Every finding on record at Del Amo Gardens Care Center

Based on observation, interview, and record review, the facility failed to ensure medical records for three of five sampled residents (Residents 1, 5, and 7) were accurate, complete and readily accessible by failing to: 1. Document Resident 1 received Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment on 12/19/2025, 12/26/2025, 1/13/2026, and 1/19/2026. 2. Document Resident 5 received RNA treatment on 12/26/2025, 12/31/2025, and 1/19/2026. 3. Document Resident 7 received RNA treatment on 12/26/2025, 12/31/2025, and 1/19/2026. 4. Clarify daily dose of Risperdal ([Generic name - Risperidone] a medication used to treat bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]) for Resident 1.These deficient practices resulted in inaccurate and unclear medical documentation, misunderstanding among facility's licensed nursing staff and had the potential to cause inaccurate care planning, medication errors and/or inappropriate treatment of mental disorders for Residents 1, 5 and 7.Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to metabolic encephalopathy (brain dysfunction caused by chemical imbalances), dementia (a progressive state of decline in mental abilities), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool) dated 10/25/2025, the MDS indicated Resident 1 was severely impaired in cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 did not have any limitations in range of motion (ROM, full movement potential of a joint) in either side of the upper extremity (UE, shoulder, elbow, wrist/hand) and had functional limitations in ROM in one side of the lower extremity ([NAME], hip, knee, ankle/foot). The MDS indicated Resident 1 required dependent assistance with dressing, bathing, and maximal assistance with sit to lying and rolling left and right. During a review of Resident 1's Order Summary Report dated 1/21/2026, the Order Summary Report indicated an order dated 11/26/2025 for RNA program for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to both [NAME] once a day five times a week as tolerated. During a review of Resident 1's Care Plan initiated on 11/25/2025, the Care Plan indicated Resident 1 was at risk for developing both [NAME] contractures (loss of motion of a joint). The Care Plan goal indicated Resident 1 will have reduced risk for developing both [NAME] contractures related to impaired mobility. The Care Plan intervention indicated for RNA program for PROM exercises to both [NAME] once a day five times a week as tolerated. During an observation and interview on 1/21/2026 at 9:03 a.m., Certified Nursing Assistant (CNA 3) and Certified Nursing Assistant (CNA 1) assisted Resident 1 to put on clothes. Resident 1 was lying on his back and the left leg was crossed over the upper right leg. The left knee was bent and the right leg was straight. CNA 3 and CNA 1 required multiple attempts to put on jeans on Resident 1's legs. CNA 3 stated it was difficult to put on the pants because the right leg could not move and the left leg was bent. During a concurrent interview and record review on 1/22/2026 at 10:37 a.m., with the Director of Staff Development (DSD), Resident 1's December 2025 and January 2026 RNA DSR were reviewed. The DSD stated if the RNA DSR was blank, it meant Resident 1 did not receive RNA treatment that day or the RNAs did not document any treatments for that day. DSD confirmed the RNA DSR was blank on 12/19/2025, 12/26/2025, 1/13/2026, and 1/19/2026. The DSD reviewed the Nursing Sign-In sheets and DSD stated one or two RNAs worked on those days. The DSD stated if RNAs completed the RNA treatment, then RNAs should document each time an RNA treatment was completed right after the treatment or at least by the end of the shift. The DSD stated it was important to document each treatment timely so that staff could know if the resident completed their RNA treatments and the resident's tolerance to the RNA treatment. During a concurrent interview and record review on 1/22/2026 at 1:58 p.m., with Restorative Nursing Aide (RNA 3), Resident 1's December 2025 and January 2026 RNA DSR were reviewed. RNA 3 confirmed she completed PROM exercises with Resident 1 on 12/19/2025, 12/26/2025, and 1/13/2026, but did not realize she did not document on Resident 1. RNA 3 stated she did not double-check if the documentation was completed and should ensure that documentation was completed for each resident. During a concurrent interview and record review on 1/22/2026 at 2:24 p.m., with Restorative Nursing Aide (RNA 1), Resident 1's January 2026 RNA DSR was reviewed. RNA 1 stated she performed RNA PROM exercises with Resident 1 on 1/19/2026 but did not have time to complete the documentation because she was the only RNA working that day. RNA 1 stated she should document all RNA treatments by the end of the shift but stated she did not always have time to complete the documentation. During an interview on 1/22/2026 at 3:34 p.m., the Director of Nursing (DON), the DON stated all RNA staff were supposed to document each time they provide RNA treatment with a resident. The DON stated it was important to document each time so that staff knew the job (RNA treatment) was completed, how the resident responded to the treatment, or if the RNA treatment did not happen. The DON stated RNA staff should be given time to complete documentation because it was important to document everything that was done for each resident. During a review of the facility's policies and procedures (P&P) titled, Documentation Policy, revised 1/2025, the P&P indicated it is the policy of this facility to document relevant findings in the clinical record. 2. During a review of Resident 5's admission Record , the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to metabolic encephalopathy, hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left non-dominant side. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 5 did not have any limitations in ROM in both sides of the upper extremities and had functional limitations on both sides of the lower extremities. The MDS indicated Resident 5 required maximal assistance with eating, oral hygiene. The MDS indicated Resident 5 required dependent assistance with dressing, sit to lying, and bed to chair transfers. During a review of Resident 5's Order Summary Report dated 1/21/2026 the Order Summary Report indicated an order dated 11/25/2025 for RNA program for PROM exercises to both [NAME] once a day five days a week as tolerated. During a review of Resident 5's Order Summary Report dated 1/21/2026, the Order Summary Report indicated an order dated 11/25/2025 for RNA program for RNA to perform PROM exercises on left UE once a day five days a week as tolerated. During a review of Resident 5's Order Summary Report dated 1/21/2026, the Order Summary Report indicated an order dated 11/25/2025 for RNA program for RNA to apply resting hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) on left hand for four hours once a day five days a week as tolerated. During a review of Resident 5's Care Plan initiated on 11/25/2025, the Care Plan indicated Resident 5 was at risk for decline in left UE ROM. The Care Plan goal indicated Resident 5 will be able to maintain current left UE ROM. The Care Plan intervention indicated for RNA to perform PROM exercises on left UE once a day, five times a week as tolerated. RNA to apply resting hand splint on left hand for four hours once a day five times a week as tolerated. During a review of Resident 5's Care Plan initiated on 11/25/2025, the Care Plan indicated Resident 5 was at risk for developing contractures to both [NAME]. The Care Plan goal indicated Resident 5 will have reduced risk of developing both [NAME] contractures. The Care Plan intervention indicated for an RNA program for PROM exercises to both [NAME] once a day five times a week as tolerated. During an observation and interview on 1/21/2026 at 9:32 a.m., with Resident 5, Resident 5 was lying in bed. Resident 5 was wearing a resting wrist/hand splint on the left wrist/hand. Resident 5's left arm was straight, and the left wrist/hand was resting on a pillow. Resident 5 denied any pain and was able to move the right arm a little. During a concurrent interview and record review on1/22/2026 at 10:37 a.m., with the Director of Staff Development (DSD), Resident 5's December 2025 and January 2026 RNA DSR were reviewed. DSD stated if the RNA DSR was blank, it meant Resident 5 did not receive RNA treatment that day or the RNAs did not document any treatments for that day. DSD confirmed the RNA DSR was blank on 12/26/2025, 12/31/2025, and 1/19/2026. DSD reviewed the Nursing Sign-In Sheet and DSD stated one or two RNAs were staffed on those days. DSD stated if RNAs completed the RNA treatment, then RNAs should document each time an RNA treatment was completed right after the treatment or at least by the end of the shift. DSD stated it was important to document each treatment timely so that staff can know if the resident completed their RNA treatments and the resident's tolerance to the RNA treatment. During a concurrent interview and record review on 1/22/2026 at 1:58 p.m., with Restorative Nursing Aide (RNA 3), Resident 5's December 2025 RNA DSR were reviewed. RNA 3 confirmed she completed ROM exercises with Resident 5 on 12/26/2025, 12/31/2025, but did not realize she did not document on Resident 5. RNA 3 stated she did not double check if the documentation was completed and should ensure that documentation was completed for each resident RNA 3 performed RNA treatment with. During a concurrent interview and record review on 1/22/2026 at 2:24 p.m., with Restorative Nursing Aide (RNA 1), Resident 5's January 2026 RNA DSR was reviewed. RNA 1 stated she performed RNA PROM exercises with Resident 5 on 1/19/2026 but did not have time to complete the documentation because she was the only RNA working that day. RNA 1 stated she should document all RNA treatments by the end of the shift but stated she did not always have time to complete documentation. During an interview on 1/22/2026 at 3:34 p.m., the Director of Nursing (DON) stated all RNA staff were supposed to document each time they provide RNA treatment with a resident. DON stated it was important to document each time so that staff knew the job was completed and how the resident responded to the treatment or if the RNA treatment did not happen. DON stated RNA staff should be given time to complete documentation because it was important to document everything that was done for each resident. During a review of the facility's policies and procedures (P&P) titled, Documentation Policy, revised 1/2025, the P&P indicated it is the policy of this facility to document relevant findings in the clinical record. 3. During a review of Resident 7's admission Record , the admission Record indicated Resident 7 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to acute kidney failure (sudden loss of kidney function to filter waste products) and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had severe impairment in cognitive skills. The MDS indicated Resident 7 did not have any limitations in ROM in both upper extremities and had impairments on both sides of the lower extremities. The MDS indicated Resident 7 required supervision with eating. The MDS indicated Resident 7 required dependent assistance from staff for sit to lying, bed to chair transfers, and lower body dressing. During a review of Resident 7's Order Summary Report dated 1/21/2026, the Order Summary Report indicated an order dated 9/11/2025 for RNA to perform PROM exercises on both upper extremities and both lower extremities once a day, five days a week as tolerated. During a review of Resident 7's Care Plan initiated on 9/11/2025, the Care Plan indicated Resident 7 was at risk for decline in ROM and strength in both UE. The Care Plan goal indicated Resident 7 will be able to maintain current ROM and strength in both UE. The Care Plan intervention indicated RNA to perform PROM exercises on both UE once a day five times a week as tolerated. During a review of Resident 7's Care Plan initiated on 9/11/2025, the Care Plan indicated Resident 7 was at risk for contracture on both [NAME] related to impaired mobility. The Care Plan goal indicated Resident 7 will have reduced risk/delay onset of contractures on both [NAME]. The Care Plan intervention indicated RNA to perform PROM exercises on both [NAME] once a day, five days a week as tolerated. During an observation and interview on 1/21/2026 at 1:43 p.m., Restorative Nursing Aide (RNA 1) performed RNA ROM exercises with Resident 7 in Resident 7's room. Resident 7 was lying in bed and RNA 1 was able to lift Resident 7's arm up and down to around shoulder level. Resident 7 was able to bend and straighten both elbows, wrists, and fingers. RNA 1 was able to bend both hips and knees about halfway and move both ankles up and down. During a concurrent interview and record review on1/22/2026 at 10:37 a.m., with the Director of Staff Development (DSD), Resident 7's December 2025 and January 2026 RNA DSR were reviewed. DSD stated if the RNA DSR was blank, it meant Resident 7 did not receive RNA treatment that day or the RNAs did not document any treatments for that day. DSD confirmed the RNA DSR was blank on 12/26/2025, 12/31/2025, and 1/19/2026. DSD stated one to two RNAs were staffed on those days. DSD stated if RNAs completed the RNA treatment, then RNAs should document each time an RNA treatment was completed right after the treatment or at least by the end of the shift. DSD stated it was important to document each treatment timely so that staff can know if the resident completed their RNA treatments and the resident's tolerance to the RNA treatment. During a concurrent interview and record review on 1/22/2026 at 1:58 p.m., with Restorative Nursing Aide (RNA 3), Resident 7's December 2025 RNA DSR were reviewed. RNA 3 confirmed RNA 3 completed ROM exercises with Resident 7 on 12/26/2025, 12/31/2025, but did not realize she did not document on Resident 7. RNA 3 stated she did not double check if the documentation was completed and should ensure that documentation was completed for each resident RNA 3 performed RNA treatment with. During a concurrent interview and record review on 1/22/2026 at 2:24 p.m., with RNA 1, Resident 7's January 2026 RNA DSR was reviewed. RNA 1 stated she performed RNA PROM exercises with Resident 7 on 1/19/2026 but did not have time to complete the documentation because she was the only RNA working that day. RNA 1 stated she should document all RNA treatments by the end of the shift but stated she did not always have time to complete documentation. During an interview on 1/22/2026 at 3:34 p.m., the Director of Nursing (DON) stated all RNA staff were supposed to document each time they provide RNA treatment with a resident. DON stated it was important to document each time so that staff knew the job was completed and how the resident responded to the treatment or if the RNA treatment did not happen. DON stated RNA staff should be given time to complete documentation because it was important to document everything that was done for each resident. During a review of the facility's policies and procedures (P&P) titled, Documentation Policy, revised 1/2025, the P&P indicated it is the policy of this facility to document relevant findings in the clinical record. 4. During a review of Resident 1's admission Record , dated 1/22/2026, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] with initial admission date of 8/19/2025 and readmission date as 10/23/2025 with diagnoses that included but not limited to unspecified dementia (a progressive state of decline in mental abilities), unspecified severity with mood disturbance, bipolar disorder, unspecified and depression (a mental disorder with depressed mood or loss of pleasure or interest in activities for long periods of time), unspecified. During a review of Resident 1's History and Physical, dated 11/4/2025, the document indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 1 needed supervision or touching assistance from the facility staff for performing activities of daily living (ADLs – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating and oral hygiene, and was dependent for toileting hygiene, showering, upper body dressing, lower body dressing, putting on or taking off footwear and personal hygiene. During a review of Resident 1's Order Summary Report dated 1/22/2026, the order summary report indicated but not limited to the following physician order: Risperdal oral tablet 2 milligrams ([mg] a unit of measurement for mass), give 1 tablet by mouth at bedtime for Bipolar with psychotic features manifested by (m/b) kicking, inform consent obtained by doctor, from resident's daughter for the use of Risperdal, order date 10/23/2025, start date 10/24/2025. Monitor behavior manifested by (m/b) hitting staff and document number (no.) of episodes every shift, order date 10/23/2025, start date 10/23/2025. Monitor episodes of kicking every shift, order date 10/23/2025, start date 10/23/2025. During a concurrent interview and record review on 1/22/2026 at 2:58 p.m. with Registered Nurse Supervisor (RNS) 1, Resident 1's Monthly Psychotropic Summary Sheet, dated 11/4/2025 to 11/30/2025 and 12/1/2025 to 12/31/2025, and informed consent, dated 12/5/2025 for Risperdal were reviewed. The psychotropic summary sheet indicated, Medication: Risperdal 2 mg PO (by mouth) QHS (every night at bedtime) and 1 mg PO QAM (every day in the morning), Behavioral manifestations: bipolar with psychotic features m/b kicking. The document indicated number of behavior episodes per shift, total episodes, adverse reactions, observation comments, date and the nurse's signature. The document indicated a section for dosage changes with the note, 12/5/2025: Decrease Risperdal 0.5 mg 1 tab PO (by mouth) daily, GDR (gradual dose reduction). RNS 1 stated there was a GDR for Resident 1's Risperdal to reduce to Risperdal 0.5 mg 1 tablet po (by mouth) daily. RNS 1 stated, this was an incorrect order. RNS 1 scratched the note by drawing a line over it, stated the note was documented for a wrong resident and that it was a typographical error because Resident 1 was still on Risperdal 2 mg, 1 tablet by mouth at bedtime. RNS 1 stated there was a risk that the inaccurate documentation could have led to change in dosage when Resident 1's behaviors did not indicate the dose should be lowered. RNS 1 then pointed out that the informed consent for Resident 1's Risperdal indicated Risperdal 0.5 mg, 1 tablet by mouth daily for psychotic features m/b kicking. RNS 1 stated the dose on informed consent was incorrectly documented. RNS 1 stated he would need to check with medical records if there were other facility residents on Risperdal. During a concurrent interview and record review on 1/22/2026 at 3:37 p.m. with RNS 1 and Licensed Vocational Nurse (LVN) 2, LVN 2 stated there were no other residents who were supposed to be on Risperdal. LVN 2 stated there was a GDR. RNS 1 stated there was no GDR because he could not find a progress note from the physician. RNS 1 stated he would call Resident 1's psychiatrist or medical doctor (MD) 2 to verify current dose of Risperdal. RNS 1 stated the psychiatrist (MD 2) was not aware of any dose changes. LVN 2 stated it was Resident 1's primary physician (MD 1) who reduced Resident 1's Risperdal dose not the psychiatrist (MD 2). During an interview on 1/22/2026 at 3:44 p.m. with LVN 2 and RNS 1, LVN 2 stated she had requested a GDR from MD 1 during his evening visit to the facility on [DATE]. LVN 2 stated MD 1 reduced Resident 1's Risperdal from 1 mg every morning to 0.5 mg every morning and to continue Risperdal 2 mg at bedtime on 12/4/2025. LVN 2 stated Resident 1's Risperdal 0.5 mg every morning was discontinued on 1/9/2026 and Risperdal 2 mg daily at bedtime was continued as per physician's orders. RNS 1 and LVN 2 stated it caused a lot of confusion regarding Resident 1's Risperdal order because of missing documentation and lack of communication. RNS 1 stated the GDR note would not reflect accurate treatment for Resident 1. RNS 1 rewrote the note 12/5/2025: Decrease Risperdal 0.5 mg PO (by mouth) daily, GDR. During a concurrent interview and record review on 1/23/2026 at 10:34 a.m. with the Director of Nursing (DON), Resident 1's Monthly Psychotropic Summary Sheet, dated 11/4/2025 to 11/30/2025 and 12/1/2025 to 12/31/2025 was reviewed. The DON stated a psychiatrist (MD 2) would usually recommend GDR for residents taking psychotropic medications. The DON looked at the Psychotropic Summary Sheet and stated she was really confused and did not know what to say. The DON stated the orders would need to be transcribed in the electronic health record (EHR) first before being handwritten on Psychotropic Summary Sheet. The DON stated the nurses would not check the paper every day but they should check the EHR daily. The DON stated there should be one system that involved psychiatrist (MD 2) to change psychotropic medication doses for Resident 1 to avoid confusion. DON stated the licensed nursing staff should inform MD 2 if MD 1 changed psychotropic medication order. The DON stated she needed time to read through all progress notes because she could not figure out history of dose changes for Resident 1's Risperdal and the handwritten transcription and order for Risperdal was very unclear and confusing. During a review of the facility's policy and procedure (P&P), titled Dignity and Respect Psychoactive Medications, dated 01/2025, the P&P indicated, Gradual Dose Reduction - The facility shall document evidence that a GDR has been attempted unless clinically contraindicated in the medical record. The P&P indicated, GDR Documentation – The medical record shall reflect the date the gradual dose reduction was attempted, the outcome of the dose reduction attempt, and the plan regarding future GDR attempts. Physician documentation should contain the rationale for why GDR attempts are clinically contraindicated for the resident.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to prevent the infestation of gnats (fruit flies: flying, winged insects) by not ensuring a sanitary environment for three of five residents (Residents 6, 22, and 69). This deficient practice had the potential to cause an increased risk of pest infestation, which could compromise infection control measures and negatively impact the health, safety, and well-being of 73 residents that reside in the facility. Findings:During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool) dated 12/6/2025, the MDS indicated Resident 6's cognition (ability to think, understand, learn, and remember) was severely impaired and required moderate assistance (helper does less than half the effort) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves).During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) and immunodeficiency (the decreased ability of the body to fight infections and other diseases).During a review of Resident 22's MDS dated [DATE], the MDS indicated Resident 22's cognition was severely impaired and required maximal assistance with oral hygiene, toileting, and showering.During a review of Resident 69's admission Record, the admission Record indicated Resident 69 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular heartbeat) and urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of Resident 69's MDS dated [DATE], the MDS indicated Resident 69's cognition was moderately impaired and required maximal assistance with ADLs.During an observation 1/20/2026 at 9:28 a.m., in Resident 22's room, three gnats were observed on Resident 22's pillow, a cord next to Resident 22's bed, and one flying around Resident 22's coffee mug.During an interview on 1/20/2026 at 9:57 a.m., with Resident 6, Resident 6 stated the care was great except for the gnats in his room. Resident 6 stated he notices the gnats every day and has told the staff about it. During a subsequent interview on 1/21/2026 at 8:56 a.m., with Resident 6, Resident 6 stated gnats were still present, stating, In fact, there is one flying around me right now. Resident 6 expressed concern that the gnats were unsanitary.During an interview on 1/22/2026 at 1:50 p.m., with Restorative Nurse Assistant (RNA) 2, RNA 2 stated she observed gnats while feeding a resident and the resident attempted to swat the gnat and hit herself in the face. RNA 2 stated the gnats could potentially land on the resident's food which was unsanitary.During an interview on 1/22/2026 at 2:12 p.m., with the Infection Prevention Nurse (IPN), IPN stated there has been an ongoing issue with gnats. IPN stated the gnats were not sanitary, especially if they land on residents' food.During an interview on 1/23/2026 at 11:19 a.m., with the Director of Nursing (DON), DON stated the gnats were unsanitary and could potentially land in the residents' food causing the residents to feel uncomfortable.During a review of the facility's policy and procedure (P&P) titled, Pest Control Program, dated 1/2025, the P&P indicated, To maintain a safe, sanitary environment that is free from insects, rodents, and other pests through an effective, integrated pest management program.

Based on interview and record review, the facility failed to develop an individualized care plan with measurable objectives, timeframes, and interventions to meet the resident's needs for one of three sampled residents (Resident 34). The facility failed to include goals and interventions related to Resident 34's antibiotic therapy (medication prescribed to treat infection).This deficient practice had the potential to negatively impact on the delivery of necessary care and services to Resident 34. Findings:During a review of Resident 34's admission Record, Resident 34 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and dementia (a progressive state of decline in mental abilities).During a review of Resident 34's Minimum Data Set (MDS- a resident assessment tool) dated 10/17/2025, the MDS indicated Resident 34's cognition (ability to think, understand, learn, and remember) was severely impaired and required moderate (helper does less than half the effort) assistance with toileting, bathing, and dressing.During a review of Resident 34's Order Details dated 8/15/2025, the Order Details indicated an order for Ceftriaxone (antibiotic- medication to treat infection) one gram (g- unit of measurement) for urinary tract infection (UTI- infection in the bladder/urinary tract) for five days.During a concurrent interview and record review on 1/22/2026 at 9:11 a.m., with the Infection Prevention Nurse (IPN), the IPN stated Resident 34 was readmitted to the facility on [DATE] with a UTI and prescribed an antibiotic.During a subsequent interview on 1/22/2026 at 10:23 a.m., with the IPN, the IPN stated there was not a care plan for Resident 34's antibiotic but one should have been developed to ensure the resident was properly monitored.During an interview on 1/23/2026 at 11:20 a.m., with the Director of Nursing (DON), the DON stated Resident 34's care plan should have been developed for Resident 34's antibiotic usage. The DON stated the care plan was essential because it guides how residents were monitored, the approach taken in their care, and the goals that need to be met. During a review of the facility's policy and procedure (P&P) titled, Develop-Implement Comprehensive Care Plans, dated 1/2025, the P&P indicated, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Residents 22) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) and mobility by failing to provide Resident 22 Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment for ambulation (walking) on 1/19/2026. This deficient practice had the potential for Resident 22 to decline in ambulation and overall physical functioning.Findings: During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to non-Hodgkin lymphoma (cancer in white blood cells) and encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of serious illness). During a review of Resident 22's Minimum Data Set (MDS, resident assessment tool) dated 10/16/2025, the MDS indicated Resident 22 was moderately impaired in cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 22 did not have any limitations in range of motion in both arms and legs. The MDS indicated Resident 22 required supervision with eating and oral hygiene and moderate assistance with sit to stand, bed to chair transfer and with walking 10 feet. During a review of Resident 22's Order Summary Report dated 1/22/2026, the Order Summary Report indicated a physician order dated 7/7/2025 for RNA for ambulation with front-wheeled walker (FWW, type of mobility aid with wide base of support and two wheels in the front) once a day five times a week. During a review of Resident 22's Care Plan dated 7/7/2025, the Care Plan indicated Resident 22 was at risk for decline in ability to ambulate with assistance. The Care Plan goal indicated Resident 22 will maintain ability to ambulate with assistance of RNA. The Care Plan interventions indicated RNA for ambulation with FWW once a day five times a week as tolerated. During a review of Resident 22's RNA Documentation Survey Report for January 2026, the RNA Documentation Survey Report indicated no documentation (blank) for RNA treatment on 1/19/2026. During an observation and interview on 1/22/2026 at 10:30 a.m., Restorative Nursing Aide 2 (RNA 2) approached Resident 22 who was sitting in a wheelchair outside of Resident 22's room. Resident 22 stood up and walked using a FWW with RNA 2 down the hallway and sat down to rest after the nursing station. Resident 22 stated she was tired and wanted to rest. During a concurrent interview and record review on 1/22/2026 at 10:37 a.m., with the Director of Staff Development (DSD), Resident 22's January 2026 RNA Documentation Survey Report was reviewed. DSD stated if the RNA Documentation Survey Report was blank, it meant Resident 22 did not receive RNA treatment that day or the RNAs did not document any treatments for that day. DSD confirmed on 1/19/2026, the RNA treatment was blank and was not documented. DSD reviewed the Nurse Staff Sign-In Sheet and indicated only one RNA worked on 1/19/2026 (Restorative Nursing Aide 1 [RNA 1]). DSD stated the other RNA assigned that day (1/19/26) did not report to work that day. DSD stated the facility did not have a process to make up any missed RNA treatments if an RNA did not come to work on a scheduled day. DSD stated it was important for residents who had RNA treatment orders to receive their RNA treatments as ordered, because if residents did not receive their RNA treatments, residents could have a decrease in mobility or their joints could get stiff and cause contractures (loss of motion of a joint). During an interview on 1/22/2026 at 2:24 p.m., RNA 1 stated she was the only RNA that worked on 1/19/2026. RNA 1 confirmed she did not perform any RNA treatments for ambulation for Resident 22 because she did not have time and focused on residents who required ROM exercises and splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) first. During an interview on 1/22/2026 at 3:34 p.m., with the Director of Nursing (DON), the DON stated the RNA program was to help residents maintain their present level of functioning such as their ROM and ambulation. The DON stated if a scheduled RNA did not come to work, then the facility should offer overtime to the working RNA until all the RNA treatments were completed and documented. The DON stated on 1/19/2026, this process did not happen and currently the facility did not have a process to make up any missed RNA treatments on a different day that week. The DON stated residents should receive their RNA treatments as ordered and if a resident did not receive their RNA treatments as ordered, then residents could develop stiffness, contractures, or may not be able to walk any more. During a review of the facility's policies and procedures (P&P) titled, Restorative Nurse Services, revised 1/2025, the P&P indicated The facility provides and each resident shall receive restorative nursing care as needed to help promote optimal safety and independence.as determined by their comprehensive care plan.

Based on observation, interviews, and record review, the facility failed to ensure that six discontinued medication orders, contained in seven medication bubble packs for Resident 92 who was discharged from the facility more than two years ago were removed from medication storage and properly disposed of in accordance with the facility's policy and procedure titled Medication Destruction (revision date: 01/2025). This deficiency affected one of five sampled medication storage locations (Director of Nursing [DON] office). This deficient practice of failing to ensure removal of discontinued medications that could be expired, ineffective or toxic increased the risk for misuse and drug diversion of Resident 92's medications.Findings:During a review of Resident 92's admission Record, dated [DATE], the admission Record indicated Resident 92 was admitted to the facility on [DATE] and discharged on [DATE].During a review of Resident 92's History & Physical, dated [DATE], the document indicated Resident 92 had fluctuating capacity to understand and make decisions.During a concurrent observation and interview on [DATE] at 12:57 p.m. with the DON in the DON's office, regarding disposition of controlled (drugs or chemicals regulated by the government because they have a high potential for abuse, misuse, and addiction) and noncontrolled medications, the DON opened the locked storage cabinet and one of the drawers of the locked storage cabinet contained an opaque linen bag which contained Resident 92's Discharge summary, dated [DATE], with discharge date of [DATE] and the following seven medication bubble packs (a method of organizing medication where individual doses [pills or capsules] are sealed in small plastic cavities [bubbles] ) or cards:1. 25 tablets of Quetiapine fumarate (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought], bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs] and as an adjunct treatment option for depression (a serious mood disorder causing persistent sadness and loss of interest, affecting thoughts, feelings, and daily activities) 25 milligrams ([mg] a unit of measurement for mass) that indicated, A.M. (morning dose), Give 1 tablet by mouth two times a day for dementia (a progressive state of decline in mental abilities) w/ (abbreviation for with) behavioral.2. 24 tablets of Quetiapine fumarate 25 mg that indicated, P.M. (evening dose), Give 1 tablet by mouth two times a day for dementia w/ behavioral.3. 26 tablets of Quetiapine fumarate 50 mg that indicated, bedtime, Take 1 tablet by mouth every night at bedtime.4. One capsule of Duloxetine hydrochloride (HCl) (a medication used to treat depression and other mood disorders) delayed release (DR) 20 mg that indicated, A.M., Give 1 capsule by mouth one time a day for depression mb (abbreviation for manifested by) sad.5. One tablet of Pantoprazole sodium delayed release (DR) 40 mg that indicated, A.M. before meals, Give 1 tablet by mouth before meals for gastrointestinal (GI) prophylaxis.6. Zero quantity of Allopurinol (a medication used to treat gout [a painful inflammatory form of arthritis caused by high uric acid levels forming crystals in joints]) 300 mg that indicated, A.M., Give 1 tablet by mouth one time a day for gout).7. 12 tablets of Olmesartan medoxomil (a medication used to treat high blood pressure) 40 mg that indicated, A.M., Give 1 tablet by mouth one time a day for hypertension (HTN): hold for systolic blood pressure (SBP) less than 110. The DON stated, I'll be very honest and I am sorry, I forgot these medications were here in storage. The DON stated the resident's family was supposed to pick up the medications. The DON stated she did not write on any piece of paper that she contacted the resident. The DON stated she forgot because it was covered by thermometer, other supplies in the cabinet and was hidden in the bag. The DON stated usually the medications would be safe in the DON's office instead of the medication room. The DON stated, unfortunately they (referring to the resident's family) never returned the call. The DON stated if a noncontrolled medication was discontinued, then it should be destroyed within 90 days or sooner. The DON stated she would not be able to return those medications to Resident 92, because they were probably outdated or not the right doses anymore. The DON stated she would inform the physician, Resident 92 and resident's family about this. During a review of the facility's P&P, titled Medication Destruction, dated 01/2025, the P&P indicated, Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. The P&P indicated, Disposal of non-controlled medications, Facility should dispose of discontinued medication, out-dated medications, or medications left in facility after a resident has been discharged within 90 days of the date the medication was discontinued by Physician/Prescriber. Non-controlled medications shall be disposed of in the presence of two nurses, in accordance with applicable State Law.

Based on observation, interview, and record review, the facility failed to maintain the ice machine and scoop bucket under sanitary conditions. The facility failed to:1.Ensure the ice machine does not contain black dust-like substances during inspection.2.Ensure the scoop bucket was clean and sanitary, which had multiple stains in black, brown, and pink colors.This deficient practice had the potential to cause food-borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins ).Findings:During an initial kitchen tour observation and interview on 01/20/26 at 08:33 am, with the Director of Food Services (DFS). The iced machine was observed filled with black dusty substance. The scoop bucket was filled with multiple stains inside the bucket. The DFS stated the ice machine, and the scoop bucket should be always kept clean and sanitary. The DFS stated the maintenance staff was responsible for cleaning the ice machine.During an interview on 01/21/26 at 1:12 pm with the Housekeeping Supervisor (HS), the HS stated that he had spent several hours cleaning the ice machine but may have missed the area containing dust. The HS stated he will ensure the machine will be properly cleaned and will follow the manufacturer's guidelines moving forward. The HS stated that the scoop bucket was cleaned earlier that morning (1/20/26) but will make sure it was thoroughly cleaned and maintained in a sanitary condition to prevent contamination.During a review of the facility's policy and procedures (P&P) titled, Ice Machine and Storage Chest revised in 1/2025, the P&P indicated, Ice machine shall be maintained in accordance with manufacturer cleaning and sanitizing schedules to prevent biofilm, mold, and scale buildup. Ice machines shall be visually inspected weekly for scale, slime mold and or residue. The policy indicated that the ice scoop will be cleaned and sanitized daily by the dietary department. The ice scoop will be kept in a clean container when not in use and will not contain standing water.

Based on observation, interview, and record review the facility failed to ensure:Certified Nursing Assistant (CNA) 1 was wearing gloves when handling soiled linen.Clean linen carts were accessed only by facility staff.Staff performed hand hygiene after touching the trash can lid to open the trash receptacle.This failure had the potential to increase the risk of infection and cross-contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) among residents. Findings: 1. During an observation on 1/20/2026 at 8:46 a.m. in room [ROOM NUMBER], CNA 1 was observed handling soiled linen without gloves. During an interview on 1/21/2026 at 1:15 p.m. with CNA 1, CNA 1 stated gloves should have been worn when handling the soiled linen. CNA 1 stated the importance of wearing gloves when handling soiled linen was to prevent the spread of infection to other residents. CNA 1 stated there would be an increased risk of infection that may result in other residents getting sick and placing their overall health at risk. During an interview on 1/22/2026 at 8:58 a.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated it was important to wear gloves while handling soiled linen to prevent spread of bacteria or cross-contamination to other residents. RNS 1 stated if gloves were not worn and hand washing was not performed after handling soiled linen, there would be a risk for infection and the spread of bacteria to other residents. During a review of the facility policy and procedure (P&P) titled Personal Protective Equipment Gloves revised January 2025, indicated The purpose of this protocol is to provide guidelines for the appropriate use of gloves in the skilled nursing facility to reduce the risk of infection transmission and to protect resident and staff from exposure to blood, body fluids, and other potentially infectious materials.1. Gloves shall be worn when there is anticipated contact with blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, or contaminated items. 2. During an observation on 1/20/2026 at 12:34 p.m. in hallway near room [ROOM NUMBER], a visitor was seen accessing linen from the clean linen cart without staff assistance. During an interview on 1/22/2026 at 8:55 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated clean linen carts should only be accessed by facility staff to prevent the spread of bacteria. CNA 5 stated if visitors were seen accessing clean linen carts without staff assistance there would be a risk for infection to other residents due to cross-contamination. During an interview on 1/22/2026 at 8:58 a.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated the importance of staff assisting visitors to obtain linen from the clean linen cart was to prevent cross-contamination. RNS 1 stated residents may contract infection from linen that was potentially contaminated. During a review of the facility's policy and procedure (P&P) titled Linens revised January 2025, the P&P indicated .4. Laundry and nursing staff will use standard precautions and us PPE (personal protective equipment) while handling all soiled linen. During a review of the facility's policy and procedure (P&P) titled Linens revised January 2025, the P&P did not indicate a procedure for individuals who were designated to access clean linen carts. 3.During a concurrent observation and interview on 1/22/2026 at 11:34 a.m. with the Director of Food Services (DFS), kitchen staff, including the DFS, were observed washing their hands and then touching the trash can lid to dispose of trash. The DFS stated to avoid direct contact with the lid, staff use a clean paper towel to open the trash can; however, he stated this practice could lead to cross-contamination and increase the risk of staff recontamination their hands. The DFS stated that the hands-free trash can was recently broken and that a replacement has already been ordered. During an interview on 01/22/2026 at 2:18 p.m. with the Director of Nursing (DON), the DON stated she was not aware that the kitchen trash was not hands-free. The DON stated from an infection control perspective, the current situation poses a risk for staff to inadvertently contaminate their hands after washing their hands. During an interview on 01/22/2026 at 2:18 p.m., with the Director of Nursing (DON) , the DON states she was not aware that the kitchen trash can was not hand free but will follow up and get a new one. DON states for infection control, it is potential for staff to mistakenly get hands dirty again. During a review of the facility's policy and procedure (P&P) dated 01/2025, titled Hand Washing-Hand Hygiene, the P&P indicated This Facility considers hand hygiene the primary means to prevent the spread of infections. Personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel and residents.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed at risk for falls, and who had Care Plan interventions indicating Resident 1's bed to be in a low position, did not fall. This failure resulted in Resident 1 having an unwitnessed fall from her bed on 7/13/2025 and because of the fall, Resident 1 sustained an abrasion (wound caused by rubbing or scraping the skin against a rough surface) and redness to her forehead, and bilateral knee. Resident 1's bed was found at medium height level (approximately three feet from the floor) per the facility's Post Fall Evaluation dated 7/13/2025, upon her fall. Resident 1 was subsequently transferred to a General Acute Hospital (GACH) for evaluation of her injuries on 7/13/2025 via 911 (emergency transportation). This failure had the potential for Resident 1 to sustain greater injuries.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental activities), muscle weakness and encephalopathy (brain disease, damage, or malfunction).During a review of Resident 1's History and Physical (H&P) dated 1/18/2025, the H&P indicated Resident 1 did not have the capacity to understand and make medical decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 4/23/2025, the MDS indicated Resident 1's cognition (ability to register and recall information) was severely impaired and was sometimes understood and was sometimes able to be understood by others. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half of the effort) from staff for rolling left to right (ability to roll from lying on back to left and right side, and return to lying on back on the bed), sit to lying (ability to move from sitting on side of the bed to lying flat on the bed), lying to sitting on the side of the bed (ability to move from lying on the back to sitting on the side of the bed with no back support), and sit to stand (ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed). The MDS indicated Resident 1 was incontinent (involuntary voiding of urine and stool) in both her bowel and bladder functions). During a review of Resident 1's Fall Risk Evaluation, dated 1/17/2025, the Fall Risk Evaluation indicated Resident 1 was at risk for falls. During a review of Resident 1's Care Plan, revised 1/18/2025, the Care Plan indicated Resident 1 is at risk for falls related to gait and balance problems. The Care Plan interventions included always keep the environment clear of clutter and hazards and position Resident 1's bed in a low position.During a review of Resident 1's Change of Condition (COC) Evaluation, dated 7/13/2025, the COC Evaluation indicated Resident 1 had an unwitnessed fall and was found by Certified Nursing Assistant (CNA) 1, next to her bed, face down on the floor, with her knees on the floor. The COC Evaluation indicated Resident 1 hit her forehead on the floor and had a small abrasion (measurement unknown) and redness on her forehead, and redness on both of her knees.During a review of Resident 1's Order Summary Report (Physician's Orders), dated 7/13/2025, the Physician's Orders indicated to transfer Resident 1 to a GACH via 911 due to an unwitnessed fall with head trauma (an injury to the head, including the scalp, skull, brain and underlying tissues). During a review of Resident 1's Post Fall Evaluation, dated 7/13/2025, the Post Fall Evaluation indicated Resident 1 sustained an unwitnessed fall in her room on 7/13/2025 at 5:40 p.m. The Post Fall Evaluation indicated Resident 1's activity at the time of the fall was unknown, and her bed was found at medium height at the time of her fall. During a review of the Emergency Department (ED) documents dated 7/13/2025, the ED documents indicated Resident 1 was transferred to the ED on 7/13/2025 at 6:42 p.m.During a review of Resident 1's GACH History and Physical (H&P), dated 7/14/2025, the H&P indicated Resident 1 was found to have forehead abrasions (unknown measurement). During an interview on 7/22/2025 at 3:05 p.m., Registered Nurse (RN) 1 stated she was called into Resident 1's room on 7/13/2025 at approximately 5 p.m. by Licensed Vocational Nurse (LVN) 1. RN 1 stated when she entered Resident 1's room she (RN 1) saw Resident 1 on the floor next to her bed. RN 1 stated Resident 1 appeared to be kneeling face down with her forehead on the floor. RN 1 stated she assessed Resident 1 and observed redness on Resident 1's forehead and bilateral knees and an abrasion (unknown measurement) to Resident 1's forehead. RN 1 stated she observed Resident's 1 bed being at a medium height, measuring approximately three feet from the ground. RN 1 stated Resident 1's bed height should have been positioned at the lowest level, as Resident 1 was at risk for falls. RN 1 stated the bed positioned at medium height placed Resident 1 at risk for injuries.During an interview on 7/22/2025 at 3:20 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she was called into Resident 1's room by Certified Nurse Assistant (CNA) 1 on 7/13/2025 at approximately 5 p.m. LVN 1 stated she saw Resident 1 on the floor next to her (Resident 1's) bed. LVN 1 stated Resident 1 was face down, with her knees bent under her and her hands to her side. Resident 1's bed was not at the lowest level. LVN 1 stated the bed must be at the lowest level due to Resident 1 being at risk for falls and injury.During an interview on 7/23/2025 at 1:30 p.m., the Director of Nursing (DON) stated the nursing staff should have implemented safety measures as indicated in Resident 1's Care Plan which was to position Resident 1's bed height at a low position. The DON stated failure to ensure Resident 1's bed was positioned to the lowest level placed Resident 1 at risk for falls which could lead to severe injuries, including death. During a review of the facility's policy and procedure (P&P) titled, Free of Accident Hazards/Supervision/Devices, revised 1/2025, the P&P indicated the facility provides an environment that is free from accident hazards over which the facility had control, and each resident receives adequate supervision and assistive devices for each resident to prevent avoidable accidents. The P&P indicated factors which may result in resident falls include but are not limited to incorrect bed height or width.During a review of the facility's P/P titled Quality of Care, revised 1/2025, the P&P indicated the facility ensures that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person -centered care plan and resident's choices based on the comprehensive assessment of the resident.

Based on interview and record review the facility's Quality Assessment and Assurance (QAA committees established for the purpose of improving the safety and quality of health services) and Quality Assurance Performance Improvement (QAPI- approach to maintain and improve safety and quality in nursing homes) committee failed to implement corrective action to the potential systemic problems identified: 1. Maintain a system to monitor weight loss. 2. Maintain a system to ensure the reporting of falls with major injury. 3. Maintain a system to ensure pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) preventive measures were implemented. Findings: During an interview on 11/23/2024 at 4:40 p.m., with the Director of Nursing (DON), the DON stated the QAA discuss monthly falls, pressure injuries and weight loss. The DON stated there was a need for improvement and will be working on the issues identified as deficient practices. During a review of the facility's policy and procedures (P&P) titled, Quality Assurance Performance Improvement, revised dated 3/2023, the P&P indicated the facility's Purpose Statement was, To provide facility staff with a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety.

Based on interview and record review the facility failed to accurately account for the use of controlled substances (medications with a high potential for abuse) for three out of four sampled residents (Resident 31, Resident 46, and Resident 12) reviewed. 1. Resident 31, the facility failed to accurately account for the administration of a lorazepam 0.5 milligrams ([mg-unit of measurement] a controlled substances used to relieve anxiety, a mental disorder characterized by persistent feelings of worry, nervousness, or unease strong enough to interfere with daily activities) on 10/5/2024 and 10/6/2024. 2. Resident 46, the facility failed to accurately account for the administration of tramadol (a controlled substances used to treat moderate to severe pain) 50 mg on 10/5/2024. 3. Resident 12, the facility failed to accurately account for the administration of tramadol 50 mg on 10/2/2024. These failures increased the risk that controlled medications to treat pain and anxiety may not be administered as ordered for Resident 31, Resident 46, and Resident 12 with the potential for the residents to experience uncontrolled pain, discomfort, or anxiety. And the facility's risk for the potential loss, diversion (transfer of a medication from a legal to an illegal use), medication errors, or accidental exposure to controlled substances. Findings: 1. During a review of Resident 31 ' s Admission Record, the Admission Record indicated Resident 31 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis including anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress) disorder. During a review of Resident 31's History and Physical (H&P), dated 11/8/2024, the H&P indicated Resident 31 does not have the capacity to make decisions and dependent on facility staff for all Activities of Daily Living (ADL, include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During a review of Resident 31's Physician Order Summary Report, included an order for lorazepam 0.5 mg, instructions to give one tablet by mouth every four hours as needed for anxiety as manifested by fidgeting (small movements), order date 10/3/2024. During a concurrent interview and record review on 11/21/2024 at 11:27 a.m., with Licensed Vocational Nurse (LVN) 3 and Director of Nursing (DON) on Station 2, at Medication Cart (Med Cart) 2, reviewed Resident 31's Medication Administration Record (MAR) and Controlled Drug Record (CDR, a complete and accurate record to help maintain inventories to avoid diversions and losses) and the following discrepancy was found between the CDR and the MAR for Resident 31: Resident 31's CDR indicated licensed nurse initialed the removal of two tablets of lorazepam 0.5 mg on 10/5/2024 at 9 p.m., and again on 10/6/2024 at 9 p.m. Resident 31 ' s MAR for the month of 10/2024 was missing licensed nurse's initials to indicate Resident 31 was administered two doses of lorazepam 0.5 mg on 10/5/2024 and 10/6/2024 at 9 p.m. on each of the two days. During a concurrent interview on 11/21/2024 at 11:27 a.m. with LVN 3 and the DON, LVN 3 stated, the licensed nurses signed for the lorazepam removal in the CDR but did not click on the MAR to document the administration of lorazepam 0.5 mg to Resident 31 on 10/5/2024 at 9 p.m. and 10/6/2024 at 9 p.m. The DON stated, the lorazepam used as needed for Resident 31 was not documented on as administered, on the MAR. 2. During a review of Resident 46's Admission record, the Admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and osteomyelitis (inflammation of bone, usually due to infection). During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool), dated 9/19/2024, the MDS indicated Resident 46 was able to understand and be understood by others. The MDS indicated Resident 46 required setup or clean up assistance for eating and oral hygiene and partial assistance (helper performs less than half of the effort) for toileting and dressing. During a review of Resident 46's Physician Order Summary Report, included an order for tramadol 50 mg, instructions indicated to give one tablet by mouth every 24 hours as needed for moderate to severe pain (pain rating 4 to 10), order date 9/12/2024. During a review of Resident 46 ' s Care Plan titled Resident 46 at risk for pain and discomfort dated 9/13/2024, indicated, interventions to administer analgesic as ordered. Encourage rest period to facilitate relief. Re-check for efficacy at least 30 minutes after administration. If symptoms persist, notify physician (MD). During a concurrent interview and record review on 11/21/2024 at 11:30 a.m., with LVN 3, Resident 46's MAR and CDR for the month of 10/2024 was reviewed. The following discrepancy was found between the CDR and the MAR for Resident 46, Resident 46's CDR indicated licensed nurse initialed the removal of tramadol 50 mg on 10/5/2024 at 10:10 p.m., but Resident 46's MAR was missing a licensed nurse's initials to indicate the administration of the medication on 10/5/2024. LVN 3 stated, if the administration of the medication was not documented on the resident's MAR, the licensed nurses would not know if the resident was administered the medication. LVN 3 stated the licensed nurse must document on the MAR and on the CDR, both records must match and that did not happen for Resident 46. 3. During a review of Resident 12's Admission Record, the Admission Record indicated Resident 12 was admitted to the facility on [DATE], with diagnosis of wedge compression fracture of second lumbar vertebra (a type of spinal fracture that occurs when the front of the vertebra collapses, giving the bone a wedge shape). During a review of Resident 12's MDS dated [DATE], indicated the resident had severe cognitive (ability to think, understand, learn, and remember) impairment. During a review of Resident 12's Physician Order Summary Report, included an order for tramadol 50 mg, instructions indicated to give one tablet by mouth every eight hours as needed for moderate pain (pain rating 4 to 6), order date 9/21/2024. During a review of Resident 12 ' s Care Plan titled Resident 12 at risk for pain and discomfort dated 9/23/2024, indicated, interventions to administer analgesic as ordered. Encourage rest period to facilitate relief. Re-check for efficacy at least 30 minutes after administration. If symptoms persist, notify physician (MD). During a concurrent interview and record review on 11/21/2024 at 11:30 a.m., Med Cart 3, with LVN 2, Resident 12's MAR and CDR for the month of 10/2024 was reviewed. The following discrepancy was found between the CDR and the MAR for Resident 12, Resident 12's CDR indicated licensed nurse initialed the removal of tramadol 50 mg on 10/2/2024 at 11 a.m., but Resident 12's MAR was missing a licensed nurse's initials to indicate the administration of tramadol 50 mg on 10/2/2024. LVN 2 stated Resident 12's tramadol should have been documented on both the MAR and CDR to indicate the medication was administered. LVN 2 stated the discrepancy could lead to another nurse administering the tramadol again to Resident 12, or if the resident was not administered the medication could cause the resident to experience more pain. LVN 2 stated diversion of the medication could occur if the tramadol was popped out and not administered to the resident. During an interview on 10/21/2024 at 12:35 p.m., with a Registered Nurse Supervisor (RN) 4, RN 4 stated the CDR and MAR documentation for medication administration should match, if not it may indicate the medication was not given to the resident. RN 4 stated if the controlled medications, lorazepam, and tramadol was not documented as administered to the residents (Resident 31, Resident 46, and Resident 12) it could lead to drug (medication) diversion; residents experiencing pain or anxiety if the medications were not administered, or the residents could receive duplicate therapy if the medication is mistakenly administered again. During an interview on 10/21/2024 at 1:21 p.m., with the Registered Nurse Consultant (RNC), RNC stated the licensed nurse must during medication pass follow the steps of pour, pass, and chart any medication given to the resident on the MAR and for controlled medication, must document on the CDR. RNC stated if not documented it was not considered done. During a review of the facility's policy and procedures (P&P) titled, General Dose Preparation and Medication Administration, revised, 1/2013, indicated, Prior to administration of medication .Confirm that the MAR reflects the most recent medication order .During the medication administration .Document the administration of controlled substances in accordance with applicable law .After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given .) on appropriate forms.

Based on observation, interview, and record review, the facility failed to ensure: a. Ensure Restorative Nursing Aides (RNA- trained nursing staff who help residents gain an improved quality of life by increasing their level of strength and mobility) 1 was competent to perform passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 2's both arms. b. Ensure RNA 1 was competent to perform PROM exercises to Resident 18's right arm. These failures had the potential to cause resident pain, harm, injury, and inefficient delivery of ROM exercises resulting in decreased the range of motion and function for residents receiving RNA services. c. Performance Evaluation was completed on Registered Nurse (RN)4 and Licensed Vocational Nurse according to facility's policy and procedure. This failure had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety. Findings: a. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including right sided hemiplegia (weakness to the right side of the body) and hemiparesis (inability to move one side of the body) following a non-traumatic intracerebral hemorrhage (bleeding in the brain) and contractures (loss of motion of a joint associated with stiffness and joint deformity) of both hands and the lower leg. During a review of Resident 2's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation and Plan of Treatment (OT Eval), dated 6/26/2024, the OT Eval indicated Resident 2 had impaired ROM on both arms and had rigid muscle tone (the amount of tension [resistance to movement] in muscles) with a muscle tone severity of two (slight increase in muscle tone with minimal resistance). During a review of Resident 2's Physician Order Summary Report, the Physician Order Summary Report indicated a physician's order, dated 9/11/2024, for RNA to perform PROM exercises to Resident 2's both arms, five times a week. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/2/2024, the MDS indicated Resident 2 had severely impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 2 was dependent in eating, hygiene, bathing, dressing, rolling to both sides, and transfers. The MDS indicated Resident 2 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During an observation of an RNA session on 11/21/2024 at 9:51 a.m., in Resident 2's room, Resident 2 was lying in bed with both elbows bent and both hands held in fists. RNA 1 provided PROM exercises to Resident 2's both shoulders, elbows, wrists, and hands for ten repetitions each at every joint (where two bones meet) at a very fast speed. Resident 2 bent both elbows and tightened both fists when RNA 1 tried to quickly straighten both elbows and all the fingers on both hands. Resident 2 moaned, grimaced, and appeared to be in pain during PROM exercises of both elbows and both hands. RNA 1 continuously told Resident 2 to relax and stop closing her hands so tightly during PROM exercises because it was hurting RNA 1's hands. During an interview on 11/21/2024 at 1:06 p.m., RNA 1 stated she provided PROM exercises to Resident 2's arms and hands at a very fast rate of speed. RNA 1 stated she noticed Resident 2's arms and hands became tighter and harder for her to move and straighten when she was doing PROM exercises quickly. RNA 1 stated Resident 2 had pain during PROM exercises because she noticed Resident 2 became more resistive to the exercises as the session progressed, moaned, grimaced, and needed a lot of rest breaks in between exercises. During a concurrent interview and record review on 11/21/2024 at 1:10 p.m., the Director of Rehabilitation (DOR) who was also an OT stated Resident 2 had hypertonicity (condition where the muscles are in a constant state of contraction or increased tension usually due to neurological issues, injury, or certain medical conditions) in both arms and always held both hands in a fist. The DOR reviewed Resident 2's OT Eval, dated 6/26/2024, and confirmed Resident 2 had hypertonicity in both arms. The DOR stated ROM exercises must be done slowly for any resident with hypertonicity because providing ROM at a fast pace could cause the muscles of the arm to bend more instead of straightening which could cause pain. b. a. During a review of Resident 18's Admission Record, the Admission Record Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including right sided hemiplegia hemiparesis following a cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death), muscle weakness, and aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 18's OT Eval, dated 1/18/2024, the OT Eval indicated Resident 18 had impaired ROM of the right arm and had rigid muscle tone in the right arm. During a review of Resident 18's Order Summary Report, the Order Summary Report indicated a physician orders, dated 3/12/2024, for RNA to perform PROM exercises to Resident 18's right arm, five times a week. During a review of Resident 18's MDS, dated [DATE], the MDS indicated Resident 18 was cognitively intact. The MDS indicated Resident 18 required set-up assistance for eating, required partial/moderate assistance for upper body dressing and personal hygiene, and required substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 18 had functional limitations in ROM in one arm and one leg. During an observation of an RNA session on 11/21/2024 at 9:23 am, in Resident 18's room, Resident 18 was sitting in a wheelchair watching television. RNA 1 assisted Resident 18 with sit to stand exercises in the hallway, RNA 1 assisted Resident 18 with PROM of the right arm. RNA 1 provided Resident 18 with right arm shoulder, elbow, wrist, and hand PROM exercises for ten repetitions each at every joint at a very fast speed. Resident 18's right elbow, wrist, and fingers were observed to bend more while RNA was trying to quickly straighten each joint. Resident 18 grimaced, stated he had pain during PROM exercises, and asked RNA to stop. During an interview on 11/21/2024 at 1:06 pm, RNA 1 stated she provided PROM exercises to Resident 18's right arm and hand at a very fast rate of speed. RNA 1 stated she noticed Resident 18's right arm and hand became tighter and harder to move and straighten when she was doing PROM exercises quickly. RNA 1 stated Resident 18 had pain during PROM exercises because she noticed Resident 18 became more resistive to the exercises as the session progressed, moaned, grimaced, and had difficulty tolerating a lot of ROM exercises. During a concurrent interview and record review on 11/21/2024 at 1:10 p.m., the DOR who was also an OT reviewed Resident 18's OT Eval, dated 1/18/2024, and confirmed Resident 18 had hypertonicity in the right arm. The DOR stated ROM exercises must be done slowly for any resident with hypertonicity because providing ROM at a fast pace could cause the muscles of the arm to bend more instead of straightening which could cause pain. During a concurrent interview and record review on 11/22/2024 at 9:54 a.m., the DSD stated the RNAs in the facility were CNAs specialized training in RNA services. The DSD stated she was responsible for completing CNA competencies yearly but never completed any competencies for the RNAs. The DSD stated she did not know who was responsible for completing RNA competencies in the facility and did not know if they were being done. The DSD stated the CNA competency checklist did not assess staff's competency of RNA tasks such as ROM exercises, splinting, and ambulation exercises. The DSD stated it was important for the facility to have recurring competency assessments for staff to ensure the care and services provided were appropriate and safe. The DSD stated it placed the residents in the facility at risk for harm if staff were not competent in the services they were providing. During an interview on 11/22/2024 at 10:14 am, the DON and ADM stated conducting staff competencies were important to ensure staff were up to date and competent in performing their job duties. The DON stated there were three RNAs in the facility. The DON stated the RNAs assisted residents with activities such as ROM exercises, ambulation exercises, splinting, and feeding to ensure the residents in the facility maintained their current level of function and did not experience a functional decline. The DON and ADM stated the facility did not have a way to ensure the RNA staff were competent in their job duties since they did not conduct RNA competencies. The DON stated a licensed therapist from the contracted rehabilitation department provided the initial RNA certification but did not return to provide any additional training or competencies after the initial RNA certification was issued. The DON and ADM stated competencies for all staff should be done annually to ensure staff were competent in the services provided but were not being done for the RNAs. The DON and ADM stated if RNA competencies were not completed at least annually, the facility would not know the staff were up to date and competent in their job duties which could potentially lead to injury of staff and/or residents. During a review of the facility's policy and procedures (P&P), titled, Nursing Services, revised 3/2023, the P&P indicated the facility had sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. 45269 c.During a concurrent interview and record review on 11/23/2024, at 9:19 a.m., with Director of Staff Development (DSD), reviewed Certified Nursing Assistant (CNA 5) employment file. DSD stated CNA 5 Performance Review was not on file and was missing. DSD stated Performance Evaluation of any staff should be conducted annually and after 90 days from hire if a staff is a newly hired. During a concurrent interview and record review on 11/23/2024, at 9:19 a.m., with DSD, reviewed Licensed Vocational Nurse (LVN 2) employment file, DSD stated LVN 2 had no annual performance evaluation on file. DSD stated the Director of Nursing (DON) oversees performance evaluations of licensed nurses. During an interview on 11/23/2024, at 12:38 p.m. with Registered Nurse (RN 4), RN 2 stated he just had his performance review a few days ago. RN 4 stated all staff should be evaluated for their performance annually. RN 4 stated it was important to have your performance evaluated to know your weaknesses and strength which was important in providing quality of care to the residents. During an interview on 11/23/2024, at 2:51 p.m. with Director of Nursing (DON), the DON stated LVN 2 did not have her Performance Evaluation on file. The DON stated the facility conducts an annual Performance Evaluation to ensure staff competency because they are dealing with residents and to ensure safe delivery of care. During a review of facility's policy and procedure (P&P) titled 'Performance Evaluation dated 3/2024, the P&P indicated Job performance of each employee must be reviewed and evaluated per company guidelines and in accordance with State and Federal regulatory requirements. The P&P indicated performance evaluations are conducted to evaluate the employee's work performance and to be used as a tool for determination of employee eligibility for promotion, disciplinary actions and education, terminations, shift changes, transfers, improvement of quality and overall review of the employees 'work performance. The P&P indicated the employee's immediate supervisor or designee will be responsible for completing performance evaluation.

Based on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent (%) or greater as evidenced by four medication errors out of 27 opportunities for error to yield a medication error rate of 14.81 %, for three of five residents (Residents 29, Resident 48, and Resident 42) observed during medication administration (med pass). The facility failed to ensure: 1. Resident 29's blood pressure ([BP] the force of blood against artery [blood vessel that carries blood away from the heart] walls as the heart pumps) and/or heart rate/pulse ([HR] the number of times the heart beats per minute [bpm]) was accurately assessed as a parameter ordered by the physician to determine whether to hold or administer resident's BP medication, amlodipine 2.5 milligrams (mg, unit of mass) 2a. Resident 48's BP and/or HR was accurately assessed as a parameter ordered by the physician to determine whether to hold or administer resident's BP medication, amlodipine 10 mg. 2b. Resident 48's ClearLax (also known as MiraLAX [polyethylene glycol 3350 powder, for solution] used to treat occasional constipation) was prepared in accordance with the physician's order and manufacturer's specification. 3. Resident 42 was administered metformin (a medication that treats type 2 diabetes [a long-term condition in which the body has trouble controlling blood sugar and using it for energy] 1000 mg, with food or a meal as order by the physician. These failures of medication administration error rate of 14.81 % exceed the five (5) percent threshold. Findings: 1. During a review of Resident 29's Admission Record, the Admission record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure) and fall on same level from slipping, tripping, and stumbling. During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool) dated 10/12/2024, the MDS indicated Resident 29's cognitive (ability to think, understand, learn, and remember) skills for daily decisions making was severely impaired. During a review of Resident 29's Care Plan titled, At risk for altered level of comfort/pain; At risk for weakness or activity intolerance due to alteration in cardiovascular (relating to the heart and blood vessels) function r/t (related to) HTN (hypertension - high blood pressure). The care plan interventions included, amlodipine besylate (treat high blood pressure) oral tablet, give one tablet by mouth one time a day for hypertension. Hold for systolic blood pressure ([SBP] pressure in the arteries when the heart beats) less than 110 millimeters of mercury (mmHg) or heart rate less than 55 bpm, date initiated 3/22/2023 . Administer medication as ordered; monitor side effects and effectiveness and notify MD if ineffective or for any indication of side effects .monitor BP as needed, monitor pulse (heart rate) as needed . During a review of Resident 29's Physician Order Summary Report, included an order for amlodipine 2.5 mg, instructions to give one tablet by mouth one time a day for hypertension. Hold for SBP less than 110 mmHg or HR less than 55 bpm, order date 7/6/2023. During a Medication Pass observation on 11/20/2024 at 10:14 a.m., at Station 2 Medication Cart (MedCart) 2 with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared and administered to Resident 29 four medications which included a BP medication, amlodipine without checking the resident's BP as a parameter ordered by the physician to determine when to administer or not administer the resident's BP medication. LVN 1 prepared and administered the following medications to Resident 29: 1. Amlodipine 2.5 mg, one tablet 2. Aspirin (prevention of cerebrovascular accident [CVA] a stroke, caused by interrupted blood flow to the brain) 81 mg, one tablet 3. Docusate Sodium (stool softener) 100 mg, one capsule 4. Multivitamin with Minerals (supplement), one tablet During an interview on 11/20/2024 at 11:06 a.m., with LVN 1, LVN 1 stated he was supposed to check resident's BP right before administering the BP medication when there is a parameter to indicated when to administer or hold the BP medication. LVN 1 stated resident's (Resident 29) BP could change or drop, which could lead to the resident experiencing a fall or injury. 2. During a review of Resident 48's Admission Record, the Admission Record indicated Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension, orthostatic hypotension (a drop in blood pressure when standing up from sitting or lying down, causing dizziness), difficulty walking, ulcerative colitis (a chronic, inflammatory bowel disease that causes inflammation in the digestive tract), and diverticulitis (inflammation that causing pain and disturbance of bowel function). During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48's cognitive skills for daily decisions making was severely impaired. During a review of Resident 48's care plan title At risk for altered level of comfort/pain; At risk for weakness or activity intolerance due to alteration in cardiovascular function related to HTN, orthostatic hypotension, and hypokalemia (low potassium level) initiated on 7/27/2023. Resident 48's care plan interventions included, amlodipine besylate 10 mg, give one tablet by mouth one time a day for HTN. Hold for SBP less than 110 mmHg or HR less than 55 bpm .monitor BP as needed, monitor pulse (HR - heart rate) as needed. During a review of Resident 48's care plan titled Has altered gastrointestinal (GI - stomach) status, at risk for: GI discomfort, decreased food intake, irregular bowel elimination, and signs and symptoms of constipations initiated on 7/27/2023. Resident 48's care plan interventions included, administer medications as ordered to facilitate relief of GI symptoms. Notify MD if ineffective .MiraLAX (used to treat occasional constipation) Powder (polyethylene glycol 3350), give 17 grams (gm, unit of mass), one time a day for constipation. Mix with 4 (four) to 8 (eight) ounces ([oz] - a unit of measure for volume) of water. Monitor for GI symptoms (i.e., abdominal pain, nausea, vomiting, diarrhea, constipation, blood in stool) and notify MD if present. During a review of Resident 48's Order Summary Report, included orders for: Amlodipine 10 mg, instructions indicated to give one tablet by mouth one time a day for HTN. Hold for SBP less than 110 mmHg or HR less than 55 bpm, order date 6/23/2023. MiraLAX Powder, instructions indicated to give 17 gm by mouth one time a day for constipation, mix with 4-8 oz of water, order date 6/23/2023 During a Medication Pass observation on 11/20/2024 at 10:30 a.m., on Station 2 at MedCart 2 with LVN 1, LVN 1 prepared and administered to Resident 48 six medications which included a BP medication, amlodipine without checking the resident's BP as a parameter ordered by the physician to determine when to administer or not administer the resident's BP medication. LVN 1 prepared the following medications for Resident 48: 1. Amlodipine 10 mg, one tablet 2. Vitamin C (supplement) 500 mg, one tablet 3. Docusate Sodium (treat constipation) 100 mg one capsule 4. Ferrous sulfate (used to treat and prevent iron deficiency anemia [lack of red blood cells]) 325 mg, one tablet 5. Fludrocortisone (a corticosteroid, used to help control the amount of sodium and fluids in the body) 0.1 mg, two tablets 6. MiraLAX 17 gm During a concurrent Medication Pass observation and interview on 11/20/2024 at 10:44 a.m. with LVN 1, LVN 1 after preparing Resident 48's medications entered the resident's room. LVN 1 stated he added five oz of water to the MiraLAX Powder, and the powder was observed undissolved at the bottom of the medication cup. Resident 48 began sipping the undissolved MiraLAX while taking the oral pills. LVN 1 stated he would let Resident 48 drink some of the MiraLAX and then add more water. LVN 1 was stopped and asked to fully mix and dissolve the MiraLAX before continuing to administer to Resident 48. During an interview on 11/20/2024 at 11:06 a.m., with LVN 1, LVN 1 stated he was supposed to check resident's (Resident 48) BP right before administering the BP medication when there was an ordered parameter to indicated when to administer or hold the BP medication. LVN 1 stated Resident 48's BP could change or drop, which could lead to the resident experiencing a fall or injury. During an interview on 11/20/2024 at 11:10 a.m., with LVN 1, LVN 1 stated he should have fully dissolved the MiraLAX Powder before allowing Resident 48 to drink it. During a concurrent interview and record review on 11/21/2024 at 9:46 a.m., with the Director of Nursing (DON), Resident 29 and Resident 48's physician orders were reviewed. The DON stated the licensed nurse must take the resident's (that include Resident 29 and Resident 48) BP first and then administer the medication if within the parameters per physician's order to administer. The DON stated residents BP could change and be low or high, if the resident's BP was low giving the BP medication could cause the resident to experience dizziness, increase risk for falls, change of condition, and possible to lead to hospitalization . DON stated licensed nurse needs to mix MiraLAX thoroughly prior to administering to the resident (Resident 48). During a concurrent interview on 11/21/2024 at 9:54 a.m., with the DON, the DON provided and read the manufacturer's specification for MiraLAX preparation that indicated: Mix with 4 to 8 oz of any beverage, hot or cold temperature Stir and dissolve one packet of powder in 4 to 8 ounces of any beverage, hot or cold Ensure that the powder is fully dissolved before drinking Do not drink if there are any clumps. 3. During a review of Resident 42's Admission Record, the Admission Record indicated Resident 42 was admitted to the facility on [DATE]. With diagnosis of type 2 diabetes mellitus (DM - a group of disease that result in too much sugar in the blood). During a review of Resident 42's Physician Order Summary Report, included an order for metformin oral tablet, instructions indicated to give 1000 mg by mouth two times a day for DM. Take with food/meals, order date 10/24/24 During a Medication Pass observation on 11/20/2024 at 11:14 a.m., on Station 1 at MedCart 1 with a Registered Nurse (RN) 1, RN 1 prepared and administered to Resident 42 ten medications which included a medication to treat DM, metformin without food or a meal as ordered by the physician. RN 1 prepared the following medications for Resident 42: 1. Aspirin 81 mg, 1 tablet 2. Bethanechol (treat urinary and bladder problems) 25 mg, 1 tablet 3. Biotin (supplement) 1000 mcg, 1 tablet 4. Clopidogrel (an antiplatelet, used to prevent blood clots from forming) 75 mg, 1 tablet 5. Lisinopril (lower blood pressure) 40 mg, 1 tablet 6. Metformin (lower blood glucose (a type of sugar) 1000 mg, 1 tablet 7. Metoprolol Tartrate (lower blood pressure) 50 mg, 1 tablet 8. Multivitamin (supplement), 1 tablet 9. Vitamin D3 (supplement) 25 mcg (1000 IU) 1 tablet 10. Heparin (a substance medication that slows the formation of blood clots) 5000 international units (IU, standardized unit of measure)/ milliliter ([ml] - a unit of measure for volume), one ml. During an interview on 11/20/2024 at 2:57 p.m., with RN 1, RN 1 stated he did not give Resident 42's metformin with food or a meal. RN 1 stated must give Resident 42's metformin with food according to the physician's order and to prevent the resident from experiencing an upset stomach. During a concurrent interview and record review on 11/21/2024 at 10:32 a.m., with the DON, Resident 42's physician order for metformin was reviewed. The DON stated Resident 42's order indicated to administer metformin with food or a meal. The DON stated by administering metformin without food or a meal could cause Resident 42 to experience side effects that include diarrhea, nausea, and upset stomach. The DON stated by taking metformin with a meal can help reduce the side effects for the resident. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised 3/2022, indicated, Medications must be administered in accordance with the orders .The following information must be checked/verified for each resident prior to administering medications .Vital signs, if necessary. During a review of the facility's P&P titled, General Dose Preparation and Medication Administration, revised 1/2013, indicated, Follow manufacturer medication administration guidelines (e.g.providing medication with fluids or food .)

Based on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 11/19/202024 when: 1.Facility failed to ensure five residents on mechanical soft chopped diet (for residents who have limited chewing ability and intact swallowing ability) received Chicken alfredo texture in the form that meet their needs when the broccoli was not chopped and there were large pieces of chicken and pasta in the Chicken alfredo. (chicken measured at 1.5 inches using a ruler). 17 residents who were on mechanical soft ground diet received chopped chicken alfredo instead of the ground chicken alfredo per the food production guides (food portion and serving guide). These failures had the potential to result in meal dissatisfaction, decreased nutritional intake, weight loss and increased risk of choking for the residents who were on mechanical soft chopped and or ground diet. Findings: 1.During an observation in the kitchen on 11/19/202024 at 11:50 a.m., [NAME] 1 was mixing the sauce for the Chicken alfredo and preparing the chopped diet. [NAME] 1 stated the chopped Chicken alfredo was served with pasta and it was for residents on mechanical soft chopped or ground diet. Cook1 stated the pieces of the chicken, and the pasta should be about one inch long for the chopped diet. Cook1 stated the residents on ground diet receives the same chopped chicken. During an observation of the tray line service for lunch on 11/19/2024 at 12:00 p.m., the chopped Chicken alfredo had large chunks of chicken. The broccoli florets were big and not chopped. During the same observation for lunch service on 11/19/202024 at 12:00 p.m., residents on ground diet received the chopped Chicken alfredo with pasta there was no ground Chicken alfredo prepared. During an observation in the kitchen for lunch service on 11/19/202024 at 12:40 p.m., one plate was returned to kitchen requesting chopping the broccoli and chicken into smaller pieces. During an interview with Cook1 on 11/19/202024 at 12:45 p.m., Cook1 stated based on her understanding of the menu, all resident on the mechanical soft diet which includes chopped and ground diet, will receive the same food which was chopped Chicken alfredo with pasta today. Cook1 stated she chopped the chicken and pasta into one inch size using a knife. During an interview with [NAME] 1 and review of the production guides for noon meal dated 11/19/202024, Cook1 looked at the production guide and stated according to the guide [NAME] 1 should prepare five servings of chopped chicken alfredo and 17 servings of ground chicken alfredo. [NAME] 1 stated he thought all residents will receive the same chopped chicken alfredo with pasta. [NAME] 1 stated he should have prepared ground chicken alfredo and ground pasta. During a concurrent interview and taste test on 11/19/202024 at 1:00 p.m., for the mechanical soft chopped chicken alfredo and pasta with dietary supervisor (DS), the chopped chicken and pasta contained inconsistent sizes of chicken and pasta. There were some large pieces of chicken and pasta on the plate. The broccoli florets were not chopped. The size of the pieces of food was measured using a measuring tape and the chicken was at 1.5 inches long and the broccoli was at 2 inches long. During an interview on 11/19/202024 at 1:00 p.m., with DS, DS stated for the chopped diet, the chicken should be chopped into less than one inch long and the ground should be ground like ground beef. DS stated [NAME] 1 should have used the food blender to chop the chicken into smaller pieces. DS stated the residents on chopped and ground diet received large pieces of chicken. when the resident eats large pieces of chicken they can choke. DS stated he will in-service staff to make sure to follow the food production guide when serving meals. During an interview on 11/19/202024 at 2:00PM, with Registered Dietitian (RD), RD stated for chopped diet, the food should be chopped into half inch pieces. RD stated it was for our residents who require less chewing. RD stated resident on the ground diet, the food is served ground same consistency as ground beef. RD stated when the pieces are large the food can hardly get down and it will be hard for residents to swallow. During an interview on 11/20/202024 at 10:30 a.m., with Speech Therapist (SLP), SLP stated she orders the appropriate diet for the residents per their chewing and swallowing evaluation. SLP stated ground diet is when the meats are ground consistency and sometimes the vegetables can also be ground. SLP stated the Mechanical soft chopped diet, the meat is chopped. SLP cannot remember exactly how small the meat is chopped in the chopped diet. During a review of facility policy and procedure (P&P) titled Mechanical Soft/Ground (dated 4/2024) indicated, This order is for residents who have limited chewing ability and intact swallowing ability .All meat (such as beef, fish, poultry and pork) should be ground or chopped .some cooked vegetables may need to be chopped .Chopped is half inch - half inch pieces, Ground is 1/8 inch or less - consistency of ground meat During a review of the facility's P&P titled Menu (dated 11/2017) indicated, Residents receive food in the amount, type, consistency, and frequency to maintain normal body weight and acceptable nutritional values. During a review of the recipe for chicken alfredo indicated for mechanical soft chop or grind meat to desired texture. During a review of the recipe for broccoli florets indicated for mechanical soft chop portions prior to service. During a review of the production guide for the noon meal dated 11/19/202024 indicated to prepare five serving of chopped chicken alfredo and 17 servings of ground chicken alfredo.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1.Nutritional supplement labeled store frozen with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. One box 30 single serve cartons of vanilla flavored high protein nutrition supplement and another box with 30 single serve cartons of sugar free chocolate high calorie nutrition supplements were stored in the walk-in refrigerator with no thaw date. This failure had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) in 16 residents who were receiving nutrition supplements at the facility. 2.One large tray of boneless chicken thighs thawing on the bottom rack with no thaw date. 3.One bottle of thickened water stored in the reach in refrigerator with open date of [DATE] exceeding storage period for the thickened water. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illnesses in 68 out of 70 residents who receive food from facility. Findings: 1.During an observation in the kitchen on [DATE] at 9:00 a.m., there was one box with 30 single serve cartons of vanilla flavor nutrition supplement and another box with 30 single serve sugar free chocolate flavored nutrition supplement stored in the walk-in refrigerator with no date. During a concurrent interview with Dietary Supervisor (DS) stated the supplements are delivered frozen and was stored in the freezer, every two days facility goes through the whole box and there was a fast turn over. DS stated once they were thawed the product was safe for 14 days. DS agreed there should be a date on the supplements to monitor date of thaw and when to discard. 2.During an observation in the kitchen on [DATE] at 9:00a.m., there was one large tray with raw boneless chicken thighs thawing on the bottom shelf in the walk-in refrigerator. There was no date on the chicken, and it was soft to touch. During a concurrent observation and interview with DS, DS stated the chicken was pulled out of the freezer and was thawing in the walk-in refrigerator. DS does not know when the chicken was removed from the freezer. DS stated there should be a thaw date to make sure food was stored safely and then cooked. During an interview with cook (Cook 1) on [DATE] at 9:30 a.m., [NAME] 1 stated she removed the chicken from the freezer this morning and place them in the walk-in refrigerator to thaw. [NAME] 1 stated she was rushing and forgot to mark the thaw date on the chicken. [NAME] 1 stated when there was no thaw date on the food then food was not stored safely, and it can exceed storage period for chicken in the refrigerator. During an observation in the kitchen on [DATE] at 9:35a.m., there was one bottle of honey thickened water (honey-thick liquids pour slowly like honey or molasses for people who have difficulty swallowing) stored with open date of [DATE] and manufacturers use by date of [DATE]. During a concurrent interview with DS and Dietary aide (DA1), DS stated the honey thickened water was expired and should have been discarded. DS reviewed the manufacturer recommendation use by date on the bottle and verified that it was exceeding the storage period for the honey thickened water and discarded the bottle of the thickened water. DS stated when food or beverage exceeds use by date it decreases the quality and can be food safety issue. During the same observation and interview on [DATE] at 9:35 a.m., DA 1 pointed to single serve containers of thickened water and stated, residents receive single serve containers of honey thickened water, DA 1 stated we don't use the bottle and we forgot to discard it. During a review of facility policy and procedure (P&P) titled Food Receiving and Storage (revised ,d+[DATE]) indicated, Practices to maintain safe refrigerated storage include: labeling, dating and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use by date, or frozen or discarded. During a review of the 2022 U.S. Food and Drug Administration Food Code titled Ready to Eat, Time/Temperature control for safety food, Date Marking Code#,d+[DATE].17, indicated, Ready to eat, time temperature control for safety food prepared and packaged by food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 2024 hours, to indicate the date or day by which the food shall be consumed, sold, or discarded.

Based on observation, interview, and record review, the facility failed to maintain right to privacy for one of six sampled residents (Resident 25) by failing to ensure privacy curtains was long enough to cover the resident's room during wound care dressing change. This failure violated Resident 25's right to privacy and had the potential for Resident 25 feeling of embarrassment. Findings: During a review of Resident 25's Admission Record, the Admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paroxysmal atrial fibrillation (fast, irregular heartbeat that occurs suddenly and typically last for a short time), chronic kidney disease stage 3 (kidneys are moderately damaged and are not filtering waste and fluid from the blood as it should be), pulmonary hypertension( condition that affects the blood vessels in the lungs that makes the heart work harder than normal to pump). On 7/14/2020 Resident 25 had a diagnosis of moderate protein -calorie malnutrition (state of inadequate intake of food- during resident stay in the facility). During a review of Resident 25's Minimum Dat Set (MDS- resident assessment tool) dated 11/2/2024, the MDS indicated Resident 25 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 25 was dependent (helper does all of the effort) on staff with bed mobility, bathing, toileting hygiene, personal hygiene, dressing, and transfer to and from the bed to chair. The MDS indicated Resident 25 was always incontinent of urine and stool. The MDS indicated the resident was at risk of developing pressure injury and had a Stage 1 pressure injury (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness). During an observation 11/21/1014 at 9:49 a.m., in Resident 25's room, privacy curtains was pulled by a staff before changing the wound dressing located in the coccyx (small bone at the bottom of the spine) area and left buttock of Resident 25. Observed the privacy curtains were not long enough to cover the room of Resident 25 and only covered the area in between Resident 25 and Resident 25's roommate. During an interview on 11/21/2024, at 10:02 a.m., with Certified Nursing Assistant (CNA 3), CNA 3 stated he noticed the privacy curtains had been short since he started working in the facility a month ago. CNA 3 stated the privacy curtains should be able to cover the resident's care area because the resident will not have privacy, and someone could walk in during the middle of provision of personal care where the resident was being cleaned or bathed. During an interview on 11/21/2024, at 10:14 a.m., with Treatment Nurse (TN 1), TN 1 stated the privacy curtains for Resident 25 had been short for a long time and was not sure if someone knew about it. TN 1 stated the privacy curtains should be completely cover the resident's care area to ensure privacy and maintain resident's dignity. During an interview on 11/23/2024, at 2:51 p.m., with Director of Nursing (DON), the DON stated privacy curtains need to cover the whole resident care area during provision of personal care to provide privacy and maintain resident's dignity. During a review of facility's policy and procedure (P&P) titled Dignity and respect dated 6/2018, the P&P indicated Residents' private space and property shall be always respected. The P&P indicated all residents will be always treated with respect and dignity.

Based on observation, interview, and record review the facility failed to ensure two of 27 sampled residents (Resident 1 and Resident 49), was provided a safe, clean and homelike environment by failing to provide a room that did not have peeling paint and exposed wall on the bedroom walls. This deficient practice had the potential for Resident 1 and Resident 49 to affect the residents' dignity, mood, and violation of residents' rights to have a homelike environment. Findings: During a review of Resident 1's Admission record, the Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (a condition that causes weakness or an inability to move on one side of the body). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/4/2024, the MDS indicated Resident 1 had severe cognitive impairment (ability to think and reason) and was dependent on staff for activities of daily living (ADLs) such as oral hygiene, toileting, dressing, showering, and positioning. During a review of Resident 49's Admission record, the Admission Record indicated Resident 49 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain dysfunction due to an underlying condition that can cause confusion, memory loss and loss of consciousness) and dementia. During a review of Resident 49's MDS dated [DATE], the MDS indicated Resident 49 had severe cognitive impairment and was dependent on staff for activities of daily living (ADLs) such as oral hygiene, toileting, dressing, showering, and positioning. During an observation on 11/19/2024 at 9:35 a.m., in Resident 1 and Resident 49's room, observed peeling yellow paint and cracked wall on the wall facing the residents above the baseboards. During a concurrent observation and interview on 11/23/2024 at 12:19 p.m., with Certified Nurse Assistant (CNA) 6 in Resident 1 and Resident 49's room, CNA 6 stated the chipped paint and exposed wall did not reflect a homelike environment. CNA 6 stated maintenance should have been notified. During a concurrent observation and interview on 11/23/2024 at 12:24 p.m., with the Maintenance Supervisor/Account Manager (MS) in Resident 1 and Resident 49's room, the MS stated the wall was not intact, and the facility was working on repainting the room. The MS stated the peeling paint and exposed wall does not reflect a homelike environment. During an interview on 11/23/24 2:51 p.m., with the Director of Nursing (DON), the DON stated, Resident 1 and Resident 49's room should be a homelike environment. The DON stated there should not be paint that has chipped or dirty bedroom walls. The DON stated this could potentially affect the residents' dignity, the residents' mood, and violate residents' rights to have a homelike environment. During a review of the facility's policy and procedure (P&P), titled Homelike Environment, last revised 3/2023, The P&P indicated It is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs.

Based on interview and record review the facility failed to ensure one of 18 sampled residents (Resident 39) unwitnessed fall that caused a right hip fracture (a break or crack in a bone), required surgical repair and hospitalization at a General Acute Care Hospital (GACH) for four days (9/10/2024 to 9/14/2024) was reported to the state agency (California Department of Public Health [CDPH]). This failure resulted in a delay of an onsite investigation by CDPH to ensure Resident 39's fall was investigated and prevent further falls. Findings: During a review of Resident 39's Admission Record, the Admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including to fracture (broken bone) of the right femur (thigh bone), legal blindness ( a term used to describe a person's visual field of vision that is so limited that they are unable to see as well as most people), Alzheimer's disease, (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 39's History and Physical (H&P), dated 9/14/2024, the H&P indicated Resident 39 had fluctuating capacity to understand and make decisions due to dementia. The H&P indicated Resident 39 had a diagnosis of a right hip fracture and was status post (a patient's condition after a significant event such as surgery) intramedullary nailing (a surgical procedure that involves inserting a metal rod into the center of a bone to treat a fracture). During a review of Resident 39's Minimum Data Set (MDS -resident assessment tool) dated 9/19/2024, the MDS indicated Resident 39 had severely impaired cognition (ability to think, understand, learn, and remember) and never and or rarely made decisions. The MDS indicated Resident 39 needed substantial to maximal assistance (helper does more than half the effort) with eating, oral hygiene, upper body dressing, personal hygiene, rolling from left to right, moving from a sitting to lying position, the ability to stand from a sitting position, and transferring from the bed to a chair. The MDS indicated Resident 39 was dependent on staff (helper does all of the effort to complete the activity) for toileting, lower body dressing, and putting on and taking of footwear. The MDS indicated Resident 39 did not attempt to transfer on and off the toilet, transferring in and out the shower, and walking due to medical condition or safety concerns. During an interview on 11/23/2024 at 9:58 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 39 was blind in both eyes and dependent on nursing staff for feeding, bathing, and toileting. RN 1 stated Resident 39 had two falls in the past (5/2023 and 4/17/2024). RN 1 stated Resident 39 was found on the floor the morning of 9/10/2024. RN 1 stated Resident 39 was transferred to a GACH for a right hip fracture. During an interview on 11/23/2024 at 10:34 a.m., with RN 4, RN 4 stated on 9/10/2024 during the change of shift he was informed that Resident 39 was found on the floor at 6 a.m. and complained of right hip pain. RN 4 stated Resident 39 was found by a certified nursing assistant (CNA-unknown) sitting on the floor in between the bed of her roommate facing the wall. RN 4 stated Resident 39 had pain in the right leg and a right hip x-ray (create images of the inside of the body) was done. RN 4 stated the x-ray showed Resident 39 had a right hip fracture and Resident 39 was transferred to GACH on 9/10/2024 at 12:10 p.m., RN 4 stated Resident 39 had right hip surgery and returned to the facility on [DATE]. RN 4 stated Resident 39 had an unwitnessed fall that resulted in a fracture of the right hip. RN 4 stated Resident 39's fall was witnessed by a confused resident who was only alert and oriented to name and place. RN 4 stated an unwitnessed fall was when the staff or resident does not know what happened. RN 4 stated Resident 39's roommate was not a reliable witness because she was confused and cannot tell the details of the fall. RN 4 stated if a resident had an unwitnessed fall the resident should be assessed for any injury, the doctor and family notified. RN 4 stated if there was an injury like a fracture it should be reported to the California Department of Public Health. RN 4 stated an unusual occurrence should be reported as soon as possible and needs to be investigated right away. During a concurrent interview and record review on 11/23/2024 at 11:38 a.m., with the Program Manager (PM), Resident 39's roommate MDS was reviewed. The PM stated Resident 39's roommate's MDS dated [DATE], indicated Resident 39's roommate had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of nine. PM stated a BIM score of nine means moderate cognitive (thinking, reasoning, or remembering) impairment (a stage of cognitive decline where the ability to think, learn, and remember is significantly affected, interfering with daily activities). PM stated when she spoke to Resident 39's roommate after the fall the roommate stated she was in a dream like state when she was awakened by Resident 39 and does not remember seeing Resident 39's fall. During an interview on 11/23/2024 at 4:06 p.m., with the Director of Nursing (DON), the DON stated if a fall was unwitnessed, and after the investigation it does not make sense why and how the resident fell , then the fall was reportable to CDPH. The DON stated an unwitnessed fall was when nobody sees what happen and the resident was found on the floor. The DON stated she does not know exactly what happened and did not report the fall based on Resident 39's roommate's interview at the time of the fall. During a review of the facility's Fall Incident report, dated 9/10/2024, the Fall Incident report indicated, at 6 am the charge nurse was summoned by a certified nurse assistant to Resident 39's room. Resident 39 was found on the floor in a sitting position facing the wall in between the residents' bed and Resident 39's roommate. Resident 39 was assisted back to bed and complained of pain on the right hip. Resident 39's roommate was interviewed and stated Resident 39 came to Resident 39's roommate bedside while she was asleep and held her hand and both residents were startled possibly causing Resident 39 to fall. During a review of Resident 39's Change in condition Evaluation, dated 9/10/2024, the Change in condition Evaluation indicated, an x-ray was done on the right hip and resulted in an acute right hip fracture. During a review of the GACH records, titled History & Physical, dated 9/10/2024, the History & Physical indicated an intertrochanteric fracture of the right femur. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, date revised 3/2023, the P&P indicated, Following comprehensive evaluation of the resident, notification of the appropriate persons, and after the resident is stable, the facility staff member in charge will complete applicable report and forward to management as indicated; or required by State law. During a review of the facility's policy and procedure (P&P) titled, Reporting Unusual Occurrences, date revised 3/2023, the P&P indicated, The facility asserts there are no requirements in the California Code of Regulations, Title 22, for facilities to report events, such as falls, or residents wandering outside of the building, unless the circumstances are unusual, as with suspected abuse or neglect. This remains true when the event results in an injury to the resident, unless the injury is unusual for the resident given the resident's current health status.

Based on interview and record review the facility failed to ensure Minimum Data Set Coordinator (MDSC) completed a significant change in status assessment (SCSA- a comprehensive assessment that must be completed when the Interdisciplinary Team [IDT- team of healthcare professionals who discuss and manage resident's care] has determined that a resident meets the significant change guidelines to either major improvement or decline) to one of six sampled residents (Resident 25). This failure had the potential for not providing appropriate care and services to Resident 25. Findings: During a review of Resident 25's Admission Record, the Admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paroxysmal atrial fibrillation (fast, irregular heartbeat that occurs suddenly and typically last for a short time), chronic kidney disease stage 3 (kidneys are moderately damaged and are not filtering waste and fluid from the blood as it should be), pulmonary hypertension( condition that affects the blood vessels in the lungs that makes the heart work harder than normal to pump). On 7/14/2020 Resident 25 had a diagnosis of moderate protein -calorie malnutrition (state of inadequate intake of food- during resident stay in the facility). During a review of Resident 25's Minimum Dat Set (MDS- resident assessment tool) dated 11/2/2024, the MDS indicated Resident 25 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 25 was dependent (helper does all of the effort) on staff with bed mobility, bathing, toileting hygiene, personal hygiene, dressing, and transfer to and from the bed to chair. The MDS indicated Resident 25 was always incontinent of urine and stool. The MDS indicated the resident was at risk of developing pressure injury and had a Stage 1 pressure injury (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness). During a review of Resident 25's COC Evaluation dated 11/11/2024, timed at 3:58 p.m., the COC indicated there was a small opening in the coccyx area where the redness was observed on 10/30/2024. During a review of Resident 25's Pressure Sore Management Record dated 11/11/2024, the Pressure Sore Management Record indicated Stage II pressure injury on the coccyx measured two and half (2.5) cm. in length and two (2) cm. in width. During an interview on 11/22/2024, at 3:03 p.m., with Minimum Data Set Coordinator (MDSC), MDSC stated significant change in status assessment (SCSA- a comprehensive assessment that must be completed when the Interdisciplinary Team (IDT- team of healthcare professionals who discuss and manage resident's care) has determined that a resident meets the significant change guidelines to either major improvement or decline) was triggered by two major areas like weight loss and pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). MDSC stated when she conducted her assessment the pressure injury was Stage 1 and weight loss. MDSC stated she will review Resident 25's medical records, talk to Treatment Nurse (TN1) and will do a significant change in status assessment. MDSC stated MDS should be accurate because the information was submitted to Center of Medicare (CMS) and wrong resident's information will affect the resident's care by not receiving the proper care and treatment. During an interview on11/23/2024, at 3:40 p.m., with Director of Nursing (DON), the DON stated SCSA was triggered if a resident had two major changes in their condition. The DON stated it was important to complete SCSA to target a specific action for an identified problem. During a review of facility's policy and procedure (P&P) titled Comprehensive Assessments Timing revised 3/2023, the P&P indicated a SCSA is appropriate if there are either two or more MDS areas of decline or two or more areas of improvements or if the IDT determines that the resident would benefit from the SCSA assessment and subsequent care plan revision.

Based on interview and record review the facility failed to ensure two of 18 sampled Residents (Resident 39 and 68 ) entry on the Minimum Data Set (MDS -resident assessment tool) assessment entries were accurate. The facility failed to: a. Ensure Section M in the MDS titled Skin Conditions was accurately documented to reflect Resident 39's current skin condition. b. Ensure Resident 68 discharge status was accurately documented to reflect Resident 68 was discharged home. This failure had the potential to result in a negative effect of Resident 39 and 68's plan of care and delivery of necessary care and services. Findings: a.During a review of Resident 39's Admission Record, the Admission Record indicated Resident 39 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including fracture (broken bone) of the right femur (thigh bone), legal blindness, Alzheimer's disease, (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 39's History and Physical (H&P), dated 9/14/2024, the H&P indicated Resident 39 had fluctuating capacity to understand and make decisions due to dementia. The H&P indicated Resident 39 had a diagnosis of a right hip fracture and was status post (a patient's condition after a significant event such as surgery) intramedullary nailing (a surgical procedure that involves inserting a metal rod into the center of a bone to treat a fracture). During a review of Resident 39's MDS dated [DATE], the MDS indicated Resident 39 had severely impaired cognition and never and or rarely made decisions. The MDS indicated Resident 39 needed substantial to maximal assistance with eating, oral hygiene, upper body dressing, personal hygiene, rolling from left to right, moving from a sitting to lying position, the ability to stand from a sitting position, and transferring from the bed to a chair. The MDS indicated Resident 39 was dependent on staff for toileting, lower body dressing, and putting on and taking of footwear. The MDS indicated Resident 39 did not attempt to transfer on and off the toilet, transferring in and out the shower, and walking due to medical condition or safety concerns. The MDS indicated Resident 39 had a Stage II (partial-thickness loss of skin, presenting as a shallow open sore or wound) and stage III (a full-thickness tissue loss where subcutaneous fat is visible within the wound, but bone, tendon, or muscle are not exposed) pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During an interview on 11/22/2024 at 2:05 p.m., with Treatment Nurse (TN) 1, TN 1 stated Resident 39 was readmitted to the facility after surgery with Stage II pressure ulcer located at coccyx (the last bone at the bottom of the spine) on 9/14/2024. TN 1 stated Resident 39 has not developed Stage III pressure ulcer or Stage IV (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) pressure ulcer and was not receiving any wound care. TN 1 stated the Stage II pressure ulcer is resolved. During an interview on 11/22/2024 at 3:38 p.m., with Minimum Data Set Coordinator (MDSC), MDSC stated Resident 39 came to the facility with a Stage II pressure ulcer. MDSC stated the MDS was miscoded inaccurately by documenting Resident 39 had a Stage III pressure ulcer. 50144 b.During a review of Resident 68's Admission record, the Admission Record indicated Resident 68 was admitted to the facility on [DATE] with diagnoses including wedge compression fractures (type of spine fracture [broken bone] that occurs when the front of a vertebra collapses or compresses, giving it a wedge shape) of the thoracic (middle section of spine) and lumbar (lower section of spine) vertebrae (bones of the spine), fracture of the sacrum (a bony structure at the base of the lumbar vertebrae that is connected to the pelvis-hip bone), and repeated falls. The face sheet indicated Resident 68 was discharged on [DATE] to a private home with home health services. During a review of Resident 68's History and Physical (H&P), dated 10/23/2024, the H&P indicated Resident 68 did not have the capacity to understand and make decisions. During a review of Resident 68's Interdisciplinary Discharge Summary, dated 10/31/2024, the document indicated Resident 68 was discharge to home on 10/31/2024 with arranged home health services including physical therapy, occupational therapy, and registered nurse visits. During a concurrent interview and record review on 11/22/2024 at 10:03 a.m., with the MDS Coordinator (MDSC), Resident 68's MDS dated [DATE] was reviewed. The MDSC indicated Resident 68 had an unplanned discharge to a Short-Term General Hospital on 10/31/2024. The MDS nurse stated the MDS was incorrect, and the MDS should have reflected that Resident 68 was discharged home. The MDS nurse stated they will submit a correction. During an interview on 11/23/2024 at 2:51 p.m. with the Director of Nursing Services (DON), the DON stated it is important for the MDS to be accurate and reflect the resident to be able provide accurate care and services for the residents. During a review of the facility's policy and procedure (P&P) titled, Accuracy of Assessments, date revised 3/2023, the P&P indicated, The assessment must represent an accurate picture of the resident's status during the observation period of the MDS .When the MDS is completed, only those occurrences during the observation period will be captured on the assessment. In other words, if it did not occur during the observation period, it is not coded on the MDS.

Based on interview and record review, the facility failed to review and revise the comprehensive care plan for two of five sampled residents (Resident 2 and Resident 46). The facility failed to: a. Update the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) plan of care when OT services were discontinued. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Residents 2. b. Review and revise the care plan after the Resident 46 experienced a change of condition. This failure had the potential to result in Resident 46 experiencing repeated hypoglycemic (low blood sugar) events, diabetic coma (a life-threatening condition that occurs when someone with diabetes [ DM a disorder characterized by difficulty in blood sugar control and poor wound healing] has dangerously high or low blood sugar and becomes unconscious), or death. Findings: a.During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including right sided hemiplegia (weakness to the right side of the body) and hemiparesis (inability to move one side of the body) following a non-traumatic intracerebral hemorrhage (bleeding in the brain) and contractures (loss of motion of a joint associated with stiffness and joint deformity) of both hands and the lower leg. During a review of Resident 2's Physician Order Summary Report, the Physician Order Summary Report indicated a physician's order, dated 6/28/2024, for OT to discontinue OT services for exercises, neuromuscular re-education (rehabilitation techniques to restore muscle function and movement), and splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) management. During a review of Resident 2's Care Plan titled Resident 2 had decreased balance, coordination, safety, endurance, and range of motion (ROM, full movement potential of a joint) in both hands, initiated on 6/26/2024, the Care Plan indicated interventions to address Resident 2's impairments were for OT services, three times a week for four weeks, for exercises, neuromuscular re-education (rehabilitation techniques to restore muscle function and movement), and splint management. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/2/2024, the MDS indicated Resident 2 had severely impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 2 was dependent in eating, hygiene, bathing, dressing, rolling to both sides, and transfers. The MDS indicated Resident 2 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During a concurrent interview and record review on 11/21/2024 at 1:06 p.m., with the Director of Rehabilitation (DOR), the DOR stated the licensed therapists which included the OTs, Physical Therapists (PT, licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function), and Speech Therapists (ST, licensed professional aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) were responsible for developing, reviewing, and revising the section of a resident's care plans related to therapy services. The DOR stated everything related to therapy should be care planned. The DOR reviewed Resident 2's care plans, physician's orders, and therapy notes. The DOR confirmed Resident 2's care plans indicated Resident 2 was receiving OT services but was not. The DOR confirmed Resident 2's care plan was not updated and stated the OT interventions should have been discontinued when Resident 2 was discharged from OT services on 6/28/2024. The DOR stated it was important care plans were revised and updated to avoid confusion and to ensure the facility was addressing the resident's care appropriately. During an interview on 11/22/2024 at 9:15 am, the Minimum Data Set Coordinator (MDSC) stated the Rehabilitation Department was responsible for developing and updating all the care plans related to therapy services. The MDSC stated it was important for care plans to be accurate and updated to ensure the resident was receiving the appropriate type of care. During an interview on 11/22/2023 at 10:14 am, the Director of Nursing (DON) stated the comprehensive care plan was a guide used by staff to identify a resident's goals and problem areas and create interventions to address those concerns. The DON stated the care plan should be updated for any change of condition, upon discovery of any new concern, quarterly, and as needed. The DON stated it was important for care plans to be accurate and updated to ensure staff knew how to provide the appropriate care to the residents. During a review of the facility's Policy and Procedure (P&P), revised 3/2023, titled Comprehensive Care Plans - Timing, the P&P indicated the residents shall have a person-centered, comprehensive care plan, developed, reviewed, and revised by the facility interdisciplinary team including the resident and resident representative, if applicable. The P&P indicated the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments. 50144 b. During a review of Resident 46's Admission record, the Admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and osteomyelitis (inflammation of bone, usually due to infection). During a review of Resident 46's History and Physical (H&P), dated 9/13/2024, the H&P indicated Resident 46 had the capacity to understand and make decisions. During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool), dated 9/19/2024, the MDS indicated Resident 46 was able to understand and be understood by others. The MDS indicated Resident 46 required setup or clean up assistance for eating and oral hygiene and partial assistance (helper performs less than half of the effort) for toileting and dressing. During a review of Resident 46's Medication Administration Record (MAR) for July 2024, the MAR indicated the following orders: a.Basagalar KwikPen subcutaneous solution pen-injector 100 unit/ml (milliliter) (Insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) Glargine ((long acting type of insulin that works slowly over time] ) Inject 64 unit subcutaneously (administered in the fatty tissue just under the skin layer) one time a day for DM , Start Date: 5/23/2024. b.Farxiga oral tablet five mg (milligrams) (Dapagliflozin Propandediol) Give 1 tablet by mouth one time a day for Type 2 DM, Start Date: 1/17/2024. c.NovoLin R FlexPen Injection Solution Pen-Injector 100 unit/ml (Insulin Regular (Human)) (a short acting type of insulin usually given 30 minutes prior to meal based on sliding scale parameters (the amount of insulin to be administered changes or slides up or down based on the person's blood sugar.) Inject as per sliding scale subcutaneously before meals for DM2, Start date 4/10/2024, Schedule times: 6:30 a.m., 11:30 a.m., and 4:30 p.m. d.NovoLin R FlexPen Injection Solution Pen-Injector 100 unit/ml (Insulin Regular (Human)) Inject as per sliding scale subcutaneously at bedtime for DM2, scale Start date 4/10/2024 During a review of Resident 46's Situation, Background, Assessment, Recommendation [SBAR]a communication tool used by healthcare workers when there is a change of condition among the residents) Summary dated 7/18/2024 at 8:00 a.m., the SBAR indicated Resident 46: a.Experienced confusion and skin were cold and clammy (common symptoms of hypoglycemia). b.Blood glucose (sugar) was 42 milligrams per deciliter (mg/dL -unit of measurement). c.Resident 46 was given two glasses of orange juice and 3 packets of sugar. d.One hour after orange juice administration, Resident 46's blood sugar was 80 mg/dL and was back to baseline mentation. During a review of Resident 46's Physician Order Summary dated 11/23/2024, the Order Summary indicated on 7/19/2024 at 9:38 a.m., the physician decreased Resident 46's scheduled Insulin Glargine from 64 units to 30 units. During a review of Resident 46's care plans, the care plan indicated Registered Nurse (RN) 4 initiated a care plan on 7/19/2024 regarding Resident 46's episode of hypoglycemia. The Care plan was cancelled on 8/29/2024 when Resident 46 was transferred to the acute care hospital. During a concurrent interview and record review on 11/23/2024 at 10:08 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 46's SBAR Summary dated 8/18/2024 at 4:04 p.m. was reviewed. The SBAR indicated Resident 46: a.Experienced symptoms of increased confusion, feeling cold and clammy b.Blood glucose was checked by an LVN (TN1) and was 34 mg/dL. c.TN 1 attempted to give a glass of apple juice with 3 packs of sugar, but Resident 46 was unable to swallow. TN 1 administered glucagon (medication to increase blood glucose) 1 mg intramuscular (IM-given in the muscle). d.Blood glucose was rechecked 10 minutes after glucagon administration and was 49mg/dL e.30 minutes after glucagon administration, Resident 46 was not verbally responsive and blood glucose was 61 mg/dL. f.TN 1 gave Resident 46 a glass of orange juice with 3 packets of sugar. g.15 minutes after orange juice administration, Resident 46 became verbally responsive and blood sugar was 106. During an interview on 11/23/2024 at 10:08 a.m., with LVN 3, LVN 3 stated any situation that the resident experiences a change of condition, a care plan should be initiated or revised. During a review of Resident 46's Physician Order Summary dated 11/23/2024, the Physician Order Summary indicated on 8/18/2024 at 7:14 p.m , the physician discontinued Resident 46's scheduled Insulin Glargine 30 units. During an interview on 11/23/2024 at 10:50 a.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated Resident 46's care plans were not revised after the hypoglycemic event on 8/18/2024. The MDSC stated it was important that the care plan was revised to prevent continued hypoglycemic events. During a concurrent interview and record review on 11/23/2024 at 2:51 p.m., with the Director of Nursing Services (DON), Resident 46's electronic health record (EHR) was reviewed. The DON stated care plans should always be initiated or revised when there was a change of condition to have a clear picture of what the interventions are and what needs to be monitored. During a review of the facility's policy and procedure (P&P), titled Comprehensive Care Plans-Timing, last revised March 2023, The P&P indicated Each resident shall have a person-centered, comprehensive care plan, developed, reviewed and revised by the facility interdisciplinary team.

Based on interview and record review the facility failed to ensure the resident, who was assessed as a high risk for developing a pressure ulcer (prolonged pressure on the skin that results in injury to the skin and underlying tissue, usually occur over bony prominence because of long-term pressure), did not develop a deep tissue injury ([DTI] (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on the right heel for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was turned and repositioned every two hours and provided with a pressure reducing device in bed. 2. Ensure staff-maintained offloading (minimizing or removing weight placed on the foot to help prevent and heal pressure ulcers) of Resident 1's right heel away from having a constant pressure against the surface while in bed. These failures resulted in Resident 1 on 4/16/2024 developing DTI measured 6.0 centimeters ([cm] a unit of measurement) in length by 6.0 cm in width on the right heel and on 4/23/2024 measured 6.0 cm in length by 7.0 cm in width. The right heel DTI evolved from a Stage 1 pressure ulcer measured 6.0 cm in length by 6.0 cm in width identified on 4/15/2024. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis that affects only one side of the body), hemiparesis (weakness on one entire side of the body), dysphagia (difficulty in swallowing), aphasia (a brain disorder that affects speaking or understanding language), muscle weakness, and abnormalities of gait and mobility. During a review of Resident 1's Nutritional Assessment and Data Collection Form, dated 3/18/2024, the Nutritional Assessment and Data Collection Form indicated Resident 1 was non-ambulatory (not able to walk or exit safely without the physical assistance of another person) and bedfast (a person who is confined to bed) had poor food intake, and was malnourished (when a person's diet does not provide enough nutrients or the right balance for optimal nutrition).The Nutritional Assessment and Data Collection Form indicated Resident 1 had no skin problems. During a review of Resident 1's History and Physical (H&P), dated 3/20/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS]- a standardized assessment and care screening tool), dated 4/12/2024, the MDS indicated Resident 1 was dependent on nursing staff for eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear, personal hygiene, rolling from left to right, sitting, lying, and transferring between surfaces. The MDS indicated Resident 1 required maximum assistance from nursing staff with standing. The MDS indicated Resident 1 was at risk for developing a pressure ulcers/injuries and did not have any pressure ulcers or skin injuries. The MDS section M indicated Resident 1 had a pressure reducing device for bed and was on turning and repositioning program. The MDS section H indicated Resident 1 was always incontinent (no episodes of continent voiding [urination] and bowel movements) of both urine, and bowel. During a review of Resident 1's Braden Scale (an assessment tool to quantify resident risk for developing pressure ulcer represented by a total score and risk categories [low, mild, moderate, high]) for the prediction of pressure ulcer development dated 3/15/2024 indicated Resident 1 had a score of 15 (Severe Risk: Score 9, High Risk: Total score 10-12. Moderate Risk: Total score 13-14 Mild Risk: Total score 15-18.). During a review of Resident 1's care plan titled, At risk for development of pressure injury due to immobility, hemiplegia and hemiparesis, dated 3/18/2024, the care plan indicated the goal for Resident 1 was to be free of avoidable skin breakdown. The care plan interventions included to encourage and assist to offload (no specified information what to offload) as needed, reposition the resident in bed as needed, use a pressure reducing device in bed. During a review if Resident 1's Pressure Ulcer Management Record for the month of 4/2024 indicated Resident 1 had a Stage 1 pressure ulcer to the right heel measured 6.0 cm in length by 6.0 cm in width on 4/15/2024. On 4/16/2024 Resident 1 had the right heel skin injury measured 6.0 cm in length by 6 cm in width and assessed as DTI. On 4/23/2024 Resident 1's right heel skin injury was measured 6.0 cm in length by 7.0 cm in width and assessed as DTI. During an interview on 5/3/2024 at 12:53 p.m., the Licensed Vocational Nurse (LVN 1) stated Resident 1 was admitted to the facility on [DATE] and on 4/4/2024 was admitted to hospice (care provided to a person who is terminally ill and in the last stages of life) due to not eating. LVN 1 stated on 4/15/2024 Resident 1 developed a Stage 1 pressure ulcer with redness to the right heel. LVN 1 stated a physician's order was received on 4/15/2024 to offload both heels for 14 days when Resident 1 in bed. LVN 1 stated Resident 1's Stage 1 pressure ulcer become a DTI on 4/16/2024 with purple discoloration. LVN 1 stated on 4/16/2024 the doctor ordered to cleanse the right heel DTI with Normal Saline (cleansing solution), pat dry, paint with Betadine (an antiseptic used for skin disinfection) solution, cover with dry dressing, and wrap with kerlix (bandage roll). LVN 1 stated Resident 1 was at high risk for developing pressure ulcers due to Resident 1's medical condition, poor food intake, immobility, and incontinence (having no or insufficient voluntary control over urination or defecation) of bowel and bladder. LVN 1 stated Resident 1 developed a pressure ulcer when a pillow, used to offload the resident's right foot away from the mattress, was removed and was left lying directly on the mattress for a long time. During an interview on 5/3/2024 at 1:25 p.m., the Registered Nurse Supervisor (RNS) stated a plan of care for Resident 1, who was at risk for developing a pressure ulcers, should have included the offload of both heels with a pillows, and turning and repositioning of the resident every two hours. RNS stated Resident 1 was at risk for developing a pressure ulcer due to immobility and left sided weakness. RNS stated the cause of Resident 1's pressure ulcer was poor nutrition and constant pressure on the right heel against the mattress. RNS stated there should be a change of condition ([COC] a sudden clinical change from a resident's baseline in physical, cognitive {process of thinking and reason} pressure, behavioral, or functional) completed and Resident 1's reassessment on the Braden Scale to ensure the required interventions to prevent deterioration of the existing pressure sore and improve health process were implemented. RNS stated COC and Braden scale was not done on 4/25/2024 when Resident 1 developed a Stage 1 pressure ulcer on the right heel (4/15/2024) and developed to DTI the next day (4/16/2024). During an interview on 5/6/2024 at 9:40 a.m., LVN 1 stated Resident 1's pressure ulcer to the right heel was avoidable if Resident 1 was being turned, checked, and monitored every 2 hours to ensure both heels were elevated on a pillow to offload the pressure and to prevent DTI. LVN 1 stated Resident 1's Braden scale was not done on 4/15/2024 when there was a change in condition (development of a Stage 1 pressure ulcer to the right heel). During a concurrent interview and record review on 5/7/2024 at 11:46 a.m., with the Director of Nursing (DON), Resident 1's Documentation Survey Report for March 2024 and April 2024, for monitoring the resident's turning and repositioning, were reviewed. The Documentation Survey Report indicated an N (for not turned) was documented on these dates and times: 1. On 3/17/2024 at 4 p.m., 6 p.m., and 8 p.m. 2. On 3/21/2024 at 4 p.m. and 8 p.m. 3. On 3/22/2024 at 4 p.m., 6 p.m., and 10 p.m. 4. On 3/23/2024 at 4 p.m., 6 p.m., and 10 p.m. 5. On 3/24/2024 at 4 p.m., 6 p.m., and 10 p.m. 6. On 3/25/2024 at 4 p.m., 6 p.m., and 10 p.m. 7. On 3/26/2024 at 10 p.m. 8. On 3/29/2024 at 4 p.m., 6 p.m., and 10 p.m. 9. On 3/30/2024 at 12 a.m., 2 a.m., 4 a.m., 6 a.m., 4 p.m., 6 p.m., and 8 p.m. 10. On 3/31/2024 at 12 a.m., 2 a.m., 4 a.m., 6 a.m., 4 p.m., 6 p.m., and 8 p.m. 11. On 4/1/2024 at 12 a.m., 4 p.m., 8 p.m., and 10 p.m. 12. On 4/4/2024 at 10 p.m. 13. On 4/5/2024 at 4 p.m., 6 p.m. and 8 p.m. 14. On 4/6/2024 at 4 p.m., 6 p.m. and 8 p.m. 15. On 4/7/2024 at 4 p.m., 6 p.m. and 10 p.m. 16. On 4/8/2024 at 4 p.m., 6 p.m. and 8 p.m. 17. On 4/12/2024 at 12 a.m., 2 a.m., 4 a.m., and 6 a.m. 18. On 4/14/2024 at 12 a.m., 2 a.m., 4 a.m., and 6 a.m. 19. On 4/18/2024 at 6 p.m. 20. On 4/24/2024 at 12 a.m. 21. On 4/26/2024 at 8 a.m., 10 a.m., 12 p.m., and 2 p.m. no documentation (blank) 22. On 4/28/2024 at 10 p.m. The Documentation Survey Reports indicated Resident 1 was not turned and repositioned every two hours. The DON stated Resident 1 was at risk for developing pressure ulcers and should have been turned every two hours. The DON stated Resident 1's plan of care for the high risk for developing a pressure ulcer usually includes to turn resident every two hours, hygiene, moisturizing the skin, keeping the skin clean and dry, using pressure reducing devices for the bed and a Registered dietician consultation. The DON stated interventions to prevent a skin break down should be the same regardless of the Braden Scale assessment score. The DON stated repositioning and turning the residents every two hours was a standard nursing practice. The DON stated it was possible for Resident 1 to develop a Stage 1 pressure ulcer and progressed to a DTI with a compromised condition and not implemented preventative measures. The DON confirmed prior to Resident 1 developing a Stage 1 pressure ulcer to the right heel on 4/15/2024, the resident was not turned and repositioned consistently as indicated on the Documentation Survey Reports. According to the nationally recognized Journal of Clinical Nursing, article titled, The Standardized Pressure Injury Prevention Protocol nurses working in health care settings must address pressure ulcer development prevention. The early intervention to prevent pressure injury is required and be integrated into the workflow process. https://onlinelibrary.[NAME].com/doi/full/10.1111/jocn.14691 During a concurrent interview and record review on 5/7/2024 at 11:46 a.m. with the DON, Resident 1's care plan titled, Altered skin integrity due to actual pressure ulcer (right heel) regressed to DTI dated 4/16/2024 was reviewed. The DON confirmed Resident 1's plan of care for DTI did not include interventions for repositioning, turning every two hours and offloading of the right heel. The DON stated it was important to have a resident centered plan of care to prevent progression of a pressure ulcer to DTI. During a review of the facility's policy and procedure (P&P) titled, Treatment Services to Prevent/Heal Pressure Ulcers, revised 3/2023, the P&P indicated, repositioning or relieving constant pressure is a common, effective intervention for an individual with a pressure ulcer/pressure injury or who is at risk of developing one. Assessment of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive care plan consistent with the resident's need and goals. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning, as the resident is unable to make small movements on their own that would help to relieve prolonged pressure to one area.

Based on interview and record review, the facility failed to follow its policy and procedure for change of condition (C[NAME]) when one of three sample residents (Resident 1) had significant change in clinical condition and a need to alter treatment. For Resident 1, who had a fall with injuries, Licensed Vocational Nurse 1 (LVN 1) failed to immediately notify and consult the resident's physician (Cross referenced F684). This deficient practice resulted in a delay in diagnosis, care and services and a decline in Resident 1's health. Resident 1 sustained a subdural hematoma (a collection of blood outside the brain caused by severe head injuries) after the fall due to [MEDICATION NAME] head trauma (BHT) and was transferred to a general acute care hospital (GACH) where the resident died the next day, on [DATE]. Findings: A review of Resident 1's Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care planning tool, dated [DATE], indicated Resident 1 had no memory problems, no impaired decision-making, was able to make needs known and be understood by others. The MDS indicated Resident 1 required extensive assistance of a one-person physical staff assistance for transferring, dressing, toileting, personal hygiene and bed mobility. The MDS indicated Resident 1 was impaired of range of motion (ROM) of bilateral (both) lower extremities. According to the MDS, Resident 1 sustained a fall in the last month. A review a facility's Situation, Background, Assessment and Recommendation ((SBAR) internal communication form) written by LVN 1, dated [DATE] and timed at 3:30 a.m., indicated Resident 1 had an unwitnessed fall that resulted on a bump to the left side of the forehead. The SBAR indicated Resident 1 was alert, verbal, and was placed back in bed. A neurological check (an assessment of sensory neuron and motor responses, especially reflexes, to determine if the nervous system was impaired) were initiated. A review of a Progress Note written by LVN 1, dated [DATE] and timed at 3:30 a.m., indicated Certified Nursing Assistant 1 (CNA 1) responded to Resident 1's call light and upon entering the room, Resident 1 was found on the floor next to the bed after an unwitnessed fall. The progress note indicated Resident 1 was alert and verbally responsive, with no signs of distress and was able to move upper and lower extremities, no dizziness, no headache, or nausea and vomiting. According to the progress note, Resident 1 had a large bump on left side of the forehead and a bluish discoloration to the right side of the chin, but denied pain. A review of the Licensed Progress Notes written by LVN 1, dated [DATE] and timed at 4:05 a.m., indicated LVN 1 notified Resident 1's physician of the unwitnessed fall. The note indicated Physician 1 ordered an x-ray of the skull and left hip. A review of Physician 1's telephone order (T/O), dated [DATE] and timed at 4:05 a.m., written by LVN 1, indicated STAT (instantly or immediately) X-ray of the right hip, left side of forehead and skull. The T/O indicated to apply an ice pack to the left forehead every shift for 15 minutes for three days and do neuro checks per protocol for 48 hours. A review of a Licensed Progress note, dated [DATE] and timed at 5 a.m., indicated Resident 1 was awake, with no complaints of pain, and/or discomfort. A review of the 48 hours Neuro-Checklist, dated [DATE] and timed at 5 a.m., written by LVN 1 indicated Resident 1's vital signs were blood pressure ,[DATE] (normal reference range (NRR) ,[DATE]), body temperature was 97.8 Fahrenheit (F) (NRR = 97.9 to 99), and heart rate was 74 (NNR = ,[DATE]), with respirations of 18 (NRR = ,[DATE]). Resident 1 was alert, verbal, and had no change of L[NAME]. A review of a Licensed Progress note, dated [DATE] and timed at 6 a.m., indicated LVN 1 notified Resident 1's Family member (FM 1) about the resident's fall, x-rays were ordered, and that Resident 1 denied pain/discomfort denial. The note further indicated that Resident 1 was administered [MEDICATION NAME] (a medication to treat heartburn) without any problem. A review of the 48 hours Neuro-Checklist, dated [DATE] and timed at 6 a.m., written by LVN 1, indicated Resident 1's vital signs were as follows: blood pressure ,[DATE], body temperature was 97.8 F, and heart rate was 72 with respirations of 20. Resident 1 was alert, verbal, and had no change of level of consciousness (L[NAME]). A review of the Licensed Nurses Progress Note, dated [DATE] and timed at 7:10 a.m., indicated CNA 2 reported to Registered Nurse 1 (RN 1) that Resident 1's unidentified Family member came to visit and Resident 1 was not responding or opening her eyes when FM 1 attempted to talk to resident. The note indicated RN 1 was unable to wake up Resident 1. Resident 1's vital signs were documented as follows: blood pressure ,[DATE], body temperature 101.6 F, heart rate 85, respirations of 18, and Oxygen saturation (measurement of how much oxygen is in the blood) was 96 percent (%) (NRR 92 to 100). RN 1 called 911 paramedics to transport Resident 1 for medical evaluation to the nearest GACH due to unresponsiveness. A review of a Physicians' Telephone Order, dated [DATE] and timed at 7:15 a.m., written by RN 1 indicated for Resident 1 to be transferred to the nearest GACH via 911 (emergency response number) for medical evaluation due to unresponsiveness. A review of the facility's Record of Termination, dated [DATE], indicated that LVN 1 was terminated after Resident 1's fall incident that occurred on [DATE]. The termination record indicated that the nursing home lost confidence in LVN 1's abilities due to in-accurately assessing the resident, documenting assessment, and [MEDICATION NAME] out of her scope of practice by writing a physician's orders [REDACTED]. On [DATE] at 10:03 a.m., during an interview, an associate physician of the primary care provider (Physician 2) stated, I am not sure who wrote the phone order, the Physician assistant (PA 1) who works with the primary care provider (Physician 1) was off. Another provider was on call, not the primary care provider. On [DATE] at 10:12 a.m., during a phone interview the diagnostic lab representative stated, We do not have an order for [REDACTED]. On [DATE] at 1:42 p.m., during a phone interview Physician 2 stated, No provider gave that order from our office. Another provider was on duty, and did not receive a call from the facility. On [DATE] at 9:59 a.m., during a concurrent interview and record review, LVN 1 stated and she confirmed that on [DATE], she did not receive orders for x-ray of the skull and neuro check from Resident 1's physician. LVN 1 stated that she left a message, but did not receive orders or made a second attempt to notify the physician of Resident 1's fall with injury. LVN 1 stated that Resident 1 suffered a fall that resulted in an elevated bump to the left side of the forehead that appeared slight green in color and measured 3 to 4 centimeters (cm) in diameter. LVN 1 stated that she wrote the order for the x-ray because she believed Resident 1 would benefit from it and that it would not hurt her. A review of the facility's policy and procedures titled, Change of Condition, Physician Contact, revised [DATE], indicated to notify the physician of any significant change in patient's condition, or to report an incident. In case of an emergency, call the attending physician if physician not available, call the alternative, or the medical director if any of the physicians are available.

Based on interview and record review, the facility failed to follow its policy when a resident had a change of condition and provide the necessary care and services when one of three sampled residents had a change of condition (Resident 1). Resident 1 had a fall with injuries and Licensed Vocational Nurse 1 (LVN 1) failed to notify the physician for the necessary care and interventions. This deficient practice resulted in a delay in diagnosis, care and services and a decline in Resident 1's health. During the fall, Resident 1 had [MEDICATION NAME] head trauma (BHT) and sustained a subdural hematoma (a collection of blood outside the brain caused by severe head injuries) and was transferred to a general acute care hospital (GACH) and died the next day, on [DATE]. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care planning tool, dated [DATE], indicated Resident 1 had no memory problems, no impaired decision-making, was able to make needs known and be understood by others. The MDS indicated Resident 1 required extensive assistance of a one-person physical staff assistance for transferring, dressing, toileting, personal hygiene and bed mobility. The MDS indicated Resident 1 was impaired of range of motion (ROM) of bilateral (both) lower extremities. According to the MDS, Resident 1 sustained a fall in the last month. A review a facility's Situation, Background, Assessment and Recommendation ((SBAR) an internal communication form) written by LVN 1, dated [DATE] and timed at 3:30 a.m., indicated Resident 1 had an unwitnessed fall that resulted in a bump to the left side of the forehead (BHT). The SBAR indicated Resident 1 was alert, verbal, and was placed back in bed. A neurological check (an assessment of sensory neuron and motor responses, especially reflexes, to determine if the nervous system was impaired) were initiated. A review of a Progress Note written by LVN 1, dated [DATE] and timed at 3:30 a.m., indicated Certified Nursing Assistant 1 (CNA 1) responded to Resident 1's call light and upon entering the room, Resident 1 was found on the floor next to the bed after an unwitnessed fall. The progress note indicated Resident 1 was alert and verbally responsive, with no signs of distress and was able to move upper and lower extremities, no dizziness, no headache, or nausea and vomiting. According to the progress note, Resident 1 had a large bump on left side of the forehead and a bluish discoloration to the right side of the chin, but denied pain. A review of the Licensed Progress Notes written by LVN 1, dated [DATE] and timed at 4:05 a.m., indicated LVN 1 notified Resident 1's physician of the unwitnessed fall. The note indicated Physician 1 ordered an x-ray of the skull and left hip. A review of Physician 1's telephone order (T/O), dated [DATE] and timed at 4:05 a.m., written by LVN 1, indicated STAT (instantly or immediately) X-ray of the right hip, left side of forehead and skull. The T/O indicated to apply an ice pack to the left forehead every shift for 15 minutes for three days and do neuro checks per protocol for 48 hours. A review of a Licensed Progress note, dated [DATE] and timed at 5 a.m., indicated Resident 1 was awake, with no complaints of pain, and/or discomfort. A review of the 48 hours Neuro-Checklist, dated [DATE] and timed at 5 a.m., written by LVN 1 indicated Resident 1's vital signs were blood pressure ,[DATE] (normal reference range (NRR) ,[DATE]), body temperature was 97.8 Fahrenheit (F) (NRR = 97.9 to 99 F), and heart rate was 74 bpm (beats per minute) (NRR = ,[DATE]), with respirations of 18 (NRR = ,[DATE]). Resident 1 was alert, verbal, and had no change of L[NAME]. A review of a Licensed Progress note, dated [DATE] and timed at 6 a.m., indicated LVN 1 notified Resident 1's Family member (FM 1) about the resident's fall, x-rays were ordered, and that Resident 1 denied pain/discomfort denial. The note further indicated that Resident 1 was administered [MEDICATION NAME] (a medication to treat heartburn) without any problem. A review of the 48 hours Neuro-Checklist, dated [DATE] and timed at 6 a.m., written by LVN 1, indicated Resident 1's vital signs were as follows: blood pressure ,[DATE], body temperature was 97.8 F, and heart rate was 72 with respirations of 20. Resident 1 was alert, verbal, and had no change of level of consciousness (L[NAME]). A review of the licensed nurses progress note, dated [DATE] and timed at 7:10 a.m., indicated CNA 2 reported to Registered Nurse 1 (RN 1) that Resident 1's unidentified Family member came to visit and Resident 1 was not responding or opening her eyes when FM 1 attempted to talk to resident. The note indicated RN 1 was unable to wake up Resident 1. Resident 1's vital signs were documented as follows: blood pressure ,[DATE], body temperature 101.6 F, heart rate 85, respirations of 18, and Oxygen saturation (measurement of how much oxygen is in the blood) was 96 percent (%) (NRR 92 to 100). RN 1 called 911 paramedics to transport Resident 1 for medical evaluation to the nearest GACH due to unresponsiveness. A review of a physicians' telephone order, dated [DATE] and timed at 7:15 a.m., written by RN 1 indicated for Resident 1 to be transferred to the nearest GACH via 911 (emergency response number) for medical evaluation due to unresponsiveness. A review of the facility's Record of Termination, dated [DATE], indicated that LVN 1 was terminated after Resident 1's fall incident that occurred on [DATE]. The termination record indicated that the nursing home lost confidence in LVN 1's abilities due to in-accurately assessing the resident, documenting assessment, and [MEDICATION NAME] out of her scope of practice by writing a physician's orders [REDACTED]. On [DATE] at 10:03 a.m., during an interview, an associate physician of the primary care provider (Physician 2) stated, I am not sure who wrote the phone order, the Physician assistant (PA 1) who works with the primary care provider (Physician 1) was off. Another provider was on call, not the primary care provider. On [DATE] at 10:12 a.m., during a phone interview the diagnostic lab representative stated, We do not have an order for [REDACTED]. On [DATE] at 1:42 p.m., during a phone interview Physician 2 stated, No provider gave that order from our office. Another provider was on duty, and did not receive a call from the facility. On [DATE] at 9:59 a.m., during a concurrent interview and record review, LVN 1 stated and she confirmed that on [DATE], she did not received orders for x-ray of the skull and neuro check from Resident 1's physician. LVN 1 stated that she left a message, but did not received orders or made a second attempt to notify the physician of Resident 1's fall with injury. LVN 1 stated that Resident 1 suffered a fall that resulted in an elevated bump to the left side of the forehead that appeared slight green in color and measured 3 to 4 centimeters (cm) in diameter. LVN 1 stated that she wrote the order for the x-ray because she believed Resident 1 would benefit from it and that it would not hurt her. A review of the facility's policy and procedures titled, Change of Condition, Physician Contact, revised [DATE], indicated to notify the physician of any significant change in patient's condition, or to report an incident. In case of an emergency, call the attending physician if physician not available, call the alternative, or the medical director if any of the physicians are available.

Based on observation, interview and record review, the facility failed to ensure Resident 1 who had dementia, confusion, poor safety awareness, and exhibited elopement risk behaviors, as evidenced by trying to get in and out of the bed, looking for his family and verbalizing wanting to go home for one out of four sampled residents (1), from eloping from the facility by failing to: 1. Conduct an assessment of the resident's elopement risk behaviors upon admission to the facility, and periodically reviewing that assessment upon change of condition to ensure the safety of the resident. 2. Develop a care plan to address Resident 1's elopement risk behaviors. 3. Ensure all staff were aware of the resident's elopement risk and not only the registered nurse 2 (RN 2), and certified nursing assistant 1(CNA 1. This deficient practice resulted in Resident 1 eloping from the facility undetected and missing for three consecutive days. Consequently, the police department found Resident 1, approximately 22 miles away from the facility. Resident 1 was then transferred to the general acute care hospital (GACH) where he was hospitalized for [REDACTED]. Findings: On February 17, 2016, at 7 a.m., an unannounced visit was made to investigate an entity-self reported (ERI) regarding Resident 1 who walked out of the facility and was still missing. On the same day, accompanied by RN 1, during the environmental observation, the front entrance, the kitchen, and the laundry room doors leading to the outside of the building were not equipped with alarms to alert staff when opened. The wooden gate located to the side of the building (close to the resident's room) that led to the street was wide open and not latched closed. The side and the back parameter of the facility was either fenced, or had concrete walls. There were no gates. The parameters in the front of the facility were the only areas with a gated fence. On February 17, 2016, at 7:50 a.m., the DON stated Resident 1 was found in another city by the police and the resident was transferred to the acute care hospital (GACH) for an evaluation. On the same day and time, according to the Administrator the facility's surveillance cameras recorded the resident leaving the side exit doors adjacent to his room around 4:57 p.m. The resident eloped (common behavior of resident's with dementia who leave an area without permission or notification which usually places that individual in a potentially dangerous situation (Wandering and Elopement in Nursing Homes Annals of Long-Term Care, Clinical Care and Aging Source)), and could not be found. The resident was found on the ground, three days later by the police department in another city (approximately 22 miles away from the facility). He was taken to the acute hospital and was diagnosed with [REDACTED]. The resident was administered Intravenous ((IV) fluids (injecting through a vein, usually in the arm). On the day of the elopement the facility documented and notified the family to visit with the resident because he was trying to get in and out of the bed and wheelchair, was looking for his family, and verbalized wanting to go home. According to Resident 1's admission record the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. infections), and hypertension ((HTN) high blood pressure) and was assessed as having poor safety awareness, ambulatory, and was admitted to a room next to the side exit doors. The resident's responsible person was listed as his wife, and his son. According to the facility's physician's orders [REDACTED]. On February 12, 2016, there was a physician's orders [REDACTED]. Due to the resident ' s elopement he did not receive the above listed medications as ordered by the physician. According to the plan of care, developed on February 10, 2016, for the potential for high blood pressure related to HTN and COPD, one of the approaches was to administer medications to the resident per physician's orders [REDACTED]. The care plan included a medication sticker which warned against abrupt withdrawal of Metoprolol medication, which could result in Myocardial Infarction ((MI) also called a heart attack because of the blockage of blood flow to the heart muscle). A review of the care plan dated February 11, 2016, indicated Resident 1 was also at risk for fall/injury related to unsteady gait, poor safety awareness, confusion, dementia, COPD, asthma, and generalized weakness. The listed care plan goal indicated the resident would be free from injuries. The approaches included to assess the resident for safety awareness and to determine his safety needs, to maintain a safe and hazard free environment, and to monitor the resident's alarm. A review of Resident 1's clinical record indicated, although the resident was assessed at risk for injuries, and exhibited further behaviors that put him in harm's way, including getting out of his bed and wheelchair, and verbalizing wanting to go home, there was no documented evidence these elopement risk factors were assessed and care planned to reduce the risk for injuries. A review of the daily licensed nurses notes dated February 14, 2016, on the 3 p.m., to 11 p.m., shift, indicated Resident 1 was confused, forgetful to person, place, and time, but was able to recognize his family members. The licensed nurses documented, although the resident was provided with reality awareness after he verbalized he wanted to go home to look for his family, he was still trying to get out of his bed and wheelchair. A review of the licensed nurse ' s notes dated February 14, 2016, at 4 p.m., indicated RN 2 called the family about the resident's behavior and requested them to come to the facility to be with the resident. At 5 p.m., the licensed nurse documented the resident stayed in his room, was closely monitored. At 5:30 p.m., the resident's wife informed the nurses she could not find the resident. It was further documented that the staff searched the facility and the parameters but still were unable to locate the resident. At 5:40 p.m., the police department was called to report that Resident 1 missing. A review of the fire department emergency medical services report form dated February 16, 2016, indicated the paramedics were called at 8:57 p.m., because Resident 1 was found lying on the ground. According to this report the resident was confused with blood sugar of 268 milligram per deciliter (mg dl) (normal blood sugar is below 110 mg dl to 140). The resident was transferred to a GACH for further evaluation. A review of Resident 1's history and physical from the GACH, dated February 18, 2016, indicated Resident 1, who had an advanced dementia, and resided at a skilled nursing, facility was brought to the emergency room (ED) by the police after he was found wondering out in the streets. The resident was reported missing for three days after he eloped. According to the GACH's laboratory report , the resident had a high sodium level of 148 milimole per liter (mmol/L - unit in medicine for measuring concentrations of substances in the blood) (normal range 135 - 147 mmol/L), had a renal failure with a blood urea nitrogen (BUN - test is done to see how well your kidneys are working) of 69 milligram per deciliter (mg/dl) (normal range 9- 23 mg/dl), Creatinine of 1.6 (mg/dl) (normal range 0.70 - 1.30 mg/dl), with white blood cells count of 14.4 cubic milliliter (k/ul) (normal range 4.3 -10.0 k/ul). According to the ED physician's note the resident's had an altered mental status (a disruption in brain that causes a change in behavior) likely secondary to toxic metabolic [DIAGNOSES REDACTED] (exposure to toxic substances) brought by dehydration. The resident was hydrated with Normal Saline (is the name for the 0.9% strength of sodium chloride (salt) solution in water), with daily blood testing to monitor the electrolyte levels. On February 18, 2016, the resident was discharged to another facility. On February 17, 2016 at 2:30 p.m., during a phone interview a certified nursing assistant 1 (CNA 1) assigned to the resident on the day he went missing, stated Resident 1 was ambulatory without using his walker, very confused and always asked where he was going. On February 14, 2016, when CNA 1 started her shift the resident was brought to the nurse ' s station, attached to a wheelchair because he was getting in and out of his chair. CNA 1 stated the resident's wife came to the facility but could not find the resident so she alerted the staff. CNA 1 stated the resident's wife was saying you guys have to look for him; he does not know what he is doing. That was when the RN 1 called the police department and searched the parameters but failed to locate the resident. CNA 1 stated the facility used a chair alarm to alert the staff for confused residents. CNA 1 stated the door the resident exited from had an alarm. CNA 1 could not understand why no one heard the door alarm and why the staff did not hear the resident's chair alarm. CNA 1 confirmed the resident could not have protected and supported himself without staff's assistance. On February 17, 2016 at 4 p.m., the DON stated the facility had an elopement risk assessment but did not use it because they do not admit residents with an elopement behavior. The DON stated if there was an elopement problem the facility would use 72 hour charting, nurse ' s notes, and the communication book to monitor the resident ' s behavior. The DON identified any resident's elopement risk factor as one or two attempts at leaving the facility, and or standing by the exit doors. When asked if [DIAGNOSES REDACTED]. The DON could not find a care plan addressing the resident's elopement risk behaviors prior to leaving the facility. On February 26, 2016 at 10:28 a.m., during a phone interview with Resident 1's family member, it was stated the resident was very confused, and needed constant monitoring. The family member stated the resident had wondered from their home on couple of occasions, which was typical for dementia patients. The family member stated the facility was informed about the resident ' s confusion and could not understand why the staff did not communicate that information to each other. The family member stated even though the facility may have not been aware of the fact the resident had eloped in the past, the facility should have known that dementia patients are confused and tend to wander. The family member stated it should have given the facility staff a clue when they placed an alarm on the resident, and when they called the family to sit with the resident. The family member further stated that on February 14, 2016, at between 1 p.m., to 2 p.m., both he and his mother received a call from the facility begging them to come back because the resident was very agitated and was getting in and out of his chair trying to look for family. On March 2, 2016, at 1:20 p.m., during a phone interview with RN 2, who was at the facility on the day of Resident 1's elopement, described Resident 1 as confused, who constantly got in and out of his bed/chair, and who wanted to find his family. RN 2 stated she called the resident's family members to visit with the resident because he was very agitated and the agitation could have been relieved by the family visit, but when his wife arrived, she could not find him. RN 2 stated she alerted the staff and called the police department. RN 2 was asked if a dementia, confused, ambulatory resident was ever at risk of leaving the facility, she stated she had never thought about that. RN 2 stated the only people aware of the resident's behavior on the day of elopement were the facility's charge nurse, herself, and CNA 1. RN 2 confirmed she did not alert all staff about his behavior, did not care plan the resident ' s behavior in order to safeguard him, and did not hear the resident's tab alarm and or the door alarm before the resident left the building. A review of the facility's policy on Elopement and Wandering dated February 14, 2011, indicated that it was the policy of the facility to assess the residents at risk for elopement on an individual basis, and all residents who are at risk for harm because of wandering behavior will have an assessment and care plan that addresses the issue.

Based on observation, interview, and record review, the facility failed to ensure the Invacare lift (mechanical lift device used to move heavy immobile residents) connected to a full body mesh sling (works like a hammock by supporting the body) was inspected after each laundering for wear, tears, loose stitching as indicated in the manufacturer's guideline, inspected the sling prior to each use for wear and/or frayed (unraveled, worn at the edges) areas, and ensure the staff used two plus persons physical assist while transferring the resident from wheelchair to the bed using a mechanical lift as indicated in the resident's assessment to prevent fall and/or injury from the fall for one of three sampled residents (1). On [DATE] at 1 p.m., Resident 1 was being transferred from the chair to the bed using the Invacare lift sling, when one of the lift sling straps broke. Resident 1 slid out of the sling onto the floor, hit the back of her head, sustaining a laceration (cut) measuring 5 centimeters (cm) by 5 cm. The resident also sustained skin tears to her right forearm and left posterior (back) upper ear. At 1:30 p.m., Resident 1 was transferred by the paramedics to the general acute care hospital (GACH) emergency department (ED), and expired on the same day at 3:06 p.m. (two hours and six minutes after the fall incident). The death certificate indicated Resident 1 expired because of traumatic hemothorax (the presence of blood in the lungs) that was caused by a blunt force trauma (injury caused by an impact). The failure resulted in Resident 1 falling out of the sling and sustaining injuries, which resulted in death. Findings: On [DATE] at 1 p.m., an unannounced visit was made to the facility to investigate an Entity Self-Reported (ERI) incident involving Resident 1. On [DATE] at 1 p.m., Resident 1 sustained a fall out of the mechanical lift during the transfer from her wheelchair to the bed. The resident sustained [REDACTED]. According to the facility's admission record, it indicated Resident 1 was a [AGE] year-old female readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a standardized assessment care and screening tool) dated [DATE], indicated Resident 1's cognitive skills for daily decision-making was moderately impaired. The resident was assessed as totally dependent on one person physical assistance with locomotion on and off the unit, dressing, and personal hygiene and two plus person-assist with toileting, and transfers. The resident was five feet and three inches tall, and weighed 164 pounds. The care plan dated [DATE], indicated Resident 1 was at risk for falls/injury. The approach was to maintain a safe and hazard free environment. Another care plan dated [DATE], for activity of daily living (ADL, routine activities that resident's perform every day like eating, bathing, dressing) rehabilitation indicated the resident needed total assistance from staff for transferring. The approach was to assist the resident with all transfers. The care plan did not address how to transfer the resident or what equipment to use. A review of the Licensed Personnel Progress notes, dated [DATE] at 12:25 p.m., indicated Resident 1 was lifted using the Invacare lift. According to the documentation the resident fell from the Invacare lift sling, hit her head on the floor, and sustained a right forearm skin tear measuring 1 cm by 1 cm, left posterior (back) upper ear skin tear measuring 1 cm by 1 cm, and a laceration to the left posterior head measuring 5 cm by 5 cm, that was bleeding. The resident's vital signs (clinical measurements of the pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of the resident's essential body functions) were as follows: blood pressure (the pressure of the blood in the circulatory system, often measured for diagnosis) was ,[DATE] millimeters of mercury (mm Hg) (systolic (top number, which is also the higher of the two numbers which measures the pressure in the arteries between the heartbeat when the heart muscle contracts) normal ranges 120 mm Hg systolic) 96 mm Hg diastolic (The bottom number, which is also the lower of the two numbers, measures the pressure in the arteries between heartbeats when the heart muscle is resting between beats and refilling with blood)), pulse rate was 87 beats per minute (bpm) (normal range 60 to 100 bpm), respirations were 24 breaths per minute (normal range 12 to 20 breaths per minute), temperature was 97.1 degrees Fahrenheit (normal range 98.6 degrees Fahrenheit), and her blood oxygen saturation (amount of oxygen in the blood) was 58 percent (normal ranges 95 to 100 percent, and 90 percent is considered low) using three liters of oxygen per minute via nasal cannula. Resident 1 was switched to a non re-breathable face mask (NRB, allows for the delivery of higher concentrations of oxygen), and after three minutes the resident's blood oxygen saturation levels increased from 88 to 90 percent. At 12:40 p.m., the Licensed Personnel Progress Notes indicated the resident's responsible party was called and notified of incident. At 12:50 p.m., the Licensed Personnel Progress Notes indicated a message was left with the health management organization (HMO). The notes indicated transportation was called to transfer the resident to her HMO hospital for evaluation of laceration to resident's head. At 12:55 p.m., the Licensed Personnel Progress Notes indicated Resident 1's vital signs were rechecked, and indicated; BP ,[DATE], PR 76 bpm, RR 24 breaths per minute, pain ,[DATE] (no pain) and oxygen saturation was 89 percent at 15 liters per minute via NRB. The note indicated the transportation was canceled. At 1:00 p.m., the Licensed Personnel Progress Notes indicated 911 (emergency number) was called due to resident's low oxygen saturation and head laceration. At 1:05 p.m., the paramedics arrived, and assessed Resident 1. The note indicated report was given regarding the resident's condition, incident of fall, head laceration and medical history. The resident was transferred out to GACH via paramedics at 1:30 p.m. The Emergency Medical Services (EMS) Report dated [DATE] at 1:14 p.m., indicated Resident 1 was sitting in bed, and complained of shortness of breath, times 30 minutes. The notes indicated per nursing staff resident was in a wheelchair moving device when it malfunctioned and the resident fell . Resident had a positive laceration at the back of her head approximately 5.5 cm. The notes indicated after the resident fell , nursing staff noticed low oxygen saturation, and per staff resident's oxygen saturation was normally 89 to 91 percent. At 1:40 p.m., the notes indicated care transferred to facility (GACH). Resident 1 vital signs as follows: BP ,[DATE], PR 86 bpm, RR 22 breaths per minute and oxygen saturation 88 percent with NRB. A review of the GACH - ED notes dated [DATE] at 2:50 p.m., indicated Resident 1's BP was ,[DATE] mmHg, PR 37 bpm, RR 28 bpm, and oxygen saturation was 26 percent. At 3:00 p.m., BP was ,[DATE] mmHg, PR 19 bpm, RR 14 breaths per minute and oxygen saturation was 16 percent. Resident 1's Do not Resuscitate (DNR) status was confirmed, and because of possible pneumonia (lung infection) antibiotics were administered. The resident was put on a bi level positive airway pressure (a bipap machine to deliver pressurized oxygen) to ease the resident's breathing. The resident's head laceration approximately 10 cm, with no bleeding, that was repaired. According to the notes the resident was not stable enough for a computerized axial tomography scan (a procedure that assists in diagnosing tumors, fractures, bony structures, and infections in the organs and tissues of the body). When the resident's blood pressure continued to drop, Levophed (medication to treat low blood pressure and heart failure) was started, but the resident's condition continued to deteriorate. Resident 1 expired at 3:06 p.m. (two hours and six minutes after the fall incident). A review of the facility's investigative notes dated [DATE] at 5:40 p.m., indicated CNA 1 stated as she was waiting for someone to help her, she lifted the resident up over the wheelchair. Then suddenly the corner of the sling strap ripped, and the resident slid out and fell to the floor. At the same time the Invacare lift tipped over, and the resident ended up on top of the base legs of the Invacare lift. The notes indicated prior to the use of the Invacare lift sling, CNA 1 thought that the sling looked strong enough, and that she could not have controlled it from ripping. On [DATE] at 1:20 p.m., during an interview the director of nursing (DON) stated she spoke to CNA 1, who was with the resident when the resident fell out of the Invacare lift. The DON stated CNA 1 told her as she was waiting for assistance from another staff member she raised the lift to adjust the straps. When she raised the resident up and out of her wheelchair, one of the straps that held the sling broke off, resulting in the resident falling to the floor. The DON stated the resident was responsive, her vital signs were normal and she was not complaining of any pain. When the resident's blood oxygen saturation levels got too low, the facility called the EMS. The resident was then transferred to the GACH's emergency department. On [DATE] at 1:35 p.m., the DON provided the Invacare lift machine and the administrator provided the same sling that was used during the incident involving Resident 1 fall. During the inspection, the four slings were observed to be frayed. One of the straps was completely broken in half. The straps were observed with lose stitching, worn and over-used. On the same date a photo was taken of the same sling that was used to transfer Resident 1 on [DATE], showing three connecting straps and one that was broken in half. On [DATE] at 1:45 p.m., after showing the maintenance supervisor and the laundry staff person the same sling that was used during the incident, they both stated that sling should have never been used. When asked why, they did not answer. The maintenance supervisor stated he usually asks the director of staff developer (DSD) and/or the administrator for permission to discard frayed slings. The maintenance supervisor and the laundry staff were both asked why that particular frayed sling was not removed from use, they both did not answer. The maintenance supervisor and the laundry staff person were unable to provide documented evidence that the Invacare lift slings were inspected after laundering. On [DATE] at 2:40 p.m., in a phone interview with CNA 1, she stated on [DATE], that morning she obtained the mesh sling from the laundry room, in order to transfer Resident 1 to her bed. CNA 1 stated she hooked the sling straps to the Invacare lift, and while waiting for another staff member to help her, she lifted the resident up and out of her wheelchair. CNA 1 stated suddenly one of the sling straps broke off, and the resident hit her head on the machine and screamed help, help, the resident denied having pain. CNA 1 stated the sling was old but she did not think it would rip. On [DATE] at 1:05 p.m. during an interview the DSD, stated that on [DATE], an in-service was given to CNAs to have two-staff assist if the Invacare lift is used to transfer a resident. DSD stated one staff was to hold the sling and guide the sling with resident, to prevent any injuries. The DSD further stated if there was only one person using Invacare, the other could not guide the resident and the residents could bump their legs, which could result in skin tears or falls. On [DATE] at 1:29 p.m. during an interview, the administrator he stated prior to the incident the facility had no specific person or formal training to check and/or inspect the Invacare lift slings. There was no systems in place to identify the age of the slings. The new and old slings were mixed together. The tag attached to the same type of full body sling used in Resident 1's transfer indicated that bleached, torn, cut, frayed or broken slings are unsafe and could result in injury. The tag indicated to discard immediately. A review of the Invacare owner's operator and maintenance manual for patient slings dated 2008, indicated after each laundering inspect sling(s) for wear, tear, and lose stitching. The Certificate of Death dated [DATE], indicated the immediate cause of death (final disease or condition resulting in death) was (A) Traumatic hemothorax (the presence of blood which may be from the chest wall, lung, heart, or great vessels that is in the pleural space (the thin covering that protects and cushions the lungs). Sequentially, list conditions if any, leading to cause on Line A. Enter underlying cause (disease or injury that initiated the events resulting in death). (B) Blunt force trauma (injury caused by an impact). According to the U.S. National Library of Medicine (a national library) defined head injury as a trauma to the scalp, skull, or brain. The injury may be only a minor bump on the skull or a serious brain injury. Head injuries may cause bleeding in the brain tissue and the layers that surround the brain. Symptoms of a head injury can occur right away or symptoms develop slowly over several hours or days. Even if the skull is not fractured, the brain can hit the inside of the skull and be bruised. The head may look fine, but problems could result from bleeding or swelling inside the skull which can lead to coma, and or death.

Based on interview and record review, the facility failed to ensure the facility's policy and procedures for falls were followed and the resident was accurately assessed after a fall. The facility also failed to ensure a resident who was assessed and determined to be high risk for fall was provided adequate supervision and assistance according to the plan of care for 1 of 17 sample residents (5). The facility failed to revise a resident's plan of care to address the resident not asking for assistance to go to the bathroom (see F279). The facility failed to notify the resident's physician of a fall incident and change of condition for 12 hours (refer to F157). The facility failed to perform adequate investigation regarding a fall incident (refer to F501). The facility failed to notify the Department within 24 hours of an unusual occurrence that threatens the welfare of a resident (refer to F501). Resident 5 sustained a bump on the head, had right hip pain, the resident complained of pain on the scale of 6/10 (the pain scale measures a resident's pain intensity based on a scale from zero to 10, a pain level zero represents no pain at all while 10 represents the worst), medicated three times with Vicodin 5/500 milligrams (mg) two tablets, a narcotic medication. Resident 1 was transferred to the acute hospital emergency roiagnom on [DATE] at 6:15 a.m. and undergone surgery. Failure to accurately assess the resident resulted to delayed implementation of acute hospital medical care and services for 18 hours for an injury from the fall on November 2, 2010, and actual harm occurred, a right proximal hip fracture (a fracture in the proximal end of the femur the long bone running through the thigh near the hip joint - Wikipedia, the free encyclopedia). Findings: According to the admission record, Resident 5 was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) for Nursing Home Resident Assessment and Care Screening, dated August 4, 2010, indicated Resident 5 required extensive assistance with transferring and ambulating in the corridors, personal hygiene, toilet use, and bathing from the nursing staff. The resident is incontinent of her bowel and bladder. Under Physical Functioning and Structural Problems with Activities of Daily Living self-performance indicated extensive assistance meaning the resident can perform part of the activities of daily living (ADLs), but requires assistance three or more times in seven days. According to Wikipedia, the free encyclopedia, basic Activities of Daily Living (ADLs) consists of self-care tasks, personal hygiene and grooming, dressing and undressing, feeding and ambulating. The health professionals routinely refer to the ability or inability to perform ADLs as a measurement of the functional status of a person, particularly in regards to people with disabilities and the elderly. http://en.wikipedia.org/wiki/Activities_of_daily living. According to the Mayo Clinic, not dated, dementia is not a specific disease, instead dementia describes a group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning. Dementia is caused by conditions or changes in the brain. Dementia indicates problems with at least two brain functions, such as memory loss along with impaired judgment or language. A record review of the physician's orders [REDACTED].(treats diabetes), administer subcutaneously, per sliding scale coverage. A physician's orders [REDACTED]. A review of the Fall Risk Assessments, dated July 23, 2010, and October 11, 2010, indicated the resident was high risk for falls due to a history of falls in the past three months. The resident's ambulatory and gait/balance exercises the resident was not able to perform. The resident takes antihypertensive (treats high blood pressure), diuretics (medicines that help reduce the amount of water in the body), [DIAGNOSES REDACTED] (an abnormally low level of blood sugar) and narcotic medications and a score of 14 on the Fall Risk Assessment indicating the resident high risk for falls. The plan of care dated July 23, 2010, indicated the resident was at risk for falls due to an unsteady gait and a history of a fall due to a proximal humeral fracture. The resident uses an assistive device and incontinent of bowel and bladder. The nursing intervention was to monitor the resident's whereabouts due to falls. A review of the clinical record indicated no documented evidence the nursing staff members monitored the whereabouts of the resident. The plan of care dated July 24, 2010, indicated a self care deficit, the resident requires assistance with bed mobility, transfer, locomotion due to a left hip fracture and status [REDACTED]. The nursing intervention was to assist the resident to move around the facility as needed. According to the Physical Therapy Functional Range of Motion and Voluntary Movement Screen dated July 25, 2010, indicated partial loss in the resident's left leg. The resident was able to initiate and complete voluntary movement in her left leg, but movement was slow. A record review of the Physical Therapy Initial Evaluation, dated July 25, 2010, indicated the resident fell at home and sustained a left hip and humeral fracture approximately one year ago and sustained a right proximal humeral fracture three weeks ago. The resident required stand-by assists with bed mobility, transferring from bed to wheelchair and wheelchair to bed. The resident's modes of locomotion were a front wheel walker and a wheelchair. A review of the Activities Assessment, dated July 26, 2010, indicated the resident was alert and verbally responsive with periods of confusion and only able to express herself in Japanese/Chinese. The Physical Therapy Progress Notes, dated September 20, 2010, indicated the resident requires stand-by assists from her bed to a wheelchair. During gait training, the resident requires an assistive device, a front wheel walker with stand-by assists. A review of the Restorative Nursing Assistant Charting Notes, dated September 25, 2010, indicated the resident ambulated 50 to 100 feet with the use of her front wheel walker. A record review of the Licensed Personnel Progress Notes, dated November 2, 2010, on the 7 a.m. to 3 p.m. shift, indicated at 12 p.m., the resident was found lying on her right side on the floor. The resident stated she walked to the bathroom, came out then lost her balance and fell and hit her head on the floor, where a small bump was observed. Further review of the Licensed Personnel Progress Notes, indicated there was no bleeding, no nausea or vomiting, no complaints of a headache. A review of the Licensed Personnel Notes, dated November 2, 2010, on the 7 a.m. to 3 p.m. shift, indicated no documentation the resident's entire body was assessed for swelling and/or deformity from 12 p.m. to 3 p.m., a total of 3 hours. A record review of the Daily Licensed Nurses Notes, dated November 2, 2010, on the 3 p.m. to 11 p.m. shift, indicated at 9 p.m. the resident complained of pain on the scale of 6/10 (the pain scale measures a resident's pain intensity based on a scale from zero to 10, a pain level zero represents no pain at all while 10 represents the worst). According to the Daily Licensed Nurses Notes, the resident's pain level was 6 due to the fall and after one hour the resident verbalized a pain level of 3/10. A review of the Licensed Personnel Progress Notes dated November 2, 2010, on the 3 p.m., to 11 p.m. shift, there was no documentation the resident's entire body was assessed for swelling and/or deformity after complaining of right hip pain on the pain scale of six, from 3 p.m. to 11 p.m., a total of 8 hours. A review of the Licensed Personnel Progress Notes, dated November 2, 2010, on the 11 p.m. to 7 a.m. shift, indicated the resident's Certified Nursing Attendant was trying to change the resident's brief. The resident complained of pain on the right hip when the Certified Nursing Attendant was trying to turn the resident and observed slight redness on the resident's right hip. The resident could not bend her knee. The physician was notified and ordered a Stat (emergency) x-ray of the right and left hip. Further review of the record indicated on November 2, 2010 at 4:45 a.m., the physician was notified of the resident's x-ray result that revealed a proximal right femur with displacement (a break in the thigh bone). The physician ordered to transfer the resident to an acute hospital for further evaluation. The resident was transferred on November 3, 2010, at 6:15 a.m. A review of the resident's x-ray result dated November 2, 2010, indicated a fracture involving the proximal right femur with displacement and identified the age of the fracture as recent. According to the facility's procedures on Falls/Fractures, not dated, under Step I indicated to assess/observe the resident's entire body for swelling and deformity and pain. The resident fell on Tuesday, November 2, 2010 at 12 p.m., there were no documented Licensed Personnel Progress Notes that indicate the resident's body was assessed for swelling and/or deformity. A review of the 3 p.m. to 11 p.m., shifts Daily Licensed Nurses Notes, dated November 2, 2010, Registered Nurse 2 documented the resident complained of right hip pain at 9 p.m., and the physician was not notified of the resident's right hip pain; and no documentation in the Licensed Personnel Progress Notes the resident's body was assessed for swelling and/or deformity. The resident remained at the facility for 9 hours after the resident complained of right hip pain to Registered Nurse 2 on the 3 p.m. to 11 p.m. shift. The resident was transferred to an acute hospital on Wednesday, November 3, 2010, at 6:15 a.m. The resident remained in the facility from Tuesday, November 2, 2010, 12 p.m., the time of the fall, until transferred on Wednesday, November 3, 2010 at 6:15 a.m. The resident remained in the facility for a total of 18 hours after the resident fell at 11:30 a.m., Tuesday, November 2, 2010. A review of the November 2010 Medication Administration Record indicated the resident received Vicodin 5/500 mg, two tablets orally for severe pain on November 3, 2010 at 5 a.m. Further review of the Individual Resident's Narcotic Record indicated the resident received Vicodin 5/500 mg, two tablets on November 2, 2010 at 12 p.m. and November 2, 2010 at 9 p.m. A review of the Investigation Report Summary dated November 2, 2010, indicated the resident's daily activity consists of attending morning activity and sometimes in the afternoon. The resident likes to eat by her room in her chair for lunch and dinner. On November 2, 2010, after the morning activity, the resident wheeled herself back to the outside of her room to get ready for lunch. A staff member saw the resident sitting in the hallway in her usual place with the bedside table in front of her at approximately 11:30 a.m. According to the staff member, the resident was not asking for anything. At noon, the resident was found laying on her right side between the bathroom and her bed. The resident explained she hit her head on the floor and the nurse observed a small bump on the right side of her head. The resident did not complain of pain at that time. However, when the Certified Nursing Attendant was changing the resident on the PM shift (according to the 11 p.m. to 7 a.m. Licensed Personnel Notes, the CNA on the 11 p.m., to 7 a.m., shift was trying to change the resident's diaper not the 3 p.m. to 11 p.m. shift). The resident complained of pain and pain medication was given and the pain seemed to have decreased. The physician ordered an x-ray and the result was a fracture involving the proximal right femur with displacement. The resident has been observed to go to the bed, get out of bed and go to the bathroom on her own, in the past, without asking for help. The resident refuses any type of restraint, a lap buddy or an alarm. A review of the resident's clinical record indicated there was no plan of care, or a revised plan of care with nursing interventions addressing the resident would not ask for assistance to get out of bed/chair and would go to the bathroom on her own. The Incident/Accident Prevention Program policy, dated January 2004 indicated to promote proactive healthcare practices in resident care planning to minimize the risk for a fall. On December 13, 2010 at 2 p.m., during an interview with the Administrator, she stated she conducted an investigation on November 2, 2010. The surveyor requested a copy of the Investigation Report and a copy of verbal interviews of staff members. The Administrator stated she did not have the staff members' interviews of the resident's fall. The Administrator stated she threw away the Investigation Report of staff members' interviews, because she does not keep the interviews after an investigation. The Administrator stated there was no telephone call made to the Department of Health to report about the resident's fall and the resident sustaining a proximal right femur fracture. The facility's policy, Unusual Occurrences, not dated, indicated an unusual occurrence included a fall resulting in a fracture, and would be reported by phone to the Local Health Officer and Department of Health Licensing and Certification Section within 24 hours of the incident. The designated person responsible for reporting the incident would be the Administrator or the Director of Nursing. During a telephone interview on December 15, 2010 at 7 a.m., with Licensed Vocational Nurse 3 (LVN 3) assigned to the 11 p.m. to 3 p.m. shift, stated the resident's assigned Certified Nursing Attendant 3 (CNA 3) went to change the resident's diaper and the resident started yelling complaining of pain. Licensed Vocation Nurse 3 stated, she observed slight redness on the resident's right hip area. The resident was unable to bend her right knee. The physician was notified and ordered a Stat (emergency) x-ray of the left and right hip. During a telephone interview on December 17, 2010 at 9 a.m., with Registered Nurse 2 assigned to the 3 p.m., to 11 p.m., shift stated on November 2, 2010 at 9 p.m., the physician was not notified when the resident pointed to her right leg near her right hip area and complained of right hip pain. The surveyor asked Registered Nurse 2 was the resident's right leg pain a complaint of pain the resident had not verbalized to staff members. Registered Nurse 2 stated, "Yes, the resident requested her pain medication." Registered Nurse 2 stated the resident wad given Vicodin 5/500 mg, two tablets, orally and after one hour the resident verbalized the right hip pain was a three. The surveyor asked Registered Nurse 2, if she understood and spoke Japanese. Registered Nurse 2 stated, " No, not really, I understand the Japanese word Toutsuu (pain in Japanese)." Registered Nurse 2 stated the resident can speak a little English and could understand Registered Nurse 2. During the telephone interview on December 17, 2010, at 9 a.m., with Registered Nurse 2 stated she did not assess the resident on the 3 p.m., to 11 p.m., shift on November 2, 2010, for swelling and/or deformity. A review of the resident's clinical record revealed there was no documentation that Registered Nurse 2 assessed the resident for swelling and/or deformity on the 3 p.m. to 11 p.m. shift. A review of the acute hospital's Emergency admitted d November 3, 2010, indicated a right hip fracture and a past surgical history of a left hip fracture. The resident's physical examination indicated the resident's right lower extremity was externally rotated. The resident cannot move the right hip because of apparent discomfort, but the resident is comfortable when she is lying still. The acute hospital's Emergency Department's x-ray of the resident's Anteroposterior (AP) pelvis and right hip shows a right intertrochanteric (hip) fracture. According to the acute hospital's Orthopedic Surgery Consultation, dated November 3, 2010, indicated the resident's right lower extremity was shortened and externally rotated. A review of the Operative Report, dated, November 15, 2010, indicated a preoperative and postoperative diagnosis, Subacute Right Intertrochanteric (below the neck of the femur - the femur is the bone between the hip and knee joint - Orthopedics About) Fracture. The operative procedure performed was a Closed Reduction and Insertion of Advanced Orthopaedic Solutions (AOS) trochanteric nail. The operative procedure performed was a Closed Reduction and Insertion of Advanced Orthopaedic Solutions (AOS) trochanteric nail (an operation in orthopedics that involves the surgical procedure for the purpose of repairing a bone using an intramedullary nail an implant, an intramedullary rod, also known as an intramedullary nail, a metal rod, used to treat fractures of long bones of the body - Wikipedia the free encyclopedia).