Every finding on record at Crystal Ridge Care Center

Based on observations, interviews and record review, the facility failed to ensure services provided met professional standards of quality for six (6) out of 27 sampled residents (Resident 105, Resident 23, Resident 56, Resident 47, Resident 5 and Resident 28 when:1. Foam heel pads to float (the practice of putting a pillow or pressure relieving device below the legs of a resident to prevent the heels from touching the bed) Resident 105's heels were not applied as ordered by the physician;2. Physician orders were not followed for the use of a low air loss mattress (LAL, a specialized medical support surface designed to keep patients comfortable while protecting their skin from breakdown) for Resident 23;3. The physician's physical therapy (PT) referral order was not carried out in a timely manner for Resident 56;4. Medications were not administered as scheduled for Resident 5;5. Physician orders were not followed for Resident 47 and Resident 28; and6. Schedule for breathing treatment was not followed as ordered for Resident 28These failures had the potential to place Resident 105 at increased risk for pressure ulcer development (injuries to the skin and underlying tissue); place Resident 23 at risk for pain and discomfort; cause increased emotional distress and immobility related complications for Resident 56; leave Resident 47 on an altered diet without a timely, documented assessment to verify swallowing safety; and result in medications not being administered according to the prescriber's orders, with potential impact on Residents 5, 28, and 48's clinical conditions. Findings: 1. Resident 105 was admitted to the facility in June of 2026 with diagnoses that included a fracture of the right femur (biggest bone in the upper leg) and muscle weakness. A review of Resident 105's Minimum Data Set (MDS, a standardized assessment tool used in skilled nursing facilities) section GG (MDS section that assesses a resident's functional abilities), dated 7/5/26, indicated Resident 105 required maximal assistance from staff to reposition himself in bed. A review of Resident 105's MDS section M (MDS section that assess a resident's skin), dated 6/27/26, indicated Resident 105 was at risk for developing pressure ulcers. A review of Resident 105's document titled, Order Details, dated 6/17/26, indicated, TX [treatment]: Heel protectors [Foam heel pads] while in bed every shift. A review of Resident 105's document titled, Order Details, dated 6/17/26, indicated, TX [treatment]: Float heels while in bed every shift. During an observation on 7/13/26 at 9:07 a.m., Resident 105 was observed sleeping in his bed face up. Resident 105 did not have heel pads on and did not have his heels offloaded to relieve pressure. During an observation on 7/13/26 at 10:48 a.m., Resident 105 was again observed sleeping in his bed without his heel pads on or with his heels floated. During an observation on 7/14/26 at 8:17 a.m., Resident 105 was observed sitting up in bed eating his breakfast. Resident 105 did not have his heel pads on or have his heel floated. During an observation on 7/15/26 at 7:50 a.m., Resident 105 was observed lying in bed without his heel pads on or his heels floated. During a concurrent observation and interview on 7/15/26 at 9:14 a.m. with Licensed Nurse 2 (LN 2), Resident 105 was observed to be sleeping in bed without his heel pads on or his heels floated. LN 2 verbally confirmed the observations. During an interview on 7/15/26 at 10:15 a.m. with the Treatment Nurse (TN), the TN confirmed that Resident 105 had orders to wear his heel pads and float his heels while in bed. The TN indicated that these orders were to prevent the development of pressure ulcers and that staff should be implementing them as ordered. During a concurrent observation and interview on 7/16/26 at 9:04 a.m. with Certified Nursing Assistant 1 (CNA 1), Resident 105 was observed sleeping in his bed without his heel pads on or his heel floated. CNA 1 verbally confirmed the observations. During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Ulcers/Injuries, revised 10/25, the P&P indicated, Provide support devices and assistance as needed. 2. Resident 23 was admitted to the facility in mid-2026 with diagnoses that included anal cancer and cancer related pain. During a review of Resident 23's Order Summary Report [OSR], dated 6/29/26, the OSR indicated, Mattress: Low Air Loss. During a review of Resident 23's Progress Notes [PN], dated 6/29/26, the PN indicated Resident had a cancer wound and required additional care, Mattress with pump. During a review of Resident 23's Care Plan Report [CP], dated 6/30/26, the CP indicated, Resident [23] has impaired skin integrity present on admission as evidenced by cancer wound sacrococcyx extended to perineum [wound began at the tailbone area and extended to the area of skin between the genitals and the anus].Goal: to prevent of delay deterioration of skin integrity to the extent possible.Interventions: Low air loss mattress. During an observation on 7/13/26 at 10:10 a.m., Resident 23 was lying in bed and stated he had a sore on his bottom from a cancerous tumor. Resident 23 did not have a low air loss mattress on his bed. During a concurrent observation and interview on 7/13/26 at 11:25 a.m., with the Director of Nursing (DON) in Resident 23's room, the DON confirmed that Resident 23 did not have a low air loss mattress. During a concurrent observation and interview on 7/13/26 at 2:43 p.m., with the Director of Environmental Services (DES), the DES stated the facility had five low air loss mattresses available for use. The DES confirmed Resident 23 did not have a low air loss mattress and stated the physician order should have been communicated to her. During an interview on 7/14/26 at 10:27 a.m., with the treatment nurse (TN, nurse responsible for wound care in the facility), the TN stated that LAL were used to promote wound healing and prevent further skin breakdown. During an interview on 7/16/26 at 11:08 a.m., with the DON, the DON acknowledged that staff did not place a low air loss mattress on Resident 23 as ordered on 6/29/26, calling it an oversight. The DON stated that she expected staff to follow physician orders. 3. Resident 56 was admitted to the facility on Fall of 2024 with diagnoses which included cirrhosis of the liver [an advanced scarring of the liver caused by chronic diseases] and difficulty in walking. A review of Resident 56's MDS, section GG, dated 5/9/26, indicated Resident 56 has an impairment of one leg and used a wheelchair. A review of Resident 56's document titled, Order Summary Report (ORS), dated 1/23/26, indicated, Resident has capacity to make his decisions.capable of understanding rights, responsibilities, and informed consent. A review of Resident 56's document titled, Progress Notes (PN), dated 1/6/26, indicated, The patient was admitted to hospital for an elective right total hip arthroplasty [surgical reconstruction or replacement of a joint to relieve pain and restore mobility] which was performed on August 1, 2025, to address severe right hip osteoarthritis [a degenerative joint disease]. A review of Resident 56's document titled, ORS, dated 6/24/26, indicated, TRANSPORTATION NEEDED FOR [Resident 56], 6/25/26 BRACE PICKUP . A review for Resident 56's referral request document referral dated, 7/1/26, indicated, PHYSICAL THERAPY.[Hospital's Name].Reason for Request: Veteran is referred for (required): Functional deficits or decline in mobility.Pt. [Patient] requesting for right knee brace. Pt. was seen by PCP [Primary Care Physician] in March 17, 2026 and noted right knee replacement.Patient is requesting treatment to makeit [sic] possible to extend knee so that he can stand and ambulate. During a concurrent observation and interview with Resident 56 on 7/13/26 at 8:33 a.m. inside the resident's room, while sitting on the side of the bed, Resident 56 stated, PT won't touch my brace because they wanted some order from [hospital's name]. Resident 56 stated that the order for PT to apply his brace was missing and that PT needed that order to apply the brace. Resident 56 added that (hospital's name) had sent the required document to [facility's name] on 7/1/26 and that it was received and confirmed by (staff name). Resident 56 further stated that he needed the brace to walk safely, and without the brace, he remained confined to his wheelchair. During an interview with the Business Office Assistant (BOA) on 7/15/26 at 12:06 p.m., the BOA confirmed that she had received a faxed document from (hospital's name) and had handed the documents to the physical therapy department on or around 7/1/26. During a concurrent records review and interview with the Medical Director (MD) on 7/15/26 at 1:25 p.m., the MD stated that he was not aware of any referral from (hospital's name) and that it was his first time seeing the referral document dated 7/1/26 presented by the Department. The MD further stated, The process was, all the orders have to come to me and I write it for the facility, but I did not know of this order, and it should have been relayed to me so it could have been started early. The MD added that Resident 56 wanted to walk and needed the brace for stability. During an interview with the Physical Therapy Director (PTD) on 7/15/26 at 1:47 p.m., contrary to the statements provided by the BOA on 7/15/26 at 12:06 p.m., the PTD stated, I just got it [referral] yesterday [7/14/26] from [BOA's name]. Had we gotten this earlier, we could've started the eval [evaluation] early. During an interview with the Director of Nursing (DON) on 7/16/26 at 9:58 a.m., the DON confirmed the findings and stated that it was important for staff to process and initiate any physician orders timely, including referrals for evaluations. The DON further stated that it was important to assess residents timely and accurately so the facility could provide the care each resident needed. She added that it was important for staff to document any care provided to residents in their medical records. The DON further stated that when an order was not completed in a timely manner, it could result in complications and possible hospitalization if the order was urgent. A review of the facility's policy and procedures (P&P) titled, Physicians Odes, reviewed 10/25, The P&P indicated, The licensed staff shall carry out physicians/nurse practitioners orders. A review of the facility's P&P titled, Resident Assessments, revised 12/2025, the P&P indicated, Assessment are completed by staff members who are knowledgeable about the resident's needs. 4. During a review of Resident 5's admission records, the records indicated Resident 5 was admitted to the facility in March 2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 5's Medication Admin Audit Report, the following medications were scheduled at 8 a.m. and were administered at 10:37 a.m. on 7/15/26: - Empagliflozin (used to lower blood sugar) 25 mg (milligrams, a unit of measurement) by mouth in the morning for DM - Metformin (helps keep blood sugars in a normal range) 1000 mg by mouth two times a day for DM - Hydroxyzine (used to relieve anxiety and tension) 25 mg by mouth every 8 hours for anxiety - Cyclobenzaprine (muscle relaxant) 5 mg by mouth every 8 hours for muscle spasms During an interview on 7/15/26 at 11:07 a.m. with Licensed Nurse 1 (LN 1), LN 1 confirmed Resident 5's Empagliflozin, Metformin, Hydroxyzine, and Cyclobenzaprine were scheduled at 8 a.m. but was administered at 10:37 a.m. LN 2 stated medication administration was supposed to be one hour before and one hour after the scheduled time. LN 1 further stated the expectation for staff was to follow physician order and schedule. During a concurrent interview and record review on 7/16/26 at 8:58 a.m. with the Director of Nursing (DON), the DON confirmed Resident 5's Empagliflozin, Metformin, Hydroxyzine, and Cyclobenzaprine were scheduled at 8 a.m. but was administered at 10:37 a.m. on 7/15/26. The DON stated the expectation was for medications to be given an hour before and an hour after the scheduled time. During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated 12/2025, the P&P indicated, .3. Medications are administered within one (1) hour before and (1) hour after the prescribed time, unless otherwise specified. 5. A review of Resident 47's physician order, dated 1/23/26, indicated an order for Levetiracetam (used to treat seizures) 1500mg by mouth two times a day for seizure prevention. The order further indicated, .Wear gloves for med administration. During a medication administration observation on 7/14/26 at 8:35 a.m. with LN 4, LN 4 was observed preparing medications for Resident 47 including Levetiracetam 750mg 2 tablets. LN 4 administered the medications without wearing gloves during the preparation and the administration of the medications. A review of Resident 28's physician order, dated 1/22/26, indicated an order for Divalproex Sodium (used for seizures and bipolar disorder) Delayed Release capsule (allows contents of capsules to remain intact through the stomach) 125mg by mouth two times a day. The order further indicated, .wear gloves for med administration. During a medication administration observation on 7/14/26 at 8:47 a.m. with LN 4, LN 4 was observed preparing medications for Resident 28 including Divalproex Sodium 125mg 1 capsule. LN 4 prepared and administered the medication to the resident without wearing gloves. During an interview on 7/14/26 at 12:48 p.m. with LN 4, LN 4 confirmed that gloves were not worn during the administration of Resident 47's Levetiracetam and Resident 28's Divalproex Sodium contrary to the physician orders. LN 4 stated the expectation was for staff to follow physician orders. During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated 12/2025, the P&P indicated, .Medications are administered in a safe and timely manner, and as prescribed.15. Certain medications require special precautions when being handled where gloves are necessary, when the hands are in direct contact with the medications or when medications enteric coating is broken. 6. During a medication administration observation on 7/14/26 at 9:05 a.m. with LN 4, LN 4 was observed administering Ipratropium Bromide (used to treat chronic obstructive pulmonary disease [COPD-a chronic lung disease causing difficulty in breathing]) 0.02% one vial via nebulizer to Resident 28 per Resident 28's request. A review of Resident 28's Medication Administration Audit Report, the report indicated Resident 28 had an order for Ipratropium Bromide inhalation 0.02% one vial to inhale orally via nebulizer every six hours for COPD. The report further indicated Resident 28's Ipratropium Bromide was scheduled at 5 a.m. and was administered at 5:07 a.m. on 7/14/26. The report further indicated Resident 28's Ipratropium Bromide was scheduled to be given next at 11 a.m. but was documented as administered at 10:02 a.m. on 7/14/26 contrary to the medication administration observation at 9:05 a.m. on 7/14/26. During an interview on 7/14/26 at 12:48 p.m. with LN 4, LN 4 confirmed that the breathing treatment was administered to Resident 28 during the medication administration observation at 9:05 a.m., not 10:02 a.m. LN 4 further confirmed that Resident 28's Ipratropium Bromide was not due to be given, and the physician order was every 6 hours and not as needed. LN 3 stated medications should be given as ordered and as scheduled. During a concurrent interview on 7/16/26 at 8:58 a.m. with the DON, the DON stated staff were expected to follow the physician order and schedule because medications were given for certain reasons. During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated 12/2025, the P&P indicated, .2. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rates remained below 5% when three medication errors were identified out of 32 opportunities, resulting in a medication error rate of 9.38% for a census of 94. This failure resulted in Resident 60 and Resident 64 not receiving medications as ordered by their physician. Findings:1a. During a medication administration observation on 7/14/26 at 9:29 a.m. with Licensed Nurse 5 (LN 5), LN 5 administered medications for Resident 60 including a medication containing Guaifenesin (medication used to treat chest congestion) 600mg (milligrams, a unit of measurement) with Dextromethorphan (cough suppressant) 30 mg.During a review of Resident 60's physician orders, dated 7/14/26, the physician orders included Guaifenesin ER (extended release - dissolve slowly and release its active ingredients gradually over a prolonged period) 600 mg tablet by mouth two times a day as opposed to Guaifenesin Dextromethorphan that was administered to Resident 60 in the morning. During an interview on 7/14/26 at 12:31 p.m. with LN 5, LN 5 confirmed Resident 60's physician order indicated Guaifenesin ER and the medication administered to Resident 60 was Guaifenesin combined with Dextromethorphan. LN 5 stated the order should have been clarified with physician to know if the physician wanted the medication to include Dextromethorphan.1b. During a review of Resident 64's physician order, dated 1/24/26, the order indicated, Gabapentin [medication used to treat nerve pain] Oral Tablet 100 mg.Give 1 tablet by mouth two times a day for nerve pain. The order further specified gabapentin 100mg was to administer at 8 a.m.During a review of Resident 64's physician order, dated 7/14/26, the order indicated Zinc [nutrient that helps with immune system function and wound healing] Oral Tablet.Give 34 mg by mouth one time a day.During a medication pass observation on 7/14/26 starting at 9:39 a.m. with LN 5, LN 5 was observed preparing medications for Resident 64 and stated Zinc 34 mg was not available either in the medication cart or in the medication storage room. LN 5 administered 1 tablet of gabapentin 100mg to Resident 64 together with the other medications. During an interview on 7/14/26 at 12:31 p.m. with LN 5, LN 5 confirmed Resident 64's gabapentin dose was scheduled at 8 a.m. and acknowledged that the dose was administered more than an hour after the scheduled time. LN 5 stated that if medications were scheduled at 8 a.m., the medication should be given an hour before or an hour after the schedule. LN 5 also confirmed that Resident 64's Zinc 34 mg was not given because it was not available. and stated that if there were any issues with medication doses, it should have been clarified with the physician.During an interview on 7/16/26 at 8:58 a.m. with the Director of Nursing (DON), the DON stated medications should be given an hour before and an hour after the scheduled time and the expectation was for staff to follow physician order and administration schedule because medications were given for certain reasons. The DON further stated that the expectation was for staff to notify and clarify with physician if there are issues with dosage and availability of medications.During a review of the facility's policy and procedure (P&P) titled Administering Medications, dated 12/2025, the P&P indicated, .2. Medications are administered in accordance with prescriber orders, including any required time frame.3. Medications are administered within one (1) hour before and (1) hour after the prescribed time, unless otherwise specified.During a review of the facility's P&P titled Pharmacy Services, dated 10/2025, the P&P indicated, .D. The pharmacy provider agrees to perform the following pharmaceutical services, including:.2). Accurately dispensing prescriptions based on authorized prescriber orders.6) Providing routine and timely pharmacy service seven days per week.c. All other new medication shall be available on the same day ordered unless the drug normally be started until the next day.

Based on observation and interview, the facility failed to store food in accordance with professional standards of food safety for 94 residents eating facility prepared food, when several food items were not dated, and a food item was not disposed of once past the use-by date.These failures present a potential risk of foodborne illnesses for residents eating facility prepared meals.Findings:During the initial kitchen tour on 7/13/26 at 8:03 a.m., with the Kitchen Supervisor (KS) for confirmation, the following prepared or opened items were not dated in the reach-in refrigerator: one container of prepared thickened juice, one container of thickened dairy, and one container of thickened cranberry concentrate. The following items were not dated in the walk-in refrigerator: a tray of seven cups of diced fruit, a box of raw tomatoes, and a tray of 16 cups that contained juice, milk, water, and lemonade. Additionally, a container of prepared cream of chicken soup was found past its use-by date of 6/29/26 in the reach-in refrigerator. During an interview on 7/15/26 at 10:02 a.m. with the Registered Dietitian (RD), the RD indicated that she expected staff to date opened containers and prepared food and to toss any foods past their use-by date.During a review of the facility policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2023, indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.Newly opened food items will need to be closed and labeled with an open date.All prepared foods need to be covered, labeled, and dated.Produce is to be dated with received date.

Based on interview and record review, the facility failed to ensure medical records were accurate and consistent for three of 27 sampled residents (Resident 24, Resident 84, and Resident 90) when the residents' Controlled Drug Records (CDR - a log used to track the receipt, storage, dispensing, administration, and disposal of high-risk medications) were not reconciled accurately with the Medication Administration Records (MAR - a record that tracks medications given, including dosage, time, route, and who administer it). This failure resulted in the facility not having accurate accountability of controlled medications (drugs that carry a risk of misuse, abuse, and dependence) and the potential for abuse or misuse of these medications for a census of 94.Findings:A review of Resident 24's physician order, dated 5/25/26, indicated Resident 24 had an order for Hydrocodone-Acetaminophen (used to relieve severe pain) 10-325 mg (milligrams, a unit of measurement) one tablet by mouth every four hours as needed for pain. Resident 24's CDR indicated Resident 28's hydrocodone-acetaminophen was administered on 6/19/26 at 8 a.m., 7/1/26 at 9 a.m., and 7/8/26 at 9:40 a.m., but Resident 24's MARs for June 2026 and July 2026 did not indicate that the medication was administered to Resident 24 on 6/19/26 at 8 a.m., 7/1/26 at 9 a.m., and 7/8/26 at 9:40 a.m.A review of Resident 84's physician order, dated 6/16/26, indicated an order for Morphine Extended Release (a potent, long-acting medication used to manage severe, chronic pain) 15 mg one tablet by mouth twice daily for chronic pain. Resident 84's CDR indicated Resident 84's morphine was administered on 7/8/26 at 8 a.m. and 7/9/26 at 9 a.m. Resident 84's MAR did not indicated Resident 84's morphine was administered on 7/8/26 at 8 a.m. and 7/9/26 at 9 a.m. and was coded as 8 indicating resident preference.A review of Resident 90's physician order, dated 6/3/26, indicated an order for Hydrocodone-Acetaminophen 10-325 mg one tablet by mouth every four hours as needed for pain. Resident 90's CDR indicated Resident 90's hydrocodone-acetaminophen was administered on 7/5/26 at 6:20 a.m., 7/6/26 6:20 a.m., 7/8/26 at 8:45 a.m., 7/8/26 at 1:50 a.m., 7/11/26 at 6 a.m., 7/12/26 at 9:50 a.m., 7/12/26 at 2 p.m., 7/13/26 at 2:10 p.m., but Resident 90's MAR for July 2026 did not indicate that the medication was administered to Resident 90 on those dates.During a concurrent interview and record review on 7/16/26 at 8:58 a.m. with the Director of Nursing (DON), the DON reviewed the CDR and the MAR for Resident 24, Resident 84 and Resident 90, and confirmed the discrepancies between the CDR and the MAR for the three residents. The DON stated the nurse should have documented Resident 84's morphine as wasted if it was not administered for any reason. The DON stated accuracy was expected in the administration and documentation of controlled medications and accuracy was important for the residents' safety and for accountability on narcotics (class of drugs to manage moderate to severe pain that have a high addiction potential).During a review of the facility's policy and procedure (P&P) titled Controlled Medications, dated 10/2025, the P&P indicated, .D. When a controlled medication is administered, the licensed nurse administering the medication enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration.2) Amount administered.3) The signature of the nurse administering the dose, completed after the medication is administered.E. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing the dose.

Based on observation, interview, and record review, the facility failed to maintain infection control practices for four of 27 sampled residents (Resident 21, Resident 23, Resident 41 and Resident 82) when:1. Oxygen tubing was not labeled or dated for Resident 23;2. Oxygen tubing was not changed according to physician orders for Resident 82, Resident 41; 3. Enhanced Barrier Precautions (EBP, involves use of gown and gloves during high contact resident care designed to reduce transmission of Multi Drug Resistant Organisms [MDRO, bacteria resistant antibiotics]) were not in place or used during care for Resident 82; and,4. Nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not stored properly and was not labeled with the date it was first used, and another nasal cannula was not replaced timely for Resident 21.These failures increased the risk of respiratory infection for Resident 23, Resident 21, Resident 82, Resident 41 and increased the risk for a wound infection for Resident 41.Findings: 1. Resident 23 was admitted to the facility mid 2026 with diagnoses that included atelectasis (partial or complete collapse of a lung). During a concurrent observation and interview on 7/13/26 at 11:19 a.m. of Resident 23's, oxygen tubing with the Director of Staff Development (DSD), Resident 23 was lying in bed wearing a nasal cannula (flexible plastic tubing that delivers supplemental oxygen directly into the nose). The oxygen tubing did indicate the date it was changed. The DSD confirmed the oxygen tubing was not dated and stated the tubing should have a date on it of when it was last changed. During a review of Resident 23's Progress Note [PN], dated 7/4/26, the PN indicated on 7/4/26 facility staff placed oxygen on Resident 23. During a review of Resident 23's Order Summary Report [OSR], dated 7/13/26, the OSR indicated an order to change the nasal cannula tubing weekly. There was no documentation in Resident 23's medical record that the oxygen tubing had been changed since it was initiated on 7/4/26. 2. Resident 82 was admitted to the facility in early 2026 with diagnoses that included dependence on supplemental oxygen. During a review of Resident 82's OSR dated 1/24/26, the OSR indicated, Change Nasal Cannula, every day shift every Fri [Friday]. During a review of Resident 82's OSR dated 5/29/26, the OSR indicated, Change HHNEB [hand held nebulizer, a small medical device that turns liquid medicine into a fine mist] mask/tubing weekly. During a concurrent observation and interview on 7/13/26 at 8:53 a.m., of Resident 82, with the Clinical Consultant (CC), Resident 82 was lying in bed with oxygen being administered by a nasal cannula. The oxygen tubing did not have a date that indicated when the oxygen tubing was last changed. An HHNEB was observed on a nightstand next to the bed. The tubing of the HHNEB had a hot pink colored piece of paper with a typed dated of 6/26/26. The CC confirmed Resident 82's oxygen tubing was not dated and the HHNEB was dated 6/26/26. During an interview on 7/14/26 at 9:45 a.m. with the Infection Preventionist (IP), the IP was shown a photo of Resident 82's oxygen tubing and HHN. The IP confirmed the HHN tubing was labeled as being changed over two weeks ago and no date was found on the oxygen tubing. The IP stated she would expect them both to be changed weekly, Bacteria can get into the tubing.Two weeks is too long. Resident 41 was admitted to the facility in late 2025 with diagnoses that included palliative care (specialized medical care for people with serious illness with the goal to relieve pain and emotional stress) and dependence on supplemental oxygen. During a review of Resident 41's OSR dated 1/23/26, the OSR indicated, Change Nasal Cannula weekly. During an observation on 7/13/26 at 9:59 a.m. of Resident 41, Resident 41 was lying in bed with oxygen being administered by a nasal cannula. The oxygen tubing had a hot pink colored piece of paper attached to it with a typed date of 6/19/26. During a concurrent observation and interview on 7/13/26 at 10:02 a.m. with Licensed Nurse (LN 3) of Resident 41's oxygen tubing, LN 3 confirmed the oxygen tube last change date was 6/19/26. LN 3 stated it was important to change tubing to avoid infection, That is too long, it [oxygen tubing] should be changed. During an interview on 7/16/26 at 11:08 a.m. with the Director of Nursing (DON), the DON confirmed Resident 23's oxygen tubing was not dated; Resident 82 and Resident 41's oxygen tubing was not changed weekly per the physican order and stated oxygen tubing should be changed weekly for the prevention of infection. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/25, the P&P indicated, .Oxygen therapy is administered by way of an oxygen mask, nasal cannula.The Oxygen tube is changed at least weekly, labeled with the date it was changed. 3. Resident 41 was admitted to the facility in late 2025 with diagnoses that included palliative care. During a review of Resident 41's OSR dated 4/21/26, the OSR indicated, Enhanced barrier precaution due to PI2 [pressure injury 2, open wound caused by pressure, damage to the skin and underlying soft tissue] on coccyx [tailbone area] every shift. During a review of Resident 41's Care Plan Report [CP], dated 4/21/26, the CP indicated Resident 41 had a pressure injury to their coccyx, and interventions included, Utilize Enhanced Barrier Precautions [EBP] during high-contact resident care. During an observation on 7/14/26 at 9:12 a.m. in Resident 41's room, Resident 41 did not have any signage or personal protective equipment (PPE- gowns, gloves, mask) outside their room to indicate EBP were needed. During a concurrent observation and interview on 7/14/26 at 9:18 a.m. with the DSD in Resident 41's room, the DSD confirmed room [ROOM NUMBER] did not have any indicators that Resident 41 required EBP. The DSD and the department looked inside the room and observed a staff member providing high contact care for Resident 41 without wearing the required PPE. The DSD confirmed the observation and stated a person with an open wound required EBP during care, and she would expect to see some type of indicator outside the room to inform staff that PPE was required. The DSD further stated PPE was important to prevent the spread of infection. During an interview on 7/16/26 at 11:08 a.m. with the DON, the DON confirmed Resident 41 had a physician order for EBP because of the open wound on Resident 41's coccyx and stated she would expect Resident 41 to have EBP signage outside her room and staff to follow EBP precautions. During a review of the facility's P&P titled, Multidrug-Resistant Organisms; Infection Precaution & Enhanced Standard Precautions, dated10/25, the P&P indicated, .Infection Precautions.Enhanced Barrier Precaution will be integrated in the care of residents with chronic wounds or indwelling medical device during high-contact residents care activities regardless of their multidrug-resistant organism status.Enhanced Barrier Precautions [EBP] refer to an infection control intervention designed to reduce transmission of multi-drug resistant organism that employs targeted gown and glove use during high contact resident care activities.EBP are indicated for residents with any of the following.EBP use in wounds generally include chronic wounds.Examples of chronic wounds include, but are not limited to pressure ulcers.For residents for whom EBP are indicated, EBP is employed when performing high-contact resident care activities: Dressing, Bathing/Showering, Transferring, Providing Hygiene, Changing Linens, Changing briefs. 4. During a review of Resident 21's admission records, the records indicated Resident 21 was admitted to the facility in June 2026 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing), emphysema, and dependence on supplemental oxygen. During a review of Resident 21's physician orders, dated 7/2/26, included the following: - Oxygen @ 2 liters per minute (lpm) via nasal cannula - Change nasal cannula as needed and every day shift every Friday During a review of Resident 21's care plan, initiated on 7/12/26, the care plan indicated, Oxygen: Resident requires the use of oxygen.related to Chronic Obstructive Pulmonary Disease (COPD).Change humidification and O2 [oxygen] tubing as indicated. During an observation on 7/13/26 at 9:05 a.m. in Resident 21's room, Resident 21 was observed lying in bed, with nasal cannula on nostrils dated 7/3/26, connected to oxygen concentrator set at 2 lpm. Another nasal cannula observed inside the room, connected to an oxygen tank, hanging on wheelchair and unlabeled. During a review of Resident 21's Medication Administration Record (MAR) for July 2026, the MAR indicated Resident 21's Nasal Cannula was last changed on 7/3/26. During a concurrent interview and record review on 7/16/26 at 9:34 a.m. with the Director of Nursing (DON), the DON confirmed that Resident 21's nasal cannula was last changed on 7/3/26 and was not changed as scheduled on 7/10/26. The DON stated it was important for nasal cannulas to be changed weekly for infection control. The DON further stated nasal cannulas should be kept in the antimicrobial bag and should be labeled. During a review of the facility's P&P titled Oxygen Administration, revised 10/2025, the P&P indicated, .c. The Oxygen tubing is changed at least weekly, labeled with the date it was changed, and tip of the cannula is stored in the Anti-microbial bag.

Based on observation, interview, and record review, the facility failed to obtain a physician order for continuous oxygen therapy for one of 27 sampled residents (Resident 23) for nine days after initiating oxygen in response to a change in Resident 23's condition.This failure placed Resident 23 at risk for receiving inappropriate oxygen therapy, inadequate monitoring or complications associated with unregulated oxygen use. Findings: Resident 23 was admitted to the facility mid-2026 with diagnoses that included atelectasis (partial or complete collapse of a lung).During an observation on 7/13/26 at 10:10 a.m. of Resident 23's oxygen tubing, Resident 23 was lying in bed; he was receiving oxygen at 2 liters per minute by way of a nasal cannula (flexible plastic tubing that delivers supplemental oxygen directly into the nose).During a concurrent observation and interview on 7/13/26 at 11:19 a.m. with the Director of Staff Development (DSD) of Resident 23's oxygen. The DSD confirmed Resident 23 was receiving oxygen therapy.During a review of Resident 23's Progress Notes [PN], dated 7/4/26, the PN indicated, [Resident 23] noted to be febrile [fever] vital signs revealed hypotension [low blood pressure].and O2 [oxygen] of 86% [oxygen of 90% or less is typically considered low oxygen levels] on room air.supplemental oxygen initiated per protocol 2 Litter (sic) nasal cannula.During a review of Resident 23's medical record on 7/13/26, the medical record did not include any physician orders for oxygen therapy, monitoring or tubing change. During a concurrent interview and record review on 7/16/26 at 11:08 a.m., with the Director of Nursing (DON) Resident 23's PN dated 7/4/26 was reviewed. The DON stated staff placed oxygen on Resident 23 during an emergency, but if they kept using the oxygen she would expect staff to obtain a physician order. The DON stated the use of oxygen required a physician order and confirmed there were no physician orders for the use of oxygen, including the amount of oxygen used, and monitoring from 7/4-7/13/26 (nine days) for Resident 23. The DON stated it was important to have a physician order so staff would know the treatment plan for the residents.During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/25, the P&P indicated, Verify that there is a physician's order for this procedure.

Based on interviews and record reviews, the facility failed to administer medication as prescribed for one of 27 sampled resident (Resident 45) when fluoxetine (a medication used to treat depression) was unavailable during scheduled medication administration on two consecutive days.This failure resulted that Resident 45 missed one scheduled dose of fluoxetine on the first day and received a dose borrowed from another resident on the second day. Findings:A review of Resident 45's admission record indicated that the resident was admitted on 01/25 with diagnoses included depressed mood disorder (feeling unusually sad or depressed while coping with a stressful life event or major change).A review of Resident 45's Order Summary Record (OSR) indicated that Resident 45 had a physician order, dated 6/8/26, for fluoxetine oral capsule 20 mg (milligrams, unit of measurement) to take one capsule by mouth in the morning for depression.A review of Resident 45's Medication Administration Record (MAR) for July 2026 indicated that on 7/15/26 at 9 a.m. the fluoxetine was not given by Licensed Nurse (LN) 1 because the medication was not available. During an interview on 7/15/26 at 11:44 a.m. with Resident 45, Resident 45 stated that he did not receive his dose of fluoxetine that morning.During an interview on 7/15/26 at 2:45 p.m. with LN 1, LN 1 confirmed that fluoxetine was not given because the medication was not available. LN 1 stated that she expected all her medications to be available during medication administration and that nurses should order medications once there were five tablets left in the medication bubble pack.During an observation on 7/16/26 at 10:30 a.m. in Resident 45's room, the Department heard LN 1 told Resident 45 that she had borrowed the fluoxetine from another resident for his administration.During an interview on 7/16/26 at 10:50 a.m. with LN 1, LN 1 confirmed that she borrowed the fluoxetine from another resident with the same dose and administered the medication to Resident 45. LN 1 acknowledged that she should not have borrowed medication from another resident. LN 1 explained that she was trying to appease Resident 45.During a concurrent interview and record review on 7/16/26 at 11:52 a.m. with the Director of Nursing (DON), the DON stated that nursing staff were expected to order medications timely and that nurses should not borrow medications from another resident. The DON reviewed Resident 45's MAR and confirmed that the medication was not given on 7/15/26 and was documented as given on 7/16/26.During a phone interview on 7/16/26 at 1:09 p.m. with the Pharmacist (RPh), the RPh stated that they missed the refill request on 6/28/26 and were not able to deliver the fluoxetine refill. A review of the facility's policy and procedure (P&P) titled Administering Medications, dated 12/25, indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered within one (1) hour before and one (1) hour after the prescribed time.A review of the facility's P&P titled Emergency Kits, dated 11/25, indicated, 2. Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency box or from the provider pharmacy.

Based on interview and record review, the facility failed to accurately and consistently monitor fluid intake status for one of three sample residents (Resident 1).This failure had the potential to delay care and treatment and adversely affect Resident 1's hydration status.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted on [DATE] with diagnoses which included displaced intertrochanteric fracture of right femur (fracture on upper part of thigh bone), dementia (a progressive state of decline in mental abilities) and dysphagia (difficulty swallowing).During a review of Resident 1's Order Summary Report (OSR), the OSR indicated Resident 1 had an order of Hydration-Notify MD (doctor) if Weekly (7 days) fluid intake average is less than 1500 mL/day (milliliters/day)During a review of Resident 1's Nutritional Risk Assessment (NRA), dated 3/5/26, NRA indicated Resident 1 had a goal of .fluid at least 1500 mL/day to meet nutrition and hydration needs.During a review of Resident 1's Care Plan (CP), the CP indicated Resident 1 was at risk for malnutrition and dehydration, with interventions that included .monitor intake and output.provide nutritional/dietary supplements as ordered.During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/1/26-3/31/26, the MAR indicated there was missing documentation for the amount consumed for the following:237 mL house nourishment on 3/12, 3/17 and 3/18 at 1800; and240 mL of fluid for hydration with medication pass on 3/11, 3/12, 3/17, 3/18 and 3/19 at 2100.Total Intake and output every shift on 3/11, 3/12, 3/15 evening shift and 3/5, 3/11 and 3/12 night shift.During a review of Resident 1's CNA (certified nursing assistant) Fluid Intake documentation (CNA-ID), CNA-ID indicated there was one missing documentation on 3/18/26.During a review of Resident 1's Nursing Weekly Summary (WS), dated 3/15/26, the WS indicated that Resident 1's average 24-hour intake was .approx. 1000.During a review of Resident 1's Discharge Summary and Post-Care Instructions (DS), dated 3/21/26, the DS indicated Resident 1 was discharged on 3/21/26 at 1300. Resident 1 was seen at the emergency room on 3/22/26 at 8:17 p.m.During a concurrent interview and record review on 4/3/26 at 10:16 a.m. with Director of Nursing, Resident 1's chart was reviewed. DON stated there was no total daily fluid intake calculated; intake was calculated per shift on the MAR based on CNA intake documentation and the fluid nursing has given. Discrepancies were identified in the total fluid intake documented on the MAR, as the totals did not match the combined amounts recorded by the CNAs and nursing staff. The DON stated nurses averaged fluid intake weekly and had an order to notify the physician if the average weekly intake was less than 1500 mL/day. The DON stated Resident 1's weekly summary on 3/15/26 indicated that he had an average intake of 1000mL/day, and there was no documented evidence the physician was notified of this.During an interview on 4/3/26 at 10:24 a.m. with DON, DON stated if residents did not meet their daily fluid intake, she and the MD should have been notified in order to implement appropriate interventions.During a concurrent interview and record review on 4/3/26 at 11:40 p.m. with DON, Resident 1's CNA-ID was reviewed. The DON stated that all residents were placed on I&O monitoring for 14 days, during which nurses documented on the MAR, after the 14-day period, CNAs were expected to continue documenting I&O under tasks. The DON confirmed there was missing documentation for fluid intake and stated documentation should be complete to ensure an accurate assessment of the resident's status, as incomplete documentation could affect outcomes and care provided.During a review of Resident 1's History and Physical (H&P) from the Acute Care Hospital, dated 3/22/26, the H&P indicated Resident 1 was discharged from [skilled nursing home name] to home and became extremely lethargic the next day. H&P indicated that on 3/22/26, Resident 1's sodium level was 171. The H&P also indicated .patient was found to have evidence of severe dehydration with elevated BUN level, acute kidney injury, very dry mucous membrane.During a telephone interview on 4/8/26 at 1:54 p.m. with Attending Physician (AP), AP stated that a sodium level of 171 could not have occurred overnight and would have developed gradually that can be due to inadequate fluid intake.During a telephone interview on 4/8/26 at 2:20 p.m. with Registered Dietician, RD stated that the 1500 mL/day fluid intake goal for Resident 1 was calculated based on his needs and weight and represented the amount required for adequate nutrition and hydration. The RD stated that goals were measured based on weekly intake summaries and intake & output (I&O) monitoring. The RD stated that accurate documentation was important, as it was used to guide care and interventions.The facility failed to accurately monitor and document Resident 1's fluid intake, as intake totals were inconsistent and incomplete, including missing documentation and failed to notify the physician as ordered when average intake was 1500mL/day. The DON and RD indicated that complete and accurate documentation was necessary to guide care and interventions for nutrition and hydration.During a review of the facility's policy and procedure (P&P) titled, Intake and Output, revised 10/20, the P&P indicated, .intake and output shall be recorded by each shift.nursing assistant shall measure and record oral fluids taken by the resident during meals and during care. the licensed nurse shall measure oral fluid taken by the resident during medication pass.the license nurse shall record intake consumed during medication pass.licensed nurse shall document resident's intake and output at the end of each shift on the intake and output record.intake and output record shall be reviewed by a designated licensed nurse on a weekly basis to determine adequate hydration and fluid balance. deficiencies in fluid intake or fluid balance shall be reported to the physician by the licensed nurse.

Based on observation, interview and record review the facility failed to ensure resident safety for one resident (Resident 1) when the facility did not provide adequate monitoring and supervision of Resident 1, for a census of 98.This failure resulted in Resident 1 eloping from the facility and reducing the facility's potential in keeping Resident 1 safe from harm.Resident 1's admission Record (AR), indicated that Resident 1 was admitted in September of 2024 with diagnoses including unspecified dementia (memory loss), with anxiety (persistent, excessive fear and worry) and mood disturbance.Resident 1's Order Summary dated 1/10/26 indicated, Check placement of wander guard located on left ankle every shift, monitor skin and notify MD [physician] as needed.Resident 1's MDS (MDS-a federally mandated resident assessment tool), the MDS dated [DATE] indicated Resident 1 had severe cognitive impairment.Resident 1's Care plan (CP) initiated 9/19/24, the CP indicated that Resident 1 had an elopement score of 14 (very high elopement risk), a goal: Resident will not leave the facility without a responsible party and an intervention: assure identification band or other form of identification is in place.During an interview on 1/15/26 at 11:18 a.m., with the Director of Staff Development (DSD), the DSD stated that Resident 1 left the facility through a door near the smoking area and unlatched a gate and walked to a road behind the facility. A green truck picked him up and took him to a nearby apartment complex where a resident called 911.During an interview on 1/15/26 at 12:17 p.m. with Licensed Nurse (LN) 1, LN 1 stated that Resident 1 will frequently try to elope and will take off wander guard.During an interview on 1/15/26 at 12:46 p.m. with LN 2, LN 2 stated she was here the day Resident 1 eloped from the facility. LN 2 stated she did not hear an alarm go off. LN 2 stated that Resident 1 has tried to elope before and will wiggle out or cut off his wander guard.During a concurrent observation and interview on 1/15/26 at 2:19 p.m. in Resident 1's room with LN 1, Resident 1 was not wearing an identification band and LN 1 confirmed this finding.During an interview on 1/15/26 at 2:30 p.m. with the Director of Nursing (DON) and LN 1, LN 1 stated she replaced the identification band for Resident 1. DON asked LN 1, Did he take his identification band off again? The DON acknowledged that a wander guard is only effective when a resident is wearing it and that residents have the right to be safe in the facility.Review of the facility policy (P&P), Wandering and Elopements dated March 2019, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm .

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse when Resident 2 hit Resident 1 on the left side of the face.This failure resulted in Resident 1 sustaining a discoloration on the left jaw and had the potential for Resident 1 to experience fear or distress.Findings:During a review of Resident 1's admission record, the record indicated Resident 1 was admitted to the facility in September 2024 with diagnoses that included cerebral atherosclerosis (a condition where plaque builds up in the brain's arteries, narrowing and blocking them) and dementia (a progressive state of decline in mental abilities). Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had severe cognitive impairment and had behaviors of wandering that occurred daily.During a review of Resident 2's admission record, the record indicated Resident 2 was admitted in March 2024 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (brain tissue dies due to a lack of blood supply), depression, and adjustment disorder (a condition where a person has difficulty coping with or adjusting to a specific stressful life event or change). Resident 2's MDS indicated Resident 2 was cognitively intact.During a review of Resident 3's admission record, the record indicated Resident 3 was admitted in June 2025 with diagnosis that included intracapsular fracture of left femur (a break in the bone within the joint capsule of the hip, specifically involving the neck of the thigh bone). Resident 3' MDS indicated Resident 3 was cognitively intact.During a review of Resident 1's Change in Condition (CIC) notes, dated 7/22/25, the notes indicated, .[Resident 1] was struck one time by another resident [Resident 2] while standing in the hallway in front of the other resident's room and witnessed by another resident [Resident 3], staff immediately responded and re-directed the incident and was able to remove [Resident 1] and was assessed for injury, small red mark was noted to left jaw.During a review of Resident 1's care plan, initiated 7/22/25, the care plan indicated, [Resident 1] has a small red mark to left jaw and is at risk for bruising/swelling and emotional distress related to recipient of physical aggression.During a review of Resident 2's CIC notes, dated 7/22/25, the notes indicated, .[Resident 2] was seen to have struck at another resident [Resident 1] one time who was walking down the hallway in front of [Resident 2's] room.During a review of Resident 2's care plan, initiated 7/22/25, the care plan indicated, .[Resident 2] struck another resident and is at risk for injuring others.During an interview on 7/24/25 at 10:55 p.m. with Resident 2, Resident 2 stated, Guy [Resident 1] came in the room I told him to leave he didn't want to leave.[Resident 1] moved away and came back.It's not the first time.It was 11 in the evening.[Resident 1] came back at me.I kind of pushed him a little bit.During an interview on 7/24/25 at 11:48 a.m. with Resident 3, Resident 3 stated, .I was sitting on bed, the curtain and door was open, [Resident 1] was outside, two feet out from our door.I heard [Resident 2]. [Resident 2] then slap [Resident 1] on the side of the face.I physically saw him do it.[Resident 2] stepped out to hit [Resident 1].It was on the left side of the face.It was evening close to 11 o'clock Monday [7/21/25].[Resident 2] hit [Resident 1] one time.It was hard enough to hear it.[Resident 2] did not react, I would have reacted differently.I've seen and heard it. [Resident 1] is a wanderer.It was in the hallway.[Resident 2] is known to be kind of aggressive.During an interview on 7/24/25 at 1:06 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated, .It was around 10:55 p.m.[7/21/25], I heard a verbal altercation, I heard an audible sound like someone was hit, I heard [Resident 2] yelling.I was sitting charting at the nurses station.I saw both residents, [Resident 2] was yelling at [Resident 1], [Resident 1] was very upset.[Resident 2] was saying [Resident 1] was trying to go to [Resident 2's] room. [Resident 1] was in the middle of the hallway, [Resident 2] got really angry and said he was going to hit [Resident 1]. LN 1 stated she did an assessment on Resident 1 after the incident and Resident 1 pointed to his face on the left cheek. LN 1 added Resident 2 had a history of getting angry and upset, mostly about personal space.During an interview on 7/24/25 at 2:29 p.m. with the Administrator (ADM), the ADM stated LN 1 called him around 11:20 p.m. on 7/21/25 regarding the incident. The ADM stated, We are confident that it happened. The ADM stated Resident 2 had a resident-to-resident altercation before. The ADM further stated LN 1 have heard a little bit of a smack and the ADM stated, .There was a slight redness on [Resident 1's] left jaw. The ADM added, .We are aware that [Resident 2] gets frustrated sometimes.If [Resident 3] hadn't seen anything, we wouldn't even think there was a hit. The ADM stated he was confident it happened because of the history of Resident 2 and the statement of Resident 3 and stated, .I believe [Resident 3, the witness] .During a review of the facility provided document titled .Patients' Rights, undated, the document indicated, .(a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated.Patient shall have the right:.(10) To be free from mental and physical abuse.During a review of the facility's policy and procedure (P&P) titled Reporting Abuse to Facility Management, revised 10/2009, the P&P indicated, .1. Our facility will not condone resident abuse by anyone, including staff members,.other residents, friends, or other individuals.7. To help with recognition of incidents of abuse, the following definitions of abuse are provided: a. Abuse is defined as the willful infliction of injury.with resulting physical harm, pain, or mental anguish.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent one of three sampled residents (Resident 1) from elopement (to leave an area of safety unsupervised and undetected) outside the facility. This failure had the potential to result in serious injury or death for Resident 1. Findings: A review of Resident 1's admission Record indicated, Resident 1 was admitted to the facility in 2025 with a diagnoses that included Dementia (a group of symptoms affecting memory, thinking, and social abilities). A review of Resident 1's, Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive (having full understanding) Patterns, dated 6/23/25, indicated Resident 1 had a Brief Interview for Mental Status (a tool to assess a person's full understanding) score of 00 which indicated Resident 1 did not have full understanding and thus, not able to be interviewed. A review of Resident 1's, Wandering Risk Observation/Assessment dated 3/19/25, indicated Resident 1 had a score of 12 which indicated a high risk for elopement and wondering. A review of Resident 1's Care Plan dated 3/19/25, indicated Elopement: Resident is at risk for elopement/exit-seeking/wondering related to dementia . During an interview with the Director of Nursing (DON) on 6/25/25 at 11:36 a.m., the DON stated Resident 1 has dementia and is confused. The DON further stated Resident 1 is ambulatory (able to walk) and is at high risk for elopement. On 6/20/25 Resident 1 eloped from the facility and was missing for 45 minutes. Lastly the DON stated, The expectation is for no residents to elope. During an interview with the Licensed Nurse 1 (LN 1) on 6/25/25 at 12:27 p.m., LN 1 stated, Resident 1 had started exit seeking behavior a few days prior to the elopement. LN 1 further stated, We should have been watching him closer since he was exit-seeking. A review of Resident 1's Progress Note dated 6/20/25 indicated Resident 1 was last seen in their room on 6/20/25 at 1:45 p.m. by the DON. On 6/20/24 at 2:30 p.m., the facility received a call from the police department, Resident 1 had been found. A review of the facility policy titled, Wandering and Elopements dated 10/2024 indicated, The facility will identify residents who are at risk of unsafe wandering and provide interventions to decrease the risk and keep residents safe.

Based on observation, interview and record review the facility failed to ensure that food was stored in accordance with professional standards for food service when expired or undated food was observed in freezer and dry food cupboards. These failures placed 94 residents out of a census of 95 who received food served by the facility at risk for receiving expired foods. Findings: During an Initial Kitchen tour on 5/20/25 at 8:23 a.m. with the Dietary Supervisor (DS), the following was observed: -in the dessert freezer, a bag of cream puffs was found in a plastic bag that was undated, -in the cupboards dried parsley in a shaker container, a bag of brown gravy mix and bowl of cereal in a covered plastic container were undated and, - powdered cherry jello mix in a shaker container prepared 12/1/24 and be used by 5/1/25. During an observation and interview on 5/20/25 at 8:30 a.m. the DS confirmed the above observations and stated her expectation was that dietary staff should properly label and throw away expired foods. The DS stated that if these items were served to residents, they may not be palatable or safe for residents to eat. During an interview on 05/21/25 at 2:20 p.m. with the Registered Dietician (RD), the RD stated the expectation was that staff should throw out food that was undated or expired. RD further stated that for those food items the issue would be lack of palatability for the residents. Review of the Policy and Procedure (P&P) titled, Storage of Food Supplies dated October 2024, the P&P indicated, Food supplies will be stored properly and in a safe manner. Dry food items which have been opened, such as pudding, gelatin, pancake mix, dry cereal .will be tightly closed, labeled and dated.

Based on interview and record review the facility failed to ensure an irregularity was identified during the medication regimen review for one of 26 sampled residents (Resident 82) when Resident 82 had an order for a PRN (as needed) psychotropic medication (a drug that affects brain activities associated with mental processes and behavior) without a stop date. This failure had the potential for Resident 82 to receive unnecessary medication. Findings: A review of an admission record indicated Resident 82 was admitted in September 2024 with diagnoses including anxiety. A review of Resident 82's Order Summary Report dated 3/6/25 indicated, an order for lorazepam (an anti-anxiety medication) 0.5 milligrams (mg, a unit of measurement) every four hours PRN. A review of Resident 82's Medication Administration Record (MAR) revealed, Resident 82 received lorazepam 31 times in March 2025, 38 times in April 2025, and 27 times in May 2025. In an interview on 5/22/25 at 3:36 p.m. with the Pharmacy Consultant (PC), the PC after reviewing Resident 82's clinical record confirmed that the PRN order for lorazepam did not have an end date. PC stated a medication regimen review should have been completed for Resident 82's lorazepam order with a recommendation to the doctor to put a 14 day stop date per regulation. A review of the facility's policy titled Psychotropic Medication Use revised in October 2024 indicated The need to continue PRN orders for psychotropic medications requires . the physician . clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. A review of the facility's policy titled Medication Regimen Review revised in October 2024 stipulated The pharmacist shall review each resident's medication regimen monthly . when a clinically significant adverse consequence is confirmed or suspected . the pharmacist and/or physician . will identify situations where medications should be tapered, discontinued, or changed.

Based on interview and record review the facility failed to ensure a significant change in status assessment (SCSA, an assessment that indicates major decline or improvement in the resident's status) was initiated for one of 26 sampled residents (Resident 294) when Resident 294 developed a stage four pressure ulcer (PU, deep wound reaching the muscles, ligaments, and bones) to the sacrococcyx (joint that connects the sacrum- triangular bone and the coccyx - tail bone). This failure decreased the facility's potential to provide appropriate care and services to Resident 294 based on his status. Findings: A review of an admission record indicated Resident 294 was admitted in February 2025 with diagnoses including Guillain-Barre Syndrome (GBS, a rare neurological disorder where the body's immune system attacks the peripheral nervous system resulting in muscle weakness or temporary paralysis) and adult failure to thrive (FTT, a decline in an older adult's overall health and function). A review of the Skilled Wound Care consult notes for Resident 294 on 4/3/25, 4/10/25, and 4/17/25 indicated that a stage four PU to the sacrococcyx area had already developed, was evaluated and treated by the wound doctor. A review of Resident 294's Order Summary Report dated 5/16/25 indicated an order for the treatment of a stage four PU to Resident 294's sacrococcyx daily and as needed. In a concurrent interview and record review on 5/21/25 at 10:10 a.m. with the Minimum Data Set (MDS, a federally mandated resident assessment tool) Coordinator 1 (MDSC 1), Resident 294's MDS assessments were reviewed, MDSC 1 confirmed that an SCSA was not done for Resident 294 and should have been initiated 14 days after the stage four PU was established by the wound doctor. In an interview on 5/22/25 9:07 a.m. with the Director of Nursing (DON) DON stated it was her expectation that the MDSCs should complete resident assessments properly and on time. A review of the facility's policy titled Change in a Resident's Condition or Status revised in October 2024 indicated If a significant change in the resident's physical or mental or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA [Omnibus Budget Reconciliation Act, for Nursing Homes] regulations governing resident assessments and as outlined in the MDS RAI [Resident Assessment Instrument] Instruction Manual.

Based on observation, interview, and record review, the facility failed to ensure the care plan to monitor newly identified behaviors was followed for one of 26 sampled residents (Resident 50). This failure increased the potential for Resident 50 to take medications without a physician's order and potentially cause side effects or adverse effects to resident. Findings: A review of the clinical records indicated Resident 50 was admitted [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), post- traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), and mental disorder (a condition that affects thinking, feeling, mood, and behavior). A review of Resident 50's Minimum Data Set (MDS- federally mandated resident assessment tool) dated 2/25/25 indicated Resident 50 had moderate cognitive impairment with a score of 11 out of 15 in the Brief Interview of Mental Status (BIMS- an assessment tool used screen and identify memory, orientation, and judgement status of the resident). In a concurrent observation and interview on 5/20/25 at 9:01 a.m., Resident 50 took out a medication bottle from his closet. The medication bottle indicated cholecalcif [sic, cholecalciferol] 25 mcg [microgram- unit of measurement] (D3- 1,000 units). The label on the bottle indicated to take one tablet every other day for Vitamin (Vit) D supplementation. Resident 50 stated the medication came from home and he was supposed to take it every day. An interview was conducted on 5/20/25 at 9:38 a.m. with LN 4 outside Resident 50's room. LN 4 confirmed there was a bottle of Vit D3 medication in Resident 50's room and he was not aware of it. In a follow up interview on 5/20/25 at 1:24 p.m., Resident 50 stated there was probably 50 pills inside the bottle of the Vit D3. Resident 50 further stated he had been taking 1 pill from this bottle since he had been in the facility and he did not know if nurses were aware he was taking the medication. A subsequent observation and interview was conducted on 5/20/25 at 1:54 p.m., inside Resident 50's room. Resident 50 took out a plastic container inside his closet then placed the contents in a piece of napkin. Resident 50 stated these were the medications he had collected since admission. Resident 50 stated he did not take these medications because he had no idea what they were. Resident 50 further stated he did not report not taking these medications. Resident 50 further stated these medications were left at bedside and he was not sure what they were. In an interview on 5/21/25 at 4:32 p.m., the LN 5 stated if a resident was admitted from the hospital, the admitting nurse sends a list of medications to the pharmacy and the pharmacy delivered the medications. The LN 5 further stated they never allowed medications to be kept at resident's bedside including over the counter medications. The LN 5 answered no when she was asked if residents can self-administer medication. A concurrent interview and record review was conducted on 5/21/25 at 4:42 p.m. with LN 5. LN 5 accompanied State surveyor in Resident's 50's room. Resident 50 refused to talk with LN 5 and State surveyor. Once outside Resident 50's room, the State surveyor showed LN 5 the picture of Resident 50's medications taken on 5/20/25. LN 5 stated that's concerning after LN 5 saw the picture and LN 5 stated she would inform the Director of Nursing regarding the medications in Resident 50's room. In an interview on 5/21/25 at 4:52 p.m., the Infection Preventionist (IP) stated she worked with Resident 50 since admission. The IP described Resident 50 as very delusional, resident comes off as very alert and oriented but has extreme behaviors, such as accusing kitchen of poisoning his food. The IP further stated Resident 50's capacity (ability to use and understand information to make a decision) was taken away and he was conserved (a legal process where court determines an individual cannot manage their own affairs and appoints a conservator on their behalf). The IP stated she was not aware of Resident 50's storing medications in his room. The IP further stated Resident 50 would not take medications from her if he did not see [IP] prepare them. A concurrent interview and record review was conducted on 5/23/25 starting at 9:49 a.m. with the Director of Nursing (DON). The DON stated this was the first time the facility was made aware of the medications in Resident 50's room. The DON's concern was for Resident 50 to have an escalation of behavior. The DON reviewed Resident 50's care plan at 10:25 a.m. and stated the care plan was updated on 5/22/25 for psychosocial behavior of hiding medications in the room, ordering over the counter medications from outside sources and refusing staff to enter the room and retrieve item. The DON further stated her expectation was for staff to be monitoring these behaviors. The DON confirmed she could not find Resident 50's behavior monitoring in the clinical records. In an interview on 5/23/25 at 11:35 a.m., the Medical Records Director (MRD) stated there was no monitoring for Resident 50's behaviors in the MAR. A review of the facility's policy & procedure reviewed October 2024 and titled, Care Plans, Comprehensive indicated, A comprehensive 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 care plan interventions are derived from analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure care and services were provided according to accepted standard of practice for three of 26 sampled residents (Resident 50, Resident 88, and Resident 74) when: 1. Resident 50's medications were left at bedside; 2. Resident 88 had no physician's order on the use of neck brace; and 3. Resident 74's order to check placement of resident's Gastrostomy Tube (GT, tube inserted into the stomach to deliver nutrition, and medications) was not followed. These failures had the potential to negatively impact the physical, mental, and psychosocial wellbeing of Resident 50, Resident 88, and Resident 74. Findings: 1. A review of the clinical records indicated Resident 50 was admitted [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), post- traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), and mental disorder (a condition that affects thinking, feeling, mood, and behavior). A review of Resident 50's Minimum Data Set (MDS- federally mandated resident assessment tool) dated 2/25/25 indicated Resident 50 had moderate cognitive impairment with a score of 11 out of 15 in the Brief Interview for Mental Status (BIMS- an assessment tool used to screen and identify memory, orientation, and judgement status of the resident). A review of Resident 50's physician order dated 5/19/25 indicated Amoxicillin-Pot (Potassium) Clavulanate (antibiotic) 875-125 mg (milligram, unit of measurement) give one tablet by mouth two times a day for sinusitis (inflammation of the sinuses or the hallow spaces in the bones surrounding the nose) for 10 days. During a concurrent observation and interview conducted on 5/20/25 at 8:58 a.m., inside Resident 50's room. Observed a medication cup containing eight medications in Resident 50's meal tray. Resident 50 stated the medications were given this morning. Resident 50 further stated he had an antibiotic, a decongestant, two of his vitamins he brought with him, a stool softener, and 3 other medications he was not able to identify inside the medication cup. In a subsequent observation and interview on 5/20/25 at 9:01 a.m., Resident 50 took out a medication bottle from his closet. The medication bottle indicated cholecalcif [sic, cholecalciferol] 25 mcg [microgram- unit of measurement] (D3- 1,000 units). The label on the bottle indicated to take one tablet every other day for Vitamin D supplementation. Resident 50 stated the medication came from home and he was supposed to take it every day. A concurrent interview and record review was conducted on 5/20/25 starting at 9:19 a.m. with Licensed Nurse 4 (LN 4). LN 4 confirmed he gave Resident 50's medications at around 7:55 a.m. LN 4 opened the electronic Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and he stated he gave Resident 50 a total of eight pills namely Vitamin B12 (Cyanocobalamin-keeps nerve cells healthy), docusate sodium (stool softener), Men's vitamins (provides essential vitamins and minerals), Amoxicillin, Mucinex (helps reduce chest congestion), Multivitamins with minerals, Vitamin D3 (for healthy bones) and Osteo joint health triple strength (to support joint health). LN 4 stated he observed Resident 50 take his medications this morning. In an interview on 5/20/25 at 9:27 a.m., LN 4 stated he saw Resident 50 take his antibiotic and the rest of his medications were set side by resident. In an interview on 5/20/25 at 9:29 a.m., LN 4 stated they were not allowed to leave medications at bedside and since Resident 50 was waiting for the food, LN 4 left seven pills at bedside. In a concurrent interview, and record review on 5/20/25 at 9:32 a.m., LN 4 stated he took the antibiotic from the bubble pack and the count sheet for Resident 50's antibiotic was signed by LN 4 on 5/20/25 at 8:20 a.m. A follow up observation and interview was conducted on 5/20/25 at 9:33 a.m. inside the room with LN 4 and Resident 50. LN 4 saw the medication cup in Resident 50's meal tray. LN 4 stated he saw Resident 50 take his antibiotic and Resident 50 responded he did not take any medications. LN 4 clarified he gave the medication cup to Resident 50 and LN 4 did not see [Resident 50] take his medications. LN 4 further stated Resident 50 told LN 4 he wanted to take his medications with meals. A follow up interview was conducted on 5/20/25 at 9:38 a.m. with LN 4 outside Resident 50's room. LN 4 stated Resident 50 specifically wanted his privacy, and resident would refuse medications if [LN 4] was with him. LN 4 confirmed there was a bottle of Vitamin D3 medication in Resident 50's room and he was not aware of it. LN 4 further stated he cannot leave medications at bedside. LN 4 stated Resident 50 was by himself in the room, nobody can take the medications, and he trusted Resident 50. In a review of Resident 50's 'Medication Admin [Administration] Audit Report' dated 5/20/25, LN 4 documented the administration time for the eight medications was from 8:12 a.m. to 8:18 a.m. and the LN 4's documentation time was 5/20/25 at 8:20 a.m. In an interview on 5/21/25 at 4:32 p.m., LN 5 stated if a resident was admitted from the hospital, the admitting nurse sends a list of medications to the pharmacy and pharmacy delivered the medications. LN 5 further stated they never allowed medications to be kept at bedside including over the counter medications. LN 5 answered no when she was asked if residents can self-administer medication. In an interview on 5/21/25 at 4:37 p.m., the Assistant Director of Nursing (ADON) stated the facility had one resident who can self-administer medications, and it was not Resident 50. The ADON further stated they have interdisciplinary (IDT) conference, care plan, and a physician order if a resident is able to self-administer medications. In a subsequent interview on 5/21/25 with LN 5, LN 5 stated all medications refused by a resident were crushed and placed in a bottle stored in the narcotic box inside the medication cart. LN 5 further stated medications are not left at bedside. A concurrent interview and record review was conducted on 5/21/25 at 4:42 p.m. with LN 5. LN 5 accompanied State surveyor in Resident 50's room. Resident 50 refused to talk to LN 5 and State surveyor. Once outside Resident 50's room, the State surveyor showed LN 5 the picture of Resident 50's medications taken on 5/20/25. LN 5 stated that's concerning when LN 5 saw the picture and LN 5 stated she would inform the Director of Nursing regarding the medications in Resident 50's room. In an interview on 5/21/25 at 4:52 p.m., the Infection Preventionist (IP) stated she worked with Resident 50 since admission. The IP described Resident 50 as very delusional, resident comes off as very alert and oriented but has extreme behaviors such as accusing kitchen of poisoning his food. The IP further stated Resident 50's capacity (ability to use and understand information to make a decision) was taken away and he was conserved (a legal process where court determines an individual cannot manage their own affairs and appoints a conservator on their behalf). A review of Resident 50's Attending physician's notes dated 5/22/25 indicated, .Records show that currently [Resident 50] is conserved because has been determined that patient does not have capacity. In an interview on 5/23/25 at 9:49 a.m., the Director of Nursing (DON) stated her expectation was for licensed nurses to stay at bedside and make sure resident swallowed the medications before leaving the resident's room. The DON further stated the signing of the eMAR should be done after the resident had taken the medications. The DON further expected licensed nurses (LNs) to not leave medications at bedside and if a resident refused, LNs should take away the refused medications. A review of the facility's policy and procedure revised October 2024 and titled, Administering Medications indicated, Medications are administered in a safe and timely manner, and as prescribed .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall make a note in the eMAR .Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. 45770 2. A review of an admission record indicated Resident 88 was admitted in March 2025 with diagnoses that included cervical [neck] disc disorder after a cervical spine fusion. During a concurrent observation and interview on 5/20/25 at 9 a.m. Resident 88 was observed wearing a cervical collar while lying in bed. According to Resident 88 the nurse told him to always wear the collar per doctor's order due to the surgical incision at the back of his neck. A review of Resident 88's Order Summary Report (OSR) indicated an order for the use of a cervical collar dated 3/26/25 and an order to discontinue its use dated 4/24/25. A review of Resident 88's Skin/Wound Note dated 4/24/25 indicated that Resident 88's surgical incision at the back of the neck has been resolved and no further treatment was ordered by the doctor. In a concurrent interview and record review on 5/21/25 at 11:50 a.m. with MDS Coordinator 2 (MDSC 2) Resident 88's OSR and Progress Notes were reviewed, MDSC 2 confirmed Resident 88 wears a cervical collar. MDSC 2 added that the order for the use of the cervical collar had been discontinued. In an interview on 5/23/25 at 9:07 a.m. with the DON, the DON stated the nurse should have clarified the order, nurses should follow the doctor's order to safely care for the residents. A review of the facility's policy titled Physician Orders revised in October 2024 indicated, Prescribed medication and treatment orders will be carried out in accordance with the physician order . The licensed staff shall carry out physician/nurse practitioner's orders as prescribed. 39489 3. A review of Resident 74's Admission Record, indicated Resident 74 was admitted to the facility on [DATE] with diagnosis that included, Dysphagia, Oropharyngeal Phase, (swallowing disorder that affects the ability to move food from the mouth to the throat). During a concurrent observation and interview with LN 1 on 5/21/25 at 1:45 p.m., LN 1 took out the medications for Resident 74 from her medication cart, prepared the medications to be given via GT, and went inside Resident 74's room. LN 1 connected the 60 ml Enteral Syringe (ES, device used to administer nutrition and medications) to the GT, and poured the crushed pill, mixed with water into the ES. LN 1 did not check the placement of the GT and did not flush the GT with 30 cc of water before medication administration as ordered by the physician. LN 1 stated she forgot to bring her stethoscope (instrument used to listen of someone's heartbeat or breathing), however, she decided to administer Resident 74's medication via GT without knowing if the GT is in the correct position inside Resident 74's stomach. LN 1 acknowledged she did not do a pre flush to the GT prior infusing Resident 74's medication. LN 1 stated, for Resident 74's safety, she should have checked the placement of the GT and flushed the GT with water before giving his medication. During an interview with the DON on 5/23/25 at 7:45 a.m., the DON stated, the licensed nurses must follow the physicians' orders. The parameters indicated in the physician's order must be followed for the resident's safety. The DON continued, nurses must check the placement of the GT, flush the GT with water before and after medications administration and practice infection control to promote quality of care. A review of Resident 74's Order Summary Report, indicated, Enteral Feed Order every shift for GTUBE CHECK TUBE PLACEMENT & PATENCY before each feeding. A review of Resident 74's Medication Administration Record, indicated, Enteral Feed Order every shift for GTUBE CHECK TUBE PLACEMENT & PATENCY before each feeding. A review of Resident 74's Order Summary Report, indicated, Enteral Feed Order every shift for GTUBE FLUSH TUBE FEEDING WITH 30 CC/H2O [cubic centimeters, measurements, water] BEFORE AND AFTER EACH MEDICATION ADMINISTRATION . A review of Resident 74's Medication Administration Record, indicated, Enteral Feed Order every shift for GTUBE FLUSH TUBE FEEDING WITH 30 CC/H2O BEFORE AND AFTER EACH MEDICATION ADMINISTRATION. A review of the facility's policies and procedures, titled, enteral Feedings, revised September 2024, indicated, Purpose To ensure the safe administration of enteral nutrition . The facility will remain current and follow accepted best practices I enteral nutrition . 1. Always maintain strict aseptic technique when working with enteral nutrition systems . Preventing misconnection error . 2. Regularly inspect tubing for proper and secure connections . Preventing aspiration 1. Check enteral tube placement prior to feeding or administration of medication .

Based on observation, interview and record review, the facility failed to ensure resident's needs were met for one of 19 sampled residents (Resident 77) when the dining room table was too high for the resident during the lunch meal. This failure had the potential to diminish Resident 77's self-esteem and self-worth. Findings: A review of an admission Record indicated Resident 77 was admitted to the facility in May 2025 with multiple diagnoses including dementia (a progressive decline in mental abilities) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor would healing). Review of Resident 77's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/28/25 indicated Resident 77 had severely impaired cognition. Further review of MDS indicated that Resident 77 needed set up or clean-up assistance for eating. A review of Resident 77's Care Plan dated 5/12/25, indicated Resident 77 had Nutritional Risk: Moderate .interventions . assist resident to the dining room for all meals as tolerated for queuing and feeding assistance as needed. During a concurrent observation and interview on 5/20/25 at 12:20 p.m., observed Resident 77 in the main dining room at a table. A staff member brought Resident 77's lunch tray and placed it on the table. The table was noted at chest level and too high for Resident 77 to eat his food comfortably. Licensed Nurse 3 (LN 3) confirmed that the table was too high for Resident 77. During an interview on 5/22/25 at 11:20 a.m. with the Director of Nursing (DON), the DON stated her expectation was for the staff to assist residents to a comfortable position while dining. Review of the facility's Policy and Procedure (P&P) titled, Assistance with Meals, dated October 2024, the P&P indicated, Residents will be encouraged to eat in the dining room .assistance will be provided as needed.

Based on observation, interview and record review, the facility failed to ensure one of 26 sampled residents (Resident 86) was evaluated and treated by a podiatrist (foot doctor) when Resident 86's toenails were thick, discolored and long. This failure resulted in Resident 86 having pain when walking and had the risk potential to cut the skin. Findings: A review of the facility's document titled admission Record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During an interview on 5/21/25, at 11:25 a.m., Responsible Party 1 (RP 1) stated she was concerned about her father's long toenails. She stated she noted the toenails were long and had fungus in March. RP 1 further stated she was going to cut them myself but realized his toenails were too thick to do it safely. During an observation and concurrent interview in Resident 86's room with Resident 86 and Certified Nurse Assistant 2 (CNA 2) on 5/21/25, at 1:04 p.m., CNA 2 removed socks from Resident 86's feet. The toenails on both feet were thick, long and curved inward toward the toe, they were discolored yellow and black. Resident 86 stated my feet hurt. CNA 2 acknowledged Resident 86's toenails were discolored, long and thick. During an interview on 5/21/25, at 1:08 p.m., Licensed Nurse 1 (LN 1) stated Resident 86's toenails should have been addressed by the Podiatrist. LN 1 confirmed Resident 86's toenails were long, curved towards the toes and discolored. LN 1 stated Resident 86's toenails looks like he has fungus on all his nail beds. LN 1 further acknowledged toenails of this length could cause pain and had the potential to cut Resident 86's skin. During an interview on 5/22/25, at 10:55 a.m., the Social Services Director (SSD) stated a Podiatrist was scheduled every month and treated all residents who needed foot care. The SSD stated a binder titled Ancillary Services was at each nurse's station and provided the name of those residents who needed ancillary treatment. The SSD found no evidence of Resident 86 having received podiatric visit since his admission to the facility in January 2025. During a record review of the facility's policy titled Social Services, dated September 2024, indicated, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being .the social services department may be responsible for .making referrals for ancillary services such as .Podiatry .

Based on observation, interview, and record review the facility failed to promote safety measures for one of 26 sampled residents (Resident 82) when Resident 82's order for the use of a wanderguard (a device that activates sensors on doors to alarm, alerting staff to intervene when wandering residents attempt to elope) was not followed. This failure increased Resident 82's risk for elopement. Findings: A review of an admission record indicated Resident 82 was admitted in September 2024 with diagnoses including dementia (a progressive state of decline in mental abilities) with behavioral disturbance. During an observation on 5/20/25 at 8:40 a.m. Resident 82 was noted pacing up and down the hallway. Resident 82 was observed being redirected by staff to keep him from wandering to other resident's rooms. A review of Resident 82's Order Summary Report (OSR) dated 4/15/25 and 5/16/25 indicated an order for Resident 82 to wear a wanderguard bracelet to the right ankle for safety related to wandering/exit seeking behavior. The order directed nursing staff to check placement of the wanderguard every shift. A review of Resident 82's Medication Administration Record (MAR) dated 5/20/25 morning (a.m.) shift indicated the a.m. nurse signed the MAR that Resident 82 was wearing his wanderguard. In a concurrent observation, interview, and record review on 5/20/25 at 1:25 p.m. Resident 82's OSR, MAR, and care plans were reviewed. Resident 82 was observed seated in front of the nurse's station and had no wanderguard bracelet to the right ankle. Minimum Data Set (MDS, a federally mandated resident assessment tool) Coordinator 1 (MDSC 1) and MDSC 2 who were both present confirmed that Resident 82 was not wearing the wander guard bracelet. MDSC 2 stated Resident 82 must have taken it off. In an interview on 5/23/25 at 9:07 a.m. with the Director of Nursing (DON), the DON stated Resident 82 should always have the wanderguard on as ordered for proper monitoring and to keep the resident safe. A review of the facility's policy titled Wandering and Elopements revised in October 2024 indicated The facility will identify residents who are at risk of unsafe wandering and provide interventions to decrease the risk and keep residents safe. A review of the facility's policy titled Assistive Devices and Equipment revised in September 2024 indicated Devices and equipment that assist with resident . safety .are provided for residents. These include . wanderguard.

Based on interview and record review, the facility failed to ensure physician visits were provided timely for one of 26 sampled residents (Resident 14) when Resident 14 was not seen by the attending physician every 30 days during the first 90 days of admission. This failure had the potential to delay detection of declining health and the provision of care. Findings: A review of the facility's document titled admission Record, indicated Resident 14 was admitted to the facility late 2024 with diagnoses of Diastolic Heart Failure (the heart cannot pump enough blood to meet the body's needs causing multiple symptoms), Sleep Apnea (a disorder characterized by repeated pauses in breathing during sleep) and Peripheral Vascular Disease (a condition where circulating blood has difficulty in reaching the body's tissues due to narrowing of blood vessels). A review of Resident 14's Minimum Data Set (MDS-a federally mandated assessment tool), dated 5/5/25 indicated a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation and judgement status of the resident) score of 12, which indicated moderate cognitive (related to processes of thinking and reasoning) impairment. During an interview on 5/22/25, at 8:45 a.m., Resident 14 stated I'm not sure how often I get to see my doctor. There are so many people in and out of here. During an interview on 5/22/25 at 9:45 a.m., the Director of Nursing (DON) stated physicians were expected to visit residents every 30 days for the first 90 days upon admission and every 60 days thereafter. During a concurrent interview and record review on 5/22/25, at 12:49 p.m., the Medical Records Director (MRD) confirmed there was no documented evidence of a physician or nurse practitioner (an advanced practice Registered Nurse who has advanced clinical education and training to diagnose, treat, and manage various health conditions) visit in Resident 14's medical chart for the months of November and December of 2024. During an interview on 5/22/25 at 1:48 p.m., the Medical Director (MD) stated he tried to be here every month to see the residents but found it difficult to find practitioners to assist with this facility. During a review of the facility's document titled Physician Visits, dated September 2024, indicated The attending physician must make visits in accordance with applicable state and federal regulations. The attending physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter.

Based on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 1) was free from a significant medication error when RN A administered 50 mg (milligrams) of [MEDICATION NAME] (a potent opiate ([MEDICATION NAME]-like) narcotic) to Resident 1 in error, without a physician's orders [REDACTED]. This resulted in an adverse, significant change in condition for Resident 1 (lethargy, slurred speech, decreased respiratory rate, decreased level of consciousness and increased confusion), requiring her transfer to a hospital emergency room (ER) for further evaluation and treatment where Resident 1 required [MEDICATION NAME] (used to reverse the effects of drug overdose) for an adverse drug effect. Findings: The California Department of Public Health (CDPH) received a complaint alleging Resident 1 had a change in condition and was sent to a hospital emergency room where she was found to have tested positive for opioids (potent [MEDICATION NAME]-like opiate narcotic medication) and found to have been given [MEDICATION NAME] (opiate narcotic medication) by mistake. During an observation and interview on 11/8/16 at 9:45 am, Resident 1 was observed in her bed and was asked if she recalled the event when she was taken to the ER in December 2015. Resident 1 stated that she remembered the event last December 2015 when she was administered the wrong medication. She stated, I remember seeing my curtains moving all around. It was really weird. My television was dancing! I remember going to the hospital and then I didn't know where I was. I thought they took me to my house, but they told me I was in the hospital. I was confused! She stated that the administrator came to visit her and that the facility owned up to the error right away. In an interview with Registered Nurse (RN) A on 11/14/16 at 10:45 am, she stated that she had a hard time remembering, but she thought that she had just poured morning medications around 10 or 10:30 am for both Residents 1 and 2 but she was interrupted by three different people. I signed out 5 [MEDICATION NAME] 10 mg tablets from the narcotic control sheet for Resident 2. I lost my focus and all the pills that I had just poured were white. I must have given Resident 1 Resident 2's [MEDICATION NAME] pills in the same cup. Later that day, Resident 1 became lethargic, had an increase in confusion and slurred speech and I called the doctor and we sent her to the hospital where we found out she had [MEDICATION NAME] in her urine. That is when the Director of Nurses came to me and did a thorough investigation to figure out how this medication error happened. Review of the facility's admission record for Resident 1 indicated that she was an alert, oriented [AGE] year old with [DIAGNOSES REDACTED]. The liver carries out several necessary functions, including detoxifying harmful substances in your body), restless leg syndrome (an uncontrollable urge to move your legs), depression, and [DIAGNOSES REDACTED] (a narrowing of the aortic valve in the heart). Review of a nurses notes, dated 12/1/15 at 3:30 pm, indicated Resident 1 has trouble speaking and slurred speech noted. Facial symmetry while smile. No facial drooping. Resident able to raise both arms. Grips strong bilaterally. Breath sounds clear all lobes, even and unlabored. Received order to send resident to ER for evaluation. Resident went to ER with gurney accompanied by 2 EMT at 1530 (3:30 pm). The Hospital ER record review indicated upon arrival, Resident 1 had a low respiratory rate of 14-15 (normal is 20), was Very lethargic, barely arousable and remained nonconversant (not verbally communicating) although she is following commands. She was given a dose of [MEDICATION NAME] and she actually responded to this. Her urine tested positive for [MEDICATION NAME]. A review of the hospital physician's history and physical examination [REDACTED]. Review of a hospital physician's progress note, dated 12/4/15, indicated Resident 1 was very weak, confused, disoriented, and slowly improving and needed close neurologic (related to brain function) monitoring. According to the Internet website, Drugs.com, [MEDICATION NAME] is a long-acting opiate that is not for short term use due to increased risk of overdose and death. The Food and Drug Administration (FDA) has issued a warning that [MEDICATION NAME] use may result in serious, life-threatening or fatal respiratory depression, especially during initiation. Accidental ingestion of even one dose, can result in a fatal overdose. The suggested maximum starting dose is 10 mg for the elderly. Special considerations for low dosing and close monitoring should be used in patients with liver disease. Review of the hospital's discharge summary for Resident 1, dated 12/5/15, indicated her discharge [DIAGNOSES REDACTED]. A review of the facility's undated policy for Medication Errors, indicated medication errors consist of, in part: a. Wrong medication administered . A review of the facility's medication error investigation documents, dated 12/14/15, indicated the narcotic sheets were reviewed and found that additional [MEDICATION NAME] pills were removed from Resident 2's narcotic card within one hour of a previous removal of [MEDICATION NAME] pills. RN A was questioned and stated she had prepared [MEDICATION NAME] pills for Resident 2, but Resident 2 declined them, so she placed the pills in the top drawer of the medication cart. RN A stated when she went back to the medication cart to retrieve the [MEDICATION NAME] pills, they were not there, so she prepared another dose for administration to Resident 2. RN A stated she did not know what happened to the first prepared dose of [MEDICATION NAME] that she had left in the medication cart. The documents indicated whenever a prepared medication is not administered, it should be wasted (discarded of) at that time. Review of the facility's Medication Error Report, dated 12/14/15 at 5:15 pm, indicated, Describe error: Possible medication given to (Resident 1) that was prescribed for another (resident). The report indicated Resident 1 had not received any physician ordered narcotics. Resident 1 was sent to the hospital for evaluation and treatment if indicated based on her change of condition. The hospital called and stated (Resident 1) had been given [MEDICATION NAME] and responded, that toxicology reports [MEDICATION NAME].

Based on interview and record review the facility did not ensure that one of one sampled resident's (Resident 1) physician, family, or legal representative were notified when a significant change occurred requiring physician intervention and had the potential for death. This resulted in a delay of Resident 1 being transferred to a local acute care hospital and treatments not being started for more than five hours after her change of condition. Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE] where she was being treated for [REDACTED]. Resident 1 was receiving occupational therapy (a type of therapy to help with rehabilitation to perform activities of daily living) and was progressing toward her goals in preparation for discharge home with her granddaughter and her family. The California Department of Public Health (CDPH) received a complaint alleging that the family of Resident 1 was not notified of a change of condition in Resident's 1 health status on 2/27/16 when she had a massive stroke and that care and services were not provided for Resident 1 in a timely manner resulting in Resident's 1 death. The complaint alleged that Licensed Nurse (LN) 2 called the family at 3:15 pm on 2/27/16 to report that Resident 1 had difficulty speaking and moving since about 7:45 am but that LN 2 had not called 911 or reported to the Medical Doctor (MD) because LN 2 was hoping that the symptoms would resolve and because Resident 1 was a DNR (do not resuscitate). In a phone interview on 8/19/16 with Licensed Nurse (LN) 2, who took care of Resident 1 on 2/27/16 from 7 am until 4 pm, he stated and documented in Residents 1's chart that Resident 1 was alert and responsive to tactile (touch) stimuli. According to LN 2, Resident 1 was feeling down and appeared weaker than normal. LN 2 stated that he was not sure what was wrong with Resident 1 that day, he then stated, I thought maybe she is having a bad day or had a urinary tract infection [MEDICAL CONDITION], because she had a history of [REDACTED]. I was not sure what was wrong with her. When LN 2 was asked what actions did he take next he stated, I didn't want to call Nurse Practitioner (NP) 6 but I did, and she said to call the granddaughter (of Resident 1) and send her (Resident 1) out (to the hospital). LN 2 then added to his statement , I watched her that day and then called the granddaughter (of Resident 1), who told me to call an ambulance, and the doctor. When asked how much later after he noticed that Resident 1 was not her usual self, did he call NP 6, LN 2 stated, I was real busy that day, and I couldn't call until later that afternoon. LN 2 then stated, I don't remember. In a phone interview with Certified Nursing Assistant (CNA) 4 on 5/24/16 at 4:20 pm, when asked about her interaction with Resident 1 on 2/27/16 she stated, I had worked with Resident 1 the previous day and I knew she was a one person assist. At around 6:30 am, I went to help get her up and was unable to. I was called by my partner (CNA 3) to help, and together we both were hardly able to get her up. I told her nurse (LN 2) , around 7 am, that something was wrong with her (Resident 1) and he told us to get her up anyway and take her to the dinning room. Resident 1 did not eat at all. CNA 4 proceeded to say she would ask Resident 1 questions and Resident 1 would just stare at her. After breakfast CNA 4 stated that it took both her and CNA 3 together to transfer Resident 1 back to her wheelchair. CNA 4 stated that she told LN 2 how hard it had been to transfer Resident 1 and that Resident 1 would not move or help with the transfers. CNA 4 was told by LN 2 to take Resident 1 back to her room and put her back to bed. CNA 4 stated that,We (CNA 3 and 4) told the nurse again that Resident 1 was not her usual self and he said he would take care of it. We knew something was wrong and we passed the information on to the next shift. In a phone interview on 5/25/16 at 3:30 pm, with CNA 3 she stated that Resident 1 was in bed the morning of 2/27/16, not moving or talking to her as she usually did. CNA 3 stated that she sat Resident 1 up on the side of the bed and proceeded to gather her clothes. CNA 3 stated when she turned around Resident 1 was leaning forward and to the side almost falling forward. CNA 3 stated that when LN 2 came in the room to assess Resident 1 per the insistence of CNA 3 and 4, Resident 1 would not answer any of the questions LN 2 asked her and would not squeeze his fingers when told. According to CNA 3, just after 2 pm, the roommate (Resident 5) of Resident 1 told CNA 3 and 4 to tell LN 2 to call 911 for Resident 1. After the ambulance arrived, CNA 3 stated she heard the ambulance driver ask LN 2, How long has she been like this and LN 2 replied, since noon. CNA 3 stated that just was not true, we told him at 7 am, that morning and he just lied about that. According to the National Institutes of Health, [DATE], When it comes to life threatening conditions like [MEDICAL CONDITION] or stroke, every minute counts. Acting fast could save a life. [MEDICAL CONDITION] can happen to anyone, but risk increases with age. A person with a history of [MEDICAL CONDITION] or stroke also raises the risk. Treating them quickly can dramatically reduce your risk. According to Resident 1's record, Resident 1 was not transferred to a hospital for eight hours or more before she received medical attention regarding the symptoms she had displayed starting at 6:30 am on 2/27/16. According to Resident 1's admission sheet to the hospital, Resident 1 was admitted with a [DIAGNOSES REDACTED].

Based on record review and interview the facility failed to provide necessary care and services for one of one sampled resident (Resident 1) when a change of condition had occurred. Licensed Nurse (LN 2) did not notify the physician regarding a change of condition of Resident 1. This failure prevented Resident 1 from receiving emergency care in a timely manner. Findings: Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE] where she was being treated for [REDACTED]. Resident 1 was receiving occupational therapy (a type of therapy for rehabilitation to peform activities of daily living) and was progressing toward her goals in preparation for discharge home with her granddaughter and her family. Resident 1 had a change of condition at 7:45 am, on the morning of 2/27/16. In a phone interview with Certified Nursing Assistant (CNA) 4 on 5/24/16 at 4:20 pm, when asked about her interaction with Resident 1 on 2/27/16 she stated, I had worked with Resident 1 the previous day and I knew she was a one person assist. At around 6:30 am, I went to help get her up and was unable to. I was called by my partner (CNA 3) to help, and together we both were hardly able to get her up. I told her nurse (LN 2) , around 7 am, that something was wrong with her (Resident 1) and he told us to get her up anyway and take her to the dinning room. Resident 1 did not eat at all. CNA 4 proceeded to say she would ask Resident 1 questions and Resident 1 would just stare at her. After breakfast CNA 4 stated that it took both her and CNA 3 together to transfer Resident 1 back to her wheelchair. CNA 4 stated that she told LN 2 how hard it had been to transfer Resident 1 and that Resident 1 would not move or help with the transfers. CNA 4 was told by LN 2 to take Resident 1 back to her room and put her back to bed. CNA 4 stated that,We (CNA 3 and 4) told the nurse again that Resident 1 was not her usual self and he said he would take care of it. We knew something was wrong and we passed the information on to the next shift. In a phone interview on 5/25/16 at 3:30 pm, with CNA 3 she stated that Resident 1 was in bed the morning of 2/27/16, not moving or talking to her as she usually did. CNA 3 stated that she sat Resident 1 up on the side of the bed and proceeded to gather her clothes. CNA 3 stated when she turned around Resident 1 was leaning forward and to the side almost falling forward. According to CNA 3, both CNA 3 and CNA 4, notified LN 2 at that time that something was wrong with Resident 1. LN 2 came in the room and did a brief assessment on Resident 1 by asking questions such as, What day is it? and Do you know where you are? According to CNA 3 and CNA 4, Resident 1 did not respond and would not squeeze LN 2 fingers when asked. CNA 3 stated that she and CNA 4 were told to dress Resident 1 and take her to the dining room to eat. After breakfast LN 2 inquired about how Resident 1 did with breakfast. CNA 3 and CNA 4, told him that Resident 1 did not eat anything and she could not feed herself. LN 2 assessed Resident 1 by asking more questions (like what is your name) which she did not answer. CNA 4 stated that again LN 2 was told that something is wrong with Resident 1 and that both CNA 3 and CNA 4 were told to put Resident 1 back to bed and he would take care of it. According to CNA 3, just after 2 pm, the roommate (Resident 5) of Resident 1 told CNA 3 and 4 to tell LN 2 to call 911 for Resident 1. After the ambulance had arrived, CNA 3 stated she heard the ambulance driver ask LN 2, How long has she been like this and LN 2 replied, since noon. CNA 3 stated that just was not true, we told him at 7 am, that morning and he just lied about that. Resident 5's record was reviewed. Resident 5 was the roommate of Resident 1. Resident 5 was a [AGE] year old female that was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 5 was alert and orientated to person, place and time and was her own responsible party. In an interview on 5/26/16 at 12:45 pm, Resident 5 stated that she was a witness to much of the interactions on the day of 2/27/16, between Resident 1, LN 2, CNA 3 and CNA 4. A written account by Resident 5, as well as verbal statement regarding the interactions that took place was reviewed According to Resident 5, LN 2 was attempting to closely observe Resident 1 by having Resident 1 placed in the hallway so LN 2 could keep an eye on her while completing medication pass. Resident 1 was taken to lunch by CNA 3 and was not able to consume her lunch. Resident 1 was returned back to her room, placed back in the hallway to be observed by LN 2. Resident 5 stated that she attempted to comfort Resident 1 by talking to her and stroking her face. Resident 5 stated she then insisted that LN 2 call an ambulance for Resident 1. Resident 5 stated that according to LN 2 a call was placed to the family of Resident 1 on 2/27/16 at approximately 3:50 pm. In an interview with LN 2, on 8/19/16 at 2:45 pm, who took care of Resident 1 on 2/27/16 from 7 am until 4 pm, he stated and documented in Residents 1's chart that Resident 1 was alert and responsive to tactile (touch) stimuli. According to LN 2, Resident 1 was feeling down and appeared weaker than normal. LN 2 stated that he was not sure what was wrong with Resident 1 that day, he then stated, I thought maybe she is having a bad day or had a urinary tract infection [MEDICAL CONDITION], because she had a history of [REDACTED]. I was not sure what was wrong with her. When LN 2 was asked what actions did he take next he stated, I didn't want to call Nurse Practitioner (NP) 6 but I did, and she said to call the granddaughter (of Resident 1) and send her (Resident 1) out (to the hospital). LN 2 then added to his statement , I watched her that day and then called the granddaughter (of Resident 1), who told me to call an ambulance, and the doctor. LN 2 stated that he then called a transport service to take Resident 1 to the emergency room . When asked how much later after he noticed that Resident 1 was not her usual self, did he call NP 6, LN 2 stated, I was real busy that day, and I couldn't call until later that afternoon. LN 2 then stated, I don't remember. A review of the transport service documentation, indicated that Resident 1 was transferred to the hospital after 4 pm, approximately eight to nine hours after her first symptoms were observed. The care plan for Resident 1, dated 10/20/15 read under the section titled, Problem: Resident is at risk for repeat cardiovascular accident ([MEDICAL CONDITION], stroke) as resident has previously had a [MEDICAL CONDITION]. The Long Term Goal Date was 4/19/16. Under the Approach section the first intervention read: Be observant for s/s (sign and symptoms) that may indicate an impending [MEDICAL CONDITION]/TIA (i.e Change in baseline LOC (level of consciousness)/1 sided weakness ([MEDICAL CONDITION]) slurred speech/c/o (complaints of) acute intense headache/N/V (nausea, vomiting)/visual deficit/facial droop--Notify MD PRN (Medical Doctor as needed). According to documentation in the Progress Notes written by LN 2 dated 2/27/16, there was no evidence that the care plan was followed. No documentation could be found regarding notification to the MD. Resident 2 was not sent to the hospital until after the granddaughter told LN 2 to send her grandmother to the hospital. According to the transport company records dated, 2/27/16, Resident 1 was picked up at 4 pm and taken to the hospital at 4:04. A review of to the hospital Admission Facesheet indicated that Resident 1 was admitted to the Intensive Care Unit on 2/27/16 at 10:10 pm, with a [DIAGNOSES REDACTED]. The facility policy titled Job Description - Charge Nurse under the Position Summary indicated; The Charge Nurse assumes responsibility and accountability for nursing services delivered to all residents of a designated unit for one shift. The Charge Nurse provides direct care, administers treatments and medications, organizes and distributes daily assignments to direct care staff consistent with staff competency and each resident's comprehensive assessment and plan of care. Supervises direct care staff and makes decisions about resident care needs during shift within scope of clinical competence, consistent with community policies and procedures. Under the portion listing ESSENTIAL JOB FUNCTIONS, it read: 1. Make daily rounds on assigned unit to observe, assess or interview residents 4. Describe care plan goals Seek input from nurse aides about residents condition, functional abilities . 6. Perform physical assessment of new admissions and current residents as indicated by change in condition 7. Based on assessment of the resident's condition, develop or revise the plan of care with interventions . 9. Promptly consult with nursing supervisor and Social Worker if unsure of proper course of action that respects resident's rights 11. Complete required documentation of care and services delivered during shift, including subjective findings, objective symptoms, interventions and resident responses to interventions. 14. Immediately inform the resident, consult with the resident's physician and notify the designated family member and/or resident legal representative when there is an accident involving an injury which has the potential for requiring physician intervention; a significant change in the resident's physical, mental or psycho social status; a need to alter treatment significantly or a decision to transfer the resident from the community. Promptly notify the resident, designated family member when there is a change 17. Report all injuries to self or others to supervisor immediately. Under JOB FUNCTIONS it read: 21. Demonstrate knowledge of, and respect for, the rights, dignity,of each resident in all interactions. 24. Knowledge of geriatric nursing principles and professional standards of nursing practice and ability to apply to resident specific circumstances. 25. Demonstrate competency in clinical skills needed 26. Demonstrate competency in assessment of long term resident's physical, behavior and functional status. In an interview with LN 2 on 8/19/16, LN 2 stated that, Resident 1 was a DNR (do not resuscitate) resident. According to the facility policy, Do Not Resuscitate Order (DNRO), under policy Interpretation and Implementation, #3 indicated, Should the resident be transferred to the hospital, a photocopy of the DNRO form must be provided to the EMT (Emergency Medical Transport) personnel transporting the resident to the hospital. The facility resident admission record dated 10/20/15 (which was current on the date Resident 1 was transferred to the hospital) under the Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) section read, There are no Advanced Directive selected for this resident. This indicated that Resident 1 had not given any instructions that she did not want to be resustitated if she needed emergency treatment.

Based on interview and record review, the facility failed to provide Resident 1 the necessary care and services, in accordance with the professional standards of quality of the American Medical Directors Association (AMDA) for 1 of 1 sampled resident, when they failed to: * Notify Resident 1's physician, of her increased [MEDICAL CONDITION] ([MEDICAL CONDITION], failing heart that has lost ability to pump enough blood to body's tissues, which results in [MEDICAL CONDITION], excess fluid in the lungs and tissues) symptoms including weight gain, [MEDICAL CONDITION], wheezing ([MEDICATION NAME] air passageway narrowing from excess fluid) and shortness of breath prior to discharging her home on [DATE]. *Accurately assess Resident 1's weight gain, [MEDICAL CONDITION], wheezing and shortness of breath as signs and symptoms of worsening [MEDICAL CONDITION]; * Review, revise, and implement Resident 1's [MEDICAL CONDITION], Nutrition, and [MEDICAL CONDITION] (CKD, concurrently causes excess fluid) care plans; This failure to provide the necessary care and services, in accordance with a comprehensive assessment and plan of care, led to Resident 1's decline in clinical status and discharge home on [DATE], where she died of [MEDICAL CONDITION] the following morning on [DATE]. Findings: Resident 1 was admitted to the facility on [DATE], following an acute care hospitalization on [DATE] for acute [MEDICAL CONDITION] secondary to acute [MEDICAL CONDITION] exacerbation (increase in signs, symptoms and severity). The facility's minimum data set (an assessment tool), dated [DATE], described her as able to make her own health care decisions. The acute care hospital's admission documentation for Resident 1, dated [DATE], showed she was treated for [REDACTED]. On [DATE] at 8:50 am, Family Member (FM) G was interviewed. FM G stated that she attended a care conference with facility staff on approximately [DATE], and was told Resident 1 had gained 11 lbs in 2 weeks. FM G stated that when she said the 11 lb weight gain was not good for Resident 1, the facility staff did not respond to her. FM G stated that on [DATE] (the day before Resident 1's discharge), when she told Social Services Director (SSD) F that Resident 1 was not feeling well, not breathing well, and should not be sent home, SSD F told her that the facility staff had checked Resident 1's lungs and heart and that, "She was fine." FM G stated that Resident 1 seemed almost as sick as when she had previously entered the acute care hospital on [DATE] for acute [MEDICAL CONDITION] exacerbation. On [DATE], Resident 1's death certificate listed the cause of the death was [MEDICAL CONDITION] due to [MEDICAL CONDITION]. A review of the AMDA 2010 clinical practice guidelines for Heart Failure in the Long-Term Care Setting showed, "Ongoing monitoring of the resident's condition and response to treatment is imperative ...Assess fluid volume status by monitoring weight at least three times per week...Weight gain in a known heart failure resident is an important "clue" that the resident may be going into heart failure." On [DATE], the facility's ,[DATE] weekly weight report showed Resident 1's weights as follows: 153 lbs on [DATE], admitted ; 157 lbs on [DATE] (4 lbs in 7 days); 164 lbs on [DATE] (7 lbs in 7 days); 168 lbs on [DATE] (4 lbs in 7 days), a total of 15 lbs in 21 days. A review of Resident 1's Nutritional Progress Note entry, dated [DATE], showed that the registered dietician (RD) D documented that Resident 1 gained 4 lbs in one week, that her weight should not exceed 160 lbs, and was eating 50 to 75 % of her meals. RD D documented that Resident 1 was hyponatremic (excess fluid volume and low sodium levels) and might benefit from a fluid restriction (limit fluid intake). A second entry on [DATE], showed that RD D recommended a fluid restriction a second time and that the facility would request a physician's orders [REDACTED]." ([MEDICAL CONDITION]). On [DATE] at 2 pm, RD D confirmed that she advised the facility to obtain the fluid restriction order from the physician on ,[DATE], ,[DATE], and [DATE]. Resident 1's nurse notes showed that fluids were encouraged (rather than restricted) to her on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. Resident 1's nurse notes reflected the following signs and symptoms of fluid overload (causes heart to work very hard to pump the excess fluid volume, which can worsen heart failure, cause shortness of breath, weight gain, and [MEDICAL CONDITION] of the feet or legs): On [DATE] at 4:10 pm, she had 2+ pedal [MEDICAL CONDITION] (significant fluid buildup in feet/ankles that leaves a dent in skin when pressed with thumb, sign of fluid overload in [MEDICAL CONDITION]); On [DATE] at 7:15 pm she had 1 to 2 + [MEDICAL CONDITION] and a cough; On [DATE] (no times noted), she was tachypnic (rapid breathing, normal respiration rate ,[DATE] breaths per minute) at 24 breaths per minute during the morning and afternoon shifts; and On [DATE] at 4 am (the day of her discharge), she was anxious, complained of being short of breath, and was wheezing. Resident 1's daily nurse notes, dated ,[DATE] to [DATE], showed there was no documentation that Resident 1's continuous weight gain totaling 15 lbs, 2+ pedal [MEDICAL CONDITION], tachypnea, shortness of breath or wheezing were assessed as signs and symptoms of [MEDICAL CONDITION] exacerbation. Resident 1's signed physician telephone orders, dated [DATE], showed that on [DATE] (3 days prior to discharge) the facility obtained Resident 1's 1500 milliliter (ml) fluid restriction and discharge orders for [DATE]. On [DATE] at 9:52 am, Administrative (Adm) Nurse B confirmed that nursing was responsible for assessing the resident to determine if they were medically cleared for discharge from the facility. Adm Nurse B stated the facility policy was that Nursing staff then communicated this information to the physician and asked for the discharge order. On [DATE] at 3:25 pm, the nursing services documentation portion of the "Final Summary of the Patient's Status" section of Resident 1's Interdisciplinary Discharge Summary, dated [DATE], showed she had a 15 pound weight increase since admission and was concurrently reviewed with Adm Nurse C. Adm Nurse C confirmed that he had completed the nursing portion of the form. Adm Nurse C stated that he was not aware of Resident 1's shortness of breath and wheezing (signs and symptoms of [MEDICAL CONDITION] fluid overload), noted by nursing at 4 am on [DATE], the day of her discharge. Adm Nurse C stated that he had not noted Resident 1's 15 lb weight gain as a sign of fluid overload at the time of her discharge assessment. The AMDA 2010 clinical practice guideline for Heart Failure in the Long-Term Care Setting, showed that fluids should be restricted in patients who are hyponatremic, that patients with signs of fluid overload ([MEDICAL CONDITION]) should receive a loop (type of diuretic that stops sodium/water from reentering the body) diuretic medication (for example, [MEDICATION NAME]) to decrease fluid overload, and be monitored for condition and response to treatment. The guideline specified that if patients did not achieve explicit goals, the reasons should be documented and the care plans should be modified. Resident 1's nutritional care plan, dated [DATE], was not completed. The boxes for the identified problems of diuretic use and fluid restriction were left unchecked. The nutritional care plan goal for Resident 1 to maintain her weight was also not filled in or checked. Resident 1's admission orders [REDACTED]. Her ,[DATE] medication administration records showed she had received the daily [MEDICATION NAME]. There was no physicians order for a loop diuretic found in Resident 1's record. On [DATE] at 2 pm, RD D confirmed she had advised the facility to obtain a physicians order for fluid restriction on ,[DATE], ,[DATE], and [DATE]. RD D stated that as of [DATE], Resident 1 had gained 15 lbs in three weeks. Resident 1's signed physician telephone orders, dated [DATE], showed the 1500 ml fluid restriction was ordered for Resident 1. On [DATE] at 3:20 pm, Adm Nurse B confirmed that Resident 1 did not receive a loop diuretic and that her nutritional care plan was not updated for diuretic use or the 1500 ml fluid restriction. Resident 1's heart failure care plan, dated [DATE], showed she was at risk for shortness of breath, [MEDICAL CONDITION] and anxiety related to [MEDICAL CONDITION]. The care plan's approach showed that nursing would evaluate and report effectiveness of Resident 1's medications (diuretics), assess for fluid excess (weight gain,...shortness of breath,...wheezing, [MEDICAL CONDITION], worsening of [MEDICAL CONDITION]), and monitor and report signs of respiratory distress (rapid or difficult breathing). Resident 1's nurse notes showed that on [DATE] at 4:10 pm, she had 2+ pedal [MEDICAL CONDITION] and at 7:15 pm she had 1 to 2 + [MEDICAL CONDITION] and a cough; On [DATE] (no times noted), she was tachypnic at 24 breaths per minute during the morning and afternoon shifts; and was anxious, complained of being short of breath, and was wheezing at 4 am on [DATE] (the day of her discharge). Resident 1's record did not contain documentation that her signs and symptoms of excess fluid, shortness of breath, tachypnea, wheezing, or the ineffectiveness of her diuretic were reported to Resident 1's medical doctor (MD) E, as specified in her heart failure care plan. On [DATE] at 2:05 pm, Adm Nurse B, confirmed she had not contacted MD E about the ineffectiveness of Resident 1's diuretic, her [MEDICAL CONDITION], or her breathing problems, as directed in her heart failure care plan. On [DATE] at 3:20 pm, Adm Nurse B confirmed the facility had not used their assessments to update or implement Resident 1's heart failure care plan, when they did not report the weight gain, [MEDICAL CONDITION], or breathing problems to MD E. Resident 1's care plan for her CKD, dated [DATE], also showed that the facility would assess for excess fluid. The care plan's approach showed that nursing would notify MD E of respiratory distress and significant weight gain. RD D's progress note, dated [DATE], showed that Resident 1 had gained 15 lbs in the previous three weeks. During a concurrent interview on [DATE] at 2 pm, RD D confirmed Resident 1's significant weight gain of 15 lbs in three weeks. There was no evidence found in Resident 1's record that MD E was notified of her significant 15 lb weight change or her respiratory problems that were noted in her ,[DATE] and [DATE] nursing notes. On [DATE] at 3:35 pm, Adm Nurse B confirmed Resident 1's physician was not immediately notified following each documented weekly weight gain. The AMDA 2010 clinical practice guideline for Acute Change of Condition, showed that [MEDICAL CONDITION] in a resident with heart and/or kidney disease, should be reported to the practitioner immediately when it is sudden, accompanied by sudden onset of shortness of breath, or has sudden onset of [MEDICAL CONDITION] in one leg. This guideline showed that gradually progressive [MEDICAL CONDITION] accompanied by weight gain should be reported to the practitioner on the next office day. Resident 1's Rehabilitation Skilled Therapy Progress Note, dated [DATE], showed that she complained of right calf swelling ([MEDICAL CONDITION]) and that the therapist notified nursing. Resident 1's nurse notes showed that: On [DATE] at 4:10 pm, she had 2+ pedal [MEDICAL CONDITION] and at 7:15 pm she had 1 to 2 + [MEDICAL CONDITION] and a cough; On [DATE] (no times noted) showed that she was tachypnic at 24 breaths per minute during the morning and afternoon shifts; and On [DATE] (day of her discharge from the facility) at 4 am, she was anxious, complained of being short of breath, and was wheezing. On [DATE] at 2 pm, RD D confirmed she had completed a Weight Variance Report on [DATE] that included a request to Resident 1's physician to place her on a fluid restriction and had given it to nursing to fax to MD E. RD D stated nursing was responsible for notifying the MD E of Resident 1's weight and getting the order for the fluid restriction. RD D stated the facility was to follow up her recommendations by contacting the physician, if they had not received a response within 72 hours. RD D confirmed that she requested the fluid restriction for Resident 1 again on ,[DATE] and [DATE]. RD D stated that as of [DATE], Resident 1 had gained 15 lbs in three weeks and had stated that her legs were "puffy." Resident 1's record did not show any documentation that MD E had been notified about her [MEDICAL CONDITION]. There was no documentation that MD E was notified about Resident 1's weight gain prior to [DATE]. On [DATE] at 2:05 pm, Adm Nurse B, confirmed she had not contacted Resident 1's physician about the ineffectiveness of Resident 1's diuretic, her [MEDICAL CONDITION], or her breathing problems. On [DATE] at 2:10 pm, Adm Nurse A (Patient Care Coordinator) stated he was not able to provide documentation or verify that Resident 1's physician was contacted on ,[DATE] or [DATE], about her 15 lb weight gain or RD D's request for the fluid restriction order. Adm Nurse A confirmed that on [DATE], MD E was faxed Resident 1's [DATE] Weight Variance Report that showed a 7 lb weight gain, as part of the request for the fluid restriction order. Adm Nurse A confirmed that Resident 1's actual weight gain on [DATE] was 15 lbs, not the 7 lbs indicated on the Weight Variance Form dated [DATE] (8 days earlier). On [DATE] at 3:35 pm, Adm Nurse B confirmed Resident 1's physician was not immediately notified following each documented weekly weight gain. On [DATE] at 11:30 am, MD E was interviewed about Resident 1's care at the facility. MD E stated that she was not made aware of Resident 1's weight gain until she received the Weight Variance Report and request for fluid restriction, that indicated a 7 lb weight gain, which was not significant in and of itself. MD E stated she was not contacted by the facility about Resident 1's 15 lb weight gain, [MEDICAL CONDITION], shortness of breath or wheezing. MD E stated that when the facility contacted her to discharge Resident 1, she understood Resident 1's condition was "super stable." When asked what she expected the facility's nursing staff to do when monitoring weight gain in [MEDICAL CONDITION] patients, MD E stated it should be similar to outpatients, who are educated to contact their physician for a two to three lb weight gain over several days. On [DATE] at 3:15 pm, when Adm Nurse A and B were concurrently asked how MD E was able to effectively decide to discharge Resident 1, based on the inaccurate weight gain they had provided to her on [DATE] and the lack of communication about Resident 1's [MEDICAL CONDITION], shortness of breath, and wheezing (all signs of worsening heart failure), neither Adm Nurse A or B was able to answer. On [DATE] at 3:35 pm, Adm Nurse B confirmed the facility did not have a nursing policy for management of heart failure patients. Adm Nurse B was not able to verbalize when nursing would be expected to contact a physician about a residents worsening heart failure signs and symptoms. Adm Nurse B was not able to explain why Resident 1's physician was not notified of her 15 lb weight gain in three weeks, the presence of [MEDICAL CONDITION], or her wheezing and shortness of breath the morning of discharge [DATE], all indications of fluid overload and exacerbation of heart failure.

Unannounced visits were made to the facility on [DATE], [DATE], [DATE] and [DATE] to investigate entity reported incident 4 regarding Resident 1's death after sustaining a fall. This citation was written as a result of observations, staff written statements, and interviews and clinical record review. The Department determined that the facility failed to: Ensure that Resident 1 remained free of injury while being transferred out of a bathtub via a mechanical lift chair, when on [DATE] at 9:45 am, certified nursing assistant (CNA 1)transferred Resident 1 out of a bathtub via a mechanical lift chair by herself. Based on the facility's Mechanical Lift policy, CNA 1 was required to have two persons to transfer Resident 1 when using a mechanical lift chair. This failure resulted in Resident 1 falling out of the mechanical lift chair into the bottom of the empty bathtub, where he sustained a large gash on his head, and three breaks in the bones in his neck. Resident 1 died four days later on [DATE]. On [DATE], the facility notified the Department that Resident 1 had died on [DATE] after sustaining a fall at the facility on [DATE]. Resident 1's skilled nursing facility (SNF) clinical record was reviewed on [DATE], [DATE] and [DATE]. Resident 1 had been readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's care plan, dated [DATE], indicated that he was at risk for falls related to his poor body posture, weakness, inability to reposition self, and need for assist with transfer. The initial Physical Restraint Assessment form, dated [DATE], contained documentation that the facility was using a self release seat belt for safety due to Resident 1's inability to consider his own lack of independence and that he falls/slides out of chairs. The Minimum Data Set (an assessment tool), dated [DATE], noted that Resident 1 was alert and able to make his needs known. He required extensive assistance (meaning that Resident 1 was involved in the activity but required staff to provide weight-bearing support) for transfers. On [DATE], Resident 1 had been placed on hospice care due to his declining condition, which included progressive muscle weakness that resulted in his inability to sit upright without support. CNA 1 was a hospice CNA who had been caring for Resident 1 on [DATE] through a facility contract with the hospice agency. The facility's Mechanical Lift policy, undated, provided by the facility's Director of Staff Development indicated that, "...Assistance of two personnel will be used with Mechanical Lift..." On [DATE] at 9:45 am, CNA 1 transferred Resident 1 out of a bathtub via a mechanical lift chair by herself. CNA 1 turned away from Resident 1 to get a towel and he fell forward from the lift chair into the bottom of the empty bathtub. He sustained a nine and a half inch gash on the top of his head and was complaining of neck pain. In an interview with CNA 1 on [DATE] at 4:30 pm, she stated that [DATE] was the first time she had provided care for Resident 1 and she was not familiar with his care needs. She also stated that the last time she had given a resident a tub bath using a mechanical lift was a, "few months prior." CNA 1 also stated that she was aware that the use of a mechanical lift chair for transfers required two persons. She stated that on the morning of [DATE], she and a second CNA (CNA 5), transferred Resident 1 from his bed to the portable portion of the chair lift, wheeled him into the shower room, and together transferred him into the bathtub. She declined further assistance from CNA 5 who then left the room. In the written statement by CNA 1, dated [DATE], she indicated that when she was asked by CNA 5 if she had ever used the bathtub before when they were assisting Resident 1 into the bathtub, she documented, "yes, but it was a long time ago." CNA 1 stated that, at approximately 9:45 am, while bathing Resident 1, he began leaning forward into the water. CNA 1 began draining the bathtub of water as she assisted Resident 1 back to an upright position, but he fell forward again. CNA 1 stated she requested assistance from other CNAs in the shower room, pulled the emergency cord and heard the alarms. At this point, she opted to transfer Resident 1 from the bathtub by herself. She had raised Resident 1 out of the bathtub via the mechanical lift chair and turned to grab a towel. CNA 1 stated she heard a sound and turned to see Resident 1 lying into the bottom of the empty bathtub. He was complaining of pain in his neck. Review of investigative statements made by CNAs 2, 3, 4, and 5 document that CNA 4 was in the shower room when CNAs 1 and 5 brought Resident 1 into the room and transferred him into the bathtub. CNA 4 wrote that she heard CNA 1 say to Resident 1, "If you cannot keep your head above the water, then we will have to get out." CNA 4 asked CNA 1 if she needed help transferring Resident 1 out of the bathtub. CNA 1 responded that she, "Was okay, but in hindsight, she would not have given him a tub bath if she realized how contracted he was, he kept leaning very forward." CNAs 2 and 3 were in the shower room with another resident when they heard a noise and CNA 1 calling, "I need help". CNA 3 responded and saw CNA 1 trying to get Resident 1 out of the bathtub but it was too deep. CNAs 2 and 3 pulled the emergency light and CNA 2 went for help. CNA 4 had left the shower room, saw the red light on, and responded with several other CNAs. Resident 1 was removed from the bathtub by paramedics and transferred by ambulance to an emergency roiagnom on [DATE] at 10 am. The emergency room record, dated [DATE], noted that Resident 1's head wound was stitched closed. X-rays of his neck revealed, "1. Acute mildly displaced obliquely oriented (diagonally or slanted) fracture through the odontoid process (a tooth like projection from the upper surface of the body of the second cervical (neck) vertebra (one of 7 bony segments of the spinal column in the neck); 2. Acute mildly displaced fracture of the anterior arch (front bowlike structure) of C1 (first neck vertebra); 3. There is antero-infero-lateral (a frontward, downward, to the side) subluxation (partial or incomplete dislocation) of the right lateral mass (right side of second neck vertebra) and there is a small associated impaction (ends of bones wedged together) fracture of the pedicle (the bony process which projects backward from the body of the vertebra) of C2 (second neck vertebra). Resident 1 had two broken vertrebrae in the neck. One of those two vertebrae (C2) had two separate breaks. He was returned to the facility on [DATE] at 4:05 pm. Physician (MD) A's progress notes, dated [DATE] at 6 am, read that Resident 1, "...had a very traumatic fall 2 days ago with UNSTABLE C1-C2 (cervical neck) fracture (broken bones in neck) and closed head injury...was not a surgical candidate and was unable to be fitted with a traditional C-spine collar (neck support) due to severe kyphosis...Spoke with wife...bluntly told her that with patient's... non immobilization that he would probably die from aspiration pneumonia or P.E. (pulmonary embolism - a clot in the lungs)...goal with patient will be comfort care and ultimately a peaceful death." During an interview with MD A on [DATE] at 4:50 pm he stated that C1-C2 fracture injuries (broken neck bones) often caused interference with the functioning of a major nerve from the neck region of the spine that carried impulses to the diaphragm (breathing muscle). This interference had the potential to cause paralysis of the diaphragm and lead to respiratory (breathing) failure and death. A certified copy of the Death Certificate, dated [DATE], listed the cause of death on [DATE] as, " (A) Respiratory Failure; (B) C1-C2 Fracture - Unstable; (C) Head Trauma; (D) Mechanical Fall." In an interview with Director of Staff Development (DSD 6) on [DATE] at 10:50 am, she stated she had not performed any training to CNAs, including hospice CNAs for the use of the mechanical lift chair for the bathtub. She stated that she took the hospice CNAs "word" that they were competent to use the mechanical lifts. In an interview with the Administrator on [DATE] at 2:45 pm, he stated that the facility did not use a checklist to verify competencies of hospice CNAs. The Orientation Checklist provided by the Hospice facility for CNA 1 did not contain any documentation that she had been trained on the use of a mechanical lift. The document titled, "Evaluation of Hospice Aide Competency" dated [DATE] for CNA 1, had a blank area for evaluating her competency to perform a, "tub bath." In an interview with CNA 1 on [DATE] at 3:30 pm, she stated she had been trained on the use of a chair lift in 1998 but did not remember being checked that she was competent to use the lift. Therefore, the facility failed to ensure that Resident 1 remained free of injury while being transferred out of a bathtub via a mechanical lift chair. On [DATE] at 9:45 am, CNA 1 transferred Resident 1 out of a bathtub via a mechanical lift chair by herself. She was required to have two persons to transfer him when using a mechanical lift chair. This resulted in Resident 1 falling out of the mechanical lift chair into the bottom of the bathtub, where he sustained a large gash on his head and three breaks in the bones in his neck. Resident 1 died four days later on [DATE]. This violation presented, either an imminent danger that death or serious harm would result or, substantial probability that death or serious physical harm would result and was the direct proximate cause of the death of Resident 1.