in giving services, organizing , developing and doing the day-today functions of the Nursing Service Department.Conducts initial and ongoing assessments of resident's health status.administers medications, and observes any changes in condition.Notifies the RN or healthcare provider of any significant changes or concerns.Administers medications as prescribed by the healthcare provider .Ensures accurate dosage, proper route, and timely administration.Monitors and records residents response to medications. Review of facility P & P titled, Dental Consultant, revised 4/07, indicated, .Dental care shall be provided through the services of a Consultant Dentist.Our facility does not maintain a resident dentist on staff and therefore does not provide on premises dental services.A consultant dentist is retained by our facility and responsible for.providing consultation to physicians and providing other services relative to dental matters.assuring that emergency dental services are available.providing necessary information concerning other residents to appropriate staff, care planning conferences and/or committees. Review of facility policy and procedure (P & P) titled, Social Services, revised 10/10, indicated, .Our facility provided medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being.The Director of Social Services is a qualified social worker and is responsible for.Consultation with other departments regarding program planning.priority setting of social services.Consultation of allied professional health personnel regarding provisions for the social and emotional needs of the resident and family.Medically related social services to maintain or improve each resident's ability to control everyday physical needs (e.g., appropriate adaptive equipment for eating.); and mental and psychosocial needs (.coping abilities.).Factors that have a potentially negative effect on psychosocial functioning include.Institutional attitudes a and practices which affect the resident's dignity and sense of control.Disability or loss of function.Maintaining regular progress and follow-up notes indicating the resident's response to the plan and adjustment to the institutional setting.Maintaining appropriate documentation of referrals.Making supportive visits to residents and performing needed services (.coordinating resources and services to meet the resident's needs.). 2. During a review of Resident 78's admission Record, the record indicated Resident 78 was admitted to the facility with a diagnoses that included bilateral primary osteoarthritis of knee (pain in both knee joints caused by wearing down of the cushion between bones) and pressure ulcer of sacral region, stage 4 (very deep bedsore near the tailbone that can reach muscle or bone and causes severe pain). Review of Resident 78's PAIN ASSESSMENT INTERVIEWABLE & NON-INTERVIEWABLE (WGC)-V2), dated 10/10/25, indicated, . [Resident 78] States she has pain all over but most of the time it is in her arms.What makes the pain better? It depends sometimes medication sometimes repositioning. In the section MEDICATIONS/TREATMENTS/MODALITIES, the document indicated .Describe all methods of alleviating pain and their effectiveness: Medication and repositioning. Review of Resident 78's Care Plan, initiated on 6/5/24, in the section titled Focus, the document indicated, The resident has possible pain. In the section titled, Interventions, the document indicated, .Administer analgesia [pain relief] as per orders.Anticipate the resident's need for pain relief and respond immediately to any complaint of pain.Offer non medication approaches such as repositioning, massage, immobilizing the area causing pain. During an observation on 12/16/25 at 12:08 PM in Resident 78's room, Certified Nursing Assistant (CNA) 9 answered Resident 78's call light (a handheld device that when activated, alerts the staff that the resident needs assistance). Resident 78 complained of pain and CNA 9 stated the nurse was on break and would return in about 10 minutes, and that Resident 78 would need to wait. CNA 9 then left the room. During an interview on 12/16/25 at 12:11 PM, Resident 78 stated that she had severe pain in her right arm. Resident 78 further stated that staff did not help right away and that she would need to wait a long time for her pain to be addressed. During an interview on 12/16/25 at 12:12 PM, CNA 9 stated that when a resident reported pain, CNA could ask about the pain level (using the numerical pain scoring system; 0=no pain and 10=severe pain) and location and could offer non-medication pain relief, such as repositioning. CNA 9 stated that a resident's pain needed to be communicated to the nurse right away, and that if the assigned nurse was on break, another nurse on the floor could assist with pain relief. CNA 9 stated that when she answered Resident 78's call light, she did not ask additional questions about the pain and did not offer non-medication pain relief. CNA 9 further stated that if resident's pain continued, it could worsen and could cause anxiety and increase the risk of a fall. During an interview on 12/16/25 at 12:39 PM, Resident 78 stated that she continued to have severe pain and that the nurse had not yet come to see her to provide pain relief. During an observation on 12/16/25 at 12:40 PM in Resident 78's room, CNA 10 answered Resident 78's call light. Resident 78 stated she had pain. CNA 10 stated she would notify the nurse. CNA 10 then left the room. During an interview on 12/16/25 at 12:48 PM with Licensed Nurse (LN) 2, LN 2 stated that when a CNA answered a resident's call light and the need was for pain relief, the CNA was expected to notify the nurse right away, especially if the pain level was above 5 (moderate pain or higher), so the pain could be addressed promptly. LN 2 further stated that if a resident's pain was not communicated to the nurse, the resident could experience increased pain, restlessness, and an increased risk of a fall. Review of Resident 78's doctor's order titled, Order Listing Report, the record indicated on 1/9/25, Resident 78 had a doctor's order to administer acetaminophen (pain reliver medication) Tablet 325 milligrams (mg-a unit measure) two tablets every six hours as needed for mild pain (pain level 1 through 3) and a doctor's order dated, 12/4/25 to administer oxycodone-acetaminophen (stronger pain medication) tablet 5-325 mg every six hours as needed for pain management. During a concurrent interview and record review on 12/18/25 at 10:52 AM with the Assistant Director of Nursing (ADON), Resident 78's Medication Administration Record (MAR), dated 12/2025 was reviewed. The MAR indicated that Resident 78 received oxycodone-acetaminophen on 12/16/25 at 1:04 PM for a pain level of 5 and acetaminophen on 12/16/25 at 6:24 PM for a pain level of three. Resident 78's care plan, initiated on 6/5/24, was also reviewed. In the section titled Focus, indicated [Resident 78] experience(s) Related to: wound and Pain Locations Medication Regimen containing Opioid Analgesic(s). (strong pain medicine like oxycodone-acetaminophen used for moderate to severe pain). In the section titled Interventions, indicated, .Observe effectiveness of pain management interventions. The ADON stated that Resident 78 waited 56 minutes to receive pain medication on 12/16/25 and that pain medication should have been provided as soon as possible. The ADON stated that when Resident 78 reported pain to CNAs, CNAs were expected to ask basic questions about the pain and offer non medication comfort measures, such as repositioning. The ADON stated that CNAs were expected to report the resident's pain to the nurse right away, and if the assigned nurse was on break, the covering nurse should be notified so the resident's pain could be addressed without delay. The ADON further stated that delays in pain management could cause restlessness and increase the risk of accidents, including falls. During an interview on 12/18/25 at 1:18 PM with the Director of Nursing (DON), the DON stated that staff were expected to include a resident's pain as part of vital signs (basic body measurements that show how the body is working, heart rate, temperature, blood pressure, and breathing rate) and that residents' pain should be assessed by a nurse as soon as possible. The DON further stated that if pain relief was not provided to residents in a timely manner, the pain could worsen and increase safety risks. Review of facility policy and procedure (P&P) titled Pain-Clinical Protocol revised on 03/2018, the P&P indicated, .Staff will provide the elements of a comforting environment, and appropriate physical and complementary interventions; for example, local heat or ice, repositioning. Review of facility policy and procedure (P&P) titled Activities of Daily Living (ADL), Supporting revised on 03/2018, the P&P indicated, .Care and services to prevent and/or minimize functional decline will include appropriate pain management.

Based on interview and record review the facility failed to ensure one resident (Resident 71), in a sample of 35 residents, had person-centered care plans (a personalized document outlining an individual's health, support, and personal needs, detailing what care is required, how it will be given (tasks, timing, by whom), and the goals, preferences, and choices of the person receiving it, ensuring consistent, high-quality, person-centered support) when care plans for Resident 71's diagnoses of diabetes and anxiety were not developed and implemented.This failure had the potential for health care needs to go unrecognized, negatively affecting Resident 71's health, well-being, and psychosocial health and well-being. Findings:A review of Resident 71's clinical record titled, admission RECORD, (contains clinical and demographic data) indicated Resident 71 was admitted on [DATE] to the facility with diagnoses which included diabetes (problems regulating blood sugar) and anxiety disorder (a mental health condition where you experience excessive, persistent worry, fear, or nervousness that doesn't go away and interferes with daily life, causing physical symptoms like a racing heart, trouble concentrating, and sleep issues, making it hard to control and enjoy everyday activities).A review of Resident 71's care plans indicated the facility had not developed and implemented care plans for Resident 71's diagnoses of diabetes and anxiety.A review of Resident 71's clinical document, untitled, containing physician orders indicated, . busPIRone [a medication used to treat anxiety] . every 12 hours for ANXIETY . M/B [manifested by] INABILITY TO RELAX .During an interview with the Director of Staff Development (DSD) on 12/18/25 at 1:19 PM, the DSD confirmed there was not a care plan developed and implemented for Resident 71's diagnosis of anxiety. The DSD explained the importance of having care plans in place was to ensure licensed nurses were aware of the resident's care plan for specific health issues. The DSD further explained without a care plan in place the resident may not get appropriate care.A review of Resident 71's clinical document, untitled, containing physician orders indicated, . Insulin Lispro [a rapid-acting insulin used to control high blood sugar] three times a day for DIABETES . and, . Insulin Lispro . Inject as per sliding scale [amount of insulin to inject based on blood sugar level] three times a day for DIABETES .During an interview with the DSD on 12/18/25 at 1:19 PM, the DSD confirmed there was not a care plan developed and implemented for Resident 71's diagnosis of diabetes. The DSD explained licensed nurses need to know how to care for a person with diabetes. The DSD further explained care plans are the roadmap on how to care for a resident with diabetes. The DSD explained the risk of Resident 71 not having a diabetic care plan in place was staff would not be aware of and understand specific interventions and it could cause Resident 71 to experience adverse physical effects.During an interview with the Director of Nursing (DON) on 12/19/25 at 10:25 AM, the DON stated Resident 71's diabetic and anxiety care plans should have been developed and implemented on admit. The DON explained the risk to Resident 71 not having a diabetic care plan would be if she had a change in condition related to diabetes staff would not be able to provide appropriate care. The DON further explained the risk to Resident 71 not having an anxiety care plan in place is staff would not be aware of interventions to utilize when Resident 71 was having anxiety.A review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated, . A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan is developed within seven (7) days . and no more that 21 days after admission . The comprehensive, person-centered care plan . includes measurable objectives and timeframes . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . reflects currently recognized standards of practice for problem areas and conditions .

Based on observation, interview, and record review, the facility failed to ensure one of 35 sampled residents' (Resident 3) PRN (as needed) order for Ativan (a medication used reduce anxiousness) did not exceed 14 days without a documented clinical rationale for extending the medication timeframe order.This failure placed Resident 3 at increased risk for adverse outcomes, including over-sedation, falls, and the potential use of a chemical restraint (a medication used to control a person's behavior or restrict their freedom of movement for reasons other than a standard treatment).Findings:Findings:During a review of Resident 3's admission RECORD, the record indicated Resident 3's diagnosis included anxiety (feeling of fear, nervousness or restlessness).A review of Resident 3's Order Listing Report, dated 12/1/25, indicated, .Ativan Oral Tablet 0.5 MG [milligram - unit of measurement] (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for Anxiety m/b [manifested by] severe restlessness for 30 days aeb [as evidenced by] constant moving aimlessly.During a concurrent interview and record review on 12/18/25 at 7:40 AM with the Director of Nursing (DON), the DON confirmed that the PRN Ativan order had been written for a 30-day duration. The DON stated that the facility typically applied a 14-day stop date for PRN psychotropic (drug that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medications. The DON stated that if a physician determined continued use of the PRN medication was clinically necessary, the physician would write the order for up to 90 days, provided there was a documented clinical justification.During a follow up concurrent interview and record review on 12/19/25 at 10:58 AM with the DON, the document titled, Progress Note, dated 12/18/25 was reviewed. The DON stated that after the Department identified the PRN medication order had been extended past the 14 days, the DON requested that the physician document the justification for the extension of the medication in Resident 3's medical record. The DON further stated that no previous clinical justification was available in Resident 3's medical record.A review if the facility's policy titled, Psychotropic Medication Use, dated 7/22, the policy indicated .PRN orders for psychotropic medication are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.

Based on observation, interview and record review, the facility failed to ensure that a resident who lacked the capacity to make medical decisions (the ability to understand medical information and make informed choices about healthcare) had an appropriate legal representative (a person legally authorized to make decisions for someone who cannot decide for themselves) to participate in healthcare decisions, when the facility failed to initiate a timely referral for a representative for one of 35 sampled residents (Resident 9) who was identified as lacking decision-making capacity, had no family, no Power of Attorney (POA, a person you choose to make decisions for you if you are unable to do so), while being listed as her own Responsible Party (RP, indicating the resident is considered able to make her own decisions, sign paper work, and consent to treatments and care decisions).This failure resulted in medical decision-making documents, including a Physician Orders for Life-Sustaining Treatment (POLST, a medical form that states what kind of life-saving treatment a person wants if they get very sick), being completed without verified informed consent and placed the resident at risk for delays, omissions, or inappropriate medical care.FINDINGS:During observation and an attempted interview of Resident 9 on 12/17/25 at 8:16 AM, Resident 9 was observed sitting up in bed and eating breakfast independently. During the attempted interview, Resident 9 was unable to answer simple questions.During an attempted interview on 12/17/25 at 8:30 AM with Resident 9's friend listed as Emergency Contact #1, the individual could not be reached.A review of the document titled, Physician Orders for Life-Sustaining Treatment, signed by the physician on 11/1/22, under Section D (Information and Signatures) revealed the following: The document did not indicate with whom the document was discussed The document did not clearly identify who signed the form The document did not indicate the date the document was signed During a concurrent interview and record review with the Director of Nursing (DON) on 12/18/25 at 7:40 AM, the DON verified the following: Resident 9 does not have the capacity to make medical decisions, as indicated in the document titled EXT REFERRAL SKILLED NURSING FACILITY, dated 10/26/22. Resident 9 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (a progressive brain disorder that slowly destroys memory, thinking, and daily functioning), Dementia (a condition affecting memory, reasoning, and the ability to perform everyday activities), and PTSD (Post -Traumatic Stress Disorder, a mental health condition where someone feels stressed or fearful long after a terrifying event). Resident 9 does not have the mental capacity to make healthcare decisions, as indicated in the document titled, Order Listing Report, dated 10/31/22 Resident 9 was listed as her own Responsible Party as documented on her undated admission RECORD Resident 9 does not have family or legal representative on record, and no conservatorship or alternate legal authorization has been obtainedDuring the same concurrent interview and record review, the DON stated that because Resident 9 lacked the capacity to make medical decisions since the admission date and was listed as her own RP, the facility should have initiated a referral under the Epple Act (allows doctors to make necessary decisions for a patient who cannot decide for themselves and has no legal decision-maker) at the time of admission to address the resident's care needs. The DON further stated that the Epple Act process was no longer in use and had been replaced by CAPRIS (California Patient Representative Information System, a secure web-based system used to obtain a representative for residents who lack decision-making capacity, have no family and have no POA, guardian [a person legally appointed by the court to make decisions for someone who cannot make decisions for themselves] or conservator [person appointed by the court usually responsible for financial, medical or personal decisions]). The DON stated that CAPRIS allowed the facility to obtain timely consents needed for medical interventions, including behavioral health treatment, stating, .it is like a conservator but faster, so we can provide proper care. The DON stated the facility was currently auditing residents who lack decision-making capacity and/or family representation due to turnover within the Social Services Department and that facility would contact CAPRIS immediately to correct the POLST for Resident 9. The DON further stated that without a conservator or authorized representative, the facility was unable to make medical decisions on behalf of Resident 9, which placed the resident at risk for delays or omissions in appropriate care.During a concurrent record review and interview with the DON on 12/19/25 at 7:11 AM, the DON verified that Resident 9 did not have a Power of Attorney.During an interview with the Social Services Director (SSD) on 12/19/25 AT 11:07 AM, the SSD stated that when a resident lacked the mental capacity to make healthcare decisions and did not have a Power of Attorney, the Social Services Department was responsible for initiating the conservatorship process. The SSD stated that residents without capacity and without a conservator were at risk for inability to make informed decisions, unmet needs, potential neglect, and compromised safety. The SSD further stated her expectation was that an interdisciplinary team meeting (a group of different healthcare professionals meeting together to discuss about a patient and agree on the best plan of care) would be held to discuss Resident 9's case and determine the next steps.During an interview with the DON on 12/19/25 at 11:51 AM, the DON stated that when a resident lacked the mental capacity and had no family or legal representative, the social Services Department was responsible for pursuing conservatorship. The DON started that while conservatorship was pending, the facility must coordinate with CAPRIS to obtain immediate consents necessary to provide care.A review of the facility's policy titled Resident Representative, revised on 2/21, the policy indicated, .If the resident is determined to be incompetent under the laws of the State by a court of competent jurisdiction, the rights of the resident will devolve to and will be exercised by the resident representative appointed to act on the resident's behalf.The facility will treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or authorized by the resident (in accordance with the applicable laws).Documentation designating that the representative has been delegated the necessary authority to exercise the resident's rights for decision-making issues is obtained by the director of nursing or designee.A review of the facility's policy titled Social Services, revised on 10/10, the policy indicated, .Our facility provides medically-related social services to assure that each resident can attain or maintain the highest practicable physical, mental, or psychosocial well-being.3(b) & (j). Factors that have a potentially negative effect on psychosocial functioning include: The lack of family/social support system.legal services needs. 4 (a) & (b) The Social services department is responsible for: Obtaining pertinent social data about personal and family problems.identifying individual social and emotional needs.A review of the facility's policy titled Advance Directives, revised on 9/22, the policy indicated, .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.Health care decision-making capacity refers to possessing the ability (as defined by State law) to make decisions regarding health care and related treatment choice.Legal Representative.a person designated and authorized by an advance directive or state law to make treatment decisions for another person in the event the other person becomes unable to make necessary health care decisions.A POLST paradigm form is not an advance directive.Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.If a resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative.Upon admission the interdisciplinary team assesses the resident's decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity.The interdisciplinary team conducts ongoing review of the resident's decision-making capacity and invokes the resident representative or health care agent if the resident is determined not to have decision-making capacity.

Based on observation, interview, and record review the facility failed to ensure two of 35 sampled residents (Resident 2 and Resident 27) were treated with dignity, privacy and respect when: 1. Two staff members, Certified Nursing Assistant (CNA ) 10 and CNA 11 did not protect Resident 2's privacy by leaving the room door and privacy curtain open while providing care, which allowed care activities to be seen by others passing by the room, and2. Two staff members, licensed nurse (LN) 1 and certified nursing assistant (CNA) 1 called Resident 27 a feeder (a derogatory term used to describe someone who requires assistance with meals).This failure had the potential to negatively impact on Resident 2's and Resident 27's dignity and feelings of self-worth and could cause emotional discomfort to Resident 2 and Resident 27. Findings: 1. Review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility with diagnoses including unspecified dementia (affects the person's ability to remember, think clearly, and understand daily activities), depression, schizoaffective disorders (condition that affects a person's thinking, mood, and behavior, causing problems with reality and emotions), and contracture left knee (the left knee is stiff and hard to move). During a concurrent observation and interview on 12/16/25 at 12:23 PM with LN 8 by the room door in Resident 1's room, LN 8 stated that CNA 10 and CNA 11 were providing personal care to Resident 2 without maintaining privacy because the room door and privacy curtain were left open. LN 8 stated that the room door and privacy curtain should be closed while providing care to prevent others passing by from seeing care activities. LN 8 further stated that providing care without privacy could affect a resident's self-esteem and dignity. During an interview on 12/16/25 at 12:32 PM, CNA 10 stated that she provided care to Resident 2. CNA 10 stated that she repositioned Resident 2, adjusted the resident's clothing, and asked CNA 11 to assist pulling Resident 2 up in bed. CNA 10 stated that she should have closed the privacy curtain to provide privacy while Resident 2 was receiving care. During an interview on 12/18/25 at 10:24 AM, the Assistant Director of Nursing (ADON) stated that the staff should close the privacy curtain or room door when providing care, such as changing clothes or repositioning. The ADON further stated that not closing the privacy curtain or room door while providing care was a dignity issue because it could reveal Resident 2's limited mobility to others. During an interview on 12/18/25 at 1:18 Pm, the Director of Nursing (DON) stated that staff should ensure privacy by closing the privacy curtain or the room door when providing care, such as repositioning. The DON further stated that failing to maintain privacy during care was a dignity issue because residents should not be seen by others while in a helpless state. A review of the facility policy titled, Dignity, revised 2/2021, indicated, . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . Residents are treated with dignity and respect at all times . When assisting residents with care, residents are . provided with a dignified dining experience .Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care . A review of the facility policy titled, Resident Rights, revised 2/2021, indicated, . Employees shall treat all residents with kindness, respect, and dignity .basic rights to all residents .These rights include .privacy and confidentiality . 2. A review of Resident 27's clinical record titled, admission RECORD, (contains clinical and demographic data) indicated Resident 27 was admitted to the facility with diagnoses which included dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, judgment, and behavior). During a concurrent interview and observation of Resident 27's breakfast tray, with LN 1, on 12/18/25 8:07 AM, LN 1 stated Resident 27 was a feeder. LN 1 stated she should not have called Resident 27 a feeder as it would affect her integrity and could negatively affect her feelings. During a concurrent interview and observation Resident 27's breakfast tray, with CNA 1, on 12/18/25 8:09 AM, CNA 1 stated Resident 27 was a feeder. CNA 1 stated she should not have called Resident 27 a feeder, stating it was a dignity issue. During an interview with the Registered Dietitian (RD), on 12/18/25 at 8:34 AM, the RD stated staff should not be calling the residents feeders. The RD explained it was a dignity issue and it could negatively affect the resident's feelings. During an interview with the Director of Nursing (DON) on 12/19/25 at 10:30 AM, the DON stated staff should not refer to residents as feeder. The DON explained that referring to residents as feeders as a dignity issue. A review of the facility policy titled, Dignity, revised 2/2021, indicated, . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . Residents are treated with dignity and respect at all times . When assisting residents with care, residents are . provided with a dignified dining experience .

Based on interview and record review, the facility failed to report an allegation of alleged abuse to the Department (the states licensing and certification agency whom conducts inspections of health care facilities) for one resident (Resident 1), in a sample of four residents when, Resident 1 reported to Family Member (FM) 1 that she had been hit on the head by a staff person while care was being provided to Resident 1, FM 1 reported the allegation made by Resident 1 to facility staff on 7/30/25, and the allegation was not reported to the Department by the facility.This failure had the potential to result in continued abuse of Resident 1, with the potential to negatively affect Resident 1's physical and psychosocial well-being.Findings:A review of Resident 1's clinical document titled, admission RECORD, (contains clinical and demographic data) indicated Resident 1 was admitted to the facility with diagnoses which included hemiplegia (paralysis or weakness on one side of the body) of her right dominant side.A review of Resident 1's clinical document titled, GRIEVANCE / COMPLAINT RESOLUTION REPORT, dated 7/30/25, indicated, .Specific Date of Alleged Occurrence: 07/30/2025. In the section titled Investigative Actions/Pertinent Findings, did not indicate that other residents were interviewed during the facility's investigation of Resident 1's alleged abuse.During an interview with the Director of Nursing (DON) on 9/23/25, at 4:14 p.m., the DON confirmed no other residents were interviewed regarding Resident 1's allegations of abuse.During an interview with Social Services Director (SSD) 2 on 9/26/25, at 11:22 a.m., SSD 2 stated she did not know why other residents were not interviewed. SSD 2 explained it was part of the investigation process for alleged abuse that other residents were interviewed. A review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 4/21, the policy indicated, . All allegations are thoroughly investigated . The individual conducting the investigation as a minimum . interviews the resident's roommate, family member, and visitors . interviews other residents to whom the accused employee provides care or services .

Based on interview and record review, the facility failed to report an allegation of alleged abuse to the Department (the states licensing and certification agency whom conducts inspections of health care facilities) for one resident (Resident 1), in a sample of four residents when, Resident 1 reported to Family Member (FM) 1 that she had been hit on the head by an unknown person, FM 1 reported the allegation made by Resident 1 to facility staff on 7/30/25, and the allegation was not reported to the Department by the facility.This failure had the potential to result in continued abuse of Resident 1, with the potential to negatively affect Resident 1's physical and psychosocial well-being.Findings:A review of Resident 1's clinical document titled, admission RECORD, (contains clinical and demographic data) indicated Resident 1 was admitted to the facility with diagnoses which included hemiplegia (paralysis or weakness on one side of the body) of her right dominant side.During an interview with Family Member (FM) 1 on 9/18/25 at 1:42 p.m., FM 1 stated Resident 1 had complained to her that someone had hit her in the head while providing care. FM 1 explained she had informed the facility, and the facility stated they would investigate the allegation.During a follow-up interview with FM 1 on 9/23/25 at 12:12 p.m., FM 1 stated Resident 1 told her two staff were providing care to Resident 1 and one of them hit Resident 1 in the head. FM 1 stated she did not know if it was intentional or unintentional, that Resident 1 just did not like it the way she was hit, and Resident 1 said it hurt but not for very long.During an interview with the Social Services Director (SSD) 1 on 9/23/25 at 12:45 p.m., SSD 1 stated FM 1's allegation of abuse should have been reported to the Department and had not been. During an interview on 9/23/25 at 1:21 p.m., with the Director of Nursing (DON), the DON confirmed the allegations of abuse were not reported. The DON further confirmed a care plan was not initiated for Resident 1 regarding the allegations of abuse.During an interview on 9/23/25 at 3:45 p.m., with Licensed Nurse (LN) 3, LN 3 stated if a resident reported abuse to her, she would inform her supervisor and fill out form SOC 341 (State of California Department of Social Services; form used to report suspected abuse to the Department).During an interview on 9/23/25, at 4:14 p.m., the Director of Staff Development (DSD) stated that staff were mandated reporters (a person legally obligated to report suspected abuse or neglect), and it was their duty to report allegations of abuse weather or not they know it is factual or not. The DSD stated that any type of abuse, including an allegation of being hit on the head, should be reported to the Department, to the ombudsman (a government official who investigates and tries to resolve complaints), and to law enforcement. The DSD explained the investigation regarding the alleged abuse was what told you if the allegation was true or not. During an interview on 9/26/25 at 11:22 a.m., SSD 2 stated Resident 1's allegation of abuse should have been reported, and it was not. SSD 2 stated allegations of abuse not being reported could have been a risk to Resident 1's health and well-being. A review of Resident 1's clinical document titled, GRIEVANCE / COMPLAINT RESOLUTION REPORT, dated 7/30/25, indicated, .Specific Date of Alleged Occurrence: 07/30/2025. In the section titled Nature of Complaint / Concern, indicated, Please see Attached Statement . The attached statement indicated the following, On 7/30/2025 around 3:30pm notified by DON on [Resident 1] stating to [FM 1] that someone had hit her on her head, Statement was made to SSA [Social Services Assistant] and DON. SSA used translation services, but [Resident 1] unable to answer the questions, SSD called [FM 1] to follow up on statement, Per [FM 1] she stated [Resident 1] expressed a lady with black hair, medium build, light in color hit her on the head. SSD explained to [FM 1] that facility will follow up with investigation. [FM 1] said she knows [Resident 1's] mind is not sharp, and she has moments of forgetfulness .DON and SSA called language line (Cantonese) to communicate with [Resident 1]. DON asked [Resident 1] several question [sic] regarding abuse allegations, language line person was unable to understand [Resident 1]. DON and ssa [sic] then called [FM 1], [FM 1] let [NAME] [sic] and ssa [sic] know that she would need to visibly see [Resident 1] that is how she is able to understand [Resident 1] and is able to communicate better. DON and SSA video called [Resident 1's FM 1]. [FM 1] asked [Resident 1] what happened, [Resident 1] pointed to her head and according to [FM 1] who was translating for DON and SSA, [FM 1] stated that [Resident 1] said that someone hit her. [FM 1] translated that [Resident 1] stated that someone came in her room and hit her on the head and left out of the room.A record review of Resident 1's clinical record did not indicate any progress notes (a record of patient condition and care received), care plans (outlines a patient's health conditions, treatment and support required to achieve health goals), and social services notes regarding Resident 1's allegations of abuse.A review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 4/21, the policy indicated, .All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies . and thoroughly investigated by facility management. Findings of all investigations are documented and reported . If resident abuse . is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies . The state licensing/certification agency responsible for surveying/licensing the facility . 'Immediately' is defined as within two hours of an allegation involving abuse or result in serious bodily injury . within 24 hours of an allegation that does not involve abuse or result in serious bodily injury .

Based on interview, and record review, the facility failed to ensure an Infection Preventionist (IP) was consistently employed by the facility from January 1, 2021 through December 31, 2022. This failure had the potential to increase the spread of illnesses within the facility and communicable illnesses not to be appropriately tracked and assigned the appropriate precautions; negatively impacting the health and safety of all residents residing in the facility.During an interview on 8/6/25, at 2:15 PM, with Payroll/Human Resources (Payroll/HR), Payroll/HR was unable to provide information on the IPs working in the facility between 1/1/21 and 12/31/22 as the facility no longer had the files. Payroll/HR explained the facility had shipped the employee files to the previous corporation (that owned/ managed the facility) the prior week.During an interview on 8/7/25, at 10:15 AM, with the Administrator (ADM), the ADM stated he had the names of IP 1 and IP 2 and was able to provide their names. The ADM was not able to provide details from the employee files for IP 1 and IP 2 as the ADM was waiting for a response from the previous corporation regarding the employee files.During an interview on 8/21/25, at 12:29 PM, with the ADM, the ADM stated they received the employee files they had sent to the previous corporation. The ADM explained the facility had not had a chance to look for IP 1 and IP 2's employee files located somewhere in the 25 boxes that the facility received.During an e-mail exchange, on 8/21/25, at 4:38 PM, with the ADM, the ADM attached IP 2's employee file. The ADM confirmed IP 2's IP certification was not in the file.A review of IP 2's personnel file did not reveal an Infection Preventionist Certificate for IP 2.A review of IP 2's untitled employee document containing employment dates and job titles indicated, .[IP 2].Infection Preventionist.Action Date.5/4/2022.TER [termination].Reason Code.Accepted Other Employment.Action Date.3/15/24.A review of IP 1's untitled employee document containing employment dates and job titles indicated, .[IP 1].Infection Preventionist.Action Date.7/31/2020.Job Code.LVN/LPN [licensed vocational nurse/licensed practical nurse].Action Date .12/3/2021.A record review did not reveal any other IP's working in the facility from January 1, 2021, through December 31, 2022. As indicated above, IP 1 was the only IP with a documented IP certificate. During an interview on 8/21/25, at 5:24 PM, with IP 2, IP 2 stated she had completed an IP course, and it should have been on file with the facility. IP 2 explained she had not retained a copy of the IP certificate. IP 2 further explained she was a new IP, and her mentor had been a corporate IP. During an interview on 9/24/25, at 9:23 AM, with the Director of Nursing (DON), the DON stated it was required for the facility to have a full-time IP. The DON explained it was important in order to ensure infection prevention in the facility was followed. The DON further explained the risk of not having a qualified infection preventionist was infection prevention protocols not being followed. The DON stated it could lead to infections and outbreaks within the facility.During a record review of IP 1 and IP 2's limited employee records, the records indicated the facility did not have an infection preventionist from 12/3/21 through 5/4/22. Further review of the records indicated the facility did not have a qualified IP when IP 2 was working as the IP, as there was no documented evidence of IP 2 having taken specialized training to become an IP.

Based on observation, interview, and record review, the facility failed to provide sufficient protection to prevent abuse and/or neglect for five of eight sampled residents, when: 1. Resident 5 was assaulted by Resident 2, who was accompanied by Resident 1, on 10/24/21, and then by Resident 1 on 11/4/21, and suffered from fear and increased anxiety, 2. Resident 3 was assaulted by Resident 1 on 10/11/21, and was injured on her chest and right wrist, 3. Resident 4 was assaulted by Resident 1 on 10/12/21, and experienced emotional distress with tearfulness, 4. Resident 6 was slapped by Resident 1 on 10/24/21, with the potential to cause emotional distress, and, 5. Resident 7 was not able to swallow and was given food by mouth by Resident 1 on 10/24/21, with the potential for choking and death. Findings: 1. A review of Resident 5's Admission Record indicated Resident 5 was admitted to the facility in early 2021. According to the Minimum Data Set (MDS, an assessment tool) dated 11/3/21, Resident 5 scored 14 out of 15 in a BIMS (brief interview for mental status) which indicated Resident 5 had intact cognition (normal memory). A review of Resident 5's clinical record titled, SBAR-Alleged Abuse Report of Incident - 8hr- V3 dated 10/24/21, indicated, . [Resident 5] was involved in an incident of alleged Physical Abuse .at 16:10 [4:10 p.m.] . [Resident 5] .anxiously verbalizing the sequence of event, when an allege [sic] attacker [Resident 2] came in to [Resident 5's] room and tried to choked [sic] [Resident 5] using a plastic bag . During an interview on 10/26/21, at 12:07 p.m., Resident 5 described the event on 10/24/21 . [Resident 1] and [Resident 2] both came into my room. They wanted my roommate's wheelchair. I was telling them to leave, leave now please. They didn't respond to me . [Resident 2] grabbed the long white plastic bag and [Resident 2] stretched the bag out and came at me and tried to put it over my neck. I took it away from her, at the same time I was hollering . Resident 5 further stated, .[staff name] the licensed nurse took the bags away and don't want me to be exposed to the possibility of a bag over my head while I'm sleeping . Resident 5 stated, In my lifetime I have been abused a lot, I don't put up with it . Resident 5 expressed, I thought I lost my mind when [Resident 2] came at me with the bag, she was so mad, she was shaking . During an interview on 10/26/21, at 2:50 p.m., CNA 3 stated there was screaming from Resident 5's room on 10/24/21, and upon entry, Resident 1 and Resident 2 were both found in Resident 5's room. CNA 3 stated [Resident 5] was in shock . CNA 3 indicated Resident 5 wanted her door kept closed after the event. CNA 3 indicated there were three altercations involving Resident 1 with Resident 5, Resident 6, and Resident 7, during the evening of 10/24/21, and stated Resident 1's persistent behavior of going to other resident rooms and taking personal belongings contributed to the altercations with other residents. CNA 3 stated, [Resident 1] have [sic] a cart full of stolen stuff of residents . CNA 3 further stated, .I wish we could do more to prevent this, I do not think other resident is safe here . A review of Resident 5's clinical record, Social Services Note, dated 10/25/21, indicated, . [Resident 5] was asked how she was doing and became agitated as SS [Social Services] asked about the alleged abuse report. [Resident 5] .stated that she does not feel safe . A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility in late 2020, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's clinical record titled, SBAR-Alleged Abuse Report of Incident- 8hr- V3 dated 10/24/21 indicated, .[Resident 2] Known to have unpredictable behavior. Most often time wonders [sic] to other Residents room. Difficult to redirect triggering behavioral aggression .Place on Distant supervision for behavioral aggression .Pt [patient] continue [sic] to be unpredictable . During a telephone interview on 10/25/21, at 11:55 a.m., the Assistant Director of Nursing (ADON) stated the facility was, .Monitoring [Resident 2]'s behavior very closely via visual watch. When [Resident 2] is in the hall we redirect .Not on one-on-one [one staff assigned to be with the resident at all times]. We can start [one-on-one] though . A review of Resident 2's care plan dated 10/25/21, indicated, .1:1 [one-on-one] staff monitoring until determined no longer necessary . A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility in late 2020, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's clinical record titled, SBAR [SBAR-situation, background assessment, recommendation] Communication Form dated 9/14/21, indicated, .Resident seems to be getting more agitated than usual, resident wandering the hallway going in other residents rooms taking their personal belongings, when staff tried re-directing resident, resident got angry and yelling with clench fists in her language, grabbing staff and her roommate . A review of Resident 1's care plan, in the Focus section showed The resident has behavior .hard to redirect and physical aggression (hitting others) dated 10/24/21, indicated an intervention was initiated 10/25/21, 1:1 staff monitoring . A review of Resident 1's clinical record, General Note, dated 10/25/21, at 3:39 p.m., indicated, [Resident 1] is place on [1:1] for safety . A review of facility document titled, [facility name] EVENT 5-DAY FOLLOW UP dated 10/26/21, indicated, .With [Resident 1's] behavior escalating, she will be kept on 1:1 until new medications can take effect. A review of Resident 1's clinical record titled, Psychiatry Follow Up Note dated 10/29/21, indicated, .referred for .increase physical aggression towards other residents .Plan .Monitor [MEDICATION(S)] [an antipsychotic medication used to treat mental conditions] .Monitor for worsening target symptoms . A review of Resident 1's clinical records showed no evidence of monitoring the effectiveness of the [MEDICATION(S)]. A review of Resident 1's clinical record titled, Social Services dated 11/3/21, indicated, Psychiatrist adjusting medications due to increase in behaviors. Continue to monitor for changes in mood/ behavior and wandering. No further need for 1:1. DON aware. During an interview on 11/4/21, at 4:10 p.m., LN 5 confirmed he observed Resident 1's tendency to wander the facility and collect other residents' personal items from their rooms. LN 5 stated Resident 1's behavior was unpredictable and, .I have a hard time keeping track of [Resident 1] when I have other residents to take care of. A review of Resident 5's clinical record titled, SBAR-Alleged Abuse Report of Incident- 8hr- V3 dated 11/5/21 indicated, .[Resident 5] was involved in an incident of alleged Physical Abuse .at 23:30 [11:30 p.m.] .loud and angry voices coming from the St. 2/3 hallway [an area of the facility where residents reside] .on approach CNA was trying to redirect the aggressor [Resident 1] from [Resident 5's room] .Aggressor difficult to redirect .[Resident 1] went to [Resident 5's] room .slapped [Resident 5] on the right hand] . During a concurrent observation and interview on 11/5/21, at 2:02 p.m., Resident 5 stated while she slept on 11/4/21 .I realize someone was in the room with me. This didn't feel right, I sat up in bed. [Resident 1] was standing to left of my bed. I sat up and pulled my bedside table. I told [Resident 1] you need to leave. [Resident 1] was still touching my stuff, [Resident 1] really wanted my rose that my daughter gave me .She slapped me on my right hand .I screamed .I called 911 that minute as soon as they took her away .It's not very safe here .It took me a while to calm down . Resident 5 further stated she remembered the door was closed and blocked with a locked wheelchair before going to bed. When asked, Resident 5 stated, I started to do this after prior incident [on 10/24/21] . I didn't do this before. Resident 5 had a bluish- purple discoloration on the back of her right hand, approximately the size of a penny. Resident 5 further stated, .I do not trust what is going on, I am afraid to close my eyes at night, [Resident 1] in my room and aggressively in my room, I am afraid of that . During an interview on 11/5/21, at 3:04 p.m., CNA 5 indicated one-to-one monitoring of Resident 1 helped to protect the other residents in the facility. CNA 5 stated the one-to-one monitoring was stopped a few days prior, and she was not aware of additional interventions to prevent further incidents. CNA 5 indicated Resident 5 asked her why the one-to-one monitoring was stopped and stated Resident 5's expression was fearful. During a phone interview on 11/10/21, at 4:06 p.m., the private social worker (PSW) stated Resident 5 claimed Resident 1 and Resident 2 were threatening her verbally and physically. The PSW further stated Resident 5's mood was affected after the altercations with Resident 1 and Resident 2. The PSW explained Resident 5 had begun to block her room door at night with a wheelchair. The PSW further stated Resident 5 was scared and requested for placement at a different facility. During an interview on 11/12/21, at 2:17 p.m., CNA 5 confirmed Resident 5 placed her wheelchair against the door every night in order to know who came into the room. During a phone interview on 12/2/21, at 1:16 p.m., the Assistant Director of Nursing (ADON) stated, I don't know why [Resident 1] was removed from one-to-one monitoring .it's usually social services, the DON [Director of Nursing] and the Administrator who will discuss if one-to-one monitoring is continued or removed. During a phone interview on 12/2/21, at 2:37 p.m., the SSD (Social Services Director) stated, [Resident 1's] meds were being adjusted so it was determined one-to-one monitoring was no longer needed. It was a directive from the Interim DON [IDON] . The SSD confirmed no interdisciplinary meeting was held to discuss the removal of one-to-one monitoring for Resident 1, and no specific recommendation was made by the physician. The SSD stated she did not review Resident 1's behavior prior to removal of Resident 1's one-to-one monitoring. The SSD stated, I don't know who the IDON discussed with about removing [Resident 1's] one-to-one monitoring. The SSD further stated the expectation was to look if a resident showed any behaviors before making changes to a resident's interventions. During a phone interview on 12/2/21, at 2:56 p.m., the Administrator (ADM) stated, [IDON] had a brief conversation he was going to try [Resident 1] without one-to-one monitoring. The ADM further stated, I don't know, I'm not usually involved . when asked who was involved in determining when to remove a resident from one-to-one monitoring. The ADM stated the interdisciplinary meeting could have met to discuss the removal of Resident 1's one-to-one monitoring. During a phone interview on 12/2/21, at 4:30 p.m., the DON stated she expected the following: a resident interview, staff interviews, a meeting of the interdisciplinary team which consisted of the DON, the Infection Preventionist (IP), the Director of Staff Development (DSD), the activities director, the SSD, and other members of staff to discuss whether a resident's one-to-one monitoring should be removed. The DON further stated she would involve the physician, and in cases of abuse, notify corporate before removing a resident's one-to-one monitoring. 2. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility in 2016. According to the Minimum Data Set (MDS, an assessment tool) dated 10/7/21, Resident 3 scored 14 out of 15 in a Brief Interview for Mental Status (BIMS) which indicated Resident 3 had intact cognition (normal memory). A review of Resident 3's clinical record titled, General Note dated 10/10/21, indicated .Reported physical abuse; witnessed by [CNA 1] .Stated she was attach [sic] by [Resident 1] after a dispute to prevent walker to be taken . During a concurrent observation and interview on 10/14/21, at 10:55 a.m., Resident 3 indicated she was getting up to go for a walk on 10/10/21, and stated, [Resident 1] wanted my walker .I told her no, and she got angry and grabbed me . Resident 3 pointed to her mid-upper chest where the skin had reddish purple discoloration approximately the size of a silver dollar coin, and to an area approximately two inches long on her right outer wrist which appeared bruised. Resident 3 indicated she was injured trying to stop Resident 1 from taking her walker. During an interview on 10/14/21, at 11:54 a.m., CNA 15 stated, .[Resident 1] likes to collect wheelchairs and put them in her room. At first, she says no, but the next day she lets the staff take out the wheelchairs . During an interview on 10/14/21, at 3:24 p.m., Licensed Nurse (LN) 1 stated, [Resident 1] is aggressive . needs serious monitoring .[Resident 1] might do it again with another resident . During an interview on 10/15/21, at 12:47 p.m., LN 4 stated Resident 1 wandered into other residents' rooms and collected their personal items. LN 4 stated Resident 1's behavior increased the chance of another altercation. A review of Resident 3's clinical record titled, Treatment Administration Record dated, October 2021, indicated an order to begin treatment on 10/11/21, .Hematoma [a pool of mostly clotted blood that forms in an organ, tissue, or body space caused by a broken blood vessel that was damaged by injury or surgery] over senile purpura [bruising that affects older adults] on midsternal chest [breastbone]. Apply [MEDICATION(S)] [antibiotic ointment to treat/prevent infection] .monitor for skin breakdown .every shift . A review of Resident 1's care plan initiated on 10/12/21 indicated, .[Resident 1] is physically aggressive towards other .episode of aggression towards other .going into residents' rooms and unable to be redirected . Further review of Resident 1's care plan Interventions/Tasks indicated, .Monitor for behavior of physical aggression towards other redirect if behavior seen . Psychiatric/Psychogeriatric consult as indicated .[Resident 1] was transfer to Rm [room number] . During an interview on 11/5/21, at 3:51 p.m., LN 2 stated Resident 1's room was changed often to separate her from residents with whom she had altercations. LN 2 stated the room changes made Resident 1 more confused and did not help her. 3. A review of Resident 4's Admission Record indicated Resident 4 was admitted to the facility in January of 2021. According to the MDS dated [DATE], Resident 4 scored 15 out of 15 in a BIMS which indicated Resident 4 had normal memory. A review of Resident 4's clinical record titled, SBAR .Alleged Abuse Report of Incident- 8hr -V 3 dated 10/12/21, indicated, .[Resident 4] heard alarm from emergency door by the kitchen and saw .[Resident 1] was outside .[Resident 4] was trying to help bring [Resident 1] back in .[Resident 1] .hit [Resident 4] on .upper left arm . During an interview on 10/26/21, at 12:41 p.m., Resident 4 stated Resident 1 hit him on the left shoulder near the kitchen on 10/12/21. Resident 4 further stated, I feel hurt when I see [Resident 1] .every time I see [Resident 1 and Resident 2], I know they are laughing at me and pointing at me. During an interview on 11/5/21, at 5:02 p.m., LN 3 stated .[Resident 4] is consistently telling us of incidence [with Resident 1] and crying. A review of Resident 4's clinical record titled, Social Services Note dated 10/13/21 indicated, .[Resident 4] expressed being upset incident took place .was able to recall .reported event and verbalized being unhappy the situation happened . A review of Resident 4's clinical record titled, Social Services 2 dated 10/14/21 indicated, .[Resident 4] expressed being upset about the situation . A review of Resident 4's clinical record titled, Social Services 3 dated 10/15/21 indicated, .[Resident 4] expressed being unhappy and stated that [Resident 4] believes there has been no resolution to the incident that [Resident 4] reported [between Resident 4 and Resident 1] . A review of Resident 1's clinical record titled, Psychiatry Diagnostic Interview dated 10/15/21, indicated, .Per staff pt [patient] with physical aggression starting in 9/2021 with reports of pts grabbing pts staff and residents arms. Recent bx [behavior] have increase rt [related to] pt wandering in pts room, grabbing their items then physically assaulting resident when approached about the items taken. Pt has been involved in 2 physical assaults towards other residents this past weekend .Recommend [MEDICATION(S)] [an antipsychotic medication] .for Dementia agitation m/b [manifested by] increase assaults towards residents .Monitor for worsening target symptoms . 4. A review of Resident 6's Admission Record indicated Resident 6 was admitted to the facility in mid-2021. According to the MDS dated [DATE], Resident 6 scored out 7 of 15 in a Brief Interview for Mental Status (BIMS) which indicated Resident 6 had severe cognitive impairment. A review of Resident 6's clinical record titled, SBAR-Alleged Abuse Report of Incident- 8hr- V3 dated 10/24/21, indicated, . [Resident 6] was involved in an incident of alleged Physical Abuse .at 16:40 [4:40 p.m.] .Residents [Resident 1 and Resident 6] pulling at sheet fighting for belongings and .[Resident 1] hit him [Resident 6] on side of left arm . During an interview on 10/26/21, at 2:50 p.m., CNA 3 stated on 10/24/21 following the incident in Resident 5's room, .I heard another resident [Resident 6] say Get out.By the time I went to the room both [Resident 1 and Resident 6] is fighting . CNA 3 indicated multiple altercations were the result of Resident 1's behavior of going to other resident rooms and taking personal belongings. CNA 3 further stated these events were preventable and, I wish we could do more to prevent this, I do not think other residents is safe here. 5. A review of Resident 7's Admission Record indicated Resident 7 was admitted to the facility in the early part of 2021. The admission record indicated Resident 7 was diagnosed with, GASTRIC [stomach] CONTENTS IN RESPIRATORY TRACT [the organs involved in breathing] .CAUSING ASPHYXIATION [suffocation] on 8/12/21. Review of Resident 7's MDS dated [DATE], indicated, Resident 7 required extensive assistance to move in bed, and was dependent on staff to transfer out of her bed. The MDS further indicated Resident 7 had a feeding tube (a medical device inserted into the stomach to provide nutrition when a person cannot eat or swallow). During an interview on 10/26/21, at 2:50 p.m., CNA 3 stated at approximately 7:15 p.m., on 10/24/21, following the incidents in Resident 5 and Resident 6's rooms respectively, she saw Resident 1 on Resident 7's bed. CNA 3 further stated [Resident 1] fed [Resident 7] .by mouth which caused [Resident 7] to throw up . CNA 3 indicated Resident 7 was not permitted any food or liquid by mouth and was fed with a feeding tube. A review of Resident 7's clinical record titled, eINTERACT Change in Condition Evaluation-V 5.1 dated 10/24/21 indicated .ingested oral food and on strict NPO [nothing by mouth] orders . A review of Resident 7's physician orders, dated 8/12/21 indicated, NPO diet . and an order dated 10/24/21, indicated, Chest X-ray due to ingesting of oral food. A review of Resident 1's clinical record titled, General Note dated 10/25/21, indicated .Monitoring behavior r/t [related to] attempting to feed NPO roommate . During an interview on 10/26/21, at 5:32 p.m., Resident 7 stated, I threw up, I threw up . when questioned about the incident with Resident 1. When asked to clarify, Resident 7 was unable to describe the incident further. During an interview on 11/5/21, at 3:51 p.m., LN 2 stated Resident 1's room was changed often in order to separate her from residents with whom she had altercations. LN 2 stated the room changes made Resident 1 more confused and did not help her. Resident 1 was Resident 7's roommate on 10/24/21. LN 2 described the incident between Resident 1 and Resident 7, and stated CNA 2 saw Resident 1 feed Resident 7 by mouth. LN 2 was with LN 3 to assess Resident 7. LN 2 stated upon assessment, LN 3 performed back blows on Resident 7. LN 2 explained Resident 7 was not able to eat by mouth, so a chest x-ray was done to rule out aspiration (something enters your airways or lungs can cause coughing, difficulty breathing, discomfort and sometimes choking). During a telephone interview on 11/12/21, at 3:22 p.m., LN 3 confirmed Resident 1 fed Resident 7 on 10/24/21. LN 3 stated Resident 7 was bed bound and had a feeding tube so nothing should be placed in her mouth. LN 3 stated, .[Resident 7] was in a supine (lying flat, face up) position [in bed] coughing . LN 3 further stated he turned Resident 7 to her side, checked her mouth for food, and performed nine back blows (measures used to clear foreign body obstruction from the airway of a choking person). LN 3 stated Resident 7 stopped coughing after he completed the back blows. LN 3 indicated he did not find solid food, but there was liquid in Resident 7's mouth. During a telephone interview on 11/23/21, at 3:03 p.m., the speech therapist (ST) stated she completed an evaluation of Resident on 8/17/21 and indicated Resident 7 had severe dysphagia (difficulty swallowing) and was not able to swallow. The ST further stated Resident 7 was recommended to remain as nothing by mouth (NPO) with nutrition provided through a feeding tube. The ST stated there was a risk for aspiration if a person with swallowing problems took any food or liquid by mouth. Review of the facility policy titled, Abuse Prevention, Intervention, Investigation & Crime Reporting Policy, dated November 2016, indicated, .The facility is responsible for assuring resident safety by prohibiting verbal, mental, sexual, or physical abuse .the facility will monitor the adequacy of assessment, care planning and monitoring of resident with needs or behaviors that may likely lead to conflict, altercation, abuse . Review of the facility policy titled, Residents' Rights, revision date 06/15, indicated, It is the policy of [facility name] to provide our residents with a comfortable, private and safe environment in which to live .Residents have the right to be free from all forms of physical, mental and verbal abuse .Each resident has the right to have their belongings treated with respect .

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and/or heal pressure injuries (areas of damaged skin caused by staying in one position for too long) for two of four sampled residents (Resident 5, and Resident 61) when: 1. Resident 5 developed a pressure injury to his right heel, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident 61 was admitted with a pressure injury to his sacrum (tailbone) and interventions were not in place to heal the pressure injury, or to prevent new pressure injuries from forming. These failures resulted in Resident 5 developing a pressure injury to his right heel and had the potential to delay the healing of Resident 61's pressure injury to his sacrum. Findings: 1. According to the admission record, Resident 5 was admitted to the facility in mid- 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS, an assessment tool) dated 11/17/21, revealed Resident 5 scored five out of fifteen on the Brief Interview for Mental Status which indicated Resident 5 was cognitively impaired. A review of Resident 5's pressure injury risk assessment, dated 6/3/20, indicated he was at risk of developing pressure injuries with a score of 17. A subsequent pressure injury risk assessment, dated 12/3/20, indicated the same score. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's meal intake percentages for December 2020, and January 2021, indicated he had a significant decrease in meal intake compared to previous months since his admission. A review of Resident 5's weights indicated he weighed 189 pounds on 12/3/20, 176 pounds on 1/6/21, 168 pounds on 2/1/21, and 165 pounds on 3/3/21. This was a cumulative weight loss of 24 pounds in three months. Resident 5's weight on 12/1/21 was 165.8 pounds. A review of Resident 5's nurse progress note, dated 1/4/21, indicated a Deep Tissue Injury (DTI, an injury to tissue below the skin's surface that results from prolonged pressure causing the tissue to die) was discovered on his right heel. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RD 1's note, dated 2/4/21, indicated the drink was for weight loss. A review of Resident 5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 5's MAR for April revealed licensed nurses documented the high calorie drink was offered starting on 4/22/21, indicated by an initial and the amount consumed, confirmed by the Director of Nursing (DON) on 12/16/21, at 2:50 p.m. During an interview on 12/16/21, at 1:45 p.m., Registered Dietician (RD) 2 indicated interventions for poor meal intake would not be a large portioned diet, but may include reviewing food preferences, a fortified diet (higher fat content), high calorie drinks and supplements, or an appetite stimulant. RD 2 went on to say relevant nutritional laboratory tests may also be requested from the resident's physician which may include protein and electrolyte (essential minerals-like sodium, calcium, and potassium) levels. RD 2 confirmed Resident 5 had a significant weight loss over three months and should have been put on weekly weights to monitor the weight loss but was not. When asked if RD 1's notes indicated she addressed the weight loss with new interventions, RD 2 confirmed she did not, but should have, and stated the RD gets a copy of all completed resident weights. RD 2 also confirmed the weight loss was not care planned (an outline of each resident's care they should receive) but should have been. She went on to say a significant weight loss and poor meal intake could attribute to the formation of a pressure injury, and the high calorie drink could help heal a pressure injury due to the increased calories and protein contained in the drink. On 12/14/21, at 10:28 a.m., Medical Records (MR) confirmed Resident 5 did not have any nutritional relevant laboratory tests on file. During an interview on 12/16/21, at 2:50 p.m., the DON confirmed Resident 5's weight changes were a change in condition and an appropriate clinical assessment should have been completed by licensed staff but was not. A review of the wound physician's notes, dated 1/25, 6/21, and 6/28/21, confirmed Resident 5's DTI to his right heel was caused by pressure. The 1/25/21 physician's note recommended interventions for Resident 5 which included to float heels in bed (to elevate without putting pressure on the wound), reposition per facility protocol, and to off-load the wound (to keep pressure off the wound). The physician performed a surgical procedure on 6/28/21, by cutting away the dead tissue with a sharp blade and established the DTI was a stage 4 pressure injury (a very deep pressure injury, reaching into muscle and bone and causing extensive damage). A review of Resident 5's clinical record indicated a care plan for the pressure injury to Resident 5's heel was initiated on 1/26/21. The care plan interventions included monitoring for infection or worsening of the wound, to notify the physician if the wound worsened, and wound care treatment as ordered by the physician. There were no interventions on the care plan which included relieving pressure to the pressure injury site. A subsequent care plan related to Resident 5's pressure injury to his heel, dated 5/27/21, indicated interventions which included to float heels, provide off-loading for the pressure injury, re-positioning every two hours in bed, a low air loss mattress (an air mattress to prevent/heal pressure injuries), and an alternating pressure mattress (a mattress which alternates pressure on the body using air within the mattress to prevent/heal pressure injuries). The care plan read Resident 5 needed the assistance of two staff members for turning and re-positioning. During an observation on 12/8/21, at 12:59 p.m., Resident 5 was witnessed lying in bed asleep with his knees pulled up and both sock covered feet were resting flat on the bed. One heel protector boot (a cushion for the heel to prevent and/or heal pressure injuries) was seen on the nightstand next to his bed. During an observation and interview on 12/9/21, at 8:49 a.m., Resident 5 was witnessed lying in bed asleep with both heels resting on the bed, and one heel protector boot was seen on the nightstand next to his bed. During a concurrent observation, interview and record review on 12/9/21, at 2:25 p.m., the Treatment (TX) Nurse was asked what interventions were in place for Resident 5's pressure injury. The TX Nurse stated a heel protector boot, re-positioning, and the use of pillows to float his heel. A review of his clinical record revealed there was not a care plan for the heel protector boot and the TX Nurse confirmed there should have been. A visit to Resident 5's room revealed he was not in bed and the TX Nurse stated he was at a doctor appointment. The heel protector boot was seen on the nightstand next to his bed, confirmed by the TX Nurse. When asked if Resident 5 should have an air mattress, the TX Nurse stated no. She went on to say an air mattress was only for residents with stage 3 pressure injuries or higher, and because Resident 5's stage 4 pressure injury was on his heel, he only qualified for a heel protector boot. The TX Nurse went on to say if Resident 5's stage 4 pressure injury was anywhere else on his body, he would have an air mattress. During an interview on 12/16/21, at 2:50 p.m., the DON confirmed to ensure continuity of care across all disciplines, care plans should be accurate and personalized to reflect a resident's care. During a concurrent observation and interview on 12/10/21, at 8:05 a.m., Resident 5's heel protector boot was seen on the nightstand next to his bed, confirmed by the TX Nurse. During a concurrent observation and interview on 12/10/21, at 9:56 a.m., Resident 5 was witnessed lying in bed with a heel protector boot on his right foot. Resident 5 stated when asked about the heel protector boot, I don't mind it. According to the National Pressure Injury Advisory Panel (NPIAP) website, updated 2016, the NPIAP indicated recommendations for the prevention and healing of pressure injuries which included, .Avoid positioning an individual on an area of [CONDITION(S)] [redness] or pressure injury .Assist the individual at mealtimes to increase oral intake . Encourage all individuals at risk for pressure injury to consume .a balanced diet . Assess weight changes over time . Assess the adequacy of oral .intake . Provide nutritional supplements between meals and with oral medications . Use heel offloading devices .on individuals at high-risk for heel ulcers . https://npiap.com/page/PreventionPoints 2. Resident 61 was admitted to the facility in mid-2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS, an assessment tool) dated 9/30/21, revealed Resident 61 scored 11 out of fifteen on the Brief Interview for Mental Status which indicated Resident 61 was mildly cognitively impaired. A review of Resident 61's pressure ulcer risk assessment, dated 6/26/20, indicated he was at risk for developing pressure injuries with a score of 15. A review of Resident 61's skin care plan, dated 6/26/20, indicated he was at risk for skin breakdown related to impaired mobility. Another skin care plan, dated 6/26/20, indicated Resident 61 was admitted with a pressure ulcer to his sacrum. Documented interventions did not include re-positioning or off-loading of the pressure site. A review of Resident 61's Actual Pressure Ulcer care plan for his sacral pressure injury, dated 1/14/21, indicated interventions which included off-loading of the pressure site, and re-positioning every two hours and as needed. A review of multiple wound physician notes ranging in dates from 11/2020-11/2021, indicated Resident 61's stage 4 wound was caused by pressure. The physician recommended interventions on each visit for Resident 61 which included to re-position per facility protocol, and to off-load the wound. A review of Resident 61's Interdisciplinary Team (IDT, a team of professional staff or a care team consisting of different disciplines) meeting notes, dated 9/30/21, indicated he was completely dependent on staff for his daily needs. Further review of the note revealed sections regarding a turning and repositioning program, self-re-positioning devices, and Restorative Nurse Aid (RNA, CNA's who help residents to exercise) were not checked. During a concurrent observation and interview on 12/8/21, at 2:39 p.m., Resident 61 was witnessed lying flat in bed on an air mattress. The bed did not have re-positioning siderails but did have a transfer pole (a floor to ceiling bar used to aid residents with standing, sitting, or moving) on the left side of the bed. When asked, Resident 61 stated he only used the transfer pole to pull himself to the left which helped staff change his adult brief, and not to re-position himself. Resident 61 stated staff had not provided any re-positioning pillows to help off-load his sacral pressure injury and pulled back his sheet to confirm. During a concurrent observation and interview on 12/9/21, at 3:45 p.m., Resident 61 was witnessed lying flat on his back. When asked, Resident 61 confirmed he did not have any re-positioning pillows in use. During a concurrent interview and record review on 12/9/21, at 2:25 p.m., the TX Nurse was asked what types of interventions were in place for Resident 61 to prevent new pressure injuries and to heal his current pressure injury. The TX Nurse stated he had an air mattress, was being repositioned routinely, had dietary supplements, and used a foot cradle (a device attached to the end of the bed to keep pressure from blankets off the feet and toes). When asked if he ever got out of bed, she stated no. When asked if heel protector boots would be an appropriate intervention for a resident who never got out of bed, the TX Nurse confirmed they would be but had not been provided to him. The TX Nurse also confirmed the air mattress was not care planned. During multiple observations on 12/10/21, at 7:20 a.m., 8:16 a.m., 9:53 a.m., and 10:29 a.m., Resident 61 was observed lying flat on his back without any positioning pillows in use. During an interview on 12/10/21, at 10:55 a.m., Certified Nurse Assistant (CNA) 10 was asked how often she repositioned Resident 61. She stated every two hours, or as often as she could. She went on to say he has the transfer pole at the side of his bed but confirmed he can only use it to turn to the left. When CNA 10 was asked if she had used pillows, or any other repositioning device, for Resident 61 since the start of her shift she stated no. When asked when her shift started, CNA 10 stated approximately four hours ago. During an interview on 12/16/21, at 2:50 p.m., the DON stated interventions to prevent pressure injuries for a bed bound resident may include pillows for re-positioning, re-positioning devices for the resident to use while in bed such as side rails at the head of the bed, floating the heels, RNA involvement for range of motion exercises. When asked if Resident 61 received RNA services, the DON confirmed he did not. According to the The National Pressure Injury Advisory Panel (NPIAP) website, updated 2016, the NPIAP indicated recommendations for the prevention and healing of pressure injuries which included, .Turn and reposition all individuals at risk for pressure injury . Turn the individual into a 30-degree side lying position and use your hand to determine if the sacrum is off the bed . Avoid positioning the individual on body areas with pressure injury . Continue to reposition an individual when placed on any support surface . https://npiap.com/page/PreventionPoints A review of the facility's procedure titled, Pressure Ulcer, Prevention of, dated 2006, indicated, .To prevent skin breakdown and development of pressure sores .ASSESSMENT GUIDELINES .impaired circulation .cognitive impairment .nutritional status .incontinence .weight .bedfast .refusing .care .EQUIPMENT .support surface for bed .foot cradle .pillows .PROCEDURE .develop care plans to eliminate or minimize risk factors .establish a turning and repositioning schedule in bed protect bony promininences .range of motion .to improve circulation .assist resident at mealtime .monitor nutritional status .CARE PLAN DOCUMENTATION GUIDELINES .Identify the problem .treat the underlying cause .list instructions unique to this resident .adequate nutrition .monitoring of weight .diagnostic tests .pressure reducing or relieving surfaces .frequency of positioning .

A review of Resident 1's Admission Nursing assessment dated [DATE], indicated, Resident 1 was alert and oriented to person, place, time, and situation, and her cognition was intact. During a review of Resident 1's clinical record, a progress note dated [DATE], at 11:55 a.m. indicated, IDT (interdisciplinary team) met w/ (with) res (resident) . Res was previously living home alone .plan is to DC (discharge) back home w/ cg (care giver) support .She (Resident 1) was previously independent with all ADLs (activities of daily living) and walking. A review of Resident 1's progress note dated [DATE], timed 2:40 p.m. indicated, Resident 1's short and long-term memory was intact. An additional progress note on the same day at 2:22 p.m. indicated Resident 1's projected discharge date to home was [DATE]. A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated [DATE], revealed her BIMS (Brief Interview for Mental Status) score was 15 out of 15 indicating her cognition was intact. Resident 1's clinical record revealed a Physical Therapy Plan of Care dated [DATE], which indicated, Resident 1 was independent for walking, using stairs, bed mobility, sit to stand, transfers from a chair and car, and walking 150 feet at home, prior to her recent acute care hospitalization . Per the physical therapy evaluation, Resident 1 had decrease lower extremity strength after a recent hospitalization with a [DIAGNOSES REDACTED]. The goal was for Resident 1 to be discharged home with caregiver supervision. Resident 1's rehab potential was Excellent. The goal of the above physical therapy plan of care for Resident 1 was to walk 150 feet with stand-by-assistance using a front wheeled walker, have good muscle strength for bilateral lower extremities, bed mobility to be contact guard assist (one or two hands on body but provides no assistance to perform the functional task), and minimal assistance for transfers by [DATE]. Review of physical therapy progress and discharge summary dated [DATE], indicated, on [DATE], Resident 1 was ambulating 150 feet times two with stand-by-assistance using a front wheeled walker and had good muscle strength for bilateral lower extremities, stand-by-assist for bed mobility, and was a stand-by-assistance for transfers. A review of an occupational therapy plan of care dated [DATE], indicated, Resident 1's goal for upper body dressing to be with minimal assistance (,[DATE]% assist), and for lower body dressing and toileting moderate assistance (,[DATE]% assist) by [DATE]. A review of an occupational therapy note dated [DATE], indicated Resident 1 was at modified independent for upper body dressing, supervision/modified independent for lower body dressing, and needed supervision for moving around the bathroom in both sitting and standing. Review of Resident 1's diet order, dated [DATE], was CCHO (controlled carbohydrate diet) regular texture with regular, thin consistency (liquids) and on [DATE], her diet order was changed to a regular diet with regular texture and regular, thin consistency (liquids). A review of a facility document titled, SBAR (Situation, Background, Appearance and Review) Communication Form for Resident 1 dated [DATE], at 7:50 a.m. indicated, a change in condition, symptoms, or signs observed and evaluated was Stroke/[MEDICAL CONDITION]/TIA/new neurological signs and these started on [DATE]; and, since the start it (Stroke/[MEDICAL CONDITION]/TIA/new neurological signs) has gotten worse. Resident 1's oxygen level was 85% (percent, normal oxygen level readings usually range from 95 to 100 percent. Values under 90 percent are considered low), she had weakness or [MEDICAL CONDITION] (Muscle weakness or [DIAGNOSES REDACTED] on one side of the body that can affect the arms, legs, and facial muscles), an altered level of consciousness and she was unresponsive. The recommendation from the primary clinician was, May send out to ER (emergency room ). Review of Resident 1's History and Physical dated [DATE], from the GACH, where Resident 1 was transferred, indicated, Resident 1 presented to the emergency department unresponsive with right-sided [MEDICAL CONDITION] and right facial droop. Resident 1 was administered tPA (tissue plasminogen activator, a protein involved in the breakdown or dissolving of blood clots) with no immediate improvement in the weakness on the right side or her facial droop. Resident 1 remained unresponsive. Review of Resident 1's History and Physical from the GACH dated [DATE], indicated, a head CT (computerized tomography scan combines a series of X-ray images taken from different angles) was completed on [DATE]. The scan revealed an evolving recent ischemic (deficient supply of blood to a body part such as the brain that is due to obstruction of blood (the narrowing of arteries)) event with an assessment of an acute ischemic infarct (sudden stopping of adequate amounts of blood reaching parts of the brain) likely due to left [MEDICAL CONDITION] thrombus from [MEDICAL CONDITION] and subtherapeutic INR. Review of Resident 1's GACH labs (blood work results) indicated on [DATE], when Resident 1 was transferred to the GACH, her INR was 1.3. (a range of 2.0 to 3.0 is generally an effective therapeutic range for people taking [MEDICATION NAME] for disorders such as [MEDICAL CONDITION]). Resident 1's INR for subsequent days were as follows: [DATE], 1.3; [DATE], 1.4; [DATE], 1.5; [DATE], 1.5; [DATE], 1.9; [DATE], 2.1; [DATE], 2.0. Resident 1 was administered [MEDICATION NAME] and [MEDICATION NAME] (prevents the formation of blood clots, works faster than [MEDICATION NAME] for immediate treatment of [REDACTED]. A review of Resident 1's physical therapy initial evaluation at the GACH dated [DATE], indicated, Resident 1's prior level of function was living alone at home and independent using a front wheel walker and single point cane. The evaluation indicated, Resident 1, while at the GACH, required assistance to maintain balance to take a few steps alongside edge of bed, and moderate assistance for transfers. Resident 1 had impaired attention, concentration and orientation. Review of speech therapy progress notes from the GACH for Resident 1 dated [DATE], indicated, Resident 1 was placed on a dysphagia (swallowing difficulties) level 2 mechanical soft ground diet with nectar thick liquid (moist, soft foods done by blending, chopping, grinding, mashing, shredding, or cooking the food. Thin liquids need to be thickened because they are hard to swallow) and to follow strict aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airways) precautions. Review of occupational therapy's initial evaluation from the GACH for Resident 1 dated [DATE], indicated, Resident 1's cognition had impaired sustained attention. A progress note dated [DATE], indicated, Pt (patient) observed many times throughout tx (treatment) with a vacant stare and pleasant smile, almost wax figure like, and non-responsive. Resident 1 was at moderate assistance for upper body dressing and minimal assistance for lower body dressing. Review of a physical therapy progress noted dated [DATE], indicated, Resident 1 had .limited responses and inappropriate answers to verbal questions, appears confused: no response when asked name, states '(incorrect birthdate) when asked birthday, [AGE] years old (Resident 1 was [AGE] years of age) when asked what month it is. Prior to discharge to a skilled nursing facility on [DATE], from the GACH, review of a physical therapy progress noted dated [DATE], indicated Resident 1 needed minimum assistance for bed mobility and stand by assistance for walking 85 feet using a front wheeled walker. Resident 1 exhibited increased fatigue and dragging of lower extremity. Review of speech therapy progress notes from the acute care hospital for Resident 1 dated [DATE], indicated, Resident 1 was at risk for aspiration and had dysphagia. Resident 1 was placed on a dysphagia level 3, mechanical soft chopped diet (moist foods in bite-sized pieces) with thin/regular liquids and to be on STRICT aspiration precautions. Review of Resident 1's Discharge Summary from the GACH dated [DATE], indicated, [DIAGNOSES REDACTED]. Resident 1 had subtherapeutic INR prior to admission. In an interview on [DATE] at 10:35 a.m., with LN 5, who works in Resident 1's cardiologist office monitoring blood thinning medication levels and INRs, stated when medication is deceased or stopped, the affect will be noticed within 1 to 1.5 days later and will be reflected in the INR level. LN 5 stated when the medication is decreased the INR will decrease, resulting in throwing a clot if the INR is not in therapeutic range. A review of correspondence from Resident 1's cardiologist (doctor with special training and skill in finding, treating and preventing diseases of the heart and blood vessels, MD 1) dated [DATE], indicated, Resident 1 .had a recurring stroke because of subtherapeutic INR levels which were not aggressively managed . MD 1 indicated Resident 1's INR levels were 2.0 (therapeutic) when she was at the GACH prior to her first admission to the skilled nursing facility and an INR of 1.44 (subtherapeutic) on [DATE], 1.27 on [DATE], and 1.25 on [DATE]. MD 1 indicated Resident 1 was started on [MEDICATION NAME] when Resident 1 was diagnosed with [REDACTED]. MD 1 indicated, The correlation is therefore very clear that her [MEDICAL CONDITION] because of subtherapeutic INR levels and underdosing of her anticoagulation with [MEDICATION NAME]. Based on interview and record review, the facility failed to ensure the physician or the nurse practitioner supervised the use of [MEDICATION NAME] (a medication which prevents blood clots from forming; the presence of blood clots can stop the flow of blood to the heart or brain) for one of three sampled residents (Resident 1) when a therapeutic dose (right amount of medication to produce a desired effect for treatment) of [MEDICATION NAME] was not ordered in order to maintain a therapeutic International Normalized Ratio (INR- a blood test used to measure how well blood clots, and how [MEDICATION NAME] is working) between 1XXX,[DATE].5 for Resident 1. This failure resulted in: 1. Resident 1 received sub-therapeutic (less than what was needed to achieve the desired effect, treat, or prevent disease) dosages of [MEDICATION NAME] which increased the risk of stroke (blood flow to the brain was cut-off or impaired which could be related to a blood clot), and, 2. Resident 1 was transferred to a General Acute Care Facility (GACH) on [DATE] with [DIAGNOSES REDACTED]. Findings: 1. A review of a GACH note titled, Consultation by Resident 1's cardiologist (heart doctor), dated [DATE], indicated Resident 1 had the following health problems: 1. Chronic persistent [MEDICAL CONDITION] (a heart rhythm problem) on [MEDICATION NAME]. 2.[MEDICAL CONDITION]([MEDICAL CONDITION]-a stroke) She suffered a [MEDICAL CONDITION] stroke (caused by a blood clot which interrupted the blood supply to part of the brain) in 2009, and 3. CAD ([MEDICAL CONDITION]-[MEDICAL CONDITION]): She has a history of MI ([MEDICAL CONDITION] infarction-a [MEDICAL CONDITION]) .in 2007 .felt to be due to [MEDICAL CONDITION] (a blood clot) . A record review of Resident 1's face sheet disclosed Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a form titled, Discharge Information from the GACH, dated [DATE], indicated Resident 1 had an appointment on [DATE] with Disease Management Anticoagulant Treatment (DMAT-an outside clinic at the GACH that monitors [MEDICATION NAME] dosages) to have her INR checked. A higher INR number means less clotting and more protection against a blood clot. A review of Resident 1's facility admission Physician orders, dated [DATE], indicated: [MEDICATION NAME] Sodium Tablet 1 MG (milligram a unit of measurement) Give 1 tablet every Tue, Wed, Thu, Sat, Sun . and, [MEDICATION NAME] Sodium Tablet 1 MG Give 0.5 tablet .every Mon, Fri . This dose provided a total of 6 mg of [MEDICATION NAME] in one week. Review of a progress note titled, Physician's Order Note, dated [DATE] at 2:51 p.m., indicated Resident 1 left the facility for an appointment with the DMAT clinic at the GACH. A review of the DMAT clinic note in Resident 1's facility record, dated [DATE] at 11:34 a.m., indicated an INR result of 2.0 which was therapeutic. The note indicated an .MD (medical doctor-from the GACH) specified INR (range of) 1XXX,[DATE].5 . This range was determined to be therapeutic for Resident 1 in order to prevent harmful blood clots. Resident 1's instruction included a new [MEDICATION NAME] dose of, [MEDICATION NAME] Sodium Tablet 1 MG Give 0.5 tablet every Monday, Wednesday, and Friday and, [MEDICATION NAME] Sodium Tablet 1 MG Give 1 tablet every Tuesday, Thursday, Saturday, and Sunday. The DMAT clinic directed her to come back to the clinic on [DATE] for an INR recheck. Review of Resident 1's facility record indicated no therapeutic range information was entered in the physician orders or in the Medication Administration Record [REDACTED] A review of the Physician orders dated [DATE], indicated the facility physician ordered [MEDICATION NAME] Sodium Tablet 1 MG Give 0.5 tablet every Mon, Wed, Fri . and, [MEDICATION NAME] Sodium Tablet 1 MG Give 1 tablet .every Tue, Thu, Sat, Sun . This dosage provided a total of 5.5 mg of [MEDICATION NAME] in one week and coincided with the [DATE] DMAT [MEDICATION NAME] dose instructions. A review of the facility Lab Results Report, dated [DATE] and timed at 6:45 p.m., indicated Resident 1 had an INR test drawn at the facility (not the DMAT clinic). The INR result was 1.44. This INR was reported to the facility on [DATE] at 9:22 a.m. The result was flagged L (low). The report was marked with an initial on [DATE]. A handwritten note on the lower portion indicated, Followed by (GACH) anticoagulation clinic (DMAT). This result indicated Resident 1's [MEDICATION NAME] dose was not therapeutic. Further record review revealed there was no documentation in Resident 1's clinical record of a physician order to increase the [MEDICATION NAME] dose in response to the sub-therapeutic INR of 1.44 on [DATE]. Review of a progress note titled, Laboratory, dated [DATE], indicated that the result of the [DATE], 6:45 p.m. INR result was forwarded to Resident 1's attending physician for review. Review of Resident 1's nursing care plan titled, .Anticoagulant Therapy, initiated [DATE], indicated, Place prompt call to MD (medical doctor-facility physician) if lab values fall outside pre-identified therapeutic (ordered) parameters . A progress note titled, General Note, dated [DATE] at 1:57 p.m., written by assistant director of nurses (ADON) 1 indicated, Spoke with resident's (Resident 1's family member) regarding her concerns with resident's [MEDICATION NAME] order .I spoke with (GACH) [MEDICATION NAME] clinic (DMAT) and (clinic) gave order for [MEDICATION NAME] 1 mg today and check PT/INR level . Resident 1's INR level was sub-therapeutic for 4 days when this call was made. A review of Resident 1's clinical record indicated the attending physician ordered a facility INR test which was collected on [DATE] at 4:30 p.m. On [DATE], the INR result was sent to the facility at 6:48 p.m. The INR result was 1.27. This indicated the [MEDICATION NAME] dosage was less therapeutic than on [DATE]. A progress note titled, Laboratory, dated [DATE], at 7:40 p.m., indicated Resident 1's INR result was called to the attending physician. NP 2 was on call for the attending physician and provided new orders for [MEDICATION NAME] and a lab order for the next INR on [DATE]. The orders from NP 2 for Resident 1, dated [DATE], indicated: [MEDICATION NAME] Sodium Tablet 1 MG Give 0.5 tablet every Tue, Thu, Sat, Sun . [MEDICATION NAME] Sodium Tablet 1 MG Give 1 tablet .every Mon, Wed, Fri . This dosage provided a total of 5.0 mg of [MEDICATION NAME] in one week. This order was 0.5 mg per week less than the ordered dose on [DATE]. A higher dose of [MEDICATION NAME] was necessary to achieve the desired therapeutic range of 1XXX,[DATE].5. A review of Resident 1's lab result, dated [DATE], revealed an INR result of 1.25. This indicated the [MEDICATION NAME] was less therapeutic than on [DATE]. The physician was notified by the facility on [DATE]. Resident 1's INR result was sub-therapeutic for 7 days as of [DATE]. Resident 1's attending physician increased Resident 1's [MEDICATION NAME] dose on [DATE] The order from the attending physician, dated [DATE], indicated: [MEDICATION NAME] Sodium Tablet 1 MG Give 1mg . every Mon, Tues, Wed, Thu, Fri Sat, Sun . This dose provided a total of 7 mg of [MEDICATION NAME] in one week. During an interview with ADON 1 on [DATE] at 4:30 p.m., ADON 1 stated, It (INR) was forwarded to (attending physician) for review on [DATE] .The (NP 1) reviewed it and there were no new orders .It (INR) was done again on ,[DATE] .they changed her (Resident 1's) order .it looks the same .actually he (NP 2) just switched the days and she was getting less ([MEDICATION NAME]) . ADON 1 confirmed the INR was not therapeutic and the [MEDICATION NAME] dose was not increased based on the INR results received on [DATE] and [DATE]. She further stated, .(physicians) need to talk to each other. During an interview with the assistant director of nurses (ADON) 2 on [DATE] at 3:15 p.m., ADON 2 stated, Resident 1's physician requested INR's every Monday and Thursday for his residents. The INR performed on [DATE] for Resident 1 was completed on a Monday. She stated if an INR was low, (below therapeutic level of 1XXX,[DATE].5) the physician was called. She further stated, The target (therapeutic INR range) should be in the (physician's) order. During an interview and concurrent record review with the DON on [DATE], at 2:50 p.m., the DON reviewed Resident 1's clinical record and was unable to find documentation of an INR target range in the MAR indicated [REDACTED] During an interview with Resident 1's attending physician on [DATE] at 11:21 a.m., the physician stated, the [MEDICATION NAME] dose should have been increased after each of the low INR results from [DATE] and [DATE]. He stated, The (brand name-[MEDICATION NAME]) dose should have been increased .I would have increased the dose. The next one (INR) was on [DATE]. That one (INR result) was relayed to someone on call. Again it was low. I don't know why that person did not increase the dose. Per the standard of care, the dose should have been increased, not decreased .the patient had [MEDICAL CONDITION] understood. (NP 2) should not have been slightly decreasing the dose .series of problems .We take responsibility for the dosage when we order the INR. During an interview with nurse practitioner (NP) 1 on [DATE] at 12:35 p.m., NP 1 stated, Actually, I didn't see the patient (Resident 1). I signed it (lab report from [DATE]) .We (facility physicians) usually check it (INR) every Monday and Thursday .I didn't change the dose. If I order the lab I will receive it . We are responsible if we order it .I assumed it would be followed up by them (the DMAT clinic). NP 1 stated the facility attending physician ordered the lab for [DATE] and NP 1 did not verify the lab was followed up on, or that Resident 1 was followed by the DMAT clinic. NP 1 failed to confirm Resident 1 was followed by the DMAT clinic, and failed to act on Resident 1's sub-therapeutic INR. During an interview with Pharmacist (Pharm) 2 from the DMAT clinic, on [DATE] at 1:20 p.m., Pharm 2 stated, They (facility) weren't getting the right dosage for (Resident 1) I think, and not adjusting it. We have no input on INRs done by facilities. They (facility physician) need to do her adjustment .We only make adjustments (of [MEDICATION NAME] dosing) for those who come into the clinic. (Resident 1's physician) did not call us to ask us about following her. We would have told them we can't, especially not when their lab does the test (of the INR). She was planning to come in here on ([DATE]) and we could have adjusted it ([MEDICATION NAME] dose) based on that test (an INR performed by the DMAT clinic). We are an ambulatory clinic. Pharm 2 indicated the clinic received a call from the facility on [DATE] when Resident 1's family member raised concerns about Resident 1's low INR. Review of the facility policy titled, Anticoagulant Therapy, dated [DATE] indicated, .Purpose .to monitor anticoagulant therapy so that therapeutic drug parameters are maintained .Document therapeutic lab parameters desired by the physician for both high and low values .therapeutic parameters obtained should be included in, or transcribed next to orders for anticoagulant therapy on the MAR. 2. During an interview with the occupational therapist (OT) on [DATE], at 12:20 p.m., the OT stated she walked into Resident 1's room in the morning on [DATE] to provide therapy. The OT reported Resident 1 was seated in her wheelchair. The OT stated she spoke to Resident 1, but she did not respond and her face looked blank. Review of a Communication Form, dated [DATE] at 7:50 a.m., indicated, The occupational therapist alerted us that something is not right with the resident, on observation she (resident 1) is unresponsive . Review of a Change of Condition/Transfer note, dated [DATE] at 8:29 a.m., revealed Resident 1 was transferred to the GACH when she was found unresponsive by staff. A review of the GACH record titled, History and Physical, dated [DATE], indicated Resident 1 was admitted to the GACH with unresponsiveness and right sided weakness. An INR was taken at the GACH and the result was 1.3. The assessment listed problems including, Acute ischemic infarct (stroke-blood flow to brain impaired) most likely due to left [MEDICAL CONDITION] (a chamber in the heart) thrombus (blood clot) from [MEDICAL CONDITION] .Sub therapeutic INR. A review of American Heart Association information indicated INR levels below the target range are associated with increased risk of [MEDICAL CONDITION] (blood clot). If the INR is too low, blood clots will not be prevented.

Based on interview, clinical record review, and facility document review, the facility failed to provide needed care and services for 1 of 55 sampled residents (Resident 322) when the facility delayed the transfer of Resident 322 to a general acute care hospital while Resident 322 was in severe pain and bleeding. This failure resulted in Resident 322 experiencing physical and psychosocial harm which included fear, anger, 10/10 pain (on a scale from 0 to 10 where 0 is no pain and 10 is the worst pain), and a delay of emergency treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: According to Resident 322's Admission Record, dated 8/22/19, Resident 322 was admitted to the facility in the Spring of 2019 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also indicated Resident 322 was his own responsible party (health care decision maker). A Nurse's Progress Note, dated 8/8/19, at 8:05 a.m., indicated, Resident [322] alert and verbally responsive, able to make needs known. C/o [complains of] burning upon urination and urgency to urinate. Distended abdomen noted, called on call [nurse practitioner, NP], advised straight cath [straight catheter, a device that is temporarily inserted into the body to drain urine from the bladder through the urethra, a tube that transports urine from the bladder to the body's exterior] .Upon straight cath resident had an output of about 400cc [cubic centimeters, a unit of measurement] of clear yellow urine .C/o lower abdominal pain . A Nurse's Progress Note, dated 8/8/19, at 9:29 a.m., indicated, .Resident [322] continued to complain of being unable to urinate. Resident refused breakfast. Resident is putting on the call light every few minutes stating he can't urinate and wants to go to the hospital. Supervisors are aware. A Nurse's Progress Note, dated 8/8/19, at 10:06 a.m., indicated, .resident [322] had called 911 for an ambulance to be dispatched to take resident to the hospital. Supervisor spoke with ambulance company and the ambulance was returned to base and wasn't dispatched an order to cath resident .was carried out .Resident was still complaining of abdimonal [sic] pain. A Nurse's Progress Note, dated 8/8/19, at 10:25 a.m., indicated, resident [322] complained of unable to urinate .at 1020am inserted [brand name] cath [a catheter that is left in the urethra to continuously drain urine from the bladder into an attached bag] .still awaiting for output [drainage of urine] endorsed to charge nurse . A Nurse's Progress Note, dated 8/8/19, at 12:47 p.m., indicated, Checked urine bag and there was a scant amount of blood in tubing only. No visible urine in bag. Notified supervisor .Resident [322] was still complaining of pain in abdominal area. Abd [abdomen] is Slightly distended, will notify MD [medical doctor] of residents [sic] lack of urine in catheter and was still complaining of abd pain .[NP] wood [sic] be in to examine resident. I went to finish the lunch med [medication] pass. A Nurse's Progress Note, dated 8/8/19, at 1:03 p.m., indicated, .resident [322] had x2 ex-large emesis [two extra large episodes of vomiting] .Received phone call from ambulance service that resident had called 911 again and they were at the facility . A Nurse's Progress Note, dated 8/8/19, at 2:05 p.m., indicated, EMT's [emergency medical technicians] spoke with resident [322]. Resident was placed on gurney and taken to [general acute care hospital, GACH] .resident left facility via ambulance .DON aware that resident himself dialed 911. A facility document titled, Transfer/Discharge Report, dated 8/9/19, indicated Resident 322 was transferred to the GACH on 8/8/19, at 2:10 p.m. due to abdominal pain with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a GACH document titled, History and Physical, signed 8/10/19, indicated, .Hematuria [blood in the urine] most likely from the urethral trauma from the catheter .Patient following admission was taken to the operating room . Review of a GACH MD's Progress Note, signed 8/10/19, indicated, Assessment .Hematuria .Urethral trauma .[CONDITION(S)]. Review of a GACH Interfacility Transfer Report, dated 8/14/19, indicated Resident 322 required two Major Procedures .8/8/19 cystoscopy [procedure that assesses the urethra internally with a camera] .8/9/19 resection prostate laser transurethral, greenlight prostate vaporization[surgery to enlarge the urethral opening by removing surrounding tissue]. A Nurse's Progress Note, dated 8/14/19, at 10:06 p.m., indicated Resident 322 was readmitted to the facility from the GACH. During an interview with Resident 322 on 8/20/19, at 12:45 p.m., Resident 322 reported he called an ambulance to take him to the hospital, but the facility staff sent the ambulance away. Resident 322 stated he called an ambulance a second time and was transported by ambulance to the GACH where he required surgical intervention. During an interview with a family member (FM) 1 on 8/20/19 at 1:53 p.m., FM 1 reported Resident 322 was admitted to the operating room upon arrival to the GACH due to urethral trauma. During an interview with Resident 322 on 8/22/19 at 5:48 p.m., Resident 322 stated the facility's dismissal of the ambulance he requested on 8/8/19, made him scared and angry. Resident 322 stated he was bleeding and in 10/10 pain for the hours between when he first requested to go to the hospital, and when he was taken (four hours and 36 minutes total). Resident 322 reported he pressed his call light multiple times, called 911 twice, and had to beg to be taken to the GACH for emergency care. During an interview with the director of nursing (DON) on 8/22/19, at 6:01 p.m., the DON confirmed Resident 322 was his own responsible party, and confirmed it was not ok to refuse him to go to the hospital. The DON stated it is never ok to not allow a resident to go to the GACH if they want to. The DON explained, when inserting a [brand name] catheter, the licensed nurse (LN) should ensure it is in the bladder. The DON stated catheter placement is confirmed by checking for output. According to the DON, if no output is observed, steps should be taken immediately to confirm placement in the bladder, the balloon (device used to secure [brand name] catheter in place after insertion) could be deflated, and the [brand name] catheter could be further advanced to try for output. The DON confirmed the absence of urine output for two hours post [brand name] catheter insertion, with the presence of blood in the tubing, was a problem that absolutely needed intervention. During an interview with Assistant Director of Nursing (ADON) 1 on 8/22/19, at 6:21 p.m., ADON 1 reported she had been notified that Resident 322 had called 911 for an ambulance and wanted to go to the hospital. ADON 1 confirmed the resident had the right to go to the hospital. ADON 1 reported Resident 322 complained of inability to urinate, and upon assessment, she observed the presence of blood at the tip of Resident 322's penis (the exit-point of the urethra) and stated there was distention (swelling). ADON 1 stated she received report from a certified nursing assistant (CNA), that Resident 322's penis had been bleeding. Per ADON 1, Resident 322 reported he had been hurt that morning when he was catheterized with a straight catheter. ADON 1 reported she subsequently attempted to insert a [brand name] catheter into Resident 322's urethra, and received no output of urine. ADON 1 confirmed there was not a drop of urine observed to confirm the [brand name] catheter was correctly in the bladder. ADON 1 also confirmed it was unusual to not get urine output upon [brand name] catheter insertion. ADON 1 stated she instructed staff to monitor for output, but was not told until that afternoon that no output and only scant blood had occurred. During an interview with the DON on 8/23/19, at 9:52 a.m., the DON stated she cancelled the first ambulance requested by Resident 322 because she did not believe an ambulance was needed. The DON stated she was informed by staff that Resident 322 was just upset and agitated. The DON stated had she known the seriousness of the whole situation regarding Resident 322, she would have called the ambulance herself. During an interview with licensed nurse (LN) 11 on 8/23/19, at 11:33 a.m., LN 11 stated Resident 322 received a straight catheterization during the prior shift, and was complaining of pain and inability to urinate. Per LN 11, Resident 322 stated numerous times he wanted to go to the hospital and called 911 for an ambulance. LN 11 confirmed the first ambulance did not come for Resident 322. Per LN 11, Resident 322 subsequently received a [brand name] catheter, and the only observable output was blood. LN 11 reported Resident 322 started howling and called 911 again. Per LN 11, Resident 322 was taken by ambulance because he was his own responsible party and was alert and oriented. LN 11 stated the resident had the right to go to the hospital if he wanted to, and it wasn't acceptable to turn the ambulance away if the resident called 911. Review of a facility document titled, Catheter Insertion and Removal, Male, dated 2006, indicated, DO NOT USE FORCE .and advance catheter until urine flows freely. Review of an emedicinehealth document titled [brand name] Catheter, dated 1/17/19, indicated, .if the balloon is opened before the [brand name] catheter is completely inserted into the bladder, bleeding, damage and even rupture of the urethra can occur. In some individuals, long-term permanent scarring and strictures of the urethra could occur .When to Seek Medical Care for [brand name] Catheter Complications .Any pink or red urine or bleeding from the urethra .urgency .increased lower abdominal pain .swelling in the genital area .pain in the urethral area or genital area .If the patient .has had a catheterization performed, he or she should go to the hospital's emergency department if they notice any of the following: Bleeding from the urethra .nausea and vomiting .urgency, or pain .increased lower abdominal pain . (retrieved 9/3/19 from https://www.emedicinehealth.com/[brand name]_catheter/article_em.htm).

Based on interview and record review, the facility failed to allow one of 55 sampled residents (Resident 322) to exercise their right to seek emergency services. This failure resulted in Resident 322 experiencing physical and psychosocial harm which included fear, anger, 10/10 pain (on a scale from 0 to 10 where 0 is no pain and 10 is the worst pain), and a delay of emergency treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: According to Resident 322's Admission Record, dated 8/22/19, Resident 322 was admitted to the facility in the Spring of 2019 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also indicated Resident 322 was his own responsible party (health care decision maker). A Nurse's Progress Note, dated 8/8/19, at 8:05 a.m., indicated, Resident [322] alert and verbally responsive, able to make needs known. C/o [complains of] burning upon urination and urgency to urinate. Distended abdomen noted, called on call [nurse practitioner, NP], advised straight cath [straight catheter, a device that is temporarily inserted into the body to drain urine from the bladder through the urethra, a tube that transports urine from the bladder to the body's exterior] .Upon straight cath resident had an output of about 400cc [cubic centimeters, a unit of measurement] of clear yellow urine .C/o lower abdominal pain . A Nurse's Progress Note, dated 8/8/19, at 9:29 a.m., indicated, .Resident [322] continued to complain of being unable to urinate. Resident refused breakfast. Resident is putting on the call light every few minutes stating he can't urinate and wants to go to the hospital. Supervisors are aware. A Nurse's Progress Note, dated 8/8/19, at 10:06 a.m., indicated, .resident [322] had called 911 for an ambulance to be dispatched to take resident to the hospital. Supervisor spoke with ambulance company and the ambulance was returned to base and wasn't dispatched an order to cath resident .was carried out .Resident was still complaining of abdimonal [sic] pain. A Nurse's Progress Note, dated 8/8/19, at 10:25 a.m., indicated, resident [322] complained of unable to urinate .at 1020am inserted [brand name] cath [a catheter that is left in the urethra to continuously drain urine from the bladder into an attached bag] .still awaiting for output [drainage of urine]. endorsed to charge nurse . A Nurse's Progress Note, dated 8/8/19, at 12:47 p.m., indicated, Checked urine bag and there was a scant amount of blood in tubing only. No visible urine in bag. Notified supervisor .Resident [322] was still complaining of pain in abdominal area. Abd [abdomen] is Slightly distended, will notify MD [medical doctor] of residents [sic] lack of urine in catheter and was still complaining of abd pain .[NP] wood [sic] be in to examine resident. I went to finish the lunch med [medication] pass. A Nurse's Progress Note, dated 8/8/19, at 1:03 p.m., indicated, .resident [322] had x2 ex-large emesis [two extra large episodes of vomiting] .Received phone call from ambulance service that resident had called 911 again and they were at the facility . A Nurse's Progress Note, dated 8/8/19, at 2:05 p.m., indicated, EMT's [emergency medical technicians] spoke with resident [322]. Resident was placed on gurney and taken to [general acute care hospital, GACH] .resident left facility via ambulance .DON aware that resident himself dialed 911. A facility document titled, Transfer/Discharge Report, dated 8/9/19, indicated Resident 322 was transferred to the GACH on 8/8/19 at 2:10 p.m. due to abdominal pain with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a GACH document titled, History and Physical, signed 8/10/19, indicated, .Hematuria [blood in the urine] most likely from the urethral trauma from the catheter .Patient following admission was taken to the operating room . Review of a GACH MD's Progress Note, signed 8/10/19, indicated, Assessment .Hematuria .Urethral trauma .[CONDITION(S)]. Review of a GACH Interfacility Transfer Report, dated 8/14/19, indicated Resident 322 received two Major Procedures .8/8/19 cystoscopy [procedure that assesses the urethra internally with a camera] .8/9/19 resection prostate laser transurethral, greenlight prostate vaporization[surgery to enlarge the urethral opening by removing surrounding tissue]. A Nurse's Progress Note, dated 8/14/19, at 10:06 p.m., indicated Resident 322 was readmitted to the facility from the GACH. During an interview with Resident 322 on 8/20/19, at 12:45 p.m., Resident 322 reported he called an ambulance to take him to the hospital, but the facility staff sent the ambulance away. Resident 322 stated he called an ambulance a second time and was transported by ambulance to the GACH where he required surgical intervention. During an interview with a family member (FM 1) on 8/20/19, at 1:53 p.m., FM 1 reported Resident 322 was admitted to the operating room upon arrival to the GACH due to urethral trauma. During an interview with Resident 322 on 8/22/19, at 5:48 p.m., Resident 322 stated the facility's dismissal of the ambulance he requested on 8/8/19, made him scared and angry. Resident 322 stated he was bleeding and in 10/10 pain for the hours between when he first requested to go to the hospital and when he was taken (four hours and 36 minutes total). Resident 322 reported he pressed his call light multiple times, called 911 twice, and had to beg to be taken to the GACH for emergency care. During an interview with the director of nursing (DON) on 8/22/19, at 6:01 p.m., the DON confirmed Resident 322 was his own responsible party, and confirmed it was not ok to refuse him to go to the hospital. The DON stated it is never ok to not allow a resident to go to the GACH if they want to. Continuing the interview with the DON on 8/22/19, the DON stated when inserting a [brand name] catheter, the licensed nurse (LN) should ensure it is in the bladder. The DON stated catheter placement is confirmed by checking for output. According to the DON, if no output is observed, steps should be taken immediately to confirm placement in the bladder. The DON confirmed the absence of urine output for two hours post [brand name] catheter insertion, with the presence of blood in the tubing, was a problem that absolutely needed intervention. During an interview with Assistant Director of Nursing (ADON) 1 on 8/22/19, at 6:21 p.m., ADON 1 reported she had been notified that Resident 322 had called 911 for an ambulance and wanted to go to the hospital. ADON 1 reported she did not know who cancelled the ambulance requested by Resident 322, and confirmed the resident had the right to go to the hospital. ADON 1 reported Resident 322 complained of inability to urinate, and upon assessment, she observed the presence of blood at the tip of Resident 322's penis (the exit-point of the urethra) and stated there was distention (swelling). Per ADON 1, Resident 322 reported he had been hurt that morning when he was catheterized with a straight catheter. ADON 1 reported she subsequently attempted to insert a [brand name] catheter into Resident 322's urethra, and received no output of urine. ADON 1 confirmed there was not a drop of urine observed to confirm the [brand name] was correctly in the bladder. ADON 1 also confirmed it was unusual to not get urine output upon [brand name] catheter insertion. During an interview with the DON on 8/23/19, at 9:52 a.m., the DON stated she cancelled the first ambulance requested by Resident 322 because she did not believe an ambulance was needed. The DON stated she was informed by staff that Resident 322 was just upset and agitated. The DON stated had she known the seriousness of the whole situation regarding Resident 322, she would have called the ambulance herself. During an interview with Licensed Nurse (LN) 11 on 8/23/19, at 11:33 a.m., LN 11 stated Resident 322 received a straight catheterization during the prior shift, and was complaining of pain and inability to urinate. Per LN 11, Resident 322 stated numerous times he wanted to go to the hospital and called 911 for an ambulance. LN 11 confirmed the first ambulance did not come for Resident 322. Per LN 11, Resident 322 subsequently received a [brand name] catheter, and the only observable output was blood. LN 11 reported Resident 322 started howling and called 911 again. Per LN 11, Resident 322 was taken by ambulance because he was his own responsible party and was alert and oriented. LN 11 stated the resident had the right to go to the hospital if he wanted to, and it wasn't acceptable to turn the ambulance away if the resident called 911.

Based on interviews, record reviews, and facility policy review, the facility failed to prevent an accident for one of four sampled residents (Resident 1) when staff did not provide a two person assist for repositioning during bowel and bladder care (toilet use), as specified in the care plans and resulted in Resident 1 falling out of bed. This failure resulted in Resident 1 being admitted to the hospital with [REDACTED]. Findings: According to the admission record, Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. A record review of a care plan for Self-Care Deficit initiated on 4/18/15, for Resident 1, indicated, Two-person physical assistance required for Bed Mobility and Toilet Use. A record review of the Minimum Data Set (MDS, an assessment tool) dated 8/30/18, Section G - Functional Status indicated Resident 1 required a two-person assist for bed mobility (turns side to side) and toilet use (cleanses self after elimination). In addition, the MDS's Brief Interview for Mental Status (a screening for memory and thought process) for Resident 1 indicated she had a score of 10 out of 15 (mildly impaired cognition). During an interview with Certified Nurse Assistant (CNA) 1 on 11/29/18, at 9:45 a.m., CNA 1 stated she was giving Resident 1 and her roommate a bed bath at the same time on the morning of 11/15/18, when Resident 1 had a bowel movement. Both residents were regularly assigned to CNA 1. CNA 1 stated while cleaning Resident 1, she was on the left side of the bed. While Resident 1 was on her back, CNA 1 pushed Resident 1's left back side to assist her onto her right side. Resident 1 grabbed the right side rail of the bed, pulled herself to her right side, and rolled out of bed, landing on her knees. CNA 1 stated she yelled for help, staff arrived and helped Resident 1 back to bed using a (Brand name) mechanical lifting device. CNA 1 stated she did not know Resident 1 was a two-person assist, as listed in the Self-Care Deficit care plan and the Kardex (a quick reference sheet for the care needs of each specific patient), for bed mobility and bowel and bladder care. An Emergency Department progress note for Resident 1, dated 11/15/18, revealed there was a complete dislocation at the right artificial knee joint from the thigh bone, which had a comminuted (where the bone breaks into multiple pieces) displaced fracture (where the bones no longer line up together). The orthopedic surgeon recommended amputation of the right leg. During an interview with the Assistant Director of Staff Development on 11/29/18, at 11:35 a.m., she stated newly hired CNAs are shown how to find and read the Kardex, as it is more specific to required staff assistance for resident's Activities of Daily Living (ADL's such as feeding, bathing, and toilet use), than the care plans. During a concurrent interview and record review of the Kardex for Resident 1, the administrator stated on 11/30/18 at 3:30 p.m., this was the Kardex in place prior to the incident on 11/15/18. The Kardex indicated Resident 1 required a two person assist for: bed mobility, toilet use, and bowel and bladder care. A facility policy reviewed on 3/5/19 titled, Clinical Practice Standard, dated (MONTH) (YEAR), indicated, CNA's have access to each resident's specific care details, such as ADL self-performance & support, any devices used, & any other individualized plans of care, by accessing the Kardex on the residents' profile. In an interview with the Director of Staff Development, on 12/19/18, at 12:45 p.m., she stated the CNA should check with the Licensed Nurse and the Kardex prior to each shift, and to always check the Kardex if unsure. CNA 1 knows Resident 1 requires a two person assist and should have called in another staff to help with bowel and bladder care.

Based on observation, resident and staff interviews, and facility document and policy reviews, the facility failed to ensure a safe living environment for 63 mobile residents (either ambulatory or with the use of a wheel chair) in a facility census of 138 when they failed to: 1. Identify the use of blankets and buckets in common resident areas to catch water leaking through the ceiling as a potential accident hazard; and 2. Implement immediate interventions to reduce the risks of falls and/or injuries to the facility's residents when the roof/ceiling began leaking on 1/16/19. These failures resulted in Resident 3, a blind, ambulatory Resident to trip on a blanket and bucket and fall, and potentially placed all other mobile residents at potential risk for serious harm and injury. Findings: In an interview with Resident 2, on 1/17/19, at 1:59 p.m., she stated there were three to four buckets on the floor, in the hallway by the kitchen because the roof was leaking. Resident 2 stated the roof leaked Every time it rains. In an interview with Housekeeper 1 (HSK 1) on 1/17/19, at 2:17 p.m., she stated the roof between the kitchen and the laundry room leaked When it rains. In an interview with Licensed Nurse (LN) 1 on 1/17/19, at 2:20 p.m., he said, I have seen the light fixture (on the ceiling by the kitchen) with patch discoloration from previous leaks approximately a month ago. LN 1 added, Right now it's (roof) leaking. He stated Resident 3 was complaining about a leaking roof this morning. On 1/17/19, at 2:25 p.m., a light brown stain was noted on the ceiling of the hallway in front of room [ROOM NUMBER]. There was no wet spot or bucket on the floor underneath the stained area. In an interview with Certified Nursing Assistant (CNA) 1 on 1/17/19, at 2:25 p.m., she explained, When it rains really hard, water dripped and was Collected with buckets from the spot on the ceiling with the brown stain in front of room [ROOM NUMBER]. On 1/17/19, at 2:32 p.m., five buckets of different sizes, which all contained water, were observed on the floor in the hallway between the laundry room and the kitchen. There was water on the floor around the five buckets and two yellow caution signs next to the wet floor. Water was dripping from the air vent on the ceiling and from the electrical light fixture. During an interview with the Manager of Environmental Services (MES) on 1/17/19, at 2:37 p.m. and at 2:45 p.m., he stated the roof had been leaking since he got hired on 11/13/18. He added, It had been going on for a while. The MES stated staff Make sure wet floor signs are out when the floor is wet. The janitor put out buckets to try to keep the floor as dry as possible, and tried to empty the buckets when they became full. The MES explained the facility administrator had copies of quotes for roof repair from different roofing companies. He provided copies of the quotes from four different roofing companies with the earliest date of 11/28/18. In an interview with Resident 3 on 1/17/19, at 2:53 p.m., she stated the staff put out buckets in the hallway to contain water When it rains. She said, I walked out there and tripped over a wet blanket and the buckets. Resident 3 was blind and walked around the facility on her own. She lived close to the area of water leaks, and close to the laundry room. She verbalized feeling safe in the facility but when it rains, I don't feel safe because something might fall on me or I'll trip. Resident 3 stated she mentioned and complained of the leaking roof in the Resident Council (group of residents who met every month to discuss issues in the facility) meeting. Review of the Resident Council meeting notes dated 1/8/19, indicated, under Concern/Request Identified by the Resident Council: Roof is still leaking and not being fixed. The facility's response dated 1/8/19 was, Quotes for roof repair were sent in (MONTH) to those who make those decisions. Waiting on response . On 1/17/19, at 3:26 p.m., two employees who carried meal trays and one male resident in a wheelchair (who wheeled himself), were seen going through the wet floor, past the buckets, and the yellow caution signs, to go to the kitchen. In an interview with Resident 5 on 1/17/19, at 3:31 p.m., she stated she has seen buckets in the hallway. Resident 5 said, When it rains, there're (buckets) out. On 1/17/19, at 3:36 p.m., two buckets of different size, which contained water, were observed on the floor in the hallway behind room [ROOM NUMBER] and close to an exit door leading to the center courtyard. There was water on the floor around the buckets. Water was dripping from the air vent on the ceiling and the light fixture was crooked. There was a piece of wooden board attached to the ceiling close to the light fixture; the wooden board was painted the same color as the ceiling. Part of the ceiling showing from under the edge of the wooden board appeared to be coming off. In an interview with LN 3 on 1/17/19, at 3:42 p.m., she stated she first saw water dripping from the air vent and light fixture in the hallway behind room [ROOM NUMBER] on 1/16/19. She informed environmental services, and buckets were put in place to Catch the water. LN 3 stated, Not safe in my opinion. In an interview with LN 8 on 1/17/19, at 3:56 p.m., she expressed the leaking roof posed a hazard to residents Who move around on their own. She said, Quite a few residents complained about it. On 1/17/19, at 6:49 p.m., a trash can and a yellow caution sign were noted on the floor in the hallway in front of room [ROOM NUMBER] and water on the floor next to a trash can. On 1/17/19, at 6:57 p.m., Resident 3 was observed walking by herself toward room [ROOM NUMBER] while using a probing cane (cane used by blind people to find out what's on the ground ahead of them). Review of four roofing company's price proposals for roofing repairs, identified the earliest proposal was dated 11/28/19. Continued review revealed none of the four proposals were accepted by the facility until the Immediate Jeopardy (IJ, a situation that has threatened or likely to threaten the health and safety of a resident) was identified by the Department, and the facility's Action Plan, dated 1/17/19 confirmed a roofing contract had been accepted. The facility had knowledge of the need for roofing repairs, but did not enter a roofing repair contract for 50 days after the first roofing repair proposal was obtained from a roofing company. The facility policy and procedure titled Fall Management, dated (MONTH) 2014, indicated, .Purpose .To evaluate risk factors and provide interventions to minimize risk, injury, and occurrences .Assessment Guidelines may include, but are not limited to: Fall Risk Factors . The facility's Administrator, support Administrator, and interim Director of Nursing were informed of the IJ on 1/17/19 at 5:20 p.m. The IJ was a result of the facility's failure to provide an environment without accident hazards when multiple buckets used to contain water leakage from the roof were found in common areas of the facility. This failure placed residents at risk for tripping and/or falling for 63 mobile residents, in a census of 138, when one blind Resident (Resident 3) tripped on one of the buckets, and other mobile (either ambulatory or with the use of a wheel chair) residents had to navigate through water on the floor in front of the kitchen and in the Club station (name of a nursing station) hallway. An interim action plan of correction (P[NAME]) was presented by the facility to the Department which included: 1. Staff members assigned, with no other care duties, to both hallway problem areas, 24 hours a day to monitor the hallways and ensure resident safety, 2. Caution tape was placed at both hallway areas to prevent resident entry, 3. Documented schedules and logs for the staff monitoring the areas, 4. In-service with the staff on Resident Safety Monitoring, and 5. Confirmation from a roofing contractor to begin roof repairs starting on 1/23/19. The P[NAME] was accepted by the Department and the IJ immediacy was removed on 1/17/19 at 7:13 p.m.

Based on interview and record review, the facility failed to adequately assess, monitor, re-evaluate, and implement interventions to prevent a decline of a foot wound for 1 of 3 sampled residents (Resident 1). These failures contributed to Resident 1 developing a wound infection to his left toes, which lead [MEDICAL CONDITION] (a potentially life threatening blood infection). Findings: Review of the Admission Record indicated Resident 1 was admitted to the facility in (YEAR) with multiple [DIAGNOSES REDACTED]. Review of the clinical record for Resident 1 included: A physician's order dated 1/11/16 for head to toe weekly assessment every Wednesday. Review of Resident 1's Care Plan for an open wound to right (sic) 2nd toe initiated 6/30/17, directed nurses to administer treatment as ordered, monitor for signs and symptoms of infection, and notify MD for any C[NAME] (change of condition). The goal of treatment was to resolve the wound by the next review of the care plan. The care plan was not revised based on re-evaluations, changing condition, or the patient's response to the treatment. A physician's order dated 7/4/17, written by the Facility Medical Doctor (MD) directed, Open wound on left 2nd toe; cleanse with NS (Normal Saline), pat dry and apply silver alginate (an ointment) and cover with dry dressing. Re-eval (re-evaluate) on 7/13/17. D/C (discontinue) when healed, two times a day. Resident 1's Nursing Weekly Summary Review Sheets were reviewed. For the month of (MONTH) (YEAR) nurses documented that Resident's 1 skin was clear and the rest of the form was left blank. There was no documented evidence Resident 1's wound on his left toe was re-evaluated on 7/13/17 as was ordered by the MD. A physician's order dated 8/3/17 directed, Open wound on left 2nd toe; cleanse with NS, pat dry and apply silver alginate and cover with dry dressing. Re-eval 8/19/17, D/C when healed, two times a day. Skin assessment on the Nursing Weekly Summary Review Sheet for the month of (MONTH) (YEAR) revealed documentation that Resident's 1 skin was clear and the rest of the form was left blank. There was no documented evidence Resident 1's wound on his left toe was re-evaluated on 8/19/17 as was ordered by the MD. A physician's order dated 9/5/17 directed, Open wound on left 2nd toe; cleanse with NS, pat dry and apply silver alginate and cover with dry dressing, re-eval 9/18/17, D/C when healed, every day and evening shift. Skin assessment on the Nursing Weekly Summary Review Sheet for the month of (MONTH) (YEAR) revealed documentation that Resident's 1 skin was clear and the rest of the form was left blank. There was no documented evidence Resident 1's wound on his left toe was re-evaluated on 9/18/17 as was ordered by the MD. Skin assessment on the Nursing Weekly Summary Review Sheet for the month of (MONTH) (YEAR) revealed documentation that Resident's 1 skin was clear and the rest of the form was left blank. There was no documented evidence Resident 1's wound on his left toe was re-evaluated in (MONTH) as was ordered by the MD. On 11/2/17 the physician's order for left toe wound dressing was changed from twice a day to once a day and directed nurses to re-evaluate the wound on 11/16/17. There was no documented evidence Resident 1's wound on his left toe was re-evaluated on 11/16/17 as was ordered by the MD. Review of an 11/16/17 Nurse Practitioner (NP) note indicated Resident 1's skin had no rashes, but the extremities were swollen with dressings. Skin assessment on the Nursing Weekly Summary Review Sheet for the month of (MONTH) (YEAR) revealed documentation that Resident's 1 skin was clear and the rest of the form was left blank. Review of the clinical record for Resident 1 contained no documented evidence that the treatment for [REDACTED]. There was no wound care documentation in Resident's 1 records reflecting his wound description and condition. Review of a facility policy titled, Skin Integrity Standard, updated April, (YEAR), instructed, If the wound has shown not (sic) signs of improvement in two to four weeks re-evaluate current treatment, interventions and the plan of care. Review of the records from the dermatologist (a skin doctor), who was treating Resident 1's [MEDICAL CONDITION] (skin inflammation) in his office from (MONTH) (YEAR) to (MONTH) (YEAR) were reviewed. During Resident 1's last office visit with dermatologist on (MONTH) 18, (YEAR) the dermatologist noted, No sign of tissue necrosis (tissue death due to irreversible damage caused by infection) on the tip of the toes. The (MONTH) 18, (YEAR) dermatologist note indicated Resident 1's care should be assumed by his family doctor. Review of the facility policy titled, Skin Integrity Standard updated (MONTH) (YEAR), stipulated, Comprehensive 'head to toe' assessment of all patients by licensed nurse conducted weekly. Documentation must include: description of skin tissue, color, turgor, rashes, bruising, skin tears .and any other skin related issue . Skin integrity change of condition noted on the 24-hour report to be reviewed at daily Clinical Meeting. In a telephone interview with the Assistant of Director of Nursing (ADON), on 12/28/17 at 2:40 p.m., the ADON validated that weekly head to toe assessment documentation for Resident 1's skin was not accurate. The ADON was not able to find documentation in the nursing progress notes or other clinical records that Resident 1's left toe wounds were evaluated per physician's order or that the physician was informed of the wound condition. The ADON stated the re-evaluation of Resident 1's wounds should have been documented on the weekly summary assessments and it was not done. During a telephone interview with the Nurse Practitioner (NP), on 1/2/18 at 1:50 p.m., the NP was interviewed regarding how often she observed Resident 1's wounds without the dressings on. The NP stated she had never actually looked at Resident 1's wounds because he was followed by his dermatologist. The NP was not able to recall nursing staff reporting the condition of Resident 1's wounds. During a concurrent interview and record review with LN 2 on 2/1/18, at 10:20 a.m., LN 2 verified Resident 1 had chronic wound to his left toes and nurses changed the dressings twice a day for several months. LN 2 stated Resident 1's left toe wound should be evaluated every 14 days as was ordered by his physician and documented on the weekly skin summary sheets and it was not done. LN 2 confirmed nursing documentation on weekly skin summary sheets indicating Resident's 1 skin was clear were not accurate. In an interview with Licensed Nurse 1 (LN 1) on 2/1/18 at 3:50 p.m., LN 1 was asked to review the medical records and to verify that she evaluated and documented Resident's 1 left toe wound condition. LN 1 confirmed that she failed to document the condition of Resident's 1 wound on his left toe. LN 1 stated she did not communicate with physician or nurse practitioner addressing the condition of Resident's 1 left toe. During an interview with the ADON, on 2/1/18 at 4 p.m., the ADON stated that when nurses perform the skin assessment, they should document all existing skin issues, including a description of any present wounds, and identify if there were new skin issues. During an interview with Resident 1's Facility Medical Doctor (MD) on 2/2/18 at 10:30 a.m., the MD stated he assessed Resident's 1 wounds, including left toes every few weeks. The MD could not recall if nurses ever communicated with him regarding the deterioration of Resident 1's toes and was unable to find notification notes where nurses addressed Resident 1's wounds or the worsening condition of the left toes. MD stated he was unaware that Resident's 1 toes became infected and gangrenous. (Gangrene is the localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection.) The MD stated he would definitely expect nurses to report the condition of Resident 1's left toe wound, especially when it got infected and changed color, and he stated he was not notified. During an interview with the Dermatologist's Office Manager on 2/2/18 at 9 a.m., she stated there was no record of any communication from the facility to the doctor after (MONTH) 18, (YEAR). Review of the hospital discharge summary indicated that on 11/26/17 Resident 1 was transferred to the hospital with a [DIAGNOSES REDACTED]. Review of the Emergency Department (ED) physician's notes for Resident 1 dated 11/26/17 revealed, Significant for diffuse denuded (hairless, indicating poor circulation) skin below the knees bilaterally .the toes, there is some area of necrosis . L (left) hallux (area of the foot) has large gash in between the 1st and 2nd toe .worrisome for bone involvement. Review of the hospital consultant podiatrist (foot doctor) notes dated 11/28/17, the podiatrist recorded, Bilateral lower extremity ulcerations and infection .there are obvious gangrenous changes (potentially life-threatening condition from death and decomposition of tissue, resulting in black appearance and odor) to the toes on the left foot. Review of a Case Management Forms document dated 11/28/17, indicated the hospital admitting nurse made a report to Adult Protective Services due to concerns of abuse/neglect due to reports of wound dressing were green and skin was growing on top of dressing. An interview with the Wound Care Nurse (WCN), who was assessing Resident's 1 wounds at the hospital was conducted on 12/7/17 at 1:32 p.m. The WCN described the 2nd toe on his left foot as being black, very wet looking, smelly, and when the other nurse touched the toe, the wound opened half-way and the toe almost fell off .it looked horrible.

Based on interview and record review, the facility failed to ensure the drug regimen of one of three sampled residents (Resident 1), was free of unnecessary drugs. Resident 1, a diabetic on [MEDICAL TREATMENT] (a process in which a machine filters waste products from the blood when the kidneys are not working), was prescribed and administered [MEDICATION NAME], a medication contraindicated in "diabetics with significant renal impairment (kidney disease)." This failed practice resulted in Resident 1's transfer to a higher level of care, a hospital Emergency Department (ED), where she required urgent medication, intravenous fluid resuscitation, placement on a ventilator (breathing machine), emergency [MEDICAL TREATMENT] and intensive care unit admission to survive. Findings: Resident 1 was a [AGE] year-old diabetic [MEDICAL TREATMENT] patient admitted to the SNF (skilled nursing facility) 6/8/13 after a recent general acute care hospital stay (GACH). Her [DIAGNOSES REDACTED]. She was receiving several medications for her cardiovascular diagnoses. Review of Resident 1's 6/6/13 GACH laboratory report indicated that prior to entering the SNF, her last creatinine level (a laboratory test which estimates how well the kidneys are filtering waste) was elevated at 4.95 milligrams/deciliter (mg/dl, a unit of measurement, with normal range 0.6 - 1.1 mg/dl for women)(http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm). Review of Resident 1's SNF record indicated that on 6/22/13 at 2 p.m., Licensed Vocational Nurse 1 (LVN1) contacted the physician on call (POC) for Resident 1's doctor because laboratory results from 5:50 a.m. on 6/19/13 showed the resident's blood sugars were high (ranging from 186-358; preferred pre-meal blood sugar levels for Type 2 diabetic adults ranges from 70-130 milligrams/deciliter (mg/dl, a unit of measurement) (http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/ 6.htm)). The physician ordered [MEDICATION NAME], 500 milligrams twice daily to help control the amount of sugar in Resident 1's blood. According to July, 2013 "Physician order [REDACTED]. July, 2013 "Medication Administration Records" show Resident 1 received a total of 22 doses of [MEDICATION NAME] while in the facility, from 6/22/13 at 5 p.m. to her last dose at 5 p.m., 7/7/13. Review of the 5 a.m., 7/8/13 "Change of Condition SBAR (Situation/Background/Assessment/Recommendation) - Mental Status Change" form indicated Resident 1 was found to have had a change in level of consciousness and rapid breathing at 5 a.m., 7/8/13. She could open her eyes but was otherwise unable to respond to staff. Her physician ordered her transported by ambulance to the ED for evaluation. The GACH ED summary indicated that upon arrival, Resident 1's blood pressure was low at 85/38 (her baseline on SNF admission was 134/90 millimeters of mercury (mm/Hg, a unit of measurement) with normal range defined as less than 120 over less than 80 mm/Hg (http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Understanding-Blood-Pressure-Readings_UCM_ 4_Article.jsp)), her blood sugar was 56 (abnormally low blood sugar is generally defined as less than 70 mg/dl (http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/[DIAGNOSES REDACTED]-low-blood.html)) and her creatinine was 10.29 mg/dl. According to ED physician notes, 50 per cent [MEDICATION NAME] (a highly-concentrated sugar given intravenously) was administered with "no improvement in mental status." Both the 10:21 a.m., 7/8/13 GACH physician's "History and Physical" & the GACH nephrologist's (kidney specialist's) consultation, dictated at 9:32 a.m. on 7/8/13, the day of admission, cited the medication [MEDICATION NAME]'s negative effect on Resident 1. The admitting physician wrote, "Assessment: 1. Severe metabolic acidosis (a condition in which the body produces too much acid or when the kidneys are not removing enough acid from the body) with lactic acidosis (accumulation of lactic acid in the bloodstream). The likely culprit is [MEDICATION NAME], given the patient's history of [MEDICAL CONDITION] discontinue the patient's [MEDICATION NAME] since this is the main cause of the patient's lactic acidosis...Patient is in very critical condition...If she is not able to be dialyzed given her low blood pressure, then she has a very poor prognosis and likely will not survive this hospitalization ." Resident 1's nephrologist wrote, "The patient will need emergency [MEDICAL TREATMENT] for [MEDICAL CONDITION] and severe lactic acidosis. Hopefully, the patient will be able to tolerate the treatment. I have discussed this with the son, the risk of the [MEDICAL TREATMENT] procedure, but this is her only chance to survive...Lactic acidosis. This is [MEDICATION NAME]-induced...will dialyze the patient daily until the patient's clinical status stabilizes or improves...." During an 8/7/13 telephone interview at 11:46 a.m., Resident 1's nephrologist Medical Doctor 1 (MD1) stated [MEDICATION NAME] was "a contraindication" in [MEDICAL TREATMENT] patients and "absolutely (could) not" be safely used with end-stage kidney failure patients. When asked how much of Resident 1's lactic acidosis could be attributed to her receipt of [MEDICATION NAME], he estimated "more than 50%." He stated she required [MEDICAL TREATMENT] "several days in a row" to remove it from her system. The United States Food and Drug Administration (FDA) Drug Safety Communications program requires drug manufacturers to include warnings in package inserts "to identify and describe a discrete set of adverse reactions and other potential safety hazards that are serious or are otherwise clinically significant because they have implications for prescribing decisions or patient management." (http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm 6.pdf) A "boxed warning" is the strongest warnings the FDA requires and is placed in a prominently-displayed box on package inserts. According to the American Society of Consultant Pharmacists, "This warning is reserved for prescription drugs that pose a significant risk of serious or life-threatening adverse effects, based on medical studies." (https://www.ascp.com/articles/black-box-warning-resources) The FDA states boxed warnings are required on medication packaging when there is a potential for "an adverse reaction so serious in proportion to the potential benefit from the drug (e.g., a fatal, life-threatening or permanently disabling adverse reaction) that it is essential that it be considered in assessing the risks and benefits of using the drug or there is a serious adverse reaction that can be prevented or reduced in frequency or severity by appropriate use of the drug (e.g., patient selection, careful monitoring ...avoiding use in a specific clinical situation)." (http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm 6.pdf) [MEDICATION NAME] package inserts include a boxed warning regarding the potential development of lactic acidosis in with renal impairment. In addition, inserts contain information indicating use of [MEDICATION NAME] is contraindicated in patients with [MEDICAL CONDITION]. Drug [MEDICATION NAME] USA 7/12 [MEDICATION NAME] package insert contained the following boxed warning: "WARNINGS Lactic Acidosis: Lactic acidosis is a rare, but serious, metabolic complication that can occur due to [MEDICATION NAME] accumulation during treatment with [MEDICATION NAME] tablets; when it occurs, it is fatal in approximately 50% of cases. Lactic acidosis may also occur in association with a number of pathophysiologic conditions, including diabetes mellitus...Lactic acidosis is characterized by elevated blood [MEDICATION NAME] levels (greater than 5 millimoles/liter (mm/L, a unit of measurement)), decreased blood pH (amount of acidity in the blood with normal range 7.38 - 7.42 (http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm)), electrolyte disturbances...(Resident 1's ED [MEDICATION NAME] level was 20.3 mm/L, ph was critically low at 6.84, and the electrolyte potassium was critically high at 8.2 milliequivalents/liter (meq/L, a unit of measurement), above that expected in [MEDICAL CONDITION])... Reported cases have occurred primarily in diabetic patients with significant [MEDICAL CONDITION] (poor kidney function)...The risk of lactic acidosis increases with the degree of renal dysfunction and the patient's age...In particular, treatment of [REDACTED]. Lactic acidosis is a medical emergency that must be treated in a hospital setting. In a patient with lactic acidosis who is taking [MEDICATION NAME] tablets, the drug should be discontinued immediately and general supportive measures promptly instituted...Prompt [MEDICAL TREATMENT] is recommended to correct the acidosis and remove the accumulated [MEDICATION NAME] also CONTRAINDICATIONS and PRECAUTIONS... CONTRAINDICATIONS [MEDICATION NAME] tablets are contraindicated in patients with: 1. [MEDICAL CONDITION] or renal dysfunction (e.g., as suggested by serum creatinine levels ...greater than or equal to 1.4 mg/dl in females)..." PRECAUTIONS... Monitoring of renal function-[MEDICATION NAME] is known to be substantially excreted by the kidney, and the risk of [MEDICATION NAME] accumulation and lactic acidosis increases with the degree of impairment of renal function. Thus, patients with serum creatinine levels above the upper limit of normal for their age should not receive [MEDICATION NAME] tablets...." (http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=3286eb86-9650-44b3-8353-847b4c 4) During a 7/23/13 interview at 4:20 p.m., the Director of Nursing (DON) accessed the facility's online drug reference. She stated the reference listed "[MEDICAL CONDITION]" as a "contraindication" for the use of [MEDICATION NAME]. During a 7/24/13 telephone interview at 12:03 p.m., the POC stated, "I'd have ordered insulin or something else" had he realized Resident 1 was receiving [MEDICAL TREATMENT]. During a 7/24/13 telephone interview at 2:36 p.m., the reordering physician stated he was uncertain why the POC chose to order [MEDICATION NAME] and added, "There were probably better things to be used."

F327 - Sufficient Fluid To Maintain Hydration 483.25(j) The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. The following citation was written as a result of an unannounced visit on 9/13/10 for the investigation of complaint number CA 974. The Department determined the facility failed to ensure sufficient fluids were provided to Resident A to maintain hydration. This failure resulted in Resident A developing an altered mental status which required transfer to the General Acute Care Hospital (GACH). Resident A was admitted to the GACH with profound dehydration and acute renal (kidney) failure (dehydration can cause [MEDICAL CONDITION]). Resident A was an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS - standardized assessment tool), dated 3/23/10, indicated Resident A had moderately impaired cognition. She was dependent on staff for eating and drinking. Resident A would leave 25% or more of her food uneaten at most meals. A care plan entry, dated 3/23/10, revealed Resident A was at high risk for dehydration related to her impaired cognition. The care plan interventions included fluids at bedside, remind and assist to consume fluids, monitor intake, report poor meal and or fluid consumption, and observe for signs and symptoms of dehydration which included lethargy (fatigue), thirst, dry mucus membranes, dry and cracked lips and poor skin turgor (when the skin is pinched it remains in a tented position). A Nursing Admission Assessment, dated 3/23/10, indicated Resident A's skin turgor was "good." She needed assistance to eat and her fluid intake was "fair." Resident A weighed 150.6 pounds when she was admitted . The Admission History and Physical from the GACH, dated 3/17/10, identified Resident A's baseline laboratory values for kidney function were: BUN (Blood Urea Nitrogen) 29 (normal 8 - 22) and Creatinine 0.99 (normal 0.35 - 1.18). Resident A's Intake and Output Record, dated 3/23/10 through 3/28/10, indicated she averaged 1028 cubic centimeters (ccs) of fluid every 24 hours and there were no signs or symptoms of dehydration. The section of the form for the residents' estimated fluid needs and minimum fluid requirements was not completed. On 3/29/10 Resident A was evaluated by the Speech Therapist (ST). The ST documented Resident A was alert with poor intake and she required feeding assistance. Nurse Assistant Care Records, dated 3/23/10 through 3/31/10, recorded Resident A's food consumption as follows: Breakfast: Refused on 7 of 8 opportunities and 15% on 3/29/10. Lunch: Refused on 3 of 8 opportunities and averaged 28% on 5 of 8 opportunities. Dinner: Averaged 40.5% on 9 of 9 opportunities. Nurse Assistant Care Records, dated 4/1/10 through 4/10/10, indicted Resident A's food consumption as follows: Breakfast: Refused 8 of 11 opportunities and averaged 28.3% on 3 of 11 opportunities. Lunch: Refused 3 of 11 opportunities and averaged 26.4% on 7 of 11 opportunities. Dinner: Refused 1 of 10 opportunities and averaged 31.6% on 9 of 10 opportunities. Laboratory Studies, completed on 4/2/10, indicated Resident A's BUN was 19 (normal 8 - 22) and Creatinine was 0.94 (normal 0.35 - 1.18). Resident A's Intake and Output Records, dated 3/29/10 through 4/4/10, indicated she averaged 897 ccs of fluid every 24 hours. The estimated fluid needs section of the form indicated Resident A's minimum fluid requirements were 1600 ccs per 24 hours. A Notice of Reduced Fluid Intake form was faxed to Resident A's physician on 4/4/10. Documentation indicated Resident A's intake was poor and she showed no signs of dehydration. The physician signed that he had reviewed the information on 4/21/10, 10 days after Resident A was discharged to the GACH with dehydration. An interview was conducted with Licensed Nurse (LN) 1 on 9/13/10 at 1 p.m. LN 1 stated she faxed the information on the Reduced Fluid Intake form to Resident A's physician on 4/4/10. LN 1 acknowledged the physician did not respond to the faxed information until 10 days after Resident A was discharged and the facility did not follow up to ensure he was aware of Resident A's decreased fluid intake. On 4/6/10, the ST documented Resident A was not opening her mouth to accept food or drink. On 4/7/10, the ST documented Resident A was non-responsive to verbal or tactile (touch) stimulation and she would not accept food or drink during the morning meal. On 4/6/10 the Registered Dietician (RD) documented Resident A had a significant weight loss of 7 pounds and she consumed less than 1000 ccs of fluid per day. Her food intake was less than 50% at each meal. The estimated caloric, protein, and fluid needs section of the form was blank. The RD documented Resident A was at high nutritional risk as evidenced by weight loss, difficulty swallowing, and dementia. The RD recommended puddings, Jell-O, ice cream, and 4 ounces of health shake three times a day. An interview was conducted with the RD on 9/13/10 at 12:40 p.m. She acknowledged she had not calculated Resident A's fluid requirements. She stated whatever Resident A's fluid requirements were she wasn't meeting them. A physician's orders [REDACTED]. Resident A's Fluid Intake and Output Record, dated 4/5/10 through 4/11/10, indicated Resident A averaged 554 ccs of fluid intake daily. Resident A's clinical record indicated her minimum fluid requirement was 1600 ccs per day. There was no documented evidence Resident A's physician was notified of her reduced fluid intake. Nurse's Notes, dated 4/10/10 at 11 p.m., documented Resident A was "weak looking" and fluid intake was encouraged. "Unable to consume health shake 2 boxes" and "refused to eat and drink." "Unable to take medications also..." A Change of Condition - Unplanned Weight Loss notification, dated 4/5/10, was sent to the physician. The notification indicated Resident A weighed 143.5 pounds. A notification, dated 4/11/10, indicated Resident A weighed 137.7 pounds, a loss of 13 pounds between admission on 3/23/10 and transfer to the GACH on 4/11/13. There was no documented evidence the physician received or responded to the notifications. Nurse's Notes, dated 4/11/10 at 6 a.m., documented Resident A slept through the night and was "Awake/alert (at) times, though unable to answer verbally." There was no further documentation regarding Resident A's condition until approximately 11 hours later on 4/11/10 at 4:45 p.m. which indicated Resident A was refusing to eat and would not open her mouth. She was "lethargic." Resident A's family member was notified and she was asked if the facility could send Resident A to the hospital. Resident A was discharged to the emergency room for evaluation on 4/11/10 at 5 p.m. A History and Physical (H&P) was completed by the hospitalist at the GACH on 4/11/10. The hospitalist documented that three weeks previously Resident A had been discharged from the GACH "in good shape, communicative, and with normal laboratories. She comes back now 3 weeks later with profoundly altered mental status." Information in the H&P indicated upon examination Resident A's mouth and throat were extremely dry. Her [DIAGNOSES REDACTED]. A Consultation Report was completed by Resident A's admitting physician on 4/11/10. He indicated since Resident A was not eating and not taking her medications, it "may explain her blood pressure being out of control and her severe dehydration." He further indicated, "There is absolutely no turgor in the upper or lower extremities, chest wall..." He also indicated she had been "eating almost nothing for 3 weeks...interval severe deterioration in her electrolytes (sodium and calcium)... BUN is well over 100, her creatinine is less than 3, suggesting a severe prerenal (acute [MEDICAL CONDITION])...The acute findings are of hypertension (high blood pressure), severe dehydration, a prerenal state, hypercalcemia (increased calcium) and [MEDICAL CONDITION] (increased sodium)..." Resident A's laboratory values when she arrived at the GACH on 4/11/10 were: Sodium level 160 (normal 136-143) Blood Urea Nitrogen (BUN) 111 (normal 8-22) Creatinine 2.12 (normal 0.35-1.18) Calcium 13.9 (normal 8.4 - 10.5) Common causes of elevated sodium ([MEDICAL CONDITION]) include: Inadequate intake of water, typically in the elderly...who are unable to take in water... This is the most common cause of [MEDICAL CONDITION]. Reference: Answers.com. A greatly elevated BUN (>60) generally indicates a moderate to severe degree of [MEDICAL CONDITION]. Impaired renal excretion of urea may be due to temporary conditions such as dehydration... Reference: LabTest On Line. The facility's Hydration Policy and Procedure, dated 9/08, included, in part: Policy: Residents at risk for dehydration will be identified, assessed, and provided with sufficient fluid intake to maintain proper hydration and health to the extent medically possible. Risk factors for dehydration will be identified through continual nursing assessment to assure that each resident receives sufficient amounts of fluids based on individual need to prevent dehydration and maintain health. Procedure: 1. Calculations of fluid needs are generally based on the following estimates: Residents without renal or cardiac distress 30 milliliters (ml)/kilogram (kg) body weight (2.2 pounds = 1 kilogram). (On admission Resident A weighed 150 pounds or 68 kilograms. With the above formula, Resident A's estimated fluid needs would have been 2040 mls per 24 hours. 1 ml = 1 cc) 2. Residents are assessed for hydration status by the Licensed Nurse using common clinical indicators of proper hydration. Rick factors included, dementia and refusal of fluids. b. Clinical signs of possible insufficient fluid intake are assessed through continual nursing assessment and (RAP) protocol for dehydration. Dry skin and mucous membranes and significant weight loss. 3. Residents with poor hydration status or at risk for dehydration will be identified and dietary notified. Resident A remained hospitalized at the GACH from 4/11/10 through 4/18/10. The Department determined the facility failed to ensure sufficient fluids were provided to Resident A to maintain hydration. These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom.